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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
 Largest tendon in the
body
 Origin from
gastrocnemius and
soleus muscles
 Insertion on calcaneal
tuberosity
Lacks a true synovial
sheath-
 Paratenon has visceral
and parietal layers
 Allows for 1.5cm of
tendon glide
Paratenon
 Anterior – richly vascularized
 The remainder – multiple thin
membranes
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
 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
 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
1. Close injury/rupture
2. Open injury/rupture
• Acute injury
• Neglected injury
1. Accidental cut injury
(bath room injury, road
traffic injury)
2. Social/political
Violence
1. Diagnosis and
assessment of extend
of injury.
2. Primary care
3. Operative treatment
 Pathophysiology
 Repetitive microtrauma
in a relatively
hypovascular area.
 Reparative process
unable to keep up
 May be on the
background of a
degenerative tendon
 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.
History
 Feels like being kicked in the leg
 Case reports of fluoroquinolone use,
steroid injections
Mechanism
Eccentric loading (running backwards in tennis)
Sudden unexpected dorsiflexion of ankle
(Direct blow or laceration)
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
 Partial
Localized tenderness +/-
nodularity
 Complete
Defect
Cannot heel raise
Positive Thompson test
 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
This lateral x-ray of the
calcaneus shows an
avulsion fracture at the
insertion of the Achilles
tendon, with marked
separation of fragments.
.
 Inexpensive, fast, reproducable,
dynamic examination possible
 Operator dependent
 Best to measure thickness and gap
 Good screening test for complete
rupture
 Expensive, not dynamic
 Better at detecting partial
ruptures and staging
degenerative changes,
(monitor healing)
Restore musculotendinous length and
tension.
Optimize gastro-soleous strength and
function
Avoid ankle stiffness
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
 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
 Acute case : usually end
to end repair is enough
 Neglected case:
Advancement plasy (V-Y)
or reconstruction by
other tendons
 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
 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.
Achilis tendon rupture  I Dr.RAJAT JANGIR JAIPUR

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Achilis tendon rupture I Dr.RAJAT JANGIR JAIPUR

  • 1.
  • 2. 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
  • 3.
  • 4.  Largest tendon in the body  Origin from gastrocnemius and soleus muscles  Insertion on calcaneal tuberosity
  • 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 mesotenal vessels on anterior surface of paratenon (in adipose) – Transverse vincula  Fewest @ 2 to 6 cm proximal to osseous insertion
  • 8.  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
  • 9.  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
  • 10. 1. Close injury/rupture 2. Open injury/rupture • Acute injury • Neglected injury
  • 11. 1. Accidental cut injury (bath room injury, road traffic injury) 2. Social/political Violence
  • 12. 1. Diagnosis and assessment of extend of injury. 2. Primary care 3. Operative treatment
  • 13.  Pathophysiology  Repetitive microtrauma in a relatively hypovascular area.  Reparative process unable to keep up  May be on the background of a degenerative tendon
  • 14.  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.
  • 15.
  • 16. History  Feels like being kicked in the leg  Case reports of fluoroquinolone use, steroid injections
  • 17. Mechanism Eccentric loading (running backwards in tennis) Sudden unexpected dorsiflexion of ankle (Direct blow or laceration)
  • 18.
  • 19. 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
  • 20.  Partial Localized tenderness +/- nodularity  Complete Defect Cannot heel raise Positive Thompson test
  • 21.
  • 22.
  • 23.
  • 24.  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
  • 25. This lateral x-ray of the calcaneus shows an avulsion fracture at the insertion of the Achilles tendon, with marked separation of fragments. .
  • 26.  Inexpensive, fast, reproducable, dynamic examination possible  Operator dependent  Best to measure thickness and gap  Good screening test for complete rupture
  • 27.  Expensive, not dynamic  Better at detecting partial ruptures and staging degenerative changes, (monitor healing)
  • 28. Restore musculotendinous length and tension. Optimize gastro-soleous strength and function Avoid ankle stiffness
  • 29. 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
  • 30.  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
  • 31.
  • 32.  Acute case : usually end to end repair is enough  Neglected case: Advancement plasy (V-Y) or reconstruction by other tendons
  • 33.
  • 34.
  • 35.
  • 36.  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
  • 37.  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.