CME OnDemand: Managing Achilles Ruptures and Tendinopathy: Where Are We in 2023?-Foot & Ankle Focus: Managing Achilles Ruptures and Tendinopathy: Where Are We in 2023?

Foot & Ankle Focus: Managing Achilles Ruptures and Tendinopathy: Where Are We in 2023?

Video Transcription

On behalf of AOFAS, I want to welcome you to tonight's webinar, Managing Achilles Ruptures and Tendinopathy, Where Are We in 2023? Tonight's moderator is Dr. Eric Tan.  Joining him are Drs. Bonnie Sheem, Martin O'Malley, Lou Schon, and Norman Waldrop. You can find their full biographies and disclosures, as well as disclosures for program planners,  in the program document posted in the chat box and in the AOFAS OnDemand Education Center.  2023 webinars are provided free to AOFAS members and orthopedic residents, fellows, and medical students with funding from the Orthopedic Foot and Ankle Foundation, supported by a  major grant from Stryker, and additional funding from Arthrex. To support education programs like this, donate to the foundation on our website or by texting GIVEAOFAS to 41444.  I'd like to run through a few housekeeping items before we kick off the presentations. For technical difficulties, please try closing your browser and logging back in the same  way you did the first time. Registered attendees may earn one hour of AMA PRA Category 1 CME credit by completing the evaluation and CME claim form at the end of the webinar.  You can find the link to claim CME in the chat tab, and we will follow up with an email following the conclusion of this broadcast.  This webinar is being recorded and will be available for on-demand viewing on the OnDemand Education Center content library in approximately 24 hours.  We encourage you to ask questions during the presentations. To send your question to faculty, click on the Q&A tab on your navigation bar.  If you cannot get to your question during the live broadcast, the faculty will reach out to you following the broadcast to respond.  Finally, please visit our website to register for upcoming events, including our in-person  course, Sports Injuries of the Foot and Ankle, this April in Boulder, Colorado, and the AOFAS Winter Meeting taking place next month at the Saddlebrook Resort in Tampa, Florida.  If you need more CME before the end of the year, make sure to check out the AOFAS OnDemand Education Center.  You can earn CME credit on your schedule, and AOFAS members get discounted rates. I will now turn the program over to Dr. Tannen again. Thank you. Perfect. Thank you.  Thank you, Lucas. So, I just want to thank everybody for joining us tonight. We have a pretty big group on, and we have great faculty today.  We are going to kind of review the state of the Achilles rupture in 2023. There's been a lot of kind of controversies and just thoughts surrounding just who gets  surgery, who doesn't get surgery, different techniques that evolved, and the chronic and  acute situations, as well as looking at rehabilitation and trying to bring people back faster. So in this webinar, we're basically trying to elucidate what's the evidence there and  sort of how to move forward with those things. Again, please feel free to ask questions. We'll try to take a few questions in between each of the talks and then go from there.  So the first talk we have is Dr. Bonnie Chen from Columbia University. She's going to review basically the kind of evidence that surrounds non-operative versus  operative treatment of acute Achilles tendon ruptures.  Can you see my screen? Yes. Perfect. In presentation mode. All ready to go. Amazing. All right.  So it's really an honor to be part of this panel with some of the most esteemed experts as well as mentors in this field.  So my role today is just to take us on a little historical tour through time of the evidence behind non operative versus operative treatment of the acute Achilles tendon rupture.  And through the current evidence that I hope to share and many of us are familiar with already is to help us make a decision as surgeons to develop an individualized treatment plan for each of our patients.  So just a brief history, starting from the 80s and just so everybody knows sometimes it's hard to keep track of what generation is what the 80s were the generation X, and in the late 80s, these were the millennials.  And so already we already had some start of randomized trials comparing operative versus non operative treatment of acute Achilles tendon ruptures, demonstrating that there was a higher rupture rate in a non operative group and relatively equal strength in terms of comparing these two groups.  Then we move forward to the 90s, which is really full millennial generation. Again, more prospective randomized trials comparing surgery versus no surgery, and similarly demonstrating that non operative treatment seems to have a higher rate of ruptures compared to surgical treatment.  In the operative group, some of these early studies seem to suggest and favor surgery to offer greater return to sports, less muscle atrophy, as well as greater ankle range of motion.  Going to the 2000s, this is generation Z, more randomized control trials, similar sample sizes of about 100 patients with 50 patients in each group, and the rupture rate consistently again seems to suggest that in no surgery, the rupture rate is higher than if you do receive surgery.  And again, with this study, perhaps slightly favoring the benefit of doing surgery.  And if we take into account and assimilate many of these randomized control trials and combine numerous patients, the number that has been quoted in the literature often is that with open repair versus non operative treatment, the rupture rate seems to be about 3.5% versus 12.5% respectively.  As can be expected, operative repair is associated with a higher rate of complications, unsurprisingly with infection, adhesions from scarring, nerve injury. And now we're seeing a little bit of a glimmer introduction of perhaps some of the functional rehabilitation, which one of my other co-speakers will address into some of these studies, perhaps demonstrating that a functional brace and not being in a cast and fully immobilized may perhaps lower the rate of complications as well.  Now we're going into the 2010s, which is generation alpha, as we have come to the end of the alphabet. And with open repair versus non operative repair, and now the fold, the extra fold is the addition of early functional rehabilitation.  And as we know, many of these functional rehabilitation protocols can vary across the studies, vary across surgeons. Typically, it means that weight bearing or partial weight bearing as well as range of motion can be initiated at about two weeks with an injury or surgery.  This is the relatively well known Willett study that was published in JBJS in 2010 with a slightly greater sample size of patients that were followed for two years. And these researchers did measure a number of different outcome measures of their patients.  What they found was that, as expected, again, with surgery, there can be a higher rate of complications. And what they found were mainly wound healing issues. However, they did not find a difference in rerupture rate between surgery and no surgery.  And some of the limitations or criticisms may be that their study was underpowered. Their number of about 3% seemed to be lower, 3 to 4% seemed to be lower than what has been published previously in the literature.  The only main difference they found was that when they measured their patients at about a year after surgery or nonoperative treatment at the highest philosophies of plantar flexion, meaning how fast or how much strength can you exert to achieve 240 degrees of plantar flexion in a second, it seemed to be that the surgical group performed better.  If we take into account all of these studies from the 80s to the 2000s, what we can see in this table here is that generally these studies all had a similar number of patients, about 100. And if we were really to take a statistical standpoint and a step in terms of looking at what we can do to really calculate a clinical real-world difference, we really need a sample size of about 1,200 patients, which as we know can be quite challenging to do in a randomized controlled trial setting.  So then we take into account various different systematic reviews and meta-analyses, and we combine these groups of patients. So we have thousands of patients in each group. And some of these meta-analyses have been able to take into account a good number of high-quality, high-level studies that have been published.  And the bottom line seems to suggest that operative treatment, again, lowers rerupture rate. Now we're 2022, still generation alpha. This was the study that was published in the New England Journal of Medicine that many of us saw, published in Norway. And whenever any orthopedic paper may be published in the New England Journal of Medicine, it probably deserves a little bit of a double take.  And this study was multi-center. And not only did it just compare non-surgery, non-operative versus surgery, within surgery, they also stratified between open repair as well as a minimally invasive technique. Now of note, they did use a slightly different system than what many of us in North America may be more familiar with using.  And what they found was that there really was no difference in the outcome score. They noted the different surgical complications. And the rupture rate, although lower than what has been published in the literature previously, still at about 6%, was higher than if patients underwent surgery, the 6% being in the non-surgical group. And then finally, with their minimally invasive technique, they found a slightly higher rate of nerve injury, about 5%, compared to open repair.  So, so far we've compared different outcomes, particularly rupture rate, complications, and then strength, and then of key interest is return to sport or function on a daily, regular activity basis.  We know that with complications, as has been mentioned and reported in the literature, things can go wrong, certainly with surgery. Infection, wound dehiscence, sterile nerve injury, neuritis, scarring, skin adhesions. And the literature rates have been in a broad range, 5% to 10%, so not insignificant.  Some of the complications, potentially that may be worse with non-operative management, perhaps DBT, but I'll leave that for another seminar or webinar that we may have in the future, as this is a completely different topic of vast interest.  So in terms of strength, as many of us know, we have treated injuries like this, acute Achilles tendon rupture is even chronic, as will be spoken about a bit later. Early in recovery, the strength differences can really not be that perceptible. And it takes patients a really long time to recover their strength and something seemingly as easy as a single heel rise, sometimes can take six months up to a year for a patient to really be able to perform that.  And just going back to the Willett study from JBJS mentioned earlier, the main strength difference that they found was at about a year after treatment, that surgery may increase the strength at the highest velocities of plantar flexion. However, this is a mechanical measure. How does that really translate to everyday function, higher level of activity, sports?  And so some of these other studies that have looked at returns to sport, not in the professional setting, one study looked at five-year follow-up of non-operative treatment of these acute Achilles tendon rupture. And they defined low-level versus high-level returns to sport. And their rates, as would be expected in the low-level group, was relatively high, 90%, whereas only about two-thirds of patients really returned to high-level sports, such as tennis, volleyball, basketball, what we can imagine as being more high impact and intense.  And if we look at another group of patients that may be comparable in terms of activity level, active, relatively young, it was a study that was done in the military population comparing operative versus non-operative treatment. And they found that while there was no difference in the rate of return to duty, there did seem to be a benefit of surgery in terms of how quickly these patients in the military could return to duty.  So in summary, the take-home points seem to be that with modern operative techniques, such as minimally evasive or percutaneous techniques, as well as increased awareness with soft tissue handling, all of these have contributed to reducing the rate of certain complications in surgery that we have seen in the past.  Similarly, an advancement are the functional rehabilitation protocols that have come out to help supplement and augment the benefit of non-operative treatment that may help mitigate the risk of tendon rupture and provide the opportunity for comparable outcomes to surgery.  I think there's a lot of opportunity for all of us to look into what this means for the treatment course for high performance athletes, what kind of outcome measures we use for patients and how that can correlate with function.  Furthermore, future study opportunities can include as well minimally invasive percutaneous techniques comparing head-to-head with functional rehabilitation protocols that have now been modernized and really well studied.  So I'm going to pass it on to my next colleague. We'll talk about if we fix them, how do we do it? Thank you so much.  Awesome. Thank you, Bonnie. So a quick question for you, Bonnie. So with the information that you presented and everything, how do you contextualize that?  So when you see a patient, do you counsel them based on age, activity level, expectations, or just kind of in a nutshell, how do you use that information to influence sort of how you speak to or influence the decision-making of patients?  Well, I think age is one relative measure. I think many of us know that age is sometimes just a number and physiologic age can be important. It's not just that patients in their 20s, 30s, or even 40s get surgery.  Some patients who may be very active and in sharing this information with them about the rupture rates, about weighing the relative risks and benefits of that versus surgery, and for even some of the older patients in their 60s and 70s who are very active to make a decision together.  And again, hopefully this information helps not just in terms of the surgeon educating the patient, but for the patient to feel that this is the best decision for themselves.  And I think the expectation that I often set is that regardless really of surgery or no surgery, perhaps yes, surgery may give you better strength, particularly if you may be participating in activities or sports that require that higher degree of push-off strength or achieving like very rapid plantar flexion and the strength to do that.  But that may or may not mean that everybody needs that particular function to benefit from an acute Achilles tendon repair. And whether it's surgery or no surgery, I always inform patients that the recovery period is still long, whether it's from the wound healing and then the rehabilitation that goes into it.  Perfect. Thank you. And so we'll go to our next speaker. So Dr. Martin O'Malley from the Hospital for Special Surgery. He's had a long day of Achilles surgery, so he will lighten us on how he fixes it and some of the decision-making things that he considers in doing so.  Great. Can you see my slides? Yes. Perfect.  How that worked. Thank you very much for having me. And it was a wake this time of night on the East Coast. I commend you for your efforts. That's my disclosures. I'm going to start just by talking how we diagnose Achilles tendon ruptures. We don't really need an MRI.  It's been shown by the Academy and also by Steve Rankin that if you have a positive Thompson test, decreased tension, and palpable defect, you can diagnose your Achilles. It's about 100% sensitive. The MRIs are often very confusing and unnecessary.  So Turner did a great job on this. MRI assessment is a generation of tendon Achilles ruptures. Often in a completely normal 27-year-old with ruptured Achilles, the MRIs don't look very good. And so I think that the problem with getting an MRI is it really delays things.  So one of my first points is if surgery for Achilles tendon has better outcomes and lower adverse events in the first 48 hours, in Rankin's study, if you got an MRI, it took you 12 days to get an operation. If you get an MRI, it's 5.6 days. And so the faster you get it, I think the better results you have.  And so for me, if you call my office and you ruptured your Achilles tendon, I say, don't eat. We don't need an MRI. Come in. I try and fix it the same day. I treat these, not like rushing the emergency room, but I try and get them within 48 hours. And I think that that is probably one of the reasons I'm having success with, I'll show you what I do for these patients.  So again, the non-operative treatment, I did a great job. I learned a lot about some of the studies I forgot about, but basically it's a high re-rupture. We don't need to go into that. But the way I look at patients, is there any role for non-operative treatment? It goes back to your expectations or requirements.  This is my son getting in college, getting a header. He expects to be back fully if he ruptures Achilles tendon, and basically to play his position, it's required. This is me doing a layup. If I rupture my Achilles, it probably doesn't matter. We've done some very strict analysis. It's shown my vertical leap is 11.6 inches. If I lose 10 to 15%, I'm still above the average 50 to 59 year old. I'm 63. So I'm still above average. I just get back to average.  So it probably doesn't make a difference how I treat mine. And I would actually consider non-operative treatment for mine because I would get back faster to work. I don't want to go to the operating room. And it's not going to affect my athletic career.  So what are our choices? It's open, PARs, and Speedbridge. Speedbridge is the Aaron Rodgers we all know that's in the news. I'm sure everyone's just getting questions about this for the past two months. So no matter what your treatment is, you want to restore the muscle tendon integrity and the resting tension. It's all about the tension. Because your forced tension relationship will allow your muscle mass return to normal and get your pre-injury level activity. Of course, avoid complication.  So you don't want to get past on the Brooks curve. You don't have a stretched out Achilles tendon. And that's all I talk about when I see a patient. We know the resting angle relates to tendon length and function. When you're in my office, if you ruptured your Achilles, I saw four patients today, they all got on their stomach first thing. And they know they have to go on their stomach and bend their knee. And we look at their tension.  We know that even if you put yourself in a cast and with little radio symmetric beads and a cast non-weight bearing, you're still stretched out 16 millimeters. So this is the big concern. And the greatest length is between two and six weeks. It's the stretch out. That's all I talk about patients. I talk about your tension. Because at three months, if you're stretched out like this guy, it doesn't tighten up. It's not good. If you're stretched out at three months, and that's the problem with the therapist, I got all their motion back. I don't want their motion back that early.  I want to keep them tight to eight to 10 weeks. So let's talk about surgery. Open PAR Speed Bridge. People are still doing open surgery. Curt Cousins had open surgery. Jalen Phillips had more traditional. Now it's called more traditional surgery because of the Speed Bridge stuff. He values me back stronger than ever. The pros allows direct and most secure construct and tightness to the repair. Well, tightness to the repair is paramount for a good result. Really safe range of motion. It minimizes the stretch out, which everyone does.  It can visualize a certain nerve. And I think repairing the peritoneum is really important. And I think the peritoneum is easiest to repair in the first couple of days. The con, of course, is open incision, longer operation, and potentially more wound complication.  The only thing you can predict of heel height that you can control are really the tightness of repair. And that's what everyone doesn't like at the end. They can't get up on their heel. You can't do anything about a patient's age, but you can make it tight.  So you set your tension. Here's a 28-year-old NBA guy. This is his Achilles. This is his MRI, which you see had a complete rupture. This is his second section, and this is his other Achilles. We don't miss this with any sort of minimally invasive technique. We open it up. We just make it tighter than the opposite side. And if it's not tighter than the opposite side, we take the whole thing down and redo it.  So my technique, I stay medial, take time to develop the peritoneum. I use two Keith needles. I do a locked bunnel with a number two orthocord. I don't grab the tendon with a Alice cramp. I use a zero-vicral. I prep the other leg, and I make sure it's tight on the opposite side. I look at inversion and plantar flexion. And then I do an epitoneum stitch.  So all this is sort of based on reading. It's based on 30 years of doing this. You stay medial because this lateral branch of the peritoneal artery has a great blood supply to the area, right? So this is where you wanna make your incision right in here.  We know other people have made it on the outside. This can get this from the internet, from Kobe Bryant. You have a long lateral incision.  I go medial, I develop the peritoneum. So I spend a few minutes, I just make my skin incision and I develop the peritoneum. Once I have the peritoneum, then I open it,  it looks like this. It protects my sutures wherever I put inside and gives me a good gliding layer on top of it and actually brings more blood supply to the repair.  So here's the peritoneum. This is, those last two guys were both NFL guys. This is the peritoneum, this is the tendon. And then this is after I close it. So it feels so much better  after you close that peritoneum. Again, I'd use the zero grasping sutures. I use these two Keith needles, do a locked bunnel. Get it on this side, grab the other side,  I do my epitoneum stitch and so when I'm done, this is what my tendon looks like. I've taken this mass of this nonsense, made it look nice like a tendon  and then repaired the epitoneum over it and closing this. And so I think this is really probably my responsible for my really low infection rate of open surgery.  So this is afterwards, this is how tight we make it. This is hot off the presses from five o'clock today. So the epitoneum stitch clearly increases your strength,  average load by 119%. So you can either do just a running one. It seems to be a little stronger if you do this locked epitoneum cross stitch.  Again, so you have to think about an open repair. You make your primary repair, then you do your epitoneum stitch, then you do peritoneum and then you do your skin.  So whether you do PRP or BMAC is optional. The data is a little bit suspect. A lot of people request it. The data is not in any clinical trials shown to really be effective.  There's some animal studies that show it could be effective. So this is what it should look like. My incisions should stay medial. I think doing an open technique  prevents it from bunching up.  I think it allows me to set the tension. And this guy's three months post-op. It looks like a tendon. So that's my technique, open traditional surgery  and doing the peritoneum and the epitoneum stitch. Okay, so now the PARs. So I was a PARs guy for about a year. I trust Dr. Anderson implicitly. He was doing PARs.  I was like the last guy to jump on the PARs bandwagon. So PARs is a smaller incision. Okay, everyone likes it. It's slick. You don't make a big incision.  And all you need is one incision like this, one guy to roll into your office like this, and you'll never not do a PARs again in your life.  When you see one guy who's had an open procedure that's gone south. This is a 20-year-old football player who had an Achilles rupture, and they sat on it, it just got infected.  So if you look at the data, I think the best data comparing PARs to open is out of Charlotte. It's four or five really talented foot and ankle guys.  And they found that treated with PARs, they returned to baseline activities by five months compared to the open group. They're a little quicker.  But overall, the complication rate was the same with no re-ruptures. In most of the patients, 88% returned to baseline activities by five months.  And if you look at the complications of open versus PARs, and these are big numbers, it didn't really make a difference. Maybe a little superficial wound in his sense,  but re-ruptures zero in both groups. They had a re-operation of foreign body to fiber wiring to the patients in the PARs group.  So that's a 2%. And one and a half patients or two patients with a deep infection. But overall, complication rate's slightly high, but not really significant.  So the problem with the PARs and the problem with adenomyelin-based, and this is what Tom Clanton really showed, was that they have a tendency to stretch out.  So if they're gonna stretch out a little bit more, you probably have to protect them a little bit longer. So my whole thing is tension, and stretching out in the Achilles tendon.  And that's in the first six to eight weeks.  So if I'm doing a PARs technique, I was always worried about how fast I could push it. So then I had my aha moment, which changed my life. I would start to get these guys  with these red areas after a PARs procedure. And this is pictures from Dr. Anderson's article, and you see how the Achilles is kind of red and brawny around that incision.  So I had three or four of these guys in my first few of it. I converted about half my PARs to an open procedure because I felt like I couldn't get the tension.  I would do the tension, I would compare to the other side, and it wasn't tight enough. And I was like, all right, I gotta make it tighter.  I can't start to have it a little stretched out. So I would just, I'd make my PARs incision longitudinally so I could open it if I needed to.  But I would get these guys who'd come in in like three or four weeks, and it'd be red and swollen, and if it was infected or not infected.  And then, so that got me some concern. And then I had a couple of guys. Here's an NFL lineman who's seven or eight weeks post-op,  just walking after his PARs, felt a pop, tension's off.  Here he is after his PARs right here. He returned in 10 months with a hamstring graft, but that was one. Two months later, another guy, six, three, 270 pounds,  NFL edge rusher, felt a pop, big hole from the PARs.  He got a hamstring graft, he returned back too. So I had a couple of guys in a row with doing this. Then I have a 31-year-old pro hockey player. This is his red area.  I didn't do the PARs, but it stayed red, stayed swollen.  Everyone told him he was fine. Went back, second game back, grabbed his Achilles, re-ruptured. There he is.  He needed a graft after that. So then I had my dentist. My dentist had all this swelling. He's a healthy 28-year-old guy. He calls me from the E.L. in South Hampton.  He was jogging on the beach. Sends me this picture on the phone. He had an open re-rupture. You see all this briny induration he got? And I think it's because when you do the PARs,  you lock these sutures under there. And we don't know who's gonna make a reaction to the fibro wire. We know people do make reaction to the fibro wire.  So he reopened right through the skin. And there's been a couple of other cases of this report of going back through there. So once you get that, then I said, okay, I'm done.  I've never had anything like that with an open procedure. So I stopped doing the PARs because of this. So my experience, I didn't feel like the PARs  were gonna get the tension right half the time. The soft tissue reaction and the fibro wire just killed me for months and months and months.  I think the contour of the tendon, you bunch it up. You can't make it thin like a nice tendon. Serial nerve injury. I did one serial nerve injury, my second patient.  It's not as strong, so it can get more elongation. So I couldn't really find an advantage for the PARs because the wound complication rate was the same as the old open.  I can make an open incision tighter.  And I can rehab them faster. So now we go to the mid-substance speed bridge, the Aaron Rodgers.  This is the technique where we use the PARs device to go approximately, and then we pass some suture lasses and do anchors into the heel.  And then, I mean, this is a stable construct.  So anchors and calcaneus is clearly more secure fixation. It's a small incision. The cons of this are we're really stress shielding the repair site.  We know the tendon likes a little bit of motion, a little bit of stress to heal. But if you have the fiber tapes on either side, are you really stress shielding that area?  And I called Arthrex. I called Dr. Ella Trash too. I said, can anyone give me some data on mid-substance Achilles tendon ruptures with the speed bridge device?  Couldn't get anything. Arthrex gave me a couple knotless techniques  for this to do it. They gave me Arthrex research developed that was as strong as the crack out, maybe a little stronger, but there's no clinical studies on it, right?  So Roger's had a surgery. This is three weeks post-op. He's doing it. I mean, we're watching this thing. I'm in New York, so I get to watch this every day, that him doing this.  And he had the speed bridge procedure. He's using high levels of curcumin, which I don't even know what that was. High levels of collagen and drinking freaking bone broth  every single day. So this is what all my patients are doing now.  This is curcumin. It's sort of like turmeric, a powerful anti-inflammatory agent.  And this is his theory. This is his words.  The risk is re-tearing his Achilles again. Instead of trying to clear obstacles, he'd do them in a more conservative level. He'd have to wait eight months for a training camp.  So he says, if I re-rupture, I can just go and re-fix it the other way. But we all know once you rupture your Achilles tendon a second time, it's never the same.  It's hard to get an elite athlete back after the first time. With a re-rupture, it's really difficult. So he's supposed to be medically cleared by Christmas Eve,  which would make him just about three and a half months from the Achilles. So, pros. For the mid-substance speed bridge, accelerated recovery. This may be a giant step forward  in operative treatment of Achilles tendons. It may be perfect for me. Like a 63-year-old guy who just wants to get back to work faster, and I can get out of a boot faster,  and I can control my plantar flexion. This may be the people, we should do a bunch of studies on older patients with this technique. First, the cons is the instrument in the heel.  We've all done these fiber, these swivel locks in the heel for Haglunds. I have so much edema in the calcaneus from those swivel locks,  it scares me to put the swivel locks in the heel. And then the other thing is you're setting the tension. So if I'm not setting the tension on mine,  I'm setting the tension on my tendon. If I'm setting the tension with the speed bridge, am I setting the sutures? What am I doing with this tension on the tendon? I have no idea.  I'm just setting those suture tape.  So we think it could stress shield it. I'm a little bit worried about the subcutaneous nature. And again, there's no data. And then of course, I have this.  23 year old, the same day as Ann Rogers, she ruptures her Achilles and Boseman. She gets an infection. They wash her out a couple of times. They take the anchors out of her heel.  She's infected in her heel. She got osteomyelitis, a re-rupture, a VAC device, and this is what she rolls in. So this was completely unavoidable. She had a mid-substance rupture.  Part device, no problem, anyone wants to do that. If I have a PARS device, I would just go a little slower for her. You know, if she wanted to do a PARS device, fine.  I think that's fine. We just be a little careful about the rehab. This, to put anchors in the heel, just adds a whole number of complexity, either from potential infection  and also just from pain in the heel. So everyone asks me, how did Kevin Durant beat the worst injury in basketball? This was not MIS surgery. This was a long incision.  You know, we have an MRI beforehand. There's some degeneration up and down, so you gotta double down on that. We have a series of AMPO braces. He was casted for three days,  and he started plantar flexion exercises at three days, so he worked that calf right away. He had a secure repair. We zoomed every other day. That's a medial incision.  Doesn't look that much different than the other side, just a little bit thicker.  Here's his first game back.  I don't know if you can see it. Seems to be working pretty well, even on the slip. I thought he redid it. Here's another, here's a soccer player. Open procedure.  This is at five months.  And here he is, we did his right Achilles. This is right before he went out in the training room.  So a five to six month timeframe is not that unreasonable for an open repair.  Yep.  And here's another guy, nine months. Just nine months and two days after an open repair.  And I think that's a reasonable timeframe to return to sports.  So open surgery, I stayed medial for the blood supply. I value the peritoneum. I think the peritoneum has made my infection rate lower than normal.  I've had one infection in 30 years on an open procedure,  besides the PARS one that opened that way. Locke-Bonell, I think the orthocord is a little bit more friendly than the fibro-ward. The epitene on the stitch, I think helps.  It helps contour the tendon. I make it tighter than the opposite side. You can't make it too tight. There's no Achilles tendon that I've ever seen  has been repaired primarily that's too tight. I think the PARS is a viable alternative, but in my hands, when I was doing it, I couldn't really set the tension very well.  That bothered me. Complication rates was the same as the open procedure, so I didn't see an advantage. And then I had the one guy with the open repair.  The speed bridge, it may be the new frontier, but we need some data on it. I'm worried about the suture tape. I'm worried about putting swivel locks in someone's calcaneus,  but maybe the answer for a fast return. Again, I don't try and get anyone to neutral to eight weeks. I just work with plantar flexion the whole time. They just, plantar flexion.  They work on end range plantar flexion the entire time, from the time they come out of the cast. And again, just a word of the wise, don't hesitate pre and post-op ultrasound,  if you're worried about their calf, because DVT rates are high. We get DVTs all the time in Achilles. We have 14 people doing foot and ankle here.  Every month at M&M, there's a DVT for Achilles. So I'll leave you on a good note. Here's my kid, 20-year-old college football player. This is, he's been dealing with this a year.  He comes in with pus straight out of there. He was on SportsCenter three days before catching a touchdown. This is a guy who's just powering through it. Got a big washout.  Then he got a propeller flap, which I had never even heard of. And we took, we cleaned him up, we vac'd him. They did a propeller flap, did like this. We put an FHL underneath it.  Scored two touchdowns this year. He's not playing much, but he scored two touchdowns. So if you get in trouble, find a plastic surgeon knows how to do a propeller flap.  I'd never even heard of one. This is my pearl for the night.  Thank you, happy holidays from my family to you guys. Thanks for listening.  Awesome. Thank you, O'Malley. Quick question for you. Someone in the chat asked, in terms of more proximal ruptures, like a myotendinous rupture in an elite athlete,  do you try to go after that? Or, I mean, the general dogma is always sort of let that heal, but is that something you go after? What are your thoughts on that?  Well, it's hard because some of these guys' calves are so big. So the ones that are like, some of them are 12 centimeters above the insertion. So I think that, for me,  that eliminates any PARs device, right? Because you just can't get it around the muscle. So I still probably would go after it.  Elite athlete, I would still go up and high and fix it, fix them in all of them. I mean, it is rare for an elite athlete not to want their Achilles tendon fixed.  And if you look at the data, the data is, you know, they're 240 degrees at plantar flexion strength. They need everything they can get. Do you feel it's a satisfying though?  Can you, you know, in terms of what you grab? I can still get the tension set. If I get the tension set compared to the opposite side, then I'm happy. Okay.  And then one other question in terms of, do you use any incisional wound vacs or TXA, anything like that in terms of- We started to use TXA the last year.  I don't use the incisional wound vac. It's not against it. I just don't use it. I haven't needed to use it unless, I would use it if I had like a little questionable closure.  Awesome. Thank you, sir. So for the next talk, we're going to have Dr. Lou Schoen over out of Mercy as well as NYU, talk about kind of chronic Achilles tendinopathy  as well as, you know, revision or salvage surgery. And it was a great kind of end to Dr. O'Malley's talk there to introduce us here.  All right. Can you hear me? Yes, sir. Perfect. Okay. So we're going to go through this faster than O'Malley. So we got a lot of things to cover with the chronic Achilles tendon.  Here are my disclosures. The only thing really relevant is I am a co-inventor of the Prostop for Arthrex, which makes the PARDS and other products.  So with the chronic Achilles tendon disorders, we have both mechanical problems, like tension and compression and shear, as well as biological stresses. What's going on?  Why are these things not healing? What's going on molecularly, cellularly? What's up with the tissue? Is there stuff going on systemically?  So the mechanical stress is like for here, there's a chronic Achilles tendon problem. We see we have an insertional tendinopathy and this guy actually ruptured,  but he ruptured as a result of degeneration. He had his rubbing on the shoe going on and then this thing popped. Now that's a combination of mechanical and biologic.  Here's a case of insertional tendinopathy. And you can see on this MRI that that Achilles tendon starts to degenerate. It's got fibrosis. It's got changes at the insertion.  Now that's still an intact tendon, but then we have this tendon and this is a chronic tendinopathy with rupture. And here you can see the loss of tension of the tendon.  And this is a very different case than the one I just showed you where the tendon was degenerative, but intact. So like Marty said, when we have a patient that has a tendinopathy,  it's one thing if he has good tension versus one with bad tension. Same thing with the chronic, the acute stuff with repair. You want to keep that tension maximum.  So if you've got tension, you're going to win. If you don't have tension, you're going to lose. If you don't have tension, you have to do something mechanically  to restore the tension. And in this case, you have to operate, reconnect the tendon ends. You just can't treat the biological issue here that caused it to fail.  So here's an issue with a chronic tendon with a rupture. It's going to be stretched out. As you can see, they have way more dorsiflexion than the other side and it's weak.  That is a losing proposition mechanically.  Different than something where, again, you just have a stretched tendon that's unhappy and weak because it's painful, but it has good tension.  The biologic stress, that's a whole nother lecture, but basically here's a tendon from our lab, from someone with a tendinopathy.  You can see that there is some cellular infiltration. There is derangement of the collagen. There is some fibrillations of the tendon and there's space between the tendon fibers.  And here, this is a normal tendon with the kind of solid appearance of the collagen fibers. Again, tendinopathy. So when we have tendinopathy and we have chronic situation,  we've got to think likewise with the treatment of non-operative stuff and operative stuff. And also in those categories, mechanical and biological, mechanical and biological.  Both those elements are important to address. And if you're planting a tree, you're gonna put the tree in the ground, make a nice big hole, put the root ball in,  put a nice stake, rope that thing up, give it plenty of water and fertilizer. That's the mechanical and the biologic together. That's what we're gonna do for the tendon.  So always think boot's gonna be important. You gotta keep it the conditioning. I like what Marty said about keeping him in plantar flexion for six weeks.  I do six weeks, he does eight weeks, but keeping him down, don't stretch it out, let it heal up and then you can stretch it out. Use your boot to protect you  and do a range of motion and extend the stretching, avoiding that overstretching position. Now, in a chronic case, I'm not gonna get into this in great detail,  but shockwave can be done. If you have a tendon that's not stretched out, this is a study that we did that won the Goldner Award. And this is some more recent studies  on extracorporeal shockwave musculotendinous disorders. And it can be helpful to improve a tendinopathy that's chronic, that's due to a biologic failure,  less so than a mechanical failure. The more stretching that you get, the more likely that's not gonna work.  Now, PRP is also something, there's lots of literature on it. It's been sometimes, I think it's about 80% effective in non-insertional cases.  In insertional cases, I think it's about 50% at best. And again, the bigger the heel, the bigger the mechanical problem, even less effective  because you have mechanical things. These were studies that were done. This was one that was in favor of Achilles tendinopathy treated with PRP, partial teres, Monto, 30 patients,  and there's a lot of these retrospective studies that show good results. This was a study, Voss and Jama, that killed PRP from a insurance point of view.  They did a double blind study. They had 54 patients, patients came off the street. They got eccentric stretching and PRP for Achilles tendinopathy in one group  and the other group got eccentric stretching and saline. No boot brace, they were being stretched like crazy. And guess what? No difference, of course not. So that killed it.  But people still do it because it works and you're avoiding a surgery in a chronic case. Now, I took it another level after Hernigo's study  that showed bone marrow can be very useful in non-units of the tibia in J.B. Jess in 2005. I started to think about it, doing it for tendons. So I started to do it in certain cases.  And this is a study, Eric Tan was a co-author, which is probably why it is a credible study. But here we are taking the bone marrow, concentrating it.  Here is the bone marrow being harvested. And we do multiple trajectories so that we get a high concentration of the cells. And then the cells, which is not just MSCs  are then injected into the tendon. And then we treat them with appropriate rest and progressively increase them. And we had really nice results with less pain, no adverse effects.  And patients had statistically improvement in their VSS and functional score. We did another study, again, the famous Dr. Tan on this. I'm not sure if he's here still, but he's,  but anyway, other people are here on the study, but basically 15 patients, different group of patients with a very nice results with bone marrow instead of PRP.  Very different because in the PRP, you just have platelets and in the bone marrow, you have cells as well as the platelets. So for insertional problems, if that everything fails,  the old way we used to do it was a central midline incision. You went in, you took down the heel bone, you debrided the tendon, and then you took that down, reattached the tendon  and then you reattached it. That's what we used to do. Now, if they had more chronic tendinopathy, proximally, not just at the insertion, then we were doing this procedure.  And again, this is the old way. And we did a study on this in JBGS, Dr. Guyton and myself, a prospective study. And here we're doing a resection of the heel  and we're taking the FHL behind the ankle, pulling that in and attaching that as well. And these are for the patient with tendinopathy  that went above the calcaneus, not just at the insertion, but a more diffuse tendinopathic process  in addition to the insertional problem, they had a more diffuse tendinopathic process. So they got the FHL and that's it going into the bone. You got to tighten it down.  You got to make it appropriately tight because you want to tension it so that you don't over-restrict it because your Achilles tendon is going to be tensioned as well.  So you've got to do a little balancing game. But as Dr. O'Malley says, you want to make it tight, but you don't, I think you can make it too tight,  but you want to go about five to 10 degrees more than the other side is my rule of thumb. And many people agree with that. And then we're now reattaching with an anchor  the Achilles tendon. And this was the study in JBJS, which demonstrated in 46 patients prospectively  excellent scores and function. That was the study. You could look it up. Here was my group that did the study. That's been done by other people.  Ken Hunt did a randomized prospective study as well. It was an FAI and not in JBJS. I'm not saying that that's not significant, but it's 39 patients with FHL Achilles debridement  and had really nice results. That was the old way. Then I had looked at the FHL problem, FHL, and I said, is there a problem if we take the FHL?  Well, if it's one of the high-performance athletes, it's going to be a problem because they missed their big toe push-off. So I didn't do it for those patients. I did the FDL.  And that's after this study where we found in this JBJS study that about a third of the patients had some minor problems with their FHL.  None of them were really regretting having their FHL, but some of them couldn't wear tongs. Some of them had a push-off weakness. Some of them had trouble climbing a ladder,  but they were still much better. So they were very happy. But then I started doing the FDL because it wasn't going to sacrifice a FHL,  which is more critical. It's like the most critical tendon in the foot outside of the Achilles tendon, especially for a running and cutting athlete. So I figured let's do the FDL,  not just in the athletes, but with everybody. And this is a study that we did, again, Eric Tan. I don't know how he gets in these papers. He must've worked hard at some point.  But anyway, this was in 2019, FDL transfer for Achilles tendinopathy. And we had a very nice series of patients with excellent results with the tendon transfer with the FDL  and no functional limitations from it. So here we are doing it a little bit more minimally invasive. You pick up the FDL here, you pick it up over here, you pull it out.  Once you've found it over here, usually that's about 10, 11 centimeters above it. We've isolated it. We cut it distally.  We then pull it out. We're going to run it superficial to the retinaculum, not in the retinaculum. You're going to do it above the area of the tarsal tunnel.  And you have to do a high incision here because you don't want to crisscross the tarsal tunnel and compress it. And then we've done the debris month here,  and it's done medially instead of posteriorly. So the patient doesn't have to be prone. They're supine with a little extra rotation. We take that down from the medial approach,  debride the Achilles, take down the calcaneus, reattach the Achilles to the calcaneus and the FDL. And then post-op, I'm keeping them in Aquinas. I let them walk on it at two weeks,  depending on their overall quality of health. But generally you could do it at two weeks. Some people we wait a little bit longer. We're going to keep them in Aquinas for six weeks.  Now, what about the non-insertional Achilles tendonitis? What's the operative treatment? There's a lot of different ways to do this. I'm going to cover it as quickly as I can.  This is the old way we used to do it for chronic failed cases. We'd open it, release the paratenon, and that could be good. If they have more degenerative tendon,  we would take out pieces of the tendon. And that was good, but it was destructive. Mufuli had this technique where he did these linear cuts in the Achilles tendon  and cut them as he moved the tendon up and down. I call it a biologicoplasty, and that did work in cases. But I did one case, Meyerson did a bunch of cases.  We were both not very happy, and you do run at risk of having the seromer of cut. Another thing you could do for the non-insertional Achilles tendonitis  and some Achilles insertional tendonitis, if they don't have a big bump, is do a gastric release. And here's several studies in the literature  showing good results doing a gastric release if you feel you have an overly tight Achilles tendon, which is definitely a different problem  than having somebody with one that's slack. So this is someone's tight, chronic overpull of the Achilles tendon. You can do the gastric release. I don't do it.  I'd like to hear what the other experts on our panel have to say about this. But here's another study more recently out of Holly Johnson did this. I don't know if this was done  while she was at special surgery or in Boston, but basically this is a release of the gastric for insertional Achilles tendonitis showing some nice results.  You can also do an endoscopic debridement if you have a non-insertional tendonitis. And I've been doing this more and more. I think it adds value  because you could release the tendon,  peritoneum around it and kind of freshen up the tendon a bit. And then I inject them in BMAC. And this is my partner in NYU, Dr. John Kennedy,  the master of needle arthroscopy in the office. He's doing the tendoscopy and has some nice results with it. That if I have a patient that has more disease, I tend to open them up.  And this is a patient I did a debridement, took the FDL and passed the FDL to the calcaneus and attached it. And then I always augment with BMAC. As Dr. O'Malley said,  there's no absolute literature on this. It's good animal studies. We do it because we feel the biology makes sense and patients do request it, but I feel it does help.  And we've had cases where we did treatment with just BMAC alone, as you saw, where they got better 90% of the time. So here's a case with a chronic degeneration,  overstretched tendon. We get in there, there's a gap. Now I'm gonna repair the tendon and here I am repairing it after debriding. And this is a chronic case  and you see I'm now pulling it down and it is way too tight. I can't get that thing closed. So I've got a gap of about two to three centimeters and that's the ideal case for a V-Y.  And here I'm doing a V-Y and keeping that muscle belly intact here. And then I could do my reconnection here with a modified cracker sutures, four strands crossing the site.  And then I've got this V here and then I'm gonna close that V once I get the tension, usually about five degrees more than the other side. And then I stitch that up as well.  That's the V-Y. And there's some nice studies looking at, this is from Cesar Donato and a former fellow, but he did this when he was in Alabama  and basically showed that this approach can be just as good as the FHL transfer. So again, if you have that stretched out tendon and you can't close it,  I think this is a good way to do it, but I would still tend to augment that with an FDL and not just rely on the V-Y alone. This is a study looking at operative management  for insertion tendinopathies in young versus elderly. And basically shows that chronic cases generally do well with surgery and operative intervention is still valuable.  This is now a case where we have a chronic case. This is now about four months out, huge void. What do we do? We've got two centimeters with the old one.  This now is a six centimeter void. So what do you do with this? Generally, I'm doing a FHL or an FDL transfer in conjunction with the turndown  because I want to reconnect the gastroc soleus to something distally. Here I'm doing a turndown central peel and I'm going to flip that from posterior to anterior  and then run that into the Achilles tendon. Again, looking at the tension, about 10 degrees difference from side to side. You could do the tendon transfer with an FHL or FDL.  If you want a long tendon, you could take it from the arch of the foot. You don't have to take it from the medial aspect of the ankle where it's shorter.  If you want a longer tendon, you'd go into the arch of the foot. That's another way to do it. Usually I do it at the medial ankle.  Here's that case that I showed earlier in the talk. She's got a stretched out tendon. She was treated conservatively after a rupture over a year and a half.  She was equestrian, she couldn't function, really stretched out tendon. Here's the tendon, just totally lax. Here I'm going to close it and re-tension it.  So I had tissue to work with. And then once I had that re-tension, she had to get into a dorsiflexion position because she's an equestrian. So I don't want to over tighten her  or she can't get her heels down. And there I am getting the FDL, picking that up and then attaching that FDL to the medial side of the heel  in addition to my reconnection of the tendon. And she went back to equestrian skills.  So in conclusion, I augment everything with BMAC because it's biology. I think it's the best thing we got and way better than PRP. And then for the mechanical problems,  you got to address the mechanical problems as I showed you with the array of procedures. Thank you so much, happy holidays. Dr. Sheldon, quick question before we move on.  In terms of when you get the BMAC or PRP or whatnot, do you inject it into the tendon, around the tendon?  Where do you put it? For the cases where I'm not gonna be doing anything surgically and I'm just treating them alone, chronic tendonitis, I go in with the needle,  I'll do multiple trajectories through multiple puncture holes. So if it's like an area of five centimeters, that's usually bad. I'm doing two, three or four puncture holes.  And through those puncture holes with a 22 gauge needle, I'm doing multiple trajectories into and around the tendon. So they may end up with a five centimeter area,  say three puncture holes. And then through those puncture holes, about seven to eight trajectories through those puncture holes. Perfect, all right, thank you.  And I wanna leave enough time for Dr. Waldrop. So Dr. Norman Waldrop out of the Andrew Sports Medicine Orthopedic Center, kind of talking about really, you know, Achilles rehab.  Really, you know, just the question of how fast is too fast? What are the things we've learned? You know, he brings a lot of, you know, his athletes back pretty quickly.  And so just kind of his considerations with that. So Dr. Waldrop.  All right, I'm having trouble naturally  sharing my screen. While we're doing that, so you struggle with that, but let's ask some more questions. Bonnie, you're out there in the real world, okay?  Well, you got a patient with chronic Achilles tendinopathy and they're not stretched out and they failed to boot brace. What's your next move, Bonnie?  More non-operative management options or going to surgery?  They've done everything non-operatively, pretty much. The only thing, they haven't done bone marrow. They've done PRP, they did shockwave, did boot. It's been over a year.  Not stretched out.  So I would get an MRI first and take what things look like. And I think as much, many gray or white hairs  as everybody else on this panel. But I think from the ones that I've seen, it's often hard to directly correlate with imaging. A lot of it depends on kind of what you see  in vivo and real life. So if it's not stretched out and the tendon substance just looks unhealthy, I think Dr. Shum mentioned some of the debridement of the tendon that you can do,  depends on kind of how much of the tendon, like both the quality and the quantity of the tendon that's involved. If it's not that much,  like some of the numbers that are thrown out are like 50%, then you might just debride that tendon and leave it alone. And you can add your organs if you'd like,  or biologics that you like. And then if it's a bit more, then it's consideration of some of the tendon transfers that you mentioned, whether FHL, FDL,  or in some cases, if it's wanting to add more collagen,  then you can also consider, if you don't want to sacrifice some of the native tendons and do an autologous tendon transfer, that you can consider adding allograft.  And then I think as the void, if it's within a certain limit, then you can do VY, you can do the turndown. But I think allograft is another option  that we could add to the discussion as well. Yeah, I agree. Allograft is definitely part of the, if I can't do a turndown or I can't do a VY, I'm gonna allograft it.  Eric, same question to you. You're more seasoned with that. Let me pass real quick. I didn't hear the question, actually. I'm just- Okay, nevermind. Let me go to Marty.  I'm just, I'm looking to stall. Marty. Thank you. I'm good. I'm good now. Let me see. I got the talk here. Let's, let me get it done. Hamstrings. I take a lot of hamstrings.  Autogenous hamstring. Yep. I hate the allograft. I just took one out tonight, a woman who was in the Olympics in Paris, in the Paris, no, the West, Tokyo Olympics.  Achilles, kind of a chronic big area. She didn't want her hamstrings. She didn't want her toe tendon because she's a shot putter. I put an allograft in her five months ago.  It has been swollen the entire time with an effusion or other thing. We aspirated it twice, no infection. So I was doing today. I just took it out.  It looked like I just put the hamstring in. Look, I just put the allograft in. She's had an immune response to it. So I had that about 10 years ago and I swore off allografts.  So I went to, I go to hamstrings all the time. It's hard not to, for us to take your hamstring. I've gotten pretty good at it.  First, it was kind of anxiety provoking, but I've taken over a hundred hamstrings for different, you know, Achilles tendon type things now. We use it for Achilles,  we use it for perineals routinely, bad perineal tendons.  Sorry about that. And I don't know why it's doing it, but we will find a way to make this work. So I'm going to talk a little bit about Achilles rehabilitation.  You know, what's too fast, what's too slow. And that's obviously a very hot topic these days. Next slide has my disclosures on it. These are my disclosures. Next slide.  So obviously, as we've mentioned, the Aaron Rodgers cases has become front page news for the past several months. And it's, you know, this isn't just new.  It's not a new topic for debate, but it certainly brought it to the forefront and brought about a lot of questions for me personally in clinic.  And I know it's for everybody else, you know, is there a way for us to quicken the process? You know, are we tempting biology by doing this?  Or are there ways that technology can help us maybe overcome that biology? And these are kind of questions that this case in particular has brought up. Next slide.  Dr. O'Malley showed this earlier, but I think this study is interesting. It was published three years ago in KSSTA, but repair within the first 48 hours  achieved better biomechanical and histologic outcomes. And I think that's really important. And not just the repair allow us to get us better repair,  but the better biomechanical and histological advantages we have, perhaps the quicker we can rehab them and the better we can do in our treatment post-operatively. Next slide.  So what's traditional rehabilitation? Generally speaking in the past in the literature, and that's taking a whole lot of studies and putting them into one,  it generally referred to some type of plantar flexion casting a treatment of medium to long-term non-weight bearing often four to six weeks, sometimes even longer,  protected weight bearing in a cam boot following that period of non-weight bearing using heel lifts and our unexpected return to full activity of eight to 12 months.  Sometimes that traditional mode of treatment can lead to a more prolonged recovery from the patient. Sometimes that's a good thing, sometimes not necessary,  can lead to a 10 to 30% reduction in the calf strength and calf circumference can differ back to 25%. And if you have a 25% difference in calf circumference,  that tends to be a cosmetic issue and one that's noticeable to other people. Next slide.  So what about accelerated rehabilitation? It's certainly been a hot topic across all boards in most everything we do. And generally that refers to a program with early mobilization.  It's progressive weight bearing over four weeks. We begin an early motion program. Generally that requires limiting dorsiflexion  with some kind of stop, but allowing tendon excursion. And I think that's really important in the healing process and strengthening earlier in the process.  And ultimately the earlier we strengthen, if we strengthen appropriately, that can mitigate long-term strength losses. Next slide.  So collagen healing, much of what we look at when we go through these rehab programs is trying to get better organized healing. And that's been shown through various studies.  And the basic science of this is really important. If you have motion, it more mimics the normal healing. Next slide.  So the basic science of that is important to think about when we're rehabbing a patient. Mechanical stimulation early on improves tendon repair  and it allows for better collagen organization that decreases muscle atrophy, has a chance to decrease our stiffness, less rate of adhesions. They're all decreased with early motion  and weight bearing. Next slide.  So what is functional rehabilitation? I see that buzzword all the time, but it's really hard to find a good definition for it. If you just go Google it,  it's very difficult to find what a good definition is. And generally it's inconsistent across the board  when looking it up. It's basically considered early range of motion protocols with controlled weight bearing for improved healing and tendon organization,  just like we were talking about. But what does that mean? It's hard to know because there are not really any standardized protocols across the literature. Next slide.  So we talked about this Willett study and I think this was a landmark study in JBJS. This was the Canadian study that really changed the way a lot of people thought  about the Achilles tendon rupture and sort of brought about that, hey, can we treat these non-operatively? It was a multi-center randomized controlled trial.  And essentially it looked at early weight bearing with functional non-operative treatment. And it basically showed you can increase the strength  without significantly increasing the risk of re-rupture. Next slide.  Next slide.  So in the group out of, I believe they're out of Detroit,  looked at a comparison of tendon lengthening and Marty mentioned this in his talk, but all tendons had lengthening in this study. And I thought that was very interesting  that they all lengthened and most commonly between weeks two and six. And that is a critical period when we're undergoing our rehab process.  That dropped off significantly after six weeks. There was no difference found between the rehab techniques, whether we used a more traditional  versus a more accelerated early weight bearing early motion, but we did see the lengthening at two to six weeks, but we saw it in both groups.  And that drops off, as I said, after six weeks. And so that's important to think about when tailoring your protocols to your patients. Next slide.  So in AJSM three years ago, they looked at this elongation and they looked at a, it was a prospective cohort study and they looked at immediate weight bearing  in a boot versus a plaster cast for two to four weeks. The earth, they certainly showed that there was,  elongation was greater at two weeks in the early weight bearing group, but it equalized. And at a year, there was no difference in the tension between those two groups,  but the early weight bearing group had less muscle atrophy. And so this tends to back up some of the, some of the literature that says maybe motion  and earlier weight bearing is good. Next slide.  So in FAI last year, there was a, Dr. Mufulla and his group  kind of flipped out a little bit on its head. He looked at intermediate weight bearing in both groups using percutaneous repair. And one group had the slow removal of wedges  and they, he stretched it out over time versus a group that had it two times faster and had their heel on the ground by six weeks. The slower group had less elongation  and improved cast circumference. And it was more close, it was closer to the contralateral side. So this kind of throws a little bit of salt in the wound  that there is probably a sweet spot in there that we need to think about without overdoing it. Next slide.  So technology, kind of what role does that play in the rehabilitation? And we'll kind of quickly go through this. Next slide. Cause we've talked about the PARS mid substance  and essentially what it is. Next slide.  Keep running, you can run through these. So essentially in this case, you know, why do it? Well, the suture tendon interface is the most common site of failure.  So if we can hook it into the Achilles, potentially we can take one of the, one of that interfaces out. But certainly the heel pain as Dr. O'Malley talked about, that's a real risk  and it must be discussed with the patient. You gotta understand that you are placing tension at the heel that wouldn't be there otherwise.  And that's something that we need to think about when we're rehabbing. Next slide.  So Dr. Clanton has done a ton of fantastic biomechanical work and this just kind of added to his library of good research, much of which I owe to him.  But he looked at these different repairs and ultimately all repairs failed at the suture interface, the suture tendon interface, which we showed.  But the open repair seemed to be improved  relative to the percutaneous repairs  when it came to looking at elongation. Next slide.  So let's go through a case. Obviously, these are the things that scare us, right? So classic mid-substance rupture. And this is one that was provided to me by Dr. Anderson.  So I appreciate him giving me this when we were discussing it. It had no prodromal symptoms, no contralateral issues. Next slide.  He had an uncomplicated repair using an open technique, matched the resting tension to the contralateral side.  He was in a boot up until six, seven weeks. He was kept non-weight bearing for about a week and then allowed to weight bear at about a week.  Sutures out at two, no signs of infection. Six months post-op, he had significant calf atrophy, could still could not perform a single leg heel raise.  And on Biodex testing had a 65% plantar flexion deficit compared to the contralateral side. Next slide.  So what are your options at this point? Do we continue to rehab? You know, are there things that we can do through plyometrics that can improve that?  It's six months, that's kind of, you're kind of in the middle. Can you get it stronger at that point? And as Dr. O'Malley pointed out in his talk,  you know, at three months, it starts to get hard. He's already missed an entire season. So now what do we do? Next slide.  So this is what we worry about, right? The Dan Marino syndrome.  You know, where you get over-lengthening in rehab. And as many people know, Dan played his last five years in an AFO with a dorsiflexion stop.  And it's led to problems down the road. And that's certainly something that we worry about with these aggressive rehabilitation protocols. Next slide.  There's not much in the literature about it. You know, what do we do if we fail? Shortening procedures have been shown to work,  but there's not a lot out there. Next slide.  Next slide.  So in this case, you used a Z shortening and tried to match him to the other side, look at the other side, and tension it a little more than the other side.  So it required a little bit of eyeballing, but certainly giving yourself the most amount of tendon surface to heal to using the Z shortening technique. Next slide.  You can see the tension that we restored here.  Ultimately, it's all about the tension. You feel like you can get it to heal if you can get his wound to heal. And so getting that good gauge  using the contralateral side is important. Next slide.  Post-op, kept him non-weight bearing for about four to six weeks. We used as many modalities as possible, BFR, plantar flexion against resistance, gradual return to neutral.  And I think that's key. Dr. O'Malley talked about that. And I agree. I do not allow mine to get to neutral past eight weeks. I always use the term.  We can stretch out tight. We cannot tighten loose. And so I would rather them tell me they feel tight at three months than them tell me they feel fantastic and they couldn't believe  they got their range of motion back so quick. And you gotta remember,  in some cases it's important to go slow and does take a longer time to recover. And I think it's important to individualize that with your patient, the athlete,  how old they are, what their goals are. Next slide.  So why does it happen? And that's a tough question. Sometimes it can be the repair wasn't good enough. And I think that some of the pearls  that Dr. O'Malley gave at his, I think are important. If you don't feel, if you are using the PARs and you don't feel like you have good tension, don't be afraid to open it.  I agree. I don't know that I've ever seen one too tight and I feel very strongly about trying to get that tension. Too aggressive of postdoc course.  Is it necessary to be in a hurry in some of these cases or is it a case of bad college? Sometimes it can be all three. It just depends. Next slide.  So ultimately the biggest risk of elongation is in those first six weeks.  I believe that cast immobilization for prolonged periods of time is unnecessary. And a lot of the newer protocols have gone that way.  Heel lifts are a fantastic way to allow the patient to start using the tendon appropriately early  in the process and can be beneficial to healing to allow for tendon organization without worrying about stretching it out. And strength is paramount to return to play.  So it's important to understand  through the rehab process that strength is what takes the longest and is what allows you to return to play at the level that you'd like.  And that's something that needs to be focused on really once you feel like you're out of the woods of over lengthening the tendon. And the data is consistent.  It's a nearly year to return to play and often not at previous levels. And certainly there are cases out there  where we try to speed that up. And I think that's a reasonable to do, but as a whole, I think we need to avoid getting out of whack with our expectations to patients. Next slide.  Can we speed it up? Perhaps, but I think understanding the risk is important. Technology is without a doubt improved and it's probably done more to improve complication rates  than it has at least at this point in the literature  to relative to rehabilitation rates and return to play. And I think the improvement in the rehab process is really dependent on the merger of all three,  technology, biology, and physiology. And we got to understand that when we talk with our patients. Sorry about the issues with the Zoom, but I appreciate it.  And I'll turn it back over to you, Eric.  All right, thank you guys. Now, great talk, great kind of overview of everything. I know we're kind of hitting our hard stop here. So there are a couple more questions in here,  but we'll try to kind of answer that offline. But I wanted to thank everybody for coming on today, for the speakers, for kind of sharing their insight and their wisdom.  I think it gives us a sense of sort of where we've been, where we're going, and just some of the still things that we struggle with.  And so I appreciate everybody staying up late too. It's around 10, 15 on the East Coast too. So everybody have a great holiday and if you can send in any additional questions  and hopefully we'll get them answered on the backend. So I really appreciate it. Thank you guys.  Thank you.

Video Summary

This webinar discusses the current evidence and techniques for managing Achilles tendon injuries. The speakers analyze the pros and cons of non-operative versus operative treatment for acute Achilles tendon ruptures. They highlight that surgical treatment reduces the risk of re-rupture, but it should be personalized based on patient factors. The speakers then delve into surgical techniques for repairing Achilles tendon ruptures, including open surgery, peritendinous repair, and careful tensioning during surgery. They also discuss the perist technique and briefly mention the mid-substance speed bridge technique. In the context of chronic Achilles tendinopathy, the speakers emphasize addressing both mechanical and biological factors in treatment. They discuss non-operative treatments like shockwave therapy and PRP injections, as well as surgical options like tendon transfers and debridement procedures. Tensioning and the use of biologics like BMAC are considered important for optimal healing. The speakers also discuss challenges and considerations in rehabilitation, including collagen healing, tendon organization, and progressive strengthening. They highlight the role of technology, such as the ProStop device, in rehabilitation. The need for individualized treatment plans and restoring strength and function is emphasized. Overall, the webinar provides insights into current approaches and ongoing challenges in managing Achilles tendon injuries.

Asset Subtitle

Moderator: Eric W. Tan, MD
Faculty: Bonnie Y. Chien, MD; Martin J. O'Malley, MD; Lew C. Schon, MD; Norman E. Waldrop, MD

This webinar focuses on the literature, management options, and rehabilitation involved in the treatment of Achilles tendon ruptures and chronic tendinopathy. Expert faculty will review the evidence and considerations surrounding surgical techniques and rehabilitation protocol involved in treating Achilles ruptures and tendinopathy.

At the conclusion of this webinar, you will be able to:

Understand the evidence guiding treatment of acute Achilles ruptures
Understand the management options available to treat acute Achilles ruptures
Understand the management considerations to treat chronic Achilles tendinopathy and revision surgery
Understand the evidence and guidelines that influence Achilles rehabilitation

Keywords

Achilles tendon injuries

non-operative treatment

operative treatment

acute Achilles tendon ruptures

surgical techniques

chronic Achilles tendinopathy

shockwave therapy

tendon transfers

tensioning

rehabilitation challenges

individualized treatment plans