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CME- on Tendo Achillis Injury
Citation preview
CME ON
TENDO - ACHILLIS
Prepared By:Dr. Md Nazrul IslamMBBS, M.sc.(Biomedical Engineering)Presenting By:Dr. Golam Mahmud (Suhash)
Dept. Of Orthopaedics & Traumatology Saheed Surahwardy Medical College Hospital, Dhaka-1207,Bangladesh.
Largest tendon in the body
Origin from gastrocnemius and soleus muscles
Insertion on calcaneal tuberosity
Anatomy
Lacks a true synovial sheath-
Paratenon has visceral and parietal layers
Allows for 1.5cm of tendon glide
Anatomy
Paratenon Anterior – richly
vascularized The remainder – multiple
thin membranes
Anatomy
Blood supply1) Musculotendinous junction2) Osseous insertion on
calcaneus3) Multiple mesotenal vessels on
anterior surface of paratenon (in adipose)
– Transverse vincula Fewest @ 2 to 6 cm
proximal to osseous insertion
Anatomy
Remarkable response to stress Exercise induces tendon
diameter increase Inactivity or immobilization
causes rapid atrophy Age-related decreases in cell
density, collagen fibril diameter and density Older athletes have higher injury
susceptibility
Physiology
Gastrocnemius-soleus-Achilles complex Spans 3 joints
Flex knee Plantar flex tibiotalar joint Supinate subtalar joint
Up to 10 times body weight through tendon when running
Biomechanics
1. Close injury/rupture 2. Open injury/rupture
• Acute injury• Neglected injury
Classification Of Tendo Achillis injury-
1. Accidental cut injury (bath room injury, road traffic injury)
2. Social/political Violence
Open Tendo Achilles injury
1. Diagnosis and assessment of extend of injury.2. Primary care3. Operative treatment
Management of open injuries
PathophysiologyRepetitive
microtrauma in a relatively hypovascular area.
Reparative process unable to keep up
May be on the background of a degenerative tendon
Achilles Tendon Rupture(close injury)
Antecedent tendinitis/tendinosis in 15%
75% of sports-related ruptures happen in patients between 30-40 years of age.
Most ruptures occur in watershed area 4cm proximal to the calcaneal insertion.
Achilles Tendon Rupture: Textbook Facts
Classification of tendon inflammation & degeneration
History Feels like being kicked in the leg Case reports of fluoroquinolone use,
steroid injections Mechanism
Eccentric loading (running backwards in tennis)
Sudden unexpected dorsiflexion of ankle
(Direct blow or laceration)
Achilles Tendon Rupture
A case of Tendo-achilis injury (closed)-
Prone patient with feet over edge of bedPalpation of entire length of muscle- tendon unit during active and passive ROMCompare tendon width to other sideNote tenderness, crepitation, warmth, swelling, nodularity, palpable defects
Physical Examination-
Partial
Localized tenderness +/- nodularity
CompleteDefectCannot heel raisePositive Thompson test
Achilles Tendon Rupture-
Physical-
Positive Thompson test-
NEGATIVE THOMPSON TEST IN UNINJURED TENDOACHILIS-
Gap in rupture Tendo-achillis injury-
Diagnostic Pitfalls 23% missed by Primary Physician
(Inglis & Sculco) Tendon defect can be masked by
hematoma Plantar-flexion power of extrinsic foot
flexors retained Thompson test can produce a false-
negative if accessory ankle flexors also squeezed
Achilles Tendon Rupture-
X-RAY-
This lateral x-ray of the calcaneus shows an avulsion fracture at the insertion of the Achilles tendon, with marked separation of fragments..
Imaging
Inexpensive, fast, reproducable,
dynamic examination possible Operator dependent Best to measure thickness and
gap Good screening test for
complete rupture
Imaging
Ultrasound
Expensive, not dynamic Better at detecting partial
ruptures and staging degenerative changes, (monitor healing)
Imaging
MRI
Restore musculotendinous length and tension.
Optimize gastro-soleous strength and function
Avoid ankle stiffness
Management Goals-
Cast in Plantarflexion CAM Walker or cast with plantarflexion q 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
Conservative Management
Preserve anterior paratenon blood supply
Beware of sural nerve Debride and approximate tendon
ends Use 2-4 stranded locked suture
technique May augment with absorbable
suture Close paratenon separately
Surgical Management-
Exposed ruptured tendoachilis-
Acute case : usually end to end repair is enough
Neglected case: Advancement plasy (V-Y) or reconstruction by other tendons
Surgical Management (cont.)
V-Y plasty and repair Tendoachilis-
After repair of Tendo-achilis-
IMMOBILIZATION, POSITIONING & CAST-
Assess strength of repair, tension and ROM intra-op.
Apply long leg cast with ankle in the least amount of planterflexion(gravity equinus) & knee 60 degree flexion with window at operated site.
Stitch removal after 2 wks. Short leg cast after 3 wks with partial
equinus correction
Surgical Management : Post Operative Care-
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.
Post-op. management(continue)-
Acute rupture of tendon Achilles. A prospective randomised
study ofcomparison between surgical and non-surgical treatment.Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8
112 patients
Surgery +
Early functional rehab in brace
Casted x 8 wks
21 % re-rupture 1.7% re-rupture
5% infection
2% Sural nerve inj.No difference in functional outcome
Conservative vs. Surgical-
AFTER CARE-
PATIENT SATISFACTION & SMILE-
Special Thanks To-
Associate Prof. Dr. P C DebenathAssociate Prof. Sheikh Abbas Uddin
Assistant Prof. Dr. Kazi ShamimuzzamanDr. Subir Hossain Shuvro
Sponsored By-Incepta Pharmaceuticals Ltd.
Dhaka, Bangladesh.
THANK YOUFrom Orthopaedics’ & Traumatology DepartmentShaheed Suhrawardy Medical College HospitalSher- E- Bangla-Nagor,Dhaka-1207,Bangladesh.