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Wang T, Yu H, Tian GF, Zhao RX. A pilot study on lengthening potentials and biomechanical effects of double and triple hemisection on tendon with slide lengthening. Sci Rep 2023; 13:3922. [PMID: 36894616 PMCID: PMC9998391 DOI: 10.1038/s41598-023-30791-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/01/2023] [Indexed: 03/11/2023] Open
Abstract
The current study explored the slide-lengthening potentials of double and triple hemisections and the biomechanical effects of different inter-hemisection distances. Forty-eight porcine flexor digitorum profundus tendons were divided into double- and triple-hemisection groups (Groups A and B) and a control group (Group C). Group A was divided into Group A1 (distance between hemisections were the same as Group B) and Group A2 (distance between hemisections corresponded to the greatest distance between hemisections in Group B). Biomechanical evaluation, motion analysis, and finite element analysis (FEA) were performed. Failure load of intact tendon was significantly highest among groups. When the distance was 4 cm, the failure load of Group A increased significantly. When the distance between the hemisections was 0.5 or 1 cm, the failure load of Group B was significantly lower than Group A. Tendon elongation and failure load of Group B were significantly lower than those in Group A when the greatest distance between hemisections was the same. Consequently, Double hemisections had a similar lengthening ability to that of triple hemisections with the same distance, but better when the distances between extreme hemisections matched. However, the driving force for the initiation of lengthening may be greater.
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Affiliation(s)
- T Wang
- Burn and Plastic Surgery Department, Shenyang 242 Hospital, No.3 Leshan Road, Shenyang, 110000, China
- Graduate School, Shenyang Medical College, No.5 South Qi West Road, North Huanghe Street, Shenyang, 110000, China
| | - H Yu
- Department of Orthopedics, The First Hospital of China Medical University, 155 Nanjing North Street, Shenyang, 110000, China.
| | - Guo-Fu Tian
- School of Mechanical Engineering, Shenyang University Of Technology, Shenyang, China
| | - Rui-Xiang Zhao
- School of Mechanical Engineering, Shenyang University Of Technology, Shenyang, China
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Zetterström SM, Boone LH, Farag R, Weimar WH, Caldwell FJ. Effect of single and double hemitenotomy on equine deep digital flexor tendon length and strength in experimental load challenges. Vet Surg 2022; 51:1153-1160. [PMID: 35437771 DOI: 10.1111/vsu.13808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/25/2022] [Accepted: 03/12/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate a double hemitenotomy (DHT) technique as an alternative to complete deep digital flexor (DDFT) tenotomy. STUDY DESIGN Experimental ex vivo study. SAMPLE POPULATION Isolated DDFTs (n = 30) and cadaveric forelimbs (n = 16). METHODS In part 1, 15 isolated DDFT pairs were used. Two hemitenotomies were created in 1 DDFT while the other served as reference. Monotonic tensile load was applied. Tendon lengthening, load reduction, and load at failure were recorded. In part 2, 16 cadaveric forelimb pairs were subjected to DHT followed by complete tenotomy (CT) under monotonic compressive load. Differences between DHT and controls were assessed with Wilcoxon signed rank tests or Friedman tests. RESULTS In isolated tendons and cadaveric forelimbs, DHT resulted in DDFT lengthening (median, +1.9 mm and + 3.05 mm) and load reduction (median, -16.7 and -11.2 kg). Less lengthening was achieved with DHT compared to CT (P = .008). Load reduction did not occur between DHT and CT was observed during compressive testing (P = 1). Load reduction following the first hemitenotomy incision was smaller when compared to the second (P = .022). Isolated DHT tendons failed at a tensile load of 195 kg, while no intact tendons failed (P = .0001). CONCLUSION Double hemitenotomy was comparable to CT in load reduction. It reduced tensile strength, but load at failure was similar or exceeded the estimated DDFT load at stance. CLINICAL SIGNIFICANCE Hemitenotomy may be a useful alternative for surgical management of horses with laminitis, but in vivo studies are needed to confirm these findings.
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Relation of the Sural Nerve and Medial Neurovascular Bundle With the Achilles Tendon in Children With Cerebral Palsy Treated by Percutaneous Achilles Tendon Lengthening. J Pediatr Orthop 2022; 42:e201-e205. [PMID: 34995262 DOI: 10.1097/bpo.0000000000002020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND One of the most common treatment options for a short Achilles tendon (AT) in cerebral palsy is percutaneous AT lengthening using 3 hemisections. Because of proximity of neurovascular structures around the tendon, iatrogenic injury to them have been a concern about this technique. The sural nerve (SN) is under risk of injury at the site of the lateral incomplete cut, especially if it is done proximally. The medial neurovascular bundle is under injury risk at medial cuts. The aim of the article was to study the anatomical relations of the SN and medial neurovascular bundle to the AT, and define dangerous levels for injury with the help of magnetic resonance imaging (MRI). METHODS Patients operated for percutaneous Achilles lengthening were called for MRI investigation of the SN and medial neruvascular bundle integrity and their anatomical relation with the AT. The distance of 5 mm was taken as the threshold for increased risk of injury. Measurements were done on MRI at each cm from the insertion of the tendon on both medial and lateral sides, and at the level of the middle cut. RESULTS Thirty ankles operated and followed at least 1 year were included to the study. On the medial side, the tibial nerve, and the posterior tibial artery lied more than 5 mm away from the tendon at all levels in all patient. On the lateral side, the first 4 cm were relatively safe for the middle lateral cut, while increased risk of SN damage was detected in more proximal levels. Overall, 6 of 30 ankles had radiographically detectable SN injury. CONCLUSIONS The first 4 cm of the AT on the lateral side was detected to be safe for the middle lateral directed cut, while whole tendon length were found to be safe for the first and the third cuts of the percutaneous Achilles lengthening surgery using 3 hemisections in children with cerebral palsy. LEVEL OF EVIDENCE Level III.
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Zhang CG, Zhao XY, Cao J, Lin YJ, Yang L, Duan XJ. Triple Hemisection Percutaneous Achilles Tendon Lengthening for Severe Ankle Joint Deformity. Orthop Surg 2021; 13:2373-2381. [PMID: 34806335 PMCID: PMC8654661 DOI: 10.1111/os.13096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 05/08/2021] [Accepted: 05/11/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate the efficacy of modified percutaneous Achilles tendon lengthening for severe ankle joint deformity. Methods This retrospective case series study included 33 patients with an average age of 25.2 years who underwent surgery in our hospital from April 1, 2010 to March 1, 2018. Triple hemisection percutaneous Achilles tendon lengthening was performed. One stage surgery, other soft tissue surgery or bone correction surgery could be performed. After surgery, a plaster cast was used to fix the functional position, and rehabilitation training was carried out as planned. Complications during the perioperative period were recorded. Statistical analysis of the patients' visual analogue scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) score before and at the last follow‐up was performed. The recurrence rate of Achilles tendon contracture at the last follow‐up and the patients' satisfaction rate were investigated. Results All patients were followed up, with an average follow‐up period of 56.31 months (8–104 months). All achieved good ankle joint function and appearance improvement And there were no infection or skin necrosis complications. In two cases, the incision was poorly healed at non‐Achilles tendon site and was cured by change of dressing. The average VAS score at the last follow‐up was reduced from (2 ± 1.48) points before surgery to (0.26 ± 0.51) points (P = 0.001), and the average AOFAS score was increased from (64.97 ± 13.56) points before surgery to (90.06 ± 10.06) points (P = 0.001). During the follow‐up period, there was no chronic rupture of Achilles tendon. There were two cases of recurrence of foot drop (5.7%), and the patients' satisfaction rate was 93.9%. Conclusion In the surgical treatment of severe ankle joint deformity, the application of triple hemisection percutaneous Achilles tendon lengthening for Achilles tendon contracture has the advantages of less trauma, beautiful incision, and reliable efficacy. The satisfaction rate of patients with this treatment is high, and it is worth promoting in the clinic.
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Affiliation(s)
- Chang-Gui Zhang
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xing-Yu Zhao
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jin Cao
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yang-Jing Lin
- 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
| | - Xiao-Jun Duan
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
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Williamson PM, Pennings JP, Harlow E, Hanna P, Lechtig A, Okajima S, Biggane P, Nasr M, Zurakowski D, Duggal N, Nazarian A. Tendon lengthening after achilles tendon rupture-passive effects on the ankle joint in a cadaveric pilot study simulating weight bearing. Injury 2020; 51:532-536. [PMID: 31685206 DOI: 10.1016/j.injury.2019.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/12/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND In recent years, primary Achilles tendon ruptures have increased due to the aging population's participation in physically demanding activities. These injuries commonly occur during recreational sports and frequently lead to a long-term reduction in activity despite treatment. Non-operative methods of treatment for Achilles tendon ruptures may result in the Achilles healing in a lengthened position compared to the pre-injury state. This study uses a cadaveric model that simulates static weight bearing to explore the effect of a lengthened Achilles tendon on ankle joint load distribution. METHODS Five lower limb cadaveric specimens were placed on a custom jig, where a 334 N (75 lb) load was applied at the femoral head, and the foot was supported against a plate to simulate static double-leg stance. A pressure mapping sensor was inserted into the ankle joint. A percutaneous triple hemiresection tendo-Achilles lengthening procedure (Hoke procedure) was performed on each specimen to simulate tendon lengthening after conservative treatment. Contact pressure, peak pressure, and center-of-pressure were measured for native and tendon-lengthened conditions. RESULTS Tendon rupture did not significantly alter average contact pressure, peak contact pressures, or center-of-pressure in the ankle joint compared with native tendon. CONCLUSION Achilles lengthening does not significantly change contact pressures of the ankle joint in this model . This result suggests that the passive restraint on ankle joint translation imposed by the Achilles tendon is minimal without muscle activation.
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Affiliation(s)
- Patrick M Williamson
- Boston University, Mechanical Engineering Department. Boston, MA, USA; Center for Advanced Orthopaedic Studies at Beth Israel Deaconess Medical Center, Harvard Medical School. Boston, MA, USA
| | - Jan Ph Pennings
- Center for Advanced Orthopaedic Studies at Beth Israel Deaconess Medical Center, Harvard Medical School. Boston, MA, USA
| | - Ethan Harlow
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center. Cleveland, OH, USA
| | - Philip Hanna
- Center for Advanced Orthopaedic Studies at Beth Israel Deaconess Medical Center, Harvard Medical School. Boston, MA, USA
| | - Aron Lechtig
- Center for Advanced Orthopaedic Studies at Beth Israel Deaconess Medical Center, Harvard Medical School. Boston, MA, USA
| | - Stephen Okajima
- Center for Advanced Orthopaedic Studies at Beth Israel Deaconess Medical Center, Harvard Medical School. Boston, MA, USA
| | - Peter Biggane
- Center for Advanced Orthopaedic Studies at Beth Israel Deaconess Medical Center, Harvard Medical School. Boston, MA, USA
| | - Michael Nasr
- Center for Advanced Orthopaedic Studies at Beth Israel Deaconess Medical Center, Harvard Medical School. Boston, MA, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Naven Duggal
- Syracuse Orthopaedic Specialists, Department of General Orthopedics and Trauma, Foot and Ankle Division. Syracuse, NY, USA
| | - Ara Nazarian
- Center for Advanced Orthopaedic Studies at Beth Israel Deaconess Medical Center, Harvard Medical School. Boston, MA, USA; Department of Orthopaedic Surgery, Yerevan State Medical University. Yerevan, Armenia.
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Modified Percutaneous Achilles Tendon Lengthening by Triple Hemisection for Achilles Tendon Contracture. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1491796. [PMID: 31781592 PMCID: PMC6874878 DOI: 10.1155/2019/1491796] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/10/2019] [Indexed: 01/04/2023]
Abstract
Background Both percutaneous Achilles tendon lengthening by triple hemisection and the traditional open Z-lengthening are effective methods for Achilles tendon contracture. This study aims to evaluate the efficacy and safety of this new therapeutic method, which is based on the percutaneous sliding technique with three hemi-cuts in the tendon, as compared with the traditional open Z-lengthening. Methods Retrospective analysis of the Achilles tendon contracture cases in our hospital between January 2010 and September 2016 was conducted. Twenty-five cases received percutaneous Achilles tendon lengthening (group A), and 30 patients who underwent open Z-lengthening during the same period were in the control group (group B). Operative time and hospital stay were statistically analyzed. Incision complication, equinus recurrence rate and Achilles tendon rupture morbidity were recorded. The function was assessed by American Orthopaedic Foot & Ankle Society (AOFAS) score. All cases in group A received Magnetic Resonance Imaging (MRI) of ankle preoperatively and in the follow-ups. Results The mean follow-up period was 42.04 months in group A and 61.7 months in group B. The entire operative time and the mean hospitalization days were lower in group A than in group B. No incision and infection complication occurred in group A. The infection rate in group B was 3.3%. Equinus recurrence rate was 4% in group A and the equinus recurrence rate in group B was 21.4%. In group A, the mean AOFAS score increased from 64 ± 10.16 points preoperatively to 96.08 ± 3.17 at final follow-up, while the score in group B increased from 63.48 ± 6.2 points to 85.4 ± 10.3. MRI showed continuity of the Achilles tendon and homogeneous signal in group A. Conclusion Modified surgery can significantly reduce the risk of Achilles tendon rupture, provide better balance in soft tissue strength between ankle dorsiflexion and ankle plantarflexion, helping to avoid recurrence of the deformity.
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Du D, Zhang C. Two-Incision, Wire-Assisted Achilles Tendon Z-Lengthening: Surgical Technique and Case Report. J Foot Ankle Surg 2019; 58:604-606. [PMID: 31047029 DOI: 10.1053/j.jfas.2018.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Indexed: 02/03/2023]
Abstract
Achilles tendon lengthening is an important surgical procedure to manage gastrocnemius-soleus complex contracture. Because the Achilles tendon fibers twist like Manila rope and torsion varies widely, it is very difficult for any current lengthening procedure to be performed that accurately follows the rotation of the fibers; thus, irregular sliding or repeated cutting of the fibers may result. We present a patient with Achilles tendon contracture in whom the tendon was divided coronally along the twisted fibers using a stainless-steel wire before hemisection for Z-lengthening; thus, hemisection could be performed not only with minimal invasion but also accurately. After tendon lengthening, ankle function was restored to near normal. After a 15-month follow-up time, improvement of ankle function was well maintained, and no complication, such as crouch gait, was observed. We believe this was owed to accurate division of the tendon fibers before lengthening, preservation of the paratenon and deep fascial tube, and the use of Z-lengthening.
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Affiliation(s)
- Dajiang Du
- Professor, Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Changqing Zhang
- Professor, Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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Volpon JB, Natale LL. Critical evaluation of the surgical techniques to correct the equinus deformity. ACTA ACUST UNITED AC 2019; 46:e2054. [PMID: 31017177 DOI: 10.1590/0100-6991e-20192054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/08/2019] [Indexed: 12/19/2022]
Abstract
The equinus deformity causes changes in the foot contact and may affect more proximal anatomical regions, such as the knee, hip and trunk, potentially leading to gait disorders. The equinus is usually secondary to retraction, shortening and/or spasticity of the triceps surae, and it may require surgical correction. Surgery for the correction of equinus is one of the oldest procedures in Orthopedics, and it was initially performed only at the calcaneus tendon. The technique has evolved, so that it could be customized for each patient, depending on the degree of deformity, the underlying disease, and patient´s profile. The aim is to correct the deformity, with minimal interference in muscle strength, thus reducing the incidence of disabling complications such as crouch gait and calcaneus foot. We conducted a literature search for the most common surgical techniques to correct the equinus deformity using classic books and original articles. Further, we performed a database search for articles published in the last ten years. From the anatomical perspective, the triceps surae presents five anatomical regions that can be approached surgically for the equinus correction. Due to the complexity of the equinus, orthopedic surgeons should be experienced with at least one procedure at each region. In this text, we critically approach and analyze the most important techniques for correction of the equinus, mainly to avoid complications.
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Affiliation(s)
- José Batista Volpon
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Ribeirão Preto, SP, Brasil
| | - Leonardo Lima Natale
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Ribeirão Preto, SP, Brasil
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Phillips S, Shah A, Staggers JR, Pinto M, Godoy-Santos AL, Naranje S, de Cesar Netto C. Anatomic Evaluation of Percutaneous Achilles Tendon Lengthening. Foot Ankle Int 2018; 39:500-505. [PMID: 29254448 DOI: 10.1177/1071100717745559] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of the study was to evaluate the accuracy of percutaneous Achilles tendon lengthening (TAL) using a triple hemisection technique and the improvement in ankle dorsiflexion. METHODS Ten fresh-frozen above-knee cadaveric specimens were used. A percutaneous triple hemisection of the Achilles tendon (proximal, intermediate, and distal) was performed. Maximum ankle dorsiflexion was evaluated pre- and postprocedure with a digital goniometer. After proper dissection, the relative width of the cuts was noted. Following forced ankle dorsiflexion, displacement in the tensile gaps was measured in all 3 cuts with a precision digital caliper. RESULTS The overall relative width of the percutaneous cut was 51.3% ± 16.3% of the Achilles tendon diameter, 44.3% ± 13.6% for the proximal cut, 50.3% ± 15.6% for the intermediate cut, and 59.3% ± 18.4% for the distal cut. Tendon excursion averaged 13.0 ± 3.8 mm for the proximal cuts, 12.5 ± 4.7 mm for the intermediate cuts, and 8.2 ± 3.7 mm for the distal cuts. One cadaver had a complete rupture of the Achilles tendon and was excluded from the excursion data analysis. The mean range of motion for ankle dorsiflexion was 8.1 ± 3.9 degrees preprocedure and 27.6 ± 5.3 degrees postprocedure. The dorsiflexion angle significantly increased ( P < .0001) at an average of 19.5 ± 5.0 degrees following TAL. CONCLUSION Our cadaveric study demonstrated that the percutaneous triple hemisection of the Achilles was an accurate technique that provided successful lengthening of the tendon and increased ankle dorsiflexion. Complete ruptures are possible complications. CLINICAL RELEVANCE Our cadaveric study showed that in a clinical situation, triple hemisections of the Achilles tendon can be performed reliably, with significant improvement of the ankle dorsiflexion, mainly through increased tendon excursion at the proximal and intermediate cuts, and with low risk of complete ruptures.
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Affiliation(s)
- Sierra Phillips
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Ashish Shah
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Jackson Rucker Staggers
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Martim Pinto
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | | | - Sameer Naranje
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Cesar de Cesar Netto
- 1 Department of Orthopaedic Surgery, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
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Chen L, Ma X, Wang X, Huang J, Zhang C, Wang C. Comparison of Four Methods for Percutaneous Achilles Tendon Lengthening: A Cadaveric Study. J Foot Ankle Surg 2017; 56:271-276. [PMID: 28117253 DOI: 10.1053/j.jfas.2016.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Indexed: 02/03/2023]
Abstract
Percutaneous Achilles tendon lengthening can result in Achilles tendon rupture. This complication has been controversially linked to torsion effects in the Achilles tendon. Routine percutaneous triple-hemisection techniques (group A), rotary triple-hemisection (group B), distal double-hemisection (group C), and proximal double-hemisection (group D) were compared in cadaveric specimens to provide insights into the mechanism of uneven incision lengthening and inadvertent Achilles tendon rupture. The degree of Achilles tendon torsion on various planes was measured in 20 lower limb pairs from fresh cadavers. The increase in postoperative maximum ankle joint dorsiflexion degree and the length of the lengthened Achilles tendon were greater in group B (p < .05) and group C (p < .05) compared with the routine percutaneous triple-hemisection technique (group A). The width of the tensile gap of the distal incision was significantly greater in group B (p < .05) and group C (p < .05) compared with that in group A. Rotary triple-hemisection was shown to eliminate the effect of Achilles tendon torsion on percutaneous Achilles tendon lengthening. Because proximal double-hemisection is performed away from the distal Achilles tendon where the fibers rotate sharply, the technique results in more even extension of the incisions and achieves a greater increase in the maximum degree of ankle joint dorsiflexion. Uneven incision lengthening was observed with the routine percutaneous triple-hemisection and distal double-hemisection techniques. Achilles tendon torsion affected the surgical outcomes. Rotary triple-hemisection and proximal double-hemisection techniques resulted in more even extension of the incisions and achieved a greater increase in the degree of maximum ankle joint dorsiflexion.
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Affiliation(s)
- Li Chen
- Orthopedist, Department of Orthopedics, Huashan Hospital of Fudan University, Shanghai, China
| | - Xin Ma
- Professor, Department of Orthopedics, Huashan Hospital of Fudan University, Shanghai, China.
| | - Xu Wang
- Professor, Department of Orthopedics, Huashan Hospital of Fudan University, Shanghai, China
| | - Jiazhang Huang
- Assistant Professor, Department of Orthopedics, Huashan Hospital of Fudan University, Shanghai, China
| | - Chao Zhang
- Orthopedist, Department of Orthopedics, Huashan Hospital of Fudan University, Shanghai, China
| | - Chen Wang
- Orthopedist, Department of Orthopedics, Huashan Hospital of Fudan University, Shanghai, China
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Mansour T, Derienne J, Daher M, Sarraf D, Zoghbi Y, Ghanem I. Is percutaneous medial hamstring myofascial lengthening as anatomically effective and safe as the open procedure? J Child Orthop 2017; 11:15-19. [PMID: 28439304 PMCID: PMC5382331 DOI: 10.1302/1863-2548-11-160175] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Medial hamstring fractional lengthening is commonly performed in children with cerebral palsy (CP) to decrease contracture and/or to improve gait. Percutaneous procedures are gaining more and more popularity, even in the paediatric population, with equivocal results. The purpose of this paper was to determine the efficacy and safety of percutaneous medial hamstring myofascial lengthening (PHL). METHODS This is a prospective randomised controlled trial including 31 knees from 18 consecutive patients with CP scheduled for medial hamstring lengthening in the setting of multilevel tendon lengthening procedures in a university hospital. Other concomitant lower extremity surgeries were not exclusionary. A first paediatric orthopaedic surgeon executes the PHL at one level, as recently described in the literature. Another surgeon opens and extends the wound to explore what had been cut during the PHL and completes fractional lengthening (OHL) of both the semimembranosus (SM) and semitendinosus (ST) when possible. Popliteal angle (PA) was assessed by a third surgeon immediately before PHL, after PHL and then after OHL, using a goniometer in a standardised reproducible manner. All three surgeons were blinded to the others' findings. Primary endpoints included ease of performing PHL, the percentage of tendon-fascia/ muscle portion sectioned percutaneously and improvement of PA. Comparison between improvement of PA after PHL and OHL was done using a paired t-test with a 95% confidence interval. RESULTS The first surgeon was at ease in palpating and identifying the semimembranosus tendon before PHL in ten knees only. PHL led to an undesirable cut of the semimembranosus muscle fibres to more than 50% of the muscle section area in eight cases (<50% in 23 cases, between 50% and 75% in eight cases), and of the semitendinosus muscle fibres to more than 50% in all cases (complete rupture in six cases, more than 75% in eight cases and approximately 50% in 17 cases). Mean PA measured 52° pre-operatively and decreased to 40° after PHL. After OHL, the PA averaged 22°. There was a significant difference between the PA value after PHL (M = 40, SD = 11.8) and the PA value after OHL (M = 22, SD = 8.7), p < 0.0001. The gain in PA did not correlate with the extent of semimembranosus muscle divided (p = 0.38) nor with the extent of semitendinosus muscle divided (p = 0.35). No major iatrogenic neurovascular injury was observed. CONCLUSIONS To the authors' knowledge, this is the first prospective study concerning the anatomic effects of PHL. Although it is a quick procedure, it is often associated with difficulty by the operating surgeon to identify and evaluate what should be cut percutaneously, leading to abusive injury of the muscle itself rather than the fascia alone. In addition, the gain in PA is statistically less following PHL than following OHL despite undesirable extensive muscle injury following PHL. This may be due to the multiple fascial cuts (fractional lengthening) usually performed in OHL.
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Affiliation(s)
- T. Mansour
- Department of orthopedic surgery, Hotel-Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon,Correspondence should be sent to: Dr Toni Mansour, Hotel-Dieu de France Hospital, Boulevard Alfred Naccache, Achrafieh, Beirut, Lebanon.
| | - J. Derienne
- Department of orthopedic surgery, Hotel-Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - M. Daher
- Department of orthopedic surgery, Hotel-Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - D. Sarraf
- Department of orthopedic surgery, Hotel-Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Y. Zoghbi
- Department of orthopedic surgery, Hotel-Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - I. Ghanem
- Department of orthopedic surgery, Hotel-Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
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Hachache B, Eid T, Ghosn E, Sebaaly A, Kharrat K, Ghanem I. Is percutaneous proximal gracilis tenotomy as effective and safe as the open procedure? J Child Orthop 2015; 9:477-81. [PMID: 26499454 PMCID: PMC4661155 DOI: 10.1007/s11832-015-0699-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 10/06/2015] [Indexed: 02/03/2023] Open
Abstract
PURPOSE There is currently an increasing trend for percutaneous surgical interventions mainly in children with cerebral palsy (CP). The purpose of this study was to evaluate the effectiveness and safety of percutaneous proximal gracilis tenotomy (PPGT) in children with CP scheduled for hip adductor tenotomy. METHODS This is a prospective study of 59 hips in 31 consecutive patients with CP scheduled for hip adductor tenotomy in the setting of multilevel tenotomies or hip osteotomy (femoral or Dega). A pediatric orthopedic surgeon conducted a percutaneous adductor longus and gracilis tenotomy through the same stab wound. Another surgeon extended the wound to explore what had been cut during the PPGT, and completed the tenotomy if necessary (open proximal gracilis tenotomy; OPGT). Hip abduction with the hip and knee extended (HA) was assessed by a third surgeon (1) immediately before PPGT, i.e., directly after percutaneous adductor longus tenotomy (prePPGT), (2) after PPGT (postPPGT), and (3) following OPGT (postOPGT), using a goniometer, in a standardized reproducible manner. All three surgeons were blinded to each other's findings. Primary end-points included the percentage of muscle portion sectioned percutaneously and the improvement of HA angle. Comparison between HA before and after PPGT was performed using a paired t test with 95 % confidence interval (CI), and comparison between HA after PPGT and OPGT was performed using a Student's t-test with 95 % CI. The bleeding was assessed and other iatrogenic lesions were identified. The relationship between HA after PPGT and the percentage of muscle portion sectioned percutaneously was evaluated by calculating the Pearson correlation coefficient (p < 0.01). RESULTS Mean HA measured 33.71 degrees prePPGT and increased to 45.90 degrees postPPGT (p < 0.0001). The postOPGT HA averaged 48.71 degrees with no statistically significant gain compared with postPPGT (p = 0.21). The muscular portion of gracilis origin was cut to an average of 91.95 %; completely in only 14 hips, between 90 and 100 % in 35 hips, between 70 and 90 % in 9 hips, and between 60 and 70 % in 1 hip. The gain in HA did not correlate with the extent of the muscular portion sectioned percutaneously (R = -0.043). Minimal accidental section of adductor brevis postPPGT was encountered in 39 hips. Considerable bleeding postPPGT with hematoma formation requiring hemostasis during the open control procedure occurred in 30 hips. Partial iatrogenic injury of the anterior branch of the obturator nerve was encountered in one patient bilaterally with severe adductor contracture, due to an anatomic too medial variant. CONCLUSIONS This is the only prospective study concerning the outcome of PPGT. Although PPGT is fast, simple and effective, it is not as safe as the open procedure even when performed correctly by an experienced surgeon, mainly because of the increased risk of bleeding. The findings of the current study do not support its use as a 'standard-of-care' technique in children with hip adductor contracture. LEVEL OF EVIDENCE Level II therapeutic study-prospective comparative study.
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Affiliation(s)
- Bilal Hachache
- Department of Orthopaedic Surgery, Hôtel-Dieu de France Hospital, Saint-Joseph University, Alfred Naccache Street, Ashrafieh, Beirut, Lebanon
| | - Tony Eid
- Department of Orthopaedic Surgery, Hôtel-Dieu de France Hospital, Saint-Joseph University, Alfred Naccache Street, Ashrafieh, Beirut, Lebanon
| | - Elias Ghosn
- Department of Orthopaedic Surgery, Hôtel-Dieu de France Hospital, Saint-Joseph University, Alfred Naccache Street, Ashrafieh, Beirut, Lebanon
| | - Amer Sebaaly
- Department of Orthopaedic Surgery, Hôtel-Dieu de France Hospital, Saint-Joseph University, Alfred Naccache Street, Ashrafieh, Beirut, Lebanon
| | - Khalil Kharrat
- Department of Orthopaedic Surgery, Hôtel-Dieu de France Hospital, Saint-Joseph University, Alfred Naccache Street, Ashrafieh, Beirut, Lebanon
| | - Ismat Ghanem
- Department of Orthopaedic Surgery, Hôtel-Dieu de France Hospital, Saint-Joseph University, Alfred Naccache Street, Ashrafieh, Beirut, Lebanon
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Abstract
Pain and reduced function caused by disorders of either the plantar fascia or the Achilles tendon are common. Although heel pain is not a major public health problem it affects millions of people each year. For most patients, time and first-line treatments allow symptoms to resolve. A proportion of patients have resistant symptoms. Managing these recalcitrant cases is a challenge. Gastrocnemius contracture produces increased strain in both the Achilles tendon and the plantar fascia. This biomechanical feature must be properly assessed otherwise treatment is compromised.
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Affiliation(s)
- Matthew C Solan
- Department of Trauma and Orthopaedic Surgery, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 5XX, UK; University of Surrey, Guildford, UK; Surrey Foot and Ankle Clinic, Guildford, UK; London Foot and Ankle Centre, London, UK.
| | - Andrew Carne
- Department of Trauma and Orthopaedic Surgery, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 5XX, UK
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Von Forell GA, Bowden AE. A damage model for the percutaneous triple hemisection technique for tendo-achilles lengthening. J Biomech 2014; 47:3354-60. [PMID: 25194459 DOI: 10.1016/j.jbiomech.2014.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 07/31/2014] [Accepted: 08/08/2014] [Indexed: 11/30/2022]
Abstract
A full understanding of the mechanisms of action in the percutaneous triple hemisection technique for tendo-achilles lengthening has yet to be acquired and therefore, an accurate prediction of the amount of lengthening that occurs is difficult to make. The purpose of this research was to develop a phenomenological damage model that utilizes both matrix and fiber damage and replicates the observed behavior of the tendon tissue during the lengthening process. Matrix damage was triggered and evolved relative to shear strain and the fiber damage was triggered and evolved relative to fiber stretch. Three examples are given to show the effectiveness of the model. Implementation of the damage model provides a tool for studying this common procedure, and may allow for numerical investigation of alternative surgical approaches that could reduce the incidence rates of severe over-lengthening.
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Affiliation(s)
- Gregory A Von Forell
- Department of Mechanical Engineering, Brigham Young University, Provo, UT 84602, USA
| | - Anton E Bowden
- Department of Mechanical Engineering, Brigham Young University, Provo, UT 84602, USA.
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Kim HT, Oh JS, Lee JS, Lee TH. Z-lengthening of the Achilles tendon with transverse skin incision. Clin Orthop Surg 2014; 6:208-15. [PMID: 24900904 PMCID: PMC4040383 DOI: 10.4055/cios.2014.6.2.208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 07/04/2013] [Indexed: 11/09/2022] Open
Abstract
Background The risk of various complications after Achilles tendon lengthening is mainly related to the length of surgical exposure and the lengthening method. A comprehensive technique to minimize the complications is required. Methods The treatment of Achilles tendon tightness in 57 patients (95 ankles) were performed by using a short transverse incision on a skin crease of the heel and by Z-lengthening of the tendon. In the severe cases, two or three transverse incisions were required for greater lengthening of the tendon, and a serial cast or Ilizarov apparatus was applied for the gradual correction. The results of these 95 ankles were compared to those of 18 ankles, which underwent percutaneous sliding lengthening, and to the 19 ankles, which received Z-lengthening with a medial longitudinal incision. Results The functional and cosmetic satisfaction was achieved among those who underwent the tendon lengthening with the new technique. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score improved from 56.1 to 81.8. The second operations to correct recurrence were performed in the two cerebral palsy patients. Conclusions The new technique has a low rate of complications such as scarring, adhesion, total transection, excessive lengthening, and recurrence of shortening. The excellent cosmesis and the short operation time are the additional advantages.
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Affiliation(s)
- Hui Taek Kim
- Department of Orthopaedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jong Seok Oh
- Department of Orthopaedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jong Seo Lee
- Department of Orthopaedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Tae Hoon Lee
- Department of Orthopaedic Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
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Emara KM, Diab RA, El Ghazali S, Farouk A, El Kersh MA. Foot and ankle function after tibial overlengthening. J Foot Ankle Surg 2013; 53:12-5. [PMID: 23860130 DOI: 10.1053/j.jfas.2013.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Indexed: 02/03/2023]
Abstract
Lengthening the tibia more than 25% of its original length can be indicated for proximal femoral deficiency, poliomyelitis, or femoral infected nonunion. Such lengthening of the tibia can adversely affect the ankle or foot shape and function. The present study aimed to assess the effect of tibial lengthening of more than 25% of its original length on the foot and ankle shape and function compared with the preoperative condition. This was a retrospective study of 13 children with severe proximal focal femoral deficiency, Aitken classification type D, who had undergone limb lengthening from June 2000 to June 2008 using Ilizarov external fixators. The techniques used in tibial lengthening included lengthening without intramedullary rodding and lengthening over a nail. The foot assessment was done preoperatively, at fixator removal, and then annually for 3 years, documenting the range of motion and deformity of the ankle and subtalar joints and big toe and the navicular height, calcaneal pitch angle, and talo-first metatarsal angle. At fixator removal, all cases showed equinocavovarus deformity, with decreased ankle, subtalar, and big toe motion. The mean American Orthopedic Foot and Ankle Society score was significantly reduced. During follow-up, the range of motion, foot deformity, and American Orthopedic Foot and Ankle Society score improved, reaching nearly to the preoperative condition by 2 years of follow-up. The results of our study have shown that tibial overlengthening has an adverse effect on foot and ankle function. This effect was reversible in the patients included in the present study. Lengthening of more than 25% can be safely done after careful discussion with the patients and their families about the probable effects of lengthening on foot and ankle function.
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Affiliation(s)
- Khaled M Emara
- Professor, Department of Orthopaedic Surgery, Ain Shams University, Cairo, Egypt
| | - Ramy Ahmed Diab
- Lecturer, Department of Orthopaedic Surgery, Ain Shams University, Cairo, Egypt.
| | - Sherif El Ghazali
- Assistant Professor, Department of Orthopaedic Surgery, Ain Shams University, Cairo, Egypt
| | - Amr Farouk
- Assistant Lecturer, Department of Orthopaedic Surgery, Ain Shams University, Cairo, Egypt
| | - Mohamed Ahmed El Kersh
- Assistant Lecturer, Department of Orthopaedic Surgery, Ain Shams University, Cairo, Egypt
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Barg A, Knupp M, Henninger HB, Zwicky L, Hintermann B. Total ankle replacement using HINTEGRA, an unconstrained, three-component system: surgical technique and pitfalls. Foot Ankle Clin 2012; 17:607-35. [PMID: 23158373 DOI: 10.1016/j.fcl.2012.08.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Total ankle replacement (TAR) has become a valuable treatment option in patients with end-stage ankle osteoarthritis. One popular 3-component system, the HINTEGRA TAR, is an unconstrained system that provides inversion-eversion stability. More natural biomechanics of the replaced ankle may be expected when anatomic considerations drive prosthesis design. The HINTEGRA prosthesis includes 2 anatomically contoured metal components and a polyethylene insert, providing axial rotation and physiologic flexion-extension mobility. This article describes the HINTEGRA TAR design and surgical technique. Use of the prosthesis for complex hindfoot reconstruction in patients with an osteoarthritic, varus, or valgus ankle deformity is described.
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Affiliation(s)
- Alexej Barg
- Clinic of Orthopaedic Surgery, Kantonsspital Liestal, Rheinstrasse 26, Liestal CH-4410, Switzerland,
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Weiner RD, Hlad LM, McKenna DR. Recurrence of diabetic pedal ulcerations following tendo-achilles lengthening. Diabet Foot Ankle 2011; 2:DFA-2-6417. [PMID: 22396818 PMCID: PMC3284268 DOI: 10.3402/dfa.v2i0.6417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Foot and ankle surgeons are frequently challenged by the devastating systemic consequences of diabetes mellitus manifested through neuropathy, integumentary and joint breakdown, delayed healing, decreased ability to fight infection, and fragile tendon/ligaments. Diabetic neuropathic pedal ulcerations lead to amputations at an alarming rate and also carry a high mortality rate. This article will discuss causes of diabetic pedal ulcerations that persist or recur after tendo-Achilles lengthening and will highlight areas that need to be addressed by the practitioner such as infection, vascular and nutritional status, glucose control, off-loading, biomechanics, and patient compliance.
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Affiliation(s)
- Richard D. Weiner
- Residency Director, Podiatric Medicine and Surgery, Grant Medical Center, Columbus, OH, USA
- Ohio University-College of Osteopathic Medicine, Athens, OH, USA
| | - Lee M. Hlad
- PGY-II, Grant Medical Center, Columbus, OH, USA
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Functional outcome after percutaneous tendo-Achilles lengthening. Foot Ankle Surg 2011; 17:29-32. [PMID: 21276562 DOI: 10.1016/j.fas.2009.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2009] [Revised: 11/30/2009] [Accepted: 12/31/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND Percutaneous tendo-Achilles lengthening (PTAL) is a common procedure performed as an adjunct to other procedures that are used to treat a variety of foot and ankle disorders. Despite the widespread use of PTAL, the only literature to substantiate its efficacy comes from the treatment of forefoot ulceration in diabetics. The complications of the procedure include pain along the Achilles tendon, difficulty using stairs, weakness with toe-off, inadvertent complete tenotomy, and cosmetic appearance. We sought to investigate the functional outcomes specific to PTAL when performed in tandem with triple arthrodesis and subtalar fusion. MATERIALS AND METHODS A retrospective review of 107 patients who underwent 117 procedures was performed. Outcomes were assessed by telephone interview using a standard questionnaire. The most common procedure in the study population was triple arthrodesis (91%). RESULTS Fifty-eight percent of the patients reported moderate improvement in motion postoperatively, but 80% reported some degree of persistent stiffness. Despite 38% of patients reporting postoperative weakness, 66% and 61% stated that ascending and descending stairs, respectively, was easier. CONCLUSION Overall, 81% of the study population had a positive opinion regarding their surgery. In this heterogeneous population, we showed modest improvement in Achilles tendon-related outcomes when PTAL was performed in tandem with other surgeries.
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Abstract
BACKGROUND Percutaneous adductor longus tenotomy (PAT) is a frequently used procedure, yet no study has ever compared its effectiveness and safety with those of open adductor longus tenotomy (OAT). We conducted this prospective study to describe the effects of PAT and to compare them with those of OAT. METHODS This consisted of a cross-over randomized controlled trial including 50 consecutive hips from 27 patients with cerebral palsy scheduled for adductor tenotomy in the setting of multilevel tendon lengthening/release procedures or hip surgery (femoral or Dega osteotomy) in a university hospital. A pediatric orthopaedic surgeon conducted a PAT. Another surgeon extended the wound to explore what had been cut during the PAT, and completed the tenotomy if necessary. Hip abduction (HA) was assessed by a third surgeon immediately before PAT, after PAT, and then after OAT, using a goniometer, in a standardized reproducible manner. All 3 surgeons were blinded to the others' findings. Primary end-points included the percentage of tendon/muscle portion sectioned percutaneously, and the HA measure. Comparison between HA after PAT and OAT was done using a paired t-test with a 95% confidence interval. The influence of anatomic variants of adductor longus origin was also assessed. RESULTS Mean HA (hips flexed) measured 40.36 degrees preoperatively and increased to 50.04 degrees after PAT (P<0.0001). After OAT, HA averaged 53.32 degrees with no statistical gain compared with that observed after PAT (P=0.2). The tendinous portion of adductor longus was cut to an average of 98% by PAT (completely in 46 cases and more than 75% in only 4 cases). The muscular portion of adductor longus origin was cut to an average of 83.7% (completely in only 15 cases, cut to more than 75% in 26 cases, and approximately 50% in 9 cases). The gain in HA positively correlated with the extent of the tendinous portion divided (P=0.03) but not with the extent of muscular portion divided. Results were independent of the anatomic variants of adductor longus origin. Partial section of adductor brevis after PAT was encountered in 6 cases. No major iatrogenic lesion was observed (obturator nerve, major vessels). CONCLUSIONS This is the only prospective study concerning the effects of PAT. The anatomic factor associated with gain in HA seems to be the extent of the section of the tendinous portion of adductor longus origin, which was found to be cut to more than 90% in all cases after PAT. The extent of muscular portion section does not seem to influence the gain in HA. The researchers detail the technique of percutaneous adductor tenotomy and show that when done correctly, PAT is a fast and simple procedure, as reliable and effective as the open release and without any major risks. LEVEL OF EVIDENCE Level II therapeutic study-prospective comparative study.
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Abstract
Toe walking is a common feature in immature gait and is considered normal up to 3 years of age. As walking ability improves, initial contact is made with the heel. Toe-walkers will stand out as different once heel-strike is achieved by most of their peers. This difference gives rise to parental concern. Therefore toe-walkers are often referred at 3 years of age. This article examines the evidence for the management of children who have idiopathic toe walking and reviews the literature on surgery for the lengthening of a calf contracture.
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