TIP OF THE MONTH: June/July 2013
How the Orthotech Can Play a Vital Role in Serial Casting for Achilles Tendon Repair with FHL Transfer
First-Place Winning Article, 2013 Paper of the Year Competition
by Sylvie Henley, OTC
The Achilles tendon repair with Flexor Hallicus Longus (FHL) transfer is a surgical procedure that can be done to repair a ruptured Achilles tendon that has a gap that is too large (>1-3 cm) for a traditional repair. The goal is to build a bridge between the proximal and distal stumps of the Achilles tendon. Oftentimes, this is the case with chronic ruptures or re-ruptures of the Achilles tendon. This can be determined through a thorough physical evaluation, the Thompson Test, and an MRI.
There are many factors which may cause the ends of the Achilles tendon to become too far apart to put back together with a traditional repair. In addition to traditional tendon retraction, it may be that the condition was undiagnosed for a period of time, or was misdiagnosed. The patient may also have failed conservative management or suffered a re-injury. There may have been complications to an initial repair like an infection or a re-rupture. No matter how the condition came to be, the result is a large gap that needs to be bridged. The FHL tendon and muscle serves that necessary purpose to assist in bridging this gap.
This intra-operative image demonstrates a completed repair with use of the FHL tendon and muscle to bridge the gap.
Many times the result of a repair like this is a very tight Achilles that is not in the neutral position immediately following surgery. This is often seen clinically at the first or second post-operative appointment when it is time to remove the splint and apply a cast. In cases such as these, the Orthotech will find it useful to do serial castings at intentional intervals designed to bring the patient closer to neutral at each casting. Changing these casts every two weeks works well to allow for pain and swelling to subside and also does not put undue pressure on patients who travel long distances to get to the clinic.
One step which may not have been previously considered is having the patient stretch in between cast changes. This is performed by placing a Chux disposable pad on the floor and having the patient slowly move their heel backwards under their knee. They should be instructed to attempt to get their foot as flat as possible on the floor. The patient can use their hands to put gentle downward pressure on their knee if the weight of their limb is not sufficient enough on its own. Have the patient do this stretching while they’re waiting for the doctor to come in and see them and while the cast cart is being set up after they have been evaluated by the physician. Around the post-operative six-week mark, a patient’s pain may be reduced enough that they might be able to try and stand with a walker to further stretch out the Achilles tendon. The walker helps keep the patient balanced safely and can offload the affected lower extremity while stretching.
Next, it is also recommended to use a cast stand for the cast application. This can be more successful than placing the patient’s foot on the Orthotech’s knee. With a cast stand the patient can maintain a downward force the entire time the cast is being applied. This method is more effective than picking up and putting down the foot on the knee numerous times while the initial part of the cast is being built. Some range of motion (ROM) might be lost with each pick up and put down of their foot.
There are cast stands that are so versatile and adjustable they can easily accommodate a tight Achilles by simply changing the angle and height of the foot plate.
The first few casts are the toughest. The patient is in pain, their ROM is minimal, and many patients are nervous about re-injuring the Achilles tendon. Changing the cast every two weeks may help improve the patient’s ROM. The first six weeks are non-weight-bearing in a short leg cast followed by six weeks of weight-bearing in a short leg walking cast. Ideal position may not yet be obtained at the post-operative six-week mark. Patients are eager to improve and are generally willing to come in again to attain that ideal position, so they can walk again without the use of crutches. It turns out to be several cast changes, but it is well worth it in the end. Patients are generally very happy to be a part of the team and a part of their own recovery. I am confident adding in the stretching piece will really help yield good results for your patients.
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About the Author
Sylvie Henley, OTC, graduated from Castleton State College in Vermont in 1996 with a B.S. in Athletic Training. A year later, she joined Fletcher Allen Health Care and quickly transferred to orthopaedics in 1999. She has been casting ever since. She now works in the Orthopedic Specialty Center, which has 35 providers and treats approximately 55,000 patients each year. “One of the things I like most about being an Orthotech is that you are constantly using your hands, moving, and being creative. I also love how being a part of NAOT gives me a profession, not just a job. I have found my calling, and it’s being an OTC!”
Sylvie’s paper, “How the Orthotech Can Play a Vital Role in Serial Casting for Achilles Tendon Repair with FHL Transfer” was selected as the first place winner in the 2013 NAOT Paper of the Year Competition, sponsored by BSN medical. All articles submitted in the competition underwent a blind review by the NAOT Editorial Review Committee and were judged based on originality, timeliness, accuracy, and relevance to the profession of Orthopaedic Technology.