Single Heel Research Articles

Comparison of open repair and modified percutaneous repair techniques for the treatment of acute achilles tendon ruptures

Background: This study compared acute Achilles tendon repairs' functional and clinical outcomes with two different surgical techniques; modified percutaneous and open repair.
 Material and Method: This retrospective study analyzed 57 patients with an acute Achilles tendon rupture (AATR) who underwent modified percutaneous and open repair. 46 patients who met the eligibility criteria were enrolled and divided into two groups based on the surgical technique. 23 patients from Group 1 were treated using modified percutaneous repair under local anesthesia, and 23 patients from Group 2 were treated with an open repair under regional anesthesia. Postoperatively, patients were evaluated using American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot Questionnaire score at final follow-up. The other outcomes included return to work, return to sports activities, capacity to complete single heel rise, leg circumference, estimated limb symmetry indices, Achilles tendon resting angle (ATRA), complications, and timing of index surgery.
 Results: At the time of surgery, the mean age of the patients was 35.9 7.5 years (range, 25–47 years). The average follow-up was 34.8±6.5 months (24–52 months). The mean age, gender, body mass index (BMI), rupture level, duration from injury to surgery, and mean follow-up time were similar in both groups. At a minimum 2-year follow-up, good pain relief was achieved for all patients. The AOFAS scores were 93.4±4.1 (88-100) in Group 1 and 92.2±5.2 (82-100) in Group 2. There was no statistically significant difference between groups concerning the Achilles tendon resting angle (ATRA), calf circumference, single-leg heel rise, return to work, and return to sports activities. However, the percutaneous repair procedure had a shorter surgical time than the open repair technique (p

The STAMP Test: A Novel Clinical Test in Diagnosing Achilles Tendon Ruptures

Category:AnkleIntroduction/Purpose:Achilles tendon ruptures are common injuries, and an estimated 20-25% injuries are missed acutely. Chronic and acute Achilles tendon rupture patients typically present with nonspecific complaints and physical exam findings. Commonly used physical exam maneuvers such as the Thompson test have variable sensitivity and reliability for the examiner. The patient with an Achilles tendon rupture will have expected plantar-flexion weakness, however clinical data utilizing plantarflexion weakness to develop a physical exam maneuver is lacking. We propose two new tests with sensitivity and specificity analysis to evaluate this understanding in the clinical setting: the Stand and Maintain Plantarflexion (STAMP) and Tendo-Achilles Rise (TAR) tests. We hypothesize that the STAMP and TAR exams maneuvers will have high sensitivity for diagnosis of acute and chronic Achilles tendon rupture.Methods:Data was collected from a single surgeon's practice at two large urban treatment centers. Data was retrospectively acquired over a period of 7 years and then prospectively acquired over a period of 5 years. Patients with mid-substance Achilles tendon rupture confirmed with MRI imaging or operative treatment were included. We examined clinical data regarding ambulation, resting tension, palpable Achilles gap, Thompson test, and STAMP and TAR tests on initial presentation. The STAMP test is performed by the patient attempting a wall assisted double leg heel rise and lifting the uninjured foot off the ground. It is consistent with an Achilles tendon rupture if the patient is unable to maintain this position for five seconds. The TAR test is performed by the patient attempting a wall assisted single leg heel rise. It is consistent with an Achilles tendon rupture if the patient is unable to maintain this position for five seconds.Results:71 patients with complete mid-substance Achilles tendon ruptures that met inclusion criteria were identified. 45 (63%) presented acutely and 26 patients (37%) presented chronically. The Thompson test displayed a diagnostic sensitivity of (12 26 46%) for chronic ruptures and (38 45 84%) for acute ruptures. The STAMP and TAR tests displayed a diagnostic sensitivity of (22 26 85%) for chronic ruptures and (45 45 100%) for acute ruptures with a diagnostic specificity of (89%).Conclusion:Achilles tendon ruptures can be difficult to diagnose due to inconsistent symptoms and clinical exam findings. The STAMP and TAR physical exam tests have high sensitivity to clinically diagnose Achilles tendon rupture both in the acute and chronic setting and are superior to well-described physical exam tests. The findings support that the addition of the STAMP and TAR diagnostic protocol may be clinically beneficial when diagnosing Achilles tendon ruptures in both the acute and chronic setting. Future work should be focused on providing direct comparison to other exam maneuvers as well as identifying data reliability.

Runners with chronic mid-portion Achilles tendinopathy have greater Triceps surae intracortical inhibition than healthy controls

Background: Achilles tendinopathy (AT) is an overload injury, affecting mostly runners. Persistent triceps surae muscle weakness has been reported in AT patients. Muscle force is influenced by inhibitory and excitatory circuits, and imbalances between these (e.g., increased short-interval intracortical inhibition - SICI) may negatively affect strength. Increased SICI has been observed with patella tendinopathy; however, it is unclear if this increased inhibition is present in chronic mid-portion AT patients. Thus, this study aimed to investigate the intracortical inhibitory mechanisms in runners with mid-portion AT. Methods: Runners with chronic mid-portion AT (n=11; 44.1±8.4 years) and healthy controls (n=13; 33.9±4.25 years), with a running routine of at least twice weekly for more than 4 months, were recruited. All completed the VISA-A questionnaire AT (AT= 70.7±7.0) and Control (100±0). The most symptomatic leg (8 unilateral AT and 3 bilateral AT) was compared with control group dominant legs. Plantar flexor maximal voluntary isometric contraction (MVIC) torque was measured via isokinetic dynamometer (knee fully extended, ankle at 0°). Triceps surae endurance was measured with standing single leg heel raise to failure (SLHR) test. SICI was assessed using paired-pulse transcranial magnetic stimulation to the motor cortex area associated with the leg, delivering 20 paired-pulses at 0.8x (first pulse) and 1.2x (second pulse) of active motor threshold (AMT) with 3ms interval and 20 single pulse stimulation at 1.2 AMT, all during a 10% plantar flexion contraction. Two-way repeated measures ANOVA was used to compare SICI between muscles (Soleus, and Gastrocnemii) and groups. Independent t-test was used to compare SLHR and MVIC peak torque between groups. Results: SICI was higher in AT group (67.4±9.0) than controls (54.0±9.0); (p=0.039,) independent of the tested muscle (no muscle vs group interaction; p =0.828). AT group performed ~28% fewer SLHR repetitions than the controls (AT, 27.5.0±6.8 and control 38.5±5.3 repetitions, p=0.004). There was no difference in MVIC peak torque corrected for body mass (N.m/Kg), (AT=1.4±0.3; Control=1.6±0.4, p =0.093). Discussion: The AT group displayed greater intracortical inhibition of the triceps surae muscles and reduced SLHR endurance, without deficit in maximal isometric torque. SICI could be negatively influencing SLHR endurance in AT; thus, rehabilitation aiming to reduce intracortical inhibition should be considered for better outcomes. Conflict of interest: The authors declare no conflict of interest related to the present work.

Reliability and usefulness of the single leg heel raise balance test in patients with chronic ankle instability

We aimed to analyze the differences in static (including conventional and modified [single-leg heel-raise balance]) and dynamic postural stability and muscle endurance between patients with chronic ankle instability (CAI) and healthy controls, and to determine the reliability and usefulness of the single-leg heel-raise balance test in patients with CAI. In total, 26 patients with CAI and 26 healthy controls were enrolled. Postural stability was assessed using a postural stabilometry system. Muscle endurance was measured in dorsiflexion and plantarflexion using an isokinetic device. Modified static postural stability (P < 0.001) and dynamic postural stability (P < 0.001) were significantly poorer in the affected ankles of patients with CAI than in the controls. Plantarflexion endurance was significantly lower in the affected ankles of the patients with CAI than in the controls (P = 0.023). Modified static postural stability significantly correlated with plantarflexion endurance in both groups (CAI group: r = − 0.470, P = 0.015; healthy controls group: r = − 0.413, P = 0.036). Plantarflexion endurance was a significant risk factor for modified static postural stability in both the CAI group (R2 = 0.221, P = 0.015) and healthy controls (R2 = 0.170, P = 0.036). Given the reliability of the modified static postural stability test, clinicians and therapists should consider using it to assess improvements in postural stability and muscle endurance in patients with CAI before and after rehabilitation.

The modified mini-open Maffulli's technique for repairing open Achilles tendon laceration using fiber wires with calcaneal fixation. A prospective case series of 14 patients

IntroductionOpen Achilles tendon laceration was managed surgically by wound irrigation, debridement and Achilles tendon repair. The poor vascularization at the midsection of Achilles tendon and surrounding skin, extensile open approaches were factors, that contributed to higher complication rate of wound healing and infection. We had not seen a report of minimal invasive repair techniques for treatment of open Achilles tendon injury. Material and methodsBetween January 2018 and May 2020, 14 patients with open Achilles tendon laceration had been enrolled in the study and underwent the modified Maffulli's procedure at the Central Military Hospital 108. The characteristics of the patients, ATRS score AOFAS score and complications were recorded. ResultsNo wound infection was encountered in our series. The range of ankle movement was restored in all patients. After one year post-operatively, the ATRS score was 92.2 ± 1.5 (range: 90–96), and AOFAS score was 97.4 ± 1.8 (range: 92–100). All patients could return to their work and their light sporting activities at the time of 16.7 ± 2.5 weeks (range, 14–20) and 19.8 ± 4.6 weeks (range: 17–25) postoperatively, respectively. 14 out of 14 patients were able to perform single heel raise. ConclusionWe showed the modified Maffulli's technique using fiber wire with calcaneal fixation for repairing open Achilles tendon laceration to be a safe and reliable method without increasing financial cost and specially designed tools. Level of evidenceLevel IV, a prospective case series study.

Effects of Resistance Exercise with or without Whey Protein Supplementation on Ocular Changes after a 21-Day Head-Down Bed Rest.

Neuro-ophthalmological changes have been reported after prolonged exposure to microgravity; however, the pathophysiology remains unclear. The objectives of the present study were twofold: (1) to assess the neuro-ophthalmological impact of 21 days of head-down bed rest (HDBR) and (2) to determine the effects of resistance vibration exercise (RVE) alone or combined with nutritional supplementation (NeX). In this case, 12 healthy male subjects completed three interventions of a 21-day HDBR: a control condition without countermeasure (CON), a condition with resistance vibration exercise (RVE) comprising of squats, single leg heel and bilateral heel raises and a condition using also RVE associated with nutritional supplementation (NeX). Intraocular pressure (IOP) was assessed by applanation tonometry. Retinal nerve fiber layer thickness (RNFLT) was assessed with spectral-domain optical coherence tomography, before HDBR and between Day 2 and Day 4 after each session of HDBR. In CON condition, IOP was preserved; while in RVE and NeX conditions, IOP was increased. In CON condition, RNFLT was preserved after HDBR. RVE and NeX conditions did not have significant effects on RNFLT. This study showed that a 3-week HDBR did not induce significant ophthalmological changes. However, RVE induced an elevation in IOP after HDBR. Nutritional supplementation did not reduce or exacerbate the side effects of RVE.

Impact of blood sampling technique on reproducibility of viscoelastic coagulation monitor (VCM™) system test results in the neonate

Purpose: To evaluate the reproducibility of the results of the viscoelastic coagulation test (VCT) performed with a new viscoelastic coagulation monitor (VCM™ – Entegrion) on native blood obtained by heel prick blood sampling with two different techniques compared to the standard blood collection in the newborn. Methods: Three blood samples were tested with the VCM analyzer in each of the 67 study subjects admitted to our level 3 neonatal intensive care unit. Standard blood collection (S) was performed by direct puncture of a peripheral vessel or by drawing of blood in a syringe connected to an arterial or venous catheter. Then, two more blood samples were drawn through a single heel prick. The first heel prick blood sample (HP1) was collected in the sample well through the attached metal capillary while the second (HP2) was poured directly into the sample well. Blood samples were automatically drawn into their pre-warmed cartridges and inserted into the VCM analyzers set up for analyses, which ran for one hour. VCT blood variables included clotting time (CT), clot formation time (CFT), angle alpha (α), amplitude at 10 and 20 min (A10 and A20), maximum clot firmness (MCF), and lysis indexes at 30 and 45 min (LY30 – LY45). Agreement was quantified by calculating the mean difference and SD between measurements of VCT blood variables from S, HP1 and HP2 blood samples. The 95% limits of agreement were calculated by the Bland & Altman method, using the upper or lower limit of agreement to interpret the variability of the measurements. The Kendall’s τ correlation coefficient evaluated the interdependence between SD and intra-measurement mean. Results: S blood samples were easily obtained in all the study subjects, while mild difficulties were recorded in 3/67 infants (4.5%) with the HP1 blood sampling and in 5/67 infants (7%) with the HP2 blood sampling. Pairwise comparison of test results performed on blood samples drawn with HP1 and HP2 techniques showed moderate agreement for CT and α-angle, strong agreement for CFT, LY30 and LY45 and almost perfect agreement for A10, A20 and MCF. In pairwise comparison of VCM analyses performed on blood samples drawn with S technique vs HP1 and HP2 techniques, Kendall’s τ correlation coefficient was significant for CT (S vs HP1 and HP1 vs HP2), CFT (S vs HP1 and S vs HP2), α-angle (S vs HP1) and MCF (S vs HP1). This suggests that the measurement error depends on the extent of the measurement. The overall ICC for blood sampling techniques ranged from 0.289 to 0.879 with best agreement observed for CFT (strong) and for A10, A20 and MCF (almost perfect). The LY30 index was the least repeatable measurement (poor agreement). The VCM analysis performed on the blood sample drawn with the HP1 technique showed the best repeatability compared with that performed with the S blood-sampling technique. Conclusion. VCT test results performed with the VCM analyzer on native blood drawn by heel prick in neonates are comparable to those obtained from standard blood samples. This could allow for a widespread, real-time assessment of the overall bedside haemostasis of these small patients.

Functional outcome of early weight bearing for acute Achilles tendon rupture treated conservatively in a weight-bearing orthosis

BackgroundThe optimal management for Achilles tendon (AT) ruptures is controversial and still continues to encourage debate. Conventionally, operative repair was favoured secondary to its lower rates of re-rupture, however in more recent years, we have seen promising results and a reduction in complications with conservative management. One reason for this improvement may be due to the introduction of a functional weight-bearing orthosis, however, results for complete AT ruptures is still unclear. This study aims to evaluate the functional outcomes of early weight bearing in a functional orthosis for conservatively managed, complete AT ruptures. MethodologyThis study was done at East Kent Hospital University Foundation Trust in between 2019−2020. In this prospective study, we have analysed data from 41 patients with US diagnosed compete AT ruptures, with a gap less than 5 cm. Every patient was treated in a functional weight-bearing orthosis (VACOped®) for 8 weeks with early weight-bearing following a specific treatment protocol, followed by rehabilitation with a trained physiotherapist. All patients received a final follow-up at 1 year post injury, where we recorded the following functional outcome measurements on each leg: calf girth, single leg heel raise height, single leg heel raise repetitions and the ATRS score. ResultOur study population was predominantly male with an average age of 50 (range 22−79). The majority of the cohort were physically active, with more than 75% involved in a form of sporting activity pre-injury and 15% involved in higher level activity and competitive sport. The mean ATRS score was 82.1, with a re-rupture rate of only 2%. The average calf bulk difference was 1.6 cm, average heel raise height difference was 1.8 cm and a heel raise repetition difference of 6. There was a statistically significant correlation between ATRS score and calf muscle girth (p = 0.02). However, there was no significant correlation between ATRS score and heel raise height or single heel raise repetitions. ConclusionEarly weight-bearing in a functional orthosis provides excellent functional outcomes for conservatively managed, complete AT ruptures, and is associated with very low re-rupture rates. However, a multidisciplinary approach with a guided rehabilitation programme is essential for optimising functional outcome.

Conventional vs Accelerated Rehabilitation Protocol Following Reattachment of Achilles Tendon for Insertional Achilles Tendinopathy.

No studies have compared early vs conventional postoperative weightbearing following suture bridge Achilles tendon reattachment. We, therefore, evaluated postoperative functional outcomes in these patients. We collected data on 49 patients who underwent surgical treatment of insertional Achilles tendinopathy using a central Achilles tendon-splitting approach and reattachment with suture bridge technique by a single surgeon. Functional outcomes were measured by a visual analog scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM), and Short Form Health Survey (SF-36) at 3, 6, and 12 months postoperatively. The differences in outcomes were analyzed using multiple linear regression. Eighteen and 31 patients underwent the conventional and accelerated protocols, respectively; their corresponding mean ages were similar, 53 and 57 years, as were all other baseline characteristics. The mean scores (conventional vs accelerated group) for VAS for pain, FAAM, and SF-36 in the conventional group at 3 months postoperatively were 4 ± 1 vs 3 ± 1 points, 53 ± 8 vs 68 ± 3 points, and 57 ± 15 vs 67 ± 10 points (P < .05 for each comparison). There were no statistically significant differences between the groups at 6 and 12 months postoperatively. All patients could perform the single heel raise test at 6 months, and none experienced complications. In this small study, short-term functional outcomes were better in the accelerated group. More data are needed before the accelerated program can be recommended. Level II, prospective comparative study.

Acute Achilles Tendon Rupture Repair in Athletically Active Patients: Results on 188 Tendons

We report on the outcome of acute Achilles tendon ruptures by a single surgeon using open and percutaneous techniques was performed. This prospective study included 186 patients with 188 ruptured Achilles tendons. A traditional open technique was primarily performed on patients from January 2001 to December 2011. From January 2012 to January 2018, a percutaneous repair was primarily performed. Outcome measures included the Roles and Maudsley (RM) score, ability to perform a single leg heel raise, calf atrophy and return to activity. There were 149 males (average age 42.5 ± 12.7 years) and 39 females (average age 41.7 ± 11.4 years). Of the 188 ruptured tendons (92 repairs on the right Achilles and 96 on the left), 103 were repaired percutaneously and 85 had open repairs. There were 18 (9.6%) complications. Three re-ruptures occurred, one following open and two following percutaneous repairs, all within 12 weeks of the original repair. Two patients developed a Venousthromboembolism (1.0%). Thirteen patients had suture reactions; three infections (1.6%), 11 wound complications (5.8%), and 3 required surgical excision of the suture material (1.6%). Non-absorbable sutures were associated with more wound complications and were more frequently used in open repairs (p = .003). Patients who underwent open repair experienced more wound complications (p = .0001). Patients who underwent percutaneous repair using absorbable suture experienced a lower rate of overall complications (p = .0007). Basketball (n = 29) was the most common sport during which ruptures occurred. Return to activity (RTA) was 8.2 ± 2.9 months. There was no difference for RTA between males and females (p = .54) and RM scores (p= .69), nor surgical technique, and no difference for RTA based on the desired activity (p = .47). 123 of the 188 patients returned to their desired activity (65.5%). There was a statistically significant evidence of a positive association between inability to perform heel-raises and decreased activity (p = .01).

Lower leg muscle structure and function are altered in long-distance runners with medial tibial stress syndrome: a case control study

BackgroundMedial tibial stress syndrome (MTSS) is a common lower leg injury experienced by runners. Although numerous risk factors are reported in the literature, many are non-modifiable and management of the injury remains difficult. Lower leg muscle structure and function are modifiable characteristics that influence tibial loading during foot-ground contact. Therefore, this study aimed to determine whether long-distance runners with MTSS displayed differences in in vivo lower leg muscle structure and function than matched asymptomatic runners.MethodsLower leg structure was assessed using ultrasound and a measure of lower leg circumference to quantify muscle cross-sectional area, thickness and lean lower leg girth. Lower leg function was assessed using a hand-held dynamometer to quantify maximal voluntary isometric contraction strength and a single leg heel raise protocol was used to measure ankle plantar flexor endurance. Outcome variables were compared between the limbs of long-distance runners suffering MTSS (n = 20) and matched asymptomatic controls (n = 20). Means, standard deviations, 95 % confidence intervals, mean differences and Cohen’s d values were calculated for each variable for the MTSS symptomatic and control limbs.ResultsMTSS symptomatic limbs displayed a significantly smaller flexor hallucis longus cross-sectional area, a smaller soleus thickness but a larger lateral gastrocnemius thickness than the control limbs. However, there was no statistical difference in lean lower leg girth. Compared to the matched control limbs, MTSS symptomatic limbs displayed deficits in maximal voluntary isometric contraction strength of the flexor hallucis longus, soleus, tibialis anterior and peroneal muscles, and reduced ankle plantar flexor endurance capacity.ConclusionsDifferences in lower leg muscle structure and function likely render MTSS symptomatic individuals less able to withstand the negative tibial bending moment generated during midstance, potentially contributing to the development of MTSS. The clinical implications of these findings suggest that rehabilitation protocols for MTSS symptomatic individuals should aim to improve strength of the flexor hallucis longus, soleus, tibialis anterior and peroneal muscles along with ankle plantar flexor endurance. However, the cross-sectional study design prevents us determining whether between group differences were a cause or effect of MTSS. Therefore, future prospective studies are required to substantiate the study findings.

Short-term Outcomes of Open “Crown” Type v. Percutaneous Bunnell Type Repair of Acute Achilles Tendon Ruptures. Randomized Control Study

Background. The optimal treatment of acute Achilles tendon ruptures is still under debate. The purpose of this randomized controlled trial was to evaluate outcomes of open repair comparing with percutaneous procedure for Achilles tendon ruptures. Methods. 100 patients with acute Achilles tendon rupture were randomized in two groups: open “crown” type (group A) and percutaneous Bunnell type repair (group B). Absorbable suture was used in both groups. 87 patients were available for the mean follow up of 6 months. Results. No statistically significant difference was observed between groups in ATRS (Achilles Tendon Total Rupture Score), leg circumference, single heel rise, Achilles resting angle, time back to work and sports and overall patient satisfaction. Percutaneous technique was much faster. Overall 13 complications occurred in both groups (5 and 8 respectively). No deep infection occurred, no revisions were needed. Conclusions. Both techniques showed to be effective and safe when using absorbable suture material with a high patient satisfaction and a low complication rate, but percutaneous repair was significantly faster.

Self-reported pain with single leg heel raise or single leg hop offer distinct information as measures of severity in men with midportion and insertional Achilles tendinopathy: An observational cross-sectional study

ObjectivesTo investigate if self-reported pain with single leg heel raise (SLHR) or single leg hop (SLH) are concurrently valid to assess midportion (MPAT) or insertional Achilles tendinopathy (IAT) symptom severity, compared to the VISA-A. Additionally, if SLHR or SLH pain accounts for VISA-A variability, and if they are associated with psychological factors. Participants60 men with MPAT, 26 men with IAT. Main outcomesParticipants rated SLHR and SLH pain on a numerical rating scale (0 = none, 10 = worst). We investigated relationships between loading task pain, VISA-A, VISA-A constructs, and psychological outcomes (Pearson’s correlation coefficients). Linear regression determined best model accounting for VISA-A variability. ResultsIn MPAT, load tests shared fair-negative relationship with VISA-A, and VISA-A function. In IAT, SLHR had moderately strong-negative relationship with VISA-A, and pain and function constructs, and SLH shared fair-negative relationship with VISA-A, and pain and function constructs. Relationships were negligible between load tests and VISA-A activity in both conditions, and VISA-A pain in MPAT. In IAT, there was fair-positive relationship between pain catastrophising and load tests. Remaining psychological outcome relationships were negligible. Best model accounting for VISA-A included SLH in MPAT, and SLHR in IAT. ConclusionsDespite VISA-A and selected VISA-A construct associations, self-reported SLHR and SLH pain appears to provide distinct information.

Medial Displacement Calcaneal Osteotomy as a Novel Treatment for Recurrent Pain after Kidner Procedure for Accessory Navicular Syndrome

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:The accessory navicular is often considered to be related to flatfoot deformity. While the Kidner procedure is commonly utilized in treating painful accessory navicular, its ability to correct flatfoot deformity is debated. Patients may also have recurrent pain due to increased tension of the posterior tibial tendon (PTT) in the setting of an uncorrected flatfoot. In the literature, both PTT lengthening and tendon transfer are techniques described to address this issue with varying success and outcomes. Because medial displacement calcaneal osteotomy (MDCO) is a powerful procedure capable of reducing tension of the medial column and correcting hindfoot valgus deformity, we investigated its use in addressing these symptoms. We report outcomes of a novel use of MDCO in treating patients with recurrent pain following Kidner procedure.Methods:We retrospectively identified 21 patients who underwent MDCO for recurrent pain after Kidner procedure at our institution. MDCO was indicated when patients failed to perform single heel raise due to pain at the PTT attachment site at minimum 6 months following index surgery. Pre- and postoperative radiographic parameters were measured: lateral talo-1st metatarsal angle (Meary’s), talonavicular coverage angle (TNC), calcaneal pitch (CP), and hindfoot moment arm (HMA). Using previously validated cut-offs in describing flatfoot deformity, a Meary’s angle less than -4 degrees was considered a flattened arch, and a HMA more than 3.2mm was considered a valgus heel deformity. Measurements were also performed in x-rays of the contralateral foot to determine whether foot deformity in the involved foot was attributed to Kidner procedure or a preexisting deformity. Pre- and postoperative visual analogue scale (VAS) and FAOS outcome scores were compared to assess for improvement in patient-reported outcomes.Results:The mean age was 25.7 years (range, 21-49) and the mean follow-up was 20.1 months (range, 14-26). The average time from the index surgery was 7.3 months (range, 6-10). Average size of the accessory navicular before excision was 11 mm (range, 4.6-18.3). Concomitant procedures included medial head gastrocnemius recession (n=11), plantarflexion osteotomy of first metatarsal bone (n=1), and talocalcaneal coalition excision (n=1). Radiographically, 12 patients (57%) had a flattened arch and all patients (100%) had heel valgus deformity. All radiographic parameters except Meary’s angle (p=0.885) improved postoperatively. Contralateral radiographs revealed that fifteen patients (71%) had a flattened arch, and 19 patients (90%) had heel valgus deformity. There were no differences between both sides. VAS and FAOS improved significantly (p <0.001).Conclusion:Our data suggest that recurrent pain after Kidner procedure may be related to unaddressed preexisting hindfoot valgus deformity. MDCO provided satisfactory outcomes in relieving this symptom without performing surgery to the PTT. Therefore, MDCO can be a viable option for treatment of recurrent pain following Kidner procedure while potentially avoiding loss of inversion power and donor-site comorbidities associated with PTT lengthening and tendon transfer.

Targeted Achilles Tendon Training and Rehabilitation Using Personalized and Real-Time Multiscale Models of the Neuromusculoskeletal System.

Musculoskeletal tissues, including tendons, are sensitive to their mechanical environment, with both excessive and insufficient loading resulting in reduced tissue strength. Tendons appear to be particularly sensitive to mechanical strain magnitude, and there appears to be an optimal range of tendon strain that results in the greatest positive tendon adaptation. At present, there are no tools that allow localized tendon strain to be measured or estimated in training or a clinical environment. In this paper, we first review the current literature regarding Achilles tendon adaptation, providing an overview of the individual technologies that so far have been used in isolation to understand in vivo Achilles tendon mechanics, including 3D tendon imaging, motion capture, personalized neuromusculoskeletal rigid body models, and finite element models. We then describe how these technologies can be integrated in a novel framework to provide real-time feedback of localized Achilles tendon strain during dynamic motor tasks. In a proof of concept application, Achilles tendon localized strains were calculated in real-time for a single subject during walking, single leg hopping, and eccentric heel drop. Data was processed at 250 Hz and streamed on a smartphone for visualization. Achilles tendon peak localized strains ranged from ∼3 to ∼11% for walking, ∼5 to ∼15% during single leg hop, and ∼2 to ∼9% during single eccentric leg heel drop, overall showing large strain variation within the tendon. Our integrated framework connects, across size scales, knowledge from isolated tendons and whole-body biomechanics, and offers a new approach to Achilles tendon rehabilitation and training. A key feature is personalization of model components, such as tendon geometry, material properties, muscle geometry, muscle-tendon paths, moment arms, muscle activation, and movement patterns, all of which have the potential to affect tendon strain estimates. Model personalization is important because tendon strain can differ substantially between individuals performing the same exercise due to inter-individual differences in these model components.

Full thickness open tear of the tendoachilles - Functional outcomes following a stable, single stage repair

ObjectiveOpen injuries of the Tendoachilles present a challenge to the treating surgeon. Although, common in our setting, there is a paucity of literature regarding management of the same. The purpose of this retrospective study was to analyse the functional outcomes following debridement and primary repair of open tears of the Tendoachilles. Materials and methodsPatients with open tears of the tendoachilles, between January 2012 to January 2017. After obtaining demographic data, including mechanism of injury, all patients were managed by adequate debridement and primary repair, by Pennington’s modification of Kessler’s technique in a single sitting, paratenon closed circumferentially, plantaris reinforcement used when end to end repair couldn’t be achieved. Below knee cast for 2 months. Weight bearing started at three months. Statistical analysis using paired t-test for calf circumference, ankle range of motion comparing with uninjured limb. Functional outcome assessment by AOFAS hindfoot score and Achilles tendon rupture score. Results23 male patients, mean age 35, were analysed. Field injury was the most common mechanism, with slip in Indian lavatory pans accounting for four patients. Average time to surgery from injury was 22 hours. Plantaris reinforcement in one case. No case of wound dehiscence, scar adherence, tendon rerupture or infection. One patient had serous discharge at three weeks which settled with oral antibiotics. 21 patients performed single heel raise. There was no significant difference in calf circumference and ankle range of motion compared to uninjured limb. Mean AOFAS score was 92, mean Achilles tendon rupture score 77. ConclusionThough open injuries of the tendoachilles is fraught with complications, early debridement, adequate repair of the tendon edges with circumferential closure of the paratenon, yields adequate functional outcomes with minimal complications.

Repair of Achilles sleeve avulsion: a new transosseous suture technique

BackgroundAchilles sleeve avulsion usually occurs from pre-existing insertional Achilles tendinopathy, leaving a calcific spur at the insertional site. The purpose of this study was to introduce a new technique using the spur base on the insertional site to drill the suture tunnel to repair Achilles sleeve avulsion.MethodsIn total, 11 patients diagnosed with Achilles sleeve avulsion underwent this new surgical technique and were followed for a mean time of 40 months. Clinical outcomes were measured using the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Tegner score, and time taken to return to activities. Preoperative and postoperative MRI, the ability to perform heel rise, and complications were also evaluated.ResultsAll cases (11/11) had insertional Achilles tendinopathy with calcific spur formation on the tendon’s insertion. At final follow-up, the average VAS score improved from 5.3 to 0.1, AOFAS score improved from 44.8 to 97.9, VISA-A score improved from 23.6 to 96.6, and Tegner score improved from 0.9 to 4.9. Tendinopathy symptoms were eliminated. Patients returned to daily activities, work, and sports 3.5 months, 2.8 months, and 12.3months after operation, respectively. Patients took an average of 18.1 weeks after operation to perform the single heel rise test. No severe complications such as infection and rerupture were observed.ConclusionOur new transosseous suture technique is a promising alternative option in treating Achilles sleeve avulsion. More cases and longer follow up are needed in order to find the best reconstructive option for this pathology.Levels of evidenceLevel IV

A simple instrumented insole algorithm to estimate plantar flexion moments

BackgroundPlantar flexion is critical for ambulatory function but there are few wearable solutions to monitor loading. Research questionThe purpose of this study was to develop and validate a method to calculate plantar flexion moment using a commercially-available instrumented insole. MethodsSeven healthy young adults completed a battery of functional activities to characterize a range of plantar flexion loading which included single leg heel raise, step down, and drop jump as well as walking and running at comfortable speeds. Lower extremity trajectories were captured using motion capture and ground reaction forces were recorded with embedded force plates as well as the instrumented insole. We compared plantar flexion moment calculated by the instrumented insole to ‘gold standard’ inverse dynamics. ResultsWe found that estimating plantar flexion moment using our instrumented insole algorithm compared favorably to moments calculated using inverse dynamics across all activities. Errors in the maximum plantar flexion moments were less than 10 % for all activities, averaging 4.9 %. Root mean square errors across the entire activity were also small, averaging 1.0 % bodyweight * height. Additionally, the calculated wave forms were strongly correlated with inverse dynamics (Rxy > 0.964). SignificanceOur findings demonstrate the utility and fidelity of a simple method for estimating plantar flexion moment using a commercially available instrumented insole. By leveraging this simple methodology, it is now feasible to prospectively track and eventually prescribe plantar flexion loading outside of the clinic to improve patient outcomes.

The acute effects of two different rigid taping methods in patients with hallux valgus deformity

Hallux valgus (HV) is one of the most common deformities of the foot, and it causes great difficulties for the patients. We aimed to investigate the effects of different rigid taping techniques on HV angle, foot motor performance, balance and walking parameters. Twenty-two voluntary individuals (12 males, 10 females) with flexible HV deformities between 18 and 35 years of age were included in the study. All measurements were done before and after placebo, athletic and Mulligan tapings were applied. After a three-day interval, new taping was applied on the same subject. HV angle was measured by goniometer. Foot motor performance (single leg heel rise test), balance (unilateral stance, limits of stability, sensory integration of balance) and temporospatial parameters of gait (step length, stride length, step width, foot angle and cadence) were evaluated. HV angles were reduced in all taping groups (p< 0.05). The Mulligan taping method was the most effective method in reducing HV angle. Foot motor performance was not affected by any type of taping (p> 0.05). Athletic taping increased step length and step width but reduced foot angle and cadence. The Mulligan taping increased cadence and reduced foot angle (p< 0.01). Both taping methods did not affect the postural stability and fall risk (p> 0.05). Stability limits were increased in Mulligan taping group (p< 0.05). It can be concluded that Mulligan taping method may be an alternative treatment method for HV rehabilitation especially as it increased the limits of stability and maintaining the balance. Mulligan method is more effective than athletic taping in terms of reducing instant HV angle.

Platelet rich plasma injection for acute Achilles tendon rupture: PATH-2 randomised, placebo controlled, superiority trial

ObjectiveTo determine whether an injection of platelet rich plasma improves outcomes after acute Achilles tendon rupture.DesignRandomised, placebo controlled, two arm, parallel group, participant and assessor masked, superiority trial.SettingSecondary care trauma...