Traditional Repair Consistent Results The Following relationships - - PowerPoint PPT Presentation

The Following relationships exist: Royalties and stock options – Smith and Nephew, Wolters Kluwer Consulting income – Smith and Nephew, Research and educational support – Mitek, DJO, Smith & Nephew

Traditional Repair Consistent Results

Achilles Mythology

Greatest Greek Warrior and Athlete Vulnerable Only in Heel & Killed by Trojan Arrow Achilles Injury → End of Athletic Career (?)

Anatomy - Achilles

Largest Tendon in Body Connects Triceps Surae

(M/L Gastroc + Soleus) to Os Calcis

1.2 - 2.5 cm Wide at Insertion 5-6 mm

Thick at Ankle

TENDON INSERTION Upper 25% - Free Area PLANTAR FASCIA

Plantar Fascia &Tendoachilles MERGE w/ PERIOSTEUM

(Lower 50%)

ANTERIOR TRIANGLE

CROSS SECTION OF HEEL

Plantar Fat Pad TENDO ACHILLES

Blood Supply - Achilles Tenuous at Best Worst 2-6 cm Above Insertion into Calcaneus

Biomechanics - Achilles

Tendon Tensile Strength 2 x of Associated Muscle Tension Applied to Tendon Resisted 1º by Collagen Collagen Crosslinks Fail 8% Strain

Incidence of Acute Achilles Tendon Ruptures Has Increased Over the Past 50 Years More “Weekend Warriors” Doing Sports Pts = 30-50 Yrs, M > F Most Occur in Watershed Area 2-6 cm Above Calcaneal Insertion

Complete Achilles Rupture

Acute

Complete Achilles Rupture

Acute Acute Achilles Tendon Ruptures: 18 per 100,000/yr Incidence in Professional Athletes Is Much Lower Than General Population

NBA: 18 ruptures in 23 Seasons (0.78 Ruptures/Season) NFL: 31 Ruptures in 5 Seasons (6.2 Ruptures/Seasons)

Complete Achilles Rupture

Acute

Pain, Swelling, Difficulty Walking “Feels Like Someone Kicked Me” PE: Palpable Gap, (+) Thompson Test MRI, Ultrasound Only Indicated in Large Pts to Verify Rupture

Acute Achilles Repair Rules

Re-Establish Physiologic Tension – Prep Out Both Legs Prevent Shortening or Lengthening Obtain Secure Fixation Pajala et al. – Direct Repair Alone as Good as Repair with G-S Augmentation

Krackow Achilles Stitch

Described by Krackow et al in 1986 Originally Developed to Facilitate Capsule and Ligament Advancement for TKR Locking Stitch That Resists Pull Out But Does Not Constrict Tissues

JBJS 68-A: 764, 1986

Complete Achilles Tears

Acute - Operative Open Medial Incision to Avoid Injuring Sural Nerve Use Only Suture Retraction On the Skin Edges to Avoid Necrosis Irrigate Out Hematoma and Minimal Debridement of Tendon

1 2 3

Weave #2 Nonasorbable Strong Suture with Krackow Stitches Release Deep Fascia to Allow Easier Paratenon Closure Compare Normal Achilles to Injured One to Verify Correct Tension With Sutures

Complete Achilles Tears

Acute - Operative

1 2 3

Tie Sutures With Foot Plantar Flexed. Then Tie Suture Ends Together Laterally Oversew Edges With 3-0 PDS Reinforce With Plantaris Tendon if Present BEWARE of Sural Nerve Place in SLCNWB With 5-10° Plantarflexion

Complete Achilles Tears

Acute - Operative

1 2 3

Acute Achilles Repair Rehab

Traditional (Cast) vs. Early Motion (Boot) Depends on Quality of Tendon & Repair You Must Trust Patient To Use Early Motion Boot = Use “Achilles Set- Up” With Full PF & Block DF Past Neutral (0°)

Maxey & Magnusson – Rehab of Post Surgical Orthopedic Pt, 2013

Acute Repair Rehab

Early Functional Activities Start in Pool Therapy Phase I → IV Program At 6 Months – Return to 94% of Preinjury Functional Level

Maxey & Magnusson – Rehab of Post Surgical Orthopedic Pt, 2013

Open Achilles Repair Complications

Infection Adhesions Nerve Injury (Sural) Wound Dehiscence Rerupture of Achilles DVT or PE Scar Sensitivity

Achilles Tendon Repair Facts

Rerupture Rate: Non-op 12.6% Open-op 3.5% Wound Complications: Non-op 0% Open-op 26.1% PerQ – op 8.3% Strength & Activity – Non-op Rx Associated With Signif. Deficits in High Speed PF Strength & Hopping Ability Return to Sports: Non-op 63% Open-op 71%

Achilles Tendon Rupture: Surgery vs. Non Surgery

Lantto et al – Prospectively Studied 30 Pts – Non Surgery; 30 Pts – Open Repair Leppilahti Score: 79 – Surgery, 75 – Non Surgery Surgery Resulted in Faster & Better Recovery of Calf Muscle Strength at 6 & 18 Months Surgery Pts Had Better Physical Function & Less Bodily Pain on RAND 36 Health Survey at 18 Months

AJSM 44:2406, 2016

Repair of Acute Achilles Tendon Tears in NBA Players Amin et al. – Studied 18 Players Ave Age = 30 Years; Ave BMI = 26 Ave Playing Experience = 7.6 Years Results:

Never Returned to Play = 7 Played One Season = 11 (8 Played at Least 2 Seasons)

Players Showed Signif. ↓ In Playing Time and Performance

ASSM 41:1864, 2013

DeAngelo Hall Slips, Tears Achilles Tendon “Mini Open” Repair During Late-Night Pizza Run

Don’t Believe Phinit!

Pearls – Open Achilles Tendon Repair Prep Both Legs

Use Only Suture to Retract Skin Edges Save the Paratenon and Release Deep

Fascia Use #2 Strong Suture With Krackow Stitches Match Tension on Injured Tendon With Uninjured Achilles Tendon

Open Achilles Repair Conclusion

Open Achilles Repair is the Choice of Champions!

Kobe Bryant Wesley Matthews