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2. Case History
Patient Medical History
 70 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. Case History
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. Case History
Physical examination
 Inspection:
There was swelling around left posterior
ankle joint.
Archived, identical image
(not the patient own image)

5. Case History
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. Case History
Physical examination
 Palpation:
 The Thompson calf squeeze test was positive for
a subcutaneous Achilles tendon rupture.
Normal Abnormal (tendon rupture)

7. Case History
Ultrasonography
Archived, identical image
(not the patient own image)
 A complete disruption of the fibrillar structure
of the tendon
 The gap between the ruptured tendon ends
was filled by a hematoma

8. Diagnosis of Rupture Tendo-
Achilles was confirmed
Case History
Diagnosis

9. Tendinopathy in Hemodialysis
First Report
Tendinopathy
(Inflammation & Spontaneous rupture)
Vol. 1, No. 1, October 2016, 23-26
Prominent in Hemodialysis patients

10. Tendinopathy - Tendon Rupture
Causes
 Tendon rupture has been described as a
complication of:
 ESRD
 SLE
 Gout
 Rheumatoid arthritis
 Diabetes mellitus
 Obesity
 Sports activity and Trauma
And its risk factors
2017;37:341-3

11.  Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture Hemodialysis
Talk Outline

12. Spontaneous Tendon Rupture Hemodialysis
Talk Outline
 Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention

13. Spontaneous Tendon Rupture Hemodialysis
Which Tendon?
Quadriceps
tendon
Achilles
tendon
Patellar
tendon
The most frequently affected tendons

14. Ho LC et al. Clin Nephrol. 2009 Apr;71(4):451-3.
Spontaneous Tendon Rupture Hemodialysis
Which Tendon?

15.  Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture Hemodialysis
Talk Outline

16.  Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture Hemodialysis
Talk Outline

17. Spontaneous Tendon Rupture Hemodialysis
Risk Factors
Vol. 1, No. 1, October 2016, 23-26
Known Risk Factor Is it present in our patient?
Long-term hemodialysis
2ry hyperparathyroidism
β-2 microglobulin
associated amyloidosis
Fluoroquinolone use
Corticosteroid use
Malnutrition / Chronic
inflammation
Chronic Acidosis
The most important
risk factor
The most important
risk factor

18. Tendinopathy in Hemodialysis
The Hidden Face of CKD-MBD
MBD
+
MVD
+
MSD

19. Known Risk Factor Is it present in our patient?
Long-term hemodialysis
2ry hyperparathyroidism
β-2 microglobulin
associated amyloidosis
Fluoroquinolone use
Corticosteroid use
Malnutrition / Chronic
inflammation
Chronic Acidosis
Case History
Risk Factors

20. Known Risk Factor Is it present in our patient?
Long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism
β-2 microglobulin
associated amyloidosis
Fluoroquinolone use
Corticosteroid use
Malnutrition / Chronic
inflammation
Chronic Acidosis
Case History
Risk Factors

21. Known Risk Factor Is it present in our patient?
Long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism Yes:
β-2 microglobulin
associated amyloidosis
Fluoroquinolone use
Corticosteroid use
Malnutrition / Chronic
inflammation
Chronic Acidosis
Lab Variable Result
Calcium 9.7mg/dl
Phosphorus 5.5mg/dl
PTH 450 pg/ml
Alkaline Phosphatase Not available
Case History
Risk Factors

22. Known Risk Factor Is it present in our patient?
Long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism Yes:
β-2 microglobulin
associated amyloidosis
Yes:
Serum β-2 microglobulin: 460 mg/L
Fluoroquinolone use
Corticosteroid use
Malnutrition / Chronic
inflammation
Chronic Acidosis
Case History
Risk Factors

23. Known Risk Factor Is it present in our patient?
Long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism Yes:
β-2 microglobulin
associated amyloidosis
Yes:
Serum β-2 microglobulin: 460 mg/L
Fluoroquinolone use No
Corticosteroid use No
Malnutrition / Chronic
inflammation
Chronic Acidosis
Case History
Risk Factors

24. Known Risk Factor Is it present in our patient?
Long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism Yes:
β-2 microglobulin
associated amyloidosis
Yes:
Serum β-2 microglobulin: 460 mg/L
Fluoroquinolone use No
Corticosteroid use No
Malnutrition / Chronic
inflammation
Not sever
Chronic Acidosis
Lab Variable Result
Hb 11g/dl
Serum Albumin 3.7 g/dl
Case History
Risk Factors

25. Known Risk Factor Is it present in our patient?
Long-term hemodialysis Yes: 12 years old HD
2ry hyperparathyroidism Yes:
β-2 microglobulin
associated amyloidosis
Yes:
Serum β-2 microglobulin: 460 mg/L
Fluoroquinolone use No
Corticosteroid use No
Malnutrition / Chronic
inflammation
Not sever
Chronic Acidosis Yes
Case History
Risk Factors

26.  Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture Hemodialysis
Talk Outline

27.  Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture Hemodialysis
Talk Outline

28. Spontaneous Tendon Rupture Hemodialysis
Diagnosis
Ultrasonography
good sensitivity (96–100%)
and specificity (83–100%)
MRI
29 March 2013. 41(4) 1378–1383.

29. Spontaneous Tendon Rupture Hemodialysis
Diagnosis
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
Volume 2016 (3 October, 2016)
Article ID 4713137

30.  Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture Hemodialysis
Talk Outline

31.  Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture Hemodialysis
Talk Outline

32. The tendon itself due
to degenerative
changes
secondary
hyperparathyroidism →
increased osteoclastic cortical
bone resorption at the tendon
insertion site
At the tendon
insertion site
(Enthesitis )
Our patient
Spontaneous Tendon Rupture Hemodialysis
Which Part of the Tendon?
Feb 23, 2016; 2(1): 1030

33.  Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture Hemodialysis
Talk Outline

34.  Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture Hemodialysis
Talk Outline

35. Spontaneous Tendon Rupture Hemodialysis
Treatment
Early surgical repair
Leg Cast
Control of 2ry
Hyperparathyroidism
Physiotherapy
2017;37:341-3

36. Archived, identical image
(not the patient own image)
During exploration:
1.The colour of the tissue stump
is dark brown due to poor blood
2.Signs of chronic inflammatory
infiltration
3.Degenerative weak tendon
fibers
Case History
Treatment

37. Archived, identical image
(not the patient own image)
Non absorbable
mono-filamentous
sutures
Tear at the lower 1/3
of the tendon
Case History
Treatment

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

39. Early surgical repair
Leg Cast
Case History
Treatment
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

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

41.  Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture Hemodialysis
Talk Outline

42.  Which Tendon?
 Risk Factors
 Diagnosis
 Which part of the tendon?
 Treatment
 Prevention
Spontaneous Tendon Rupture Hemodialysis
Talk Outline

43. Spontaneous Tendon Rupture Hemodialysis
Prevention
Control Risk Factor
2ry hyperparathyroidism Control
β-2 microglobulin associated amyloidosis !!
Avoid Fluoroquinolone use
Avoid Corticosteroid use
Malnutrition / Chronic inflammation Control
Chronic Acidosis Control

44. Quality of Life

45. Home Messages

46. Take Home Messages
ESRD is a risk factor for tendon rupture

47. Take Home Messages
Most affected tendons:
Quadriceps, Patellar and Achilles
tendon

48. Take Home Messages
The most important risk factor is
2ry hyperparathyroidism

49. Take Home Messages
Up to 50% of quadriceps
tendon rupture may be misdiagnosed

50. Take Home Messages
Don’t misdiagnose
High suspicion → MRI

51. Take Home Messages
Early surgical repair of ruptured tendons
results in better outcomes than delayed
treatment

52. Take Home Messages
Physiotherapy is mandatory

53. Take Home Messages
Control risk factors especially 2ry
hyperparathyroidism

54. Thank You