Surgical management of chronic Achilles tendon ruptures using less invasive techniques

Transversal calcaneal anchored Achilles tendon reconstruction with free semitendinosus tendon autograft for acute rupture of Achilles tendon: clinical evaluation

Achilles tendon reconstruction is an effective method of repairing Achilles tendon rupture defects. We introduce a new approach for Achilles tendon reconstruction using transversal calcaneal anchored autogenous semitendinosus tendon graft. The study aimed to evaluate the clinical role of this new Achilles tendon reconstruction. We retrospectively enrolled patients who underwent Achilles tendon reconstruction using transversal calcaneal anchored autogenous semitendinosus tendon graft for acute Achilles tendon rupture defects from 2016 to 2021. The clinical and radiological results were assessed at the preoperative and the final postoperative follow-up with Visual Analog Score (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores and Achilles tendon Total Rupture Scores (ATRS). Besides, at the last postoperative follow-up, the difference in ankle range of motion between the two side of the patients and the incidence of postoperative complications were recorded. Results revealed patients had significantly lower VAS and higher AOFAS and ATRS (P < 0.01). Compared to the healthy ankle, the operative ankle showed significant deficits in ankle range of motion (P < 0.01). Additionally, radiological results showed no noticeable signs of tunnel enlargement in the calcaneus and no patient had re-rupture. Transversal calcaneal anchored Achilles tendon reconstruction with free semitendinosus tendon autograft is an effective treatment option for patients with acute Achilles tendon rupture with large defects and have high postoperative exercise demands.

Salvage Reconstruction of a 12-cm Tendon Defect Following Chronic Achilles Rerupture-15-Year Follow-Up: A Case Report

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.

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines

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.

Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts are effective in the treatment of chronic Achilles tendon ruptures - a systematic review

INTRODUCTION

A chronic Achilles tendon rupture (ATR) is defined as an ATR that has been left untreated for more than four weeks following rupture. This systematic review aims to summarize the outcomes of chronic ATR treated using either a gastrocnemius aponeurosis flap or semitendinosus tendon graft.

METHODS

A systematic search was conducted in three databases (PubMed, Scopus and Cochrane), for studies describing outcomes after surgical treatment of chronic ATR using gastrocnemius aponeurosis flaps or semitendinosus tendon grafts with more than 10 patients included. The studies were assessed for quality and risk of bias using the Methodological Items used to assess risk of bias in Non-Randomized Studies (MINORS).

RESULTS

Out of the 818 studies identified with the initial search, a total of 36 studies with 763 individual patients were included in this systematic review. Gastrocnemius aponeurosis flap was used in 21 and semitendinosus tendon graft was used in 13 of the studies. The mean (SD) postoperative Achilles tendon Total Rupture Score (ATRS) for patients treated with a gastrocnemius aponeurosis flap was 83 (14) points and the mean (SD) American Orthopaedic Foot and Ankle Score (AOFAS) was 96 (1.7) points compared with ATRS 88 (6.9) points and AOFAS 92 (5.6) points for patients treated with a semitendinosus tendon graft. The included studies generally had low-quality according to MINORS, with a median of 8 (range 2-13) for all studies.

CONCLUSION

Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts give acceptable results with minimal complications and are valid methods for treating chronic ATR. The main difference is more wound healing complications in patients treated with a gastrocnemius aponeurosis flap and more sural nerve injuries in patients treated with a semitendinosus grafts. The current literature on the subject is of mainly low quality and the absence of a patient-related outcome measure validated for chronic ATR makes comparisons between studies difficult.

LEVEL OF EVIDENCE

Level IV.

Surgical Management of Chronic Achilles Tendon Ruptures: A Systematic Review and Proposed Treatment Algorithm

Background

As no evidence-based treatment guidelines exist for chronic Achilles tendon rupture (CATR), a systematic review of the literature was performed to compare the different treatment options and recommend a literature-based algorithm.

Methods

In June 2022, MEDLINE, Embase, and Cochrane Library databases were systematically reviewed based on the PRISMA guidelines. The level of evidence (LOE) and quality of evidence were evaluated, and statistics on clinical outcomes and complications were calculated.

Results

Twenty-seven studies with 614 patients were included. Three studies were LOE III and 25 studies were LOE IV. The mean Achilles tendon rupture score improved from a preoperative weighted mean of 38.8 ± 12.4 to a postoperative score 90.6 ± 4.7. The overall complication rate was 11.4%. Single techniques were used in 23 studies and dual techniques were used in 5 studies. The FHL tendon transfer was the most frequently used technique. We devised an algorithmic approach based on time from injury to surgical intervention and the length of the gap between the tendon stumps: >3 months: FHL transfer; <3 months (a) gap <2 cm, end-to-end repair; (b) gap 2 to 5 cm, gastrocnemius transfer, (c) gap >5 cm, semitendinosus autograft.

Conclusion

Surgical management of CATR produced improvements in patient-reported outcome scores at midterm follow up, but a high complication rate (11.4%) was noted. Our proposed treatment algorithm may assist in shared decision making for this complex problem.

Long-term outcome of flexor hallucis longus tendon transfer for chronic Achilles tendon rupture with large defect: A retrospective series

There are multiple surgical options for treatment of chronic Achilles tendon (AT) rupture according to the classifications and length of defect. However, no gold standard method has been confirmed, and there is no clear evidence to support the superiority of 1 procedure over others. This study aimed to evaluate the long-term clinical outcome of flexor hallucis longus tendon (FHL) transfer for chronic AT rupture with large defect. Clinical data of patients treated with FHL transfer due to chronic AT rupture between January 2009 and October 2019 were reviewed retrospectively. All cases were presented with AT rupture for more than 4 weeks after injury. The gap between ruptured ends was > 5 cm after debridement in all patients. The harvest of FHL was performed through a single incision in accordance with AT rupture debridement in all cases. Clinical outcomes were assessed with AOFAS ankle-hindfoot scale, Achilles tendon total rupture score and AOFAS hallux metatarsophalangeal-interphalangeal scale. Twenty-eight patients were followed successfully for 62.6 ± 22.2 months. According to the complete datasets obtained from 28 patients, none of the tendons re-ruptured. The AOFAS ankle-hindfoot scale and Achilles tendon total rupture score at last follow-up visit was 90.4 ± 5.7 and 89.8 ± 5.3 respectively, which revealed statistically significant improvement from the preoperative score of 61.1 ± 6.7 and 53.8 ± 8.3. The AOFAS hallux metatarsophalangeal-interphalangeal scale at last follow-up visit was 87.5 ± 6.1. The FHL transfer through a single incision for chronic AT rupture with large defect is a safe and simple method with low risk of morbidity and complications.

Early satisfactory results of percutaneous repair in neglected achilles tendon rupture

PURPOSE

This investigation aimed to study the outcome of percutaneous repair of Achilles tendon ruptures regarding patient-reported and objective outcomes.

METHODS

This is a retrospective review of a cohort of patients (n = 24) who underwent percutaneous repair of neglected Achilles rupture in the period between 2013 and 2019. Included patients were adults with closed injuries, presented 4-10 weeks after rupture, with intact deep sensation. All underwent clinical examination, X-rays to exclude bony injury and MRI for diagnosis confirmation. All underwent percutaneous repair by the same surgeon, using the same technique and rehabilitation protocol. The postoperative assessment was done subjectively using ATRS and AOFAS score and objectively using a percentage of heel rise comparison to the normal side and calf circumference difference.

RESULTS

The mean follow-up period was 14.85 months ± 3 months. Average AOFAS scores at 6,12 months were 91 and 96, respectively, showing statistically significant improvement from pre-op level (P < 0.001). Percentage of heel rise on the affected side and calf circumference showed statistically significant improvement over the 12 month follow up period (P < 0.001). Superficial infection was reported in two patients (8.3%), and two cases reported transient sural nerve neuritis.

CONCLUSION

Percutaneous repair of neglected Achilles rupture using the index technique proved a satisfactory patient-reported and objective measurement at a one-year follow-up. With only minor transient complications.

A Case of Chronic Rupture of Achilles Tendon Managed Using a Combination of Multiple Surgical Techniques

Achilles tendon rupture is a common injury that occurs due to sudden dorsiflexion of the plantar-flexed foot. Both acute and chronic ruptures are frequently misdiagnosed and mistreated. Acute Achilles tendon rupture commonly occurs in middle-aged individuals (30-40 years). Although several operative procedures are available for Achilles tendon repair, the management of choice remains controversial and debatable. A 27-year-old male came to our clinic complaining of pain over the left ankle for the last five months. History revealed trauma caused by a heavy metal object five months ago. Physical examination revealed tenderness and swelling over the left heel. Ankle plantar flexion was restricted, and painful and squeeze test was positive. Magnetic resonance imaging was suggestive of a tear of the Achilles tendon in the left ankle. Surgical management was done with multiple techniques which included flexor hallucis longus tendon graft augmentation, end-to-end suturing (Krackow technique), V-Y plasty, and bioabsorbable suture anchor. Although complications such as scar stiffness and wound gaping are common in such cases, the postoperative outcome was excellent in our case according to the American Orthopedic Foot and Ankle Score.

Minimally invasive excision and reconstruction of Achilles tendon xanthoma using free autologous semitendinosus tendon transfer: a surgical technique

BACKGROUND

Tendon xanthomatosis is often associated with familial hypercholesterolemia, but it can also occur in other medical conditions. The Achilles tendon is the most common site of tendon xanthomas. Reconstruction of large defects after the xanthoma excision, can be challenging.

METHODS

We propose a novel technique for Achilles tendon reconstruction with the use of an ipsilateral autologous semitendinosus tendon graft. The technique consists of six steps.

RESULTS

This procedure has a low rate of complications and provides results that are at least comparable with those reported with other surgical approaches.

Local Tendon Transfers for Chronic Ruptures of the Achilles Tendon: A Systematic Review

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.

Primary augmentation of percutaneous repair with flexor hallucis longus tendon for Achilles tendon ruptures reduces tendon elongation and may improve functional outcome

PURPOSE

Achilles tendon ruptures (ATR) result in loss of strength and function of the gastrosoleus-Achilles tendon complex, probably because of gradual tendon elongation and calf muscle atrophy, even after surgical repair. Flexor hallucis longus (FHL) augmentation not only reinforces the repair and provides new blood supply to the tendon, but also protects the repair, internally splinting the repaired Achilles tendon, maintaining optimal tension. We prospectively compared the clinical outcomes of patients with acute ATR, managed with either percutaneous repair only or percutaneous repair and FHL augmentation.

METHODS

Patients with acute ATR undergoing operative management were divided into two groups. Thirty patients underwent percutaneous repair under local anesthesia, and 32 patients underwent percutaneous repair augmented by FHL tendon, harvested through a 3 cm longitudinal posteromedial incision, and transferred to the calcaneus, under epidural anesthesia. All patients were treated by a single surgeon between 2015 and 2019 and were followed prospectively for 24 months.

RESULTS

The percutaneous only group was younger than the augmented one (35.4 ± 8.0 vs 40.4 ± 6.6 years, p = 0.01). In the augmented group, 25 patients stayed overnight and only 5 were day cases, whereas in the percutaneous only group 4 patients stayed overnight and 28 of them were day cases (p < 0.001). The duration of the procedure was significantly longer in the augmented group (38.9 ± 5.2 vs 13.2 ± 2.2 min, p < 0.001). At 24 months after repair, the Achilles tendon resting angle (ATRA) was better in the augmented group (-0.5 ± 1.7 vs -4.0 ± 2.7, p < 0.001), as was Achilles tendon rupture score (ATRS) (91.7 ± 2.2 vs 89.9 ± 2.4, p = 0.004). Calf circumference of the injured and the non-injured leg did not differ between the groups, as did the time interval to single toe raise and the time interval to walking in tiptoes. Although plantarflexion strength of the operated leg was significantly weaker than the non-operated leg in both groups, the difference in isometric strength of the operated leg between the groups was not significant at 24 months (435 ± 37.9 vs 436 ± 39.7 N, n.s.).

CONCLUSION

Percutaneous repair and FHL tendon augmentation may have a place in the management of acute Achilles tendon ruptures, reducing tendon elongation and improving functional outcome.

LEVEL OF EVIDENCE

Level II.

Return to Sports Activities After Flexor Hallucis Longus Transfer for Neglected Achilles Tendon Rupture

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.

Supervised Physiotherapy Improves Three-Dimensional (3D) Gait Parameters in Patients after Surgical Suturing of the Achilles Tendon Using an Open Method (SSATOM)

BACKGROUND

The aim of this study was to assess the effectiveness of 38 supervised postoperative physiotherapy (SVPh) visits conducted between 1 and 20 weeks after SSATOM on the values of 3D gait parameters measured at 10 and 20 weeks after surgery.

MATERIAL

Group I comprised male patients (n = 22) after SSATOM (SVPh x = 38 visits) and Group II comprised male patients (n = 22) from the control group.

METHODS

A non-randomized, open-label, controlled clinical trial was performed in the two groups to obtain the following values: Step length (cm), stride length (cm), step width (cm), next stance phase (%), swing phase (%), double support (%), gait velocity (m/s), and walking frequency (step/min). The measurements were carried out using the BTS SMART system (Italy).

RESULTS

Orthopedic examination showed no pain, a negative result of Thompson and Matles tests, and proper healing of Achilles tendon (ultrasound image). In Group I, between 10 and 20 weeks after SSATOM, there was a statistically significant improvement in all tested gait parameter values (p ≤ 0.001 to 0.009).

CONCLUSIONS

Conducting 38 SVPh visits significantly improved the values of the analyzed kinematic and spatiotemporal gait parameters in patients in the twentieth week after SSATOM, which were mostly close to the non-operated side and the results of the control group. However, the gait speed and stride length were not close to the results of the control group.

Advances in Regenerative Sports Medicine Research

Regenerative sports medicine aims to address sports and aging-related conditions in the locomotor system using techniques that induce tissue regeneration. It also involves the treatment of meniscus and ligament injuries in the knee, Achilles’ tendon ruptures, rotator cuff tears, and cartilage and bone defects in various joints, as well as the regeneration of tendon–bone and cartilage–bone interfaces. There has been considerable progress in this field in recent years, resulting in promising steps toward the development of improved treatments as well as the identification of conundrums that require further targeted research. In this review the regeneration techniques currently considered optimal for each area of regenerative sports medicine have been reviewed and the time required for feasible clinical translation has been assessed. This review also provides insights into the direction of future efforts to minimize the gap between basic research and clinical applications.

Disappointment and frustration, but long-term satisfaction: patient experiences undergoing treatment for a chronic Achilles tendon rupture—a qualitative study

Background

Delayed treatment of Achilles tendon ruptures is generally due to either misdiagnosis or patient delay. When the treatment is delayed more than 4 weeks, the rupture is defined as “chronic”, and almost always requires more invasive surgery and longer rehabilitation time compared with acute Achilles tendon ruptures. There is insufficient knowledge of patient experiences of sustaining and recovering from a chronic Achilles tendon rupture.

Methods

To evaluate patients’ experiences of suffering a chronic Achilles tendon rupture, semi-structured group interviews were conducted 4–6 years after surgical treatment using a semi-structured interview guide. The data were analyzed using qualitative content analysis described by Graneheim and Lundman.

Results

The experiences of ten patients (65 ± 14 years, 7 males and 3 females) were summarized into four main categories: (1) “The injury”, where the patients described immediate functional impairments, following either traumatic or non-traumatic injury mechanisms that were misinterpreted by themselves or the health-care system; (2) “The diagnosis”, where the patients expressed relief in receiving the diagnosis, but also disappointment and/or frustration related to the prior misdiagnosis and delay; (3) “The treatment”, where the patients expressed high expectations, consistent satisfaction with the surgical treatment, and addressed the importance of the physical therapist having the right expertise; and (4) “The outcomes”, where the patients expressed an overall satisfaction with the long-term outcome and no obvious limitations in physical activity, although some fear of re-injury emerged.

Conclusions

An Achilles tendon rupture can occur during both major and minor trauma and be misinterpreted by both the assessing health-care professional as well as the patient themselves. Surgical treatment and postoperative rehabilitation for chronic Achilles tendon rupture results in overall patient satisfaction in terms of the long-term outcomes. We emphasize the need for increased awareness of the occurrence of Achilles tendon rupture in patients with an atypical patient history.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03103-7.

Slowed-Down Rehabilitation Following Percutaneous Repair of Achilles Tendon Rupture

BACKGROUND

Following percutaneous repair of acute Achilles tendon (AT) ruptures, early postoperative weightbearing is advocated; however, it is debatable how aggressive rehabilitation should be. We compared the clinical and functional outcomes in 2 groups of patients who followed either our "traditional" or a "slowed down" rehabilitation after percutaneous surgical repair.

METHODS

Sixty patients were prospectively recruited to a slowed down (29 patients) or a traditional (31 patients) rehabilitation program. Both groups were allowed immediate weightbearing postoperatively; a removable brace with 5 heel wedges was applied at 2 weeks. In the slowed-down group, 1 wedge was removed after 4 weeks. Gradual removal of the boot took place after 4 wedges were kept for 4 weeks. In the traditional group, 1 wedge was removed every 2 weeks, with removal of the boot after 2 wedges had been kept for 2 weeks. The AT Resting Angle (ATRA) evaluated tendon elongation. Patient reported functional outcomes were assessed using the AT Rupture Score (ATRS). Calf circumference difference and the isometric plantarflexion strength of the gastro-soleus complex were evaluated.

RESULTS

At the 12-month follow-up, both ATRA and ATRS were more favorable in the slowed-down group. The isometric strength and the calf circumference were more similar to the contralateral leg in the slowed-down group than in the traditional one.

CONCLUSION

Following percutaneous repair of acute Achilles tendon patients undergoing slowed down rehabilitation performed better than the traditional one. These conclusions must be considered within the limitations of the present study.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Patient reported outcomes and satisfaction following single incision Flexor Hallucis Longus (FHL) augmentation for chronic Achilles tendon pathologies

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.

Long Term Clinical-Functional and Ultrasound Outcomes in Recreational Athletes after Achilles Tendon Rupture: Ma and Griffith versus Tenolig

Background and Objectives: The purpose of this retrospective study was to compare the long-term clinical-functional and ultrasound outcomes of recreational athletes treated with two percutaneous techniques: Ma and Griffith (M&G) and the Tenolig technique (TT). Materials and Methods: recreational athletes, between 18 and 50 years of age, affected by acute Achilles tendon rupture (AATR), treated by M&G or Tenolig techniques were recruited. Clinical-functional outcomes were evaluated using Achilles Tendon Rupture Score (ATRS), AOFAS Ankle-Hindfoot score, VAS (for pain and satisfaction) questionnaires, and ultrasound analysis (focal thickening, hypoechoic areas, presence of calcifications, tendinitis and alteration of normal fibrillar architecture). Results: 90 patients were included: 50 treated by M&G, 40 by TT. In all, 90% of patients resumed sports activities, with pre-injury levels in 56% of cases after M&G and in 60% after TT. In the M&G group, the averages of the questionnaires were ATRS 90.70 points, AOFAS 91.03, VAS satisfaction 7.08, and VAS pain 1.58. In the TT group: ATRS 90.38 points, AOFAS 90.28, VAS satisfaction 7.76, and VAS pain 1.34. The TT group showed a significantly higher satisfaction and return to sport activities within a shorter time. In the M&G group, ultrasound check showed a significantly greater incidence of thickening and an alteration of fibrillar architecture in the treated tendon. Three infections were reported, including one deep after M&G, two superficial in the TT group, and two re-ruptures in the Tenolig group following a further trauma. Conclusions: At long-term follow-up, M&G and TT are both valid techniques for the treatment of AATRs in recreational athletes, achieving comparable clinical-functional results. However, TT seems to have a higher patient satisfaction rate, a faster return to sports and physical activities, and fewer ultrasound signs of tendinitis. Finally, the cost of the device makes this technique more expensive.

Augmented Repair of Acute Total Achilles Tendon Rupture With Peroneus Brevis Tendon Transfer Using Oblique Transosseous Calcaneal Tunnel: A Prospective Case Series

Acute Achilles tendon rupture is one of the most common tendon injuries. This prospective study aimed to evaluate the functional outcomes of augmented repair of acute Achilles tendon rupture with peroneus brevis tendon transfer and fixation to an oblique calcaneal transosseous tunnel. Functional evaluation was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and Achilles Tendon Total Rupture Score (ATRS). Postoperative complications were recorded. This study included 33 males and 9 females, with a mean age of 26.1 ± 4.2 years. The Achilles tendon ruptures were right in 24 patients and left in 18 patients. The cause of rupture was sports injuries in all patients. The mean distance from the calcaneal insertion to the tear site was 4.4 ± 1.3 cm. The mean time from injury to surgery was 2.4 ± 1.6 days. The mean follow-up time was 40.3 ± 4.9 months. The mean AOFAS and ATRS scores were 99.3 ± 1.2 and 95.9 ± 1.9, respectively, at 12 months of follow-up. The mean time to return to work was 12.1 ± 1.2 weeks. The mean time to return to light sports activities was 16.1 ± 1.8 weeks postoperatively. None of the patients developed re-rupture. Augmented repair of acute Achilles tendon ruptures with peroneus brevis tendon transfer is a robust repair with excellent functional outcomes and early weight-bearing and return to sports activities.

Endoscopic reconstruction for chronic Achilles tendon ruptures using a hamstring tendon autograft

BACKGROUND

To determine the safety and efficacy of endoscopic reconstruction of chronic Achilles tendon ruptures using a hamstring tendon autograft at mid-term follow-up.

METHODS

We reviewed the medical records of patients with chronic Achilles tendon rupture treated surgically by endoscopic reconstruction using a hamstring tendon autograft at our institution between March 2010 and October 2015. Radiologic outcomes were assessed using pre- and postoperative magnetic resonance imaging (MRI). Functional outcomes were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Plantar Flexion Strength (PFS), the Victorian Institute of Sport Assessment-Achilles (VISA-A) scale, the Visual Analogue Scale (VAS) pain score, and the Arner-Lindholm standard. All patients achieved primary healing with no lengthening of the Achilles tendon, skin necrosis, infection, deep vein thrombosis or other complications.

RESULTS

Mean follow-up period was 15 ± 3 months (range, 12-18 months). There was no Achilles tendon re-rupture. MRI examination revealed that Achilles tendon continuity was restored. Patients' mean AOFAS, PFS, and VISA-A scores were significantly higher and mean VAS pain score was significantly lower after surgery compared to before (P < 0.05). According to Arner-Lindholm standards, there were twenty (76.9%) excellent, six (23.1%) good, and zero bad outcomes.

CONCLUSION

Endoscopic reconstruction utilizing a hamstring tendon autograft is a safe and efficacious option for repair of chronic Achilles tendon ruptures. Studies with larger sample sizes and a longer follow-up are required to confirm the advantage of this technique compared to open surgery.

Evaluation of a Modified Spoon-Shaped Medial Incision in the Surgical Repair of a Chronic Achilles Tendon Rupture

This study aims to investigate the clinical significance of preventing incision skin necrosis and the improved function offered in patients with a chronic Achilles tendon rupture treated surgically with a modified spoon-shaped medial incision. From January 2013 to January 2017, 50 patients (N = 50) who were admitted to our department with a clinically and radiologically confirmed chronic Achilles tendon rupture met inclusion criteria and were divided retrospectively into two groups. In group A (n = 26), a modified spoon-shaped medial incision in the surgical repair of Achilles tendon rupture was performed. In group B (n = 24), a traditional posterior medial incision was used. All skin healing was observed. Functional evaluation was performed using American Orthopedic Ankle & Foot Society scale(AOFAS) hindfoot score and Achilles tendon total rupture score(ATRS). Return-to-work time and major complications were also measured. The patients were followed for 12 to 48 months. All incisions exhibited primary healing in group A, while four incisions healed delay for skin necrosis which includes superficial, deeper necrosis, and skin defection caused by the necrosis in group B. Both groups had similar results regarding return-to-work time. There were no infections in either group. There was no rerupture of the Achilles tendon in either group. Patients in group A had better AOFAS hindfoot score (p = .020) and ATRS (p = .010), and the difference was significant (p ≤ .05).Using the modified spoon-shaped medial incision in the surgical repair of a chronic Achilles tendon rupture seems to be a safe and effective method that may reduce risk of incision skin necrosis and offers better function in patients with a chronic Achilles tendon rupture.

Delayed Achilles tendon rupture presentation: Non-operative management may be the SMART choice

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.

Flexor hallucis longus hypertrophy secondary to Achilles tendon tendinopathy: an MRI-based case-control study

PURPOSE

The purpose of this study was to outline an indirect sign of advanced Achilles tendinopathy on magnetic resonance imaging (MRI), based on the hypothesis that these patients would present with secondary hypertrophy of the flexor hallucis longus muscle (FHL).

METHODS

MRI scans of Achilles tendon were analyzed retrospectively in two cohorts. The study group consisted of consecutive patients presenting with clinical signs of Achilles tendinopathy and no previous surgeries, while the control group were patients that had an MRI due to other reasons and no signs of tendinopathy. Two parameters from two muscle bellies were measured and compared on axial MRI scans 4-5 cm above the ankle joint line at the level of greatest thickness: area and diameter of the triceps surae (TS) and of the FHL muscle. Ratios (FHL/TS) were calculated for area (Ar) and diameter (Dm) measurements. Interobserver agreement was analyzed. A receiver operating characteristic (ROC) curve was created for both ratios to assess potential cutoff points to differentiate between the groups.

RESULTS

A total of 60 patients for each study group were included. Both ratios Ar(FHL/TS) and Dm(FHL/TS) showed significant higher values in the tendinopathy group (p < 0.001). There were strong to very strong intraclass correlation coefficients (ICC = 0.75-0.93). A diameter ratio Dm (FHL/TS) of 2.0 or higher had a sensitivity of 49% and specificity of 90% for concomitant Achilles tendinopathy.

CONCLUSION

In our patient cohort, FHL hypertrophy was observed in patients with Achilles tendinopathy as a possible compensatory mechanism. Measuring a diameter ratio Dm(FHL/TS) of 2.0 or higher on an axial MRI, may be indicative as an indirect sign of functional deterioration of the Achilles tendon.

Achilles Tendon Lesions - Part 2: Ruptures

The increasing incidence of calcaneal tendon ruptures has substantially impacted orthopedic care and costs related to its treatment and prevention. Primarily motivated by the increasing of life expectancy, the growing use of tenotoxic drugs and erratic access to physical activity, this injury accounts for considerable morbidity regardless of its outcome. In recent years, the evolution of surgical and rehabilitation techniques gave orthopedists better conditions to decide the most appropriate conduct in acute tendon rupture. Although still frequent due to their high neglect rate, Achilles chronic ruptures currently find simpler and more biological surgical options, being supported by a new specialty-focused paradigm.

Clinical outcomes of chronic Achilles tendon rupture treated with flexor hallucis longus grafting and flexor hallucis longus grafting plus additional augmentation: A meta-analysis

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.

Higher Rate of Postoperative Complications in Delayed Achilles Tendon Repair Compared to Early Achilles Tendon Repair: A Meta-Analysis

BACKGROUND

Some authors found that delayed repair of Achilles tendon ruptures achieved similar functional outcomes when compared with acute repair of Achilles tendon ruptures. The purpose of our study was to compare functional outcomes and complication rates of acute repair to delayed repair after Achilles tendon ruptures.

METHODS

PubMed, Embase (Ovid) and the Cochrane Library were searched.

RESULTS

For Achilles tendon rupture score (ATRS), the overall result revealed that there was no significant difference in ATRS between acute repair groups and delayed repair groups (P = 0.59). For Tegner scores, Halasi scores and Achilles tendon resting angle (ATRA), there was no significant difference between the two groups (P = 0.28, P = 0.47 and P = 0.68). There was no significant difference in the subjective assessment between acute repair groups and delayed repair groups (P = 0.84). However, delayed repair groups showed a higher incidence of complications than acute repair groups (P = 0.01). Subgroup analyses showed that the mean time from injury to surgery of delayed repair groups affect the pooled result substantially. For mean time less than 28d, there was no difference in the incidence of complications between acute repair groups and delayed repair groups (P = 0.09). However, for mean time more than 28d, delayed repair groups showed a higher incidence of complications than acute repair groups (P = 0.05).

CONCLUSION

Our study showed delayed repair could obtain similar functional outcomes and subjective assessment when compared with acute repair. However, the rate of complications after delayed repair was higher than that of early repair. Further high-quality randomized controlled trials (RCT) are needed to evaluate the difference.

Ipsilateral free semitendinosus graft with interference screw fixation for surgical management of insertional acute Achilles tendon tears

INTRODUCTION

Very distal tears of the Achilles tendon are uncommon, and poor quality tendinous tissue of the calcaneal stump can compromise healing. Little has been published about the characteristics and surgical management of such injuries. We present a surgical technique, developed by the senior author, to restore continuity of the gastrosoleus-Achilles tendon-calcaneus complex using a free ipsilateral semitendinosus graft, and clinical outcomes of a case series of 28 consecutive patients. Our hypothesis was that this is a safe technique, and patients can return to pre-injury occupation and athletic activities.

PATIENTS AND METHODS

A total of 28 patients (mean age 46 years) underwent minimally invasive reconstruction using a free ipsilateral semitendinosus graft for acute insertional rupture of tendo Achillis. The procedure required two small incisions along the course of the Achilles tendon, and one posteromedial incision at level of the ipsilateral knee to harvest the semitendinosus tendon. Patients were assessed at minimum 2 years (range, 2-2.5 years) following the index procedure.

RESULTS

The median Achilles tendon Rupture Score (ATRS) at the latest follow-up was 88. Two patients developed a superficial wound infection. All patients returned to their preinjury occupation, whilst 22 out of 28 patients (79%), returned to their preinjury level of physical activity at a mean of 6.7 months after surgery, reporting good or excellent overall satisfaction in 88.5% of cases.

CONCLUSION

This minimally invasive technique was safe, and allowed most of patients to return to preinjury daily and sport activities within 9 months from surgery.

[Clinical analysis of autogenous tendon reconstruction under total arthroscopy in treatment of chronic Achilles tendon rupture]

Objective

To investigate the effectiveness of autogenous tendon reconstruction under total arthroscopy in the treatment of chronic Achilles tendon rupture.

Methods

Between June 2015 and June 2018, 16 patients with chronic Achilles tendon ruptures were treated by autogenous tendon reconstruction under total arthroscopy. Of the 16 patients, 11 were males and 5 were females. Their mean age was 40.7 years (range, 21-55 years). The disease duration was 14-20 months (mean, 16.4 months). Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 41.2±2.2 and the pain visual analogue scale (VAS) score was 7.9±1.2. MRI and B-ultrasonography examinations showed that the Achilles tendon was not continuous. The length of Achilles tendon defect was 5.0-10.3 cm, with an average of 5.8 cm. The rupture of the Achilles tendon happened on top of the insertion of the tendon in 4 cases and at the tendon-muscle belly connection in 12 cases. The operation time, intraoperative blood loss, hospital stay, and related complications were recorded. The AOFAS score and VAS score were used to evaluate the improvement of ankle joint function and pain.

Results

The average operation time was 77.2 minutes (range, 60-90 minutes). The average intraoperative blood loss was 20.5 mL (range, 15-30 mL). The average hospital stay was 7.2 days (range, 5-10 days). All incisions healed by first intention. There was no skin necrosis, infection, or deep vein thrombosis. All the patients were followed up 8-18 months, with an average of 12 months; and 10 cases were followed up more than 12 months. During the follow-up, there was no Achilles tendon re-rupture, and the symptoms of pain and heel lifting failure significantly improved. MRI reexamination showed that the continuity of Achilles tendon recovered. At 1, 3, 6, and 12 months postoperatively, AOFAS scores significantly improved and VAS scores significantly reduced, except for 1 month postoperatively, the scores at other time points were superior to that before operation, the differences were significant ( P<0.05).

Conclusion

Autogenous tendon reconstruction under total arthroscopy in the treatment of chronic Achilles tendon rupture has the advantages of small trauma, rapid functional recovery, and satisfactory surgical efficacy.

No difference in strength and clinical outcome between early and late repair after Achilles tendon rupture

PURPOSE

This retrospective study aimed to determine the patient-reported and functional outcome of patients with delayed presentation, who had received no treatment until 14 days following injury of Achilles tendon rupture repaired with minimally invasive surgery and were compared with a group of sex- and age-matched patients presenting acutely. Based on the outcomes following delayed presentation reported in the literature, it was hypothesized that outcomes would be inferior for self-reported outcome, tendon elongation, heel-rise performance, ability to return to play, and complication rates than for acutely managed patients.

METHODS

Repair was performed through an incision large enough to permit mobilisation of the tendon ends, core suture repair consisting of a modified Bunnell suture proximally and a Kessler suture distally and circumferential running suture augmentation.

RESULTS

Nine patients presented 21.8 (14.9) days (range 14-42 days) after rupture. The rate of delayed presentation was estimated to be 1 in 10. At 12 months following repair, patients with delayed treatment had median (range) ATRS score of 90 (69-99) compared with 94 (75-100) in patients treated acutely presenting 0.66 (1.7) (0-5) days. There were no significant differences between groups: ATRA [mean (SD) delayed: - 6.9° (5.5), acute: - 6° (4.7)], heel-rise height index [delayed: 79% (20), acute: 74% (14)], or heel-rise repetition index [delayed: 77% (20), acute: 71% (20)]. In the delayed presentation group, two patients had wound infection and one iatrogenic sural nerve injury.

CONCLUSIONS

Patients presenting more than 2 weeks after Achilles tendon rupture may be successfully treated with minimally invasive repair.

LEVEL OF EVIDENCE

III.

Delayed (14-30 Days) Percutaneous Repair of Achilles Tendon Ruptures Offers Equally Good Results As Compared With Acute Repair

BACKGROUND

Minimally invasive repair of acute Achilles tendon ruptures has been performed for several years, resulting in reduced morbidity as compared with open repair.

HYPOTHESIS

A minimally invasive technique can be used to manage Achilles tendon ruptures in patients presenting between 14 and 30 days from injury.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We prospectively recruited 21 consecutive patients who presented between 14 and 30 days after the index injury, and we compared them with 21 patients who were matched according to sex, age (±2 years), and level of activity, who presented within 14 days of the index injury. All patients underwent the same minimally invasive procedure under local anesthesia: a core suture repair consisting of a modified Bunnell suture in the proximal stump and a modified Kessler suture in the distal stump.

RESULTS

At 12 months after minimally invasive repair, patients with delayed treatment had a median Achilles tendon rupture score of 91 (SD, 2.4; range, 87-96) as compared with 91 (SD, 2.2; range, 86-96) in patients treated acutely, who presented at a median 2.4 days (range 1-6 days) from the injury. There were no significant differences between groups in terms of mean (SD) Achilles tendon resting angle: delayed repair group, -3.9° (2.0); acute repair group, -3.7° (1.9) (P = .69). No patient in either group developed a wound infection. One patient in the acute group experienced an iatrogenic sural nerve injury.

CONCLUSION

Patients with Achilles tendon rupture treated by percutaneous repair 14 to 30 days after injury achieved similar results at 1 year as patient treated <14 after injury.

Achilles tendon reconstruction with peroneus tendon transfer following epithelioid sarcoma resection: a rare case report at 5 years follow-up

BACKGROUND

Soft-tissue sarcomas (STS) are rare in hand and foot. In this paper we present a case of reconstruction of Achilles tendon defect with peroneus brevis transfer reinforced with medial gastrocnemius fascia and plantaris tendon after excision of a local recurrence of epithelioid sarcoma.

CASE PRESENTATION

Fifty-five years-old female. MRI showed a lump of 5 × 2,5 × 2 cm into Achille's tendon with invasion of the anterior fat tissue but no invasion of the surrounding bones. The patient underwent excision of the tumour and reconstruction of the tendinous defect with peroneus brevis transfer. Surgical technique has been widely described.

DISCUSSION AND CONCLUSIONS

Epithelioid sarcoma arising from the Achilles tendon is an extremely rare malignant tumour in an atypical site and may easily be confused with other soft tissue masses. It presents a technical challenge because of the large tendon defect remaining following wide resection. Reconstruction with peroneus brevis transfer, reinforced with medial gastrocnemius fascia and plantaris tendon, restore appropriate structural continuity and resistance. Functional results are satisfactory.

Reconstruction of Myerson type III chronic Achilles tendon ruptures using semitendinosus tendon and gracilis tendon autograft

BACKGROUND

Reconstruction of Myerson type III (defect size more than 5 cm) chronic Achilles tendon ruptures (CATRs) is a surgical challenge due to its large Achilles tendon defect. This study aims to describe our operative technique for Myerson type III CATR and its clinical outcomes.

PATIENTS AND METHODS

From May 2012 to April 2015, we treated seven patients (6 males, 1 female) with Myerson type III CATR using semitendinosus tendon and gracilis tendon autograft. The mean age was 47.3 years (range: 37-56). Patients were followed for a mean time of 31.3 months. All patients' defect size between Achilles ends after debridement was more than 5 cm and hence classified as Myerson type III. The clinical outcomes were evaluated by visual analog scale (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, Achilles tendon total rupture score (ATRS), and the Short Form 36 (SF-36).

RESULTS

All patients reported good postoperative clinical outcomes. The average AOFAS score increased from 54.29 points (range: 46-65 points) preoperatively to 97.57 points (range: 90-100 points) at last follow-up. The average ATRS increased from 51.43 points (range: 40-61 points) preoperatively to 92.71 points (range: 83-100 points) at last follow-up. And the average VAS for pain was 0 at the last follow-up. The mean value of SF-36 physical increased from 32.14 points (range: 25-35 points) to 90 points (range: 80-95 points). And the mean value of SF-36 mental was improved from 37.14 points (range: 32-40 points) to 90.86 points (range: 84-96 points).

CONCLUSIONS

Semitendinosus tendon combined gracilis tendon autograft is a safe and effective technique in the reconstruction of Myerson type III CATR.

Peroneus Brevis flap in Achilles tendon reconstruction. Clinical, radiological and functional analysis

BACKGROUND

We would like to describe our experience with Peroneus Brevis flap in complicated Achilles tendon re-ruptures with fringed stumps.

METHODS

Eight patients with monolateral re-rupture of Achilles tendon were selected as eligible for surgical repair with Peroneus Brevis flap. Patients' outcome was evaluated clinically (ATRS and ROM), functionally (Gait analysis) and MRI was performed before and after surgery.

RESULTS

Effective coverage of tissue defect was reached in all patients. Functional assessment evaluation results were registered in a follow-up time that ranged from 12 to 18 months. ATRS and ROM tests' results showed good functional recovery without functional limitations or subjective reports pain. Post-operative MRI showed no signs of inflammation or tissue gaps. Gait analysis showed a partial reduction of performance in the affected side that did not affect patients' quality of life.

CONCLUSIONS

In the presence of fringed stumps in Achilles tendon re-rupture, tendon flaps have the benefits of autologous tissues transfers and present less risks of failure than free flaps. Among them, Peroneus Brevis flap is easy to perform and leads to donor site's low morbidity. Our preliminary experience provides support for this technique to be potentially validated in larger more controlled trial.

Minimally invasive reconstruction technique for chronic Achilles tendon tears allows rapid return to walking and leads to good functional recovery

PURPOSE

Chronic Achilles tendon tears, including chronic ruptures with end gap over 6 cm making end-to-end suturing impossible, can be treated with autologous hamstring graft reconstruction. The primary goal of this study was to present the biomechanical and long-term clinical results of recently developed minimally invasive Achilles tendon reconstruction technique.

METHODS

Minimally invasive Achilles tendon reconstruction was applied to 8 foot and ankle cadaveric specimens as well as 18 patients with chronic Achilles tendon tears. Repaired cadavers were subjected to the biomechanical testing using a cyclic loading protocol. Patients with reconstructed Achilles tendon were subjected to the clinical, functional and isokinetic tests at 12 months after the treatment.

RESULTS

All of tested Achilles cadaveric specimens survived 2 loading blocks (250 cycles of 10-100 N load followed by additional 250 cycles of 10-200 N load). With three specimens, it was possible to perform the third cyclic loading block with 20-300 N load and two specimens survived the fourth block with 20-400 N load. Therefore, a mean number of 838 cycles (±178) within the range of 509-1000 was recorded. Two specimens which survived all 1000 cycles were pulled to failure at 25 mm/s rate. The results obtained in the load to failure testing were as follows: 398 N and 608 N of maximum load. The results of functional heel rise endurance test and single leg hop for distance test indicated a decrease in the endurance and strength of the injured limb. However, the results of the weight-bearing lunge tests indicated no tendency for elongation of the Achilles tendon. A comparative analysis of the isokinetic test results for the non-injured and injured limb was revealed no statistically significant differences for every isokinetic test (n. s.), with significant difference for isometric strength parameters (p = 0.0006).

CONCLUSIONS

The results of the biomechanical tests as well as 1-year extensive functional, clinical and isokinetic results of the minimally invasive technique for chronic Achilles tendon tears are encouraging. Patients returned to their normal physical activity, including sport pre-injury level in most cases.

LEVEL OF EVIDENCE

III.

Anatomical Study of the Compositions and Internal Connections of the Chiasma Plantare (Master Knot of Henry): Exploring Its Possible Clinical Impact

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.

Management of Chronic Achilles Tendon Injuries-Review of Current Protocols and Surgical Options

Chronic Achilles tendon injury is a challenging problem. A review of the different options available and their technical considerations is required. Reconstruction of the Achilles tendon depends on numerous factors such as the gap between the debrided tendon ends, the presence of a distal stump, and the and presence of scar tissue. Various protocols have been described for reconstruction. Methods of reconstruction vary from direct repair, bridging of the tendon gap with tendon grafts or tendon transfers. We review and enumerate the different protocols enumerated for the reconstruction of chronic Achilles tendon lesions in the literature and look at the authors preferred methods of reconstruction.