NIEK VAN DIJK Las Vegas 2017 Achilles Tendinopathy Isolated - - PowerPoint PPT Presentation

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NIEK VAN DIJK Las Vegas 2017 Achilles Tendinopathy Isolated - - PowerPoint PPT Presentation

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NIEK VAN DIJK Las Vegas 2017 Achilles Tendinopathy Isolated Syndesmotic Instability Arthrodesis still the Best Option Academic Medical Centre Amsterdam Ripoll de Prado Sport Clinic Madrid Clinica Do Dragao

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NIEK VAN DIJK Las Vegas 2017

www.ankleplatform.com

Academic Medical Centre Amsterdam Ripoll de Prado Sport Clinic Madrid Clinica Do Dragao Porto

Achilles Tendinopathy Isolated Syndesmotic Instability Arthrodesis still the Best Option

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NIEK VAN DIJK Las Vegas 2017

www.ankleplatform.com

Academic Medical Centre Amsterdam Ripoll de Prado Sport Clinic Madrid Clinica Do Dragao Porto

Achilles Tendinopathy

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This presentation and the information contained herein was prepared exclusively by the presenter, Dr. C. Niek van Dijk, M.D. The views and opinions expressed in this presentation are those of the presenter and do not reflect the position,

  • pinion, or guidelines for clinical care of any other person,

institution, scientific association, or product manufacturer.

Disclaimer

Achilles Tendinopathy Isolated Syndesmotic Instability Arthrodesis still the Best Option

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Hindfoot Endoscopy 2005

  • Non-insertional
  • Paratendinopathy
  • Paratendinopathy + Tendinopathy
  • Tendinopathy
  • Insertional
  • Retrocalcaneal Bursitis
  • Retrocalc. Bursitis +

Insertional Tendinopathy

  • Insertional Tendinopathy

Achilles Tendon Pathology

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Achilles Tendon Pathology

MRI

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Tendinopathy Conservative Treatment Eccentric Calf Muscle Training

Conservative treatment

Set A: extended knee 90x Set B: 30° flexed knee 90x

Alfredson H, Am.J.Sp.M. 1998

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AMC (n=53) accepted AJSM: – 56% still complaints at 6 wks – 2.7-5.2 yr FU (n=40): all had additional treatments 3 (7.5%) same complaints Rationale: Sclerosing injections obliterate neovessels – 2005: 95% good results

Polidocanol by Alfredson and co-workers

Ohberg 2002 (AT), Alfredson 2005 (AT), 2005 (shoulder), 2006 (PT)

M van Sterkenburg et al ,2010

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RCT Platelet Rich Plasma

De Vos 2010 JAMA PRP vs. saline : Same outcome at 6 months

De Vos, Tol 2010

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Surgical Treatment

70’s

Kvist &Kvist 1980

Induction of Chemical Inflammation

Outcome 50-50

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  • Complaints > 1 year
  • Localized symptoms
  • Mechanically intact tendon
  • MRI < 40% degeneration
  • Medial pain

Extra-Articular Endoscopy

Tendinopathy + Paratendinopathy Endoscopic Treatment 1995

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  • Sport Resumption : 42 days (35-70)
  • Work Resumption : 21days (10-56)
  • FAOS
  • SF 36 : Normal
  • Overal Satisfaction : All Patients Satisfied

with the Outcome

Tendinopathy + Paratendinopathy 1995-2002 n=21

Pain 93 (8) Other Symptoms 90(10) ADL 99 (2) Sports 92(10) F.Steenstra 2005

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Origin of the Pain? Tendinopathy

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Achilles Tendinopathy: Cause of pain?

Increased demand Adequate repair Inadequate repair

  • f microrupture

Increased vulnerable to injury Further decrease

  • f collagen& matrix

Tenocyte Inadequate collagen& matrix production disruption

Tendinopathy

Cycle

Tendinopathy Origin of the Pain?

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Achilles Tendinopathy: Cause of pain?

Neoangiogenesis & Nerve proliferation Increased demand Adequate repair Inadequate repair

  • f microrupture

Increased vulnerable to injury Further decrease

  • f collagen& matrix

Tenocyte Inadequate collagen& matrix production disruption Cytokines: VEGF PDGF EGF

Cycle

Neurogenic Inflammation

Tendinopathy

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Achilles Tendinopathy: Cause of pain?

Neoangiogenesis & Nerve proliferation Degradation of extracellular matrix Increased demand Adequate repair Inadequate repair

  • f microrupture

Increased vulnerable to injury Further decrease

  • f collagen& matrix

Tenocyte Inadequate collagen& matrix production disruption Cytokines: VEGF PDGF EGF

Cycle

Neurogenic Inflammation

Tendinopathy

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Achilles Tendinopathy: Cause of pain?

Neoangiogenesis & Nerve proliferation Degradation of extracellular matrix Myofibroblast proliferation Increased demand Adequate repair Inadequate repair

  • f microrupture

Increased vulnerable to injury Further decrease

  • f collagen& matrix

Tenocyte Inadequate collagen& matrix production disruption Cytokines: VEGF PDGF EGF

Cycle

Neurogenic Inflammation

Tendinopathy

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Achilles Tendinopathy: Cause of pain?

Neoangiogenesis & Nerve proliferation Degradation of extracellular matrix Myofibroblast proliferation Scarring & Shrinkage Increased demand Adequate repair Inadequate repair

  • f microrupture

Increased vulnerable to injury Further decrease

  • f collagen& matrix

Tenocyte Inadequate collagen& matrix production disruption Cytokines: VEGF PDGF EGF

Neurogenic Inflammation

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Achilles Tendinopathy: Cause of pain?

Neoangiogenesis & Nerve proliferation Degradation of extracellular matrix Myofibroblast proliferation Scarring & Shrinkage Increased demand Adequate repair Inadequate repair

  • f microrupture

Cytokines: VEGF PDGF EGF Obliteration of vessels

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Achilles Tendinopathy: Cause of pain?

Endoscopic surgery The Rationale for Endoscopic release

  • f the paratenon &

Release of the Plantaris Tendon

Denervation

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Conclusion

  • The pain originates from neonerves in peritendineum
  • Operative treatment options have traditionally been directed

towards tendon

  • Treat the peritendineum: denervation!
  • Consequences for degenerative tendon proper unknown

– no evidence that tendinopathy  rupture

Achilles Tendinopathy

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Tendinosis Reconstruction

Achilles Tendon Pathology

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Tendinosis Reconstruction

Achilles Tendon Pathology

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Hindfoot Endoscopy 2005

  • Non-insertional
  • Paratendinopathy
  • Paratendinopathy + Tendinopathy
  • Tendinopathy
  • Insertional
  • Retrocalcaneal Bursitis
  • Retrocalc. Bursitis +

Insertional Tendinopathy

  • Insertional Tendinopathy

Achilles Tendon Pathology

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Hindfoot Endoscopy 2005

  • Non-insertional
  • Paratendinopathy
  • Paratendinopathy + Tendinopathy
  • Tendinopathy
  • Insertional
  • Retrocalcaneal Bursitis
  • Retrocalc. Bursitis +

Insertional Tendinopathy

  • Insertional Tendinopathy

Achilles Tendon Pathology

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Achilles Tendon Pathology

Endoscopic calcaneoplasty

Technique

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Endoscopic calcaneoplasty

Hindfoot Endoscopy 2006

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Endoscopic calcaneoplasty

Technique

Hindfoot Endoscopy 2006

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Endoscopic calcaneoplasty

Technique

Hindfoot Endoscopy 2006

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Hindfoot Endoscopy 2006

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Endoscopic calcaneoplasty

Technique

Hindfoot Endoscopy 2006

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Achilles Tendon Pathology

Insertional tendinopathy

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www.ankleplatform.com

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Insertional tendinopathy

www.ankleplatform.com

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Insertional tendinopathy

www.ankleplatform.com

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Insertional tendinopathy

www.ankleplatform.com

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Insertional Tendinopathy

Achilles Tendon Pathology

www.ankleplatform.com

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Fig_01_27_Sec_ACTR_3D_COMPOSITE Fig_07_127_Sec_ACTR_3D_CORRECT_STILL Fig_09_141_A_Sec_ACTR_3D_STILL Fig_08_127_Sec_ACTR_3D_INCORRECT_STILL

Keepers for Technique Guide; note Fig. 7 & 8 replaced 1/14 with images that show lasermarks

Fig_02_35_Sec_ACTR_3D_STILL Fig_03_48_Sec_ACTR_3D_STILL Fig_04_57_Sec_ACTR_3D_STILL Fig_05_107B_Sec_ACTR_3D_STILL Fig_10_09_Sec_ACTR_3D_STILL

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End

Thank You