Achilles Tendon Ruptures

Yanuarso, MD Indonesian Army Central Hospital

Achilles: Hero of the Iliad

Led Greeks to conquer Troy Killed by arrow shot to heel Hippocrates this tendon if bruised or cut, causes the most acute fevers, induces choking, deranges the mind and at length brings death. Strongest tendon in the human body

Achilles Tendon

Formed by tendinous portion of gastrocnemius and soleus Plantaris lies medial and is distinct tendon Achilles progresses from round to flat as it travels distally to insert on calcaneal tuberosity Fibers of tendon rotate 90 degrees distally with medial fibers terminating posteriorly

Biochemistry

Collagen comprises 70% of tendon

95% type I Small amount of elastin

Collagen organized into fascicles surrounded by epitenon Ruptured tendon contains significant type III collagen

Blood Supply

Musculotendinous junction Surrounding connective tissue (paratenon) Bone-tendon junction Poor vascularization in midportion of tendon
Ref: Schmidt-Rolfing, Int. Orthop., 1992

Biomechanics

Peak force of 2233 newtons within achilles in vivo- Fukashiro 1995 Force builds just before heel strike, then released Force builds again and peaks at the end of push off Injury can be produced by asynchronous contraction of triceps surae

Epidemiology

Incidence 18 per 100,000 - Finland Most ruptures occur during sports (Badminton) More common in males in third and fourth decade of life Blood type O?

Etiology

Inflammatory and autoimmune conditions Collagen disorders Infectious disease Neurologic conditions Blood flow to tendon decreases with age Area prone to rupture relatively hypovascular

Etiology continued

Histologic evidence of collagen degeneration in all studies of patients with rupture Collagen degeneration occurs prior to rupture Alternating exercise with inactivity Accumulation of trauma leads to degeneration Corticosteroids injection into rabbit tendons showed necrosis and delayed healing. Several studies showed collagen damage with injected steroids Oral steroids also implicated

Fluoroquinolones and Tendon Rupture

Ciprofloxacin Direct deleterious effect on tenocytes Decreased transcription of Decorin which may modify architecture of tendon and alter mechanical properties

Bernard-Beaubois 1998

Mechanism of Rupture

Pushing off foot while extending knee- 53%

Jumping in basketball Volleyball

Sudden dorsiflexion of ankle- 17%

Fall down steps or into hole

Violent dorsiflexion of plantar flexed foot10%

Fall from height

Clinical Presentation

Sudden pain in affected limb Report being struck in back of leg Edema and bruising Palpable gap in tendon + Thompson test- 1962 Frequently missed!!

Imaging

Radiographs- usually not helpful unless avulsion of calcaneus Ultrasound used to assess gap in tendon and apposition of torn ends of tendon
Helpful with nonoperative tx

MRI useful in partial tears and tendinosis

Achilles Tendon Healing

Rabbit model Thermann et al Germany

Foot and Ankle July 2002

Nonoperative vs. operative

No difference within first week
Nonop tx showed aligned fibroblasts after 1 week At 12 weeks, nonop=op tx

High levels of type III collagen in healing tissue of ruptured tendons

Achilles Tendon Healing

Balb-C mice with ruptured achilles treated either with mobilization or immobilization More rapid restoration of load to failure in mobilized group 112 days mobilized group regained original tendon stiffness Mobilization lead to increased inflammatory cells at rupture site.

Palmes et al J of Orthopaedic Research 2002

Nonoperative Treatment

Cast immobilization 6-8 weeks Functional brace Use ultrasound to ensure tendon apposition Higher rerupture rate vs. operative repair Fewer overall complications

Surgical Treatment

First advocated by Pare 1575 1-2% deep infection rate Rerupture rate 2-8% Pajala et al JBJS 2002 409 patients, 5.6% rerupture rate
2.2% deep infection- Finlan

Surgical Repair vs. Casting

7.7% rerupture rate with cast vs. 3% with surgery AOFAS scores similar at 3.5 years post rupture. Greater calf atrophy with cast Fewer overall complications with nonoperative tx
Beskin et al Foot/Ankle December 2001

Complications of Surgical Treatment

Wound necrosis Wound infection Sural nerve injury DVT and PE Rerupture 2-5%

Percutaneous Achilles Repair

Developed by Ma and Griffith 1977 6 small incisions to pass sutures Faster return to normal strength than cast Sural nerve entrapment Higher rerupture rate vs. open repair

Percutaneous vs. Open Repair

Percutaneous
6.4% rerupture rate

Open repair
2.7% rerupture

Percutaneous does not reestablish length Injury to sural nerve Fewer wound complications with percutaneous tx

JBJS Br 1999

Chronic Ruptures

Use V-Y advancement if gap < 4cm Central turn down for larger gaps > 4cm Augmentation with FHL tendon Allografts?

Achilles Tendonitis

Thickening and swelling of tendon May occur at insertion or midsubstance Often associated with tight gastroc Insidious onset

Achilles Tendonitis Treatment

Immobilization Physical therapy Heel lift NSAIDS PRP injection NO CORTISONE!

Operative vs. Nonoperative Treatment

Willits et al, JBJS Dec 2010 144 patients with achilles rupture Randomized to operative and nonoperative Fewer complications in nonoperative group Functional outcome no statistical difference

Summary

Functional outcome better with surgery and early motion Fewer complications with nonsurgical tx Rerupture rate
Surgery 2% Cast 8-10%

Future
Functional bracing Percutaneous repair

Postoperative Protocol

Non weight bearing x 4 weeks Cam walker brace x 6 weeks Active ROM exercises only No passive stretching for 8 weeks