Ankle Society Ankle-Hindfoot Scale Score Research Articles

Simultaneous ossicle resection and lateral ligament repair give excellent clinical results with an early return to physical activity in pediatric and adolescent patients with chronic lateral ankle instability and os subfibulare.

To elucidate surgical outcomes in pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare. A retrospective chart review was conducted of pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare following simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active range of motion exercises for the ankle in our department between 2013 and 2017. Clinical outcomes were evaluated by comparing preoperative and final follow-up American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and Karlsson-Peterson ankle function scores. Intervals between surgery and return to physical education in school were determined. 31 feet of 15 male and 16 female patients were examined. Mean postoperative follow-up duration was 40.7 ± 12.7 (range 24-66) months. Mean AOFAS score increased significantly from 66.3 ± 2.5 (range 62-77) preoperatively to 96.5 ± 4.9 (range 87-100) at final follow-up (p < 0.001). Mean Karlsson-Peterson score increased significantly from 51.7 ± 4.0 (range 47-70) preoperatively to 95.3 ± 6.7 (range 80-100) at final follow-up (p < 0.001). Mean interval between surgery and return to physical education in school was 11.4 ± 1.6 (range 10-18) weeks. Simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active ankle range of motion exercises may give excellent clinical outcomes with early return to physical activity for chronic lateral ankle instability with os subfibulare in pediatric/adolescent patients desiring an early return to physical activity. Level of evidence III.

Intra and interobserver analysis of the Sanders classification for calcaneal fractures

Objective: To evaluate the intra and interobserver variation in the Sanders classification of calcaneal fractures and the clinical-radiological correlation of postoperative X-ray images and computed tomography (CT) scans. Methods: We sent pre- and postoperative images in the form of a questionnaire to 18 foot and ankle surgeons with varying experience and examined evaluations of the postoperative reduction and Sanders classification quality criteria of 12 calcaneal fractures. The kappa (Ƙ) values were calculated and compared to those in the literature, and the quality of the reduction was compared to the patient's American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS) score. Results: The mean intraobserver Ƙ of the Sanders classification was 0.49. Disregarding the subclasses, the intraobserver Ƙ was 0.55, and when type III and IV fractures were grouped, the intraobserver Ƙ was 0.57. The interobserver Ƙ values in these same three conditions were 0.22, 0.20, and 0.21, respectively. We also observed that the group of less experienced surgeons showed better intraobserver Ƙ values than the more experienced surgeons. In the analysis of the reduction quality based on X-ray images and the AOFAS-AHS score of the patient, we found a value of p=0.043. Conclusion: The Ƙ values were consistent with previous studies, confirming moderate intraobserver reproducibility and acceptable interobserver reliability. We also confirmed the presence of a significant relationship between the reduction quality based on X-ray images and the AOFAS-AHS score of the patient. Level of Evidence III; Diagnostic Studies; Nonconsecutive patients, no uniformly applied reference gold standard.

Intermediate-term Experience With the STAR Total Ankle in the United States.

Limited intermediate and no real long-term follow-up data have been published for total ankle arthroplasty (TAA) in the United States. This is a report of clinical follow-up data of a prospective, consecutive cohort of patients who underwent TAA by a single surgeon from 1999 to 2013 with the Scandinavian Total Ankle Replacement (STAR) prosthesis. Patients undergoing TAA at a single US institution were enrolled into a prospective study. These patients were followed at regular intervals with history, physical examination, and radiographs; American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale scores were obtained and recorded. Primary outcomes included implant survivability and functional outcomes scores. Secondary outcomes included perioperative complications such as periprosthetic or polyethylene fracture. Between 1999 and 2013, a total of 138 STAR TAAs were performed in 131 patients; 81 patients were female. The mean age at surgery was 61.5 ± 12.3 years (range, 30-88 years). The mean duration of follow-up for living patients who retained both initial components at final follow-up was 8.8±4.3 years (range 2-16.9 years). The mean change in AOFAS Ankle-Hindfoot scores from preoperative to final follow-up was 36.0 ± 16.8 ( P < .0001). There were 21 (15.2%) implant failures that occurred at a mean 4.9 ± 4.5 years postoperation. Ten polyethylene components in 9 TAAs (6.5%) required replacement for fracture at an average 8.9 ± 3.3 years postoperatively. Fourteen patients died with their initial implants in place. This cohort of patients with true intermediate follow-up after TAA with the STAR prosthesis had acceptable implant survival, maintenance of improved patient-reported outcome scores, and low major complication rates. Level IV, case series.

Treatment of Chronic Subluxation of the Peroneal Tendons Using a Modified Posteromedial Peroneal Tendon Groove Deepening Technique

The present study investigated the clinical efficacy of a modified approach for the treatment of chronic subluxation of the peroneal tendons using posteromedial peroneal tendon groove deepening. We retrospectively analyzed the data from 21 patients who had undergone posteromedial peroneal tendon groove deepening combined with repair of the tendon sheath for the treatment of chronic subluxation of the peroneal tendons from March 2006 to October 2012. The lateral edge of the peroneal tendon groove was left untouched. A posterior osteocartilaginous flap was detached from the posterior fibula from medially to laterally. The retromalleolar groove was deepened through impaction of the posterior fibula. A visual analog scale and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale were used. All patients achieved healing after the first surgery. No postoperative complications developed. Sixteen patients were followed up for 24 to 69 months. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score improved from 55.0 to 93.6 points after surgery. The mean visual analog scale score decreased from 5.3 to 1.2 points. Five patients had moderate hindfoot rigidity and achieved improvements after rehabilitation training. None of the patients had specific requirements for shoes and ground flatness. All patients had a normal gait. No case of recurrent subluxation developed. These results indicate that posteromedial peroneal tendon groove deepening combined with repair of the tendon sheath can achieve satisfactory efficacy.

Arthroscopic Subtalar Arthrodesis: Does the Type of Fixation Modify Outcomes?

The goal of the present study was to analyze a modified American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score, time to union, and the incidence of fusion after isolated arthroscopic posterior subtalar arthrodesis using either 1 or 2 screws of different diameters. We reviewed a consecutive series of 65 patients, mean age 50.0 ± 15.6 years, including 38 males (58.5%) and 27 females (41.5%), who had undergone arthrodesis from May 2004 to February 2011. The mean follow-up duration was 57.5 (range 24 to 105) months. The patients were divided into 3 groups according to the fixation method used: group 1 (n = 12; 18.5%) underwent fixation with one 6.5-mm screw; group 2 (n = 40; 61.5%) with one 7.3-mm screw; and group 3 (n = 13; 20%) with two 7.3-mm screws. An overall statistically significant (p < .0001) improvement was seen in the modified AOFAS scale score for all 3 fixation groups; however, the difference was not statistically significant (p = .79) among the fixation groups. Fusion was achieved in 62 patients (95.4%) after a mean of 12.1 (range 9 to 16) weeks. The difference in the time to union was not statistically significant (p = .781) among the fixation groups. Nine patients (13.8%) experienced complications, and nonunion was significantly (p = .005) more prevalent in the single 6.5-mm screw group. In conclusion, all 3 screw configurations led to improved modified AOFAS scale scores, although nonunion was more common among patients fixed with a single 6.5-mm screw.

Takedown of Ankle Arthrodesis With Insufficient Fibula: Surgical Technique and Intermediate-Term Follow-Up

Conversion of ankle arthrodesis to total ankle arthroplasty has recently gained popularity. However, technical challenges are present when treating patients without a sufficient fibular buttress. We describe a technique for restoration of an adequate fibular buttress using an iliac crest bone graft or malleolar relocation. The results of 10 patients with an average follow-up period of 56 (range 24 to 123) months are presented. Of the 10 patients, 3 underwent tricortical iliac bone augmentation of the fibula, 4 underwent repositioning of the remnant fibula, and in 3, the in situ fibula was used. The average interval from fusion to takedown was 15.1 (range 5 to 35) years, and the average age at takedown was 52.8 (range 33 to 75) years. The average improvement in the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale and Buechel-Pappas scale scores was 35.8 (range 30 to 46) and 34 (range 25 to 42), respectively. Three patients underwent a total of 7 subsequent operations related to the ankle implant. Only 1 of the patients had any residual frontal plane deformity. None of the patients exhibited any component subsidence; however, 2 patients experienced asymptomatic lateral talar component overgrowth. The improvement in the clinical scores in this group of patients suggests that takedown of an ankle arthrodesis with an insufficient fibula is a viable option to improve function. Various techniques to restore the lateral buttress can be used even with complete absence of the distal fibula.

Stair-shaped Achilles tendon lengthening in continuity — A new method to treat equinus deformity in patients with spastic cerebral palsy

BackgroundEquinus of the ankle is a common deformity in spastic cerebral palsy. Achilles tendon lengthening is one of the effective options for the treatment of equinus deformity. MethodsIn the study, a new stair-shaped Achilles tendon lengthening (ATL) procedure that preserves of the tendon continuity was performed in 28 tendons with equinus deformity (20 patients, mean age=10.5±2.6 years). The results were compared with a group of patients treated with the Z-lengthening procedure. During the latest follow-up visit, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot scale score was much higher in the stair-shaped ATL group than in the Z-lengthening group (p<0.05). ResultsThe two groups showed similar surgical correction angle after ATL(37.2±3.5° for stair-shaped ATL and 36.1±4.5° for Z-lengthening). During the latest follow-up visit, the correction angle in the Z-lengthening group decreased to 21.6±4.3°, which was lower than in the stair-shaped ATL group (29.0±3.1°; p<0.05). In addition, the data regarding the time required by each patient before being able to start rehabilitation and walking as well as gaining better stability for running indicated that the stair-shaped ATL group recovered significantly quicker than the Z-lengthening group. ConclusionsThe stair-shaped ATL procedure resulted in a successful correction of the equinus deformity in spastic cerebral palsy, with the advantage of preserving a degree of continuity without a complete section of the tendon. This confers greater antigravity stability and quicker recovery in patients.

Surgical Treatment of Confirmed Intraosseous Lipoma of the Calcaneus: A Case Series

Intraosseous lipoma of the calcaneus is a benign lesion formed by mature adipose tissue. When the lesion is symptomatic, the most frequent presentation is localized pain and soft tissue swelling. Because these lesions can regress spontaneously, conservative treatment methods are recommended. Operative excision is mostly required for painful lesions and pathologic fractures. The data from 14 patients with calcaneal intraosseous lipoma, who had undergone surgery in our clinic, were evaluated retrospectively. Using Milgram’s classification system, 9 lesions were classified as stage 1, 4 as stage 2, and 1 as stage 3. All lesions were occupying 100% of intracalcaneal cross-section in the coronal plane and >30% in the sagittal plane of magnetic resonance imaging sections. The mean preoperative visual analog scale score was 5.29 ± 1.14 (range 4 to 7), and the mean postoperative visual analog scale score at the last follow-up visit was 1.14 ± 0.36 (range 1 to 2), which was significantly better (p < .01). The mean Maryland foot score at the last follow-up visit was 97.71 ± 2.02 (range 95 to 100). The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was 97.86 ± 2.11 (range 94 to 100) at the last follow-up visit. The differences between the pre- and postoperative values were statistically significant (p < .01). No recurrence had been detected within a median follow-up period of 84 months. Operative management of symptomatic lesions related to intraosseous lipoma of the calcaneus provides better results compared with the preoperative state.

Foot Pressure Changes Before and After Ankle Fusion: A Pedobarograph Study

We performed a case-control study with the purpose of establishing the pressure patterns in the soles of the feet of patients with ankle osteoarthritis, determining whether the pattern changed after treating the arthritis with ankle joint fusion (arthrodesis), and whether the change is significant. We also studied the benefits of ankle fusion with respect to the Short-Form 36-item Health Survey and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale. The study included 18 participants (9 in the study group and 9 in the control group) to reach statistical significance with a 95% confidence interval (CI). A demonstrable increase was found in both forefoot and hind-foot pressures in the study group preoperatively compared with the control group. Also, a demonstrable increase was found in the pressure in both the forefoot (mean difference 50.56 ± 267.39 kPa) and the hindfoot (mean difference 57.44 ± 160.27 kPa) from preoperatively to postoperatively. This difference was not statistically significant (p = .59 [t(8) = 0.57]; 95% CI 256.10 to −154.98) for the forefoot pressures and for the hindfoot pressures (p = .31 [t(8) = 1.08]; 95% CI 180.64 to −65.76). The Short-Form 36-item scores significantly improved from preoperatively to postoperatively (p = .000054 for the physical component and p = .018 for the mental component). The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score also improved significantly (p = .0000005). The foot pressures, as measured by using the insole sensors, showed an increase in forefoot and hindfoot pressures that was not statistically significant.

Short-term outcome of Lisfranc injuries treated with single dorsal plate fixation

Category: Ankle, Trauma Introduction/Purpose: Several methods like cortical screw, Kirschner (K) wire have been used for stabilizing the Lisfranc joint. We performed this study to assess whether single dorsal plating can be used as an alternative treatment method for a Lisfranc injury. Methods: Patients were followed up for more than 1 year after the initial surgery.Following open reduction of the joint with a bone reduction clamp, a single dorsal plate was used to perform Lisfranc joint fixation. The plate was fixed with 2.7-mm locking screws on the first metatarsal, second metatarsal, medial cuneiform, and intermediate cuneiform. Three weeks postoperatively, the cast was removed, and patients progressively advanced to full weight bearing while wearing a postoperative shoe. The plate was removed 3 months postoperatively. One year postoperatively, weight-bearing foot radiographs and the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score were obtained. Results: Eighteen patients with a Lisfranc injury who were treated with open reduction and internal fixation using a single dorsal plate were included. The average AOFAS midfoot score for pain was 35, and the total score was 80.8 (range, 67–95). Six patients (33.3%) had an excellent outcome (score =90); eight (44.4%) had a good outcome (90 &gt; score = 75); and four (22.2%) had a fair outcome (75 &gt; score = 50). Radiographs during the follow-up period showed no loss of reduction or arthritic change. Screw breakage occurred in 3 cases. But the injury ultimately healed anatomically. Conclusion: Single dorsal plating can be an alternative treatment method for a Lisfranc injury, as it provides a good short-term outcome without causing further joint injury.

Management of Intra-Articular Calcaneal Fractures: Clinical Results of Reduction Technique Using a Bone Spreader

The purpose of the present study was to examine the clinical results of surgery for intra-articular calcaneal fractures using a calcaneal locking plate and a bone spreader as a reduction tool. Ten patients with intra-articular calcaneal fractures were treated. An extended lateral approach was used. The reduction of the intra-articular fragments of the posterior facet was temporarily held using a bone spreader and Kirschner wires. Internal fixation was achieved with a locking calcaneal plate. Böhler's angle and Preiss' angle were assessed on the day of injury and the day of the final follow-up examination. The step off and gap of the posterior facet were assessed on the day of injury and the first week after surgery. The functional outcome was evaluated using the American Orthopaedic Foot and Ankle Society ankle hindfoot scale score. The mean Böhler's angle ranged from 2.1° ± 11.0° to 30.4° ± 5.0° (p < .0001), the mean Preiss' angle ranged from 23.5° ± 4.5° to 15.5° ± 2.9° (p < .0001), the mean step off ranged from 4.0 ± 1.9 mm to 0.1 ± 0.2 mm (p = .0002), and the mean gap ranged from 2.6 ± 1.0 mm to 1.2 ± 0.6 mm (p = .0035). The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was 89.2 (range 85 to 100) at a mean of 14.3 months after surgery. Our results suggest that a locking calcaneal plate can be used to restore and reduce an intra-articular calcaneal fracture and achieve good clinical results.

Endoscopic Plantar Fasciotomy; Deep Fascial Versus Superficial Fascial Approach: A Prospective Randomized Study

In the present randomized prospective study, 2 different surgical techniques of endoscopic plantar fascia release were compared. Of 547 patients with a diagnosis of plantar fasciitis, 46 with no response to conservative treatment for ≥6 months were included. Of the 46 patients, 5 were lost to follow-up. In group 1 (n = 21), plantar fascia release was performed using a deep fascial approach (DFA), and in group 2 (n = 20), the superficial fascial approach (SFA) with a slotted cannula technique was used. Patients were evaluated using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot scale and visual analog scale at baseline and 3 weeks and 3, 6, and 12 months after the initial surgery. At the final follow-up appointment, the Roles-Maudsley score was used to determine patient satisfaction. At the final follow-up examination, the mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale scores had increased from 53.12 to 83.68, with a decrease in the mean visual analog scale score from 7.95 to 1.65 noted. According to the Roles-Maudsley score, the success rate after 1 year was 90.47% for DFA group, 95% for the SFA group, and 92.68% for all patients. Although no significant difference was found between the final functional scores, better early postoperative scores were found in the SFA group. The mean duration of the procedure was measured as 27.22 ± 9.41 minutes overall, 35 ± 5.62 minutes in the DFA group, and 19.05 ± 4.01 minutes in the SFA group. Two early and two late complications occurred in the DFA group with none reported in the SFA group. In conclusion, the SFA is a faster and safer method of endoscopic plantar fascia release with better early postoperative scores.

Surgical Correction of Haglund's Triad Using a Central Tendon-Splitting Approach: A Retrospective Outcomes Study

We evaluated the surgical outcomes of Haglund's triad using a central tendon-splitting approach, with Achilles tendon partial detachment and debridement, excision of the retrocalcaneal bursa, resection of Haglund's prominence, and reattachment of the Achilles tendon. The medical records of 22 patients (22 heels) who had undergone surgical correction of Haglund's triad from January 2010 to December 2015 were reviewed retrospectively. The visual analog scale pain score, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score, and 36-item Short-Form Health Survey physical and mental component scores were prospectively collected preoperatively, 6 months postoperatively, and at the last visit. The scores of a subjective question involving satisfaction were prospectively collected at the last visit. Possible risk factors were also evaluated. We reviewed the data from 12 females and 10 males, with the mean age of 59.2 ± 7.3 years and a mean follow-up duration of 15.1 ± 4.6 months. Significant improvement was found in the mean visual analog scale pain score, average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score, and 36-item Short-Form Health Survey physical component scale score. The overall satisfaction rate was 77.3% (17 of 22). Postoperative complications included 2 cases of delayed wound healing and 1 case of sensation loss over the heel wound. No Achilles tendon rupture or wound infection developed. Gender and body mass index did not affect the surgical outcomes. The surgical technique we used for Haglund's triad provided effective pain relief, function improvement, and overall enhancement of patients' health condition. More research is required to further evaluate the outcomes of our surgical approach to treat Haglund's triad and the possible risk factors.

Posterior Arthroscopic Subtalar Arthrodesis: Clinical and Radiologic Review of 19 Cases

Arthroscopic subtalar arthrodesis has recently gained popularity in the treatment of primary subtalar or post-traumatic arthritis, coalition, or inflammatory diseases with subtalar arthritis. The present study reports the clinical and radiologic results of 19 patients (19 feet) who underwent posterior arthroscopic subtalar arthrodesis using 2 posterior portals. A total of 19 posterior arthroscopic subtalar arthrodeses (minimum follow-up of 24 months) performed without a bone graft and with 2 parallel screws were prospectively evaluated. The fusion rate was 94% (mean time to fusion 9.8 weeks). Modified American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score (maximum 94 points) improved significantly from 43 to 80 points and the visual analog scale for pain score improved from 7.6 to 1.2. The 12-item short-form physical and mental scores at the last follow-up point were 52.5 and 56.4, respectively. One (5.3%) patient underwent open repeat fusion for nonunion, 2 (10.5%) patients required a second procedure for implant removal, and 1 (5.3%) experienced reversible neuropraxia. In conclusion, posterior arthroscopic subtalar arthrodesis is a safe technique with a good union rate and a small number of complications in patients with no or very little hindfoot deformity.

Acute Achilles Tendon Rupture Treated by Double Side-Locking Loop Suture Technique With Early Rehabilitation.

Although early accelerated rehabilitation is recommended for the treatment of acute Achilles tendon rupture, most traditional rehabilitation techniques require some type of brace. We retrospectively analyzed 44 feet of 44 patients (25 male and 19 female) with a mean age of 31.8 years who had an acute Achilles tendon rupture related to athletic activity. Patients had been treated by a double side-locking loop suture (SLLS) technique using double antislip knots between stumps and had undergone early accelerated rehabilitation, including active and passive range of motion exercises on the day following the operation and full weight-bearing at 4 weeks. No brace was applied postoperatively. The evaluation criteria included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS) score; active plantar flexion and dorsiflexion angles; and the intervals between surgery and the time when patients could walk normally without any support, perform double-leg heel raises, and perform 20 continuous single-leg heel raises of the operated foot. Despite postoperative early accelerated rehabilitation, the AOFAS score and active dorsiflexion angles improved over time (6, 12, and 24 weeks and 2 years). A mean of 4.3 ± 0.6 weeks was required for patients to be able to walk normally without any support. The mean period to perform double-leg heel raises and 20 continuous single-leg heel raises of the injured foot was 8.0 ± 1.3 weeks and 10.9 ± 2.1 weeks, respectively. All patients, except one who was engaged in classical ballet, could return to their preinjury level of athletic activities, and the interval between operation and return to athletic activities was 17.1 ± 3.7 weeks. The double SLLS technique with double antislip knots between stumps adjusted the tension of the sutured Achilles tendon at the ideal ankle position and provided good clinical outcomes following accelerated rehabilitation after surgery without the use of a brace. Level IV, retrospective case series.

Posteromedial peroneal tendon groove deepening treatment of the chronic subluxation of the peroneal tendons

Objective To investigate the clinical curative result of the new method of postermedial deepen of the fibular groove in the treatment of chronic peroneal tendon subluxation. Methods From March 2006 to October 2012, 21 patients (15 male, 6 female) with chronic peroneal tendon subluxation via a novel method of postermedial deepen of the fibular groove. In this group: I grade 5 cases; II grade 9 cases; III grade 5 cases; IV grade 2 cases. All patients were followed up for at least 24 months. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score and visual analogue score (VAS) were used to evaluate the clinical outcomes. Operation time, time to heal and complications were also recorded. Results The average operation time was 50 minutes (30-70 minutes). The blood loss was 30-60 ml, average 40 ml. All incisions healed after operation, no case of incision infection, skin necrosis and sural nerve,vascular injuryed. Mean AOFAS score was significantly increased from (55.2±7.1) preoperative to (93.6±5.6) postoperative. 15 patients with excellent, good for 1 cases. The excellent and good rate was 100% (16/16). VAS score by an average of (5.3±2.1) points down to (1.2±1.1) points postperative. All the patients can wear normal shoes postoperative, waking with normal gait. No patients had peroneal tendon tenosynovitis, tendon adhesion, fracture of lateral malleolus and other serious complications, no dislocation recurrent, strength of the peroneal muscle returns to normal. Conclusion The novel method of postermedial deepen of the fibular groove in the treatment of chronic peroneal tendon subluxation was safe and effective for ankle instability with a relatively short time. Key words: Tendinopathy; Clinical protocols; Comparative effectiveness research

The Gift Box Open Achilles Tendon Repair Method: A Retrospective Clinical Series

Previous biomechanical studies have shown that the gift box technique for open Achilles tendon repair is twice as strong as a Krackow repair. The technique incorporates a paramedian skin incision with a midline paratenon incision, and a modification of the Krackow stitch is used to reinforce the repair. The wound is closed in layers such that the paratenon repair is offset from paramedian skin incision, further protecting the repair. The present study retrospectively reviews the clinical results for a series of patients who underwent the gift box technique for treatment of acute Achilles tendon ruptures from March 2002 to April 2007. The patients completed the Foot Function Index and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale. The tendon width and calf circumference were measured bilaterally and compared using paired t tests with a 5% α level. A total of 44 subjects, mean age 37.5 ± 8.6 years, underwent surgery approximately 10.8 ± 6.5 days after injury. The response rate was 35 (79.54%) patients for the questionnaire and 20 (45.45%) for the examination. The mean follow-up period was 35.7 ± 20.1 months. The complications included one stitch abscess, persistent pain, and keloid formation. One (2.86%) respondent reported significant weakness. Five (14.29%) respondents indicated persistent peri-incisional numbness. The range of motion was full or adequate. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score was 93.2 ± 6.8) and the mean Foot Function Index score was 7.0 ± 10.5. The calf girth and tendon width differences were statistically significantly between the limbs. The patients reported no repeat ruptures, sural nerve injuries, dehiscence, or infections. We present the outcomes data from patients who had undergone this alternative technique for Achilles tendon repair. The technique is reproducible, with good patient satisfaction and return to activity. The results compared well with the historical repeat rupture rates and incidence of nerve injury and dehiscence for open and percutaneous Achilles tendon repairs.

Arthroscopic Talocalcaneal Coalition Resection in Children

To present the technique and outcomes of arthroscopic talocalcaneal coalition (TCC) resection in pediatric patients. We performed a prospective study of 16 consecutive feet with persistent symptomatic TCCs in 15 children. The mean age was 11.8 years (range, 8 to 15 years), and the mean follow-up period was 28 months (range, 12 to 44 months). A posterior arthroscopic TCC resection was performed. The plantar footprint, subtalar motion, pain, and the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot scale score were evaluated preoperatively and postoperatively. Preoperative computed tomography (CT) scans were used to classify the coalition according to the Rozansky classification, to measure the percentage of involvement of the surface area, and to determine the degree of hindfoot valgus. Postoperative CT scans at 1 year (n= 15) and 3 years (n= 5) were used to assess recurrences. Patient satisfaction was also evaluated. The TCC distribution according to the Rozansky classification was type I in 7 cases, type II in 3, type III in 3, and type IV in 3. In all cases the arthroscopic approach enabled complete coalition resection. All patients increased by at least 1 stage in the footprint classification and showed clinical subtalar mobility after surgery. All patients showed a statistically significant improvement in pain after surgery except for 1 patient in whom complex regional pain syndrome developed (P < .001). The mean American Orthopaedic Foot & Ankle Society score was 56.8 (range, 45 to 62) preoperatively versus 90.9 (range, 36 to 100) postoperatively, showing a statistically significant increase (P < .001). Preoperative CT scans showed that all TCCs involved the medial subtalar joint facet, with mean involvement of 40.8% of the articular surface. All postoperative CT scans showed complete synostosis resections with no recurrences at final follow-up. At final follow-up, all patients were either satisfied (n= 4 [27%]) or extremely satisfied (n= 10 [67%]) with the outcome, except the 1 patient (7%) in whom complex regional pain syndrome developed. Arthroscopic TCC resection provides good outcomes (symptom relief and restoration of subtalar motion), with no recurrence of the coalition. Level IV, therapeutic case series.

Operative Treatment of Haglund Syndrome With Central Achilles Tendon-Splitting Approach

Haglund syndrome is characterized by chronic posterior heel pain associated with a posterosuperior calcaneal prominence. We assessed the clinical and radiologic outcomes after operative treatment of Haglund syndrome using the central tendon-splitting approach. Fifteen feet in 15 patients were investigated retrospectively after surgery. Of the 15 patients, 14 were males (93.3%) and 1 was female (6.7%). Their mean age was 33.1 ± 8.2 (range 20 to 50) years. The mean follow-up duration was 3.5 ± 1.5 years (range 24 to 90 months). The American Orthopaedic Foot and Ankle Society ankle-hindfoot Scale and Victorian Institute of Sport Assessment-Achilles scores were investigated to assess the clinical outcomes. Patient satisfaction was assessed at the latest follow-up visit. The lateral talo-first metatarsal angle, calcaneal pitch angle, Fowler-Philip angle, and parallel pitch line were measured to assess the foot shape and radiographic outcomes. Clinically, the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score increased from 62.1 ± 7.5 preoperatively to 92.5 ± 3.5 at the latest follow-up visit. The mean Victorian Institute of Sport Assessment-Achilles score increased from 53.2 ± 7.4 to 89.6 ± 3.4. All patients were satisfied with the operative results. Radiographically, all patients had cavus feet with an increased lateral talo-first metatarsal angle (mean +5.9° ± 5.0°) and calcaneal pitch angle (mean 26.0° ± 3.8°). The mean Fowler-Philip angle decreased from 58.9° ± 15.0° to 32.5° ± 7.2° postoperatively, and the positive parallel pitch line had changed to a negative value in all cases. Operative treatment with the central tendon-splitting approach appears to be safe and satisfactory for intractable Haglund syndrome.

Ankle Plantar-Flexion Contracture Complication After Aesthetic Calf Volume Reduction Procedure.

Minimally invasive, aesthetic calf volume reduction procedures are considered to be relatively safe. Published complications are mostly transient, with minimal functional loss. We hereby report debilitating ankle plantar-flexion contracture after aesthetic calf volume reduction procedure by selective neurectomy, with magnetic resonance imaging analysis and surgical treatment outcomes of this complication. From 2009 to 2010, 11 patients (17 lower legs) were surgically treated for this complication. The average preoperative ankle contracture angle of all involved lower legs was -22 degrees (range, -5 to -30 degrees). Magnetic resonance imaging performed in 14 lower legs showed lesions indicative of denervation atrophy, with fibrotic lesions causing longitudinal shortening of the gastrocnemius muscle. Of the 17 ankle contractures, 15 Silfverskiöld test-positive cases received miniopen gastrocnemius release, whereas 2 Silfverskiöld test-negative cases received Achilles tendon lengthening by percutaneous triple hemiresection. At last follow-up, the dorsiflexion angle of all ankles improved to an average of 25 degrees (range, 20-30 degrees) with full plantar flexion in all patients, whereas the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale scores improved from an average of 59.2 to 94.2. Surgeons and patients alike should be aware of debilitating ankle planter flexion contractures after aesthetic calf volume reduction procedures. Using minimally invasive gastrocnemius and Achilles tendon release, we were able to provide symptomatic and functional relief from this complication with minimal cosmetic sacrifice.