insertional achilles rupture and calcaneal avulsion fractures

13 Pages·2011·2.05 MB·English

CHAPTER 29
INSERTIONAL ACHILLES RUPTURE
AND CALCANEAL AVULSION FRACTURES
A. Louis Jimenez, DPM
Jocelyn M. Kelly, DPM
INTRODUCTION easily weaken the Achilles tendon insertion resulting in
rupture. There has been a historical correlation of
Overuse tendon injuries may account for up to 50% of all fluroquinolone antibiotic use with an increased risk of
sports injuries, with Achilles tendonopathy being a major Achillestendonrupturesthathasrecentlybeenprovento
factor in this number. The term tendonopathy is the have a similar magnitude to that associated with oral
preferred term as a generic descriptor of the clinical corticosteroidsornon-fluroquinoloneantibiotics.3
conditions(bothpainandpathologicchanges)inandaround Elderlypatientsandthosewithsignificantosteopenia
tendons arising from overuse. The histologic description are prone to insertional Achilles ruptures. Osteopenia
of tendonosis (a degenerative pathologic condition with a createsthincortices,whichmaynotbeabletoresistsevere
lack of inflammatory change) and tendonitis (implying tension placed on them at tendon attachments and
an inflammatory process) should only be used after therefore, a segment of bone may be pulled off by the
histopathologicconfirmation.1Tendonosismayexhibitfiber tendon during sudden tendonous contractures. Avulsion
disorientation, scattered vascular ingrowth, and either fractures of the posterior superior calcaneus often occur
hypo- or hypercellularity, which may not always be fromaforceddorsiflexioninjuryagainstanintactgastroc-
accompanied by pain. When symptoms do develop, the solealcomplexfollowingalow-energyfallorstumble.
degenerated tendon may have undergone microtrauma or Calcaneal fractures represent approximately 2% of all
progressivefailureleadingtopartialtears,inflammation,and fractures, of which 25-40% are classified as extra-articular.4
subsequent symptoms of concomitant acute tendonitis or Therareavulsionoftheposteriorsuperiortuberosityusually
paratendonitis.2 doesnotinvolvethesubtalarjoint.Historically,thisfracture
Tendonopathy is a pathological state or process that isclassifiedinto2typesdistinguishedbytheinvolvementof
can predispose a tendon to rupture. Insertional Achilles theAchillestendon,leadingtoabeakfractureoranavulsion
ruptures can occur as a result of acute trauma, chronic fracture. However, Perotheroe questioned this distinction,
trauma,retrocalcanealexostoses/enthesopathies,multiple suggesting that the 2 fractures are of the same entity and
steroid injections, a post-surgical complication from variations are only due to the insertion of the Achilles
retrocalcaneal exostectomy, antibiotic therapy, or tendon.Itshouldalsobenotedthatthebeakfracturemaybe
osteopeniaofthecalcaneus. aresultofadirectblunttraumatotheposteriorcalcaneus.
AlthoughmostAchillestendonrupturesoccurinthe Thisavulsiontypefracturehasalsobeendocumentedin
watershed zone following an intense sudden contracture non-traumatic cases. The literature reports a pathological
ofthegastroc-soleuscomplex,occasionallythetendonwill avulsion fracture of the calcaneus secondary to Paget’s
ruptureatitsinsertion.Chronicmicrotraumacreatestears sarcoma. This patient presented with a 1-year history of
in the tendon at or near the insertion, which may create pain to the heel with increased swelling over a period of 2
poorattachmentandmay,withthecorrectmechanismof months. Radiographs demonstrated an avulsion fracture of
injury, result in complete loss of its attachment. Various the superior calcaneus with typical Paget features. Needle
exostoses and enthesopathies may weaken the tendon by biopsyrevealedafibroushistocytoma,whichlaterleadtoa
encompassingandthinningtheAchillestendoninsertion. below the knee amputation 3 weeks later.5 The calcaneal
It is not unusual for a patient who has had a long term insufficiencyavulsionfracturehasbeendescribedinagroup
retrocalcaneal exostosis to notice a sudden weakness in of diabetic neuropathic patients. This fracture has been
his/hergaitpatternasaresultofthetendoninsertionloss. considered similar to the site of a fatigue fracture without
Thisprovidesagoodargumentfortakingthesepatientsto history of trauma or overuse activity. Of interest, there is a
surgery earlier. Chronic steroid injections, especially the slight variation in the traditional fracture pattern.
acetateornon-solublesteroids,arecollagenolyticandcan Radiographically,thefracturelineisparalleltotheapophyseal
152 CHAPTER 29
growth plate, usually only encompassing the superior
calcaneusandextendshorizontallyjustdistaltotheAchilles
insertion(Figure1).6
Lossofthegastroc-soleuscomplexresultsinacalcaneus
gait.Thesepatientsmustrelyonthedeepposteriormuscle
grouprecruitmenttoassistduringthemidstanceandtoe-off
phasesofgait.Overtime,theipsilateralhamstringscontract
resulting in knee symptoms. The contralateral limb gets
more compensatory stress resulting in symptomatology of
that limb and proximal to the knee. The symptoms can
affectthefoot,ankle,leg,andback.Chronicityofacalcaneus
gaitresultsingastrosoleusatrophy,flexorsubstitution,and
significanthammertoedeformity.
CLINICAL EXAMINATION
Clinical examination of the extremity with an insertional
Achillestendonrupturerevealsedemaabouttheankleand
Figure1.Nondisplacedinsufficiencyfracturein
lower leg. The patient will usually present with weakness
aninsulin-dependentdiabetesmellituspatient.
ofthatextremityandreducedabilitytostandandpropel.
One will see that there is a dell at the previous insertion
siteoftheAchillestendonandecchymosismaybepresent
peripherally about the ankle depending on the length of
time after the injury. Thompson’s sign is positive
indicating loss of the gastroc-soleus complex, which is a
squeeze test of the gastrosoleus muscle belly that will fail
to produce plantarflexion of the foot. However, patients
areabletorecruittheotherdeepposteriorcompartment
musclesanditmayappearasthoughtheyhaveafunctional
Achillestendon.
Duetothelimitedsofttissuecoverageattheposterior
calcaneus, an avulsion fracture may produce an open
lesion at the site of the bony fragment. This wound may
appearimmediatelyatthetimeofinjuryoratalaterdate
Figure2.Achillestendonhascreatedlargecalcaneal
withdelayedtreatment.Withdecreasedvascularitytothis
avulsionfracture.
area, a necrotic ulceration may develop which can
negativelyaffectsurgicalcorrection. statusismaintainedfor8to12weeks,initiallyinagravity
Roentgenographically,Kager’sTriangleisobliterated equinus cast with slow transition to neutral positioning.
and the insertional Achilles rupture may reveal a small or Physical therapy is paramount to restore plantarflexory
large segment of bone pulled away from the posterior strength and range of motion. Patients who are not
superior calcaneus (Figure 2). MRI will reveal loss of surgical candidates can do well with an AFO with a
continuity between the end of the tendon and the “dorsiflexion stop,” which will create a retrograde force
posteriorsuperiorcalcaneus. onthekneeandestablishstability.
Surgical intervention is usually the treatment of choice
TREATMENT and revolves around reattachment of the Achilles tendon
and/or fixation of the calcaneus. Methods and techniques
InitialtreatmentforinsertionalAchillesrupturesrevolves forprimaryrepairofthetendonincludedirectreinsertionof
around reducing edema and offloading the extremity. the Achilles tendon to the calcaneus using various bone
Non-operative treatment is used for patients with non- anchoringtechniquese.g.,Mitek,Opus,Parafix,andArthrex,
displacedorminimallydisplacedfracturesandincomplete etc.Thechoiceofboneanchormayvarydependingonthe
ruptures of the Achilles tendon. A nonweight bearing qualityofbonestock,theconditionoftherupturedtendon,
CHAPTER 29 153
In chronic cases, myotendinous contracture has
occurred resulting in a very atrophic muscle belly and
shortening of the myotendinous unit. Various intra-
tendinous lengthening and augmentation techniques are
available for use (V-Y, tongue-in-grove, tendon flaps,
muscle tendon transfers, etc.). The most common tendon
transfersincludeFHL,PB,andPT.Whenosseousavulsion
fracturesarepresent,screws,wires,etc.,willneedtobeused
forstabilizationofbonetobone.
POSTOPERATIVE CARE
Following primary tendon repair patients are casted non-
weightbearingforaminimumof4weeks.Thisisthetime
Figure3.Techniquedemonstratinglateralparatendinousapproachto
necessary for collagen fibers to become longitudinally
stabilize avulsion fracture to main body of calcaneus. Adapted from
reference4. oriented.Forthecalcanealavulsionfracture,thenonweight
bearing status is maintained for 6-8 weeks or until
thedesiredsuturematerial,orthesurgeon’spreference.Ifa radiographic consolidation is verified. We generally
bone fragment is present, then reattachment may also be recommendearlyrehabilitationoftheseconditionsassuming
accomplished with a lateral paratendinous approach and that the attachment of the tendon to bone is solid. We
tensionbandwiring(Figure3).Thistechnique,firstdescribed routinelysendthepatienttothephysicaltherapistfor6-12
byBrunnerandWeber,wasmodifiedbyCoughlintoinclude weeksinordertoregainsufficientstrengthontheoperated
alagscrewfixationofthebonefragmentswitha6.5-8.0mm extremityforthepatienttofunctionindependently.Usually
cannulated screw. The tension band (18 or 20 gauge) was the physical therapist will consider it successful when the
used to neutralize to the distraction forces of the Achilles patientcanraisetheheeloffthegroundwithonefoot.For
tendononthesuperiorfragment.4Alargercalcanealfragment avulsion fractures where the patient has severe osteopenia,
mayrequire2cannulatedlagscrewsinaparallelfashionfor appropriate time is allowed for osseous bridging to occur
adequatefixation. beforesignificantstressesareplacedonthebonyfracture.
154 CHAPTER 29
CASE PRESENTATIONS
painoftheleftankleandfoot.Figures4-10takethereader
Case #1 throughthesurgicalrepairusingOpusMagnumanchorsfor
RS is a 62-year-old woman that missed the last step as she stabilization of tendon to bone. The patient was taken
wasdescendingstairs.Uponstanding,theleftlegfeltweak throughstandardpostoperativecareandreleasedfromour
andshelaterpresentedtoourofficewithedema,LOM,and officetobeseenasneededafter11months.
Figure 4A. Significant edema noted about the ankle S/P Achilles Figure4B.Notetheindexfingerindentifyingdellwherethe
insertionalrupture. tendonhaspulledawayfrombone.
Figure5.MRIidentifyinglossofinsertionalpoint
ofAchillestendonfromposteriorcalcaneus.
CHAPTER 29 155
Figure6A.Achillesinsertionlostandnotesmallcorticalsegmentsof Figure6B.
boneattachedtotheAchillesrupturesite.
Figure7A.Opus-magnuminstrumentationshowinganchorsbeingin- Figure7B.
sertedintobodyofcalcaneus.
Figure8.SuturesfromeachtackhavebeenattachedtotheAchillestendon Figure9.Sutureshavestabilizedthetendontotheosseoussegment.
distallypriortostabilization.
156 CHAPTER 29
Figure10A.Opusmagnumanchorsnotedwithin Figure10B.
bodyofthecalcaneus.
Case #2 A Bunnell suture for the proximal tendon was used,
RC is a 65-year-old man who was descending stairs at Krakowsuturetechniqueforthedistalremnantoftendo-
home, slipped and proceeded to “tumble” 5 more steps. achilles,Mitekanchorsandbelow-kneecastingwerethen
Pain and swelling was instantaneous and referred for our used. The patient had excellent postoperative recovery
services.HewasplacedinaJonessplintandscheduledfor followingstandardcareandwaslastseeninourofficefully
surgery.Figures11-20takethereaderthroughhisrepair. recoveredafter6months.
Figure11A.Notedorsiflexionoftherightfootcomparedwiththeintact Figure11B.
contralateralfootdemonstratingappropriateplantarflexion.
CHAPTER 29 157
Figure12A.Intra-operativeviewidentifieslossofinsertionpointofthe Figure12B.
Achillestobone.Notethesignificanthematomaattheinsertionpointof
wheretheAchilleswaslostfromcalcaneus.
Figure13A.Retrocalcanealexostosisidentifyingbonysubstanceinretro- Figure13B.
calcanealarea.
Figure14A.Intra-operativeviewoflargeretrocalcanealexostosisthat Figure14B.
thinnedtheinsertionofthetendoAchillesandtendononceithasbeen
stabilizedwith2.0Ethibondsuture.
158 CHAPTER 29
Figure15A.KrakowsutureplacedwithinremnantsoftendoAchillesat Figure15B.
distal inferior calcaneus and Bunnell suture placed within the distal
tendoAchilles.
Figure16A.PosteriorsuperiorcalcaneusbeingremodeledandMitek Figure16B.
suturesbeingplacedwithinbodyofthecalcaneus.
Figure 17B. Note plantarflexion equal to that of contralateral view
followingrepair.
Figure 17A. Excellent repair noted of Achilles
tendontobodyofthecalcaneus.
CHAPTER 29 159
Figure18A.Woundclosedinlayers. Figure18B.
Figure 19A. Preoperative and postoperative radiograph identifying Figure19B.
absenceafterresectionoflargeexostosisposteriorcalcaneusandevidence
ofMiteksuturesstabilizingtheconstruct.
Figure 20. Chronic tendo Achilles repair has been undertaken and
neededlengthoftheproximaltendonwasaccomplishedusingaV-Y
plasty.
160 CHAPTER 29
Case #3 Once the hematoma and fibrous tissue was excised, the
RB is a 51-year-old man with a past medical history superiorcalcaneuswascurettedtobleedingcancellousbone
significant for chronic renal insufficiency with dialysis (Figure 25). Under fluoroscopic guidance, two 5-mm
treatments, insulin-dependent diabetes mellitus, peripheral Parafix bone anchors were inserted posteriorly into the
neuropathy, and mid-foot Charcot breakdown with calcaneus from superior to inferior. With the foot in
ulceration of the right foot. He presented to the VA plantarflexion,theconnectedsuturewasusedtoreattachthe
Podiatry clinic for regular wound care when he related Achillestendontothecalcaneus(Figures26-30).
havingdifficultywalkingbecausehisrightfoot“feltfloppy.” After adequate closure, the patient was placed in a
Clinical examination revealed a palpable bony mass just below-knee fiberglass cast with nonweight bearing for 6
proximaltothecalcaneuswithaskindell,increasedwidthof weeks. He was transferred to a weight-bearing
the distal Achilles tendon and a positive Thompson’s test plantarflexed CAM boot and started on physical therapy.
(Figure 21). Radiographic evaluation showed a superior Plantarflexion of the CAM walker was gradually reduced
calcaneal avulsion fracture and the magnetic resonance from 20 degrees to neutral over the course of 2 months.
image confirmed a 2.5 cm retraction of the Achilles At the 6-month follow up, the patient was walking
tendonwithsignificantedemaaboutthesuperiorcalcaneus uneventfully in a custom shoe to accommodate the
(Figures22-23). previous midfoot breakdown. He also has full plantar-
Given this patient’s significant co-morbidities, surgical flexion strength of the gastroc-soleus complex and no
intervention was carefully planned. The surgical dissection residual ulcerations. Radiographic evaluation showed
revealedaninsertionalruptureoftheAchillestendonwith recalcification of the superior calcaneus to the distal
fragmentedbonethroughoutthedistalaspect(Figure24). Achillestendon(Figure31).
Figure21A.Moderateedemaabouttheposteriorankleandcalcaneus Figure21B.
andslightdorsiflexedpositionoffoottolegfollowingrupture.
Figure 22. Note wafer of bone distracted proximally from superior
posterior calcaneus. Significant midfoot collapse is noted as result of
Charcotjoints.
Figure21C.UlceratmidfootfromCharcotjoints.