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TENDOACHILLES RUPTURE: MANAGEMENT

Dr Rohan Vakta
M.S.Ortho
AASH Arthroscopy Center
Ahmedabad,India
Anatomy
 Largest

tendon in the

body
 Origin from
gastrocnemius and
soleus muscles
 Insertion on
calcanealtuberosity
Physiology
 Remarkable

response to stress

Exercise induces increase in tendon
diameter
 Inactivity causes rapid atroph...
 Gastrocnemius-soleus-Achilles

complex


Acts on 3 joints
Flexion of knee
 Plantarflexion of
tibiotalar joint
 Supina...
RISK FACTORS
 Recreational

athlete : Basketball , Volleyball ,
Rugby , Soccer

[There may be a history of a recent incre...
RISK FACTORS (CONT.)
Obesity
 Diabetes Mellitus
 Previous tendon injury


Previous Steroid injections or
fluoroquinolon...
Close

Open

Acute

Neglected

-Athletics
injuries

-Degenerative
Injuries
STAGES OF DEGENERATIVE TENDON INJURY

AASH Arthroscopy
Center
PATHOPHYSIOLOGY OF DEGENERATIVE
TENDON INJURY

 Repetitive

microtrauma
 Relatively hypovascular
area.
 Reparative proc...
ATHLETIC INJURY

Indirect : Eccentric force applied to a dorsiflexed foot ;
Sudden unexpected dorsiflexion of ankle

Direc...
Acute

 Feels

like being kicked in the leg
 Feeling of sudden Snap
in the lower calf
 Acute sever pain
 Walk with a l...
DEGENERATED TENDON

•Swelling , nodularity due to
thickening and calcification
•crepitation along
the tendon sheath

Parti...
Physical Examination
Prone patient with feet over edge of bed

Normal TA

Ruptured Tendon
not
Visible/Palpable

Palpation ...
 “Hyperdorsiflexion”

sign –
With the patient prone and knees flexed to
90º,maximal passive dorsiflexion of both feet
may...
Imaging

Avulsion fracture at the
insertion , with marked
separation of
fragments.
Kager’s Fat pad







Inexpensive
fast, reproducable,
dynamic examination possible
Best to measure thickness and
gap
Good screening ...
MRI
MRI
ACUTE RUPTURE
HEALTHY TENDON

•Expensive, not dynamic
•Better at detecting partial ruptures
•Staging of degenerati...
Management Goals
Optimize

gastro-soleous
strength and function
Restore
musculotendinous length
and tension.
Avoid ankl...
Conservative Management
Controversial
2 wks

CAM Walker or cast with
plantarflexion at 2 wks
4 weeks

Start physio for ROM...
Surgical management
Principles:
 Preserve

anterior paratenon bl. supply
 Beware of sural nerve
 Debride and approximat...
Operative Treatment

A: Defects of 1 cm or less
Direct end to end repair without augmentation
 Bunnell

Suture

 Modifie...
B: Defects 1 - 2 cm
Muscle mobilization augmentation (plantaris)
Can gain up to 2 cm with mobilization
C: Defects 2 - 5 cm

No consensus on best reconstruction technique
 Semi-T tendon

transfer
 Flexor hallucis longus (FHL...
CASE OF TENDOACHILLES RUPTURE
•M/28
•3 Months old injury
•USG : 25 mm gap , 38
mm proximal to calcaneal
tuberosity
Surgical Technique

Chronic rupture
with
fibrosed tissue
Plantaris

5 cm GAP
Semi-T Harvested
Semi-T passed through the proximal
Musculo-Tendinous junction
Semi-T passed
through Calcaneum
SemiT fixed to
calcaneum
using IF Screw
SemiT and Plantaris are sutured
with distal & proximal TA
using nonaborbable suture
Cast in Equinus for 3 Weeks
Defects > 5 cm
SemiT Transfer

V-Y myotendinous lengthening
PERCUTANEOUS VS. OPEN
 Less


wound complications

Lim et al.
33 patients
 7 infections


 Higher


re-rupture rate
...
OPEN INJURY
•Extensive
debridement
•Wound Care

•Plastic Coverage
And
•Tendon Transfer
POST OP
COMPLICATIONS
•Deep infection (1%)
• Fistula (3%)
• Skin necrosis (2%),

• Rerupture (2%).
Neither Patient nor the Surgeon
want Second Surgery or
Rerupture
PREVENTION OF
REINJURY
•Good conditoning and proper
stretching before running
•Adequate warm‐up!
•Adequate rehabilitation
...
SUMMARY
 Chronic Achilles
Operative

tendon rupture

treatment when possible

 Acute Achilles

tendon rupture



Opera...
Pateients’
recovery
depends
largely on

Their motivation
, Focus
& their desired
postinjury
activity
THANK YOU
Tendoachilles rupture and its management
Tendoachilles rupture and its management
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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.

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Tendoachilles rupture and its management

  1. 1. TENDOACHILLES RUPTURE: MANAGEMENT Dr Rohan Vakta M.S.Ortho AASH Arthroscopy Center Ahmedabad,India
  2. 2. Anatomy  Largest tendon in the body  Origin from gastrocnemius and soleus muscles  Insertion on calcanealtuberosity
  3. 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. 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. 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. 6. RISK FACTORS (CONT.) Obesity  Diabetes Mellitus  Previous tendon injury  Previous Steroid injections or fluoroquinolone use  Inustrial Accidents 
  7. 7. Close Open Acute Neglected -Athletics injuries -Degenerative Injuries
  8. 8. STAGES OF DEGENERATIVE TENDON INJURY AASH Arthroscopy Center
  9. 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. 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. 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. 12. DEGENERATED TENDON •Swelling , nodularity due to thickening and calcification •crepitation along the tendon sheath Partial tear :- fusiform swelling
  13. 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. 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. 15. Imaging Avulsion fracture at the insertion , with marked separation of fragments.
  16. 16. Kager’s Fat pad
  17. 17.      Inexpensive fast, reproducable, dynamic examination possible Best to measure thickness and gap Good screening test for complete rupture
  18. 18. MRI MRI ACUTE RUPTURE HEALTHY TENDON •Expensive, not dynamic •Better at detecting partial ruptures •Staging of degenerative changes, (monitor healing) CHRONIC RUPTURE
  19. 19. Management Goals Optimize gastro-soleous strength and function Restore musculotendinous length and tension. Avoid ankle stiffness
  20. 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. 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. 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. 23. B: Defects 1 - 2 cm Muscle mobilization augmentation (plantaris) Can gain up to 2 cm with mobilization
  24. 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. 25. CASE OF TENDOACHILLES RUPTURE •M/28 •3 Months old injury •USG : 25 mm gap , 38 mm proximal to calcaneal tuberosity
  26. 26. Surgical Technique Chronic rupture with fibrosed tissue
  27. 27. Plantaris 5 cm GAP
  28. 28. Semi-T Harvested
  29. 29. Semi-T passed through the proximal Musculo-Tendinous junction
  30. 30. Semi-T passed through Calcaneum
  31. 31. SemiT fixed to calcaneum using IF Screw
  32. 32. SemiT and Plantaris are sutured with distal & proximal TA using nonaborbable suture
  33. 33. Cast in Equinus for 3 Weeks
  34. 34. Defects > 5 cm SemiT Transfer V-Y myotendinous lengthening
  35. 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. 36. OPEN INJURY •Extensive debridement •Wound Care •Plastic Coverage And •Tendon Transfer
  37. 37. POST OP COMPLICATIONS •Deep infection (1%) • Fistula (3%) • Skin necrosis (2%), • Rerupture (2%).
  38. 38. Neither Patient nor the Surgeon want Second Surgery or Rerupture
  39. 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. 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. 41. Pateients’ recovery depends largely on Their motivation , Focus & their desired postinjury activity
  42. 42. THANK YOU

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