SAM A. L ABI B, MD F AOA E mo ry Unive rsity. Atla nta , GA. e - - PowerPoint PPT Presentation

e mo ryhe a lthc a re .o rg / o rtho

CHRONIC ACHIL L E S RE PAIR: RE SE CT T HE SCAR AND SUT URE , NO GRAF T .

SAM A. L ABI B, MD F AOA E mo ry Unive rsity. Atla nta , GA.

DISCLOSURES

• Re se a rc h/ F

e llo wshi p F unding : Arthre x, Ossur, L inva te c

• Co nsulta nt:

Arthre x, Me dsha pe , Stryke r

ACHILLES TENDON RUPTURE TESTS

• THOMPSON’S 96%
• PRONE KNEE

FLEXION (MATLES) 88%

• AT RESTING ANGLE

= 45.1 DEGREES

• PALPABLE TENDON

DEFECT 73% Missed Dx up to 25%

ACHILLES TENDON RUPTURE

• RUNNE

RS, MAL E S, OVE RUSE

• 60-75% SPORT

S RE L AT E D

• MAL

E S, BL OOD GROUP 0

• DE

VE L OPE D COUNT RI E S = 18/ 100,000

• RUPT

URE : I N 2017- MAY OF F E R RE PAI R I N ACT I VE PAT I E NT S?

• F

UNCT IONAL RE HAB

RCT- OPERATIVE VERSUS NON OPERATIVE: JBJS OCT 2010

• Ac c le ra te d

F unc tiona l Re ha b for both

• NWB Splint X 2 wks
• 2 c m He e l L

ift

• PWB Bo o t 2 - 4 wks
• F

WB Bo o t 4 - 8 wks NO I MPORT ANT DI F F BUT

• 144 e nro lle d
• 80% c o mple te d F

/ U

• 63-68% Cyb e x
• Co le ma n Sc o re = 95
• PF

stre ng th 15- 20% le ss in Non Op g roup*

• Ca lf Girth 4-5 c m

sma lle r in No n Op

HOW ABOUT CHRONIC RUPT URE ?

• GAP F

ORMAT ION AND L E NGT HE NING

• RE

ST I NG ANGL E = 45.1 DE G.

• YOUNG + ACT

I VE

• MANUAL

WORK E RS

• WE

AK NE SS

• T

E NDI NOSI S PAI N

• L

OSS PF ST RE NGT H

• SI

NGL E HE E L RI SE –ve

• DE

SI RE T O RT P

KRAEUTLER MJ, PURCELL JM, HUNT KJ. CHRONIC ACHILLES TENDON

• RUPTURES. FOOT & ANKLE INTERNATIONAL. 2017 MAY.

CURRENT CONCEPT REVIEW

• T

able 3. Sc he me fo r the

Surg ic a l T re a tme nt o f Chro nic

• Ac hille s T

e ndon Ruptur e s on the Basis of Gap Size .

• De fe c t Size Sur

gic al Pr

• c e dur

e

• 1-2 c m

E nd-to -e nd a na sto mo sis a nd po ste rio r c o mpa rtme nt fa sc io to my

• 2-5 c m

V-Y le ng the ning , a ug me nte d with te ndo n tra nsfe r if ne e de d

• >5 c m

T e ndo n tra nsfe r a lo ne o r in c o mb ina tio n with V-Y a dva nc e me nt o r turndo wn

Mye rso n MS. Ac hille s te ndo n rupture s. I

• nstr. Co urse L

e c t. 1999;48:219-230.

• T

able 2. Summa ry o f Gra de s o f

Re c o mme nda tio n.

T r e atme nt Gr ade of Re c omme ndation

• No no pe ra tive ma na g e me nt

I

• Prima ry re pa ir

I

• V-Y te ndo n pla sty

C

• T

e ndo n tra nsfe r B

• T

urndo wn fla p C

• Allo g ra ft re c o nstruc tio n

I

• Auto g ra ft re c o nstruc tio n

B

e mo ryhe a lthc a re .o rg / o rtho

YASUDA T

, SHI MA H, MORI K , K I ZAWA M, NE O M. DIRE

CT RE PAIR OF CHRONIC ACHIL L E S T E NDON RUPT URE S USING SCAR T ISSUE L OCAT E D BE T WE E N T HE T E NDON ST

• UMPS. JBJS. 2016 JUL

20;98(14):1168-75.

• 33 Ac hille s te ndo n rupture s with a de la y in dia g no sis o f

>4 we e ks unde rwe nt re mo va l o f a se c tio n o f sc a r a nd he a ling tissue with dire c t prima ry suture o f the e nds o f the te ndo n witho ut the use o f a llo g ra ft o r a uto g ra ft.

• Me a n F

/ U 33 mo nths. L e ng th o f Ga p= 43 mm( 25-80 mm)

• Amo unt o f sc a r tissue re se c te d = 26mm (15- 50 mm)
• AOF

AS sc o re s we re 98.1 po ints po sto pe ra tive ly. T he me a n po sto pe ra tive AT RS wa s 92.0 po ints.

• Po sto pe ra tive T

2-we ig hte d MRI : fusifo rm-sha pe d te ndo n thic ke ning a nd ho mo g e ne o us lo w-sig na l a lte ra tio ns o f the te ndo ns in a ll pa tie nts.

• Histo lo g ic a lly, the inte rpo se d sc a r tissue c o nsiste d o f

de nse c o lla g e n fib e rs.

Me dia l Appro a c h. Pre se rve Pa ra te no n. K ra c ko w Suture . Ankle 20-30 de g re e s Pla nta r-F le x.

MODIFIED KRACKOW TECHNIQUE= GIFTBOX

• FOR EACH PAIR, ONE TENDON

WAS REPAIRED WITH A SINGLE KRACKOW WHILE THE OTHER WAS REPAIRED WITH A MODIFIED KRACKOW.

• #2 FORTIFIED POLYESTER. EACH

SUTURE WAS PASSED PERIPHERALLY AND TIED ACROSS THE OPPOSITE TRANSVERSE LIMB

• WE CALLED THE “CRISS-CROSS”

PATTERN “ GIFTBOX SUTURE”

MY PREFERRED METHOD: GIFTBOX TECHNIQUE

GIFTBOX BIOMECHANICAL ADVANTAGE

Maximum Load to Failure

LABIB SA, ROLF R, DACUS R, HUTTON WC. THE “GIFTBOX” REPAIR OF THE ACHILLES TENDON: A MODIFICATION OF THE KRACKOW TECHNIQUE. FOOT & ANKLE INTERNATIONAL. 2009 MAY;30(5):410-414.

THE “GIFTBOX” OPEN REPAIR OF THE ACHILLES TENDON: A MODIFICATION OF THE TRADITIONAL KRACKOW TECHNIQUE THAT INCREASES THE STRENGTH OF THE REPAIR.

e mo ryhe a lthc a re .o rg / o rtho

L ABI B SA, HOF F L E R CE , SHAH JN, ROL F RH, T I NGAN A. T

HE GIF T BOX OPE N ACHIL L E S T E NDON RE PAIR ME T HOD: A RE T ROSPE CT IVE CL INICAL SE RIE

• S. T

HE JOURNAL OF F OOT AND ANK L E SURGE

• RY. 2016 F

E B 29;55(1):39-44.

• Ma rc h 2002 to April 2007: A to ta l o f 44 sub je c ts, me a n a g e 37.5 ± 8.6

ye a rs, unde rwe nt surg e ry a ppro xima te ly 10.8 ± 6.5 da ys a fte r

• T

he pa tie nts c o mple te d the F

• o t F

unc tio n I nde x a nd the Ame ric a n Ortho pa e dic F

• o t a nd Ankle So c ie ty a nkle -hindfo o t sc a le . T

he te ndo n width a nd c a lf c irc umfe re nc e we re me a sure d b ila te ra lly a nd c o mpa re d

using paired t tests with a 5% α level. injury.

• T

he re spo nse ra te wa s 35 (79.54%) pa tie nts fo r the q ue stio nna ire a nd 20 (45.45%) fo r the e xa mina tio n. T he me a n fo llo w-up pe rio d wa s 35.7 ± 20.1 mo nths.

• Co mplic a tio ns inc lude d o ne stitc h a b sc e ss, pe rsiste nt pa in, a nd ke lo id

fo rma tio n. One (2.86%) re spo nde nt re po rte d sig nific a nt we a kne ss. F ive (14.29%) re spo nde nts indic a te d pe rsiste nt pe ri-inc isio na l numb ne ss.

• T

he me an AOF AS sc or e was 93.2 ± 6.8) and the me an F

• ot F

unc tion Inde x F F I sc or e was 7.0 ± 10.5.

• T

he c alf gir th and te ndon width diffe r e nc e s we re sta tistic a lly sig nific a ntly

b e twe e n the limb s.

• T

he pa tie nts re po rte d no r

e pe at r uptur e s, sur al ne r ve injur ie s, de hisc e nc e , or infe c tions.

e mo ryhe a lthc a re .o rg / o rtho

–

T

• inve stig a te the func tio na l o utc o me s o f the L

indho lm a nd Vuplius me tho ds fo r c hro nic Ac hille s te ndo n rupture

• Me tho ds

–

Re tro spe c tive a na lysis o f 15 pa tie nts, 13 ma le s a nd 2 fe ma le s, me a n a g e 35.2 ye a rs

–

8 pa tie nts unde rwe nt the L indho lm te c hniq ue , 7 unde rwe nt prima ry re pa ir with Vulpius le ng the ning te c hniq ue

–

Ho o ke r sc a le wa s use d to me a sure the a nkle func tio na l c a pa c ity in a ll pa tie nts. T he pa tie nts we re e va lua te d o n the b a sis o f the ir c a pa b ility to sta nd o n tipto e o n the a ffe c te d limb a nd the time re q uire d to re turn to pre -injury da ily a c tivitie s.

• Re sults

–

Me a n fo llo w-up o f 19.6 mo nths

–

Me a n inte rva l b e twe e n injury a nd time to surg e ry wa s 42 da ys

–

Pa tie nts re turne d to da ily a c tivity in a n a ve ra g e time o f 3.2 mo nths

–

Ho o ke r sc o re s e xc e lle nt fo r 11 pa tie nts a nd sa tisfa c to ry fo r 4

e mo ryhe a lthc a re .o rg / o rtho

• L

indho lm T e c hniq ue

–

Do ub le fla ps fro m g a stro c ne mius a po ne uro sis a re use d to re c o nstruc t the Ac hille s te ndo n

• Vulpius Me tho d

–

A “V” inc isio n is ma de in the pro xima l g a stro c ne mius with the a pe x pro xima l

–

Arms o f the inc isio n e a c h me a sure d 10c m in le ng th

–

Pro xima l stump o f the Ac hille s te ndo n is pulle d dista lly to b ridg e g a p with fo o t in pla nta r fle xio n

e mo ryhe a lthc a re .o rg / o rtho

RE F E RE NCE S

• Co sta ML

, Do ne ll ST , T uc ke r K . T he lo ng -te rm o utc o me o f te nd o n le ng the ning fo r c hro nic Ac hille s te nd o n pa in. F

• o t & a nkle inte rna tio na l. 2006 Se p;27(9):672-6.
• L

a b ib SA, Ro lf R, Da c us R, Hutto n WC. T he “Giftb o x” re pa ir o f the Ac hille s te nd o n: a mo d ific a tio n o f the K ra c ko w te c hniq ue . F

• o t & a nkle inte rna tio na l. 2009

Ma y;30(5):410-4.

• L

a b ib SA, Ho ffle r CE , Sha h JN, Ro lf RH, T ing a n A. T he g ift b o x o pe n Ac hille s te nd o n re pa ir me tho d : a re tro spe c tive c linic a l se rie s. T he Jo urna l o f F

• o t a nd Ankle

Surg e ry. 2016 F e b 29;55(1):39-44.

• Ma ffulli N. T

he c linic a l d ia g no sis o f sub c uta ne o us te a r o f the Ac hille s te nd o n. T he Ame ric a n jo urna l o f spo rts me d ic ine . 1998 F e b ;26(2):266-70.

• Oza n F

, Do g a r F , Gurb uz K , E kinc i Y, K

• yunc u S, Se kb a n H. Chro nic Ac hille s T

e nd o n Rupture Re c o nstruc tio n Using the L ind ho lm Me tho d a nd the Vulpius Me tho d . Jo urna l o f Clinic a l Me d ic ine Re se a rc h. 2017 Jul;9(7):573.

e mo ryhe a lthc a re .o rg / o rtho

OUR NE W E MORY SPORT S ME DICINE CE NT E R/ AT L ANT A HAWKS

• Emory will serve as the official

sports medicine provider for the Atlanta Hawks

• 90,000 square foot training and

sports medicine center

• First NBA practice facility to be co-

located with a sports medicine center occupying 30,000 sq. ft.

• Regional offices in John’s Creek,

Dunwoody, Smyrna, Spivey Station and Stonecrest

e mo ryhe a lthc a re .o rg / o rtho

E MORY SPORT S ME DICINE CE NT E R

• 28 exam rooms and 2 radiology

suites

• 3 Tesla MRI scanner
• Peak Performance Project (P3) will

also be housed at the new facility

• 3D motion capture and force plates
• Indoor and outdoor pools
• On-site blood/sweat testing and

analysis for nutritional deficits

e mo ryhe a lthc a re .o rg / o rtho

T HANK YOU

WWW.DRSAML ABIB.COM