Dr. Edward Magur Cherry Blossom Seminar 2012

1. Operative Management ofOperative Management of
Achilles TendonAchilles Tendon
DisordersDisorders
Edward G. Magur, MDEdward G. Magur, MD
Cherry Blossom SeminarCherry Blossom Seminar
April 2012April 2012

2. Disclosure StatementDisclosure Statement
• Author receives noAuthor receives no
compensation fromcompensation from
any commercialany commercial
entityentity

3. IntroductionIntroduction
• Largest/strongest tendon in human bodyLargest/strongest tendon in human body
• Treatment tailored to pathology andTreatment tailored to pathology and
patient demandspatient demands
• Initial treatment typically non-operativeInitial treatment typically non-operative
– Exception: rupturesException: ruptures
• Surgical intervention ranges from simpleSurgical intervention ranges from simple
to complexto complex

4. Surgical PrinciplesSurgical Principles
• Approach and soft tissue handlingApproach and soft tissue handling
• Primary repair best when possiblePrimary repair best when possible
• Reconstructive goalsReconstructive goals
– Bridge gapsBridge gaps
– Restore blood supply/healing potentialRestore blood supply/healing potential
– Provide tissue for repairProvide tissue for repair
– Augment strengthAugment strength

5. Pathologic ConditionsPathologic Conditions
• RupturesRuptures
– AcuteAcute
– ChronicChronic
• ParatenonitisParatenonitis
• TendinosisTendinosis

6. Acute Achilles RuptureAcute Achilles Rupture
• LocationLocation
– Anywhere alongAnywhere along
course of tendoncourse of tendon
– MRI when in doubtMRI when in doubt
– Very distal rupturesVery distal ruptures
and avulsions notand avulsions not
rarerare

7. Acute Achilles RuptureAcute Achilles Rupture
• Open RepairOpen Repair
– Remains “goldRemains “gold
standard”standard”
– TechnicallyTechnically
straightforwardstraightforward
– Allows earlyAllows early
rehabilitationrehabilitation
– Low (<2%) re-Low (<2%) re-
rupture ratesrupture rates

8. Acute Achilles RuptureAcute Achilles Rupture
• Open RepairOpen Repair
– WoundWound
complicationscomplications
• Highest with openHighest with open
repairrepair
• PotentiallyPotentially
devastatingdevastating

9. Acute Achilles RuptureAcute Achilles Rupture
• PercutaneousPercutaneous
RepairRepair
– Gain in popularityGain in popularity
last 10 yearslast 10 years
– CommerciallyCommercially
available systemsavailable systems
• Easier passage ofEasier passage of
suturessutures
• Less sural nerveLess sural nerve
entrapmententrapment

10. Percutaneous RepairPercutaneous Repair
• AdvantagesAdvantages
– Smaller wound, less sloughSmaller wound, less slough
– Decreased painDecreased pain
+/- Earlier mobilization+/- Earlier mobilization
• DisadvantagesDisadvantages
– Tendon apposition??Tendon apposition??
– Higher rates of sural nerve injuryHigher rates of sural nerve injury
– Transverse incision????Transverse incision????

11. Acute Achilles RuptureAcute Achilles Rupture
• Trends and pearlsTrends and pearls
– Small medial incisionSmall medial incision
• ““Mini-open”Mini-open”
– Full thickness flapFull thickness flap
– Range to neutralRange to neutral
– Shorter absolute immobilizationShorter absolute immobilization
• Dorsiflexion-limited ROM bootDorsiflexion-limited ROM boot
– Earlier weightbearingEarlier weightbearing

12. Chronic Achilles RuptureChronic Achilles Rupture
• 4+ weeks after injury4+ weeks after injury
• Missed ruptureMissed rupture
• ““Silent rupture”Silent rupture”
• Function based on M-T unit lengthFunction based on M-T unit length
• Operative RxOperative Rx
– Based on function and patient requirementBased on function and patient requirement
– Higher risksHigher risks

13. Chronic Achilles RuptureChronic Achilles Rupture
• Reconstructive OptionsReconstructive Options
– V-Y lengtheningV-Y lengthening
– Turndowns and local graftingTurndowns and local grafting
– Tendon transferTendon transfer
– Free graftsFree grafts
• AllograftAllograft
• AutograftAutograft
• Collagen matrix productsCollagen matrix products

14. V-Y LengtheningV-Y Lengthening
• Defects <5cmDefects <5cm
• Limbs 2x defectLimbs 2x defect
• AdvantageAdvantage
– Local tissueLocal tissue
• DisadvantageDisadvantage
– Limited to 5 cmLimited to 5 cm
– Initial weaknessInitial weakness

15. TurndownsTurndowns
• Multiple techniquesMultiple techniques
• Central thirdCentral third
• AdvantagesAdvantages
– Bridge large gapsBridge large gaps
– Local tissueLocal tissue
• DisadvantagesDisadvantages
– ““lump” at TD sitelump” at TD site
– Two anastomosesTwo anastomoses

16. TransfersTransfers
• FHL most commonFHL most common
– In phase transferIn phase transfer
– Brings blood supplyBrings blood supply
with musclewith muscle
– Minimal donorMinimal donor
morbiditymorbidity
• Exception: AthletesException: Athletes
& performing artists& performing artists
• CombinationsCombinations

17. AllograftsAllografts
• Minimal tissueMinimal tissue
remainingremaining
– InfectionInfection
– Previous failedPrevious failed
repairs/reconsrepairs/recons
• Multiple fixationMultiple fixation
pointspoints
– Slow incorporationSlow incorporation

18. ParatenonitisParatenonitis
• Generally RxGenerally Rx
nonoperativelynonoperatively
• InjectiblesInjectibles
– NO STEROIDSNO STEROIDS
– BrisementBrisement
• Breaks upBreaks up
adhesionsadhesions

19. Platelet Rich Plasma (PRP)Platelet Rich Plasma (PRP)
• Blood drawn &Blood drawn &
CentrifugedCentrifuged
– Platelets, stem cellsPlatelets, stem cells
• Injected intoInjected into
paratenonparatenon
• ““Growth Factors”Growth Factors”
Make tendon healMake tendon heal

20. ParatenonitisParatenonitis
• SurgerySurgery
– Rarely necessaryRarely necessary
– Strip inflamedStrip inflamed
tissuetissue
– Early motionEarly motion
– 70-100% success70-100% success
ratesrates

21. TendinosisTendinosis
• Degeneration ofDegeneration of
tendontendon
– Poor bloodPoor blood
supplysupply
– Normal tendonNormal tendon
replaced withreplaced with
scar tissuescar tissue
• Insertional vs.Insertional vs.
NoninsertionalNoninsertional

22. Insertional TendinosisInsertional Tendinosis
• Haglund’s DeformityHaglund’s Deformity
– Typically presentTypically present
• Calcification commonCalcification common
– Long standing casesLong standing cases
– Insertion becomes ossifiedInsertion becomes ossified
• Associated bursitisAssociated bursitis
– RetrocalcanealRetrocalcaneal
– AchillesAchilles

23. Insertional TendinosisInsertional Tendinosis
• Surgical RxSurgical Rx
– Remove bonyRemove bony
impingementimpingement
– Resect allResect all
degenerated anddegenerated and
calcified tendoncalcified tendon
– Prepare forPrepare for
lengthening +/-lengthening +/-
transfertransfer

24. TendinosisTendinosis
• Resect allResect all
degenerativedegenerative
tendontendon
• <50% requires<50% requires
augmentaugment
– FHL transfer mostFHL transfer most
commonlycommonly

25. Pearls and PitfallsPearls and Pitfalls
…and speaker’s biases…and speaker’s biases
- When feasible, approach off midlineWhen feasible, approach off midline
- Avoid water-tight closureAvoid water-tight closure
- Hematoma---Hematoma--- Infection and sloughInfection and slough
- Check wound early and oftenCheck wound early and often
- Don’t get surprised in ORDon’t get surprised in OR
- MRI and pre-op planningMRI and pre-op planning
- Adjunctive and multiple proceduresAdjunctive and multiple procedures
- Anchors, biotenodesis screws, allograftsAnchors, biotenodesis screws, allografts

26. Pearls and PitfallsPearls and Pitfalls
…and speaker’s biases…and speaker’s biases
- Address all pathologyAddress all pathology
- Set tension to neutralSet tension to neutral
- Trend early mobilization and WBTrend early mobilization and WB
- Largest factorLargest factor
- ““Lay the crepe”Lay the crepe”
- Big reconstructions take 12-18 monthsBig reconstructions take 12-18 months
- Risk for complications increase with bigRisk for complications increase with big
surgerysurgery

27. Thank YouThank You