Bokaro General Hospital

1. TENDOACHILLES RUPTURE
By- Chandramani Roy

2.  Often misdiagnosed as an ankle sprai​n
• May be missed in up to 2​5% cases
• Epidemio​logy -inc​idence 18:100,000 p​er year
Demo​graphics -more comm​on in men
The Achilles tendon is a large band of fibrous
tissue in the back of the ankle that connects the
powerful calf muscles to the heel
bone (calcaneus)

3.  When the calf muscles contract, the Achilles
tendon is tightened, pulling the heel
 It is vital to such activities such
as walking, running, and jumping

4.  Largest tendon in the
body
 Origin from
gastrocnemius and
soleus muscles
 Insertion on calcaneal
tuberosity
Anatomy

5. Lacks a true synovial
sheath-
 Paratenon has visceral
and parietal layers
 Allows for 1.5cm of
tendon glide

6. Paratenon
 Anterior – richly vascularized
 The remainder – multiple thin
membranes

7. Blood supply
1) Musculotendinous junction
2) Osseous insertion on calcaneus
3) Multiple mesostenal vessels on
anterior surface of paratenon (in
adipose)
– Transverse vincula
 Fewest at 2 to 6 cm proximal to
osseous insertion

8. Remarkable response to stress
 Exercise induces increase in tendon
diameter
 Inactivity or immobilization causes
rapid atrophy
 Age-related decreases in cell density&
collagen fiber diameter and density
 Older athletes have higher injury
susceptibility
Physiology

9. 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

10. RISK FACTORS
 Recreational athlete : Basketball , Volleyball ,
, football
[There may be a history of a recent increase in physical
activity/training volume]
 Age (30‐50 years)

11.  Obesity
 Diabetes Mellitus
 Previous tendon injury
RISK FACTORS (CONT.)
 Previous Steroid injections or
fluoroquinolone use
 Inustrial Accidents
 Spoke wheel injury
 Injury in Bathroom

12. Acute
-Athletics
injuries
Neglected
-Degenerative
Injuries
CloseOpen

13. KUWADA CLASSIFICATION OF ACHILLES
TENDON TEAR
 This classification was proposed by Kuwada in 1990
 Achilles tendon tears may be grouped (according to
severity of the tear and degree of retraction) into 4 types:
 type I: partial ruptures ≤50%
 typically treated with conservative management
 type II: complete rupture with tendinous gap ≤3 cm
 typically treated with end-to-end anastomosis
 type III: complete rupture with tendinous gap 3 to 6 cm
 often requires tendon/synthetic graft
 type IV: complete rupture with defect of >6 cm
(neglected ruptures)
 often requires tendon/synthetic graft and gastrocnemius
recession

14. STAGES OF DEGENERATIVE TENDON INJURY

15.  Repetitive microtrauma
 Relatively hypovascular
area.
 Rupture usually occurs 4-6
cm above the calcaneal
insertion in hypovascular
region
( “Watershed area” )
 Antecedent
tendinitis/tendinosis in
15%
PATHOPHYSIOLOGY OF DEGENERATIVE
TENDON INJURY

16. ATHLETIC INJURY
Indirect : Eccentric force applied to a dorsiflexed foot ;
Sudden unexpected dorsiflexion of ankle
Direct : May occur as the result of direct trauma

17. 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
Acute

18. DEGENERATED TENDON
•Swelling , nodularity due to
thickening and calcification
•crepitation along
the tendon sheath
Partial tear :- fusiform swelling

19.  Partial
Localized tenderness +/-
nodularity
 Complete
Defect
Cannot heel raise

21. Physical Examination
Normal TA
Ruptured Tendon
not
Visible/Palpable
Prone patient with feet over edge of bed
Palpation of entire length of muscle-tendon
unit during active and passive ROM

22.  Thompson test: with the patient prone,
squeezing the calf of the extended leg may
demonstrate no passive plantar flexion of the
foot if its Achilles tendon is ruptured
Clinical Tests

25.  “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

26.  Diagnostic Pitfalls
 23% missed by Primary Physician
(Inglis&Sculco)
 Tendon defect can be masked by hematoma
 Plantar-flexion power of extrinsic foot flexors
retained
 Thompson test can produce a false-negative if
accessory ankle flexors also squeezed

27. Avulsion fracture at the
insertion , with marked
separation of
fragments.
Imaging

28. Kager’s Fat pad

29.  Imaging 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.


30.  Inexpensive
 fast, reproducible,
 dynamic examination possible
 Best to measure thickness and
gap
 Good screening test for
complete rupture

31. ACUTE RUPTURE
CHRONIC RUPTURE
HEALTHY TENDON
•Expensive, not dynamic
•Better at detecting partial ruptures
•Staging of degenerative changes,
(monitor healing)
MRI
MRI

32. Management Goals
Optimize gastro-soleous
strength and function
Restore
musculotendinous length
and tension.
Avoid ankle stiffness

33. CAM Walker or cast with
plantarflexion at 2 wks2 wks
Allow progressive weight-
bearing in removable cast
Remove cast and walk with shoe
lift. Start with 2cm x 1 month,
then 1cm x1 month then D/C
4 weeks
Start physio for ROM
exercises
When Weight bearing
allowed and foot is
plantigrade
Start a strengthening
program
2- 4 weeks
Controversial
40% Re-Rupture rate
Conservative Management

34. Preserve anterior paratenon bl. supply
Beware of sural nerve
Debride and approximate tendon ends
Use 2-4 stranded locked suture technique
Close paratenon separately
Principles:
Surgical management

35. Operative Treatment
A: Defects of 1 cm or less
Direct end to end repair without augmentation
 Bunnell Suture
 Modified Kessler
 Many techniques
available

36. B: Defects 1 - 2 cm
Muscle mobilization ± augmentation (plantaris)
Can gain up to 2 cm with mobilization

37. 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
C: Defects 2 - 5 cm

38. CASE OF TENDOACHILLES RUPTURE
•M/28
•3 Months old injury
•USG : 25 mm gap , 38
mm proximal to calcaneal
tuberosity

39. Surgical Technique
Chronic rupture
with
fibrosed tissue

40. Plantaris
5 cm GAP

41. Semi-T Harvested

42. Semi-T passed through the proximal
Musculo-Tendinous junction

43. Semi-T passed
through Calcaneum

44. SemiT fixed to
calcaneum
using IF Screw

45. SemiT and Plantaris are sutured
with distal & proximal TA
using nonabsorbable suture

47. Cast in Equinus for 3 Weeks
Follow up at 6 wks & 2 Months

48. Defects > 5 cm
SemiT Transfer ± V-Y myotendinous lengthening

49.  Assess strength of repair, tension and ROM
intra-op.
 Apply long leg cast with ankle in the least
amount of planterflexion(gravity equinus) &
knee 60 degree flexion with window at
operated site.
 Stitch removal after 2 wks.
 Short leg cast after 3 wks with partial equinus
correction

50.  2 weekly plaster change with gradual equinus correction (4-6
episode ).
 Walking with heel raised shoe & regular physiotherapy.
 Reverse ankle stop brace up to 6 months.

51. Acute rupture of tendon Achilles. A prospective randomised
study ofcomparison between surgical and non-surgical treatment.
Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8
112 patients
Surgery +
Early functional rehab in
brace
Casted x 8 wks
21 % re-rupture 1.7% re-rupture
5% infection
2% Sural nerve inj.
No difference in
functional outcome

52. OPEN INJURY
•Extensive
debridement
•Wound Care
•Plastic Coverage
And
•Tendon Transfer

53. POST OP
COMPLICATIONS
•Deep infection (1%)
• Fistula (3%)
• Skin necrosis (2%),
• Rerupture (2%).

54. Neither Patient nor the Surgeon
want Second Surgery or
Rerupture

55. PREVENTION OF
REINJURY
•Good conditoning and proper
stretching before running
•Adequate warm‐up!
•Adequate rehabilitation
Wearing appropriate and properly
fitting shoes during activities also
should be stressed to all athletes

56. 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 co-morbidities
Functional rehabilitation when possible
SUMMARY

57. Pateients’
recovery
depends
largely on
Their motivation
, Focus
& their desired
postinjury
activity

58. DIFFERENTIAL DIAGNOSIS
 Ankle fracture
 Ankle sprain
 Calcaneofibular ligament injury
 Talofibular ligament injury
 Avulsion fracture of Calcaneal tuberosity

59. THANK YOU