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Open primary Achilles repair
3%
120/3803
Nonoperative treatment with early functional rehabilitation
6%
246/3803
Haglund excision, Achilles debridement, reconstruction with bone block achilles allograft
14%
544/3803
Haglund excision, gastrocnemius recession, Achilles repair, flexor hallucis longus tendon transfer
70%
2657/3803
Percutaneous primary Achilles repair
5%
203/3803
Select Answer to see Preferred Response
The patient presents with an open insertional Achilles tendon rupture. Based on his pre-injury radiographs and treatment he has a dorsal calcaneal exostosis (Haglund deformity) and insertional Achilles tendinopathy. The best treatment based on his clinical picture and radiographs consists of Haglund excision, gastrocnemius recession, Achilles repair, and augmentation with flexor hallucis tendon transfer. Treatment of Achilles ruptures in the setting of chronic Achilles tendon disorders requires careful evaluation of the location of the disease as well as the functional demands of the patient. Surgical treatment typically consists of debridement of the diseased tendon, repair of the tendon with proximal lengthening procedure, along with tendon transfer to augment or reconstruct the Achilles tendon. Johnson et al conducted a survey of members of the AOFAS regarding their use of corticosteroid injections in disorders of the foot and ankle. The authors found that foot and ankle surgeons who responded were reluctant to perform injections for either midsubstance or insertional Achilles tendon pathology. Reddy et al reviewed the diagnosis and treatment of chronic disorders of the Achilles tendon. The authors review treatment of insertional Achilles tendinosis (as seen in this patient). Debridement with reattachment (with or without V-Y lengthening) or debridement with FHL transfer are viable treatment options. Figure A is a non-weight bearing lateral radiograph demonstrating a dorsal calcaneal exostosis (Haglund lesion) and a large enthesophyte at the Achilles insertion consistent with insertional Achilles tendinosis. Incorrect Answers: Answer 1. Open primary repair in isolation would be difficult in this situation because of the significant disease within the distal Achilles tendon. Adjunctive procedures such as proximal lengthening would be required. Answer 2. Early functional rehabilitation has shown promising outcomes in acute mid substance Achilles tendon ruptures, however has never been studies for a patient with Achilles tendinopathy or with insertional rupture. Answer 3: Achilles tendon reconstruction with allograft tissue is typically reserved for patients whose defect cannot be reconstructed with local tissue transfer (defects >10cm). Answer 5: Percutaneous repair techniques have not been studied for insertional Achilles ruptures with defects.
2.7
(13)
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