Abstract
Background
Although differences in Achilles tendon injuries have been described based on sex and ethnicity, their impact on surgical presentation patterns and outcomes remains underreported. This study aims to compare demographics and complications between patients who underwent surgery for acute Achilles tendon rupture with those for chronic tendinopathy. All patients were operated by a single surgeon in a metropolitan region in the western United States between June 2016 and June 2022.
Methods
A retrospective review of a prospectively collected data was conducted. Data included age, sex, ethnicity, surgical indication, return to activity (RTA), and complications (re-rupture, infection, suture reaction, venous thromboembolism). Statistical analyses included Student’s t-test and Fisher’s exact/Chi-square test, with a significance set at P <.05.
Results
A total of 186 patients (121 males, 65 females; mean age: 47.5 ± 14.6 years) were included. Males were significantly more likely to undergo surgery for acute Achilles tendon repair (93 males, 5 females; P <.0001). Females were more likely to undergo surgery for chronic Achilles tendon pathology (76 %). There were no significant sex-based differences in complications or return to activity. There were variations in ethnicity, with Asian patients having a higher likelihood of acute tendon repair (87 %) whereas White patients were more likely to undergo surgical intervention for chronic tendinopathy (89 %; P <.00001).
Conclusion
Males were significantly more likely to have operative intervention for acute Achilles rupture, while females more often underwent surgery for chronic tendinopathy. There were ethnic differences in presentation patterns. Complication rate postoperatively and return to activity following surgical intervention did not vary between sex or ethnicity.
Level of evidence
III; Retrospective comparative study
1
Introduction
Racial and gender differences in acute and chronic Achilles tendon ailments have been poorly studied. Acute Achilles tendon ruptures occur from a rapid acceleration or forced dorsiflexion of a plantarflexed ankle , , and are more commonly seen in sports such as basketball, football, racquet sports, and running , . Acute Achilles tendon ruptures are 2–8 times more common in male athletes compared to female . As more women are competing at higher levels in sports involving jumping and rapid accelerations, one would expect the gender gap to narrow , . However, men have thicker, less compliant Achilles tendons, which may explain the higher incidence of acute rupture . Women experience these chronic injuries more commonly, with poorer outcomes and higher complication rates post intervention compared to acute ruptures , .
Gender differences exist in other orthopedic conditions as well. For example, anterior cruciate ligament tears are significantly more frequent in female athletes compared to their male counterparts, at a 4.5:1 ratio , . The reasons for this are multifactorial, but one is landing biomechanics, with increased knee valgus when landing in female athletes . Women are less likely to undergo surgery for acute Achilles ruptures (63 %) compared to men (83 %) . Two studies on chronic Achilles surgery showed differences in return to activity, with females being slower , .
Racial differences in Achilles tendon ruptures have been studied even less. In the military population in the United States, two studies demonstrated a higher incidence of Achilles tendon ruptures in Black individuals but was not the case in the United States population at large ,, .
The purpose of this study is to assess whether there are differences between biological gender and ethnicity within a cohort of acute Achilles rupture repair patients versus chronic Achilles surgery patients from a single surgeon’s practice, along with differences of specific complications.
2
Methods
A cross sectional retrospective review of a prospective database of Achilles tendon surgery was performed. IRB approval was obtained to evaluate Achilles tendon surgery patients from a single surgeon’s practice (this approach allowed to control surgeon variability in technique and protocol). Patients from a metropolitan region in the western United States were prospectively followed from June of 2016 through June of 2022. All operations were performed by one single surgeon. In 2020, the reported ethnic breakdown of the region was: White 36 %, Asian 28 %, Hispanic 24 %, and Black 6 % 1. Patients’ demographic information, biological sex and gender identity, ethnicity, type of Achilles surgery (procedure), ability to return to activity (RTA) were recorded in Excel (Microsoft™ Redmond, WA USA). Ethnicity was documented as Asian (“A”), Black (“B”), Hispanic (“H”) or White (“W”). Mixed race was identified (“M”) but not broken down into specific ethnicities. In addition, complications were recorded and analyzed for differences seen with gender and ethnicity for incidence of re-rupture, infection, suture reaction, VTE (PE or DVT). Other aspects of Achilles tendon surgery were not evaluated as that information is reported for some of the cohort in separate studies. Patients were excluded if the information above was not available. Data were analyzed with Students’ T-test and Fisher’s Exact/Chi-squared, p-value P < 0.05, using STAT SAK (Andover, MA USA).
3
Results
A total of 186 patients were included in the study; all patients identified with their biological sex (cis gender) and met inclusion criterion for the study period. There were 65 females and 121 males included, with an average age of 47.5 ± 14.6 years. There were an equal number of limbs involved (93 each). There was no difference between the ages of females versus males, 49.0 ± 13.8 versus 46.8 ± 15.0 years (95 % CI −2.2–6.6, P =.32), respectively. There was an equal number of complications between the sexes with one infection and one suture reaction in each group (P =.60). All patients were able to return to activity, though some patients electively decided not to fully return to the inciting sport, three females versus two males, (P =.34).
There were 98 patients with acute Achilles tendon ruptures and 88 with chronic Achilles tendon tears. Males comprised 61 % of this cohort and were more likely to have acute rupture surgery, 93 males versus 5 females, P <.0001. Females with Achilles surgery were a predominantly chronic (non-acute) cohort, 49 out of 65, (76 %). Table 1 , Figs. 1 and 2 summarize the differences between males and females.
Table 1
Comparison of males and females undergoing surgery for acute Achilles tendon ruptures versus chronic Achilles tendon tears.
| Category | Males | Females | P-Value |
|---|---|---|---|
| Total Patients | 121 | 65 | – |
| Acute Ruptures | 93 | 16 | <.0001 |
| Chronic Tears | 28 | 49 | <.0001 |
Achilles tendon surgeries in males for acute rupture versus chronic tendinopathy.
Percentage of Achilles tendon surgeries in females for acute rupture versus chronic tendinopathy.
There was no difference in age between non-white ethnicity (n = 47) and white patients (n = 139), 44.7 ± 12.9 versus 48.5 ± 15.1 years (95 % CI −8.7–1.0, P =.12), respectively. Whites comprised 74.7 % of the total cohort. Asians comprised the highest number (n = 36) of the non-white cohort (n = 47), 76.6 %, and 19.4 % of the overall Achilles surgeries, followed by Hispanic (n = 7), Black (n = 3) and one Mixed. Whites were more represented in the chronic Achilles surgery cohort, 89 % (P <.00001). Non-whites had a higher incidence of acute rupture than chronic surgery 80.8 % versus 19.2 % of whites. Asians predominantly underwent surgery for acute rupture, 31 out of 36 (87 %). Table 2 , Figs. 3 and 4 summarize the differences in ethnicities. The ethnicities evaluated in this study are shown in Table 3 and Fig. 5 . Runners comprised most of the chronic surgery cohort (n = 52),59.1 %. Basketball was most frequent inciting sport activity for acute rupture(n = 34), 34.7 %.
Table 2
Comparison of White versus Non-White patients undergoing Achilles tendon surgery.
| Category | White | Non-White | P-Value |
|---|---|---|---|
| Total Patients | 139 | 47 | – |
| Age (years, mean ± SD) | 48.5 ± 15.1 | 44.7 ± 12.9 | 0.12 |
| % of Total Cohort | 74.70 % | 25.30 % | – |
| Acute Rupture | 27 | 38 | <.0001 |
| Chronic Tear | 112 | 9 | <.0001 |
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