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Home » Muscles Tendons » Achilles Tendon Rupture

Achilles Tendon Rupture

(see also: 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

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
  • 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

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;
      • immediately beneath the gastroc fascia, the surgeon will note the soleus muscle;
    • 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 plantaris tendon can be fanned out to make a 2.5 cm membrane that is then sutured around the repair site;
  • attempt to close paratenon, especially over the tendon repair site; this is important both for healing and prevention of adhesions;

post operative care »

Complications

Deep Infection and Wound Breakdown

(see also: prevention of infection)

Wound Vac Therapy »

(followed by STSG)

Chronic Tear

References