Evaluation of the ankle function after Achilles tendon resection: a retrospective clinical study.

INTRODUCTION: The Achilles tendon is the strongest tendon in the human body and has the function of plantar ankle flexion. When the tendon is exposed, the peritendineum has been breached and the thick avascular tendon colonized with bacteria, a complete resection of the tendon may be indicated to achieve infection control and facilitate wound closure. The Achilles tendon reconstruction is not mandatory, as the plantar flexion of the ankle joint is assumed by the remaining flexor hallucis longus, flexor digitorum longus and tibialis posterior muscles. Our study aimed to evaluate the impact of Achilles tendon resection without reconstruction on leg function and quality of life. MATERIAL AND METHODS: We retrospectively evaluated all patients who were treated with an Achilles tendon resection between January 2017 and June 2022 in our quaternary institution. After evaluating the data, the patients who survived and were not amputated were contacted for re-evaluation, which included isokinetic strength measurement of both ankle joints, evaluation of the ankle range of motion and collection of several functional scores. RESULTS: Thirty patients were included in the retrospective study, with a mean age of 70.3 years, including 11 women and 19 men. The most frequent cause of the infection was leg ulcer (43.3%), followed by open tendon suture (23.3%). No tendon reconstruction was performed. Fifteen patients could be gained for reevaluation. The average difference in ankle flexion torque on the injured side compared to the healthy side at 30 degrees/second was 57.49% (p = 0.003) and at 120 degrees/second was 53.13% (p = 0.050) while the difference in power was 45.77% (p = 0.025) at 30 degrees/second and 38.08% (p = 0.423) at 120 degrees/second. The follow-up time was between 4 and 49 months and a positive correlation could be determined between the time elapsed from surgery and the ankle joint strength. There was a significant loss of range of motion on the operated side compared to the healthy side: 37.30% for plantar flexion, 24.56% for dorsal extension, 27.79% for pronation and 24.99% for supination. The average Lepillhati Score was 68.33, while the average American Orthopedic Foot and Ankle Score was 74.53. CONCLUSION: The complete Achilles tendon resection leaves the patient with satisfactory leg function and an almost normal gait. Especially in elderly, multimorbid patients, straightforward tendon resection and wound closure provide fast infection control with acceptable long-term results. Further prospective studies should compare the ankle function and gait in patients with and without Achilles tendon reconstruction after complete resection.

[Surgical treatment of calcifying insertional Achilles tendinopathy via a lateral approach]. / Operative Therapie der kalzifizierenden Insertionstendinopathie der Achillessehne über einen lateralen Zugang.

OBJECTIVE: Reduction of pain and swelling over the Achilles tendon insertion while maintaining function. INDICATIONS: Strong, intolerable pain over the Achilles tendon insertion with chronic, calcifying insertional tendinopathy that does not respond to non-operative treatment over a minimum of 6 months. CONTRAINDICATIONS: Chronic wounds or severe circulatory deficits at the foot or ankle, irradiating or projected pain, complex regional pain syndrome (CRPS). SURGICAL TECHNIQUE: The intratendinous heel spur is resected via a lateral approach. The superior surface of the calcaneal tuberosity is trimmed by resection of the dorsal heel spur with the oscillating saw. A second osteotomy at the medial edge of the tuberosity extends to the insertion of the plantaris tendon. With the third osteotomy, the Haglund deformity is resected. At the resulting area with cancellous bone, the Achilles tendon is reinserted with a suture anchor. POSTOPERATIVE MANAGEMENT: A ventral plastic splint in 20° plantar flexion is worn for a week. Full weight-bearing is allowed in a walking boot with 4 cm heel lift for 6 weeks. The heel lift is then gradually reduced for another 2 weeks. After 8 weeks only an elastic wedge of 1 cm is worn. Physical therapy (isometric exercises) starts in the boot and is intensified after removal of the boot. RESULTS: Seven of 12 patients treated with that technique for calcifying insertional Achilles tendinopathy (58%) stated being pain free according to the Likert scale, while the remaining 5 patients (42%) reported a "substantial improvement". The VISA­A score averaged 84 of 100 points. Postoperative complications have not been observed.

[Less invasive turn-down flap tendinoplasty in chronic Achilles tendon rupture]. / Weniger invasive Umkippplastik der Achillessehne bei chronischer Ruptur.

OBJECTIVE: Bridging the defect in chronic ruptures of the Achilles tendon via a turn-down flap of the aponeurosis sparing the skin of the rupture zone. INDICATIONS: Chronic Achilles tendon rupture with a defect distance ≤ 6 cm. CONTRAINDICATIONS: Extended Achilles tendon defect interval ≥ 7 cm, chronic wounds or infections near the surgical approach, higher degrees of arterial or venous malperfusion, complex regional pain syndrome. SURGICAL TECHNIQUE: Dorsomedial surgical approach proximal to the rupture zone, splitting of the crural fascia, loading of the distal Achilles tendon stump with a nonresorbable augmentation suture using the Dresden instrument, preparation of the turn-down flap of the aponeurosis securing the turning point with a catching suture. Transfer of the turn-down tendon flap under the skin bridge and suture to the distal tendon stump tying the augmentation suture under adequate pretension simultaneously closing the gap in the aponeurosis. Alternative technique: free advancement of the autologous tendon graft. POSTOPERATIVE MANAGEMENT: Anterior splint in 20° of plantar flexion, consecutive mobilization and rehabilitation similar to the percutaneous technique in acute Achilles tendon rupture with the Dresden instrument. Lower leg orthosis with 20° of plantarflexion for 8 weeks, then stepwise reduction of the heel height. Physiotherapy beginning from the 2nd postoperative week, active full-range of ankle motion from 6 weeks after surgery. RESULTS: In general, worse results than in percutaneous reconstruction of acute Achilles tendon injuries. Despite this, high degrees of patient satisfaction with a low rate of postsurgical complications and good functional outcome with admittedly poor data availability. Relevant increase of plantar flexion strength depending on the amount of degeneration of the triceps surae muscle.

Prolonged Application of Continuous Passive Movement Improves the Postoperative Recovery of Tibial Head Fractures: A Prospective Randomized Controlled Study.

METHODS: 60 patients with THFs were randomly and equally divided into the CPM group and non-CPM group. Both groups immediately received CPM and conventional physical therapies during hospitalization. After discharge, the non-CPM group was treated with conventional physical therapy alone, while the CPM group received conventional physical training in combination with CPM treatment. At 6 weeks and 6 months postoperatively, the primary outcome which was knee ROM and the secondary outcome which was knee functionality and quality of life were evaluated. RESULTS: The CPM group had a significantly increased ROM at both follow-up time points. The Knee Society Score, UCLA activity score, and the EuroQoL as well as the pain analysis showed significantly better results of the CPM group than the non-CPM group. CONCLUSIONS: The prolonged application of CPM therapy is an effective method to improve the postoperative rehabilitation of THFs.

Percutaneous Achilles tendon repair with the Dresden instrument. Clinical and MRI evaluation of 90 patients.

BACKGROUND: This study aims at evaluating a substantial number of patients treated with a percutaneous, paratenon preserving technique for Achilles tendon repair using three different incisions with clinical follow-up and magnetic resonance imaging (MRI). METHODS: Ninety patients with percutaneous Achilles tendon repair using the Dresden technique for acute rupture were evaluated. Fifteen patients were treated using a central approach, 15 patients using a posterolateral approach and the original posteromedial approach was used in 60 patients. All patients were followed clinically and with MRI after 1 and 6 months post-operatively. RESULTS: Using the standard posteromedial approach no complications were seen. With the central approach 4 (27%) wound healing problems were observed and with the posterolateral approach 2 (13%) sural nerve lesions occurred. One patient (1.1%) had a rerupture. MRI revealed an increased diameter at the rupture site and distal to it as well as an increasingly homogeneous signal over time. CONCLUSIONS: Percutaneous Achilles tendon repair with the Dresden technique yields excellent clinical results and a low complication rate. Modification of the original incision is discouraged.

Interlocking Nail Fixation for the Treatment of Displaced Intra-Articular Calcaneal Fractures.

INTRODUCTION: Less invasive restoration of joint congruity and calcaneal shape in displaced intra-articular calcaneal fractures via a sinus tarsi approach followed by percutaneous internal fixation with an interlocking nail results in a low rate of soft-tissue complications and good short-term outcomes1 (Video 1). STEP 1 PATIENT PLACEMENT: Place the patient in the lateral decubitus position, supporting the involved extremity with a soft radiolucent pillow, flex the contralateral knee, check with fluoroscopy before draping, and obtain lateral radiographs. STEP 2 INCISION: Use a sinus tarsi approach for control of the articular reduction. STEP 3 PERCUTANEOUS MANIPULATION OF THE MAIN FRAGMENTS: Percutaneously manipulate the main fragments to facilitate reduction of the main tuberosity fragment toward the sustentacular fragment and subsequent joint reduction. STEP 4 JOINT REDUCTION WITH DIRECT MANIPULATION OF THE MAIN FRAGMENTS THROUGH THE SINUS TARSI APPROACH: Reduce the joint with direct manipulation of the main fragments through the sinus tarsi approach. STEP 5 JOINT FIXATION WITH SCREWS: Check the congruency of the posterior subtalar joint facet, stabilize the posterior facet with 2 screws, reduce the tuberosity against the joint block and anterior process, and temporarily fix with Kirschner wires. STEP 6 INTRODUCTION OF THE INTRAMEDULLARY NAIL: Make a 10-mm vertical incision below the attachment of the Achilles tendon, direct the guidewire toward the center of the calcaneocuboid joint, place the guidewire centrally within the calcaneal body, ream over the guidewire, and introduce the intramedullary nail with the attached aiming device. STEP 7 LOCKING OF THE NAIL: Use the aiming device to position the proximal Kirschner wire into the sustentacular fragment, place the nail so that it hits the sustentaculum tali properly, insert a second Kirschner wire through the other hole of the guiding arm, exchange the wires after drilling for locking screws, apply an end cap to extend the length of nail, if needed, and then verify proper reduction and implant position fluoroscopically. STEP 8 POSTOPERATIVE MANAGEMENT: Manage the patient with continuous passive motion and active range-of-motion exercises of the ankle beginning on postoperative day 2 and allow partial weight-bearing of 20 kg for 6 to 10 weeks. RESULTS: Recently, we reported on 103 patients with 106 intra-articular calcaneal fractures treated with the C-Nail by 4 senior surgeons from February 2011 to October 20131.

Introduction of a New Locking Nail for Treatment of Intraarticular Calcaneal Fractures.

OBJECTIVES: To reduce the complication rate associated with open reduction and internal fixation of displaced intraarticular calcaneal fractures through extensile approaches, a locking nail system (C-Nail) was developed for internal fixation. DESIGN: Prospective case-control study. SETTING: Two level I trauma centers (university hospital) and 1 large regional hospital in the Czech Republic and Germany. PATIENTS: One hundred three patients (89 male and 14 female; mean age, 45.6 years) with 106 calcaneal fractures were treated between February 2011 and October 2013. INTERVENTION: In all 106 cases, the stainless steel C-Nail with a length of 65 mm, a diameter of 8 mm, and 7 locking options was used for internal fixation. Previous reduction of the posterior facet was performed in 15 cases percutaneously, assisted by arthroscopy and fluoroscopy, and in 91 cases by a sinus tarsi approach. The reduced joint surface was fixed by 1 or 2 compression screws. All other fragments were fixed after reduction and temporary K-wire fixation with the C-Nail introduced percutaneously through the tuberosity and 5 to 6 interlocking screws. The latter were introduced into the sustentacular, the tuberosity, and the anterior process fragments with an aiming device consisting of 3 arms. MAIN OUTCOME MEASURES: Patients were assessed for complications, restoration of Böhler angle, posterior facet reduction with postoperative computed tomography, and weight-bearing radiographs at 6 months. Functional outcome was assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot scale after 6 and 12 months for all patients. RESULTS: Wound edge necrosis was seen in 2 cases (1.9%), and soft tissue infection was observed in 1 case (0.9%). Böhler angle improved from 7.3 degree preoperatively to 28.7 degree at 6 months. The posterior facet step-off was reduced from 5.3 mm preoperatively to 0.7 mm postoperatively. The average AOFAS score averaged 89.5 at 6-month and 92.6 at 12-month follow-up. CONCLUSIONS: The C-Nail is a new locking system for treatment of displaced intraarticular calcaneal fractures combining a primary stability with reduced soft tissue complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Direct plantar approach to Henry's knot for flexor hallucis longus transfer.

BACKGROUND: Transfer of the flexor hallucis longus (FHL) tendon is an established method to replace a dysfunctional Achilles tendon. When using a single incision, the FHL tendon has to be transferred as a single stranded graft into the calcaneus and the distal FHL stump cannot be directly attached to the flexor digitorum longus tendon (FDL). Another concern with tendon retrieval is neurovascular damage. We report our results with a direct plantar approach for tendon harvest. METHODS: A direct plantar approach to the master knot of Henry with reattachment to its distal stump while protecting the medial plantar nerve was used allowing a double stranded FHL-transfer in 25 cases of a severely dysfunctional Achilles tendon in 24 consecutive patients. Patients were evaluated prospectively and at an average followup of 73 (range, 20 to 121) months. RESULTS: No wound healing problems and no lesion of the medial plantar nerve occurred. The subjective result was rated as excellent in 18 (72%), good in five (20%), and fair in one case (8%).The AOFAS hindfoot score averaged 95.4 (range, 61 to 100) points and the AOFAS hallux score averaged 97.6 (range, 87 to 100) points. No loss of plantarflexion force was observed in the big toe as compared to the contralateral side. CONCLUSION: The plantar approach to Henry's knot allowed the use of a double stranded FHL transplant. The distal stump was attached to the FDL tendon to preserve flexion at the great toe without damaging to the medial plantar nerve.

Ultrasonographic classification of achilles tendon ruptures as a rationale for individual treatment selection.

Purpose. This work introduces a distinct sonographic classification of Achilles tendon ruptures which has proven itself to be a reliable instrument for an individualized and differentiated therapy selection for patients who have suffered an Achilles tendon rupture. Materials and Methods. From January 1, 2000 to December 31, 2005, 273 patients who suffered from a complete subcutaneous rupture of the Achilles tendon (ASR) were clinically and sonographically evaluated. The sonographic classification was organized according to the location of the rupture, the contact of the tendon ends, and the structure of the interposition between the tendon ends. Results. In 266 of 273 (97.4%) patients the sonographic classification of the rupture of the Achilles tendon was recorded. Type 1 was detected in 54 patients (19.8%), type 2a in 68 (24.9%), type 2b in 33 (12.1%), type 3a in 20 (7.3%), type 3b in 61 (22.3%), type 4 in 20 (7.3%), and type 5 in 10 (3.7%). Of the patients with type 1 and fresh ASR, 96% (n = 47) were treated nonoperative-functionally, and 4% (n = 2) were treated by percutaneous suture with the Dresden instrument (pDI suture). Of the patients classified as type 2a with fresh ASR, 31 patients (48%) were treated nonoperatively-functionally and 33 patients (52%) with percutaneous suture with the Dresden instrument (pDI suture). Of the patients with type 3b and fresh ASR, 94% (n = 34) were treated by pDI suture and 6% (n = 2) by open suture according to Kirchmayr and Kessler. Conclusion. Unlike the clinical classification of the Achilles tendon rupture, the sonographic classification is a guide for deriving a graded and differentiated therapy from a broad spectrum of treatments.

Percutaneous treatment of less severe intraarticular calcaneal fractures.

UNLABELLED: Percutaneous treatment of calcaneal fractures is intended to reduce soft tissue complications and postoperative stiffness of the subtalar joint. We assessed the complications, clinical hindfoot alignment, motion, functional outcome scores, and radiographic correction of percutaneous arthroscopically assisted reduction and screw fixation of selected, less severe fractures. We performed percutaneous reduction and screw fixation in 61 patients with Type II (Sanders et al.) calcaneal fractures. In 33 of 61 patients with displaced intraarticular fractures (types IIA and IIB), anatomic reduction of the subtalar joint was confirmed arthroscopically; these patients form the basis of this report. We observed no wound complications or infections. In two patients, one prominent screw was removed after 1 and 3 years, respectively. In one patient, arthroscopic arthrolysis was performed 1 year after the index procedure. Twenty-four of 33 patients (73%) were followed a minimum of 24 months (mean, 29 months; range, 24-67 months). The average American Orthopaedic Foot and Ankle Society ankle-hindfoot score at last followup was 92.1 (range, 80-100). Böhler's angle and calcaneal width were reduced close to the values of the uninjured side. We believe percutaneous fixation is a reasonable alternative for moderately displaced Type II fractures provided adequate control over anatomic joint reduction with either subtalar arthroscopy or high-resolution (3-D) fluoroscopy. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Transsection of the rectus abdominis muscle in the treatment of acetabular fractures: operative technique and outcome in 21 patients.

BACKGROUND: A standard ilioinguinal approach is often insufficient for reduction and stabilization of the medial acetabular wall and the dorsal column in acetabular fractures. To avoid extended approaches, we have used a medial extension of the approach by transverse splitting of the rectus abdominis muscle. We have thus been able to reduce and stabilize transverse and oblique fractures of the dorsal column and the medial acetabular wall and to fix plates in a mechanically better position below the pelvic brim. To evaluate the procedure, especially the risk of abdominal hernia, we started a prospective study. PATIENTS AND METHODS: Over 2 years, we treated 21 consecutive patients using a transverse splitting of the rectus abdominis muscle-either as an extension of the standard ilioinguinal approach or in combination with parts of this approach or a Kocher-Langenbeck approach. The patients were evaluated clinically and radiographically after 1 year. RESULTS: The clinical and radiographic results were excellent or good in 18 patients. Complications occurred in 5 patients. No hernias were observed. CONCLUSIONS: Our small study indicates that the procedure described is a useful and safe complement to the intrapelvic approaches. The procedure does not provide better reduction than extended approaches, but may help to avoid them in some cases.

Results of dorsal or volar plate fixation of AO type C3 distal radius fractures: a retrospective study.

PURPOSE: The aim of this study was to define the outcome after dorsal or volar plating of Association for Osteosynthesis (AO) type C3 distal radius fractures based on the fracture morphology. METHODS: Twenty-nine patients with AO type C3 distal radius fractures were surgically managed between 1996 and 2005. Group 1 (n = 15) had volar plating. Group 2 (n = 14) had dorsal plating. Outcomes were evaluated at an average of 22 months after surgery. Statistical analysis was performed using the Wilcoxon test and chi-square test. RESULTS: No significant differences were seen for the scores of Gartland and Werley, Castaing, Stewart I and II, Green and O'Brien, and Disability of the Arm, Shoulder and Hand between the 2 groups. The visual and verbal pain analog scales did not show significant differences between the 2 groups. Radiology analysis showed significant difference in comparison with the contralateral side in terms of dorsopalmar inclination (3 degrees +/- 3) and distal radioulnar joint angle (98 degrees +/- 8) for the patients in group 1, whereas there were no significant differences in group 2. The development of radiographic post-traumatic arthritis was significant in both groups. Significant functional differences were seen for flexion (45 degrees +/- 15) and hand span (20 cm +/- 2) in group 1 as well as for extension (37 degrees +/- 19), flexion (42 degrees +/- 12), and radial deviation (16 degrees +/- 10) in group 2. We found more complications after dorsal plate osteosynthesis than after volar plate osteosynthesis. CONCLUSIONS: This study shows satisfactory functional and subjective outcome results in both groups. Group 1 had non-significant better functional results than group 2, whereas both groups showed good to very good radiology results.

The percutaneous suture of the Achilles tendon with the Dresden instrument.

OBJECTIVE: Minimally invasive suture of the torn Achilles tendon without opening the rupture site, reduction in the risk of a sural nerve lesion, and optimization of stump apposition. INDICATIONS: Fresh Achilles tendon rupture. CONTRAINDICATIONS: Chronic achillodynia, local corticoid injections, immunosuppressive therapy, old Achilles tendon ruptures, rerupture. SURGICAL TECHNIQUE: Suture of the Achilles tendon with a special instrument via a skin incision proximal to the rupture, without opening the peritenon or the rupture site, whereby the suture in the area of the proximal Achilles tendon is placed in the layer between the lower-leg fascia and the peritenon with the threads running in a paratendinous direction. RESULTS: From January 1, 2000 to December 31, 2003, 61 patients with 62 Achilles tendon ruptures were sutured using the percutaneous technique with the Dresden Instrument. No sural nerve lesions and only two reruptures (3.2%) were observed. In one patient (1.6%) a superficial late infection occurred after 8 weeks, when the tendon was already healed. Of 47 patients with a follow-up time of at least 1 year, 39 with 40 Achilles tendon ruptures were followed up (83%). According to the criteria of Trillat & Mounier-Kuhn, the result was very good in 62% and good in 30%. On the AOFAS Score, an average of 96 points (78-100 points) was achieved. 78% of the patients assessed the result of the treatment as very good and 20% as good.

Minimally-invasive treatment of calcaneal fractures.

Percutaneous reduction methods play an important role in the management of calcaneal fractures with severe soft tissue compromise, particularly open fractures, and they offer a treatment alternative in patients with local or systemic contraindication to open reduction. Percutaneous reduction by pin leverage (Westhues or Essex-Lopresti maneuver) followed by minimally invasive screw fixation is a treatment option that yields good to excellent results in tongue-type fractures with posterior facet displacement as a whole (Sanders-type IIC). This method can be applied to selected Sanders-type IIA or IIB fractures if the quality of joint reduction is controlled arthroscopically. Although some authors have expanded the use of percutaneous reduction by traction, leverage, and compression with subsequent K-wire or screw fixation with remarkable results, the uniform application of percutaneous methods to all intra-articular calcaneus fractures is critical. Inadequate joint reduction and redislocation of the fragments in highly unstable fractures may occur in a considerable percentage of cases. Prolonged transfixation of the subtalar and calcaneocuboid joints is strongly discouraged, because functional aftertreatment is an important part of the rehabilitation after calcaneal fractures.