Achilles Tendon Ruptures

1. Achilles Tendon Ruptures Steven B. Weinfeld, MD Associate Professor of Orthopaedic Surgery Chief; Foot and Ankle Service Mount Sinai Medical Center, NY

2. 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

3. 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

4. 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

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

6. 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

7. Biomechanics – continued At rest, tendon has wavy configuration Tensile stress causes loss of waves Collagen fibers respond linearly to stresses Can return to original configuration with physiologic loads If force greater than physiologic, cross links damaged and ultimately macroscopic rupture occurs – Kannus 1997

8. 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?

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

10. 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

11. 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

12. 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 foot- 10% Fall from height

13. Histology of Rupture Degeneration of tendon Patches of mucoid degeneration Marked inflammatory reaction Hypertrophy of tunica media of large peritendinous vessels All based on biopsy at time of surgical repair

14. 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!!

17. 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

18. 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

19. 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

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

21. 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

22. 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

28. Complications of Surgical Treatment Wound necrosis Wound infection Sural nerve injury DVT and PE Rerupture 2-5%

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34. 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

35. 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

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

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

52. Achilles Tendonitis - Treatment Immobilization Physical therapy Heel lift NSAIDS PRP injection NO CORTISONE!

56. 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

57. 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

58. Postoperative Protocol Non weight bearing x 4 weeks Cam walker brace x 6 weeks Active ROM exercises only No passive stretching for 8 weeks ½” heel lift x 6 months

59. That’s All Folks!