Paul J. Hecht

Repair of Chronic Achilles Tendon Rupture with Flexor Hallucis Longus Tendon Transfer

A new technique is described for reconstruction of chronic Achilles tendon rupture using the flexor hallucis longus tendon. Follow-up on seven patients (mean age 52 years) is provided (average follow-up 17 months, range 3–30 months). All patients were re-examined to assess postoperative range of motion, scar healing, and sensation. Motor strength was assessed by Cybex testing. Subjective satisfaction was examined by completion of a questionnaire. There were no postoperative infections, skin losses, or re-ruptures. Each patient developed a small but functionally insignificant loss in range of motion in the involved ankle and great toe. All patients had a satisfactory return of function. One patient required a molded foot-ankle orthosis for extended ambulation but was able to play golf.

MR imaging of the Achilles tendon: overlap of findings in symptomatic and asymptomatic individuals.

Abstract Objective: To differentiate MR imaging characteristics of symptomatic as compared with asymptomatic Achilles tendons. Design: 1.5 T MR images of 94 feet (88 patients) with ”abnormal” MR examinations were retrospectively evaluated and clinically correlated. Two masked, independent observers systematically evaluated for intratendon T2 signal, tendon thickness, presence of peritendonitis, retrocalcaneal bursal fluid volume, pre-Achilles edema, bone marrow edema at the Achilles insertion, and tears (interstitial, partial, complete). These findings were correlated with symptoms (onset and duration) and physical examination results (tenderness, palpable defects, increased angle of resting dorsiflexion). Results: Of the 94 ankles, 64 ankles (32 females, 29 males) were clinically symptomatic. No relationship between Achilles tendon disorders and age or gender was identified. Asymptomatic Achilles tendons frequently demonstrated mild increased intratendon signal (21/30), 0.747 cm average tendon thickness, peritendonitis (11/30), pre-Achilles edema (12/30), and 0.104 ml average retrocalcaneal bursal fluid volume. Symptomatic patients had thicker tendons (0.877 cm), greater retrocalcaneal fluid volume (0.278 ml), more frequent tears (23/64), a similar frequency of peritendonitis (22/64) but less frequent pre-Achilles edema (18/64). Sixty-four percent of the Achilles tendon tears were interstitial. Except for two interstitial tears in control patients, the majority of Achilles tears were in symptomatic patients (14/16). Only symptomatic tendons demonstrated partial or complete tendon tears. In addition, calcaneal edema was found almost exclusively in actively symptomatic patients. Thicker tendons were associated more often with chronic symptoms and with tears. When present in symptomatic patients, peritendonitis was usually associated with acute symptoms. The presence of pre-Achilles edema, however, did not distinguish acute from chronic disorders. Conclusion: There is significant overlap of MR findings in symptomatic and asymptomatic Achilles tendons. Furthermore, there is apparently a spectrum of disease in symptomatic tendons ranging from subtle intratendinous and peritendinous signal to partial and complete tendon tear.

Complications after Ankle Fracture in Elderly Patients

Background: Controversy exists regarding the risks and benefits of ankle fracture treatment in elderly patients. The purpose of this study was to use the United States Medicare database to determine the complication rate for ankle fractures in elderly patients treated operatively and to compare it to fractures treated nonoperatively. Methods: We used the National Medicare Claims History System to study all enrollees who sustained ankle fractures between 1998 and 2001. A total of 33,704 patients were identified and their outcomes at numerous time points were evaluated. These outcomes included mortality, rate of repeat hospitalization, rate of medical and operative complications, and the rate of additional surgery. The predictor variables were either nonoperative or operative intervention. Covariates included patient age, gender, race, medical comorbidity status, and fracture type. Results: Patients treated nonoperatively had significantly higher mortality (p < 0.05) than those treated operatively at all time periods except for 30 days. However, patients treated operatively had significantly higher rehospitalization rates (p < 0.05) at all time periods studied. The medical and operative complication rates at all time periods were less than or equal to 2% for patients who had either operative or nonoperative treatment. In the group that had operative management, a relatively small number of patients had additional procedures. Eleven percent had removal of hardware. Less than 1% of all patients had revision of the internal fixation, arthroplasty, arthrodesis, or amputation. Conclusion: In properly selected cases, the complication rates of both operatively and nonoperatively treated elderly patients are low.

Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments

OBJECTIVE The objective of our study was to provide a pictorial survey of MR images of ankle ligaments in various conditions from intact to disrupted. CONCLUSION MR images of ankle ligaments from a sample of patients with ankle pain or injury are presented and reviewed.

Morphology of tibiotalar osteophytes in anterior ankle impingement.

The purpose of this study was to document radiographic trends in the size and location of osteophytes occurring in patients who have undergone surgical treatment of bony anterior ankle impingement. All patients over a period of 31 months who had undergone surgical excision of anterior ankle osteophytes were identified. 9 patients (10 ankles) in whom preoperative CT scans were available were selected as the study group. This group was retrospectively reviewed in terms of basic preoperative characteristics (age, sex, symptomatology, sports history, systemic disease, passive dorsiflexion). Osteophyte size was measured on plain lateral radiographs, and axial CT images were used to determine both tibial and talar osteophyte location by referencing them to the midline of the talar dome. 95% confidence intervals demonstrated that the talar spur peak lies medial to the midline, the tibial spur peak lies lateral to the midline, and the spurs typically do not overlap each other. Further, the tibial spur is wider than the talar spur, and the talar spur usually protrudes medially off the medial edge of the talar neck. Thus, there is evidence that anterior tibiotalar osteophytes may have a relatively consistent pattern of formation, with the talar spur occurring on the medial aspect of the talar neck, and the tibial spur peaking lateral to the midline. This information, if substantiated with additional patients, may provide insight into the pathophysiology of anterior ankle impingement, as well as facilitate the open and arthroscopic approaches toward resection of these lesions.

Current Concepts Review: Noninsertional Achilles Tendinopathy

Achilles tendinopathy is characterized by the clinical triad of pain, limitation in activities, and focal swelling associated with degenerative change in the tendon.27,45 The histologic change in the area of swelling and degeneration is best defined as Achilles tendinosis. Pathologic findings include areas of disorganized collagen and abnormal neovessels in the absence of inflammatory cells. Often, Achilles tendinopathy is improperly referred to as Achilles tendonitis. The clinical entity of Achilles tendinopathy often occurs in elite and recreational athletes but is also seen in more sedentary populations.68 Achilles tendinopathy is the most common tendinopathy associated with running and was diagnosed in 56% of one group of elite middle-aged runners.36 It can be characterized as insertional (at the calcaneus-Achilles tendon junction) or noninsertional (2 to 6 cm proximal to the insertion of the Achilles tendon into the calcaneus). Each type has its own pathophysiology and treatment strategies. This review will address noninsertional Achilles tendinopathy only. Considerable controversy surrounds the management of noninsertional Achilles tendinopathy. Rest, eccentric and concentric stretching exercise, nonsteroidal anti-inflammatory medications, noninvasive modalities, injections, and surgery have all been utilized. A 2001 Cochrane Review, however, found little evidence to support the use of any one particular therapy for this condition.53 The application of cytokines, growth factors, gene therapy, and stem cells for the future management of this disorder are under investigation. This

POSTERIOR TIBIAL TENDON DYSFUNCTION : SECONDARY MR SIGNS

We evaluated four potential secondary magnetic resonance imaging signs to aid in clinical diagnosis of posterior tibial tendon (PTT) tears. Seventy-one ankles (25 PTT tears and 46 controls) were evaluated for the following secondary signs: (1) PTT sheath fluid, (2) a distal tibial spur located just anterior to the PTT, (3) unroofing of the talus, and (4) “bone bruise”-like medullary lesions. Two musculoskeletal radiologists rated their confidence using a scale and were compared for level of agreement. The presence of PTT sheath fluid had modest specificity and fair to moderate sensitivity. Tibial spurring and unroofing of the talus had excellent specificity and fair sensitivity. Bone bruise-like lesions were commonly seen in cases and controls. Examination of divergence of opinion between the two radiologists revealed pitfalls in interpretation of PTT sheath fluid and bone bruise-like lesions, which were commonly the result of adjacent vessels and inhomogeneous fat saturation, respectively. We conclude that secondary signs of PTT tears with high specificities include unroofing of the talus, tibial spurring, and PTT sheath fluid.

Evaluation and treatment of chronic ankle pain.

The evaluation and treatment of chronic ankle pain presents a challenge to the orthopaedic surgeon. A detailed history helps to determine causative factors resulting from earlier trauma or surgery. A careful physical examination and radiographic studies also are helpful in making an accurate diagnosis, which is the basis for choosing a specific and effective treatment regimen.

Regional anesthesia in foot and ankle surgery

A method of regional anesthesia use in forefoot and midfoot surgery is described. Careful identification of the peripheral sensory nerves allows for effective anesthesia using bupivacaine and lidocaine in addition to sedation for comfort. A review of 355 patients showed that 98% received an effective surgical block of the sensory nerves. Complications were found to be minimal and patient satisfaction was high. This method provides a safe and effective anesthesia alternative for foot and ankle surgery.

Repair of chronic achilles tendon rupture with flexor hallucis longus tendon transfer

A new technique is described for reconstruction of chronic Achilles tendon rupture using the flexor hallucis longus tendon. Follow-up on seven patients (mean age 52 years) is provided (average follow-up 17 months, range 3-30 months). All patients were re-examined to assess postoperative range of motion, scar healing, and sensation. Motor strength was assessed by Cybex testing. Subjective satisfaction was examined by completion of a questionnaire. There were no postoperative infections, skin losses, or re-ruptures. Each patient developed a small but functionally insignificant loss in range of motion in the involved ankle and great toe. All patients had a satisfactory return of function. One patient required a molded foot-ankle orthosis for extended ambulation but was able to play golf.