ACHILLES SENAN. - Nya synpunkter - Jon Karlsson. Sahlgrenska University Hospital Gothenburg Sweden

Transcription

1 ACHILLES SENAN - Nya synpunkter - Jon Karlsson Sahlgrenska University Hospital Gothenburg Sweden

2 ACHILLES SENAN Operation vs icke-operation Tidigare studier; Nistor, MöllerM Aktuell studie; Nilsson-Helander Kommande studie; Olsson

3 Tack

4 Case history (true( true) No history of trauma, complaints of pain, and now unable to play or train soccer Pain on palpation, around 3-66 cm proximal to insertion

5 Case history (true( true) No swelling,, no bursitis,, no palpable thickening of tendon Diagnostic work-up up; ; Ultrasonography shows tendinosis, but just mm and no vessles at all

6 Case history (true( true) Treatment; eccentric training (supervised) But,, the player is no better and is starting to get frustrated. What to do now? Surgery? In why? In such a case, what to operate and

7 Previous speaker Mini-surgery surgery, ultrasonography-guided guided Balance with maxi-surgery surgery? Classical techniques Problems? Not very much evidence from RCT:s

8 Major advances in recent years Eccentric training Sclerosing injections Mini-surgery Problems? Not Not very much evidence from RCT:s; no comparisons between different techniques

9 What are we dealing with? Paratenon problem Tendon problem; either general or localized Combined; paratenon and tendon Tendinosis; partial rupture (does it exist?)

10 Indication for surgery Failed non-surgical treatment, including eccentric training Pain and functional deficit At least 6 months duration

11 Surgical technique Excision of paratenon Excision of degenerated tendon Longitudinal incisions (scarring) In selected cases; reinforcement using turn-down flap(s)

12 Day-care surgery Supine, local anesthesia Always medial approach (less morbidity) Longitudinal incision of fascia Incision and/or excision of paratenon

13 In case of macroscopic tendon changes,, excision of tendon tissue (until macroscopic normal tissue) 2-33 longitudinal tendon incisions Immobilization for days,, in order to rest the tendon; slow rehabilitation.

14 Surgical technique; local anesthesia

15 Surgical technique; paratenon

16 Surgical technique; tendon damage

17 Surgical technique; excision of tendon tissue

18 Surgical results % Excellent/Good results Wide variation Problems; long rehabilitation (6-9 months) and surgical morbidity Surgical complications (11%; Paavola et al, 2000)

19 Alternative technique Arthroscopic tendon cleaning, combined with arthroscopic longitudinal tendon incisions Advantage? Less surgical morbidity and easier rehabilitation Can be done via 4 small wounds

20 Distal tendon pain Haglund s heel (1907) Osteochondrosis; ; juvenile

21 Distal tendon pain Haglund s heel Tendon injury/tendinosis Calcaneal osteophytes Broad heel Bursitis; retrocalcanear or subcutaneous

22 Surgical treatment Removal of osteophytes Open Arthroscopic; calcaneoplasty Can always be done with the arthroscope

23 Surgical treatment Calcaneal osteotomy Open Screw fixation Low morbidity

24 Surgical treatment Distal tendon injury Excision; midline tendon incision Longitudinal tendon incision Reinforcement if needed

25 Surgical treatment Bursitis Excision Open Arthroscopic - preferred -

26 Conclusion My own experience

27 Thank you

28 Thank you