AOFAS Resident Review Course September 28, Andrew J. Elliott, MD Assistant Attending Surgeon Hospital for Special Surgery Foot and Ankle Service

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1 Course September 28, 2013 Andrew J. Elliott, MD Assistant Attending Surgeon Hospital for Special Surgery Foot and Ankle Service

2 Disclosure I have a financial relationship with Bacterin. Its products are not mentioned in this talk.

3 Problems Acute Tendonitis Rupture Chronic Paratenonitis Midsustance Tendonosis Insertional Tendonosis Haglunds Bursitis

4 Achilles Heel Repetative microtrauma (8-10 X Body weight) Males Age increase stiffness loss of elasticity loss of collagen fibrils decreased bloodflow

5 Achilles Heel Intrinsic Factors Hypovascular zone Tight heel cords Functional Overpronation foot pronation-tibia rotated internally knee extension-tibia rotated externally Achilles whip Cholesterol, gout, sero(-) arthropathy

6 Achilles Heel Extrinsic factors improper training improper shoes steroids fluoroqunolones

7 Peritendinitis Acute (<3 mos) morning stiffness, start up pain, crepitus Chronic (>3 mos) more constant with adherent paratenon

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9 Peritendinitis Acute tendonitis (90%-95% success) rest, heel lift, NSAIDS, massage stretching and training modifications Chronic Paratenonitis (72%-90% success) Brisement excise hypertrophic/fibrotic tissue

10 Retrocalcaneal Bursitis Pain just above insertion (medial lateral squeeze) Pain 100% with running and 40% during ADL Often with tendinosis or Haglunds

11 Haglunds Deformity

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13 Retrocalcaneal Bursitis Usual non-operative treatment Consider injection INTO bursa After 6 months consider exostectomy and bursectomy

14 Insertional/Calcific Tendonosis

15 Heavy Load Eccentric Exercises Alfredson H et al Br JSM % of patients with insertional tendonosis responded with classic eccentric treatment 67% were satisfied after treatment with a new eccentric loading regime 3X15 reps, 2X/day, 7X/week, 12 weeks. VAS 70 to 21

16 MRI

17 Gastrocnemius Recession Significant improvement in pain for midsubstance tendonosis Anderson et al., FAI 2013 Not as good for insertional

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24 Gaining Length/Decreasing Tension Variation on Vulpius technique

25 Gaining Length/Decreasing Tension Baker or Z-lengthening

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27 Midsubstance Tendinosis Degeneration within tendon mucoid degeneration (+MRI) increased fibroblasts irregular oriented collagen mesotenal capillary invasion

28 Non-Insertional Achilles Tendinosis Before PRP 4 months after PRP

29 Midsubstance Tendinosis Activity/training modification Orthoses/rocker sole Ultrasound Stretching Heel lift with activity Heavy load eccentric training 70% w improv.

30 Debridement and FHL Transfer

31 Debridement and FHL Transfer

32 Debridement and FHL Transfer Can use peroneals as alternative

33 Debridement and FHL Transfer An outcome study of chronic Achilles tendinosis after excision of the Achilles tendon and flexor hallucis longus tendon transfer. Foot Ankle Int Sep;26(9): Pain decreased in 95.5% (n = 42) patients, and 86.4% (n = 38) patients were satisfied with the result. The average AOFAS score 91.6 (SD 7.7). Strength deficits were 30% on average; however, all but one patient could do a heel raise.

34 RUPTURE!...Thompson Test Rupture

35 Treatment Goal is to establish correct resting tension while preserving tendinous strength Rupture

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37 Non-Op vs. Op Rerupture 8% vs 4% (Nistor; pro/rand) 16% vs 9% (Cetti; pro/rand) 18% vs 1% (Kellam;lit review) 12% vs 3% (Lo;metaanalysis) Complications 4% vs 17% (Carden) 15% vs 5% (Cetti) Rupture

38 Non-Op vs. Op Kellam Return to preinjury 69% vs 83% Satisfaction 66% vs 93% Rupture

39 Non-operative treatment 8 weeks in specialized CAM boot with functional rehab program Outcome equal to surgical repair at 12 mos., but 10% vs. 0% rereupture. Karlsson et al, AJSM 2013 Kirkley et al, JBJS 2010

40 Delayed Repair Defect 1-2 cm mobilize tendon proximally place sutures add stress relaxing tension for 8-10 min. Consider gastroc recession Rupture

41 Delayed Repair Defect 2-5 cm mobilize tendon proximally place sutures add stress relaxing tension for 8-10 min. V-Y advancement (arms 2X size of defect) or Z slide Expect 25% Cybex deficiency Rupture

42 Delayed Repair Defect >5 cm FHL transfer Tension FHL at 10 PF Assess contractility of muscle Add stress relaxing tension for 8-10 min. Tenodese to FHL if contractility Rupture

43 Elongated Scar Tissue Yasuda T, et al. Am J Sports Med. 35(4) MRI with high signal scar 22 weeks post injury Scar tissue resection and primary repair. Mean f/u 31 mos. AOFAS 98

44 Complications 20 deg PF near normal perfusion 40 deg PF 51% of normal perfusion Poynton et al. FAI 22(7)