Recent and ancient rupture of the calcaneal tendon of the adult

 

Recent and ancient rupture of the calcaneal tendon of the adultEpidemiology:

The rupture of the calcaneal tendon has been known since antiquity, but its original description comes back to Ambroise Paré, who in 1575 treated King Charles IX for this lesion by lengthened rest.

Its incidence has long been considered rare (70 world cases described in 1929); the marked development of sporting and leisure activities has considerably increased it from 18 to 37 cases per 100 000 people per year at present, according to epidemiological surveys, with a male predominance between 30 and 50 years.

Anatomic pathology:

The calcaneal tendon is the most voluminous and strongest tendon in the body. Termination of the sural triceps, it results from the union of the tendons of the solar and gastrocnemius muscles.

In this vertical tendon, about 15 cm long, 12-15 mm wide and 5-6 mm thick, the fibers are not rectilinear, but spirally wound. This helical structure is composed of bundles of collagen fibers or fascicles, separated by conjunctive partitions (containing vessels and nerve ramifications), surrounded by a peritendinous sheath. In all its course, it is enclosed in a doubling of the legs aponeurosis.

Between this aponeurotic sheath and the peritendon, there exists a paratendinous sheath made up of two sheets whose role is both trophic, but also mechanical to facilitate sliding.

The force necessary to break this tendon is around 4000 N (for example, 3000 N = tensile force during a sprint start), corresponding to five or six times the weight of the body.

The physical properties of the tendon vary with age: it becomes less elastic and less resistant by decreasing the amount of proteoglycans, the water content and the quantitative and qualitative variation of the collagen fibers with aging. Thus, rupture of the calcaneal tendon occurs most often in an unpredictable manner on an aged tendon.Exaggerated tensioning when receiving a jump or a forward fall (ski) or during a sudden extension of the knee while the foot is in dorsiflexion (sprint start , tennis start), then causes the break. More rarely, it occurs in a context of known and progressive tendinopathy: microtrauma related to sporting, inflammatory (rheumatic) or metabolic (gout, chondrocalcinosis, renal insufficiency, diabetes), it is then favored by general corticosteroid therapy or, especially by local infiltration (catabolic risk with mechanical dissociation of the fibers or excessive recovery of the activities by disappearance of the pain). Finally, it is necessary to recall the existence of atypical and sometimes bilateral ruptures occurring as a result of drug administration, in particular of fluoroquinolones for which an immunological mechanism has been evoked.

From an anatomical and prognostic point of view, it is necessary to distinguish the ruptures in the hypovascularized middle zone, the most frequent, the ruptures of the musculotendinous junction and the low ruptures with tendinous disintegration.

The rupture may occur at the same level of the different collagen bundles, equivalent to a tendinous section with retraction of the ends resulting in a true continuity solution or at different levels performing a fibrous entanglement dilation and tendon pseudocontinuity.

The aponeurotic sheath, always respected during rupture (with the tendon of the small plantar), preserves in the lesional hematoma the cellular factors responsible for the regeneration of the tendon.

Recent rupture of the calcaneal tendon:

Clinical signs:

At the first consultation, 20 to 30% of breaks are not diagnosed. Yet the diagnosis is easy and should not be overlooked urgently through simple interrogation and rigorous clinical examination.

Functional signs:

The circumstances of the trauma are always stereotyped.

After a false step or a sudden start, the patient feels a squealing such as a whiplash or a direct shock to the posterior face of the lower third of the leg.

The pain is always acute and the immediate impotence sometimes leads to the fall. Quickly, all the initial signs change: the patient can get up, go back, sometimes leaving only a discreet lameness on the rise and the descent of the stairs, which may explain a late consultation and a delayed diagnosis.

Signs of examination:

The clinical examination carried out in standing position, then lying down, supine and especially ventral decubitus, makes it possible to affirm the diagnosis.

At inspection:

The patient walks by pressing the entire foot to the ground (  heeling  ) by loss of propulsion, associated with a disappearance of the tendon relief masked by the edema that fills the retro-luminal gutters.

If the bipodal station on the tip of the foot is possible by a hyper-support on the sound side, the unipodal station is still impossible.

In supine position:

The palpation of the tendon finds a notch, usually 3 to 4 cm above the calcaneal insertion.

The palpation of this notch triggers a pain related to the lesional hematoma collected in the observed aponeurotic sheath, which can sometimes hamper the demonstration of the increase of the passive dorsiflexion compared to the healthy side.

One must beware of active plantar flexion in the discharge which is always partially preserved due to the action of the flexor muscles of the toes and long fibular of the posterior tibial. It is a common cause of diagnostic error.

In prone position:

In fact, it is this position that is the most contributory.

With the feet protruding from the table, the right angle falls from the foot to the injured side, while on the healthy side there is a physiological equinus related to the triceps tone.

The maneuver of Thompson makes it possible to affirm the diagnosis: it consists in exercising a manual compression of the muscular masses of the calf; if the tendon is intact, an automatic plantar flexion occurs; in the event of a break, the maneuver does not cause any movement of the foot.

At this stage, the diagnosis is formal and complementary examinations should not delay immediate measures to equip the foot, as well as landfilling to limit the extent of the hematoma inside the sheath and retraction of the tendinous extremities.

Imaging:

The complementary examinations are only useful for clarifying the topography and the type of rupture.

More than the loss of the parallelism of the tendinous fibers or the existence of one or more hematomas, they must seek the persistence or not of a tendon continuity (frank rupture or dilaceration) and above all to analyze the approximation and / or contact of the two extremities of the tendon after equine insertion of the foot.

In this context, ultrasound by its possibilities of dynamic examination, more than MRI, should take a more important place in the future, not only in the management but also in the follow-up of a rupture of the calcaneal tendon.

Therapeutic strategies:

Orthopedic treatments:

History:

The first description of a preliminary orthopedic treatment can be attributed to Petit in 1772, who used an elastic bandage to limit the tension of the twins (maximum foot flexion associated with knee flexion) and a walk without support. This bandage was followed by the wearing of a knee brace in slight flexion and now foot equine footing.

As early as 1841, de Lavacherie laid down the main principles of orthopedic treatment, still in force today:  a simple device preventing the mobility of the tendon tips will always suffice to second the healing work by allowing the wandering  .

Therefore, the use of techniques and protocols as varied as they are poorly systematized, in particular on the duration of immobilization, will contribute to encourage the iterative breaks. This formidable complication, attributed to orthopedic treatment in general, causes the development of surgical treatment.

It was not until quite recently that Lea and Smith in 1968 revitalized orthopedic treatment. Based on experimental studies demonstrating the spontaneous healing capacities of the calcaneal tendon, they propose a therapeutic protocol in two parts: eight weeks of immobilization per boot in equine gravity, the support being protected by two English rods, followed by a footing with heel of 25mm for four weeks.

In 1975, Rodineau, in France, emphasized the value of orthopedic treatment. His protocol is as follows: boot in equine gravity for four weeks, with support authorized from the 48th hour under cover of a shoe with elevated heel. A second plaster is made for four weeks with reduction of the equine in the absence of increase of the dorsal flexion. At the removal of the plaster is set up a heel of 2 to 3cm whose height is decreased gradually during the following weeks.Rehabilitation is then begun as follows: the exercises proposed are designed to support and organize the callus by an active work of the triceps in internal race, then average against progressive resistance.

The various subsequent publications will not only confirm the good results of orthopedic treatment, but above all identify risks and disadvantages compared to surgical treatment:

 risk of iterative rupture (8 to 30% depending on the series);

 risk of stretching with increased dorsal flexion;

 amyotrophy and decreased tricipital strength;

 longer immobilization and recovery periods than after surgical treatment.

Evolution :

Many authors will propose changes to the initial protocol in order to reduce the risk of iterative rupture and functional sequelae. Three main parameters will be discussed: the immobilization technique (knee or boot), the duration of immobilization (strict or relative), the support authorized or not.

The immobilization technique. Since gastrocnemius is a biarticular muscle, immobilization of the knee has been proposed by some to reduce the traction and limit the risk of diastasis of the two stumps of the ruptured tendon. The comparison of the results with the series leaving the knee free reveals no benefit to this type of immobilization as to the risk of iterative rupture. On the other hand, the functional discomfort caused by the blockage of the knee only increases the side effects of orthopedic treatment (stiffness, muscular atrophy, longer occupational unavailability).

The duration of immobilisation:

It varies according to the series. It includes a period of equine gravity of one to six weeks allowing to obtain a tendinous callus by confrontation of the extremities, followed by a period with progressive reduction of the equine over an additional four to six weeks in order to favor a setting in progressive tension of the primary fibrous callus. In most cases, this strict immobilization is relayed by a heel restraining the dorsal flexion in support during the phase of reeducation. The analysis of the literature does not allow to conclude on an ideal duration of immobilization.

Complications were found in each of the three phases of treatment:

 stiffening in case of prolonged immobilisation;

 tendon sequellar elongations with increased dorsal flexion in case of early equine reduction;

 iterative breaks noted in all series, which may occur up to the end of the second month after the asset has been removed.

Despite all the variants proposed, some principles seem to have been acquired:

 immobilization in equine gravity or forced should not exceed six weeks, limiting the risk of joint stiffness;

 the gradual reduction of the equine must be done by successive plasters, changed weekly, to reduce the risk of tendon elongation, but if, during the change of plaster, there is a tendency for the persistence of a flexion dorsal enhancement, we must not hesitate to return to the previous stage;

 to limit the risk of iterative breakdown, the immobilization must be sufficiently long (at least ten weeks);

 at the lifting of the immobilization, wearing a 2 cm degressive heel is recommended in order to reduce the risk of sudden tensioning of the tendon by uncontrolled dorsal flexion, while allowing a  mechanization  of the tendon walking.

Authorization for support:

Some authors have adopted from the outset the walking boot in equine gravity, with the addition of a boot with raised heel or a stirrup allowing a stable walking in complete support. The analysis of the results of the series using this method did not reveal any significant difference in the iterative breaking rate with those prohibiting support. On the other hand, the comfort of the patient for walking and his autonomy not only allowed him to accept a prolonged immobilisation but also to resume professional activities more quickly. The absence of support is therefore not an essential condition for tendon healing, subject to controlling the equine by a technique of immobilization adapted to walking.

Results of orthopedic treatments:

With the precautions mentioned, the effectiveness of orthopedic treatment on the tendon healing of recent ruptures is no longer to be demonstrated.

Wound healing, however, varies according to the topography, type and time of the lesion. It is known that high ruptures (musculotendinous junction) heal better than low ruptures (calcaneal insertion) and, probably, tendinous dilatations better than open ruptures. Similarly, the early onset of orthopedic treatment is a factor of better prognosis: a delay of more than eight days (organization of the lesional hematoma) can prevent the confrontation of the tendon extremities and alter the quality of the healing.

In practice, to reduce the inevitable risk of iterative rupture below 10%, or even 5%, it is necessary to avoid offering orthopedic treatment in these unfavorable cases, but above all to respect certain principles:

 extended tenure (at least ten weeks);

 progressive rehabilitation of mobility and muscular strength;

 protection of ankle dorsal flexion in the two months following the lifting of the immobilization.

In the case of an iterative rupture after orthopedic treatment, the tendency is to move towards a surgical recovery, both for reasons of secondary healing potential and psychological for the patient, given the failure of the conservative method and its constraints socioprofessional and sports.

Due to immobilization and tendon protection (four to five months), functional recovery occurs in nine to 12 months, a relatively long delay compared to other methods.

Functional treatment:

History:

Swiss and especially German authors proposed a truly functional treatment from 1990 onwards.

The principle is simple: to use a means of immobilization preventing the passive dorsal flexion while allowing the plantar flexion active, the support not being prohibited.

To achieve this objective, they first used artisanal means such as the simple addition of a heel under the shoe with or without added port of an orthosis preventing dorsiflexion. Subsequent work has resorted to footwear already manufactured by the manufacturer (Variostabil®, Vacoped®, Donjoy®, Aircast® …) offering the advantage of simple use, being allowed) and the possibility of a progressive tensioning of the tendon since the equine is adjustable.

The evaluation of this type of treatment has benefited from the contribution of the ultrasound to analyze the reducibility of the diastasis of the extremities tendinous by the equine placement of the foot and the monitoring of the healing.

The current protocol:

It includes a short immobilization (one to three days) per equine plaster splinter, without support to decrease the initial edema and to favor the tendinous contact (controlled by ultrasound).

The orthosis is set up by keeping the foot in equine. It usually includes a rear hull and an anterior shell joined by straps and a removable wedge system to raise the heel and adjust the angle of plantar flexion.

Thus, the ankle is not only immobilized with a modular equine in a rigid and comfortable orthosis, but the possibility of removing the anterior shell allows a safe removal for hygienic care and clinical and ultrasound control examinations, while keeping the foot in plantar flexion.

Once the orthosis is in place, the patient can regain full support and begin exercises in isometric muscular contractions to combat amyotrophy.

The orthosis must be maintained day and night for six weeks, then only the day during the following weeks.

The recommended initial height of the heel is 3 to 4 cm. From the sixth week, the height of the bilge system can be reduced in successive 1 cm increments depending on the clinical and ultrasound balance.

Results of functional treatment:

Analysis of the first series shows that the results are as good as with orthopedic treatment. The risk of iterative rupture is related to the persistence of a diastasis in plantar flexion during the initial ultrasound and to the patient’s compliance with the treatment constraints. The authors recommended this treatment only in cases of diastasis tendon less than 5 mm and insist that clear and precise information is given to the patient so that the patient is not tempted to wear the orthesis at his convenience or to shorten the duration of treatment. Besides, the major advantage of the freedom to wander with a shorter occupational unavailability, the functional method leads to less muscular atrophy with muscle strength tests such as Cybex ® or Biodex ® very satisfactory.

Moreover, the possibility of clinical and ultrasound checks during the treatment makes it possible to adapt the progressive decrease of the equine and the duration of the wearing of the orthesis. However, other multicentric publications confirming the good results of the early German and Swiss studies are still needed to confirm its superiority over conventional orthopedic treatment.

Conventional surgical treatment:

History:

It was in 1883 that Pollailon described the first intervention inaugurating the surgical era of ruptures of the calcaneal tendon.

The  open sky  repair then appears to be the surest way of ensuring a solid contact of the ends allowing a satisfactory cicatrization and restoring an optimum tendon length from a biomechanical point of view.

This concept will be reinforced by the results of the first retrospective study of Quenu and Stoianovich in 1929 comparing surgery with conservative treatment.

Conventional surgical techniques:

They were particularly numerous and varied according to the patient’s installation, the approach, the method and the means used for the repair (absorbable and nonabsorbable yarns) and the postoperative protocols.

Despite all these diversities, there is a reference technique, consensus of the review of the literature:

 under general or locoregional anesthesia, pneumatic tourniquet at the root of the limb, the patient is most often placed in a prone position with the free foot extending beyond the end of the table to promote equine placement;

 the approach is rather para-achillian internal to avoid any subsequent conflict of the scar with the footwear and avoid secondary neurological disorders in the territory of the branches of the short saphenous nerve;

 the incision of the aponeurotic sheath must be made without detachment, in the plane of the cutaneous incision.

The opening of this fibrous sheath, initially free, must be carried out without traumatic forceps or aggressive retractor to avoid the risk of secondary skin complications;

 the tendinous extremities are then regularized after cleaning of the hematoma by minimal excision of the para and peritendon at the area of ​​rupture, respecting the tendon of the small plantar which is practically always continuous.

The lesional balance can then specify the type of rupture: frank or dilaceration, medium or low with or without deinsertion to adapt the repair technique.

In case of breakage. A direct tendon suture may be performed by U-shaped stitches with a sufficiently strong thread.

Some authors use a slowly absorbing yarn, others use a nonabsorbable yarn and more recently, for some, a more resilient elastic yarn.

The suture must allow for anatomical and stable tendon confrontation during ankle mobilization and tensioning of the tendon.

In case of maceration. The repair uses a laurel with slowly absorbed or nonabsorbable threads passed into each end of the tendon. The surgeon is supported about 2 cm from the area of ​​rupture, by providing lateral knots and taking care not to over tighten them so as not to compromise the vascularization or tear the tendon. Peripheral points (or surjections) complement the lake to face the banks of the rupture and regulate, as perfectly as possible, the entire area of ​​broken fibers.

In the event of dislocation of the tendon on the calcaneus:

Transosseous reinsertion should be performed. It can be performed in a bone trench by transosseous U-shaped points or by a double inverted U-shaped framing, which is more resistant.

More recently, the use of anchors has developed and replaced the staples and stool screws used by some to fix the tendon on the posterosuperior face of the calcaneus.

Since the tendon repair is performed and its resistance evaluated, the aponeurotic sheath must be systematically and carefully closed.

The placement of an anterior plaster splint in an equine equilibrium (to avoid an ischemic effect on the skin) allows the scar to be monitored until the redon is removed and a plaster or resin boot is made, in physiological equine.Postoperative immobilization is usually six weeks, mostly without support, before rehabilitation begins. The step in full support is then taken again, under cover of a heel of 2 cm whose height is decreased gradually.

Analysis of the surgical series:

The results of the conventional surgical treatment in the different series published are regularly very satisfactory in the absence of problem of cutaneous healing.

Tendon healing is obtained in more than 98% of cases with a thickened tendon, without an increase in dorsal flexion, with a moderate stiffness in plantar flexion. The period of gradual resumption of sport is three months, earlier and safer than after orthopedic treatment, although the persistence of triceps muscular atrophy (1.5-2 cm) often results in a deficit of strength (30-40%), which does not always allow a return to sport at the previous level.

More than the risk of iterative rupture (less than 2%), it is mainly the problems of cutaneous healing (estimated between 10 and 25%) that penalize the results of conventional surgical treatment. They can cause serious infectious complications (2-3%) with cutaneous disunion and septic necrosis of the tendon, requiring surgical excision. This is most often followed by a prolonged open-pit treatment with directed healing, under cover of a fenestrated boot in equine. The use of plastic surgery and flap reconstruction is sometimes necessary. Despite sometimes satisfactory anatomical results, the functional sequelae are rarely compatible with the sporting recovery. Most commonly, scarring complications are benign, but very frequent (up to 20% depending on the series), including adhesions, unstable crust scars and sometimes neuromas or shoe conflicts. They cause pain in the resumption of walking or running, as well as a more or less permanent functional discomfort without a really effective therapeutic solution.

Evolution of techniques:

As a result of these complications, some modifications were made as follows:

Tendinous plasty:

In front of a tendon with dilated tendinous extremities making the suture difficult, some authors immediately performed a plasty by the small plantar, the short fibular or a reversal of a triceps aponeurosis flap (Bosworth technique) to strengthen the suture . However, the increase in the volume of the tendon and the number of sutures exposed to excessive tension on the scar and to secondary skin problems.

These techniques are rather reserved for old breaks and must be avoided in recent breaks in favor of simple laying technique.

Organic glue:

The use of a biological glue, already used alone by some, can become a simple and effective alternative to the tendon suture if the results of the first series are confirmed.

Minimally invasive techniques:

To avoid more surely complications skin and therefore infectious, some authors have proposed minimal invasive techniques.

The principle is to reduce the approach to the area of ​​rupture by a limited horizontal cutaneous incision (2 to 3 cm), but sufficient to realize and verify the contact of the tendinous extremities. The visual control of the tendon contact and the strength of the suture by a limited cutaneous incision then allow an earlier reeducation with protected support to promote the quality of the tendon healing and decrease the amyotrophy secondary to the immobilization.

The analysis of the published surgical series seems to show better anatomical and functional results than with conventional techniques. There is virtually no local complication, but a risk of persistent iterative rupture explained by the type of tendon lesion whose suture is not always accessible at a limited initial pathway or by a postoperative protocol that is not respected given the simplicity of the suites.

In spite of these good results, in the early 1990s, technical difficulties or the availability of an adapted device favored the development of percutaneous techniques.

Percutaneous techniques:

The first technique of percutaneous repair of the rupture of the Achilles tendon was published in 1977 by Ma and Griffith with successive passages of the sutures of suture using the same cutaneous orifices and knots buried on the lateral face of the tendon.

It is mainly Delponte in France that has taken over the concept of percutaneous tenorphography, proposed a material adapted to a simple and reproducible technique (Tenolig ® ) and published the first results in 1992.

The surgical technique of Tenolig ®:

The material includes two Dacron threads, a 5mm wide harpoon, a triangular tip needle, a silastic washer and a perforated lead.

The procedure can be performed on an outpatient basis or with a short hospital stay, under general, local or regional anesthesia, without tourniquet.

On a patient in a ventral decubitus, the rupture is localized by palpation and drawn by dermographic pencil.

The needle is modeled in curvature according to the estimation of the entry and exit points (about 6 cm above the sensed rupture zone and 1.5 cm apart for the proximal entry points).

A short skin incision (less than 1 cm) with dissection of the subcutaneous tissue makes it possible to introduce the needle under the control of the sight at the level of the sheath of the proximal fragment. A digital control allows to follow its progression, especially in the zone of rupture, and facilitates its passage in the distal fragment. The end of the needle is recovered in the retromalleolar dimple and the wire pulled until the harpoon is fixed to the sheath of the proximal tendon. A second thread is then placed in the same way, parallel, before putting the foot in equine, controlling palpation the tendinous contact and stretching the two threads which will be blocked by the pellets on the silastic washer. The proximal end of the wires is left free for future ablation. A simple dressing is made and sometimes a protective splint placed in place.

The postoperative protocol of a percutaneous technique:

The surgical follow-up is very variable according to the operators with regard to the beginning of the active ankle rehabilitation (to fight against adhesions and amyotrophy) and the resumption of the support before the ablation of the Tenolig® threads under local anesthesia on the 45th day.

The rehabilitation protocol has given rise to numerous divergences and sometimes to disappointing anatomical and functional results (tendon elongation, secondary partial rupture, intratendinous cyst), which are the source of severe criticism of the technique by the advocates of orthopedic and surgical treatments conventional. Surgeons from the Talus group proposed a clear and precise protocol, validated by a prospective multicentre study. This postoperative protocol comprises four phases:

 phase I: period of hospitalization:

 the principles of rehabilitation must be clearly explained to the patient for cooperation. Active ankle mobility is evaluated on the basis of pain before immobilizing it in a bivalve boot without support for three weeks. The prescription of the special walking orthosis is made at the exit;

 phase II: up to j21:

 Support is not allowed. The active rehabilitation with ankle off immobilization is continued in the home at the average rate of three times a week under the supervision of a physiotherapist. It is progressive, limited by tension and pain, with the objective of recovering the neutral position in three weeks. At the end of this period, the clinical assessment makes it possible to check the good evolution of the healing (tendon palpation, active Thompson maneuver, active ankle mobility) and the good tolerance of the threads. the walking orthosis (with heel or rounded sole);

 phase III: from j21 to j45:

 resumption of support with the removable orthosis; continuation of active ankle rehabilitation and static contraction of the triceps.

During this period, a podological assessment can be carried out to make thermoformable soles with raised heel (2 cm).

The ablation of the Tenolig ® wires is carried out on day 45, on an outpatient basis, under local anesthesia. A new clinical review allows the start of Phase IV;

 phase IV: intensification of rehabilitation:

 reinforcement of the triceps against progressive manual resistance and proprioceptive re-education of the ankle in discharge and then in charge; weaning of the orthesis relayed by the heel soles.

Results:

This protocol applied in a prospective multicentric study of 421 ruptures confirmed the reliability of the technique.

The analysis of the sports population (35 patients including ten competitors) showed the quality of the functional results with a recovery of the sport at the same level for 85% of the competitors and 72% of the recreational sportsmen, a score of Kitaoka to 99.2 % and Biodex muscle tests at 90% plantar flexion recovery at slow speeds and 81% at high speeds.

These results compared to the published series evaluating not only the anatomical result but also the functional result seem to promote percutaneous technique as a technique of choice for the sports population, subject to an active, progressive and controlled postoperative protocol.

However, other surgical techniques, even orthopedic techniques, retain their a fortiori when sports demand is not at the forefront for several reasons:

 cooperation and monitoring constraints (which may explain the persistence of iterative breaks;

 Material tolerance (skin lesions) in older patients;

 the existence of pain (cutaneous, but sometimes neurological) with difficulty adapting to the walking orthosis.

Recently, Delponte modified the material (fully bioresorbable at three months) and the technique (four V-shaped wires, anchored in the calcaneus, passed from distal to proximal). If the first results seem to show an improvement on the tolerance of the material, new multicentric studies are necessary to affirm the superiority compared to the original technique.

Update of therapeutic indications in the recent rupture of the calcaneal tendon:

To the classic controversy between surgical and orthopedic treatment, the appearance and development of percutaneous and functional techniques has not yet made it possible to conclude that one treatment is superior to another.

The results are comparable to one year, in the absence of complications (although the objective and subjective evaluation criteria were not always identical).

Given the impossibility of considering prospective and randomized studies of the four therapeutic proposals, only the analysis of the results and the complications with evaluation of the benefit / risk ratio of each technique would make it possible to specify the therapeutic indications.

Thus, orthopedic and functional treatments do not require hospitalization or anesthesia, do not present any risk of skin or infectious complications, but orthopedic treatment requires prolonged immobilization of the ankle (greater than or equal to ten weeks) with delays long and often partial recovery of the strength of the triceps. As for the functional treatment, it is necessary to control the tendinous contact after equine insertion by an ultrasound and a good cooperation of the patient for the wearing of the orthesis in order to avoid the sequellar tendon elongation with a bad final result.

Open surgical suture treatments are more certain to obtain tendon contact favorable to a solid healing respecting the length of the tendon, but impose hospitalization and difficulties of suture or lacçage which can lead to complications skin and sometimes infectious serious.

Preoperative clinical and ultrasound assessment may, however, allow less invasive approaches to perform lacemaking, the use of a functional treatment orthosis and earlier rehabilitation, which is conducive to the quality of the tendon scar and to trophicity of the triceps.

Percutaneous treatment may be the ideal compromise between surgical and conservative treatment, with results in the most effective muscle strength test, making it the technique of choice for sports and motivated patients. The problems of material tolerance and the constraints for the patient and the surgeon in the follow-up of the rehabilitation protocol are still not adapted to the sedentary patients whose functional demand is less important.

In practice, it is possible to propose a therapeutic decision tree according to:

 the type of rupture: level, age, but also importance of the dilaceration and its appearance after equine foot evaluation by the clinic, but especially by ultrasound;

 the patient: age, level, sports activities and professional constraints;

 the practitioner’s experience and habit.

Depending on the type of rupture:

The high ruptures are mainly orthopedic and the low ruptures, a fortiori with disintegration, are always surgical. The most frequent full-body ruptures can be used for all emergency treatments, but if the lesion is longer than eight days, open surgical techniques should be preferred.

In the case of dilation with an aspect of pseudocontinuity on ultrasound after equine treatment, conservative treatment is more indicated than surgical treatment.

In contrast, a clear rupture with persistence of diastasis between the tendinous extremities justifies a surgical technique.

Depending on the patient:

A sporting subject, a fortiori competitor, will benefit more easily from a surgical technique, at best percutaneous, with sequences of functional treatment. On the other hand, an elderly subject or presenting local or general contraindications to a surgical gesture, or even a prolonged immobilization, represents the ideal profile for a functional treatment.

In fact, the indication is especially difficult for the active patient having recreational sports activities and which shows a frank rupture in full body of the calcaneal tendon.

Absolutely, it is the balance between his desire to return to his previous sporting level and his socioprofessional constraints, sometimes incompatible with hospitalization or a postoperative protocol binding, which must guide the choice of treatment. But it is still too often the habits of the therapist: surgical treatment for surgeons and conservative treatment for physicians, which influence the choice of treatment and expose the patient to complications especially surgery, poorly respected constraints or insufficient functional results explaining the persistence of old rupture of the calcaneal tendon seen secondarily.

The ancient rupture of the calcaneal tendon:

Physical examination:

It may be the consequence of an initial treatment failure that is responsible for an iterative break but is still too often linked to the lack of knowledge of emergency diagnosis.

Functional signs:

The functional signs are variable according to the anatomopathological type of the sequal lesion, ranging from simple moderate discomfort with ankle swelling to stress, painful lameness with difficulty walking and climbing and descending stairs. In all cases, the stroke is impossible by loss of propulsion at the level of the injured foot.

Signs of examination:

The diagnosis is most often easy by interrogation and simple clinical examination.

The interrogation finds the traumatic antecedent and specifies the initial treatment and its consequences.

Clinical examination confirms the diagnosis by demonstrating the three specific signs of functional deficiency of the muscle-tendon-bone chain:

 walking is done by  heeling  with tricipital amyotrophy;

 the unipodal surge on tip is impossible;

 there is a net increase in passive dorsiflexion of the ankle with the tendon no longer functional.

At this stage of the examination, the diagnosis is formal: palpation confirms the negativity of Thompson’s maneuver and analyzes the anatomy of the tendon to search for either a healing with excessive length (continuous and thick tendon) or absence of cicatrization (persistence of a solution of continuity or heterogeneous thickness).

In fact, the anatomopathology of the lesion is best defined by complementary examinations.

Imaging:

If the radiograph of the foot of the profile is systematic to study the enthesis and to look for calcifications or sequelae of tearing, it is mainly the ultrasound and the MRI which are the most useful. As much as ultrasound is the examination of choice in recent ruptures by its dynamic possibilities to evaluate the tendinous contact after equine footing, the MRI performs well in the chronic stage to specify the structure of the tendon and to allow, by l analysis of the T1, T2 fat sat sequences and the different cutting planes (frontal, sagittal, axial), to map between healthy tendon fibers, fibrosis and sometimes cicatricial cysts.

Therefore, therapeutic indications will depend on the anatomopathology of the sequal lesion, the functional discomfort and the requirements of the patient.

Therapeutic strategies:

Functional treatment:

A functional treatment by rehabilitation, heel soles and compression stockings can improve functional discomfort for everyday life in the case of moderate elongation, but usually only represents a treatment waiting for a surgical procedure of tendinous plasty , especially if there is a demand for resumption of sporting activities.

Surgical treatment:

The surgical techniques are numerous and varied and have been perfectly described by Kouvalchouk. They are adapted to the anatomopathological type of the sequellar lesion, better defined by MRI and confirmed by the intraoperative lesional assessment. The aim of the procedure is to restore a satisfactory length of the tendon (judged by the physiological equine in peroperative ventral decubitus), but also a sufficient tendon volume.

The installation, the approach and the precautions with respect to the skin coating are the same as in the context of a recent rupture. The opening of the fibrous sheath must allow tenolysis over the entire length of the tendon, releasing particularly frequent adhesions but respecting the aponeurotic tissue to allow the secondary closure of the sheath, if necessary, with the artifice of a discharge incision :

 in the case of excessive length healing, on a thick and continuous tendon, shortening Z in the sagittal plane on the height of the tendon is a safe and effective technique;

 in the case of complete tendon discontinuity after tenolysis, it is sometimes possible to perform a simple suture or lachrymatism if the tendinous contact after the ends of the tendon does not impose too much equine equilibrium. retraction of the extremities favored by the age of the lesion imposes a tendinous plasty. Several transplants have been proposed as follows:

 the small plantar, but its small thickness makes it more a reinforcement plasty by lacing or framing rather than a filling plasty,

 the flexor digitorum which requires an incision complementary to the inferomedial edge of the foot to sever the tendon after suture of its distal part lateral on the flexor clean,

 the flexor of the big toe with two thirds of the tendinomuscular chain that allows a local transfer through the proximal end and bridging the loss of substance by a thicker and vascularized transplant,

 the fibular short which requires a short lateral incision centered on the base of the fifth metatarsal and sometimes external retromalleolae to cut the distal part and perform the tendinomuscular sampling which will then be mobilized to fill the loss of tendon substance and sutured in framing with or without calcaneal bone tunnel,

 a bone-tendon transplant from the homolateral knee extensor system in low separation or disintegration sequences to allow distal reconstruction of the enthesis.

These different techniques, however, pose problems of sampling and volume of the transplant to be reserved in addition, if necessary, techniques much simpler using the aponeurosis of the triceps. Indeed, if the triceps aponeurosis is always required to be taken extensively up to the upper third of the leg, the length, width and thickness of the transplant can be adapted to the loss of tendinous substance with the possibility of closing the lateral removal site.

In addition, the aponeurotic flap can be returned and sutured to the distal fragment, passed through the tendinous extremities or translated globally to the distal fragment.

Some teams currently use a triceps aponeurosis flap by transplant free. A priori simple technique of reconstruction requiring confirmation of the results, notably with regard to the tolerance of the graft and the anatomical aspect.

In all techniques of tendinous plasty, the careful closure of the sheath on redon aspiration, after careful haemostasis, remains a determining factor in the prevention of skin and infectious complications.

Operative after surgery of an old rupture poses the same problems as in recent surgery. If, at present, immobilization without support for 45 days remains the rule as a precautionary measure, the quality and strength of the tendinous plasty may allow more functional follow-ups, subject to the patient’s cooperation and regular monitoring of the evolution by clinical and ultrasound assessment.

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