Risk Of Achilles Tendon Rupture Research Articles

Hyperuricemia May Increase Risk of Achilles Tendon Rupture: A Case Control Study

It has been demonstrated in a number of studies that high levels of uric acid can cause crystal deposition in the tendons of the lower extremities, which in turn can impair the Achilles tendon. This study aimed to interpret whether hyperuricemia is relevant with Achilles tendon rupture. Patients diagnosed with Achilles tendon rupture at the same institution between 2013 and 2022 were included in the case group. Healthy subjects who had physical examinations during the same period were included in the control group. Propensity score matching was used to match in a 1:1 ratio. Demographic and clinical characteristics of patients in both groups were compared. Five hundred and fourteen patients were included in the study (ATR=257; Control group=257). The proportion of individuals with hyperuricemia varied significantly between the 2 groups (Achilles tendon rupture group=43.6%; control group=27.6%; p<0.001). The Achilles tendon rupture and hyperuricemia were linked by conditional logistic regression (p<0.001; OR=2.036; 95CI%=1.400-2.961). Compared with healthy subjects, patients with hyperuricemia have a higher risk of Achilles tendon rupture. Further studies are required to verify the effects of hyperuricemia and monosodium urate crystals on Achilles tendon structure.

Delayed Achilles Tendon Rupture at 17 Years of Age After Treatment of Clubfoot with Ponseti Method: A Case Report.

Traumatic pediatric Achilles ruptures are rare, and few cases have been reported among patients with a history of Achilles tenotomy. A 17-year-old boy with a history of Achilles tenotomies for congenital clubfoot as an infant presented with acute midsubstance Achilles tendon rupture of the right leg. The gastrocnemius fascia was dissected to allow for approximation of the ruptured Achilles tendon segments. Furthermore, the plantaris tendon was harvested and sutured around the Achilles tendon-rupture site to improve strength. Patients with a history of clubfoot and chronic Achilles tendon pain should be alerted to the risk of Achilles tendon rupture.

A case of nontraumatic simultaneous bilateral Achilles tendon rupture.

Patients with corticosteroid-managed chronic obstructive pulmonary disease (COPD) are at increased risk of Achilles tendon rupture. This risk is further augmented in the setting of an acute COPD exacerbation in which antibiotics may be indicated, namely fluoroquinolones. This case concerns a 76-year-old man who experienced simultaneous nontraumatic bilateral Achilles tendon rupture during an acute COPD exacerbation. Treatment was conservative with analgesics, activity modification, and bilateral controlled ankle movement boots. Surgery was not advised because of his multiple medical comorbidities predisposing him to impaired wound healing and potential amputation. Included is a discussion on the pathophysiology, diagnosis, and treatment of Achilles tendon rupture. There is a need for greater awareness of the risk of Achilles tendon rupture from combined use of corticosteroids and fluoroquinolones. After this report, we hope to raise awareness of this complication and prevent patient suffering.

Intrasound Therapy Improves the Mechanical Properties and the Morphology of Tendons in Fluoroquinolone-Induced Achilles Tendinopathy

&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Fluoroquinolones (FQs), especially Pefloxacin (PEF) have been reported to increase risk of Achilles tendon rupture. However, prior studies showed that intrasound therapy (ITR) significantly improved the morphology of the healing tendon. This study aimed to compare the effects of 7, 14 and 21 days intrasound treatment on the mechanical properties and morphology of the Achilles tendon in fifty (50) male Sprague-Dawley rats induced with FQ and randomized into three main categories designated as Normal control (A), Experimental control (B) and Treatment groups (C). All animals in groups B and C were orally administered PEF 400mg/kg in a fixed volume of 2.5 ml/kg daily for 6 consecutive days. The Achilles tendon of both hind limbs in group C were treated with the lowest intensity ITR 5 minutes daily for 7, 14 and 21 consecutive days. All the animals were serially sacrificed on days 8, 15 and 22 and the tendons excised and processed. Data were analyzed with RSTUDIO version 4.0.02 and the level of significance set at 0.05. Kruskal Wallis showed no significant differences (p &gt;0.05) in all the biomechanical parameters across all the groups. Compared with group B, ITR 14 days treatment had the best improvement in all biomechanical variables, though insignificant (p&gt;0.05). In the Intrasound groups, there were significant positive correlations of Nitric Oxide Synthase (NOS) with ultimate tensile stress and tensile load (p= 0.005; p=0.003) respectively. Intrasound treatment to the Achilles tendon for 14 days improved the mechanical properties and morphology of tendons in Fluoroquinolone-induced tendinopathy.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D;

Association Between Third-Generation Fluoroquinolones and Achilles Tendon Rupture: A Self-Controlled Case Series Analysis

We investigated whether use of third-generation fluoroquinolones is associated with occurrence of Achilles tendon rupture using a case series analysis in which patients served as their own control. We used administrative claims data to identify residents in a single Japanese prefecture who were enrolled in National Health Insurance and Elderly Health Insurance from April 2012 to March 2017 and experienced Achilles tendon rupture after receiving an antibiotic prescription. Antibiotics were categorized into 3 groups: first- and second-generation fluoroquinolones, third-generation fluoroquinolones, and nonfluoroquinolones. We used a conditional Poisson regression model to estimate the incidence rate ratio (IRR) of Achilles tendon rupture during the antibiotic exposure period relative to the nonexposure period for each patient. An exposure period was defined as 30 days from start of the prescription. Analyses were based on 504 patients with Achilles tendon rupture who had received antibiotic prescriptions. Risk of rupture was not significantly elevated during exposure to third-generation fluoroquinolones (IRR = 1.05; 95% CI, 0.33-3.37) and nonfluoroquinolones (IRR = 1.08; 95% CI, 0.80-1.47). In contrast, risk was significantly elevated during exposure to first- and second-generation fluoroquinolones (IRR = 2.94; 95% CI, 1.90-4.54). Findings were similar across subgroups stratified by sex and by recent corticosteroid use. Our analysis showed that third-generation fluoroquinolone use was not associated with an increased risk of Achilles tendon rupture. These antibiotics may be a safer option for patients in whom this risk is elevated, such as athletes.

Prognosis of elite basketball players after an Achilles tendon rupture

ObjectiveProfessional Basketball players are at high risk of Achilles tendon rupture. Despite this, there remains limited research into the factors affecting rehabilitation and the long term outcomes of these players. Our aim is to quantify the effect of a player’s Achilles tendon rupture on their post-injury performance, and also to explore for correlations between their recovery timeline and pre-injury characteristics. Creation of an injury timeline of past incidents will allow injured players to better track their progress and also inform them about the probable impact on their careers. HypothesisPlayers with Achilles tendon rupture injury will exhibit decreased performance compared to their pre-injury self and their non-injured peers after recovery. MethodsProfessional basketball players who sustained a unilateral Achilles tendon rupture from 1992 to 2016 were collected. 12 players met our inclusion criteria and their Player Efficiency Ratings (PER) were obtained as primary outcome measures; matched controls were chosen based on the PER, Age and playing position. The players’ index season PER was compared against the PER during the 10 games immediately following the players’ return and the PER of their post-injury peak performing season. The same data analysis was performed against their control group. To investigate the factors affecting the recovery and long-term consequences of their injury, we correlated the variables of Age, BMI, Time of Injury and pre-injury PER with the player’s time to return to play and their post-injury PER. Results2 out of 12 players failed to return to playing in the elite professional league following an Achilles Tendon Rupture, others returned after a mean recovery time of 10 months. When compared to players’ index PER, the mean PER reduction during the 10 games immediately following the players’ return was 7.15 (P < .000). Players on average took 1.8 seasons to reach their post-injury peak performance, with only 1 player returning to his pre-injury performance. Others suffered a mean PER reduction of 3.5 (P = .004) when compared to their index PER and 5.4 (P = .045) against their matched controls. ConclusionAchilles tendon rupture can be a career-ending injury for professional basketball players. They are expected to miss 10 months for rehabilitation and reach their post-injury peak performance level at the 2nd season back. The post-injury peak performance is significantly worse than the pre-injury level, but is similar to matched non-injured players.

Downregulation of type I collagen expression in the Achilles tendon by dexamethasone: a controlled laboratory study

BackgroundSpontaneous Achilles tendon rupture associated with long-term dexamethasone (Dex) use has been reported. However, few studies have investigated the potential mechanism. The aim of this study was to evaluate the effects of oral Dex on type I collagen in humans and rats and its association with tendon rupture.MethodsFirst, six Achilles tendons from patients who received long-term Dex treatment, and another six normal tendons were harvested for histological evaluation. Secondly, 8-week-old rats (n = 72) were randomly assigned to a Dex group or a control group. Type I collagen was studied at the mechanical, histological, and molecular levels after 3 and 5 weeks. Tenocytes isolated from normal human and rat tendon were used to investigate the effect of Dex on cellular scale.ResultsHistological analysis of human and rat tendon tissue revealed an irregular, disordered arrangement of type I collagen in the Dex group compared with the control group. In addition, In the Dex+ group, type I collagen expression decreased in comparison with the Dex− group in both human and rat tenocytes. The mechanical strength of tendons was significantly reduced in the Dex group (68.87 ± 11.07 N) in comparison with the control group (81.46 ± 7.62 N, P = 0.013) after 5 weeks. Tendons in the Dex group were shorter with smaller cross-sectional areas (10.71 ± 0.34 mm2, 1.44 ± 0.22 mm2, respectively) after 5 weeks than those in the control group (11.13 ± 0.50 mm2, P = 0.050, 2.74 ± 0.34 mm2, P < 0.001, respectively).ConclusionsThis finding suggests long-term use of Dex that decreases the expression of type I collagen at molecular and tissue levels both in human and rat Achilles tendons. Furthermore, Dex decreases the mechanical strength of the tendon, thereby increasing the risk of Achilles tendon rupture.

Modified Percutaneous Achilles Tendon Lengthening by Triple Hemisection for Achilles Tendon Contracture.

Background Both percutaneous Achilles tendon lengthening by triple hemisection and the traditional open Z-lengthening are effective methods for Achilles tendon contracture. This study aims to evaluate the efficacy and safety of this new therapeutic method, which is based on the percutaneous sliding technique with three hemi-cuts in the tendon, as compared with the traditional open Z-lengthening. Methods Retrospective analysis of the Achilles tendon contracture cases in our hospital between January 2010 and September 2016 was conducted. Twenty-five cases received percutaneous Achilles tendon lengthening (group A), and 30 patients who underwent open Z-lengthening during the same period were in the control group (group B). Operative time and hospital stay were statistically analyzed. Incision complication, equinus recurrence rate and Achilles tendon rupture morbidity were recorded. The function was assessed by American Orthopaedic Foot & Ankle Society (AOFAS) score. All cases in group A received Magnetic Resonance Imaging (MRI) of ankle preoperatively and in the follow-ups. Results The mean follow-up period was 42.04 months in group A and 61.7 months in group B. The entire operative time and the mean hospitalization days were lower in group A than in group B. No incision and infection complication occurred in group A. The infection rate in group B was 3.3%. Equinus recurrence rate was 4% in group A and the equinus recurrence rate in group B was 21.4%. In group A, the mean AOFAS score increased from 64 ± 10.16 points preoperatively to 96.08 ± 3.17 at final follow-up, while the score in group B increased from 63.48 ± 6.2 points to 85.4 ± 10.3. MRI showed continuity of the Achilles tendon and homogeneous signal in group A. Conclusion Modified surgery can significantly reduce the risk of Achilles tendon rupture, provide better balance in soft tissue strength between ankle dorsiflexion and ankle plantarflexion, helping to avoid recurrence of the deformity.

Fluoroquinolones and the risk of tendon injury: a systematic review and meta-analysis.

Tendinopathy is a known adverse reaction associated to fluoroquinolones, but a meta-analysis was not yet published. The aim of this study was to conduct a systematic review and a meta-analysis of the scientific evidence evaluating the risk of tendon injury associated with fluoroquinolones. A literature search was conducted to identify observational studies which reported results on the risk of Achilles tendon rupture (ATR), risk of Achilles tendinitis (AT), or risk of any tendon disorders (ATD). A meta-analysis was performed by pooling odds ratios (ORs) with their 95% confidence intervals (CIs). Fifteen studies were included in the meta-analysis. Treatment with fluoroquinolones was associated with an increased risk of ATR (OR 2.52 (95% CI 1.81-3.52), p < 0.001, I2 = 76.7%), an increased risk of AT (OR 3.95 (95% CI 3.11-5.01), p < 0.001, I2 = 0%), and increased risk of ATD (OR 1.98 (95% CI 1.62-2.43), p < 0.001, I2 = 84.5%). The initial risk estimates remained statistically significant among patients aged ≥ 60years old. Risk estimates did not significantly change after depending on the concomitant use of corticosteroids or studies methodological quality assessment. The analysis according to the type of fluoroquinolones was only possible for ATR, which were ofloxacin and norfloxacin were found to increase the risk of this outcome, but not ciprofloxacin and levofloxacin. The results of this meta-analysis confirm the risk of tendon injuries associated with fluoroquinolones. Older age and concomitant use of corticosteroids seem to be additional risk factors for tendinopathy.

A PROSPECTIVE STUDY OF SURGICAL MANAGEMENT OF CHRONIC NEGLECTED TENDOACHILLES RUPTURE USING PERONEUS BREVIS TENDON

Objective of the study is to find out functional outcome and complications associated with surgical reconstruction of chronic degenerative tendoachilles rupture using peroneus brevis tendon and role of local steroid injection in chronic rupture of tendon. We studied 10 cases with chronic degenerative Achilles tendon rupture who were treated with peroneus brevis tendon augmentation procedure. In 8 cases rupture of tendon was secondary to local corticosteroid injection given for retro calcaneal bursitis. Patients came to hospital with pain over the Achilles tendon and difficulty in walking, climbing stairs, diagnosed of Achilles tendon rupture through physical examination and subjected to USG for confirmation. Patients have undergone operative treatment in the form end to end suturing of ruptured tendon using Krakow technique and augmentation of tendon using peroneus brevis tendon as explained by Teuffer. Post operatively patient immobilized in above knee cast with foot in 15-20 plantar flexion and 45 degree of knee flexion. Suture removal done after 14 days of surgery. After 4 weeks cast converted to short leg cast. Mobilization started after 6 weeks on the cast. Cast discontinued after 8 weeks and full weight bearing started at 8-12 weeks. Follow up done for 18 months. Of 10 patients 7 patients were male and 3 were female. Age range was 30-60 years with mean age of 45 years. 7 patients had right tendon rupture, 3 had left tendon rupture. 8 patients gave previous history of corticosteroid injection given for retro calcaneal bursitis. Postoperatively 2 patients had skin necrosis which healed by secondary intention and scar. According to AOFAS scoring system for functional outcome of patients increased from preoperatively 65 to postoperatively 95(range 90-100). There is increased risk of Achilles tendon rupture after local steroid injection for inflammatory lesions of tendon or around the tendon, so it’s better to avoid giving local steroid injections in or around the Achilles tendon. Peroneus brevis can be easily used for Achilles tendon augmentation with good functional outcome. Keywords: Achilles tendon rupture, peroneus brevis tendon, corticosteroid, Teuffers technique, AOFAS scoring system.

Clinical implications of the association between fluoroquinolones and tendon rupture: The magnitude of the effect with and without corticosteroids.

To estimate the relative, absolute and attributable risk of non-traumatic tendon rupture, at various sites, associated with use of fluoroquinolones, with and without concomitant corticosteroids. We conducted cohort and nested case-control studies among fluoroquinolone users in the United Kingdom Clinical Practice Research Datalink Gold. We estimated the excess risk (cohort analysis) and odds ratios (ORs) (case control) of tendon rupture by fluoroquinolone (current, recent and past use versus unexposed) and corticosteroid (current versus unexposed) use. Among 740926 patients with a fluoroquinolone prescription, 3957 cases of tendon rupture were identified. The excess risk due to current fluoroquinolone use was low: any tendon rupture 3.73 (95% confidence interval, CI, 2.08-5.39) per 10000 person-years (PY) and Achilles tendon rupture 2.91 (1.71-4.11) per 10000 PY. The excess risk of any tendon rupture was much higher for current concomitant fluoroquinolone and corticosteroid use versus corticosteroids alone: 21.2 (11.3-31.2) per 10000 PY. In the case-control, OR (95% CI) among current fluoroquinolone users versus unexposed patients was elevated: any tendon rupture 1.60 (1.22-2.09), Achilles tendon 2.71 (1.76-4.17) and bicep tendon 1.53 (0.85-2.73). The risk of any tendon rupture was higher among women (OR 2.27 [1.54-3.34]), patients aged 60+ (OR 2.42 [1.74-3.37]), and concomitant corticosteroid use (OR 6.64 [3.99-11.1]). Fluoroquinolones increase the risk of Achilles tendon rupture and, to a lesser extent, bicep tendon rupture, but the attributable risk is low. The risk is materially increased with concomitant use of corticosteroids.

Achilles tendon structure is negatively correlated with body mass index, but not influenced by statin use: A cross-sectional study using ultrasound tissue characterization.

IntroductionStatins are widely used to inhibit cholesterol production in the liver among people with hypercholesterolemia. A recent epidemiological study in the UK has shown that statin use (unlike elevated BMI) is not associated with an increased risk of Achilles tendon rupture. However, because of laboratory reports suggesting a negative influence of statins on tenocyte metabolism, we decided to directly compare the Achilles tendon structure (cross-sectional area and longitudinal collagen organization) in regular statin users compared to non-users.MethodsWe conducted ultrasound tissue characterization (UTC) of the Achilles tendon in statin users and a comparison group of similar age and gender. Statin users and control participants were recruited from May 10 2015 to February 17 2017 through a cardiovascular health centre and from the general community. Cross-sectional area of the Achilles tendon and longitudinal collagen organization (% type I echoes) were assessed using quantitative ultrasound tissue characterization by a blinded observer at a predetermined location (2 cm proximal to the calcaneus).ResultsSixty-six individuals who were either taking statins for at least one year (ST, n = 33) or a comparison group who had never taken statins (CG, n = 33) were included in the study. The Achilles tendon cross-sectional area (ST 59.7 (13) mm2, CG 59.9 (8.5) mm2) and proportion of echo-type I patterns [ST 70 (10)%, CG 74 (13)%] were equivalent in the two groups. In contrast, there was a negative correlation between BMI (rs = -0.25, p = 0.042) and type I echo values. Obese individuals demonstrated a significantly lower percentage of type I echoes (62 (11)%) than individuals of normal body mass index (73 (10)% p<0.05).ConclusionThese findings demonstrate that there is no evidence of a negative statin influence on Achilles tendon structure. Given earlier reports that the risk of Achilles injury is equivalent in statin users and non-users, weightbearing exercise may be prescribed without placing the Achilles tendon at a higher risk of injury than among the general population. The results of this study are consistent with the known negative effects of elevated BMI on tendon structure, suggesting that an assessment of the Achilles tendons prior to prescribing weightbearing exercise may be prudent in obese individuals.

Endoscopic Achilles Tendon Augmentation With Suture Anchors After Calcaneal Exostectomy in Haglund Syndrome.

Haglund syndrome is a common cause of heel pain. Risk for tendon detachment after calcaneoplasty can exist. Open Achilles tendon detachment, calcaneoplasty, bursectomy, pathologic tendon-tissue debridement, and tendon reattachment of the Achilles tendon is a common surgical management of Haglund syndrome combined with insertional Achilles tendinopathy. The aim of this study was to describe the endoscopic calcaneoplasty and anchor suture augmentation of the Achilles insertional area, and the results obtained in patients with an increased risk of Achilles tendon rupture after calcaneoplasty. Between 2012 and 2015, endoscopic calcaneal ostectomy and suture anchor augmentation was performed in 12 patients. Mean age was 44.8 years (range, 35-52 years), and mean follow-up was of 33.5 months (range, 21-46 months). The mean AOFAS score increased from 70 preoperatively (range, 55-85) to 92 (range, 63-100) at final follow-up. The mean VISA-A questionnaire increased from 34 preoperatively (range, 15-63) to 92 (range, 30-100) at follow-up. No major complications were reported. All patients returned to their daily activities without limitations, but 2 described complaints with sports activity. Endoscopic calcaneoplasty and tendon augmentation with suture anchor for the treatment of Haglund syndrome was a reproducible and safe technique that offered the advantages of the endoscopic technique. Level IV, retrospective case series.

The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States.

Introduction. Disorders of the Achilles tendon can be broadly classified into acute and chronic entities. Few studies have established chronic Achilles tendinopathy as a precursor to acute Achilles ruptures. In this study, we assessed the relationship between Achilles tendinopathy and rupture, clarifying the incidence of rupture in the setting of underlying tendinopathy. Methods. The United Healthcare Orthopedic Dataset from the PearlDiver Patient Record Database was used to identify patients with ICD-9 codes for Achilles rupture and/or Achilles tendinopathy. The number of patients with acute rupture, chronic tendinopathy, and rupture following a prior diagnosis of tendinopathy was assessed. Results. Four percent of patients with an underlying diagnosis of Achilles tendinopathy went on to sustain a rupture (7,232 patients). Older patients with tendinopathy were most vulnerable to subsequent rupture. Conclusions. The current study demonstrates that 4.0% of patients who were previously diagnosed with Achilles tendinopathy sustained an Achilles tendon rupture. Additionally, older patients with Achilles tendinopathy were most vulnerable. These findings are important as they can help clinicians more objectively council patients with Achilles tendinopathy.

Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle?

The purpose of the study is to explain the cause-effect relationship in three patients who reported combined ruptures of the Achilles tendon and the gastrosoleus complex 6 months after they had received corticosteroids injections for the management of retrocalcaneal bursitis. Three cryopreserved cadavers (three men, three left legs) were examined to assess the anatomic connection between the retrocalcaneal bursa and the Achilles tendon (distal and anterior fibers). Blue triptan medium contrast was injected. An unexpected connection between the retrocalcaneal bursa and the anterior fibers of the Achilles tendon was found in all instances. Local corticosteroid injection of the retrocalcaneal bursa may help the symptoms of retrocalcanear bursitis, but pose a risk of Achilles tendon rupture. This risk-benefit has to be taken into account when corticosteroid injections are prescribed to professional and high-level athletes.

Could Low Total and Free Testosterone Levels be risk factor for Achilles Tendon Ruptures in Males

Objectives:Age related decline in sex hormone levels has been associated with decreased muscle mass, bone density, and changes in metabolism in both males and females[1-3]. Although the effect of estrogen levels on tendon size and architecture has been studied in females [4,5], the influence of testosterone levels on tendons in males is unknown. The purpose of the present study was to retrospectively compare free testosterone (FT) and total testosterone (TT) level in males diagnosed with Achilles tendon rupture and healthy normal historical data as a means of evaluating if decreased sex hormone level is a risk factor for tendon injury. We hypothesized males diagnosed with Achilles tendon ruptures will have lower FTand TT levels than age-matched normal levels in the literature.Methods:22 males diagnosed with Achilles injury that had their FT (nmol/L) and TT (nmol/L) levels measured as part of their initial clinical evaluation were retrospectively identified. The FT and TT levels of these injured men were directly compared to age matched historical data [5-7]. The mean FT and TT levels, and 95% confidence intervals were then compared. The difference of means was reported as statistically significant if the confidence interval for the difference in means test did not include zero.Results:Six males age 24-33, ten age 34-43, four age 44-53 and two males age 54-63 had FT and TT levels recorded as part of their care. For each age group, the mean FT and TT levels of males with Achilles tendon rupture were lower than the respective age-matched normal controls reported in the literature. Males in their 30s, 40s and 50s had statistically significant lower FT and TT levels compared to normal controls in the literature (Figure 1a, b, * indicates difference of means test statistically significant, P<0.05). The variability in males in the 20s, and the smaller sample size in our case cohort did not allow us to detect differences for males in third decade of life. Males between age 34-43 had largest difference in means compared to historical data.Conclusion:Our study showed the average FT and TT levels of males with Achilles tendon rupture were lower than corresponding age-matched historical data for each age group. Males in their 30s, 40s and 50s had statistically significant lower FT and TT levels compared to normal controls in the literature. Past studies have shown there is an increased incidence of Achilles tendon rupture for males during this same decade of life [8]. Overall, we believe our findings suggest low hormone levels maybe associated with the risk of Achilles tendon rupture. The main limitation of this retrospective study design is fact that the FT and TT levels were not redrawn to account for the impact of injury on these hormone levels. Future studies will be repeated with larger sample size, and include albumin and sex-binding globulin levels to help adjust for other biological factors that may influence these measures. Cited1.Tenover. Testosterone and the aging male. Journal of andrology, 1997. 2. Clarke. Archives of biochemistry and biophysics, 2010. 3.Figueroa. The journals of gerontology. Series A, Biological sciences and medical sciences, 2003 4.Cook.Scandinavian journal of medicine & science in sports, 2007. 5.Finni. Journal of applied physiology, 2009 6.Mohr.Clinical endocrinology, 2005. 7.Vermeulen.The Journal of clinical endocrinology and metabolism, 1996. 8. Halmenschlager. International urology and nephrology, 2012.

Four consecutive cases of Achilles tendon disorders associated with levofloxacin treatment in hemodialysis patients

To the Editor Quinolone-induced tendon injury is an uncommon complication with an estimated rate of only 0.14–0.4 % in an otherwise healthy population [1]. However, an epidemiologic study clearly showed that current exposure to quinolone increased the risk of Achilles tendon rupture (adjusted odds ratio 4.3) [2]. Although the mechanism by which quinolones are thought to cause tendon injury has not been established, a number of suggestions, including an ischemic vascular process, direct toxicity to the collagen, oxidative damage, and the structure activity of the quinolone molecule, have been made [1]. Moreover, there is an accumulation of case reports related to quinolone use in patients with renal impairment, including a case described in Clinical and Experimental Nephrology [3]. Renal transplantation, advanced age, renal failure and/or hemodialysis (HD), hyperparathyroidism, rheumatic diseases, gout, and use of corticosteroids have been proposed as predisposing factors [1]. It is of particular interest to nephrologists that patients with end-stage renal diseases are prone to these conditions. We herein report four cases of Achilles tendon disorders following levofloxacin administration in HD patients that occurred in a 2-year period from May 2009 to May 2011 at our hospital. The clinical characteristics of the patients are summarized in Table 1. On careful examinations by an orthopedist, rupture was not evident in any of cases. In consideration of the following clinical courses, bilateral tendonitis was the most likely disorder. All were undergoing thrice-weekly HD and received oral levofloxacin administration: patient 1 at a daily dose of 200 mg (twice a day) and the other three patients at 500 mg on the first day and then 250 mg every 48 h according to the revised dose for patients with severe renal impairment. In Japan, the regimen for levofloxacin was revised in 2009 in this manner, with the intention of enhancing efficacy and avoiding bacterial resistance based on pharmacokinetics and pharmacodynamics [4]. Thus, it is intriguing that we experienced four consecutive cases of Achilles tendon disorders in patients taking a relatively high dose of levofloxacin in this transition period. These observations implicate dose dependency and reduced drug clearance in the development of the tendon disorder, in support of previous reports [1, 2]. Incidentally, levofloxacin was prescribed simply because of the availability at our facility. In fact, other quinolones such as pefloxacin, ciprofloxacin, and norfloxacin accounted for the greater proportions of quinolone-associated tendinopathy in a literature review [1]. Second, the manifestations emerged shortly after administration, within a couple of days in most cases, and completely disappeared 2–4 months later without requiring hospitalization or surgery. Consistent with our experience, Khaliq et al. [1] documented that 50 % of tendonitis cases occurred within 6 days after initiation of fluoroquinolone therapy, during the time when the antimicrobial therapy might still be in effect. Interventions included discontinuation of the drug in the majority of cases [1]. Similarly, levofloxacin was presumptively discontinued in three of our patients, and in patient 1 medication had already ceased at the time of onset because of resolution of the infectious disease. Magnetic resonance imaging was performed only in the latest case (patient 4) with reference to an Images in S. Takeda T. Imai Y. Chaki Dialysis Center, Oyama Municipal Hospital, 1-15 Wakagi-cho, Oyama, Tochigi, Japan

Use of fluroquinolone and risk of Achilles tendon rupture: a population-based cohort study

Several case-control studies have reported that the use of fluoroquinolone increases the risk of rupture of the Achilles tendon. Our aim was to estimate this risk by means of a population-based cohort approach. Data on Achilles tendon ruptures and fluoroquinolone use were retrieved from three population-based databases that include information on residents of Funen County (population: 470,000) in primary and secondary care during the period 1991-1999. A study cohort of all 28,262 first-time users of fluoroquinolone and all incident cases of Achilles tendon ruptures were identified. The incidence rate of Achilles tendon ruptures among users and non-users of fluoroquinolones and the standardised incidence rate ratio associating fluoroquinolon use with Achilles tendon rupture were the main outcome measures. Between 1991 and 2002 the incidence of Achilles tendon rupture increased from 22.1 to 32.6/100,000 person-years. Between 1991 and 1999 the incidence of fluoroquinolone users was 722/100,000 person-years, with no apparent trend over time. Within 90 days of their first use of fluoroquinolone, five individuals had a rupture of the Achilles tendon; the expected number was 1.6, yielding an age- and sex-standardised incidence ratio of 3.1 [(95% confidence interval (95%CI): 1.0-7.3). The 90-day cumulative incidence of Achilles tendon ruptures among fluoroquinolone users was 17.7/100,000 (95%CI: 5.7-41.3), which is an increase of 12.0/100,000 (95%CI: 0.0-35.6) compared to the background population. Fluoroquinolone use triples the risk of Achilles tendon rupture, but the incidence among users is low.

Increased risk of achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids.

In several case reports, the occurrence of Achilles tendon rupture has been attributed to the use of quinolones, but the epidemiologic evidence for this association is scanty. We conducted a population-based case-control study in the General Practice Research Database in the United Kingdom during the period 1988 through 1998. Cases were defined as all persons who had a first-time recording of an Achilles tendon rupture, and who had at least 18 months of valid history before the index date. As a control group, we randomly sampled 50 000 patients with at least 18 months of valid history who were assigned a random date as index date. We identified 1367 cases that met the inclusion criteria. The adjusted odds ratio (OR) for Achilles tendon rupture was 4.3 (95% confidence interval [CI], 2.4-7.8) for current exposure to quinolones, 2.4 (95% CI, 1.5-3.7) for recent exposure, and 1.4 (95% CI, 0.9-2.1) for past exposure. The OR of Achilles tendon rupture was 6.4 (95% CI, 3.0-13.7) in patients aged 60 to 79 years and 20.4 (95% CI, 4.6-90.1) in patients aged 80 years or older. In persons aged 60 years and older, the OR was 28.4 (95% CI, 7.0-115.3) for current exposure to ofloxacin, while the ORs were 3.6 (95% CI, 1.4-9.1) and 14.2 (95% CI, 1.6-128.6) for ciprofloxacin and norfloxacin, respectively. Approximately 2% to 6% of all Achilles tendon ruptures in people older than 60 years can be attributed to quinolones. Current exposure to quinolones increased the risk of Achilles tendon rupture. The risk is highest among elderly patients who were concomitantly treated with corticosteroids.