Tendo-Achilles-Injury-And-Its-Management.pptx

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					 Largest   tendon in the
  body
 Origin from
  gastrocnemius and
  soleus muscles
 Insertion on
  calcaneal tuberosity
    Lacks a true synovial
    sheath-


 Paratenon has
  visceral and parietal
  layers
 Allows for 1.5cm of
  tendon glide
    Paratenon
 Anterior – richly
  vascularized
 The remainder – multiple
  thin membranes
Blood supply
1)   Musculotendinous junction
2)   Osseous insertion on calcaneus
3)   Multiple mesotenal vessels on
     anterior surface of paratenon (in
     adipose)
     –   Transverse vincula
           Fewest @ 2 to 6 cm proximal
            to osseous insertion
   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
   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
1.   Close injury/rupture
2.   Open injury/rupture

     • Acute injury
     • Neglected injury
1.   Accidental cut injury
     (bath room injury,
     road traffic injury)
2.   Social/political
     Violence
1. Diagnosis and
assessment of extend
of injury.
2. Primary care
3. Operative treatment
      Pathophysiology
     Repetitive microtrauma
      in a relatively
      hypovascular area.
     Reparative process
      unable to keep up
     May be on the
      background of a
      degenerative tendon
 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.
    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)
Prone   patient with feet over edge of
 bed
Palpation of entire length of muscle-
 tendon unit during active and
 passive ROM
Compare tendon width to other side
Note tenderness, crepitation,
 warmth, swelling, nodularity,
 palpable defects
 Partial
  Localized tenderness

   +/- nodularity
 Complete
  Defect

  Cannot heel raise

  Positive Thompson test
 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
  This lateral x-ray of the
calcaneus shows an
avulsion fracture at the
insertion of the Achilles
tendon, with marked
separation of fragments.
.
 Inexpensive, fast, reproducable,
  dynamic examination possible
 Operator dependent
 Best to measure thickness and gap
 Good screening test for complete
  rupture
   Expensive, not dynamic
   Better at detecting partial
    ruptures and staging
    degenerative changes,
    (monitor healing)
 Restore
  musculotendinous length
  and tension.
 Optimize gastro-soleous
  strength and function
 Avoid ankle stiffness
                                   CAM Walker or cast with
                        2 wks      plantarflexion q 2 wks

                                                 4 weeks

Start physio for ROM            Allow progressive weight-
exercises                       bearing in removable cast

                         When WBAT and          2- 4 weeks
                         foot is plantigrade

Start a strengthening           Remove cast and walk with shoe
program                         lift. Start with 2cm x 1 month,
                                then 1cm x1 month then D/C
 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
 Acute  case : usually end
  to end repair is enough
 Neglected case:
  Advancement plasy (V-
  Y) or reconstruction by
  other tendons
 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
 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.
             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


Casted x 8 wks                                 Surgery +
                                               Early functional rehab
                                               in brace


21 % re-rupture                                    1.7% re-rupture
                                                   5%     infection
                      No difference in
                      functional outcome           2% Sural nerve inj.

				
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