ANATOMY OF GASTROCSOLEUS COMPLEX AND TEAR OF TENDO.pptx

G

1. ANATOMY OF GASTROCSOLEUS COMPLEX AND TEAR OF TENDO ACHILLES TENDON DR. DHARMIK PATEL 3 RD YEAR , ORTHO RESIDENT

2. The gastrocnemius crosses three major joints: (1) knee, (2) ankle, and (3) subtalar . The soleus muscle lies deep to the gastrocnemius muscle and it crosses only the (1) ankle (2) subtalar joints .

3. Gastronemius muscle has two heads: Medial and lateral. The medial head of the gastrocnemius muscle arises from behind the medial supracondylar ridge and adductor tubercle on the posterior surface of the femur. The lateral head arises from the lateral surface of the lateral condyle of the femur, proximal and posterior to the lateral epicondyle , and attaches above the knee to the posterior aspect of the medial and lateral femoral condyles . The medial head is broader and thicker than the lateral head. Each of these heads has additional attachments from the posterior capsule of the knee joint and from the oblique popliteal ligament

4. SOLEUS MUSCLE ORIGIN: It originates from the upper part of the posterior tibia, fibula, and interosseus membrane. The calcaneal or Achilles tendon is the largest and most powerful tendon in the ankle. At its insertion it is 1.2 to 2.5 cm wide and 5 to 6 mm thick at the ankle

5. FUNCTION Gastrocnemius : ankle plantar flexion when knee extended. The main function of the gastrocnemius muscle is propulsion of the body forward during gait, Soleus : ankle plantar flexion when knee flexed. the soleus is a postural muscle that also acts as a peripheral vascular pump .   In a cadaver study, Silver and colleagues 7 determined that the power of plantar flexion resides primarily in the soleus and not in the gastrocnemius .

6. In their proximal aspects, both the gastrocnemius and soleus muscles form an aponeurosis , from each of which originates a tendon. These two tendons freely glide independently before they coalesce into the Achilles tendon, approximately 5 to 6 cm proximal to the calcaneal insertion. The tendinous components of these two muscles are variable. The gastrocnemius component is longer (11–26 cm) than that of the soleus (3–11 cm ). The tendon is larger at the insertion on the inferior half of the posterior calcaneal surface. Some of the insertional fibers are in continuity with the plantar aponeurosis 10 ; however, the number of fibers that connect the Achilles tendon to the plantar fascia decreases with age.

7. PLANTARIS MUSCLE : The plantaris muscle arises in close association with the lateral head of the gastroc - nemius . it is absent in 7% of individuals. This flat fusiform muscle is followed by a long, slender tendon that courses obliquely downward and medially between the soleus and both heads of gastrocnemius .

8. RETROCALCANEAL BURSAE: The retrocalcaneal bursa lies deep and just proximal to the insertion of the Achilles tendon, between the posterior calcaneal tuberosity and the tendon . Anteriorly , it is composed of fibrocartilage ; posteriorly it blends with the paratenon and commonly connects to the posterior Achilles tendon. Superficial to the tendon, the pre-Achilles bursa lies between the tendon and the skin.

9. BLOOD SUPPLY OF TENDO ACHILLES: The Achilles tendon has no true synovial sheath; it is surrounded by a paratenon , a double-layered sheath composed of an inner, visceral layer and an outer, parietal layer. The visceral layer is connected to the parietal layer by bridges called ‘‘ mesotenon .’’ Nerves and blood vessels run through the paratenon , which is the main blood supply to the middle portion of the tendon. A recurrent branch of the posterior tibial artery supplies the proximal part of the tendon, whereas the distal part is vascularized supplied by the lateral peroneal and posterior tibial arteries.

10. BIOMECHANICS OF THE GASTROSOLEUS COMPLEX DURING GAIT During gait : the plantar flexors consistently are active in stance, and the dorsiflexors are swing-phase muscles. From heel-strike to midstance , the gastrocnemius-soleus complex remains inactive, allowing progressive eversion of the subtalar joint . As the hindfoot assumes a valgus position, the axes of the talona - vicular and calcaneal-cuboid joints become parallel, unlock, and permit abduction through the transverse tarsal joints. 23 This creates the ideal environment for the shock-absorbing function of the midfoot during midstance .

11. During the late midstance and terminal stance, just before the For this purpose the subtalar inversion caused by the contraction of the posterior tibial muscle causes the axes of the talonavicular and calcaneal joints to diverge. The subtalar inversion shifts the insertion of the Achilles tendon medial to the axis of rotation of the subtalar joint This locks the midtarsal joint into relative plantar flexion. Such mechanism transforms the foot into a rigid lever, which together with the contraction of the Achilles complex makes the foot capable of propelling the body forward through push-off from the metatarsal heads.

12. TENDO ACHILLES RUPTURE: Site: 2 to 5 cm above the calcaneal insertion is the most common site. Reasons : The tendon is rounded proximally and relatively flat distally. Approximately 12 to 15 cm proximal to its insertion, rotation begins and becomes more marked in the distal 5 to 6 cm. the poorest blood supply it has very low metabolic rate so it shows slowest recovery and healsing rates

13. ETIOLOGY

14. CLINICAL FEATURES: CLINICAL FEATURES: Sudden snap or pop Pain over the back of ankle which is sudden in onset. inability to walk Acute onset swelling and formation of hematoma. On examination: Palpable gap present on posterior aspect of lower leg in region of tendo-achilles . Inability to toe walk Weakness of gastrocsoleus and painful plantar flexion

15. CLINICAL TEST: THOMPSON-SIMMONDS-DOHERTY TEST: MAY FALSE POSITIVE IN CHRONIC TEAR DUE TO FIBROUS BAND

16. MATLES TEST: When patient prone, ask the patient to flex knee upto 90 degree, neutral or dorsiflexion of ankle suggest torn tendon.

17. Needle Test Of O’brien test: insert a needle 10cm above insertion of TA,on dorsiflexion outer portion of needle moves proximally. Sphygmomanometer test( copelan test): Wrap the cuff around calf region and inflate it 100mmhg , do dorsiflex ion of foot and pressure rises to 140mmhg, it indicate intact tendon. Single leg heel raise test: ask patient to stand on injured leg with heel raised– not possible.

18. X ray : calcanium lateral view Kager’s triangle : fat filled triangular space in front of TA—disappearance is suggestive of torn. Toygar sign : it involves measurement of angle posterior skin surface . With loss of triangle and tendon rupture the angle reduces to 130-150 degree. USG : investigation of choice. MRI : for infected pthology

19. CONSERVATIVE TREATMENT OF TENDO ACHILLES RUPTURE GOALS: Restore length and tension. Restore strength and function Avoid ankle stiffness. Immobilization of ankle in below knee cast in planter flexion for 4 weeks followed by flexion orthotics for 4 weeks than gradual mobilisation and eccentric strenghthening exercise. INDICATION: If gap is less than 5mm in usg Less than 10mm on neutral position Reasonable apposition of the tendon on 20 degree of plantar flexion.

20. SURGICAL MANAGEMENT OF TENDOACHILLES RUPTURE C /I: Arterial insufficiency Poor skin and soft tissue quality Principles: Preserve paratenon blood supply. Close paratenon seperately Prevent sural nerve injury Debride tendon ends.

21. For acute injury: End to end repair by modified kessler or Bunnell or Krackow + plantaris augmentation is preferable. Approach: midline transverse incision to prevent sural nerve and decrease rerupture rates.

22. If can’t approx: Lindholm’s technique: For reinforcement turn down gastrocnemius aponeurotic flap. Lynn : Plantaris Teuffer : Peroneus brevis (uncommon) Mini open indirect repair using achillon system

23. For old tears(more than 4 weeks) Myerson’s classification: Type 1 defect (1-2 cm): End to end repair & posterior component fasciotomy . Type 2 defect(2-5 cm) : V-y lenghthening with or without tendon transfer. Type 3 defect( more than 5 cm ): Tendon transfer along with or without v-y plasty . Kuwada’s classification: Type 1: partial tear: conservative management. Type 2 complete tear: Less than 3 cm –end to end repair 3-6cm – debride + tendon transfer with or without augmentation. More than 6cm – debride + tendon graft with or without augmentation

24. For tendon augmentation: FHL FDL Peroneous brevis Why FHL is most ideal? In phase muscle Very close to TA Increase vascularity of TA Strong plantar flexor of ankle

25. AUTOLOGUS GRAFT Fascial advancement: V-y plasty Gastrosoleus turn down graft Free fascia tendon graft TFL Synthetic: Polyglycol threads Dacron graft Carbon fiber Allograft tendon

26. COMPLICATIONS Skin necrosis Inability to close the skin Infection Hematoma formation Wound Dehiscence Formation of chronic ulcer/sinus Re-rupture Secondary deformities such as equinus and valgus , if the repair was too tight with augmentation Dorsiflexion lag for lax repair Functional deficit and chronic pain is seen in half of the patients irrespective of the method chosen Deep vein thrombosis , pulmonary embolism may be seen as in all orthopedic lower limb surgeries

27. POST-OPERATIVE MANAGEMENT PROTOCOL Immobilisation in slab in plantar flexion 20 degree for 2 weeks. Remove sutures at 14-18 days 2-4 weeks: apply posterior splint with maintaining plantar flexion. Allow passive plantar flexion and active dorsiflexion . Provide a boot with heel raise. 4-6 weeks: partial weight bearing and physiotherapy as above. 6-8 weeks: passive dorsiflexion stretching 8-12 weeks: full weight bearing on crutch support. Gradually wean crutches by 12 th week.

28. THANK YOU