Achilles Tendon Rupture

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Achilles Tendon Rupture

• Corolinda S. Helu, DPM
• Sherry S. Nazarian, DPM
• Podiatric Surgical Residents
• New York Community Hospital

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Achilles

• Greek warrior

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Discussion

• Anatomy
• Physical Exam Findings
• Operative Repair
• Mitek
• Statek
• Case Presentation

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Anatomy Soleus

• Innervation
• Tibial nerve (S1 S2)
• Action
• Plantarflex AJ
• Maintain erect position
• Prevents xs DF during

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Anatomy Gastrocnemius

• Innervation
• Tibial nerve (S1 S2)
• Action
• Plantarflex AJ
• Flex KJ

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Anatomy Plantaris

• Innervation
• Tibial nerve (S1 S2)
• Action
• Weak flexor KJ AJ

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Anatomy Gastroc-Soleus Complex

• Retrocalcaneal Bursa
• deep surface of AT, upper 1/3 calcaneus
• Haglunds, insertional tendinitis,
• Achilles Tendon
• Thickest, strongest
• 12-15 cm long
• Aponeurosis of G S
• S medially
• G laterally
• Vascular watershed 2-6 cm above insertion
• Quinolone abx rupture

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Tibial Artery Nerve
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Causes?

• Etiology
• Direct Blow
• Laceration
• Abnormal Muscle Pull
• Overuse
• Running on hills/hard surfaces
• Tight calf muscles
• Worn out shoes
• Flat feet

• Sign Symptoms
• Popping or snapping sound
• Pain swelling _at_ heel
• Inability to PF or ambulate

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Diagnosis?

• Pain at site of insertion
• Palpable tendon gap
• Increased soft tissue mass
• Loss of PF strength
• Inability to walk on toes

• Positive Thompson test
• Pt unable to PF when calf is squeezed
• Plantaris rupture w/ nl Thompson test
• Obrien Needle Test
• 25 gauge inserted w/in AT
• Motion of needle w/ PF DF intact AT

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Non Operative Rx

• Indications
• Older
• Medically unstable
• Management
• Full equinus BK cast X 3 wks
• Gravity equinus BK cast X 3 wks
• Heel lifts
• Expected Outcome
• Decrease in strength endurance, pt not satisfied

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Operative Rx

• Indications
• Younger pt
• clinically displaced rupture
• earlier return to sports
• earlier return of muscle power
• Management
• Surgical repair
• BK NWB cast X 3 wks
• BK WB cast X 3 wks
• Heel lifts (19 13 6 mm)
• Expected outcome
• 83 return to pre-injury level
• 93 satisfied w/ result

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Surgical Approaches Lynn Procedure

• Up to10 days DISTAL rupture
• McLaughlin (prox, screw in calcaneus, wire
  suture)
• Medial incison
• Paratenon midline incision
• Foot 20 deg PF
• W/O excising ends, suture
• Intact plantaris, membrane to cover AT

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Surgical Approaches Lindholm Procedure

• Late repair
• Bosworth (incision, 1 strip, transverse)
• Midcalf to calcaneus incision
• Ruptured ends debrided sutured
• Proximal end
• 2 flaps 7 cm long
• Attached 3cm proximal rupture
• Twist 180 deg
• Distal end
• Suture external to SQ

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MITEK Superanchor

• Ethicon, a Johnson and Johnson Company
• Fixation of 2-5 sutures to bone
• Proper drill hole size is 2.9mm x 17.5mm
• Bone stock must be adequate to allow proper
  placement

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Mitek Anchor

• The anchor is Nickel titanium alloy
• The needle is stainless steel
• Suture type varies

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Indications

• Many from shoulder to the knee
• Podiatrically, it may be used for achilles tendon
  repair or reconstruction

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Contraindications

• Pathological conditions of bone such as cystic
  changes Severe osteopenia which will
  impair the anchors ability to securely fixate.
• Pathological conditions in the ST sutured to the
  bone which would prevent its secure fixation by
  the suture.

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Contraindications cont

• Comminuted bone surface which wont allow secure
  anchor fixation.
• Blood supply limitations
• Previous infections
• Mental illness
• alcoholism
• Not for artificial ligaments or other implants

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Directions

• Drill bone site using Mitek drill.
• Proper hole depth is achieved when the mark on
  the drill is in line with the top of the Mitek
  drill guide (15mm). All axes must be kept the
  same or drill tip may break.
• Do not twist or apply bending force into the
  inserter.
• Incomplete insertion or poor bone quality results
  in anchor pullout.

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Directions continued

• Apply approximately 8 lbs of tension on the
  suture lengths to set the anchor in the bone.
• Mitek anchors are designed to lock into
  cancellous bone so after insertion, pause
  momentarily to allow the titanium alloy wire
  components to regain the preformed arc shape

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STATAK ST Attachment Device

• Zimmer product
• Consists of suture anchor w/ an attached suture
  assembled to a driver.
• Precise and efficient reattachment of ST to bone
• Suture anchored to cortical or cancellous bone

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Statak cont

• Each of the two free ends of the anchored suture
  is then loaded through the eyelet of a curved
  free needle
• The needle/ suture assembly is then passed
  through the free end of the ST and the suture is
  tied to approximate the ST to bone.
• Suture anchor is self tapping, selfdrilling
  threaded device

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Materials

• Suture anchor 2.5mm diameter Titanium
• driver stainless steel
• Suture braided polyester, nonabsorbable s 0,2

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Indications in podiatry

• Medial or lateral instability repairs/
  reconstructions
• AT repair/ reconstruction
• Midfoot reconstruction
• Hallux valgus reconstruction

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Directions for Statak ST attachmet device

• Secure the metal driver shaft w/in the jaws of
  the Jacobs chuck on the anchor
• Predrill pilot hole 0.5mm smaller into thick
  cortical bone (recommended).
• Insert driver to a depth of 0.5 inches
• Place the drill point of the Statak assembly
  through the cannula at the desired point of
  implantation and begin to apply pressure to the
  drill and begin drilling.

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Cont directions

• When the shoulder of the driver contacts the bone
  cortex and no longer advances, turn the driver
  2-5 more times then stop drilling.
• The anchor will automatically disassociate from
  the driver assembly.
• Discard driver
• Trim excess suture after hand tying

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Contraindications

• Moderate to severe osteopenia
• Use in any bone w/ diameter smaller than the
  length of the suture anchor plus countersink

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Warnings

• Immediate ROM should be avoided to allow
  biological bony/ ST healing.
• Do not implant this device w/in cartilage
  epiphyseal growth plates or bone apophyses
• Do not use where prehealing suture tension will
  exceed 20 pounds for size no 2 14
  pounds for size no 0

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Case Report

• 64 YO african american male
• Presented to DPM office 1 wk after sudden DF
  trauma to foot w/ resulted complete AT tear.
• Few days later pt had MRI
• PMH denies
• Social history denies

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Case report cont

• Allergies NKDA
• Meds denies
• Vitals afebrile, vss
• Lab noncontibutory
• Xray showed calcifications in AT and Posterior
  spur

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Podiatric exam

• Vascular DP/PT 2/4 TG WNL CFT 1sec
• Neuro intact protective sensation
• Ortho Dell in distal end of AT near calc
  insertion. Low arch
• DermNoncontributory

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