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CTA /RTHOPAEDICA n
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4HE OPTIMAL TREATMENT FOR ACUTE RUPTURE OF THE !CHIL
LES TENDON IS STILL CONTROVERSIAL 4HERE HAVE BEEN
ONLY PROSPECTIVE RANDOMIZED TRIALS COMPARING
NONOPERATIVE AND OPERATIVE TREATMENT .ISTOR
#ETTI ET AL 4HERMANN ET AL -AJEWSKI
ET AL -OLLER ET AL ALL OF THEM REACH
ING SOMEWHAT DIFFERENT CONCLUSIONS )N SYSTEMATIC
REVIEW ARTICLES AND METAANALYSES THE CONCLUSION
IS OFTEN THAT SURGICAL TREATMENT HAS A SUBSTANTIALLY
LOWER RISK OF RE
RUPTURE COMPARED TO NONOPERATIVE
TREATMENT BUT THE RISK OF INFECTION AND OTHER COM
PLICATIONS OF SURGICAL REPAIR IS INCREASED 7ILLS ET
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!T THE $EPARTMENT OF /RTHOPEDICS IN ,UND 5NIVER
SITY (OSPITAL 3WEDEN EVERY PATIENT VISIT AND EVERY
OPERATION IS RECORDED IN A COMPUTERIZED MEDICAL
RECORD DATABASE UNDER A GIVEN DIAGNOSIS NUMBER
!CHILLES TENDON RUPTURE HAS A UNIQUE CODE NUMBER
! COMPUTER SEARCH OF THE MEDICAL DATABASE AND THE
OPERATION LOG FROM THROUGH WAS PER
FORMED AND INDIVIDUALS WERE IDENTIlED WITH
ACUTE TOTAL !CHILLES TENDON RUPTURE 4HE MEDICAL
CHARTS OF ALL PATIENTS WERE REVIEWED 4HE FOLLOW
ING PATIENTS WERE EXCLUDED THOSE WHO ONLY HAD
A PARTIAL RUPTURE AND WERE TREATED ACCORDINGLY BUT
WERE INCORRECTLY RECORDED AS HAVING A TOTAL !CHIL
LES TENDON RUPTURE N PATIENTS WHO DID NOT
#OPYRIGHT 4AYLOR &RANCIS )33. n 0RINTED IN 3WEDEN n ALL RIGHTS RESERVED
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RECEIVE THEIR INITIAL OR lNAL TREATMENT AT ,UND 5NI
VERSITY (OSPITAL N AND N RESPECTIVELY
PATIENTS WHO DID NOT RECEIVE ANY ACTIVE TREAT
MENT DUE TO THE GENERAL CONDITION OF THEIR HEALTH
N AND PATIENTS WHO RECEIVED SURGICAL TREAT
MENT N 4HE LATTER WERE FOLLOWED IN THE SAME
WAY AS THOSE TREATED NONOPERATIVELY SEE HEADING
BELOW
)N THE REMAINING PATIENTS MEDICAL CHARTS
WERE ANALYZED AND DATA EXTRACTED ACCORDING TO
A STANDARDIZED PROTOCOL ON AVERAGE n
YEARS AFTER THE INJURY PATIENTS WERE DECEASED AT
FOLLOW
UP DEATH BEING RELATED TO THE TENDON RUP
TURE 4HIS PATIENT COMMITTED SUICIDE AFTER THE INSUR
ANCE SYSTEM REFUSED TO ACCEPT HIS BILATERAL !CHILLES
TENDON RUPTURE
AS A SIDE
EFFECT OF QUINOLONE TREAT
MENT ! QUESTIONNAIRE WAS SENT TO THE REMAINING
PATIENTS TO CONlRM THE DATA FROM THE MEDI
CAL CHARTS AND TO OBTAIN A SUBJECTIVE EVALUATION OF
THEIR FUNCTIONAL STATUS 4HE INDIVIDUALS WERE ASKED
TO ANSWER A QUESTIONNAIRE REGARDING THEIR MEDICAL
CONDITION AT THE TIME OF INJURY WHETHER THEY HAD
HAD A RE
RUPTURE DEEP VENOUS THROMBOSIS OR PUL
MONARY EMBOLISM DURING OR AFTER TREATMENT AND
WHETHER THEIR PRESENT FUNCTION HAD BEEN AFFECTED
DAILY SOMETIMES OR NEVER BY THE PREVIOUS !CHIL
LES TENDON RUPTURE TRAUMA PATIENTS
ANSWERED THE QUESTIONNAIRE IN CASES AFTER BEING
INTERVIEWED BY TELEPHONE )N CASES WE FAILED TO
MAKE CONTACT
4HE INFORMATION COLLECTED IN THE QUESTIONNAIRE
AND TELEPHONE INTERVIEWS CONlRMED THE DATA FOUND
IN THE MEDICAL CHARTS AND GENERATED SOME PREVI
OUSLY UNKNOWN DATA MORE PATIENTS HAD SUFFERED
A RE
RUPTURE OF THESE INCLUDING A DEEP VENOUS
THROMBOSIS DURING IMMOBILIZATION OTHER PATIENTS
HAD HAD A DEEP VENOUS THROMBOSIS !LL OTHER COM
PLICATIONS WERE ALREADY NOTED IN THE CHARTS )N
PATIENTS INFORMATION REGARDING COMPLICATIONS WAS
BASED ON THE MEDICAL CHARTS ONLY DECEASED AND
NON
RESPONDING 4HIS STUDY WAS APPROVED BY THE
LOCAL RESEARCH ETHICS COMMITTEE AT THE &ACULTY OF
-EDICINE ,UND 5NIVERSITY
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4HE STANDARD NONOPERATIVE TREATMENT AT OUR DEPART
MENT DURING THE INCLUSION PERIOD WAS A CAST FOR
WEEKS N $URING THE LAST YEARS ORTHOSIS WAS
USED EITHER CAST FOLLOWED BY ORTHOSIS N OR
!CTA /RTHOPAEDICA n
ORTHOSIS ALONE N 4HE ANKLE WAS IMMOBILIZED
IN PLANTAR mEXION FOR WEEKS MEAN DAYS 3$
AND IN NEUTRAL POSITION FOR ANOTHER WEEKS MEAN
DAYS 3$ )F AN ORTHOSIS WAS USED PLANTAR mEX
ION WAS ALLOWED DURING WEEKS n )N ALL PATIENTS
WEIGHT BEARING WAS ADVISED FROM DAY
!LL PATIENTS EXCEPT ONE WERE PRESCRIBED A HEEL
RAISE OF CM FOR WEEKS AFTER REMOVAL OF THE
CASTORTHOSIS ! PHYSIOTHERAPIST AT THE DEPARTMENT
INSTRUCTED ALL BUT PATIENTS BOTH ORALLY AND IN WRIT
ING HOW TO AMBULATE AND EXERCISE DURING AND AFTER
THE IMMOBILIZATION PERIOD !LL PATIENTS WERE ALSO
REFERRED TO A LOCAL PHYSIOTHERAPIST FOR FOLLOW
UP OF
EXERCISE
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4HE MEAN AGE AT DIAGNOSIS FOR THE PATIENTS TREATED
NONOPERATIVELY WAS n YEARS PATIENTS
WERE MALE )N MOST PATIENTS DIAGNOSIS AND
START OF TREATMENT WAS ON THE SAME DAY AS INJURY N
)N CASES TREATMENT STARTED DAY
AFTER INJURY IN CASES IT STARTED BETWEEN AND
DAYS AFTER INJURY AND IN PATIENTS BETWEEN
AND DAYS AFTER INJURY PATIENTS HAD DIABETES
HAD IMMUNOSUPPRESSIVE MEDICATION AND HAD
ONGOING TREATMENT WITH QUINOLONES AT THE TIME OF
THE RUPTURE 4HE CAUSE OF THE RUPTURE WAS SPORTS
RELATED IN OF THE CASES IN WHICH THE
ETIOLOGY WAS KNOWN IN CASES DUE TO BADMINTON
IN CASES DUE TO SOCCER AND IN CASES DUE TO
!CTA /RTHOPAEDICA n
OTHER SPORTING ACTIVITIES AT TIME OF THE RUPTURE
PATIENTS RELATED THE TRAUMA TO AN ACTIVITY OTHER THAN
SPORT AND IN CASE WITH BILATERAL !CHILLES TENDON
RUPTURE THE ETIOLOGY WAS QUINOLONE TREATMENT
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OF PATIENTS HAD A RE
RUPTURE 4HE MEAN
TIME TO RE
RUPTURE AFTER REMOVAL OF PLASTER OR ORTHO
SIS WAS n DAYS RE
RUPTURES OCCURRED
WITHIN DAYS OF REMOVING THE ANKLE IMMOBILIZ
ING TREATMENT AND THE REMAINING RE
RUPTURES
WERE EVENLY SPREAD UP TO DAYS !LL PATIENTS
HAD STARTED THE INITIAL TREATMENT IN PLASTER AND
SWITCHED TO ORTHOSIS AFTER WEEKS 4HE MEAN AGE
AT RE
RUPTURE WAS n YEARS AND ALL PATIENTS
BUT WERE MEN PATIENTS HAD PREVIOUSLY RUPTURED
THE CONTRALATERAL !CHILLES TENDON
.ONE OF THE FOLLOWING PARAMETERS COULD BE COR
RELATED TO AN INCREASED RISK OF RE
RUPTURE SEX TYPE
OF IMMOBILIZATION CAST OR ORTHOSIS START OF TREAT
MENT DAYS OR DAYS FROM INJURY ETIOLOGY
OF RUPTURE AND IMMUNOSUPPRESSIVE TREATMENT OF
THE PATIENTS WITH A RE
RUPTURE UNDERWENT SURGICAL
TREATMENT FOLLOWED BY A NEW
WEEK PERIOD IN CAST
OR ORTHOSIS 4HE REMAINING PATIENTS RECEIVED NON
OPERATIVE TREATMENT ONCE AGAIN
PATIENTS HAD A DIAGNOSED DEEP VENOUS THROMBO
SIS AND OF THEM ALSO HAD A DIAGNOSED PULMONARY
EMBOLISM PATIENT HAD BOTH A RE
RUPTURE AND A
DEEP VENOUS THROMBOSIS !T FOLLOW
UP AFTER n
YEARS OF THOSE WHO RESPONDED
REPORTED FULL RECOVERY REPORTED THAT
THEY CONSIDERED THAT THE !CHILLES TENDON RUPTURE
HAD RESTRAINED THEIR DAILY LIVES AND
CONSIDERED THAT THEY WERE SOMETIMES RESTRAINED BY
THE RUPTURE 4HERE WAS NO DIFFERENCE BETWEEN AGE
GROUPS REGARDING SUBJECTIVE RECOVERY 4HERE WAS
A SIMILAR RECOVERY LEVEL IN PATIENTS WITH RE
RUP
TURE WITH REPORTING DAILY RESTRAINTS AND
REPORTING RESTRAINTS SOMETIMES
V
4O OUR KNOWLEDGE THE PRESENT REPORT DESCRIBES
THE LARGEST STUDY TO DATE OF CONSECUTIVE PATIENTS
WITH ACUTE TOTAL !CHILLES TENDON RUPTURES THAT WERE
TREATED NONOPERATIVELY 7E BELIEVE THAT IN OUR STUDY
OF CASES ALL CONSECUTIVE PATIENTS WITH ACUTE
TOTAL !CHILLES TENDON RUPTURES HAVE BEEN INCLUDED
AND THAT ALL MAJOR COMPLICATIONS ASSOCIATED WITH
THE !CHILLES TENDON RUPTURE HAVE BEEN REPORTED
!LL OUR PATIENTS WERE FOLLOWED UNTIL CLINICAL HEAL
ING AND OUR FOLLOW
UPWITH OF THE PATIENTS
ANSWERING THE QUESTIONNAIREHAS MINIMIZED BIAS
BY SELECTION 4HE RE
RUPTURE RATE WAS ONLY
WHICH IS LOWER THAN IN PUBLISHED REVIEWS AND META
ANALYSES 7ILLS ET AL #ETTI ET AL ,O
ET AL 0OPOVIC AND ,EMAIRE "HANDARI
ET AL +OCHER ET AL +HAN ET AL
!CCORDING TO THE CURRENT #OCHRANE REVIEW TRIALS
PATIENTS PATIENTS TREATED OPERATIVELY HAD A
POOLED RE
RUPTURE INCIDENCE OF WHICH CAN BE
COMPARED WITH IN THE NONOPERATIVE GROUP REL
ATIVE RISK 22 #) n 4HE RATE
OF COMPLICATIONS OTHER THAN RE
RUPTURE WAS MUCH
HIGHER OPERATIVE AND NON
OPERATIVE
INCLUDING INFECTION ADHESIONS AND DISTURBED SKIN
SENSIBILITY 22 #) n 4HE AUTHORS
CONCLUDED THAT THERE IS EVIDENCE THAT OPEN OPERATIVE
TREATMENT OF ACUTE !CHILLES TENDON RUPTURES SIGNIl
CANTLY REDUCES THE RISK OF RE
RUPTURE COMPARED TO
NONOPERATIVE TREATMENT BUT HAS THE DRAWBACK OF
A SIGNIlCANTLY HIGHER RISK OF OTHER COMPLICATIONS
INCLUDING WOUND INFECTION +HAN ET AL
)F ONE COMPARES THE RE
RUPTURE RATE IN OUR NON
OPERATIVELY TREATED PATIENTS TO AN EQUIVALENT GROUP
IN A RECENTLY PUBLISHED RANDOMIZED STUDY FAVORING
SURGICAL TREATMENT -OLLER ET AL OUR RATE IS
CONSIDERABLY LOWER AS OPPOSED TO 4HE
REASON FOR THIS LARGE VARIATION IS NOT KNOWN AND
ONE CAN ONLY SPECULATE 4HE RISK OF RE
RUPTURE IN
PATIENTS WITH !CHILLES TENDON RUPTURE IN OPERATED
AS WELL AS NONOPERATED PATIENTS IS PROBABLY RELATED
TO THE QUALITY OF THE REHABILITATIONBOTH DURING
AND ALSO AND PERHAPS EVEN MORE IMPORTANTLY AFTER
REMOVAL OF THE PLASTER OR THE ORTHOSIS 4HE QUALITY
OF THE REHABILITATION IN A NONOPERATIVELY TREATED
PATIENT MATERIAL EXPERIENCING A RE
RUPTURE FRE
QUENCY OF GREATER THAN -OLLER ET AL
MUST BE QUESTIONED 4HE TREATMENT STRATEGY WE
!CTA /RTHOPAEDICA n
EFFECTIVE PROCEDURES AND MAYBE IT WOULD EVEN BE
POSSIBLE TO FURTHER LOWER THE RE
RUPTURE RATE OF NON
OPERATIONALLY TREATED RUPTURES
.O COMPETING INTERESTS DECLARED