Achilles Tendon Surgery: Early and late problems What I need - PowerPoint PPT Presentation

Achilles Tendon Surgery: Early and late problems What I need post-op • Michael J. Coughlin, MD • Co-chair NFL Foot and Ankle Committee

Anatomy • Gastrocsoleus – Largest muscle in the calf • 5-10 mm. thick at level of supramalleoli • 1.5-2 cm. wide – Zone of avascularity – Rotates 90 degrees • Spiral allows elongation and recoil – Paratenon-little vascularity

Younger patient -less than 25 years- -rupture- • Hyper-pronation • Tight Achilles • Faulty footwear

Area of rupture -the same area as tendinosis in older patients \

Rupture of the Achilles Tendon The most common injury method is caused by a rapid dorsiflexion force during a jump or running push off which overstretches the tendon causing it to tear

David Beckham Achilles Tendon Rupture

Achilles Rupture Demographics Ruptures peak in 2 nd , 3 rd and 4 th decades. Men > women Results from: Raikin SM, Garras DN, Krapchev PV. Achilles tendon injuries in a United States population. Foot Ankle Int 2013;34(4):475-480 .

General population – Football much smaller segment Results from: Raikin SM, Garras DN, Krapchev PV. Achilles tendon injuries in a United States population. Foot Ankle Int 2013;34(4):475-480.

Achilles Ruptures in the NFL 2010 – 2014 Total Achilles Tendon Ruptures = 66 players Preseason = 33 ruptures Regular Season = 31 ruptures Postseason = 2 ruptures

Most Common Activities – Cut/Change in Direction = 22 injuries – Sprinting/Running = 17 injuries

Unanswered questions: • Do they return to prior condition, strength, and performance? • Age and conditioning-a factor?

Does small exposure and dissection mean better recovery and better performance

Pars technique

7/9 returned to play at 6 months

The problem • These don ’ t hurt much • The patient often doesn ’ t get it • Can re-injure due to lack of cooperation

Postop treatment • Week one PF splint • Week 2-3 drop out cast

• Wt. bearing at week 5 • Boot at week 4 with heel lifts • Out of boot gradually at week 10

Why do we choose to operate? Mark Glazebrook MD SUTURES give strength! Resist Aggressive or reckless Rehab Especially weeks 2-12

Achilles Rupture: Primary Operative Treatment Is the Dissection & Blood Supply Stripping Worth it ??? Complications Higher ~ 3 x Higher for OR

Non-operative Achilles Rupture Treatment M.Glazebrook

Results Primary outcome: Complications -Surgery 13, Non-surgery 2 • NO Significant Difference in Re- rupture: – Operative 2 of 72 – Non Operative 3 of 72 MG

Serious Complications Less Frequent but real!! MG Infection, pulm. embolus

Conclusion: This study provides Level I Support: 1. Accelerated functional rehabilitation and Non operative treatment for Achilles tendon ruptures. 2. Application of a nonoperative protocol will avoid complications MG

Is the pendulum changing? MAYBE?

Older patient > 25 years- • Intrinsic tendon problem

Thick tendon -mid-substance tendinosis or rupture- • Etiology – Extrinsic stress – Degeneration – Microtrauma • Aging tendon is at risk!

Force across the Achilles (6-10 times body weight) Mann mathamatics • Walking 1 mile = 63 tons a mile • Running 1 mile = 110 tons a mile • Running a marathon = 2860 tons (For a 150 lb person)

Clinical findings

Pathology • Aging process and extrinsic stress • Inflammation, degeneration and microtrauma • The aging tendon is at risk!!!

Radiographic findings Calcification in the tendon!

Operative treatment WHAT IS THE PROBLEM?

Early problems –less than 4 weeks- • Rupture and repair – Infection – Wound dehiscence – Wound slough – Re-rupture

Eradicate infection • Antibiotics • Debridement • Skin graft • Wound vac

Wound sinus

Clostridia infection Courtesy A. Younger M.D.

Intermediate problems - between 4-12 weeks- • Draining sinus tract • Re-rupture

Late problem- Old rupture

Late problems  12 weeks • Over lengthening (stretching out) • Re-rupture • Tendinoses

History and Physical exam • Pain in area 2-6 cm proximal to insertion • Infection • Weakness, atrophy • Painful scar • Inadequate skin coverage – -an unforgiving area • Over-lengthened or incompetent Achilles

Conservative care • Brace • AFO

Conservative treatment • Below knee cast

Preventative treatment • Prevention • Full thickness skin flaps • Placing the foot in equinus in the cast initially

Surgical treatment - Principles of salvage- • Keep an intact musculo- tendinous unit • Use of substitute tendon as a scaffolding for the tendon repair • Advance all or part of the Achilles tendon

Surgical treatment • Tendon transfers – FHL • Gastrocsoleus “ plasties ” – Turn down flap – “ V-Y ” plasty

FHL transfer • Distal tendinoses

Tendinoses? • Is tendon salvageable?

Tendon resection

FDL Tendon transfer

Tendon turndown

Comprehensive resection and reconstruction!!!

Turn-down flat

“ V-Y plasty ”

“ V-Y ” plasty J. DeOrio MD

Single incision technique

Harvest the tendon, just above the tunnel

Using the fiber loop to secure the tendon

Size the tendon

Drill pin out the plantar aspect

Drilling hole with ACL reamer

Passing the suture, and then the tendon

Secure with appropriate tendon with biotenodesis screw

Post-op care • Immobilize in cast for 6 weeks • Partial weight bearing at 3 weeks • Cam-boot, FWB with ROM at 6 weeks • Jogging, speed walking -12 wks

Wound problems

Successful healing

Post-op care-following reconstruction-these are slower! (major P.T. work to rehab the calf) • Ankle in 10 ° equinus • Neutral at 4 weeks • Wt. bearing at 4-6 weeks • AFO at 12 weeks • Athletics at 6 months

Two more points – Active quad sets, leg lifts immedicately post op and going forward – Anti-coagulation (ASA usually)

Complications • Infections-disasterous • Delayed wound healing • Aggressive PT post-ops • Tailor surgery to the individual – Magnitude of problem – Duration of symptoms