Robert E. Leach

Surgical management of Achilles tendinitis

Inflammation of the Achilles tendon and its contiguous structures is one of the most common overuse prob lems seen in runners. There are actually several etiol ogies. Involvement of the tendon itself is secondary to areas of mucinoid or fibrotic degeneration, or may be a result of a partial rupture. The sheath (or mesotenon) may also become chronically inflammed. Retrocalca neal bursitis seems to be a separate entity with hyper trophy and fibrosis of the bursa usually occurring in conjunction with a prominent posterior superior angle of the os calcis. The vast majority of patients can be successfully treated nonoperatively; however, there is a group of patients who are refractory to nonoperative management who would like to continue running, par ticularly if they are competitive. A retrospective review of 45 surgical cases in 37 patients was performed. All but two of these patients were competitive long-distance runners. There were 24 cases of Achilles tendinitis and/or tenosynovitis, 14 cases with retrocalcaneal bursitis, and 7 with a combi nation of both. Mean followup was 3 years (range, 1½ to 8 years). Overall there were 87% satisfactory results. Ninety-two percent of the patients with involvement with the tendon and/or sheath had a satisfactory out come as compared with 71 % of patients with retrocal caneal bursitis. Passive dorsiflexion in the 29 unilateral cases improved from a mean of 17° preoperatively to a mean of 25° postoperatively. We feel that surgery offers a solution for highly motivated runners with chronic posterior heel pain who would like to continue running when conservative measures have failed.

Surgical Management of Achilles Tendon Overuse Injuries A Long-term Follow-up Study

We studied 79 cases of surgically treated Achilles ten don overuse injuries in 66 patients. Fifty-three (80%) of these patients were competitive or serious recreational runners operated on between 1978 and 1991. There were 49 men and 17 women with a mean age of 33 years (range, 17 to 59). The cases were divided into surgical subgroups based on their site of primary symp toms and abnormalities: paratenonitis (23), tendinosis (partial rupture or degeneration) (15), retrocalcaneal bursitis (24), insertional tendinitis (7), and combined ab normalities (10). Followup included a comprehensive patient questionnaire and office examination. There were 79% satisfactory (51% excellent, 28% good) and 21 % unsatisfactory (17% fair, 4% poor) results. The per centages of satisfactory results in the paratenonitis group (87%) were best and those in the tendinosis group were the worst (67%). Satisfactory results were obtained in 75% of the patients with retrocalcaneal bur sitis and 86% with insertional tendinitis. Seven of the 45 cases with longer than 5-year followup with initially sat isfactory results deteriorated with time and required re operation (16%). Of these, 4 were in the tendinosis group, 2 had retrocalcaneal bursitis, and 1 had paratenonitis. One of the 34 patients followed less than 5 years required reoperation.

Results of Surgery in Athletes with Plantar Fasciitis

Plantar fasciitis is a common cause of pain, particularly in runners and certain other athletic groups. This syndrome must be distinguished from certain other conditions, such as the tarsal tunnel syndrome and achillodynia. Conservative therapy including rest, orthotics, heel cups, anti-inflammatory agents, and icing reduce symptoms in most patients. A few athletes may need surgery to continue running. The authors released the plantar fascia and excised areas of mucinoid degeneration in 15 athletes. Fourteen returned to full athletic activity.

Reconstruction of malunited fractures of the lateral malleolus.

The cases of twenty-six patients who had a reconstructive surgical procedure for treatment of a malunion of a displaced fracture of the fibula were evaluated. In these patients, who had pain, swelling of the ankle, and stiffness at an average of six years after the injury, the malunions were classified radiographically as either occult (eighteen patients) or overt (eight patients). An occult malunion was one in which the talus remained in its normal position, but the lateral malleolus showed residual displacement, characterized by external rotation and shortening. In an overt malunion, there were similar changes in the lateral malleolus, but the talus was displaced. All of the patients were treated by osteotomy of the lateral malleolus to correct the external rotation and shortening, to reduce the lateral subluxation of the anterior aspect of the tibiofibular joint, and to restore the stability of the talus. At an average follow-up of seven years (range, six months to eleven years), twenty of the twenty-six patients were able to resume the preinjury level of activity; three had improvement in the ability to walk and in the level of functional activity, although they still had intermittent pain; and three had not benefited from the procedure.

Long-term results of surgical management of Achilles tendinitis in runners.

Achilles tendinitis is a common occurrence in long-distance runners. Although most respond well to conservative therapy, there are some who require operative intervention. The short-term results of surgical treatment are good, with a success rate more than 85%. The authors present nine successful long-term results in runners. However, in two of the runners who continued to compete and train at long distances, symptoms recurred. Reoperations were performed to permit successful running careers for five and nine years. Runners resumed their careers after the second operation by supervised training and long-distance, competitive activities.

Results of a Modified Putti-Platt Operation for Recurrent Shoulder Dislocations and Subluxations

In 78 consecutive cases of a modified Putti-Platt operation using an anterior shoulder incision, only on recurrent dislocation occurred in a 19-year-old male athlete who suffered an insulin seizure. All other patients have returned to athletic activity. This study indicates that external rotation is greater if measured with the arm at 90 degrees of abduction. Inasmuch as this is the more functional position for the arm, measurements to determine limitation of shoulder rotation should be done in this position. Results show that there is a definite individual variation in external rotation of the shoulder. The Putti-Platt operation limits external rotation by 12 degrees to 19 degrees as measured at 90 degrees of abduction. This however, has not been a functional problem in any of our patients. The modified Putti-Platt operation is a sound, surgical procedure that gives excellent functional results in an athletic population.

Anterior tibial compartment syndrome in soccer players

was initially treated with ice and elevation of the leg, but the pain persisted and he sought further attention. When he presented in our emergency room, the physical examinationshowed swelling and erythema of the right anterior tibial compartment. The compartment was tense, but both the dorsalis pedis and the posterior tibial pulses were intact. There was decreased sensation in the first dorsal web space. There was weak active dorsiflexion of the right extensor hallucis longus and of the anterior tibial muscle. Plantar flexion of the right great toe caused pain in the anterior compartment. X-ray films revealed no lesion or abnormality. The diagnosis of an anterior tibial compartment syndrome was made and the patient was taken to surgery where a complete anterior fasciotomy was performed. After decompression, the anterior tibial muscula-

Fracture of the ulnar sesamoid bone of the thumb

Skiers and physicians realize Alpine skiing involves a substantial risk of injury. However, with improved equipment and increasing emphasis on prevention there has been an apparent decrease in the number of injuries. There also seems to be a changing pattern. Although most injuries affect the lower extremity, the number of accidents involving the upper extremity seems to be increasing. A tear of the ulnar collateral ligament complex of the thumb which leads to instability of the metacarpal phalangeal joint is

The Response of Transplanted Articular Cartilage to Growth Hormone

The response of transplanted articular cartilage in dogs to a biological stimulus was studied by injecting the recipient of the homograft with growth hormone and observing the activity of H3-hydroxyproline and 35S. There was a tenfold increase in activity of H3-hydroxyproline and 35S in those animals which received growth hormone.

Ankle Injuries in Skiing

With the development of new ski equipment and improvement in skiing techniques and slope grooming, the incidence, mechanism, and type of ankle injuries suffered during skiing have changed. Ankle sprains, peroneal tendon dislocations, Achilles tendon ruptures, and ankle fractures all can happen as the result of skiing. However, the incidence of these injuries has been dramatically lowered in the past two decades. All of these injuries should be treated aggressively to allow the skier to return to skiing. The early functional treatment of acute ankle sprains will return many skiers to activity quickly. With ankle fractures, lateral subluxation of the talus must be diagnosed and will be the determinant as to whether nonoperative or operative treatment is necessary. Open reduction with plating of the fibula and early weight-bearing in a brace allows early functional return to the ankle.