1. Achilles Tendon Rupture M.Mazloumi MD

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

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

4. Anatomy Paratenon Anterior – richly vascularized The remainder – multiple thin membranes

5. Anatomy Blood supply 1) Musculotendinous junction 2) Osseous insertion on calcaneus 3) Multiple mesotenal vessels on anterior surface of paratenon (in adipose) – Anterior mesentery Hypovascular area at 2 to 6 cm proximal to osseous insertion

6. 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

7. 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

8. Achilles Tendon Rupture Pathophysiology Repetitive microtrauma in a relatively hypovascular area. Reparative process unable to keep up

9. Achilles Tendon Rupture May be on the background of a degenerative tendon

10. Achilles Tendon Rupture Antecedent tendinitis/tendinosis in 11% 75% of sports-related ruptures happen in patients between 30-40 years of age. Most ruptures occur in 4cm proximal to the calcaneal insertion.

11. Achilles tendon disorders

12. Achilles Tendon Rupture History Case reports of fluoroquinolone use, steroid injections Mechanism Eccentric loading (running backwards in tennis) Sudden unexpected dorsiflexion of ankle Direct blow or laceration Fall from a hight

13. Achilles Tendon Rupture Physical Partial Localized tenderness +/- nodularity Complete Defect Can not heel raise Positive Thompson test

14. Imaging Ultrasound Inexpensive, dynamic examination possible Good screening test for complete rupture

15. Imaging MRI Expensive Better at detecting 1-partial ruptures 2- staging degenerative changes 3- monitor healing

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

18. Conservative Management Cast in Plantarflexion CAM Walker or cast with plantarflexion q 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

19. Functional Bracing

20. 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

21. Surgical Management Kerachow suture technique Dynamic loop suture of Peroneus brevis

22. Surgical Management Lynn techniquePercutaneous repaire

23. Old rupture Bosworth technique for repairing old ruptures of Achilles tendon Wapner technique with FHL tendon

24. Percutaneous versus open repair Percutaneous repairOpen repair

25. 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.

26. Conservative vs Surgical Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment. Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8 112 patients Surgery + Early functional rehab in brace Casted x 8 wks 21 % re-rupture 1.7% re-rupture 5% infection 2% Sural nerve inj. No difference in functional outcome

27. Conservative vs Surgical Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial. Am J Sports Med. 2008 Sep;36(9):1688-94. Epub 2008 Jul 21. 83 patients Surgery + Early functional rehab in brace Casted x 8 wks 5 \ 41 re-rupture 3 \ 42 re-rupture 0.5% infection 0.1% Sural nerve in No difference in functional outcome

28. Limited open technique 1. Outcome of achilles tendon ruptures treated by a limited open technique. Jung HG, Lee KB, Cho SG, Yoon Foot Ankle Int. 2008 Aug;29(8):803-7. 2. Repair of achilles tendon rupture under endoscopic control. Fortis AP, Dimas A, Lam Arthroscopy. 2008 Jun;24(6):683-8. 3. Minimally invasive repair of ruptured Achilles tendon. Chan SK, Chu Hong Kong Med J. 2008 Aug;14(4):255-8.

29. Summary of Pooled Outcome Measures

30. متشكرم