Achilles Tendon Rupture

Topic updated on 07/31/16 4:24pm
  • Acute rupture of the achilles tendon
    • often misdiagnosed as an ankle sprain
    • may be missed in up to 25%
  • Epidemiology
    • incidence
      • 18:100,000 per year
    • demographics
      • more common in men
      • most common in ages 30-40
    • risk factors
      • episodic athletes, "weekend warrior"
      • flouroquinolone antibiotics
      • steroid injections
  • Mechanism
    • usually traumatic injury during a sporting event
    • may occur with
      • sudden forced plantar flexion
      • violent dorsiflexion in a plantar flexed foot
  • Pathoanatomy
    • rupture usually occurs 4-6 cm above the calcaneal insertion in hypovascular region
  • Achilles tendon
    • largest tendon in body
    • formed by the confluence of
      • soleus muscle tendon 
      • medial and lateral gastrocnemius tendons 
    • blood supply from posterior tibial artery
  • History
    • patient usually reports a "pop"
  • Symptoms
    • weakness and difficulty walking
    • pain in heel
  • Physical exam
    • inspection
      • increased resting ankle dorsiflexion in prone position with knees bent
      • calf atrophy may be apparent in chronic cases
    • palpation
      • palpable gap
    • motion
      • weakness to ankle plantar flexion
    • provocative test
      • Thompson test
        • lack of plantar flexion when calf is squeezed
  • Radiographs
    • indications
      • used to rule out other pathology
  • Ultrasound
    • indications
      • may be useful to determine complete vs. partial ruptures
  • MRI
    • indications
      • equivocal physical exam findings
      • chronic ruptures
    • findings
      • will show acute rupture with retracted tendon edges
  • Nonoperative
    • functional bracing/casting in resting equinus
      • indications
        • acute injuries with surgeon or patient preference for non-operative management
        • sedentary patient
        • medically frail patients
      • outcomes
        • decreased plantar flexion strength compared to operative management
          • new studies show that this may not be true
        • increased risk of re-rupture compared to operative management
          • new studies show that this may not be significant 
        • fewer wound complications compared to operative treatment
  • Operative
    • end-to-end achilles tendon repair 
      • indications
        • acute ruptures (approximately <6 weeks)
      • outcomes
        • decreased rate of re-rupture compared to non-operative management
          • new Level 1 evidence has suggested no difference in re-rupture rates
        • increased plantar flexion strength compared to non-operative management
          • new Level 1 evidence has suggested no significant difference in plantar flexion strength
    • percutaneous achilles tendon repair
      • indications
        • concerns over cosmesis of traditional scar
      • outcomes
        • higher risk of sural nerve damage
    • reconstruction with VY advancement
      • indications
        • chronic ruptures with defect < 3cm
    • flexor hallucis longus transfer +/- VY advancement of gastrocnemius     
      • indications
        • chronic ruptures with defect > 3cm
Surgical Techniques
  • Functional bracing/casting in resting equinus
    • technique
      • cast/brace in 20 degrees of plantar flexion
      • early functional rehab for those treated without a cast
  • End-to-end achilles tendon repair
    • approach
      • make incision just medial to achilles tendon to avoid sural nerve
    • technique
      • incise paratenon
      • expose tendon edges
      • repair with heavy non-absorbable suture
    • postoperative care
      • immobilize in 20° of plantar flexion to decrease tension on skin and protect tendon repair for 4-6 weeks
  • Percutaneous achilles tendon repair
    • technique
  • Reconstruction with VY advancement
    • technique
      • make V cut with apex at musculotendinous junction with limbs divergent to exit the tendon
      • V is incised through only the superficial tendinous portion leaving the muscle fibers intact
  • Flexor hallucis longus transfer +/- VY advancement of gastrocnemius
    • technique
      • excise degenerative tendon edges
      • release FHL tendon at the Knot of Henry and transfer through the calcaneus
  • Re-rupture
    • incidence
      • generally considered to be higher with non-operative management (~10-40% vs 2%)
        • new Level 1 evidence has shown no difference in re-rupture rates
    • treatment
      • surgical repair
  • Wound healing complications
    • incidence
      • 5-10%
    • risk factors
      • smoking (most common)
      • female gender
      • steroid use
      • open technique (versus percutaneous)  
    • treatment
      • deep infection
        • debridement of necrotic/infected achilles tendon
        • culture-specific antibiotics for 6 weeks
  • Sural nerve injury
    • incidence
      • higher when percutaneous approach is used


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Qbank (13 Questions)

(OBQ13.51) When comparing operative versus non-operative treatment of acute Achilles tendon ruptures, which of the following outcomes has consistently been reported in the literature with operative treatment? Topic Review Topic

1. Improved ankle dorsiflexion strength at 6 month follow-up
2. Improved ankle dorsiflexion range-of-motion at 6 month follow-up
3. Improved mean SMFA scores at 12 months
4. A statistically significant decrease in re-rupture rates
5. Increased complication rates

(OBQ12.36) A 36-year-old man presents with fever, pain, and wound drainage 4 months after repair of an acute Achilles tendon rupture. A clinical image is shown in Figure A. Laboratory studies show an ESR of 29 (reference range 0-22 mm/hr). It is decided that he will undergo debridement and irrigation followed by culture specific antibiotic therapy. In the operating room, the Achilles tendon is found to have re-ruptured with a 5 cm defect. What is the most appropriate surgical treatment at this time? Topic Review Topic
FIGURES: A          

1. Primary repair of the re-ruptured Achilles tendon
2. Debridement of necrotic and infected tendon tissue, with no attempt at reconstruction
3. V-Y plasty of the re-ruptured Achilles tendon
4. Repair of the re-ruptured Achilles tendon with a turndown procedure
5. Repair of defect with flexor hallucis longus tendon transfer

(OBQ10.36) A 58-year-old golfer fell stepping into a sand trap and ruptured his Achilles tendon one year ago. He initially chose non-operative treatment, but became unsatisfied with a tender fullness behind his ankle and ankle weakness noticeable during his tee shots. At the time of surgery, a large disorganized fibrous mass is found at the site of rupture. Following extensive debridement there is a 5 cm gap between viable tissue ends. Which of the following surgical techniques provides the greatest likelihood of a successful clinical outcome? Topic Review Topic

1. Gastocnemius turndown repair augmented with transfer of the posterior tibial tendon
2. Gastocnemius turndown repair augmented with transfer of the extensor digitorum longus
3. Gastocnemius turndown repair augmented with transfer of the flexor hallucis longus
4. Reconstruction with hamstring autograft
5. Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program

(OBQ08.269) What is the greatest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks? Topic Review Topic

1. Lower rate of infection
2. Higher rate of normal skin sensation
3. Better skin cosmesis
4. Lower rate of dehiscence
5. Lower rate of re-rupture

(OBQ07.54) A 38-year-old patient has an acute Achilles tendon rupture. He is active in sports and is deciding between operative and nonoperative treatments. Which of the following statements applies to patients undergoing conservative treatment with a cast for 6 weeks followed by a progressive rehabilitation protocol? Topic Review Topic

1. They have lower patient satisfaction scores
2. They are less likely to return to sport
3. Their ultimate strength is decreased
4. They have a higher risk for rerupture
5. They have a higher risk of skin problems

(OBQ06.270) Which factor increases the chance of wound complications after Achilles tendon repair? Topic Review Topic

1. Increased body mass index
2. Immediate surgery
3. Male gender
4. Age over 40 years old
5. Tobacco use

(OBQ04.136) A 41-year-old female feels a pop in her ankle while playing tennis. She is diagnosed with an acute Achilles tendon rupture and elects to undergo nonoperative management. Which of the following is a difference seen with nonoperative management with early functional rehabilitation compared with operative treatment? Topic Review Topic

1. decreased incidence of deep venous thrombosis
2. no significant differences
3. increased rate of re-rupture
4. earlier return to sport
5. increased complication rate

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