SLIDE 1 Achilles Tendon Surgery: Early and late problems What I need post-op
- Michael J. Coughlin, MD
- Co-chair NFL Foot and Ankle
Committee
SLIDE 2 Anatomy
– 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
SLIDE 3 Younger patient
- less than 25 years-
- rupture-
- Hyper-pronation
- Tight Achilles
- Faulty footwear
SLIDE 4 Area of rupture
- the same area as tendinosis
in older patients
\
SLIDE 5 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
- verstretches the tendon causing it to tear
SLIDE 6 David Beckham Achilles Tendon Rupture
SLIDE 7
SLIDE 8 Achilles Rupture Demographics
Ruptures peak in 2nd, 3rd and 4th 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.
SLIDE 9 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
SLIDE 10 Achilles Ruptures in the NFL
2010 – 2014
Total Achilles Tendon Ruptures = 66 players Preseason = 33 ruptures Regular Season = 31 ruptures Postseason = 2 ruptures
SLIDE 11 Most Common Activities
– Cut/Change in Direction = 22 injuries – Sprinting/Running = 17 injuries
SLIDE 12 Unanswered questions:
- Do they return to prior condition, strength,
and performance?
- Age and conditioning-a factor?
SLIDE 13
Does small exposure and dissection mean better recovery and better performance
SLIDE 14
Pars technique
SLIDE 15
SLIDE 16 7/9 returned to play at 6 months
SLIDE 17 The problem
- These don’t hurt much
- The patient often doesn’t get it
- Can re-injure due to lack of
cooperation
SLIDE 18 Postop treatment
- Week one PF splint
- Week 2-3 drop out cast
SLIDE 19
- Wt. bearing at week 5
- Boot at week 4 with heel
lifts
week 10
SLIDE 20 Why do we choose to operate? Mark Glazebrook MD
SUTURES give strength! Resist Aggressive or reckless Rehab Especially weeks 2-12
SLIDE 21 Achilles Rupture: Primary Operative Treatment
Is the Dissection & Blood Supply Stripping Worth it ??? Complications Higher ~ 3 x Higher for OR
SLIDE 22 Non-operative Achilles Rupture Treatment
M.Glazebrook
SLIDE 23 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
SLIDE 24 Serious Complications Less Frequent but real!!
Infection, pulm. embolus
MG
SLIDE 25 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
SLIDE 26
Is the pendulum changing? MAYBE?
SLIDE 27 Older patient
> 25 years-
problem
SLIDE 28 Thick tendon
- mid-substance tendinosis or rupture-
- Etiology
– Extrinsic stress – Degeneration – Microtrauma
is at risk!
SLIDE 29 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)
SLIDE 30
Clinical findings
SLIDE 31 Pathology
and extrinsic stress
degeneration and microtrauma
is at risk!!!
SLIDE 32
Radiographic findings
Calcification in the tendon!
SLIDE 33
Operative treatment WHAT IS THE PROBLEM?
SLIDE 34 Early problems
–less than 4 weeks-
– Infection – Wound dehiscence – Wound slough – Re-rupture
SLIDE 35 Eradicate infection
- Antibiotics
- Debridement
- Skin graft
- Wound vac
SLIDE 36
Wound sinus
SLIDE 37 Clostridia infection
Courtesy A. Younger M.D.
SLIDE 38 Intermediate problems
- between 4-12 weeks-
- Draining sinus tract
- Re-rupture
SLIDE 39
Late problem- Old rupture
SLIDE 40 Late problems
12 weeks
- Over lengthening (stretching out)
- Re-rupture
- Tendinoses
SLIDE 41 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
SLIDE 42 Conservative care
SLIDE 43 Conservative treatment
SLIDE 44 Preventative treatment
- Prevention
- Full thickness skin flaps
- Placing the foot in equinus
in the cast initially
SLIDE 45 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
SLIDE 46 Surgical treatment
– FHL
– Turn down flap – “V-Y” plasty
SLIDE 47 FHL transfer
tendinoses
SLIDE 48 Tendinoses?
salvageable?
SLIDE 49
Tendon resection
SLIDE 50
FDL Tendon transfer
SLIDE 51
Tendon turndown
SLIDE 52
Comprehensive resection and reconstruction!!!
SLIDE 53
Turn-down flat
SLIDE 54
“V-Y plasty”
SLIDE 56
SLIDE 57
Single incision technique
SLIDE 58
Harvest the tendon, just above the tunnel
SLIDE 59
Using the fiber loop to secure the tendon
SLIDE 60
Size the tendon
SLIDE 61
Drill pin out the plantar aspect
SLIDE 62
Drilling hole with ACL reamer
SLIDE 63
Passing the suture, and then the tendon
SLIDE 64
Secure with appropriate tendon with biotenodesis screw
SLIDE 65
SLIDE 66 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
SLIDE 67
Wound problems
SLIDE 68
Successful healing
SLIDE 69 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
SLIDE 70 Two more points
– Active quad sets, leg lifts immedicately post
– Anti-coagulation (ASA usually)
SLIDE 71 Complications
- Infections-disasterous
- Delayed wound healing
- Aggressive PT post-ops
- Tailor surgery to the individual
– Magnitude of problem – Duration of symptoms
