Achilles Repair Syllabus
2013-05-20
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5/17/2013 VuMedi Webinar 20.05.2013 Chronic tear of the Tendo Achillis Minimally Invasive Achilles Repair with Soft Tissue Augmentation Nicola Maffulli MD, MS, PhD, FRCS(Orth) DISCLOSURE • None relevant to this presentation Chronic rupture of the Achilles tendon Epidemiology • The Achilles tendon (AT) is the most commonly rupture tendon in the human body. • Complete ruptures of the AT: sedentary and athletes patients • Common in middle participate in sport. aged men who occasionally Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999; 81(7):1019-36 Longo UG, Ronga M, Maffulli N. Acute ruptures of the achilles tendon. Sports Med Arthrosc 2099;17(2):127-38 Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients. Am J Sports Med 1998; 26(2):266-70 1 5/17/2013 Chronic rupture of the Achilles tendon Definition • Variable • Timeframe is to 4 to 6 weeks from the time of injury. • When there has been a delay in treatment, ruptures may be called chronic, neglected, or old. Boyden EM, Kitaoka HB, Cahalan TD, An KN. Late versus early repair of Achilles tendon rupture. Clinical and biomedical evaluation. Clin Orthop Relat Res 1995; (317):150-8. Gabel S, Manoli A, 2nd. Neglected rupture of the Achilles tendon. Foot Ankle Int 1994; 15(9):512-7. Mann RA, Holmes GB, Jr., Seale KS, Collins DN. Chronic rupture of the Achilles tendon: a new technique of repair. J Bone Joint Surg Am 1991; 73(2):214-9. Zadek I. Repair of old rupture of the tendo-Achilles by means of fascia. Report of a case. J Bone Joint Surg 1940; 22(4):1070-1071. Chronic rupture of the Achilles tendon CASE 1 Chronic rupture of the Achilles tendon • 32 year old gentleman • Not known allergies • Not relevant medical history • No quinolones • No corticosteroids • No prodromal symptoms • Sports (running and soccer) twice/week • July 2012: “I felt a hit in the calf of the left leg while running” 2 5/17/2013 Chronic rupture of the Achilles tendon Case • Attends A&E • Can walk, can plantar flex against gravity • ‘Sprained ankle’ • Given a walker, told to rest • Discharged October 2012 • 6 weeks of immobilization • 6 weeks of physiotherapy • After 4 months, patient walks flat footed, nonpropulsive gait, swollen ankle • Can feel a three finger gap at the back of the ankle • Reassured!!! What to do next? October 2012 • Physical examination: - Calf squeeze test: no movement - Knee flexion test: fall of affected foot All the above documented in notes Reassured 3 5/17/2013 November 2012 Goes to a pub, sees a friend (a rugby playing lawyer), who makes the diagnosis Referred to CSEM Diagnosis: chronic Achilles tendon rupture Gap: 6 cm clinically • US study: scar tissue formation in the mid body of the Achilles tendon • MRI: 6 cm of scar tissue formation Chronic rupture of the Achilles tendon Operative management • V-Y Tendinous flap • Fascial turn down flaps • Peroneus brevis transfer • Flexor digitorum longus • Flexor hallucis longus • Fascia Lata • Gracilis • Semitendinosus • Allografts 4 5/17/2013 Chronic rupture of the Achilles tendon Classification Kuwada’s classification system Myerson’s classification system 1. Defects 1-2 cm end to end repair and posterior compartment fasciotomy 2. Defects 2-5 cm V-Y lengthening +/tendon trasnfer 3. Defects > 5 cm tendon transfer +/- V-Y advancement I. Plaster cast immobilisation II. Defects < 3 cm end to end repair III. Defects 3-6 cm debridement of tendon ends, tendon graft/flap +/augmentation IV. Defect >6 cm gastrocnemius recession, a free tendon graft and/or synthetic tendon graft Myerson MS. Achilles tendon ruptures. Instr Course Lect. 1999; 48:219-30. Kuwada GT. Classification of tendo Achillis rupture with consideration of surgical repair techniques. 1990; J Foot Surg 29(4):361-5. Chronic rupture of the Achilles tendon Whatever we do • We want to prevent problems and complications 5 5/17/2013 Chronic rupture of the Achilles tendon Operative management Less invasive techniques • Peroneus Brevis transfer Carmont MR, Maffulli N. Less invasive Achilles tendon reconstruction. BMC Musculoskelet Disord. 2007; 8:100. • Ipsilateral free semitendinosus tendon graft transfer Maffulli N, Longo UG, Gougoulias N, Denaro V. Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon. BMC Musculoskelet Disord. 2008; 9:100. Chronic rupture of the Achilles tendon Ipsilateral free semitendinosus tendon graft transfer Maffulli N, Longo UG, Gougoulias N, Denaro V. Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon. BMC Musculoskelet Disord. 2008; 9:100. 6 5/17/2013 7 5/17/2013 8 5/17/2013 Chronic rupture of the Achilles tendon Postoperative management • Immediate weight bear on metatarsal heads with crutches • Mobilise toes against resistance • 2/52 : Walker with heel raises (remove one every other week); WB as able • Physiotherapy: – Prevent dorsiflexion of the ankle – Focus on eversion • propioception, plantar-flexion, inversion and 8/52: discard walker; learn to walk properly Maffulli N, Tallon C, Wong J, Peng Lim K, Bleakney R. No adverse affect of early weight bearing following open repair of acute tears of the Achilles tendon. J Sports Med Phys Fitness. 2003; 43(3):367-79. Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the Achilles tendon. Am J Sports Med. 2003; 31(5):692-700. Chronic rupture of the Achilles tendon Postoperative management • Intensive mobilisation • Prevent excessive dorsiflexion • Gradual return to normal activities over 6 to 9/12 Chronic rupture of the Achilles tendon Conclusions • Chronic ruptures of tendo Achillis are uncommon but debilitating. • The choice of management is partly guided by the size of the tendon defect with the optimal management likely being surgical. • Many different reconstruction. techniques can be used for • Less invasive techniques provide similar results to those obtained with open surgery, with decreased perioperative morbidity, decreased hospital stay, and reduced costs 9 5/17/2013 If you wish to know more … 10 5/17/2013 Thank you n.maffulli@qmul.ac.uk 11 5/20/2013 Achilles rupture - non-surgical augmentation James Calder TD, MD, FRCS(Tr & Orth), FFSEM(UK) Chelsea & Westminster Hospital NHS Trust, London The Fortius Clinic, London www.fortiusclinic.com Mechanical Stimulation NSAIDs Neuronal Factors Growth Factors www.fortiusclinic.com Mechanical Stimulation Activates myofibroblasts Lack of stimulation detrimental +ve effects in animals: External fixators Disarticulated limbs www.fortiusclinic.com 1 5/20/2013 Mechanical Stimulation Botulinum group: Force to failure ↓30% @ 2/52 Stimulated group: Callus larger and stronger Virchenko, Asenberg; Acta Orthop 2006 Increased activity – shortening of tendon callus (myofibroplastic) Ackermann, Calder; Current Concepts 2008 www.fortiusclinic.com Mechanical Improvements? • Intermittent pneumatic compression – wound healing – fracture healing • Action: – ↑neuro-vascular in-growth – 2x expression sensory neuropeptides – ↑ tissue perfusion ? → speeds fibroblast → proliferation/collagen organisation Dahl et al, J Orthop Res 2007 www.fortiusclinic.com Evaluation of recovery – ultra-high resolution ultrasound • • • • 600 axial images/0.2mm Reconstructed saggital & coronal planes Pixel brightness correlates with intact, discontinuous, fibrillous, cellular and fluid Dr Hans van Schie (Netherlands) www.fortiusclinic.com 2 5/20/2013 NSAIDs www.fortiusclinic.com NSAIDs Platelets Leucocytes Blood-derived Monocytes Cells Lymphocytes Eicosanoids Inflammatory Cytokines Nitric Oxide Mediators Growth Factors Chemotaxis Vasodilation Angiogenesis Protein synthesis Macrophages Collagen synthesis Fibroblasts Tissue-derived Myofibroblasts CellsCells Endothelial Mast Cells www.fortiusclinic.com NSAIDs Blood-derived Cells Inflammatory Mediators Cox inhibitors - ↓ 1/3 fibrous strength - ↓bone-tendon strength in PT - effect lasts 2/52 Magra, N Clin J Sp Med 2006 Ferry, Am J SP Med 2007 Virchenko, Am J Sp Med 2004 HOWEVER Start day 6 (inflammatory phase over) - +ve effect on mech properties - thinner / stronger - celecoxib improves tendon healing Forrester, J Tr-injury inf crit care 1970 Forslund, Act Orthop Scand 2003 www.fortiusclinic.com 3 5/20/2013 Growth Factors Many Implicated – delivery & short ½ life Growth and Differentiation Factors (GDF) Part of BMP family Cartilage Derived Morphogenic Protein (CDMP) www.fortiusclinic.com Growth Factors Many Implicated – delivery & short ½ life - GDF 5 & 6 on collagen sponges - ↑ tensile strength - dose-dependent Aspenberg, Acta Orthop Scand 1999 www.fortiusclinic.com Growth Factors Many Implicated – delivery & short ½ life - GDF-5 coated polyglactin suture - 80 rats, Achilles tendon Rickert, Growth Factors 2001 - 44 rabbits, zone II flexor Henn, J Hand Surg 2010 - tendons thicker and stronger at 1,2 & 4 weeks www.fortiusclinic.com 4 5/20/2013 Growth Factors Many Implicated – delivery CDMP1,2 or 3 injected into haematoma @ 6hrs - 30% ↑ tensile strength in rat Forslund, J Orth Res 2003 - 65% ↑ tensile strength in rabbit at 14 days - No difference at 28 days Virchenko, J Med Sci Sports 2005 www.fortiusclinic.com Useful for early rehabilitation? Platelet Rich Plasma • PRP injection @6hrs ↑strength 30% up to 3/52 Aspenberg Acta Orthop Scand 2004 • Relies upon mechanical stimulation • rhPDGF-BB increases strength in rat model Shah, J Orth Res 2012 Virchenko Act Orthop 2006 – Early benefit – Botox abolishes PRP effect @ 2/52 Short-lived proliferative response allows mechanical stimulation to begin earlier? www.fortiusclinic.com Platelet Rich Plasma • Thrombin alone – ↑10% strength PRP Thrombin • PRP gel with activated thrombin have combined effect – ↑42% strength Strength Virchenko Act Orthop 2006 • PRP gel with neutralised thrombin ↑42% ↑22% – ↑22% strength www.fortiusclinic.com 5 5/20/2013 PRP - Human models Schepull AJSM 2011 Sanchez AJSM 2007 • No effect on strength of repair However: • 17 x physiological concentration of platelets (?overstimulation) • Very high inter-patient variability (confounding variables at play?) • Faster healing • Less thickening of tendon repair • Higher levels of growth factors in wound edges • Supports earlier animal work and also work on ACLs (faster healing and greater maturity) • Cross-over with animal models and other anatomical areas www.fortiusclinic.com PRP overall evidence Systematic review • No effect in tendinopathy • Medium – large effect in rupture • Enhanced scar effect? • Consistent improvement in biomechanical properties 0.5 SD across all animal models Sadoghi, J Orth Res 2013 www.fortiusclinic.com PRP overall evidence Systematic review • No effect in tendinopathy • Medium – large effect in rupture • Enhanced scar effect? • Consistent improvement in biomechanical properties 0.5 SD across all animal models Sadoghi, J Orth Res 2013 www.fortiusclinic.com 6 5/20/2013 PRP – questions? • Which PRP? – ? Too many variables – Internal variation (day to day) – Different concentrations – Bone marrow derived stem cells possibly superior Okamoto, JBJS(A) 2010 Chang, JBJS(A) 2007 ?Bucket chemistry! www.fortiusclinic.com Thrombo-embolism • Continuous LMWH Dabigatran – ↓33% strength • Injection LMWH twice daily – No effect Rivaroxaban • Long-acting thrombin and factor Xa inhibitors – ?cause for concern – ?intermittent use of LMWH OK www.fortiusclinic.com Neuropeptides • Substance P (SP) – Gives initial boost to tendon healing – Accelerates reparative phase • Injection of SP into paratenon after tendon repair in rats – enhances fibroblast aggregation at 1 st week (no difference after this) – collagen orientation faster from 2 nd week Burssens, FAI 2005 • Increase tensile strength of Achilles repair by 100% Steyaert, Arch Phy Med Rehab 2006 www.fortiusclinic.com 7 5/20/2013 Neuropeptides • Nerve Growth Factor • In rats MCL – ↑Angiogenesis – ↑Nerve in-growth – ↑Mechanical strength 55% Mammotto J Orth Res 2008 www.fortiusclinic.com So what does this mean to the practical orthopaedic surgeon today? • Use mechanical stimulation – Early wt-bear – Electrical calf stimulator? www.fortiusclinic.com So what does this mean to the practical orthopaedic surgeon today? • Use mechanical stimulation – Early wt-bear – Electrical calf complex? • NSAIDs not for 1/52 post injury (beneficial from 1/52) www.fortiusclinic.com 8 5/20/2013 So what does this mean to the practical orthopaedic surgeon today? • Use mechanical stimulation – Early wt-bear – Electrical calf complex? • NSAIDs not for 1/52 post injury (beneficial from 1/52) • Significant risk of VTE but consider problems with Xa inhibitors for thromboembolic prophylaxis www.fortiusclinic.com So what does this mean to the practical orthopaedic surgeon today? • Use mechanical stimulation – Early wt-bear – Electrical calf complex? • NSAIDs not for 1/52 post injury (beneficial from 1/52) • Significant risk of VTE but consider problems with Xa inhibitors for thromboembolic prophylaxis • Current evidence appears to support PRP or even concentrated bone-marrow aspirates www.fortiusclinic.com Achilles rupture - non-surgical augmentation James Calder TD, MD, FRCS(Tr & Orth), FFSEM(UK) Chelsea & Westminster Hospital NHS Trust, London The Fortius Clinic, London www.fortiusclinic.com 9 5/20/2013 University Campus Bio-Medico of Rome Department of Trauma and Orthopaedic Surgery Head Prof Vincenzo Denaro Percutaneous Achilles Repair Presenter: Umile Giuseppe Longo MD, MSc, PhD Conflicts of interest No conflicts to declare Achilles tendon ruptures • INCIDENCE – Annual average of 5 to 18 ruptures per 100,000 people – More common in males in the third or fourth decade of life • ETIOLOGY – Most acute AT ruptures are traumatic – Possible occult degeneration 1 5/20/2013 ATR Summary of Recommendations: number 8 • Open, limited open and percutaneous techniques are options for treating patients with acute Achilles tendon rupture. • Strength of Recommendation: Weak Achilles tendon ruptures • Operative management of acute AT ruptures significantly reduces the risk of rerupture compared with nonoperative treatment • Open operative treatment is associated with a significantly higher risk of other complications • Operative risks may be reduced by performing surgery percutaneously Khan RJ et al Cochrane 2010 Percutaneous Achilles tendon repair • Several percutenaous techniques available • Pros – Faster recovery time – Shorter hospital stays – Improved functional outcomes • Cons – Sural nerve damage 2 5/20/2013 Biomechanics of minimally invasive techniques for Achilles tendon There were no differences in mean strength of suture, mean maximum load, mean failure elongation, tension value, mean stiffness and mode of failure Longo UG, Forri ol F, Ca mpi, S, Ma ffulli N a nd Denaro V KSSTA (2012);20(7):1392-7 Percutaneous Achilles tendon repair • 1 incision over the defect • 4 longitudinal stab incisions 6 cm proximal to the palpable defect Carmont and Maffulli KSSTA (2008) 16:199-203 Percutaneous Achilles tendon repair Carmont and Maffulli KSSTA (2008) 16:199-203 3 5/20/2013 Percutaneous Achilles tendon repair 1 2 3 4 5 Carmont and Maffulli KSSTA (2008) 16:199-203 Percutaneous Achilles tendon repair Carmont and Maffulli KSSTA (2008) 16:199-203 Percutaneous Achilles tendon repair • The ankle is held in full plantar flexion, and in turn opposing ends of the Maxon thread are tied together Carmont and Maffulli KSSTA (2008) 16:199-203 4 5/20/2013 Percutaneous Achilles tendon repair • At 2 weeks, the back shell of the cast is removed • The front shell remains in place for 6 weeks to prevent forced dorsiflexion of the ankle. Carmont and Maffulli KSSTA (2008) 16:199-203 ATR Summary of Recommendations: number 6 • In the absence of reliable evidence, it is the opinion of the work group that although operative treatment is an option, it should be approached more cautiously in patients with diabetes, neuropathy, immunocompromised states, age above 65, tobacco use, sedentary lifestyle, obesity (BMI >30), peripheral vascular disease or local/systemic dermatologic disorders. • Strength of Recommendation: Consensus Percutaneous Achilles tendon repair • 26 men and 9 women with a mean age of 73.4 • Follow up 49 months • The ATRS had a postoperative average rating of 69.4 ± 14 (range, 56–93) • Two patients experienced a re-rupture (protected the operated limb in the cast for only 2 and 4 weeks after surgery, respectively) Ma ffulli N, Longo UG, Ronga M, Kha nna A, Denaro V CORR 2011 5 5/20/2013 Percutaneous Achilles tendon repair • 3 patients had superficial infection • 3 patients had hypesthesia over the area of distribution of the sural nerve • The hypesthesia resolved over 6 months in two of the three patients. • In the third patient, the hypesthesia persisted but did not interfere with the patient’s activities of daily living or with the wearing of shoes Ma ffulli N, Longo UG, Ronga M, Kha nna A, Denaro V CORR 2011 Percutaneous Achilles tendon repair • 39 subjects • ATRS score: post-operative average rating of 70.4 ± 13 (range 55– 92). • All patients were able to fully weight bear on the operated limb by the end of the eighth post-operative week. • Eight patients suffered from a superficial infection of the surgical wound. Ma ffulli N, Longo UG, Ma ffulli GD, Khanna A, Denaro V AOTS 2011;131(1):33-8 Percutaneous Achilles tendon repair • Seventeen elite athletes • Average time to return to full sport participation was 4.8 ± 0.9 months • Two of the 15 elite athletes on whom we have full data suffered from a superficial infection of the surgical wound Ma ffulli N, Longo UG, Ma ffulli GD, Khanna A, Denaro V FAI 2011;32(1):9-15 6 5/20/2013 Percutaneous Achilles tendon repair Conclusions • Similar results to those obtained with open surgery • Decreased perioperative morbidity • Decreased duration of hospital stay • Reduced costs • Randomized controlled trials are required Umile Giuseppe Longo - Email: ug.longo@gmail.com University Campus Bio-Medico of Rome Department of Trauma and Orthopaedic Surgery 7
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