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Metasynchronous bilateral achilles tendon rupture.

Abstract

Although Achilles tendon ruptures are a common occurrence, bilateral ruptures of the Achilles tendon are not. We present the case of a 33-year-old female who sustained metasynchronous (i.e., very close in time) bilateral ruptures of her Achilles tendons with no obvious predisposing factors. She was treated using a percutaneous technique and six months following surgery has returned to her normal activities.

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Achilles tendon ruptures are relatively common. (1) The true incidence is difficult to determine, but has probably increased over the last decade, (2) but bilateral ruptures are uncommon. They are associated with rheumatoid arthritis, (3) systemic lupus erythematosus, (4) renal transplantation, (5) use of systemic (6,7) and local corticosteroids, (8) and use of quinolone antibiotics. (9,10)

We report a 33-year-old female who sustained bilateral ruptures of the Achilles tendon approximately 48 hours apart with no obvious predisposing factors.

Case Report

A previously fit and well 33-year-old Caucasian female experienced sudden onset of severe pain in her right calf while dancing. She felt her right calf snap, and was unable to bear weight on her left leg. She presented to the accident and emergency department on the following day. Examination revealed a palpable defect 3 cm proximal to the right os calcis and a positive calf squeeze test. A complete rupture of the right Achilles tendon was diagnosed. She was placed into a below knee equinus cast and referred to the next available fracture clinic. The patient had not been taking corticosteroid or fluoroquinolone antibiotic medication, had not been previously diagnosed with connective tissue diseases, and gave no previous history of Achillodynia. Serology was unremarkable; calcium, uric acid and blood glucose were all within normal values. She smoked 20 cigarettes per day.

On the way to the fracture clinic, two days later, the patient was descending a step at home with crutches when she felt something snap and experienced excruciating pain over the posterior aspect of her left ankle. She was unable to bear weight, and had to be carried by her husband to the fracture clinic where examination revealed a palpable defect in the left Achilles tendon 3 cm proximal to its insertion on the calcaneum. She had a positive calf squeeze test. A diagnosis of complete rupture of the left Achilles tendon was made. The treatment options were discussed at length, and the patient elected to undergo a percutaneous repair. The patient was admitted from the fracture clinic and listed for surgery on the following day.

At surgery, a complete rupture of both Achilles tendons was confirmed (Fig. 1). With the patient prone, bilateral percutaneous repairs (11,12) were undertaken. Samples from both rupture sites were sent for histological examination. The patient was placed in a full Plaster of Paris cast in gravity equinus postoperatively; this was followed by four weeks in an anterior synthetic cast, plantigrade, full weight bearing. She was advised that full recovery would take on average six months and that she was likely to be able to recommence dancing at that time. Postoperatively, she had a stitch abscess on her left side that resolved with antibiotic treatment. She is now mobilizing normally and has a full range of motion of both ankles and normal strength. She has returned to her normal activities of daily living, including dancing. She has been discharged from our care.

[FIGURE 1 OMITTED]

Histological examination from both tendons revealed fascicles of dense collagen containing ovoid fibroblast-like cells. Small pale eosinophilic acellular foci with a degenerative appearance were seen in keeping with features associated with tendon rupture (Fig. 2). No cellular atypia was seen. The histological picture was compatible with the degenerative features typical of acute Achilles tendon rupture.

[FIGURE 2 OMITTED]

Discussion

The Achilles tendon is the largest and strongest human tendon, resulting from the joining of the tendons of the two heads of gastrocnemius and soleus. The tendon fibers spiral through 90[degrees] as they descend to insert into the posterior calcaneal surface. (3) Despite its strength, Achilles tendon ruptures are common occurrences. The true incidence is difficult to determine, but has probably increased over the last decade. (2) Achilles tendon ruptures are more common in males, with a male to female ratio ranging from 1.7:1 to 12:1. (13,14) Typically, acute ruptures occur in men in the third or fourth decade of life, particularly those that work in a white-collar profession and play sports occasionally. (15,16)

Type I collagen is the main constituent of tendons. (17) However, microtrauma may cause an increase in production of Type III collagen, (1) which predisposes the tendon to rupture due to its decreased ability to resist tensile forces. (18) Achilles tendon rupture has also been shown to be associated with a definable band on magnetic resonance imaging just posterior to the region of the tendon 2 to 6 cm proximal to the insertion of the Achilles tendon in the calcaneus. (19) This is the region where the majority of the pathology of the Achilles tendon takes place. (1)

Bilateral ruptures of the Achilles tendon are uncommon (Table 1). They are associated with rheumatoid arthritis, (3) systemic lupus erythematosus, (4) renal transplantation, (5) and use of quinolone antibiotics. (9,10) Quinolone antibiotics produce disruption of the extracellular matrix of cartilage in animal models. If the same mechanism exists in humans, a weakened tendon predisposed to rupture may result.

Ruptures associated with systemic corticosteroid (6,7) and local steroid injections8 have been reported. The exact mechanism is unknown, but the analgesic and anti-inflammatory effects of steroids may mask the pain of tendinopathy. This may allow individuals to continue the offending activities, further damaging the tendon. Systemic steroid use also acts by suppressing healing in degenerate tendons, thus predisposing the tendon to rupture after only minor trauma. (1)

Although cases of bilateral rupture of the Achilles tendon have been reported, they are a usually associated with other pathology. Our patient was a healthy, previously asymptomatic 33-year-old female who sustained bilateral ruptures of the Achilles tendon approximately 48 hours apart and with no obvious predisposing factors. Smoking has been shown to delay healing (36) and lead to reduced tissue oxygenation of subcutaneous tissues. (37) We were not able to find any published data to suggest a link between tendon degeneration and smoking, but it is possible that in this patient it may have played a role.

References

(1.) Maffulli N: Rupture of the Achilles tendon: current concepts review. J Bone Joint Surg 81A(7):1019-1037, 1999.

(2.) Maffulli N, et al: Changing incidence of Achilles tendon rupture in Scotland a 15-year study. Clin J Sport Med 9(3):157-160, 1999.

(3.) Rask MA: Achilles tendon rupture owing to Rheumatoid disease. J Am Med Assoc 239:435-436, 1978.

(4.) Formiga F, Moga I, et al: Spontaneous tendinous rupture in systemic lupus erythematous: presentation of two cases. Rev Clin Esp 192(4):175-177, 1993.

(5.) Hestin D, Mainard D, Pere P, et al: Spontaneous bilateral rupture of the Achilles tendons in a renal transplant recipient. Nephron 65:491-492, 1993.

(6.) Haines JF: Bilateral rupture of the Achilles tendon in patients on steroid therapy. Ann Rheum Dis 42(6):652-654, 1983.

(7.) Kotnis RA, Halstead JC, Hormbrey PJ: Atraumatic bilateral Achilles rupture: an association of systemic steroid treatment. J Accid Emerg Med 16(5):378-379, 1999.

(8.) Unverferth LJ, Olix ML: The effect of local steroid injections on tendon. J Sports Med 1(4):31-37, 1973.

(9.) Lee WT, Collins JF: Ciprofloxacin associated bilateral Achilles tendon rupture. Aust NZ J Med 22(5):500, 1992.

(10.) Poon CC, Sundaram NA: Spontaneous bilateral Achilles tendon rupture associated with ciprofloxacin. Med J Aust 166(12):665, 1997.

(11.) McClelland D, Maffulli N: Percutaneous repair of ruptured Achilles tendon. J R Coll Surg Edinb 47(4):613-618, 2002.

(12.) Webb JM, Bannister GC: Percutaneous repair of the ruptured tendo Achilles. J Bone Joint Surg 81B(5):877-880, 1999.

(13.) Carden DG: Rupture of the calcaneal tendon: the early and late management. J Bone Joint Surg 69B(3):416-420, 1987.

(14.) Puddu G, Ippolito E, et al: A classification of Achilles tendon disease. Am J Sports Med 4:145-150, 1976.

(15.) Boyden EM, Kitaoka H, et al: Late versus early repair of Achilles tendon rupture: clinical and biomechanical evaluation. Clin Orthop 317:150-158, 1995.

(16.) Hattrup SJ, Johnson KA: A review of the ruptures of the Achilles tendon. Foot Ankle 6:34-38, 1985.

(17.) Haggmark T, Liedberg H, Eriksson E, Wredmark T: Calf muscle atrophy and muscle function after non-operative versus operative treatment of Achilles tendon ruptures. Orthopedics 9(7):160-168, 1986.

(18.) Jozsa L, Lehto M, et al: Fibronectin and laminin in Achilles tendon. Acta Orthop Scand 60:469-471, 1989.

(19.) Saxena A, Bareither D: Magnetic resonance and cadaveric findings of the "watershed band" of the achilles tendon. J Foot Ankle Surg 40(3):132, 2001.

(20.) Mahan KT, Maxwell J, Smith T, Solomon M: Bilateral Tendo Achillis rupture after gastrocnemius recession. J Am Pod Med Assoc 76:457-461, 1986.

(21.) Baruah DR: Bilateral spontaneous rupture of the Achilles tendons in a patient on long-term systemic steroid therapy. Brit J Sports Med 18(2):128-129, 1984.

(22.) Burchhardt H, Krebs U: Einzeitige und zweizeitige spontane bilaterale Achillessehnenrupturen nach langdauernder Steroid-Therapie und bei Diabetes mellitus. Chirurg 62:830-831, 1991.

(23.) Cowan MA, Alexander S: Simultaneous bilateral rupture of the Achilles tendon due to Triamcinolone. Br Med J 1:1658, 1961.

(24.) Dickey W, Patterson V: Bilateral Achilles tendon rupture simulating peripheral neuropathy: unusual complication of steroid therapy. J Roy Soc Med 80:386-387, 1987.

(25.) Hanlon DP: Bilateral Achilles tendon rupture: an unusual occurrence. J Emerg Med 10:559-560, 1992.

(26.) Herreman G, Puech H, Raynaud J, Galezowski N: Rupture bilaterale du tendon d'Achille au cours d'un syndrome de Cushing. La Presse Medicale 14(38):1972, 1985.

(27.) Khurana R, Torzillo PJ, Horsley M, Mahoney J: Spontaneous bilateral rupture of the Achilles tendon in a patient with chronic obstructive pulmonary disease. Respirology 7(2):161-163, 2002.

(28.) Lambert M, Coppens JP: Rupture spontanee bilaterale simultanee du tendon d'achille due a la corticotherapie. La Presse Medicale 14(18):1038, 1985.

(29.) Lee MLH: Bilateral rupture of Achilles tendon. Br Med J 1:1829, 1961.

(30.) Mayer JH: Bilateral rupture of Achilles tendon. Br Med J 1:1830, 1961.

(31.) Melmed EP: Spontaneous bilateral rupture of the calcaneal tendon during steroid therapy. J Bone Joint Surgery 47B:104-05, 1965.

(32.) Shukla DD: Bilateral spontaneous rupture of Achilles tendon secondary to limb ischemia: a case report. J Foot Ankle Surg 41(5):328-329, 2002.

(33.) Skovgaard D, Feldt-Rasmussen BF, Nimb L, et al: Bilateral Achilles tendon rupture in individuals with renal transplantation. Ugeskr Laeger 159(1):57-58, 1996.

(34.) Smaill GB: Bilateral rupture of the Achilles tendon. Br Med J 1:1657-1658, 1961.

(35.) Vovor V-M, Montagnon J, Johnson O: Rupture spontane bilaterale simultanee du tendon d'Achille. Bull Soc Med Afr Noire Lgue Frse 16:58-63, 1971.

(36.) Mosely LH, Finseth F: Cigarette smoking: impairment of digital blood flow and wound healing in the hand. Hand 9(2):97-101, 1977.

(37.) Jensen JA, Goodson WH, Hopf HW, Hunt TK: Cigarette smoking decreases tissue oxygenation. Arch Surg 126(9):1131-1134, 1991.

(38.) Weinstabl R, Hertz H: Gleichzeitige beidseitige Ahillessehnruptur nach Bagatelltrauma bei Steroidtherapie Fallbericht. Unfallchirurgie 16:50-54, 1990.

Timothy Hayes, M.B., Ch.B., is the Senior House Officer, Damian McClelland, F.R.C.S.(Tr&Orth), is a Specialist Registrar, and Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth), is a Professor in the Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, Stoke-on-Trent, Staffordshire, United Kingdom.

Correspondence and reprint requests: Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth), Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, Hartshill, Thornburrow Drive, Stoke-on-Trent, Staffordshire, United Kingdom, ST4 7QB.
Table 1 Published Cases of Bilateral Achilles Tendon Ruptures

Source Nos Age Sex Cause

Mahan et al (20) 1 31 M Postoperative
 complication
Poon and 1 70 F Ciprofloxacin
Sundaram (10)
Baruah (21) 1 46 F Long term
 corticosteroid
 therapy
Burchhardt 1 61 M Long term
and Krebs (22) corticosteroid
 therapy
Cowan (23) 1 52 M Chronic discoid
 lupus
 erythematosus
Dickey and 1 43 F Long term
Patterson (24) corticosteroid
 therapy
Haines (6) 4 86 M Chronic
 bronchitis
 Oral steroids for
 three months
 55 M Chronic
 bronchitis
 Oral steroids for
 five years
 57 M Chronic
 bronchitis
 Oral steroids for
 12 years
 79 M Polymyalgia
 rheumatica
 Oral steroids for
 5 months
Hanlon (23) 1 33 F Trauma
Hestin et al (5) 1 61 M Renal
 transplantation
Herreman et al (26) 1 43 F Cushing's
 disease
Khurana et al (27) 1 69 M Chronic
 obstructive
 pulmonary
 disease
Lambert and 1 56 M Long term
Coppens (28) corticosteroid
 therapy
Lee (29) 1 61 M Lupus
 erythematosus
 Polyarthritis
 Oral Steroids
Lee and 1 33 M Renal failure,
Collins (9) Insulin-
 dependent
 diabetes
 mellitus,
 Ciprofloxacin
Mayer (30) 1 46 F
Melmed (31) 1 68 M Shortness of
 breath
Shukla (32) 1 61 M Limb ischemia
Skovgaard et al (33) 2 36 M Renal
 50 M transplantation
Smaill (34) 1 68 M Chronic
 bronchitis,
 Oral Steroids
Vovor et al (35) 1 49 M Trauma
 57 M Insulin
 dependent
 diabetes
 mellitus
Weinstabl 1 69 F Long term
and Hertz (36) corticosteroid
 therapy,
 Rheumatoid
 arthritis

Source Comments Treatment

Mahan et al (20) Bilateral gastrocnemius Surgical repair
 equinus treated by
 gastrocnemius recession
Poon and 2 days between ruptures. Surgical repair
Sundaram (10) 5 days after starting
 course of ciprofloxacin.
 Also taking oral
 corticosteroids.
Baruah (21) 24 hours between Surgical repair
 ruptures.
Burchhardt Synchronous ruptures Surgical repair
and Krebs (22)
Cowan (23) Conservative
Dickey and 12 month duration Conservative:
Patterson (24) corticosteroids for cast for 5
 asthma weeks
Haines (6) Spontaneous rupture Conservative
 while walking management
 Synchronous ruptures Conservative
 management
 Partial rupture Conservative
 management
 At presentation complete Conservative
 rupture of left, partial management
 rupture of right. After
 3 weeks examination
 revealed complete rupture
 of both tendons
Hanlon (23) Sky-diving Surgical repair
Hestin et al (5) Spontaneous rupture. 12 Conservative:
 days prior to rupture cast for 8 weeks
 complained of pain in the
 region of the Achilles
 tendon. No injury.
Herreman et al (26) Asynchronous ruptures--1 Conservative
 year between each
Khurana et al (27) Inhaled steroids for 4.5 Surgical repair
 years
Lambert and 30 year duration steroid Conservative:
Coppens (28) therapy for COPD. cast for 6 weeks
Lee (29) Sequel to triamcinolone Surgical repair
 therapy
Lee and Four day after starting Conservative:
Collins (9) on Ciprofloxacin Cast for 12
 developed pain in weeks
 tendoachilles regions.
 Two days later bilateral
 rupture while alighting
 from car.
Mayer (30) Traumatic Conservative
Melmed (31) Betamethasone Conservative
Shukla (32) Asynchronous ruptures-- Reconstruction
 Two weeks between each
Skovgaard et al (33) Surgical repair
Smaill (34) Presented with ruptured Conservative
 Achilles, ruptured management
 remaining Achilles tendon
 while being examined in
 the clinic.
Vovor et al (35) Synchronous ruptures Surgical repair
 Asynchronous ruptures--2 Surgical repair
 years between each.
Weinstabl Synchronous ruptures Surgical repair
and Hertz (36) with minor trauma
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Author:Hayes, Timothy; McClelland, Damian; Maffulli, Nicola
Publication:Bulletin of the NYU Hospital for Joint Diseases
Date:Dec 22, 2003
Words:2504
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