Achilles Tendon Rupture and Dysmetabolic Diseases: A Multicentric, Epidemiologic Study

New Insights on the miRNA Role in Diabetic Tendinopathy: Adipose-Derived Mesenchymal Stem Cell Conditioned Medium as a Potential Innovative Epigenetic-Based Therapy for Tendon Healing

BACKGROUND

Adipose-derived mesenchymal stem cell conditioned medium (ASC-CM) improved the viability and wound closure of human tenocytes (HTCN) exposed to high glucose (HG) by activating the transforming growth factor beta 1 (TGF-β1) pathway.

OBJECTIVES

Since ASC-CM can also modulate microRNAs (miRNAs) in recipient cells, this study investigated the effects of ASC-CM on the miRNAs regulating tendon repair (miR-29a-3p, miR-210-3p and miR-21-5p) in HG-HTNC.

METHODS

ASC-CM was obtained by ASCs isolated from the abdominal fat tissue of seven non-diabetic patients. HTNC were cultured in HG for 20 days, then scratched and exposed for 24 h to ASC-CM. qRT-PCR and ELISAs assessed miRNA and target levels.

RESULTS

HG-HTNC exhibited a significant downregulation of miRNAs. ASC-CM restored the levels of miRNAs and their related targets involved in tendon repair.

CONCLUSIONS

The epigenetic modulation observed in HG-HTNC exposed to ASC-CM could be an innovative option in the management of diabetic tendinopathy.

A Case Report of Acute Achilles Tendon Rupture in a Patient With Multimorbidity Treated With Endoscopic Flexor Hallucis Longus Transfer

Acute Achilles tendon rupture (AATR) in patients with multimorbidity poses a significant therapeutic challenge to surgeons because of the increased risk for wound-healing-related complications. Thus, nonoperative management has been these individuals' most widely adopted treatment. We report a case of a 66-year-old patient with AATR who was treated with endoscopic flexor hallucis longus (FHL) transfer. His medical history was remarkable for recent stroke, hypertension, prediabetes, pemphigus under oral methylprednisolone, smoking, and recent pneumonia. The patient was evaluated up to two years postoperatively and was satisfied with the outcome since he was able to maintain his pre-traumatic activity level. No complications were noted. The Achilles tendon total rupture score was 92 out of a maximum of 100. This favorable outcome indicates that endoscopic FHL transfer may be a safe alternative treatment option for patients with an increased risk of surgical complications.

High-volume injections in Achilles tendinopathy: a systematic review

INTRODUCTION

Achilles tendinopathy (AT) is common, particularly in runners. High-volume injections (HVIs) may be beneficial in the management of AT compared to other conservative management options, including exercise regimens, platelet-rich plasma (PRP) injections, and extracorporeal shockwave therapy. The published research on the effectiveness of HVI in the treatment of AT was evaluated in this systematic review.

SOURCES OF DATA

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed when conducting this systematic review. The electronic databases PubMed, Embase, Cochrane, Web of Science, CINAHL, and OVID were thoroughly searched, from inception to 13 September 2023, for articles assessing HVI for AT.

AREAS OF AGREEMENT

A total of 10 studies with 460 participants met the inclusion criteria. HVI typically consisted of saline, local anaesthetic, and corticosteroids. HVI combined with corticosteroids demonstrated immediate and long-term improvements in ankle function. Compared to HVI without corticosteroids, HVI with corticosteroids exhibited greater, early improvements in pain and function, with no significant differences at later follow-up points. Significant reductions in tendon thickness and neovascularity were also found with HVI treatment over time.

AREAS OF CONTROVERSY

No adverse events were reported with HVI, despite the use of corticosteroids.

GROWING POINTS

HVI is an effective and safe modality, particularly in the short term, to significantly reduce pain and discomfort in the Achilles tendon, especially when supplemented with corticosteroids.

AREAS TIMELY FOR DEVELOPING RESEARCH

More robust randomized controlled trials, with longer-term follow-ups and homogeneity, are needed to fully establish its efficacy for AT.

Recent developments in Achilles tendon risk-analyzing rupture factors for enhanced injury prevention and clinical guidance: Current implications of regenerative medicine

Background

In recent years, many countries have actively implemented programs and strategies to promote physical education and sports. Despite these efforts, the increase in physical activity has been accompanied by a significant rise in muscle and tendon-ligament injuries, with Achilles tendon rupture being the most prevalent, accounting for 47 % of such injuries. This review aims to summarize all significant factors determining the predisposition of the Achilles tendon to rupture, to develop effective personalized prevention measures.

Objective

To identify and evaluate the risk factors contributing to Achilles tendon rupture and to develop strategies for personalized prevention.

Methods

This review utilized data from several databases, including Elsevier, Global Health, PubMed-NCBI, Embase, Medline, Scopus, ResearchGate, RSCI, Cochrane Library, Google Scholar, eLibrary.ru, and CyberLeninka. Both non-modifiable and modifiable risk factors for Achilles tendon injuries and ruptures were analyzed.

Results

The analysis identified several non-modifiable risk factors, such as genetic predisposition, anatomical and functional features of the Achilles tendon, sex, and age. These factors should be considered when selecting sports activities and designing training programs. Modifiable risk factors included imbalanced nutrition, improper exercise regimens, and inadequate monitoring of Achilles tendon conditions in athletes. Early treatment of musculoskeletal injuries, Achilles tendon diseases, foot deformities, and metabolic disorders is crucial. Long-term drug use and its risk assessment were also highlighted as important considerations. Furthermore, recent clinical advancements in both conventional and surgical methods to treat Achilles tendon injuries were described. The efficacy of these therapies in enhancing functional outcomes in individuals with Achilles injuries was compared. Advancements in cell-based and scaffold-based therapies aimed at enhancing cell regeneration and repairing Achilles injuries were also discussed.

Discussion

The combination of several established factors significantly increases the risk of Achilles tendon rupture. Addressing these factors through personalized prevention strategies can effectively reduce the incidence of these injuries. Proper nutrition, regular monitoring, timely treatment, and the correction of metabolic disorders are essential components of a comprehensive prevention plan.

Conclusion

Early identification of Achilles tendon risk factors allows for the timely development of effective personalized prevention strategies. These measures can contribute significantly to public health preservation by reducing the incidence of Achilles tendon ruptures associated with physical activity and sports. Continued research and clinical advancements in treatment methods will further enhance the ability to prevent and manage Achilles tendon injuries.

The translational potential of this article

This study identifies key modifiable and non-modifiable risk factors for Achilles tendon injuries, paving the way for personalized prevention strategies. Emphasizing nutrition, exercise, and early treatment of musculoskeletal issues, along with advancements in cell-based therapies, offers promising avenues for improving recovery and outcomes. These findings can guide clinical practices in prevention and rehabilitation, ultimately reducing Achilles injuries and enhancing public health.

Hyperuricemia May Increase Risk of Achilles Tendon Rupture: A Case Control Study

It has been demonstrated in a number of studies that high levels of uric acid can cause crystal deposition in the tendons of the lower extremities, which in turn can impair the Achilles tendon. This study aimed to interpret whether hyperuricemia is relevant with Achilles tendon rupture. Patients diagnosed with Achilles tendon rupture at the same institution between 2013 and 2022 were included in the case group. Healthy subjects who had physical examinations during the same period were included in the control group. Propensity score matching was used to match in a 1:1 ratio. Demographic and clinical characteristics of patients in both groups were compared. Five hundred and fourteen patients were included in the study (ATR=257; Control group=257). The proportion of individuals with hyperuricemia varied significantly between the 2 groups (Achilles tendon rupture group=43.6%; control group=27.6%; p<0.001). The Achilles tendon rupture and hyperuricemia were linked by conditional logistic regression (p<0.001; OR=2.036; 95CI%=1.400-2.961). Compared with healthy subjects, patients with hyperuricemia have a higher risk of Achilles tendon rupture. Further studies are required to verify the effects of hyperuricemia and monosodium urate crystals on Achilles tendon structure.

Platelet Rich Plasma Therapy in Achilles and Patellar Tendinopathies: Outcomes in Subjects with Diabetes (A Retrospective Case-Control Study)

Introduction: Diabetes mellitus (DM) is associated with a high risk of chronic degenerative Achilles (AT) and Patellar (PT) tendinopathies and ruptures. Growth factors (GFs) synthesis in diabetics is substantially decreased in human connective tissues, including in tendons. Platelet Rich Plasma (PRP), which is enriched in GFs, might prove of great help in tendon healing. The aim of the study was to assess whether pre-existent DM or Impaired Glucose Tolerance (IGT) could influence the clinical outcome in subjects undergoing PRP treatment. Methods: Sixty subjects with diabetes/pre-diabetes and sixty euglycemic controls, matched for sex and age, were enrolled. Patients suffering from proximal insertional PT and mid-portion AT, treated with PRP therapy, were included in the study. To assess the basal status and the efficacy of the therapy after 3 and 6 months, the Victorian Institute of Sport Assessment (VISA) questionnaire and the Ultrasound methodology study were used. Patient satisfaction was assessed by means of the Likert Scale. Results: In the population study at 6 months, the mean VISA-score increased (8.92 ± 0.67; p-value < 0.001). The improvement in the diabetic group was less evident compared to the controls (-2.76 ± 0.95; p-value = 0.003). Even though the improvement was poor, it was still significant. MCID analysis revealed that diabetics had higher risk of therapeutic unsuccess. Logistic regression analysis was applied to assess factors associated with unsatisfactory results (Likert-scale) of PRP treatment: AT (O.R.: 3.05; 95%CI: 1.40-6.64; p-value = 0.005), higher BMI values (O.R.: 1.02; 95%CI: 1.01-1.04; p-value = 0.01), and lower VISA score values at baseline (O.R.: 0.95; 95%CI: 0.90-0.99; p-value = 0.04). Conclusions: PRP treatment in AT and PT chronic tendinopathies resulted in less favorable results in subjects with diabetes compared with euglycemic subjects. Moreover, the subjects with PT showed better results than those with AT.

Advanced glycation end products impair the repair of injured tendon: a study in rats

BACKGROUND

The AGEs levels in tissues of diabetics and elderly tend to be higher than in normal individuals. This study aims to determine the effects of AGEs on Achilles tendon repair.

MATERIALS AND METHODS

Thirty-six male eight-week-old Sprague Dawley rats were selected in this study. The rats were randomly divided into two experimental groups and a control group after the transection of the Achilles tendon. During the tendon repair, the experimental groups were injected around the Achilles tendon with 350mmol/L (low dose group) and 1000mmol/L (high dose group) D-ribose 0.2 ml respectively to increase the AGEs level, while in the control group were given the same amount of PBS. The injections were given twice a week for six weeks. Collagen-I, TNF-α, and IL-6 expression in the healed Achilles tendon was assessed. Additionally, macroscopic, pathological, and biomechanical evaluations of Achilles tendon repair were conducted.

RESULTS

The repaired Achilles tendons in the high dose group showed severe swelling and distinctive adhesions. The histological score went up with the increase of the AGEs in the Achilles tendon (p<0.001). TNF- α and IL-6 in the Achilles tendon increased (p<0.001, p<0.001), and the production of collagen-I decreased with the accumulation of AGEs in the repaired Achilles tendon (p<0.001). The tensile strength of Achilles tendon in the high dose group was impaired significantly.

CONCLUSION

In current study, the compromised tendon repair model induced by AGEs was successfully established in rat. The study demonstrated that AGEs significantly impair Achilles tendon repair.

Paratenon preserving repair of the midsubstance acute Achilles tendon rupture: a systematic review and meta-analysis with best- and worst-case analyses for rerupture rates

INTRODUCTION

Paratenon preserving techniques to facilitate acute Achilles tendon rupture repair (AATR) functions by maintaining vascularity and biology for optimal healing response. Therefore, the purpose is to evaluate the outcomes following paratenon preserving repair of the midsubstance AATR. The hypothesis was that paratenon-preserving techniques demonstrate high return to play rates and low complication rates for the repair of the midsubstance AATR.

MATERIALS AND METHODS

A systematic review of the PubMed, Embase, and the Cochrane Library databases was performed by two authors using specific search terms and eligibility criteria. The assessment of the evidence was two-fold: level and quality of evidence. A meta-analysis of proportions for the various complication rates was performed using the restricted maximum likelihood method following the Freeman-Tukey double-arcsine transformation. Fixed effects models were employed if I2 < 25% (low heterogeneity), and random effects models were employed if I2 ≥ 25% (moderate to high heterogeneity).

RESULTS

The pooled return to play rate was 90.3%. The pooled rerupture rate as reported was 0.9% (best-case scenario 0.8% and worst-case scenario 6.8%). No meaningful subgroup analysis for rerupture rates could be performed based on the meta-regression. The pooled complication rate other than reruptures was 4.8%. The pooled infection rates were 0.3%, DVT rates were 1.6%, and sural nerve injury rates were 0.3%.

CONCLUSIONS

Paratenon preserving techniques that are minimally invasive in nature demonstrated safe and favorable outcomes with high return to play rates and low complication rates for the repair of the midsubstance AATR.

Peritendinous Submembrane Access Technique for Management of Acute Ruptures of the Achilles Tendon: A Retrospective Study of 249 Cases

OBJECTIVE

Percutaneous repair is an alternative to open surgical repair of the Achilles tendon with comparable, functional results and low re-rupture and infection rates; however, sural nerve injury is a known complication. The purpose of this study is to design a new surgical procedure, the minimally invasive peritendinous submembrane access technique (MIS-PSAT). It offers optimal results, with excellent functional outcomes, and with minimal soft tissue complications and sural nerve injury.

METHODS

This retrospective study included 249 patients with acute closed Achilles tendon ruptures treated at our institution between 2009 and 2019. All patients underwent MIS-PSAT at our institution and were followed up for 8-48 months. Functional evaluation was based on the Achilles tendon total rupture score (ATRS) and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS), associated with local complications and isokinetic tests.

RESULTS

None of the patients had infection, necrosis, or sural nerve injury. Re-rupture occurred in two cases. The average times to return to work and sports was 10.4 and 31.6 weeks, respectively. The average ATRS and AOFAS-AHS scores were 90.2 and 95.7, respectively, with an excellent rate of 99.5%. Isokinetic tests showed that ankle function on the affected side was comparable with that on the healthy side (p > 0.05).

CONCLUSION

The MIS-PSAT for acute Achilles tendon rupture is easy to perform with few complications. Importantly, the surgical technique reduces the risk of sural nerve injuries. Patients have high postoperative satisfaction, low re-rupture rates, and muscle strength, and endurance can be restored to levels similar to those on the healthy side.

Metabolic Syndrome and Tendon Disease: A Comprehensive Review

Metabolic syndrome (MS) is a multifaceted pathological condition characterized by the atypical accumulation of various metabolic components such as central obesity or excess weight, hyperlipidemia, low-density lipoprotein (LDL), hypertension, and insulin resistance. Recently, MS has been recognized as a notable contributor to heart and circulatory diseases. In addition, with increasing research, the impact of MS on tendon repair and disease has gradually emerged. Recent studies have investigated the relationship between tendon healing and diseases such as diabetes, dyslipidemia, obesity, and other metabolic disorders. However, diabetes mellitus (DM), hypercholesterolemia, obesity, and various metabolic disorders often coexist and together constitute MS. At present, insulin resistance is considered the major pathological mechanism underlying MS, central obesity is regarded as the predominant factor responsible for it, and dyslipidemia and other metabolic diseases are known as secondary contributors to MS. This review aims to evaluate the current literature regarding the impact of various pathological conditions in MS on tendon recovery and illness, and to present a comprehensive overview of the effects of MS on tendon recovery and diseases, along with the accompanying molecular mechanisms.

Percutaneous vs Open Zadek Osteotomy for Treatment of Insertional Achilles Tendinopathy and Haglund's Deformity: A Systematic Review

Background

Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines.

Methods

A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy, Calcaneus, Syndrome, Insertional, Achilles tendon, and Tendinopathy. Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies.

Results

A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO.

Conclusion

Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund's deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

Modified gastro-soleus turn-down flap for chronic or neglected achilles tendon ruptures

BACKGROUND

Achilles' tendon chronic rupture is a common entity that is usually misdiagnosed or mistreated. Hence, she was presented to us later or with complications affecting her gait. Surgical resection is needed to either bridge the gap or reinforce the strength of the tendon repair.

OBJECTIVES

Our study's goal was to assess the clinical results of repairing chronic Achilles' tendon lesions employing the middle segment of the proximal portion of the tendon (gastro-soleus), as a turn-down flap.

METHODS

Our prospective interventional single arm study included 18 patients with chronic Achilles' tendon rupture attending at Al-Azhar university hospitals in Cairo, Egypt from May 2020 to April 2023. Diagnosis of the patients was confirmed by radiographic and clinical investigations. They were all treated with the same open reconstruction procedure using a modified GSF. The average follow-up was 12 months. The results of this study were assessed by the Achilles tendon rupture score (ATRS), American Orthopedic Foot and Ankle Society (AOFAS) score, and capacity to perform repeated heel raises on the affected side.

RESULTS

The mean operative time was 72.77 min. The median (IQR) time of reconstruction was 10 (8-12) after the injury. The median (IQR) length of flab was 4.5 (4.3-5) 9 (Table 2). No intraoperative complications occurred. The typical follow-up period was 12 months (6-18 months). In terms of the ATRS, we found a significant reduction from 82.8 ± 3 preoperatively to 20.8 ± 6.7 at 12 months postoperatively (P value = 0.001). As regards the AOFAS score, it was increased from 49.5 ± 10 preoperatively to 83.8 ± 8.5 12 months postoperatively (P = 0.001). In terms of the post operative complications, there was no re-rupture. Two patients experienced superficial wound infection which improved with daily dressing and antibiotics. Additionally, two patients had slight ankle stiffness four months after the operation, which improved after programmed rehabilitation at the sixth month.

CONCLUSION

The modified GSTF is a simple, safe, well-tolerated and effective method of treatment with excellent functional results and greater patient content.

Comparison of percutaneous and open repair of Achilles tendon rupture: results and complications from a single institution

BACKGROUND

The Achilles tendon is the strongest tendon in the human body, but it is prone to injury, especially in modern times when recreational sports are growing in popularity. As a result, Achilles tendon rupture is becoming an increasingly common medical problem in modern society. The main objective of this study was to compare the outcomes of percutaneous repair and open repair for the treatment of Achilles tendon rupture.

METHODS

A retrospective study was conducted involving a total of 316 patients who had undergone surgical treatment for Achilles tendon rupture between 2013 and 2021. The data collected from the medical history of these patients included the type of surgical procedure, the mechanism of injury, the age and sex of the patients, the time spent in the hospital, and any possible complications of the surgical treatment (such as infections, reruptures, or sural nerve injuries).

RESULTS

The study revealed that there was no significant difference between percutaneous and open surgical approaches in terms of sural nerve injury. However, there was a statistically significant advantage of the percutaneous method in terms of the number of infections, which was significantly lower than that of the open method. Additionally, the median length of hospital stay was found to be four days longer with the open approach. However, the study noted that a statistically significant advantage of the percutaneous method for rerupture could not be established due to the small number of patients with rerupture and the insufficient ratio of patients with rerupture in relation to the size of the observed population.

CONCLUSIONS

Percutaneous repair is an effective treatment option for Achilles tendon rupture and has outcomes equal to or better than those of open repair. Therefore, this approach is recommended as the preferred method of treatment due to the presence of fewer complications, provided that the indications for this technique are appropriate.

Efficacy of ultrasound-guided galvanic electrolysis technique and physical therapy in patients with Achilles' tendinopathy: A pilot randomised controlled trial

BACKGROUND

Ultrasound-guided galvanic electrolysis technique (USGET) is an innovative mini-invasive intervention with the potential to optimise outcomes in the treatment of Achille's tendinopathy (AT).

OBJECTIVE

The aim of this pilot study is to evaluate the efficacy of adding USGET to conventional eccentric exercise treatment in patients with chronic AT.

METHODS

Inclusion criteria were patients with unilateral non-insertional AT, pain lasting > 3 months, aged 25-60 years. Patients were randomised in two groups receiving the same physiotherapy treatment (2 sessions per week for 8 weeks). In addition, the experimental group received three USGET stimulations, one every 15 days. Outcome measures were assessment of Achilles tendinopathy severity using the Victorian Institute of Sport Assessment-Achilles (VISA-A) and pain intensity using the Visual Analogue Scale (VAS). Assessment points occurred at the onset of treatment (T0), its conclusion (T1), and subsequent follow-ups at one (T2) and two months (T3).

RESULTS

Out of the 52 patients who met the study inclusion criteria, two participants withdrew from the study, resulting in a total of 50 subjects who completed the research. None of the parameters showed a different distribution at T1 (p> 0.337). At T2, there was a statistical difference in VISA-A (p= 0.010) and its subscales and VAS (p= 0.002) in the USGET group. At T3, both groups improved with a statistical difference observed in VISA-A (p< 0.001) and its subscales Pain (p= 0.004), Function (p= 0.003) and Sport (p= 0.002), but the EG patients showed a greater improvement. No adverse events were reported.

CONCLUSION

The effect of USGET combined with eccentric exercise appears to be a safe and effective technique for achieving pain relief and functional recovery in the medium term, supporting the integrated use of USGET as a rehabilitative treatment option for patients with chronic AT.

Percutaneous cruciate repair of ruptured Achilles tendon

Percutaneous repair is a safe and reliable method to restore continuity after acute Achilles tendon ruptures, with a lower incidence of wound complications compared to open techniques. We describe a novel percutaneous cruciate suture performed through 5 stab skin incisions, four of which are longitudinal and parallel to the course of the sural nerve to minimize the risk of injury and one transverse incision at the site of rupture, with a total of 16 suture threads and the knot outside the tendon body, increasing the tensile strength of the suture and minimizing the risk of re-rupture. Clinical studies are necessary to ascertain whether the theoretical advantages of the cruciate suture technique translate into better clinical outcomes compared to established percutaneous techniques.

Early satisfactory results of percutaneous repair in neglected achilles tendon rupture

PURPOSE

This investigation aimed to study the outcome of percutaneous repair of Achilles tendon ruptures regarding patient-reported and objective outcomes.

METHODS

This is a retrospective review of a cohort of patients (n = 24) who underwent percutaneous repair of neglected Achilles rupture in the period between 2013 and 2019. Included patients were adults with closed injuries, presented 4-10 weeks after rupture, with intact deep sensation. All underwent clinical examination, X-rays to exclude bony injury and MRI for diagnosis confirmation. All underwent percutaneous repair by the same surgeon, using the same technique and rehabilitation protocol. The postoperative assessment was done subjectively using ATRS and AOFAS score and objectively using a percentage of heel rise comparison to the normal side and calf circumference difference.

RESULTS

The mean follow-up period was 14.85 months ± 3 months. Average AOFAS scores at 6,12 months were 91 and 96, respectively, showing statistically significant improvement from pre-op level (P < 0.001). Percentage of heel rise on the affected side and calf circumference showed statistically significant improvement over the 12 month follow up period (P < 0.001). Superficial infection was reported in two patients (8.3%), and two cases reported transient sural nerve neuritis.

CONCLUSION

Percutaneous repair of neglected Achilles rupture using the index technique proved a satisfactory patient-reported and objective measurement at a one-year follow-up. With only minor transient complications.

Minimally invasive excision and reconstruction of Achilles tendon xanthoma using free autologous semitendinosus tendon transfer: a surgical technique

BACKGROUND

Tendon xanthomatosis is often associated with familial hypercholesterolemia, but it can also occur in other medical conditions. The Achilles tendon is the most common site of tendon xanthomas. Reconstruction of large defects after the xanthoma excision, can be challenging.

METHODS

We propose a novel technique for Achilles tendon reconstruction with the use of an ipsilateral autologous semitendinosus tendon graft. The technique consists of six steps.

RESULTS

This procedure has a low rate of complications and provides results that are at least comparable with those reported with other surgical approaches.

Development and growth of the calcaneal tendon sheath with special reference to its topographical relationship with the tendon of the plantaris muscle: a histological study of human fetuses

BACKGROUND AND PURPOSE

The calcaneal tendon sheath has several vascular routes and is a common site of inflammation. In adults, it is associated with the plantaris muscle tendon, but there are individual variations in the architecture and insertion site. We describe changes of the tendon sheath during fetal development.

MATERIALS AND METHODS

Histological sections of the unilateral ankles of 20 fetuses were examined, ten at 8-12 weeks gestational age (GA) and twelve at 26-39 weeks GA.

RESULTS

At 8-12 weeks GA, the tendon sheath simply consisted of a multilaminar layer that involved the plantaris tendon. At 26-39 weeks, each calcaneal tendon had a multilaminar sheath that could be roughly divided into three layers. The innermost layer was attached to the tendon and sometimes contained the plantaris tendon; the multilaminar intermediate layer contained vessels and often contained the plantaris tendon; and the outermost layer was thick and joined other fascial structures, such as a tibial nerve sheath and subcutaneous plantar fascia. The intermediate layer merged with the outermost layer near the insertion to the calcaneus.

CONCLUSION

In spite of significant variations among adults, the fetal plantar tendon was always contained in an innermost or intermediate layer of the calcaneal tendon sheath in near-term fetuses. After birth, mechanical stresses such as walking might lead to fusion or separation of the multilaminar sheath in various manners. When reconstruction occurs postnatally, there may be individual variations in blood supply routes and morphology of the distal end of the plantaris tendon.

Allograft and Autologous Reconstruction Techniques for Neglected Achilles Tendon Rupture: A Mid-Long-Term Follow-Up Analysis

Achilles tendon ruptures that are not immediately recognized and treated are sometimes diagnosed as delayed injuries and may require different surgical repair options based on gap size. The potential complications associated with using an allograft for reconstruction may lead some surgeons to prefer the use of autologous techniques. However, allografts are often considered a salvagement option when large defects are present. In this study, we examined the long-term clinical outcomes and complications of 17 patients who underwent surgical repair for chronic ruptures with large gaps using both autologous and allograft techniques. During an 11-year period, nine patients were treated with autologous techniques (mean gap of 4.33 ± 1.32 cm) and Achilles allograft reconstruction was performed in eight patients (47.1%) (mean gap of 7.75 ± 0.89 cm). At a mean of 82 ± 36.61 months of follow-up, all 17 patients (100%) were able to perform a single heel rise and improved AOFAS (American Orthopaedic Foot and Ankle Society) and ATRS (Achilles Tendon Total Rupture Score) scores. No infections, complications, or re-ruptures were recorded at the end of the follow-up. No significant differences were found in the AOFAS and ATRS scales between both techniques. When an extensive defect is present, the reconstruction with an Achilles tendon allograft can be considered a proper treatment option, as it does not show a higher rate of complications than autologous techniques achieving similar functional outcomes.

A one-health lens offers new perspectives on the importance of endocrine disorders in the equine athlete

Endocrine disorders are associated with joint pain and tendon injury in humans, but the effects in the horse are only starting to be understood. Similar patterns of clinical signs and injury appear to affect horses and humans for both orthopedic and endocrine disorders, supporting the use of a one-health approach to tackle these issues. In this Currents in One Health, we will discuss common equine endocrinopathies, current testing recommendations, dietary management, genetic predispositions, and endocrine disorders' effects on performance. Our aim is to use a one-health lens to describe current comparative research so that veterinarians can employ cutting-edge preventative, diagnostic, and therapeutic recommendations. Identified key gaps in knowledge include whether equine metabolic osteoarthritis exists, if steroid joint injections are safe in horses with endocrine disorders, and if the return to performance percentage improves with concurrent treatment of endocrine and musculoskeletal disorders. Key takeaways include that the relationship between endocrine disorders and musculoskeletal disease in the horse goes beyond laminitis to include lameness, muscle atrophy, suspensory ligament degeneration, osteochondritis dissecans, and potentially metabolic osteoarthritis. Approaches learned from human and equine comparative studies can offer insight into injury recognition and management, thus mitigating the impact of endocrine disorders on performance in both species. Readers interested in an in-depth description of current and future research involving pathophysiology, novel interventions, and multiomic approaches to identify individuals with athletic limitations induced by endocrine disorders are invited to read the companion Currents in One Health by Manfredi et al, AJVR, February 2023.

A one-health approach to identifying and mitigating the impact of endocrine disorders on human and equine athletes

Endocrinopathies affect multiple species in ever-increasing percentages of their populations, creating an opportunity to apply one-health approaches to determining creative preventative measures and therapies in athletes. Obesity and alterations in insulin and glucose dynamics are medical concerns that play a role in whole-body health and homeostasis in both horses and humans. The role and impact of endocrine disorders on the musculoskeletal, cardiovascular, and reproductive systems are of particular interest to the athlete. Elucidation of both physiologic and pathophysiologic mechanisms involved in disease processes, starting in utero, is important for development of prevention and treatment strategies for the health and well-being of all species. This review focuses on the unrecognized effects of endocrine disorders associated with the origins of metabolic disease; inflammation at the intersection of endocrine disease and related diseases in the musculoskeletal, cardiovascular, and reproductive systems; novel interventions; and diagnostics that are informed via multiomic and one-health approaches. Readers interested in further details on specific equine performance conditions associated with endocrine disease are invited to read the companion Currents in One Health by Manfredi et al, JAVMA, February 2023.