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Achilis tendon rupture

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SPORTS INJURY

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Achilis tendon rupture

  1. 1. Articular Cartilage Injury Dr.RAJAT JANGIR Consultant Arthroscopy and Orthopedic Surgeon Saket Hospital, Mansarovar Assistant Professor Mahatma Gandhi Medical College, Jaipur Fellowship In Arthroscopy(South Korea) International Olympic Committee Diploma Sports Medicine(UK) Sports Physician RIO Olympic 2016
  2. 2.  Largest tendon in the body  Origin from gastrocnemius and soleus muscles  Insertion on calcaneal tuberosity
  3. 3. Lacks a true synovial sheath-  Paratenon has visceral and parietal layers  Allows for 1.5cm of tendon glide
  4. 4. Paratenon  Anterior – richly vascularized  The remainder – multiple thin membranes
  5. 5. Blood supply 1) Musculotendinous junction 2) Osseous insertion on calcaneus 3) Multiple mesotenal vessels on anterior surface of paratenon (in adipose) – Transverse vincula  Fewest @ 2 to 6 cm proximal to osseous insertion
  6. 6.  Remarkable response to stress  Exercise induces tendon diameter increase  Inactivity or immobilization causes rapid atrophy  Age-related decreases in cell density, collagen fibril diameter and density  Older athletes have higher injury susceptibility
  7. 7.  Gastrocnemius-soleus-Achilles complex  Spans 3 joints  Flex knee  Plantar flex tibiotalar joint  Supinate subtalar joint  Up to 10 times body weight through tendon when running
  8. 8. 1. Close injury/rupture 2. Open injury/rupture • Acute injury • Neglected injury
  9. 9. 1. Accidental cut injury (bath room injury, road traffic injury) 2. Social/political Violence
  10. 10. 1. Diagnosis and assessment of extend of injury. 2. Primary care 3. Operative treatment
  11. 11.  Pathophysiology  Repetitive microtrauma in a relatively hypovascular area.  Reparative process unable to keep up  May be on the background of a degenerative tendon
  12. 12.  Antecedent tendinitis/tendinosis in 15%  75% of sports-related ruptures happen in patients between 30-40 years of age.  Most ruptures occur in watershed area 4cm proximal to the calcaneal insertion.
  13. 13. History  Feels like being kicked in the leg  Case reports of fluoroquinolone use, steroid injections
  14. 14. Mechanism Eccentric loading (running backwards in tennis) Sudden unexpected dorsiflexion of ankle (Direct blow or laceration)
  15. 15. Prone patient with feet over edge of bed Palpation of entire length of muscle- tendon unit during active and passive ROM Compare tendon width to other side Note tenderness, crepitation, warmth, swelling, nodularity, palpable defects
  16. 16.  Partial Localized tenderness +/- nodularity  Complete Defect Cannot heel raise Positive Thompson test
  17. 17.  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
  18. 18. This lateral x-ray of the calcaneus shows an avulsion fracture at the insertion of the Achilles tendon, with marked separation of fragments. .
  19. 19.  Inexpensive, fast, reproducable, dynamic examination possible  Operator dependent  Best to measure thickness and gap  Good screening test for complete rupture
  20. 20.  Expensive, not dynamic  Better at detecting partial ruptures and staging degenerative changes, (monitor healing)
  21. 21. Restore musculotendinous length and tension. Optimize gastro-soleous strength and function Avoid ankle stiffness
  22. 22. cast with plantarflexion q 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 WBAT and foot is plantigrade Start a strengthening program 2- 4 weeks
  23. 23.  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
  24. 24.  Acute case : usually end to end repair is enough  Neglected case: Advancement plasy (V-Y) or reconstruction by other tendons
  25. 25.  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
  26. 26.  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.

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