Tendo achilles

Tendo achilles

1. Achilles tendon Dr Pratik Dhabalia

2. INTRODUCTION The Achilles tendon is the largest and strongest tendon in the human body. The incidence rises rapidly after 25 years of age with males in their fourth or fifth decade accounting for the overwhelming majority of acute ruptures. Another peak is seen between the sixth and eighth decade, which predominantly occurs from a longstanding degenerative condition of the tendon, with the incidence remaining higher in men.

3. ANATOMY The tendon receives equal contributions from both the gastrocnemius and soleus muscle and tendinous fibers . These fibers converge approximately 15 cm from the insertion point. As the tendon courses inferiorly in the posterior aspect of the leg, the fibers twist approximatedly 120° internally before its insertion point on the calcaneal tuberosity .

4. The Achilles tendon lacks a true synovial sheath. Rather, the tendon is enveloped within a paratenon . The paratenon permits gliding of the tendon between the skin and surrounding posterior soft tissues of the leg. The paratenon is responsible for a significant portion of the tendon’s blood supply through a highly vascularized areolar tissue on its anterior aspect.

5. Dense net of small arteries inserts into the paratenon of the Achilles tendon in its lower 20 cm and seems to provide ample blood supply. The Achilles’ remaining blood supply is derived from the musculotendinous junction proximally, and from the osseous insertion, distally. The pattern of blood supply leaves the Achilles tendon vulnerable to injury in a watershed area approximately 2–6 cm from its insertion on the posterior calcaneus . Rupture occurs in this watershed area approximately 75 % of the time. Furthermore, ruptures can occur at the distal insertion (10 %–20 %) and the myotendinous junction (5 %–15 %) as well.

6. Gastrocnemius - soleus-achilles 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

7. Risk factors for rupture Local corticosteroids Systemic corticosteroids Peritendinous injection Flouroquinolones Degenerative changes in tendon Obesity Diabetes mellitus Vascular degeneration/ irregularitiees Hyperthermia of tendon Training error Malalignment of foot and/or ankle Chronic tendinopathy ( with haglund’s deformity) Previous tendon injury

8. Presentation, physical examination and diagnosis Patient will often describe sudden onset of pain in the posterior aspect of the foot and ankle, usually during activity that calls for maximum forceful plantar flexion. Patients will describe feeling a “pop” or a sensation of being kicked in the back of the leg. They will often lose the ability to bear weight and/or report weakness in plantar flexion of the ankle. Interestingly enough, patients rarely present with significant pain. Rather, they present with bruising and a functional deficit.

9. Physical examination findings include increased passive ankle dorsiflexion . weak plantar flexion strength, palpable defect overlying the tear. Positive Thompson test. The test is performed by squeezing the musculature of the posterior calf and observing motion of the foot. A positive Thompson test reveals little or no plantar flexion of the foot relative to the contralateral leg.  very forceful calf squeeze may recruit the deep compartmental musculature and yield a false negative result. False positives can occur when the patient has an intact plantaris tendon and in the setting of a chronic rupture, where scar tissue and fibrosis of the paratenon can mimic continuity between the gastroc-soleus muscle belly and the calcaneus . 

10. Palpable defect overlying the tear

11. Investigation X ray MRI USG

12. X ray This lateral x-ray of the calcaneus shows an avulsion fracture at the insertion of the Achilles tendon, with separation of fragments.

13. MRI Better at detecting partial ruptures and staging degenerative changes, (monitor healing)

14. USG Inexpensive, fast, reproducable , dynamic examination possible Operator dependent Best to measure thickness and gap Good screening test for complete rupture

15. MANAGEMENT The fundamental goals of treatment of an acute Achilles tendon rupture are to restore length and tension of the tendon in order to optimize a patient’s ability to return to their desired level of activity.  Treatment options include nonoperative regimens, traditional open repair, and percutaneous or mini-open repairs.

16. Conservative management Conservative treatment regimens vary greatly but commonly involve immobilisation with rigid casting or functional bracing. The foot is initially placed in full equinus (30° namely full plantarflexion ). The foot is then brought into neutral sequentially over a period of 8-12 wk. Once ankle position permits it, weight bearing is allowed.  patients can be allowed to weight-bear early in an off-the-shelf orthosis /CAM walker/Sheffield splint with no detriment in any long term outcomes. Rerupture rate is high

17. 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

18. A: Defects of 1 cm or less: Direct end to end repair without augmentation Bunnell Suture Modified Kessler Many techniques available B: Defects 1 - 2 cm Muscle mobilization augmentation ( plantaris ) Can gain up to 2 cm with mobilization

19. 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 D: Defects > 5 cm: SemiT Transfer, V-Y myotendinous lengthening

20. Chronic rupture

21. Post op complication •Deep infection (1%) • Fistula (3%) • Skin necrosis (2%), • Rerupture (2%)

22. Post op care Assess strength of repair, tension and ROM intra-op. Apply long leg cast with ankle in the least amount of planterflexion ( gravityequinus ) & knee 60 degree flexion with window at operated site. Stitch removal after 2 wks. Short leg cast after 3 wks with partial equinus correction

23. 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

24. Thank you