- See:
Achilles Tendonitis
- Discussion:
- ruptures typically occur after age 30, more often in people beyond middle age;
- rupture at musculous tendinous junction occurs most often in young people, but ruptures near the calcaneus also occur;
- inciting event may be related to atrophy of the
soleus muscle, and commonly occur in weekend athletes;
- in 5-33% of patients there will be a prodromal incident of pain several days beforhand;
- mechanism usually involves eccentric loading on a dorsiflexed ankle with the knee extended (soleus and gastroc on maximal stretch);
- unlike flexor tendons in the hand, the Achilles tendon has no true synovial sheath, but rather is covered only by a paratenon;
- hence, exogenous healing (from synovial fluid) would not be expected to occur;
-
inciting causes:
- consider systemic conditions such as
gout or
hyperparathyroidism (esp with pure avulsion injury);
- inquire about previous steroid injections;
- injections of steroids into or around the Achilles tendon may provoke rupture and should generally be avoided;
- flouroquinolones may also contribute to tendon rupture;
- Exam Findings:
- Radiographic Studies:
- references:
-
Roentgenographic diagnoses of ruptured Achilles tendons.
- Non Operative Rx:
- Operative Repair:
-
discussion:
- most indicated in a younger patient w/ a clinically displaced rupture;
- may allow earlier return to sports, earlier return of muscle power, and a lower re-rupture rate as compared to non operative treatment;
- main complication is wound slough;
-
positioning:
- place the tourniquet on the leg in the supine position, before turning the patient prone (its difficult to place the tourniquet in the prone position);
- before prepping, note the resting equinus position of the uninjured leg (and attempt to reproduce this equinus position during surgery);
- if a surgical assistant is not available, position the patient so that the dorsum of the forefoot remains on the table (not
dangling off the table), so that the foot can be held in equinus during the tendon repair;
- incision:
- longitudinal incision is made just medial to achilles tendon;
- a medially placed incision may be less likely to slough from the pressure that the repaired tendon exerts on the overlying skin;
- additionally a medially placed incision is less likely to develop postop adhesions;
- a laterally placed incision may injure the
sural nerve and the lesser saphenous venous plexus;
- para-tenon:
- w/o creating a flap, the incision is carried down to the para-tenon;
- some surgeons will attempt to cut the paratenon straight over the tendon (as opposed to the the medial side in line with the incision);
- evaluate tendon defect:
- identify the level of the rupture of the Achilles tendon;
- attempt to identify the plantaris tendon;
- mobilize the proximal Achilles tendon by sweeping a finger circumferentially aroung the tendon border (thus breaking up adhesions);
- using non-traumatic clamps, match the ends of the ruptured tendon to achieve optimal length;
- suture repair:
- consider using a Krachow whip stitch, along each tendon edge, using No 5 Tycron or Ethibond
on a Non Cutting Needle;
- alternatively consider a running "Tajima stitch" which provides good strength but does
not create the overlying prominent sutures;
- Becker suture technique:
- has been studied extensively for flexor and extensor tendon lacerations in the hand;
- in the study by Singer et al 1998, the core suture technique was the most important element in establishing both
strength and stiffness of the repair;
- repair consists of criss-crossing running suture using a double armed needle;
- sutures should be placed 0.75 cm from the cut edge of the tendon;
- as noted in the report by Howard and Greenwald 1997, the MGH tendon repair technique (crossing running
suture repair) was signficantly more resistant to gap formation than the Bunnel or the Krackow technique;
- MGH tendon repair has superior suture purchase which is probably related to superior resistance to gap formation;
- the tendon edges are approximated together w/ non traumatic clamps, before the suture arms are
brought thru the tendon edges;
- before tying the sutures, note the degree of equinus in the opposite ankle (it is essential to optimize tension);
- each side is tied simultaneously to optimize tendon oposition;
- following the core suture repair, run a 2-0 Vicryl suture on a non-cutting needle to further oppose the irregular edges of the ruptured tendon;
- fascial augmentation:
- gastrocnemius aponeurosis:
- make rectangular 1-2 cm wide by 8 cm long flap from proximal tendon and gastroc aponeurosis which is raised to with in 3 cm of rupture site;
- don't cut out the previously inserted core sutures during this step;
- immediately beneath the gastroc fascia, the surgeon will note the soleus muscle;
- the proximal flap edge is then flipped distally across the repair site and sutured down;
- the fascial defect is closed with interrupted sutures;
- stated advantageous include less adhesion formation and a stronger repair;
- plantaris tendon augmentation:
- can be used to augment the repair by weaving it across the repair site;
- it can be left attached either proximally or distally;
- alternatively the plantaris tendon can be fanned out to make a 2.5 cm membrane that is then sutured around the repair site;
- attempt to close the paratenon, especially over the tendon repair site;
- this is important both for healing and prevention of adhesions;
- references:
-
Repair of the calcaneal tendon. An improved technique.
-
Repair of Achilles tendon ruptures with Dacron vascular graft.
-
A flap augmentation technique for Achilles tendon repair. Postoperative strength and functional outcome.
-
A new treatment of ruptured Achilles tendons. A prospective randomized study.
-
Surgical repair of Achilles tendon ruptures.
-
Separation of tendon ends after Achilles tendon repair: a prospective, randomized, multicenter study.
-
A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open repair.
- Repair of acute Achilles tendon ruptures. CA Soma and BR Mandelbaum. Orthop Clin North Am. Vol 26. 1995. p 239-247.
-
post operative care:
- Chronic Tear:
- in the report by Ernesto Pintore MD, presented the results of a single-center, single-surgeon study
in 59 patients with a fresh (4 women and 23 men; mean age, 43.6 ± 8.8 years) or a neglected (1
woman and 21 men; mean age, 41.3 ± 7.4 years) Achilles tendon rupture;
- patients with a fresh rupture were operated on using end-to-end suture, and patients with a
neglected rupture received the tendon of the peroneus brevis as an autologous graft;
- patients were generally satisfied with the procedure, but those with a neglected rupture tended to have a
greater postoperative complication rate, greater loss of isokinetic strength variables
at high speeds, and greater loss of calf circumference;
- patients with a neglected rupture are at a slightly greater risk of postoperative complications,
and their ankle plantar flexion strength can be reduced;
- references:
- Peroneus Brevis Tendon Transfer in Neglected Tears of the Achilles Tendon. Ernesto Pintore, MD; J Trauma 2001 January;50(1):71-78
-
Chronic rupture of the Achilles tendon : a new technique of repair.
-
Neglected rupture of the Achilles tendon. Treatment by V-Y tendinous flap.
-
Late versus early repair of Achilles tendon rupture. Clinical and biomechanical evaluation.
-
Flexor hallucis longus transfer for repair of chronic achilles tendinopathy.
Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical treatment.
Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective randomized study.
The results of tenodesis of the tendo achillis to the fibula for paralytic pes calcaneus.
Alterations in the in vivo torque-velocity relationship after Achilles tendon rupture. Further evidence of speed-specific impairment.
Transposition of the tendo calcaneus for post-traumatic bone defects of the tibia.
Partial achilles tendon tears.
C. Allenmark. Clinical Sports Med. Vol 11. 1992. p 759-769.
Early Weightbearing and Ankle Mobilization after Open Repair of Acute Midsubstance Tears of the Achilles Tendon.
Achilles tendon rupture: an alternative treatment.
