Modified Percutaneous Achilles Tendon Lengthening by Triple Hemisection for Achilles Tendon Contracture

Subtalar arthroereisis with metallic implant is a safe and effective treatment for pediatric patients with symptomatic flexible flatfeet. A 10-year clinical and radiographic follow-up

BACKGROUND

Subtalar arthroereisis (SA) is an increasingly applied minimally invasive approach for flexible flat foot (FFF) not responsive to conservative treatment. This study aimed at evaluating the long-term clinical and radiographic outcomes of SA in pediatric patients with symptomatic FFF.

METHODS

Thirty-seven patients (11.9 ± 1.6yy) underwent SA (74 feet), with outcomes assessed after a mean 10-year follow-up. Pain, quality of life, foot functionality, and alignment were evaluated using validated tools and radiographic parameters, calculated on weightbearing x-rays pre- and post-operatively.

RESULTS

Clinical outcomes reached excellent postoperative results (FFI: 9.1, AOFAS: 94.5) with a low 0.9 NRS pain (p < 0.01) and a 92 % satisfaction. All radiographic parameters improved significantly towards normal values: CP 17.5 ± 3.9, MA 4.3 ± 5.8, TCA 42.8 ± 6.2, TNCA 21.1 ± 8.5, TNU% 26.6 ± 8.4 (all p < 0.01).

CONCLUSIONS

SA with a metallic endosinotarsal device provided significant long-term clinical and radiographic improvements, with low complication rates and high patient satisfaction, supporting its efficacy as a treatment option for pediatric symptomatic FFF.

LEVEL OF EVIDENCE

IV.

Arthroscopic Management of Melorheostosis-Induced Ankle Deformity: A Case Report

Melorheostosis is a rare congenital sclerosing bone dysplasia characterized by a distinctive "candle-like flowing wax" radiological appearance. This study presents a case of an 80-year-old male who presented with a decade-long history of left ankle pain and rigid equinus deformity, which substantially impaired his mobility and activities of daily living. Conservative interventions, including physical therapy and custom orthotics, failed to alleviate his symptoms. Subsequent arthroscopic osteotectomy and Achilles tendon lengthening engendered substantial postoperative improvements in pain relief, range of motion, and gait stability, enabling him to resume previous activities such as cycling. This study highlights the potential of minimally invasive surgical techniques in managing melorheostosis-related deformities to optimize patient outcomes and quality of life. Nevertheless, long-term follow-up is essential for assessing the risk of recurrent ankle deformity and the potential requirement for revision surgery.

Correction of a Hyperflexed Hallux in a Saker Falcon (Falco cherrug) by Hemisectioning the Deep Digital Flexor Tendon

A 3-year-old male saker falcon (Falco cherrug) was presented with a history of hyperflexion of the first digit of the left pelvic limb with what appeared to be a hypercontracted distal end of the deep digital flexor tendon (m. flexor hallucis longus). Conservative treatment, bandaging, and splinting techniques failed to resolve the hypercontraction of the deep digital flexor tendon and improve digit function. Intraoperatively, the deep digital flexor tendon was found to have formed adhesions with the tendon sheath as well as the bone and soft tissue structures underneath it, impeding its ability to move freely within the tendon sheath. The adhesions were surgically resolved, and the tendon was lengthened by hemisectioning the deep digital flexor tendon at its distal end. Postsurgically, the digit was maintained in an extended position by bandaging. Mild physiotherapy was provided at 5-day intervals to retain function and prevent adhesions. Digit extensibility and function were restored to nearly normal levels after 4 weeks.

The Role of Equinus in Flatfoot Deformity

Equinus plays an important role in flatfoot deformity. Proper evaluation and surgical management are critical to comprehensively treat and successfully resolved patients' symptoms. We have discussed the cause, evaluation, and some of the common surgical options. Each procedure has its inherent benefits and risks. It is imperative that the foot and ankle surgeon identify and include these procedures as part of the complete reconstructive surgery.

A pilot study on lengthening potentials and biomechanical effects of double and triple hemisection on tendon with slide lengthening

The current study explored the slide-lengthening potentials of double and triple hemisections and the biomechanical effects of different inter-hemisection distances. Forty-eight porcine flexor digitorum profundus tendons were divided into double- and triple-hemisection groups (Groups A and B) and a control group (Group C). Group A was divided into Group A1 (distance between hemisections were the same as Group B) and Group A2 (distance between hemisections corresponded to the greatest distance between hemisections in Group B). Biomechanical evaluation, motion analysis, and finite element analysis (FEA) were performed. Failure load of intact tendon was significantly highest among groups. When the distance was 4 cm, the failure load of Group A increased significantly. When the distance between the hemisections was 0.5 or 1 cm, the failure load of Group B was significantly lower than Group A. Tendon elongation and failure load of Group B were significantly lower than those in Group A when the greatest distance between hemisections was the same. Consequently, Double hemisections had a similar lengthening ability to that of triple hemisections with the same distance, but better when the distances between extreme hemisections matched. However, the driving force for the initiation of lengthening may be greater.

Management of arthrofibrosis in neuromuscular disorders: a review

Arthrofibrosis, or rigid contracture of major articular joints, is a significant morbidity of many neurodegenerative disorders. The pathogenesis depends on the mechanism and severity of the precipitating neuromuscular disorder. Most neuromuscular disorders, whether spastic or hypotonic, culminate in decreased joint range of motion. Limited range of motion precipitates a cascade of pathophysiological changes in the muscle-tendon unit, the joint capsule, and the articular cartilage. Resulting joint contractures limit functional mobility, posing both physical and psychosocial burdens to patients, economic burdens on the healthcare system, and lost productivity to society. This article reviews the pathophysiology of arthrofibrosis in the setting of neuromuscular disorders. We describe current non-surgical and surgical interventions for treating arthrofibrosis of commonly affected joints. In addition, we preview several promising modalities under development to ameliorate arthrofibrosis non-surgically and discuss limitations in the field of arthrofibrosis secondary to neuromuscular disorders.

Effect of single and double hemitenotomy on equine deep digital flexor tendon length and strength in experimental load challenges

OBJECTIVE

To evaluate a double hemitenotomy (DHT) technique as an alternative to complete deep digital flexor (DDFT) tenotomy.

STUDY DESIGN

Experimental ex vivo study.

SAMPLE POPULATION

Isolated DDFTs (n = 30) and cadaveric forelimbs (n = 16).

METHODS

In part 1, 15 isolated DDFT pairs were used. Two hemitenotomies were created in 1 DDFT while the other served as reference. Monotonic tensile load was applied. Tendon lengthening, load reduction, and load at failure were recorded. In part 2, 16 cadaveric forelimb pairs were subjected to DHT followed by complete tenotomy (CT) under monotonic compressive load. Differences between DHT and controls were assessed with Wilcoxon signed rank tests or Friedman tests.

RESULTS

In isolated tendons and cadaveric forelimbs, DHT resulted in DDFT lengthening (median, +1.9 mm and + 3.05 mm) and load reduction (median, -16.7 and -11.2 kg). Less lengthening was achieved with DHT compared to CT (P = .008). Load reduction did not occur between DHT and CT was observed during compressive testing (P = 1). Load reduction following the first hemitenotomy incision was smaller when compared to the second (P = .022). Isolated DHT tendons failed at a tensile load of 195 kg, while no intact tendons failed (P = .0001).

CONCLUSION

Double hemitenotomy was comparable to CT in load reduction. It reduced tensile strength, but load at failure was similar or exceeded the estimated DDFT load at stance.

CLINICAL SIGNIFICANCE

Hemitenotomy may be a useful alternative for surgical management of horses with laminitis, but in vivo studies are needed to confirm these findings.

Triple Hemisection Percutaneous Achilles Tendon Lengthening for Severe Ankle Joint Deformity

Objective

To investigate the efficacy of modified percutaneous Achilles tendon lengthening for severe ankle joint deformity.

Methods

This retrospective case series study included 33 patients with an average age of 25.2 years who underwent surgery in our hospital from April 1, 2010 to March 1, 2018. Triple hemisection percutaneous Achilles tendon lengthening was performed. One stage surgery, other soft tissue surgery or bone correction surgery could be performed. After surgery, a plaster cast was used to fix the functional position, and rehabilitation training was carried out as planned. Complications during the perioperative period were recorded. Statistical analysis of the patients' visual analogue scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) score before and at the last follow‐up was performed. The recurrence rate of Achilles tendon contracture at the last follow‐up and the patients' satisfaction rate were investigated.

Results

All patients were followed up, with an average follow‐up period of 56.31 months (8–104 months). All achieved good ankle joint function and appearance improvement And there were no infection or skin necrosis complications. In two cases, the incision was poorly healed at non‐Achilles tendon site and was cured by change of dressing. The average VAS score at the last follow‐up was reduced from (2 ± 1.48) points before surgery to (0.26 ± 0.51) points (P = 0.001), and the average AOFAS score was increased from (64.97 ± 13.56) points before surgery to (90.06 ± 10.06) points (P = 0.001). During the follow‐up period, there was no chronic rupture of Achilles tendon. There were two cases of recurrence of foot drop (5.7%), and the patients' satisfaction rate was 93.9%.

Conclusion

In the surgical treatment of severe ankle joint deformity, the application of triple hemisection percutaneous Achilles tendon lengthening for Achilles tendon contracture has the advantages of less trauma, beautiful incision, and reliable efficacy. The satisfaction rate of patients with this treatment is high, and it is worth promoting in the clinic.

Plantar Foot Ulcer Recurrence in Neuropathic Patients Undergoing Percutaneous Tendo-Achilles Lengthening

Equinus contracture carries 3- and 4-fold associations with diabetes and plantar foot ulceration, respectively. Percutaneous tendo-Achilles lengthening is a useful method to alleviate peak plantar pressure resulting from equinus. We aimed to evaluate the effectiveness of percutaneous tendo-Achilles lengthening and estimate the relative longevity of the approach in reducing ulcer recurrence. The medical records of patients with equinus contracture who underwent percutaneous tendo-Achilles lengthening from 2010 to 2017 were reviewed. Included patients presented with plantar ulcers and a gastroc-soleus equinus of any angle <10° of ankle dorsiflexion with the affected knee extended and flexed. Patients who received concomitant tendon lengthening procedures (including anterior tibial tendon or flexor digitorum longus) were excluded. Outcome measures included time to wound healing, time to ulcer recurrence, and development of transfer lesion. Ninety-one patients underwent percutaneous tendo-Achilles lengthening with subsequent pedal ulceration without concomitant procedures. A total of 69 (75.8%) patients had a plantar forefoot ulcer, 7 (7.7%) had midfoot ulcers, 5 (5.5%) had hindfoot ulcers, and 3 (3.3%) had ulcers in multiple locations. Seven patients received prophylactic tendo-Achilles lengthening. At a mean follow-up of 31.6 months (±26), 66 (78.6%) wounds healed at a median 12.9 weeks. A total of 29 patients (43.9%) experienced ulcer recurrence at a mean of 12 months. Twelve patients (13%) experienced a transfer lesion at a mean of 16.6 months. Tendo-Achilles lengthening can be an effective adjunctive approach to achieve wound healing and reduce long-term ulcer recurrence in patients with equinus contracture and neuropathic plantar foot ulcers. A relengthening procedure may be needed within approximately 12 months from index surgery.

Management of flexible cavovarus foot in patients with Charcot-Marie-Tooth disease: midterm results

INTRODUCTION

Charcot-Marie-Tooth disease (CMT) is a hereditary motor sensory neuropathy that frequently results in a cavovarus foot in the adult. Surgical treatment allows correction of the deformity while preserving an adequate range of motion.

OBJECTIVE

The objective of this study was to assess the result of posterior tibial tendon transfer, first metatarsal ascent osteotomy, and calcaneal valgus osteotomy in the treatment of cavovarus foot secondary to CMT.

MATERIAL AND METHODS

Retrospective cohort of CMT patients who received surgical treatment of their cavovarus foot. Collected data included demographics, CMT genetic variant, neurologic involvement, surgical technique, range of motion, functionality, radiology, and postoperative satisfaction.

RESULTS

16 patients met the inclusion criteria, mostly women (62.5%) with the CMT1A variant (62.5%), and a mean age of 39.5 years. 13 patients required additional surgical techniques: lengthening of the Achilles tendon, interphalangeal arthrodesis and/or plantar fascia section. 2 patients underwent a secondary procedure: subtalar arthrodesis due to persistence of the varus deformity, and a lengthening of the extensor hallux longus due to initial undercorrection. The mean follow-up was 42 months. Significant differences (p = 0.003) were observed between the pre-surgical AOFAS and at 12 months postoperatively (37.25 vs. 86.5). 75% of the patients reported «excellent» or «good» satisfaction after surgery. All radiographic parameters showed significant improvement.

CONCLUSIONS

The combination of the aforementioned surgical techniques for the cavovarus foot in CMT results in adequate functionality, good radiological correction and a high degree of satisfaction, avoiding primary arthrodescent surgery.

Changes in the bony alignment of the foot after tendo-Achilles lengthening in patients with planovalgus deformity

Background

This study was performed to investigate the change in the bony alignment of the foot after tendo-Achilles lengthening (TAL) and the factors that affect these changes in patients with planovalgus foot deformity.

Methods

Consecutive 97 patients (150 feet; mean age 10 years; range 5.1–35.7) with Achilles tendon contracture (ATC) and planovalgus foot deformity who underwent TAL were included. All patients underwent preoperative and postoperative weight-bearing anteroposterior (AP) or lateral (LAT) foot radiographics. Changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, LAT talo-1st metatarsal angle, and calcaneal pitch angle and the factors affecting such changes after TAL were analyzed using lineal mixed model.

Results

There were no significant change in AP talo-1st metatarsal angle and AP talo-2nd metatarsal angle after TAL in patients with cerebral palsy (CP) (p = 0.236 and 0.212). However, LAT talo-1st metatarsal angle and calcaneal pitch angle were significantly improved after TAL (13.0°, p < 0.001 and 4.5°, p < 0.001). Age was significantly associated with the change in LAT talo-1st metatarsal angle after TAL (p = 0.028). The changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, and calcaneal pitch angle after TAL were not significantly associated with the diagnosis (p = 0.879, 0.903, and 0.056). However, patients with CP showed more improvement in LAT talo-1st metatarsal angle (− 5.0°, p = 0.034) than those with idiopathic cause.

Conclusion

This study showed that TAL can improve the bony alignment of the foot in patients with planovalgus and ATC. We recommend that physicians should consider this study’s findings when planning operative treatment for such patients.