CHRONIC ACHIL L E S RE PAIR: RE SE CT T HE SCAR AND SUT URE , NO GRAF T . SAM A. L ABI B, MD F AOA E mo ry Unive rsity. Atla nta , GA. e mo ryhe a lthc a re .o rg / o rtho
DISCLOSURES • Re se a rc h/ F e llo wshi p F unding : Arthre x, Ossur, L inva te c • Co nsulta nt: Arthre x, Me dsha pe , Stryke r
ACHILLES TENDON RUPTURE TESTS - THOMPSON’S 96% -PRONE KNEE FLEXION (MATLES) 88% - AT RESTING ANGLE = 45.1 DEGREES -PALPABLE TENDON DEFECT 73% Missed Dx up to 25%
ACHILLES TENDON RUPTURE • RUNNE RS, MAL E S, OVE RUSE • 60-75% SPORT S RE L AT E D • MAL E S, BL OOD GROUP 0 • DE VE L OPE D COUNT RI E S = 18/ 100,000 • RUPT URE : I N 2017- MAY OF F E R RE PAI R I N ACT I VE PAT I E NT S? • F UNCT IONAL RE HAB
RCT- OPERATIVE VERSUS NON OPERATIVE: JBJS OCT 2010 • Ac c le ra te d BUT F unc tiona l Re ha b -144 e nro lle d for both -80% c o mple te d F / U • NWB Splint X 2 wks -63-68% Cyb e x • 2 c m He e l L ift -Co le ma n Sc o re = 95 • PWB Bo o t 2 - 4 wks - PF stre ng th 15- 20% • F WB Bo o t 4 - 8 wks le ss in Non Op g roup * NO I MPORT ANT DI F F -Ca lf Girth 4-5 c m sma lle r in No n Op
HOW ABOUT CHRONIC RUPT URE ? • GAP F ORMAT ION AND L E NGT HE NING • RE ST I NG ANGL E = 45.1 DE G. • YOUNG + ACT I VE • MANUAL WORK E RS • WE AK NE SS • T E NDI NOSI S PAI N • L OSS PF ST RE NGT H • SI NGL E HE E L RI SE –ve • DE SI RE T O RT P
KRAEUTLER MJ, PURCELL JM, HUNT KJ. CHRONIC ACHILLES TENDON RUPTURES. FOOT & ANKLE INTERNATIONAL. 2017 MAY. CURRENT CONCEPT REVIEW • • able 3. Sc he me fo r the able 2. Summa ry o f Gra de s o f T T Surg ic a l T re a tme nt o f Chro nic Re c o mme nda tio n. • Ac hille s T e ndon Ruptur e s on the T r e atme nt Gr ade of Basis of Gap Size . Re c omme ndation • De fe c t Size Sur gic al Pr oc e dur e • • 1-2 c m E nd-to -e nd No no pe ra tive ma na g e me nt I a na sto mo sis a nd po ste rio r • Prima ry re pa ir I c o mpa rtme nt fa sc io to my • V-Y te ndo n pla sty C • 2-5 c m V-Y le ng the ning , • T e ndo n tra nsfe r B a ug me nte d with te ndo n • T urndo wn fla p C tra nsfe r if ne e de d • Allo g ra ft re c o nstruc tio n I • >5 c m T e ndo n tra nsfe r • a lo ne o r in c o mb ina tio n with Auto g ra ft re c o nstruc tio n B V-Y a dva nc e me nt o r turndo wn Mye rso n MS. Ac hille s te ndo n rupture s. I nstr. Co urse L e c t. 1999;48:219-230.
Y ASUDA T , SHI MA H, MORI K , K I ZAWA M, NE O M. DIRE CT RE PAIR OF CHRONIC ACHIL L E S T E NDON RUPT URE S USING SCAR T ISSUE UMPS . JBJS. 2016 JUL L OCAT E D BE T WE E N T HE T E NDON ST 20;98(14):1168-75. • 33 Ac hille s te ndo n rupture s with a de la y in dia g no sis o f >4 we e ks unde rwe nt re mo va l o f a se c tio n o f sc a r a nd he a ling tissue with dire c t prima ry suture o f the e nds o f the te ndo n witho ut the use o f a llo g ra ft o r a uto g ra ft. • Me a n F / U 33 mo nths. L e ng th o f Ga p= 43 mm( 25-80 mm) • Amo unt o f sc a r tissue re se c te d = 26mm (15- 50 mm) • AOF AS sc o re s we re 98.1 po ints po sto pe ra tive ly. T he me a n po sto pe ra tive AT RS wa s 92.0 po ints. • Po sto pe ra tive T 2-we ig hte d MRI : fusifo rm-sha pe d te ndo n thic ke ning a nd ho mo g e ne o us lo w-sig na l a lte ra tio ns o f the te ndo ns in a ll pa tie nts. • Histo lo g ic a lly, the inte rpo se d sc a r tissue c o nsiste d o f de nse c o lla g e n fib e rs. e mo ryhe a lthc a re .o rg / o rtho
Me dia l Appro a c h. Pre se rve Pa ra te no n. K ra c ko w Suture . Ankle 20-30 de g re e s Pla nta r-F le x.
MODIFIED KRACKOW TECHNIQUE= GIFTBOX • FOR EACH PAIR, ONE TENDON WAS REPAIRED WITH A SINGLE KRACKOW WHILE THE OTHER WAS REPAIRED WITH A MODIFIED KRACKOW. • #2 FORTIFIED POLYESTER. EACH SUTURE WAS PASSED PERIPHERALLY AND TIED ACROSS THE OPPOSITE TRANSVERSE LIMB • WE CALLED THE “CRISS-CROSS” PATTERN “ GIFTBOX SUTURE”
MY PREFERRED METHOD: GIFTBOX TECHNIQUE
GIFTBOX BIOMECHANICAL ADVANTAGE
Maximum Load to Failure
LABIB SA, ROLF R, DACUS R, HUTTON WC . THE “GIFTBOX” REPAIR OF THE ACHILLES TENDON: A MODIFICATION OF THE KRACKOW TECHNIQUE. FOOT & ANKLE INTERNATIONAL. 2009 MAY;30(5):410-414 . THE “GIFTBOX” OPEN REPAIR OF THE ACHILLES TENDON: A MODIFICATION OF THE TRADITIONAL KRACKOW TECHNIQUE THAT INCREASES THE STRENGTH OF THE REPAIR .
L ABI B SA, HOF F L E R CE , SHAH JN, ROL F RH, T I NGAN A. T HE GIF T BOX OPE N ACHIL L E S T E NDON RE PAIR ME T HOD: A RE T ROSPE CT IVE CL INICAL S. T HE JOURNAL OF F OOT AND ANK L E SURGE RY. 2016 F E B SE RIE 29;55(1):39-44. • Ma rc h 2002 to April 2007: A to ta l o f 44 sub je c ts, me a n a g e 37.5 ± 8.6 ye a rs, unde rwe nt surg e ry a ppro xima te ly 10.8 ± 6.5 da ys a fte r • T he pa tie nts c o mple te d the F o o t F unc tio n I nde x a nd the Ame ric a n Ortho pa e dic F o o t a nd Ankle So c ie ty a nkle -hindfo o t sc a le . T he te ndo n width a nd c a lf c irc umfe re nc e we re me a sure d b ila te ra lly a nd c o mpa re d using paired t tests with a 5% α level. injury. • T he re spo nse ra te wa s 35 (79.54%) pa tie nts fo r the q ue stio nna ire a nd 20 (45.45%) fo r the e xa mina tio n. T he me a n fo llo w-up pe rio d wa s 35.7 ± 20.1 mo nths. • Co mplic a tio ns inc lude d o ne stitc h a b sc e ss, pe rsiste nt pa in, a nd ke lo id fo rma tio n. One (2.86%) re spo nde nt re po rte d sig nific a nt we a kne ss. F ive (14.29%) re spo nde nts indic a te d pe rsiste nt pe ri-inc isio na l numb ne ss. • T he me an AOF AS sc or e was 93.2 ± 6.8) and the me an F oot F unc tion e was 7.0 ± 10.5 . Inde x F F I sc or • e nc e s we re sta tistic a lly sig nific a ntly T he c alf gir th and te ndon width diffe r b e twe e n the limb s. • T he pa tie nts re po rte d no r e pe at r uptur e s, sur al ne r ve injur ie s, de hisc e nc e , or infe c tions. e mo ryhe a lthc a re .o rg / o rtho
– T o inve stig a te the func tio na l o utc o me s o f the L indho lm a nd Vuplius me tho ds fo r c hro nic Ac hille s te ndo n rupture • Me tho ds – Re tro spe c tive a na lysis o f 15 pa tie nts, 13 ma le s a nd 2 fe ma le s, me a n a g e 35.2 ye a rs – 8 pa tie nts unde rwe nt the L indho lm te c hniq ue , 7 unde rwe nt prima ry re pa ir with Vulpius le ng the ning te c hniq ue – Ho o ke r sc a le wa s use d to me a sure the a nkle func tio na l c a pa c ity in a ll pa tie nts. T he pa tie nts we re e va lua te d o n the b a sis o f the ir c a pa b ility to sta nd o n tipto e o n the a ffe c te d limb a nd the time re q uire d to re turn to pre -injury da ily a c tivitie s. • Re sults – Me a n fo llo w-up o f 19.6 mo nths – Me a n inte rva l b e twe e n injury a nd time to surg e ry wa s 42 da ys – Pa tie nts re turne d to da ily a c tivity in a n a ve ra g e time o f 3.2 mo nths – Ho o ke r sc o re s e xc e lle nt fo r 11 pa tie nts a nd sa tisfa c to ry fo r 4 e mo ryhe a lthc a re .o rg / o rtho
• L indho lm T e c hniq ue – Do ub le fla ps fro m g a stro c ne mius a po ne uro sis a re use d to re c o nstruc t the Ac hille s te ndo n • Vulpius Me tho d – A “V” inc isio n is ma de in the pro xima l g a stro c ne mius with the a pe x pro xima l – Arms o f the inc isio n e a c h me a sure d 10c m in le ng th – Pro xima l stump o f the Ac hille s te ndo n is pulle d dista lly to b ridg e g a p with fo o t in pla nta r fle xio n e mo ryhe a lthc a re .o rg / o rtho
RE F E RE NCE S • Co sta ML , Do ne ll ST , T uc ke r K . T he lo ng -te rm o utc o me o f te nd o n le ng the ning fo r c hro nic Ac hille s te nd o n pa in. F o o t & a nkle inte rna tio na l. 2006 Se p;27(9):672-6. • L a b ib SA, Ro lf R, Da c us R, Hutto n WC. T he “Giftb o x” re pa ir o f the Ac hille s te nd o n: a mo d ific a tio n o f the K ra c ko w te c hniq ue . F o o t & a nkle inte rna tio na l. 2009 Ma y;30(5):410-4. • L a b ib SA, Ho ffle r CE , Sha h JN, Ro lf RH, T ing a n A. T he g ift b o x o pe n Ac hille s te nd o n re pa ir me tho d : a re tro spe c tive c linic a l se rie s. T he Jo urna l o f F o o t a nd Ankle Surg e ry. 2016 F e b 29;55(1):39-44. • Ma ffulli N. T he c linic a l d ia g no sis o f sub c uta ne o us te a r o f the Ac hille s te nd o n. T he Ame ric a n jo urna l o f spo rts me d ic ine . 1998 F e b ;26(2):266-70. • Oza n F , Do g a r F , Gurb uz K , E kinc i Y, K o yunc u S, Se kb a n H. Chro nic Ac hille s T e nd o n Rupture Re c o nstruc tio n Using the L ind ho lm Me tho d a nd the Vulpius Me tho d . Jo urna l o f Clinic a l Me d ic ine Re se a rc h. 2017 Jul;9(7):573. e mo ryhe a lthc a re .o rg / o rtho
OUR NE W E MORY SPORT S ME DICINE CE NT E R/ AT L ANT A HAWKS • Emory will serve as the official sports medicine provider for the Atlanta Hawks • 90,000 square foot training and sports medicine center • First NBA practice facility to be co- located with a sports medicine center occupying 30,000 sq. ft. • Regional offices in John’s Creek, Dunwoody, Smyrna, Spivey Station and Stonecrest e mo ryhe a lthc a re .o rg / o rtho
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