Download - Achilis tendon rupture
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TENDO - ACHILLIS
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Largest tendon in the body
Origin from gastrocnemius and soleus muscles
Insertion on calcaneal tuberosity
Anatomy
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Lacks a true synovial sheath-
Paratenon has visceral and parietal layers
Allows for 1.5cm of tendon glide
Anatomy
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Paratenon
Anterior – richly vascularized
The remainder – multiple thin membranes
Anatomy
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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
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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
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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
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1. Close injury/rupture 2. Open injury/rupture
• Acute injury• Neglected injury
Classification Of Tendo Achillis injury-
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1. Accidental cut injury (bath room injury, road traffic injury)
2. Social/political Violence
Open Tendo Achilles injury
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1. Diagnosis and assessment of extend of injury.2. Primary care3. Operative treatment
Management of open injuries
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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)
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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
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History Feels like being kicked in the leg Case reports of fluoroquinolone use,
steroid injections
Achilles Tendon Rupture
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Mechanism
Eccentric loading (running backwards in tennis)
Sudden unexpected dorsiflexion of ankle
(Direct blow or laceration)
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A case of Tendo-achilis injury (closed)-
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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-
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Partial
Localized tenderness +/- nodularity
CompleteDefectCannot heel raisePositive Thompson test
Achilles Tendon Rupture-
Physical-
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Positive Thompson test-
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NEGATIVE THOMPSON TEST IN UNINJURED TENDOACHILIS-
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Gap in rupture Tendo-achillis injury-
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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-
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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
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Inexpensive, fast, reproducable,
dynamic examination possible Operator dependent Best to measure thickness and
gap Good screening test for
complete rupture
Imaging
Ultrasound
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Expensive, not dynamic Better at detecting partial
ruptures and staging degenerative changes, (monitor healing)
Imaging
MRI
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Restore musculotendinous length and tension.
Optimize gastro-soleous strength and function
Avoid ankle stiffness
Management Goals-
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Cast in Plantarflexion cast with plantarflexion q 2 wks2 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
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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-
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Exposed ruptured tendoachilis-
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Acute case : usually end to end repair is enough
Neglected case: Advancement plasy (V-Y) or reconstruction by other tendons
Surgical Management (cont.)
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V-Y plasty and repair Tendoachilis-
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After repair of Tendo-achilis-
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IMMOBILIZATION, POSITIONING & CAST-
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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-
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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)-
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AFTER CARE-