Achilles rupture during TAL

[deleted1142046]

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Hey all,

I've asked a few people regarding this and I wanted to get some thoughts.

Say you are doing a flatfoot reconstruction and also doing a tendo achilles lengthening. If you accidentally rupture the tendon, are you typically repairing it? I've seen it happen a few times in residency and it was never repaired, but I've spoken to a few other docs I really respect saying in an otherwise healthy individual you typically should repair it. However, it's going to be a nightmare to flip a 250 pound patient intraoperatively at the surgery centers I work with.

I've done some research but couldn't find much information regarding the topic.

Thanks all and Merry Christmas!

 

[Pronation]

Should probably repair, but would probably be ok if casted in plantarflexion.

Also what kind of TFPs are still doing TALs instead of a gastroc for a flatfoot…

 

[Feli]

I would guess you're talking 3-stab perc? That's the wrong procedure in fairly active people to begin with. If they rupture, they are likely to cause calc gait or apropulsive or worse from tripping with a plantarflex cast.
Those 3-stab are really only for little kids and diabetic Charcot/ulders who are going into a cast or frame and are minimal ambulators to begin with (so tendonotomy wouldn't hurt them much anyways).

I agree that bona fide gastroc + soleal equinus is very, very rare... usually neuromuscular, cavus, congenital, etc. You should be doing gastroc on basically everything else from flat foot to TMAs to symptomatic equinus (metatarsalgia, forefoot ulcers, HAV with midfoot sag on WB lateral, etc). Even on bona fide gastroc+soleal equinus pts, the gastroc will still weaken it substantially if the equinus wansn't the major problem.

If you are going to do flat foot recons, cavus, etc with TALs, they need to be open and sutured (start prone then go supine for the rest of the case)... frontal plane Z, saggital Z, Hoke sutured, etc. You can't just do 3-stab perc TALs on big folks or active ppl. A lot of surgeons try to do just that (simple things for simple ppl), but it can crash and burn.

 

[Nard_Dog]

Agree with above. I’m a big fan of a traditional gastroc release for most anything, minus Charcot or old, inactive flatfoot recon with fusions. The Hoke triple release is just not controllable or predictable with amount of release you get.

That being said, I have seen what appeared to be a total rupture in residency. We ended up splinting them in plantarflexion and casting them plantarflexed as well throughout the postoperative period. They did okay, however, these were people who were definitely not young or active.

 

[AttackNME]

Hey all,

I've asked a few people regarding this and I wanted to get some thoughts.

Say you are doing a flatfoot reconstruction and also doing a tendo achilles lengthening. If you accidentally rupture the tendon, are you typically repairing it? I've seen it happen a few times in residency and it was never repaired, but I've spoken to a few other docs I really respect saying in an otherwise healthy individual you typically should repair it. However, it's going to be a nightmare to flip a 250 pound patient intraoperatively at the surgery centers I work with.

I've done some research but couldn't find much information regarding the topic.

Thanks all and Merry Christmas!

Just repair supine or frog leg, medial incision. It’s not hard

 

[diabeticfootdr]

Hey all,

I've asked a few people regarding this and I wanted to get some thoughts.

Say you are doing a flatfoot reconstruction and also doing a tendo achilles lengthening. If you accidentally rupture the tendon, are you typically repairing it? I've seen it happen a few times in residency and it was never repaired, but I've spoken to a few other docs I really respect saying in an otherwise healthy individual you typically should repair it. However, it's going to be a nightmare to flip a 250 pound patient intraoperatively at the surgery centers I work with.

I've done some research but couldn't find much information regarding the topic.

Thanks all and Merry Christmas!

Done hundreds of perc TALs in a different patient population. Only ruptured one on the table, but they were going in a frame for 3 months after, so I left it and it did fine.

Had 2 rupture in the post-op period. Both resulted in calcaneal ulcers and subsequent BKAs.

If that happened now, I’d fuse the ankle early with a rod before they even got an ulcer. I include that in my consent discussion now.

In a different patient population, just thinking medicolegally, probably should fix it on the table. Plenty of plaintiff attorneys and experts would grasp on to the care after you recognized the complication. Although, what is the “standard of care”, TAL vs gastroc, fix vs cast, is probably still debatable.

 

[Pronation]

Had 2 rupture in the post-op period. Both resulted in calcaneal ulcers and subsequent BKAs.

If that happened now, I’d fuse the ankle early with a rod before they even got an ulcer. I include that in my consent discussion now.

Or, ya know, maybe do the indicated procedure which is an FHL transfer?...

 

[DYK343]

I had two rupture (both as a resident). 1 TMA 1 charcot. We casted both slightly plantarflexed and discussed with the patient what happened. Both times they did fine as far as I know but may have had complications as I never had long term follow up.

Everytime I've done a gastroc recession (My go to is baumann) in a diabetic its impressive how much release I get.

When I do gastrocs in non neuropathic patients I commonly run into sural nerve issues. My go to is the Baumann. Maybe I should go back to Strayer. I feel gastroc lengthening is prone to have sural nerve issues lengthening regardless of approach. Do you guys get sural neuritis post gastroc recession?

Im not on board with cutting the P fascia. Minus sural neuritis (which eventually calms down) ive had good results with topaz and gastroc lengthening for chronic P fasciitis.

- - -

Edit. I forgot I had a lady I did a TMA on. Super non compliant. Walked day 1 post discharge hosptial after refusing SNF. She ruptured it "jumping to get something from the top shelf". She heard a loud pop. I tried to cast her. She declined. Never developed a calcaneal ulcer. She did great actually.

 

[air bud]

Honestly never had an issue of sural neuritis that I am aware of. Often times I don't even repair deep fascia. I do strayer's exclusively. But you can feel rushed and stressed asking a 110 pound girl to hold a 300lb leg at shoulder level for 10 min while you do the procedure....in my residency the attendings said you hold the leg I will do the gastroc then you can do the triple/Evans mcdo cotton. I would like to switch to the bauman.

Related to this, I have started doing less TAL for TMAs and more gastrocs. Part of this is because have begun walking TMA around 1 week in a TCC with good results. A mentor of mine who is involved in teaching at a large university program had been doing this so I said ok I guess I willl. Ensure clean margins, do repeat I and D's while in the hospital and can cut down on SNFs with earlier WB and oral antibiotics.

 

[Feli]

...Do you guys get sural neuritis post gastroc recession?

Im not on board with cutting the P fascia. ....

I cut both medial mini open...

Gastroc is almost always 3-4cm medial approach Strayer... frog leg. I do it without much assist, but it helps if the tech can hold the leg external rotation (like when you put thigh cuffs on) and if they dorsiflex foot as you release gastroc so you know you got the lateral fibers. If you get the tissue plane right (nerve is immediately superficial to paratenon of aponeurosis... usually snip into paratenon and finger dissect for me) and put a wide ribbon retractor in, almost no way to damage the sural with mayo scissors or scalpel gastroc release. That's not to say post-op scarring couldn't irritate the nerve, though.

The biggest complication I get with gastrocs is just pain... mostly on walking. It's usually incision pain or just pain in the calf where they won't trust the leg for a few weeks, and small fraction get sent to do PT. I have a feeling these are hematomas when I nick the soleus, but who knows. I would never consider Bauman much as I'd imagine it'd be worse pain due to more dissecting and retracting. I have also gotten away from doing bilateral gastroc in non-neuropathic patients... one side, heal it, contra-lat later date.

I do open V gastroc with Achilles ruptures a lot when I need major length since I repair ruptures open anyways (yes i know thats stone age, but most I get are weeks out and I value good repair over pretty, lol).

For plantar fascia, its rare not to get there non-op. I just open 2cm incision medial, freer to get the plane, release medial third or half with mayo scissor after the plane is established... I don't rasp calc spur unless it's a real whopper, good amount have gastroc with it. I just tell patients, "were just getting that bit of stretch and length that PT and your stretching couldn't quite do." The worst that ever happens is thet aren't much better. I did EPF, ablation, InStep, ShockWave, various stuff in training... just not sure they do a lot, and I can finish open release faster than tech can set up cam tower and white out EPF scope.

 

[Pronation]

Honestly never had an issue of sural neuritis that I am aware of. Often times I don't even repair deep fascia. I do strayer's exclusively. But you can feel rushed and stressed asking a 110 pound girl to hold a 300lb leg at shoulder level for 10 min while you do the procedure....in my residency the attendings said you hold the leg I will do the gastroc then you can do the triple/Evans mcdo cotton. I would like to switch to the bauman.

Related to this, I have started doing less TAL for TMAs and more gastrocs. Part of this is because have begun walking TMA around 1 week in a TCC with good results. A mentor of mine who is involved in teaching at a large university program had been doing this so I said ok I guess I willl. Ensure clean margins, do repeat I and D's while in the hospital and can cut down on SNFs with earlier WB and oral antibiotics.

I also don’t think I’ve ever had a sural neuritis from a gastroc and I do Strayers exclusively, frog legged.

I also do same for TMA. Gastroc, one week in a profore with a splint and 2 weeks in a TCC. Works amazing and I have had a 100% success rate with this 50% of the time.

 

[DYK343]

Baumann patients dont really complain of much muscle pain. Some but not as much as you would think. THey dont get cankles either post baumann like the strayer sometimes can do. Theyre supposed to complain of less weakness but I dunno about that. Never had much weakness with strayer or baumann.

With the Baumann approach you shouldnt be anywhere near the sural nerve coming from a medial approach.
I think the baumann gets some serious length correction and this is what stretches the nerve resulting in neuritis.
Its seriously impressive howmuch length you can get with a baumann. I did one on a bad diabetic for FF ulcer about 8-12 months ago. It made a loud "pop" noise upon release. If freaked both me and the tech out. I thought I was in the wrong plane and screwed up (which would be hard to do...) because ive never experienced that before.

I might go back to Strayers for non neuropathic patients.

 

[deleted1142046]

Thanks for the discussion guys, much appreciated.

 

[deleted285117]

Another thought on why to repair it - you’ll have some wicked flexor substitution hammertoes in about a year if ignored.

 

[Pronation]

Another thought on why to repair it - you’ll have some wicked flexor substitution hammertoes in about a year if ignored.

Practice management bro

 

[air bud]

Am I the only one dumb enough to be doing upside down gastrocs? It's just the way I trained....have been wanting to do medial but whenever you go to these courses they are ankles not legs.

 

[Nard_Dog]

Am I the only one dumb enough to be doing upside down gastrocs? It's just the way I trained....have been wanting to do medial but whenever you go to these courses they are ankles not legs.

Only do these when they’re prone personally. If you go 3 fingers down from the medial head of the gastroc, and 2-3 fingers posterior from the medial tibial face, you will always be in the right spot