Johannes I. Wiegerinck

Terminology for Achilles tendon related disorders

The terminology of Achilles tendon pathology has become inconsistent and confusing throughout the years. For proper research, assessment and treatment, a uniform and clear terminology is necessary. A new terminology is proposed; the definitions hereof encompass the anatomic location, symptoms, clinical findings and histopathology. It comprises the following definitions: Mid-portion Achilles tendinopathy: a clinical syndrome characterized by a combination of pain, swelling and impaired performance. It includes, but is not limited to, the histopathological diagnosis of tendinosis. Achilles paratendinopathy: an acute or chronic inflammation and/or degeneration of the thin membrane around the Achilles tendon. There are clear distinctions between acute paratendinopathy and chronic paratendinopathy, both in symptoms as in histopathology. Insertional Achilles tendinopathy: located at the insertion of the Achilles tendon onto the calcaneus, bone spurs and calcifications in the tendon proper at the insertion site may exist. Retrocalcaneal bursitis: an inflammation of the bursa in the recess between the anterior inferior side of the Achilles tendon and the posterosuperior aspect of the calcaneus (retrocalcaneal recess). Superficial calcaneal bursitis: inflammation of the bursa located between a calcaneal prominence or the Achilles tendon and the skin. Finally, it is suggested that previous terms as Haglund’s disease; Haglund’s syndrome; Haglund’s deformity; pump bump (calcaneus altus; high prow heels; knobbly heels; cucumber heel), are no longer used.

Eponyms of the Kager triangle.

The area of the Kager triangle contains numerous structures, diseases, approaches, or tests that are described with the use of eponyms1-6. Even the triangle itself is an eponym, named for Dr. Hans Kager7. The Kager triangle, also known as the pre-Achilles fat pad, is the region bordered by the superior part of the calcaneus, the flexor hallucis longus tendon, and the Achilles tendon7,8. Much has been written about eponyms9,10, and the use or misuse of eponyms has been discussed previously11-14. Recent publications have questioned whether eponyms should be used in medical practice or merely be reserved for use by those interested in the historical perspective15-17, but, to date, no consensus has been reached. Although the use of eponyms can cause confusion for scientific and clinical purposes, they remain a tribute to the pioneers of anatomy and pathology18,19. The problem with eponyms seems to be that the original description sometimes has been forgotten or replaced by more recent authors, leading to different meanings1,19-29. We performed an extensive review of the scientific literature to identify the original publication that described the exact structure and pathology of the area of the Kager triangle in order to provide a clear overview of its multiple eponymous structures and diseases (Fig. 1, Table I). Fig. 1 Anatomical structures in and around the Kager triangle ( Fig. 1-A ); eponymous pathologies around the Kager triangle ( Fig. 1-B ). View this table: TABLE I Overview of Eponymous Structures and Corresponding Noneponymous Terminology The Achilles tendon is located on the posterior border of the Kager triangle. The most well-known tendon of the human body was named after Achilles, a hero in the Trojan War …

Posterior Hindfoot Arthroscopy A Review

In recent years, minimally invasive surgery has developed and progressed the standard of care in orthopaedics and sports medicine. In particular, the use of posterior hindfoot arthroscopy in the treatment of posterior ankle and hindfoot injury is increasing rapidly as a means of reducing pain, infection rates, and blood loss postoperatively compared with traditional open procedures. In athletes, hindfoot arthroscopy has been used effectively in expediting rehabilitation and ultimately in minimizing the time lost from competition at previous levels. Van Dijk et al were the first to describe the original 2-portal technique, which remains the most commonly used by surgeons today and forms the basis for this review. The current evidence in the literature supports the use of 2-portal hindfoot arthroscopy as a safe, primary treatment strategy for symptoms of posterior ankle impingement, including resection of os trigonum, treatment of flexor hallucis longus and peroneal tendon injury, treatment of osteochondral lesions of the ankle, and the resection of subtalar coalitions. In this review, we present where possible an evidence-based literature review on the arthroscopic treatment of posterior ankle and hindfoot abnormalities. Causes, diagnosis, surgical technique, outcomes, and complications are each discussed in turn.

Injection Techniques of Platelet-Rich Plasma into and around the Achilles Tendon a Cadaveric Study

Background Platelet-rich plasma (PRP) injections are used to treat (Achilles) tendinopathies. Platelet-rich plasma has been injected at different locations, but the feasibility of PRP injections and the distribution after injection have not been studied. Purpose To evaluate (1) the feasibility of ultrasound-guided PRP injections into the Achilles tendon (AT) and in the area between the paratenon and the AT and (2) the distribution of PRP after injection into the AT and in the area between the paratenon and AT. Study Design Descriptive laboratory study. Methods Fifteen cadaveric lower limbs were injected under ultrasound guidance with Indian blue–dyed PRP. Five injections were placed into the AT at the midportion level; 5 injections were located anterior between the paratenon and AT and 5 posterior between the paratenon and AT. The limbs were anatomically dissected and evaluated for the presence and distribution of PRP. Results All injections into the AT showed PRP infiltration in the AT as well as in the area between the paratenon and AT (median craniocaudal spread, 100 mm; range, 75-110 mm); 1 of 5 limbs showed PRP leakage into the Kager fat pad after AT injection. All anterior and posterior injections showed PRP infiltration in the area between the paratenon and AT (median, 100 mm; range, 75-150 mm). The AT was infiltrated with PRP after 3 of 10 paratenon injections. Conclusion The “AT” and “paratenon” injections under ultrasound guidance proved to be accurate. Injections into the AT showed distribution of PRP into the AT as well as in the area between the paratenon and AT. All injections between the paratenon and AT showed PRP distribution in that area, as well as in the Kager fat pad. Clinical Relevance Different PRP injection techniques were evaluated. This aids in the optimization of PRP injections in the treatment of midportion Achilles tendinopathy.

Surgical Treatment of Chronic Retrocalcaneal Bursitis

PURPOSE The purpose of this systematic review was to analyze the results of surgical treatments for chronic retrocalcaneal bursitis (RB). METHODS Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, and the Cochrane Library (1945 to December 2010) were systematically searched for the following terms: calcaneal AND (prominence OR exostosis) OR ((retrocalcaneal OR calcan(*)) AND (burs(*) OR exosto(*) OR prominence)) OR Haglund[tw] OR Haglunds[tw] OR ((retrocalcaneal OR calcan(*)) AND (ostectom(*) OR osteotom(*) OR resect(*))). Therapeutic studies on 10 or more subjects with RB were eligible. Quality was assessed by use of the GRADE scale and Downs and Black scale. RESULTS Of 876 reviewed abstracts, 15 trials met our inclusion criteria evaluating 547 procedures in 461 patients. Twelve trials reported an open surgical technique; three studies evaluated endoscopic techniques. Differences in patient satisfaction favored the endoscopic technique. The complication rate differed substantially, favoring endoscopic surgery over open surgery. CONCLUSIONS There are many different surgical techniques to treat RB. Regardless of technique, resecting sufficient bone is essential for a good outcome. Even though the level of evidence of included studies is relatively low, it can be concluded that endoscopic surgery is superior to open intervention for RB. More evidence is a necessity to be more conclusive regarding the best surgical treatment. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.

Treatment of midportion Achilles tendinopathy: an evidence-based overview.

In Achilles tendinopathy, differentiation should be made between paratendinopathy, insertional- and midportion Achilles tendinopathy. Midportion Achilles tendinopathy is clinically characterized by a combination of pain and swelling at the affected site, with impaired performance as an important consequence. The treatment of midportion Achilles tendinopathy contains both non-surgical and surgical options. Eccentric exercise has shown to be an effective treatment modality. Promising results are demonstrated for extracorporeal shockwave therapy. In terms of the surgical treatment of midportion Achilles tendinopathy, no definite recommendations can be made.Level of evidenceIV.

Arthroscopic Treatment for Anterior Ankle Impingement: A Systematic Review of the Current Literature

PURPOSE To provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement. METHODS A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was performed. Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Two reviewers independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review. RESULTS Twenty articles were included in this systematic review. Overall, good results were found for arthroscopic treatment in patients with anterior ankle impingement. In the studies that reported patient satisfaction rates, high percentages of good to excellent satisfaction were described (74% to 100%). The percentages of patients who would undergo the same procedure again under the same circumstances were also high (94.3% to 97.5%). Complication rates were low (4.6%), particularly with respect to major complications (1.1%). The high heterogeneity of the included studies made it impossible to compare the results of the studies, including between anterolateral impingement and anteromedial impingement. CONCLUSIONS Arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the findings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome. LEVEL OF EVIDENCE Level IV, systematic review of Level II and IV studies.

Ankle Fracture Eponyms

The acute ankle fracture has often been cited as one of the most commonly treated musculoskeletal injuries. As such, considerable research has been conducted, along with many clinical studies, aiming to evaluate conservative versus surgical management, as well as radiographic classifications and long-term outcomes. Several types of ankle fractures are known historically by their eponyms. Eponyms are frequently used in orthopaedic surgery to denominate fractures, fracture-dislocations, and classifications, which are most commonly named after the physicians who first described them. In 2007, a debate entitled “Should Eponyms Be Abandoned?” evoked strong responses both in favor and against the use of medical eponyms, and added interesting insights into their current use1,2. The opponents of the use of eponyms in the medical literature recommend abandoning them because they “lack accuracy, lead to confusion, and hamper scientific discussion in a globalized world.”1 Some disadvantages are obvious. Some eponyms do not refer to the correct person but to a later researcher who made the same discovery. For example John Langdon Down did not discover the syndrome “mongolism,” but rather coined the term, which was later changed to Down syndrome because the former name was considered racist. Additionally, the person behind a medical eponym might have been involved in crimes against humanity, as was the case with Hans Conrad Julius Reiter in Nazi Germany. Other disadvantages are subtle. For example, pronunciation and spelling may be incorrect. Foreign eponyms that have diacritics (e.g., acute or grave accents) are often misspelled or mispronounced. Sometimes it is hard to establish the exact spelling when you hear someone using an eponym. Finally, an eponymous fracture or classification system is only clinically relevant when it has consequences for treatment or when it influences prognosis. This has resulted in abandoning the scientific use of many of …

Treatment of Calcaneal Apophysitis: Wait and See Versus Orthotic Device Versus Physical Therapy: A Pragmatic Therapeutic Randomized Clinical Trial.

Background: Calcaneal apophysitis is a frequent cause of heel pain in children and is known to have a significant negative effect on the quality of life in affected children. The most effective treatment is currently unknown. The purpose of this study is to evaluate 3 frequently used conventional treatment modalities for calcaneal apophysitis. Methods: Three treatment modalities were evaluated and compared in a prospective randomized single-blind setting: a pragmatic wait and see protocol versus a heel raise inlay (ViscoHeel; Bauerfeind) versus an eccentric exercise regime under physiotherapeutic supervision. Treatment duration was 10 weeks. Inclusion criteria: age between 8 and 15 years old, at least 4 weeks of heel pain complaints due to calcaneal apophysitis based, with a minimal Faces Pain Scale-Revised of 3 points. Primary exclusion criteria included other causes of heel pain and previous similar treatment. Primary outcome was Faces Pain Scale-Revised at 3 months. Secondary outcomes included patient satisfaction and Oxford Ankle and Foot Questionnaire (OAFQ). Points of measure were at baseline, 6 weeks, and 3 months. Analysis was performed according to the intention-to-treat principles. Results: A total of 101 subjects were included. Three subjects were lost to follow-up. At 6 weeks, the heel raise subjects were more satisfied compared with both other groups (P<0.01); the heel raise group improved significantly compared with the wait and see group for OAFQ Children (P<0.01); the physical therapy group showed significant improvement compared with the wait and see group for OAFQ Parents (P<0.01). Each treatment modality showed significant improvement of all outcome measures during follow-up (P<0.005). No clinical relevant differences were found between the respective treatment modalities at final follow-up. Conclusions: Treatment with wait and see, a heel raise inlay, or physical therapy each resulted in a clinical relevant and statistical significant reduction of heel pain due to calcaneal apophysitis. No significant difference in heel pain reduction was found between individual treatment regimes. Calcaneal apophysitis is effectively treated by the evaluated regimes. Physicians should deliberate with patients and parents regarding the preferred treatment. Level of Evidence: Level 1—therapeutic randomized controlled trial.

Eponyms in elbow fracture surgery.

Eponyms are common in medicine and in orthopaedic surgery. For future reference and historical considerations, we present common eponyms in elbow fracture surgery. We describe in short the biography of the name giver and give, where possible, the original description on which the eponym was based. Whether eponyms should continue to be used is a question that remains unanswered, but if we use them, knowledge of the original description can prevent confusion and knowledge of the historical background sheds light on the interesting roots of our profession.