achiles rupture, meniscal lession
DESCRIPTION
Achiles Rupture, Meniscal LessionTRANSCRIPT
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.