Achilles tendon ruptures J. Heger, D. Matejíčka Achilles tendon • Tendon of m. triceps surae (m. gastrocnemius, m. soleus) • Proximal part of tuber calcanei • Subcutaneous, visible Achilles tendon ruptures • spontaneous x traumatic • partial x total Spontaneous rupture • Rare (incidence 0,7 / 100 000) • During minimal stress (normal gait) Spontaneous rupture • patologically changed tendon – local or systemic (p.o.) longtime use of corticosteroids – Longtime use of fluorochinolons – genetic predispozition (abnormality of collagen) – autoimmune diseases – repeated microtraumatisation Traumatic rupture • More frequent ( incidence 7 / 100 000) • During sports – sudden spring (take-off) or stop Traumatic rupture • Higher age – wrong step + rugged ground Predisposition of rupture • 90% 2-6 cm above insertion – the worst blood supply of tendon • Less than 3% up to 2 cm above insertion • Other cases - musculo-tendineous junction or tear at insertion Predisposition of rupture Diagnostics - anamnesis • risk factors, mechanism of injury • Typical symptoms: – Sudden pain – Weakness of affected extremity, in some cases with fall – Feeling of sudden tendon rupture – Sometimes hearable phenomenon Diagnostics – clinical picture • pain • swelling • Palpable defect of tendon • Visible hematoma around malleoli • Weakness and limited plantiflexion Diagnostics Tests • Thompson test – Prone position (or on knees) – Legs hanging over bed margin – Compression of m. gastrocnemius causes plantiflexion in normal tendon – In case of rupture of Achilles tendon plantiflexion is not possible – positive test Thompson test Clinical tests • Matles test – Prone position – Call to active knee flexion up to 90° – Normal tendon –shortening of m. gastrocnemius causes leg plantiflexion – In case of rupture – no motion or slight dorsiflexion Matles test Imaging methods • Exclusion of bone defect • Confirmation of unclear cases • Standard – lateral X-ray + sonography, in unclear cases MRI Imaging methods – X-ray physiological rupture ultrasonography MRI Tx Conservative X Surgical Conservative x surgical tx • partial rupture – conservative tx • complete rupture – preference of surgery • existence of conservative schools • conservative tx in pts with contraindication of surgery conservative x surgical tx • Recurrent ruptures (Khan a spol.) – 13% in conservative tx – 3,5% in surgical tx • Complications with wound healing, up to20% (Arner a Lindholm, Inglis) • Pts satisfaction (Kellam a spol.) – 66% in conservative tx – 93% in surgical tx Conservative tx • classic method – High plaster of Paris bandage - ankle plantiflexion + knee semiflexion for 6-8 weeks (Lea a Smith, Inglis, Jacobs, Garden et al.) – Risk of ankle contractures due to long term fixation in maximum plantiflexion Conservative tx • Fowler protocol with early functional tx – for 2 weeks fix in plantiflexion, then 4 weeks splin with adding of 10 deg. of dorsiflexion per week, after 8 weeks loading (McComis a spol.) Surgery • Acute rupture – open suture – miniinvasive suture – endoscopically assisted percutanneous suture • Extensive or old, chronic rupture – static plasty – dynamic plasty Open suture • Posteromedial approach – direct visualisation of rupture • Many different techniques • of suture Bunnell Kessler Krackow Tripple bundle Miniinvasive suture • To decrease complications • Percutaneous Ma a Griffith Carmont a Maffulli Webb a Bannister Achillon system Achillon system Endoscopically assisted percutanneous suture • enables – Evaluation of tendon ends – debridement + mobilisation of tendon – Check of needle insertion – Check of approximation of tendon ends during tightening Plasties of Achilles tendon • Tendon strengthening in injuries with significant tendon defect or old injuries with retraction of tendon ends Plasties of Achilles tendon • static – without support of other muscles (fascia m. gastrocnemius, tendon or fascial graft) • dynamic – muscle transfer with muscle function and blood supply Static plasties Silfverskiöld • Turn over of strip of central part fascia m. gastrocnemius Bosworth • Long thin strip from central part of fascia m. gastrocnemius with specific anchoring of graft to distal tendon and calcaneus Lindholm • Two strips from medial and lateral part of fascia of m. gastrocnemius VY plasty (Abraham a Pankovich) Bugg a Boyd • Strips of fascia lata Dynamic plasties Teuffer • transfer of musculus peroneus brevis tendon, která se po uvolnění od úponu na bazi V. MTT provleče tunelem do calcanea a fixuje proximálně Modification after Turco a Spinella • Different anchoring – provlečení přes tunel v distálním pahýlu bez vrtání kanálu do calcanea Wapner • transfer of flexor hallucis longus (FHL) tendon k přemostění defektu, fixace přes kostní kanál do calcanea a distálního pahýlu Aftertreatment Indication of techniques • Many different schemes Indication scheme Kuwada • Defekt parciální : konzervativní terapie fixací • Defekt do 3 cm : end to end sutura • Defekt 3 – 6 cm : překlopení části fascie „flap“ musculus gastrocnemius, případně syntetická náhrada • Defekt víc než 6 cm : „VY“ plastika fascie musculus gastrocnemius, doplnění o volný šlachový štěp, nebo syntetickou náhradu Indication scheme Myerson • Defekt 1 – 2 cm : end to end sutura, fasciotomie zadního kompartmentu • Defekt 2 – 5 cm : „VY“ plastika fascie musculus gastrocnemius, příležitostně šlachový transfer • Defekt víc než 5 cm : šlachový transfer, případně kombinace s překlopením části fascie „flap“ musculus gastrocnemius Indication scheme Den Hartog • Defekt méně než 2 cm : end to end sutura • Defekt 2 - 5 cm : transfer šlachy FHL a „VY“ plastika fascie musculus gastrocnemius • Defekt víc než 5 cm : transfer šlachy FHL a překlopení části fascie „flap“ musculus gastrocnemius • Defekt víc 10 cm : transfer šlachy FHL, allograft Achillovy šlachy Komplikace operační terapie Aftertreatment • In early postoperative period – wound care, positioning, elevation, ice, prevention of TED Aftertreatment • classic: – fixace sádrovou dlahou z dorzální strany v plantiflexi hlezna a semiflexi kolena na 3 týdny – po 3 týdnech zkrácení sádry pod koleno a zmenšení plantiflexe v hleznu – celková doba fixace dle perioperačního nálezu 6-8 týdnů • alternative – mezi 2.-6. týdnem naložení CAM Walker boot Aftertreatment • 1.-6. week – analgetics, wound massage, kryotherapy • 6.-12. week – early mobilisation - USG check, isometric a isotonic exercises, gradual loading, gait with crutches • 12.-20. week – early strengthening – physiotherapy, extent of motion, balance training, heel lifting Shrnutí Zdroje