Achilles Ruptures

Selene G. Parekh, MD, MBAAssociate Professor of Surgery

Partner, North Carolina Orthopaedic Clinic

Department of Orthopaedic Surgery

Adjunct Faculty Fuqua Business School

Duke University

Durham, NC

919.471.9622

http://seleneparekhmd.com

Twitter: @seleneparekhmd

Controversies

• Treatment:

• Operative vs. non-operative

• If surgery:

• Open vs percutaneous

• Augmentation

• Post-op rehab

Who gets them?

• Men (5x) > Women (4-6:1) (80% vs 20%)

• Avg age: 42 yo (increased after age 25)

• About 0.01% of US population

• 11-18/100,000 people

• 68% occur during sports (at least)

Nyyssonen, Scan J Surg, 2008

Who gets them?

• Contributing factors:

• Age: >40yo

• Blood flow decreases

• Stiffness of tendon increases

• Prior rupture: 6-8%

• Steroid injections into tendon

• Medications: fluoroquinolones, statins

Vosseller, FAI, 2013

Kujala, Clin J Sports Med, 2005

Hess, Foot Ankle Spec, 2009

Who gets them?• Elite Athletes

• More likely to get Achilles tendinopathy instead of

a frank rupture

• Older athletes (27 yo vs 25 yo)

• Sprinters more than distance athletes

Gajhede-Knudsen, Br J Sports Med, 2013

Elite Athletes

• Parekh et al, 2009

• NFL players, 1997-2002

• 31 Achilles ruptures (~6/year) in 28 players

• Avg age: 29 years old (avg age of NFL player:

26yo)

• 35% in preseason, 65% in regular seasons

• None occurred in practice

• 36% of athletes never returned to play in NFL

Fluoroquinolone Use

• Exposure increases risk tendon injuries

• Achilles tendon more than others

• Increased risk:

• First month of use (even first 7 days)

• Combined with oral corticosteroids

• >60 yo

• Renal disease

• Type of fluoroquinolone

• Black Box warningStephenson, Drug Saf. 2013

Parmar, FAI, 2007

Corticosteroid Use

• No clear etiological role

• Injections:

• Animal studies:

• Necrosis at site of injection

• Delay in healing response

• Clinical studies: case reports

• 5 athletes after injection: residual corticosteroid steroid found at the site of injection

• Oral:

• Case reports suggest increased risk of rupture

Balasubramaniam, JBJS-Br, 1972

Unverferth, JBJS, 1973

Mechanism

• 53% at push off (eccentric contraction)

• Occurs during running or jumping

• Tears 2-6cm from insertion (80%)

Hess, Foot Ankle Spec, 2010

Anatomy

• Conjoint tendon of

gastrocnemius &

soleus

• Tendon is 10-15 cm

• Largest, strongest

tendon

• Forces

• 6-8x w jumping

• 12.5x w sprinting

Anatomy

• Contribution variable

• More from gastroc

• Fibers rotate 90o

• Gastroc contribution is lateral

• Maximum rotation of fibers is at 2-5cm proximal

to insertion

Anatomy

• Insertion:

• Middle third posterior

surface calcaneal tuberosity

• 1cm distal to superior

aspect of calcaneus

Nunley JA, The Achilles

Tendon

Vascular Supply

Chen, Clin Anat, 2009

Vascular Supply

Vascular Supply

• Posterior longitudinal midline incision

• Least disruptive

• Close the paratenon and deep fascia

• Thought to help healing

• Skin perfusion

• Maximized at 20o plantar flexion

Poynton, FAI 2001

Presentation

• Sudden pain

• “kicked in the back of my calf”

• Audible snap

• Weakness in ankle

• Initial diagnosis missed as often as 25%

• Commonly diagnosed as ankle sprain

Kvist, Sports Med. 1994

Diagnosis

• “Should not pose a diagnostic problem”

• At least 2 positive physical exam tests

• Palpation: least sensitive

• Calf squeeze: most sensitive

• Maltes: knee flexion test (88% sensitive)

• Copeland: blood pressure cuff test

• O’Brien: needle test

Maffulli, Am J Sports Med. 1998

Diagnosis

• Calf squeeze test

• Thompson test

• 96% sensitive

• 93% specific

• Prone position, knee

flexed

• Squeeze calf, watch for

plantarflexion

• Test both sides

Thompson, Acta Orthop Scandinavica, 1962

Diagnosis

O’Brien’s test

Imaging

• Should not rely on imaging

• Radiographs:

• Useful for distal avulsions

• Particularly with chronic insertional disease

• Loss of configuration of Kager’s triangle

• Toygar’s sign

MRI

• Findings

• Complete rupture on T1

• T2: increase in signal intensity with edema and hemorrhage

• Time consuming:

• 5 days to obtain

• Expensive

• Treatment delays

• Delayed initial eval by 6 days

• Delayed surgery by 7 days

Garras, CORR, 2012

Ultrasound

• Performed in office

• Faster

• Cheaper

• Can examine healing or repair

• Best method to follow treatment

• Still not necessary

Maffulli, Internat J Sports Med, 1990

Treatment

• AAOS guidelines, published in 2009:

• Conflicting Evidence

• No definitive answer on operative vs

nonoperative treatment

• 16 recommendations:

• None graded as strong

• 2 consensus statements

• 2 moderate strength recommendations

AAOS Clinical Practice

Guidelines• Consensus:

• Detailed history & physical exam (2 physical exam

tests)

• Surgery is option

• Approach cautiously in pts >65, systemic issues,

obesity, or tobacco

• Moderate:

• Early protected weight bearing after surgical repair

• Protective device for mobilization b/t 2-4wk post-op

Operative vs Non-operative

Non-Operative Treatment

• Traditionally treated w immobilization

• 6-8wks cast

• High re-rupture rates

• Lee and smith, 1972: 13%

• Person and Wedmark, 1976: 32%

• Inglis, 1976: 39%

Non-Operative Treatment

• Functional rehab instead of cast immobilization

• Post-op: mobile cast is better than immobilization

Cetti, CORR 1994

• Meta-analysis of operative vs non-operative

• 12 trials w over 800 patients

• Less re-ruptures w surgery

• Higher complications with surgery (wound)

• Post-op:

• Functional brace with lower complication rate

than castingKhan, JBJS 2005

• Largest series of pts with non-op, functional rehab

• 2.8% re-rupture rate overall

• 2.7% re-rupture rate w delayed presentation (>2

wks)

Non-Operative Treatment

• Willits et al. JBJS 2010

• Prospective, randomized, multicenter trial

• 144 pts (72 operative, 72 non-op)

• All patients with accelerated rehab

• No difference in:

• Re-ruptures (2 in operative, 3 in nonoperative)

• Strength

• ROM

• Functional score (leppilahti score)

• Calf circumference

• Complications:

• 13 in operative group

• 6 in non-operative group

• No difference in:

• Re-rupture rate

• Strength and calf size

• Lower complications in non-operative group

• Faster return to work

• Concluded: consider non-op treatment if center

has functional rehab protocol

Comparison Study

• Gwynne-Jones, FAI, 2011

• Functional rehab in both operative and non-

operative

• Pts <40 yo with improved outcomes with surgery

• Lower re-rupture

• Low complications (1.4% wound complications)

• Non-operative is better in pts >40

• <40 yo: 13.1%

• >40 yo: 4.1%

• Recommend surgery for younger pts and athletes

Non-operative treatment

• Strong evidence for both non-operative and

operative treatment

• Must be functional rehab (if not, operate)

• Patients should be informed, ultimately their

decision

• Athletes may favor operative treatment

• Faster return to work and sport

• Questionable improved outcomes

Functional Rehab

Who should have surgery

• Elite athletes

• Delayed presentation

• Inability for functional rehab

If surgery…

• More controversy

• How to repair

• Open vs percutaneous

• Post-op rehab

• Augment repair?

How to repair

• Watson, FAI, 1995

• Single Kessler

• Single Bunnel

• Double Krackow

• Double Krackow had double the strength

Suture Type

• McCoy and Haddad, FAI, 2010

• Double Krackow, double Bunnell, and double Kessler

• No difference in strength

• All failed at the knot

• No conclusion on technique of repair

Percutaneous Repair

• Minimizes trauma to tenuous skin

• Reduces surface area for adhesion formation

• Decreases possibility of contamination

• Minimal complications (11%)

• Skin dimple at operative site

• Tender nodule at operative site

Does Incision Size Matter?

• Cochrane review in 2010 (Khan et al)

• Percutaneous surgery vs open:

• Lower risk of infection

• Interpret with caution

• JBJS meta-anaylsis (Khan, 2005)

• Percutaneous with lower complication rate

Open vs Percutaneous

• Meta-analysis of randomized controlled trials

• No difference between groups:

• Re-rupture

• Sural nerve injury

• Deep infection

• Minimally invasive:

• Less superficial wound infection

• 3 times greater patient satisfaction

Foot Ankle Surg, 2011

Achillon device

PARS

• Device by Arthrex

• Allows for 2 locking sutures

• Sutures in multiple planes

PARS

• Charlotte experience

• AOFAS 2012

• 46 pts

• AOFAS: 97

• 45/46 satisfied at 6 months

• No re-ruptures

• No sural nerve complications

• No wound healing issues

• Paid consultants

• 62 ruptures

• 2 re-ruptures (3.2%)

• 1 superficial infection

• No sural nerve injuries

Problems with Percutaneous

Repair?

• Aracil, FAI, 1992

• Sural nerve injury

• Taken back to OR for suture to be cut

• Re-rupture

• 33% re-rupture rate

• Didn’t limit dorsiflexion

• Hockenbury, Foot Ankle, 1990

• 60% sural nerve injury

• All within 2.5 cm from rupture site

Sural nerve

• Webb, FAI, 2000

• Sural nerve crosses

lateral border of

Achilles

• B/t 8-12cm from

insertion

• Usually 2.5cm from

tendon rupture

Avoid Sural Nerve

• Don’t place percutaneous sutures in lateral half

of proximal tendon

• Make small proximal incision to find the nerve

(Webb, JBJS-Br, 1999, Klein, 1991)

• Place suture in medial half of proximal tendon

Post-op Rehab

• Maffulli, AJSM, 2003

• Prospective randomized study

• Early weight-bearing and ROM after open repair

• Fewer outpatient visits

• Discarded crutches early

• Higher satisfaction

• No difference in:

• Ultrasound appearance of tendon

• Isometric strength

Conclusions

• Increasing evidence for non-operative treatment

• Must be functional rehab

• Elite athletes still favor operative repair

• Safe, low re-rupture

• Best functional outcome (fastest)

• Pressure (athlete, coach, media)

• Maffulli, FAI, 2011

• Mini-open is a good option

• Risk of sural nerve injury

• Do what works in your hands

RE

ECTthe ankle

the foot