Hello everybody, my name is Ken DeFantis and I am here today to talk about Achilles tendon tears. Today we're going to basically just discuss kind of an update on the diagnosis treatment of Achilles tendon tears, acute Achilles tendon tears is what we're going to focus on today, as well as some outcomes. I currently practice at Towson with the Big Associates which is affiliated with the University of Maryland St. Joseph Medical Center in Baltimore, Maryland. So disclosures, I have no disclosures directly related to this talk. So we do have some objectives to go over today. First we're going to review the presentation and diagnosis of acute Achilles tendon ruptures. We're going to discuss the breadth of treatment options including both operative and non-operative techniques. We'll review those techniques as well as the literature on the outcomes of non-operative and operative treatment. We'll then focus on the outcomes of minimally basic repair and I'll kind of give you my technique of how I approach the Achilles tendon rupture today. And then we'll review some of the data comparing the more traditional open techniques to the minimally invasive techniques which have become much more widespread and popular over the last 10 to 15 years. So incidents and demographics, we'll not spend too much time on this but just to kind of just you know some more global level numbers. You know Achilles tendon ruptures are relatively common although you know total incidents within the population is still below less than 0.2 percent. Most you know foot and ankle surgeons who are seeing 100 foot and ankle do see a fair amount of Achilles tendon ruptures. It is much more likely to happen in men than women greater than three to one. Common in young adults traditionally but the age range varies. Anecdotally I've actually seen a lot more Achilles tendon ruptures in the older population. Many can be thanks to pickleball has definitely increased the incidence in my area where I practice. Fluoroquinolone antibiotics are also something that we know can be a contributing factor to Achilles tendon ruptures and there's a high rate of initial misdiagnosis. The literature quotes around 20-ish percent misdiagnosis meaning initially presented to an urgent care or an emergency department for example and might have been told that they had a sprain or maybe a partial rupture and then obviously they come to the office and we and we give them the diagnosis of full thickness rupture. So the anatomy you know the watershed region obviously we're all taught about you know mid portion in this watershed region is the most common area to get a rupture. It's roughly four to six centimeters from the insertion but varies on the depending on how tall the patient is how long their tendon is. In general with regard to anatomy though it's just valuable to determine the location of the rupture in the patient that you suspect has an Achilles tendon rupture. Mid portion being the most common proximal meaning almost at the myotinous junction or even more proximal or right at the insertion because that can help determine number one obviously your your surgical plan and also about whether or not they're more likely to be treated operatively or non-operatively. Predisposing factors that we like to consider so inflammatory conditions have a higher risk of rupture endocrinopathies fall into that category. The fluoroquinolone antibiotics as I mentioned and we'll talk about that briefly shortly. Corticosteroid use and then you know the presence of pre-existing Achilles tendinosis which we will also touch on. So in particular fluoroquinolone antibiotics you know ciprofloxacin levofloxacin and moxifloxacin the most common ones that we hear about. In my practice it's almost exclusively ciprofloxacin and it's usually for the treatment of UTIs. So during the history when someone comes in with an acute rupture or concern for an Achilles tendon injury I always ask them about recent illness and recent antibiotic use. I find that asking about you know recent illness a lot of times someone will say oh I had a UTI in the last two months I was on antibiotic I wasn't sure what it was and that can help tease out that it may be the ciprofloxacin. And then so with this association the question is should we counsel our patients to avoid fluoroquinolone antibiotics when they're being treated both operatively and non-operatively in the in the post-treatment period to avoid these antibiotics and whether or not there's any data to suggest that. So I did want to just share this study this is a retrospective study of 124,000 patients who underwent primary tendon repairs. Now this also includes biceps, Achilles, and rotator cuffs. So but a significant portion of the patients were Achilles tendon repairs. They identified patients who basically had any type of exposure to fluoroquinolone antibiotics in the 90-day post-operative period and all comers including the three different tendons, repaired biceps, Achilles, and rotator cuff. Patients with fluoroquinolone exposure within 90 days after their surgery had a statistically significant risk of a higher reoperation rate and 3.8 percent versus 1.8 percent. So I think it's reasonable to say that it should be part of routine counseling for patients to avoid a fluoroquinolone antibiotic in the immediate post-operative period if possible. So Achilles tendinosis, there's always I think a somewhat controversial to determine about does pre-existing Achilles tendinosis or degeneration of the tendon increase the risk of rupture. I mean historically you know the degeneration of this tendon has been suggested as a factor leading to rupture and there have been histological studies you know from Achilles tendon ruptures where tissue has been sent and the majority of them have some degeneration at the site of the rupture consisted with some tendinosis. To my knowledge there's not any definitive studies have directly linked this but I think most people it's considered a predisposing factor and something to consider. So here's just a classic case presentation of somebody very common that I see in my practice. A 32 year old male playing basketball last weekend about to pop in his left ankle. He's what we call the weekend warrior where he hasn't played basketball in a few years and he decided to go out and play recently getting back into sports. He had difficulty bearing weight he went to urgent care. Most of these patients aren't presenting to the emergency room anymore they're going to urgent cares but due to the long waits and the ease of urgent cares and it's a very common scenario that I get was they get told that they have a partial rupture they're placed in a splint or boot and sent to me for follow-up. So now we're going to touch a little bit more about the diagnosis of Achilles tendon ruptures both clinical and imaging modalities. So obviously diagnosis the three components are the history the physical exam and our imaging modalities we have available to us. So history again we won't focus too much on this because everyone is pretty familiar with it but it's often a non-contact force dorsiflexion with the muscle contraction. So often sports related people say I felt a pop or I felt that someone kicked me in the back of the ankle. Often if their Achilles tendon is functionally out they will have difficulty bearing weight. It's important in the history again as I talked about previously recent antibiotic used to ask about make sure you check their past medical history for any inflammatory atrophies or endocrinopathies whether or not they had the antecedent pain concerning for Achilles tendinosis or whether that they had a recent course of steroids or you know or had a recent steroid injection along the Achilles tendon. Clinical exam relatively straightforward bruising obviously along the posterior ankle and heel with a palpable gap in the tendon is often the most common thing that we see. When they're most of these patients we initially examine them supine and when they press down their gastroc soleus is weak compared to the contralateral side and can cause some discomfort. The two tests that I find most useful and I think are commonly used are the Thompson's test which we're all familiar with and the resting plantar flexion. And so when it comes to performing these tests you know the Thompson's test can be performed in either prone position or with the knee bent on a chair while standing. I much prefer the prone position because I really think it's the best evaluation of both and you can compare it to the contralateral side as well. When you squeeze the calf on the uninjured side you should have some active plantar flexion of the ankle. On the injured side if the Achilles tendon is functionally out when you squeeze the calf there should be no active plantar flexion of the ankle. In my experience in the more proximal the rupture is the more likely that there may be a partially intact Thompson's test or where somebody may where when you squeeze the calf even though they may have a rupture you might still be able to get a little bit of active plantar flexion. The decreased resting plantar flexion I think is also very helpful and be done in the prone position. You basically do it right after the Thompson's test you look at both ankles with the knee bent at 90 degrees and oftentimes the resting tension of the uninjured side you know normally sits around 5 to 10 degrees of plantar flexion and the injured side is often in neutral. So now when it comes to imaging the three different imaging modalities that are commonly used are plane radiographs, ultrasound, and MRI. So with an x-ray a lateral radiograph can sometimes be helpful. I do obtain a lateral radiograph when all at least 10 ruptures if one is not already presented from the urgent care just to make sure that this is not an avulsion from the calcaneus for which you see sometimes insertional pairs which can give you a clue about the location of it. You can sometimes see that Kager's triangle can be disrupted on a lateral radiograph but it can be difficult to interpret. Ultrasound is also a great modality. It is cheap and can be an effective tool. It can confirm or rule out a rupture and then there's a lot of suggestion of well can it can you use ultrasound to show is there a partial or complete rupture? How much is the gap at the tendon? Is there any use intraoperatively? One of the things you have to always be comfortable always understand is that it is extremely user dependent. Personally myself I don't have a lot of experience with ultrasound and so it's not something that I use in my practice and so I think it totally depends on your comfort level and and your training whether or not this is something that you'd like to employ in your practice. So this is just a study from an emergency medicine journal that looked at basically a bunch of patients that in 2021 met analysis about whether or not ultrasound was helpful basically to diagnose your Achilles tendon and Achilles tendon rupture and a negative ultrasound effectively rules out a rupture. So it can be helpful in that sense to you know maybe more so in the emergency setting rather than in the office setting. So something interesting while preparing this talk I came around came across I just thought I would share with everyone is just is there any use of ultrasound intraoperatively or you know at the time of surgery and can it be useful? And so here's a research article that I pulled looking at 16 patients it's a small series. They used a sterile ultrasound probe prior to the incision and basically to identify the location of the rupture and to identify anatomic landmarks such as the sural nerve and the small sapenous vein. They noted they had no obvious sural paresthesis after surgery. This test really didn't, this study was just more so trying to say well what can you really do with an ultrasound intraoperatively? All these patients actually had MRIs so really this wasn't really a cost efficient thing but I thought it was interesting that someone has been using it intraoperatively. I've never used an ultrasound intraoperatively. And then here was another test basically looking to identify the location of the rupture thoughts to basically center the incision directly over the rupture. MRI is by far the best imaging study to evaluate the Achilles tendon. There is an associated cost with it. The average MRI I think in the United States is around $750 for recent data. They can be as cheap as $500 or as expensive as in the thousands of range. So that is something that you should definitely think about when ordering MRIs. It is not needed for the diagnosis but it can be helpful in cases where the diagnosis is unclear. I've found that many of my patients you know feel very, almost not request an MRI but you know they feel that that's part of the generalized process. So I find that a lot of times I will order the MRI to confirm the diagnosis prior to proceeding with surgery but again it's not 100% necessary. I find it to be helpful for surgical planning. I do a minimally invasive technique and I find that actually measuring the distance from the calcaneus to the site of the rupture can be helpful to minimize my incision. It can also be helpful to evaluate background tendinosis. So here's just an example of an MRI that I had in my practice of an Achilles tendon rupture and this is just how I preoperatively measured the distance of about seven centimeters which helped me plan my surgical incision. Here's just another example of another MRI. So when it comes to Achilles tendon tears there's various treatment options. Obviously the big question is non-surgical management versus surgical management. We'll go over all of these in brief and then focus on the minimally invasive techniques. So for non-operative management the two types of non-operative management is either a cast immobilization versus early functional rehabilitation. I think more traditionally people were casted for about six weeks in plantar flexion and gradually brought up to neutral. That is still a technique that is used today but in the early 2000s early functional rehabilitation began and there's good data suggests that early weight bearing and sorry some data suggests that early motion and early weight bearing are safe and have similar outcomes to casting for six weeks and late weight bearing. So again few randomized controlled trials but the data suggests that it's I wouldn't necessarily always say superior but equivalent and patients that seem to be happier because they're not casted again for six weeks but that is still obviously a viable treatment option. So now we'll go on to focus on operative treatment. Again we'll circle back at the end of this talk about comparing non-operative to operative treatment and going over a review of the data and some of the new data that's out there to help counsel our patients and help make our decisions about how we treat these ruptures. So open repair you know the two standard types of approaches are either a midline open incision or a post-treatment incision. When it comes to stitch type there's been many different types of stitches described. I think many people use a crack cowl stitch and either a two or four strand repair. The modified box stitch basically has also been described although I'm not sure how common that is. Kessler has also been described and we're a shout out to my residency program at UE Memorial where there's a stitch called the core weave that was developed which is in my references which is a another unique way to repair Achilles tendon minimizing the amount of suture that's actually exposed on the tendon. So when we look at this is a study from back in 2005 out of JBJS looking at acute tendon ruptures meta-analysis of randomized clinical trials. This was the study that basically initially had said that open surgical repair decreases the rupture rate compared to non-operative treatment but it was not it was associated but not statistically significant. So I think that's where some of the or some of the initial thoughts of you know by fixing these Achilles tendons obviously they're going to have a lower risk of rupture given that some of the newer data has showed equivalent rates. So minimally invasive repair obviously the Achilles tendon area there's not a lot of skin over there there's always concerns about wound complications and part of I think one of the big driving factors in the development of these minimally invasive repairs and why they become popular is to reduce there is the thought of reducing the risk of a wound complication because obviously if you do develop a deep infection there's significant morbidity associated with that often requires a repeat debridement the section of a large portion of tendon and potentially other reconstructive options to regain function once the infection is cleared. For minimally invasive techniques, there are various methods out there. There are companies that provide jigs that can be used to help guide the passages of sutures. The technique that I'll highlight is the technique that I learned in my fellowship where we use a bent sponge stick to basically grab the tendon and percutaneously thread the suture through, similar to a jig assistant, but it doesn't require the use of the jig and there are other methods that have been described as well. This is the technique that I use, which is, like I said, we use a modified ring forceps or a sponge stick and this study was published out of Boston. And just to explain my variation of it, I make a midline vertical incision of about two centimeters. I do measure from the insertion on the calcaneus or the ruler corresponding to the MRI if I have it, to basically, you know, really minimize the length of the incision. Three sutures proximal, three distal. I usually maximally tension it. I do examine the contralateral side to look at the rest of the tension, but I don't prep the other side in. I close it through a monocle and through a nylon and split the gentle plantar flexion. So this is just an example of the ones that I use in the OR. I have three of them and they're bent at different angles to help with different body habit. This is for various locations along the tendon. So small incisions made, we use a malleable to free up the tendon edges, approximately distally. Once we do that, we basically take a clamp, usually an Alice clamp and grab the tendon. We pass this sponge dip clamp that's bent through there on both sides of the tendon, deep to the peritoneum. What's not shown in these pictures is that we also always have retractors in place to make sure that we're always deep to the peritoneum to reduce the risk of damage to the serral nerve. We pass the suture percutaneously and pull it out through, pull the edges out through the incision. We do this three times, approximately distally to get good grip of the tendon. We tie the ends together. As you can see here, the knots are buried underneath and we'll close with just a few stitches. This is just an example of a recent one that I did as well, which we had to make a slightly larger incision. So what about augmentation? So patients coming with chronic tears or a delayed presentation, as we talked about, there is a portion, significant portion of patients who do have a missed Achilles tendon rupture. That's really not the focus of this talk. We could go on an entire talk on chronic tears and reconstructive options. We're just focusing mostly on acute tears, but there are definitely obvious reconstructive options that you can have basically in your armamentarium. There's the BY that we've all taught, turn downs, FHL tendon transfers, allograft augmentation, and other biological augmentations that have been described. So now we'll touch on post-operative care. So with Achilles tendon ruptures, for me, and I think for a lot of providers, operative and non-operative treatment does not necessarily substantially change in the post-operative rehabilitation, which I think is helpful to patients to counsel them as I think there's sometimes a general conception that by fixing the tendon, you can rehab faster, really not the case in my hands. So I guess various post-operative care, some people cast six weeks implantar flexion with no weight-bearing, others go to early functional rehabilitation or early weight-bearing both with operative and non-operative treatment. So when we look at weight-bearing benefits, the thought is, well, does allowing somebody to weight-bear early after repair or non-operative treatment make a difference, or does it increase your risk of a problem? And there has been some studies out there, there was one in 2008 that basically showed really no difference in the outcomes or rupture rate early weight-bearing as opposed to delayed weight-bearing. So there's not evidence to suggest that there's significant benefits over it, but it sounds like it's not inferior. And therefore, I think it's safe to weight-bear early. And I'll go through just a sample protocol of what I use for both my operative and non-operative treatment. The question is, you know, is there just a better quality of life allowing somebody to weight-bear a few weeks after their injury or surgery rather than going to pull six weeks off of it? So this is just a sample rehabilitation protocol. My actual one that I use is a lot more detailed in each of these areas, but just roughly this is a technique that is a combination of some of the training that I got in Boston, and then obviously some of the things that I've added myself. But for the first two weeks, I do keep them non-weight-bearing until they come to the office. Once the stitches are out, they go into a tall boot with two wedges. I start PT right away, and I allow them to 50% weight-bear with crutches until the month mark from surgery. Once they're at a month out, we transition them to fully weight-bearing the boot, continue PT, slowly start taking the wedges out. By six to eight weeks, we're really removing the wedges. They're fully weight-bearing in a boot, getting some gentle biking and gait training. At eight weeks, we begin the process of weaning them from the boot to 12 weeks when they're in a regular shoe. At that point, from the three to six months, we start some sports-specific training, advance PT with strengthening, but really no cutting or full activities until about six to nine months. For most of my recreational athletes, around six months is when I would release them to start getting back to things with the understanding that depending on their level of activity, we may need to go as long as nine months before we get back to any type of sports. Now, again, this is both my non-operative and operative rehab protocols, which are identical. When it comes to complications, the biggest complications that we think about are re-rupture, wound dehiscence, superficial or deep infection with the understanding that if deep infections, although rare, do have a high morbidity associated with them and often require another surgery to remove necrotic tissue and or a reconstructive option down the road once the infection is cleared. The nerve injury that we are most commonly concerned about is the sural nerve, and we'll talk a little bit about that in comparing open and minimally invasive techniques. With regard to deep venous thrombosis, it is slightly higher in Achilles tendon than other foot and ankle conditions in some reports, and therefore, I think it's important to consider chemoprophylaxis in both non-operative and operative cases. I personally use aspirin for patients who are no longer at any elevated risk of DVT other than the Achilles rupture themselves but is definitely provider dependent. We have $3 million questions that we're going to go over. I think this is going to be the bulk of the talk that really says where are we at, how do we counsel our patients, and what does the data show? The first one, is operative treatment superior to non-operative treatment? Are there benefits of operative treatment? The second question is, are there advantages to minimally invasive techniques versus traditional open techniques when it comes to complications and outcomes? And then, who should I fix, who should I not opt, and who should I opt for the choice? So, we'll start with the first one with operative versus non-operative, and we're just going to do just briefly summarize some of the data, present one or two papers here or there, obviously, to present all the data. It would be a very, very long lecture, so we're just going to kind of briefly just highlight a few areas that I think are important. So, when it comes to operative versus non-operative, the short answer is yes and no. So, there's multiple studies that have looked at this over the years, but honestly, when it comes down to a few randomized controlled trials, the earlier studies that came out suggested a slightly higher re-rupture rate with non-operative treatment, but some of the newer studies have demonstrated no statistical difference in the re-rupture rates. And so, the only difference that I could definitively find in both looking through a few different reviews and through the literature is that time to return to work and plantar flexion strength have been documented in studies to be slightly different, that in patients who had surgeries with non-operative treatment in this one study, they were able to return to work 19 days earlier. The question is whether that is really that significant in terms of the rehabilitation is really unclear. And patients in this other study that's quoted in my references, there's a small increase in their plantar flexion strength one to two years comparatively to non-operative treatment. In my experience, I think both have reasonable outcomes and we'll talk about that moving forward. This is a study I just wanted to highlight recently in FAI in 2022, more so just discussing the analysis of the evidence and looking through, I thought it was a very interesting paper to read about saying, just because when we say equivalent outcomes to non-operative and operative treatment, the authors basically have said that the data shows that non-operative treatment is not inferior to operative treatment, but just because it's not inferior does not necessarily mean it's equal. So, just looking at some specific things, an interesting paper to read kind of say, especially with there seems to be this general trend that heading back towards now some more operative treatment over non-operative treatment in patients because of the new minimally invasive techniques. So, minimally invasive versus open repair. So, just to highlight a few papers, again, there's a lot more literature coming out on this. This is an example of 270 cases, most abusing and out of this 270, 39% of them were minimally invasive. They looked at complications mainly, and there was no significant difference in complications, including cerebral nerve injury. And here's another paper as well, looking at 185 cases in this cohort of patients, 64% were MIS as opposed to the other paper that I showed, which only about 40% were MIS, and there was no statistically, no difference in promise scores between the two, and no difference in complication rates. So, patient counseling. So, this is just a little bit anecdotal, but after reading through some more of the historical literature, the pendulum, pre-2000s, 1900s, there was obviously, there was this initial resurgence of operative treatment as we started doing more open repairs. And then in the 2000s with early functional rehabilitation and some of the different literature, particularly a lot of literature that's come from out of the United States has showed that non-operative treatment can have similar outcomes, and there's definitely been a trend back towards non-operative treatment in the 2000s. And it seems to be in the recent years, the pendulum may be swinging back more towards operative treatment, especially with these advances in minimally invasive techniques and new data. I'm not sure that there's any clear data on this to suggest that that's the case, but it seems like the papers, more people are getting a minimally invasive repair. So, this study was back from JBGS in 2005, and this is a meta-analysis of randomized control trials and about almost 800 patients. And this is the study that showed not a statistically significant decrease in re-rupture rate, but did show an association toward a lower re-rupture rate in operative treatment versus non-operative treatment. It's another good paper to familiarize yourself with. So, risk factors to consider when it comes to deciding whether not to operate or to not operate. The two main ones that I think about are smoking and diabetes mellitus. I obviously ask all my patients about smoking, and if they do use tobacco products, I counsel them on smoking cessation, and obviously that they're at increased risk of a wound complication or infection. Diabetes mellitus, everybody gets a hemoglobin A1c that's considering surgery. We like it to be less than seven to reduce your wound complication risk. Obesity has been described as another factor that can increase complication risk, although really doesn't play as much into consideration for Achilles tendon ruptures. As we are seeing more patients, at least anecdotally, of increasing age with Achilles tendon ruptures, we may continue to see more patients that are more medically complex, and that all needs to be taken into account when we decide whether or not surgery is a good option. Pearls that I found, number one, when someone comes in with an Achilles tendon rupture, this is a long discussion. It's not a five-minute visit, unfortunately, so you've got to spend some time with them. You have to really kind of go over everything. I want to assess their age, their risk factors, and activity level. If it's straightforward, and so I have a young, healthy patient who had an acute rupture who wants to get back to high-level activities, and that's a no-brainer for me, I'm going to guide them towards operative treatment. When it's not straightforward, though, when you have some of those risk factors in place, you know, a lot of times we have to have a very long discussion. We basically have to go over the data. This is what the outcomes are. This is what the studies show. You know, we need to come to a mutual decision together. I found that in some of these patients, too, who are really on the fence, offering them a second opinion is important and valuable. I'll frequently send them to my partner or to one of the other groups in town to, you know, just have somebody else take a look at it and say, hey, you know, this is the way I'd help guide you, as long as we can get to it within a quick period of time, because obviously we do like to get to Achilles tendon ruptures within a few weeks. So, and I think one of the most important things is also to set expectations, especially for return to activities and sports in the timeline. I think a lot of people see people, professional athletes, and, you know, think Achilles tendon rupture is not that big of an injury. It's a very, obviously, big injury with a slow recovery. And, you know, when we actually look at the data about return to sports, it's not as great as you'd think. This is a study that looks at return to play in professional athletes. So this is NFL, NBA, soccer, the return to play in any way, shape, or form was 75%. That means 25% of patients in the professional athlete population in this study did not return to play at all because they, because for whatever reason. So, you know, that's one in four, which is pretty high. The mean time to return to play was 11 months, which I think is a little bit longer than we sometimes think or counsel our patients. And then when they looked at patients that did return to play, there was a decline in their player efficiency, player efficiency ratings, power ratings, and sports specific statistics. So just the things to think about when you look at and compare it to ACL meniscus and other major orthopedic injuries, the return to play is slower. So I think it's just really important to, you know, have that discussion with the patients and not to be negative or, you know, but just say, you know, this, this is what the data shows. We're going to do our best to get you back to the level of participation, but there's no guarantee. So just a brief summary, what do I do in my practice? I fix young, healthy individuals. I trend towards non-operative treatment in older individuals, although by no means is age a cutoff for me. It really depends on their activity level and risk factors. I think it is totally fine to offer surgery to active older individuals after informed discussion, discussing the risks and benefits and coming to a mutual decision. And this is just a great review from the Yellow Journal in 2018, kind of going at acute Achilles tendon ruptures and update on treatment if you just want to kind of get a nice good overview of things and where we're at. So just some conclusions, one, both non-operative and operative treatment for Achilles tendons, ruptures are reasonable options. There's no part cutoff surgery really is a mutual decision between the surgeon and the patient. Patient counseling and management of expectations is crucial. And, you know, I think it's safe to say that percutaneous and many open or many open techniques have pretty equivalent outcomes and complication rates to open techniques. And so it's totally reasonable to offer. Obviously there's more minimally invasive techniques to your patients safely. So just here, I have solicits and my references, which we will also have available. Thank you guys very much.

Achilles tendon tears

diagnosis

treatment options

outcomes

minimally invasive repair techniques

non-operative management

operative management