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LAY VIE

STASE SUB BAGIAN BEDAH ORTHOPEDI


MARET 2016
• Largest tendon in the
body
• Origin from
gastrocnemius and
soleus muscles
• Insertion on calcaneal
tuberosity
Lacks a true
synovial
sheath
• Paratenon
has visceral
and parietal
layers
• Allows for
1.5 cm of
tendon glide
Paratenon
• Anterior – richly
vascularized
• The remainder – multiple
thin membranes
Blood supply
1) Musculotendinous junction
2) Osseous insertion on calcaneus
3) Multiple mesotenal vessels on anterior surface of
paratenon (in adipose)
– Transverse vincula
• Fewest @ 2 to 6 cm proximal to osseous insertion
• Remarkable response to stress
• Exercise induces tendon diameter increase
• Inactivity or immobilization causes rapid atrophy
• Age-related decreases in cell density, collagen fibril diameter
and density
• Older athletes have higher injury susceptibility
• Gastrocnemius-soleus-Achilles complex
• Spans 3 joints
• Flex knee
• Plantar flex tibiotalar joint
• Supinate subtalar joint

• Up to 10 times body weight through tendon when running


1. Cedera langsung
2. Cedera tidak langsung
Terbuka Tertutup

Akut Neglected
1. Accidental cut injury (bath room
injury, road traffic injury)
2. Social/political Violence
1. Diagnosis and assessment of extend of injury.
2. Primary care
3. Operative treatment
Pathophysiology
• Repetitive microtrauma in a
relatively hypovascular area.
• Reparative process unable
to keep up
• May be on the background
of a degenerative tendon
• Antecedent tendinitis/tendinosis in 15%
• 75% of sports-related ruptures happen in patients between
30-40 years of age.
• Most ruptures occur in watershed area 4 cm proximal to the
calcaneal insertion.
Anamnesis
• Gerakan tiba tiba di belakang kaki
• Sensasi robekan kadang terdengar dibelakang tumit. Biasanya
pasien sering dilaporkan melihat berkeliling untuk mencari
siapa yang memukul belakang tumitnya, lalu merasa nyeri dan
jatuh tiba – tiba.
• Riw. Penggunaan fluoroquinolone, steroid injections
Mechanism
• plantarflexi kuat dari kaki dan
pergelangan kaki (squash, badminton,
sepak bola, tennis, volli)
• Eccentric loading (running backwards in
tennis)
• Sudden unexpected dorsiflexion of ankle
• (Direct blow or laceration)
Ruptured Tendon
Normal TA not
Visible/Palpable
• Prone patient with feet over edge of bed
• Palpation of entire length of muscle tendon unit during active
and passive ROM
• Compare tendon width to other side
• Note tenderness, crepitation, warmth, swelling, nodularity,
palpable defects, gap tendon, hematom
• Partial
• Localized tenderness +/-
nodularity
• Complete
• Defect
• Cannot heel raise
• Positive Thompson test
• Diagnostic Pitfalls
• 23% missed by Primary Physician (Inglis & Sculco)
• Tendon defect can be masked by hematoma
• Plantar-flexion power of extrinsic foot flexors retained
• Thompson test can produce a false-negative if accessory
ankle flexors also squeezed
This lateral x-ray of
the calcaneus
shows an avulsion
fracture at the
insertion of the
Achilles tendon, with
marked separation
of fragments.
.
Ultrasound
• Inexpensive, fast, reproducable,
dynamic examination possible
• Operator dependent
• Best to measure thickness and
gap
• Good screening test for
complete rupture
• Expensive, not dynamic
• Better at detecting partial
ruptures and staging
degenerative changes,
(monitor healing)
Diferensial diagnosis
1. Robekan incomplete, jika rupture complete tidak tampak
dalam 24 jam, gap sulit diraba. Pasien masih bisa jinjit
sejenak menggunakan flexor panjang jempol kaki.
2. Robekan muskculus soleus, robekan pada batas
muskulotendineus menyebabkan nyeri dan nyeri tekan pada
pertengahan atas betis. Ini bisa sembuh sendiri dengan
fisioterapi dan meninggikan tumit sepatu.
• Restore musculotendinous length and
tension.
• Optimize gastro-soleous strength and
function
• Avoid ankle stiffness
CAM Walker or cast with
2 wks plantarflexion q 2 wks

4 weeks

Start physio for ROM Allow progressive weight-


exercises bearing in removable cast

When WBAT and 2- 4 weeks


foot is plantigrade

Start a strengthening Remove cast and walk with shoe


program lift. Start with 2cm x 1 month,
then 1cm x1 month then D/C
Prosedur operasi
1. Pasien dioperasi di posisi tengkurap dengan anestesi umum
2. Pasang tourniquet paha.
3. Buat sayatan curvilinear longitudinal pada aspek
posteromedial kaki di atas luka
4. Kulit dan jaringan subkutan dibuka, insisi peritenoneum, dan
letak tendon yang rupture exposed.
5. Preservasi suply darah dari anterior paratenon, hati – hati
terhadap nervus sural
6. Debridement dan approximasi akhiran tendon
7. Tendon yang putus disambung dan repair dengan benang
poliester 5 mm melalui tendon secara tranversal sekitar 3 cm
proksimal tendo yang putus. Gunakan teknik jahit 2-4
stranded locked. Bisa ditambah absorbable suture
Prosedur operasi
6. Kemudian benang dilingkarkan proksimal ke ekstremitas
transversal dan distal keluar dari akhiran tendon yang robek.
Sebuah jahitan serupa ditempatkan di bagian distal dari
tendon. Jahitan cambuk juga dapat digunakan.
7. Permukaan tendo yang robek kemudian ditarik bersama-
sama dan ujung jahitan diikat.
8. Tepi tendon yang compang-camping kemudian didekatkan
dengan benang chromic 2-0 jahitan interupted.
9. Paratenoneum ditutup terpisah menggunakan benang
chromic 4-0 dan jaringan subkutan dengan jahitan
subcuticular.
Prosedur operasi
10. Penanganan hati-hati dari jaringan lunak penting untuk
mencegah komplikasi. Ketika tendon yang rupture dekat
insersio, benang dilewatkan bagian proximal tendon lalu
melewati lubang bor transversal di calcaneus.
11. Gips short leg diterapkan dengan kaki plantarflexi 20 derajat
selama 3 minggu, kemudian kaki digips dengan ankle pada
sudut yang tepat selama 4-6 minggu.
12. Saat melepas gips, pasien diberikan ankle foot orthosis (AFO)
ganda dengan posisi dorsiflexi 90 derajat untuk mencegah
trauma berulang.
• Acute case : usually end
to end repair is enough
• Neglected case:
Advancement plasty (V-
Y) or reconstruction by
other tendons
A, Conventional Bunnell stitch. B,
Crisscross stitch

. E, Modified Kessler stitch with single


knot at repair. F, Tajima modification of . C, Mason-Allen (Chicago) stitch. D,
Kessler stitch with double knots at Kessler grasping stitch
repair site.
Immobilization, Positioning &
Cast
• Assess strength of repair, tension and ROM intra-op.
• Apply long leg cast with ankle in the least amount of
plantarflexion (gravity equinus) & knee 60 degree flexion with
window at operated site.
• Stitch removal after 2 wks.
• Short leg cast after 3 wks with partial equinus correction
• 2 weekly plaster change with gradual equinus
correction (4-6 episode ).
• Walking with heel raised shoe & regular
physiotherapy.
• Reverse ankle stop brace up to 6 months.
Acute rupture of tendon Achilles. A prospective randomised
study ofcomparison between surgical and non-surgical treatment.
Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8

112 patients

Casted x 8 wks Surgery +


Early functional rehab in
brace

21 % re-rupture 1.7% re-rupture


5% infection
No difference in
functional outcome 2% Sural nerve inj.
Komplikasi
• Rupture berulang
• Pembentukan sinus dan Infeksi
• Kelemahan betis
• Nekrosis kulit
• Perlengketan tendon yang di repair ke kulit
Patient Satisfaction & Smile
Daftar Pustaka :

1. Handbook of Fractures, 3ed, McGraw-Hill, 2006.pdf. Pg : 393-


394
2. Apley’s System of Orthopaedics and Fractures, 9ed, Hodder
Arnold, 2010.pdf. Pg : 615-616
3. Bailey and Loves Short Practice of Surgery, 26ed, CRC,
2013.pdf. pg : 522

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