Achilles Tendon Issue.

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Achilles Tendon Disorders. Daniel Penello Foot & Ankle Rounds. 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
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Achilles Tendon Disorders Daniel Penello Foot & Ankle Rounds

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Anatomy Largest ligament in the body Origin from gastrocnemius and soleus muscles Insertion on calcaneal tuberosity

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Anatomy Lacks a genuine synovial sheath Paratenon has instinctive and parietal layers Allows for 1.5cm of ligament skim

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Anatomy Paratenon Anterior – lavishly vascularized The rest of numerous thin layers

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Anatomy Blood supply Musculotendinous intersection Osseous addition on calcaneus Multiple mesotenal vessels on foremost surface of paratenon (in fat) Transverse vincula Fewest @ 2 to 6 cm proximal to rigid inclusion

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Physiology Remarkable reaction to stress Exercise actuates ligament distance across increment Inactivity or immobilization causes fast decay Age-related reductions in cell thickness, collagen fibril breadth and thickness Older competitors have higher harm defenselessness

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Biomechanics Gastrocnemius-soleus-Achilles complex Spans 3 joints Flex knee Plantar flex tibiotalar joint Supinate subtalar joint Up to 10 times body weight through ligament when running

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Achilles Tendon Rupture Pathophysiology Repetitive microtrauma in a moderately hypovascular territory. Reparative process not able to keep up May be on the foundation of a degenerative ligament

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Achilles Tendon Rupture: Textbook Facts Antecedent tendinitis/tendinosis in 15% 75% of games related cracks happen in patients between 30-40 years old. Most cracks happen in watershed range 4cm proximal to the calcaneal inclusion.

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Achilles Tendon Rupture History Feels like being kicked in the leg Case reports of fluoroquinolone utilize, steroid infusions Mechanism Eccentric stacking (running in reverse in tennis) Sudden unforeseen dorsiflexion of lower leg (Direct blow or slash)

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Physical Exam Prone patient with feet over edge of bed Palpation of whole length of muscle-ligament unit amid dynamic and inactive ROM Compare ligament width to opposite side Note delicacy, crepitation, warmth, swelling, nodularity, obvious deformities

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Achilles Tendon Rupture Physical Partial Localized delicacy +/ - nodularity Complete Defect Cannot heel raise Positive Thompson test

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Achilles Tendon Rupture Diagnostic Pitfalls 23% missed by Primary Physician ( Inglis & Sculco) Tendon imperfection can be conceal by hematoma Plantar-flexion force of outward foot flexors held Thompson test can deliver a false-negative if embellishment lower leg flexors additionally crushed

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Imaging Ultrasound Inexpensive, quick, reproducable, dynamic examination conceivable Operator subordinate Best to gauge thickness and crevice Good screening test for finish burst

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Imaging MRI Expensive, not rapid Better at distinguishing halfway breaks and arranging degenerative changes, (screen mending)

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Management Goals Restore musculotendinous length and pressure. Advance gastro-soleous quality and capacity Avoid lower leg solidness

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Conservative Management CAM Walker or cast with plantarflexion q 2 wks Cast in Plantarflexion 2 wks 4 weeks Allow dynamic weight-bearing in removable cast Start physio for ROM practices When WBAT and foot is plantigrade 2-4 weeks Start a fortifying project Remove cast and stroll with shoe lift. Begin with 2cm x 1 month, then 1cm x1 month then D/C

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Surgical Management Preserve front paratenon blood supply Beware of sural nerve Debride and surmised ligament closes Use 2-4 stranded bolted suture system May enlarge with absorbable suture Close paratenon independently

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Surgical Management Bunnell Suture Modified Kessler Many procedures accessible

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Surgical Management : Post– operation Care Assess quality of repair, pressure and ROM intra-operation. Apply cast with lower leg at all measure of plantarflexion that can be securely achieved. Tolerant comes back to break facility 2 weeks post-operation.

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Variations in Post-operation Protocols

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Functional Bracing

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Post-Op Care Remove sutures, apply a mobile cast with heel lift Cast connected in OR 2 wks Touch WB 2 weeks Allow dynamic weight-bearing in removable cast Start physio for ROM works out. No dynamic plantarflexion When WBAT and foot is plantigrade 2-4 weeks Start a reinforcing program Remove cast and stroll with a 1cm shoe lift x 1 month then D/C.

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Surgical Management: Post-operation Care Early practical treatment versus early immobilization in pressure of the musculotendinous unit after Achilles burst repair: a forthcoming, randomized, clinical review. Kangas J et al. J Trauma. 2003 Jun;54(6):1171-80; exchange 1180-1. 50 pts had repair of Achilles burst 25 Casted in nonpartisan x 6 weeks. WBAT at 3 weeks Immediate dynamic ROM from PF to nonpartisan. WBAT at 3 wk Two re-bursts One profound disease Same fulfillment Better calf quality just for initial 3 months. One re-break

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Conservative versus Surgical Acute burst of ligament Achillis. An imminent randomized investigation of correlation amongst surgical and non-surgical treatment. Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8 112 patients Casted x 8 wks Surgery + Early practical recovery in support 21 % re-crack 1.7% re-break 5% contamination 2% Sural nerve inj. No distinction in useful result

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Summary of Pooled Outcome Measures

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Risk of Re-Rupture Surgery = 68% hazard decrease for re-crack

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