1. Achilles Ruptures
Selene G. Parekh, MD, MBA
Associate Professor of Surgery
Partner, North Carolina Orthopaedic Clinic
Department of Orthopaedic Surgery
Adjunct Faculty Fuqua Business School
Duke University
Durham, NC
919.471.9622
http://seleneparekhmd.com
Twitter: @seleneparekhmd
3. Who gets them?
• Men (5x) > Women (4-6:1) (80% vs 20%)
• Avg age: 42 yo (increased after age 25)
• About 0.01% of US population
• 11-18/100,000 people
• 68% occur during sports (at least)
Nyyssonen, Scan J Surg, 2008
5. Who gets them?
• Elite Athletes
• More likely to get Achilles tendinopathy instead of
a frank rupture
• Older athletes (27 yo vs 25 yo)
• Sprinters more than distance athletes
Gajhede-Knudsen, Br J Sports Med, 2013
6. Elite Athletes
• Parekh et al, 2009
• NFL players, 1997-2002
• 31 Achilles ruptures (~6/year) in 28 players
• Avg age: 29 years old (avg age of NFL player:
26yo)
• 35% in preseason, 65% in regular seasons
• None occurred in practice
• 36% of athletes never returned to play in NFL
7. Fluoroquinolone Use
• Exposure increases risk tendon injuries
• Achilles tendon more than others
• Increased risk:
• First month of use (even first 7 days)
• Combined with oral corticosteroids
• >60 yo
• Renal disease
• Type of fluoroquinolone
• Black Box warning
Stephenson, Drug Saf. 2013
Parmar, FAI, 2007
8. Corticosteroid Use
• No clear etiological role
• Injections:
• Animal studies:
• Necrosis at site of injection
• Delay in healing response
• Clinical studies: case reports
• 5 athletes after injection: residual corticosteroid
steroid found at the site of injection
• Oral:
• Case reports suggest increased risk of rupture
Balasubramaniam, JBJS-Br, 1972
Unverferth, JBJS, 1973
9. Mechanism
• 53% at push off (eccentric contraction)
• Occurs during running or jumping
• Tears 2-6cm from insertion (80%)
Hess, Foot Ankle Spec, 2010
10. Anatomy
• Conjoint tendon of
gastrocnemius &
soleus
• Tendon is 10-15 cm
• Largest, strongest
tendon
• Forces
• 6-8x w jumping
• 12.5x w sprinting
11. Anatomy
• Contribution variable
• More from gastroc
• Fibers rotate 90o
• Gastroc contribution is lateral
• Maximum rotation of fibers is at 2-5cm proximal
to insertion
12. Anatomy
• Insertion:
• Middle third posterior
surface calcaneal tuberosity
• 1cm distal to superior
aspect of calcaneus
Nunley JA, The Achilles
Tendon
15. Vascular Supply
• Posterior longitudinal midline incision
• Least disruptive
• Close the paratenon and deep fascia
• Thought to help healing
• Skin perfusion
• Maximized at 20o plantar flexion
Poynton, FAI 2001
16. Presentation
• Sudden pain
• “kicked in the back of my calf”
• Audible snap
• Weakness in ankle
• Initial diagnosis missed as often as 25%
• Commonly diagnosed as ankle sprain
Kvist, Sports Med. 1994
17. Diagnosis
• “Should not pose a diagnostic problem”
• At least 2 positive physical exam tests
• Palpation: least sensitive
• Calf squeeze: most sensitive
• Maltes: knee flexion test (88% sensitive)
• Copeland: blood pressure cuff test
• O’Brien: needle test
Maffulli, Am J Sports Med. 1998
18. Diagnosis
• Calf squeeze test
• Thompson test
• 96% sensitive
• 93% specific
• Prone position, knee
flexed
• Squeeze calf, watch for
plantarflexion
• Test both sides
Thompson, Acta Orthop Scandinavica, 1962
20. Imaging
• Should not rely on imaging
• Radiographs:
• Useful for distal avulsions
• Particularly with chronic insertional disease
• Loss of configuration of Kager’s triangle
• Toygar’s sign
21. MRI
• Findings
• Complete rupture on T1
• T2: increase in signal
intensity with edema and
hemorrhage
• Time consuming:
• 5 days to obtain
• Expensive
• Treatment delays
• Delayed initial eval by 6 days
• Delayed surgery by 7 days
Garras, CORR, 2012
22. Ultrasound
• Performed in office
• Faster
• Cheaper
• Can examine healing or repair
• Best method to follow treatment
• Still not necessary
Maffulli, Internat J Sports Med, 1990
23. Treatment
• AAOS guidelines, published in 2009:
• Conflicting Evidence
• No definitive answer on operative vs
nonoperative treatment
• 16 recommendations:
• None graded as strong
• 2 consensus statements
• 2 moderate strength recommendations
24. AAOS Clinical Practice
Guidelines
• Consensus:
• Detailed history & physical exam (2 physical exam
tests)
• Surgery is option
• Approach cautiously in pts >65, systemic issues,
obesity, or tobacco
• Moderate:
• Early protected weight bearing after surgical repair
• Protective device for mobilization b/t 2-4wk post-op
28. • Meta-analysis of operative vs non-operative
• 12 trials w over 800 patients
• Less re-ruptures w surgery
• Higher complications with surgery (wound)
• Post-op:
• Functional brace with lower complication rate
than casting
Khan, JBJS 2005
29. • Largest series of pts with non-op, functional rehab
• 2.8% re-rupture rate overall
• 2.7% re-rupture rate w delayed presentation (>2
wks)
30. Non-Operative Treatment
• Willits et al. JBJS 2010
• Prospective, randomized, multicenter trial
• 144 pts (72 operative, 72 non-op)
• All patients with accelerated rehab
• No difference in:
• Re-ruptures (2 in operative, 3 in nonoperative)
• Strength
• ROM
• Functional score (leppilahti score)
• Calf circumference
• Complications:
• 13 in operative group
• 6 in non-operative group
31. • No difference in:
• Re-rupture rate
• Strength and calf size
• Lower complications in non-operative group
• Faster return to work
• Concluded: consider non-op treatment if center
has functional rehab protocol
32. Comparison Study
• Gwynne-Jones, FAI, 2011
• Functional rehab in both operative and non-
operative
• Pts <40 yo with improved outcomes with surgery
• Lower re-rupture
• Low complications (1.4% wound complications)
• Non-operative is better in pts >40
• <40 yo: 13.1%
• >40 yo: 4.1%
• Recommend surgery for younger pts and athletes
33. Non-operative treatment
• Strong evidence for both non-operative and
operative treatment
• Must be functional rehab (if not, operate)
• Patients should be informed, ultimately their
decision
• Athletes may favor operative treatment
• Faster return to work and sport
• Questionable improved outcomes
35. Who should have surgery
• Elite athletes
• Delayed presentation
• Inability for functional rehab
36. If surgery…
• More controversy
• How to repair
• Open vs percutaneous
• Post-op rehab
• Augment repair?
37. How to repair
• Watson, FAI, 1995
• Single Kessler
• Single Bunnel
• Double Krackow
• Double Krackow had double the strength
38. Suture Type
• McCoy and Haddad, FAI, 2010
• Double Krackow, double Bunnell, and double
Kessler
• No difference in strength
• All failed at the knot
• No conclusion on technique of repair
39. Percutaneous Repair
• Minimizes trauma to tenuous skin
• Reduces surface area for adhesion formation
• Decreases possibility of contamination
• Minimal complications (11%)
• Skin dimple at operative site
• Tender nodule at operative site
40. Does Incision Size Matter?
• Cochrane review in 2010 (Khan et al)
• Percutaneous surgery vs open:
• Lower risk of infection
• Interpret with caution
• JBJS meta-anaylsis (Khan, 2005)
• Percutaneous with lower complication rate
41. Open vs Percutaneous
• Meta-analysis of randomized controlled trials
• No difference between groups:
• Re-rupture
• Sural nerve injury
• Deep infection
• Minimally invasive:
• Less superficial wound infection
• 3 times greater patient satisfaction
Foot Ankle Surg, 2011
46. Problems with Percutaneous
Repair?
• Aracil, FAI, 1992
• Sural nerve injury
• Taken back to OR for suture to be cut
• Re-rupture
• 33% re-rupture rate
• Didn’t limit dorsiflexion
• Hockenbury, Foot Ankle, 1990
• 60% sural nerve injury
• All within 2.5 cm from rupture site
47. Sural nerve
• Webb, FAI, 2000
• Sural nerve crosses
lateral border of
Achilles
• B/t 8-12cm from
insertion
• Usually 2.5cm from
tendon rupture
48. Avoid Sural Nerve
• Don’t place percutaneous sutures in lateral half
of proximal tendon
• Make small proximal incision to find the nerve
(Webb, JBJS-Br, 1999, Klein, 1991)
• Place suture in medial half of proximal tendon
49. Post-op Rehab
• Maffulli, AJSM, 2003
• Prospective randomized study
• Early weight-bearing and ROM after open repair
• Fewer outpatient visits
• Discarded crutches early
• Higher satisfaction
• No difference in:
• Ultrasound appearance of tendon
• Isometric strength
50. Conclusions
• Increasing evidence for non-operative treatment
• Must be functional rehab
• Elite athletes still favor operative repair
• Safe, low re-rupture
• Best functional outcome (fastest)
• Pressure (athlete, coach, media)
• Maffulli, FAI, 2011
• Mini-open is a good option
• Risk of sural nerve injury
• Do what works in your hands
Still linked to biceps, rotator cuff, EPL, and anterior tibial tendon
Ofloxacin (mostly eye drop in US now) is worst, cipro is least likely to cause rupture
Hard to quantify the risk with oral steroids based on case studies, but it is likely a higher incidence with oral steroid use
Don’t inject Achilles’ with corticosteroid
Rotation of fibers occurs at 12-15cm proximal from insertion
Supplied by 2 arterial sources: peroneal aa laterally and posterior tibial artery medially
3 vascular territories: proximal is supplied by posterior tibial aa. Midsection, about 4-7 cm from insertion, is supplied by peroneal aa. This is the least vascular zone. Distally, posterior tibial artery supplies most of the tendon.
Paratenon is how most of the vascular supply enters, is a vascular rich zone.
Area 4-7 cm proximal from insertion has the least vascular supply, as seen here in cross section
Knee flexion test, aka maltes test: prone, pt actively flexes knee. If foot on affected side falls into neutral or dorsiflexion, they have an achilles rupture
Copeland: pt prone. place blood pressure cuff around midportion of calf. Inlfate to 100mmHg. Then dorsiflex foot. If pressure rises to over 140mmHg, then musculotendinous unit is intact. If it does not rise, then not intact.
O’Brien test: aka needle test, picture coming up
Thompson test, originally described by Simmonds
O’Brien: pt prone, knee flexed. place need into achilles tendon, about 10cm prox to foot. Dorsiflex foot. If intact, needle will point distally (tendon will pull the tip distally). If needle points proximally, tendon rupture
Should be a clinical diagnosis primarily
Toygar’s sign: measurement of the angle of the posterior skin surface curve
Basically, MRIs are not needed. Don’t get them!
AAOS guidelines are biased in their own regard…they put most weight on prospective, randomized double blind studies.
Weak recommendation: surgical treatment is an option
A weak recommendation that open and percutaneous repairs are both options
Operative vs non-operative treatment is controversial.
Many papers, but maybe not a definitive answer yet…
Most of the studies looking at non-operative care used cast immobilization as their protocol.
All of these studies that favored surgery, had immobilization in the rehab.
What about functional rehab instead?
Again, no functional therapy for non-op pts
Largest series of non-op, functional rehab—945 pts—published in JBJS-British, 2011
2 year follow-up.
Functional rehab protocol: 4 weeks of NWB, equinus cast, 4 weeks of boot with heel lift. At 8 weeks after injury, D/C boot use and start therapy.
All re-ruptures occurred within first 3 months of treatment
6 patients (0.6%) went on to have surgery due to overlengthening and weakness in plantar flexion
Complications included:
DVT, 4 superficial infections, 1 deep infection, 2 small wound dehiscence in operative group.
In non-op group: 3 re-ruptures, 1 DVT, 1 that failed to heal, and 1 pt with persistent pain
JBJS, 2012 from Glazebrook’s group
If not functional rehab with early ROM, there was an 8.8% re-rupture rate.
Complications were 3.9X higher in surgical group vs non-operative (taking out re-rupture rate)
Non-op treatment is still acceptable and successful, but in younger pts and athletes, strongly consider surgery
Crutch walking at 2 weeks. Start ROM, but no dorsiflexion past neutral
D/C crutches, WBAT in boot at 4 weeks
Start dorsiflexion at 6 weeks.
Out of boot at 8 weeks.
Sport specific training at 12 weeks.
Gwynne-Jones in 2011: delayed is >24hrs
Glazebrook says delayed is >48hrs
Thought is there will be too much tendon retraction
Not really a fair comparison. Flawed b/c comparing 1 double vs 2 other single repairs
6 studies, 277 achilles ruptures
Weight bearing group (26pts): allowed to weight bear in equinus cast immediately as they tolerated, switched to dorsi-flexion blocking splint at 2 weeks
Non-weight bearing group (27 patients): NWB cast x 4 weeks (casts changed to decrease amount of equinus)
