The incidence of deep venous thrombosis after Achilles tendon rupture was highly variable in the literature. The reported incidence ranges from less than one percent to thirty-four percent () [4
]. Lapidus et al. noted a DVT incidence of 34% in ninety-one patients after surgical repair with no reported PEs [6
]. Nilsson-Helander et al. studied ninety-five patients and recorded similar DVT incidences after Achilles tendon rupture in both the operative and nonoperative study groups (34%). They also found that 3% of these patients developed PEs [7
]. Furthermore, Healy et al. noted a DVT incidence of 6.3% and a PE incidence of 1.5% in 208 patients [8
]. They found this rate similar to that of PE in patients having undergone elective hip surgeries. They suggest that this may be secondary to a lack of DVT prophylaxis in patients with lower limb immobilization after Achilles tendon rupture. Saragas and Ferrao found DVT incidence of 5.7% in 88 patients and one patient had developed near fatal pulmonary embolism [12
]. Recently, Makhdom et al. found that the symptomatic DVT incidence after Achilles tendon rupture repair was 23.47% in 115 patients [10
]. The authors noted that one-third of the 23.47% had developed DVT prior to their surgery. On the other hand, Patel et al. recently performed a retrospective analysis, which looked at 1172 patients for the incidence of DVT and PE with Achilles tendon rupture. They found an incidence of 0.43% and 0.34%, respectively [9
]. Hence, there is a discrepancy in the reported incidence of DVT in patients with Achilles tendon rupture in both the operative and nonoperative groups. The reasons for this difference remain unclear. It seems reasonable to conclude that this variation, at least partly, stems from the different study designs; some studies reported symptomatic DVTs, whereas others reported both symptomatic and asymptomatic DVTs.
Reported incidence of deep vein thrombosis and pulmonary embolism in patients treated surgically (S) and nonsurgically (N-S) for Achilles tendon rupture.
In the literature, there are few case reports documenting Achilles tendon rupture with subsequent DVT and PE. One such report documented a PE in a patient with a prothrombotic condition [13
], and two were in individuals believed to be generally healthy [14
]. Furthermore, the PE was fatal in one patient who had undergone conservative management for Achilles tendon rupture [14
]. To our knowledge, this is the first case of fatal PE following surgical repair of an Achilles tendon rupture in the English medical literature.
A number of factors are believed to contribute to the risk of developing DVT/PE with cast immobilization of the lower limb following injury. These include trauma, prolonged immobilization, and surgery [11
]. However, several authors disagree that surgery for Achilles tendon rupture is a risk factor for DVT/PE [7
]. Although our patient had some of these risk factors, we recognize the possibility that he may have developed an asymptomatic DVT prior to his surgery. Additionally, in our report, we noted that our patient had a history of isotretinoin use. Although there are several case reports suggesting the possibility of an increased risk of thromboembolic events with the use of this medication [16
], most of these case reports were in patients suffering from leukemia treated with all-trans-retinoic acid [17
]. No studies to date have demonstrated such an association [20
Thromboembolism has been reported with many orthopaedic procedures [21
]. Although in the hip and knee there are clear consensus guidelines regarding DVT prophylaxis [3
], the optimal DVT/PE prophylaxis following below the knee injury requiring immobilization remains unclear. There is recent evidence from a Cochrane meta-analysis which has noted a decreased incidence of symptomatic DVT from 2.5% to 0.3% between patients randomized to placebo versus LMWH [21
] in this population. On the other hand, others believe the use of routine prophylaxis to be unwarranted due to a low frequency of symptomatic DVTs and PEs [9
]. International consensus guidelines vary significantly on recommendations for injuries below the knee requiring immobilization [3
]. Further research should therefore be conducted to investigate the risks and benefits of chemical DVT prophylaxis in patients following Achilles tendon rupture. For low-risk patients, the use of milder forms of prophylaxis such as aspirin should also be explored [8