Operative Management of Operative Management of Achil les Tendon Achil les Tendon

DisordersDisorders

Edward G. Magur, MDEdward G. Magur, MDCherry Blossom SeminarCherry Blossom Seminar

April 2012April 2012

Disclosure StatementDisclosure Statement

• Author receives no Author receives no compensation from compensation from any commercial any commercial entityentity

IntroductionIntroduction

• Largest/strongest tendon in human bodyLargest/strongest tendon in human body• Treatment tailored to pathology and Treatment tailored to pathology and

patient demandspatient demands• Initial treatment typically non-operativeInitial treatment typically non-operative

– Exception: rupturesException: ruptures

• Surgical intervention ranges from simple Surgical intervention ranges from simple to complexto complex

Surgical PrinciplesSurgical Principles

• Approach and soft tissue handlingApproach and soft tissue handling• Primary repair best when possiblePrimary repair best when possible• Reconstructive goalsReconstructive goals

– Bridge gapsBridge gaps– Restore blood supply/healing potentialRestore blood supply/healing potential– Provide tissue for repairProvide tissue for repair– Augment strengthAugment strength

Pathologic ConditionsPathologic Conditions

• RupturesRuptures– AcuteAcute– ChronicChronic

• Paratenonitis Paratenonitis

• Tendinosis Tendinosis

Acute Achilles RuptureAcute Achilles Rupture

• LocationLocation– Anywhere along Anywhere along

course of tendoncourse of tendon– MRI when in doubtMRI when in doubt– Very distal ruptures Very distal ruptures

and avulsions not and avulsions not rarerare

Acute Achilles RuptureAcute Achilles Rupture

• Open RepairOpen Repair– Remains “gold Remains “gold

standard”standard”– Technically Technically

straightforwardstraightforward– Allows early Allows early

rehabilitationrehabilitation– Low (<2%) re-Low (<2%) re-

rupture ratesrupture rates

Acute Achilles RuptureAcute Achilles Rupture

• Open RepairOpen Repair– Wound Wound

complicationscomplications• Highest with open Highest with open

repairrepair• Potentially Potentially

devastatingdevastating

Acute Achilles RuptureAcute Achilles Rupture

• Percutaneous Percutaneous RepairRepair– Gain in popularity Gain in popularity

last 10 yearslast 10 years– Commercially Commercially

available systemsavailable systems• Easier passage of Easier passage of

suturessutures• Less sural nerve Less sural nerve

entrapmententrapment

Percutaneous RepairPercutaneous Repair

• AdvantagesAdvantages– Smaller wound, less sloughSmaller wound, less slough– Decreased painDecreased pain+/- Earlier mobilization+/- Earlier mobilization

• DisadvantagesDisadvantages– Tendon apposition??Tendon apposition??– Higher rates of sural nerve injuryHigher rates of sural nerve injury– Transverse incision????Transverse incision????

Acute Achilles RuptureAcute Achilles Rupture

• Trends and pearlsTrends and pearls– Small medial incisionSmall medial incision

• ““Mini-open”Mini-open”– Full thickness flapFull thickness flap– Range to neutralRange to neutral– Shorter absolute immobilizationShorter absolute immobilization

• Dorsiflexion-limited ROM bootDorsiflexion-limited ROM boot– Earlier weightbearingEarlier weightbearing

Chronic Achilles RuptureChronic Achilles Rupture

• 4+ weeks after injury4+ weeks after injury• Missed ruptureMissed rupture• ““Silent rupture”Silent rupture”• Function based on M-T unit lengthFunction based on M-T unit length• Operative RxOperative Rx

– Based on function and patient requirementBased on function and patient requirement– Higher risksHigher risks

Chronic Achilles RuptureChronic Achilles Rupture

• Reconstructive OptionsReconstructive Options– V-Y lengtheningV-Y lengthening– Turndowns and local graftingTurndowns and local grafting– Tendon transferTendon transfer– Free graftsFree grafts

• AllograftAllograft• AutograftAutograft• Collagen matrix productsCollagen matrix products

V-Y LengtheningV-Y Lengthening

• Defects <5cmDefects <5cm• Limbs 2x defectLimbs 2x defect• AdvantageAdvantage

– Local tissueLocal tissue

• DisadvantageDisadvantage– Limited to 5 cmLimited to 5 cm– Initial weaknessInitial weakness

TurndownsTurndowns

• Multiple techniquesMultiple techniques• Central thirdCentral third• AdvantagesAdvantages

– Bridge large gapsBridge large gaps– Local tissueLocal tissue

• DisadvantagesDisadvantages– ““lump” at TD sitelump” at TD site– Two anastomosesTwo anastomoses

TransfersTransfers

• FHL most commonFHL most common– In phase transferIn phase transfer– Brings blood supply Brings blood supply

with musclewith muscle– Minimal donor Minimal donor

morbiditymorbidity• Exception: Athletes Exception: Athletes

& performing artists& performing artists

• CombinationsCombinations

AllograftsAllografts

• Minimal tissue Minimal tissue remainingremaining– InfectionInfection– Previous failed Previous failed

repairs/reconsrepairs/recons

• Multiple fixation Multiple fixation pointspoints– Slow incorporationSlow incorporation

ParatenonitisParatenonitis

• Generally Rx Generally Rx nonoperativelynonoperatively

• InjectiblesInjectibles– NO STEROIDSNO STEROIDS– BrisementBrisement

• Breaks up Breaks up adhesionsadhesions

Platelet Rich Plasma (PRP)Platelet Rich Plasma (PRP)

• Blood drawn & Blood drawn & CentrifugedCentrifuged– Platelets, stem cellsPlatelets, stem cells

• Injected into Injected into paratenonparatenon

• ““Growth Factors” Growth Factors” Make tendon healMake tendon heal

ParatenonitisParatenonitis

• SurgerySurgery– Rarely necessaryRarely necessary– Strip inflamed Strip inflamed

tissuetissue– Early motionEarly motion– 70-100% success 70-100% success

ratesrates

TendinosisTendinosis• Degeneration of Degeneration of

tendontendon– Poor blood Poor blood

supplysupply– Normal tendon Normal tendon

replaced with replaced with scar tissuescar tissue

• Insertional vs. Insertional vs. NoninsertionalNoninsertional

Insertional TendinosisInsertional Tendinosis

• Haglund’s DeformityHaglund’s Deformity– Typically presentTypically present

• Calcification common Calcification common – Long standing casesLong standing cases– Insertion becomes ossifiedInsertion becomes ossified

• Associated bursitisAssociated bursitis– RetrocalcanealRetrocalcaneal– AchillesAchilles

Insertional TendinosisInsertional Tendinosis

• Surgical RxSurgical Rx– Remove bony Remove bony

impingementimpingement– Resect all Resect all

degenerated and degenerated and calcified tendoncalcified tendon

– Prepare for Prepare for lengthening +/- lengthening +/- transfertransfer

TendinosisTendinosis

• Resect all Resect all degenerative degenerative tendontendon

• <50% requires <50% requires augmentaugment– FHL transfer most FHL transfer most

commonlycommonly

Pearls and PitfallsPearls and Pitfalls…and speaker’s biases…and speaker’s biases

- When feasible, approach off midlineWhen feasible, approach off midline- Avoid water-tight closureAvoid water-tight closure

- Hematoma---Hematoma--- Infection and slough Infection and slough

- Check wound early and oftenCheck wound early and often- Don’t get surprised in ORDon’t get surprised in OR

- MRI and pre-op planningMRI and pre-op planning- Adjunctive and multiple proceduresAdjunctive and multiple procedures- Anchors, biotenodesis screws, allograftsAnchors, biotenodesis screws, allografts

Pearls and PitfallsPearls and Pitfalls…and speaker’s biases…and speaker’s biases

- Address all pathologyAddress all pathology- Set tension to neutralSet tension to neutral- Trend early mobilization and WBTrend early mobilization and WB

- Largest factorLargest factor

- ““Lay the crepe”Lay the crepe”- Big reconstructions take 12-18 monthsBig reconstructions take 12-18 months- Risk for complications increase with big Risk for complications increase with big

surgerysurgery

Thank YouThank You