Achilles Tendon In Children Research Articles

Relation of the Sural Nerve and Medial Neurovascular Bundle With the Achilles Tendon in Children With Cerebral Palsy Treated by Percutaneous Achilles Tendon Lengthening.

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). 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. 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. 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 III.

Muscle architecture and passive lengthening properties of the gastrocnemius medialis and Achilles tendon in children who idiopathically toe-walk.

Children who idiopathically toe‐walk (ITW) habitually operate at greater plantarflexion angles and thus, at shorter muscle‐tendon unit (MTU) lengths than typically developing (TD) children. Therefore, it is often assumed that habitual use of the gastrocnemius muscle in this way will cause remodelling of the muscle‐tendon architecture compared to TD children. However, the gastrocnemius muscle architecture of children who ITW has never been measured. It is essential that we gain a better understanding of these muscle‐tendon properties, to ensure that appropriate clinical interventions can be provided for these children. Five children who ITW (age 8 ± 2 years) and 14 TD children (age 10 ± 2 years) participated in this study. Ultrasound was combined with isokinetic dynamometry and surface electromyography, to measure muscle architecture at common positions and passive lengthening properties of the gastrocnemius muscle and tendon across full range of motion. Regardless of which common condition groups were compared under, both the absolute and normalised to MTU muscle belly and fascicle lengths were always longer, and the Achilles tendon length was always shorter in children who ITW than TD children (p < 0.05; large effect sizes). The passive lengthening properties of the muscle and tendon were not different between groups (p > 0.05); however, passive joint stiffness was greater in children who ITW at maximum dorsiflexion (p = 0.001) and at a joint moment common to all participants (p = 0.029). Consequently, the findings of this pilot study indicate a remodelling of the relative MTU that does not support the concept that children who ITW commonly experience muscle shortening. Therefore, greater consideration of the muscle and tendon properties are required when prescribing clinical interventions that aim to lengthen the MTU, and treatments may be better targeted at the Achilles tendon in children who ITW.

Step-advanced rectangular flap: A novel technique for the reconstruction of soft-tissue defects overlying the Achilles tendon in children (an observational study).

Soft-tissue defects overlying the Achilles tendon are common complications after bicycle or motorcycle spoke injuries in children and usually require surgical management by various flaps. There is no apparent consensus on the optimal choice of flaps for these injuries. We designed a novel step-advanced rectangular flap to reconstruct small to moderate soft-tissue defects around the Achilles tendon. This study was performed to review our experience and evaluate the clinical effectiveness of the step-advanced rectangular flap.From May, 2014 to September, 2016, 12 consecutive children with soft-tissue defects overlying the Achilles tendon caused by spoke injuries were treated with the step-advanced rectangular flap. The patients’ general information, surgical details, and postoperative complications were recorded. The Mazur evaluation system was used to assess clinical outcomes.All patients were followed up for ≥12 months (range 12–38 months). All flaps survived completely. Superficial infection occurred in 2 patients and healed by second intention after dressing changes; the other patients’ surgical wounds healed by primary intention. The scars around the flaps in 2 patients were remarkable, and all others showed good results in terms of flap color and texture. Ankle function was normal, and satisfactory results were obtained in all cases. According to the Mazur evaluation system, the results were excellent in 9 patients and good in 3, with an excellent and good rate of 100% at 12 months postoperatively.The rectangular advancement flap appears to be a simple and reliable method for small to moderate soft tissue defects overlying the Achilles tendon in children.

Effects of Two Plyometric Protocols at Different Surfaces on Mechanical Properties of Achilles Tendon in Children

Objectives: The purpose of this study was to compare the changes in muscle strength and Achilles tendon strain after two plyometric training programs performed on different surfaces in children. Methods: Thirty six children (21 girls, 15 boys) aged 9.30 ± 0.55 years were assigned into a mini-trampoline plyometric group (TPLG), a ground-plyometric group (GPLG) and a control group (CG). The training groups completed a 4-week plyometric intervention (PL) (three-times a week), consisting of hopping exercises performed either on a mini-trampoline (TPLG) or ground (GPLG). Achilles tendon strain, peak ankle plantar flexion torque (PAT), and rate of torque development (RTD) at 3 different angular positions of the ankle (15°, 0° and -15°) were measured before and after training. Results: The main finding of this study was that Achilles tendon strain decreased significantly after plyometric training performed on a mini-trampoline or ground surface ( 25% and 15%, for the TPLG and GPLG, respectively (P < 0.05)). This was accompanied by an increase in maximum ankle MVC torque and an increase in RTD (at 15°, 0° positions) for both experimental groups. Especially, statistically significant increases in PAT (30%) and RTD (14%) (P < 0.05) were found for the TPLG while for the GPLG group the increase was 19 % and 8% for PAT and RTD, respectively (P < 0.05). Conclusions: Both protocols show similar adaptations regardless of the surface of training. Training on elastic surface should be incorporated into exercise programs aiming either to enhance strength performance safely, or to achieve the target goal which is not only the safe performance but also the muscle-tendon system efficiency.

Real-time ultrasound elastography of the Achilles tendon in patients with cerebral palsy: is there a correlation between strain ratio and biomechanical indicators?

Our aim was to comparatively investigate the strain ratio and thickness of the Achilles tendon in children with cerebral palsy (CP), and to elucidate whether there is a correlation between biomechanical features of the Achilles tendon and strain ratio. A total of 155 participants (72 CP patients and 83 healthy controls) who underwent real-time elastography of both Achilles tendons were studied. A linear transducer (4.8-11.0MHz) was used to obtain the images. Correlation analysis between age, length, and thickness of the Achilles tendon, and strain ratio (SR) was performed by means of Pearson correlation and Spearman's rho tests. Comparison of results obtained from CP patients and controls showed that the length of the Achilles tendon was shorter (p<0.001) and SR was higher (p<0.001) in CP patients. In CP patients, there was a positive correlation between SR and age and between SR and the thickness and length of the Achilles tendon (p<0.001 for all). Furthermore, the length of the tendon and age were positively associated (p<0.001). ROC analysis revealed that the cut-off value for SR was 1.89. The results of the present study demonstrated that real-time elastography can constitute a simple, practical, and noninvasive method for evaluation of the elasticity of the Achilles tendon in children with CP.

Reconstruction of skin defects around the Achilles tendon with rectangle advancement flap in children

Objective To explore the clinical efficacy of rectangle advancement flaps used in the re-construction of skin defects around the Achilles tendon in children. Methods From May 2014 to June 2015, 7 children with skin defects around the Achilles tendon were admitted to our trauma center. The areas of skin defect ranged from 3.4 cm × 2.7 cm to 5.5 cm × 4.0 cm. The integrity of Achilles tendon was preserved in 6 cases but the tendon insertion was partly disrupted in one case. The skin defects were reconstructed with self-designed rectangle advancement flaps after debridement. In the one case with the Achilles tendon partly disrupted, the contaminated tendon ends were excised before wound closure. The injured ankles were immobilized in plantar flexion with one 1.5 mm K-wire and plaster splint to decrease the postoperative tension of the flap. Results All the flaps survived completely by primary intention but local infection occurred in 2 wounds which was cured by second intention of dressing change. The follow-up periods ranged from 8 to 12 months (average, 11.5 months). The scar around the flap was remarkable in 2 cases, but the flaps in the other cases ap-peared normal in terms of color and texture. The ankle function was satisfactorily normal in all the cases. Conclusion Our self-designed rectangle advancement flaps provide a simple, safe and reliable way to repair skin defects around the Achilles tendon in children. Key words: Foot; Wounds and injuries; Surgical flaps; Child

Mechanical and material properties of the plantarflexor muscles and Achilles tendon in children with spastic cerebral palsy and typically developing children

BackgroundChildren with spastic cerebral palsy (CP) experience secondary musculoskeletal adaptations, affecting the mechanical and material properties of muscles and tendons.CP-related changes in the spastic muscle are well documented whilst less is known about the tendon. From a clinical perspective, it is important to understand alterations in tendon properties in order to tailor interventions or interpret clinical tests more appropriately. The main purpose of this study was to compare the mechanical and material properties of the Achilles tendon in children with cerebral palsy to those of typically developing children. MethodsUsing a combination of ultrasonography and motion analysis, we determined tendon mechanical properties in ten children with spastic cerebral palsy and ten aged-matched typically developing children. Specifically, we quantified muscle and tendon stiffness, tendon slack length, tendon strain, cross-sectional area, Young׳s Modulus and the strain rate dependence of tendon stiffness. FindingsChildren with CP had a greater muscle to tendon stiffness ratio compared to typically developing children. Despite a smaller tendon cross-sectional area and greater tendon slack length, no group differences were observed in tendon stiffness or Young׳s Modulus. The slope describing the stiffness strain-rate response was steeper in children with cerebral palsy. InterpretationThese results provide us with a more differentiated understanding of the muscle and tendon mechanical properties, which would be relevant for future research and paediatric clinicians.

Ultrasonographic evaluation of Achilles tendon in children with flatfoot: A case-control morphometric study.

The purpose of this study was to investigate whether any relationships exist between the presence of flatfoot and ultrasonographic morphometric findings of Achilles tendon in children. The study included 30 pediatric patients with a mean age of 11.96±2.44 (SD) years (range: 9-16 years) with flexible flatfoot and 29 healthy pediatric controls who were matched for age and served as a control group. Demographic data of both groups such as age, height and weight, and anthropometric measurements including leg length and, length and cross-sectional area of the Achilles tendon on ultrasonography were tabulated. Relationships between the cross-sectional area of Achilles tendon and flatfoot and the other parameters were searched for using backward multiple regression analysis. No associations between flatfoot and length and cross-sectional area of the Achilles tendon, age, height, leg and foot length were found. A negative correlation was found between the cross-sectional area of Achilles tendon and presence of flatfoot (Beta=-4.93, P=0.01) and age (Beta=-1.96, P=0.04). A positive correlation was found between the cross-sectional area of Achilles tendon and shoe size (Beta=2.13, P=0.007). Flatfoot, shoe size, age and weight must be kept in mind as a clue for a thinner Achilles tendon morphometry which can be a risk factor in lower limb pathologies.

Compartmental pressure after percutaneous tenotomy of the Achilles tendon in children with infantile cerebral palsy

Our objective was to study the pressure of the posterior superficial compartment of legs of children with spastic cerebral palsy and equinus deformity before and after a percutaneous tenotomy of the Achilles tendon. We studied compartmental pressure in 28 percutaneous tenotomies of the Achilles tendon (18 patients). All patients suffered cerebral palsy: 19 were tetraplegics (67.9%) (Ashworth Grade 4, Gross Motor Function Classification System (GMFCS) Level IV), and 9 were hemiplegics (32.1%) (Ashworth Grade 3, GMFCS Level III). Exclusions were previous surgery and those who had previously been treated with botulinum toxin. An auto-calibration monitor (measurement error ±1 mmHg) was used to calculate the pressure of the posterior superficial compartment of the leg. The ankle equinus was measured using a goniometer (measurement error ±2°). The systolic and diastolic arterial pressures and the weight were measured simultaneously. Descriptives, Wilcoxon test, and Kruskal-Wallis test were performed. The mean total age was 9.1 years, the mean total weight was 27.7 kg, and the mean systolic and diastolic pressures were 96.4 and 43.6 mmHg, respectively. The compartmental pressure was 11.3 mmHg pre-tenotomy and decreased by 30.1% post-tenotomy to 7.9 mmHg. Compartmental pressure pre-tenotomy was 10.2 mmHg in hemiplegics and 11.8 mmHg in tetraplegics and was reduced to 2.3 and 10.5 mmHg post-tenotomy in hemiplegics and tetraplegics, respectively. The pressure was significantly reduced in post-tenotomy hemiplegics (p = 0.001). Compartmental pressure was independent of weight, systolic/diastolic pressure, both pre- and post-tenotomy. Compartmental pressure decreased significantly in spastic boys after percutaneous tenotomy of the Achilles tendon. Compartmental pressure was higher in tetraplegic than in hemiplegic boys.

Real time evaluation of monolateral clubfoot with sonoelastography

This study was undertaken to assess the feasibility of real-time elastosonography (RTE) of Achilles tendon in the clinical evaluation of a cohort of children affected by unilateral clubfoot, not surgically treated. Twenty patients affected by unilateral clubfoot were evaluated. The study group consisted of 8 males and 12 females (mean age, 16 ± 7.3 months), all treated with the Ponseti method. Children were divided into two groups according to age: group 1 aged 0-18 months, and group 2 aged 18-60 months. Any further systemic pathological conditions were considered exclusion criteria. For each subject, RTE examination of the Achilles tendons was performed bilaterally, and then regions of interest (ROIs) were positioned. In children aged 0-18 months, the mean value ROI 1/mean value ROI 2 ratio was 2.0 ± 0.18 and it showed a statistically significant difference if compared to the same ratio from healthy tendons, 2.5 ± 0.17 (p < 0.05). In group 2 (children aged 18-60 months) the mean ROI 1/mean value ROI 2 ratio value was 1.8 ± 0.27, compared to a 2.04 ± 0.21 (p < 0.05) ratio in healthy tendons. RTE is a feasible, reliable and easily performed technique that allows an accurate study of the mechanical properties of Achilles tendon in children with clubfoot.

In Vivo Evaluations of Morphologic Changes of Gastrocnemius Muscle Fascicles and Achilles Tendon in Children with Cerebral Palsy

The Achilles tendon plays an important role in soleus and gastrocnemius muscle functions, including proper muscle force transmission and movement generation. However, few studies have examined concurrent changes of tendon and muscle properties in neurologic disorders. The objective of this study was to investigate the morphologic characteristics of both the calf muscle fascicles and the Achilles tendon in children with cerebral palsy (CP). A cross-sectional study was planned, and 12 children with CP and 11 typically developing children participated in this study. For both groups, B-mode ultrasonography was used to evaluate the architecture of the medial gastrocnemius muscle, including fascicle length and pennation angle at various ankle (20, 10, and 0 degrees plantar flexion and 10 degrees dorsiflexion) and knee (full extension and 90 degrees flexion) positions. The length and cross-sectional area of the Achilles tendon were also evaluated using ultrasonography. For both CP and control groups, muscle fascicle length, pennation angle, and Achilles tendon length and cross-sectional area varied with ankle and knee positions systematically. Compared with controls, children with CP had shorter muscle fascicles across the tested ankle range of motion (P ≤ 0.003), longer Achilles tendon (P = 0.001), and smaller cross-sectional area of the Achilles tendon (P = 0.003). The changes in Achilles tendon properties could be a result of adaptation to calf muscle fascicle shortening and stiffening, which may affect performance of the muscles. A better understanding of the interactions between calf muscle fascicles and Achilles tendon in children with CP may help treat the pathologic changes more effectively.

Avulsion Fracture of Calcaneal Apophysis in an Adolescent Gymnast : A Case Report

The avulsion fracture of calcaneal apophysis by Achilles tendon in children is quite rare. It may occur with the injury of the apophysis on the calcaneal tuberosity in the children below the age of 12 to 15 before the union of the apophysis. The authors surgically treated a 14-year-old gymnast with the avulsion fracture of the calcaneal tuberosity who injured at the landing of the floor exercise. Radiographs at the fourteen months of follow-up showed slight irregularity of the calcaneal tuberosity but there were no pain or limitation of activity. We report a case with the review of literatures.

Percutaneous elongation of the Achilles tendon in children with cerebral palsy.

From 1987 to 1990, 45 children with cerebral palsy underwent percutaneous elongation of the Achilles tendon (71 ankles); the mean age was 5.7 years. Most suffered from spastic diplegia or hemiplegia. A three-step cut technique was used, the limb immobilised in a long leg fiberglass cast and immediate weightbearing allowed. Follow up was from 2 to 5 years. Satisfactory results were obtained with significant improvement in walking in 89%.