Reply Clark, Robert A; Demer, Joseph L
American journal of ophthalmology,
02/2019, Letnik:
198
Journal Article
Recenzirano
...a nonzero departure angle would only be problematic for the arc of contact theory were it sufficiently different from 0° to materially affect the mechanics of ocular rotation. Despite wrapping ...around the globe for some distance posterior to their insertions, the tendon bulk produced a nonzero departure angle for all extraocular muscles, violating the fundamental premise of the arc of contact model. Funding/Support: This work was supported by the U.S. Public Health Service, National Institutes of Health grant EY008313, and an unrestricted grant from Research to Prevent Blindness to the Department of Ophthalmology at University of California, Los Angeles, USA.
Category:
Ankle; Sports
Introduction/Purpose:
Achilles tendon re-rupture (ATRR) during the subacute postoperative phase is the rupture of the repaired site combined with suture material failure ...induced by an unexpected traumatic event during postoperative months one to three after primary Achilles tendon repair. This study aimed to determine the effectiveness of conservative treatment for subacute ATRR.
Methods:
We retrospectively reviewed 390 cases (385 patients) who underwent primary Achilles tendon repair between January 2010 and August 2021. All patients had more than 12 months of follow-up and were divided into two groups based on the development of subacute ATRR (Group 1: 370 cases without ATRR; Group 2: 20 cases with ATRR). Then, we compared several outcome parameters between the groups after administering conservative treatment to those with ATRR. The baseline timepoints in Groups 1 and 2 were the primary repair and re-injury dates.
Results:
After primary Achilles tendon repair, 5.13% of patients experienced subacute ATRR. The time to performing a single heel raise (SHR) and performing ten repetitive SHRs did not differ between the groups (P = 0.281, 0.486). Likewise, isokinetic dynamometer results showed that the peak torque of 30o/s and 120o/s plantar flexions (the absolute value and the percentage to the contralateral side) also did not differ between the groups (P >0.05, each). However, the early Achilles tendon Total Rupture Score scale and the Foot and Ankle Ability Measure scores before six months were significantly lower in Group 2 than in Group 1 (both P < 0.05); at 12 months, the scores did not differ between the two groups (both P >0.05).
Conclusion:
Conservative treatment for subacute ATRR after primary Achilles tendon repair has comparable clinical outcomes to those without ATRR.
Category:
Hindfoot; Ankle
Introduction/Purpose:
Magnetic resonance anatomy of the hindfoot as seen at the level of the sustentaculum tali is intricate due to surrounding muscles, tendons, aponeurosis ...and ligaments. The objective of this work is to provide a mnemonic with illustrative figures to simplify this complex anatomical region on coronal T1-weighted magnetic resonance images (T1-MRIs).
Methods:
One hundred and twenty-four patients referred for foot and ankle complaints were scanned utilizing standard MRI imaging protocols for evaluation of the hindfoot. Only coronal T1-MRIs of the calcaneus at the level of sustentaculum tali of unremarkably reported patients were selected for the development of this mnemonic. T1- and T2-MRIs of an additional set of patients with hindfoot pathologies were selected to demonstrate how this mnemonic is adapted to identify specific pathologies.
Results:
Upon viewing the calcaneus with the adjacent anatomical structures on coronal T1-MRIs, the overall appearance resembles a ''Hen in the Nest with Four Eggs.'' The calcaneus represents the body of the hen, while the sustentaculum tali forms the head and neck. The posterior tibial tendon represents the crest of the hen, and the flexor digitorum longus and flexor hallucis longus tendons represent its beak and wattle, respectively. The peroneus brevis and peroneus longus tendons represent the tail, and the long plantar ligament represents the flexed legs of Haleem's hen. The plantar aponeurosis represents the hen's nest. Whereas the abductor hallucis, flexor digitorum brevis, abductor digiti minimi and quadratus plantae muscles are the four eggs. Pes planus, flexor digitorum brevis hemangioma, Baxter's neuropathy associated with chronic denervation abductor digiti minimi atrophy and peroneal tendonitis are some of the hindfoot pathologies that can be identified utilizing the mnemonic.
Conclusion:
The mnemonic, 'Haleem's Hen in the Nest with Four Eggs,' serves as a simplified phrase for orthopedic surgeons, radiologists and other physicians to easily recall the anatomy of the hindfoot when viewing it at the level of the sustentaculum tali on coronal T1-MRIs. In addition, this mnemonic could be particularly useful when utilized in medical education curriculum for residents, fellows, and medical students. Further research is required to validate this mnemonic as an educational tool in medical training and detail additional hindfoot pathologies that can be identified with it.
Category:
Sports; Ankle; Trauma
Introduction/Purpose:
Chronic achilles tendon injuries present several technical considerations. A reported 20-25% of acute ruptures may be missed and lead to late ...diagnosis. A commonly faced problem with chronic ruptures is the amount of tendon retraction that occurs, leading to the inability to perform a direct end-to-end repair. Previous studies have demonstrated that central turndown lengthening with addition of flexor hallucis longus (FHL) augmentation can be performed with good results, although it has been associated with post-surgical wound complications and infection. The following description is a turndown technique with FHL tendon transfer augmentation for chronic achilles rupture that allows increased fixation with a tendon to bone construct, accomplished with a minimally invasive approach.
Methods:
Dissection is made down to the Achilles rupture site. Scar tissue is debrided down to two stable ends. The residual gap is then measured and 2cm is added. This distance is then used to make a proximal incision. Dissection is performed to gastrocnemius tendinous raphe. The central third of this segment is incised perpendicularly. A quadriceps tendon harvester (Arthrex, Naples, FL) is utilized to cut in an antegrade fashion down the tendon portion percutaneously, leaving a 1-1.5cm of tendon spared distally. The tendon is pulled under and through the distal incision. A percutaneous achilles repair system (PARS, Arthrex, Naples, FL) Jig is used to span proximal tendon. FHL tendon transfer is then completed in usual fashion. Suture tails from proximal tendon are then passed through the distal end. Tension is pulled through the sutures, approximating repair. The suture is loaded onto anchors and secured into the calcaneus under tension.
Results:
Favorable outcomes have been observed following the 2 patients that have had chronic achilles repair with utilization of this minimally invasive turn-down technique with FHL transfer. At a follow up of at least 6 months, no patient has demonstrated wound dehiscence or breakdown. There have been no reports of re-rupture. All patients have been satisfied with the procedure and their level of returned function.
Conclusion:
Our method of repair with combination of central turndown procedure and FHL tendon transfer provides a suitable option for improved functional outcomes in the treatment of chronic achilles ruptures while providing a minimally invasive approach and avoiding the need for allograft tissue. By using the quadricep tendon harvester in a subcutaneous fashion, incision length can be reduced by nearly 50%. This technique can be performed with existing technologies and is readily reproducible. Using the tendon to bone fixation along with intra-tendinous shuttling, allows for excellent fixation strength, a knotless construct, and almost complete intra-substance suture placement.
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•The effect of estrogens on tendons and ligaments is poorly understood.•Research implies a positive effect of estrogens on tendon tissue biology and biomechanics.•However, results are ...in part conflicting, highlighting the need of for further in-depth research in the field.
Tendons and ligaments are crucial structures inside the musculoskeletal system. Still many issues in the treatment of tendon diseases and injuries have yet not been resolved sufficiently. In particular, the role of estrogen-like compound (ELC) in tendon biology has received until now little attention in modern research, despite ELC being a well-studied and important factor in the physiology of other parts of the musculoskeletal system. In this review we attempt to summarize the available information on this topic and to determine many open questions in this field.
Category:
Trauma; Hindfoot
Introduction/Purpose:
The surgical reconstruction of the Achilles tendon has evolved in favor of the use of percutaneous techniques over the traditional approach with wide ...approaches to reduce the complications inherent to this procedure. These percutaneous techniques can present lesions of the sural nerve. The objective of this study is to evaluate the distance of this structure with respect to the instruments used in the Dresden technique.
Methods:
Dissections were made in 16 anatomical pieces (ankles) to which a reproduction of the complete Achilles lesion was previously made and reconstructed using the technique to be studied. After this, the distance of the instrument position with respect to the sural nerve was measured, as well as other relevant measures, and the presence or absence of nerve injury was evaluated.
Results:
None of the pieces there was lesion of the sural nerve neither by direct injury nor by entrapment, in addition, an approximate distance of 10mm of the nerve was found with respect to the entry site of the percutaneous needles as described by the technique. The location of the nerve was always external to the Crural Fascia. We demonstrate a safety area in which the instruments can be used without lesions of the sural nerve.
Conclusion:
The technique described by Amlang with the use of Dresden instruments has a low rate of cutaneous complications and infection compared to the traditional approach for this injury, we find that if the risk of presenting injury is performed properly of the sural nerve is low and its reproduction, for the repair of Achilles injuries, should be considered as the first option over traditional open management.
Category:
Hindfoot; Sports; Trauma
Introduction/Purpose:
The incidence of Achilles tendon rupture in the United States is approximately 2.6 per 100,000 person years, with a significant increase in ...incidence over recent years reported. Should the acute rupture not be diagnosed promptly, as is the case in up to 20% of patients, the injury may be termed chronic. A number of operative treatment strategies for chronic Achilles ruptures have been described, including v-y tendinous flap, flexor hallucis longus tendon transfer, peroneus brevis graft and free gracilis transfer. Despite the extensive investigation of non-operative treatment in acute ruptures, there is a lack of similar research into chronic injuries. This article aims to address this gap in the literature, reporting treatment results of patients treated conservatively after being deemed unfit for operative intervention.
Methods:
A retrospective review of all patients receiving non-operative treatment for chronic Achilles ruptures, in the senior author's clinic between December 2014 and May 2019 was performed. A chronic injury was defined as occurring when there was a delay of at least 28 days between initial injury and start of treatment. Patients with a minimum final follow up of less than 6 months were excluded. All patients were managed according to the previously described Leicester Achilles Management Protocol (LAMP), an eight-week functional dynamic regime with use of a VACOped boot (OPED, Valley, Germany). Formal physiotherapy treatment was also provided following completion of the LAMP. Hospital records were searched for relevant data including patient age and sex, side of injury, time between injury and start of treatment and post-treatment Achilles tendon total rupture score (ATRS).
Results:
A total of 17 consecutive patients with a minimum follow up of 6 months were managed non-operatively during the stated time period. The cohort included eight males and nine females with a mean age of 63.4 14.3 years. The right side was injured in five cases, with the left side affected in 12. The mean time from initial injury to start of treatment was 43.9 days (range 30 - 102 days). The mean ATRS at 6 months post treatment was 53+-17.8. A total of 10 patients were also available for follow up at 12 months. The mean ATRS in these patients at 12 months was 73 +-15.2.
Conclusion:
The mean 12-month ATRS of 73 achieved is lower than figures of 89-92.5 reported in previous studies describing operative treatment. However, our results indicate that good outcomes may be achieved using a non-operative protocol in patients who decline or are unfit for surgery. Recent research reports that the mean age of Achilles rupture has increased by 0.721 years every five years, since 1953. It could therefore be likely that an increasing number of patients suffering chronic Achilles ruptures may be unfit for surgical treatment. It is important that further research into the non-operative treatment of these patients is conducted.
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