Research Article
The Effect of Obesity on Surgical
Jamal Ahmad, MD
Kennis Jones, BA
From the Department of Orthopaedic
Surgery, NorthShore University
HealthSystem, Lincolnshire, IL
(Dr. Ahmad), and Rothman Institute
Orthopaedics, Philadelphia, PA
(Mr. Jones).
Correspondence to Dr. Ahmad:
jahmad@northshore.org
Dr. Ahmad or an immediate family
member has received research or
institutional support from Merz North
America; has received nonincome
support (such as equipment or
services), commercially derived
honoraria, or other non-research–
related funding (such as paid travel)
from Merz North America; and serves
as a board member, owner, officer, or
committee member of the American
Academy of Orthopaedic Surgeons
and the American Orthopaedic Foot
and Ankle Society. Neither Mr. Jones
nor any immediate family member has
received anything of value from or has
stock or stock options held in a com-
mercial company or institution related
directly or indirectly to the subject of
this article.
J Am Acad Orthop Surg 2017;0:1-7
DOI: 10.5435/JAAOS-D-16-00306
Copyright 2017 by the American
Academy of Orthopaedic Surgeons.
Month 2017, Vol 0, No 0
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Treatment of Achilles Tendon
Ruptures
Abstract
Introduction: We conducted a retrospective comparison of surgical
treatment outcomes for acute Achilles tendon ruptures in nonobese
and obese patients.
Methods: Between October 2006 and April 2014, we studied 76
patients with acute midsubstance Achilles tendon rupture: 44
nonobese and 32 obese (body mass index .30 kg/m2). Preoperative
and postoperative function and pain were graded with the Foot and
Ankle Ability Measure (FAAM) Sports subscale and the visual analog
scale for pain, respectively.
Results: All 76 patients presented for follow-up. On a scale of 100, the
mean FAAM score for the nonobese patients increased from 38.1
preoperatively to 90.2 at final visit, and on a scale of 10, the mean pain
score decreased from 7.1 preoperatively to 1.6 at latest follow-up. For
obese patients, the mean FAAM score increased from 34.2
preoperatively to 83.3 at final visit, and the mean pain score decreased
from 6.2 preoperatively to 1.9 at the latest follow-up. The postoperative
scores of the two groups were not significantly different (P . 0.05).
Postoperative wound complications developed in six nonobese
patients and one obese patient (13.6% and 3.1%, respectively;
P , 0.05).
Discussion: To our knowledge, comparing outcomes from surgically
treated acute Achilles ruptures in nonobese and obese patients has
not been previously reported. We found that both obese and
nonobese patients can achieve improved Achilles tendon function and
pain as a result of surgery.
Conclusions: The findings of this study demonstrate that both
nonobese and obese patients can achieve a high rate of improvement
in ankle function and pain relief after surgical repair of the Achilles
tendon.
O besity is a growing epidemic
that affects numerous devel-
oped countries.1 In the United States
Obesity is associated with poor
quality of life, increased financial
burden on society, and certain medi-
from 2011 to 2014, the Centers for cal comorbidities (eg, non–insulin-
Disease Control and Prevention dependent diabetes mellitus, hyper-
found 36.5% of American adults to tension).3,4 As the incidence of
be obese, as defined by a body mass obesity increases, the percentage of
index (BMI) .30 kg/m2, which obese patients within an orthopaedic
accounts for .66 million adults.2 population will likely also grow. With
1
The Effect of Obesity on Surgical Treatment of Achilles Tendon Ruptures
regard to orthopaedic foot and ankle
conditions, obesity can cause a pre-
disposition to Achilles tendinopathy.5
It is important to recognize the dif-
ferences between nonobese and obese
orthopaedic patients, particularly
with regard to their postoperative
course. After orthopaedic surgery,
obese patients may be at a higher risk
of experiencing postoperative com-
plications and poor long-term out-
comes than are nonobese patients.
Joint arthroplasty literature regard-
ing total ankle arthroplasty (TAA)
has shown a higher incidence of
short-term complications and long-
term implant failure or wear among
obese patients compared with non-
obese patients.6,7 Investigators have
shown that obese patients are at a
higher risk for the development of
infection than are nonobese patients
after lumbar spinal fusion8 and pel-
vic fracture fixation.9 With the
exception of TAA-related research,
there are few studies that examine
the influence of obesity on surgical
management of foot and ankle
conditions.
Achilles tendon rupture is an
important orthopaedic foot and
ankle condition for which literature
involving the effect of obesity is
lacking. The Achilles tendon is the
most commonly injured tendon in the
lower extremity.10 Although debate
continues as to whether nonsurgical
or surgical treatment yields better
results, many patients and surgeons
opt for surgical repair of the
Achilles tendon to better prevent
re-rupture.11-13 To date, there are
no published studies to our knowl-
edge in which investigators have
assessed the effect of obesity on the
outcomes of surgical repair of
Achilles tendon ruptures.
We conducted a study to retro-
spectively evaluate and compare the
clinical outcomes of surgical treat-
ment of acute midsubstance Achilles
tendon ruptures in nonobese and
obese patients in a single surgeon’s
2 Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
practice. We hypothesized that obese
patients would have substantially
worse postoperative function and
pain and a higher incidence of
postoperative complications than
would nonobese patients.
Methods
We conducted this study in a retro-
spective manner. We searched the
primary author’s (J.A.) records
database of patients treated surgi-
cally from October 2006 through
April 2014. Our search, for which
we used MISys Vision software
(version 9.10.3, Allscripts-MISys
Healthcare Solutions), focused on
codes 727.67 and 845.09 (Achilles
tendon rupture) from International
Classification of Diseases, Ninth
Revision of Clinical Modification.
We reviewed patient charts to doc-
ument the mechanism of injury to
the midsubstance of the Achilles
tendon, time between injury and
surgery, and treatment. Inclusion
criteria included acute midsubstance
Achilles tendon ruptures that were
managed surgically within 30 days
after the time of rupture. We
excluded from this study patients
who underwent nonsurgical treat-
ment of their acute Achilles tendon
injuries, had acute injuries to the
insertional or myotendinous Achilles
tendon, and had chronic injuries to
the Achilles tendon (as defined by
Padanilam14) in which rupture had
occurred .4 weeks previously. This
research received appropriate Insti-
tutional Review Board approval, and
no funding was obtained from any
outside source.
During the study period, 80
patients sought care for an acute
midsubstance Achilles tendon rup-
ture. All patients were informed of
nonsurgical versus surgical manage-
ment and received a discussion of the
benefits and risks of both options,
which is the routine practice of the
primary author (J.A.). Four patients
pursued nonsurgical treatment with
the primary author (J.A.) and were
excluded from this study. The re-
maining 76 patients met the inclusion
criteria by choosing surgical treat-
ment of their acute midsubstance
Achilles tendon rupture. The
patients’ ages ranged between 21
and 67 years, with a mean of 40.0
years; 61 patients were male, and 15
patients were female. The Achilles
tendon injury was on the right side in
39 patients and on the left side in 37
patients. At the time of surgery, 44
patients were not obese, as defined
by having a BMI #30 kg/m2. The
remaining 32 patients in this pop-
ulation were obese, with a BMI .30
kg/m2 at the time of Achilles tendon
repair surgery.
All patients in this study were able
to describe how and when their
Achilles tendon rupture occurred,
relating a stretching or tearing sen-
sation at the posterior ankle on
injury. Four patients (5.3%) sus-
tained their injuries at work and filed
workers’ compensation claims.
At the time of initial presentation,
the acute injury that patients incurred
to the midsubstance of the Achilles
tendon was assessed clinically and
functionally. The clinician clinically
confirmed discontinuity of the
Achilles tendon by palpating for the
defect and performing a Thompson
squeeze test.15 A full series of pre-
operative radiographic images of the
ankle was obtained for each patient,
including AP, lateral, and mortise
views, to screen for conditions such
as calcaneal tuberosity fractures and
calcific Achilles tendinopathy. After
a thorough physical examination, all
patients were graded according to
two self-administered tools, the val-
idated Foot and Ankle Ability Mea-
sure (FAAM) Sports subscale and the
visual analog scale (VAS) of
pain16,17 (Table 1). We used the
FAAM Sports subscale in this study
because it is valid for a wide variety

Table 1
Preoperative Demographic Characteristics and Patient-reported Outcomes of Nonobese and Obese Study
Participants
Variable
Characteristic
Male:Female
Mean (range) age in years
Mean body mass index in kg/m2
Right:Left
Workers’ compensation:No workers’ compensation
With diabetes mellitus:Without diabetes mellitus
With inflammatory conditionsa:Without inflammatory
conditions
Nicotine users:Nonusers
Outcome
Mean preoperative FAAM scoreb (range)
Mean preoperative VAS pain scorec (range)
FAAM = Foot and Ankle Ability Measure, VAS = visual analog scale
a
Inflammatory conditions included rheumatoid arthritis, psoriatic arthropathy, and eczema.
b
Highest possible score, 100
c
Highest possible score, 10
of orthopaedic foot and ankle
conditions.16
Medical comorbidities of all study
patients were recorded at their initial
preoperative visit (Table 1). Two of
44 nonobese patients (4.5%) and 3
of 32 obese patients (9.4%) had
diabetes mellitus, which is not sta-
tistically nor significantly different
(P = 0.10). Four nonobese patients
(9.1%) and one obese patient (3.1%)
had forms of inflammatory disease,
which is significantly different (P =
0.02). Inflammatory conditions
included rheumatoid arthritis, pso-
riasis with or without arthropathy,
and eczema. None of the nonobese
or obese patients had peripheral
vascular disease, but one obese
patient (3.1%) had venous stasis of
the involved lower extremity. Five
nonobese patients and two obese
patients used nicotine by smoking
cigarettes (11.4% and 6.2%,
respectively). No study patients used
nicotine in the form of chewing
tobacco, pipe smoking, or electronic
Month 2017, Vol 0, No 0
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Patient Population
Nonobese (n = 44)
35:9
39.2 (21–64)
25.9
23:21
4:40
2:42
4:40
5:39
38.1 (28.6–69)
7.1 (4–10)
cigarettes at the time of surgery,
which is statistically and significantly
different (P = 0.03).
Surgical Technique
All 76 patients were treated surgically
on an outpatient basis. These proce-
dures were performed with the
patient in the prone position and
under general anesthesia with
regional block augmentation. A thigh
tourniquet was used to avoid com-
pression of the gastrocnemius mus-
cles and was kept inflated from the
time of leg exsanguination until
dressings were applied after skin
closure.
The clinician (J.A.) made a longi-
tudinal incision medial to the Achilles
tendon. The paratenon was carefully
dissected off the Achilles tendon and
preserved for later closure. Once
exposed, the distal and proximal
aspects of the tendon were sharply
débrided to yield a viable end. Single,
heavy, braided nonabsorbable
suture (No. 2 FiberWire; Arthrex)
Jamal Ahmad, MD, and Kennis Jones, BA
Obese (n = 32) P Value
26:6 0.55
41.1 (27–64) 0.50
33.4 0.001
16:16 0.60
0:32 0.003
3:29 0.10
1:31 0.02
2:30 0.03
34.2 (20–66.7) 0.33
6.2 (3–10) 0.27
was then sewed into the proximal
and distal portions of the ruptured
Achilles tendon with a locking
Krackow technique.18 A minimum
of four locking loops were stitched
continuously through the medial
and lateral portions of the distal
tendon, leaving the suture ends long
at the free end. The repair was
completed by tying together the
suture at the proximal and distal
ends of the ruptured Achilles ten-
don. The repair site was augmented
with an epitendinous repair using a
single, medium, braided non-
absorbable suture (No. 0 Ethibond
Excel; Ethicon).19 The ankle was
then intraoperatively ranged through
movement between plantar flexion
and neutral dorsiflexion to test the
strength of the Achilles tendon
repair.
When the Achilles tendon repair
was deemed acceptable, the posterior
ankle wound was closed in layers.
The paratenon was repaired over the
Achilles tendon as a deep covering,
3
The Effect of Obesity on Surgical Treatment of Achilles Tendon Ruptures
Table 2
Postoperative Patient-reported and Clinical Outcomes of Nonobese and Obese Patients
Outcome
Mean follow-up in months (range)
Mean postoperative FAAM score;a (range)
Mean postoperative VAS pain score;b (range)
Achilles tendon healing at 16 wk (rate)
Achilles tendon re-rupture (rate)
Wound problems (rate)
FAAM = Foot and Ankle Ability Measure, VAS = visual analog scale
a
Highest possible score, 100
b
Highest possible score, 10
followed by closure of the sub-
cutaneous tissue and skin in layers
with absorbable and nylon sutures,
respectively. With the ankle held in a
resting equinus position, the tourni-
quet was deflated and a well-padded
posterior and U-shaped plaster splint
was applied to the leg.
Postoperative Rehabilitation
All patients underwent the same
postoperative protocol. Immediately
after surgery, the involved leg was
placed in a resting ankle equinus
position with no weight bearing. At
every postoperative visit, the Achilles
tendon was assessed clinically. A
thorough physical examination,
which included a Thompson test, was
performed to confirm the integrity of
the repaired Achilles tendon. During
the first postoperative visit at 2
weeks, skin staples were removed and
patients were fitted for a removable
Achilles boot (Bledsoe Brace Systems)
with three wedges at the heel. Patients
were instructed to avoid bearing
weight on the affected leg for an
additional 2 weeks and to remove one
wedge from the boot every 2 weeks.
At 4 weeks after surgery, patients
were allowed to progressively bear
weight on the operated leg using the
Achilles boot. A physical therapy
program for the Achilles tendon was
4 Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Patient Population
Nonobese (n = 44)
47.2 (18–98)
90.2 (76.2–100)
1.6 (0–4)
44 (100%)
0 (0%)
6 (13.6%)
also started at this point, with all
exercises performed out of the boot
and with full weight bearing on the
leg. Therapy was done two to three
times per week for periods ranging
from 6 to 16 weeks. Exercise modal-
ities included tendon stretching and
strengthening and gait and balance
training. At 12 weeks after surgery,
patients were allowed to wean
themselves from use of the Achilles
boot and increase their level of
activity as tolerated. Between 12 and
18 weeks after surgery, patients were
allowed to return to full activities
within and outside of their workplace
without restrictions, as long as the
pain and function had improved.
Follow-up Evaluation
As routine practice, the primary
author (J.A.) follows patients from
the time they undergo an Achilles
tendon repair until 3 to 6 months
after surgery. For the purpose of this
specific research, all study patients
were contacted by telephone and
invited to present again to the pri-
mary author (J.A.) for long-term data
collection. Thus, the most recent
follow-up for study patients ranged
from 18 to 98 months after surgery,
with a mean of 49.4 months. At this
time, patients underwent a follow-up
FAAM Sports subscale score assess-
Obese (n = 32) P Value
52.5 (18–60) 0.22
83.3 (66.7–100) 0.10
1.9 (0–5) 0.35
31 (96.9%) 0.30
0 (0%) 0.91
1 (3.1%) 0.01
ment and pain was plotted on a
10-point VAS scale.
Physical examination of the Achil-
les tendon involved assessment of its
integrity, tightness, strength, and
function, in addition to observation
for postoperative complications,
including wound healing problems
and re-rupture at the Achilles tendon.
Data Analysis
We used the Statistical Package for
the Social Sciences (version 11.0;
IBM SPSS Statistics) for the statistical
analysis of preoperative and post-
operative data from the nonobese
and obese patient populations. We
performed analysis of variance to
evaluate the significance of differ-
ences in initial and final data
between the study groups. A P value
of ,0.05 was defined as statistically
significant.
Results
Nonobese Patients
All 44 nonobese patients who
underwent a midsubstance Achilles
tendon repair were contacted and
presented for a final postoperative
evaluation (Table 2). The patients
had a mean BMI of 25.9 kg/m2
(range, 21.4 to 30.0 kg/m2), and the

mean follow-up time was 47.2
months. The mean FAAM score
(highest possible, 100) increased
from 38.1 preoperatively to 90.2 at
the time of final follow-up. The mean
VAS pain score (highest possible, 10)
decreased from 7.1 preoperatively to
1.6 at final follow-up. All nonobese
patients achieved full Achilles tendon
healing and function with no inci-
dence of re-rupture at the most
recent follow-up.
Postoperative wound complica-
tions developed in 6 of 44 nonobese
patients (13.6%), which is signifi-
cantly higher than the amount seen in
obese patients (P = 0.01). Three of
the patients with a wound compli-
cation were of normal weight, with a
BMI ,25 kg/m2. The wound com-
plications were superficial and
resolved with nonsurgical care. Two
of these three patients were cigarette
smokers at the time of surgery; this
habit was statistically and signifi-
cantly more prevalent (P = 0.03)
among nonobese patients than
among obese patients (Table 1). The
other three patients with post-
operative wound problems were
overweight, with a BMI between 25
and 30 kg/m2. Their wounds became
infected and required irrigation and
débridement to achieve resolution.
Two of these patients had forms of
inflammatory disease (ie, psoriatic
arthropathy or eczema) conditions
statistically and significantly more
frequent (P = 0.02) among non-
obese patients than obese patients
(Table 1).
Obese Patients
All 32 obese patients who underwent
a midsubstance Achilles tendon
repair were contacted and presented
for the final postoperative evaluation
(Table 2). The patients had a mean
BMI of 33.4 kg/m2 (range, 30.2 to
42.9 kg/m2), and the mean follow-up
time was 52.5 months. The mean
FAAM score increased from 34.2
Month 2017, Vol 0, No 0
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
preoperatively to 83.3 at the time of
final follow-up. This postoperative
score is lower than that of the non-
obese group but not to a statistically
significant degree (P = 0.1). The
mean VAS pain score decreased from
6.2 preoperatively to 1.9 at final
follow-up. This postoperative score
is higher than that of the nonobese
group, but not to a statistically sig-
nificant degree (P = 0.35). Among
the obese patients, 31 (96.9%)
achieved full Achilles tendon healing,
with no incidence of re-rupture at the
most recent follow-up. In one mor-
bidly obese patient (BMI, 42.9 kg/m2),
deep wound problems developed
4 weeks after surgery, causing the
Achilles tendon to become necrotic
at its repair site.
Wound complications were signif-
icantly fewer in obese than in non-
obese patients (P = 0.01), except for
the one previously mentioned mor-
bidly obese patient. At 4 weeks after
surgery, a deep wound infection and
dehiscence developed that pene-
trated the patient’s Achilles tendon
repair and rendered the exposed
tendon necrotic. To overcome this
complication, staged surgical treat-
ment and plastic surgery were
required. In the immediate phase,
treatment consisted of excision of the
necrotic Achilles tendon repair and
two irrigation and débridement
procedures to eliminate the infection.
In the subacute phase, the patient
underwent a delayed flexor hallucis
longus tendon transfer into the pos-
terior calcaneal body20 to restore
ankle plantar flexion as well as
vacuum-assisted closure and split-
thickness skin grafting to achieve
wound healing. Although this
patient experienced a serious wound
complication, no wound problems
occurred in any of the other obese
patients.
Venous thromboembolic events
were not common after midsubstance
Achilles tendon repair among the
study population. None of the non-
Jamal Ahmad, MD, and Kennis Jones, BA
obese patients experienced venous
thromboembolic events. In one obese
patient (BMI, 35.9 kg/m2), a symp-
tomatic suprapopliteal deep vein
thrombosis developed at 8 weeks
after surgery.
Discussion
Obesity is an escalating worldwide
epidemic. As the incidence of obesity
rises, orthopaedic foot and ankle
surgeons will encounter and treat an
increasing number of obese patients.
However, limited published research
is available regarding the effect of
obesity on outcomes of orthopaedic
foot and ankle surgery. Much of what
is written pertains to three different
surgical procedures in the obese
population: TAA, hallux valgus cor-
rection, and flatfoot deformity cor-
rection. Initial studies in which
researchers compared obese with
nonobese patients after they under-
went TAA showed no differences in
clinical results and implant survivor-
ship between patient populations at
medium-term follow-up.21 However,
Schipper et al7 found that obese
patients were at a higher risk of
experiencing TAA failure at long-
term follow-up than were nonobese
patients. Chen et al22 compared
obese with nonobese patients after
they underwent a variety of surgical
methods to correct hallux valgus.
The researchers found that the two
patient populations had similar
postoperative functional and pain
scores, but that a substantially higher
percentage of obese patients, com-
pared with nonobese patients,
needed additional surgery for vari-
ous reasons. Soukup et al23 com-
pared obese with nonobese patients
after they underwent a variety of
surgical methods to correct stage II
adult acquired flatfoot deformity
and discovered no differences in
clinical and radiographic results
between the two patient populations.
5
The Effect of Obesity on Surgical Treatment of Achilles Tendon Ruptures
Although there has been an
increase in orthopaedic literature
regarding obese patient populations,
our research is unique because, to our
knowledge, the effect of obesity on
Achilles tendon repair has not been
previously reported. Our goal in
this study was to compare outcomes
of surgical treatment of acute
midsubstance Achilles tendon rup-
tures in nonobese and obese patients.
Our research is nonrandomized, ret-
rospective, and comparative, with the
hypothesis that nonobese patients
have substantially better outcomes
than obese patients after surgery. At
the time of injury to the Achilles ten-
don, the study groups had similar
functional and pain scores. At final
follow-up, both the nonobese and
obese groups had a substantial
improvement in functional and pain
scores with no incidence of tendon
re-rupture. Although the nonobese
population had mean postoperative
functional and pain scores that were
better than those of the obese pop-
ulation, these differences were not
statistically significant. Many non-
obese persons may be healthier
than those who are obese; however,
both groups of patients in this study
achieved full Achilles tendon healing
with return to function and relief of
pain.
In this study, the development of
wound problems and/or infection
was more likely to occur in nonobese
patients compared with obese
patients. This finding is likely related
to substantially fewer obese patients
having inflammatory disease or
smoking cigarettes (Table 1). In the
nonobese patients, superficial
wound complications developed in
two of the three patients (66.7%)
who were nicotine users and ciga-
rette smokers. Deep wound prob-
lems developed in two of three
overweight, yet nonobese, patients
(66.7%) who had inflammatory
conditions of psoriatic arthropathy
or eczema. Another explanation for
6 Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
this observed difference in wound
complications might be differences in
soft tissue between the study pop-
ulations. Obese patients can have a
larger soft-tissue envelope on the
lower extremities that may allow for
better healing after wound closure at
the Achilles tendon. However, no
recordings were made of patients’
ankle circumference during the pre-
operative and postoperative visits.
Prospective research with a larger
nonobese and obese patient pop-
ulation may be needed to confirm
our findings.
We acknowledge the limitations of
this study. Although our study is
comparative, it was conducted ret-
rospectively. With regard to wound
problems after Achilles tendon
repair, more attention can be directed
toward preoperative ankle circum-
ference and its possible effect on
wound healing. We also acknowl-
edge that both the nonobese and
obese study populations were limited
in size. As stated earlier, a larger
number of patients in both groups is
needed to confirm or refute our
results.
Conclusions
To our knowledge, a comparison of
outcomes of surgical treatment of
acute midsubstance Achilles tendon
ruptures in nonobese and obese
patients has not been previously re-
ported in the orthopaedic literature.
The findings of this study demon-
strate that both nonobese and obese
patients can achieve a high rate of
improvement in ankle function and
pain relief after surgical repair of the
Achilles tendon. Although nonobese
persons may be healthier than those
who are obese, we did not find
Achilles tendon healing with return
to function and relief of pain to be
significantly different between the
two types of patients. Further
research with a larger nonobese and
obese patient population may be
needed to confirm these findings.
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