Craig S. Radnay, M.D. 2/23/2018

Transcription

1 Achilles Tendon Ruptures: How I Do It Craig S. Radnay, M.D., M.P.H. Insall Scott Kelly Institute for Orthopedics & Sports Medicine NYU Langone Orthopedic Hospital Tampa, FL February 9, 2018 Achilles Tendon Ruptures Largest and strongest tendon in the body Commonly injured Annual incidence 18/100,000 Rapid acceleration/deceleration Hypovascularity, degenerative changes, repetitive microtrauma Mean age yo Increased in males (3-20:1) Gross et al, FAI 2016 Achilles Tendon Injury: Imaging X-ray? Calc avulsion? Calcific tendon changes MRI --?To diagnose partial rupture --?Extensive distal tendinopathy Ultrasound Allograft Safety

2 Operative vs Nonoperative Advantage Advantage calf/pf strength No surgical complications Faster return to work Lack of scar? Rerupture functional outcome (RTS) Disadvantage Wound complications Disadvantage Rerupture % Strict protocol adherence Skin complications Uquillas et al, JBJS-A 2015; Lantto et al, AJSM Non-operative Treatment With Early Functional Bracing 3 wks PWB in Cam boot with heel wedges Hematoma consolidation At 3 wks, WB in boot Remove wedge weekly Dorsiflexion stop Early mobilization important Passive/active plantar flexion exercises Active dorsiflexion to neutral Willits et al, JBJS 2010; Metz et al, AJSM 2008; Twaddle et al, AJSM Non-operative Treatment With Early Functional Bracing Neutral in Cam boot at 6 wks Slow increase dorsiflexion stretching Graduated resistance exercises Proprioception, gait training Hydrotherapy Back in regular shoes at wks Compliance essential!!! Willits et al, JBJS Allograft Safety

3 Operative vs Non-operative Non-op treatment Older, sick or sedentary patients Lower physical demands Limited functional and athletic goals IDDM Vasculopathy Poor nutrition (albumin) COPD Bleeding disorder Rensing et al, Foot Ankle Spec 2017 Operative vs Nonoperative Willits et al, JBJS 10 Accelerated rehab (early WB, early ROM) No diff: rerupture, ankle ROM, function Need early diagnosis (within 2 weeks) Strict protocol complians Operative group stronger plantarflexion Sorceanu et al, JBJS 12 (meta) No difference reruptures, fn w/functional rehab Operative group RTW 19d earlier Operative vs Nonoperative Renninger et al, FAI 2016 Young, active, compliant cohort Op group return to duty 1.5 mos earlier Hurley ey al, AOFAS 2017 (meta) Re-rupture rates lower in operative treatment in all studies, even when functional rehabilitation used Allograft Safety

4 My Guidelines for Operative Treatment Young, healthy patients Stronger tendon Quicker return: work, military duty, play Repair athletes of all levels Stronger tendon Improved endurance Decision is complex and requires thorough discussion of risks and benefits of the procedure Open Surgical Repair Slight medial approach Curve distally and medially to avoid scar irritation with shoewear Proximally avoid sural n. 11 cm proximal to tuberosity 3.5 cm distal to m-t junction 2 cm lateral to lateral achilles Yepes et al, JBJS 10 Open Surgical Repair Dissection sharply down to tendon, through paratenon Minimize undermining to preserve fullthickness flap for closure Minimize skin, deep tissue retraction Expose tendon fully, debride ruptured tendon edges Repair in slight plantar flexion +/- drape out contralateral limb Allograft Safety

5 Open Surgical Repair Locking Krackow stitches 4 strands across repair site No 2 or 5 non-absorbable woven suture Open Surgical Repair Epitendinous 2-0 to reinforce repair, improve tendon apposition and debulk site Increase repair strength, stiffness, failure strength +/- Release deep posterior compartment Tack FHL muscle belly medially Water-tight closure of paratenon Highly vascularized Allows for smooth gliding of tendon b/w subq tissue and deep fascia Surgery Post-op Early Protected Functional ROM, WB 3 weeks of non-wb immobilization Posterior splint x 1wk, SLC x 2 wks Primarily for wound healing Early protected ROM and WB in walking boot with 2-cm heel lift, DF stop x 3 wks PT for gentle passive and full active ROM, wound mobilization, scar adhesions Allograft Safety

6 Surgery Post-op Early Functional Mobilization Progressive WBAT, strengthening at 6 wks Bicycle, elliptical, pool exercise at 6 wks Standing calf stretch at 7 wks Double leg heel raise, wobble board at 8 wks Regular shoes full ADLs at wks Light jogging at 4-6 mos Return to sport 9-12 mos Percutaneous, Mini Open Similar Patient satisfaction Rerupture rate Lower incidence wound complications Stronger biomechanically vs Krackow load to failure with increased tendon size Quicker Return to walking, stairs, sports McWilliam et al, FAI 2016; Demetracopoulos, FAI 2014; Huffard et al, Clin Biomech 2008; Hsu et al, FAI 2015 Minimal Invasive Repair Contraindication Avoid in very proximal or insertional ruptures Distal Avulsions Subacute/Chronic Delay > 3 weeks Lee et al, FAI 2008 Allograft Safety

7 Minimal Invasive Repair: Technique Incision Transverse or longitudinal Assess tendon apposition Assess quality of repair If transverse, make approximately 1 cm proximal to palpable rupture Minimal Invasive Repair: Technique Hold tension on tendon stump as jig is advanced Tendon mobilization, jig placement easier with earlier treatment Superficial within pseudosheath Pass sutures 2 nonlocked, 1 locked Capture tendon>4cm away Minimal Invasive Repair: Technique Secure in maximum plantar flexion Unlocked sutures first, then locked Nearest to farthest from repair site Allograft Safety

8 Minimal Invasive Repair: Bone Suture Anchor Augmented Repair 3 small incisions Bypass compromised tissue proximal and distal to rupture site Fixation to bone can accelerate recovery Improved repair strength vs suture only? Better option with distal ruptures? Tendinopathy? Minimally Invasive Repair: Rehab 0-2 weeks splint 2-6 weeks progressive WB in Boot, lifts 6 weeks wean out out boot 6 mosrts Surgical Repair in the Elite Athlete: Return to Play Parekh et al, FA Spec 2008: 68% McCullough et al, J Surg Orth Adv 2014: 78% Trofa et al, AJSM 2017: 66% Fewer games, less time, lower level Jack et al, FAI 2017(NFL), ,72% Greenfield, Anderson AOFAS 2017: 74% More skilled players less likely affected and more likely to return to baseline Allograft Safety

9 Chronic Achilles Tendon Rupture 4 wks 2.5 mos Poorer healing potential Usually requires surgery Augmentation Soft-tissue Allografts Synthetics Tendon transfer Chronic Delayed Repair Debride nonviable tendon segments Excise fibroadipose scar tissue Release adhesions of proximal tendon stump to sheath and posterior fascia of FHL Chronic Delayed Repair Size Does Matter Debride nonviable tendon segments Defect <3 cm, < 3 mos old End to end repair, posterior fasciotomy Defect > 3-6 cm V-Y advancement, turndown Larger defects Fascial turndown of central third of proximal Achilles Fresh-frozen Achilles tendon allograft (10 cm) Autograft reconstruction (semit, gracilis) +/- FHL augmentation Allograft Safety

10 V-Y Lengthening: Defect 3-6 cm Sliding Advancement of G-S Aponeurosis -Debride necrotic tissue -Apex of V at most tendinous part of myotendinous jn -Limbs 1.5-2x length of rupture gap -Gently advance myotendinous jn -Repair tendon +/- FHL transfer, turndown -Repair V in Y configuration Fascial Turndown?Small defect remains following approximation and suturing of tendon edges Identify central third of tendon and peel gastroc fascia off of deeper muscle 6-8cm length, 1.5cm width From 3-4 cm proximal to the suture line Fascial Turndown Place stay stitches at base of turndown just proximal to rupture Flip fascia 180 and secure to distal stump Proximal split closed in side-toside Guclu et al, FAI 2016 Allograft Safety

11 Chronic Achilles Rupture: Augmentation Freeze-dried human acellular dermal collagen scaffold Chronic Achilles Rupture: Augmentation Autograft FHL, FDL, PB or slip from gastrocnemius Peroneus longus and plantaris weave SemiT, gracilis Allograft FHL Augmentation Mechanical support of direct repair Provide vascular bed to dysvascular site of rupture In phase transfer Minimal morbidity Exceptions: athletes performance artists Allograft Safety

12 FHL Augmentation +/- gastroc recession Harvest Through single posteromedial incision Medial arch incision for harvest and introduce into posteromedial exposure, tenodese distal stump FHL to FDL FHL augmentation Deep posterior fascia incised longitudinally FHL muscle belly exposed Release fibrous sheath b/w lateral and medial tubercles of the posterior process Right angle clamp to tension FHL muscle and tendon and see flexion of hallux Avoid tibial n/post tib a. just medial!! FHL augmentation Transect tendon under direct visualization in tunnel by the PM aspect of the subtalar joint Flex ankle and hallux for maximum length Stump of FHL tendon anchored to the calcaneus with absorbable interference screw DF ankle when drilling tunnel so co-linear, PF for appropriate tension on transfer Allograft Safety

13 Other Ways to Enhance Our Repair? Doxycycline (Nguyen et al, AJSM 2017) Inhibits elevated MMP after tendon injury Enhanced quality of tendon repair Anticoagulation Incidence symptomatic DVT in all patients with acute ruptures is 1-24% (higher VTE/PE in chronic repairs) Aggressive early rehab Risk-stratified treatment? Obesity, hx, cancer, OC, >60yo, venous stasis Bullock et al, Foot Ankle Spec 2017 Conclusions Common injury Functional non-op treatment similar outcomes to operative but early diagnosis and compliance are essential Recommend operative management for athletes of all levels Restored length m-t unit, Stronger tendon Improved endurance Quicker return to play, work Conclusions Surgical Repair Mini open repair does not have increased complications compared to open Improved wound healing Early functional mobilization Improved post-op function, return to sport/work, patient satisfaction Allograft Safety

14 Conclusions Chronic ruptures are challenging cases Lengthening Augmentation Tendon transfers Autograft Allograft Thank You For Your Attention Allograft Safety