Repair of ruptured Achilles tendon

What the Anesthesiologist Should Know before the Operative Procedure?

Spontaneous Achilles tendon rupture generally occurs in young or middle-aged male athletes engaged in recreational sport activity, the so-called “weekend warrior.” Less commonly, rupture may also occur in older nonathletes. Management of Achilles tendon rupture is controversial. Surgical repair (open or percutaneous) is generally recommended for patients interested in regaining preinjury activity levels (i.e. young, active patients) while nonoperative treatment is used for patients that are inactive or at increased risk of developing wound problems. However, recent evidence has suggested that rerupture rates among operative and nonoperative patients may be similar if centers employ the use of functional rehabilitation during nonoperative treatment of Achilles tendon rupture.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Surgical repair of Achilles tendon rupture is elective and usually performed in an outpatient setting.

• Emergent – Surgical repair of isolated Achilles tendon rupture is not emergent.

• Urgent – Surgical repair of isolated Achilles tendon rupture is not urgent.

• Elective – Surgical repair of isolated Achilles tendon rupture is elective. Ideally, repair should occur within 2 weeks of the injury when acute edema has subsided. Delay longer than 4 weeks may complicate surgical repair due to tendinous contraction and atrophy.

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2. Preoperative evaluation

Most patients presenting for surgical repair of Achilles tendon rupture are healthy and active. Rupture usually occurs in the setting of vigorous physical activity. However, tendon rupture has been associated with use of corticosteroids or fluoroquinolone antibiotics. In addition to conditions that require treatment with corticosteroids and fluoroquinolones, tendon rupture has also been associated with chronic renal insufficiency, obesity, gout, and hyperlipidemia. Preoperative evaluation should include inquiry of these potential comorbidities.

a. Medically unstable conditions warranting further evaluation: There are few medically unstable conditions associated with Achilles tendon rupture. The anesthesia provider should inquire about recent corticosteroid or fluoroquinolone antibiotic use and their indication for use. Also, like any elective procedure, unstable cardiopulmonary, renal, metabolic, or neurologic disorders unrelated to the Achilles tendon rupture should be evaluated and stabilized.

b. Delaying surgery may be indicated: Although immediate surgical repair is unnecessary, it may be necessary to delay surgery if the patient is using fluoroquinolone antibiotics for an acute infectious condition (e.g. upper respiratory illness) that might increase the risk of postoperative complications.

3. What are the implications of co-existing disease on perioperative care?

a. Cardiovascular system

• Acute/unstable conditions: Acute or unstable conditions should be evaluated and managed according to American College of Cardiology/American Hospital Association (ACC/AHA) guidelines for perioperative cardiovascular evaluation and care before proceeding with surgical repair.

• Baseline coronary artery disease or cardiac dysfunction: Goals of management: As with acute or unstable cardiovascular conditions, preoperative evaluation and management should follow the ACC/AHA guidelines. Baseline cardiovascular treatment should be continued throughout the perioperative period, with exception of platelet inhibitor therapy. Discontinuation of aspirin and GP 2b3a inhibitors (e.g. clopidogrel) for reductions in perioperative bleeding should be balanced against the risk of postoperative thrombotic complications (i.e. stent restenosis). Consultation with the primary cardiologist may be needed to adopt an appropriate “bridging” strategy in the peri-operative period.

b. Pulmonary

• Chronic Obstructive Pulmonary Disease (COPD): Patients with COPD are at increased risk of perioperative pulmonary complications. Baseline COPD should be medically optimized according to American Thoracic Society (ATS) guidelines before proceeding with surgical repair. Baseline therapy should be continued throughout the perioperative period.

• Obstructive Sleep Apnea (OSA): Patients with OSA are at increased risk for apneic episodes with the use of opiate medications for postoperative analgesia.

• Reactive airway disease (Asthma): Patients with reactive airway disease are at increased risk of perioperative pulmonary complications. Baseline reactive airway disease should be medically optimized according to the National Heart, Lung, and Blood Institute (NHLBI) guidelines before proceeding with surgical repair. Baseline therapy should be continued throughout the perioperative period.

c. Renal-Gastrointestinal (GI):

Achilles tendon rupture has been associated with chronic renal insufficiency (CRI). It is important to inquire about any history of kidney disease. Preoperative evaluation of patients with CRI should include an assessment of electrolytes, renal function, and last dialysis session (for those patients on chronic renal replacement therapy). Patients with CRI are at increased perioperative risk for volume overload, acute electrolyte abnormalities, and medication overdose (especially with drugs eliminated primarily via renal clearance).

d. Neurologic:

• Acute issues: Acute or unstable neurologic disorders (e.g. stroke, seizure) should evaluated and managed before proceeding with surgical repair of Achilles tendon rupture.

• Chronic disease: Baseline treatment for chronic neurologic conditions should be continued throughout the perioperative period.

e. Endocrine:

Achilles tendon rupture has been associated with hyperlipidemia. Though isolated hyperlipidemia isn’t known to significantly increase perioperative risk, it is important to inquire about other risk factors for cardiovascular disease and, if necessary, proceed with perioperative cardiovascular testing as indicated by the ACC/AHA guidelines. Baseline therapy, particularly statin medications, should be continued through the perioperative period as this may help reduce the risk of perioperative cardiac complications.

f. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan:

Achilles tendon rupture has been associated with systemic corticosteroid use. It is important to inquire about potential conditions requiring treatment with systemic corticosteroids, such as autoimmune, inflammatory, organ transplant, or connective tissue disorders. Acute or unstable conditions requiring chronic or acute treatment with steroids should be evaluated and stabilized before proceeding with surgical repair.

4. What are the patient's medications and how should they be managed in the perioperative period?

Usually None

a. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Achilles tendon rupture is commonly associated with use of local or systemic corticosteroids. Baseline dose of corticosteroid should be continued throughout the perioperative period. Though repair of tendon rupture is a low stress procedure, it is reasonable to consider a stress dose of corticosteroids for patients with recent or chronic systemic steroid use.

Rupture has also been associated with fluoroquinolone antibiotic use. Surgery may need to be postponed to allow for resolution of any acute infectious conditions requiring a full course of antibiotics.

b. What should be recommended with regard to continuation of medications taken chronically?

• Cardiac – Except for antiplatelet medications (see below) indicated for cardiovascular disorders, all other cardiac medications should be continued throughout the perioperative period.

• Pulmonary – Pulmonary medications should be continued throughout the perioperative period.

• Renal – Renal medications should be continued throughout the perioperative period.

• Neurologic – Except for antiplatelet medications (see below) indicated for neurologic disorders, all other neurologic medications should be continued throughout the perioperative period.

• Anti-platelet – Discontinuation of aspirin and GP 2b3a inhibitors should be balanced against the risk of perioperative thrombotic complications. (see above)

• Psychiatric – Psychiatric medications should be continued throughout the perioperative period.

c. How to modify care for patients with known allergies

Avoid medication allergens.

d. Latex allergy- If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

Prepare the operating room, preop area, and PACU with latex free products.

e. Does the patient have any antibiotic allergies

In cases of severe penicillin or cephalosporin allergies, preincisional vancomycin or clindamycin should be used for surgical antibiotic prophylaxis.

f. Does the patient have a history of allergy to anesthesia?

• Malignant hyperthermia:

  Documented- avoid all trigger agents such as succinylcholine and inhalational agents:

  Proposed general anesthetic plan:

  Insure MH cart available: [- MH protocol]

  Family history or risk factors for MH:

• Local anesthetics/ muscle relaxants: If the patient reports an allergy to local anesthetics, the history should be reviewed to determine which class is involved. There is no cross-reactivity between the amino-esters (the usual cause of allergy) and the amino-amides. In the case of muscle relaxant allergy (rare), avoid the involved drug.

5. What laboratory tests should be obtained and has everything been reviewed?

No procedure-specific testing is required.

No age-specific testing is required except that necessary to evaluate pre-existing health conditions.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

There is no consensus about the optimal anesthetic for repair of Achilles tendon rupture. General, regional (peripheral or neuraxial), and monitored anesthesia care have all been used successfully, but there is no evidence that clearly demonstrates superiority of one technique compared to the others. When planning the anesthetic, it is important to consider the patient’s comorbidities and preference as well as surgical factors and postoperative disposition. First, repair of Achilles tendon rupture is typically performed in an ambulatory setting. Therefore, the anesthetic should be tailored to facilitate rapid recovery and dismissal. Prone position is commonly used for Achilles tendon repair. Therefore, general anesthesia may be better suited to patients intolerant of prone positioning (e.g. elderly, obese). Also when considering prone position, patients with a nonreassuring airway may need either general anesthesia with a secure airway or regional anesthesia with minimal sedation.

a. Regional anesthesia

Neuraxial

• Benefits – Lower risk of postoperative nausea and vomiting (PONV), better short-term analgesia, avoidance of airway instrumentation.

• Drawbacks – As with a regional technique for any procedure, one must be mindful of the risks associated with regional anesthesia (nerve injury, bleeding, infection). Also, if the procedure is performed in an outpatient setting, recovery and dismissal may be delayed to allow full neurologic recovery. A short-acting local anesthetic would be preferred.

• Issues – Conversion to general anesthesia may be difficult in prone patients intolerant of the procedure or position.

Peripheral Nerve Block

• Benefits – Lower risk of PONV, better short-term analgesia, possible shorter recovery and dismissal, avoidance of airway instrumentation. Good long-term analgesia with continuous sciatic nerve blockade through a popliteal fossa catheter.

• Drawbacks – As with a regional technique for any procedure, one must be mindful of the risks associated with regional anesthesia (nerve injury, bleeding, infection).

• Issues – Conversion to general anesthesia may be difficult in prone patients intolerant of the procedure or position.

b. General Anesthesia

• Benefits – General anesthesia with a secure airway would be advantageous for any patient positioned prone.

• Drawbacks – As with general anesthesia for any procedure, one must be mindful of the potential risk for PONV, postoperative cognitive dysfunction (POCD), allergic reactions, malignant hyperthermia (MH), airway trauma during intubation, or lost airway during positioning.

• Other issues – Appropriate patient positioning and padding.

• Airway concerns – Prone position may require more secure airway placement.

c. Monitored Anesthesia Care (MAC)

• Benefits – MAC is often considered for percutaneous surgical repair. The greatest benefits are shortened recovery and reduction of general or regional anesthetic-related complications (e.g. PONV, airway trauma, bleeding, neurologic injury).

• Drawbacks – Prone position may preclude deep sedation due to concern for an unsecured airway. Conversion to general anesthesia may be difficult in prone patients intolerant of the procedure.

• Other Issues – MAC is usually accompanied by local anesthetic infiltration by the surgeon. As with regional and general anesthesia, neutral positioning and padding is necessary for patient comfort.

6. What is the author's preferred method of anesthesia technique and why?

At our institution, repair of ruptured Achilles tendon is typically performed under general anesthesia with the patient’s airway secured using an endotracheal tube. Anesthesia is usually maintained with propofol infusion and oxygen/nitrous oxide gas mixture. In addition to local anesthetic infiltration by the surgeon, multimodal analgesia is provided with preoperative acetaminophen and oral opioid and NSAID medications, intraoperative IV opioid and low-dose ketamine, and postoperative oral or IV opioids as needed.

• What prophylactic antibiotics should be administered? Preincisional cefazolin or cefuroxime is recommended. Vancomycin or clindamycin may be used alternatively for patients with severe penicillin or cephalosporin allergies.

• What do I need to know about the surgical technique to optimize my anesthetic care? Choice of surgical approach (open vs percutaneous) is largely based on surgeon preference and the patient’s baseline activity level. For open repair, direct end-to-end repair is preferred, but augmentation may be necessary with local or distant tissue, cadaveric grafts, or artificial tendon implants depending of the severity of tendon atrophy, injury, or retraction. A tourniquet may be used to minimize surgical site bleeding. If so, be prepared to manage tourniquet-related pain if MAC or a peripheral regional technique is selected as the primary anesthetic.

• What can I do intraoperatively to assist the surgeon and optimize patient care? Muscle paralysis may be necessary to facilitate tendon approximation depending on the severity of tendon retraction.

• What are the most common intraoperative complications and how can they be avoided/treated? Intraoperative complications are rare.

• Cardiac complications – None anticipated

• Pulmonary – Standard postoperative pulmonary complications if general anesthesia is utilized.

• Neurologic – See below

d. Neurologic:

There is a small risk of postoperative foot numbness resulting from procedure-related sural nerve injury, particularly when a lateral surgical approach is utilized.

e. If the patient is intubated, are there any special criteria for extubation?

The patient should be extubated based on usual criteria.

f. Postoperative management

• What analgesic modalities can I implement? When possible, utilize multimodal analgesia (opioids, NSAIDS, acetaminophen). Non-steroidal anti-inflammatory medications are acceptable in the setting of tendinous repair. Single injection or continuous popliteal sciatic nerve blockade may also be considered for short-term postoperative analgesia, particularly in patients intolerant of opiate-related side effects.

• What level bed acuity is appropriate? Repair of Achilles tendon rupture is commonly performed in an ambulatory setting. In cases where the patient fails to meet discharge criteria (e.g. uncontrolled postoperative pain or nausea), overnight observation on a general care floor is appropriate.

• What are common postoperative complications, and ways to prevent and treat them? The most severe complications occurring in patients with Achilles tendon rupture are deep venous thrombosis (DVT), pulmonary embolism (PE), and tendon re-rupture, regardless of operative or nonoperative management. Patients undergoing surgical repair are at higher risk for postoperative wound complications compared to nonoperative treatment.

What's the Evidence?

Movin, T, Ryberg, A, McBride, D, Maffulli, N. “Acute Rupture of Achilles Tendon”. Foot Ankle Clin N Am. vol. 10. 2005. pp. 331-56. (This review paper presented a summary of the relevant anatomy, epidemiology, etiology, diagnosis, and management of patients with acute rupture of Achilles tendon.)

Khan, R, Carey Smith, R. “Surgical Interventions for Treating Acute Achilles Tendon Rupture”. Cochrane Database of Systematic Reviews. vol. 9. 2010. pp. CD003674(This systematic review further validated the notion that open surgical treatment of acute Achilles tendon rupture significantly reduced the risk of rerupture compared with non-surgical treatment, but produced significantly higher risks of other complications such as wound infection.)

Soroceanu, A, Sidhwa, F, Aarabi, S, Kaufman, A, Glazebrook, M. “Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials”. J Bone Joint Surg Am. vol. 94. 2012. pp. 2136-43. (This meta-analysis challenged the status quo that surgical repair of acute Achilles tendon rupture resulted in lower rerupture rates compared to nonsurgical treatment. In fact, their analysis demonstrated similar rates of rerupture between operative and nonoperative treatment with fewer complications noted among nonoperative patients.)

Cretnik, A, Kosir, R, Kosanovic, M. “Incidence and Outcome of Operatively Treated Achilles Tendon Rupture in the Elderly”. Foot Ankle Int. vol. 31. 2010. pp. 14-8. (This 10-year cohort study described the incidence and management of acute Achilles tendon rupture specifically among patients older than 60 years. It was also one of the only studies to comment on anesthetic options for operative repair.)

Keller, J, Bak, B. “The Use of Anesthesia for Surgical Treatment of Achilles Tendon Rupture”. Orthopedics. vol. 12. 1989. pp. 431-3. (This descriptive study is the largest series evaluating the influence of the type of anesthesia on the treatment and outcome of Achilles tendon surgery. It demonstrated no differences in functional outcome between anesthesia types.)

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This article originally appeared on Clinical Pain Advisor