Tibialis Anterior Tendon Research Articles

Time course and variability of tendinous vibration-induced postural reactions in forward and backward directions

Mechanical vibration of tendons induces large postural reactions (PR-VIB) but little is known about how these reactions vary within and between subjects. We investigated the intra- and inter-individual variability of PR-VIB and determined the reliability of center of pressure (COP) measures. Bipodal postural control (eyes closed) of 30 healthy adults were evaluated using a force platform under 02 conditions: bilateral VIB of the tibialis anterior (TA) and Achilles tendons (ACH-T) at 80 Hz. Each condition consisted of 03 trials of 30 s duration (Baseline: 10 s; VIB: 10 s; POST-VIB: 10 s). The Amplitude and Velocity of the COP in the antero-posterior/medio-lateral (AP/ML) directions were recorded and analyzed according to 5 time-windows incremented every 2 s of vibration (i.e. the first 2 s; 4 s; 6 s; 8 s & 10 s), whereas the COP position/AP was monitored every 0.5 s. All postural parameters increased significantly during TA and ACH-T vibration compared to the Baseline. The reliability of the COP measures showed good ICC scores (0.40-0.84) and measurement errors that varied depending on the duration of VIB time-windows. The COP position/AP reveals a lower intra- and inter-subject variability of PR-VIB in the first 2 s of VIB. The metrological characteristics of PR-VIB should be investigated further to guide their future use by clinicians and researchers.

Extensor hallucis longus tendon is a new distal landmark for coronal tibial component alignment in total knee arthroplasty: A study of magnetic resonance imaging.

In total knee arthroplasty (TKA), various landmarks are generally used to ensure correct osteotomy. In this study, we examined whether the tibialis anterior tendon (TAT) or the extensor hallucis longus tendon (EHLT) could be used as a landmark of the center of the ankle joint in patients with knee osteoarthrosis (OA), using magnetic resonance imaging (MRI). The subjects were 61 patients with OA in 79 knees (males: 8 with 9 knees and females: 53 with 70 knees). With the ankle joint secured in the intermediate position, MRI from the knee joint to the ankle joint was performed in the same foot position. We prepared individual lines connecting the center of the ankle joint with the TAT or EHLT to measure the angle difference (ΔA) from Akagi's line in the knee joint. We analyzed whether the ΔA might be affected by deformity of the knee joint or foot region, and tibial torsion. At the ankle joint level, the ΔA of EHLT was the smallest, with an average of 1.6 ± 3.4°. The ΔA for the femorotibial angle, hallux valgus angle, and varus-valgus angle showed no correlations with deformity of the knee joint and foot region, or tibial torsion. MRI findings showed that EHLT would be useful as a landmark of the ankle joint center in extramedullary tibial osteotomy in TKA for medial knee OA. It was also clarified that the landmark would not be affected by severe deformity of the knee joint, deformity of the foot region, or external torsion of the tibia.

Ankle Fracture Dislocation with Interposition of the Tibialis Anterior and Tibialis Posterior Tendons: A case report

Ankle Fracture Dislocation with Interposition of the Tibialis Anterior and Tibialis Posterior Tendons: A case report

Chronic tibialis anterior rupture: An underdiagnosed condition

Rupture of the tibialis anterior tendon is a rare condition and the diagnosis is frequently delayed, due to subtle changes in foot and ankle function. However, chronic deficits can be visible over time namely progressive gait dysfunction, with a limited dorsiflexion and foot slapping. The authors describe a case report of an isolated chronic anterior tibial tendon rupture, of a 16-year-old boy, treated with a free flap interposition with gracilis tendon. The gracilis tendon can safely be used as a free flap interposition in chronic anterior tibial tendon rupture with large tendon defects, with excellent clinical results. Large gaps can be successfully bridged with this technique, with the advantage of sparing the other local tendons and lower donor site morbility.

Age-related decrease in collagen proton fraction in tibial tendons estimated by magnetization transfer modeling of ultrashort echo time magnetic resonance imaging (UTE-MRI)

Clinical magnetic resonance imaging (MRI) sequences are not often capable of directly visualizing tendons. Ultrashort echo time (UTE) MRI can acquire high signal from tendons thus enabling quantitative assessments. Magnetization transfer (MT) modeling combined with UTE-MRI—UTE-MT-modeling—can indirectly assess macromolecular protons in the tendon. This study aimed to determine if UTE-MT-modeling is a quantitative technique sensitive to the age-related changes of tendons. The legs of 26 young healthy (29 ± 6 years old) and 22 elderly (75 ± 8 years old) female subjects were imaged using UTE sequences on a 3T MRI scanner. Institutional review board approval was obtained, and all recruited subjects provided written informed consent. T1 and UTE-MT-modeling were performed on anterior tibialis tendons (ATT) and posterior tibialis tendons (PTT) as two representative human leg tendons. A series of MT pulse saturation powers (500–1500°) and frequency offsets (2–50 kHz) were used to measure the macromolecular fraction (MMF) and macromolecular T2 (T2MM). All measurements were repeated by three independent readers for a reproducibility study. MMF demonstrated significantly lower values on average in the elderly cohort compared with the younger cohort for both ATT (decreased by 16.8%, p = 0.03) and PTT (decreased by 23.0%, p < 0.01). T2MM and T1 did not show a significant nor a consistent difference between the young and elderly cohorts. For all MRI parameters, intraclass correlation coefficient (ICC) was higher than 0.98, indicating excellent consistency between measurements performed by independent readers. MMF serving as a surrogate measure for collagen content, showed a significant decrease in elderly leg tendons. This study highlighted UTE-MRI-MT techniques as a useful quantitative method to assess the impact of aging on human tendons.

Clinical outcomes and second-look arthroscopic findings of anterior cruciate ligament reconstruction with autograft, hybrid graft, and allograft

BackgroundThere is no consensus as to the choice of grafts for primary anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare the clinical and second-look arthroscopic outcomes after ACL reconstruction by use of autograft, hybrid graft, and γ-irradiated allograft.MethodsNinety-seven patients who underwent second-look arthroscopy after ACL reconstruction with autografts (28 patients, hamstring autograft), hybrid grafts (32 patients, hamstring autograft augmented with γ-irradiated tibialis anterior tendon allograft), or γ-irradiated allografts (37 patients, tibialis anterior tendons) were included in this study. The clinical outcomes were compared by using Lysholm score, International Knee Documentation Committee (IKDC) score, and Tegner activity score, and the side-to-side differences of KT-1000 measurement. Second-look arthroscopic findings were compared in terms of synovial coverage and graft tension.ResultsThere were no statistical significances among the three groups in Lysholm score, IKDC score, or Tegner activity score (P > 0.05). The KT-1000 examination showed more anterior laxity in the γ-irradiated allograft group than in the autograft or hybrid graft groups (P = 0.006, and P = 0.013, respectively). Two patients in the autograft group, 2 patients in the hybrid graft group and 4 patients in the allograft group were evaluated as graft failure on second-look arthroscopy. The synovial coverage was superior in the autograft group than that in the hybrid graft group or the allograft group (P = 0.013 and P = 0.010, respectively), and was comparable between the hybrid graft group and allograft group (P = 0.876). With regard to graft tension, the autograft group and hybrid group were comparable (P = 0.883) but showed better results than the allograft group (P = 0.011 and P = 0.007, respectively).ConclusionThe hamstring autografts and hybrid grafts used for ACL reconstruction produced equal efficacy but provided better knee stability than allografts. In addition, the hamstring autografts showed better synovial coverage than the other two graft types.

A new anchoring technique for tibialis anterior tendon transfer.

Tibialis anterior tendon transfer was described as an effective method in the management of dynamic supination as well as prevention of clubfoot relapse in children. Different successful methods were described for anchoring the transferred tibialis anterior tendon; however, each of which has its own complications that were avoided by using this novel technique. This study included 26 feet in 18 patients, who underwent tibialis anterior tendon transfer as a part of management of their congenital clubfoot. The mean age was 3.6 years (ranging from 2.5 to 5 years), all patients were followed up for 6 to 30 months (mean = 14 months). The transferred tibialis anterior tendon was anchored in the third cuneiform using transfixing K wires. This novel technique resulted in successful and stable anchoring of the transferred tibialis anterior tendon. The transferred tendon was well palpated in all patients with active dorsiflexion, with no associated tendon rupture, anchoring problems, or wound complication. Our technique is secure, reliable, and economic with no special equipment needed. It could successfully avoid the plantar skin complications associated with pullout sutures and neurovascular injury.

PO 18205 - Case report

Introduction: Anterior tibial tendon ruptures are quite rare. All studies found in the literature refer to the adult population, with no reports of this injury in the pediatric population. The literature on the treatment of this injury is scarce. Objective: To report the case of a child subjected to peroneus brevis tendon transfer for the sequela of a severe anterior tibial and extensor hallucis longus tendon injury. Methods: Male patient, 8 years of age, was run over by a car and sustained an exposed tibial fracture and major soft-tissue injury of the foot. Anterior tibial, posterior tibial and extensor hallucis longus tendon rupture were detected. Damage control, soft-tissue cover and conservative treatment of the anterior tibial and extensor hallucis longus tendons were initially performed; however, the conservative treatment failed, and valgus deformity and pronation developed. Subsequently, tenoplasty (posterior tibial tendon), the Strayer procedure (gastrocnemius recession of the Achilles tendon) and elongation of the peroneus longus and brevis tendons were also performed, but the patient experienced deformity recurrence. Subcutaneous peroneus brevis tendon transfer to the navicular was then chosen, with postoperative use of an ankle-foot orthosis (AFO) and physical therapy. Results: The deformity was improved. The patient progressed with satisfactory gait and strength. He currently walks without support using an AFO. Both the patient and his family were satisfied with the functional outcome of the tendon transfer. Conclusion: Reconstruction of anterior tibial and extensor hallucis longus tendon rupture through peroneus brevis tendon transfer is a viable and reliable treatment option. No complications such as adhesions or correction failure were observed, thus corroborating the viability of this method.

The Relationship of the Lapidus Intramedullary Nail to Neurologic and Tendinous Structures in the Foot: An Anatomic Study

Category:Bunion, Midfoot/ForefootIntroduction/Purpose:The lapidus procedure is a longstanding operation performed for the treatment of hallux valgus deformity with a concomitant hypermobile first ray. Orthopaedic surgeons have a myriad of options to choose from in performing the lapidus procedure. The implantation of orthopaedic implants comes with the risk of iatrogenic injury to surrounding anatomy. Several cadaveric studies in the humerus and femur have described potential neurovascular structures at risk during placement of intramedullary nail systems. The purpose of this study was to determine the proximity of nail insertion and interlocking mechanisms in the Lapidus Phantom Intramedullary Nail System (Paragon 28, Inc.) to neurologic and tendinous structures in the foot.Methods:A titanium intramedullary nail was inserted from the first metatarsal to the medial cuneiform spanning the first tarsometatarsal joint in 10 fresh-frozen cadaver feet. K-wires were inserted in the proximal lateral, proximal medial, and distal medial-to-lateral interlock screw paths. The tibialis anterior tendon, extensor hallucis longus tendon, and superficial peroneal nerve were carefully dissected and exposed, and the distance from each of these anatomic landmarks were then measured and recorded from four different aspects of the nail: Proximal lateral interlocking screw path, proximal medial interlocking screw path, nail insertion, distal interlocking screw path. Distances were averaged, ranges were determined.Results:The tibialis anterior tendon was in closest proximity to the proximal medial interlock K-wire with an average distance of 0.4 mm. The proximal medial interlock bisected the tibialis anterior tendon in three of the specimens. The extensor hallucis longus tendon was in closest proximity to the nail insertion with an average distance of 1.2 mm. A branch of the superficial peroneal nerve was in closest proximity to the distal interlock K-wire with an average distance of 7.5 mm, however, the nerve came in direct contact with the proximal medial interlock K-wire in two of the specimens.Conclusion:The Lapidus intramedullary nail’s proximal medial interlock screw poses the greatest threat to the tibialis anterior tendon, with the distance from the tendon to the interlock K-wire being 3 mm or less in all specimens tested. The extensor hallucis longus tendon is at risk of injury with insertion of the nail. Medial to lateral interlocking poses the greatest danger to a branch of the superficial peroneal nerve. Blunt dissection should be performed using this system with a path to bone before instrumentation to reduce the risk of nerve and tendon injury in the foot.

Surgical Anatomy of the Medial Cuneiform (Cotton) Osteotomy.

Background:The Cotton osteotomy, or dorsal-opening wedge osteotomy of the medial cuneiform (MC), is used to address medial column alignment to restore the static-triangle of support. There are many described techniques regarding the incision and osteotomy. Successful completion of the osteotomy requires knowledge of the anatomy, particularly the location of the medial dorsal cutaneous nerve (MDCN). This study describes the relationship between MDCN, tibialis anterior, extensor-hallucis-longus tendon, and ligamentous attachments to the MC. A technique to determine a safe location for the osteotomy is also described.Methods:Twelve fresh-frozen adult foot specimens were used for this study (7 male and 5 female). The MDCN and its branches were dissected and its relationship with the MC was documented. Osteotomy tilt angle and relationship to structures around the MC were measured.Results:MDCN traveled medially and distally over the dorsum of the MC, and a small branch to the MC was observed. The tilt angle was 80.1 ±1.4 degrees. There was no significant difference between the distance from the distal-articular surface to the midline of the cuneiform and to the interosseous ligament (P = .69), or between the distance from the distal-articular surface to the second tarsometatarsal joint and to the origin of the Lisfranc ligament (P = .12).Conclusions:The dorsal-medial-oblique incision effectively protected MDCN and the MC. We believe the osteotomy should be performed in the safe zone to maintain the stability of the opening wedge.Clinical relevance:The dorsal-medial-oblique incision could reduce the risk of injury to the MDCN and the tibialis-anterior tendon.

Review of Use of Amniotic Membrane Allograft in Total Ankle Replacements

Category:Ankle ArthritisIntroduction/Purpose:Wound complications after total ankle replacement (TAR) lead to increased postoperative morbidity with lasting consequences. Previous studies demonstrate delayed wound healing in 6.6% to 28% of all TARs. Soft tissue breakdown along the anterior incision can cause exposure of anterior tendons and the implants. In addition, adhesions of the extensor tendons can develop causing significant morbidity. Recent publications advocate for the use of dehydrated human amnion/chorion membrane allograft (dHACM) during closure of anterior ankle incisions during TAR. dHACM is shown to promote increased epithelial cell proliferation, recruitment, and differentiation and reduce the likelihood of tendon adhesions. The goal of this study was to review the use of dHACMs in TARs and to investigate the number and type of postoperative wound complications including extensor tendon adhesions.Methods:We retrospectively reviewed 92 TARs performed between April, 2016 through August, 2018 by two board certified, fellowship trained foot and ankle orthopaedic surgeons. A standard anterior approach was done in all cases. All TARs had dHACM graft placed deep to the tibialis anterior and extensor longus tendon and along the extensor retinaculum prior to final closure of the wound. Upon data review, we identified the subset of patients who had anterior wound dehiscence postoperatively requiring an additional procedure(s) for wound coverage. We compared the demographics, medical comorbidities, and operative characteristics of those with and without perioperative wound complications.Results:12 patients who underwent TARs sustained wound dehiscence below the subcutaneous tissue and required operative intervention (13%). Of these 12 cases, 5 required bipedical or rotational fasciocutaneous flap coverage (5.4%), 6 required less extensive soft tissue surgery (6.5%) and one case involved a deep periprosthetic infection that resulted in explant and antibiotic spacer placement (1.1%). 6 of the 12 cases required a split thickness skin graft application (6.5%) and 2 cases required tenolysis of extensor tendon adhesions (2.2%). Normal excursion of extensor tendons was seen in 90 patients (97.8%). Except for the one infected ankle, there were no cases with wound dehiscence that communicated with the joint. There were no statistically significant differences in medical comorbidities/operative characteristics between patients with wound complications and those without.Conclusion:Wound complications after total ankle replacements often lead to poor long-term outcomes for patients. Our data suggests that the application of the amniotic membrane allograft and its inherent healing potential decreases postoperative tendon adhesions and significant wound dehiscence. This may lead to less deep wound infections that communicate with the joint and may be protective against total ankle replacement failures due to these complications.

Demographic Factors Associated with Anterior Tibial Tendon Pathology

Category:Sports, tendonIntroduction/Purpose:The tibialis anterior serves an important role in ankle motion as it provides the majority of strength with dorsiflexion. Despite the importance of this muscle, there is a relative dearth of information regarding risk factors and demographic information that might predispose people to tendinopathy or rupture. The goal of this study is to further investigate the features of patients in a single institution who presented with either tibialis anterior tendinopathy or rupture. We also examined the ways in which these patient characteristics might differ in traumatic (patient remembers feeling a pop after a specific activity) versus atraumatic tendon ruptures (happened spontaneously without patient realizing).Methods:We used ICD-9 and ICD-10 codes to find patients who presented with tibialis anterior pathology to two foot and ankle surgeons at one academic medical center from 2007-2018. We made note of patient characteristics such as age, gender, BMI, and medical comorbidities. Physical examination findings, such as gastrocnemius equinus, were noted as well. Characteristics of patients with traumatic and atraumatic tibialis anterior ruptures were compared using Student’s T-tests and chi-squared tests.Results:The characteristics of 93 consecutive patients between 2007 and 2018 were analyzed. There were 80 cases of tendinopathy, and 13 cases of tibialis anterior rupture. The average age of our patient group was 56 years, and the ratio of female to male was 73:20 (3.67:1). The average BMI was 27.2 kg/m2. 15 patients had a gastrocnemius equinus (16%). 75 patients had a neutral arch (81%), 16 patients had pes planus (17%), and two patients had pes cavus (2%). With regards to those who ruptured, there were two traumatic ruptures and 11 atraumatic ruptures. Average age for traumatic rupture was 39 years compared to 73 for atraumatic rupture (p<.05). Average BMI for traumatic rupture was 21 compared to 27 kg/m2 (p>.05).Conclusion:Our study investigates the features of patients in a single institution who presented with tibialis anterior pathology. This pathology was much more common in women and generally occurred in an older cohort. With regards to tendon ruptures, though, younger patients tend to suffer traumatic ruptures, while older patients are more likely to suffer more degenerative ruptures that required less energy for tensile failure of the tendon.

Hip Labral Augmentation With Tibialis Anterior Tendon Allograft Using the Knotless Pull-Through Technique

The importance of the labrum in the biomechanics of the hip joint is well documented. Labral tears are the most common pathology in patients undergoing hip arthroscopy and therefore appropriate labral management is vital. Labral preservation has been advocated as a superior alternative to labral excision in terms of clinical outcomes. While reconstruction of the labrum is recommended for irreparable tears, labral augmentation is a viable alternative for labral function restoration under certain indications. This Technical Note will describe a method for arthroscopic hip labral augmentation using an anterior tibialis tendon allograft and the pull-through technique.

Arthroscopic Ligamentum Teres Reconstruction Using Anterior Tibialis Allograft and the Tension-Slide Technique

Once perceived to be a vestigial structure, the ligamentum teres (LT) is now increasingly understood to be critical to providing stability in the adult hip. Surgical treatment with arthroscopic debridement is usually the procedure of choice to treat LT tears. However, reconstruction is a possible alternative in select cases. The authors of a recent systematic review concluded that LT debridement may provide short-term relief of hip pain in patients with partial-thickness tears in whom conservative management has failed whereas reconstruction may be more beneficial in cases of full-thickness tears. This Technical Note describes a method for arthroscopic LT reconstruction using the tension-slide technique to fixate an anterior tibialis tendon allograft to the acetabulum.

Retinoic Acid Promotes Retinoic Acid Signaling by Suppression of Pitx1 In Tendon Cells: A Possible Mechanism of a Clubfoot-Like Phenotype Induced by Retinoic Acid.

BackgroundThe pathogenesis of idiopathic congenital clubfoot (CCF) is unknown. Although some familial patients have Pitx1 mutations, and the Pitx1+/− genotype causes a clubfoot-like phenotype in mice, the mechanism of Pitx1-induced CCF is unknown.Material/MethodsWe used tibialis anterior tendon samples to detect the expression of Pitx1 in idiopathic and neurogenic clubfoot patients. After obtaining Sprague-Dawley (SD) rat Achilles tendon cells, the expression of Pitx1 was knocked down by SiRNA. After 48 h of culture, mass spectrometry was used to quantitatively analyze proteins. Then, Gene Ontology (GO) analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis were used to assess the downstream pathway of PITX1. The relationship between Pitx1 and the promoter region of deacetylase 1 (Sirtuin-1 and Sirt1) was examined by luciferase and ChIP assays.ResultsWe found that Pitx1 expression in the tendon samples of idiopathic CCF patients was downregulated. Mass spectrometry analysis revealed that the inhibition of Pitx1 induced the downregulation of Sirt1 expression in tendon cells. Luciferase and ChIP assays confirmed that Pitx1 binds to the promoter region of SIRT1 and promotes Sirt1 gene transcription. Further results showed that, after the inhibition of Pitx1 in tendon cells, CRABP2 acetylation increased, the nuclear import of CRABP2 was enhanced, and the expression of RARβ2 increased. After the inhibition of Pitx1, RARβ2 expression was further increased by RA treatment in tendon cells. In the presence of retinoic acid, the expression of Pitx1 was inhibited in tendon cells.ConclusionsPitx1 binds to the promoter region of SIRT1 and promotes the transcription of SIRT1. Positive feedback occurs between RA signaling and Pitx1.

Anatomical study of Lapidus arthrodesis using two different plantar plate systems

BackgroundFirst tarsometatarsal arthrodesis (modified Lapidus procedure) constitutes a sufficient treatment for moderate to severe hallux valgus deformity and first ray instability. The plantar plate arthrodesis was shown to provide superior mechanical stability and less postoperative complications than screw fixation or dorsal plating. Nevertheless, the in-brought hardware may cause irritation of the tibialis anterior or peroneus longus tendon requiring explantation of the material in some cases.The purpose of this study was to investigate the potential of tendon irritation after plantar first tarsometatarsal joint arthrodesis in a cadaver study. MethodsPlantar plate arthrodesis was performed as in real surgery on twelve pairs of fresh frozen cadaveric feet. Two different plate systems were randomly allocated to each pair of feet. After plate fixation careful dissection of the feet followed to analyze potential tendon irritation and to determine a “safe zone” for plantar plate placement. ResultsA “safe zone” between the insertion sties of tibialis anterior and peroneus longus tendon was found and proven to be sufficiently exposed using a standard medio-plantar approach. Both plates were fixed in this zone without compromising central tendon parts. Peripheral tendon parts were irritated in 42% using Darco Plantar Lapidus Plating System® (Wright Medical, Memphis, TN) and in 8% using the Plantar Lapidus Plate® (Arthrex, Naples, FL). Bending of the anatomically preshaped plates is often necessary to ensure optimal fit on the bone surface. ConclusionsModified Lapidus procedure with plantar plating of the first tarsometatarsal joint can be performed safely without compromising central tendon parts via standard medio-plantar approach. Level of clinical evidence5, Cadaver Study.

Treatment of Clubfoot with Dynamic Supination and No Deformity: A Survey of the POSNA Membership

Purpose: Anterior tibialis tendon transfer (ATTT) is a procedure, which is used to treat recurrent clubfoot with dynamic supination, but there are a wide variety of guidelines or strategies for the procedure. In this study, members of the Pediatric Orthopaedic Society of North America (POSNA) were surveyed in order to determine the varied methods used in the execution of ATTT. Methods: The survey was designed using Research Electronic Data Capture (REDCap) survey software. It …

Treatment of relapsed, residual and neglected clubfoot: adjunctive surgery.

Over the past two decades, the Ponseti ‘conservative’ (non-surgical) method of clubfoot treatment has been almost universally adopted worldwide. As a result, the need for operative treatment for clubfoot has decreased dramatically. However, even Ponseti himself routinely used surgery for certain patients: at least 90% of feet need percutaneous tenotomy, and 15% to 40% may require tibialis anterior tendon transfer. Additionally, relapses are common, sometimes necessitating further surgical intervention. Relapses are recurrent deformities in previously well corrected feet. Residual deformities may be defined as persistent deformities in incompletely corrected feet. In addition, in many parts of the developing world, neglected clubfoot is still a major challenge. Many neglected feet can be treated with Ponseti principles, particularly in younger children. However, in older children and adults, surgical approaches are more likely to be needed. Major reasons for relapsed/residual clubfoot include incomplete application of the Ponseti principles, inability to adhere to the foot abduction brace protocol, failure to recommend a complete course of bracing and inadequate follow-up. Sometimes, despite excellent treatment, and perfect adherence to the bracing protocols, there are still relapses, related to intrinsic muscle imbalance. We describe several solutions that include reinstitution of Ponseti casting and ‘á la carte’ operative treatment. As an alternative for particularly stubborn cases, application of a hexapod external fixator can be a powerful tool. In order to be a full-service clubfoot specialist, and not only a Ponseti practitioner, one must have in their toolbox the full gamut of adjunctive surgical options.Level of Evidence:V

Proprioception following the Anterior Cruciate Ligament Reconstruction with Tibialis Anterior Tendon Allograft.

After the anterior cruciate ligament (ACL) reconstruction, a loss of proprioception is observed and it can continue years after the operation. The aim of this study is to evaluate proprioception in standing position at different knee flexion angles in patients who underwent ACL reconstruction with tibialis anterior tendon allograft. The study included 34 patients who underwent ACL reconstruction with tibialis anterior tendon allograft and 34 healthy individuals. Proprioception was evaluated in standing position at 15°, 30°, 60° flexion angles with the active joint position sense (AJPS) method using digital inclinometer. Proprioception deviation angle was found to be higher in the operated leg at 30° and 60° flexion angles in the patient group compared with the other leg (p < 0.05), the biggest proprioception difference was between the 15° and 60° flexion angles in both the patient and the control group (p < 0.05) that the difference between 15° and 30° flexion angles is lowest (p < 0.05), and that these differences are higher in the operated leg of the patient group compared with the other leg of the patient group and to the dominant leg of the control group (p < 0.05). As approximately 4 years after ACL reconstruction with tibialis anterior tendon allograft, loss of proprioception at 60° knee flexion continued, ACL injury related to loss of proprioception may occur at angles higher than 30° flexion. Thus, patients may be provided with proprioception-enhancing rehabilitation in the long term, particularly, at flexion angles above medium levels.

The Ponseti method of clubfoot treatment in walking age children: is it effective? A study of 56 children from 1 to 10 years of age

The Ponseti method is well-established for the treatment of clubfoot in younger babies; however, its effectiveness in older children is still unclear. The aim of our study was to report our results of the 'traditional' Ponseti method in the management of clubfoot in children of walking age. A total of 56 (81 clubfeet) children with a mean age of 3.16±2.35 years (1-10 years) were divided into two groups: group I consisted of 12 (18 clubfeet) patients with a mean age of 3.36±2.7 years (range: 1-8.4 years) who presented with an untreated clubfoot whereas group II consisted of 44 (63 clubfeet) patients with a mean age of 3.19±2.34 years (range: 1-10 years) who presented with a recurrent clubfoot. All children underwent the standard manipulation and casting technique described by Ponseti, including a percutaneous tenotomy of the Tendo Achilles. The bracing protocol was modified appropriately. All feet corrected with a mean of 7.36 (3-17) casts in group I and 4.49 (1-12) casts in group II. All children in group I and 70.45% in group II underwent a percutaneous Tendo Achilles tenotomy. There was a statistically significant change between the pretreatment and post-treatment Pirani scores in both groups. Nineteen (30.86%) patients underwent relapse at a mean follow-up of 2.84±1.25 years (1.2-5.4 years), who were treated by re-casting, bracing and tibialis anterior tendon transfer. The Ponseti method is effective even in walking age children upto the age of 10 years with a good success rate, although approximately one-third of the clubfeet relapsed and needed further treatment. No modifications to the standard casting protocol are required. Despite a high relapse rate, a supple, plantigrade and pain-free foot is achievable without the need for extensive soft-tissue surgeries or bony procedures. The Ponseti method lends itself well to developing a nation-wide program for clubfoot treatment in countries with limited resources. Level of Evidence: Level III.