Achilles Tendon Region Research Articles

Non-invasive evaluation of Achilles tendon and its enthesis using ultrashort echo time adiabatic T1ρ (UTE-Adiab-T1ρ) magnetic resonance imaging (MRI) in psoriatic arthritis

PurposeThis cross-sectional study investigates the utility of the quantitative ultrashort echo time (UTE) adiabatic T1ρ (UTE-Adiab-T1ρ) magnetic resonance imaging (MRI) in detecting potential differences in Achilles tendons and entheses of patients with psoriatic arthritis disease (PsA) compared with asymptomatic volunteers. Material and MethodThe Achilles tendons of forty-four PsA patients (59 ± 15 years old, 38 % female) and thirty-seven asymptomatic volunteers (32 ± 10 years old, 51 % female) were scanned on a 3 T clinical scanner in the sagittal plane using a 3-inch surface coil. The 3D UTE-Adiab-T1ρ sequences with fat saturation (FS) were used to measure UTE-Adiab-T1ρ. Tenderness of the tendons, the SF-12 health survey, and visual analog scale (VAS) were recorded for the patients. The Kruskal Wallis test was used to examine the differences in UTE-Adiab-T1ρ values between asymptomatic volunteers and patients, as well as subgroups of patients with pain in the Achilles tendon region and those treated with Biologics. Spearman’s correlation coefficients were calculated between UTE-Adiab-T1ρ and patient evaluations. P values < 0.05 were considered significant. ResultsUTE-Adiab-T1ρ was significantly higher for the PsA group compared with the asymptomatic group in the enthesis (11.4 ± 2.6 ms vs. 10.4 ± 2.4 ms) and tensile tendon regions (9.8 ± 2.8 ms vs. 7.7 ± 1.7 ms). PsA patients with active Achilles pain showed significantly lower T1ρ in the entheses compared with other patients (10.7 ± 2.6 ms vs. 11.7 ± 2.5 ms). PsA patients treated with Biologics showed significantly lower T1ρ values in the tendon compared with other patients (9.5 ± 2.5 ms vs. 10.3 ± 3.3 ms). The VAS score of patients showed a significant negative but weak correlation (R = -0.2) with UTE-Adiab-T1ρ of the enthesis. Correlations with SF-12 scores were not significant. ConclusionThis study highlighted the UTE-Adiab-T1ρ sequence capability in evaluating tendons and entheses and their potential involvement in PsA disease or response to therapies.

Effects of deep heating modalities on the morphological and elastic properties of the non-insertional region of achilles tendon: a pilot study

Background Over the last 20 years, both diathermy and ultrasound have been popular choices for many clinicians in treating musculoskeletal disorders. However, there is a lack of clinical evidence of deep heating modalities to treat tendon pathology, There is no study to investigate the effects of such as physical modalities on morphological and elastic properties on the human tendons. Objective the objective of the present study was to compare the effects of diathermy and ultrasound therapies on cross sectional area, transversal height and hardness percentage of the non-insertional region of the Achilles tendon in able-bodied subjects. Methods healthy volunteers were divided in diathermy and ultrasound group received six 15-min treatment sessions. Before and after treatment a sonographic assessment was conducted by mean of ultrasonography and the following parameters were recorded: cross sectional area, transversal height and hardness percentage. Results thirty-two subjects were enrolled. Between-group comparisons showed a significant change on hardness percentage (p = 0.004) after treatment in diathermy therapy group. Within-group comparison showed a significant improvement in the hardness percentage for the diathermy (p = 0.001) and ultrasound (p = 0.046) after two weeks of treatment. Conclusion this pilot study demonstrated larger effects on morphological and elastic properties of the non-insertional region of the Achilles tendon after diathermy than ultrasound therapy in normal tendons. Diathermy may be a useful deep heat modality for treating non-insertional Achilles tendinopathy.

Achilles Pathology and Surgical Approach Determine Post-Operative Infection Rate

Category:Sports; OtherIntroduction/Purpose:Post-operative infections can be a devastating complication after Achilles tendon surgery. While Achilles infection rates have decreased with the development of less invasive surgical techniques, these infections remain a challenging complication for patients and clinicians due to the relative lack of vasculature in the Achilles tendon region. This study aimed to analyze rates of postoperative Achilles tendon infection based on the type of Achilles pathology and surgical approach. We hypothesized that procedures with smaller incisions that avoided the critical zone would be associated with lower infection rates than those that require larger incisions, such as reconstructions.Methods:All patients undergoing Achilles tendon surgery at a single, multi-surgeon center between 2011 and 2020 were identified. Charts were reviewed for infection, pathology, surgical approach, incision size, and risk factors such as body mass index (BMI), smoking status, and diabetes. Rates of infection were compared between groups based on pathology and operative technique. These groups included acute rupture treated immediately, chronic pathology treated with debridement and repair, and chronic pathology treated with graft reconstruction. For patients treated for an acute rupture, minimally invasive and open approach sub-groups were compared. Further, prevalence of risk factors was compared between patients with and without post- operative infections. Statistical comparisons were performed between groups using a student's t-test or Fisher's exact test.Results:A total of 1,148 cases were identified, 23 of which involved a post-operative infection requiring a return to the operating room for irrigation and debridement. The overall infection rate was 2.00%. Cases involving chronic pathology treated with graft reconstruction were associated with an infection rate of 8.96%. Acute repairs had an infection rate of 1.32% and other chronic pathologies treated without graft reconstruction had an infection rate of 0.73%. Statistical comparisons of infection rates for these sub-groups are displayed in Table 1 alongside comparisons of risk factor prevalence between the infection and non-infection groups. The comparison of risk factors between groups did not identify any significant differences. No infections were observed following the use of a distal lateral incision to treat chronic tendon pathology (179 cases) or the use of a windows incision technique for reconstructions (8 cases).Conclusion:Analysis of infection rates indicated that treatment options requiring large incisions, such as reconstruction with a graft, pose a significantly greater risk of post-operative Achilles infection. Both minimally invasive treatments and measured open incisions were associated with similarly low infection rates for primary repair of acute ruptures. Comparison of risk factors between patients with and without infection did not reveal any significant differences. Given low infection rates for chronic pathology treated with distal lateral incisions and windows-type incisions, we recommend these whenever possible.

Standardized pain mapping for diagnosing Achilles tendinopathy

ObjectivesTo assess the level of agreement between patient-reported pain using a standardized pain map and the physician-determined clinical diagnosis of Achilles tendinopathy. DesignCross-sectional study. MethodsEligible patients were adults visiting a sports physician for symptoms in the Achilles tendon region. Patients completed a digital questionnaire and indicated one location on a pain map where they experienced their pain. The primary outcome measure was level of agreement (% and Kappa coefficient) between patient-reported pain on the pain map and the physician-determined clinical diagnosis (defined as localized pain associated with tendon-loading activities and pain on palpation with or without tendon thickening). The secondary outcome measure was the agreement between the location on the pain map (midportion/insertional region) with the clinical diagnosis of midportion/insertional Achilles tendinopathy. Results110 patients (mean (SD) age 48 (13), 61% men) with pain in the Achilles region were included. In 102 (93%, Kappa = 0.86, CI 0.78–0.95) patients who indicated pain in the Achilles tendon region on the pain map, the clinical diagnosis of Achilles tendinopathy was made by the sports physician. 82% of the patients had the clinical diagnosis of tendinopathy in the specific region of the tendon they marked on the pain map (Kappa = 0.67, CI 0.54–0.79). ConclusionsThere is almost perfect agreement between patient-reported pain on a pain map and a physician-established clinical diagnosis of Achilles tendinopathy. There was substantial agreement between the localization of the pain that was selected by the patient and the diagnosis of insertional/midportion Achilles tendinopathy by the physician. This tool could potentially aid in adequate triage for specialized care and for researchers performing large epidemiological studies.

Different Modalities of Flap Coverage of Achilles Tendon Region Defects: Functional and Aesthetic Outcomes

Abstract Background: In the decision-making process toward covering various Achilles' tendon region, knowledge about patient related outcomes after surgery and rehabilitation is important. Therefore, we aimed to present an overview of outcomes and select the most appropriate flaps used for covering soft tissue defects over Achilles' tendon region. Aim of Study: Study aimed to analyse and determine the suitable reconstructive surgical options for Achilles' tendon coverage and to evaluate the clinical, functional and aesthetic outcomes. Patients and Methods: Between September 2017 and December 2019, 25 patients with skin loss over Achilles' tendon region were admitted to Menoufia University Hospital and Shebin-Elkom Teaching Hospital. The soft tissue defects ranged from 3x2 to 16x12 cm. Six types of flaps were used for the coverage of concomitant skin defects. Results: There was no complete flap loss and all flaps survived. Lateral supra malleolar flap (28%) was used in seven patients, distally based peroneus brevis muscle flap (16%) in four patients, posterior tibial artery perforator flap (24%) in six patients, peroneal artery perforator flap (4%) in one patient, reversed sural artery flap (24%) in six patients, and free latissimus dorsi musculocutaneous flap (4%) in one patient. Two patients were subjected to debridement and covered with split thickness skin graft (STSG). One patient suffered from chronic ulcer formation which was covered with lateral supra malleolar artery flap. The algorithm of one-stage reconstruction was established, according to the defect size of skin. Conclusion: Perforator flaps, lateral supra malleolar artery flap, and the distally based peroneus brevis muscle flap were a suitable option for coverage of small to intermediate sized defects; reversed sural artery flap is best for coverage of moderate to large size defects and free flaps are the best choices for complex wide reconstructions.

Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap

IntroductionAchilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue. Methods7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel. ResultsThe size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage. ConclusionDistally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation.

A Comparative Clinical Evaluation of Agnikarma and Raktamokshana in Management of Gridhrasi (Sciatica)”

Background: Gridhrasi can be correlated with sciatica which is a severe painful condition where back pain and radiating pain of the legs are found together on the basis of symptoms. In the treatment of sciatica only symptomatic management and a very few surgical procedures are available in conventional medical science with their own limits. Various methods used for Gridhrasi treatment in Ayurveda but para-surgical methods i.e. Agnikarma &amp; Raktamokshana are more beneficial.&#x0D; Aim &amp; objective: To compare the efficacy of Agnikarma and Raktamokshana (Cupping) in the management of Gridhrasi (Sciatica).&#x0D; Materials &amp; Methods: Total 32 diagnosed cases of sciatica were registered, from which 29 patients completed the study. In group A, 4 sittings of Agnikarma were done in 16 patients with Panchadhatu Shalaka at lumbosacral region and achilles tendon region. In group B, 2 sittings of Raktamokshana was performed in 16 patients by using modified Shringa Yantra at lumbo-sacral region and four angula above Janu sandhi (Knee joint)..&#x0D; Result: The result was assessed by using wilcoxon signed rank test within the group and Mann whitney test between the group. Stastically significant relief was observed in both groups on cardinal symptoms of Gridhrasi. In Agnikarma group, 26.67% patients had got complete remission, 20% patients had marked improvement whereas 40% had moderate improvement in the symptoms of Gridhrasi. In group, Raktamokshana 50% had moderate improvement, 42.85% had marked improvement.&#x0D; Conclusion: Both para-surgical modalities have definite role in treating sciatica but Agnikarma has shown better result in comparison of Raktamokshana in the management of Gridhrasi (Sciatica).

Achilles Tendon Region Defects: Delayed Composite Anterolateral Thigh Flap With Stripping of Fascia Lata: A Case Series

The purpose of this study was to evaluate the functional and physical functioning score out-comes of patients following microsurgical reconstruction of the yarrow region, using a combination of objective, subjective, and semi-subjective measurements. Between 2007 and 2018, 15 patients underwent delayed Achilles tendon region reconstruction with different anterolateral thigh flap types. Seven (7) patients underwent tendon and soft tissue re-construction with a chimeric anterolateral thigh flap (ALT) and rolled-up fascia lata, and 8 patients underwent soft tissue reconstruction and only tendon coverage with fascia lata. Follow-up assessments included maximal range of motion (MROM) (plantarflexion and dorsiflexion), the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale score, and the Med-ical Outcomes Study 36-item Short-Form Health Survey physical functioning subscore. A total of 15 patients (11 males and 4 females with a mean age of 39.86 years) were evaluated during a mean follow-up time of 23 months (SD = 7.12). The MROM for plantarflexion and dorsiflexion was 42.71 degrees (SD = 2.9) and 24.8 degrees (SD = 4.29), respectively, in patients who underwent composite ALT with a rolled-up fascia lata. The MROM for plantarflexion and dorsiflexion was 43 degrees (SD = 5.37) and 27.37 degrees (SD = 3.2), respectively, in patients who underwent fasciocutaneous ALT. The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score was 82 for the first group and 86.87 for the second, whereas the mean Medical Outcomes Study 36-item Short-Form Health Survey scores were 82.57 and 81.5, respectively, for the 2 groups. Statistical analysis showed no significant difference between the 2 groups. The results of this case series suggest that the single-stage composite reconstruction with a fasciocutaneous flap with or without a strip of fascia lata is a safe and reliable strategy for composite reconstruction of the Achilles tendon region. Additional studies to evaluate these outcomes and instruments to evaluate functioning are necessary.

Propeller flap: Orthoplastic approach for coverage of distal leg and ankle defects

BackgroundCovering soft tissue defects of the distal one-third of the leg and the Achilles tendon region and is a challenging problem for an orthopedic surgeon. With recent advancements in the anatomical knowledge of perforating vessels, perforator-pedicled propeller flaps have become increasingly popular in recent decades. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects in the distal leg were reconstructed with propeller flaps and assessed association of complications with age, gender, flap size and arc of rotation. MethodsPatients that had a reconstruction with a propeller flap at the ankle from 2013 to 2019 were retrospectively reviewed. The main indications for the propeller flap were small- and medium-sized soft tissue defects of the distal lower limb. 20 propeller flaps were applied to 19 patients (14 male, 5 female) for various lower extremity defects. ResultsThe mean follow-up duration was 2 years (range, 6 months to 6 years). The average flap size was 82 cm2 (range, 48–125 cm2). The flap was rotated 180 degrees in nine patients The source of the perforator vessel was the tibialis posterior artery in 14 cases, the peroneal artery in 4 cases, both the tibialis posterior and peroneal arteries in 1 case. Four complications (20 %) occured postoperatively. Two patients developed partial necrosis at the tip of the flap, and two patients developed superficial epidermolysis. No correlations were found between complications and flap size and the arc of rotation. ConclusionsThe propeller flap is a reliable option for reconstruction of small to moderate defects in the lower extremity with good clinical results and minimal donor-site morbidity. It is applicable for orthopedic surgeons who do not have microsurgical experience or an available microscope in the operating room.

Long-term clinical and patient-reported outcomes in free flap reconstruction of the weight-bearing heel pad and non-weight-bearing Achilles tendon regions.

The non-weight-bearing (NWB) Achilles tendon and weight-bearing (WB) heel pad regions are technically challenging to reconstruct with distinct functional and aesthetic considerations that have not been previously considered in the literature. This study is the first to characterize the long-term clinical and patient-reported outcomes of these components to better inform patients about the postreconstruction period. A retrospective review of medical records and phone-based survey of adult patients who underwent free flap reconstruction of the heel/ankle with 6-month minimum clinical follow-up was performed. Forty-three patients, with 31 (72.1%) NWB and 12 (27.9%) WB defects, treated from January 1, 2000 to February 28, 2017 were included. Muscle flaps were more common than fasciocutaneous flaps (N = 36 [83.7%] vs. 7 [16.3%]). Flap survival rate was 95.3% and limb salvage rate was 93.0% at median follow-up of 12.0 months (interquartile range [IQR] 6.2, 25.5). Flap ulceration occurred more frequently in the WB region (41.7 vs. 6.5%, p = .0123). The survey response rate was 63.6%. The majority of patients complete daily tasks with no/little impairment (76.2%), walk half a mile or more (85.7%), returned to work (86.6%), and fit shoes "fair" or "well" (71.4%). Most patients were "very satisfied" with heel/ankle function (71.4%) and would "very likely" undergo the same procedure if needed (76.2%). Free flap reconstruction in both the NWB Achilles tendon and WB heel pad has excellent limb salvage and flap survival rates. Patients were satisfied with heel/ankle function, but additional counseling is recommended for variance in appearance and higher ulceration rates in WB defects.

Achilles Tendon Rupture: Double the Trouble

Introduction: Achilles tendon is the strongest tendon in the body . Achilles tendon rupture is a debilitating ankle injury especially among the athletes. We would like to highlight an unusual case of acute dual-level injuries of the Achilles tendon. Case report: A 30-year-old footballer presented with left ankle injury during a football tournament. Examination revealed tenderness at posterior left heel, palpable gap at Achilles tendon region and positive Thompson test. Radiological assessment showed dual-level injuries of the Achilles tendon-proximally was a rupture at musculotendinous junction and distally was an avulsion calcaneal fracture. We performed a mini-open approach Achilles tendon reconstruction for this patient. First, we reconstructed the distal avulsion calcaneal fracture using double row anchor sutures technique. Next, we repaired the proximal ruptured Achilles tendon using percutaneous Achilles reconstruction system (PARS) from Arthrex. Postoperatively, patient was put on functional rehabilitation protocol. At present, patient recovers well and regains back the Achilles tendon function. In conclusion, segmental Achilles tendon injury is rare and its surgical treatment can be challenging and must be well-planned.

Multi-Step Segmentation Algorithm for Quantitative Magnetic Resonance Imaging T2 Mapping of Ruptured Achilles Tendons

Diagnosis and treatment monitoring of Achilles tendon ruptures (ATRs) are supported by medical imaging, in particular by magnetic resonance imaging (MRI) for tendon volume and healing assessment. Therefore, we propose an automatic, multi-step segmentation algorithm for quantitative MRI T2 mapping of ATRs. Seventy retrospective post-trauma, post-surgery and follow-up studies were included in this research. The automatic segmentation algorithm for the inhomogeneous, noisy Achilles tendon region consisted of a multi-step anisotropic denoising, T2 map reconstruction with a weighted log-linear regression, thresholding with T2 time parameters, region growing and morphological closing. The automatic segmentation results were compared with those from manual contour tracing (MCT) performed by two radiologists. The Intersection over Union (IoU), specificity, sensitivity, F1-score, Yasnoff's normalized distance (YND), and type I and II errors were used to assess the segmentation accuracy. The segmentation methods were also compared with a Bland-Altman plot of the volumes of the segmented regions, with mean differences, correlation coefficients and 95% confidence intervals. The mean specificity and sensitivity values were high, 99.8± 0.1% and 85.9± 8.7%, respectively, with corresponding type I and II errors of 0.2± 0.1% and 14.1± 8.7%. The IoU, F1-score and YND were 71.0± 9.2%, 82.7± 6.3% and 0.007± 0.007%, respectively. The tendon volumes obtained by manual and automatic segmentation were strongly positively correlated ($\text{R}^{2} =0.85$ ), and the Bland-Altman plot depicted good comparability. The average difference was -28 voxels (95% confidence interval: -2726 to 2782 voxels). For ATRs, our method is reliable, with a strong positive correlation with MCT and a very high specificity.

The ‘piston’ effect of the calf muscle pump in region of Achilles tendon

Aim: The aim of the current study was to highlight the ‘piston’ effect of the calfmuscle pump using constriction mechanisms.Method: Working pressure variations of 27 lower limbs of 14 volunteers wearing 20/30mmHg elastic stockings were evaluated using a balloon catheter. The balloon catheterwas 4 x 5 cm in size, placed between the skin and the material of the stockings andconnected to a DTX Plus TM sensor; a portable device that collects and stores pressurereadings at half-second intervals. One catheter was placed in the medial region of thecalf muscle and another at the insertion point of the Achilles tendon in this muscle.The volunteers were asked to walk. The paired Student t-test was utilized for statisticalanalysis with an alpha error of 5% considered acceptable.Result: The pressure variations were greater in the region where the Achilles tendonis inserted into the muscle than in the medial region of the calf muscle (Student t-test;p-value = 0.0006).Conclusion: At the insertion point of the Achilles tendon in the calf muscle there is a‘piston’ effect during exercising, causing working pressure variations when contentionmechanisms are used.Key words: Elastic stockings–working pressure–mechanism–piston effect

Perforator flaps for the reconstruction of achilles tendon region defects of lower limb

Perforator flaps for the reconstruction of achilles tendon region defects of lower limb

CLINICO-ANATOMICAL FEATURES OF INTEGUMENTARY TISSUES IN THE ACHILLES TENDON FROM THE POINT OF VIEW OF PLASTIC SURGERY. THE ANALYSIS OF WAYS OF ELIMINATION OF CICATRICIAL DEFORMATIONS IN THE ACHILLES TENDON AREA: THEIR ADVANTAGES, DISADVANTAGES

The article deals with the features of integumentary tissues in the Achilles tendon region, which must be taken into account in the planning of reconstructive surgeries, the clinical features of this scar localization, as well as the advantages and disadvantages of existing methods of normal skin repair in the Achilles tendon area.

Surgical plantaris tendon removal for patients with plantaris tendon-related pain only and a normal Achilles tendon: a case series

ObjectivesSurgical removal of the plantaris tendon can cure plantaris-associated Achilles tendinopathy, a condition in which Achilles and plantaris tendinopathy coexist. However, rare cases with plantaris tendinopathy alone are often misdiagnosed...

Achilles Region Soft-Tissue Defects: A Reconstructive Algorithm Based on a Series of 46 Cases.

Background Several options have been described for soft-tissue reconstruction in Achilles tendon region (ATR). The best procedure should be customized according to any single case taking into account the number of structures involved, the quality of the neighboring skin, and patient's general condition. The aim of this article is to describe a simplified reconstructive algorithm based on personal experience and reviewing literature. Methods Forty-four patients, who underwent ATR soft-tissue reconstruction between 1998 and 2016, have been retrospectively reviewed. Etiologies of the defect include the following: 18 posttraumatic, 10 postoncologic, 14 dehiscence/infection, and 2 chronic ulcers. Follow-up ranges between 12 and 96 months. Free flaps have been used in 30 cases (including two secondary surgeries due to propeller flap failure) and propeller flaps have been used in 16 cases. Results Thirty-six flaps survived uneventfully (78.3%). Total flap necrosis occurred in three cases (6.5%), namely, two propeller flaps and one free flap. Partial necrosis of the flap was observed in seven cases (15, 2%): three in the free flap group and four in the propeller group. The functional recovery was very good in all the patients without involvement of the tendon and also all the patients who underwent a simultaneous reconstruction of the tendon with different techniques recovered a full weight bearing and a satisfactory range of motion. Conclusion Propeller flaps are a valuable option for skin reconstruction in case of defects of small and medium size not involving the tendon. In case of larger defects and when a simultaneous ATR reconstruction is required, a free flap seems to be a better option.

POSTERIOR TIBIAL ARTERY FLAPS FOR LEG AND ANKLE RECONSTRUCTION

Defects of the leg, ankle, and Achilles tendon regions still represent a tricky issue in lower limb surgery. Among the several reconstructive possibilities, local propeller perforator flaps have gained popularity in the last decades. The posterior tibial artery perforator flap is one of the most versatile flaps for reconstruction in these regions. Objectives: To explore the feasibility and therapeutic effect of the posterior tibial artery perforator flaps for coverage of defects around the ankle, heel and lower third of leg Methods: From June 2013 to March 2016 a total number of 15 cases of soft tissue defect on the leg, achilles tendon and ankle area in 13 patients managed by posterior tibial artery perforator flap inShebinElkom Teaching Hospital, SohagUniversity hospital and Menofia University Hospital Follow up was done for at least 6 months with good results. Results: A total number of 15 cases of soft tissue defect on the leg, achilles tendon and ankle area in 13 patients managed by posterior tibial artery perforator flap. All flaps healed well with good functional results and acceptable donor site morbidity Conclusions It was concluded that the distally based pedicled posterior tibial artery perforator flap was a reliable, easy, less time consuming, and versatile procedure for covering the defects around the ankle, heel, and lower third a leg. KEYWORDS: Lower limb reconstruction; achilis and calcaneal regions; Adipofascial flaps; posterior tibial perforators

Is human Achilles tendon deformation greater in regions where cross-sectional area is smaller?

The Achilles is a long tendon varying in cross-sectional area (CSA) considerably along its length. For the same force, a smaller CSA would experience higher tendon stress and we hypothesised that these areas would therefore undergo larger transverse deformations. A novel magnetic resonance imaging-based approach was implemented to quantify changes in tendon CSA from rest along the length of the Achilles tendon under load conditions corresponding to 10%, 20% and 30% of isometric plantar flexor maximum voluntary contraction (MVC). Reductions in tendon CSA occurring during contraction from the resting condition were assumed to be proportional to the longitudinal elongations within those regions (Poisson's ratio). Rather than tendon regions of smallest CSA undergoing the greatest deformations, the outcome was region specific, with the proximal (gastrocnemius) tendon portion showing larger transverse deformations upon loading compared with the distal portion of the Achilles (P<0.01). Transverse tendon deformation only occurred in selected regions of the distal Achilles tendon at 20% and 30% of MVC, but in contrast occurred throughout the proximal portion of the Achilles at all contraction levels (10%, 20% and 30% of MVC; P<0.01). Calculations showed that force on the proximal tendon portion was ∼60% lower, stress ∼70% lower, stiffness ∼30% lower and Poisson's ratio 6-fold higher compared with those for the distal portion of the Achilles tendon. These marked regional differences in mechanical properties may allow the proximal portion to function as a mechanical buffer to protect the stiffer, more highly stressed, distal portion of the Achilles tendon from injury.

Soft-tissue defects of the Achilles tendon region: Management and reconstructive ladder. Review of the literature

IntroductionDefects of the Achilles tendon region represent a challenge for reconstructive surgeons. Several options are available but there is still no reconstructive ladder for this specific and tricky area. An up-to-date reconstructive ladder according to local and general conditions is proposed based on our multicentre experience and an extensive review of the English literature on PubMed. Materials and methodsAn extensive review of the English literature was performed on PubMed using the following key-words: “Achilles region”, “heel”, “soft-tissue reconstruction”, “flaps”, “grafts” and “dermal substitutes”. ResultsA total of 69 complete papers were selected, covering the last thirty years’ literature. Although most of the studies were based on limited case-series, local and general conditions were always reported. A comprehensive reconstructive ladder of all the available reconstructive techniques for the Achilles region has been created based on our personal multicentre experience and the results of the literature review. ConclusionsThe reconstructive ladder is a concept that is still a mainstay in plastic surgery and guides decisions in the repair strategy for soft tissue defects. The optimal solution, according to the experience of the surgeon and the wishes of the patient, is the one that implies less sacrifice of the donor site. Perforator flaps should be the first-line option for small-to-moderate defects; the distally‐based sural flap is the most reported for moderate-to-large defects of the Achilles region, and free flaps should be reserved mainly for complex and wide reconstructions.