Muscular Vein Thrombosis Prior to Immobilization in Tendo Achilles Rupture: A Previously Unrecognized Association

CATEGORY: DTV prophylaxis INTRODUCTION/PURPOSE: Thromboembolic complications during lower-limb immobilization after Achilles tendon ruptures are common. Both operative and nonoperative treatments of Achilles tendon rupture include a period of immobilization which is a well-documented risk factor for distal vein thrombosis (DVT). The term DVT refers to the anterior/posterior tibial or the peroneal veins, and comprise the deep venous system. More recently, the role of muscular vein thrombosis (MVT) or isolated gastrocnemius or soleus vein thrombosis has been reported. However, there is no report of MVT associated with Achilles tendon rupture either before or after the initiation of treatment. We present a prospective series of patients treated for a rupture of the Achilles tendon and who were all evaluated with ultrasound for diagnosis of venous compromise prior to initiation of treatment. METHODS: 21 patients who consecutively presented for treatment for an Achilles tendon rupture at the emergency department were included. All patients sustained the injurie while playing some kind of sport. 20 of 21 patients were male, and their average age was 48.8 years (range 34 to 62 years). Our prospective protocol included a routine ultrasound prior to the initiation of treatment to identify the location of the Achilles tendon rupture and simultaneously, a color Doppler ultrasound. Upon diagnosis, all patients were immobilized in an equinus cast while waiting for definitive treatment. Patients were treated either non operatively if a diagnosis of DVT was made, or with percutaneous surgical treatment in the absence of DVT. Upon DVT diagnosis patients were enrolled in a four week LWMH at curative doses therapy supervised by our team hematologist, in order to obtain an international normalized ratio (INR) of between 2 and 3. RESULTS: Nine in the group of twenty one patients (42%) were diagnosed with a DVT in the Doppler ultrasound prior to the initial immobilization. In six of the nine patients diagnosed with a distal vein thrombosis thrombi was allocated in the muscular veins, two of the nine in the gastrocnemius veins and the remaining one in one of the posterior tibial vein. All of the patients had some kind of comorbidity, however only three of them had risk factors previously associated with the occurrence of distal vein thrombosis. In our evaluated cohort there were no cases of progression to pulmonary embolism (PE). CONCLUSION: To the authors knowledge this is the first publication that links the MVT diagnosis to the moment previous to the immobilization in Achilles tendon rupture. It is our perspective that although not well stablished there is at least a theoretical risk of further propagation to the profound venous system and subsequently to the pulmonary system, and this fact not only conditions the treatment of MVT itself, but also the treatment of the Achilles rupture. Clearly this is just a speculative concept and further evidence needs to be gathered in order to have a better understanding.