Tendoachilles rupture and its management

Achilles tendon is the strongest tendon of body. There are many causes of its rupture. It can be acute or chronic rupture. Management of chronic rupture by semitendinosus tendon is mentioned here.

1. Tendoachilles rupture: Management Dr Rohan Vakta M.S.Ortho AASH Arthroscopy Center Ahmedabad,India

2. Largest tendon in the body Origin from gastrocnemius and soleus muscles Insertion on calcanealtuberosity Anatomy

3. Remarkable response to stress Exercise induces increase in tendon diameter Inactivity causes rapid atrophy Age-related decreases in cell density& collagen Older athletes have higher injury susceptibility Physiology

4. Gastrocnemius-soleus-Achilles complex 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 Biomechanics

5. 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)

6. Obesity Diabetes Mellitus Previous tendon injury Risk factors (Cont.) Previous Steroid injections or fluoroquinolone use Inustrial Accidents

7. Classification of TA Rupture Acute -Athletics injuries Neglected -Degenerative Injuries Close Open

8. Stages of degenerative tendon injury AASH Arthroscopy Center

9. Repetitive microtrauma Relatively hypovascular area. Reparative process inadequate Most ruptures occur in “ Watershed area” Antecedent tendinitis/ tendinosis in 15% Pathophysiology of degenerative tendon injury

10. Athletic Injury Indirect : Eccentric force applied to a dorsiflexed foot ; Sudden unexpected dorsiflexion of ankle Direct : May occur as the result of direct trauma

11. Feels like being kicked in the leg Feeling of sudden Snap in the lower calf Acute sever pain Walk with a limp, unable to run, climb stairs, or stand on their toes Loss of plantar flexion power Acute

12. Degenerated Tendon Swelling , nodularity due to thickening and calcification crepitation along the tendon sheath Partial tear :- fusiform swelling

13. 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

14. 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

15. “ 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

16. X-Ray- Avulsion fracture at the insertion , with marked separation of fragments. Imaging

17. Kager’s Fat pad FHL TA

18. Inexpensive fast, reproducable , dynamic examination possible Best to measure thickness and gap Good screening test for complete rupture Ultrasound

19. ACUTE RUPTURE CHRONIC RUPTURE HEALTHY TENDON Expensive, not dynamic Better at detecting partial ruptures Staging of degenerative changes, (monitor healing) MRI MRI

20. Management Goals Optimize gastro- soleous strength and function Restore musculotendinous length and tension . Avoid ankle stiffness

21. 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

22. Preserve anterior paratenon bl. supply Beware of sural nerve Debride and approximate tendon ends Use 2-4 stranded locked suture technique Close paratenon separately Principles: Surgical management

23. Operative Treatment A: Defects of 1 cm or less Direct end to end repair without augmentation Bunnell Suture Modified Kessler Many techniques available

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

25. 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 C: Defects 2 - 5 cm

26. Case of tendoachilles rupture M/28 3 Months old injury USG : 25 mm gap , 38 mm proximal to calcaneal tuberosity

27. Surgical Technique Chronic rupture with fibrosed tissue

28. Plantaris 5 cm GAP

29. Semi-T Harvested

30. Semi-T passed through the proximal Musculo-Tendinous junction

31. Semi-T passed through Calcaneum

32. SemiT fixed to calcaneum using IF Screw

33. SemiT and Plantaris are sutured with distal & proximal TA using nonaborbable suture

34. Cast in Equinus for 3 Weeks

35. F’up at 6 wks & 2 Months

36. Defects > 5 cm SemiT Transfer ± V-Y myotendinous lengthening

37. Percutaneous vs. Open Less wound complications Lim et al. 33 patients 7 infections Higher re-rupture rate Wong et al. 367 repairs 12% re-rupture Bradley 12% perc vs. 0% open Greater Strength Cetti 111 patients General Consensus: Perc Less wound complications Better cosmesis General Consensus: Open Return to preinjury level Decreased calf atrophy Better motion Less re-rupture

38. Open Injury Extensive debridement Wound Care Plastic Coverage And Tendon Transfer

39. POST OP COMPLICATIONS Deep infection (1%) Fistula (3%) Skin necrosis (2%), Rerupture (2%).

40. Neither Patient nor the Surgeon want Second Surgery or Rerupture

41. 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

42. Chronic Achilles tendon rupture Operative 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

43. Pateients ’ recovery depends largely on Their motivation , Focus & their desired postinjury activity

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