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    Add as FriendTendo Achillis Injury: Diagnosis And Management-

    by: Dr. Md Nazrul

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    1 : CME ON TENDO - ACHILLIS Prepared By: Dr. Md Nazrul Islam MBBS, Engineering) Presenting By: Dr. Golam Mahmud (Suhash) Dept. Of Orthopaedics & Traumatology Saheed Surahwardy Medical College Hospital, Dhaka-1207,Bangladesh.
    2 : Largest tendon in the body Origin from gastrocnemius and soleus muscles Insertion on calcaneal tuberosity Anatomy
    3 : Lacks a true synovial sheath- Paratenon has visceral and parietal layers Allows for 1.5cm of tendon glide Anatomy
    4 : Paratenon Anterior – richly vascularized The remainder – multiple thin membranes Anatomy
    5 : Blood supply Musculotendinous junction Osseous insertion on calcaneus Multiple mesotenal vessels on anterior surface of paratenon (in adipose) Transverse vincula Fewest @ 2 to 6 cm proximal to osseous insertion Anatomy
    6 : Remarkable response to stress Exercise induces tendon diameter increase Inactivity or immobilization causes rapid atrophy Age-related decreases in cell density, collagen fibril diameter and density Older athletes have higher injury susceptibility Physiology
    7 : Gastrocnemius-soleus-Achilles complex Spans 3 joints Flex knee Plantar flex tibiotalar joint Supinate subtalar joint Up to 10 times body weight through tendon when running Biomechanics
    8 : Close injury/rupture Open injury/rupture Acute injury Neglected injury Classification Of Tendo Achillis injury-
    9 : Accidental cut injury (bath room injury, road traffic injury) Social/political Violence Open Tendo Achilles injury
    10 : 1. Diagnosis and assessment of extend of injury. 2. Primary care 3. Operative treatment Management of open injuries
    11 : Pathophysiology Repetitive microtrauma in a relatively hypovascular area. Reparative process unable to keep up May be on the background of a degenerative tendon Achilles Tendon Rupture(close injury)
    12 : Antecedent tendinitis/tendinosis in 15% 75% of sports-related ruptures happen in patients between 30-40 years of age. Most ruptures occur in watershed area 4cm proximal to the calcaneal insertion. Achilles Tendon Rupture: Textbook Facts
    13 : Classification of tendon inflammation & degeneration
    14 : History Feels like being kicked in the leg Case reports of fluoroquinolone use, steroid injections Mechanism Eccentric loading (running backwards in tennis) Sudden unexpected dorsiflexion of ankle (Direct blow or laceration) Achilles Tendon Rupture
    15 : A case of Tendo-achilis injury (closed)-
    16 : Prone patient with feet over edge of bed Palpation of entire length of muscle- tendon unit during active and passive ROM Compare tendon width to other side Note tenderness, crepitation, warmth, swelling, nodularity, palpable defects Physical Examination-
    17 : Partial Localized tenderness +/- nodularity Complete Defect Cannot heel raise Positive Thompson test Achilles Tendon Rupture- Physical-
    18 : Positive Thompson test-
    19 : Negative thompson test in uninjured tendoachilis-
    20 : Gap in rupture Tendo-achillis injury-
    21 : Diagnostic Pitfalls 23% missed by Primary Physician (Inglis & Sculco) Tendon defect can be masked by hematoma Plantar-flexion power of extrinsic foot flexors retained Thompson test can produce a false-negative if accessory ankle flexors also squeezed Achilles Tendon Rupture-
    22 : X-Ray- This lateral x-ray of the calcaneus shows an avulsion fracture at the insertion of the Achilles tendon, with marked separation of fragments. . Imaging
    23 : Inexpensive, fast, reproducable, dynamic examination possible Operator dependent Best to measure thickness and gap Good screening test for complete rupture Imaging Ultrasound
    24 : Expensive, not dynamic Better at detecting partial ruptures and staging degenerative changes, (monitor healing) Imaging MRI
    25 : Restore musculotendinous length and tension. Optimize gastro-soleous strength and function Avoid ankle stiffness Management Goals-
    26 : Cast in Plantarflexion CAM Walker or cast with plantarflexion q 2 wks 2 wks Allow progressive weight-bearing in removable cast Remove cast and walk with shoe lift. Start with 2cm x 1 month, then 1cm x1 month then D/C 4 weeks Start physio for ROM exercises When WBAT and foot is plantigrade Start a strengthening program 2- 4 weeks Conservative Management
    27 : Preserve anterior paratenon blood supply Beware of sural nerve Debride and approximate tendon ends Use 2-4 stranded locked suture technique May augment with absorbable suture Close paratenon separately Surgical Management-
    28 : Exposed ruptured tendoachilis-
    29 : Acute case : usually end to end repair is enough Neglected case: Advancement plasy (V-Y) or reconstruction by other tendons Surgical Management (cont.)
    30 : V-Y plasty and repair Tendoachilis-
    31 : After repair of Tendo-achilis-
    32 : Immobilization, Positioning & Cast-
    33 : Assess strength of repair, tension and ROM intra-op. Apply long leg cast with ankle in the least amount of planterflexion(gravity equinus) & knee 60 degree flexion with window at operated site. Stitch removal after 2 wks. Short leg cast after 3 wks with partial equinus correction Surgical Management : Post Operative Care-
    34 : 2 weekly plaster change with gradual equinus correction (4-6 episode ). Walking with heel raised shoe & regular physiotherapy. Reverse ankle stop brace up to 6 months. Post-op. management(continue)-
    35 : Acute rupture of tendon Achilles. A prospective randomised study ofcomparison between surgical and non-surgical treatment. Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8 112 patients Surgery + Early functional rehab in brace Casted x 8 wks 21 % re-rupture 1.7% re-rupture 5% infection 2% Sural nerve inj. No difference in functional outcome Conservative vs. Surgical-
    36 : After Care-
    37 : Patient Satisfaction & Smile-
    38 : Special Thanks To- Associate Prof. Dr. P C Debenath Associate Prof. Sheikh Abbas Uddin Assistant Prof. Dr. Kazi Shamimuzzaman Dr. Subir Hossain Shuvro Sponsored By- Incepta Pharmaceuticals Ltd. Dhaka, Bangladesh.
    39 : THANK YOU From Orthopaedics’ & Traumatology Department Shaheed Suhrawardy Medical College Hospital Sher- E- Bangla-Nagor,Dhaka-1207,Bangladesh.

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