Insertional and Noninsertional Achilles Tendonitis Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd
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Lecture 19 parekh non insertional and insertional achilles tears
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Insertional and Noninsertional Achilles
TendonitisSelene G. Parekh, MD, MBA
Associate Professor of SurgeryPartner, North Carolina Orthopaedic Clinic
Department of Orthopaedic SurgeryAdjunct Faculty Fuqua Business School
• Multinodular disease• Severe disease• Paratendinopathies
Operative Management
• Minimally invasive stripping• Large diameter sutures passed through stab
incisions• Slide anterior to tendon to strip it
• No studies to show efficacy
Operative Management - I• Excision of Haglund’s deformity
• Position• Prone vs. supine
• Incisions• Lateral, medial both, or central
• Inflamed bursa excised• Enlarged tuberosity resected
• Tendon transfers• FHL (Wapner)
• Better length than FDL• Better biomechanics than FDL
Operative Management - I
• Prone
• Central, Achilles tendon splitting approach
• Elevate 70-80% of tendon insertion
• Resect Haglund’s check on fluoro
Operative Management - I
• Debride Achilles• < 50% involvement
• Anchors into calcaneus• Tie Achilles• Close Achilles split
Operative Management - I
• Debride Achilles• > 50 % involvement single incision technique
• Open deep fascia and find FHL muscle belly• Find FHL tendon and trace into canal• Plantarflex ankle and toe and pull on tendon• Release tendon• Drill hole anterior to Achilles insertion• Pass FHL tendon and screw• Repair Achilles insertion, split and skin
• Medial foot approach and find knot of Henry• Release FHL• Open deep fascia and find FHL muscle belly• Find FHL tendon and trace into canal• Pull FHL tendon through• Create 2 drill holes: one anterior to Achilles
insertion and one medial to lateral• Pass FHL tendon and tie to self
Operative Management - NI
• Debridement with/without tenosynovectomy• Moderate/severe disease• Debride all tendinopathic tissues
• <50%• +/- tubularization
• >50%• FHL transfer (single/double incision)
• Studies• Improved pain, functional outcomes,
• Fair evidence supports treatment
Post-Op Protocol
• No Tendon Transfer• NWB in Bulky Jones splint x 2wks• SLNWBC x 2 wks• SLWBC x 2 wks
• Tendon Transfer• NWB in Bulky Jones splint x 2wks• SLNWBC x 4 wks• WB CAM boot x 4 wks, start PT