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Vosoughi AR, Akbarzadeh A, Brevis S, Kordi Yoosefinejad A. Clinical and biomechanical comparison of suture-external button versus interference screw associated with V-Y advancement or turndown flaps for flexor hallucis longus transfer in chronic Achilles tendon rupture. Musculoskelet Surg 2024:10.1007/s12306-024-00857-7. [PMID: 39251541 DOI: 10.1007/s12306-024-00857-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/29/2024] [Indexed: 09/11/2024]
Abstract
PURPOSE Surgical treatment of chronic Achilles tendon rupture is a technically challenging procedure. We aimed to compare the clinical outcomes, range of motion, and strength of ankle plantar- and dorsiflexors between two techniques for fixation of flexor hallucis longus tendon to the calcaneus: interference screw and suture-external button. METHODS Twenty-five patients participated in this retrospective comparative study. All patients underwent short harvest FHL tendon transfer for chronic AT rupture were asked for a follow-up visit, at least one year following surgery. The outcomes were evaluated by visual analog scale (VAS), AOFAS ankle-hindfoot score, and VISA-A questionnaire. Ankle ROM with possible restriction in addition to isokinetic strength of ankle plantar- and dorsiflexors was assessed. RESULTS No statistically significant difference was observed between the groups for pain (P = 0.81), AOFAS ankle-hindfoot scale (P = 0.97), and VISA-A (P = 0.44). Notably, more decrease in ankle dorsiflexion was seen in interference screw group in comparison with suture-external button group (4.4 ± 6.6 vs. 9.5 ± 6.1 degrees, P = 0.06). The difference of active dorsiflexion between operated and non-operated side in interference screw group was statistically significant (P = 0.02). Biotenodesis screw imposed more limb asymmetry in comparison with suture-external button technique. CONCLUSIONS Fixation of transcalcaneal FHL tendon transfer for chronic AT either by interference screw or suture-external button has encouraging postoperative clinical results. Although ROM of the ankle joint reduced in both techniques, interference screw may result in more reduction in dorsiflexion of the ankle.
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Affiliation(s)
- A R Vosoughi
- Orthopedic & Rehabilitation Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Orthopedic Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - A Akbarzadeh
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - S Brevis
- Orthopedic & Rehabilitation Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - A Kordi Yoosefinejad
- Orthopedic & Rehabilitation Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- Physical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.
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Oesman I, Putra NHD, Andar AA, Mardhitiyani WA. Flexor hallucis longus impingement syndrome: A case report. Int J Surg Case Rep 2024; 121:109934. [PMID: 39024995 PMCID: PMC11295693 DOI: 10.1016/j.ijscr.2024.109934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 06/16/2024] [Accepted: 06/21/2024] [Indexed: 07/20/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Long-term friction of the FHL tendon's sheath (caused by sporting activities) can result in tendinitis, which causes pain in the foot and ankle and consequently interferes with everyday life and foot function. The FHL tendon is crucial for maintaining foot stability and can be damaged by overuse. FHL tendinitis can be also caused by inflammatory tendon sheath filled. Arthroscopy can play a role in the diagnosis and treatment of this condition. CASE PRESENTATION A 28-year-old female with left ankle pain was brought to our clinic after slipping on a train platform nine months ago. X-rays and MR imaging revealed a complete tear of the ATFL, minimal joint effusion, and a bony protrusion causing impingement. Arthroscopic surgery was performed, and the patient's pain sensation improved to 0-1 in the visual analogue scale (VAS) within three weeks. The Foot and Ankle Ability Measure (FAAM) score increased from 8 % to 100 %, and the patient was able to walk and perform daily activities normally. CLINICAL DISCUSSION The FHL tendon sheath begins at the posterior tubercles of the talus and forms a fibroosseous tunnel along the medial calcaneus, potentially leading to impingement during ankle or hallux dorsiflexion. FHL tendon impingement and tendinitis share clinical manifestations, and if conservative treatments (NSAIDs, physical therapy) fail after 6 months, arthroscopic surgery is recommended for its minimally invasive benefits. Both arthroscopic and open surgical techniques yield positive outcomes for FHL pathologies; however, they carry risks such as neurovascular complications, highlighting the necessity for surgical precision and expertise. CONCLUSION We concluded that in this case, FHL impingement was caused by the bony protrusion from Stieda process fragment. It was demonstrated that the arthroscopic surgery with loose body removal was successful and practical.
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Affiliation(s)
- Ihsan Oesman
- Foot and Ankle Division, Department of Orthopaedics and Traumatology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Nurmansyah Hata Dwi Putra
- Department of Orthopaedics and Traumatology, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Anindyo Abshar Andar
- Department of Orthopaedics and Traumatology, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.
| | - Winona Andrari Mardhitiyani
- Department of Orthopaedics and Traumatology, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Eble SK, Hansen OB, Kukadia SK, Cho DJ, Kumar P, Papson AK, Drakos MC. Strength and Functional Outcomes Following Achilles Tendon Reconstruction With Hamstring Tendon Autograft Augmentation. Foot Ankle Int 2024; 45:348-356. [PMID: 38433405 DOI: 10.1177/10711007241227418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
BACKGROUND The proposed advantages of hamstring autograft reconstruction when compared to alternative procedures, such as flexor hallucis longus (FHL) transfer, V-Y lengthening, and allograft reconstruction, are improved healing and reproduction of normal tendon biomechanics and reduced morbidity within the foot and ankle. In this study, we examined the effect of Achilles tendon reconstruction using hamstring autografts on strength and functional outcomes. METHODS Patients who underwent Achilles repair with a hamstring autograft for insertional or midsubstance tendinopathy, delayed diagnosis of rupture, or infection after primary repair were evaluated for inclusion. Forty-six patients were identified; 12 further augmented with an FHL transfer are included in the analysis. Isokinetic testing was completed with a Biodex dynamometer under supervision of a physical therapist masked to surgical side. Pre- and postoperative Foot and Ankle Outcome Scores (FAOS, before March 2016) or Patient-Reported Outcomes Measurement Information System (PROMIS, after March 2016) surveys were collected. RESULTS For knee flexion, peak torque was not significantly different when comparing operative and nonoperative sides at 180 degrees/second (45.38 Nm vs 45.96 Nm; P = .69) nor at 300 degrees/second (44.2 Nm vs 47.02 Nm; P = .069). Knee extension absolute peak torque was only found to be significantly weaker on the operative side at the faster testing (75.5 Nm vs 79.56 Nm; P < .05). Peak ankle plantarflexion torque was significantly weaker on the operative side at both the slower speed (60 degrees/second: 39.9 Nm vs 48.76 Nm; P < .005) and the faster speed (120 degrees/second: 31.3 Nm vs 40.7 Nm; P < .001). Average power for ankle plantarflexion did not differ significantly from the operative side to the nonoperative side in the slower test (26.46 W vs 27.48 W; P = .60) but did significantly differ on the faster test (32.13 W vs 37.63 W; P = .041). At an average of 19.9 months postoperation, all physical function and pain-related patient-reported outcome scores showed clinically and statistically significant improvement. CONCLUSION Achilles reconstruction with a hamstring autograft ± FHL transfer allowed patients with severe Achilles pathology to return to good subjective function, with modest deficits in calf strength compared with the uninjured side. Overall knee flexion strength did not appear impaired. These results suggest that hamstring autograft reconstruction is a viable method to treat these complex cases involving a lack of healthy tissue, allowing patients to return to symptom-free physical function and athletic activity. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Stephanie K Eble
- Hospital for Special Surgery, New York, NY, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | | | | | - David J Cho
- Hospital for Special Surgery, New York, NY, USA
| | - Prashanth Kumar
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Manz WJ, Bowman J, Pongastron T, Sherwood S, Labib SA. Salvage Reconstruction of a 12-cm Tendon Defect Following Chronic Achilles Rerupture-15-Year Follow-Up: A Case Report. JBJS Case Connect 2024; 14:01709767-202406000-00044. [PMID: 38820194 DOI: 10.2106/jbjs.cc.23.00603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
CASE A 39-year-old man with a chronic Achilles rupture status post (1) failed primary repair and (2) secondary xenograft repair with graft rejection, resulting in a 12-cm Achilles tendon defect, which was reconstructed utilizing an Achilles bone block allograft and flexor hallucis longus (FHL) tendon transfer. At 15-year follow-up, the patient reported good functionality and satisfaction with the repair, with positive patient-reported outcome measures. Physical examination revealed excellent strength and range of motion. Magnetic resonance imaging confirmed the integrity and incorporation of the Achilles/FHL graft composite. CONCLUSION This case study provides valuable insight into successful long-term management of complex chronic Achilles ruptures with large defects.
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Affiliation(s)
- Wesley J Manz
- Division of Foot & Ankle Surgery, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
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Bota O, Heinzinger LM, Herzog B, Disch AC, Amlang M, Flößel P, Dragu A, Taqatqeh F. Evaluation of the ankle function after Achilles tendon resection: a retrospective clinical study. Arch Orthop Trauma Surg 2024; 144:1243-1257. [PMID: 38231207 PMCID: PMC10896776 DOI: 10.1007/s00402-023-05177-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 12/06/2023] [Indexed: 01/18/2024]
Abstract
INTRODUCTION The Achilles tendon is the strongest tendon in the human body and has the function of plantar ankle flexion. When the tendon is exposed, the peritendineum has been breached and the thick avascular tendon colonized with bacteria, a complete resection of the tendon may be indicated to achieve infection control and facilitate wound closure. The Achilles tendon reconstruction is not mandatory, as the plantar flexion of the ankle joint is assumed by the remaining flexor hallucis longus, flexor digitorum longus and tibialis posterior muscles. Our study aimed to evaluate the impact of Achilles tendon resection without reconstruction on leg function and quality of life. MATERIAL AND METHODS We retrospectively evaluated all patients who were treated with an Achilles tendon resection between January 2017 and June 2022 in our quaternary institution. After evaluating the data, the patients who survived and were not amputated were contacted for re-evaluation, which included isokinetic strength measurement of both ankle joints, evaluation of the ankle range of motion and collection of several functional scores. RESULTS Thirty patients were included in the retrospective study, with a mean age of 70.3 years, including 11 women and 19 men. The most frequent cause of the infection was leg ulcer (43.3%), followed by open tendon suture (23.3%). No tendon reconstruction was performed. Fifteen patients could be gained for reevaluation. The average difference in ankle flexion torque on the injured side compared to the healthy side at 30 degrees/second was 57.49% (p = 0.003) and at 120 degrees/second was 53.13% (p = 0.050) while the difference in power was 45.77% (p = 0.025) at 30 degrees/second and 38.08% (p = 0.423) at 120 degrees/second. The follow-up time was between 4 and 49 months and a positive correlation could be determined between the time elapsed from surgery and the ankle joint strength. There was a significant loss of range of motion on the operated side compared to the healthy side: 37.30% for plantar flexion, 24.56% for dorsal extension, 27.79% for pronation and 24.99% for supination. The average Lepillhati Score was 68.33, while the average American Orthopedic Foot and Ankle Score was 74.53. CONCLUSION The complete Achilles tendon resection leaves the patient with satisfactory leg function and an almost normal gait. Especially in elderly, multimorbid patients, straightforward tendon resection and wound closure provide fast infection control with acceptable long-term results. Further prospective studies should compare the ankle function and gait in patients with and without Achilles tendon reconstruction after complete resection.
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Affiliation(s)
- Olimpiu Bota
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
- Department of Plastic Surgery, First Surgical Clinic, Emergency County Hospital Cluj-Napoca, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Leona M Heinzinger
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Bianka Herzog
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Alexander C Disch
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
- University Center for Orthopedics, Trauma and Plastic Surgery, Section Sports Medicine and Rehabilitation, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Michael Amlang
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Philipp Flößel
- University Center for Orthopedics, Trauma and Plastic Surgery, Section Sports Medicine and Rehabilitation, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Adrian Dragu
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Feras Taqatqeh
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
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Feng SM, Maffulli N, Oliva F, Saxena A, Hao YF, Hua YH, Xu HL, Tao X, Xu W, Migliorini F, Ma C. Surgical management of chronic Achilles tendon rupture: evidence-based guidelines. J Orthop Surg Res 2024; 19:132. [PMID: 38341569 PMCID: PMC10858558 DOI: 10.1186/s13018-024-04559-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/11/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes. METHODS A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines. RESULTS Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol. CONCLUSION Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.
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Affiliation(s)
- Shi-Ming Feng
- Orthopaedic Department, Sports Medicine Department, Xuzhou Central Hospital, No. 199, the Jiefang South Road, Xuzhou, 221009, Jiangsu, China.
| | - Nicola Maffulli
- Department of Medicine and Psychology, University "La Sapienza", Rome, Italy
- Guy Hilton Research Centre, School of Pharmacy and Bioengineering, Keele University, Stoke-On-Trent, Staffordshire, ST4 7QB, England
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England
| | - Francesco Oliva
- Department of Sports Traumatology, Universita' Telematica San Raffaele, Rome, Italy
| | - Amol Saxena
- Department of Sports Medicine, Sutter-PAMF, Palo Alto, CA, USA
| | - Yue-Feng Hao
- Orthopedics and Sports Medicine Center, Suzhou Municipal Hospital, Nanjing Medical University Affiliated Suzhou Hospital, Suzhou, Jiangsu, People's Republic of China
| | - Ying-Hui Hua
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Hai-Lin Xu
- Department of Trauma and Orthopedic, People's Hospital, Peking University, Beijing, People's Republic of China
| | - Xu Tao
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Wei Xu
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy.
| | - Chao Ma
- Orthopaedic Department, Sports Medicine Department, Xuzhou Central Hospital, No. 199, the Jiefang South Road, Xuzhou, 221009, Jiangsu, China
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Ramakanth R, Sundararajan SR, Thippeswamy V, D Souza T, Palanisamy A, Rajasekaran S. "Foot peak pressures are comparable to normal foot after flexor hallucis longus transfer for chronic retracted tendo-achilles tear: A pedobarographic analysis of normal foot versus affected foot". J ISAKOS 2023; 8:442-450. [PMID: 37611871 DOI: 10.1016/j.jisako.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/23/2023] [Accepted: 08/17/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Foot pressure changes and morbidity after flexor hallucis longus (FHL) transfer in chronic retracted tendoachilles (TA) tears have not been documented. The primary aim of our study is to analyze the peak pressure changes in various zones of the foot at each successive follow-up in the affected foot versus normal foot. The secondary aim is to determine FHL tendon healing and muscle hypertrophy. METHODS This is a prospective study of 46 patients who underwent FHL augmentation for chronic retracted TA tears (between 2019 and 2022). Included TA tear > 6 weeks duration and retraction > 2.5 cm. Excluded open TA tear, < 6 weeks and retraction < 2.5 cm. Depending on the amount of retraction, FHL augmentation combined with TA repair/VY plasty/turn-down-plasty. Functional outcome was analyzed with AOFAS hallux metatarsophalangeal scale. Pedobarographic analysis was done pre-operatively and at 3, 6, 9 months, 1 year and at the final follow-up. Parameters studied included forefoot peak pressure (FFPP), hindfoot peak pressure (HFPP), great toe peak pressure (GTPP), first Mmeta-tarso phalangeal peak pressure (MTPP), area under the pedobarograph and maximum force. At final follow-up MRI was done to assess FHL healing and hypertrophy. Statistical analysis was done for these parameters using appropriate tests. RESULTS Study involved 29 male and 17 female patients, mean age 49.5 years (33-65 years) and mean follow-up 26.8 months (14-38.4months). Mean hallux MTP-AOFAS score increased from 46.04 ± 7.31 preoperatively to 96.17 ± 3.22 at the final follow-up (P < 0.01). There was gradual improvement noted in FFPP, GTPP, MTPP Peak pressures at subsequent follow-ups, and by the end of 1-year foot pressures were comparable to normal side FFPP (8.02 ± 3.8 N/cm2 to 31.35 ± 3 N/cm2), GTPP(30.78 ± 13.01 N/cm2 to23.17 ± 7.5 N/cm2), MTPP(5.22 ± 2.64 N/cm2 to 23.3 ± 9.6 N/cm2). Initial high HFPP showed decline in subsequent follow-up and restored back to normal HFPP (36.91 ± 5.7 N/cm2 to 25.09 ± 3.7 N/cm2). Changes in pressures were statistically significant (< 0.001). Six patients had superficial wound infections healed with antibiotics. 23 patients who underwent a post-operative MRI showed a mean of 27 mm muscle thickness and 7.1 mm tendon thickness with complete incorporation of the FHL. CONCLUSION Foot peak pressures though initially deranged, are restored and comparable to normal foot after FHL transfer for chronic retracted TA tear. FHL hypertrophy is observed at the muscle thickness and at the distal tendon and provides adequate strength to repair and restore foot pressures. LEVEL OF EVIDENCE III Prospective comparative study (normal versus operated foot).
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Affiliation(s)
| | | | - Venugopal Thippeswamy
- Department of Arthroscopy and Sports Medicine, Ganga Medical Center & Hospital, Coimbatore, 641043, India.
| | - Terence D Souza
- Department of Arthroscopy and Sports Medicine, Ganga Medical Center & Hospital, Coimbatore, 641043, India.
| | - Arumugam Palanisamy
- Department of Arthroscopy and Sports Medicine, Ganga Medical Center & Hospital, Coimbatore, 641043, India.
| | - Shanmuganathan Rajasekaran
- Department of Orthopaedics and Spine Surgery, Ganga Medical Center & Hospital, Coimbatore, 641043, India.
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Liao WJ, Tang SC, Shih HT, Su KC, Tu KC, Wang SP. The compensatory hypertrophy of transferred flexor hallucis longus tendon for insertional Achilles tendinopathy: a retrospective MRI study. Sci Rep 2023; 13:20475. [PMID: 37993498 PMCID: PMC10665433 DOI: 10.1038/s41598-023-47725-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/17/2023] [Indexed: 11/24/2023] Open
Abstract
Flexor hallucis longus (FHL) transfer is an effective surgery in treating insertional Achilles tendinopathy (IAT). However, limited data exist regarding the post-surgery changes in the transferred FHL. The study aimed to compare the sequential changes and hypertrophy of FHL after isolated FHL transfer (FHLT). We retrospectively enrolled patients who underwent isolated FHLT for insertional Achilles pathology from 2015 to 2020 and divided them into two groups based on whether reattachment of the residue Achilles stump to the FHL was performed or not. We recorded demographic characteristics, MRI parameters, and functional outcome. We also analyzed the correlation between the collected data and FHL hypertrophy. Results revealed no significant differences in most MRI parameters of FHL and functional outcomes between the groups. However, the fat distribution within the FHL showed significant reduction and notable 20.2% hypertrophy after FHLT. Interestingly, the hypertrophy of the FHL was significantly more pronounced in the non-reattached group. Furthermore, we observed a positive correlation between the follow-up period and FHL hypertrophy. In conclusion, the FHL demonstrated significant enlargement over time following FHLT. The compensatory hypertrophy of the transferred FHL was particularly evident and the cumulative incidences of FHL enlargement over time were higher in the non-reattached groupcompared to reattached group. However, both reattachment and non-reattachment of Achilles stump on FHL transfer for insertional Achilles tendinopathy carried similar postoperative functional outcomes.
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Affiliation(s)
- Wei-Jen Liao
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung, 407, Taiwan
| | - Shih-Chieh Tang
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung, 407, Taiwan
| | - Han-Ting Shih
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung, 407, Taiwan
| | - Kuo-Chih Su
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Biomedical Engineering, Hung Kuang University, Taichung, 433, Taiwan
| | - Kao-Chang Tu
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung, 407, Taiwan
| | - Shun-Ping Wang
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung, 407, Taiwan.
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, 40227, Taiwan.
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Choi JY, Lee SS, Song TH, Suh JS. A comparison of characteristics and outcomes of operative treatment for Achilles tendon sleeve avulsion in older versus younger patients. Arch Orthop Trauma Surg 2023; 143:6513-6520. [PMID: 37341805 DOI: 10.1007/s00402-023-04945-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 06/05/2023] [Indexed: 06/22/2023]
Abstract
INTRODUCTION Achilles tendon sleeve avulsion (ATSA) is a rare injury that often results from pre-existing insertional Achilles tendinopathy and occurs when a tendon avulses from the insertion as a continuous sleeve. To date, outcomes of operative treatment for ATSA in older patients have not been reported. Therefore, this study aims to compare the characteristics and outcomes of Achilles tendon (AT) reattachment with or without tendon lengthening for ATSA between older and younger patients. MATERIALS AND METHODS This study enrolled 25 consecutive patients who underwent operative treatment following a diagnosis of ATSA between January 2006 and June 2020. The inclusion criterion was a minimum follow-up duration of one year. The enrolled patients were divided into two groups according to their age at operation: ≥ 65 years (group 1, 13 patients) and < 65 years (group 2, 12 patients). AT reattachment was performed in all patients using two 5.0-mm suture anchors after an inflamed distal stump resection in the 30° plantar-flexed ankle position. RESULTS The degree of active dorsiflexion and plantar flexion, mean visual analog scale score, and Victorian Institute of Sports Assessment-Achilles scores at the final follow-up were not significantly different between the two groups (P > 0.05 each). The rate of satisfactory clinical outcomes (defined as fair or greater) was 84.6% and 91.7% in groups 1 and 2, respectively. CONCLUSION We observed that comparable clinical outcomes could be achieved after AT reattachment with or without lengthening for ATSA between older and younger patients.
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Affiliation(s)
- Jun Young Choi
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Sung Sahn Lee
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Tae Hun Song
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Jin Soo Suh
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
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Peters MJ, Walsh K, Day C, Younger A, Salat P, Penner M, Wing K, Glazebrook M, Veljkovic A. Level of Evidence for the Treatment of Chronic Noninsertional Achilles Tendinopathy. Foot Ankle Spec 2023; 16:406-426. [PMID: 33749355 PMCID: PMC10422862 DOI: 10.1177/19386400211001261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Noninsertional Achilles tendinopathy affects both athletes and sedentary individuals, and its incidence is rising. Conservative management is the mainstay of treatment, but a variety of operative techniques have been described to treat recalcitrant cases. We seek to outline the current available evidence for surgical management of noninsertional Achilles tendinopathy. STUDY DESIGN AND METHODS A systematic review was performed using the MEDLINE and EMBASE databases, and all articles were reviewed by at least 2 authors. Each article was assigned a level of evidence in accordance with the standards of Journal of Bone and Joint Surgery. The available data were reviewed and a level of evidence was assigned to each intervention of interest, based on the revised classifications of Wright. RESULTS AND CONCLUSION A total of 46 articles met inclusion and exclusion criteria. There is fair evidence (grade B) in support of open debridement with 1 level II study, 1 level III study, and 8 level IV studies. There is fair evidence (grade B) in support of arthroscopic or minimally invasive surgical techniques. There is poor evidence (grade C) in support of flexor hallucis longus transfer, longitudinal tenotomy, peritenolysis, gastrocnemius recession, and plantaris excision. There is insufficient evidence (grade I) to provide a recommendation about other surgical treatment methods for noninsertional Achilles tendinopathy.Levels of Evidence: Level III: Systematic review.
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Affiliation(s)
| | - Kellen Walsh
- University of British Columbia, Vancouver, BC, Canada
| | - Chris Day
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Murray Penner
- University of British Columbia, Vancouver, BC, Canada
| | - Kevin Wing
- University of British Columbia, Vancouver, BC, Canada
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Ikuta Y, Nakasa T, Kawabata S, Adachi N. Achilles Tendon Reconstruction Using a Hamstring Tendon Autograft for Chronic Rupture of the Achilles Tendon in Patients Over 70 Years of Age: A Retrospective Case Series. Cureus 2023; 15:e42788. [PMID: 37664307 PMCID: PMC10469802 DOI: 10.7759/cureus.42788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 09/05/2023] Open
Abstract
Reconstruction techniques using autologous hamstring tendons were generally applied for chronic Achilles tendon rupture with a large defect size. Previous studies have reported good clinical results of this technique for young or middle-aged patients, however, the clinical outcomes in older patients have been unclear. This retrospective case series reviewed four male patients aged >70 years (mean age, 78.5 years) who underwent Achilles tendon reconstruction using the hamstring tendon autograft for chronic rupture of the Achilles tendon with a large tendon defect. The proximal-distal length between the healthy tendon stumps was measured using sagittal T2-weighted magnetic resonance imaging (MRI). The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and postoperative complications were evaluated. The duration from the traumatic event or appearance of symptoms to surgery was 3.8 (range, 2-6) months. The mean measured gap between the healthy tendon stumps was 67.5 mm on MRI. The AOFAS ankle-hindfoot score improved from 67.3 to 99.5 at the mean follow-up period of 40.3 (range, 23-75) months. No donor site morbidity was observed in all patients. Re-rupture was detected at the five-month follow-up in one patient who had removed a hinged ankle-foot orthosis with adjustable heel wedges without permission. Achilles tendon reconstruction using a hamstring tendon is a viable option for treating selected patients with chronic rupture of the Achilles tendon with a large tendon defect even in older patients. To improve clinical outcomes, a better understanding should be provided to family members as well as older patients regarding the postoperative rehabilitation program.
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Affiliation(s)
- Yasunari Ikuta
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, JPN
| | - Tomoyuki Nakasa
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, JPN
| | - Shingo Kawabata
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, JPN
| | - Nobuo Adachi
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, JPN
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12
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Singh MS, Harna B, Singh S, Vishwakarma G. Evaluation of Flexor hallucis tendon transfer in chronic insertional Achilles tendinopathy in over 50-year-old population using validated ankle scores. Foot (Edinb) 2023; 54:101969. [PMID: 36805957 DOI: 10.1016/j.foot.2023.101969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/16/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE Chronic insertional Achilles tendinopathy is a common pathology in the over 50 years old population. Patients not relieved with conservative treatment had to undergo surgical intervention for the management. This study evaluates the clinical outcome of FHL transfer in such patients using validated ankle functional scores. METHOD It is a retrospective study including 20 patients of either gender managed with debridement of the distal degenerative remnant Achilles tendon fibers either at the insertion site or the distal end of the torn tendon, resection of Haglund deformity with FHL transfer, and reattachment of Achilles tendon. The average age of the patients was 56.55 + 11 years (50-77 years) followed by over 35.6 months (Range 22-48months). The preoperative FAAM, FADI, SF 36, VAS, and AOFAS scores were calculated and followed every 6 months. The plantarflexion and dorsiflexion of the ankle were also recorded preoperatively and at follow-up visits. RESULTS All the patients were operated on by a single surgeon (MS) with the same surgical technique, implant, and rehabilitation protocol. All the patients were followed for an average of 35.6 months (Range 22-48 months). All the ankle scores, FAAM, FADI, SF36, VAS, and AOFAS improved in follow-ups. The mean plantarflexion and dorsiflexion were 39.300+ 4.90 and 12.50+ 4.70 respectively. Three patients had minor wound complications. All the patients returned to activities of daily living. CONCLUSION FHL transfer in elderly patients with insertional Achilles tendinopathy improves the validated ankle functional scores and decreases pain significantly. Furthermore, randomized studies with a larger study population and longer follow-ups may ascertain the beneficial effects.
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Affiliation(s)
- Maninder S Singh
- Department of Orthopaedics, Indian Spinal Injuries Centre, New Delhi, India
| | - Bushu Harna
- Department of Orthopaedics, Max Super speciality Hospital, New Delhi, India.
| | - Sukhmin Singh
- Department of Orthopedics, Gautam Buddha Chikitsa Mahavidyalaya, Dehradun, Uttarakhand, India
| | - Gyatri Vishwakarma
- Department of Biostatistics, Indian Spinal Injuries Centre, New Delhi, India
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13
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Local Tendon Transfers for Chronic Ruptures of the Achilles Tendon: A Systematic Review. J Clin Med 2023; 12:jcm12020707. [PMID: 36675635 PMCID: PMC9866603 DOI: 10.3390/jcm12020707] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 01/18/2023] Open
Abstract
Introduction: A rupture of the Achilles tendon with a delay in diagnosis or treatment for more than 6 weeks is considered a chronic tear. Local tendon transfer procedures can be used in chronic Achilles tendon ruptures. This study evaluated the outcome, return to sport, and complications of local tendon transfer in patients with chronic Achilles tendon rupture. Material and methods: The present study was conducted according to the PRISMA 2020 guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in November 2022. Results: Data were retrieved from 23 articles (463 patients, mean age 50.9 ± 13.5 years). The mean duration of the follow-up was 58.3 ± 76.8 months. The VAS improved by 1.8/10 (p = 0.4), the AOFAS by 33.4/100 (p < 0.0001), and the ATRS by 32.5/100 (p = 0.0001) points. Patients were able to return to sport after a mean of 19.6 ± 16.4 weeks. A total of 79% of patients were able to return to their previous activities. The rate of complications was 13.3%. Conclusions: The use of local tendon transfer for chronic Achilles tendon ruptures using the FHL or PB tendon resulted in good clinical outcomes and a reliable return to daily activities and sports. The rate of complications reflects the chronicity of the condition and the technical complexity of the procedure. Level of evidence: IV.
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14
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Muacevic A, Adler JR, Koynarski F. Case Series Report: Reconstruction of Chronic Achilles Tendon Rupture With Semitendinosus Autograft Combined With Vulpius Technique. Cureus 2022; 14:e32325. [PMID: 36627996 PMCID: PMC9825121 DOI: 10.7759/cureus.32325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 12/13/2022] Open
Abstract
We present five patients with chronic ruptures of the Achilles tendon and a defect larger than 6 cm. The average age of patients was 47 years. The interval between the rupture and treatment was between two and seven months. The size of the defects was between 6 and 12 cm, determined by magnetic resonance imaging (MRI) and/or ultrasound. All patients had an inability to step on the patient's limbs, a positive Thompson's symptom, difficulty walking and calf atrophy. Here, we evaluated the surgical results of semitendinosus autograft combined with Vulpius lengthening of the gastrocnemius in the treatment of chronic Achilles tendon rupture with a defect larger than 6 cm during medium-term follow-up.
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15
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Ahn J, Jeong BO. Return to Sports Activities After Flexor Hallucis Longus Transfer for Neglected Achilles Tendon Rupture. J Foot Ankle Surg 2022; 61:1263-1266. [PMID: 35370054 DOI: 10.1053/j.jfas.2022.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 02/23/2022] [Accepted: 02/28/2022] [Indexed: 02/03/2023]
Abstract
Transfer of the flexor hallucis longus (FHL) is known to be effective in the treatment of neglected Achilles tendon rupture (ATR). However, evidence on the return to sports activity levels and clinical outcomes is not sufficient. The aim of this study was assessing clinical outcomes and level of sports activity after FHL tendon transfer for treatment of neglected ATR. Twenty-eight patients who underwent FHL transfer for neglected ATR were analyzed retrospectively. Sports activity status was assessed using the Tegner Activity Scale (TAS). Clinical outcomes were evaluated using the Achilles tendon total rupture score and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale. By the post hoc power analyses, the power level of more than 80% was identified. The preinjury median TAS score was 4 point and unchanged at the last follow-up. The mean Achilles tendon Total Rupture Scores and American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale scores at the last follow-up were 81 and 93, respectively. While the median TAS was unchanged, 9/28 patients suffered from lower activity level after the procedure. In conclusion, midterm results of FHL transfer for neglected ATR were shown to be favorable. The median TAS score was maintained. Nonetheless, 32% of patients returned to sports activities with a TAS score 1 point lower than that at preinjury and with less favorable clinical outcomes.
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Affiliation(s)
- Jungtae Ahn
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Bi O Jeong
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea.
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16
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Yassin M, Gupta V, Martins A, Mahadevan D, Bhatia M. Patient reported outcomes and satisfaction following single incision Flexor Hallucis Longus (FHL) augmentation for chronic Achilles tendon pathologies. J Clin Orthop Trauma 2021; 23:101650. [PMID: 34824973 PMCID: PMC8600537 DOI: 10.1016/j.jcot.2021.101650] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/02/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Various procedures exist to augment or reconstruct the Achilles tendon (AT) in patients suffering from chronic pathologies. The aim of this study is to assess patient reported outcomes and satisfaction following single incision FHL augmentation using a short tendon harvest with interference screw fixation. METHODS This is a multicentre case series where postoperative patient reported outcome and satisfaction scores were collected on 30 patients. Outcome measures included EQ-5D, EQ-VAS, Achilles Tendon Rupture Scores (ATRS), and satisfaction scores. Scores were also collected on the unaffected limbs for comparison. RESULTS Mean patient age was 61 years (range 40-79, SD 11). Mean EQ-5D index value was 0.750 (0.100-1.00, SD 0.238), and mean EQ-VAS score was 74 (36-99, SD 15), at a mean follow-up of 57 months (4-118, SD 32). For patients with ≥24 months' follow-up, a mean deficit of 16 ATRS points was found between the operated and unaffected limb. Overall satisfaction was over 86%. In cases of chronic AT rupture, younger age and increasing time from initial injury to surgery were predictors of greater residual deficit. No serious complications or failures occurred. CONCLUSIONS FHL augmentation using short tendon harvest and interference screw fixation is a safe treatment option. It appears to take at least 24 months to functionally recover following this procedure, and despite a residual function deficit, there is a high level of patient satisfaction. Further studies are required to determine optimal patient selection and timing of surgery.
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Affiliation(s)
- Mohamed Yassin
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, United Kingdom
| | - Vatsal Gupta
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, United Kingdom
| | - Andre Martins
- Department of Trauma & Orthopaedics, University Hospitals of Leicester, Leicester, United Kingdom
| | - Devendra Mahadevan
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, United Kingdom
| | - Maneesh Bhatia
- Department of Trauma & Orthopaedics, University Hospitals of Leicester, Leicester, United Kingdom
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17
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Kim J, Kim JB, Lee WC. Dynamic medial column stabilization using flexor hallucis longus tendon transfer in the surgical reconstruction of flatfoot deformity in adults. Foot Ankle Surg 2021; 27:920-927. [PMID: 33386233 DOI: 10.1016/j.fas.2020.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/30/2020] [Accepted: 12/20/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND A common challenge in flatfoot reconstruction arises when there are multiple locations of collapse within the medial column. An extension of arthrodesis may lead to complications such as stiffness or adjacent joint arthritis. The purpose of this study was to report outcomes of flatfoot reconstruction using the dynamic medial column stabilization (DMCS) technique, which transfers the flexor hallucis longus (FHL) tendon to the first metatarsal base to support the entire medial column. METHODS We retrospectively reviewed 14 consecutive patients (14 feet) who underwent DMCS as an adjunct to flatfoot reconstruction. In all cases, a medial displacement calcaneal osteotomy and gastrocnemius recession were performed to address hindfoot valgus deformity and heel cord tightness, respectively. Deformity correction was assessed using preoperative and postoperative weightbearing radiographs. The newly defined metatarsal-cuneiform articular angle (MCAA) and naviculo-cuneiform articular angle (NCAA) were measured to assess correction at each medial column joints. Clinical outcomes included the FFI and VAS scores. Any complications related to the surgery were investigated. RESULTS All radiographic parameters significantly improved postoperatively. The sagittal plane correction occurred at all three joints within the medial column. Clinically, both FFI and VAS improved significantly at the final follow-up. One patient developed plantar pain under the first metatarsal head that may have been associated with the overtightening of the transferred tendon. CONCLUSION DMCS using FHL tendon transfer to the first metatarsal base was a useful technique for restoring the medial arch and correcting three planar deformities in the setting of flatfoot deformity.
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Affiliation(s)
- Jaeyoung Kim
- Hospital for Special Surgery, New York, NY 10021, USA
| | - Ji-Beom Kim
- Seoul Foot and Ankle Center, Dubalo Orthopaedic Clinic, Seoul, Republic of Korea
| | - Woo-Chun Lee
- Seoul Foot and Ankle Center, Dubalo Orthopaedic Clinic, Seoul, Republic of Korea.
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18
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Eser C, Karagoz Ceylan OI, Gencel E, Tabakan I, Kokacya O, Yavuz M. Reconstruction of Achilles region defects: A single-centre experience. Int J Clin Pract 2021; 75:e14908. [PMID: 34547158 DOI: 10.1111/ijcp.14908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/11/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to the use of free flaps. The aim of this study was to discuss reconstruction options and to help the surgeon to select reliable approach to achieve favourable outcomes. METHOD In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single centre. RESULTS Reconstructions were performed with secondary healing (n = 2), negative pressure wound therapy and skin grafting (n = 2), free flaps (n = 6) and local and distant flaps (n = 4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting. CONCLUSION Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. The use of special digital imaging techniques facilitates flap surgery and helps minimise the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Super-thin free flaps offer a distinct advantage in skillful hands. The use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favourable outcomes.
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Affiliation(s)
- Cengiz Eser
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ozgun Ilke Karagoz Ceylan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Eyuphan Gencel
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ibrahim Tabakan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Omer Kokacya
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Metin Yavuz
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
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19
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Arshad Z, Lau EJS, Leow SH, Bhatia M. Management of chronic Achilles ruptures: a scoping review. INTERNATIONAL ORTHOPAEDICS 2021; 45:2543-2559. [PMID: 34089355 PMCID: PMC8514369 DOI: 10.1007/s00264-021-05102-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 05/25/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE This scoping review aims to systematically map and summarise the available evidence on the management of chronic Achilles ruptures, whilst identifying prognostic factors and areas of future research. METHODS A scoping review was performed according to the frameworks of Arksey and O'Malley, Levac and Peters. A computer-based search was performed in PubMed, Embase, EmCare, CINAHL, ISI Web of Science and Scopus, for articles reporting treatment of chronic Achilles ruptures. Two reviewers independently performed title/abstract and full text screening according to pre-defined selection criteria. RESULTS A total of 747 unique articles were identified, of which 73 (9.8%) met all inclusion criteria. A variety of methods are described, with flexor hallucis longus tendon transfer being the most common. The most commonly reported outcome is the American Orthopaedic Foot and Ankle Society (AOFAS) score, although 16 other measures were reported in the literatures. All studies comparing pre- and post-operative outcomes reported significant post-treatment improvement. Complications were reported in 50 studies, with an overall pooled complication rate of 168/1065 (15.8%). CONCLUSION Although beneficial results were reported following a variety of techniques, comparison between these is challenging due to the low-level study designs used and confounding factors such as treatment delay and tendon gap size. Further research comparing the efficacy of different techniques is required in order to facilitate the development of an evidence-based treatment protocol. Such work would allow clinicians to better understand the suitability of the large variety of reported techniques and select the optimal strategy for each individual patient.
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Affiliation(s)
- Zaki Arshad
- School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Box 111, Cambridge, CB2 0SP, UK.
| | - Edward Jun Shing Lau
- School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Box 111, Cambridge, CB2 0SP, UK
| | - Shu Hui Leow
- School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Box 111, Cambridge, CB2 0SP, UK
| | - Maneesh Bhatia
- Department of Trauma and Orthopaedic Surgery, University Hospitals Leicester NHS Trust, University Hospitals of Leicester Headquarters, Balmoral Building, Level 3, Leicester, UK
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20
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Gunaratne R, Chong YC, Heng Y, Hahn J, Lek J, Randazzo A, Brankov B. Chronic Achilles tendon rupture: a novel modification of surgical technique described by El Shewy. ANZ J Surg 2021; 91:1447-1450. [PMID: 33956383 DOI: 10.1111/ans.16921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic Achilles tendon rupture is commonly defined as a rupture presenting 6 weeks after the time of injury and operative management is recommended. This research aims to describe a novel modified surgical technique in the repair of chronic Achilles tendon rupture and to report the result of this technique. METHODS This is a retrospective study performed between January 2007 and January 2017, and a novel modification of El Shewy et al.'s surgical technique is described. Fifteen patients with chronic rupture of Achilles tendon repaired with the technique by a single experienced surgeon were identified. Patients were contacted via phone call and questionnaires completed. Achilles Tendon Rupture Score and pain score were assessed via questionnaires. RESULTS Thirteen patients were contacted and two patients were uncontactable. Ten patients were able to return to their premorbid level of function. Twelve patients were satisfied or very satisfied with the outcome. Only one patient was very dissatisfied with the outcome. The average Achilles Tendon Rupture score was 72 (n = 7, 54%). The average pain score was 1.23 (n = 13, 100%). CONCLUSIONS This novel modified surgical technique demonstrated good functional outcomes and high levels of patient satisfaction in patient with chronic Achilles tendon rupture. It can be considered in the repair of chronic Achilles tendon rupture.
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Affiliation(s)
- Rajitha Gunaratne
- Orthopaedic department, Fremantle Hospital, Fremantle, Western Australia, Australia.,Curtin University, Perth, Western Australia, Australia.,Orthopaedic Department, Joondalup Health Campus, Perth, Western Australia, Australia
| | - Yu Chuan Chong
- Orthopaedic department, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Yi Heng
- Orthopaedic department, Fremantle Hospital, Fremantle, Western Australia, Australia.,Orthopaedic Department, Joondalup Health Campus, Perth, Western Australia, Australia
| | - Jayhee Hahn
- Orthopaedic Department, Joondalup Health Campus, Perth, Western Australia, Australia
| | - Jeremy Lek
- Orthopaedic Department, Joondalup Health Campus, Perth, Western Australia, Australia
| | - Amy Randazzo
- Orthopaedic department, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Boris Brankov
- Orthopaedic department, Fremantle Hospital, Fremantle, Western Australia, Australia
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21
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Mosseri AV, Calaj P, Casciato DJ, Singh BN. Arthroscopic, Single-Incision, and Double-Incision Approaches to Flexor Hallucis Longus Tendon Transfer Following Achilles Tendon Rupture: A Literature Review. J Am Podiatr Med Assoc 2021; 111:466700. [PMID: 34144580 DOI: 10.7547/18-046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Achilles tendon rupture is a common athletic injury that results in a painful and antalgic gait. Flexor hallucis longus tendon transfer through arthroscopic, single-incision, or double-incision techniques is used as a treatment approach to address this rupture; however, no studies have compared postoperative complications between these three techniques. A systematic search of published articles was conducted using keywords "Achilles rupture," "flexor hallucis tendon," "transfer," and "recovery." Articles were then selected based on their title, abstract, and content following full-text review. From each article's reported surgical outcomes, a comparison was made between arthroscopic and single- and double-incision postoperative complications using a χ2 test with significance set at a value of P < .05 followed by post hoc analysis. The arthroscopic approach maintained the lowest rate of postoperative complications, followed by the single- and double-incision techniques. A significant difference in the number of postoperative complications was found between all incisional approaches. The pairwise comparisons, however, could not identify which incisional approaches significantly differed between each other. A reduction in postoperative complications places arthroscopy and the single-incision techniques as the preferred approaches for flexor hallucis longus tendon transfer following an Achilles tendon rupture. Although current literature shows arthroscopy to be superior to single- and double-incision methods, this review demonstrates the need for a greater number of published cases using arthroscopy to establish significance regarding postoperative complications.
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22
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Ishikura H, Fukui N, Iwasawa M, Ohashi S, Tanaka T, Tanaka S. Fracture of ossified Achilles tendons: A review of cases. World J Orthop 2021; 12:207-213. [PMID: 33959484 PMCID: PMC8082505 DOI: 10.5312/wjo.v12.i4.207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/27/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
Fracture of an ossification of the Achilles tendon (OAT) is a rare entity, and its etiology, pathology, and treatment remain unclear. We reviewed and scrutinized 18 cases (16 articles) of the fracture of an OAT. The most common etiologies of the ossifications include previous surgery and trauma. The fractures often occur without any trigger or with minimal trigger. The long, > 5 cm, ossification in the body of the Achilles tendon may have a higher risk of fracture. The OAT itself is often asymptomatic; however, its fracture causes severe local pain, swelling, and weakness of plantar flexion, which forces patients to undergo aggressive treatments. Regarding the treatments of the fractures, nonoperative treatment by immobilizing ankle joint could be an option for elderly patients. However, because it often cannot produce satisfactory results in younger patients, surgical treatment is typically recommended. Excision of the fractured mass and repairing the tendon is applicable if the remnant is enough. If there is a defect after the excision, reconstruction with autologous grafts or adjacent tendon transfer is performed. Gastrocnemius fascia turndown flap, hamstring tendon and tensor fascia lata are used as autologous grafts, whereas peroneus brevis and flexor hallucis longus tendons are used for the tendon transfer. If the fracture of an OAT is treated properly, the functional result will be satisfactory.
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Affiliation(s)
- Hisatoshi Ishikura
- Department of Orthopedic Surgery, University of Tokyo, Tokyo 113-8655, Bunkyo-ku, Japan
| | - Naoshi Fukui
- Department of Orthopedic Surgery, National Hospital Organization, Sagamihara Hospital, Sagamihara 252-0392, Kanagawa Prefecture, Japan
| | - Mitsuyasu Iwasawa
- Department of Orthopedic Surgery, National Hospital Organization, Sagamihara Hospital, Sagamihara 252-0392, Kanagawa Prefecture, Japan
| | - Satoru Ohashi
- Department of Orthopedic Surgery, National Hospital Organization, Sagamihara Hospital, Sagamihara 252-0392, Kanagawa Prefecture, Japan
| | - Takeyuki Tanaka
- Department of Orthopedic Surgery, University of Tokyo, Tokyo 113-8655, Bunkyo-ku, Japan
| | - Sakae Tanaka
- Department of Orthopedic Surgery, University of Tokyo, Tokyo 113-8655, Bunkyo-ku, Japan
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Winson DMG, MacNair R, Hutchinson AM, Owen NJ, Evans R, Williams P. Delayed Achilles tendon rupture presentation: Non-operative management may be the SMART choice. Foot (Edinb) 2021; 46:101724. [PMID: 33039246 DOI: 10.1016/j.foot.2020.101724] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/04/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This biomechanical study aims to assess the function of patients who were treated non-operatively for delayed diagnosis Achilles tendon rupture. Patients were treated using the Swansea Morriston Achilles Rupture Treatment protocol (SMART), which is a physiotherapy led non-operative treatment program. METHODS 19 patients (16M:3F) were enrolled and prospectively assessed using Achilles Repair Scores (ARS)/Achilles Tendon Rupture Scores (ATRS) (PROMS), Ankle ROM and isokinetic peak torque for plantarflexion of the ankle. MRI scans of both the injured and uninjured TA were performed to compare both AP diameter and length. RESULTS Both ATRS and ARS improved between short- and long-term follow-up. The mean difference in plantar torque between the injured and uninjured leg was 21.9%. There was no significant difference in ankle plantarflexion or dorsiflexion. There was no significant difference in length of the injured and uninjured TA on MRI. Three patients failed the SMART protocol requiring surgical fixation. DISCUSSION The SMART protocol can be an effective method of treatment even in younger and active patients especially if delay to treatment is less than 12 weeks. It may still be preferable for patients with a large gap size or high functional demand to elect for surgical intervention, but clinicians should consider the SMART protocol as an alternative to surgery and discuss it with some patients as a viable alternative.
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Affiliation(s)
- Daniel M G Winson
- Trauma and Orthopaedic Department, Morriston Hospital, Swansea SA6 6NL, UK.
| | - Rory MacNair
- Radiology Department, Morriston Hospital, Swansea SA6 6NL, UK
| | | | - Nick J Owen
- Applied Biomechanics Department, Swansea University, Singleton Park, Swansea SA2 8PP, UK
| | - Rhodri Evans
- Radiology Department, Morriston Hospital, Swansea SA6 6NL, UK
| | - Paul Williams
- Trauma and Orthopaedic Department, Morriston Hospital, Swansea SA6 6NL, UK
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Tsukada K, Yasui Y, Kubo M, Miki S, Matsui K, Sasahara J, Kawano H, Miyamoto W. Operative Outcome of Side-Locking Loop Suture Technique Accompanied by Autologous Semitendinosus Tendon Grafting for Chronic Rupture of Achilles Tendon. FOOT & ANKLE ORTHOPAEDICS 2021; 6:24730114211003541. [PMID: 35097441 PMCID: PMC8564925 DOI: 10.1177/24730114211003541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The purpose of this retrospective study was to clarify the operative outcomes of the side-locking loop suture (SLLS) technique accompanied by autologous semitendinosus tendon grafting for chronic Achilles tendon rupture. Methods: A chart review was conducted of consecutive patients treated with the SLLS technique at our department from 2012 to 2017. Postoperatively, a below-knee splint was applied for 2 weeks in 20 degrees of plantar flexion and then active range of motion exercise was started. Partial weightbearing exercise was allowed at 4 weeks according to patient tolerance, and full weightbearing without crutches was allowed at 8 weeks. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score and the Achilles tendon rupture score (ATRS) were used to evaluate clinical outcomes preoperatively and at the final follow-up. Results: Ten patients (6 men, 4 women) were included in the analysis. Mean AOFAS ankle-hindfoot scale score increased significantly from 64.2 ± 5.6 points preoperatively to 95.0 ± 5.3 points at the final follow-up ( P < .001). The mean ATRS also increased significantly from 29.8 ± 4.4 points to 86.2 ± 7.7 points, respectively ( P < .001). Mean time between surgery and ability to perform 20 continuous double-leg heel raises of the operated foot was 13.5 ± 3.4 (range 10-18) weeks. One patient complained of postoperative hypoesthesia in the foot, which had spontaneously resolved by 3 months after surgery. Conclusion: The SLLS technique accompanied by autologous semitendinosus tendon grafting provided successful operative outcomes for patients with chronic Achilles tendon rupture regardless of the size of the defect, and thus long-term orthotic use was not needed after surgery. Level of Evidence: Level IV, retrospective case series.
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Affiliation(s)
- Keisuke Tsukada
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Itabashi, Tokyo, Japan
| | - Youichi Yasui
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Itabashi, Tokyo, Japan
| | - Maya Kubo
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Itabashi, Tokyo, Japan
| | - Shinya Miki
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Itabashi, Tokyo, Japan
| | - Kentaro Matsui
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Itabashi, Tokyo, Japan
| | - Jun Sasahara
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Itabashi, Tokyo, Japan
| | - Hirotaka Kawano
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Itabashi, Tokyo, Japan
| | - Wataru Miyamoto
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Itabashi, Tokyo, Japan
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Rider CM, Hansen OB, Drakos MC. Hamstring Autograft Applications for Treatment of Achilles Tendon Pathology. FOOT & ANKLE ORTHOPAEDICS 2021; 6:2473011421993458. [PMID: 35097432 PMCID: PMC8702928 DOI: 10.1177/2473011421993458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Carson M. Rider
- Foot and Ankle Service, Hospital for Special Surgery, New York, NY, USA
| | - Oliver B. Hansen
- Foot and Ankle Service, Hospital for Special Surgery, New York, NY, USA
| | - Mark C. Drakos
- Foot and Ankle Service, Hospital for Special Surgery, New York, NY, USA
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26
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Jain M, Tripathy SK, Behera S, Das SS, Rana R, Gantaguru A. Functional outcome of gastrocnemius advancement flap augmented with short flexor hallucis longus tendon transfer in chronic Achilles tear. Foot (Edinb) 2020; 45:101704. [PMID: 33038661 DOI: 10.1016/j.foot.2020.101704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 05/17/2020] [Accepted: 05/19/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are various techniques of Achilles tendon (TA) repair and reconstruction in chronic Achilles tear. However, there is no clear consensus on the relevance of one method over the other. The short flexor hallucis longus tendon (FHL) transfer has recently gained popularity because of its same phasic action, ease of harvesting and tensile strength. METHODOLOGY Fifteen chronic Achilles tear (>6 weeks) were treated with tendon repair using gastrocnemius advancement flap augmented with FHL transfer. The patients were followed-up at 1.5, 3, 6, 12 and 24 months. The clinical outcome at latest follow-up was evaluated using the American Orthopedic Foot and Ankle Score (AOFAS) and the Achilles Tendon Rupture Score (ATRS). RESULTS The mean age was 43.5 ± 12.4 years and the median time from injury to surgery was 17.13 ± 9.64 weeks. The mean gap between the retracted ends of the ruptured tendon was 5.67 ± 1.63 cm (range 4-10 cm). The mean follow-up was 19.07 ± 3.15 months (range, 13-24 months). The mean AOFAS and ATRS improved from 72.07 ± 8.29 (62-83) to 98.4 ± 2.03 (94-100) and 61.73 ± 8.16 (52-70) to 98 ± 1.85 (94-100) respectively (paired t-test, p-value 0.0001). All patients resumed their pre-injury daily activities, and there was no donor site morbidity. Two patients had sterile serous discharge, and one patient had a staphylococcus infection. These patients responded to debridement with prolonged antibiotic therapy. There were no nerve injuries or re-rupture. CONCLUSION The functional outcome of chronic Achilles tear treated with gastrocnemius advancement flap augmented with short FHL transfer is rewarding.
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Affiliation(s)
- Mantu Jain
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India.
| | - Sujit Kumar Tripathy
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India.
| | - Sudarsan Behera
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India.
| | - Sudhanshu Sekhar Das
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India
| | - Rajesh Rana
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India
| | - Amrit Gantaguru
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India
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Borah DN, Rai S, Frank HC, Dutta A. Repair of chronic Achilles tendon rupture using Bosworth’s technique. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491720972713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: A large number of ruptures of the Achilles tendon occurs in the watershed hypovascular region (zone II) of the tendon which is approximately 2–6 cm proximal to the insertion of tendon at calcaneum. Chronic Achilles tendon rupture in the watershed area makes end to end repair of tendon less feasible and the neglected distal stump is often inapt for repair. A number of surgical techniques have been described for repair of chronic Achilles tendon in zone II. Our study was conducted with the objective of determining the efficacy and functional outcome of Bosworth’s technique that involves gastrocnemius-soleus turndown of proximal Achilles tendon. Materials and Methods: The study was conducted in a total of five patients with chronic tear of Achilles tendon and the Bosworth technique was used for repair in all the patients. All the patients were followed up for a period of 1 year and the functional outcome was assessed by scoring system devised by Leppilahti et al. Results: four out of the five patients showed excellent functional at the end of 1 year follow up. A good functional outcome was seen in one of the patients. All the patients were able to resume work 6 months postoperatively. Conclusion: The Bosworth’s technique is an excellent surgical procedure for repair of chronic Achilles tendon rupture in the watershed zone of the tendon.
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Affiliation(s)
- Dhruba Narayan Borah
- Department of Orthopaedic Surgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Siddhartha Rai
- Department of Orthopaedic Surgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Herman Conrad Frank
- Department of Orthopaedic Surgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Anshuman Dutta
- Department of Orthopaedic Surgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
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A histological study on the tendons at chiasma plantare in pes cavus. Morphologie 2020; 105:54-63. [PMID: 33129658 DOI: 10.1016/j.morpho.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION In the dysfunction of large muscles of the leg, tendon transfer surgery is found to be very helpful in restoring the normal function of these muscles. The tendons involved in the chiasma plantare play a major role in this regard. OBJECTIVE The present cadaveric study has been carried out in cadavers presenting pes cavus. MATERIAL AND METHODS Cadaveric feet presenting pes cavus were identified based on their foot prints. All these tendons and their interconnections were subjected to histological procedures. The sections of the tendons were stained with hematoxylin and eosin in order to identify the underlying pathologies in the tendons. RESULTS Various types of tendinous interconnections between the tendons of flexor digitorum longus and flexor hallucis longus were noted. The histological findings showed infiltration of lymphocytes in the tendon sheath indicating tenosynovitis and tendinitis. This could be attributed to the compression of the tendons. A few tendons were also stretched due to the skeletal framework of the foot in pes cavus. The bones along the medial longitudinal arch in pes cavus feet could tend to develop spurs or elongated tuberosity that could impinge on the tendons causing the tendons to stretch and elongate. CONCLUSION In harvesting the tendons for grafting, the surgeons must be aware about the pathologies involved, such as tendinitis or tenosynovitis, in order to reduce the time taken for the healing of the graft post-surgery. These variations and histological findings can sub-serve as an efficient guide for the restoration of non-functioning muscles of the lower limb.
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29
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Apinun J, Jenvorapoj S, Arirachakaran A, Kongtharvonskul J. Clinical outcomes of chronic Achilles tendon rupture treated with flexor hallucis longus grafting and flexor hallucis longus grafting plus additional augmentation: A meta-analysis. Foot Ankle Surg 2020; 26:717-722. [PMID: 31635958 DOI: 10.1016/j.fas.2019.09.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 08/25/2019] [Accepted: 09/19/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of chronic Achilles tendon rupture is still controversial. Many surgical procedures have been proposed and claim to have good post-operative clinical outcomes. These techniques include direct repair, V-Y flap, turndown flap, peroneus brevis tendon graft, flexor digitorum longus graft, FHL graft, semitendinosus graft, gracilis tendon graft or synthetic material. The two surgical techniques that are widely used include FHL grafting and the combination of FHL grafting plus additional augmentation. This meta-analysis was conducted with the purpose of comparing clinical outcomes of flexor hallucis longus (FHL) grafting and the combination of FHL grafting with additional augmentation techniques in the treatment of chronic Achilles tendon rupture. METHODS Systematic literature searches were conducted on Medline, Embase and Scopus from their inception to April 4, 2019, and proceedings of reference list and scientific meetings were also searched. Relevant clinical studies (e.g., observational, cross-sectional, cohort or randomized controlled trial (RCT)) that reported AOFAS (American Orthopedic Foot Ankle Score) and postoperative complications of either technique were identified. RESULTS Six studies (N = 68) were included for the analysis of FHL, and six studies (N = 124) were included for analysis of FHL with augmentation. A pooling of mean and standard deviation of preoperative and postoperative AOFAS were 57.09 (3.63), 92.97 (22.67) in FHL group and 66.92 (3.16), 95.25 (4.71) in FHL with additional augmentation group respectively. The pooled UMD of AOFAS in FHL with additional augmentation were 2.28 (-1.86, 6.42) scores higher when compared to the FHL group. The prevalence of complications in FHL and FHL with additional augmentation were 14 (N = 120) and 10 (N = 63) patients. The chance of having complications of FHL with additional augmentation group was 0.74 (95% CI: 0.35, 1.56) lower than FHL group. However, there is no statistically significant difference. CONCLUSIONS FHL with additional augmentation group has higher foot function scores (AOFAS) and lower complications when compared to the FHL group. However this did not reach to statistically significant. Further research that assesses a larger sample size of RCTs is necessary to further evaluate FHL with additional augmentation and FHL in the treatment of chronic Achilles tendon rupture.
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Affiliation(s)
- Jirun Apinun
- Orthopaedic Department, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Somjet Jenvorapoj
- Orthopaedic Department, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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TÜZÜN HY, ERŞEN Ö, TÜRKKAN S, ARSENİSHVİLİ A, KÜRKLÜ M. Perkütan Aşil tendon rüptürü tamiri: güvenli ve güvenilir mi? EGE TIP DERGISI 2020. [DOI: 10.19161/etd.790413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Zhang X, Ruan F, Wu Y, Lu H. Chronic bilateral asynchronous achilles tendon rupture treated using modified whole flexor hallucis longus transfer reconstruction: A case report. Medicine (Baltimore) 2020; 99:e21742. [PMID: 32871894 PMCID: PMC7458198 DOI: 10.1097/md.0000000000021742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Achilles tendon rupture is common, but bilateral ruptures are very rare. Treatment of chronic Achilles tendon rupture is very challenging due tendon retraction and atrophied. We report a case of bilateral asynchronous Achilles tendon rupture patient who was treated with modified minimally invasive whole flexor hallucis longus (FHL) tendon transfer to repair the defects. PATIENT CONCERNS A 52-year-old male farmer presented to our hospital complaining of bilateral heel pain that had disrupted his walking for 6 months. The patient had been misdiagnosed and under-treated for 1 year. Physical examination showed that his plantar flexors were tender and weak, with marked hypotrophy of the calf muscles. Bilateral ankle radiographs of both X-ray and computed topography (CT) revealed no bone injure. DIAGNOSIS Magnetic resonance imaging (MRI) indicated a bilateral Achilles tendon rupture. The diagnosis was further confirmed by postoperative histological examination, which revealed Achilles tendonitis accompanied by regional calcification and chondrometaplasia. INTERVENTIONS Surgical reconstruction of the ruptured Achilles tendons was done through a modified minimally invasive whole FHL tendon transfer followed by physiotherapy. OUTCOMES The patient was immobilized in a cast for the next 6 weeks, gradual weight bearing gradually was then encouraged for another 6 weeks, and full weight-bearing started 3 months after surgery. By 6-month postoperation, the patient could walk and jog normally returned to his pre-injury working condition. CONCLUSION Surgical intervention is among the primary treatment of chronic Achilles tendon rupture. However, one of the challenges in its treatment is providing suitable graft for tendon reconstruction. Our case presents a successful reconstruction procedure using less-invasive whole FHL transfer technique. This surgical technique provides satisfactory clinical and functional outcome and can be considered for future therapy.
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Affiliation(s)
| | - Feng Ruan
- Department of Emergency Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | | | - Huang Lu
- Department of Orthopedic Surgery
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Polidoro F, Rea R, Fascione F, Salini V, Belluati A. Neglected complete bilateral achilles tendon rupture. clinical case presentation, treatment and follow-up. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:179-182. [PMID: 32555094 PMCID: PMC7944814 DOI: 10.23750/abm.v91i4-s.9518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/10/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM OF THE WORK subcutaneous Achilles tendon lesions are common degenerative tendon tears, often related to sport activities, multiple pharmacotherapies and internal medical comorbidities. Neglect an Achilles tendon lesion can affect walk ability, while neglect a bilateral lesion could really lead to a serious limitation of self-sufficiency in daily living. We report a case of chronic bilateral Achilles tendon lesion successful treated with LARS augmentation, along with some clinical considerations concerning the clinical outcome. METHODS we report a case of a chronic bilateral Achilles tendon lesion in an elderly man with multiple comorbidities, successful treated with LARS reconstruction, along with some considerations concerning possible intraoperative issues and the clinical outcome. RESULTS good functional result was obtained as documented with pre and postoperative American Orthopedic Foot And Ankle Society Scale and the "Foot And Ankle Disability Index", without complications. CONCLUSIONS a bilateral Achilles tendon rupture is a very disabling pathology, that needs prompt diagnosis and treatment to prevent further complications. LARS reconstruction could be an effective method in selected patients to avoid some intraoperative issues related to patient comorbidities and ability to follow complex postoperative rehabilitation protocols. (www.actabiomedica.it).
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Stenroos AJ, Brinck T. Achilles Tendon Reconstruction with Semitendinous Tendon Grafts Is Associated with a High Complication Rate. J Am Podiatr Med Assoc 2020; 110:436389. [PMID: 32556230 DOI: 10.7547/18-014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND In the presence of a large gap where end-to-end repair of the torn Achilles tendon is difficult and V-Y advancement would likely be insufficient, augmentation is sometimes required. At our institute we have used primarily the hamstring autograft augmentation technique for the past two decades. The aim of this study was to analyze the complications after surgical treatment of Achilles tendon rupture with semitendinous tendon augmentation. METHODS We retrospectively analyzed 58 consecutive patients treated with semitendinous tendon autograft augmentation at the Helsinki University Hospital between January 1, 2006, and January 1, 2016. RESULTS During the study period, 58 patients were operated on by six different surgeons. Of 14 observed complications (24%), seven were major and seven were minor. Most of the complications were infections (n = 10 [71%]) The infections were noted within a mean of 62 days postoperatively (range, 22-180 days). Seven patients with a complication underwent repeated operation because of skin edge necrosis and deep infection (five patients), hematoma formation (one patient), and a repeated rupture (one patient). CONCLUSIONS In light of the experience we have had with autologous semitendinous tendon graft augmentation, we cannot recommend this technique, and, hence, we should abandon reconstruction of Achilles tendon ruptures with autologous semitendinous tendon grafts at our institute. Instead, other augmentation techniques, such as flexor hallucis longus tendon transfer, should be used.
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Affiliation(s)
- Antti J Stenroos
- Department of Orthopedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
| | - Tuomas Brinck
- Department of Orthopedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
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Veronesi F, Borsari V, Contartese D, Xian J, Baldini N, Fini M. The clinical strategies for tendon repair with biomaterials: A review on rotator cuff and Achilles tendons. J Biomed Mater Res B Appl Biomater 2019; 108:1826-1843. [PMID: 31785081 DOI: 10.1002/jbm.b.34525] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 10/07/2019] [Accepted: 11/09/2019] [Indexed: 12/19/2022]
Abstract
Tendon repair is a complex process due to the low tenocyte density, metabolism, and vascularization. Tears of rotator cuff (RCT) and Achilles tendons ruptures have a major impact on healthcare costs and quality of life of patients. Scaffolds are used to improve the healing rate after surgery and long-term results. A systematic search was carried out to identify the different types of scaffolds used during RCT and Achilles tendon repair surgery in the last 10 years. A higher number of clinical studies were reported on RCT ruptures. Biological scaffolds were used more than synthetic ones, for both rotator cuff and Achilles tendons. Moreover, platelet-rich plasma (PRP)-based scaffolds were the most widely used in RCT. A different type of synthetic scaffold was used in each of the five studies found. Biological scaffolds either provide variable results, in particular PRP-based ones, or poor results, such as bovine equine pericardium. All the synthetic scaffolds demonstrated a significant increase in clinical and functional scores in biomechanics, and a significant decrease in pain and re-tear rate in comparison to conventional surgery. Despite the limited number of studies, further investigation in the clinical use of synthetic scaffolds should be carried out.
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Affiliation(s)
- Francesca Veronesi
- Laboratory of Preclinical and Surgical Studies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Veronica Borsari
- Laboratory of Preclinical and Surgical Studies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Deyanira Contartese
- Laboratory of Preclinical and Surgical Studies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Jie Xian
- Laboratory for Orthopedic Pathophysiology and Regenerative Medicine, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.,Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | - Nicola Baldini
- Laboratory for Orthopedic Pathophysiology and Regenerative Medicine, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.,Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | - Milena Fini
- Laboratory of Preclinical and Surgical Studies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Zhao XY, Zhao HW, Yu M, Zheng ZH, Tang Y, Cui MM, Sun XY, Qin XZ, Liu YQ. Anatomical Study of the Compositions and Internal Connections of the Chiasma Plantare (Master Knot of Henry): Exploring Its Possible Clinical Impact. J Foot Ankle Surg 2019; 58:1235-1244. [PMID: 31494029 DOI: 10.1053/j.jfas.2018.09.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/08/2018] [Accepted: 09/09/2018] [Indexed: 02/03/2023]
Abstract
The purposes of this study were to integrate the types of interconnecting fibers among components of the chiasma plantare and to deduce their flexion actions. The chiasma plantare and the long flexor tendons in 52 cadaveric feet (26 left feet and 25 right feet) were dissected and removed via gross anatomic dissection. The connections among the flexor digitorum longus (FDL), flexor hallucis longus (FHL), and quadratus plantae (QP) were then classified and analyzed. The connection between the FHL and FDL was type I in 43 (86%) cases, type III in 2 (4%) cases, and type V in 5 (10%) cases, with the FHL manipulating the first through third toes and the FDL manipulating the first through the fifth toes. The shape of the QP in 28 (56%) cases exhibited a 2-headed QP, and in 22 (44%) cases, a medial-headed QP. The composition of the chiasma plantare was 2 layers in 28 (56%) cases and 3 layers in 22 (44%) cases: 9 (18%) cases were type a, 2 (4%) cases were type b1, and 1 (2%) case each was classified as type b2 and b3. The FHL controlled the second toe in 10 (20%) cases; both the second and third toes in 27 (54%) cases; and the second, third, and fourth toes in 13 (26%) cases. The QP manipulated the third and fourth toes in all cases, the second toe in 38 (76%) cases, and the fifth toe in 11 (22%) cases. These data suggest that such variations might result from tendon transfer. In conclusion, we considered the FDL to be more advanced for the recovery of both the ankle and the forefoot based on this study.
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Affiliation(s)
- Xin-Yue Zhao
- Undergraduate, Clinical Medicine, Medical College of Yanbian University, Yanji, Jilin Province, China
| | - Hong-Wei Zhao
- Associate Professor, Department of Anatomy, Medical College of Yanbian University, Yanji, Jilin Province, China
| | - Miao Yu
- Undergraduate, Clinical Medicine, Medical College of Yanbian University, Yanji, Jilin Province, China
| | - Ze-Hua Zheng
- Undergraduate, Clinical Medicine, Medical College of Yanbian University, Yanji, Jilin Province, China
| | - Yun Tang
- Undergraduate, Clinical Medicine, Medical College of Yanbian University, Yanji, Jilin Province, China
| | - Miao-Miao Cui
- Undergraduate, Clinical Medicine, Medical College of Yanbian University, Yanji, Jilin Province, China
| | - Xue-Yu Sun
- Undergraduate, Clinical Medicine, Medical College of Yanbian University, Yanji, Jilin Province, China
| | - Xiang-Zheng Qin
- Lecturer, Department of Anatomy, Medical College of Yanbian University, Yanji, Jilin Province, China.
| | - Yan-Qun Liu
- Associate Director Physician, Orthopaedic Department, Yanbian University Hospital, Yanji, Jilin Province, China.
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Abstract
The goal of treatment after Achilles tendon rupture (ATR) is to restore appropriate tension to the tendon, so that normal baseline strength and functional soft-tissue length can be achieved. The assessment of plantarflexion strength has shown widespread variability. The purpose of this study is to document variations in strength assessment after the treatment of ATR in the literature. A comprehensive literature review was performed. In total, 2758 articles were found on Achilles tendon rupture and Achilles tendon strength measurement. The full text of articles including strength as a functional outcome measurement in the abstract were assessed. All objective strength measurements performed were reviewed and recorded for comparison. One-hundred articles were included in our study. In 78 articles, a dynamometer was used to measure strength, whereas in 22 articles, an endurance test (n=14) or formal gait assessment (n=8) was applied. When a dynamometer was used, there was wide variability in the various methods used including the incorporation of both isokinetic (n = 65) and isometric (n = 29) exercises utilizing varying degrees of knee flexion and patient testing position. Furthermore, the number of measurements at certain angular velocities varied. This study illustrates that no general consensus exists regarding an optimal method for measuring strength after ATR. The variability creates difficulty and challenges medical professionals' ability to formulate consistent conclusions when determining functional performance outcomes. A more uniform way of measuring strength after ATR may allow for better comparisons between studies in the literature, potentially leading to a better understanding of strength. Levels of Evidence: Therapeutic, Level II.
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Affiliation(s)
- Henrik C Bäcker
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - Adrian J Yenchak
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - David P Trofa
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - J Turner Vosseller
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
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Abstract
Chronic Achilles tendon ruptures typically are treated with surgical intervention except in low-demand patients or patients who are unable to tolerate surgery. Although several treatment strategies are described, most literature is case reports and case series. There is no widely accepted algorithm or gold standard for surgical treatment of chronic Achilles tendon ruptures. Treatment strategy depends on the size of the tendon gap after excision of nonviable tissue and scar tissue. Smaller gaps can be treated with direct end-to-end repair. Medium-sized gaps can be treated with tendon-lengthening procedures. Tendon transfers, autograft, allograft, xenograft, and synthetic grafting are described for the reconstruction of large defects.
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Affiliation(s)
- Christopher Chen
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 12631 East 17th Avenue, B202, Aurora, CO 80045, USA
| | - Kenneth J Hunt
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 12631 East 17th Avenue, B202, Aurora, CO 80045, USA.
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Arthroskopischer Transfer der Flexor-hallucis-longus-Sehne zum Ersatz der Achillessehne. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-0297-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Khalid MA, Weiss WM, Iloanya M, Panchbhavi VK. Dual Purpose Use of Flexor Hallucis Longus Tendon for Management of Chronic Achilles Tendon Ruptures. Foot Ankle Spec 2019; 12:345-349. [PMID: 30306791 DOI: 10.1177/1938640018803695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Chronic Achilles tendon ruptures are uncommon and increase long-term morbidity when untreated. There is no standard treatment for this condition. Methods: Chronic Achilles tendon rupture was repaired in 10 patients by harvesting the flexor hallucis longus tendon (FHL) using a minimally invasive technique. It was then transferred to the calcaneus and the remnant used to bridge the gap for reconstructing the Achilles tendon itself. The patients were assessed using the American Orthopaedic Foot and Ankle Score (AOFAS) Ankle-Hindfoot Scale. Results: Patients were evaluated postoperatively to assess pain, function, and alignment of the ankle and hindfoot. Average follow-up time was 30.9 months (range = 17-43 months). The average postoperative AOFAS score was 78.5 (range = 54-94). The average postoperative score for pain was 33.5 out of 40; for function, 38.7 out of 50; and for alignment, 6.3 out of 10. A single surgical site infection requiring Incision and Drainage (I&D) was the only operative complication noted. No patient developed a significant deformity of the hallux after transfer. Conclusions: FHL transfer using a minimally invasive harvest for the treatment of chronic Achilles tendon ruptures produces good to excellent outcome measures as judged by an AOFAS score of 75 or greater while minimizing risk to the medial neurovascular bundle. Levels of Evidence: Case series, Level IV: Retrospective.
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Affiliation(s)
- Mohammed A Khalid
- Department of Orthopaedic Surgery and Rehabilitation, Rebecca Sealy Hospital, University of Texas Medical Branch, Galveston, Texas (MAK, MI, VKP).,Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Science Center-El Paso, Texas (WMW)
| | - William M Weiss
- Department of Orthopaedic Surgery and Rehabilitation, Rebecca Sealy Hospital, University of Texas Medical Branch, Galveston, Texas (MAK, MI, VKP).,Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Science Center-El Paso, Texas (WMW)
| | - Michael Iloanya
- Department of Orthopaedic Surgery and Rehabilitation, Rebecca Sealy Hospital, University of Texas Medical Branch, Galveston, Texas (MAK, MI, VKP).,Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Science Center-El Paso, Texas (WMW)
| | - Vinod K Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, Rebecca Sealy Hospital, University of Texas Medical Branch, Galveston, Texas (MAK, MI, VKP).,Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Science Center-El Paso, Texas (WMW)
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So E, Consul D, Holmes T. Achilles Tendon Reconstruction With Bone Block Allograft:Long-Term Follow-Up of Two Cases. J Foot Ankle Surg 2019; 58:779-784. [PMID: 31010771 DOI: 10.1053/j.jfas.2018.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Indexed: 02/03/2023]
Abstract
The treatment of neglected or chronically ruptured Achilles tendon is challenging. Various treatments for large defects associated with chronic Achilles ruptures have been described. Many surgeons recommend the use of a tendon transfer, turndown rotational flap, advancement flap, or reconstruction with Achilles tendon allograft with calcaneal bone block. Long-term outcomes of these procedures are unknown. We present 2 cases with the use of an Achilles tendon with calcaneus bone block allograft. At >8-year follow-up duration, both patients are afforded satisfactory levels of activity and are without pain or gait disturbance. This procedure is a viable option for Achilles ruptures with large defects, ruptures with small intact distal tendon portions, or re-ruptures of previously repaired Achilles tendons. The long-term outcomes of these case reports suggest that Achilles tendon reconstruction with bone block allograft is a viable option.
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Affiliation(s)
- Eric So
- Fellow, The CORE Institute, Phoenix, AZ.
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Tendon allograft for treatment of chronic Achilles tendon rupture: A systematic review. Foot Ankle Surg 2019; 25:252-257. [PMID: 30321974 DOI: 10.1016/j.fas.2018.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/05/2018] [Accepted: 02/02/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND To summarize available evidence and determine if tendon allograft is an effective treatment for chronic Achilles tendon rupture. METHODS A search was performed in the PubMed, Web of Science, Embase and Cochrane Database from 1960 to April 2017 to identify relevant articles. Predefined inclusion and exclusion criteria were applied to identify all eligible articles. RESULTS Total 186 articles were identified through our systematic search. Of these, 9 publications met the inclusion criteria. Five studies were case reports; three were case series; and one were expert opinion. Of a total 35 patients, 34 underwent Achilles tendon allograft repair and 1 peroneus brevis tendon allograft reconstruction. All patients experienced good clinical and functional results, but most reports used non-validated outcome measures. CONCLUSIONS The evidence suggests that tendon allograft offers favorable outcomes in patients with chronic Achilles tendon rupture. However, randomized controlled trials which use validated functional outcome measures are required to determine effectiveness of this intervention. LEVEL OF EVIDENCE Level V, systematic review of Level IV and V studies.
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Flexor hallucis longus transfer versus turndown flaps augmented with flexor hallucis longus transfer in the repair of chronic Achilles tendon rupture. Foot Ankle Surg 2019; 25:221-225. [PMID: 29409187 DOI: 10.1016/j.fas.2017.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/24/2017] [Accepted: 10/26/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Repairs of chronic Achilles tendon ruptures are technically challenging due to large defects after scar excision. Multiple techniques for repair have been proposed but little consensus on best practice established. This study aims to compare flexor hallucis longus (FHL) transfers versus turndown flaps augmented by FHL transfers. METHODS Between 2005 and 2015, 49 unilateral repairs of chronic Achilles tendon ruptures were performed. We retrospectively compared the outcomes of 20 patients who underwent FHL transfer with 19 patients who underwent turndown flaps augmented with FHL transfer before surgery and at three time points after surgery (three, six and twelve months). Visual Analogue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and the 36-Item Short Form Health Survey (SF-36) were used to evaluate outcome. RESULTS Both techniques demonstrated significant improvement in their outcome scores and were comparable to one another. At one year, the mean VAS score was 0 for both groups. The mean AOFAS Ankle-Hindfoot score was 90±11 (FHL) and 95±10 (FHL with turndown flaps); and SF-36 scores showed significant improvements in physical, role and social function scores. Turndown flaps augmented with FHL transfer however required significantly longer operative time (100±21min) compared to FHL transfer alone (73±23min). CONCLUSIONS FHL transfer required significantly less operative time compared to turndown flaps augmented with FHL transfer, with comparable outcomes. FHL transfer is a reliable and effective technique in the repair of chronic Achilles tendon ruptures.
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Lin YJ, Duan XJ, Yang L. V-Y Tendon Plasty for Reconstruction of Chronic Achilles Tendon Rupture: A Medium-term and Long-term Follow-up. Orthop Surg 2019; 11:109-116. [PMID: 30809943 PMCID: PMC6430492 DOI: 10.1111/os.12429] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 12/07/2018] [Indexed: 12/28/2022] Open
Abstract
Objective To evaluate the surgical results of V‐Y tendon plasty in the treatment of chronic Achilles tendon rupture during medium and long‐term follow‐up. Methods Between June 2005 and September 2017, 20 patients with chronic Achilles tendon rupture underwent V‐Y tendon plasty in our hospital. The mean injury‐to‐surgery time was 20.4 weeks (range, 4–96 weeks). The Matles test and an improved Thompson test was used to examine Achilles tendon rupture. These patients were not able to stand on the tiptoes of the injured lower extremity. X‐ray tests ruled out the chance of fracture and were used to examine the Kager triangle. MRI was used to confirm the final diagnosis. The function of the ankle and the foot was assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Achilles Tendon Total Rupture Score (ATRS). V‐Y tendon plasty for Achilles tendon reconstruction was performed. A below‐knee cast was used to keep the ankle in plantar flexion (up to 20°) for 4 weeks. Non‐weight‐bearing exercise was allowed with crutches. After 4 weeks, partial weight‐bearing was allowed. Physical exercises were performed under rehabilitation guidelines. At 10–12 weeks postoperation, patients began to return to daily life activity levels without restrictions. Preoperative and postoperative MRI was obtained. Results The mean follow‐up period was 32.8 months. The mean operative gap of the Achilles tendon after debridement was 5 cm (range, 4–9 cm), with 85% of the gap less than or equal to 6 cm. The mean AOFAS score increased from 59.25 ± 12.28 preoperatively to 96.55 ± 3.75 at final follow‐up (P < 0.05). The mean ATRS score increased from 39.55 ± 14.21 preoperatively to 94.05 ± 4.89 at final follow‐up (P < 0.05). All patients had no recurrent Achilles tendon rupture during the follow up. No patient had developed serious complications, such as sural nerve injury or deep vein thrombosis. Patients were able to return to daily life activity levels without restrictions. At the latest follow‐up, all patients were able to perform repetitive single heel rise on the involved limb, and to walk without a visible limp. All of the postoperative MRI showed the continuity of the Achilles tendon with no signs of cysts or inflammation, indicating perfect healing at the final follow‐up. Conclusions V‐Y tendon plasty can be used in most cases of chronic Achilles tendon rupture. It yields satisfactory functional results and low complication rates. The advantage of this procedure is that it is an easy and economic method without the need for expensive synthetic implants. V‐Y tendon plasty should be considered an acceptable first‐choice treatment.
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Affiliation(s)
- Yang-Jing Lin
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiao-Jun Duan
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Liu Yang
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
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Flexor hallucis longus tendon transfer: a definitive procedure for Achilles tendon tear in Achilles tendinopathy. A 2-year prospective study. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lever CJ, Bosman HA, Robinson AHN. The functional and dynamometer-tested results of transtendinous flexor hallucis longus transfer for neglected ruptures of the Achilles tendon at six years' follow-up. Bone Joint J 2018; 100-B:584-589. [PMID: 29701092 DOI: 10.1302/0301-620x.100b5.bjj-2017-1053.r1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Aims Flexor hallucis longus (FHL) tendon transfer is a well-recognized technique in the treatment of the neglected tendo Achillis (TA) rupture. Patients and Methods We report a retrospective review of 20/32 patients who had undergone transtendinous FHL transfer between 2003 and 2011 for chronic TA rupture. Their mean age at the time of surgery was 53 years (22 to 83). The mean time from rupture to surgery was seven months (1 to 36). The mean postoperative follow-up was 73 months (29 to 120). Six patients experienced postoperative wound complications. Results The mean postoperative Achilles tendon Total Rupture Score (ATRS) was 83 (40 to 100) and the mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 94.3 (82 to 100). Tegner scoring showed a mean reduction of one level from the pre-injury level of activity. There was a mean reduction of 24% (4 to 54) in dynamometer-measured strength of ankle plantarflexion, in comparison with the non-operated side. The hallux had a mean of only 40% (2 to 90) strength of plantarflexion in comparison with the contralateral side. Conclusion We conclude that transtendinous FHL transfer for neglected TA ruptures, with a long harvest to allow reattachment of the triceps surae, provides reliable long-term function and good ankle plantarflexion strength. Despite the loss of strength in hallux plantar flexion, there is little comorbidity from the FHL harvest. Cite this article: Bone Joint J 2018;100-B:584-9.
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Affiliation(s)
- C J Lever
- Wirral University Teaching Hospital, Wirral, UK
| | | | - A H N Robinson
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
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Abubeih H, Khaled M, Saleh WR, Said GZ. Flexor hallucis longus transfer clinical outcome through a single incision for chronic Achilles tendon rupture. INTERNATIONAL ORTHOPAEDICS 2018; 42:2699-2704. [DOI: 10.1007/s00264-018-3976-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/04/2018] [Indexed: 12/26/2022]
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Mao H, Wang L, Dong W, Liu Z, Yin W, Xu D, Wapner KL. Anatomical feasibility study of flexor hallucis longus transfer in treatment of Achilles tendon and posteromedial portal of ankle arthroscopy. Surg Radiol Anat 2018; 40:1031-1038. [PMID: 29663091 DOI: 10.1007/s00276-018-2021-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/03/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of this study was to evaluate the occurrence of anatomical variations of the musculotendinous junction of the flexor hallucis longus (FHL) muscle, the relationship between FHL tendon or muscle and the tibial neurovascular bundle at the level of the posterior ankle joint in human cadavers. METHODS Seventy embalmed feet from 20 male and 15 female cadavers, the cadavers' mean age was 65.4 (range from 14 to 82) years, were dissected and anatomically classified to observe FHL muscle morphology define the relationship between FHL tendon or muscle and the tibial neurovascular bundle. The distance between the musculotendinous junction and the relationship between FHL tendon or muscle and the tibial neurovascular bundle was determined. RESULTS Three morphology types of FHL muscle were identified: a long lateral and shorter medial muscle belly, which was observed in 63 specimens (90%); equal length medial and lateral muscle bellies, this variant was only observed in five specimens (7.1%); one lateral and no medial muscle belly, which was observed in two specimens (2.9%). No statistically significant difference was observed according to gender or side (p > 0.05). Two patterns were identified and described between FHL tendon or muscle and the tibial neurovascular bundle. Pattern 1, the distance between the neurovascular bundle and FHL tendon was 3.46 mm (range 2.34-8.84, SD = 2.12) which was observed in 66 specimens (94.3%); Pattern 2, there was no distance which was observed in four specimens (5.7%). CONCLUSION Knowing FHL muscle morphology, variations provide new important insights into secure planning and execution of a FHL transfer for Achilles tendon defect as well as for the interpretation of ultrasound and magnetic resonance images. With posterior arthroscopic for the treatment of various ankle pathologies, posteromedial portal may be introduced into the posterior aspect of the ankle without gross injury to the tibial neurovascular structures because of the gap between the neurovascular bundle and FHL tendon.
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Affiliation(s)
- Haijiao Mao
- Department of Orthopaedic Surgery, The Affiliated Hospital of Medical school, Ningbo University, No. 247, Renming Road, Jiangbei District, Ningbo, Zhejiang, China.
| | - Linger Wang
- Department of Orthopaedic Surgery, The Affiliated Hospital of Medical school, Ningbo University, No. 247, Renming Road, Jiangbei District, Ningbo, Zhejiang, China
| | - Wenwei Dong
- Department of Orthopaedic Surgery, The Affiliated Hospital of Medical school, Ningbo University, No. 247, Renming Road, Jiangbei District, Ningbo, Zhejiang, China
| | - Zhenxin Liu
- Department of Orthopaedic Surgery, The Affiliated Hospital of Medical school, Ningbo University, No. 247, Renming Road, Jiangbei District, Ningbo, Zhejiang, China
| | - Weigang Yin
- Department of Anatomy, Medical School of Ningbo University, Ningbo, Zhejiang, China
| | - Dachuan Xu
- Department of Anatomy, Southern Medical University, No. 1023 Shatai nan Road, Guangzhou, Guangdong, China
| | - Keith L Wapner
- Department of Orthopaedic Surgery, Pennsylvania Hospital, University of Pennsylvania School of Medicine, Philadelphia, USA
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Liu GT, Balldin BC, Zide JR, Chen CT. A Biomechanical Analysis of Interference Screw Versus Bone Tunnel Fixation of Flexor Hallucis Longus Tendon Transfers to the Calcaneus. J Foot Ankle Surg 2018. [PMID: 28633783 DOI: 10.1053/j.jfas.2017.04.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The flexor hallucis longus tendon transfer is commonly used to restore function in chronic Achilles tendon ruptures and chronic Achilles tendinopathy. The tendon is often secured to the calcaneus either through a bone tunnel or by an interference screw. We hypothesized that tenodesis using the bone tunnel method would be mechanically superior to interference screw fixation for flexor hallucis longus transfers. Eight matched pairs of cadaveric specimens were assigned randomly to the bone tunnel or interference screw technique and were loaded to failure. Biomechanical analysis was performed to evaluate the ultimate strength, peak stress, Young's modulus, failure strain, and strain energy. Unpaired comparison, paired comparison, and linear regression analyses were used to determine statistical significance. A slight 22% ± 9% decrease in Young's modulus and a 52% ± 18% increase of strain energy were found in the interference screw group. However, no differences in ultimate strength, peak stress, or failure strain were seen between the 2 groups on paired comparison. Our findings suggest that interference screw fixation provides similar spontaneous biomechanical properties to the use of a bone tunnel for flexor hallucis longus transfer to the calcaneus. The interference screw is a practical option for fixation of the flexor hallucis longus tendon to the calcaneus and can be performed through a single incision approach.
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Affiliation(s)
- George T Liu
- Associate Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - B Christian Balldin
- Orthopaedic Surgeon, Burkhart Research Institute for Orthopaedics, The San Antonio Orthopaedic Group, San Antonio, TX
| | - Jacob R Zide
- Orthopaedic Surgeon, Orthopaedic Associates of Dallas, Baylor University Medical Center, Orthopaedic Research, and Clinical Assistant Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Christopher T Chen
- Assistant Professor, Division of Mineral Metabolism, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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Anatomical Study of the Neurovascular in Flexor Hallucis Longus Tendon Transfers. Sci Rep 2017; 7:14202. [PMID: 29079740 PMCID: PMC5660160 DOI: 10.1038/s41598-017-13742-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/02/2017] [Indexed: 11/10/2022] Open
Abstract
The transfer of the flexor hallucis longus tendon or flexor digitorum longus tendon is frequently used for the treatment of posterior tibial tendon insufficiency or chronic Achilles tendinopathy. According to several anatomical studies, harvesting the flexor hallucis longus (FHL) tendon may cause nerve injury. Sixty-eight embalmed feet were dissected and anatomically classified to define the relationship between Henry’s knot and the plantar nerves. Two different configurations were identified. In Pattern 1, which was observed in 64 specimens (94.1%), the distance between the medial plantar nerve and Henry’s knot was 5.96 mm (range, 3.34 to 7.84, SD = 1.12). In Pattern 2, which was observed in 4 specimens (5.9%), there was no distance between the medial plantar nerve (MPN) and Henry’s knot. No statistically significant difference was observed according to gender or side (p > 0.05). A retraction was performed to harvest the FHL through the posteromedial hindfoot incision using a single minimally invasive technique, and the medial and lateral plantar nerve lesions were scrupulously assessed. In conclusion, medial and lateral plantar nerve injuries did not occur more frequently, even after performing a single minimally invasive incision to harvest the FHL tendon, due to the large distance between the FHL tendon and the medial and lateral plantar nerves.
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Shoaib A, Mishra V. Surgical repair of symptomatic chronic achilles tendon rupture using synthetic graft augmentation. Foot Ankle Surg 2017; 23:179-182. [PMID: 28865587 DOI: 10.1016/j.fas.2016.04.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 02/14/2016] [Accepted: 04/08/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Surgical repair of symptomatic chronic Achilles tendon (TA) rupture is a challenging problem due to the presence of a large defect between tendon edges. We report the results of surgical repair of symptomatic chronic TA rupture by synthetic graft augmentation. METHODS Seven consecutive patients with a symptomatic chronic TA rupture underwent surgical repair by VY plasty and augmentation with bio-absorbable synthetic graft (Artelon®). In all patients, the intraoperative tendon gap after debridement was more than 5cm (Myerson Grade 3). The total duration of plaster immobilization was 10 weeks. The complications were recorded prospectively and functional outcome was assessed by AOFAS score and Achilles tendon Total Rupture Score (ATRS). RESULTS At a mean follow up of 29 months there was no re-rupture or deep infection. All patients reported good functional outcome as shown by AOFAS and ATRS scores. There were no graft related complications. At final follow up, six patients were able to do single stance heel raise however, calf wasting was noted in all patients. CONCLUSIONS Tendon repair augmented by absorbable synthetic graft is an acceptable technique in Myerson Grade 3 chronic symptomatic TA ruptures. LEVEL OF EVIDENCE Level IV, Case series.
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