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The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The aim of this study was to describe the epidemiology of Achilles tendon re-rupture. Secondary aims were to identify factors predisposing to increased Achilles tendon re-rupture risk, at the time of primary Achilles tendon rupture.

Methods

A retrospective review of all patients with primary Achilles tendon rupture and Achilles tendon re-rupture was undertaken. Two separate databases were compiled: the first included all Achilles tendon re-ruptures presenting during the study period and described epidemiology, mechanisms and nature of the re-rupture; the second was a case–control study analysing differences between patients with primary Achilles tendon rupture during the study period, who did, or did not, go on to develop re-rupture, with minimum review period of 1.5 years.

Results

Seven hundred and eighty-three patients (567 males, 216 females) attended with primary Achilles tendon rupture and 48 patients (41 males, 7 females) with Achilles tendon re-rupture. Median time to re-rupture was 98.5 days (IQR 82–122.5), but 8/48 re-ruptures occurred late (range 3 to 50 years) after primary Achilles tendon rupture. Males were affected more commonly (OR = 7.40, 95% CI 0.91–60.15; p = 0.034). Mean Achilles tendon re-rupture incidence was 0.94/100,000/year for all ages and 1.16/100,000/year for adults (≥ 18 years). Age distribution was bimodal for both primary Achilles tendon rupture and re-rupture, peaking in the fifth decade, with secondary peaks in older age. Incidence of re-rupture was higher in less socioeconomically deprived sub-populations (OR = 2.01, 95%CI 1.01–3.97, p = 0.04). The majority of re-ruptures were low-energy injuries. Greater risk of re-rupture was noted for patients with primary rupture aged < 45 years [adjusted odds ratio (aOR) 1.96; p = 0.037] and those treated with traditional cast immobilisation (aOR 2.20; p = 0.050).

Conclusion

The epidemiology of Achilles tendon re-rupture is described and known trends (e.g. male predilection) are confirmed, while other novel findings are described, including incidence of a small but significant number of late re-ruptures, occurring years after the primary injury and an increased incidence of re-rupture in less socioeconomically deprived patients. Younger age and traditional immobilising cast treatment of primary Achilles tendon rupture were independently associated with Achilles tendon re-rupture.

Level of evidence

III.

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Abbreviations

ATR:

Achilles tendon rupture

ATRR:

Achilles tendon re-rupture

FET:

Fisher’s exact test

NHS:

National Health Service

REC:

Regional ethics committee

SEDS:

Socioeconomic deprivation status

SIMD:

Scottish Index of Multiple Deprivation

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Funding

None received.

Author information

Authors and Affiliations

  1. Department of Orthopaedic, Trauma & Sports Medicine, Mater Dei Hospital, Msida, MSD 2090, Malta

    J. F. Maempel

  2. Faculty of Medicine and Surgery, Mater Dei Hospital, University of Malta, Block A, Level 0, Msida, MSD 2090, Malta

    J. F. Maempel

  3. Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51, Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK

    T. O. White, S. P. Mackenzie & C. McCann

  4. Department of Orthopaedics, Royal Infirmary of Edinburgh, 51, Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK

    N. D. Clement

  5. University of Edinburgh Medical School, 47, Little France Crescent, Edinburgh, EH16 4TJ, UK

    T. O. White & N. D. Clement

Authors
  1. J. F. Maempel
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  2. T. O. White
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  3. S. P. Mackenzie
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  4. C. McCann
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  5. N. D. Clement
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Contributions

JM—concept/idea for study, data collection, review and statistical analysis, drafting of manuscript and editing of manuscript; TOW—guidance with initial study design and with manuscript; SPM—data collection, manuscript editing; CMcC—data collection, manuscript editing; NDC—guidance with study design, assistance with statistical analysis and editing of manuscript.

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Correspondence to J. F. Maempel.

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The authors have no conflicts of interest to declare.

Ethical approval

This study was part of a departmentally approved service review of ATR which was reviewed by the scientific officer for the regional ethics committee (REC) who advised that REC review was not necessary.

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Appendices

Appendix 1

See Table

Table 9 Actual incidence of ATRR per season compared to expected incidence of ATRR in the absence of any seasonal variation *Chi square test
Full size table

9.

Appendix 2

For the purposes of this sub-analysis, only patients presenting with a second Achilles tendon rupture within 3 years of their primary rupture (n = 40) were considered to have re-ruptures. All other presenters with ATR (n = 791) were considered to have primary ruptures. The median time between primary ATR and ATRR was 92.5 days (IQR 82–106). Males (mean 6 cases per year, range 2–9; in an average male population of 416,096) were affected more commonly than females (mean 0.67 cases per year, range 0–3; in an average female population of 439,902; p = 0.063 FET; OR = 6.34, 95% CI 0.76–52.69).

Median age at the time of ATRR was 41 years (IQR 33–47). Male preponderance for ATRR was more pronounced than for primary ATR (p = 0.014; OR = 3.43, 95% CI 1.21–9.75). The mean incidence of ATRR over the study period was 0.78/100,000 per year (range 0.34–1.05/100,000 per year) for all ages and 0.96/100,000 per year (range 0.42–1.30/100,000 per year) for the adult population (≥ 18 years). This compares to a mean incidence of primary ATR of 15.41/100,000 per year (range 13.63 to 19.18) for all ages and 19.04/100,000 per year (range 16.86–23.71) in adults (≥ 18 years). Peak incidence of both primary ATR and ATRR was in the fifth decade (Appendix 2, Fig. 

Fig. 6
figure 6

a Mean annual incidence of ATRR over the study period in the health-board population by age bracket. b Mean annual incidence of primary ATR over the study period in the health-board population by age bracket

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6a, b). ****NOTE THE END OF THIS SENTECE...i.e. "6a, b)." should be BEFORE Figure 6, with the beginning of the sentence and not over here***

Incidence of ATRR was higher in the least socioeconomically deprived population biquintile (26 cases in a population of 425,254) compared to the most deprived biquintile (10 of 294,239) but this finding did not reach statistical significance after excluding late re-ruptures (OR = 1.74, 95%CI 0.84–3.60, p = 0.13). ATRR occurred most frequently during the summer, but there was no statistically demonstrable seasonal variation (p ≥ 0.15; Appendix 2, Table  ***NOTE that throughout this section, as above with figure 6, the end of the sentence linking to the appropriate figure or table has been separated and inserted after the relevant figure or table.***

Table 10 Actual incidence of ATRR per season compared to expected incidence of ATRR in the absence of any seasonal variation. *Chi square test
Full size table

10). The majority of ATRR were low-energy injuries and two ATRR (5%) occurred while undertaking primary ATR rehabilitation exercises (Appendix 2, Table

Table 11 Mechanism of injury for primary ATR and ATRR
Full size table

11).

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Maempel, J.F., White, T.O., Mackenzie, S.P. et al. The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors. Knee Surg Sports Traumatol Arthrosc 30, 2457–2469 (2022). https://doi.org/10.1007/s00167-021-06824-0

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