Achilles Tendon Injury Miko

8/6/2019 Achilles Tendon Injury Miko

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ACHILLES TENDON INJURY

Widiyatmiko

Sport Injury Division ReferatDepartment of Orthopaedic and Traumatology

Faculty Of Medicine Padjadjaran University


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Anatomic Considerations

Achilles tendon

Paratenon

RetroAchilles bursa(a)

Retro Calcanealbursa (b)

Posterior Calcanealprocess

Blood Supply


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Anatomy


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Achilles: History

Greek warrior in Trojanwar

Mother dipped in riverStyx to makeimmortal

Invulnerable exceptheel

Killed by Paris


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Achilles Tendon Pathology

Achilles Tendinopathy

Peritendinitis

Tendinosis Insertional vs. Non-insertional

Chronic rupture

Acute rupture


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Aims

Anatomy and function

Classification

Aetiology Pathology

Clinical features

Management


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Pathogenesis

Intrinsic Factors

General

Decreased perfusion

Systemic diseases

Gender/age/weight

ocal

Valgus/Planus

Limb length

Extrinsic Factors

General

Corticosteriods

Fluroquinolone

Drugs/narcotics

Sports

Training errors

Excessive loads Environment


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Micro-Anatomy

Kastelic et al, 1978


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Function

Plantar-flexion of the ankle in late stance

700N on heel elevation

Up to 4000N in running Elasticity


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Classification of Disorders

Insertional

Retrocalcaneal bursitis

Insertional tendinopathy Non-Insertional

Paratendinitis

Paratendinitis with tendinopathy

Tendinopathy


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Retrocalcaneal Bursitis

Pain

Swelling

Footwear

Tenderness


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Ice

Anti-inflammatories

Heel lift

Low/cushioned heelcounter

Surgical resection


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Ice

Anti-inflammatories

Heel lift


Surgical resection

Bursa

Haglunds deformity


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Ice

Anti-inflammatories

Heel lift


Surgical resection

Bursa

Haglunds deformity


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Insertional Tendinitis

Pain

Swelling

Footwear

Tenderness


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Ice

Anti-inflammatories

Heel lift

Heel cushions

Splints Immobilisation


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Resection Spur

Degenerate tendon

Osteotomy

Reconstruction Eg. FHL tendon transfer


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Resection Spur

Degenerate tendon

Osteotomy

Reconstruction Eg. FHL tendon transfer


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Resection

Spur

Degenerate tendon

Osteotomy

Reconstruction

eg. FHL tendon transfer


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Non-Insertional Tendinitis

Aetiology

Overuse

Hypovascularity

Tendon twist

Heel pronation

SmallAchilles tendon

Diabetes Steroid use

Oakes, 2003


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Heat generation


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Prevention

Exercise

Hydration

Orthoses


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Paratendinitis


Tendinopathy


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Paratendinitis


Tendinopathy


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Pathology

Inflammation / Repair

Bleeding

Phagocytosis Vascular ingrowth

Fibroblast proliferation

Collagen production

Type III then Type I


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Pathology

Effect of movement

Detrimental to collagen orientation in first threeweeks leading to weaker repair

After first three weeks beneficial for collagen

orientation and ultimate tensile strength of repair


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Pathology

Remodelling / Maturation

Reduced cell numbers

Reduced water content Collagen concentration reduced, but total amount

increased

Shortening of repair, probably by myofibroblasts


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Ice

Anti-inflammatories

Modified activity Heel lift

Stretching programme

? Immobilisation


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Surgery

Paratendinitis

Excision of thickened paratenon

Tendinopathy

Debridement of diseased tendon

Reconstruction


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Achilles Tendon Rupture

Tendinopathy

Excessive force


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Epidemiology: Acute

Gender Males 2:1 over

females Carden 87

Age 30-45 and 70s

Pillet 72

Industrializedcountries

Left > Right


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Acute Rupture

Intrinsic factors

Extrinsic factors

Spontaneous

Degeneration

Mechanical


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Site of Rupture

Myotendinous Jxn

Midsubstance2-6 cm proximal toinsertion

Avulsion


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Rupture Mechanism

Direct trauma

Pushing off with foot in PF, knee extended

(concentric) Unexpected DF

At 8% tendon will fail


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Diagnosis

History

Male between 30 and 50 years

Sedentary job but in athletic activity Weekend Warrior

Pop, hit in the back of the leg

Pain posteriorly in calf

Bruising

Pain is variable


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Diagnosis

Physical Exam

Palpable defect

Thompson Test Tip-toe test

Bruising/Swelling

Weakness


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Thompson Test

Positive Test: NoPF


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Diagnosis

Diagnostic Tests

Xrays

Avulsion suspected

Ultrasound

Eval approximation

MRI

Complete rupture Tendinosis


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Goals of Treatment

Define functional and athletic goals

Prevent complications

Optimize rapid return to full function

Minimize morbidity


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Treatment Options

Nonsurgical Surgical

Cast Immobilization

Functional Bracing

Percutaneous

Open

?

? ?


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SurgicalSurgical CastsCasts

MorbidityMorbidity -- ++Hospital CostsHospital Costs -- ++

Wound ProblemsWound Problems -- ++

Strength and EnduranceStrength and Endurance ++ --

ReRe--rupture Raterupture Rate ++(2%)(2%)

--(18%)(18%)


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Nonsurgical: Cast

Start early

Equinus Casts

4 weeks Bring to neutral

4 to 6 weeks

Heel lift

Physical therapy


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Nonsurgical: Functional

Bracing Immobilization

1 to 3 weeks

Brace/Splint Prevent dorsiflextion

Keep at 20 PF coaptends

Full weightbearing


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Cast vs. Functional

Higher re-rupture with casts Lea and Smith (11%)

Therman et al. (functional) 350 patients

Re-rupture 2%

Peterson et al.

50 patients randomized into cast or CAM Re-rupture 17% in cast

General Consensus: Cast

* Decreased calf circumference

* Less plantarflexionpower

* Higher re-rupture rate


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Surgical: Percutaneous

Ma andGriffith

6 stab incisions

Less woundcomplications

Injury to sural nerve

Not anatomic

Tension hard toestablish

Guided instruments


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Surgical: Open

10 to 14 days

Decreased swelling

Organization of mopends

*Anatomic repair

*Correct tension


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Open Technique

Central Incision

Debride mop ends

Direct suture repair Krackow

Nonabsorbable

Repair paratenon

Augmentation

Turn down flap FHL transfer

Plantaris

Synthetic material


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Rehab

Immobilization for 5 - 6 weeks Equinus 4 weeks; Neutral 2 weeks

Functional treatment

PT Heel lifts

Early WB MaffulliAm J S Med 2003

Not detrimental to repair

No differ in strength Less adhesions

Earlier time to work


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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 topreinjury level

Decreased calf atrophy

Better motion

Less re-rupture


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End to End Repair vs.

Augmentation Strength of repair = suture technique

Unwarranted

Indications: Late presenting rupture

Neglected ruptures

Re-ruptures


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Surgical vs. Nonsurgical


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Conclusion

Individualize patients

Determine patient goals

Promising percutaneous repair Conservative

Functional bracing

Augmentation really not needed


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Thank you

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Achilles Tendon Injury Miko