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ACHILLES TENDON INJURY
Widiyatmiko
Sport Injury Division ReferatDepartment of Orthopaedic and Traumatology
Faculty Of Medicine Padjadjaran University
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Anatomic Considerations
Achilles tendon
Paratenon
RetroAchilles bursa(a)
Retro Calcanealbursa (b)
Posterior Calcanealprocess
Blood Supply
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Anatomy
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Achilles: History
Greek warrior in Trojanwar
Mother dipped in riverStyx to makeimmortal
Invulnerable exceptheel
Killed by Paris
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Achilles Tendon Pathology
Achilles Tendinopathy
Peritendinitis
Tendinosis Insertional vs. Non-insertional
Chronic rupture
Acute rupture
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Aims
Anatomy and function
Classification
Aetiology Pathology
Clinical features
Management
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Pathogenesis
Intrinsic Factors
General
Decreased perfusion
Systemic diseases
Gender/age/weight
ocal
Valgus/Planus
Limb length
Extrinsic Factors
General
Corticosteriods
Fluroquinolone
Drugs/narcotics
Sports
Training errors
Excessive loads Environment
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Micro-Anatomy
Kastelic et al, 1978
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Function
Plantar-flexion of the ankle in late stance
700N on heel elevation
Up to 4000N in running Elasticity
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Classification of Disorders
Insertional
Retrocalcaneal bursitis
Insertional tendinopathy Non-Insertional
Paratendinitis
Paratendinitis with tendinopathy
Tendinopathy
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Retrocalcaneal Bursitis
Pain
Swelling
Footwear
Tenderness
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Retrocalcaneal Bursitis
Ice
Anti-inflammatories
Heel lift
Low/cushioned heelcounter
Surgical resection
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Retrocalcaneal Bursitis
Ice
Anti-inflammatories
Heel lift
Low/cushioned heelcounter
Surgical resection
Bursa
Haglunds deformity
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Retrocalcaneal Bursitis
Ice
Anti-inflammatories
Heel lift
Low/cushioned heelcounter
Surgical resection
Bursa
Haglunds deformity
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Insertional Tendinitis
Pain
Swelling
Footwear
Tenderness
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Insertional Tendinitis
Ice
Anti-inflammatories
Heel lift
Heel cushions
Splints Immobilisation
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Insertional Tendinitis
Resection Spur
Degenerate tendon
Osteotomy
Reconstruction Eg. FHL tendon transfer
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Insertional Tendinitis
Resection Spur
Degenerate tendon
Osteotomy
Reconstruction Eg. FHL tendon transfer
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Insertional Tendinitis
Resection
Spur
Degenerate tendon
Osteotomy
Reconstruction
eg. FHL tendon transfer
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Non-Insertional Tendinitis
Aetiology
Overuse
Hypovascularity
Tendon twist
Heel pronation
SmallAchilles tendon
Diabetes Steroid use
Oakes, 2003
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Non-Insertional Tendinitis
Heat generation
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Prevention
Exercise
Hydration
Orthoses
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Non-Insertional Tendinitis
Paratendinitis
Paratendinitis with tendinopathy
Tendinopathy
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Non-Insertional Tendinitis
Paratendinitis
Paratendinitis with tendinopathy
Tendinopathy
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Pathology
Inflammation / Repair
Bleeding
Phagocytosis Vascular ingrowth
Fibroblast proliferation
Collagen production
Type III then Type I
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Pathology
Effect of movement
Detrimental to collagen orientation in first threeweeks leading to weaker repair
After first three weeks beneficial for collagen
orientation and ultimate tensile strength of repair
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Pathology
Remodelling / Maturation
Reduced cell numbers
Reduced water content Collagen concentration reduced, but total amount
increased
Shortening of repair, probably by myofibroblasts
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Non-Insertional Tendinitis
Ice
Anti-inflammatories
Modified activity Heel lift
Stretching programme
? Immobilisation
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Surgery
Paratendinitis
Excision of thickened paratenon
Tendinopathy
Debridement of diseased tendon
Reconstruction
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Achilles Tendon Rupture
Tendinopathy
Excessive force
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Epidemiology: Acute
Gender Males 2:1 over
females Carden 87
Age 30-45 and 70s
Pillet 72
Industrializedcountries
Left > Right
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Acute Rupture
Intrinsic factors
Extrinsic factors
Spontaneous
Degeneration
Mechanical
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Site of Rupture
Myotendinous Jxn
Midsubstance2-6 cm proximal toinsertion
Avulsion
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Rupture Mechanism
Direct trauma
Pushing off with foot in PF, knee extended
(concentric) Unexpected DF
At 8% tendon will fail
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Diagnosis
History
Male between 30 and 50 years
Sedentary job but in athletic activity Weekend Warrior
Pop, hit in the back of the leg
Pain posteriorly in calf
Bruising
Pain is variable
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Diagnosis
Physical Exam
Palpable defect
Thompson Test Tip-toe test
Bruising/Swelling
Weakness
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Thompson Test
Positive Test: NoPF
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Diagnosis
Diagnostic Tests
Xrays
Avulsion suspected
Ultrasound
Eval approximation
MRI
Complete rupture Tendinosis
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Goals of Treatment
Define functional and athletic goals
Prevent complications
Optimize rapid return to full function
Minimize morbidity
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Treatment Options
Nonsurgical Surgical
Cast Immobilization
Functional Bracing
Percutaneous
Open
?
? ?
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SurgicalSurgical CastsCasts
MorbidityMorbidity -- ++Hospital CostsHospital Costs -- ++
Wound ProblemsWound Problems -- ++
Strength and EnduranceStrength and Endurance ++ --
ReRe--rupture Raterupture Rate ++(2%)(2%)
--(18%)(18%)
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Nonsurgical: Cast
Start early
Equinus Casts
4 weeks Bring to neutral
4 to 6 weeks
Heel lift
Physical therapy
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Nonsurgical: Functional
Bracing Immobilization
1 to 3 weeks
Brace/Splint Prevent dorsiflextion
Keep at 20 PF coaptends
Full weightbearing
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Cast vs. Functional
Higher re-rupture with casts Lea and Smith (11%)
Therman et al. (functional) 350 patients
Re-rupture 2%
Peterson et al.
50 patients randomized into cast or CAM Re-rupture 17% in cast
General Consensus: Cast
* Decreased calf circumference
* Less plantarflexionpower
* Higher re-rupture rate
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Surgical: Percutaneous
Ma andGriffith
6 stab incisions
Less woundcomplications
Injury to sural nerve
Not anatomic
Tension hard toestablish
Guided instruments
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Surgical: Open
10 to 14 days
Decreased swelling
Organization of mopends
*Anatomic repair
*Correct tension
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Open Technique
Central Incision
Debride mop ends
Direct suture repair Krackow
Nonabsorbable
Repair paratenon
Augmentation
Turn down flap FHL transfer
Plantaris
Synthetic material
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Rehab
Immobilization for 5 - 6 weeks Equinus 4 weeks; Neutral 2 weeks
Functional treatment
PT Heel lifts
Early WB MaffulliAm J S Med 2003
Not detrimental to repair
No differ in strength Less adhesions
Earlier time to work
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Percutaneous vs. Open
Less wound complications Lim et al.
33 patients 7 infections
Higher re-rupture rate Wong et al.
367 repairs 12% re-rupture
Bradley 12% perc vs. 0% open
Greater Strength Cetti
111 patients
General Consensus: Perc
Less wound complications
Better cosmesis
General Consensus: Open
Return topreinjury level
Decreased calf atrophy
Better motion
Less re-rupture
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End to End Repair vs.
Augmentation Strength of repair = suture technique
Unwarranted
Indications: Late presenting rupture
Neglected ruptures
Re-ruptures
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Surgical vs. Nonsurgical
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Conclusion
Individualize patients
Determine patient goals
Promising percutaneous repair Conservative
Functional bracing
Augmentation really not needed
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Thank you