Neglected Achilles tendon rupture associated with rheumatoid arthritis: a case report and a brief review of the literature

Abstract

We report a case about a 69-year-old man, suffering from rheumatoid arthritis, diagnosed with a neglected Achilles tendon rupture. Considering the large Achilles tendon gap and the bad quality of the autologous tendons caused by rheumatoid disease, a reconstruction using an Achilles tendon with calcaneus bone block allograft was performed, with excellent clinical and functional outcomes.

Background

Rheumatoid arthritis (RA) is one of the most prevalent chronic autoimmune diseases, with a prevalence ranging from 0.4% to 1.3% of the general population.¹ RA is characterised by a synovial membrane inflammation consequent to immune activation, causing destruction of articular joints, extra-articular involvement being also usual.²

The Achilles tendon (AT) involvement, such as retrocalcaneal bursitis, AT enthesitis, AT tendonitis and AT paratenonitis, is common in patients with RA.³ However, the prevalence of AT rupture in this population is still unknown and, in the literature, only a few cases are reported.^4–8 We report the surgical treatment and outcome of a neglected AT rupture in a male suffering from RA.

Case presentation

A 69-year-old man affected by seropositive RA, chronically medicated with corticosteroid. No other medical conditions of interest. In the previous 1 year, the patient noted spontaneous right heel pain, difficulty with daily activities like walking, ascending or descending stairs and driving, and he also started using underarm crutches for ambulation. Calf atrophy and a palpable tendon defect were noted (figure 1). Thompson test was positive; weakness in plantar flexion strength and inability to perform single heel raises on the affected side were noticed. The ultrasonography of the ankle showed a discontinuity of the AT, and the MRI showed an AT rupture at the calcaneal insertion, with signs of chronicity and a large tendon gap (10 cm).

Figure 1.

Preoperative photography, showing a visible Achilles tendon gap.

Treatment

Since the patient was active and the neglected AT rupture led to substantial impairments in the daily activities, a surgical treatment was carried out. Considering the large tendon gap and the bad quality of the autologous tendons caused by the rheumatoid disease, a reconstruction using a fresh-frozen AT with calcaneus bone block allograft was the chosen method. A midline incision along the posterior aspect of the ankle was used and dissection was carried out carefully, creating full-thickeness flaps to preserve vascularisation. Debridement of proximal AT end was done until normal tendon tissue was found and the measured tendon gap was 12–13 cm. A trough was created in the native posterior calcaneus (figure 2) and the allograft bone block was contoured to fit within this trough, being attached using a 3.5 mm cancellous screw. The allograft tendon was sutured to the native AT using a non-absorbable suture and the paratenon and the subcutaneous layer were reapproximated with absorbable sutures (figure 3). A posterior mould splint in the foot in slight equinus was used for 2 weeks, and after that a walking cast with ankle in neutral position was applied for 2 weeks. At 4 weeks postoperative, active mobilisation was allowed and the rehabilitation programme started at 6 weeks postoperative. No postoperative infection was found.

Figure 2.

Intraoperative photography, showing a large tendon gap (12–13 cm) after debridement of proximal and distal native Achilles tendon ends, and the Trough created in the posterior calcaneus.

Figure 3.

Intraoperative photography, showing the allograft Achilles tendon sutured to the native tendon.

Outcome and follow-up

At 12 months of follow-up, a radiography of the right foot showed bony union of the graft (figure 4). The patient fully regained plantar flexion strength (figure 5) and normal active range of motion (10° dorsiflexion and 40° plantar flexion). He reported no pain (0/10 in Visual Analogue Scale) and he was able to perform daily activities such as walking without claudication, ascending and descending stairs and driving. The American Orthopaedic Foot and Ankle Society Score was 93/100.

Figure 4.

After 12 months, radiography of the right foot showing bony union of the graft.

Figure 5.

Postoperative photography, at 12 months, showing that patient fully regained plantar flexion strength.

Discussion

During the course of RA, several immune pathways are involved in cartilage and bone damaging. Joint swelling in RA reflects synovial membrane inflammation and is characterised by leucocyte infiltration into the normally sparsely populated synovial compartment.^{2 9} Moreover, proliferation of macrophage-like synoviocytes and fibroblast-like synoviocytes forms the pannus, which invades and promotes the cartilage destruction. Bone erosion also occurs during this immune response, because several signalling molecules are activated and contribute to osteoclast maturation.⁹ Recent studies have shown that AT involvement is common in RA.^{3 10} Using ultrasonography, Suzuki and Okamoto³ found that retrocalcaneal bursitis, AT enthesitis, AT tendinitis and AT paratenonitis were present in 39% of patients with RA; in another study, Suzuki et al¹⁰ found AT enthesitis in 22% of the symptomatic ankles examined. AT enthesitis in RA may be secondary to synovial inflammation or caused by the involvement of the synovial membrane lining the tendon sheaths and the bursae.¹⁰ In a normal AT, angiographic studies reveal a decrease vascularity in the segment of the tendon, 2–6 cm proximal to calcaneal insertion, and it corresponds to the most common rupture site.¹¹ In the case, we are reporting and in previous reports,^{4 7} AT rupture occurred in the calcaneal insertion. We hypothetised that AT enthesitis is a predisposing factor to tendon weakening in its insertional position. Regarding AT rupture in patients with RA, to our knowledge, there are only 10 case reports in the literature (table 1).^4–8 Six women and four men with RA, with ages ranging from 37 to 79 years old, and disease progression from 1 to 36 years, suffered AT rupture. Five cases occurred spontaneously, and five cases occurred following minor trauma. In two cases AT rupture occurred at the calcaneal insertion, in two cases occurred 2–3 cm from the calcaneal insertion and in four cases the rupture was located in the middle portion of the AT (in two cases the rupture site was not documented). Six cases were managed surgically and in three cases a conservative treatment was performed. In one case report, treatment was not documented.⁴ The majority of the patients with RA diagnosed with AT rupture were under corticosteroid therapy (table 1). Corticosteroid therapy contributes to AT ruptures,^12–15 and its use is very common in patients with RA. In rats, corticoid administration was shown to decrease the activity and concentration of collagen biosynthetic enzyme in AT, which can explain the ruptures.¹⁶ AT rupture in rheumatoid patients occurs commonly spontaneously or after minor trauma (table 1), and strong pain is not usually experienced, thus patients may attribute it to normal articular destruction caused by the disease and do not seek medical observation. Regarding the treatment of a chronic AT rupture in patients with RA, only information from previous case reports exist,^4–8 and no preoperatively and postoperatively foot and ankle scores were assessed, which restrains the comparison of the various techniques. Healthy patients with an AT rupture usually benefit from a surgical reconstruction to restore functional length, tension, and strength to the gastrocnemius-soleus complex so as to improve gait and function. Gap size is the most critical factor for surgery choice, and it should be assessed by preoperative MRI and intraoperative inspection. Tendon transfers and tendon augmentation are commonly used to manage a chronic AT rupture with a large gap.^{17 18} Since in the RA there may be tendon involvement, we believe that the use of a tendon autograft is not a good option for AT rupture with a large gap, and therefore, a tendon allograft should be preferred. Despite the potential disadvantages of an allograft (such as the need for local graft integration, potential immune rejection and increased costs), in this case it has multiple advantages¹⁹: (1) tissue with good quality and quantity; (2) allows for fixation with or without bone insert; (3) contributes to the shortening of the surgical time, minimising the risk of infections; (4) excellent mechanical properties, similar to the native tendon; (5) graft revascularisation will occur not only at the insertional site but also through adjacent structures, being optimised by the peritendon reconstruction and (6) allows for anatomical reconstruction without sacrificing the adjacent structures in an already functionally impaired lower limb.

Table 1.

Summary of the clinical features, management and outcomes of previous case reports on AT rupture in patient with RA

Authors	Age, y; gender	Mechanism	Time from diagnosis of RA, y	Corticosteroid therapy	Location	Treatment	Outcome
Bedi and Ellis4	48; F	Atraumatic	1	Yes	Calcaneal insertion	ND	ND
Rask5	37; M	Atraumatic	ND	No	2 cm from the calcaneal insertion	Total synoviobursectomy and tendon repair and reinforcement with plantaris tendon	ND
Matsumoto et al7	60; M	Taking a false step	2	No	Calcaneal insertion	End to end suture and reinforcement with plantaris tendon	Walking alone
Choksey et al6	55; F	ND	ND	Yes	ND	Reconstruction with Marlex mesh	Return to the pre-injury status
	67; F	Fall	ND	Yes	ND	Reconstruction with Marlex mesh	Return to the pre-injury status
Mikashima et al8	65; F	Atraumatic	4	Yes	Middle portion of AT	V-Y advancement	Able to walk using a T-cane without pain
	79; F	Sprain	6	Yes	3 cm from the calcaneal insertion	Conservative	Walking with slight pain
	65; M	Atraumatic	3	Yes	Middle portion of AT	Modified Linghols procedure	Walking alone, no pain
	63; M	Atraumatic	36	Yes	Middle portion of AT	Conservative	Walking with single cane, slight pain
	66; F	Sprain	15	Yes	Middle portion of AT	Conservative	Walking with single cane, slight pain

AT, Achilles tendon; F, female; M, male; Nd, dot documented; RA, rheumatoid arthritis; Y, years.

Learning points.

• Ruptures of Achilles tendon (AT) may occur in patients with rheumatoid arthritis (RA), and enthesitis seems to act as a predisposing factor.

• Ruptures of AT may be more likely to be neglected by the patients with RA, who do not seek medical observation, leading to late diagnosis.

• Treatment of these injuries is usually surgical and reconstruction using an AT with calcaneus bone block allograft seems to have good clinical and functional outcomes.