TENDOACHILLES RUPTURE: MANAGEMENT

Dr Rohan VaktaM.S.OrthoAASH Arthroscopy Center Ahmedabad,India

Largest tendon in the body

Origin from gastrocnemius and soleus muscles

Insertion on calcanealtuberosity

Anatomy

Remarkable response to stressExercise induces increase in tendon

diameterInactivity causes rapid atrophy

Age-related decreases in cell density& collagen

Older athletes have higher injury susceptibility

Physiology

Gastrocnemius-soleus-Achilles complexActs on 3 joints

Flexion of kneePlantarflexion of

tibiotalar jointSupination of subtalar jt.

It can transmit up to

10 times body weight through

tendon when running

Biomechanics

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)

Obesity Diabetes Mellitus Previous tendon injury

RISK FACTORS (CONT.)

Previous Steroid injections or fluoroquinolone use

Inustrial Accidents

Classification of TA Rupture

Acute-Athletics injuries

Neglected-Degenerative Injuries

CloseOpen

STAGES OF DEGENERATIVE TENDON INJURY

AASH Arthroscopy Center

Repetitive microtraumaRelatively hypovascular

area.Reparative process

inadequateMost ruptures occur in

“Watershed area” Antecedent

tendinitis/tendinosis in 15%

PATHOPHYSIOLOGY OF DEGENERATIVE TENDON INJURY

ATHLETIC INJURY

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

Direct : May occur as the result of direct trauma

Feels like being kicked in the legFeeling of sudden Snap

in the lower calfAcute sever painWalk with a limp, unable to run,

climb stairs, or stand on their toesLoss of plantar flexion power

Acute

DEGENERATED TENDON

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

Partial tear :- fusiform swelling

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

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

“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

X-RAY-

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

Imaging

Kager’s Fat pad

FH

L TA

Inexpensivefast, reproducable, dynamic examination possibleBest to measure thickness and

gapGood screening test for

complete rupture

Ultrasound

ACUTE RUPTURE

CHRONIC RUPTURE

HEALTHY TENDON

• Expensive, not dynamic• Better at detecting partial ruptures • Staging of degenerative changes,

(monitor healing)

MRI

MRI

Management Goals

Optimize gastro-soleous strength and function

Restore musculotendinous length and tension.

Avoid ankle stiffness

Cast in Plantarflexion CAM Walker or cast with plantarflexion at 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

Controversial

40% Re-Rupture rate

Conservative Management

Preserve anterior paratenon bl. supplyBeware of sural nerveDebride and approximate tendon endsUse 2-4 stranded locked suture techniqueClose paratenon separately

Principles:

Surgical management

Operative Treatment

A: Defects of 1 cm or lessDirect end to end repair without augmentation

Bunnell Suture

Modified Kessler

Many techniques available

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

No consensus on best reconstruction techniqueSemi-T tendon transferFlexor hallucis longus (FHL) tendon transfer loss of great toe flexion(Not acceptable in Athletes)Others: FDL , Peroneus BrevisV-Y myotendinous lengthening ± FHL transfer

C: Defects 2 - 5 cm

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

F’UP AT 6 WKS & 2 MONTHS

Defects > 5 cmSemiT Transfer ± V-Y myotendinous lengthening

PERCUTANEOUS VS. OPEN

Less wound complicationsLim et al.

33 patients 7 infections

Higher re-rupture rateWong et al.

367 repairs 12% re-rupture

Bradley 12% perc vs. 0% open

Greater StrengthCetti

111 patients

General Consensus: Perc

Less wound complicationsBetter cosmesis

General Consensus: Open

Return to preinjury levelDecreased calf atrophyBetter motionLess re-rupture

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

Wearing appropriate and properly fittng shoes during activites also should be stressed to all athletes

Chronic Achilles tendon ruptureOperative 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

SUMMARY

Pateients’ recovery dependslargely on

Their motivation , Focus& their desired postinjury activity

THANK YOU