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

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.

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.

Composite sural neurocutaneous flap with gastrocnemius tendon for repairing defects of Achilles tendon and overlying soft tissue

PURPOSE

Defect of Achilles tendon and overlying soft tissue remains a surgical challenge due to its insufficient blood supply and high requirement of function. This study aims to report the clinical efficacy of the composite sural neurocutaneous composite flap with gastrocnemius tendon on the complicated defect of Achilles region.

METHODS

Seven cases of defects of Achilles tendon and overlying soft tissue were reconstructed by the composite sural neurocutaneous composite flaps with gastrocnemius tendons. It is important to keep the connection between gastrocnemius tendon and deep fascia of the composite flap during operation. The smallest and the largest areas of transferred skin flaps were 7.5 cm × 4.5 cm and 11 cm × 10 cm respectively. The size of gastrocnemius tendon ranged from 5 cm × 3 cm to 9 cm × 4 cm. Patients was evaluated by using the Arner-Lindholm scale at the last follow-up.

RESULTS

Six flaps survived completely with no complication. One flap developed wound dehiscence and went on to heal by daily dressing. With 12-60 months follow-up, all patients gained satisfactory appearance and function of ankle, without tendon re-rupture or recurrent infection. Based on Arner-Lindholm scale, six cases were noted to be excellent and one was good.

CONCLUSION

The composite sural neurocutaneous flap with gastrocnemius tendon is a viable and practical method to salvage Achilles tendon defect and overlying soft tissue coverage, with minimal adhesion and satisfactory function.

New Viscoelastic Hydrogel Hymovis MO.RE. Single Intra-articular Injection for the Treatment of Knee Osteoarthritis in Sportsmen: Safety and Efficacy Study Results

Viscosupplementation by hyaluronic acid (HA) is recommended for non-surgical management of knee osteoarthritis (OA). This study investigated the efficacy and safety of a single i.a. (32 mg/4 ml) Hymovis MO.RE. injection, a new HA derivative hydrogel, for the treatment of adult regular sports players affected by knee OA arising from overuse injuries. Patients were prospectively enrolled if regularly practicing sports and diagnosed with Kellgren-Lawrence grade I-III OA. They received a single Hymovis MO.RE. intra-articular (i.a.) injection and were evaluated 30, 90, 180, and 360 days thereafter. The assessment involved measuring changes in knee function, pain, the activity of daily living (ADL), and quality of life (QOL) by using the Knee injury and Osteoarthritis Outcome Score (KOOS), GAIT analysis, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores for knee pain (WOMAC A) and function (WOMAC C), and a visual analogue scale (VAS) pain score. The study involved thirty-one patients, 23 women and eight men, whose median age was 49. KOOS function subscore, as well as GAIT cadence and velocity, showed a statistically significant increase at each time-point after injection (p < 0.0001). WOMAC, KOOS pain, symptoms, ADL, and QOL scores also significantly improved at all control visits. No severe adverse events or treatment-related events were detected. A single Hymovis MO.RE. (32 mg/4 ml) intra-articular injection provides a rapid, lasting, and safe response in regular sports players affected by knee OA, possibly representing a viable therapeutic option for this demanding patient subgroup. Further investigations are necessary to confirm these findings.

Comparison between intramedullary nailing and minimally invasive plate osteosynthesis for tibial shaft fractures

INTRODUCTION

Intramedullary nailing (IMN) is currently considered the gold standard in the surgical treatment of tibial shaft fractures in adult patients. In this case-control comparative study, we aimed to compare the efficacy of minimally invasive plate osteosynthesis (MIPO) and IMN in treating tibial shaft fractures.

MATERIALS AND METHODS

The clinical and radiological outcomes, such as a modified trauma scale, operation time, fracture healing, rate of re-operation, and complications such as malunion, nonunion, shortening, and infection were assessed between IMN and MIPO for the treatment of tibial shaft fractures.

RESULTS

Seventy-three skeletally mature patients who underwent IMN (group I) or MIPO (group M) for a closed extra-articular tibial shaft fracture (AO/OTA type 42) from June 2010 to May 2016 were retrospectively reviewed. The mean age was 51.16 (18~79) years, and the mean follow-up period was 22 (12~50) months. Bony union was achieved in all cases but one for each group - group I (35 cases) and group M (36 cases) (p > 0.05). Mean callus formation was observed in 12 (8 - 16) weeks in both groups (p > 0.05). There was no significant difference in operative time, hospital stay, bone healing, and the rate of complications among the two groups (p > 0.05). There was also no postoperative difference in functional evaluation between the two methods (p > 0.05).

CONCLUSIONS

No discrepancy was found in radiological and clinical outcomes between IMN and MIPO for tibial shaft fractures. It can be concluded that both IMN and MIPO are equally effective treatment modalities for tibial shaft fractures.

One-Step Approach for Infections After Achilles Tendon Open Repair: The Distally Based Peroneus Brevis Muscle Flap

The aim of this single-center, retrospective study is to demonstrate the effectiveness of distally based peroneus brevis muscle flap as first therapeutic option for infections after Achilles tendon open repair. We retrospectively analyzed 14 consecutive patients with complete Achilles tendon rupture and developing surgical site infection after an attempt of open surgical repair. Every patient was reconstructed with distally base peroneus brevis muscle flap. The primary outcome was the return to work and the initiation of full weight-bearing. Secondary outcomes were complication rate and time needed to return to work. A review of the literature was conducted to better define the actual standard treatment. Each patient returned to work. No flap necrosis occurred. Two minor healing delays and one hematoma were reported. Median time to wound healing was 17 days (interquartile range [IQR] = 13-20). Median time to full weight-bearing was 52 days (IQR = 47-55). Median follow-up (FU) was 21 months. Distally based peroneus brevis flap is a safe treatment for surgical site infections after Achilles tendon rupture repair. Patients regained full weight-bearing after a median time of 52 days from the surgical reconstruction. No major complications were observed. This flap clearly emerges as first reconstructive option for complications after surgery of Achilles tendon region.

Comparison of a Novel Muscle Training Device with Conventional Rehabilitation Training in Motor Dysfunction of Lower Limb Patients: A Pilot Study

BACKGROUND

Postoperative functional training for fracture or osteoarthritis is mainly focused on functional self-exercise, which aims to recover the function of the lower limbs.

PURPOSE

To compare the function and life quality recovery in patients with fracture or arthritis treated with novel muscle training device (NMT) or conventional rehabilitation training (CRT) following surgery.

PATIENTS AND METHODS

A total of 32 fracture patients were randomly divided into the NMT or the CRT groups. The evaluation was performed on the first and 7th day after surgery. The outcome measurements included the incidence of foot drop, Deep Vein Thrombosis and pressure ulcers, Hospital for Special Surgery knee score (HSS scores), pain scores for the Visual Analogue Scale (Pain scores for VAS), Zung self-rating anxiety scale (SAS), Pittsburgh sleep quality index (PSQI) and the Barthel Index score.

RESULTS

The comparison of the change scores between the two groups indicated significant differences on day 7 following surgery in the Barthel Index score (P<0.01). The Pain scores for VAS between the two groups indicated a significant difference (P<0.05, U=20.0). The HSS scores between the two groups indicated a significant difference (P<0.05, U=19.0). The HSS scores exhibited a highly significant difference in the NMT group (P<0.01). The Mann-Whitney test was used to analyze the various components of the HSS scores. The comparison of the change scores on the function between the two groups indicated a significant difference (P<0.05). The Range of Motion difference between groups exhibited highly significant differences (P<0.01).

CONCLUSION

The novel muscle training device positively influenced the decrease in pain score, which resulted in a range increase of knee joint movement and a significant overall improvement in motion.