Achilles Tendon Rupture M.Mazloumi MD. Anatomy Largest tendon in the body Origin from gastrocnemius...
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Transcript of Achilles Tendon Rupture M.Mazloumi MD. Anatomy Largest tendon in the body Origin from gastrocnemius...
Achilles Tendon Rupture
M.Mazloumi MD
Anatomy
Largest tendon in the body
Origin from gastrocnemius and soleus muscles
Insertion on calcaneal tuberosity
Anatomy
Lacks a true synovial sheathParatenon has visceral and parietal layersAllows for 1.5cm of tendon glide
Anatomy
ParatenonAnterior – richly vascularizedThe remainder – multiple thin membranes
Anatomy
Blood supply1) Musculotendinous junction
2) Osseous insertion on calcaneus
3) Multiple mesotenal vessels on anterior surface of paratenon (in adipose)
– Anterior mesentery Hypovascular area at 2 to 6 cm proximal to osseous
insertion
Physiology
Remarkable response to stressExercise induces tendon diameter increase Inactivity or immobilization causes rapid
atrophyAge-related decreases in cell density,
collagen fibril diameter and densityOlder athletes have higher injury
susceptibility
Biomechanics
Gastrocnemius-soleus-Achilles complexSpans 3 joints
Flex kneePlantar flex tibiotalar jointSupinate subtalar joint
Up to 10 times body weight through tendon when running
Achilles Tendon Rupture
Pathophysiology Repetitive
microtrauma in a relatively hypovascular area.
Reparative process unable to keep up
Achilles Tendon Rupture
May be on the background of a degenerative tendon
Achilles Tendon Rupture
Antecedent tendinitis/tendinosis in 11%
75% of sports-related ruptures happen in patients between 30-40 years of age.
Most ruptures occur in 4cm proximal to the calcaneal insertion.
Achilles tendon disorders
Achilles Tendon Rupture
History
Case reports of fluoroquinolone use, steroid injections
Mechanism Eccentric loading (running backwards in tennis) Sudden unexpected dorsiflexion of ankle Direct blow or laceration Fall from a hight
Achilles Tendon Rupture
PhysicalPartial
Localized tenderness +/- nodularityComplete
DefectCan not heel raisePositive Thompson test
Imaging
Ultrasound Inexpensive , dynamic
examination possible
Good screening test for complete rupture
Imaging
MRIExpensiveBetter at detecting
1-partial ruptures
2- staging degenerative changes
3- monitor healing
Management Goals
Restore musculotendinous length and tension.
Optimize gastro-soleous strength and function
Avoid ankle stiffness
Conservative Management
Cast in Plantarflexion CAM Walker or cast with plantarflexion q 2 wks
2 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
Functional Bracing
Surgical Management
Preserve anterior paratenon blood supply
Beware of sural nerveDebride and approximate tendon endsUse 2-4 stranded locked suture
techniqueMay augment with absorbable sutureClose paratenon separately
Surgical Management
Kerachow suture technique Dynamic loop suture of Peroneus brevis
Surgical Management
Lynn technique Percutaneous repaire
Old rupture
Bosworth technique for repairing old ruptures of Achilles tendon
Wapner technique with FHL tendon
Percutaneous versus open repair
Percutaneous repair Open repair
Surgical Management : Post– op Care
Assess strength of repair, tension and ROM intra-op.
Apply cast with ankle in the least amount of plantarflexion that can be safely attained.
Patient returns to fracture clinic 2 weeks post-op.
Conservative vs Surgical
Acute rupture of tendon Achillis. A prospective randomised study of comparison 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
Conservative vs Surgical
Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial.
Am J Sports Med. 2008 Sep;36(9):1688-94. Epub 2008 Jul 21.
83 patients
Surgery +
Early functional rehab in brace
Casted x 8 wks
5 \ 41 re-rupture 3 \ 42 re-rupture
0.5% infection
0.1% Sural nerve inNo difference in functional outcome
Limited open technique
1. Outcome of achilles tendon ruptures treated by a limited open technique. Jung HG, Lee KB, Cho SG, Yoon Foot Ankle Int. 2008 Aug;29(8):803-7.
2. Repair of achilles tendon rupture under endoscopic control. Fortis AP, Dimas A, Lam Arthroscopy. 2008 Jun;24(6):683-8.
3. Minimally invasive repair of ruptured Achilles tendon. Chan SK, Chu Hong Kong Med J. 2008 Aug;14(4):255-8.
Summary of Pooled Outcome Measures
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