Achilles Tendon

Rupture
Prepared by dr. Hunar Abdulkhalq
Supervised by dr. Rebar
5 September 2016

Introduction
Pathoanatomy
Mechanism
Epidemiology

Acute
rupture
of the
usually
occurs4-6
above the
Rupture
Incidence
usually
traumatic
injury
during acm
sporting
calcaneal
insertionin
hypovascular region
event
18:100,000
per year
achilles
tendon

may
Demographics
occur with
Often
misdiagnosed
as
sudden
more
forced
common
plantar
in men
flexion
an ankle
sprain
violent
most
dorsiflexion
common inages
in a plantar
30-40flexed
May bemissed
foot
Risk factorsin up to
25%
episodic athletes,"weekend

warrior"
flouroquinoloneantibiotics
steroid injections

Anatomy
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

Presentation
History
patient usuallyreports 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

Matles test
Needle test described by OBrien

Imaging
Radiographs
indications

used torule out other pathology

Ultrasound
indications

may be useful to determinecomplete vs.

partial ruptures

MRI
indications
equivocal physical exam findings
chronic ruptures

findings

will show acute rupture with retracted

tendon edges

Nonoperative:
Treatment

functional bracing/casting

in resting equinus
indications
outcomes
decreased
plantar
flexion
acute
injuries with
surgeon
or strengthcompared to
operative
management
patient
preference
for non-operative
new studies show that this may not be true
management
inc reasedrisk
sedentary
patient of re-rupturecompared to
operative management
medically
frail patients
U/S criteria
for conservative
treatment:
new studies show that this may not be
1. Gap of < 5 mm
with maximal planter flexion
significant

2. Gap of < 10 mm with the foot in neutral position

3. More than
75 wound
% of tendon
apposition
with the
foot in 20
No
complications
compared
to operative
degrees oftreatment
planter flexion

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 ofsural

nerve damage

Chronic Rupture
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

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

Complications
Re-ruptureincidence
generally considered to be higher with nonoperative management (~10-40% vs 2%)

new Level 1 evidence has shown no difference in rerupture rates

treatment
surgical repair

Wound healing

complicationsincidence
5-10%

risk factors
smoking (most
common)
female gender
steroid use
open technique (versus

percutaneous)

Sural nerve injury

incidence
higher when
percutaneous
approach is used

Contraindications to surgical repair:

1. Arterial insufficiency
2. Poor skin and soft tissue quality
3. Poorly controlled medical comorbidities ( e.g.

diabetes)
4. Inability to comply with postoperative
rehabilitation protocols.

References
1. Internet, Orthobullets
2. Campbell operative orthopaedics, chapter 48
3. Millers Review of Orthopaedics

Thank
you

Introduction
Acute rupture of the achilles tendon
often misdiagnosed as an ankle sprain
may bemissed in up to 25%
Epidemiology
incidence

18:100,000 per year

demographics

more common in men

most common inages 30-40

risk factors
episodic athletes,"weekend warrior"
flouroquinoloneantibiotics
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 occurs4-6 cm above the calcaneal insertionin hypovascular region