lecture 21 shah chronic achilles rupture
TRANSCRIPT
Chronic Achilles rupture
Dr.Rajiv ShahFoot & ankle surgeon‘Foot & ankle orthopaedics’Vadodara, Surat
Defined as 4-6 weeks post-trauma
Chronic ruptureNeglected ruptureLate /old repairDelayed reconstructions
Around 20-25% of acute ru
ptures are
missed by in
itial p
hysicians!!
H/o trauma, prior problems, local injection, drugs
Unsteady gaitDifficulty in ascending/descendingLimpDifficulty in rising on tip toe
Palpable gap +/- !!
Pain --- !!
Increased
dorsiflexion
Reduced plantarflexion
strength
Inability to
stand on tip
of toe ( m
ore so on
repetitions)
Haglund, spur, calcification Gap on dynamic USG MRI – degeneration, tear
Neglected/old rupture can also heal!! Defect fills up with fibrous tissues!!
Conservativ
e management:
when?
Poor skin condition DM Co-morbid conditions Smoking? Prior surgical scarring?? Patient's desire
Conservativ
e management:
what? High-topped boots Laced ankle brace Custom-moulded
leather ankle lacer
Cast? – controversialfor cases with < than 4 weeks
An aggressive calf-strengthening exercise program can enable patient to function adequately with impaired Achilles function!!
SURGERY
AUGMENTATIONFASCIA LATAGRACILLIS
SEMITENDINOSUS
PERONEIPATELLAR TENDON
PRIMARY REPAIR(UNCOMMON)
FASCIAL ADVANCEMENTV-Y PLASTYCENTRAL TURN DOWN
Local tendon transfer
• FHL • FDL • PB • PL • Plantaris
Synthetic or allograft • Polyglycol
threads • Marlex mesh • Dacron vascular graft • Carbon fibre • Allograft tendon substitution
Surgical algorithmC
hro
nic
ru
ptu
re
Gap up to 2cmsDirect repair
Pull tendon for 5 minutes
Gap up to 2-5 cmsTurn-overV-Y plasty
Gap > than 5 cms Transfer
Generous excision of fibrosis & dead tendon is a must!
9
Pull the tendon for five minutes & gain length
V-Y advancement
Tip: Make limbs twice as long as gap to be filled
Incision Closer look
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Central turn down
14
Central turn down
15
FHL + Turn down
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In phase transfer 30% of Achilles strength FHL is close to TA Increases blood supply FHL: single/double/triple
incisions
FHL transfer
FHL transfer – single incision
FHL transfer – double incision
FHL IDENTIFICATION: LEG
FHL IDENTIFICATION: FOOT
FHL transfer – double incision
FHL RETRIEVAL FHL SUTURED TO ITSELF AFTER PASSING IT THROUGH BONE TUNNEL
MIS harvest of FHL –Dr.Panchbhavi
FHL transfer – 3 incisionsT H Lui – whole length FHL transfer
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FHL transfer – function
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FHL can be sacrificed without loss of function!!
That’s all…Thank you all…