Achilles tendon is the strongest tendon of body. There are many causes of its rupture. It can be acute or chronic rupture. Management of chronic rupture by semitendinosus tendon is mentioned here.

1. TENDOACHILLES RUPTURE: MANAGEMENT
Dr Rohan Vakta
M.S.Ortho
AASH Arthroscopy Center
Ahmedabad,India

2. Anatomy
 Largest
tendon in the
body
 Origin from
gastrocnemius and
soleus muscles
 Insertion on
calcanealtuberosity

3. Physiology
 Remarkable
response to stress
Exercise induces increase in tendon
diameter
 Inactivity causes rapid atrophy
 Age-related decreases in cell density&
collagen
 Older athletes have higher injury
susceptibility


4.  Gastrocnemius-soleus-Achilles
complex

Acts on 3 joints
Flexion of knee
 Plantarflexion of
tibiotalar joint
 Supination of subtalar jt.

 It
can transmit up to
10 times body weight through
tendon when running

5. RISK FACTORS
 Recreational
athlete : Basketball , Volleyball ,
Rugby , Soccer
[There may be a history of a recent increase in physical
activity/training volume]
 Age
(30‐50 years)

6. RISK FACTORS (CONT.)
Obesity
 Diabetes Mellitus
 Previous tendon injury

Previous Steroid injections or
fluoroquinolone use
 Inustrial Accidents


7. Close
Open
Acute
Neglected
-Athletics
injuries
-Degenerative
Injuries

8. STAGES OF DEGENERATIVE TENDON INJURY
AASH Arthroscopy
Center

9. PATHOPHYSIOLOGY OF DEGENERATIVE
TENDON INJURY
 Repetitive
microtrauma
 Relatively hypovascular
area.
 Reparative process
inadequate
 Most ruptures occur in
“Watershed area”
 Antecedent
tendinitis/tendinosis in
15%

10. ATHLETIC INJURY
Indirect : Eccentric force applied to a dorsiflexed foot ;
Sudden unexpected dorsiflexion of ankle
Direct : May occur as the result of direct trauma

11. Acute
 Feels
like being kicked in the leg
 Feeling of sudden Snap
in the lower calf
 Acute sever pain
 Walk with a limp, unable to run,
climb stairs, or stand on their toes
 Loss of plantar flexion power

12. DEGENERATED TENDON
•Swelling , nodularity due to
thickening and calcification
•crepitation along
the tendon sheath
Partial tear :- fusiform swelling

13. Physical Examination
Prone patient with feet over edge of bed
Normal TA
Ruptured Tendon
not
Visible/Palpable
Palpation of entire length of muscle-tendon
unit during active and passive ROM

15.  “Hyperdorsiflexion”
sign –
With the patient prone and knees flexed to
90º,maximal passive dorsiflexion of both feet
may reveal excessive dorsiflexion of the affected
leg
 O’Brien needle test:
insert a needle 10 cm proximal to the
calcaneal insertion of the tendon. With passive
dorsiflexion of the foot, the hub of the needle
will tilt rostrally when the Achilles tendon is
intact

16. Imaging
Avulsion fracture at the
insertion , with marked
separation of
fragments.

17. Kager’s Fat pad

18. 




Inexpensive
fast, reproducable,
dynamic examination possible
Best to measure thickness and
gap
Good screening test for
complete rupture

19. MRI
MRI
ACUTE RUPTURE
HEALTHY TENDON
•Expensive, not dynamic
•Better at detecting partial ruptures
•Staging of degenerative changes,
(monitor healing)
CHRONIC RUPTURE

20. Management Goals
Optimize
gastro-soleous
strength and function
Restore
musculotendinous length
and tension.
Avoid ankle stiffness

21. Conservative Management
Controversial
2 wks
CAM Walker or cast with
plantarflexion at 2 wks
4 weeks
Start physio for ROM
exercises
Allow progressive weightbearing in removable cast
When WBAT and
foot is plantigrade
Start a strengthening
program
2- 4 weeks
Remove cast and walk with shoe
lift. Start with 2cm x 1 month,
then 1cm x1 month then D/C
40% Re-Rupture rate

22. Surgical management
Principles:
 Preserve
anterior paratenon bl. supply
 Beware of sural nerve
 Debride and approximate tendon ends
 Use 2-4 stranded locked suture technique
 Close paratenon separately

23. Operative Treatment
A: Defects of 1 cm or less
Direct end to end repair without augmentation
 Bunnell
Suture
 Modified
 Many
Kessler
techniques
available

24. B: Defects 1 - 2 cm
Muscle mobilization augmentation (plantaris)
Can gain up to 2 cm with mobilization

25. C: Defects 2 - 5 cm
No consensus on best reconstruction technique
 Semi-T tendon
transfer
 Flexor hallucis longus (FHL) tendon transfer
loss of great toe flexion(Not acceptable in Athletes)
 Others:
FDL , Peroneus Brevis
 V-Y myotendinous lengthening
FHL transfer

26. CASE OF TENDOACHILLES RUPTURE
•M/28
•3 Months old injury
•USG : 25 mm gap , 38
mm proximal to calcaneal
tuberosity

27. Surgical Technique
Chronic rupture
with
fibrosed tissue

28. Plantaris
5 cm GAP

29. Semi-T Harvested

30. Semi-T passed through the proximal
Musculo-Tendinous junction

31. Semi-T passed
through Calcaneum

32. SemiT fixed to
calcaneum
using IF Screw

33. SemiT and Plantaris are sutured
with distal & proximal TA
using nonaborbable suture

34. Cast in Equinus for 3 Weeks

36. Defects > 5 cm
SemiT Transfer
V-Y myotendinous lengthening

37. PERCUTANEOUS VS. OPEN
 Less

wound complications
Lim et al.
33 patients
 7 infections

 Higher

re-rupture rate
Wong et al.
367 repairs
 12% re-rupture


Bradley

Strength
Cetti

Less wound complications
Better cosmesis
General Consensus: Open
12% perc vs. 0% open
 Greater

General Consensus: Perc
111 patients
Return to preinjury level
Decreased calf atrophy
Better motion
Less re-rupture

38. OPEN INJURY
•Extensive
debridement
•Wound Care
•Plastic Coverage
And
•Tendon Transfer

39. POST OP
COMPLICATIONS
•Deep infection (1%)
• Fistula (3%)
• Skin necrosis (2%),
• Rerupture (2%).

40. Neither Patient nor the Surgeon
want Second Surgery or
Rerupture

41. PREVENTION OF
REINJURY
•Good conditoning and proper
stretching before running
•Adequate warm‐up!
•Adequate rehabilitation
Wearing appropriate and properly
fittng shoes during activites also
should be stressed to all athletes

42. SUMMARY
 Chronic Achilles
Operative
tendon rupture
treatment when possible
 Acute Achilles
tendon rupture

Operative treatment for the young athletic higher
demand patient
 Closed treatment for those patients with limited
functional goals or medical comorbidities
 Functional
rehabilitation when possible

43. Pateients’
recovery
depends
largely on
Their motivation
, Focus
& their desired
postinjury
activity

44. THANK YOU