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Achilles Tendon Rupture

  • Third most common tendon rupture
  • Most common in 3rd to 5th decades
  • Age related changes that facilitate Achilles rupture :
    • Decreased perfusion
    • Decrease in collagen cross linking and elasticity
    • Increased stiffness
  • Rupture occurs in a relatively hypovascular area of the tendon, 2 - 6 cm above its insertion into the calcaneus
  • Repetitive microtrauma causes an inflammatory reparative process that in presence of decreased vascularity is unable to keep up with the stress
  • Usual mechanisms :
    • Sudden push off while knee is extended
    • Forceful ankle dorsiflexion against a contracted heel cord
    • Fall from a height on plantar flexed forefoot

Clinically

  • Sharp tearing pain behind ankle following activity
  • Patients often describes incident as if someone kicked him in ankle or has been shot
  • Palpable defect of Achilles
  • Inability to 'toe-walk'
  • Simmond's test is diagnostic (also called Thompson's test)
  • Active plantar flexion is less reliable, for it can be performed by other tendons that pass behind medial malleolus

Investigation

  • Ultrasound and MRI demonstrate tear in doubtful cases
  • MRI differentiates partial tears from complete tears, tendinosis or inflammation

Treatment

Acute
Nonoperative

  • Best results obtained if :
    • Under 48 hours
    • Low demand patient
    • No palpable tendon gap in 20° plantar flexion
  • Immobilise in plantar flexion cast for 8-12 weeks
  • Gradually decrease plantar flexion in 2-week intervals; reaching neutral at 8 weeks
  • Maintain cast for another 4 weeks in neutral
  • Use heel lift for 2-3 months after cast removal
  • Higher re-rupture rate and lower power is reported in non operative management

Operative

  • Most proper for young, active patients
  • Posteromedial skin incision
  • Allows access to plantaris to augment repair
  • Suture (Kessler/Bunnell with peripheral suture)
  • Repair paratenon separately
  • Post op management is similar to no operative therapy

Late repair of chronic rupture (>4 weeks)
Old, low demand or medically unfit patients

  • Rocker bottom shoe
  • Hinged ankle brace with dorsiflexion stop

Young active patients

  • Difficult to approximate ends
  • Common methods used to close the gap are :
    • V-Y plasty (Abraham)
    • Turned down flap of proximal tendon (Lindholm/Bisworth)
    • Proximal release of muscle attachment
  • Can supplement repair with :
    • Plantaris
    • Fascia lata
    • FDL
    • FHL
    • Peroneus brevis

Complications

  • Skin slough
  • Re-rupture
  • Reduced power
  • Adhesions
  • Stiffness of ankle with reduced dorsiflexion

Prognosis

  • Earlier return to activity in operative treatment
  • Re-rupture rate:
    • Operative 2-7%
    • Non-operative 8-35%
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