Ylr

Murphy's procedure with anterior advancement of the Achilles tendon for spastic conditions. Figure 24.17. Murphy's procedure with anterior advancement of the Achilles tendon for spastic conditions. Generally, Achilles tendon or gastrocnemius lengthening should be reserved for patients requiring significant foot reconstruction related to a tight gastroc-soleus complex, and for those needing to avoid forefoot ulceration such as diabetics. Diabetic patients benefit from Achilles...

Alternative Biomechanical Theories in Insertional Tendinopathy

The traditional view of a tendon overuse injury as a result of tensile overload appears plausible. However, although this view is widely accepted, without a prospective design and adequate control groups, any conclusion regarding the etiologic role of factors such as training errors, poor technique, inadequate equipment, inflexibility, and muscle imbalance remains speculative. Only a few studies have attempted to examine these factors in a controlled, prospective manner and these have shown...

Nqh

Bacterial infections, of complex Achilles tendon region wounds, 208 Badminton players, Achilles tendon ruptures in, 43 Becker's muscular dystrophy, 248-249 Biomechanics of the Achilles tendon, 5, 7, 12 of musculoskeletal disorders, 70-73 Boots, for Achilles tendon rupture management, 145 Bruising Achilles tendon rupture-related, 142, 153 calf muscle tear-related, 156, 157 anatomy of, 9, 10, 12, 29, 133 dimensions of, 34 function of, 133 imaging of, 10, 25, 34, 136 impingement of, 135...

Cerebral Palsy

Lower Extremity Free Flap

Movement disorders in cerebral palsy result from ante-, peri- or post-natal insult to the immature brain. Although the primary neurological injury is nonprogressive, secondary musculoskeletal pathology deteriorates in untreated children. Depending on the level and extent of the brain lesion, the child may suffer from hemiplegic, spastic diplegic, or total-body-involvement cerebral palsy. This chapter focuses on ankle and foot abnormalities in cerebral palsy, and refers to the spastic rather...

Complications

Multiple Percutaneous Longitudinal Tenotomies Four patients developed a subcutaneous hematoma from one of the stab wounds, and a further patient suffered from a superficial infection of one of the stab wounds. This was treated by oral antibiotics for five days, and healed uneventfully. Three patients complained of hypersensitivity of the stab wounds. They were counseled to rub hand cream over the stab wounds several times a day, and were asymptomatic by six postoperative weeks. One patient...

Custom Foot Orthotics

Functional custom foot orthoses were initially developed between 1954 and 1966.18 These devices have long been prescribed to active individuals in their exercise shoes to increase comfort, to prevent complaints of injury, or to rehabilitate from injuries. The potential benefits of functional foot orthotics as an intervention between the foot and the ground reaction forces on the lower extremity allow individuals to pursue their sports and remain functionally active. The success rate of custom...

Differential Diagnosis

Both systemic and local conditions can mimic symptoms produced by insertional tendinopathy of the Achilles tendon. Systemic affections include gout, hyperlipidemia, sarcoidosis, systemic corticosteroids, oral fluoroquinolones, diffuse idio-pathic skeletal hyperostosis, and seronegative spondyloarthropathies. Haglund's deformity, retrocalcaneal bursitis, os trigonum posterior impingement, posterior talar process fracture, flexor hallucis longus tendinopa-thy, peroneal tendinopathy, tibialis...

Do Corticosteroid Injections for Achilles Tendinopathy Increase the Risk of Subsequent Achilles Tendon Rupture

The use of corticosteroid injections in the management of soft-tissue injuries is widespread. Corticosteroids have been injected peri- or intratendinously for many decades, particularly by rheumatologists.35 Already in 1976, Clancy36 reported on the safe use of intratendinous Achilles injections for the management of early tendi-nopathy in athletes. However, the study was confined to 5 runners. More recently, orthopedic surgeons have tended to be more circumspect with regard to the use of...

Does the Use of NSAIDs Affect Achilles Tendon Healing

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in soft-tissue disorders. Many different drugs exist within this category and their use is not without potential side-effects, such as gastrointestinal disturbances and renal damage. What is the evidence that they are helpful in the management of Achilles disorders, and is there any evidence that their use might be potentially harmful Physicians have frequently used nonsteroidal anti-inflammatory drugs (NSAIDs) in Achilles...

Etiology and Pathophysiology

Tendon injuries can be acute or chronic and are caused by intrinsic or extrinsic factors, either alone or in combination. In acute trauma, extrinsic factors predominate. Overuse injuries generally have a multifactorial origin.4 In chronic tendon disorders, interaction between intrinsic and extrinsic factors is common.5 There is sparse scientific knowledge about the etiology and patho-physiology of chronic painful tendon conditions, and most hypotheses put forward have not been substantiated by...

Genetic Susceptibility to Achilles Tendon Injury

Genetic factors may be associated with an individual's susceptibility to Achilles tendon injury.810 This was originally proposed in studies reporting an association between the ABO blood group and Achilles tendon ruptures or chronic Achilles In a retrospective study, Jozsa et al.11 compared the frequencies of the ABO and Rh blood groups of 292 Hungarian patients with primary Achilles tendon ruptures or re-ruptures and 540 patients with various other tendon ruptures with a control group...

H

Haglund's deformity, 115 clinical features of, 123 differentiated from Achilles insertional tendinopathy, 123, 130 Haglund's syndrome, 133 flexor hallucis longus tendon transfer treatment for, 101, 103 as heel pain cause, 113, 121 radiographic appearance of, 115-116,124 resection of, 125, 127, 128 surgical management of, 12, 117, 133 differentiated from Haglund's deformity, 133 Haglund's triad, 113, 115, 123 Heat therapy, 84 Heel, ulcers of, 245, 246 Heel lift, as phase of gait, 72, 73 Heel...

Info

Off perpendicular to the tendon demonstrating a hypoechoic (dark) tendon (arrowheads). off perpendicular to the tendon demonstrating a hypoechoic (dark) tendon (arrowheads). Figure 4.8. (A) Longitudinal ultrasonographic image of a normal Achilles tendon. Note the echogenic, parallel fibrillar pattern (between arrowheads). (B) Transverse ultrasonographic image of a normal Achilles tendon showing echogenic ovoid shape (arrowheads). probe frequency.22 On transverse imaging, the normal Achilles...

Injury Guidelines and Classification with a View to Treatment

The size of the Achilles tendon defect is likely to affect management. Both Myerson10 and Kuwada58 have noted this and each have provided a scheme for management. Myerson treats ruptures of the Achilles tendon based on the size of tendon defect 10 Defects of 1 to 2 cm are treated with end-to-end anastomosis and posterior compartment fasciotomy. Defects between 2 and 5 cm are repaired using V-Y lengthening, and occasionally augmented with a tendon transfer. Defects greater than 5 cm are repaired...

Management

Most patients can be successfully managed non-operatively.1,31,32 The various nonoperative modalities produce an 85 to 95 success rate.7'33 Even the more active or competitive athletes should persevere with nonoperative management.7 Modifications in training and the use of ice, nonsteroidal anti-inflammatory medication, and heel-lifts in conjunction with stretching and strengthening exercises can be effective for athletes. Nonsteroi-dal anti-inflammatory medications may only provide...

Management of Achilles Paratendinopathy

Alleviation of pain and prevention of progression of acute to chronic paratendinopathy are the main goals of management in the acute phase. In chronic cases, the alleviation of pain predominates the management strategies, while predisposing factors and etiological causes are actively sought and corrective measures are taken. Little reliable experimental or clinical scientific work has been performed on the pathophysiology, etiology, natural course, and management of Achilles tendon overuse...

Muscular Dystrophies

Duchenne muscular dystrophy (DMD) is the most common form of muscular dystrophy, occurring in 1 in 3,500 boys. DMD usually manifests before the age of 3. Becker's muscular dystrophy (BMD) is less common, with disease onset at 7 years of age. Other forms of muscular dystrophy are much less common. Both DMD and BMD are X-linked recessive genes affecting only boys. The life expectancy in BMD is significantly better than in DMD, and patients with BMD may retain independent ambulation into early...

Neurological Conditions

Achilles tendon shortening or weakness is a feature of many neurological conditions affecting the central or peripheral nervous system (cerebral palsy, poliomyelitis, spina bifida, and hereditary neuropathies) and muscles (muscular dystrophy). Achilles tendon spasticity, weakness, or contracture in these conditions leads to gait abnormalities. Understanding the role played by the triceps surae in the unique coupling of ankle and knee motion is essential in the management of gait abnormalities...

Noninsertional Achilles Tendinopathy

With the patient prone, both feet are positioned at the end of the operating table. Epidural, spinal, or general anesthesia can be used. The short saphenous vein is marked on the lateral side of the Achilles tendon, the leg is exsanguinated, and the tourniquet inflated. The distal portal is located on the lateral border of the Achilles tendon, 2-3 cm distal to the thickened portion (nodule) of the Achilles tendon. The cranial portal is located 2-4 cm above the nodule on the medial border of the...

Operative Technique

The patient is placed prone with feet protruding over the edge of the operating table. Both legs are prepped and draped, allowing intraoperative comparison to adjust the tension of the reconstruction. If considered necessary, a tourniquet is applied to the thigh of the affected leg, the leg exsanguinated, and the tourniquet inflated to 250 mmHg. A 10- to 12-cm longitudinal skin incision is made just medial to the medial border of the Achilles tendon, and sharp dissection is carried out through...

Paralysis of Triceps Surae Muscle in Poliomyelitis

Flaccid lower motor neuron paralysis of triceps surae is very disabling. The patient lacks push-off, and walks with a calcaneus limp. The lack of push-off during the third foot rocker leads to an upward displacement of the anterior end of the calcaneum and head of talus. There is increase in the range of dorsiflexion and the normal posterior heel prominence disappears. Compensation by other plantarflexors such as tibialis posterior, long toe flexors, and the peronei result in equinus of the...

Pathobiomechanics

Achilles tendon ruptures occur commonly in the midsubstance of the tendon, usually two to six centimeters proximal to the insertion to the calcaneus. Other less common locations are the musculotendinous junction and the insertion into the calcaneus. The injury can be open or closed, and may be caused by a direct blow or an indirect force. Most injuries tend to occur when pushing off with the weight-bearing foot while extending the knee. Some Achilles tendon ruptures occur following sudden ankle...

Postoperative Management

On admission, patients are taught to perform isometric contractions of their triceps surae. Patients are instructed to perform the isometric strength training at three different angles, namely at maximum dorsiflexion, at maximum plantarflexion, and at a point midway between the two. The foot is kept elevated on the first postoperative day, and oral analgesics are given for pain control. Early active dorsi- and plantarflexion of the foot are encouraged.54 On the second postoperative day,...

Postoperative Regimen

The rehabilitation program following open surgery for midsubstance tendinosis has not been studied in a controlled manner. Therefore, the regimen mainly depends on the experience and preference of the surgeon. Most reported programs emphasize early motion and avoidance of prolonged immobilization. A period of initial splinting and crutch walking is generally used to allow pain and swelling to subside. In addition, wound healing complications are difficult to manage and an initial period of...

Presentation and Diagnosis of Insertional Tendinopathy

The symptoms of insertional Achilles tendinopa-thy are specific, and are related to pain at the bone-tendon junction, frequently worse after exercise, but which ultimately become constant. Although this is a fairly common finding in athletes, other conditions and medications that cause pain in the posterior aspect of the heel should be considered, including the various causes of insertional enthesopathy, seronegative spondyloar-thropathies, gout, systemic corticosteroids, orally administered...

Stepwise Procedure

The patient is positioned according to the surgeon's preference. For an anticipated harvest from the midfoot, supine positioning with a large sandbag bump under the contralateral hip allows the leg to be externally rotated to access the medial aspect of the foot (Fig. 11.2). 2. A direct midline incision is usually utilized (Fig. 11.3). This incision follows the natural border between the angiosomes, or arterial vascular territories, of the leg.5 The risk of leaving a small segment of...

Summary

Open surgery for midsubstance tendinopathy of the Achilles tendon can be considered if prolonged nonoperative management fails. However, patients should be informed of the potential failure of the procedure, risks of wound complications, and sometimes prolonged recovery period. The surgical procedure is relatively straightforward, but on occasion may require concomitant transfer of tendon tissue to reinforce the weakened tendon. Rehabilitation is focused on early motion and avoidance of...

Surgical Technique

The patient is placed in the prone position under general or regional anesthesia. If the feet are left on the operating table, there is a tendency to push the ankle joint in hyper-plantarflexion due to the weight of the leg. During the repair, this can lead to overtightening the repair. Instead, it can be helpful to bring both feet down off the end of the table or to place a soft roll underneath the distal tibia. Both feet will assume an unforced, more neutral position. Prior to the repair, the...

The Anatomy of the Achilles Tendon

Suzuki, and H. Toumi The Achilles tendon (tendo calcaneus) is the strongest and thickest tendon in the body and serves to attach the triceps surae (soleus and the two heads of gastrocnemius) to the calcaneus (Fig. 2.1). It is a highly characteristic feature of human anatomy and it has even been suggested that the tendon has helped to shape human evolution. The emergence of man is critically linked to his ability to run, and man's unique combination of moderate...

Operative Technique Central Flap

The patient is placed in prone position. Anesthesia should ensure maximal muscle relaxation. Make a linear curvilinear medial incision (to minimize the risk of injuring the sural nerve) from the midcalf to the calcaneus, taking care not to cross the midline in the distal part, in order to avoid scarring the tendon (Fig. 19.1). Incise the deep fascia in the midline after freeing it from the skin, thus making sure that the fascial incision lies fully under the skin flap. The site of the Achilles...

Indications and Contraindications

A delay in presentation of Achilles tendon rupture of greater than 8 weeks results in filling up of the gap between the ruptured ends with fibrous nonfunctional scar that needs excision. If the gap with the ankle in maximum plantarflexion is between 5 and 9 cm, peroneus brevis transfer can be utilized. We do not use this technique if the gap between the ruptured ends of the Achilles tendon is greater than 8 cm, or the ipsilateral peroneus brevis has been used for other reconstructive procedures...

Lower Extremity Composite Free Flaps

Early composite grafts included free groin flaps with a sheet of external oblique aponeurosis, iliac bone, or abdominal fascia.27-29 Advantages of these groin flaps included the ability to transfer iliac bone with the graft for a calcaneal defect, as well as the location of the donor scar, which was usually hidden by underclothing. Disadvantages included a short and thin superficial circumflex iliac artery pedicle, the need for repair of the external oblique in the donor site with foreign...

Upper Extremity Composite Free Flaps

Radial forearm and lateral arm constructs have also been developed to address the problem of complex Achilles region reconstruction. A radial forearm flap raised with extensor carpi ulnaris and palmaris longus tendons was used to reconstruct an area of the posterior lower leg that did not require much tissue bulk.19 Other radial forearm composite flaps have included the tendons of the brachioradialis and palmaris longus as well as the superficial radial nerve or the lateral antebrachial...

What Are the Possible Complications Following Surgery for Chronic Achilles Tendinopathy

Paavola et al.61 studied 432 consecutive patients following surgery for Achilles tendinopathy. They reported an overall complication rate of11 , with the majority (54 ) due to problems with wound healing. However, other complications observed included sural nerve problems, scarring, rupture, and thrombo-embolic disorders. Overall, 3 of patients required further surgery to deal with complications. However, the authors stressed that, despite the complications, the long-term prognosis for pain...

Diagnosis of Achilles Paratendinopathy

Patients with Achilles paratendinopathy present with pain in the Achilles tendon region or posterior heel region. The severity of pain is used to classify the severity of the disorder and is also used as an outcome measure.1 Clinical examination reveals that the tendon is diffusely swollen on palpation, and is tender in the middle third of the tendon. A crepitus may be occasionally palpable in the acute phase 4,9 however, the swelling and tenderness does not move when the ankle joint is...

Paratendinopathy of the Achilles Tendon

Sayana, and Nicola Maffulli There has been a dramatic increase of Achilles tendon overuse injuries in the past four decades. This is in line with the increased prevalence of overuse sports injuries in Western countries due to increase in the demands on competitive and professional sports performances. Achilles tendon overuse injuries not only affect competitive athletes, but also affect recreational sports participants and individuals in occupations where the lower limbs...

A

Force-relaxation (A), creep (B), and mechanical hysteresis (C). The arrows at the bottom graph indicate loading and unloading directions. In the first few loading-unloading cycles in a mechanical hysteresis test, the tendon resting length increases. This is referred to as conditioning. Figure 3.1. Typical force-elongation plot in a tendon tensile test to failure. I toe region II linear region III and IV failure regions. Stiffness is the slope of the curve in the linear region....

Complex Wounds

Complications from failed surgery, severe infection, or massive trauma may leave a complex wound involving the soft tissue around the Achilles tendon. A tendon defect in the setting of large tissue loss is a more difficult problem than simple repair of a ruptured or lacerated tendon. Successful reconstruction must include three essential elements (1) tendon repair sufficient to provide strength, durability, and tension (2) a soft tissue cushion thick enough to protect the area but thin enough...

Percutaneous Hemisection Achilles Tendon

Medial Calf Tightness

Figure 24.3. (A) Stretching with the knee straight creates tension on the gastrocnemius. (B) Stretching with the knee bent creates tension on the soleus and deep posterior muscle compartment. as well. Commonly prescribed stretching regimens designed long term to eliminate contracture are probably more effective at preventing further contracture than at decreasing the tightness already present. Eccentric strengthening for up to one year is beneficial in reducing pain and allows for increased...

Operative Details

As a prosthesis is used, intravenous antibiotic prophylaxis is necessary. General anesthesia is normally used and the operation is always undertaken under tourniquet control. The patient is placed prone on the operating table with a pillow under the mid-shin area with the foot and ankle sufficiently free of the end of the table to allow accurate assessment to be made of the range of dorsiflexion and plantarflexion at each stage of the operation. This is especially important when the polyester...

The History of the Tendo Achillis and Its Rupture

The story of the tendo Achillis is bound up with both ancient Greek mythology and paleoanthropology.1 The tendo Achillis does not occur in the great apes Fig. 1.1 , our immediate ancestors, and is a hallmark of bipedal man. Its presence may be related to the greater relative length of the tarsal bones in man. The name is derived from the Iliad by the Greek poet, Homer, written between 750 and 650 B.C. Achilles was a magnificent warrior and, according to myth, made invulnerable in infancy by his...

Surgical Technique Harvest Site

Two anatomic options are available for harvesting the FHL for transfer, a long harvest at the knot of Henry and a short harvest behind the ankle through the same posterior incision used to debride the Achilles. The original descriptions of FHL augmentation of the Achilles utilized a medial midfoot incision to harvest the FHL at the level of the knot of Henry as the tendon passes over the flexor digitorum longus. This approach provides a substantial length of tendon that can then be doubled back...

Microsurgical Free Flaps

The development of microsurgical techniques made free tissue transfer possible to cover large defects in the Achilles region Fig. 23.1 . Free tissue transfer supplies vascularized tissue to enhance wound healing and to protect against infection. Skin, fascia, muscle, bone, and nerve can be transferred in various combinations to replace the function of lost tissues. The earliest microvascular free flaps were reported in 1971 and 1973 an abdominal dermis-fat graft was first transferred to a...