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Achilles tendon rupture
Achilles tendon rupture
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Achilles tendon repair

  1. 1. Achilles Tendon: Open versus Percutaneous Repair Kevin R. Stone, M.D.
  3. 3. Achilles Ruptures symptoms and goals <ul><li>Symptoms: </li></ul><ul><li>Felt like a shot – heard pop </li></ul><ul><li>Males 40-60 </li></ul><ul><li>Swollen tendon </li></ul><ul><li>Positive squeeze test </li></ul><ul><li>Palpable defect </li></ul><ul><li>Surgical Goals: </li></ul><ul><li>Complete recovery with full sports </li></ul><ul><li>Better than non operative </li></ul>
  4. 4. Achilles Ruptures Percutaneous vs Open <ul><li>Percutaneous </li></ul><ul><li>Reduced risk of infection </li></ul><ul><li>Reduced risk of painful scars </li></ul><ul><li>Saves the sheath and clot </li></ul><ul><li>Less pain/shorter surgery </li></ul><ul><li>Open </li></ul><ul><li>Traditional approach with direct visualization </li></ul><ul><li>? stronger repair </li></ul>
  5. 5. Achilles Percutaneous Repair Surgical Technique The proximal portion of the tendon, as identified by palpation and MRI, is captured with a #1 Tevdek suture placed transversely through the skin and the tendon and out the opposite side. Bradley et al. Amer J Sports Med 1990 18:2 188
  6. 6. Achilles Percutaneous Repair This suture is then crisscrossed through the tendon, the gap at the rupture site, and finally through the distal portion of the tendon just above the calcaneus, through the skin punctures.
  7. 7. Achilles Percutaneous Repair A second stitch is placed after the first one and is tied with the foot in plantar flexion. A dressing is applied and the foot is placed in a plantar flexed pre-formed padded splint.
  8. 8. Percutaneous Achilles Repair
  9. 9. Percutaneous Repair <ul><li>Percuataneous Cons: </li></ul><ul><li>Sural nerve injury (6.5% - 10.5%) 1 </li></ul><ul><li>Open Cons: </li></ul><ul><li>Significant wound complications/ Scar irritation </li></ul><ul><li>Infection </li></ul><ul><li>Healing time </li></ul><ul><li>Surgery time </li></ul><ul><li>1 Haji, et. al. Foot Ankle Int. Apr. 2004; Maes, et. al. Acta Orthop Belg. Apr. 2006; Landsdaal, et. al. Feb 2007. </li></ul>
  10. 10. When to Perform Open Repair? <ul><li>Failed Repair/Re-rupture </li></ul><ul><li>Fracture </li></ul>
  11. 11. Achilles Open Repair Beskin et al. Amer J Sports Med 1987 15:1 1
  12. 12. Open Reconstruction with Allograft For 14 month old Chronic Rupture MM 05-08-2002
  13. 13. The Stone Clinic Experience <ul><li>Achilles Repair n=21 (2000-current) </li></ul><ul><ul><li>Percutaneous n=16 (acute) n=1(revision) </li></ul></ul><ul><ul><li>Primary Open n=1 (calcaneal fx) </li></ul></ul><ul><ul><li>Revisions n=3: trauma post repair </li></ul></ul><ul><li>Complications: </li></ul><ul><ul><li>Sural nerve knot impingement n=1 </li></ul></ul><ul><ul><li>Death from DVT n=1 </li></ul></ul>
  14. 14. Patient Example: PK <ul><li>40/Male PK </li></ul><ul><li>New R Achilles Tear 6/2006 </li></ul><ul><li>Previous L Achilles Open Repair 11/2005 </li></ul>MRI: Left Achilles – 7 months Post Open Repair
  15. 15. PK: Pre-Op R Achilles Tear
  16. 16. PK: 2-Months Post-op Percutaneous vs Open
  17. 17. PK: L (Open) R (Percutaneous) 8 Months post-op percutaneous 15 Months post-op open
  18. 18. PK: R (Percutaneous) MRI 8 Mo. Post-Op Increased tendon diameter 7mm to 15mm. Healed defect in proximal Achilles.
  19. 19. Patient Example: RB <ul><li>49/Male </li></ul><ul><li>Basketball injury: L Achilles Rupture </li></ul><ul><li>Percutaneous repair 3/07 </li></ul>Pre-Op MRI
  20. 20. RB: Operative Photos
  21. 21. RB: 1 week PostOp
  22. 22. Rehabilitation: General Considerations • Progression is based on clinical presentation • Careful monitoring of soft tissue quality • Timing considerations
  23. 23. Post-operative Protection night splint ROM walker boot
  24. 24. Rehabilitation: Early Progression • 0-3 wks: Non-weight bearing , night splint • 3-8 wks: gradual progression into Walker boots with full weight bearing after 6 wks • 8-12 wks: Cowboy boots with gradual wean into regular shoes using heels lifts
  25. 25. Manual Treatment Early soft tissue mobilization (edema control) Mid-soft tissue mobilization
  26. 26. Post-operative Rehabilitation well leg biking feet on ball bridges
  27. 27. Early Rehabilitation prone on ball abduction
  28. 28. Ankle PNF Mid Rehabilitation
  29. 29. single leg squat single leg resistance Mid Rehabilitation
  30. 30. resisted gait proprioception challenge Late Rehabilitation
  31. 31. lateral leaps diagonal leap Plyometrics
  32. 32. Conclusions <ul><li>Open vs. Percutaneous: </li></ul><ul><li>No statistically significant difference in re-rupture rates (1.9%-5.7%) </li></ul><ul><ul><ul><ul><ul><li>Reidl, et. al. Chirurg. Jun 2002 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Rebeccato, et. al. J Foot Ankle Surg. Aug 2001 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cretnik, et. al. Wien Klin Wochenschr. 2004 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cretnik, et. al. AJSM 2005 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Haji, et. al. Foot Ankle Int. Apr 2004 </li></ul></ul></ul></ul></ul>
  33. 33. Conclusions <ul><li>Treatment: </li></ul><ul><li>Treat the lesion </li></ul><ul><li>• Treat it early with minimal tissue </li></ul><ul><li>disruption </li></ul><ul><li>• Rehabilitate the ankle </li></ul>
  34. 34. Thank You