STUDY MATERIAL

1. TENDOACHILLES RUPTURE
PRESENTER-Dr NAGARAJU H
MODARATER-Dr CHIDANANDA sir
SGITO BANGALORE

2. History
• According to greek mythology, Achillis was a
boy foretold that he would die in young
• So to prevent that her mother Thetis ,dipped
him to river Styx ,which provides powers
invulnerability
• But the weekest point of Achilles is heel
,which covered by the mother hand while
dipping

5. Epidemiology
Although the worldwide frequency of Achilles
tendon ruptures is not known data collected
from Finland estimates that it occurs in 18 per
100000 people yearly
The male‐to‐female ratio of rupture is estimated
from 1.7:1 to 12:1.

6.  Largest tendon in the
body
 Origin from
gastrocnemius and
soleus muscles
 Insertion on
calcaneal
tuberosity
Anatomy

7. Functional Anatomy
When viewed in cross section, the right Achilles
tendon appears to spiral counterclockwise 30‐150º
toward its insertion at the calcaneus
The spiraling of the tendon as it reaches the calcaneus
allows for elongation and elastic recoil within the
tendon, facilitating storage and release of energy during
movement
This also allows higher shortening velocities and
greater instantaneous muscle power than could be
generated by the gastrocnemius and soleus complex
alone

8. Functional Anatomy
Because the actin and myosin present in the tenocytes,
tendons have almost ideal mechanical properties for the
transmission of force from muscle to bone
Tendons are stiff, but possess a high tensile strength
They have the ability to strecth up to 4% before damage
occurs
With a stretch greater than 8% occurs macroscopic
rupture

9. Blood supply for the tendon
Derived from the posterior tibial artery and its
contributions to the musculotendinous junction, as well
as the mesosternal vessels which cross the paratenon,
infiltrating the tendon and the bone‐tendon junction at
the calcaneus
The watershed zone is an area 2‐6 cm proximal to the
calcaneus, in which the blood supply is less abundant
and becomes even sparser with age
It is in this part that most degeneration and therefore
rupture of the Achilles tendon occurs

10. 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
PHYSIOLOGY

11. 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

12. 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)
 Previous Steroid
injections or
fluoroquinolone
use
 Inustrial
Accidents

13. Systemic diseases
• Chronic renal failure
• Collagen deficiency
• Diabetes mellitus
• Gout
• Infections
• Lupus
• Parathyroid disorders
• Rheumatoid arthritis
• Thyroid disorders

14. Foot problems that increase the risk
• Cavus foot
• Insufficient gastrocsoleus flexibility and
strength
• limited ability to perform ankle dorsiflexion
• Tibia vara
• Varus alignment with functional
hyperpronation

16. STAGES OF DEGENERATIVE TENDON INJURY

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

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

19. 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
Acute

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

21. Clinical signs
“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
Thompson test:
With the patient prone, squeezing the calf of the
extended leg may demonstrate no passive
plantarflexion of the foot if its Achilles tendon is
ruptured

26. Matles test

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

28. Kager’s Fat pad

29. Toyager’s sign

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

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

32. Differential diagnosis
• Ankle sprain
• Os trigonam syndrome
• Tenosynovitis of plantar flexors
• Stress fracture of hind foot
• Bursitis
• Sural neuroma
• Malignancy
• Vascular claudication / DVT

33. Acute
-Athletics
injuries
Neglected
-Degenerative
Injuries
CLOSED
Open

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

35. CAM Walker or cast with
plantarflexion at 2 wks
2 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
Controversial
40% Re-Rupture rate
Conservative Management

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

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

38. Acute tear
Direct end to end repair with or without
augmentation
 Bunnell Suture
 Modified Kessler
 Krackow suture
o Many other
technique with
or without
augmentation by
plantaris tendon

39. Krackow suture

40. Krackow sutures

41. Kessler technique

42. LYNN TECHNIQUE

43. If end to end cannot approximated
• Then
Lindholm s techinque
DYNAMIC LOOP SUTURE TECHNIQUE
Turco and Spinella modification

44. LINDHOLM TECHNIQUE

45. DYNAMIC LOOP SUTURE TECHNIQUE

46. Turco and Spinella modification

47. Technique of repair of chronic tendon tear
 Primary repair (uncommon)
 Augmentation
■ Free fascia tendon graft
Fascia lata
Donor tendons (semitendinosus, peroneal, gracilis,
patellar tendon)
■ Fascia advancement
V-Y quadriceps plasty
Gastrocnemius-soleus fascia turn-down graft

48. ■ Local tendon transfer
Flexor hallucis longus
Flexor digitorum longus
Peroneus brevis
Peroneus longus
Plantaris
Posterior tibial
■ Synthetic or allograft augmentation

49. Comparison of Tendons for Tendon
Transfer
TENDON STRENGTH
RELATIVE TO GSC
Peroneus
brevis
18 times
weaker
Flexor
digitorum
longus
27 times
weaker
Flexor
hallucis
longus
13 times
weaker

50. For chronic repair
• Management better guided by classification
system
Myerson s classification
Type 1 : 1-2 cm defect - end to end repair with
PCF
Type 2 :2-5 cm defect-V-Y lenghthening with or
without tendon transfer
Type 3 : >5 cm –tendon tranfer with V –Y
lenghthening with augmentation

51. Kuwada’s classification
• Type I : partial tear – conservative
management
• Type II: complete tear less than 3cm –end to
end repair
• Type III :3-6 cm – Debride + ATTF +
augmentation
• Type IV: >6 cm – Debride +GR+FHTG+SG

52. GASTROCNEMIUS-SOLEUS TURN
DOWN GRAFT

53. FLEXOR HALLUCIS LONGUS
TENDON TRANSFER(wapner)

54. Post op care
• The cast is changed at 4 weeks to a short leg
walking cast or a removable cast brace with The
ankle in neutral; the cast brace is worn for an
additional 4 weeks.
• A rehabilitation program is begun with
strengthening and range-of-motion exercises at 8
weeks.
• The removable brace remains in place until grade
4 to 5 strength and 10 degrees of dorsiflexion are
obtained.
• Athletic activity is restricted for 6 months.

55. Chronic rupture
with
fibrosed tissue

56. Plantaris
5 cm GAP

57. Semi-T Harvested

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

59. Semi-T passed
through Calcaneum

60. SemiT fixed to
calcaneum
using Screw

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

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

63. V- Y Repair(Abraham & Pankovich)

64. Post op care
• At 6 to 8 weeks, the long leg cast is removed, a
short leg cast is applied and worn for 1 month,
and weight bearing is allowed.
• After cast removal, a 3- to 5-cm heel lift is
used for 1 month and
• Progressive stretching exercises are begun
immediately.

65. Achilles Tendon Turndown Flap

66. Percutaneous v/s Open
• Percutaneous
Reduce d risk of infection
Reduced risk of painful scar
Less paratenon injury
Less pain /shorter surgery
• Open
Traditional method with direct visualization
More useful in chronic repair
Good strength of repair
Decreased sural nerve injury

67. Ma and Griffith technique for
percutaneous
repair

68. Post op care
• The short leg cast is worn with non–weight bearing for
4 weeks,
• At which time a weight bearing, low-heeled, short leg
equinus cast is applied.
• At 8 weeks, the cast is removed and a therapy program
of toe-heel raising and gastrocnemius-soleus exercises
is begun.
• The patient gradually restores the foot to a neutral
position during a 4-week period. Then the patient
begins heel cord stretching exercises for an additional
4 weeks.

69. MINI OPEN REPAIR METHOD

71. Role of biologics in tendon healing
• PRP injections
• Mesenchymal stem cell transfer
• Platelet rich fibrin (PRF) injections
• Fibrin glue

72. Synthetic & Allograft augmentation
• Polyglycol threads
• Marlex mesh
• Dacron vascular graft
• Carbon fiber
• Allograft tendon

73. Complications

74. POST OP
COMPLICATIONS

75. Contraindications to operative repair
• Arterial insufficiency
• Poor skin & soft tissue quantity
• Poor controlled medical comorbidities
• Inability to comply with post op rehabilitation

76. Rehabilitation
0 to 2 weeks
Posterior slab/splint;
Non–weight bearing with crutches (immediately
postoperative or after injury)

77. Cast in Equinus

78. 2 to 4 weeks
• Aircast walking boot with 2-cm heel lift*
• Protected weight bearing with crutches. Active plantar
flexion and dorsiflexion to neutral, inversion/eversion
below neutral, modalities to control swelling
• Incision mobilization modalities(e.g., friction,
ultrasound, stretching)
• Knee/hip exercises with no ankle involvement (e.g., leg
lifts from sitting, prone, or side-lying position)
• Non–weight-bearing fitness/cardiovascular exercises
(e.g., bicycling with one leg, deep-water running)
• Hydrotherapy (within motion and weight-bearing
limitations)

80. 4 to 6 weeks
• Weight bearing as tolerated
• Continue activities as above

81. 6 to 8 weeks
• Remove heel lift from boot
• Weight bearing as tolerated
• Dorsiflexion stretching, slowly graduated resistance
exercises (open and closed kinetic chain, functional
activities)
• Proprioceptive and gait training
• Modalities, including ice, heat, and ultrasound as indicated
• Fitness/cardiovascular exercises, including weight bearing
as tolerated (e.g., bicycling, elliptical machine, walking
and/or running on treadmill, StairMaster)
• Hydrotherapy

82. 8 to 10 weeks
• Wean off boot
• Return to crutches and/or cane as necessary
and gradually wean off
• Continue to progress range of motion,
strength, proprioception

83. More than 12 weeks
• Continue to progress range of motion,
strength, proprioception
• Retrain strength, power, endurance
• Increase dynamic weight-bearing exercise,
include plyometric training
• Sport-specific training

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

85. 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

86. SUMMARY
Chronic Achilles tendon rupture
Operative 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

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

88. THANK YOU!