Achilles Tendon Rupture Kristoff Reid, MD Assistant Professor, MUSC

Introduction and Disclaimer CPG published 2009 Latest comprehensive review – JAAOS 2017, Kadakia Et al. Generally similar conclusions. Updates highlighted

Clinical Examination 1/4 – Consensus Physical exam should be performed 2 or more of: Thompson test (Simmonds squeeze) Decreased plantarflexion strength Presence of palpable gap Increased dorsiflexion with gentle manipulation

Imaging 0/4 – Inconclusive No studies of MRI or Radiographs Two level V studies for ultrasound (unreliable data)

Nonoperative management 2/4 – Limited evidence (in comparison trials) Functional outcomes positive in 1/2 Improved return to activity/sport in 1/3 1/4 showed improvement in rerupture rate Higher complication rates in operative group

Functional bracing Inconclusive Two studies. Only outcome analyzable was rerupture rate – inconclusive Update: Multiple functional bracing studies. Benefits to rerupture rates vs immobilization Overall similar outcomes to surgery with lower complications Possible diminished plantarflexion and time to activity

Operative Treatment 2/4 – Limited evidence (not comparison studies) 8 studies for open 6 studies for MIS 73-100% return to activity at 6 months 92% pain free at 12 months

Risk factors for surgery 1/4 Consensus No studies addressing comorbidities for repair Consider nonoperative treatment for patients with conditions that inhibit wound healing

Preoperative care Inconclusive Unable to recommend for or against preop immobilization or restricted weight bearing

MIS 2/4 Limited Evidence 6 comparative trials demonstrated no difference in rerupture 2 studies showed no faster recovery for percutaneous 2 studies showed improved return to activity for limited open No statistical difference in satisfaction One percutaneous study in favor of improved wound healing

Biological adjuncts Inconclusive No studies for allograft, xenograft, or biologic adjuvants 3 studies showed no benefit to autograft 1 study showed no benefit to synthetic tissue Update: Multiple studies on biologic adjuvants, no clinical benefit demonstrated

DVT Prophylaxis Inconclusive No studies

Postoperative weight bearing 3/4 Moderate Evidence Suggest early (2 weeks) protected weight bearing for operatively treated achilles tendon rupture 4 level II studies 3 studies showed improved return to activity

Postoperative mobilization 3/4 Moderate evidence Suggest use of a device that allows mobilization 2-4 weeks postop 5 studies using a device that limited dorsiflexion

Physical Therapy Inconclusive

Return to daily activity Inconclusive

(Operative) Return to sports 2/4 Limited Evidence It’s an option to return to sports 3-6 months postop

Nonop return to activity Inconclusive Unable to recommend a specific timeline to return to activity.

Questions