Motorcycle spoke injuries involving the soft tissue, Achilles tendon, and calcaneal defects are rare in children. Currently, calcaneal defects are very challenging to treat. Multiple methods have been used in clinical practice; however, an effective treatment has yet to be established, especially when Achilles tendon and soft-tissue defects are also present. It is important to address this condition, because the calcaneus plays a key role in standing and gait. Unsatisfactory treatment of calcaneal defects may significantly decrease patients' quality of life (eg, by limiting mobility). In this article, we report the effective treatment of calcaneal defects in four children using distraction osteogenesis with an external fixator framework designed by the authors. From May 2014 to May 2015, four children (age range, 6–11 years) with defects of the Achilles tendon, soft tissue, and calcaneus resulting from a motorcycle accident were treated at our hospital. The Achilles tendon and soft-tissue defects were treated with second-stage reconstruction. In the third-stage surgery, osteotomy of the residual calcaneus was performed. A customized external fixator was used to lengthen the calcaneus at a rate of 1.5 mm/day in the posterior direction and reposition it by 40° in the inferior direction. In all four children, the calcaneus was lengthened by 5 cm. Distraction osteogenesis through external fixation is effective for restoring the length, width, and height of the calcaneus in children.
Various procedures have been described for removing a retrocalcaneal exostosis. These procedures require partial or complete detachment of the insertion of the Achilles tendon and ultimate resection of the exostosis. The authors introduce a simplified technique to surgically excise a retrocalcaneal exostosis based on an important and newly reported anatomical relationship. The procedure is performed through a posterior transverse incision and requires little or no reflection of the Achilles tendon. Overall, the 14 patients studied retrospectively wore shoes and returned to usual activities fairly rapidly after this procedure; however, time until patients were free of pain averaged nearly 12 months. Two patients did not obtain relief and required additional surgery despite complete removal of the exostosis. These results challenge the assumption that retrocalcaneal pain is secondary to exostosis formation. (J Am Podiatr Med Assoc 92(10): 537-542, 2002)
Sea urchin spine injuries have been reported in the hand and foot, but there are no published cases in the Achilles tendon. We report an unusual case of Achilles tendinopathy secondary to sea urchin spine injury. The patient had Achilles tendon pain that increased over time and was worsened with weightbearing activity. His left ankle plantarflexion was limited by pain. He had received medical care 3 months earlier to remove sea urchin spines after stepping on a long-spined sea urchin. Bedside ultrasound and imaging studies revealed that there were foreign bodies related to sea urchin spines on the surface of the tendon. The patient was given education about proper footwear and activity modification. His symptoms resolved over time, and he avoided surgical intervention.
Ciprofloxacin and other fluoroquinolones are commonly used broad-spectrum antimicrobial agents for treating bacterial infections. This class of antibiotic drugs has uncommon adverse effects that include tendonitis, tendon ruptures, and other tendon abnormalities. We describe a patient with spontaneous bilateral complete Achilles tendon rupture after ciprofloxacin treatment. Surgical repair was performed successfully, and the patient completed physical rehabilitation without incident. Care should be exercised when selecting pharmaceutical agents to maintain a positive benefit-to-risk balance.
Tendinopathy in the presence of gouty arthropathy is relatively common, yet the clinical suspicion for gout involvement in acute tendon pain remains low. A 49-year-old man presented with an acute, tender, erythematous mass to the right posterior heel. A computed tomographic scan was obtained, which revealed a septated fluid collection superficial to the Achilles tendon. The patient was taken to the operating room for an incision and drainage with debridement, and the abscess was found to be filled with caseous material. The diagnosis of gout was confirmed with pathology. The calcaneus was submitted to biopsy, and the results were negative for osteomyelitis. The patient was returned to the operating room for repair of the Achilles tendon with flexor hallucis longus tendon transfer. Postoperatively, the patient was nonweightbearing for 6 weeks. Oral colchicine was used perioperatively, and a steroid taper was administered. The patient was started on allopurinol and colchicine for chronic treatment. At 14 months, the patient was walking without pain or recurrence of the mass. Although the relationship between hyperuricemia and tendinopathy is not completely understood, it is apparent that tendon involvement may be a sequela in patients with gout. When a patient presents with acute tendon pain, gout should be considered in the differential diagnosis.
Background: Tendo Achillis lengthening is performed by means of Z-plasty in the classic treatment of clubfoot. In the Ponseti method for treating clubfoot, Achilles tenotomy is performed percutaneously for residual equine deformity. A randomized study was designed to compare tendon healing after tenotomy versus Z-plasty.
Methods: Thirty-six Sprague-Dawley rats were divided randomly into two groups. On the first day, while the right tendo Achillis of group 1 rats underwent tenotomy, those of group 2 rats underwent Z-plasty. Nine rats from each group were humanely killed on days 21 and 45 postoperatively. The two groups were compared with each other biomechanically and histologically. The Achilles tendons of eight rats in each group were evaluated biomechanically, and the remaining rat in each group underwent histologic evaluation.
Results: Mean ± SD maximum load at rupture of the treated tendons on days 21 and 45 in the tenotomy group was 26.38 ± 7.31 N and 47.16 ± 15.36 N, respectively, and in the Z-plasty group was 27.37 ± 5.20 N and 45.27 ± 9.59 N, respectively. The biomechanical evaluation revealed no significant difference in terms of breaking forces between the two groups. The difference between breaking forces on days 21 and 45 was statistically significant for both groups.
Conclusions: Tendons in the tenotomy group healed as well as those in the Z-plasty group, and Achilles tenotomy in the rat was similar to Z-plasty for Achilles tendon lengthening. Human correlation may or may not exist, but this study suggests that it should be considered and investigated. (J Am Podiatr Med Assoc 99(3): 216–222, 2009)
The first metatarsal bone is a viable source for autologous bone grafting in foot and ankle surgery and may serve as another convenient graft site to correct a flail toe deformity. We aimed to determine how progressive bone removal from the first metatarsal affects the mechanical redistribution of the foot and whether this bone removal increases the risk of fracture.
A three-dimensional finite element model developed from computed tomographic images obtained from a healthy man were used to evaluate traction stresses on the first metatarsal bone as a function of applied loads on the talus and Achilles tendon at two phases of the gait cycle (and according to the depth of bone removal).
Simulations indicated that when maximum load was applied to the Achilles tendon, tensile stress increased from 2.049 MPa in the intact foot to 5.941 MPa in the area of maximum bone harvest during the stance phase. Furthermore, as the volume of bone extracted from the first metatarsal increased, there was a redistribution of stress that differed significantly from that of the intact foot.
Although the maximum stress on the first metatarsal was not significantly affected by increasing the volume of bone harvested, the ankle should be splinted in plantarflexion during the postoperative period to eliminate the stance phase of gait and reduce the risk of metatarsal fracture.
Achilles insertional tendon pathology is a common condition affecting a broad range of patients. When conservative treatments are unsuccessful, the traditional open resection, debridement, and reattachment of the Achilles tendon is a variably reliable procedure with significant risk of morbidity. Fasciotomy and surgical tenotomy using ultrasound-guided percutaneous microresection is used on various tendons in the body, but the efficacy has not been examined specifically for the Achilles tendon.
A retrospective review evaluated 26 procedures in 25 patients who underwent Achilles fasciotomy and surgical tenotomy. The Foot Function Index was used to quantify pain, disability, activity limitation, and overall scores.
Mean Foot Function Index scores were as follows: pain, 8.53%; disability, 7.91%; activity limitation, 2.50%; and overall, 6.97%. Twenty index procedures were successful, and two patients repeated the procedure successfully for an overall 84.6% success rate in patients with chronic insertional pathology with mean surveillance of 16 months. There were no infections or systemic complications.
Ultrasound-guided percutaneous microresection is a safe and minimally invasive percutaneous alternative that can be used before proceeding to a more invasive open procedure.
Background: Plantar first metatarsal ulcerations pose a difficult challenge to clinicians. Etiologies vary and include first metatarsal declination, cavus foot deformity, equinus contracture, and hallux limitus/rigidus. Our pragmatic, sequential approach to the multiple contributing etiologies of increased plantar pressure sub–first metatarsal can be addressed through minimal skin incisions.
Methods: A retrospective review was performed for patients with surgically treated preulcerations or ulcerations sub–first metatarsal head. All of the patients underwent a dorsiflexory wedge osteotomy, and the need for each additional procedure was independently assessed. Equinus contracture was treated with Achilles tendon lengthening, cavovarus deformity was mitigated with Steindler stripping, and plantarflexed first ray was treated with dorsiflexory wedge osteotomy.
Results: Eight patients underwent our pragmatic, sequential approach for increased plantar pressure sub–first metatarsal, four with preoperative ulcerations and four with preoperative hyperkeratotic preulcerative lesions. The preoperative ulcerations were present for an average of 25.43 weeks (range, 6.00–72.86 weeks), with an average size of 0.19 cm3 (median, 0.04 cm3). Procedure breakdown was as follows: eight first metatarsal osteotomies, four Achilles tendon lengthenings, and six Steindler strippings. Postoperatively, all eight patients returned to full ambulation, and the four ulcerations healed at an average of 24 days (range, 15–38 days). New ulceration occurred in one patient, and postoperative infection occurred in one patient. There were no ulceration recurrences, dehiscence of surgical sites, or minor or major amputations.
Conclusions: The outcomes in patients surgically treated for increased plantar first metatarsal head pressure were evaluated. This case series demonstrates that our pragmatic, sequential approach yields positive results. In diabetic or high-risk patients, it is our treatment algorithm of choice for increased plantar first metatarsal pressure.
Insertional Achilles tendinopathy is a common complaint among patients. Oftentimes, conservative treatment is inadequate, and surgical treatment is required. However, there is no published consensus regarding surgical intervention in reference to insertional Achilles tendinopathy.
The purpose of this systematic review was to evaluate the surgical management of insertional Achilles tendinopathy and report which surgical procedures provide the greatest pain reduction and improvement in functional outcome. A review of PubMed, OVID, Google Scholar, and Cochrane Controlled Trials Register was performed using a defined search strategy and inclusion criteria.
Of 2,863 articles identified using the defined strategy, 20 met the inclusion criteria (three prospective and 17 retrospective). Operative interventions included Achilles tendon debridement, reattachment with suture anchors, reconstruction with flexor hallucis longus tendon autograft or bone-patellar tendon autograft, and gastrocnemius recession. All of the studies, regardless of intervention, showed generalized improvement after surgery. Wide variation in outcome scoring systems prevented direct comparison between studies and interventions.
This systematic review did not identify a superior treatment for insertional Achilles tendinopathy but rather found that the surgical treatment should be based on the extent of tendon injury.