Gayle D. Maffulli

Achilles Tendon Ruptures in Elite Athletes

Background: The management of Achilles tendon (AT) ruptures in elite athletes can be challenging. We performed a retrospective review of prospectively collected data study to evaluate the results of percutaneous repair of an acute AT rupture in elite athletes. Materials and Methods: Seventeen elite athletes with prodromal tendinous problems sustained an acute tear of the AT and underwent percutaneous surgical repair. We performed preoperative evaluations the day of surgery, and report the results of postoperative evaluation at a final followup at an average of 72 months from the procedure. Each patient was evaluated for limb dominance, trauma history, duration and type of preoperative symptoms, and postoperative AT Total Rupture Score (ATRS). Results: All patients were able to fully weightbear on the operated limb by the end of the 8th postoperative week. The average time to return to full sport participation was 4.8 ± 0.9 months. Two of the 15 elite athletes on whom we have full data suffered from a superficial infection of the surgical wound. Conclusion: Our study suggests that percutaneous repair of the AT is a good option for elite athletes, allowing a safe and prompt return to sport activities. Level of Evidence: IV, Retrospective Case Series

Isolated Anterior Talofibular Ligament Broström Repair for Chronic Lateral Ankle Instability 9-Year Follow-up

Background: Lateral ankle sprains may result in pain and disability in the short term, decreased sport activity and early retirement from sports in the mid term, and secondary injuries and development of early osteoarthritis to the ankle in the long term. Hypothesis: This combined approach to chronic lateral instability and intra-articular lesions of the ankle is safe and in the long term maintains mechanical stability, functional ability, and a good level of sport activity. Study Design: Case series; Level of evidence, 4. Methods: We present the long-term outcomes of 42 athletes who underwent ankle arthroscopy and anterior talofibular Broström repair for management of chronic lateral ankle instability. We assessed in all patients preoperative and postoperative anterior drawer test and side-to-side differences, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Kaikkonen grading scales. Patients were asked about return to sport and level of activity. Patients were also assessed for development of degenerative changes to the ankle, and preoperative versus postoperative findings were compared. Results: Thirty-eight patients were reviewed at an average of 8.7 years (range, 5-13 years) after surgery; 4 patients were lost to follow-up. At the last follow-up, patients were significantly improved for ankle laxity, AOFAS scores, and Kaikkonen scales. The mean AOFAS score improved from 51 (range, 32-71) to 90 (range, 67-100), and the mean Kaikkonen score improved from 45 (range, 30-70) to 90 (range, 65-100). According to outcome criteria set preoperatively, there were 8 failures by the AOFAS score and 9 by the Kaikkonen score. Twenty-two (58%) patients practiced sport at the preinjury level, 6 (16%) had changed to lower levels but were still active in less demanding sports (cycling and tennis), and 10 (26%) had abandoned active sport participation although they still were physically active. Six of these patients did not feel safe with their ankle because of the occurrence of new episodes of ankle instability. Of the 27 patients who had no evidence of degenerative changes preoperatively, 8 patients (30%) had radiographic signs of degenerative changes (5 grade I and 3 grade II) of the ankle; 4 of the 11 patients (11%) with preexisting grade I changes remained unchanged, and 7 patients (18%) had progressed to grade II. No correlation was found between osteoarthritis and status of sport activity (P = .72). Conclusion: Combined Broström repair and ankle arthroscopy are safe and allow most patients to return to preinjury daily and sport activities.

Less-Invasive Semitendinosus Tendon Graft Augmentation for the Reconstruction of Chronic Tears of the Achilles Tendon

Background: Less-extensive and gentler exposure and dissection of deep soft tissues could reduce the times of recovery and rehabilitation after Achilles tendon reconstruction. Hypothesis: A minimally invasive semitendinosus autologous graft reconstruction of the Achilles tendon preserves skin integrity and reduces wound breakdown. Study Design: Case series; Level of evidence, 4. Methods: A total of 26 patients underwent minimally invasive semitendinosus autologous graft reconstruction for chronic ruptures to the Achilles tendon. Patients underwent a comparison of preoperative versus postoperative maximum calf circumference and isometric plantarflexion strength and evaluation of postoperative complications. The Achilles Tendon Total Rupture Score (ATRS) was administered at the final follow-up appointment. Results: All patients were reviewed at an average of 8.2 years (range, 7-10 years) from surgery. No patient was lost to follow-up. At final follow-up, the maximum calf circumference was significantly higher than preoperatively but significantly lower than the contralateral side. The isometric plantarflexion strength in the operated leg was lower than in the uninjured one. The mean ATRS was 88. Two patients developed a superficial wound infection, both healing within 2 months from the index surgery after systemic antibiotics and local dressings. One patient developed scar adhesion to the distal wound. All patients returned to their preinjury working occupation; 22 patients returned to their preinjury level of activity at a mean of 6.7 months after surgery. Conclusion: This technique is minimally invasive, is safe, and allows most of the patients to return to preinjury daily and sport activities within 9 months from surgery.

Minimally Invasive Reconstruction of Chronic Achilles Tendon Ruptures Using the Ipsilateral Free Semitendinosus Tendon Graft and Interference Screw Fixation

Background: Achilles tendon ruptures represent more than 40% of all tendon ruptures requiring surgical management. About 20% of acute Achilles tendon tears are not diagnosed at the time of injury and become chronic, necessitating more complicated management than fresh injuries. Several techniques for the reconstruction of chronic tears of the Achilles tendon have been described, but the superiority of one technique over the others has not been demonstrated. Hypothesis: Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft will result in improvement of the overall function with a low rate of complications. Study Design: Case series; Level of evidence, 4. Methods: Between 2008 and 2010, the authors prospectively enrolled 28 consecutive patients (21 men and 7 women; median age, 46 years) with chronic closed ruptures of the Achilles tendon who had undergone reconstruction with a free semitendinosus tendon graft. They assessed the Achilles tendon Total Rupture Score (ATRS), maximum calf circumference, and isometric plantarflexion strength before surgery and at the last follow-up. Outcome of surgery and rate of complications were also recorded. The median follow-up after surgery was 31.4 months. Results: The overall result of surgery was excellent/good in 26 (93%) of 28 patients. The ATRS improved from 42 (range, 29-55) to 86 (range, 78-95) (P < .0001). In the operated leg, the maximum calf circumference and isometric plantarflexion strength were significantly improved after surgery (P < .0001); however, their values remained significantly lower than those of the opposite side (P < .0001). All patients were able to walk on tiptoes and returned to their preinjury working occupation. No infections were recorded. Conclusion: Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft provides a significant improvement of symptoms and function, although calf circumference and ankle plantarflexion strength do not recover fully.

Early signs of osteoarthritis in professional ballet dancers: a preliminary study.

Objective:To investigate a cohort of professional ballet dancers for evidence of early signs of osteoarthritis (OA). Design:One radiologist and 1 orthopedic surgeon specialized in musculoskeletal disorders analyzed magnetic resonance imaging scans independently. Setting:University Teaching Hospital. Participants:Fifteen professional ballet dancers (4 males and 11 females; age range, 19-36 years) experiencing chronic pain in the hip, knee, spine, ankle, or foot joints. Main Outcome Measures:Presence of osteophytes, subchondral sclerosis, joint space narrowing, cysts, and bone marrow changes; the Kellgren and Lawrence scale was used to quantify the knee OA. Results:In the knee, there was thinning and irregularity of the articular cartilage over the medial femoral condyle and bone marrow changes within the lateral femoral condyle. In the hip, there was a loss of joint space and a frayed labrum with deep recess. The first metatarsophalangeal joint showed evidence of osteophytic development. Conclusions:Early signs of OA, in different joints, were present in a small but highly selected cohort of professional ballet dancers. In future, prospective studies among a number of ballet companies should control for medical and natural history alongside the visual analysis of images and plain radiographs to confirm these preliminary results.

Total knee arthoplasty: better short-term results after subvastus approach

The purpose of this study was to evaluate the short-term results after performing a total knee arthroplasty (TKA) using two surgical approaches: the subvastus approach (SV) and the conventional parapatellar approach. It was hypothesized that the SV approach would achieve the best short-term benefits. This is a randomized prospective and double-blind study that includes 104 patients. Evaluations were carried out preoperatively, when discharged (5 days) at one, three, and 12 postoperative months. The SV group showed significantly better range of movement and quadriceps extensor force when discharged. Statistically significant differences were found that showed a distinct improvement in favour of the SV group at one month in terms of extensor force and according to the Barthel Index. No significant difference was found between the two groups at the 12 month evaluation. It was concluded that the SV approach offers superior short-term clinical and functional results and it was shown that this approach also offers a significant advantage to the patient in the immediate postoperative period, although these differences tend to disappear over time following TKA. We strongly recommend the SV approach in the majority of TKA.

Early functional outcome after subvastus or parapatellar approach in knee arthroplasty is comparable

We read with great interest the article ‘‘Early functional outcome after subvastus or parapatellar approach in knee arthroplasty is comparable’’ [8]. We wish to bring to your attention to the paper ‘‘Sub-vastus approach is more effective than a medial parapatellar approach in primary total knee arthroplasty: a randomized controlled trial’’ [3], as we are somewhat puzzled the authors do not reference it. That study [3] was a prospective randomized doubleblind study, with 231 patients recruited, more than 5 times the number in van Hemert et al.’s [8] study. It used robust methodology, objective and functional outcome measures, and follow-up beyond 6–12 months [3]. The study by van Hemert et al. [8] set out to investigate the early postoperative differences between the parapatellar and subvastus approaches, despite the evidence already available on the subject [1, 3–5, 9]. Van Hemert et al. [8] state: ‘‘It can be questioned whether functional differences, if any, only occur in earlier phases of recovery’’ and yet only follow-up the participants for 12 weeks post-operatively. A systematic review of medial parapatellar and subvastus approaches in total knee arthroplasty [2] suggests further trials with robust methodology, objective and functional outcome measure, and follow-up beyond 6–12 months. Functional recovery following joint replacement continues beyond 6 months. Bridgman et al. [3] found that, at 12 months follow-up, the WOMAC global and pain scores, SF36 physical function and role-physical scores, and EuroQol utility and pain scores were significantly better in the subvastus group. Functional recovery after knee arthroplasty continues beyond 6 months and up to 2 years after the index procedure [7, 8]. Therefore, we do not understand why, despite this prior knowledge, the authors still felt it pertinent to study functional differences at only 12 week follow-up. The importance of long-term follow-up after prosthetic surgery is further emphasized by Hirschmann et al. [6], who outlined how long-term studies are necessary to show whether there is any difference in prosthesis longevity between both types of approach. Van Hemert et al. [8] identify a limitation of their study as being ‘‘the relatively small sample size’’. As they only included 40 patients, despite other studies having recruited much larger samples, it may be possible that the power calculated for the study was not sufficient to detect any changes in the secondary outcome measures at the time points chosen and a larger sample size with longer followup may have yielded different results.

Minimally Invasive Achilles Tendon Stripping for the Management of Tendinopathy of the Main Body of the Achilles Tendon

&NA; Achilles tendinopathy is a common cause of disability. New nerves fibers grow from the paratenon into the Achilles tendon, and they could play a central role in the development of pain. We report the results of minimally invasive Achilles tendon stripping for Achilles tendinopathy in 47 active patients. The Victorian Institute of Sports Assessment‐Achilles questionnaire score improved from 53.8 preoperatively to 85.3 postoperatively (p < .001). After a mean follow‐up period of 40.5 months, 41 patients had resumed sporting activities at an average of 3.5 months postoperatively. A sural nerve injury was recorded in 5 patients (10.6%), and all 5 complications occurred during the first 12 cases. As a result, the technique was slightly modified, and no sural nerve neuropathy was observed subsequently. One superficial infection (2.1%) was recorded. Minimally invasive Achilles tendon stripping seems to be an effective, technically simple, and inexpensive treatment of Achilles tendinopathy. Further randomized controlled trials involving more patients are needed to confirm these outcomes. &NA; Level of Clinical Evidence: 3

Surgical management of chronic Achilles tendon ruptures using less invasive techniques

BACKGROUND Surgical management of chronic Tendo Achillis (TA) ruptures usually requires tendon grafting procedures. Several techniques have been described. We examined the outcome of three different less invasive (incisions length less than 3 cm) tendon transfer techniques in the management of patients with a chronic rupture of the TA. METHODS Of 62 patients (39 males and 23 females; mean age 44.8 years; range 29.3-62 years) with chronic TA ruptures managed operatively, 21 patients had a ≥6cm gap and underwent free ipsilateral semitendinosus (ST) graft (21 patients), whereas patients with smaller gaps had either ipsilateral peroneus brevis (PB) (20 patients) or ipsilateral flexor hallucis longus (FHL) transfer (21 patients). Outcome measures included maximum calf circumference, isometric plantar flexion strength, and the Achilles tendon total rupture score (ATRS), preoperatively and at the last follow up. We also recorded the time to return to activities of daily living (ADL) and sports, and the number of single-leg heel lifts on the affected leg at the last follow up, at an average of 35.4 months. RESULTS Patient characteristics between groups were similar. All outcome measures significantly improved after surgery (p<0.001), without differences between the three groups. Return to ADL was possible at an average of 4.5 months. Patients undergoing PB transfer had a slower return to sports compared to the other groups, at 6.9±0.5months versus 6.1±0.8 for the FHL and 5.8±0.6 for the ST groups (t-test p=0.005 and p<0.001, respectively). However, 13/14 patients (90%) in the PB group returned to high impact sports, compared to 9/12 (75%) in the FHL and 6/11 (55%) in the ST groups (Fishers test, p=0.31 and p=0.056, respectively). CONCLUSION All three techniques produced significant functional improvement, and return to sports was possible in most patients. This study does not demonstrate a clear advantage of one technique over the others.