679706

research-article2016
FASXXX10.1177/1938640016679706Foot & Ankle SpecialistFoot & Ankle Specialist

vol. 10 / no. 5 Foot & Ankle Specialist 415

Clinical Research
Repair of Chronic Achilles
Ruptures Has a High Mark J. Bullock, DPM,
William T. DeCarbo, DPM,

Incidence of Venous
Mark H. Hofbauer, DPM, and
Joshua D. Thun, DPM

Thromboembolism
Abstract: Background. Despite the
low incidence of deep vein thrombosis
(DVT) in foot and ankle surgery, some
authors report a high incidence of
ruptures although this did not reach tendonitis; Achilles rupture; chronic
significance (P = .064). No VTE events Achilles rupture
were reported after repair of 28 acute
tendon ruptures or after 68 elective

symptomatic DVT following Achilles
tendon rupture. The purpose of this
study was to identify DVT risk factors
inherent to Achilles tendon repair to
determine which patients may benefit
from prophylaxis. Methods. One
hundred and thirteen patient charts
repairs of tendinopathy. Two patients
with misdiagnosed partial Achilles
tendon tears were excluded because
they experienced a VTE event 3 weeks
and 5 weeks after injury, prior to
surgery. Conclusion. In our retrospective
review, chronic Achilles ruptures had a
T
here is a lack of consensus on the
need for pharmaceutical deep
vein thrombosis (DVT)
prophylaxis following foot and ankle
surgery.1-5 Anticoagulation has
limitations as it does not completely
eliminate the possibility of propagation,

were reviewed following elective and statistically significant
nonelective Achilles tendon repair. higher incidence of
For elective repair of insertional or VTE compared with
noninsertional Achilles tendinopathy, acute Achilles ruptures
It is uncertain why there is such a
parameters examined included lateral (P = .048) or elective large variance in the incidence of
versus prone positioning and the repair (P = .0069).
presence versus absence of a flexor Pharmaceutical symptomatic DVT [deep vein
hallucis longus transfer. For nonelective anticoagulation may
repair, acute Achilles tendon ruptures be considered for repair thrombosis] following Achilles
were compared to chronic Achilles of chronic ruptures.
tendon ruptures. Results. Of 113 Repair of acute ruptures rupture.
Achilles tendon repairs, 3 venous and elective repair may
thromboembolism (VTE) events (2.65%) not warrant routine
occurred including 2 pulmonary prophylaxis due to a lower incidence does not remove the thrombus, and
emboli (1.77%). Seventeen of these of VTE. does not reduce the incidence of post-
repairs were chronic Achilles tendon thrombotic syndrome. The decision for
Levels of Evidence: Prognostic,
ruptures, and all 3 VTE events (17.6%) pharmaceutical prophylaxis must
Level III: Case Control Study
occurred within this subgroup. Elevated consider the efficacy of treatment
body mass index was associated with Keywords: deep vein thrombosis; alongside the risk of hematoma,
VTE in patients with chronic Achilles venous thromboembolism; Achilles infection, wound complications,

DOI: 10.1177/1938640016679706. From Saginaw Valley Bone and Joint Center, Saginaw, Michigan (MJB); The Orthopedic Group, Belle Vernon, Pennsylvania (WTD,
MHH); and Northwest Podiatrists, Portland, Oregon (JDT). Address correspondence to: Mark J. Bullock, DPM, Saginaw Valley Bone and Joint Center, 5483 Gratiot Road,
Saginaw, MI 48638; e-mail: markbullockdpm@gmail.com.
For reprints and permissions queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright 2016 The Author(s)
416 Foot & Ankle Specialist
Table 1.
Literature Summary of DVT Incidence Following Repair of Achilles Tendon Ruptures.
Author and Year
Patel et al (2012)7
6
Saragas et al (2011)
Makhdom et al (2013)8
Lapidus et al (2013)9
Total
Abbreviations: DVT, deep vein thrombosis; PE, pulmonary embolism.
hemorrhagic events, and heparin-
induced thrombocytopenia.
Some studies report a high incidence of
symptomatic DVT following repair of
Achilles ruptures.6 The rate of
symptomatic venous thromboembolism
(VTE) following repair of Achilles
ruptures ranges from 0.43% to 23.5%
(Table 1).6-9 It is uncertain why there is
such a large variance in the incidence of
symptomatic DVT following Achilles
rupture. Patient inherent risk factors have
been extensively studied. Inherited
hypercoagulable conditions, pregnancy,
oral contraceptives, smoking, cancer,
acute infection, diabetes mellitus, age,
and body mass index (BMI) have all
been associated with DVT.10-13 We are
not aware of studies that report risk
factors inherent to Achilles tendon repair.
We evaluated 3 variables that could
influence VTE rates following Achilles
tendon repair. In our elective cases we
compared VTE rates in a prone versus
lateral position and with a flexor hallucis
longus (FHL) transfer versus without a
FHL transfer. We hypothesize prone
positioning may increase DVT rates by
compressing venous return in the
abdomen. We hypothesize FHL transfers
may increase DVT rates by causing
inflammation in close proximity to the
posterior tibial vein. We also compared
postoperative VTE rates in acute Achilles
ruptures versus chronic Achilles ruptures.
Achilles tendon ruptures are
misdiagnosed, with rates of misdiagnosis
in the literature quoted as high as 23%.14
Number of Ruptures Total DVT
472 2 (0.42%)
88 5 (5.7%)
115 27 (23.4%)
764 55 (7.2%)
1439 89 (6.2%)
Due to late presentation these neglected
ruptures rarely undergo nonweight
bearing but often have some functional
immobility with the calf muscle pump
less effective at facilitating venous return.
One study on Achilles ruptures found a
trend toward more proximal DVT and
pulmonary embolism (PE) with increased
duration of immobilization.15 A different
study on cast immobilization did not
report this trend and found symptomatic
VTE events had the highest incidence
during the second week of below-knee
cast immobilization.16 We hypothesize
that chronic ruptures will have a higher
rate of symptomatic DVT due to the
development of asymptomatic thrombi in
the preoperative period. Chronic
inflammation caused by repeated injury
to the misdiagnosed Achilles rupture may
also contribute to thrombus formation.
Makhdom et al had a high incidence of
symptomatic postoperative DVT when
repair was performed 2 weeks from the
date of injury (Table 1).8
Methods
We performed a chart review of 115
consecutive patients who underwent
elective or nonelective Achilles repair
from January 1, 2009, to October 31,
2015. Patients followed for less than 3
months postoperatively were excluded.
We chose 3 months as a cutoff because
90% of VTE events occur within 3
months from the start of
immobilization.15 All patients were at
October 2017
Total PE
1 (0.21%)
1 (1.1%)
1 (0.8%)
0 (0%)
3 (0.21%)
least 8 months out from the surgical
repair at the time of chart review.
Patients with a history of VTE before
surgery and patients with genetic risk
factors were the only patients to receive
postoperative anticoagulation and were
excluded. Two patients with
misdiagnosed Achilles tendon tears were
excluded secondary to a DVT that
occurred while they wore an
immobilization boot in the preoperative
period. For the remaining 113 patients,
all postoperative clinical notes were
reviewed to identify patients diagnosed
with symptomatic VTE in the
postoperative period.
All DVTs were confirmed by venous
duplex ultrasound. Only patients with
symptoms of DVT in the preoperative or
postoperative period such as calf pain or
lower extremity edema underwent
venous duplex ultrasound. PE was
confirmed by ventilation/perfusion lung
scan and spiral computed tomography
scan (Figure 1). For comparison, a
literature review was performed to
identify studies that report the incidence
of postoperative VTE following Achilles
tendon ruptures (Table 1).
Patients were classified as having
chronic Achilles tendon ruptures if the
surgery was performed more than 4
weeks from the date of rupture.17
Chronic ruptures included both complete
and partial Achilles tendon tears. Partial
tears in the absence of an inciting
incident and interstitial tears were not
considered chronic ruptures and instead
vol. 10 / no. 5
Figure 1.
Bilateral filling defects secondary to
pulmonary emboli in a patient with a
chronic Achilles tendon rupture.
considered as elective repair of
noninsertional or insertional Achilles
tendinopathy.
A FHL transfer was performed during
elective repair when there was concern
the repair had insufficient tensile strength
based on the surgeons discretion. FHL
transfers were routinely performed for
complete chronic ruptures. For all
repairs, patients were kept non bearing
for 10 days in a gravity equinus posterior
splint followed by nonweight bearing in
a cast for an additional 3 weeks,
followed by weight bearing in an
immobilization boot for an additional 3
weeks. Physical therapy was initiated
when the patient began weight bearing
in a brace and this was continued for 4
to 6 weeks per our postoperative
protocol.
Statistical Analysis
Descriptive statistics were reported.
IBM SPSS version 22 (IBM, Armonk, NY)
software was utilized for all data analysis.
VTE rates between different Achilles
repair types were compared with a
Fishers exact test of independence. The
null hypothesis was that all Achilles
repair types would have the same VTE
incidence. For Achilles rupture
demographics, mean values were
compared with an independent samples
t test and categorical data were
compared with Fishers exact test. BMI
was not recorded at the time of surgery
for 2 patients with chronic ruptures and
3 patients with acute ruptures. The null
hypothesis was that demographics would
not differ based on Achilles repair type
or the presence of VTE. A power analysis
was not performed because there is a
wide variation in the incidence of DVT
following repair of Achilles tendon
ruptures in the literature. Additionally,
the VTE incidence has not been reported
for the Achilles repair subgroups within
our study.
Results
One hundred and thirteen patients met
our inclusion criteria. Three VTE events
occurred in 113 Achilles repairs (2.65%)
including 2 PE events (1.77%). All 3 VTE
events occurred in chronic ruptures
repaired more than 4 weeks from the
time of injury. Of note, all chronic
ruptures including the 3 VTE events were
repaired in a prone position. The
incidence of VTE in repair of chronic
ruptures was 3 of 17 (17.6%) and the
incidence of PE in repair of chronic
ruptures was 2 of 17 (11.8%).
Of the 3 patients with chronic Achilles
ruptures who experienced postoperative
VTE, 2 patients had partial ruptures and
1 patient had a complete rupture. Two of
these 3 patients had a FHL transfer
performed at the time of the repair. The
other patient had a detachment-
reattachment of the Achilles tendon for a
partial rupture at the insertion. One of
the 3 patients was immobilized in a CAM
walker prior to surgery and the other 2
patients were immobilized in ankle
braces preoperatively. None of the
patients with postoperative DVT was
made nonweight bearing or placed in a
short leg cast preoperatively.
Two patients misdiagnosed at an
outside facility experienced a
symptomatic VTE while waiting on
advanced imaging in the preoperative
period. One patient had a partial Achilles
tendon tear and presented with calf pain
due to a DVT 3 weeks and 3 days after
injury while waiting for a magnetic
resonance imaging scan. The second
patient presented to the hospital with
shortness of breath due to a PE 5 weeks
from the onset of Achilles pain later
confirmed as a partial tear on magnetic
resonance imaging.
Foot & Ankle Specialist 417
No patients with elective repair or
acute ruptures experienced a VTE event.
Within our study there were 28 acute
ruptures and 68 elective repairs. Of the
elective repairs, 10 were performed with
FHL transfers. There were 58 elective
repairs performed without a FHL transfer
with 26 of these repairs performed in a
prone position and the other 32 in a
lateral decubitus position (Table 2).
Patients who had chronic ruptures were
found to have a statistically significant
increased risk of VTE compared with
patients who had acute ruptures (P =
.048) or elective repair (P = .0069).
Inherited hypercoagulable conditions,
pregnancy, oral contraceptives, smoking,
cancer, acute infection, diabetes mellitus,
and age more than 70 were not
identified in any of our 3 patients with
VTE events. Comparison of demographic
data and time from injury for patients
that experienced a VTE event and
patients that did not experience a VTE
event after chronic rupture repair is listed
in Table 3.
Patients with postoperative VTE had a
higher BMI than patients that underwent
chronic Achilles rupture repair without
postoperative VTE although statistical
significance was not reached (P = .064).
BMI was a confounding variable in our
study as BMI was slightly higher in
patients with chronic ruptures compared
to patients with acute ruptures (P = .155;
Table 4). Two of the 3 (66.6%) patients
who had VTE had severe obesity defined
as BMI > 35. Severe obesity had a similar
incidence in patients with chronic
ruptures and patients with acute
ruptures, 4/17 (23.5%) versus 6/28
(21.4%), respectively.
Discussion
Low rates of symptomatic DVT in large
studies indicate that calf DVT caused by
acute Achilles ruptures are benign with
the standard duration of nonweight
bearing.7 Asymptomatic DVT are
commonly found (34%) when routine
venous duplex is performed after
Achilles tendon ruptures. The same study
found there does not appear to be an
increased risk of VTE when Achilles
418 Foot & Ankle Specialist October 2017

Table 2.
DVT Incidence by Achilles Repair Type (N = 113).

P Value Versus Chronic

Treatment Number of Repairs Total DVT Total PE Rupture
Chronic rupture 17 3 2 N/A
Acute rupture 28 0 0 .048
Elective repair 68 0 0 .0069
Elective repair with FHL 10 0 0 .27
Elective repair without FHL 58 0 0 .010
Elective repair without FHL, prone 26 0 0 .055
Elective repair without FHL, lateral 32 0 0 .037

Abbreviations: DVT, deep vein thrombosis; PE, pulmonary embolism; FHL, flexor hallucis longus.

Table 3.
Demographics of Patients With Chronic Achilles Ruptures With (N = 3) and Without VTE (N = 14).

Chronic Rupture With VTE Chronic Ruptures Without VTE

(n = 3) (n = 14) P Value
Time to repair (months), 6.8 3.3 (range 1-13) 8.8 2.18 (range 1-24) .708
mean SD
Age (years) 55.3 5.5 (range 46-65) 52.1 4.1 (range 26-77) .732
Gender, n (%) 1
Females 1 (33.3%) 6 (42.9%)
Males 2 (66.7%) 8 (57.1%)
Body mass index, mean SD 40.1 6.0 (range 29.1-49.6) (n = 3) 32.2 1.4 (range 23.8-41.9) (n = 12) .064

Abbreviations: DVT, deep vein thrombosis; PE, pulmonary embolism; FHL, flexor hallucis longus.

ruptures are treated operatively.18 These
findings suggest an Achilles tendon
rupture induces formation of thrombus at
the time of injury.
The largest study on calf DVT found
symptomatic calf DVT has a 28% rate of
progression to the popliteal vein after 3
to 4 weeks.19,20 Taken together, these
findings suggest patients with chronic
ruptures may present with a highly
developed calf DVT at the time of
surgery with an increased risk of
proximal progression postoperatively
due to immobility and venous stasis. The
risk of PE may be as high as 50% in
patients who develop a DVT above the
popliteal vein.21
The highest incidence of symptomatic
DVT following Achilles tendon repair
was 23.5% in a study involving 115
patients (Table 1). In the study,
Makhdom et al reported the average
interval from injury to surgery was 12
days.8 One case report describes a PE in
a 35-year-old women with no risk factors
when Achilles repair was performed 17
days after injury.22 Another case
describes a 42-year-old man with no risk
factors who developed a fatal PE with
Achilles repair performed 5 weeks after
injury.23
In our study, 3 of 17 (17.6%) patients
who underwent repair of chronic
Achilles ruptures had postoperative DVT
and 2 of these patients developed PE.
All 3 patients were thought to be low
risk because they were not nonweight
bearing in a below-knee cast prior to
surgery and their only established risk
vol. 10 / no. 5
Table 4.
Demographics of Patients With Acute Achilles Ruptures (N = 28) and Chronic Achilles Ruptures (N = 17).
Chronic Ruptures (n = 17)
Age (years), mean SD 52.6 3.5 (range 26-77)
Gender, n (%)
Females
Males
Body mass index, mean SD 33.8 1.7 (range 23.8-49.6) (n = 15)
factor was BMI. No patient undergoing
elective repair had a VTE associated
with prone positioning or a FHL transfer.
Our study was likely underpowered to
show a significant difference in VTE
rates for positioning or flexor transfers.
Our data on positioning and flexor
transfers may be used for future
meta-analysis.
We defined a chronic Achilles rupture
as 4 weeks from the time of injury
because this is the definition of chronic
rupture in the literature.17 It is possible
subacute ruptures repaired between 2
and 4 weeks from injury may also have
an increased risk for postoperative
VTE.8,16 One of our 2 preoperative VTE
was a subacute Achilles partial rupture.
Taking into account all preoperative and
postoperative subacute and chronic
Achilles ruptures there was a total of 5
VTE events in 22 patients (22.7%). This
provides further evidence for chemical
prophylaxis in the repair of chronic
Achilles ruptures.
The decision for prophylaxis after
repair of chronic Achilles ruptures must
weigh the benefits and risks associated
with anticoagulation. There is poor
blood supply to the skin overlying the
Achilles tendon and Achilles repair has
a risk of wound necrosis, wound
dehiscence, and hematoma formation.24
The clinician must weigh the risks
versus benefits of chemical prophylaxis.
When a decision is made for
prophylaxis, the surgeon may use
meticulous hemostasis and consider
tourniquet deflation prior to closure.
Acute Ruptures (n = 28)
46.4 2.4 (range 23-72)
7 (41.2%)
10 (58.8%)
31.0 1.1 (range 23.0-44.7) (n = 25)
A large number of studies have
investigated the association between
BMI and DVT. Alikhan et al looked at
DVT rates in 866 hospitalized patients
with acute medical illness and found
no increased incidence of VTE in the
presence of obesity.10 Pooled data from
multiple studies conflicts this result and
has shown that obesity doubles the risk
of VTE.13 Recently obesity has been
shown to increase the risk of
postoperative VTE and severe obesity
has been shown to further increase the
odds ratio of VTE.25,26 In our study
population, the BMI was higher in
patients with VTE and it was higher
in patients with chronic ruptures
compared with acute ruptures
(Tables 3 and 4). Patients with chronic
Achilles ruptures may be more likely to
have this risk factor, which further
increases the risk of VTE. While obesity
was a confounding variable, many
patients with acute ruptures were
obese or severely obese and none
developed VTE.
Conclusion
Patients with chronic Achilles ruptures
have an increased risk of postoperative
DVT or PE (P = .048) and this may be
due to long-term limited mobility and
chronic inflammation. Two studies
support our findings that time from
injury following Achilles ruptures
increases the incidence and severity of
VTE.8,14 Based on the limited available
data, surgeons repairing chronic Achilles
Foot & Ankle Specialist 419
P Value
.732
1
12 (42.9%)
16 (57.1%)
.155
ruptures may consider following the
guidelines of pharmaceutical
prophylaxis for knee and hip
arthroplasty. This consideration is based
on our study, the literature review, and
the pathogenesis of thrombus with a
time-dependent risk of proximal
propagation. A recent Cochrane review
concluded low-molecular-weight
heparin significantly reduces formation
of VTE during cast immobilization.27 In
addition, anticoagulation specifically
reduces proximal propagation of the
thrombus.19 Our study was limited by
sample size. Further studies are needed
to assess the risk of postoperative VTE
in chronic Achilles ruptures as well as
other neglected foot and ankle
trauma.
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