William C. McGarvey

Insertional Achilles tendinosis: Surgical treatment through a central tendon splitting approach

Twenty-two heels in 21 patients treated surgically for a primary diagnosis of insertional Achilles tendinosis were reviewed on the basis of preoperative and postoperative examinations, office records, and a comprehensive questionnaire administered to each subject. Each patient underwent surgical treatment using a midline-posterior skin incision combined with a central tendon splitting approach for debridement, retrocalcaneal bursectomy, and removal of the calcaneal bursal projection as necessary. The findings at surgery revealed involvement of the middle third of the insertion in 21 of 22 cases with only one patient manifesting isolated lateral involvement. Thirteen of 22 had an associated prominent calcaneal bursal projection and four of 22 a superficially inflamed bursa. Three patients required reinsertion of the tendo Achilles via drill holes and one underwent augmentation with a plantaris tendon. Operative findings and complications were reported. Eight male and 13 female patients underwent 22 procedures (one case bilaterally) with an average follow-up of 33 months. Preoperative symptoms include presence of symptoms over a range of three months to two years and pain associated with activities of daily living (17 of 22), limitation of regular activities (six of 22), and pain present at rest in six of 22. Postoperatively, 20 of 22 patients were able to return to work or routine activities by three months; only 13 of 22 were completely pain free. Only 13 of 22 also claimed that they were able to return to unlimited activities. Overall, there was an 82% (18 of 22) satisfaction rate with surgery and 77% (17 of 22) stated they would have the surgery again.

Continuous Lateral Sciatic Blocks for Acute Postoperative Pain Management after Major Ankle and Foot Surgery

We developed a continuous lateral sciatic nerve infusion technique for postoperative analgesia. Methods: A 10-cm insulated Tuohy needle connected to a nerve stimulator was introduced posteriorly between the biceps femoris and vastus lateralis groove 10 cm cephalad from the tip of the patella. After proper positioning of the insulated needle, a 20-gauge catheter was placed in proximity to the sciatic nerve. Results: Continuous lateral sciatic infusion of 0.2% ropivacaine was associated with a significant reduction of morphine consumption by 29% and 62% during postoperative days one and two, respectively, in patients who underwent open reduction and internal fixation of the ankle. Conclusion: Continuous lateral sciatic infusion of 0.2% ropivacaine represents an alternative for acute postoperative pain control after major ankle and foot surgery.

Calcaneal fractures: Indirect reduction and external fixation

Background: The current treatment of displaced intraarticular calcaneal fractures has been surgical fixation. The objective of this study was to evaluate the use of indirect reduction with Ilizarov external fixation as a viable alternative in the surgical treatment of certain calcaneal fractures. Methods: Thirty-one patients with 33 fractures of the calcaneus (Sanders types II, III, and IV) were treated using small wire circular external fixation. A limited percutaneous plantar skin incision was used to improve reduction of the posterior facet. Fractures were evaluated by preoperative CT scans and classified by an independent observer. Patients were evaluated by physical examination as well as by the AOFAS hindfoot score questionnaire. Followup ranged from 6 months to 4 years. Results: The average AOFAS score for 18 patients available for examination was 66 (42 to 92). The average score increased to 74 for patients with more than 10 months followup and to 77 for patients with isolated calcaneal fractures. Open fractures also had early debridement and soft-tissue coverage; no deep infections were seen in this subgroup. There were 11 complications, including nine superficial pin track infections, one superficial skin necrosis under an area of fracture blister, and one deep infection in a diabetic smoker with severe hemorrhagic fracture blisters. All superficial infections responded to local pin or wound care and oral antibiotics. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done. All open fractures healed and maintained soft-tissue coverage. Conclusions: Indirect reduction and external fixation is a viable surgical alternative for intraarticular calcaneal fractures. Particularly favorable results were obtained in open fractures when soft-tissue reconstruction also was done. Advantages include shorter time to surgery, immediate weightbearing, minimal invasiveness, few serious wound problems, and no residual hardware. Disadvantages include technical difficulty, incomplete reduction of fracture fragments, and the need for secondary surgery (fixator removal).

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Disorders of the Insertion of the Achilles Tendon and Achilles Tendinitis*†

Because of its size and unique functional anatomy, the Achilles tendon is susceptible to both acute and chronic injury. This paper addresses some of these injuries, including the various forms of tendinitis as well as the various pain syndromes of the retrocalcaneal space, such as retrocalcaneal bursitis and Haglund deformity. The Achilles tendon is the continuation of the triceps surae, which originates from the medial and lateral femoral condyles as the two heads of the gastrocnemius and continues as the gastrocnemius blends with the soleus distally. The Achilles tendon inserts onto the middle third of the posterior tuberosity of the calcaneus. At the bone-tendon junction, the enthesis is composed of calcified and noncalcified cartilage. Paratenon surrounds the tendon and is able to stretch two to three centimeters with movement of the tendon, thereby allowing the Achilles tendon to glide smoothly. The tendon is vascularized by anterior muscular branches as well as osseous and periosteal vessels near the site of insertion. Although there is both a proximal and a distal intratendinous vascular supply, there are considerably fewer vessels four centimeters proximal to the calcaneus than anywhere else in the tendon5,27,44. Thus, the region of the tendon three to five centimeters proximal to the insertion is a relatively avascular zone and is the area most prone to various pathological problems, including chronic tendinitis and rupture. It is assumed that this hypovascularity is one of the causes of rupture. The anatomical structures that make up the posterior aspect of the heel are the Achilles tendon, the posterior aspect of the calcaneus, the retrocalcaneal bursa, and the pretendinous bursa. The retrocalcaneal bursa lies anterior to the posterosuperior calcaneal tuberosity and lubricates the anterior aspect of the tendon as well as the superior aspect of the calcaneus14. …

Tendon transfer fixation: Comparing a tendon to tendon technique vs. bioabsorbable interference-fit screw fixation

Tendon transfer techniques in the foot and ankle are used for tendon ruptures, deformities, and instabilities. This fresh cadaver study compares the tendon fixation strength in 10 paired specimens by performing a tendon to tendon fixation technique or using 7times20–25 mm bioabsorbable interference-fit screw tendon fixation technique. Load at failure of the tendon to tendon fixation method averaged 279N (Standard Deviation 81N) and the bioabsorbable screw 148N (Standard Deviation 72N) [p=0.0008]. Bioabsorbable interference-fit screws in these specimens show decreased fixation strength relative to the traditional fixation technique. However, the mean bioabsorbable screw fixation strength of 148N provides physiologic strength at the tendon-bone interface.

Calculation of the opening wedge for a low tibial osteotomy.

Background: Medial opening wedge distal tibial osteotomy, a relatively new technique for treatment of intermediate ankle joint arthritis, is a technically demanding procedure that requires preoperative planning to determine the size of the wedge that will restore anatomic alignment of the joint surface. The purpose of this study was to facilitate the preoperative planning process for distal tibial osteotomy by determining angular correction obtained with various wedge heights. Methods: Measurements of the distal tibia were taken from cadaver specimens to develop a database of average distal tibial widths. A distal tibial osteotomy was then done on the cadaver specimens with the placement of wooden block wedges of various heights at the osteotomy site. Preoperative and postoperative radiographic measurements of the joint surface angle were obtained on all specimens. The measured amount of angular change was compared to the mathematically predicted angular change using the formula ta θ = H/W. Results: The mathematical model accurately predicted the amount of measured angular correction of the distal tibial articular surface. There was an approximate 2-degree angular change of the articular surface per millimeter of wedge height. As the tibial width increased, a smaller amount of angular correction per millimeter of wedge height was noted, and as wedge height increased with the same tibial width, less angular correction was obtained per millimeter of wedge height. Conclusion: With appropriate preoperative planning, an accurate prediction can be made as to the amount of ankle joint correction that should be obtained with surgery. The size of the wedge that will provide the desired amount of correction can be accurately determined preoperatively.

Tendon Fixation in Flexor Hallucis Longus Transfer: A Biomechanical Study Comparing a Traditional Technique Versus Biobasorbable Interference Screw Fixation

Augmentation of the Achilles mechanism utilizing the flexor hallucis longus (FHL) tendon transfer to the calcaneus is a well-described procedure. Traditional methods for this procedure require suturing the tendon onto itself after passing it through an osseous tunnel. Tendon fixation techniques that reduce dissection and thus operative time while allowing adequate fixation would be advantageous in reducing patient morbidity from the aforementioned extended operative times. The authors suggest a new technique for transfer of the FHL to the calcaneus as a treatment of chronic Achilles tendon insufficiency. The objective of this fresh cadaver study is to compare the tendon fixation pullout strength of a traditional tendon transfer technique versus bioabsorbable interference screw fixation and, subsequently, propose a less invasive but stronger and more efficient technique for FHL transfer and fixation. Clinical implications suggest more reliable fixation that may allow faster rehabilitation after the procedure. Ten cadaver foot and ankle matched pairs were used after undergoing bone densitometry. A specimen from each cadaver pair had the flexor hallucis longus tendon sutured to itself with #1 Ticron suture (Ethicon) after being pulled through an osseous tunnel. These 10 specimens were assigned to group A. In the contralateral ankle specimen, the flexor hallucis longus tendon was placed into a 6.5-mm osseous drill hole and fixed with a 7 × 25-mm bioabsorbable interference screw. These comprised group B. Mechanical testing of pullout strength was then performed; pullout strength and mode of failure were recorded during this testing. Tendon fixation in group A averaged 127.6 N, and group B 170.28 N. By paired 2-tailed Student t test, the differences between each matched pair were statistically significant (P = 0.04529). In group A, failure occurred most often at the bone tunnel (6 of 10) and tendon midsubstance (4 out of 10). Failures at the tendon midsubstance were not included in the data analysis. All Group B failures occurred at the tendon/screw interface. According to the results of our study, the bioabsorbable interference screw fixation technique was found to resist significantly higher pullout forces than the traditional approach to flexor hallucis longus transfer. The authors feel that the interference screw technique is technically easier while having the capacity to resist higher loads; subsequent to clinical testing, it could prove a superior method of flexor hallucis longus transfer for chronic Achilles tendon rupture or tendinopathy.