lecture 19 parekh non insertional and insertional achilles tears
TRANSCRIPT
Insertional and Noninsertional Achilles
TendonitisSelene G. Parekh, MD, MBA
Associate Professor of SurgeryPartner, North Carolina Orthopaedic Clinic
Department of Orthopaedic SurgeryAdjunct Faculty Fuqua Business School
Duke UniversityDurham, NC919.471.9622
http://seleneparekhmd.comTwitter: @seleneparekhmd
Etiology
Etiology
• Intrinsic factors of note:• HTN• Diabetes• Obesity• Exposure to steroids/estrogen• Advancing age• Exposure to quinolones• Variants in gene of MMP-3
Pathophysiology
• Cellular & molecular response to microscopic tearing chronic degenerative process• Incr # tenocytes• Incr concentration GSG• Disorganized/fragmented collagen• Neovascularization• Incr concentration glutamate• Incr concentration lactate
Classification
• Histopathologic• Paratenonitis
• Paratenonitis with tendinosis
• Tendinosis
Classification
• Paratenonitis• Definition
• Inflammation of only the paratenon, either lined by synovium or not
• Histo• Inflammatory cells in paratenon/peritendinous
areolar tissue• Clinical
• Warmth, edema, tender• Paratenon thickened and adhered to normal tissue
Classification
• Paratenonitis w/ tendinosis• Definition
• Paratenon inflammation w/ intratendinous degeneration
• Histo• Same as paratenonitis w/ loss tendon collagen,
fiber disorientation, scattered vascular ingrowth• Clinical
• Same as paratenonitis w/ nodule
Classification
• Tendinosis• Definition
• Intratendinous degeneration w/ atrophy• Histo
• Noninflammatory intratendinous collagen degeneration, fiber disorientation, hypocellularity, occasional necrosis and calcification
• Clinical• Often nodule in nontender, little edema
Classification
• Duration symptoms• Acute < 2 wks• Subacute 3-6 wks• Chronic > 6 wks
• Insertional vs. noninsertional
Presentation
• Symptom triad• Pain
• Swelling
• Impaired performance
Presentation
•Physical exam•Pain/tenderness @ Achilles•Morning pain, increases w/ usage•Pain will progress from activity-related to constant•Fusiform swelling
Presentation
•Physical exam•Pain/tenderness @ Achilles•Morning pain, increases w/ usage•Pain will progress from activity-related to constant•Fusiform swelling
Presentation
•Peritendinitis•Tendon normal•Peritenon thickened, fluid, adhesions
•Tendinosis•Tendon thickened, nodular, softened, yellow, & degenerated
Imaging
• X-ray• Calcifications• Haglund’s deformity
• “Pump bump”• Parallel pitch lines
Imaging
• Plain radiographs• Calcification
Imaging
• Plain radiographs• Calcification
• MRI• Helpful to evaluate extent of disease• AP diameter < 6mm
• US• User dependent
Nonsurgical Treatment
• Rest and activity modification• AFO/shoe inserts/casts/night splints• 2-6 weeks
• No studies demonstrate the efficacy of rest
Nonsurgical Treatment
• Ultrasound• Rat study suggest stimulation of tenocyte
migration
• No well designed studies show support of use
Nonsurgical Treatment
• Low level laser therapy• May increase collagen production, down regulate
MMP, decrease capillary flow of neovascularization
• 2 studies• Decr pain: rest, activity, palpation• Decr immediate pain threshold
• Insufficient evidence to support usage
Nonsurgical Treatment
• Eccentric/Concentric exercise therapy• Decrease neovascularization
• Tensile force temporary ceases blood flow repetition neovessels obliterated w/ pain receptors
• Studies• Improved pain @ 12 weeks (2)• Structural and compositional changes
• Resolution of structural anomalies• Decr tendon thickness
Nonsurgical Treatment
• Eccentric/Concentric exercise therapy• Studies
• Eccentric vs concentric exercises (4)• Eccentric exercise does not offer significant
decrease in pain over concentric exercise• @ 12 wks: eccentric patients more satisfied
and return to activities
• Specific role in treating noninsertional Achilles tendonitis unclear
Nonsurgical Treatment
• Shockwave therapy (SWT)• High energy eliminates pain
• Stimulating soft tissue healing, regenerating tendon fibers, inhibiting pain receptors
• Studies (4)• Low energy (3), differing doses, short f/u, small
cohorts
• Insufficient evidence to support SWT: most effective dose and duration unknown
Nonsurgical Treatment• Glyceryl trinitrate
• Prodrug of NO• Increase fibroblast collagen synthesis
• Topical transdermal treatment over point of maximal tenderness
• Studies• Decr tenderness, night pain, activity pain, and
improved functional outcomes• No changes in neovascularity, wound fibroblasts,
collagen synthesis, NO production• 20% discontinue treatment due to headaches
• Conflicting evidence of efficacy
Nonsurgical Management
• Corticosteroid injection• Decr pain• Decr tendon thickness• Intratendinous injection concerns re: catabolic
effects on the tendon
• Evidence of usage is insufficient. Concerns re: rupture outweighs its usage.
Nonsurgical Management
• Platelet rich plasma therapy (PRP)• Delivery of hyperphysiologic doses of cytokines• Some success HSS/Baltimore
• Evidence of usage is insufficient.
Nonsurgical Management
• Sclerosing injections/Prolotherapy• Polidocanol
• Thrombosis of vessels and destroys nerves• Proliferation of fibroblasts• Synthesis of collagen possible remodeling of
tendon• 25% dextrose solution
• Dehydrate cells influx inflammatory cells tendon healing
• Poor evidence to recommend usage
Nonsurgical Management
• Aprotinin injections• Collagenase inhibitor• Can have systemic allergic reactions• Studies
• RCT: no difference than placebo injection
• Insufficient evidence to recommend usage
Operative Management
• Used for recalcitrant cases• 3-6 months of conservative treatment
• Goals• Resect calcaneal bone• Resect degenerative tissue• Augment tendon if needed
• >50%
Operative Management
• Percutaneous longitudinal tenotomy• Mild/moderate disease• 67-97% success rates• Worse outcomes:
• Multinodular disease• Severe disease• Paratendinopathies
Operative Management
• Minimally invasive stripping• Large diameter sutures passed through stab
incisions• Slide anterior to tendon to strip it
• No studies to show efficacy
Operative Management - I• Excision of Haglund’s deformity
• Position• Prone vs. supine
• Incisions• Lateral, medial both, or central
• Inflamed bursa excised• Enlarged tuberosity resected
• Tendon transfers• FHL (Wapner)
• Better length than FDL• Better biomechanics than FDL
Operative Management - I
• Prone
• Central, Achilles tendon splitting approach
• Elevate 70-80% of tendon insertion
• Resect Haglund’s check on fluoro
Operative Management - I
• Debride Achilles• < 50% involvement
• Anchors into calcaneus• Tie Achilles• Close Achilles split
Operative Management - I
• Debride Achilles• > 50 % involvement single incision technique
• Open deep fascia and find FHL muscle belly• Find FHL tendon and trace into canal• Plantarflex ankle and toe and pull on tendon• Release tendon• Drill hole anterior to Achilles insertion• Pass FHL tendon and screw• Repair Achilles insertion, split and skin
Operative Management - I
• Debride Achilles• > 50 % involvement double incision technique
• Medial foot approach and find knot of Henry• Release FHL• Open deep fascia and find FHL muscle belly• Find FHL tendon and trace into canal• Pull FHL tendon through• Create 2 drill holes: one anterior to Achilles
insertion and one medial to lateral• Pass FHL tendon and tie to self
Operative Management - NI
• Debridement with/without tenosynovectomy• Moderate/severe disease• Debride all tendinopathic tissues
• <50%• +/- tubularization
• >50%• FHL transfer (single/double incision)
• Studies• Improved pain, functional outcomes,
• Fair evidence supports treatment
Post-Op Protocol
• No Tendon Transfer• NWB in Bulky Jones splint x 2wks• SLNWBC x 2 wks• SLWBC x 2 wks
• Tendon Transfer• NWB in Bulky Jones splint x 2wks• SLNWBC x 4 wks• WB CAM boot x 4 wks, start PT
Operative Management
•Complications•11% rate•1 year f/u
•Satisfied w/ outcomes •Return to activities
•Skin edge necrosis•Superficial/deep infections•Seroma/hematoma formation
•Sural neuritis•Partial ruptures•Sensitive/hypertrophic scars•Weakness of plantarflexion
Incision
Partial Insertion Detachment
Resect Calcified Tissue
Haglund’s Resection
Haglund’s Resection
Debride Tendon
Incise Deep Fascia
Drill Hole Anterior to Achilles
Pass Tendon
Anchors
Tie Tendon
Close Tendon
RE ECT
the ankle
the foot