Journal of Rheumatic Diseases Vol. 23, No. 2, April, 2016 http://dx.doi.org/10.4078/jrd.2016.23.2.136 Clinical Image

Spontaneous Achilles Tendon Rupture in a Patient with Ankylosing Spondylitis

Seok Kyun Park, Soo Uk Chae Department of Orthopedic Surgery, Daeun Hospital, Jeonju, Korea

A 43-year-old male patient had heel pain that was oc- eral showed loss of Kager’s triangle (Figure 2B) and con- curred spontaneously during walking 2 days before. At firmed by magnetic resonance imaging (Figure 2C). the time of visiting, bamboo spine was found in simple Ankylosing spondylitis is characterized by inflammation spine radiography, suggesting coexistence with ankylos- of the entheses and paravertebral structures, leading in ing spondylitis (Figure 1). He was diagnosed with anky- time to bone formation at those sites [1,2]. Simple lateral losing spondylitis about 3 years ago at other hospital and foot image shows rupture of the Achilles tendon at calca- treated with adalimumab (Humira; AbbVie Inc., North neal insertion site and combined with bony fragments. Chicago, IL, USA). The physical examination showed Acute Achilles tendon rupture can be managed by both swelling, ecchymosis and dimpling in the posterior aspect operative and nonoperative strategies. Operative acute of the ankle (Figure 2A). The initial radiograph of foot lat- Achilles tendon rupture treatment can effectively reduce

Figure 1. Simple anteroposterior (A) and lateral (B) L-spine radiog- raphy show a bamboo spine.

Received：November 19, 2015, Revised：(1st) December 13, 2015, (2nd) December 14, 2015, Accepted：December 14, 2015 Corresponding to：Soo Uk Chae, Department of Orthopedic Surgery, Daeun Hospital, 277 Senae-ro, Wansan-gu, Jeonju 54969, Korea. E-mail： [email protected] pISSN: 2093-940X, eISSN: 2233-4718 Copyright ⓒ 2016 by The Korean College of Rheumatology. All rights reserved. This is a Free Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

136 Achilles Tendon Rupture in Ankylosing Spondylitis

the risk of re-rupture but may also lead to more complica- tions related to open surgery. It is generally accepted that operation should be performed for athletes, young and fit patients and that conservative treatment may be suitable for the elderly. However, controversy remains with regard to optimal treatment for acute Achilles tendon rupture [3]. An operation was performed because of insertional cal- cific Achilles tendinosis is a painful and frequently dis- abling condition. The patient was placed in the prone po- sition under spinal anesthesia. Achilles tendon rupture was treated with tendon to bone repair using suture an- chors (Figure 3). As of the 6-month follow-up simple lat- eral ankle image shows intact morphology of Kager’s tri- angle (Figure 4A), ultrasonography shows normal distal Achilles tendon with fibrillar pattern at calcaneal in- sertion (Figure 4B). There was no visually altered gait or Figure 2. (A) The clinical photo shows swelling, ecchymosis problem in daily activity and he had recovered to full and dimpling in the posterior aspect of the ankle. (B) Simple activity. This case shows that we should be aware of the lateral ankle image shows loss of Kager’s triangle and bony fragments (arrow). (C) Sagittal T2 magnetic resonance image possibility of encountering an uncommon spontaneous shows rupture of the Achilles tendon at calcaneal insertion site Achilles tendon rupture in the calcaneal enthesopathies and enthesopathic spur. of a patient with ankylosing spondylitis.

Figure 3. (A) Intraoperative finding shows the rupture of the Achilles tendon at calcaneal insertion site and combined with bony fragments. (B) Achilles tendon rupture was treated with tendon to bone repair using suture anchors. (C) Postoperative finding shows complete repair tendon to bone repair.

Figure 4. Six months follow-up simple lateral ankle image shows intact morphology of Kager’s tri- angle (arrow) (A), ultrasonography shows normal distal Achilles ten- don with fibrillar pattern at calca- neal insertion (arrowheads) (B). ACHI. T: Achilles tendon, LT: left, RT: right.

www.jrd.or.kr 137 Seok Kyun Park and Soo Uk Chae

CONFLICT OF INTEREST 1379-90. 2. Kim HW, Lee SH. Pathogenesis of ankylosing spondylitis. J Rheum Dis 2015;22:61-8. No potential conflict of interest relevant to this article 3. Jiang N, Wang B, Chen A, Dong F, Yu B. Operative versus was reported. nonoperative treatment for acute Achilles tendon rupture: a meta-analysis based on current evidence. Int Orthop 2012;36:765-73. REFERENCES

1. Braun J, Sieper J. Ankylosing spondylitis. Lancet 2007;369:

138 J Rheum Dis Vol. 23, No. 2, April, 2016