Management of TendoAchillis rupture

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  • 1. Presenter: Dr. Ankur Mittal
  • 2. Diagnostic Tests •Xrays •Ultrasound •MRIImaging is rarely necessary in acute cases, but MRI or US may be helpful in the chronic cases for diagnosis and surgical planning.Ultrasound most often used for determining the thickness of the tendon and the size of the gap on a complete rupture; requires skilled / experienced hands.MRI is more expensive and has its best place in diagnosing incomplete tears and for diagnosis of and planning surgical treatment for chronic tears.
  • 3. Imaging X-rays  Indicated if fracture or avulsion fracture suspected
  • 4. KAGER’S TRIANGLE
  • 5. Imaging Ultrasound  Inexpensive, fast, reproducable, dynamic examination possible  Operator dependent  Best to measure thickness and gap  Good screening test for complete rupture
  • 6. Longitudinal sonogram shows a partial-thickness tear or tendinosis that was confirmed with surgical findings in a 49-year-old woman with chronic pain in the Achilles tendon. Hartgerink P et al. Radiology 2001;220:406-412©2001 by Radiological Society of North America
  • 7. Longitudinal sonogram shows a full-thickness tear, confirmed with surgical findings, in a 40- year-old man. Hartgerink P et al. Radiology 2001;220:406-412©2001 by Radiological Society of North America
  • 8. Imaging MRI  Expensive, not dynamic  Better at detecting partial ruptures and staging degenerative changes, (monitor healing)
  • 9. ACUTE ACHILLES TENDON RUPTUREHEALTHYACHILLESTENDONCHRONICACHILLESTENDONRUPTURE
  • 10. Management Goals Restore musculotendinous length and tension. Optimize gastro-soleous strength and function Avoid ankle stiffness
  • 11. TREATMENTAcute and Chronic Achilles Tendon Ruptures Chronic Ruptures >4-6 weeks since time of initial injury Acute Ruptures Operative repair versus nonoperative protocol Options Techniques Results Complications Rehabilitation
  • 12. ACUTE RUPTURES Treatment Controversial topic  Lack of defined universally accepted outcome measures  Multitude of different reparative techniques  Diverse range of postoperative protocols Closed treatment was widely accepted as the standard of care in the early 20th century Operative repair has gained popularity in recent decades
  • 13. Nonoperative Treatment Initial period of immobilization in equinus short leg non-weight bearing cast or splint for 2 weeks  Then convert to short leg walking cast or walking boot Boot or cast is typically worn for 6-8 weeks  Gradual return to neutral ankle position over this time period Gentle ROM exercises begin after 6-8 weeks immobilization 2-cm heel lift used during this transition period Progressive-resistance exercises begun for calf muscles at 8-10 weeks Goal is return to running at 4-6 months and near normal power at 12 months
  • 14. Essential principles of conservative management — immobilisation in equinus had to be maintained for a full 8weeks and for a further month the patient should walk with theshoe heel raised.The likelihood of rerupture was increased if the period ofimmobilisation was shortened.
  • 15. Operative Treatment  Direct primary repair  End-to-end repair  Bunnell suture with modified Kessler technique  Interlocking suture technique  Augmented repair  Fascial turn-down  Plantaris tendon augmentation  Peroneus brevis augmentation  Percutaneous repair (sural nerve entrapment)
  • 16. CHRONIC RUPTURES TreatmentBasic tenets of reconstruction 1. Restore optimal length, strength, and function 2. Reconstruct the gap with appropriately strong tissueNon-Operative TreatmentLimited indications Medically ill, household ambulatorsTreat with spring-loaded hinged AFO
  • 17. Chronic Rupture Reconstruction  Turn-down flaps  V-Y plasty  Turn-down flap  Tendon transfer  FHL  FDL  Peroneus Brevis  Artificial materials
  • 18. Operative Treatment Defects of 1 cm or less Direct repair without augmentation (rarely feasible) Defects 1 - 2 cm Muscle mobilization augmentation (plantaris) Can gain up to 2 cm with mobilization Defects 2 - 5 cm No consensus on best reconstruction technique Flexor hallucis longus (FHL) tendon transfer FHL second strongest ankle plantar flexor FHL contractile axis most closely approximates Achilles tendon Other transfers, to include flexor digitorum longus (FDL) or peroneal brevis tendons V-Y myotendinous lengthening FHL transfer
  • 19. Defects > 5 cm V-Y myotendinous lengthening FHL transfer or other augmentation Turndown procedure augmentation Requires at least 1-cm wide strip of Achilles tendon Length of strip must be long enough to span 2 cm above and 2 cm below the defect Massive incision required Bulk of residual tissue at turndown junction may become symptomatic Synthetic materials (Marlex / Dacron) Mixed results; longterm durability questionable Potential for wound healing complications
  • 20. Surgery or Not ? Taylor your treatment to the patient
  • 21. Surgery or Not ? Repair is stronger Less risk of re-rupture Earlier return to activity Open or percutaneous
  • 22. Surgical Management Preserve anterior paratenon blood supply Beware of sural nerve Debride and approximate tendon ends Use 2-4 stranded locked suture technique May augment with absorbable suture Close paratenon separately
  • 23. Many different techniques of surgical repair have been described however which byitself suggests that there may be difficulties.One of these is that when spontaneous rupture occurs the tendon is frequentlydegenerate and the torn ends can be ragged and not ideal for a neat suture.The loads transmitted through the Achilles tendon are so great that even themost perfect suture cannot be relied upon until healing is advanced and thereforethe repair must be supplemented by some method of splintage for severalweeks as in conservative management.
  • 24. It has been known for many years that tendons which are ruptured or dividedoutside synovial sheaths have a strong tendency to undergo spontaneous repair.The collagen fibres in the scar which grows between the ends becomesorganised and orientated to resemble closely the structure of tendon.Provided the tendon ends are held in close appositionthis natural repair will occur without lengthening and virtually normal functioncan be restoredsuccessful method of treatment which involved bandaging the calf and raising theheel of his shoe for a few weeks with excellent recovery.If the divided ends of the tendon are allowed to retract, healing will still take place butwith lenthening and consequent loss of power in the affected muscles.
  • 25. Suture MaterialA variety of satisfactory suture materials are available for tendon repairBUTIn clinical situations, most surgeons find that the braided polyester sutures(Ethibond,Dacron,Ticron, Mersilene) provide sufficient resistance to disruptingforces and gap formation, handle easily, and have satisfactory knotcharacteristics; consequently these sutures are widely used
  • 26. Surgical Management Bunnell Suture Modified Kessler Many techniques available
  • 27. A, Conventional Bunnell stitch. B, Crisscross stitch. E, Modified Kessler stitch with singleknot at repair. F, Tajima modification of . C, Mason-Allen (Chicago) stitch. D,Kessler stitch with double knots at Kessler grasping stitchrepair site.
  • 28. Techniques for acute Achilles tendon ruptureKrackow suture
  • 29. Lindholm devised a method of repairing ruptures of the Achilles tendonthat reinforces the sutures with living fascia and prevents adhesion of therepaired tendon to the overlying skin Lindholm technique for repairing ruptures of Achilles tendon
  • 30. Lynn described a method of repairing ruptures of the Achilles tendon in whichthe plantaris tendon is fanned out to make a membrane 2.5 cm or greater widefor reinforcing the repair. The method is useful for injuries less than about 10days old; later the plantaris tendon becomes incorporated in the scar tissue andcannot be identified easily. Lynn technique for repairing fresh rupture of Achilles tendon. A, Ruptured Achilles tendon has been sutured, and plantaris tendon has been divided distally and is being fanned out to form membrane. B, Fanned-out plantaris tendon has been placed over repair of Achilles tendon and sutured in place
  • 31. Teuffer described a method to be used when the possibility of end-to-endsuture of a ragged tendon is remote. His method uses the peroneus brevistendon as a dynamic transfer and a reinforcing tendon graft. Dynamic loop suture of peroneus brevis to itself when end-to-end suture is impossible
  • 32. Turco and Spinella described a modification in which the peroneus brevis ispassed through a midcoronal slit in the distal stump of the Achilles tendon. Thegraft is sutured medially and laterally to the stump and proximally to the tendonwith multiple interrupted sutures to prevent splitting of the distal tendon stump(Fig. 46-15). This modification can be beneficial if a long distal stump is present. Turco and Spinella modification. Peroneus brevis is passed through midcoronal slit in distal stump of Achilles tendon and sutured to stump and to tendon.
  • 33. Surgical: Percutaneous Ma and Griffith  6 stab incisions  Less wound complications  Injury to sural nerve  Not anatomic  Tension hard to establish Guided instruments
  • 34. Techniques for neglected rupture of Achilles tendon . A, Exposure of Achilles tendon and tuberosity through posterolateral incision. Peroneus brevis is passed through hole drilled in tuberosity and sutured to Achilles tendon. B, Plantaris tendon is passed through ruptured ends of tendon.
  • 35. Bosworth technique for repairing oldruptures of Achilles tendon
  • 36. V-Y repair of neglected rupture of Achilles tendon. A, Incision.B, Design of V flap. C, Y repair and end-to-end anastomosis
  • 37. Repair of chronic Achilles tendonrupture with flexor hallucis longus. A,Two incisions are made. Medial midlineincision on midfoot is used to harvestflexor tendon. Posteromedial incisionanterior to Achilles tendon is used toexpose tendon. B, Hole is drilled justdeep to Achilles tendon insertion and isdirected plantarward. Second drill holeis made from medial to lateral tointersect first drill hole midway throughposterior body of calcaneus. C, Flexorhallucis longus is woven throughremaining portion of Achilles tendon tosecure fixation and supplementation oftendon.
  • 38. TURN DOWN FLAP
  • 39. Turn down flap Artificial material
  • 40. Percutaneous vs. Open Less wound complications  Lim et al.  33 patients General Consensus: Perc  7 infections Higher re-rupture rate Less wound complications  Wong et al. Better cosmesis  367 repairs  12% re-rupture  Bradley General Consensus: Open  12% perc vs. 0% open Greater Strength Return to preinjury level  Cetti Decreased calf atrophy  111 patients Better motion Less re-rupture
  • 41. POST OP COMPLICATIONS•deep infection (1%)• fistula (3%)• skin necrosis (2%),• rerupture (2%).
  • 42. Post- Op CareCast applied in OR Remove sutures, apply a 2 wks walking cast with heel lift Touch WB 2 weeks Start physio for ROM Allow progressive weight- exercises. No active bearing in removable cast plantarflexion When WBAT and 2- 4 weeks foot is plantigrade Start a strengthening Remove cast and walk with a program 1cm shoe lift x 1 month
  • 43. Rehabilitation Physical Therapy  Stretching and flexibility exercise are key to helping tendon heal without shortening and becoming chronically painful.  Ultrasound heat therapy improves blood circulation, which may aid the healing process.  Transcutaneous electrical nerve stimulation (TENS) is sometimes used and may provide pain relief for some people.  Massage helps you increase flexibility and blood circulation in the lower leg and can help prevent further injury.  Wearing a night brace keeps your leg flexed and prevents your Achilles tendon from tightening while you sleep. An Achilles tendon that chronically tightens at night is not able to heal properly.
  • 44. Post Surgery Rehabilitation Phase I- PWB(partial weight bearing) beginning 4 weeks post-op  Gait training (wean from heel lift after 2 weeks if applicable) Soft tissue massage and/or modalities as needed Exercises:  Towel calf stretch (without pain)
  • 45. Theraband exercises – dorsi andplantar flexion, inversion, eversion
  • 46. Sitting calf raises BAPS(Biomechanical ankle platform system Straight leg raises BAPS (Biomechanical ankle platform system) in sitting Bike light if ROM (range of motion) allows May perform pool ex’s also The patient may do this mainly as an independent program if appropriate Progress to Phase II when: -tolerates all Phase I without pain or significant increase in swelling -ambulates FWB (full weight bearing) without device -ROM for plantar flexion, inversion and eversion are normal -dorsi flexion is at approximately neutral
  • 47. Post Surgery Rehab Phase II (6-8 weeks post op)  Gait training Soft tissue work and/or modalities as needed Exercises:  Standing gastroc and soleus stretches Bike light to moderate resistance as tolerated Leg press:  quads bilateral to unilateral  calf raises (sub-maximal bilateral to unilateral)  Sitting calf raises to standing at (generally 8-10 weeks) BAPS(Biomechanical ankle platform system) board standing (with support as needed)
  • 48. Step upsStep downsUnilateral stance; balance activities with challenges if appropriate (suchas ground clock)Mini-squats – bilateral to unilateralStairmaster – short steps 4", no greater than level 4 if no pain orinflammationMay continue pool if appropriate
  • 49. Post Surgery Rehab Phase III (generally not before 10-12 weeks)  Frequency at discretion of therapist Gait normal without device Standing calf raises to unilateral (generally 16 weeks) Outdoor biking Full/maximal one leg PREs [progressive resistance exercises] (generally at 16 weeks) Agility drills (generally not before 16-20 weeks. Should be discussed with physician first.) - jogging to running when pain-free -sport-specific; cutting, side shuffles, jumping, hopping
  • 50. Progress to Phase III when:-cleared by physician-can do each of Phase II activities without pain or swelling-ROM equal bilaterally-able to do bilateral calf raise without difficulty and weight equalbilaterally-unilateral stance balance equal bilaterally
  • 51. Return To Play After surgery an athlete should not return to play until they meet the criteria for progression to Phase III. Even after completing Phase III the athlete should return at the discretion of their doctor and/or physical therapist.
  • 52. • Prevention  Avoid activities that place excessive stress on your heel cords, such as hill-running and jumping activities (especially if done consistently).  If you notice pain during exercise, rest.  If one exercise or activity causes you persistent pain, try another.  Alternate high-impact sports, such as running, with low- impact sports, such as walking, biking or swimming.  Maintain a healthy weight.  Wear well-fitting athletic shoes with proper cushioning in the heels.
  • 53. Prevention To avoid reoccurrence of an Achilles tendon injury:  Use warm-up and cool down exercises and calf- strengthening exercises.  Apply ice to your Achilles tendon after exercise.  Alternate high-impact sports with low impact sports, so as not to overwork your Achilles tendons.
  • 54. SUMMARY Chronic Achilles tendon rupture Operative treatment when possible Acute Achilles tendon rupture  Operative treatment for the young athletic higher demand patient  Closed treatment for those patients with limited functional goals or medical comorbidities  Results for both options similar Functional rehabilitation when possible