16 - Reconstruction of tendons

Summary

ACHILLES TENDON REPAIR

Indications

• Controversy regarding this injury as towhethersurgical repair or cast immobilization is the most appropriate method of treatment.

• Healthy, vigorous young adults.

• Athletes.

• According to patient's age, activities, medical history.

Pre-operative planning

Clinical assessment

• Mechanism of injury: mechanical imbalance, degenerative changes, high-energy disruptions, lacerations at the posterior distal tibia aspect.

• Obtain a detailed patient's history.

• Usually sudden onset of pain, audible snap, patient unable to weight bear, unable to toe-raise at the affected site.

• Only leg weakness in chronically ruptured tendon.

• Oedema, bruising, ankle swelling.

• Clinically palpable gap that may be obscured by swelling.

• PerformThompson's test, O'Brien test.

• Compare the affected leg with the contralateral limb.

• Be alert for longstanding ruptures.

Radiological assessment

• Radiographs: only to diagnose associated bony abnormalities.

• High-resolution ultrasonography: produces an acoustic vacuum.

• MRI: to evaluate associated intra-articular injuries and neglected tears.

Operative treatment

Anaesthesia

• At induction administration of prophylactic antibiotics as per local hospital protocol.

• Spinal or general anaesthesia.

Table set up

• The instrumentation set is at the foot end of the table.

Patient positioning

• The patient is placed in prone position.

Draping and surgical approach

• Prepare the skin over lower leg, ankle and entire foot with usual antiseptic solutions (aqueous/alcoholic povidone-iodine). Prepare skin between toes thoroughly.

• Apply standard draping around lower leg in calf region.

• Apply tape aroundtoes tominimizethe risk of infection (Fig. 16.1).

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