Case Presentation 2024/02/24

報告者: Clerk 湯富樺

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Patient Profile
• Name:趙O民
• Chart number: 8190395
• Age: 50y/o
• Gender: Male
• Height: 172 cm, Weight: 76 kg, BMI: 25.6
• Admission date: 2024/02/19

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• Past History:
• 1. Hepatitis B Carrier

• Operation history:
• 1. central retinal vein occulsion (OD) s/p intravitreal injection at our
hospital on 2018/11/08, 2018/12/06;
• 2. central retinal vein occulsion (OU) s/p intravitreal injection at our
hospital on 2019/11/18;
• 3. central retinal vein occulsion (OS) s/p intravitreal injection at our
hospital on 2020/01/13, 2020/03/23

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• Personal History
• Alcohol: denied
• Betel nuts: denied
• Cigarettes : denied
• TOCC: denied
• Drug-allergy:(+), voren, Diclofenac sodium-> eye swelling

• Family History: denied

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Chief Complaint

• Left ankle pain with disability due to a sport injury (playing

badminton) on Feb 15, 2024

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Present Illness

→ According to the statement of patient, he suffered from

• Left ankle pain with disability due to a sport injury (playing

badminton)

→ He claimed that he visited local medical doctor and left

Achilles tendon rupture was told and surgical intervention was
suggested.
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 Present Illness
→ 02/19: Due to above reasons, he came to our outpatient clinic this
morning for second opinion.

Vital sign: stable (TRP: 36.4/68/17, BP:130/84 mmHg).

Physical examination: left Thompson test (+)
Lab data: no specific findings

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Review of system
1. General Condition: no fever, no chillness.
2. Integument: no abnormal pigmentation, no skin rash.
3. HEENT: Head- no headache, no dizziness, no vomiting.
Eyes- no diplopia, normal color vision.
Ears- no hearing loss, no discharge.
Nose- no epistaxis, normal sense of smell.
Throat- no hoarseness, no neck stiffness.
4. CV Condition: no dyspnea, no chest tightness.
5. Respiratory: no cough, no sore throat, no short of breath.
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Review of system

6. GI Condition: no choking, no diarrhea, no abdominal pain, no constipation.

7. Neuro Condition: no seizure, no gait disturbance.
8. Hema-Condition: no easy-bruise, no ecchymosis, no cold sweating.
9. Neph-Condition: no gross-hematuria.
10.Meta-Condition: no polyuria, no polydypsia, no superficial veins engorged.
11. Genitoreproductive:
male- no venereal disease, no discharge from penis, no hernia
12. Musculoskeletal: left ankle pain and swelling, limitation in motor activity

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 Physical Examination
• Height: 172 cm
• Weight: 76 kg
• BMI: 25.7 %
• Vital signs: BP: 130 / 84 mmHg
T: 36.4 ℃
P: 68 /min
R: 17 /min
• General appearance: fair.
• Consciousness: alert.
• Head: no skull deformity.
• Facial: symmetrical expression.
• Ears: no discharge.
• Eyes: conjunctiva: not pale.
sclera: anicteric. 10
Physical Examination

• Skin: normal skin turgor.

• Neck: no palpable mass.
• Chest: Expansion: normal expansion.
Breathing sound: bilateral clear.
• Heart: RHB without murmur.
• Abdomen: soft and flat.
no hepatosplenomegaly.
no distension.
no tenderness.
bowel sound: normal active. 11
Physical Examination

• Back: knocking pain: -/-

• Extremities: left Thompson test positive
Muscle power: no weakness.
Deep tendon reflex: no increase.
Sensory: intact.
Straight leg raising test (Right/Left): -/-

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Initial Impression

1. Left Achilles tendon rupture

2. HBV Carrier

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Admission

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Clinical course
02/19

-> Stazolin(Cefazolin)1g/vial for IV inj. for Prophylactic Antibiotic

-> Utraphen(Tramadol+Acetaminophen) 37.5/325mg/tab TID for pain

control, TraMTOR(Tramadol) 100mg/2ml/amp PRN

-> Broen-C(Bromelain and L-cysteine) 2 tab. for relief of swelling, phlegm

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Clinical course
02/19

Operation: 1. Rupture of achilles tendon primary suture

1. Under GA with prone position

2. Skin disinfection with beta-iodine
3. Longitudinal skin incision over Achilles tendon
4. Identify the ruptured Achilles tendon
5. Achilles tendon rupture was found
6. Repair the rupture Achilles tendon
7. Close the operation wound layer by layer

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Operation

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Clinical course
02/20

Active problem:
1. Left Achilles tendon rupture s/p repair, VAS: 5 (during change dressing)
-Keep pain control
-Left heel op. wound dressing
-Local ice packing
-Change position Q2H
-Educate ankle pumping exercise
-Fall prevention

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Final diagnosis

1. Left Achilles tendon rupture

2. HBV Carrier

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Discussion
Achilles tendon rupture Repair

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Causes of Achilles tendon rupture

• Sudden Forced Plantar Flexion Of The Foot,

• Direct Trauma, And
• Long-standing Tendinopathy Or
• Intratendinous Degenerative Conditions.

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 Risk factors for a rupture of the Achilles tendon

• Poor Conditioning Before Exercise,

• Prolonged Use Of Corticosteroids,
• Overexertion,
• Fluoroquinolone Antibiotics,

The average age of people with Achilles tendon injury or rupture is

29 to 40 years old, and the male to female ratio is 20:1.

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Evaluation

• Thompson test
• Squeeze the calf muscles and if
your calf muscles are squeezed
and there is no movement then
the test is positive

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Indications for surgical referral

• All complete tendon ruptures merit surgical consultation.

• Partial tendon tears and chronic tendinopathy that fail to

improve with three to six months of conservative treatment may
benefit from.

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 Krakow techniques

• The Krackow technique is

a continuous locking loop
suture technique used in
tendon repair.
• The classic Krackow stitch
involves 3 or more locking
loops placed along each
side of the ligament or
tendon.
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 The Giftbox technique
• Based on biomechanical study,
Achilles tendons repaired using the
Giftbox technique are more than
twice as strong as those repaired
using the traditional Krackow
technique.
• The mean force to failure for the
tendons using the Giftbox
technique was 168 N, whereas the
mean for the traditional Krackow
technique was 81 N (p < 0.0001).
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Labib SA, Rolf R, Dacus R, Hutton WC. The "Giftbox" repair of the Achilles tendon: a modification of the Krackow technique. Foot Ankle Int. 2009 May;30(5):410-4. doi: 10.3113/FAI-2009-0410.
PMID: 19439140.
 Complications

• Re-rupture
• Wound Healing Complications
-wound dehiscence, infection, and
deep vein thrombosis
• Sural Nerve Injury

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 Postoperative and Rehabilitation Care

• For patients treated with surgery, two to three months off from
work that requires ambulation is generally required.
• Athletes typically return to sport by three to six months, once they
have regained adequate strength and mobility.

However, additional time, one-year post-injury date, is often required

to achieve full function

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 The duration of immobilization

• In the operative approach, immobilization typically lasts for

approximately 2 to 4 weeks
• Emphasizing the need to avoid hyper dorsiflexion during this time
has been noted as an important component in avoiding elongation
of the Achilles tendon and long-term functional deficits.
• Rehabilitation exercises typically begin 2 to 4 weeks post-op.

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Outcomes

• Surgery offers a lower risk of re-rupture, it is also associated with

postsurgical complications that may delay recovery.

• Overall, the outcomes for Achilles tendon rupture are good to

excellent after treatment.

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Thank you
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