Chronic Achilles rupture

Dr.Rajiv ShahFoot & ankle surgeon‘Foot & ankle orthopaedics’Vadodara, Surat

Defined as 4-6 weeks post-trauma

Chronic ruptureNeglected ruptureLate /old repairDelayed reconstructions

Around 20-25% of acute ru

ptures are

missed by in

itial p

hysicians!!

H/o trauma, prior problems, local injection, drugs

Unsteady gaitDifficulty in ascending/descendingLimpDifficulty in rising on tip toe

Palpable gap +/- !!

Pain --- !!

Increased

dorsiflexion

Reduced plantarflexion

strength

Inability to

stand on tip

of toe ( m

ore so on

repetitions)

Haglund, spur, calcification Gap on dynamic USG MRI – degeneration, tear

Neglected/old rupture can also heal!! Defect fills up with fibrous tissues!!

Conservativ

e management:

when?

Poor skin condition DM Co-morbid conditions Smoking? Prior surgical scarring?? Patient's desire

Conservativ

e management:

what? High-topped boots Laced ankle brace Custom-moulded

leather ankle lacer

Cast? – controversialfor cases with < than 4 weeks

An aggressive calf-strengthening exercise program can enable patient to function adequately with impaired Achilles function!!

SURGERY

AUGMENTATIONFASCIA LATAGRACILLIS

SEMITENDINOSUS

PERONEIPATELLAR TENDON

PRIMARY REPAIR(UNCOMMON)

FASCIAL ADVANCEMENTV-Y PLASTYCENTRAL TURN DOWN

Local tendon transfer

• FHL • FDL • PB • PL • Plantaris

Synthetic or allograft • Polyglycol

threads • Marlex mesh • Dacron vascular graft • Carbon fibre • Allograft tendon substitution

Surgical algorithmC

hro

nic

ru

ptu

re

Gap up to 2cmsDirect repair

Pull tendon for 5 minutes

Gap up to 2-5 cmsTurn-overV-Y plasty

Gap > than 5 cms Transfer

Generous excision of fibrosis & dead tendon is a must!

9

Pull the tendon for five minutes & gain length

V-Y advancement

Tip: Make limbs twice as long as gap to be filled

Incision Closer look

12

Central turn down

14

Central turn down

15

FHL + Turn down

16

In phase transfer 30% of Achilles strength FHL is close to TA Increases blood supply FHL: single/double/triple

incisions

FHL transfer

FHL transfer – single incision

FHL transfer – double incision

FHL IDENTIFICATION: LEG

FHL IDENTIFICATION: FOOT

FHL transfer – double incision

FHL RETRIEVAL FHL SUTURED TO ITSELF AFTER PASSING IT THROUGH BONE TUNNEL

MIS harvest of FHL –Dr.Panchbhavi

FHL transfer – 3 incisionsT H Lui – whole length FHL transfer

22

FHL transfer – function

23

FHL can be sacrificed without loss of function!!

That’s all…Thank you all…