Achilles Tendon Rupture

 

Achilles tendon anatomyAchilles tendon ruptureAchilles tendon repair

 

Anatomy

 

Gastrocneumic and soleus tendon

- longest tendon in human body

- fibres spiral 90° before inserting on superior calcaneal tuberosity

     - medial gastrocs inserting posteriorly

- allows elastic recoil & energy storage

 

Paratenon

- allows smooth tendon movement

 

Blood supply

- paratenon

- small amount muscle proximally and calcaneum distally

- watershed area 2 - 6 cm proximal to calcaneal tuberosity / area of rupture

 

Plantaris

- present in 90% population

- medial to Tendo-achilles

 

Epidemiology

 

Usually age > 40 years

- M:F = 12:1

- occasional sportsman

- 75% during sports

 

Etiology

 

Systematic Factors

- age related changes

- tendonitis

- diabetes / steroid / obesity

- flouroquinolone / ciprofloxacin in elderly

 

Mechanical Overload / sudden training increase

 

Rupture Site

 

1.  Watershed area

- 5 - 7 cm proximal to insertion

- most common

 

2.  Insertion - insertional tendonitis / diabetes / obestiy

 

3.  Musculotendinous juntion

- avulsion of medial or lateral head

- may present with chronic weakness

 

Medial Head Gastrocnemius RuptureMusculotendinous Gastrocnemius Rupture 2

 

Natural history of neglected tears

 

Weakness / difficulty with push off

- compromised running / jumping / stairs 

- can still walk with use of FHL / FDL / T posterior / Peroneals

 

Symptoms

 

Sudden pain in calf

Audible snap

 

Examination

 

Acute tear

 

Calf Wasting Left LegAchilles Tendon Rupture 1

Significant swelling

 

Achilles gapAchilles gapAchilles gap

Visible / palpable gap

 

Positive Thompson Test

- patient prone

- squeezing calf doesn't produce plantarflexion of ankle

 

Maffulli et al AJSM 1998

- Thompson test

- sensitivity 0.96, specificity 0.93

 

Thompson Sign Normal PreThompson Sign Normal Post 

Thompson test

 

Chronic tear

 

Gap not palpable as gap fills with scar tissue

Excessive dorsiflexion compared with other side

 

TA rupture increased DF

 

Xray

 

Exclude bony avulsion / insertional rupture

 

Bony avulsion TAchBony avulsion

 

Ultrasound

 

Diagnose rupture and check reduction of tendon ends with plantarflexion

 

Aminlari et al J Emerg Med 2021

- systematic review

- ultrasound 95% sensitive and 99% specific for complete rupture

 

US Tach gapUS T Ach

 

MRI

 

Indication

- incomplete rupture / clinical uncertainty

- chronic tears - measurement of gap for reconstruction planning

 

Acute achilles tendon tear

Acute                                                          

 

High grade partialHIgh grade partial

High grade partial thickness

 

MRI TA rupture chronicChronic retracted achillesChronic achilles

Chronic retracted

 

Management

 

Operative v Non-operative Management

 

Issues

 

Increased complication rate with operative management

- 1.4% deep infection

- 3% nerve injury

 

Higher re-rupture rate with non operative management

- 1% versus 6%

 

Retear

 

Myhrvold et al NEJM 2022

- RCT operative versus nonoperative 526 patients

- no differences between groups in functional outcome

- 6% retear in nonoperative group

- 0.6% retear in operative group

 

Infection

 

Attia et al AJSM 2023

- meta-analysis of open versus minimally invasive

- superficial infection: open 6%, MIS 0.4%

- deep infection: open 1.4%, MIS 0%

 

Sural nerve injury

 

Myhrvold et al NEJM 2022

- RCT operative versus nonoperative 526 patients

- 3% nerve injury in open operative group

- 5% nerve injury in the minimally invasive group

 

Return to sport

 

Johns Foot Ankle Int 2021

- systematic review of elite athletes

- 76% able to RTP, at average 11 months

- those who returned often with decreased performance

- worse than ACL injuries

 

Zellers et al Br J Sports Med 2016

- systematic review of 6,500 patients

- return to sports 80%

 

Bak et al J Foot Ankle Surg 2024

- systematic review

- no difference return to sports between operative and nonoperative

 

Non-operative management

 

Technique

 

Functional rehabilitation

A.  2 weeks equinus front slab within 24 hours

- close gap before haematoma forms

B. 2 - 8 weeks full weight bear in air cast with heel raise 2 cm

- active ROM below neutral

 

Achilles Tendon Boot and heel raise

 

Results

 

Dai et al J Sci Med Sport 2021

- systematic review of non operative management

- immobilization versus early functional rehabilitation

- no difference in functional outcome / rerupture / return to sport

- safe to early mobilize and weight bear in brace

 

Operative

 

Indications

 

Athlete

Delayed initial treatment

Wish to reduce retear rate

 

Options

 

Open

Minimally invasive

 

Attia et al AJSM 2023

- meta-analysis of open versus minimally invasive

- 10 RCTs and 500 patients

- no difference functional outcome

- rerupture rate: open 2.5%, MIS 1.5% (not significant)

- sural nerve injury: open 0%, MIS 3.4% (significant)

- superficial infection: open 6%, MIS 0.4% (significant)

- deep infection: open 1.4%, MIS 0% (not significant)

 

Open tendoachilles repair

 

Krackow suture

 

Technique

 

Vumedi open achilles tendon repair

 

Prone position with tourniquet

- slightly medial incision to protect sural nerve

- full thickness skin flaps to paratenon

- identify and protect sural nerve

- divide paratenon longitudinally

- can incise paratenon in the midline anteriorly which increases tissue available for closure

- Bunnell Suture  / Krackow suture x 2 with high strength suture / fibre wire

- one in proximal and one in distal tendon ends

- tie via two knots with foot fully plantar flexed

- +/- augment with circumferential 4.0 suture to minimize bunching

- careful closure of paratenon to prevent skin adhesions

- front slab in plantarflexion 2 weeks

- then standard accelerated rehabilitation

 

ParatenonParatenon release

Anterior release of paratenon to allow posterior closure over achilles repair

 

Open repairOpen repair

Repair with proximal and distal Krackow high strength sutures

 

Minimally invasive repair

 

Percutaneous suture technique

 

Arthrex PARSArthrex PARS

Arthrex PARS

 

Vumedi percutaneous repair video

 

Arthrex PARS technique

 

Calcaneal anchor technique

 

Arthrex speedbridgeArthrex PARS

Arthrex Speedbridge technique

 

Arthrex Speedbridge PDF

 

Vumedi Arthrex Speedbridge in calcaneum

 

Vumedi stryker anchors in calcaneum video

 

Rehabilitation

 

Huan et al AJSM 2015

- systematic review of rehabilitation after operative repair

- lower complications and better outcomes with early weight bearing and ankle ROM exercises

 

Complications

 

Infection / wound breakdown

 

Infection post tendoachilles repairAchilles wound

 

Wound breakdown

- free muscle flap  + split skin graft

- fasciocutanous flap (radial or lateral thigh)

 

DVT / PE

 

Blanco et al J Foot Ankle Surg 2018

- prospective cohort and 90 incidence of DVT / PE

- achilles tendon in cast: 5%

- ankle fracture cast / no surgery:2%

- ankle fracture surgery: 3%

 

Rerupture

 

Tendoachilles Nonoperative ReruptureAchilles Tendon Rerupture0001Achilles Tendon Rerupture0002

New incomplete tear seen on MRI

 

Achilles Tendon Scar TissueAchilles Tendon Scar Tissue No Reduction Plantarflexion

Rerupture with scar tissue between tendon ends

 

Reconstruction

 

Algorithm

 

Defect Method
< 3 cm Turndown
3 - 5 cm V-Y lengthening
> 5 cm

Local tendon graft - FHL / Peroneus brevis

Free tendon graft

 

Turndown

 

Achilles Tendon Turndown

Technique

 

Vumedi turndown video

 

Bosworth technique

- harvest central third fascia

- from musculotendinus junction as far proximal as possible

- leave attached distally, detach proximally

- closure fascia above

- tubularise fascia with 2.0 ethibond

- drill hole through calcaneal tuberosity

- pass through calcaneum

- suture to itself

 

VY lengthening

 

Achilles Tendon VY TurndownVY

 

Technique

 

Vumedi VY lengthening + FHL transfer video

 

Surgical technique PDF

 

Local tendon grafts

 

Options

 

FHL

Peroneus brevis

 

Turndown and FHL HarvestFHL Transfer 2FHL Transfer 3

Turndown + FHL transfer with FHL passed through a transverse tunnel in the calcaneum

 

FHL transfer

 

Technique

 

Vumedi VY lengthening + FHL transfer video 1

 

Vumedi VY lengthening + FHL transfer video 2

 

Identify FHL tendon medially

- identify and protect tibial nerve

- pull tendon through and transect with sufficient length

- through drill hole in calcaneum and secure

 

Peroneus brevis transfer

 

Technique

 

Surgical technique PDF

 

Identify peroneus brevis tendon laterally

- small incision over base 5th metatarsal

- divide tendon

- pass through calcaneal drill hole and secure

 

Results

 

Maffulli et al J Clin Med 2023

- systematic review of local tendon grafts for achilles reconstruction

- 79% able to return to previous activity

 

Free tendon grafts

 

Gracilis transfer

 

Maffulli et al KSSTA 2023

- systematic review of chronic tears with > 6 cm

- free tendon grafts

- 22 articles and 400 patients

- 80% no activity limitations

- 50% return to sport