Tendoachilles rupture and its management

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Achilles tendon is the strongest tendon of body. There are many causes of its rupture. It can be acute or chronic rupture. Management of chronic rupture by semitendinosus tendon is mentioned here.

Achilles tendon is the strongest tendon of body. There are many causes of its rupture. It can be acute or chronic rupture. Management of chronic rupture by semitendinosus tendon is mentioned here.

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  • Watershed area 4cm proximal tocalcanealtuberosity
  • FHL: second strongest ankle plantar flexorIts contractile axis most closely approximates Achilles tendonBut loss of great toe flexion(Not acceptable in Athletes)


  • 1. TENDOACHILLES RUPTURE: MANAGEMENT Dr Rohan Vakta M.S.Ortho AASH Arthroscopy Center Ahmedabad,India
  • 2. Anatomy  Largest tendon in the body  Origin from gastrocnemius and soleus muscles  Insertion on calcanealtuberosity
  • 3. Physiology  Remarkable response to stress Exercise induces increase in tendon diameter  Inactivity causes rapid atrophy  Age-related decreases in cell density& collagen  Older athletes have higher injury susceptibility 
  • 4.  Gastrocnemius-soleus-Achilles complex  Acts on 3 joints Flexion of knee  Plantarflexion of tibiotalar joint  Supination of subtalar jt.   It can transmit up to 10 times body weight through tendon when running
  • 5. RISK FACTORS  Recreational athlete : Basketball , Volleyball , Rugby , Soccer [There may be a history of a recent increase in physical activity/training volume]  Age (30‐50 years)
  • 6. RISK FACTORS (CONT.) Obesity  Diabetes Mellitus  Previous tendon injury  Previous Steroid injections or fluoroquinolone use  Inustrial Accidents 
  • 7. Close Open Acute Neglected -Athletics injuries -Degenerative Injuries
  • 9. PATHOPHYSIOLOGY OF DEGENERATIVE TENDON INJURY  Repetitive microtrauma  Relatively hypovascular area.  Reparative process inadequate  Most ruptures occur in “Watershed area”  Antecedent tendinitis/tendinosis in 15%
  • 10. ATHLETIC INJURY Indirect : Eccentric force applied to a dorsiflexed foot ; Sudden unexpected dorsiflexion of ankle Direct : May occur as the result of direct trauma
  • 11. Acute  Feels like being kicked in the leg  Feeling of sudden Snap in the lower calf  Acute sever pain  Walk with a limp, unable to run, climb stairs, or stand on their toes  Loss of plantar flexion power
  • 12. DEGENERATED TENDON •Swelling , nodularity due to thickening and calcification •crepitation along the tendon sheath Partial tear :- fusiform swelling
  • 13. Physical Examination Prone patient with feet over edge of bed Normal TA Ruptured Tendon not Visible/Palpable Palpation of entire length of muscle-tendon unit during active and passive ROM
  • 14.  “Hyperdorsiflexion” sign – With the patient prone and knees flexed to 90º,maximal passive dorsiflexion of both feet may reveal excessive dorsiflexion of the affected leg  O’Brien needle test: insert a needle 10 cm proximal to the calcaneal insertion of the tendon. With passive dorsiflexion of the foot, the hub of the needle will tilt rostrally when the Achilles tendon is intact
  • 15. Imaging Avulsion fracture at the insertion , with marked separation of fragments.
  • 16. Kager’s Fat pad
  • 17.      Inexpensive fast, reproducable, dynamic examination possible Best to measure thickness and gap Good screening test for complete rupture
  • 18. MRI MRI ACUTE RUPTURE HEALTHY TENDON •Expensive, not dynamic •Better at detecting partial ruptures •Staging of degenerative changes, (monitor healing) CHRONIC RUPTURE
  • 19. Management Goals Optimize gastro-soleous strength and function Restore musculotendinous length and tension. Avoid ankle stiffness
  • 20. Conservative Management Controversial 2 wks CAM Walker or cast with plantarflexion at 2 wks 4 weeks Start physio for ROM exercises Allow progressive weightbearing in removable cast When WBAT and foot is plantigrade Start a strengthening program 2- 4 weeks Remove cast and walk with shoe lift. Start with 2cm x 1 month, then 1cm x1 month then D/C 40% Re-Rupture rate
  • 21. Surgical management Principles:  Preserve anterior paratenon bl. supply  Beware of sural nerve  Debride and approximate tendon ends  Use 2-4 stranded locked suture technique  Close paratenon separately
  • 22. Operative Treatment A: Defects of 1 cm or less Direct end to end repair without augmentation  Bunnell Suture  Modified  Many Kessler techniques available
  • 23. B: Defects 1 - 2 cm Muscle mobilization augmentation (plantaris) Can gain up to 2 cm with mobilization
  • 24. C: Defects 2 - 5 cm No consensus on best reconstruction technique  Semi-T tendon transfer  Flexor hallucis longus (FHL) tendon transfer loss of great toe flexion(Not acceptable in Athletes)  Others: FDL , Peroneus Brevis  V-Y myotendinous lengthening FHL transfer
  • 25. CASE OF TENDOACHILLES RUPTURE •M/28 •3 Months old injury •USG : 25 mm gap , 38 mm proximal to calcaneal tuberosity
  • 26. Surgical Technique Chronic rupture with fibrosed tissue
  • 27. Plantaris 5 cm GAP
  • 28. Semi-T Harvested
  • 29. Semi-T passed through the proximal Musculo-Tendinous junction
  • 30. Semi-T passed through Calcaneum
  • 31. SemiT fixed to calcaneum using IF Screw
  • 32. SemiT and Plantaris are sutured with distal & proximal TA using nonaborbable suture
  • 33. Cast in Equinus for 3 Weeks
  • 34. Defects > 5 cm SemiT Transfer V-Y myotendinous lengthening
  • 35. PERCUTANEOUS VS. OPEN  Less  wound complications Lim et al. 33 patients  7 infections   Higher  re-rupture rate Wong et al. 367 repairs  12% re-rupture   Bradley  Strength Cetti  Less wound complications Better cosmesis General Consensus: Open 12% perc vs. 0% open  Greater  General Consensus: Perc 111 patients Return to preinjury level Decreased calf atrophy Better motion Less re-rupture
  • 36. OPEN INJURY •Extensive debridement •Wound Care •Plastic Coverage And •Tendon Transfer
  • 37. POST OP COMPLICATIONS •Deep infection (1%) • Fistula (3%) • Skin necrosis (2%), • Rerupture (2%).
  • 38. Neither Patient nor the Surgeon want Second Surgery or Rerupture
  • 39. PREVENTION OF REINJURY •Good conditoning and proper stretching before running •Adequate warm‐up! •Adequate rehabilitation Wearing appropriate and properly fittng shoes during activites also should be stressed to all athletes
  • 40. SUMMARY  Chronic Achilles Operative tendon rupture 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  Functional rehabilitation when possible
  • 41. Pateients’ recovery depends largely on Their motivation , Focus & their desired postinjury activity
  • 42. THANK YOU