1. Presenter: Dr. Ankur Mittal

2. Diagnostic TestsXraysUltrasoundMRIImaging is rarely necessary in acute cases, but MRI or US may be helpful in thechronic cases for diagnosis and surgical planning.Ultrasound most often used for determining the thickness of the tendon and thesize of the gap on a complete rupture; requires skilled / experienced hands.MRI is more expensive and has its best place in diagnosing incomplete tears and for diagnosis of and planning surgical treatment for chronic tears. 3. Imaging X-rays Indicated if fracture oravulsion fracturesuspected 4. KAGERS TRIANGLE 5. Imaging Ultrasound Inexpensive, fast, reproducable,dynamic examination possible Operator dependent Best to measure thickness andgap Good screening test forcomplete rupture 6. Longitudinal sonogram shows a partial-thickness tear or tendinosis that was confirmed withsurgical findings in a 49-year-old woman with chronic pain in the Achilles tendon. Hartgerink P et al. Radiology 2001;220:406-4122001 by Radiological Society of North America 7. Longitudinal sonogram shows a full-thickness tear, confirmed with surgical findings, in a 40- year-old man. Hartgerink P et al. Radiology 2001;220:406-4122001 by Radiological Society of North America 8. Imaging MRI Expensive, notdynamic Better at detectingpartial ruptures andstaging degenerativechanges, (monitorhealing) 9. ACUTE ACHILLES TENDON RUPTUREHEALTHYACHILLESTENDONCHRONICACHILLESTENDONRUPTURE 10. Management Goals Restore musculotendinous length and tension. Optimize gastro-soleous strength and function Avoid ankle stiffness 11. TREATMENTAcute and Chronic Achilles Tendon Ruptures Chronic Ruptures>4-6 weeks since time of initialinjury Acute Ruptures Operative repairversus nonoperative protocol Options Techniques Results Complications Rehabilitation 12. ACUTE RUPTURESTreatment Controversial topic Lack of defined universally accepted outcome measures Multitude of different reparative techniques Diverse range of postoperative protocols Closed treatment was widely accepted as the standard of care in the early 20thcentury Operative repair has gained popularity in recent decades 13. Nonoperative Treatment Initial period of immobilization in equinus short leg non-weight bearing cast orsplint for 2 weeks Then convert to short leg walking cast or walking boot Boot or cast is typically worn for 6-8 weeks Gradual return to neutral ankle position over this time periodGentle ROM exercises begin after 6-8 weeks immobilization2-cm heel lift used during this transition periodProgressive-resistance exercises begun for calf muscles at 8-10 weeksGoal is return to running at 4-6 months and near normal power at 12months 14. Essential principles of conservative management immobilisation in equinus had to be maintained for a full 8weeks and for a further month the patient should walk with theshoe heel raised.The likelihood of rerupture was increased if the period ofimmobilisation was shortened. 15. Operative Treatment Direct primary repair End-to-end repair Bunnell suture with modified Kessler technique Interlocking suture technique Augmented repair Fascial turn-down Plantaris tendon augmentation Peroneus brevis augmentation Percutaneous repair (sural nerve entrapment) 16. CHRONIC RUPTURES TreatmentBasic tenets of reconstruction 1. Restore optimal length,strength, and function 2. Reconstruct the gap withappropriately strong tissueNon-Operative TreatmentLimited indicationsMedically ill, household ambulatorsTreat with spring-loaded hinged AFO 17. Chronic Rupture Reconstruction Turn-down flaps V-Y plasty Turn-down flap Tendon transfer FHL FDL Peroneus Brevis Artificial materials 18. Operative Treatment Defects of 1 cm or lessDirect repair without augmentation (rarely feasible)Defects 1 - 2 cmMuscle mobilization augmentation (plantaris)Can gain up to 2 cm with mobilization Defects 2 - 5 cm No consensus on best reconstruction technique Flexor hallucis longus (FHL) tendon transferFHL second strongest ankle plantar flexorFHL contractile axis most closely approximates Achilles tendon Other transfers, to include flexor digitorum longus (FDL) or peroneal brevis tendons V-Y myotendinous lengthening FHL transfer 19. Defects > 5 cmV-Y myotendinous lengthening FHL transfer or other augmentationTurndown procedure augmentationRequires at least 1-cm wide strip of Achilles tendonLength of strip must be long enough to span 2 cm above and 2 cmbelow the defectMassive incision requiredBulk of residual tissue at turndown junction may becomesymptomaticSynthetic materials (Marlex / Dacron)Mixed results; longterm durability questionablePotential for wound healing complications 20. Surgery or Not ? Taylor your treatment to the patient 21. Surgery or Not ? Repair is stronger Less risk of re-rupture Earlier return to activity Open or percutaneous 22. Surgical 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 23. Many different techniques of surgical repair have been described however which byitself suggests that there may be difficulties.One of these is that when spontaneous rupture occurs the tendon is frequentlydegenerate and the torn ends can be ragged and not ideal for a neat suture.The loads transmitted through the Achilles tendon are so great that even themost perfect suture cannot be relied upon until healing is advanced and thereforethe repair must be supplemented by some method of splintage for severalweeks as in conservative management. 24. It has been known for many years that tendons which are ruptured or dividedoutside synovial sheaths have a strong tendency to undergo spontaneous repair.The collagen fibres in the scar which grows between the ends becomesorganised and orientated to resemble closely the structure of tendon.Provided the tendon ends are held in close appositionthis natural repair will occur without lengthening and virtually normal functioncan be restoredsuccessful method of treatment which involved bandaging the calf and raising theheel of his shoe for a few weeks with excellent recovery.If the divided ends of the tendon are allowed to retract, healing will still take place butwith lenthening and consequent loss of power in the affected muscles. 25. Suture MaterialA variety of satisfactory suture materials are available for tendon repairBUTIn clinical situations, most surgeons find that the braided polyester sutures(Ethibond,Dacron,Ticron, Mersilene) provide sufficient resistance to disruptingforces and gap formation, handle easily, and have satisfactory knotcharacteristics; consequently these sutures are widely used 26. Surgical Management Bunnell Suture Modified Kessler Many techniquesavailable 27. A, Conventional Bunnell stitch. B, Crisscross stitch. E, Modified Kessler stitch with singleknot at repair. F, Tajima modification of . C, Mason-Allen (Chicago) stitch. D,Kessler stitch with double knots at Kessler grasping stitchrepair site. 28. Techniques for acute Achilles tendon ruptureKrackow suture 29. Lindholm devised a method of repairing ruptures of the Achilles tendonthat reinforces the sutures with living fascia and prevents adhesion of therepaired tendon to the overlying skin Lindholm technique for repairing ruptures of Achilles tendon 30. Lynn described a method of repairing ruptures of the Achilles tendon in whichthe plantaris tendon is fanned out to make a membrane 2.5 cm or greater widefor reinforcing the repair. The method is useful for injuries less than about 10days old; later the plantaris tendon becomes incorporated in the scar tissue andcannot be identified easily.Lynn technique for repairing freshrupture of Achilles tendon. A, RupturedAchilles tendon has been sutured, andplantaris tendon has been divideddistally and is being fanned out to formmembrane. B, Fanned-out plantaristendon has been placed over repair ofAchilles tendon and sutured in place 31. Teuffer described a method to be used when the possibility of end-to-endsuture of a ragged tendon is remote. His method uses the peroneus brevistendon as a dynamic transfer and a reinforcing tendon graft. Dynamic loop suture of peroneus brevis to itself when end-to-end suture is impossible 32. Turco and Spinella described a modification in which the peroneus brevis ispassed through a midcoronal slit in the distal stump of the Achilles tendon. Thegraft is sutured medially and laterally to the stump and proximally to the tendonwith multiple interrupted sutures to prevent splitting of the distal tendon stump(Fig. 46-15). This modification can be beneficial if a long distal stump is present.Turco and Spinella modification.Peroneus brevis is passed throughmidcoronal slit in distal stump ofAchilles tendon and sutured to stumpand to tendon. 33. Surgical: Percutaneous Ma and Griffith 6 stab incisions Less woundcomplications Injury to sural nerve Not anatomic Tension hard toestablish Guided instruments 34. Techniques for neglected rupture of Achilles tendon . A, Exposure of Achilles tendon and tuberosity through posterolateral incision. Peroneus brevis is passed through hole drilled in tuberosity and sutured to Achilles tendon. B, Plantaris tendon is passed through ruptured ends of tendon. 35. Bosworth technique for repairing oldruptures of Achilles tendon 36. V-Y repair of neglected rupture of Achilles tendon. A, Incision.B, Design of V flap. C, Y repair and end-to-end anastomosis 37. Repair of chronic Achilles tendonrupture with flexor hallucis longus. A,Two incisions are made. Medial midlineincision on midfoot is used to harvestflexor tendon. Posteromedial incisionanterior to Achilles tendon is used toexpose tendon. B, Hole is drilled justdeep to Achilles tendon insertion and isdirected plantarward. Second drill holeis made from medial to lateral tointersect first drill hole midway throughposterior body of calcaneus. C, Flexorhallucis longus is woven throughremaining portion of Achilles tendon tosecure fixation and supplementation oftendon. 38. TURN DOWN FLAP 39. Turn down flap Artificial material 40. Percutaneous vs. Open Less wound complications Lim et al. 33 patientsGeneral Consensus: Perc 7 infections Higher re-rupture rateLess wound complications Wong et al. Better cosmesis 367 repairs 12% re-rupture Bradley General Consensus: Open 12% perc vs. 0% open Greater StrengthReturn to preinjury level Cetti Decreased calf atrophy 111 patients Better motionLess re-rupture 41. POST OP COMPLICATIONSdeep infection (1%) fistula (3%) skin necrosis (2%), rerupture (2%). 42. Post- Op CareCast applied in ORRemove sutures, apply a2 wks walking cast with heel liftTouch WB2 weeksStart physio for ROMAllow progressive weight-exercises. No activebearing in removable castplantarflexion When WBAT and2- 4 weeks foot is plantigradeStart a strengtheningRemove cast and walk with aprogram1cm shoe lift x 1 month 43. Rehabilitation Physical Therapy Stretching and flexibility exercise are key to helping tendon healwithout shortening and becoming chronically painful. Ultrasound heat therapy improves blood circulation, which may aidthe healing process. Transcutaneous electrical nerve stimulation (TENS) is sometimesused and may provide pain relief for some people. Massage helps you increase flexibility and blood circulation in thelower leg and can help prevent further injury. Wearing a night brace keeps your leg flexed and prevents yourAchilles tendon from tightening while you sleep. An Achillestendon that chronically tightens at night is not able to heal properly. 44. Post Surgery Rehabilitation Phase I- PWB(partial weight bearing) beginning 4 weeks post-op Gait training (wean from heel lift after 2 weeks if applicable) Soft tissue massage and/or modalities as needed Exercises: Towel calf stretch(without pain) 45. Theraband exercises dorsi andplantar flexion, inversion, eversion 46. Sitting calf raises BAPS(Biomechanical ankle platform systemStraight leg raisesBAPS (Biomechanical ankle platform system) in sittingBike light if ROM (range of motion) allowsMay perform pool exs also The patient may do this mainly as an independent program ifappropriate Progress to Phase II when: -tolerates all Phase I without pain or significant increase in swelling-ambulates FWB (full weight bearing) without device-ROM for plantar flexion, inversion and eversion are normal-dorsi flexion is at approximately neutral 47. Post Surgery Rehab Phase II (6-8 weeks post op) Gait training Soft tissue work and/or modalities as needed Exercises: Standing gastroc and soleus stretches Bike light to moderate resistance as tolerated Leg press: quads bilateral to unilateral calf raises (sub-maximal bilateral to unilateral) Sitting calf raises to standing at (generally 8-10 weeks)BAPS(Biomechanical ankle platform system) board standing (withsupport as needed) 48. Step upsStep downsUnilateral stance; balance activities with challenges if appropriate (suchas ground clock)Mini-squats bilateral to unilateralStairmaster short steps 4", no greater than level 4 if no pain orinflammationMay continue pool if appropriate 49. Post Surgery Rehab Phase III (generally not before 10-12 weeks) Frequency at discretion of therapistGait normal without deviceStanding calf raises to unilateral (generally 16 weeks)Outdoor bikingFull/maximal one leg PREs [progressive resistance exercises] (generallyat 16 weeks) Agility drills (generally not before 16-20 weeks. Should be discussed with physician first.) - jogging to running when pain-free -sport-specific; cutting, side shuffles, jumping, hopping 50. Progress to Phase III when:-cleared by physician-can do each of Phase II activities without pain or swelling-ROM equal bilaterally-able to do bilateral calf raise without difficulty and weight equalbilaterally-unilateral stance balance equal bilaterally 51. Return To Play After surgery an athlete should not return to play untilthey meet the criteria for progression to Phase III. Even after completing Phase III the athlete shouldreturn at the discretion of their doctor and/or physicaltherapist. 52. Prevention Avoid activities that place excessive stress on your heelcords, such as hill-running and jumping activities(especially if done consistently). If you notice pain during exercise, rest. If one exercise or activity causes you persistent pain, tryanother. Alternate high-impact sports, such as running, with low-impact sports, such as walking, biking or swimming. Maintain a healthy weight. Wear well-fitting athletic shoes with proper cushioning inthe heels. 53. Prevention To avoid reoccurrence of an Achilles tendon injury: Use warm-up and cool down exercises and calf- strengthening exercises. Apply ice to your Achilles tendon after exercise. Alternate high-impact sports with low impact sports, so as not to overwork your Achilles tendons. 54. SUMMARY Chronic Achilles tendon rupture Operative treatment when possible Acute Achilles tendon rupture Operative treatment for the young athletic higher demand patient Closed treatment for those patients with limited functional goals or medical comorbidities Results for both options similar Functional rehabilitation when possible