Anatomy
Gastrocnemius tendon 10-25 cm long
- soleus 3-10 cm
- inserts superior calcaneal tuberosity
- fibres spiral 90°
- fibres that lie medially in proximal portion become posterior distally
- allows elastic recoil & energy storage
Plantaris
- present in 90% population
- medial to T Achilles
Poor blood supply midportion
- mesotenal vessels
- fewest at 2-6 cm
- other blood supply from osseous insertion
Epidemiology
Usually age > 40 years
- M:F = 12:1
- occasional sportsman
- 75% during sports
Etiology
Calf contraction with forced dorsiflexion in setting of tendon degeneration
Combination of
1. Repetitive microtrauma
2. Hypovascularity
- occurs at watershed of vascular supply
- an area of hypovascularity 5 cm proximal to tendon insertion
Factors
- corticosteroids - oral or injected
- anabolic steroids
- flouroquinolone / ciprofloxacin (especially elderly)
- gout
- hyperthyroidism
- tendinitis (10% ruptures have preexisting achilles tendon disorder)
- cavovarus OR planovalgus foot
Mechanical Overload
- footwear (low heel, inadequate shock absorption)
- sudden training increase
- cross training
Classification of Tendon Inflammation
1. Paratenonitis
- inflammation of paratenon
- swelling, pain, crepitation, tenderness, warmth
2. Paratenonitis with tendinosis
3. Tendinosis
- intratendinous degeneration due to atrophy
- aging, microtrauma, vascular compromise
- swelling absent
- +/- palpable nodule
Rupture Site
1. Watershed area
- 5 cm proximal to insertion
- most common
2. Insertion
- common with insertional tendonitis
3. Musculotendinous juntion
- avulsion of medial or lateral head
- may present with chronic weakness
NHx (if neglected)
Weakness / wasting
- difficulty with push off
- compromised running / jumping / stairs
- can still walk with use of FHL / FDL / T posterior / Peroneals
History
Sudden pain in calf
- with audible snap
- on unaccustomed exercise
- especially tennis / squash
Examination
Acute tear
Positive Thompson Test (90% sensitivity and specificity)
- patient prone
- squeezing calf doesn't produce plantarflexion of ankle
Thompson test
Gap
Chronic tear
Gap not palpable as gap fills with scar tissue
Excessive dorsiflexion compared with other side
Xray
Bony avulsion
Ultrasound
- check reduction of tendon ends with plantarflexion
MRI
Indication
- incomplete rupture
- signs of degeneration
- clinical uncertainty (two major signs not present)
- measurement of gap in chronic cases / preoperative planning for reconstruction
Management
Operative v Non-operative Management
Issues
Infect / skin breakdown / nerve injury with operative
Strength / return to sports
Rerupture rates
Results
- RCT operative v non operative 144 patients
- concept of accelerated functional rehabilitation in both groups
- 2 weeks non weight bear then 6 weeks full weight bear in aircast with 2 cm heel raise
- able to actively dorsiflex / plantar flex below neutral
- no significant difference in rerupture rate / range of motion / strength
- 13 complications in operative versus
- RCT operative versus nonoperative 526 patients
- no differences between groups
- 6% retear in nonoperative group
- 0.6% retear in operative group
- 3% nerve injury in open operative group
- 5% nerve injury in the minimally invasive group
Non-operative
Indications
- elderly, DM, PVD, smokers
- non athlete
Technique
Dorsiflexion cast first two weeks
- equinus front slab within 24 hours
- close gap before haematoma forms
Functional Rehabilition with heel raise 2 cm and air cast
- 6 weeks
- active ROM below neutral
Results
Operative
Options
Open
Minimally invasive
Open tendoachilles repair
Prone position with tourniquet
- slightly medial incision to protect sural nerve
- full thickness skin flaps to paratenon
- identify and protect sural nerve
- divide paratenon longitudinally
- can incise paratenon in the midline anteriorly which increases tissue available for closure
- Bunnell Suture / Krackow suture x 2 with high strength suture / fibre wire
- one in proximal and one in distal tendon ends
- tie via two knots with foot fully plantar flexed
- +/- augment with circumferential 4.0 prolene to minimize bunching
- careful closure of paratenon to prevent skin adhesions
- front slab in plantarflexion
Complications
Infection
Swab, washout, primary closure
Wound breakdown
Debride, manage infection
- vac dressing
- free muscle flap (usually gracilis) + SSG
- fasciocutanous flap (radial or lateral thigh) has better wear characteristics
Rerupture
Case 1
Previously non operative management / new onset severe pain with bump
- intrasubstance / incomplete tear
Case 2
Acute pain 8 weeks post non operative management rupture
- ultrasound demonstrates scar tissue
- no reduction with plantarflexion
Reconstruction / Augmentation
Indication
Unable to primary repair / chronic setting
Algorithm
| Defect | Method |
|---|---|
| < 3 cm | Turndown |
| 3 - 5 cm | V-Y lengthening |
| > 5 cm |
FHL / FDL / peroneal transfer Free gracilis graft Allograft |
Turndown
Bosworth technique
- harvest central third fascia
- from musculotendinus junction as far proximal as possible
- leave attached distally, detach proximally
- closure fascia above
- tubularise fascia with 2.0 ethibond
- drill hole through calcaneal tuberosity
- pass through calcaneum
- suture to itself
VY lengthening
Reconstruction
Turndown + FHL transfer
FDL / FHL transfer
- medial foot incision to harvest tendon
- suture distal FDL stump to FHL
- pull tendon through
- through drill hole in calcaneum
- pass tendon through and suture to itself
Peroneus brevis transfer
- lateral incision
- divide tendon
- pass through calcaneal drill hole
Free Gracilis tendon transfer
