Achiles Rupture , Meniscal Lession

Dr. Dadang Rukanta SpOT MKes

Background

• Largest, most powerful tendon in body• Formed by gastrocnemius and soleus• Incidence of rupture 18:100,000

– Incidence is increasing• As demonstrated by population based studies in

Finland, Canada, Scotland and Sweden

Anatomy

● Largest tendon in the body

● Origin from gastrocnemius and soleus muscles

● Insertion on calcaneal tuberosity

Anatomy

● Lacks a true synovial sheath● Paratenon has visceral and parietal layers● Allows for 1.5cm of tendon glide

Anatomy

● Paratenon● Anterior – richly vascularized● The remainder – multiple thin membranes

Anatomy

● Blood supply1) Musculotendinous junction2) Osseous insertion on calcaneus3) Multiple mesotenal vessels on anterior surface

of paratenon (in adipose)– Anterior mesentery

● Hypovascular area at 2 to 6 cm proximal to osseous insertion

Physiology

● Remarkable response to stress● Exercise induces tendon diameter increase● Inactivity or immobilization causes rapid atrophy

● Age-related decreases in cell density, collagen fibril diameter and density● Older athletes have higher injury susceptibility

Biomechanics

● Gastrocnemius-soleus-Achilles complex● Spans 3 joints

● Flex knee● Plantar flex tibiotalar joint● Supinate subtalar joint

● Up to 10 times body weight through tendon when running

Presentation

• Adults 40-50 y.o. primarily affected (M>F)

• Athletic activities, usually with sudden starting or stopping

• “Snap” in heel with pain, which may subside quickly

Factors to consider

• 25% of patients have previous symptoms of Achilles inflammation– Leppilahti et al. Clin Orthop 1998

• Associated conditions:– Ochronosis– Steroid use– Quinolones– Inflammatory arthritis

Achilles Tendon Rupture

● Pathophysiology● Repetitive microtrauma

in a relatively hypovascular area.

● Reparative process unable to keep up

Achilles Tendon Rupture

May be on the background of a degenerative tendon

Diagnosis

• Weakness in plantarflexion

• Gap in tendon• Positive Thompson

test

Imaging

• X-rays– Indicated if fracture or

avulsion fracture suspected• Ultrasound or MRI

– Reveal tendon degeneration, if present

Treatment

• Non-operative versus operative treatment controversial– Several methods

described for each

Imaging

● Ultrasound● Inexpensive , dynamic

examination possible

● Good screening test for complete rupture

Imaging

● MRI● Expensive● Better at detecting 1-partial ruptures 2- staging degenerative

changes 3- monitor healing

Management Goals

● Restore musculotendinous length and tension.

● Optimize gastro-soleous strength and function

● Avoid ankle stiffness

Non-operative

• Cast immobilization– Traditional recommendation is 8

weeks of immobilization– Wallace recommended patellar

tendon bearing orthosis for weeks 4-8

– Functional brace with semi-rigid tape and polypropylene orthoses for duration of treatment also described

• Rerupture rate 8-39% reported

Functional Bracing

Conservative Management

Cast in Plantarflexion CAM Walker or cast with plantarflexion q 2 wks2 wks

Allow progressive weight-bearing in removable cast

Remove cast and walk with shoe lift. Start with 2cm x 1 month, then 1cm x1 month then D/C

4 weeks

Start physio for ROM exercises

When WBAT and foot is plantigrade

Start a strengthening program

2- 4 weeks

Surgical Management

● Preserve anterior paratenon blood supply● Beware of sural nerve● Debride and approximate tendon ends● Use 2-4 stranded locked suture technique● May augment with absorbable suture● Close paratenon separately

Surgical Management

● Bunnell Suture

● Modified Kessler

● Many techniques available

Surgical Management

● Preserve anterior paratenon blood supply● Beware of sural nerve● Debride and approximate tendon ends● Use 2-4 stranded locked suture technique● May augment with absorbable suture● Close paratenon separately

Surgical Management

Kerachow suture techniqueDynamic loop suture of Peroneus brevis

Operative• Open repair

– Locking stitch, +/- augmentation with plantaris or mesh

– Post-op care = Casting for 6-8 weeks

– Risks: Infection (4-21%), Rerupture (1-5%)

Operative

• Percutaneous– Bunnell stitch– Weaker than open repair

(Rerupture 0-17%)– Risk of sural nerve injury

(0-13%)– Decreased infection risk

Surgical Management

Lynn technique Percutaneous repaire

Old rupture

Bosworth technique for repairing old ruptures of Achilles tendon

Wapner technique with FHL tendon

Percutaneous versus open repair

Percutaneous repair Open repair

Surgical Management : Post– op Care

● Assess strength of repair, tension and ROM intra-op.

● Apply cast with ankle in the least amount of plantarflexion that can be safely attained.

● Patient returns to fracture clinic 2 weeks post-op.