Management of Insertional Achilles Tendinopathy.

Insertional Achilles tendinopathy is a common condition that can lead to chronic, debilitating heel pain in athletes and nonathletes alike. Conservative treatment options include activity and shoe wear modification, physical therapy, injections, and extracorporeal shock wave therapy. When nonsurgical treatment fails, surgical treatment is recommended. Although there are options aimed at preserving the tendon and débriding the retrocalcaneal bursa and excess bone formation, others are aimed at detaching the Achilles tendon to perform a thorough débridement and subsequent reattachment. Additional or alternate procedures may include a calcaneal closing wedge osteotomy, gastrocnemius lengthening, and flexor hallucis longus tendon transfer. Recent advances in suture anchor techniques further add to the complexity of available options. This review discusses the relevant anatomy, biomechanics, and pathophysiology as well as the recent available evidence for nonsurgical and surgical management of this condition to guide surgeons in selecting the most appropriate treatment for their patients.

The Lisfranc Injury: A Literature Review of Anatomy, Etiology, Evaluation, and Management.

Despite being first described in the 1800s, the Lisfranc injury remains one of the most controversial topics in foot and ankle surgery. From the basic anatomy of the ligament complex to the optimal diagnostic and management methods, new research both sharpens and yet confounds our understanding of this unique injury. This article reviews the literature from established and classic papers to recent studies evaluating newer techniques. We discuss the unique bony and ligamentous anatomy, which confer strength to the Lisfranc complex, the typical mechanisms of injury, the most common classification systems, the clinical presentation, current imaging modalities, and conservative and surgical treatment options. We review studies comparing open reduction and internal fixation with primary arthrodesis of acute injuries, in addition to studies evaluating the various methods for obtaining fixation, including intra-articular screws, dorsal plates, and flexible fixation. It is clear from this review that despite the vast number of studies in the literature, much is still to be learned about the diagnosis and management of this challenging injury.Levels of Evidence: Level V: Expert opinion.

Percutaneous techniques for tendon transfers in the foot and ankle.

Tendon transfer procedures are useful for replacing a dysfunctional or diseased tendon or for restoring muscle imbalance. The tendon to be transferred is harvested as distal as is necessary to provide adequate length for rerouting and attachment at the different site. The harvesting of tendon itself can be attained using an open surgical approach or minimally invasive percutaneous techniques that limit surgical exposure. This article describes percutaneous techniques for tendon transfer procedures used to address foot and ankle disorders.

Minimally invasive method of harvesting the flexor digitorum longus tendon: a cadaver study.

BACKGROUND: The flexor digitorum longus (FDL) tendon is harvested for use in the reconstruction of dysfunctional adjacent tendons such as the posterior tibial and the Achilles tendons. The approach to harvest the FDL tendon in the midfoot region is through an incision along the medial border of the foot. This approach involves dissection quite deep in the foot across neurovascular structures in the vicinity placing them at risk. The purpose of this cadaver study was to test the feasibility and safety of a minimally invasive technique, and also to define the relevant topographical surface and deeper surgical anatomy. METHODS: In 83 cadaver feet, the FDL tendon was harvested proximally in the hindfoot after it was cut through a small plantar incision in the midfoot. All the tissues superficial to the FDL tendon were then reflected to check for damage to the adjacent neurovascular structures. Measurements were obtained to define the location of the point of division of the FDL tendon in relation to the plantar surface of the foot and the adjacent neurovascular structures. RESULTS: In all of the 83 feet it was possible to harvest the FDL using this technique. In 11 feet (13.25%), a connecting band to the flexor hallucis longus tendon (FHL) required division. No damage was apparent to the adjacent neurovascular structures. The FDL division was located topographically on the plantar surface of the foot, approximately midway between the back of the heel and the base of the second toe and at this midpoint, about two-thirds of the width medially from the lateral border of the foot. CONCLUSIONS: The FDL tendon can be harvested in the hindfoot after its division through a small plantar incision in the midfoot. Surface anatomy guides placement of the plantar incision over the FDL division. CLINICAL RELEVANCE: The plantar approach when compared to the medial approach for harvesting the FDL tendon in the midfoot may be associated with a smaller incision, minimal dissection, lesser risk to adjacent neurovascular structures and lesser morbidity.

Fixation of tibial pilon fractures with percutaneous cannulated screws.

Closed reduction and internal fixation with percutaneous cannulated screws was performed on seven patients with closed pilon fractures. The mean follow-up was 30.6 months. They were assessed using a subjective scoring system. The average score was 90.8/100. This method of fixation avoids extensive soft tissue dissection and gives excellent results. To our knowledge, this method of closed reduction and stabilisation of pilon fractures solely by percutaneously inserted cannulated screws has not been previously reported.