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1. End Stage Renal Disease Patient With
Spontaneous Tendo-Achilles Rupture
Mohammed Abdel Gawad
Nephrology Specialist
Kidney & Urology Center (KUC)
Alexandria – EGY
drgawad@gmail.com
Case Report
New Mansoura General Hospital
CKD MBD Day - 28/Oct/2014

2. Patient Medical History
• 68 years old male patient.
• On maintainenance hemodialysis (3 times per
week) since 12 years.
• The main cause of ESRD is
APKD.
Archived, identical image
(not the patient own image)

3. Presenting Complaint
• This patient presented to us with a sudden
onset of painful disability in the left posterior
ankle.
• This occurred while he was climbing the stairs.

4. Physical examination
• Inspection:
There was swelling around left posterior ankle
joint.
Archived, identical image
(not the patient own image)

5. Physical examination
• Palpation:
– Tenderness above the insertions of the Achilles
tendon.
– There was a gap in the Achilles tendon site.
Archived, identical image
(not the patient own image)

6. Physical examination
• Palpation:
– The Thompson calf squeeze test was positive for a
subcutaneous Achilles tendon rupture.
Archived, identical image
(not the patient own image)

7. Ultrasonography
Ultrasound examination has good sensitivity (96–100%) and specificity (83–100%)*
• A complete disruption of the fibrillar structure
of the tendon
• The gap between the ruptured tendon ends
was filled by a hematoma
Archived, identical image
(not the patient own image)
*Hartgerink P et al (2001). Radiology 220:406–412

8. Diagnosis of Rupture Tendo-Achilles
was confirmed

9. Tendon Rupture
Causes
• Tendon rupture has been described as a
complication of:
– ESRD [1]
– Systemic lupus erythematosus [2]
– Gout [3]
– Rheumatoid arthritis [4]
– Diabetes mellitus [5]
– Obesity [6]
– Sports activity and Trauma .
1. Loehr J (1983). Can Med Assoc J 129:254–256
2. Wener JA (1974). J Bone Joint Surg Am 56:823–824
3. Levy M et al (1971). J Bone Joint Surg Br 53:510–513
4. Razzano CD (1973). Clin Orthop Relat Res 91:158–161
5. Bhole R (1985). South Med J 78:486
6. Kelly BM et al (2001). Arch Phys Med Rehabil 82:415–418

10. Tendon Rupture
Causes
• Tendon rupture has been described as a
complication of:
– ESRD [1]
– Systemic lupus erythematosus [2]
– Gout [3]
– Rheumatoid arthritis [4]
– Diabetes mellitus [5]
– Obesity [6]
– Sports activity and Trauma .
And its risk
factors
1. Loehr J (1983). Can Med Assoc J 129:254–256
2. Wener JA (1974). J Bone Joint Surg Am 56:823–824
3. Levy M et al (1971). J Bone Joint Surg Br 53:510–513
4. Razzano CD (1973). Clin Orthop Relat Res 91:158–161
5. Bhole R (1985). South Med J 78:486
6. Kelly BM et al (2001). Arch Phys Med Rehabil 82:415–418

11. Spontaneous Tendon Rupture - ESRD
Which Muscle-Tendon?
The most frequently affected tendons
Quadriceps
tendon
Achilles
tendon
Patellar
tendon

12. Spontaneous Tendon Rupture - ESRD
Which Patient – Risk factors?
Known Risk Factor Is it present in our patient?
long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism Yes
Tsourvakas S et al (2004). Arch Orthop Trauma Surg 124:278–280
Palmer S (2004). Nephrology (Carlton) 9:262–264
-2 microglobulin
associated amyloidosis
Fluoroquinolone
antibiotic use
Corticosteroid use

13. Spontaneous Tendon Rupture - ESRD
Which Patient – Risk factors?
Known Risk Factor Is it present in our patient?
long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism Yes:
Lab Variable Result
Calcium 9.7 mg/dl
Phosphorus 5.5 mg/dl
Tsourvakas S et al (2004). Arch Orthop Trauma Surg 124:278–280
Palmer S (2004). Nephrology (Carlton) 9:262–264
-2 microglobulin
associated amyloidosis
Fluoroquinolone
antibiotic use
Corticosteroid use
PTH 450 pg/ml
Alkaline Phosphatase Not available

14. Spontaneous Tendon Rupture - ESRD
Which Patient – Risk factors?
Known Risk Factor Is it present in our patient?
long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism Yes:
Tsourvakas S et al (2004). Arch Orthop Trauma Surg 124:278–280
Palmer S (2004). Nephrology (Carlton) 9:262–264
-2 microglobulin
associated amyloidosis
Yes:
Serum -2 microglobulin: 460 mg/L
Fluoroquinolone
antibiotic use
Corticosteroid use

15. Spontaneous Tendon Rupture - ESRD
Which Patient – Risk factors?
Known Risk Factor Is it present in our patient?
long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism Yes:
Tsourvakas S et al (2004). Arch Orthop Trauma Surg 124:278–280
Palmer S (2004). Nephrology (Carlton) 9:262–264
-2 microglobulin
associated amyloidosis
Yes:
Serum -2 microglobulin: 460 mg/L
Fluoroquinolone
antibiotic use
No
Corticosteroid use No

16. Spontaneous Tendon Rupture - ESRD
Which Patient – Risk factors?
Known Risk Factor Is it present in our patient?
long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism Yes:
Tsourvakas S et al (2004). Arch Orthop Trauma Surg 124:278–280
Palmer S (2004). Nephrology (Carlton) 9:262–264
-2 microglobulin
associated amyloidosis
Yes:
Serum -2 microglobulin: 460 mg/L
Fluoroquinolone
antibiotic use
No
Corticosteroid use No
Malnutrition / Chronic
inflammation
No: Lab Variable Result
Hb 11 g/dl
Serum Albumin 3.7 g/dl
Luis Marcelo A. Malta. Injury , In Press: September 23, 2014

17. Spontaneous Tendon Rupture - ESRD
Which Patient – Risk factors?
Known Risk Factor Is it present in our patient?
long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism The most Yes:
important
risk factor
Tsourvakas S et al (2004). Arch Orthop Trauma Surg 124:278–280
Palmer S (2004). Nephrology (Carlton) 9:262–264
-2 microglobulin
associated amyloidosis
Yes:
Serum -2 microglobulin: 460 mg/L
Fluoroquinolone
antibiotic use
No
Corticosteroid use No
Malnutrition / Chronic
inflammation
No:
Luis Marcelo A. Malta. Injury , In Press: September 23, 2014

18. Spontaneous Tendon Rupture - ESRD
Which Part of the Tendon?
In the tendon itself
due to degenerative
changes
At the tendon
insertion site
secondary hyperparathyroidism
→ increased osteoclastic cortical
bone resorption at the tendon
insertion site
Muratli HH et al (2005). J Orthop Sci 10(2):227–232
Shiota E et al (2002). Clin Orthop Relat Res 394:236–242

19. Spontaneous Tendon Rupture - ESRD
Which Part of the Tendon?
In the tendon itself
due to degenerative
changes
At the tendon
insertion site
secondary hyperparathyroidism
→ increased osteoclastic cortical
bone resorption at the tendon
insertion site
Our patient
Muratli HH et al (2005). J Orthop Sci 10(2):227–232
Shiota E et al (2002). Clin Orthop Relat Res 394:236–242

20. Treatment
Early surgical repair
Archived, identical image
(not the patient own image)
- Tear at the lower 1/3 of
the tendon.
- Degenerative weak
tendon fibers
Non absorbable mono-filamentous
sutures

21. Treatment
Early surgical repair
Leg Cast
A short leg cast was postoperatively
applied with foot in gravity equinus
(non bearing cast)

22. Treatment
Early surgical repair
Leg Cast
Sequential change of the cast
shape and foot position with
more dorsiflextion each time
till a 90 degree position cast
3 wks 3 wks 2 wks

23. Treatment
Early surgical repair
Leg Cast
Control of 2ry
Hyperparathyroidism
Physiotherapy

24. Treatment
Early surgical repair
Leg Cast
Control of 2ry
Hyperparathyroidism
Physiotherapy
The patient almost
completely regained his
normal ankle function 4
months after surgical repair

25. Some important clinical points not
related to our case
Simultaneous, spontaneous, bilateral
ruptures may occur
Jones N, Kjellstand CM. Am J Kidney Dis 1996; 28:861-6.

26. Some important clinical points not
related to our case
Statins prescribed for treatment of
dyslipidemia in renal transplant
recipients may rarely cause tendonitis
or even tendon rupture.
Marie I, Delafenetre H, Massy N et al. Arthritis Rheum 2008; 59:367-72.

27. Some important clinical points not
related to our case
Renal transplanted patients especially at
early stages after transplantation when
they receive high doses
of steroids are at risk of tendon rupture
So correct 2ry hyperparathyroidism before
transplantation first
Basic-Jukic N et al. Kidney Blood Press Res. 2009;32(1):32-6.

28. Some important clinical points not
related to our case
Up to 50% of quadriceps
tendon rupture may be misdiagnosed
consider the possibility of a quadriceps tendon rupture in
any patient who presents with:
• acute knee pain
• an inability to extend the leg
• a palpable soft-tissue depression proximal to the
superior pole of the patella
MRI of both thighs may be helpful when the
diagnosis remains unclear
Trobisch PD, Bauman M, Weise K, et al. Knee Surg Sports Traumatol Arthrosc 2010; 18: 85–88.

30. Thank You
Mohammed Abdel Gawad