Tag Archives: Achilles tendon

Reconstruction of an Achilles rupture with 12 cm defect utilizing Achilles tendon allograft and calcaneal bone block: A case report

by Isaiah Song1*, DPM; Alvin Ngan2, DPM, FACFAS

The Foot and Ankle Online Journal 13 (4): 11

Chronic Achilles tendon ruptures, especially with extensive defects, are challenging to repair, and options are limited. We present a case of a neglected Achilles tendon rupture with a 12 cm defect, treated with an Achilles tendon allograft with a calcaneal bone block. The repair was augmented with a flexor hallucis longus (FHL) tendon transfer as well as human acellular dermal matrix. At 1-year follow-up the patient had no pain and was able to walk 2 miles at a time. There was no re-rupture of the affected limb, infection or allograft morbidity.

Keywords: Achilles tendon, chronic, tendon allograft, tendon rupture, surgical technique, FHL tendon transfer

ISSN 1941-6806
doi: 10.3827/faoj.2020.1304.0011

1 – Resident, Swedish Foot & Ankle Residency Program, Swedish Medical Center, Seattle, WA
2 – Attending Physician, Swedish Foot & Ankle Residency Program, Swedish Medical Center, Seattle, WA
* – Corresponding author: isaiahsong@gmail.com


A chronically ruptured or neglected Achilles tendon is defined as a rupture with 4-6 weeks between the time of injury and treatment [1,2]. An estimated 20-35% of Achilles ruptures have a delayed diagnosis due to unrecognized injury, misdiagnosis or late presentation [1,2]. Between injury and treatment, granulation tissue between tendon ends prevents apposition and fibrous tissue develops in the rupture site [3-5]. The triceps surae muscle continues to contract and the proximal tendon stump retracts and adheres to the surrounding fascia [6, 7]. Unrecognized injury and retraction of the tendon stump may result in large defects.

Various techniques have been described for surgical repair of the neglected Achilles tendon rupture including gastrocnemius tendon advancement, turndown flaps, autografts, allografts and tendon transfers [8-12]. Which technique provides the best outcome is unknown, and some techniques are limited to smaller defects.

We present a case of a chronic Achilles rupture with a 12 cm defect reconstructed with an Achilles tendon allograft with calcaneal bone block, augmented with a flexor hallucis longus (FHL) tendon transfer and human acellular dermal matrix.

Case Study

A healthy, very active, 71-year-old male initially presented with ankle weakness and difficulty with gait. He was treated by an outside provider for one year with presumed Achilles tendonitis. However, at presentation at the current attendings clinic, he had a palpable defect with a positive Thompson’s test for an Achilles rupture. There was minimal calf atrophy compared to the contralateral side. His gait was antalgic and apropulsive with poor balance. MRI demonstrated an Achilles rupture with approximately 9 cm retraction. The patient was initially offered permanent bracing because of his age. However, due to his good health, and very active lifestyle, he elected for surgical repair understanding the potential limitations of achieving a full recovery given the longstanding misdiagnosis. The patient was counseled on the probable use of allograft and tendon transfer because of the extensive defect.

Figure 1 Intraoperative appearance of the chronic rupture site, interposed with fatty and mucoid diseased tissue or “pseudotendon”.

Figure 2 The proximal excised portion of the diseased Achilles.

Surgical technique

The patient was placed prone on the operative table under general anesthesia with a thigh tourniquet. A linear incision was made just medial to the midline of the Achilles tendon and deepened to expose the tendon. The rupture site was identified. The defect had filled with interposed scar tissue, with fibrofatty and mucoid consistency. This non-viable tissue was excised proximally to the level of the gastrocnemius aponeurosis which was noted to be healthy. The degenerated tissue extended distally to the Achilles insertion, with minimal healthy tendon attachment to the calcaneus. Following debridement and excision of diseased tissue, the defect measured 12 cm with the ankle in near maximal plantarflexion.

Figure 3 Additional excision of nonviable, calcified degenerated tissue at the distal Achilles stump.

A frozen Achilles tendon allograft with calcaneal bone block was thawed and pre-tensioned to minimize viscoelastic creep. The calcaneal block portion of the allograft was fixated first, by creating a rectangular cut-out for insertion in the superior aspect of the patient’s calcaneus. The calcaneal bone block was tamped into place and fixated with 2 crossed 3.5 cortical screws with washers.

Before attachment of the allograft proximally, the ankle was placed in 30 degrees of plantarflexion to create a tensioned repair. The proximal portion of the Achilles allograft was then sutured to the gastrocnemius aponeurosis with approximately 3 inches of overlap utilizing a combination of simple interrupted and Krackow suturing, with #2, and #2-0 fiberwire.

In order to improve strength and vascularity to the repair, an FHL transfer was also performed. The FHL tendon was harvested by releasing at the level of the posterior talus, sewn alongside the medial aspect of the Achilles at anatomic tension. The musculotendinous portion of the FHL was also sutured to the undersurface of the proximal repair site with the intent to bring vascularity closer to the repair.

Finally, a human acellular dermal matrix product was sewn over the proximal repair with 3-0 Vicryl, to provide reinforcement, and scaffolding for host tissue ingrowth. The incision was irrigated, the tourniquet was released and the patient was placed into a non-weight bearing compression splint with anterior and posterior slabs.

Figure 4 Planning of graft placement following excision of the chronic rupture.

Figure 5 The proximal Achilles allograft was sutured into the gastrocnemius aponeurosis after securing the distal calcaneal block with 2 crossed screws.

Figure 6 A human cellular dermal matrix was overlaid as the final step.

Figure 7 Patient demonstrating ability to perform partial heel rise on the reconstructed side.

Figure 8 Patient demonstrating ability to perform heel rise on the contralateral side for comparison.

Post-operative protocol

The patient was splinted for 14 days and remained non-weight bearing. Following suture removal, the patient was casted in plantarflexion, remaining non-weight bearing for the next 4 weeks. At 6 weeks, the patient was referred to physical therapy and was also transitioned to weight bearing in a walking boot with heel lifts and progressed gradually to neutral by decreasing the heel lifts. At 12 weeks, he was transitioned out of a boot to a shoe.

Results

The patient had no complications during follow-up. At 1 year follow-up, the patient reported no pain and was able to return to normal daily activities, and walk 2 miles. His range of motion was symmetrical to the contralateral side, and manual muscle testing revealed only slight weakness. He was able to perform heel rise symmetrical to his contralateral side. X-rays showed incorporation of the calcaneal block graft. He was overall pleased with the surgery.

Figure 9 Postoperative x-ray showing incorporation of the calcaneal bone block portion of allograft.

Interestingly, he was more bothered by contralateral Achilles pain. Initially this was presumed to be compensatory tendonitis. After failing conservative care, he had ultrasound evaluation, as MRI was contraindicated due to interval placement of a pacemaker. His contralateral Achilles showed findings consistent with tendinosis or chronic tearing. During this ultrasound, his reconstructed Achilles was also examined and it showed expected findings of stable appearing heterogeneous texture of the Achilles allograft with no rupture.

While the patient was satisfied with his reconstructed Achilles, he felt he was more limited by his contralateral Achilles tendinosis and eventually elected for surgery on that side as well.

Discussion

Large defects following Achilles ruptures are challenging. Delay in diagnosis may lead to retraction of the tendon stump, and atrophy of the gastrocnemius muscle. Furthermore, if significant tendinosis was present prior to rupture, the actual defect may be larger than presumed following debridement. Ofili in 2016 reported that MRI underestimates the true extent of Achilles tendinosis [18]. Indeed, our patient had a 12 cm defect following debridement despite MRI initially predicting a 9cm defect.

While smaller defects may be typically treated by gastrocnemius advancement or flap, there is no consensus on how to manage larger Achilles defects. In the author’s experience, gastrocnemius advancement techniques allow repair of only up to 6-8 cm defects. Our patient had a 12 cm defect and therefore, with limited repair options, it was felt appropriate to utilize Achilles tendon allograft. Additionally, given the significant disease in the distal stump at the insertion, there was no viable tissue to suture the Achilles allograft, and therefore the calcaneal bone block proved useful for distal reattachment. One risk of a calcaneal bone block would be delayed or non-union. Deese in 2015 and Ofili in 2016 have reported delayed union with incorporation at the calcaneus. [12,19] Our patient showed radiographic healing at 6 weeks post-op.

Reconstruction using an Achilles tendon allograft with a calcaneal bone block has previously been demonstrated to have good results [18,19]. These studies did not include an FHL transfer. The FHL transfer is a relatively simple, in-phase transfer with the potential benefits of increasing strength of the repair and providing additional plantarflexion power. Additionally, the FHL transfer theoretically may provide additional vascularity from the flexor hallucis muscle belly to the repaired Achilles. The FHL transfer has been shown to have high patient satisfaction and minimal donor morbidity has been noted with this procedure [21-24]. From a technical standpoint, the use of a calcaneal bone block with screw fixation may limit the ability to secure an FHL transfer with biotenodesis as creating an additional bone tunnel adjacent to the screws may create stress risers. Therefore in the current case the FHL tendon was sutured side by side instead.

Disadvantages with allograft procedures are the risk of disease transmission, longer allograft incorporation time, and increased cost. There is also a potential amount of creep in allograft tendons. In addition, Hanna in 2014 reported that 4 of 6 patients with an Achilles allograft with calcaneal bone block ambulated with a limp and complained of weakness at 16-32 months [18]. It is important to counsel patients with longstanding neglected ruptures, that recovery of full strength may not be possible. Our patient, however, appeared to be able to perform a symmetrical appearing single heel rise on examination.

In our case, we augmented the allograft repair with FHL transfer and human acellular dermal matrix. Human acellular dermal matrix acts as a scaffold for host revascularization and cellular growth. [25] A few studies have described acellular dermal matrix augmentation to strengthen an Achilles tendon rupture site, all with favorable outcomes without any re-ruptures. [26-29] Therefore, the final addition of the dermal matrix in our patient was intended to assist with incorporation of the large allograft.

In conclusion, Achilles tendon reconstruction with tendon-bone block allograft augmented with FHL transfer and a human acellular dermal matrix may successfully repair a severely degenerated and neglected Achilles tendon rupture. We believe this technique can be useful for Achilles tendon ruptures with large deficits up to, and perhaps more than 12 cm.

Acknowledgements

Thank you to the Swedish Medical Center Foot and Ankle Surgery Residency Program for the support. Additional thanks to Drs. Brian Rougeux and Bryn Rowe for early input into this case study.

References

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  16. Hansen U, Moniz M, Zubak J, Zambrano J, Bear R. Achilles tendon reconstruction after sural fasciocutaneous flap using Achilles tendon allograft with attached calcaneal bone block. J Foot Ankle Surg. 2010;49(1):86.e5-10.
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Heel spoke wheel injuries in a community hospital in Togo

by Gamal AYOUBA PhD1*, Komla Séna AMOUZOU PhD2, Batarabadja BAKRIGA PhD3, Kouami AMAKOUTOU PhD4, Noufanague Kanfitine KOMBATE PhD5, Anani ABALO PhD2

The Foot and Ankle Online Journal 13 (2): 4

Motorcycles are one of the commonly used vehicles in our setting. Injuries caused by the wheels of the spokes to the heel engage the functional outcome of the foot and ankle. We aim to report the patterns of these injuries and the results of the treatment of such injuries in our community hospital. This prospective observational study included all cases with spoke wheel injury to the heel presenting between June 2014 to October 2018 in a community hospital in Kpalime, a city located northwest to the capital of Togo. Demographic and clinical data were collected from each patient including age, sex, occupation, injured side, and characteristics of the wounds. The wounds were grouped into those with Achilles tendon injury and those without Achilles tendon injury. The soft tissue injuries were classified according to Tscherne and Gotzen classification and managed accordingly. The AOFAS hindfoot score was used to assess the clinical outcome. Twenty-six patients were included, 13 females and 13 males. The mean age was 16 years (range 4-56 years). Seventeen patients were children (aged under 16 years). The right foot was affected in 21 patients and the left foot in 5 patients. The injury was classified as grade 2 (n=15) and grade 3 (n=11) of Tscherne and Gotzen. Wounds with Achilles tendon involvement accounted for 17 and without Achilles tendon accounted for 9. The mean time from injury to surgery was 18.4 hours (range 3-72 hours). Healing was achieved in 12 patients without complications. Complications included wound dehiscence (n=2), cutaneous necrosis and local infection (n=10), superficial infection (n=2). Secondary procedures performed were wound debridement (n=3) followed by skin graft (n=3), sural pedicled flap (n=2). The mean follow-up was 16.7 months (range 4-20 months). The average AOFAS score was 86.8 (range 64 – 100). The heel injuries are one of particularity of road traffic trauma in our setting. The outcome depends upon the involvement of Achilles tendon, an associated calcaneal fracture, and a high grade Tscherne and Gotzen classification.

Keywords: heel, spoke wheel, wounds, Achilles tendon, motorcycle, Africa

ISSN 1941-6806
doi: 10.3827/faoj.2020.1302.0004

1 – Department of orthopaedic and traumatology. Community Hospital of Kegue. University of Lomé. Togo
2 – Department of plastic and reconstructive surgery. University Hospital of Sylvanus Olympio. University of Lomé. Togo
3 – Department of orthopaedic and traumatology. University Hospital of Sylvanus Olympio. University of Lomé. Togo
4 – Department of orthopaedic surgery. University hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
5 – Department of orthopaedic and traumatology. Hospital of Saint-Jean de Dieu d’Afagnan, Togo
* – Corresponding author: gamal792003@yahoo.fr


Motorcycles are one of the most popular means of transportation in developing countries including sub-Sahara African countries such as Togo. Accidents associated with motorcycles are common among road traffic accidents in urban and rural areas in developing countries [1]. In Togo, during the first semester of 2019, motorcycles were involved in more than 51.36% of road traffic accidents [2]. The incidence of motorcycle spoke injuries to the heel has shown some specific features among road traffic accidents ranging from a simple laceration to a total traumatic foot amputation. [1,3-5]. Children make up a large proportion of the victims of these accidents [2]. The involvement of the Achilles tendon makes it a challenge for the orthopedic surgeons. In these cases, the exposure of the bony part of the Achilles tendon required a vascularized soft tissue resurfacing.

The main objective was to report data related to heel injuries and the secondary objectives of this study was to report patterns of the injury to the heel caused by spoke wheel, the management of these injuries, and the functional outcome.

Materials and Methods

This prospective study was carried out between June 2014 and October 2018 and included patients treated for motorcycle spoke injuries to the heel in the Department of Surgery at the community hospital of Kpalime, a city located 120km northwest from the capital of Togo in West Africa. The following demographic and clinical data of patients were recorded: gender, age, type of occupation, affected side, injury of Achilles tendon, associated injuries, number of surgical procedures and the course of treatment. We identified two groups of patients according to the clinical presentation of the wound: wounds with Achilles tendon involvement and wounds without Achilles tendon involvement. Soft tissue injuries were classified according to Tscherne and Gotzen [6] classification. Anteroposterior and lateral X-rays of the ankle were obtained in the Emergency Department. The functional outcomes were assessed using the AOFAS score (The American Orthopedic Foot and Ankle Score).

Results

Clinical and socio-demographic characteristics

The study included 26 patients, 13 males and 13 females. The average age of the patients was 16 years (range, 4-56 years). Children (under 16 years old) accounted for 17, while adults (patients above 16 year-old) accounted for 9. All the adult patients were on the back seat and were wearing sandals at the time of the accident. As a mechanism of injury, the spokes of the wheel caught the heel of the patient just after the wheels had slipped over a bump of the road. The children were seated between their mother on the back seat and the rider of the motorcycle. Their feet were dangling and caught by wheel spoke. The wound was located on the vertical bony aspect of the heel or in some cases extended from the medial to lateral aspect of the heel. The wound was located on the posterior bony surface and extended 2 to 6 cm proximally in nine cases (Figure 1A), on the posteromedial aspect in 5 cases and on posterolateral (Figure 1B) aspect in 2 patients.

Figure 1 A: Posterior wound with complete section of Achilles tendon, B: Postero-lateral wound laceration, Achilles tendon partially sectioned, C: Semicircular laceration with Achilles tendon tearing and calcaneus fracture.

In the group with Achilles tendons involvement (17 patients): 7 had tendon tearing, 8 had complete section and 2 had partial section of the Achilles tendon. The wound of the heel was semi-circular in 10 patients (Figure 1C).

In 10 patients there were some associated injuries such as calcaneus fracture (5, 19%), tibia fibula third distal fracture (4, 15%), a particular calcaneus enucleation and one toes extensors tendons section. The demographic characteristics of the patients and the clinical presentations are reported in Table 1.

Treatment protocol

All patients received upon arrival in the emergency department, IV antibiotic (amoxicillin acid clavulanic 1g) and tetanus prophylaxis. The wounds were treated with abundant irrigation, drainage, and debridement. All sectioned Achilles tendons were sutured using the Kessler suture technique using non-absorbable suture. In a case of osseous disinsertion, the tendon was fixed to the calcaneal tubercle using a non-absorbable suture. The ankle was kept in a plantar flexion with circular POP for 3 weeks in all patients with Tscherne and Gotzen grade 3. In patients presenting with grade 2, an anterior POP slab maintained the ankle in a moderate plantar flexion for 10 days. In all cases, there was a window for the wound’s daily assessment during the first week (Figure 2) and until the wound is totally healed. In 4 patients tibial and or distal fibula fractures were associated with heel injury.

Figure 2 Window in the plaster contention for the wound assessment.

Figure 3 A: healing after skin graft, B: healing after sural pedicled flap.

The treatment of these fractures was a non-operative management using a long leg slab which was kept until wound healing. Then, the POP slab was replaced by circular contention. In a particular patient with calcaneus enucleation, after wound debridement a bone cement was used to fill the space. All patients received postoperatively the IV amoxicillin and clavulanic acid as antibiotic prophylaxis for 3 days. Rehabilitation began after removal of the splint in all patients. All adult patients were sent to physiotherapy for 2 consecutive weeks. Self-physiotherapy was established and encouraged in children.

Therapeutic Results

The average waiting time for surgery was 18.4 hours (range, 3-72 hours). The outcome after surgery at 3-weeks follow-up is summarized in Table 2. The healing of the wound was obtained in 12 patients (48%) without any complication.

Revision procedures were required in 14 patients. For a patient who had an enucleation of the calcaneus, the bone cement, which was put in during the index procedure, was removed after two weeks and then the wound was closed. The calcaneus space was filled with soft tissue. The Achilles tendon was fixed to soft tissues in a neutral position of the ankle. Table 3 summarizes the different revision procedures in the Tscherne and Gotzen grades.

The average duration of immobilization was 3.3 weeks (range, 3-6 weeks). The average healing time was 25 days (range to 20-49 days). The average length of stay in hospital was 10.3 days (range, 2-24 days). Postoperative complications included cutaneous necrosis in 13 patients, and superficial infection in 2 patients, Achilles tendon necrosis in one case. The long-term complications included an obvious disturbance in walking patterns in four cases, ankle instability in four cases, hindfoot varus of 6° in two cases. The flexion/extension range of motion of the ankle was between 15° and 30° in four cases. There were unsightly and retractile scars in eight cases. The mean follow-up (Figure 3) was 16.7 months (range, 4-20 months). The average AOFAS score was 86.8 (range, 64 – 100). The AOFAS score in patients who had Achilles tendon injury was 86.1 versus 88.2 for patients without Achilles tendon injury (p = 0.67).

Discussion

The incidence of motorcycle spoke injuries to the heel has been increasing in developing countries especially in Africa and Asia [3,5,7]. In Nigeria an incidence of 4.26% has been reported among all road traffic trauma in a 10 years retrospective analysis published in 2017 by Agu TC [1]. These specific injuries occurring in the road traffic trauma affected mostly children [1,3,5,7] as confirmed in the current study. The overload of the motorcycle, inadequate footwear and sometimes bumpy roads are the main contributing factors to spoke injuries to the heel [2,4].

Our study, as well as past several studies, showed that motorcycle spoke injury is always unilateral, mostly confined to the right foot [3,4, 8]. This could be explained by the fact that the left foot is often protected by the motorcycle chain guard cover shield and therefore rarely injured.

Items N %
Sex Male 13 50
Female 13 50
Age Adult [>16 y] 9 35
Children [≤16 y] 17 65
Occupation Students 21 81
Farmers 4 15
Craftworker 1 4
Affected side Right 21 81
Left 5 19
Tscherne and Gotzen classification Grade 1 0
Grade 2 15 58
Grade 3 11 42
Achilles tendon involvement Without Achilles tendon involvement 9 35
With Achilles tendon involvement 17 65
Associated injuries None 15 58
Toes Extensors tendon section 1 4
Calcaneus fracture 5 19
Calcaneus enucleation 1 4
Tibia / fibula distal fracture 4 15

Table 1 Demographic and clinical data of the patients.

Grade Tscherne and Gotzen Healing Dehiscence of the wound Cutaneous necrosis Superficial infection Total
Grade 2 8 2 4 1 15
Grade 3 4 0 6 1 11
Total 12 2 10 2 26

Table 2 Three weeks postoperatively follow-up in the Tscherne and Gotzen grades.

Grade of Tscherne and Gotzen Healing by secondary intention Debridement + healing by secondary intention Skin graft Sural reverse pedicled flap Total
Grade 2 3 2 1 1 7
Grade 3 3 1 2 1 6
Total 6 3 3 2 14

Table 3 Second procedures according to the stage of Tscherne and Gotzen.

The shoe wearing could reduce the severity of the injuries, but the study of Naumeri et al. did not confirm this precaution [3]. The injuries are less severe (grade 0 and 1) in case of involvement of bicycle thus to low velocity of them [9]. But in our study the injuries were severe (grade 2 and 3) with extensive wound, degloving of the heel pad, and multiple associated injuries (tibia /fibula fractures, extensor tendon injuries, and a rare case of calcaneus extirpation). The injury can extend to all aspects of the heel in a semi-circular shape. In case of rupture of the Achilles tendon, the location could vary between 1 and 8 cm according to the different authors [4,10,11]. The severity of the soft tissue damages associating multiples injuries have been described by several authors [2,5,11]. This is a high velocity trauma due to wheel spokes, especially when riding at high speed. No main vascular pedicle was injured in our study. This complication has not been reported in the literature. There is no unanimous classification to describe motorcycle spoke injuries of the heel. Most authors used the classification of Tscherne and Gotzen. In our study, the treatment as well as the prognosis were evaluated using this classification. However, this classification gives little details about the fracture of the calcaneus, the rupture of the Achilles tendon and the other associated injuries.

The Grade 2 injuries required debridement and suturing of the wound without tension. The monitoring of the wound is important especially over 48 hours postoperative because secondary necrosis and sepsis are common at this step [3]. In some cases, in this study, patients initially classified grade 2 were managed secondarily for a reverse sural flap due to cutaneous necrosis. All grade 3 injuries in our study had Achilles tendon injury which was a partial or a complete rupture. The repair technique was similar to the common technique used in the literature [2,9]. Two sural pedicled flaps were performed because of secondary skin necrosis. This is the most common flap for the management of skin loss of the heel [3], [12,13]. Postoperative complications are common in motorcycle spoke injuries of the heel because of the extent of the injury and the population that is mostly affected [4,7,11].

The healing time and the duration of the hospital have not been reported to the grade of Tscherne and Gotzen. These parameters had been influenced by the complications in many patients requiring a secondary procedure. Also, Agu TC [1] found that the average duration of hospital stay was more than 3 weeks, and this depended on the degree of the injury. The major injuries including heel pad avulsions and ankle fractures stayed beyond 3 weeks in the hospital [1]. Naumeri and al [3] found that healing time was markedly increased in grade III injuries. Nevertheless, the global outcome was excellent in all patients on the AOFAS grading. However, there has been a better outcome (p=0.67) in the group of patients without Achilles tendon involvement compared to the group with Achilles tendon injuries. Only two patients that were poor had calcaneus enucleation (AOFAS=64) and Achilles tendon necrosis (AOFAS=65). In the patient with Achilles tendon necrosis, the infection and delayed treatment have hindered the reconstruction of the necrosed Achilles tendon leading to the poor result. In the second patient the loss of calcaneus had led to lack of heeling support with disturbance in walking pattern and loss of hind foot alignment which was 11° of valgus.

This excellent outcome due to the early presentation of the patients, the appropriate and timely care given, and the young ages of patients involved.

Conclusion

The heel injuries caused by motorcycle spoke wheels are a one of particularity of road traffic trauma in our setting. The difficulty to manage such patients starts with the difficulty to clinically assess the wound as no classification exists for such injuries, and to obtain reliable skin coverage. The high rate of complications works against patients that are part of the population that needed to stand for its daily food. The outcome depends upon the involvement of Achilles tendon, and a high grade of Tscherne and Gotzen and associated injuries such as calcaneus fracture. We had a satisfactory final outcome in mostly all of our patients. A dedicated team of orthopedic and plastic surgery could contribute to minimize the complications and expedite care, thus resulting in a faster return to work.

Funding declaration.

No funding to declare

Conflict of interest.

Authors declare that they have no competing interest in relation with this manuscript

Reference

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  2. Annual road traffic report. Ministry of road traffic security in Togo.
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  4. Awe AA, Esezobor EE, Aigbonoga QO. Experience with managing open Achilles tendon injuries in a tertiary hospital in southern nigeria. J West Afr Coll Surg. dec 2015;5[4]:30.
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Open tongue-type calcaneal fracture treated with the external fixation bent wire technique

by Dalton Ryba DPM1*, Jordan James Ernst DPM MS2, Kyle Duncan DPM3, Alan Garrett DPM FACFAS4

The Foot and Ankle Online Journal 11 (4): 3

Traditionally, tongue-type calcaneal fractures have been treated using internal fixation. External fixation has been described to a lesser degree in the treatment of these injuries, though not in the setting of an open fracture. We present a case of an open tongue-type calcaneal fracture treated with external fixation, utilizing a tensioned wire affixed to the frame that imparts compression across the fracture site. With this method, maximal respect to the soft tissues is rendered, and soft tissue insult is minimized. This patient achieved timely soft tissue coalescence and fracture union, with a return to pre-injury activities. To our knowledge, this technique has not been previously described in the treatment of an open calcaneal fracture of the posterior tuberosity.

Keywords: Achilles tendon, avulsion fracture, circular frame, Gustilo-Anderson, Ilizarov technique

ISSN 1941-6806
doi: 10.3827/faoj.2018.1104.0003

1 – Chief Foot and Ankle Surgery Resident, Dept. of Orthopedics, John Peter Smith Hospital, Fort Worth, Tx
2 – Fellow, Foot and Ankle Deformity Correction, The Paley Institute, West Palm Beach, Fl
3 – Attending, North Texas Foot and Ankle, Las Colinas, Tx
4 – Attending, Foot and Ankle Surgery, Dept. of Orthopedics, John Peter Smith Hospital, Fort Worth, Tx
* – Corresponding author: dalton.m.ryba@gmail.com


A fracture of the calcaneus, despite being the most common fracture regarding the tarsal bones, occurs only 11.5 instances in 100,000, according to a 10 year epidemiological study [1]. Open calcaneal fractures are diagnosed in merely 5-13 percent of these injuries collectively [2-5]. The surgical indications for calcaneal fractures are controversial. Soft tissue complications are abundantly reported in the literature concerning open reduction internal fixation of closed calcaneal fractures [6-9]. In fact, there is literature advocating non-operative treatment of displaced intra-articular fractures to attempt prevent these soft tissue complications [10]. However, an open calcaneal fracture is considered a surgical emergency. This situation presents a unique surgical obstacle regarding initial stabilization and definitive fixation. A variety of techniques have been described in the initial and subsequent management of open fractures in general [11-16]. The literature, however, is scant with recommendations addressing minimally invasive soft tissue friendly surgical options for open calcaneal fractures.

The primary goals of open fracture management include prevention of infection and soft tissue compromise, which can be achieved through aggressive surgical irrigation and debridement, parenteral antibiotics, anatomic reduction of the fracture and stabilization of the osseous fragments.

Osseous union and restoration of function are also sought, as with treatment of any orthopedic injury [17]. This often requires a staged surgical approach with initial debridement and often external fixation for stabilization, followed by internal fixation once soft tissues have coalesced [18]. This protocol, although arguably the gold standard in open fracture management, is not without drawbacks. These includes increased hospital and patient costs, length of hospital stay and associated risks such as deep vein thrombosis, as well as risks of anesthesia [19-23].  The primary aim of this case report is to present a single stage technique for the treatment of open tongue-type calcaneal fractures. In this report, one patient with an open calcaneal fracture underwent irrigation and debridement with application of external fixation and fracture fixation through bent wire technique, achieving a favorable outcome. Despite some literary evidence supporting multi-staged surgical management of open calcaneal fractures, this report provides a single stage technique that has shown promise regarding reduction of soft tissue complications and return to function, while reducing the aforementioned multi-stage surgical pitfalls.

Methods

A single patient received external ring fixation with bent wire technique after presenting to the emergency department with an open tongue-type calcaneal fracture. This was a work related injury resulting from a steel beam impact and laceration through a work boot. Clinically the patient presented with a medial heel deficit measuring 1.0 cm x 6.0 cm down to the level of bone, with minimal gross debris present (Figure 1). An adjacent full thickness deficit was noted to the plantar heel, not extending to bone (Figure 1). Tenting of the posterior heel was evident. The patient was deemed neurovascularly intact on examination. Standard radiographs diagnosed an isolated tongue-type calcaneal fracture (Figure 2), with evidence of intra-articular involvement of the posterior facet visualized on CT scan (Figure 3). The patient received TDaP tetanus vaccine and Ancef upon arrival to the emergency department.

Figure 1 Clinical photograph of the patient upon presentation to the emergency department. The large medial defect extends to bone. The smaller, more posterior defect, did not extend to bone. There was no evidence of gross contamination.

Figure 2 Lateral radiograph demonstrating the tongue-type calcaneal fracture with significant displacement.

Initial bedside irrigation and debridement was performed, however closed reduction of the posterior tuber avulsion was unsuccessful. Verbal and written consent was obtained to then proceed with surgical intervention.

Figure 3 A CT scan clearly demonstrates the intra-articular nature of the fracture. Soft tissue emphysema is clearly evident.

Figure 4 Intraoperative fluoroscopy demonstrates anatomic reduction of both fracture lines

Figure 5 Closure of the medial heel defects using subcuticular Monocryl.

Operative Technique

The patient received IV antibiotics preoperatively and under mild sedation was brought into the operating room. He was placed supine on the operating table. A formal surgical “time-out” was performed in which the patient, procedure and site were identified. The patient underwent general anesthesia without complication and the operative limb was scrubbed, prepped and draped in usual aseptic manner. A tourniquet was not raised so as to appropriately control hemostasis intra-operatively. The soft tissue defect was irrigated with 9 liters of sterile saline and closed primarily utilizing subcuticular Monocryl® (poliglecaprone, Ethicon, Inc., a division of Johnson & Johnson, Somerville, NJ). After application of a standard pre-built multi-plane Ilizarov external fixator to the operative extremity, two k-wires were placed in bicortical fashion through the superior fragment of the calcaneus and a single k-wire was placed through the inferior fragment, also bicortically. Manually, the superior wires were then bent down to the frame inferiorly, imparting compression across the fracture site. Tensiometers were then used to tension the wires to the foot plate at 75N. After tensioning, intraoperative fluoroscopy was utilized to confirm anatomic reduction and fracture compression (Figure 4). A secondary fracture of the plantar aspect was also noted on fluoroscopic imaging and fixated using two 2.0mm Steinmann Pins. The incision site was closed with subcuticular Monocryl (Figure 5). An incisional negative pressure wound vac was applied to the site of open fracture and the operative extremity was placed in a compressive dressing. The external fixator was then dressed in a sterile surgical dressing. Immediate post-operative radiographs are presented in Figure 6.

The patient was admitted for IV antibiotics based on our facility’s open fracture protocol.  The incisional vac was removed prior to discharge at post-op day 2. The laceration was reinforced with simple suture after debridement of mild skin edge necrosis at the apex.

Figure 6 Postoperative lateral radiograph demonstrating anatomic fracture reduction.

Figure 7 Clinical image at 2 weeks postoperatively after suture removal. The Steinmann pin was removed as well due to loosening.

Figure 8 Clinical image at 5 weeks showing the superficial nature of the wound.

Figure 9 Trabeculation is seen across the fracture lines on lateral and lateral oblique radiographs at 5 weeks post-operatively.

Results

The patient was evaluated in clinic at one week and two weeks postoperatively for soft tissue scrutiny. In the interim, the patient had been undergoing twice weekly dressing changes via home health with packing changes to area of apical necrosis and silver dressings along the coapted skin edges.

Figure 10 Lateral radiograph at 10 weeks postoperatively with union noted at the primary fracture line.

Figure 11 Union of both fracture lines is appreciated at 4 months post-operatively.

Sutures were removed at two weeks as well as the Steinman pin due to loosening (Figure 7). The apical wound was addressed in clinic with serial packing and ultimately porcine trilayer grafting. At 5 weeks, the wound was superficial (Figure 8 a,b). Trabeculation could be appreciated radiographically at this time via standard radiograph (Figure 9). Osseous union was visualized at eight weeks postoperatively. The patient underwent external fixator removal (Figure 10) and amniotic graft application at 9 weeks postoperatively for stagnant healing of the apical wound.

Figure 12 Clinical image of the patient 10 months post-operatively.

The patient was then transitioned to full weight bearing over the next four weeks with progression through a controlled ankle motion boot. Radiographs at 4 months display union of both fracture lines (Figure 11). At the most recent appointment, 10 months post-operative, patient has returned to work without restrictions. Currently, the patient’s only complaint is intermittent pain and tenderness to touch along the medial heel. According to the patient, the frequency of these sensations has slowly decreased over time. It is unclear at this time to what extent his neuritic symptoms will resolve. His medial heel has remained ulceration free and is in neutral position in resting calcaneal stance position (Figure 12 a,b). It was noted that the patient had a slight increase in heel width, however the patient was able to return to tennis shoes and work boots that he was wearing pre-injury without complaints.

Discussion

In their seminal work Takahashi, Mitsuaki, and Saegusa described a technique treating a similar calcaneal fracture presentation. Although their case report describes a closed injury, the principles of careful soft tissue management remain the same through the application of external fixation. While their efforts attempt to prevent an impending open fracture, the so called “open fracture in evolution”, we present an attempt to prevent further insult to an already compromised soft tissue envelope. In closed injuries, the “Hurricane Strap” form of internal fixation that we have previously described has been our preferred fixation modality for tongue-type calcaneal fractures. Ilizarov fixation was first described for this fracture pattern by Ramanujam et al., however, the reduction was maintained by placing the ankle in plantarflexion by way of the fixator and thus reducing the deforming force of the Achilles tendon. In their technique, Steinmann pins are placed across the fracture site but not affixed to the frame. Yet, prolonged immobilization of the ankle joint in a high degree of plantarflexion could result in contracture that would make weight bearing after fixator removal difficult. Takahashi et al. were the first to describe reduction by way of tensioned wires. To our knowledge, we are the first to describe this technique in the scenario of an open fracture. Fixation of the interfragmentary wires to the fixator itself in a tensioned fashion has the advantage of imparting active compression across the fracture site rather than simply holding the fragment in place and relying on a static joint position. Conceivably, the resistance to failure would be greater biomechanically superior to a non-tensioned interfragmentary pin or wire that cannot effect compression. A saw bone model allows for a true appreciation of the technique (Figure 13 a,b). A schematic is provided to further illustrate this method (Figure 13c).

We concede that this technique would be of limited use with smaller osteoporotic fragments. In contrast however, we do not suggest fixation of these fragments.

Figure 13 Bent wire construct (A) a sawbone model allows for easy visualization of the construct with the tensioned wire passing through the displaced fracture fragment. The wire is tensioned and the concave side of the arc faces in the desired direction of compression. (B) Compression across the fracture fragment from a lateral perspective. (C) A schematic of the technique superimposed on a lateral radiograph (Figure 13a and Figure 13b Reproduced from: A new treatment for avulsion fracture of the calcaneus using an Ilizarov external fixator, Injury, 44(11), Takahashi M, Noda M, Saegusa Y., 1640-3.Copyright (2013), with permission from Elsevier).

We distinguish a true tongue-type fracture, as treated in this article, from the smaller Achilles avulsion fractures described by Beavis and Rowe, and the “Iowa” fracture described by Kathol [6,7,8]. Tongue-type fractures are akin to the cleavage or “wedge” type fractures detailed by Hedlund, or the Essex-Lopresti described tongue-type fracture without frank joint collapse [9,10]. Given their size and extra-articular nature, smaller avulsion fractures can often be excised without biomechanical consequence. The Achilles can then be re-anchored to the remaining calcaneus as described by Greenhagen [11]. This is especially useful in the osteoporotic host where screw fixation is especially apt to fail, in whom these avulsion-type fractures are more common. The fracture described by Ramanujam would in fact be one such fracture pattern were we would recommend excision given its small size. Patients incurring tongue-type fractures tend to be somewhat younger than those sustaining avulsion fractures, which are largely insufficiency fractures in osteoporotic patients. In the event of a true tongue-type fracture, fixation is mandatory given their predisposition for soft tissue compromise and often concomitant articular involvement.

With respect to open fractures involving the posterior calcaneal tuber, internal fixation has been the method of choice for many authors. In this scenario, retained internal fixation could of course serve as a nidus for infection and require removal, necessitating substantial incisions and thus further soft tissue trauma. Additionally, depending on the location and size of the soft tissue deficit, their initial placement could demand further dissection into the already tenuous soft tissue environment.

Delays in the treatment of these injuries can undoubtedly lead to the need for rapid ascension of the soft tissue coverage ladder, even requiring free tissue transfer [21]. These delays can be especially common in the neuropathic host. In the scenario of free tissue transfer, our technique would provide both protection of the flap as well as minimal insult to the transferred tissue. The precarious position of the posterior lower extremity in the non weight bearing patient can make offloading of this area difficult without external fixation.

In conclusion, the bent wire technique has shown to be a valuable tool in our treatment of an open tongue-type calcaneal fracture and is our standard approach to treating these injuries. With minimal surgical insult to the soft tissues, wound healing concerns can be mitigated to the greatest extent possible. In the future, studies of larger sample sizes, biomechanical testing, and even direct comparison of this presented method to other fixation techniques would be useful.

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Effects of high and low cut on Achilles tendon kinetics during basketball specific movements

by Jonathan Sinclair1*, Benjamin Sant1pdflrg

The Foot and Ankle Online Journal 9 (4): 5

The aim of the current investigation was to examine the influence of high and low-cut specific basketball footwear in relation to minimalist and conventional athletic footwear on the loads experienced by the Achilles tendon during basketball specific movements. Ten males performed run and 45˚ cut movements whilst wearing low-cut, high-cut, minimalist and conventional athletic footwear. Achilles tendon forces were calculated using Opensim software allowing the magnitudinal and temporal aspects of the Achilles tendon force to be quantified.  Differences in Achilles tendon load parameters were examined using 4 (footwear) x 2 (movement) repeated measures ANOVA. The results show that a main effect was evident for peak Achilles tendon force, which was significantly larger in the minimalist (run = 5.74 & cut = 5.85 BW) and high-cut (run = 6.63 & cut = 6.01 BW) footwear in relation to the low-cut (run = 5.79 & cut = 5.47 BW) and conventional (run = 5.66 & cut = 5.34 BW) conditions. In addition a main effect was also evident for Achilles tendon load rate, which was significantly larger in the minimalist (run = 48.84 & cut = 43.98 BW/s) and high-cut (run = 54.31 & cut = 46.51 BW/s) footwear in relation to the low-cut (run = 43.15 & cut = 31.57 BW/s) and conventional (run = 44.74 & cut = 31.15 BW/s) conditions. The current investigation indicates that minimalist and high-cut footwear may place basketballers at increased risk for Achilles tendon pathology as a function of their training/ competition. Furthermore, it appears that for basketballers who may be susceptible to Achilles tendinopathy that low-cut and conventional conditions are most appropriate.

Keywords: basketball, Achilles tendon, biomechanics

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0005

1 – Centre for Applied Sport and Exercise Sciences, School of Sport and Wellbeing, College of Health & Wellbeing, University of Central Lancashire, Lancashire, UK.
* – Corresponding author: jksinclair@uclan.ac.uk


At all levels of play basketball is becoming a uniquely popular athletic discipline throughout the world [1]. Basketball is regarded as a physiologically demanding sport in which players are required to perform a series of different motions that typically include running, jumping and rapid changes of direction [2]. A typical competitive basketball season will require players to train frequently and perform >60 games, a regimen which serves to place high physical and mechanical demands on those involved [3].

Basketball has in recent years gained more research attention from the scientific community regarding players’ susceptibility to injury. Research investigating the prevalence of injuries in basketball players has shown that in relation to other non-contact sports basketball is associated with a comparatively high rate of injury. Information from aetiological analyses indicates that 11.6 injuries occur per 1000 appearances, and that the vast majority (65 %) are confined to the lower extremities [4]. Athletic disciplines which include frequently jumps, foot strikes and changes in direction such as basketball, place high loads on the Achilles tendon placing it at high risk from injury [5].

Given the highly physical nature of modern basketball, court footwear must now fulfill a range of biomechanical parameters such as traction, support, stability and shock attenuation [6]. Traditionally basketball specific footwear designs were available only with high-cut ankle supports which are utilized in order to promote mediolateral stability during landing [7]. In recent times however, low-cut footwear models have also been introduced and utilized at all levels of play, meaning court specific footwear can be selected based on individual preference. Recreational level players are also known to use low-cut conventional athletic footwear which may serve to enhance improve impact loading but at the expense of medio-lateral stability [7]. In comparison to other sports such as running there is currently a paucity of scientific research examining the efficacy of basketball footwear.

Appropriate footwear selection has been cited as a mechanism by which the risk from Achilles tendon pathologies during sport can be mediated. Considerable research has examined the effects of different footwear on the forces experienced by the tendon during different sports. Sinclair examined the effects barefoot and in minimalist footwear on Achilles tendon kinetics in relation to conventional running shoes [8]. Their results showed that conventional footwear significantly reduced peak Achilles tendon forces in relation to barefoot and minimalist conditions. Similarly, Sinclair et al., [9] examined the effects of minimalist and netball specific conditions on the forces experienced by the Achilles tendon during running and cutting movements. They showed that the peak force and rate of force application was significantly reduced in the netball specific condition. Finally, Sinclair et al [10] investigated the effects of minimalist energy return and convention athletic footwear on Achilles tendon loads during depth jumping. They showed the footwear did not significantly affect Achilles tendon forces during this movement. However, despite the wealth of peer reviewed literature examining the effects of different footwear on Achilles tendon kinetics there is currently no information available regarding the influence of basketball specific shoes.

Therefore, the aim of the current investigation was to examine the influence of high and low-cut specific basketball footwear in relation to minimalist and conventional athletic footwear on the loads experienced by the Achilles tendon during basketball specific movements. The findings from the current investigation may provide basketball players with important clinical information regarding the selection of appropriate footwear, which may ultimately help to attenuate their risk from developing Achilles tendon pathologies.

Methods

Participants

Ten male participants, volunteered to take part in this study. All were free from musculoskeletal pathology at the time of data collection and provided written informed consent. The mean characteristics of the participants were; age 24.26 ± 4.05 years, height 1.77 ± 0.07 cm and body mass 78.66 ± 7.43 kg. The procedure utilized for this investigation was approved by the University of Central Lancashire, Science, Technology, Engineering and Mathematics, ethical committee.

Footwear

The footwear used during this study consisted of minimalist (Vibram five-fingers Original;), high-cut (Nike Lebron XII), low-cut (Nike Lebron XII Low) footwear and conventional (New Balance 1260 v2) (shoe size 9–10 in UK men’s sizes).

Procedure

Participants completed five repeats of two sport specific movements; run and cut in each of the four footwear conditions. To control for any order effects the order in which participants performed in each footwear/ movement condition were counterbalanced. Kinematic information from the lower extremity joints was obtained using an eight camera motion capture system (Qualisys Medical AB, Goteburg, Sweden) using a capture frequency of 250 Hz. To measure kinetic information an embedded piezoelectric force platform (Kistler National Instruments, Model 9281CA) operating at 1000 Hz was utilized. The kinetic and kinematic information were synchronously obtained and interfaced using Qualisys track manager.

To define the anatomical frames of the thorax, pelvis, thighs, shanks and feet retroreflective markers were placed at the C7, T12 and xiphoid process landmarks and also positioned bilaterally onto the acromion process, iliac crest, anterior superior iliac spine, posterior superior iliac spine, medial and lateral malleoli, medial and lateral femoral epicondyles, greater trochanter,  calcaneus, first metatarsal and fifth metatarsal. Carbon-fibre tracking clusters comprising of four nonlinear retroreflective markers were positioned onto the thigh and shank segments. Static calibration trials were obtained with the participant in the anatomical position in order for the positions of the anatomical markers to be referenced in relation to the tracking clusters/markers. A static trial was conducted with the participant in the anatomical position in order for the anatomical positions to be referenced in relation to the tracking markers, following which those not required for dynamic data were removed.

Data were collected during the run and cut movements according to below procedures:

Run

Participants ran at 4.0 m.s-1 ±5% and struck the force platform with their right (dominant) limb. The average velocity of running was monitored using infrared timing gates (SmartSpeed Ltd UK). The stance phase of running was defined as the duration over > 20 N of vertical force was applied to the force platform[11].

Cut

Participants completed 45° sideways cut movements using an approach velocity of 4.0 m.s-1 ±5% striking the force platform with their right (dominant) limb. In accordance with McLean et al.,[12] cut angles were measured from the centre of the force plate and the corresponding line of movement was delineated using masking tape so that it was clearly evident to participants. The stance phase of the cut-movement was similarly defined as the duration over > 20 N of vertical force was applied to the force platform [11].

Processing

Dynamic trials were digitized using Qualisys Track Manager in order to identify anatomical and tracking markers then exported as C3D files to Visual 3D (C-Motion, Germantown, MD, USA). Ground reaction force and kinematic data were smoothed using cut-off frequencies of 25 and 12 Hz with a low-pass Butterworth 4th order zero lag filter.

Data during the stance phase were exported from Visual 3D into OpenSim software (Simtk.org), which was used give to simulations of muscles forces. Simulations of muscle forces were obtained using the standard gait 2392 model within Opensim v3.2. This model corresponds to the eight segments that were exported from Visual 3D and features 19 total degrees of freedom and 92 muscle-tendon actuators.

We firstly performed a residual reduction algorithm (RRA) within OpenSim, this utilizes the inverse kinematics and ground reaction forces that were exported from Visual 3D. The RRA calculates the joint torques required to re-create the dynamic motion. The RRA calculations produced route mean squared errors <2°, which correspond with the recommendations for good quality data.  Following the RRA, the computed muscle control (CMC) procedure was then employed to estimate a set of muscle force patterns allowing the model to replicate the required kinematics 13. The CMC procedure works by estimating the required muscle forces to produce the net joint torques.

Achilles tendon force was estimated in accordance with the protocol of Almonroeder et al [14] by summing the muscle forces of the medial gastrocnemius, lateral, gastrocnemius, and soleus muscles. Achilles tendon load rate was quantified as the peak Achilles tendon force divided by the time to peak force. All Achilles tendon load parameters were normalized by dividing the net values by body weight (BW).

Analyses

Differences in kinetic and kinematic parameters between footwear were examined using 4 (footwear) x 2 (movement) repeated measures ANOVAs, with significance accepted at the P≤0.05 level. Effect sizes were calculated using partial eta2 (pη2). Follow up comparisons on significant interactions were examined using simple main effects and post-hoc pairwise comparisons were conducted on all significant main effects. The data was screened for normality using a Shapiro-Wilk which confirmed that the normality assumption was met. All statistical actions were conducted using SPSS v22.0 (SPSS Inc., Chicago, USA).

Results

Tables 1 and Figure 1 present the footwear differences in Achilles tendon kinetics both movements. The results indicate that the experimental footwear significantly affected Achilles tendon load parameters.

 

Minimalist High-cut Low-cut Conventional
Run Cut Run Cut Run Cut Run Cut
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean
Peak Achilles tendon force (BW) 5.74 0.75 5.85 1.03 6.63 1.19 6.01 0.69 5.79 0.78 5.47 1.00 5.66 0.90 5.34
Time to peak Achilles tendon force (s) 0.12 0.01 0.16 0.04 0.13 0.02 0.16 0.02 0.14 0.01 0.19 0.04 0.13 0.02 0.18
Achilles tendon load rate (BW/s) 49.84 8.70 43.98 18.68 54.31 17.49 46.51 14.71 43.15 9.16 31.57 11.96 44.74 11.97 31.15

Table 1 Achilles tendon kinetics as a function of footwear and movement conditions.

fig1

Figure 1 Achilles tendon kinetics during the stance phase (a. = run & b. = cut) (black = minimalist, black dash = high-cut, grey dot = low-cut & grey = conventional).

For peak Achilles tendon force a significant main effect (P<0.05, pη2 = 0.64) was observed for footwear. Post-hoc pairwise comparisons showed that peak Achilles tendon force was significantly larger in the high-cut footwear in relation to the minimalist, low-cut and conventional athletic conditions. In addition it was also revealed that peak force was significantly larger in the minimalist footwear in comparison to the conventional condition.

For time to peak Achilles tendon force significant main effects were observed for both footwear (P<0.05, pη2 = 0.55) and movement (P<0.05, pη2 = 0.70). Post-hoc analysis for footwear showed that time to peak force was significantly greater in the low-cut footwear in comparison to the minimalist, high-cut and conventional conditions. Furthermore, it was also demonstrated that time to peak force was significantly greater in the conventional athletic footwear in relation to the minimalist and high-cut conditions. Finally, it was shown that time to peak force was significantly greater in the high-cut footwear in comparison to the minimalist condition. In addition post-hoc analysis for movement indicated that time to peak Achilles tendon force was significantly greater when performing the cut movement.

For Achilles tendon load rate significant main effects were observed for both footwear (P<0.05, pη2 = 0.42) and movement (P<0.05, pη2 = 0.47). Post-hoc analysis for footwear showed that Achilles tendon load rate was significantly larger in the minimalist and high-cut footwear in relation to the low-cut and conventional conditions.  

Discussion

The current study aimed to examine the effects of different basketball footwear on the loads experienced by the Achilles tendon during sport specific movements. To the authors knowledge this investigation is the first comparative examination of the effects of different footwear on Achilles tendon kinetics during basketball specific movement. The findings from this work may provide basketball players with important information regarding the selection of appropriate footwear to attenuate their risk from developing Achilles tendon pathologies.

The primary observation from the current work is that Achilles tendon loading parameters were shown to be significantly larger in the minimalist and high-cut footwear in comparison to the conventional low-cut conditions. This observation is in agreement with those of Sinclair [8] and Sinclair et al [9] who showed that minimalist footwear were associated with significant increases in Achilles tendon loading.

This observation may provide important clinically meaningful information regarding the aetiology of Achilles tendon pathologies. Achilles tendon pathologies are considered to be initiated by high loads which are experienced too frequently by the tendon itself 15. Tendon loading at an appropriate level can initiate collagen synthesis and positively influence the mechanical properties of the tendon [16]. However, when mechanical loads exceed the physiological threshold for collagen synthesis and the remodeling threshold is exceeded, this facilitates tendon degradation and ultimately leads to injury [16]. Therefore the findings from the current investigation indicate that minimalist and high-cut footwear may place basketballers at a greater risk from Achilles tendon pathologies as a function of their training/ competition.

In conclusion, although the effects of different footwear on Achilles tendon forces have been examined previously, our current knowledge of differences in Achilles tendon kinetics when performing sport specific movements in basketball footwear is limited. The current study therefore sought to provide an evaluation of Achilles tendon forces when performing sport specific movements in different basketball specific footwear. This work shows importantly that peak Achilles tendon force and the rate of Achilles tendon load rate were significantly larger in minimalist and high-cut footwear in relation to the low-cut and conventional conditions. As such given the association between Achilles tendon loading and tendon pathology the current investigation indicates that minimalist and high-cut footwear may place basketballers at increased risk for Achilles tendon pathology as a function of their training/ competition. Furthermore, it appears that for basketballers who may be susceptible to Achilles tendinopathy that low-cut and conventional conditions are most appropriate.

References

  1. Cumps, E, Verhagen R, and Meeusen R. “Prospective epidemiological study of basketball injuries during one competitive season: ankle sprains and overuse knee injuries.” J Sport Sci Med 6: 204-211, 2007. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3786241/
  2. Montgomery PG, Pyne DB and Minahan CL. The physical and physiological demands of basketball training and competition. Int J Sports Physiol Perform. 15: 75-86, 2010. https://www.ncbi.nlm.nih.gov/pubmed/20308698
  3. Narazaki K, Berg K, Stergiou N and Chen B. Physiological demands of competitive basketball. Scand J Med Sci Sport. 19: 425-322, 2009. https://www.ncbi.nlm.nih.gov/pubmed/18397196
  4. Deitch JR, Starkey C, Walters SL and Moseley JB. Injury Risk in Professional Basketball Players; A Comparison of Women’s National Basketball Association and National Basketball Association Athletes. Am J Sport Med. 34: 1077-1083, 2006. https://www.ncbi.nlm.nih.gov/pubmed/16493173
  5. Wertz, J., Galli, M., and Borchers, J. R. Achilles Tendon Rupture Risk Assessment for Aerial and Ground Athletes. Sport Health. 5: 407-409, 2013. https://www.ncbi.nlm.nih.gov/pubmed/24427410
  6. Caselli MA. Selecting the proper athletic shoe. Pod Manag. 25: 147-149, 2006.
  7. Commons AT and Low DC. Understanding the effect of high-cut shoes, running shoes and prophylactic supports on ankle stability when performing a v”-cut movement. Sport Exerc Med Open J. 1: 1-7, 2014.
  8. Sinclair, J. Effects of barefoot and barefoot inspired footwear on knee and ankle loading during running. Clin Biomech. 29: 395-399, 2014. https://www.ncbi.nlm.nih.gov/pubmed/24636307
  9. Sinclair, J., Atkins, S., Taylor, P. J., and Vincent, H. Effects of conventional and minimalist footwear on patellofemoral and Achilles tendon kinetics during netball specific movements. Comp Ex Phys. 11: 191-199, 2015.
  10. Sinclair, J., Hobbs, S. J., and Selfe, J. (2015). The Influence of Minimalist Footwear on Knee and Ankle Load during Depth Jumping. Research in Sports Medicine, 23(3), 289-301. https://www.ncbi.nlm.nih.gov/pubmed/26053415
  11. Sinclair, J., Edmundson, C.J., Brooks, D., and Hobbs, S.J. Evaluation of kinematic methods of identifying gait Events during running. Int J Sport Sci Eng. 5: 188-192, 2011.
  12. Thelen, D.G., Anderson, F.C., and Delp, S.L. Generating dynamic simulations of movement using computed muscle control. J Biomech. 36: 321–328, 2003. https://www.ncbi.nlm.nih.gov/pubmed/12594980
  13. Almonroeder, T., Willson, J.D., and Kernozek, T.W. The effect of foot strike pattern on Achilles tendon load during running. Annals Biomedical Eng. 41: 1758-1766, 2013. https://www.ncbi.nlm.nih.gov/pubmed/23640524
  14. Selvanetti, A.C.M., and Puddu, G. Overuse tendon injuries: basic science and classification. Op Tech Sport Med. 5: 110–17, 1997.
  15. Kirkendall, D.T., and Garrett W.E. Function and biomechanics of tendons. Scandinavian. J Med Sci Sport. 7: 62–66, 1997. https://www.ncbi.nlm.nih.gov/pubmed/9211605

The effects of CrossFit and minimalist footwear on Achilles tendon kinetics during running

by Jonathan Sinclair1, and Benjamin Sant1pdflrg

The Foot and Ankle Online Journal 9 (4): 2

The aim of the current investigation was to comparatively assess the influence of barefoot, CrossFit, minimalist and conventional footwear on the loads experienced by the Achilles tendon during running. Twelve male runners (27.81 ± 7.02 years, height 1.77 ± 0.11 cm and body mass 76.22 ± 7.04 kg) ran at 4.0 m·s-1 in each of the four footwear conditions. Achilles tendon forces were calculated using a musculoskeletal modelling approach allowing the magnitudinal and temporal aspects of the Achilles tendon force to be quantified. Differences between footwear were examined using one-way repeated measures ANOVA. The results showed the peak Achilles tendon force was significantly larger when running barefoot (5.81 ± 1.21) and in minimalist footwear (5.64 ± 1.03 BW) compared to conventional footwear (5.15 ± 1.05 BW). In addition it was revealed that Achilles tendon impulse was significantly larger when running barefoot (0.77 ± 0.22 BW.s) and in minimalist footwear (0.72 ± 0.16 BW.s) in comparison to both conventional footwear (0.64 ± 0.15 BW.s). Given the proposed association between high Achilles tendon forces and tendon degradation, the outcomes from the current investigation indicate that CrossFit athletes who select barefoot and minimalist footwear for their running training may be at increased risk from Achilles tendon pathology in comparison to conventional footwear conditions.

Keywords: Footwear, Achilles tendon, running, CrossFit

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0002

1 – Centre for Applied Sport and Exercise Sciences, School of Sport and Wellbeing, College of Health & Wellbeing, University of Central Lancashire, Lancashire, UK.
* – Corresponding author: jksinclair@uclan.ac.uk


CrossFit represents a relatively new activity associated with aerobic exercises, calisthenics, and Olympic weightlifting [1]. CrossFit as a discipline has expanded to become an international sport which has been linked to significant gains in aerobic and anaerobic fitness [1]. Given the novelty of CrossFit in relation to more established sports it has received a paucity of published attention in the sports science and strength and conditioning literature.

A key feature of CrossFit training is aerobic conditioning and the manner in which this is examined during competition is via distance running events. Engagement in distance running mediates numerous physiological benefits but it is known to be associated with a high rate of chronic pathologies, with around 70 % of runners experiencing an injury injured during the course of a year [2,3]. Shorten proposes that athletic footwear with suitable mechanical features may be able to manage the incidence of chronic running related injuries [4].

CrossFit athletes are able to select from a wide range of different footwear conditions with distinct design characteristics. There has been no peer reviewed research which has examined the biomechanical influence of different footwear available to CrossFit athletes. CrossFit specific footwear represents a hybrid footwear designed to incorporate the stability characteristics of a weightlifting shoe with the cushioning and flexibility of a running trainer. Currently, there is a trend for CrossFit athletes to opt to train and compete either barefoot or minimalist footwear in lieu of traditional footwear options, although the efficacy of barefoot and minimalist footwear is not yet fully established.

The effects of different footwear on the loads experienced by the Achilles tendon have been examined previously. Sinclair examined the effect running barefoot had on minimalist and conventional footwear on Achilles tendon kinetics during the stance phase of running [5]. The findings showed that peak Achilles tendon kinetics were significantly larger when running barefoot and in minimalist footwear. Similarly Sinclair et al, examined the effects of minimalist, maximalist and conventional footwear on the loads borne by the Achilles tendon during running[6] . Their findings confirmed that peak Achilles tendon force and Achilles tendon impulse were significantly larger in minimalist footwear in relation to the conventional and maximalist conditions. Currently there are no published scientific investigations regarding the effects of barefoot, CrossFit, minimalist and conventional footwear on the loads experienced by the Achilles tendon.    

Therefore the aim of the current study was to comparatively examine the influence of barefoot, CrossFit, minimalist and conventional footwear on the loads experienced by the Achilles tendon during the stance phase of running. Given that running activities are associated with a high incidence of chronic Achilles tendon pathologies, the current investigation may deliver key information to CrossFit athletes concerning the selection of suitable footwear.

Methods

Participants

Thirteen male participants took part in this investigation. All uninjured at the time of data collection and written informed consent was obtained. The mean and standard deviation (SD) characteristics of the participants were: age 27.81 ± 7.02 years, height 1.77 ± 0.11 cm and body mass 76.22 ± 7.04 kg. The research design utilized for this investigation was approved by the University of Central Lancashire, Science, Technology, Engineering and Mathematics, ethical committee. 

Procedure

Participants ran at 4.0 m·s-1 (±5%), while striking an embedded piezoelectric force platform (Kistler, Kistler Instruments Ltd., Alton, Hampshire) which sampled at 1000 Hz. Participants struck the platform with their right foot which was used for analysis. Running velocity was monitored using infrared timing gates (Newtest, Oy Koulukatu, Finland). The stance phase was delineated as the duration over which 20 N or greater of vertical force was applied to the force platform. Runners completed five trials in each footwear condition. The order that participants ran in each footwear condition was randomized. Kinematics and ground reaction forces data were synchronously collected. Kinematic data was captured at 250 Hz via an eight camera motion analysis system (Qualisys Medical AB, Goteburg, Sweden). Dynamic calibration of the motion capture system was performed before each data collection session.

Lower extremity segments were modelled in 6 degrees of freedom using the calibrated anatomical systems technique [7]. To define the segment coordinate axes of the foot and shank, retroreflective markers were placed unilaterally onto the 1st metatarsal, 5th metatarsal, calcaneus, medial and lateral malleoli, medial and lateral epicondyles of the femur. A carbon fiber tracking cluster was positioned onto the shank segment and the foot was tracked using the 1st metatarsal, 5th metatarsal and calcaneus markers. The center of the ankle joint was delineated as the midpoint between the malleoli markers[8] . Static calibration trials were obtained allowing for the anatomical markers to be referenced in relation to the tracking markers/ clusters. The Z (transverse) axis was oriented vertically from the distal segment end to the proximal segment end. The Y (coronal) axis was oriented in the segment from posterior to anterior. Finally, the X (sagittal) axis orientation was determined using the right hand rule and was oriented from medial to lateral.

Processing

Dynamic trials were digitized using Qualisys Track Manager in order to identify anatomical and tracking markers then exported as C3D files to Visual 3D (C-Motion, Germantown, MD, USA). Ground reaction force and marker trajectories were smoothed using cut-off frequencies of 50 and 12 Hz using a low-pass Butterworth 4th order zero lag filter. All data were normalized to 100% of the stance phase then processed trials were averaged. Joint kinetics were computed using Newton-Euler inverse-dynamics. To quantify net joint moments anthropometric data, ground reaction forces and angular kinematics were used.  

Achilles tendon force (BW) was determined using a musculoskeletal modelling approach. This model has been used previously to resolve differences in Achilles tendon force between different footwear [5, 6]. Achilles tendon force was quantified as a function of the plantarflexion moment (PFM) divided by the Achilles tendon moment arm (MA). The moment arm was quantified as a function of the ankle sagittal plane angle (ak) using the procedure described by Self and Paine [9]:

Achilles tendon force = PFM / MA

MA = -0.5910 + 0.08297 ak – 0.0002606 ak2

Average Achilles tendon load rate was quantified as the Achilles tendon force divided by the time over which the peak force occurred. Instantaneous Achilles tendon load rate was also determined as the peak increase in Achilles tendon force between adjacent data points. In addition to this Achilles tendon force, impulse  was quantified during running by multiplying the Achilles tendon force estimated during the stance phase by the stance time.

Experimental footwear

The footwear used during this study consisted of conventional footwear (New Balance 1260 v2), minimalist (Vibram five-fingers, ELX) and CrossFit (Reebok CrossFit CR) footwear, (shoe size 8–10 in UK men’s sizes).

Analyses

Means and standard deviations were calculated for all footwear conditions. Differences in Achilles tendon parameters between footwear were examined using one-way repeated measures ANOVAs, with significance accepted at the P≤0.05 level. Effect sizes were calculated using partial eta2 (pη2). Post-hoc pairwise comparisons were conducted on all significant main effects. The data was screened for normality using a Shapiro-Wilk which confirmed that the normality assumption was met. All statistical actions were conducted using SPSS v22.0 (SPSS Inc., Chicago, USA).

Results

Table 1 and Figure 1 present the Achilles tendon loads during the stance phase of running, as a function of the different experimental footwear. The results indicate that the experimental footwear significantly influenced Achilles tendon force parameters.

Barefoot CrossFit Conventional Minimalist
Mean SD Mean SD Mean SD Mean SD
Peak Achilles tendon force (BW) 5.81 1.21 5.50 1.32 5.15 1.05 5.64 1.03
Time to peak Achilles tendon force (s) 0.13 0.02 0.14 0.02 0.15 0.02 0.14 0.02
Achilles tendon average load rate (BW/s) 45.54 12.76 42.37 14.44 35.76 10.49 40.84 9.07
Achilles tendon instantaneous load rate (BW/s) 128.84 42.10 153.23 51.56 115.45 40.08 136.21 25.93
Achilles tendon impulse (BW.s) 0.77 0.22 0.69 0.20 0.64 0.15 0.72 0.16

Table 1 Achilles tendon forces as a function of footwear.

fig1

Figure 1 Achilles tendon forces during the stance phase as a function of footwear (black = barefoot, dash = minimalist, grey = conventional, grey dot = CrossFit).

A main effect (P<0.05, pη2 = 0.21) was shown for the magnitude of peak Achilles tendon load. Post-hoc pairwise comparisons showed that peak Achilles tendon force was significantly larger in the barefoot (P=0.01) and minimalist (P=0.04) conditions in relation to conventional footwear. A main effect (P<0.05, pη2 = 0.43) was shown for the time to peak Achilles tendon load. Post-hoc pairwise comparisons showed that time to peak Achilles tendon force was significantly larger in the barefoot (P=0.001) and minimalist (P=0.007) conditions in relation to conventional footwear. In addition time to peak Achilles tendon force was significantly shorter in the barefoot condition (P=0.007) in relation to the CrossFit footwear.  In addition a main effect (P<0.05, pη2 = 0.29) was evident for average Achilles tendon load rate. Post-hoc analysis showed that average load rate was significantly larger in the barefoot (P=0.004), CrossFit (P=0.04) and minimalist (P=0.02) conditions in relation to the conventional footwear. A main effect (P<0.05, pη2 = 0.25) was found for instantaneous Achilles tendon load rate. Post-hoc pairwise comparisons showed that instantaneous Achilles tendon load rate was significantly larger in the barefoot (P=0.01), CrossFit (P=0.003) and minimalist (P=0.01) conditions in relation to the conventional footwear. Finally, a main effect (P<0.05, pη2 = 0.34) was observed for Achilles tendon impulse. Post-hoc analyses indicated that Achilles tendon impulse was significantly larger in the barefoot (P=0.007) and minimalist (P=0.04) conditions in relation to conventional footwear.

Discussion

The aim of the current investigation was to comparatively examine the influence of barefoot, CrossFit, minimalist and conventional footwear on the loads experienced by the Achilles tendon during running. To the authors knowledge the current study represents the first comparative examination of Achilles tendon kinetics when running in these specific footwear conditions.

The key observation from the current study is that Achilles tendon force parameters were significantly larger in the barefoot and minimalist conditions in relation to the conventional running shoes. This observation is in agreement with those of Sinclair [5] and Sinclair et al. [6] who similarly noted that barefoot and minimalist footwear conditions were associated with significant increases in Achilles tendon kinetics in relation to more substantial running footwear. This observation may provide important clinical information with regards to the etiology of Achilles tendon pathologies as a function of running activities in CrossFit athletes. The initiation and progression of Achilles tendonitis is mediated by excessive tendon loads that are applied without sufficient cessation between activities [10]. Mechanisms of tendon loading that are above the systematic threshold for collagen related synthesis lead ultimately to degradation of the collagen network as the rate of resynthesis is not able to keep pace with the rate of breakdown [11]. Therefore the findings from the current investigation indicate that running barefoot and in minimalist footwear may place CrossFit athletes performing running activities at a greater risk from Achilles tendon pathology.

The specific findings from the current study may be explained by taking into account the effects of running barefoot and in minimalist footwear on the sagittal plane mechanics of the ankle joint. When running barefoot and wearing minimalist footwear, runners adopt a more plantarflexed foot position throughout the stance phase in relation to more structured running shoes [12, 13].  Increased ankle plantarflexion serves to reduce the length of moment arm of the Achilles tendon [9]. If the moment arm is shortened, this mediates an increase in the load which must be borne by the tendon when running barefoot and in minimalist footwear.

Research which has examined the influence of different footwear condition on the loads borne by the Achilles tendon during the stance phase of running, habitually examines only the peak forces experienced per footfall. Because running barefoot and in minimalist footwear mediates alterations in stance times and step frequencies, the time integral of loads experienced by the Achilles tendon are not quantified. The current study addresses this by quantifying the impulse experienced by the Achilles tendon during the stance phase which is a reflection of both the load experienced and the time interval of the load. The findings from the current investigation in relation to the Achilles tendon impulse mirror those of Sinclair et al., in that barefoot and minimalist footwear were associated with significantly larger impulse in relation to conventional running shoes [6]. This therefore further supports the notion outlines above that running barefoot and in minimalist footwear may increase the likelihood of experiencing an Achilles tendon injury compared to conventional running shoes.   

In conclusion, although differences in Achilles tendon loading as a function of different footwear conditions has been examined previously, the current knowledge with regards to the effects of minimalist, barefoot, CrossFit and conventional footwear on Achilles tendon forces is limited. As such the present study therefore adds to the current knowledge by providing a comprehensive evaluation of Achilles tendon load parameters when running in minimalist, barefoot, CrossFit and conventional footwear. On the basis Achilles tendon load and impulse parameters were shown to be significantly greater when running barefoot and in minimalist footwear, the outcomes from the current investigation indicate that CrossFit athletes who select barefoot and minimalist footwear for their running training may be at increased risk from Achilles tendon pathology in comparison to conventional footwear conditions.

References

  1. Weisenthal, B. M., Beck, C. A., Maloney, M. D., DeHaven, K. E., & Giordano, B. D. (2014). Injury rate and patterns among CrossFit athletes. Orthopaedic Journal of Sports Medicine (In press).
  2. Taunton, JE, Ryan, MB, Clement, DB, McKenzie, DC, Lloyd-Smith, DR, Zumbo, BD. A retrospective case-control analysis of 2002 running injuries. Br J Sp Med. 2002; 36: 95-101. doi: 10.1136/bjsm.36.2.95  
  3. van Gent, R, Siem DD, van Middelkoop M, van Os TA, Bierma-Zeinstra SS, Koes, BB. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British Journal of Sports Medicine 2007: 41: 469-480. http://www.ncbi.nlm.nih.gov/pubmed/17473005
  4. Shorten, MA. Running shoe design: protection and performance. pp 159-169 in Marathon Medicine (Ed. D. Tunstall Pedoe). 2000; London, Royal Society of Medicine.
  5. Sinclair J. Effects of barefoot and barefoot inspired footwear on knee and ankle loading during running. Clinical Biomechanics 2014; 29: 395-399. http://www.ncbi.nlm.nih.gov/pubmed/24636307
  6. Sinclair, J., Richards, J., & Shore, H. (2015). Effects of minimalist and maximalist footwear on Achilles tendon load in recreational runners. Comparative Exercise Physiology, 11(4), 239-244.
  7. Cappozzo A, Catani F, Leardini A, Benedeti MG, Della CU. Position and orientation in space of bones during movement: Anatomical frame definition and determination. Clinical Biomechanics 1995; 10: 171-178. http://www.ncbi.nlm.nih.gov/pubmed/11415549
  8. Graydon, R, Fewtrell, D, Atkins, S, Sinclair, J. The test-retest reliability of different ankle joint center location techniques. Foot Ankle Online J. 2015; 8: 1-11. doi: 10.3827/faoj.2015.0801.0011
  9. Self, BP, Paine, D. Ankle biomechanics during four landing techniques. Medicine & Science in Sports & Exercise 2001; 33: 1338–1344.
  10. Selvanetti, ACM, Puddu, G. Overuse tendon injuries: basic science and classification. Operative Techniques in Sports Medicine 1997; 5: 110–17. http://www.sciencedirect.com/science/article/pii/S1060187297800317
  11. Kirkendall, DT, Garrett W.E. Function and biomechanics of tendons. Scandinavian. Journal of Medicine & Science in Sports 1997; 7: 62–66. http://www.ncbi.nlm.nih.gov/pubmed/9211605
  12. Lieberman, D.E., Venkadesan, M., Werbel, W.A., Daoud, A.I., D’Andrea, S., Davis, I.S., & Pitsiladis, Y. (2010). Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature, 463, 531-535.
  13. Sinclair, J., Greenhalgh, A., Brooks, D., Edmundson, C. J., & Hobbs, S. J. (2013). The influence of barefoot and barefoot-inspired footwear on the kinetics and kinematics of running in comparison to conventional running shoes. Footwear Science, 5, 45-53.

Lumpy bumpy Achilles with gait instability could be cerebrotendinous xanthomatosis: Two case reports

by Iftikhar H Wani, MBBS MS Ortho1; Munir Farooq, MBBS MS Ortho1; M Shafi Bhat, MBBS MS Ortho1; Ansar-ul-haq Lone1; Younis Kamal, MBBS MS Ortho1; Irfan latoo, MBBS MS Ortho1pdflrg

The Foot and Ankle Online Journal 7 (1): 3

Cerebrotendinous xanthomatosis is a rare genetic metabolic disorder of cholesterol and bile acid metabolism that results in systemic and neurologic abnormalities. We report two cases of bilateral painful enlargement of the Achilles tendons who subsequently were diagnosed with cerebrotendinous xanthomatosis. It is important that orthopaedic surgeons be aware of this condition because the initial presentation may be symmetric, painful enlargement and deformity of the Achilles tendons. Early diagnosis is the key to treatment because medical therapy is effective in halting progression of, although not reversing, the devastating neurological lesions of this condition.

Keywords: Xanthomatosis; ataxia; Achilles tendon; genetic disorder; early diagnosis.

ISSN 1941-6806
doi: 10.3827/faoj.2014.0703.0003

Address correspondence to:Iftikhar H Wani MBBS MS Ortho
Registrar Hospital for Bone and Joint Surgery Barzulla Srinagar Kashmir India.
Email: drihwani@yahoo.co.in


Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive lipid-storage disease secondary to a disruption in cholesterol metabolism caused by a mutation in the sterol 27-hydroxylase (CYP27) gene [1,2]. In the absence of the key enzyme, sterol 27-hydroxylase, other metabolites are increased such as cholestanol. This elevated concentration results in characteristic clinical findings such as bilateral cataracts, tendon xanthomas, and neurologic impairments including debilitating cerebellar ataxia and cerebral degeneration.

Case 1

A 27-year-old male presented to our hospital with a four-year history of bilateral, slowly progressive, painful swelling of the Achilles tendon, but showed rapid progression in size for last 3 months to the extent that it interfered with his ability to walk. The pain was exacerbated by walking, was relieved somewhat by rest, and progressively restricted the patient’s walking distance to a maximum of two blocks at present.

The patient had been previously operated on for bilateral cataracts thirteen years before. No other family members have shown similar symptoms or signs of hypercholesterolemia.

On physical exam, each fusiform mass measured 10 cm in length starting approximately 1.5 cm proximal from the Achilles tendon insertion (Figure 1 and Figure 2). Patient had ataxic gait and exhibited symmetrical 2+ deep tendon reflexes. His muscle strength and ankle range of motion were normal. General physical examination did not disclose cutaneous xanthomas or yellowish discoloration.

Picture1

Figure 1 Bilateral Achilles tendon swelling (case 1).

Picture2

Figure 2 Bilateral Achilles tendon swelling (case 1).

Case 2

A 33-year-old male presented complaining of slowly enlarging masses overlying both distal Achilles tendons (Figure 3). They were soft and non-tender to palpation, however he did complain that closed countered shoes caused significant pain over the area. Despite being treated with nonsteroidal anti-inflammatory as well as oral steroid regimens, growth continued over the past six years.

Picture3

Figure 3 Bilateral Achilles tendon swelling (case 2).

A neurologist had previously diagnosed multiple sclerosis on the basis of the clinical findings of neuropathy in the extremities, an ataxic gait, and plaque-like changes in the cerebral cortex on magnetic resonance imaging (Figure 4). The patient had a family history of type-2 diabetes mellitus but no other inherited disorders.

No osseous pathology was noted on plain radiographs (Figure 5). Magnetic resonance images revealed a soft tissue mass on each Achilles tendon exhibiting a heterogeneous signal (Figure 6). Biopsy was done and tissue was examined under light microscopy. Fatty yellow deposits were seen infiltrating the tendinous fibers. Innumerable foamy macrophages were visualized with cleft-like spaces consistent with dissolved cholesterol secondary to cellular processing under light microscopy (Figure 7).

Picture5

Figure 4 Brain MRI (case 2).

Picture6

Figure 5 Anteroposterior and lateral radiographs and ankle showing bilateral soft tissue swelling without bony abnormality.

Blood investigations revealed a normal complete hemogram. Liver enzymes and a lipid panel found no abnormalities except for an elevated cholestanol level of 25.8 ug/mL (normal value is 4.2 +/- 1.2 ug/mL).

Picture7

Figure 6 Magnetic resonance image revealed a soft tissue mass on each Achilles tendon exhibiting a heterogeneous signal.

Picture8

Figure 7 Light Microscopy image showing innumerable foamy macrophages with cleft-like spaces (Stain, hematoxylin and eosin, original magnification ×200).

The patient was started on bile acid replacement therapy with chenodeoxycholic acid and atorvastatin. There is no further progression of swellings after treatment. There was no improvement of neurological dysfunction as seen clinically after treatment.

Discussion

Cerebrotendinous xanthomatosis was first described in 1937 by Van Bogaert and colleagues and has since been characterized clinically, biochemically, and genetically [3]. In 1968, Menkes et al described the accumulation of cholestanol, the primary metabolite found in elevated concentrations in cerebrotendinous xanthomatosis, in tissues of the CNS [4]. In 1971, Salen found that chenodeoxycholic acid (CDCA), an important bile acid, was virtually absent in patients with clinical symptoms of the disease [5]. This led to successful trials of therapy with CDCA replacement by Salen and colleagues in 1971 [6]. In 1980, defects in mitochondrial 27-hydroxylase were implicated in the biochemical pathophysiology of the disease by Oftebro et al [7]. In 1991, mutations in the gene CYP27A1 were discovered as causative [8-10].

Typically, untreated cerebrotendinous xanthomatosis follows a progressive course. Chronic, sometimes intractable diarrhea occurs, with onset typically in infancy. The diarrhea continues through adulthood if left untreated [11]. This typical presentation was not seen in our cases. Juvenile cataracts may be a presenting sign as was seen in one of our cases but the patient was not evaluated properly for the cause leading to delayed diagnosis [12]. Xanthomas are rarely seen before age 20 years, as was in our cases, although an exaggerated phenotype may be observed in patients with heterozygous familial hypercholesterolemia and cerebrotendinous xanthomatosis [13]. They are usually found on the Achilles tendon but may also be found on the patella, elbow, hand, and neck tendons. They have also been reported on the parenchyma of the lungs and brain, as well as in the bones.

Cerebrotendinous xanthomatosis is classically characterized by (1) bilateral Achilles tendon xanthoma; (2) bilateral cataract formation; and (3) progressive neurological dysfunction with mainly pyramidal tract signs, cerebellar ataxia, and cognitive impairment. Other orthopaedic manifestations of cerebrotendinous xanthomatosis include osteoporosis with an increased risk of fracture [14-16] and peripheral neuropathy [17] with secondary neuropathic deformity and/or ulceration of the feet [18,19].

The diagnosis of CTX is mostly clinical as most biochemical parameters are normal. Diagnosis depends on elevated serum cholestanol levels. MRI shows evidence of cerebral and cerebellar atrophy. T2-weighted image may show focal or diffuse high signal intensities in vertebral and cerebellar white matter. Dentate nuclei could be hyperintense on FLAIR images [20]. More recently, molecular biological techniques have been developed to assist in the diagnosis of cerebrotendinous xanthomatosis in asymptomatic homozygote family members of symptomatic patients. Heterozygotes can also be identified in these families, which is important for genetic counseling and prenatal diagnosis [21].

The differential diagnosis for a patient presenting with xanthomas of Achilles tendon and other tendons includes familial hypercholesterolemia and sitosterolemia [22]. Patients have accelerated atherosclerosis with tendon xanthomas, but absence of neurological symptoms and diarrhea differentiates them from CTX.

Conclusion

Xanthomatous Achilles tendon deposits have been reported to regress with chenodeoxycholic acid therapy [23-26]. Early diagnosis of CTX is essential and key to the treatment as pharmacological management with CDCA and HMG COA reductase inhibitors (Simvastatin) has shown to slow or even reverse the progression of disease [23-24]. Patients with childhood cataract should be thoroughly screened for this problem. Medical therapy, therefore, should be instituted at the time of diagnosis, and family members should be screened for subclinical disease. The benefits of genetic testing should be given to asymptomatic subjects for the early diagnosis of this rare disease.

References

1. Lee MH, Hazard S, Carpten JD et-al. Fine-mapping, mutation analyses, and structural mapping of cerebrotendinous xanthomatosis in U.S. pedigrees. J Lipid Res. 2001;42 (2): 159-69. [Pubmed]
2. Bjorken I, Boberg KM, Leitersdoef E. Inborn errors in bile acid biosynthesis and storage of sterols other than cholesterol. In: Scriver CR, Beaudet AL, editors. The metabolic and molecular bases of inherited disease. 8th ed. New York: McGraw-Hill; 2001. p 2970-8.
3. Van Bogaert L, Scherer HJ, Epstein E. Une forme cerebrale de la cholesterinose generalisee [dissertation/master’s thesis]. Paris: Masson et Cie. 1937.
4. Menkes JH, Schimschock JR, Swanson PD. Cerebrotendinous xanthomatosis. The storage of cholestanol within the nervous system. Arch Neurol. 1968;19 (1): 47-53. [Pubmed].
5. Salen G. Cholestanol deposition in cerebrotendinous xanthomatosis. A possible mechanism. Ann Intern Med. 1971;75 (6): 843-51. [Pubmed]
6. Salen G, Meriwether TW, Nicolau G. Chenodeoxycholic acid inhibits increased cholesterol and cholestanol synthesis in patients with cerebrotendinous xanthomatosis. Biochem Med. 1975;14 (1): 57-74. – [Pubmed]
7. Oftebro H, Björkhem I, Skrede S et-al. Cerebrotendinous xanthomatosis: a defect in mitochondrial 26-hydroxylation required for normal biosynthesis of cholic acid. J Clin Invest. 1980;65 (6): 1418-30. [Pubmed]
8. Clayton PT, Verrips A, Sistermans E et-al. Mutations in the sterol 27-hydroxylase gene (CYP27A) cause hepatitis of infancy as well as cerebrotendinous xanthomatosis. J Inherit Metab. Dis. 2002;25 (6): 501-13. [Pubmed]
9. Gallus GN, Dotti MT, Federico A. Clinical and molecular diagnosis of cerebrotendinous xanthomatosis with a review of the mutations in the CYP27A1 gene. Neurol Sci. 2006;27 (2): 143-9. [Pubmed]
10. Sugama S, Kimura A, Chen W et-al. Frontal lobe dementia with abnormal cholesterol metabolism and heterozygous mutation in sterol 27-hydroxylase gene (CYP27). J Inherit Metab. Dis. 2001;24 (3): 379-92. [Pubmed]
11. Von bahr S, Björkhem I, Van’t hooft F et-al. Mutation in the sterol 27-hydroxylase gene associated with fatal cholestasis in infancy. J Pediatr Gastroenterol Nutr. 2005;40 (4): 481-6. [Pubmed]
12. Monson DM, Debarber AE, Bock CJ et-al. Cerebrotendinous xanthomatosis: a treatable disease with juvenile cataracts as a presenting sign. Arch Ophthalmol. 2011;129 (8): 1087-8. [Pubmed]
13. Huijgen R, Stork AD, Defesche JC et-al. Extreme xanthomatosis in patients with both familial hypercholesterolemia and cerebrotendinous xanthomatosis. Clin Genet. 2012;81 (1): 24-8. [Pubmed]
14. Berginer VM, Shany S, Alkalay D et-al. Osteoporosis and increased bone fractures in cerebrotendinous xanthomatosis. Metab Clin Exp. 1993;42 (1): 69-74. [Pubmed]
15. Chang WN, Lui CC. Failure in the treatment of long-standing osteoporosis in cerebrotendinous xanthomatosis. J Formos Med Assoc. 1997;96 (3): 225-7. [Pubmed]
16. Kuriyama M, Fujiyama J, Kubota R et-al. Osteoporosis and increased bone fractures in cerebrotendinous xanthomatosis. Metab Clin Exp. 1993;42 (11): 1497-8. [Pubmed]
17. Kuritzky A, Berginer VM, Korczyn AD. Peripheral neuropathy in cerebrotendinous xanthomatosis. Neurology. 1979;29 (6): 880-1. [Pubmed]
18. Kuriyama M, Fujiyama J, Yoshidome H et-al. Cerebrotendinous xanthomatosis: clinical and biochemical evaluation of eight patients and review of the literature. J Neurol Sci. 1991;102 (2): 225-32. [Pubmed]
19. Katz DA, Scheinberg L, Horoupian DS et-al. Peripheral neuropathy in cerebrotendinous xanthomatosis. Arch Neurol. 1985;42 (10): 1008-10. [Pubmed]
20. Vadapalli S. Cerebrotendinous xanthomatosis. Indian J Orthop. 2013;47 (2): 200-3. [Pubmed]
21. Meiner V, Meiner Z, Reshef A et-al. Cerebrotendinous xanthomatosis: molecular diagnosis enables presymptomatic detection of a treatable disease. Neurology. 1994;44 (2): 288-90. [Pubmed]
22. Brodsky JW, Beischer AD, Anat D et-al. Cerebrotendinous xanthomatosis: a rare cause of bilateral Achilles tendon swelling and ataxia. A case report. J Bone Joint Surg Am. 2006;88 (6): 1340-4. [Pubmed]
23. Nakamura T, Matsuzawa Y, Takemura K et-al. Combined treatment with chenodeoxycholic acid and pravastatin improves plasma cholestanol levels associated with marked regression of tendon xanthomas in cerebrotendinous xanthomatosis. Metab Clin Exp. 1991;40 (7): 741-6. [Pubmed]
24. Kuriyama M, Tokimura Y, Fujiyama J et-al. Treatment of cerebrotendinous xanthomatosis: effects of chenodeoxycholic acid, pravastatin, and combined use. J Neurol Sci. 1994;125 (1): 22-8. [Pubmed]
25. Watts GF, Mitchell WD, Bending JJ et-al. Cerebrotendinous xanthomatosis: a family study of sterol 27-hydroxylase mutations and pharmacotherapy. QJM. 1996;89 (1): 55-63. [Pubmed]
26. Peynet J, Laurent A, De liege P et-al. Cerebrotendinous xanthomatosis: treatments with simvastatin, lovastatin, and chenodeoxycholic acid in 3 siblings. Neurology. 1991;41 (3): 434-6. [Pubmed]

Infected Gouty Tophous at the Posterior Ankle, Leg, and Achilles Tendon in a Diabetic Patient: A Case Report

by Sutpal Singh, DPM, FACFAS, FAPWCA1, Long K. Truong, DPM2, pdflrgMaria Mejia, DPM3, W. Scott Davis, DPM4, Jennifer Chen, DPM5, Kamran Chaudhary, MD6, Marie Cleto-Quiaoit, MD7

The Foot and Ankle Online Journal 6 (5): 1

The clinical presentation of a diabetic patient with an open infected lesion and concomitant chronic tophaceous gout of the Achilles tendon is evaluated and treatment is described. The 42-year-old man suffered from chronic tophaceous gout with multilobular, solid, tender, enlarged subcutaneous nodules affecting the right hand and both feet. The patient was neuropathic and wearing tight shoes which resulted in laceration of the posterior skin near the soft tissue mass. This resulted in an infected ulcer and cellulitis. He was treated by incision and drainage with removal of the tophaceous mass from the Achilles tendon, sural nerve decompression, as well as debridement of the Achilles tendon.

Keywords: Achilles tendon, Gout, Diabetic foot, surgical debridement

Accepted: April, 2013
Published: May, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0605.001


Address correspondence to: Sutpal Singh, DPM, FACFAS, FAPWCA,
Currently at St. Alexius Medical Center, Hoffman Estates, IL

1Chief Ilizarov Surgical Instructor at Doctors Hospital West Covina, California.
2,3,4,5Residency, Doctors Hospital of West Covina, California. (PM&S 36).
6Greater Chicago Rheumatology, Chicago, Illinois.
7Pathologist, St Alexius Medical Center, Hoffman Estates, Illinois.


Gout is a condition characterized by deposition of monosodium urate crystals in tissues. Acute gout is preceded by elevated serum uric acid levels, although hyperuricemia is often not present during a gouty attack.[4] It is also important to note that most patients with hyperuricemia never experience a gout flare.[1]

As crystal deposition favors areas of the body with lower temperatures, and therefore further from the heart, it has a high tendency to affect the foot, particularly the first metatarsal-phalangeal joint, in about 56-78% of patients.[10] This is known as podagra. An acute gout flare is often characterized by a red, hot, and swollen joint that is very painful to touch, representing a similar clinical presentation as cellulitis.[4]

InfGtFig1a InfGtFig1b

Figure 1 Infected right posterior ankle and lower leg area.

Definitive diagnosis of acute gout is made by observation of negatively birefringent crystals in fluid aspirated from the affected joint. Joint aspirate analysis has been shown to have sensitivity of 85 percent and specificity of 100 percent.[2,13] In the absence of joint aspirate analysis, clinical diagnosis may be made based on meeting certain criteria which include podagra, hyperuricemia, history of monoarticular arthritis followed by asymptomatic periods, palpable tophi and knowledge of certain known co-morbidities associated with gout.[15]

Gout is a multifactorial condition, and as such, must be treated in a multifactorial manner. Gout is caused by altered purine metabolism, but other factors, including high purine diet, alcohol intake, and reduced renal clearance may also contribute. Therefore, lifestyle modification must be a part of any treatment regimen.[4] Acute gout attacks usually resolve without treatment within days to weeks. However, treatment can decrease the duration of an attack and decrease frequency of future attacks. NSAIDs (i.e. indomethacin), corticosteroids (i.e. Prednisone) and colchicine are first-line therapies in cases of acute gout. Colchicine is less commonly used due to the potential side effects.[4] Uric acid lowering agents are often used to treat chronic hyperuricemia.

InfGtMRIFig2a

Figure 2 Magnetic resonance image (MRI) of the right lower extremity shows a large mass engulfing the Achilles Tendon.

These agents are not started during an acute gouty attack, as they can exacerbate the symptoms. These include allopurinol, which is the most commonly prescribed, as well as probenecid and febuxistat (Uloric®, Takeda Pharmaceuticals U.S.A., Inc).[4] The primary treatment for tophaceous gout is to lower the uric acid level with dietary and medical therapy but this may not be easy to achieve therefore, surgical treatment maybe indicated. Surgical intervention has been shown to have a high incidence of complications6, therefore it is mainly recommended when tophi cause pain, skin necrosis, ulcerations, sinuses, nerve compression, interference with tendon function, or when joints are being destroyed and painful.[12]

InfGtFig3

Figure 3 Right hand.

It is important to distinguish gout from other conditions, as symptoms of acute gout may mimic those of other conditions, and vice versa. Septic arthritis may display the involvement of a single joint, with leukocytosis and elevated erythrocyte sedimentation rate (ESR). Septic arthritis and acute gout may even occur simultaneously.[1] This report describes a case of lower extremity infection in the presence of gouty tophi in a diabetic neuropathic patient with infiltration into the sural nerve.

Case Report

A 42-year-old diabetic patient was seen in the hospital for pus draining from the ankle and back of the leg. He said that he was wearing boots and that it may have cut the back of the leg several weeks ago. He noticed large amounts of pus draining from the posterior ankle and lower leg. He was subsequently admitted. His past medical history was significant for gout and insulin diabetes mellitus. Physical examination showed an infected abscess at the posterior ankle and leg on the right, with pus draining from the ulcerated area. (Fig 1) magnetic resonance imaging (MRI) shows the extent of infiltration of the tophus on the right lower extremity. (Fig 2)

InfGtFig4

Figure 4 Left posterior ankle without any infection.

On the right hand (Fig 3) as well as the left posterior ankle (Fig 4), there were indurated soft tissue masses for which the patient denied any pain. He had a large non-infected tophi on the left lower extremity.

Surgical Technique

The patient was placed in a prone position under general anesthesia with a thigh tourniquet. A curvilinear incision was made from the middle of the leg on the medial side, going inferiorly across the open wound and ulcer and then crossing over onto the inferior lateral heel area. The incision was deepened down to the subcutaneous tissue and then down to the deep tissue. There was a tremendous amount of brown pus draining from the wound area. Culture and sensitivity for gram positive, gram negative, anaerobic and aerobic organisms were performed. There was a large amount of adhesions noted at the subcutaneous and deep tissue. There was also a large soft tissue mass engulfing the Achilles tendon and sural nerve (Fig. 5 and Fig. 6). Neuroplasty of the sural nerve with surgical loupes was performed.

InfGtFig5 InfGtFig5b

Figure 5 Infiltration of the soft tissue mass engulfing the Achilles tendon.

The entire mass from the posterior, medial, lateral and anterior aspect of the Achilles tendon was removed. The Achilles tendon was also debrided of any degenerative tissue (Fig. 7 and Fig. 8). The necrotic skin was debrided and the skin edges were approximated using 3-0 ProleneTM, Ethicon Inc in simple as well as horizontal mattresses. The open wound area was loosely approximated and packed with Iodoform gauze. The surgical site was dressed with XeroformTM, Covidien, gauze, and KerlixTM, Covidien.

Discussion

Gout, a common metabolic disorder has increased in prevalence worldwide and is estimated to have doubled in the US alone within the last three decades.[9] Though gouty tophi are typically found in joints, it may also be present in tendons and soft tissue such as Achilles tendon, ear helices, sclera, and sub conjunctivae.[2] Despite many studies which report that gout may be found in these places, there are currently little to no studies reporting the epidemiology of gout present in places like the soft tissue or rearfoot.

InfGtFig6

Figure 6 Sural nerve entrapment (forceps) with the soft tissue mass.

In this case study, we reported on an infected tophaceous wound. (Fig 7) Histology of the mass is shown in Fig 9-12. Culture and sensitivity revealed infiltration by Streptococcus agalactiae, also known as Group B streptococcus or GBS, which is a beta-hemolytic Gram-positive streptococcus. Though rare, it is important to note that tophi, when left untreated for a long duration, may accumulate and can lead to ulceration which can become infected. A 2011 case study reported a patient who was noncompliant with his allopurinol regimen, and resulted in a tophaceous ulcerated nodule overlying the dorsal first and second metatarsophalangeal joint of the left foot.[5]

InfGtFig7

Figure 7 Removal of the soft tissue mass. Gross description: 17.2 gm of dark brown to pale yellow soft tissue mass. Sectioning reveals cystic mass with chalky white substance.

The nodule and resulting ulceration were so large that amputation of the left foot was strongly considered.[5] Though bacterial cultures were negative for septic arthritis in this case, ciprofloxacin was given as prophylaxis and the patient healed well with adequate surgical debridement. [5]

It is important to monitor gout, especially in manifestations at the Achilles tendon because if left untreated it may exhibit traumatic effects. Though not as common as in the joints, tophi have been known to be found in the Achilles tendon. A 1981 case study of an acute Achilles rupture alluded to the rupture possibly being caused by gout with deposits consistent with tophi found throughout the tendon, especially at the rupture site.[14]

Often times when assessing the aspirate of a red, hot, swollen joint, if synovial crystals are found a diagnosis of a crystal arthritis such as gout or CPPD is automatically assumed. However, a retrospective study based at a US urban medical center looked at records of all the joint synovial crystal aspirates from a seven year span, containing a total of 265 synovial crystal joint aspirates.[11]

InfGtFig8

Figure 8 Surgical appearance after removal of the mass from the Achilles tendon as well as debridement of the Achilles tendon.

Of those 265 aspirates, 4, or 1.5%, came back positive for bacterial cultures confirming concomitant septic arthritis with crystal arthritis.[11] While this may seem a small amount, if left untreated may have deleterious effects on the patient.

Another study of 30 cases of concomitant septic and gouty arthritis in 2003 from Taiwan stated that wounds as the result of subcutaneous tophi rupture were the most common source of concomitant septic and gouty arthritis, with the most common infectious organism being Staphylococcus aureus.[14] Fourteen went on to receive surgical debridement with 9 having no reported complications.[14]

InfGtFig9

Figure 9 Low power of chronic gouty inflammatory reaction with foreign body giant cell proliferation.

InfGtFig10

Figure 10 Formalin Fixation has destroyed the uric acid crystals to leave amorphous eosinophilic material. Note the multinucleated giant cells indicating chronic inflammatory process (upper right).

With the degeneration in Western diet consisting of increased intake of fast food, soft drinks, and meat it is no surprise that gout and diabetes are common co morbidities. A 2008 study based at the University of Pennsylvania Medical Centre expanded on the notion that hyperuricemia, gout, and metabolic syndrome are associated with each other. This suggests that gout in men with a high cardiovascular risk profile is at a higher risk of developing type 2 diabetes.[3]

InfGtFig11

Figure 11 Low power of acute gouty inflammation showing gouty casts.

InfGtFig12

Figure 12 Note the inflammatory neutrophils.

When dealing with diabetic patients, wounds and resulting infection can lead to limb loss or even death.[9] Therefore it is pertinent to monitor both gout and diabetes, because gout left untreated could be a means for ulceration.

InfGtFig13

Figure 13 Several months after surgery shows complete healing with good Achilles tendon strength.

The case study presented in this article highlighted the significance of the necessity of a thorough examination for patients with numerous risk factors. While our outcome was positive (Fig 13), without a thorough debridement and attentive follow up, this case had the potential to result in a below the knee amputation. This is especially true with the known potentially poor healing capacity of diabetics. Moreover, it vital that in order to prevent recurrence patients with gout must be tightly controlled.

Conclusion

As discussed before, infected gouty tophus of the Achilles tendon is a rare finding even though gout commonly affects the foot and ankle. A thorough history and physical examination with assistance of advanced diagnostic tools and laboratory studies is essential to properly diagnose this condition. Differential diagnosis of gout should always be considered in patients with a history of hyperuricemia even if symptoms are masked by cardinal signs of infection. Medical and surgical therapy has been reported to successfully treat this condition. Our case report demonstrates good prognosis with early recognition and successful surgical debridement.

References

1. Becker M. Clinical manifestations and diagnosis of gout. In: UpToDate. Basow DS (Ed), Waltham, MA, 2012.
2. Chen LX, Schumacher HR. Current trends in crystal identification. Current Opinion  Rheum 2006 18: 171-73. [PubMed]
3. Choi HK, De Vera MA, Kishnan E. (2008). Gout and risk of type 2 diabetes among men with a high cardiovascular risk profile. Rheumatology 2008  47: 1567-1570. [PubMed]
4. Eggebeen AT. Gout: an update. American family Physician 2007 76: 801-808. [PubMed]
5. Falidas E, Rallis E, Bournia V, Mathioulakis S, Pavlakis E, Villas C. Multiarticular chronic tophaceous gout with severe and multiple ulcerations: a case report. J Medical Case Reports 2011 5: 1-4. [PubMed]
6. Kumar S, Gow P. A Survey of indications, results, and complications of surgery for tophaceous gout. J New Zealand MedAssoc 2002 23: 115(1160). [PubMed]
7. Larmon WA,  Kurtz JF. The surgical management of chronic tophaceous gout. JBJS 195840 :743-772. [PubMed]
8. Mahoney PG, James PD, Howell CJ, Swannell AJ.  Spontaneous rupture of the Achilles tendon in a patient with gout. Annals Rheumatic Dis 1981 40: 416-418. [PubMed]
9. Ramsey SD, Newton K, Blough D, McCullouch DK, Sandhu NS, Reiber GE, Wagner EH. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care 1999 22: 382-387. [PubMed]
10. Roddy E. Revisiting the pathogenesis of podagra: why does gout target the foot? JFAR 2011 4:13. [PubMed]
11. Shah K, SpearJ, Nathanson LA, McCauley J, Edlow JA.  Does the presence of crystal arthritis rule out septic arthritis? J Emergency Med 2007 32: 23-26. [PubMed]
12. Terkeltaub R. (2010). Update on gout: New therapeutic strategies. Nature Reviews: Rheumatology 2010 6: 30-38.[PubMed]
13. Wallace SL, Robinson H, Masi AT,  Decker JL, McCarty DJ, Yü T. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheumatism 1977 20:  895-900. [PubMed]
14. Yu KH, Luo SF, Liou LB, Wu YJJ, Tsai WP, Chen JY, Ho HH. Concomitant septic and gouty arthritis—an analysis of 30 cases. Rheumatology 2003 42: 1062-1066. [PubMed]
15. Zhang W. EULAR evidence based recommendations for gout. Part I: Diagnosis. Report of a task force of the standing committee for international clinical ctudies including Therapeutics (ESCISIT). Annals Rheumatic Dis (2006) 65: 1301-311.  

Management of Open Chronic Tendo Achilles Injuries: A case report

by Anil Thomas Oommen MS Orth1 , Pradeep Mathew Poonnoose MS Orth2 ,
Debabrata Padhy MS Orth3 , Ravi Jacob Korula MS Orth4

The Foot and Ankle Online Journal 3 (1): 2

Delayed presentation of an open Tendo Achilles injury with segmental loss of tendon and soft tissue is a challenging problem for the Orthopaedic surgeon. We present a patient who presented with a 4 x 5 cm open wound and a 4cm segmental loss of the tendon 6 months after the injury. To bridge the defect in the tendon, lengthening of the proximal tendon was done using a tongue in groove sliding technique, and a reverse sural artery flap was used to cover the soft tissue defect. At 9 months follow up, the patient was able to perform a single limb toe stance. The technique and the relative merits of this simple procedure are discussed.

Key words: Achilles tendon, Sural artery flap, Bakers slide, Tendo Achilles, tendon rupture.

Accepted: December, 2009
Published: January, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0301.0002


Open Tendo Achilles injuries commonly occur following cycle spoke injuries or after a fall into ‘Indian style’ closets. [1] If patients present within 6 to 12 hours of the injury a thorough wash followed by primary or delayed repair of the tendon can be done. Management of delayed presentation of open Tendo Achilles injuries is more complex, as there is a loss of soft tissue cover in addition to the tendon defect.

An effective surgical procedure is required to bridge the defect in the Tendo Achilles, as well as to achieve adequate soft tissue cover. [1,2] A number of procedures have been described for reconstruction of the Tendo Achilles. These include lengthening the aponeurotic tendon either in a ‘tongue in groove’ fashion as described by Baker, or the V-Y technique popularized by Abraham and Pankovich. [1,2] The other methods described for repair of neglected rupture include augmentation with the peronei (Teuffer’s modification of White and Kraynick technique), or with a strip from the median raphe of the proximal tendon (Bosworth’s technique). [2] Management of the defect in an open injury is more complex because of the associated loss of soft tissue cover. The use of vascularised extensor digitorum brevis and various composite free flaps have been described for such defects. [2] These require the expertise of a micro vascular surgeon.

We present the case of a patient who presented with a 4 x 5 cm open wound and a 4 cm segmental loss of the tendon six months following a fall. Following a thorough debridement, we opted to bridge the defect by lengthening the tendon with a Baker’s procedure, and cover the skin defect with a reverse sural artery flap. The technique and relative merits of this simple procedure are discussed.

Surgical Procedure

With the patient in prone position, the wound was debrided and the residual skin defect measured. Swabs taken from the wound confirmed the absence of active infection.

The reverse sural artery flap was elevated before the tendon was lengthened. (Fig 1) The flap was marked proximally on the calf, with the edges 0.5 cm more than the measured recipient area.

Figure 1  Presentation of injury. Elevation of the reverse sural artery flap, with insert (A) showing the skin defect over the ruptured Tendo Achilles. The flap has been cut back to a bleeding edge.

The small saphenous vein, sural artery and nerve were cut at the proximal edge of the flap and raised along with the fascio-cutaneous flap. The deep fascia was anchored to the epidermis prior to elevating the flap, in order to prevent shearing between the deep fascia and the skin. Distally, the incision was extended up to the medial border of the wound. Laterally, the flap was raised to 7.5 cm short of the lateral malleolus, in order to preserve the perforators from the peroneal artery that supply the elevated flap. At this stage, the tourniquet was released, and bleeding from the flap edge was noted. As the bleeding from the leading edge of the flap was inadequate, the flap had to be cut back until a bleeding edge was obtained. (Fig. 1) The flap was then turned over its pedicle, and laid over the defect.

Following the elevation of the flap, the aponeurosis and tendinous portion of the Tendo Achilles was exposed. The proximal edge of the defect was freshened, and a no. 5 ethibond (ETHICON, Inc.) Bunnel suture was passed through the distal end of the tendon. Care was taken not to disturb the mesotenon near the defect. A ‘tongue in groove’ lengthening of the tendon was done at the musculotendinous junction. For the defect of 4 cm, a 9 cm cut was made in the aponeurosis, to ensure adequate overlap after the lengthening. Traction was applied to the tendon with the ethibond suture to lengthen the tendon, and the defect was closed with the ankle in 10 degrees of plantarflexion. (Fig. 2)

Figure 2 Repair of the tendon using a ‘tongue in grove lengthening’ of the aponeurosis.

There was no distal remnant of the Tendo Achilles, and hence the tendon was anchored on to the calcaneum directly. The insertion site on the calcaneum was freshened, and the ethibond suture was threaded through the calcaneum using a Beath pin, and anchored tightly onto the sole of the foot over a button. (Fig. 2) Additional bony sutures were placed between the tendon and the calcaneum.

After anchoring the tendon, the flap was rotated and sutured over the defect. Multiple corrugated drains were used under the flap to ensure good drainage. The donor site was covered with split thickness skin graft. An anterior plaster splint was applied to keep the ankle in plantarflexion. Once the sutures were removed after 2 weeks, the leg was casted in 20 degrees of flexion at the ankle for 2 months, followed by another 2 months in neutral position. The button used to anchor the ETHIBOND suture was removed at 4 months. He was then allowed to bear weight, though the repair had to be protected with a cast for another 2 months. At 9 months, he was able to perform a single limb toe stance. (Fig. 3)

Figure 3 Nine months following surgery, the patient was able to stand on one leg without support.

Discussion

Delayed presentation of open Tendo Achilles injuries require careful repair of the tendon defect, and adequate soft tissue cover. [1,2] Reconstruction of the defect can be challenging, as the blood supply of the Tendo Achilles at its insertion is extremely poor. [3] The reconstruction of Tendo Achilles injuries require meticulous handling of the remnant segments. The mesotenon of the tendon segment near the defect should be preserved in order to maintain vascularity and achieve healing at the site of reconstruction. [3] Bosworth advocated elevation of a full thickness central strip of the proximal tendon, which is turned over and sutured to the distal end of the defect. The ‘turned over’ section of the graft has poor vascularity, and the healing at the repair site could potentially be compromised.

If the defect is bridged by lengthening the tendon proximally, the dissection of the mesotenon near the defect is less extensive, and hence the vascularity at the repair site is relatively well preserved. The repair is more biological and is more appropriate for reconstruction of the Tendo Achilles. The repair is also less bulky near the insertion site.

For protection of the reconstructed tendon, a full thickness soft tissue cover is necessary, as split thickness skin graft is unlikely to heal over the repair site.

The options for soft tissue cover include free vascularised composite tensor fascia lata flap, medial plantar flap with plantar aponeurosis or a free flap. [1,4] These free flaps often require micro vascular expertise.

The reverse sural artery flap is a neuro-cutaneous flap that has the advantages of having a fairly constant blood supply with associated ease of elevation and preservation of major vascular trunks in the lower extremity. [2,3] This flap is based on the distribution of the sural nerve and the retrograde perfusion is maintained by the anastomoses of the cutaneous perforating branches of the peroneal artery and the median superficial sural artery. [2,3]

This flap remains the workhorse for soft tissue cover over the posterior distal third of the leg and heel. [2,3] It is a relatively simple flap that can be performed by most orthopaedic surgeons. [2,4] The Tendo Achilles slide can be done through the same incision used for elevation of the flap. The resultant flap is however, often quite bulky. Where expertise is available, an adipo-fascial flap can be used to make the repair more aesthetic. [1]

Conclusion

The sliding technique for bridging defects in the Tendo Achilles followed by a reverse sural artery flap is an excellent option for management of delayed presentation of open Tendo Achilles injuries.

Acknowledgements

No benefits in any form have been received or will be received from any commercial party related directly or indirectly to the subject of this article.

References

1. Mohanty A, Jain P: Reconstructing and resurfacing open neglected Achilles tendon injury by distal posterior tibial artery based adipofascial flap. Eur J Plastic Surgery 27: 196 – 199, 2004.
2. Bullocks JM, Hickey RM, Basu CB, Hollier LH, Kim JY: Single-stage reconstruction of Achilles tendon injuries and distal lower extremity soft tissue defects with the reverse sural fasciocutaneous flap. J Plast Reconstr Aesthet Surg 61(5): 566 – 572 , 2008.
3. Carr AJ, Norris SH: The blood supply of the calcaneal tendon. J Bone Joint Surg 71B (1):100 – 101, 1989.
4. Jeng SF, Wei, FC: Distally based sural island flap for foot and ankle reconstruction. Plastic and Reconstructive Surgery 99 (3): 744 – 750,1997.


Address Correspondence to : Anil Thomas Oommen, Assistant Professor, Unit 2,Department of Orthopaedics,Christian Medical College and Hospital, Vellore, India, 632004 Email : lillyanil@cmcvellore.ac.in

Assistant Professor,Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282172.
Associate Professor, Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282173.
Assistant Professor,Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282081.
Professor and Head, Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282167.

© The Foot and Ankle Online Journal, 2010

The Achilles Musculotendinous Junction: A Survey of Orthopaedic Surgeons

by Richard Cove1 , David Weller2, Mark Westwood3

The Foot and Ankle Online Journal 2 (12): 4

Background: Achilles tendon rupture is a common injury, which can frequently affect young, active people. Consequently, there are important socio-economic implications in choosing the correct treatment. There is considerable debate in the literature concerning surgical versus non-surgical treatment and most surgeons would elect not to repair a rupture within the muscle belly above the musculotendinous junction. There is a wide anatomical variation in the exact location of the Achilles musculotendinous junction, which can lead to confusion among surgeons when trying to identify the location of a rupture and treatment plan.
Materials and Methods: Delegates at a regional orthopaedic meeting were asked to fill in a questionnaire, which showed a photograph of a lower limb. They were asked to draw two transverse lines, the first identifying the musculotendinous junction, and the second marking the highest level at which they would consider a surgical repair. They were asked about their understanding of the term “musculotendinous junction”.
Results: Twenty two delegates (n =22) of various degrees of seniority responded. There was a wide variety of answers, with the average level of the musculotendinous junction identified as being 10.1cm above the insertion into the calcaneum. The average highest level for considering surgical intervention was 8.71cm above the insertion into the calcaneum. Cadaveric measurements have shown that in fact the Achilles musculotendinous junction lies on average 5.51cm above the tendons attachment to the calcaneum.
Conclusion: There is confusion regarding the exact location and nature of the Achilles musculotendinous junction among the orthopaedic surgeons in our survey. Although most surgeons stated that they would not operate on a rupture above the musculotendinous junction, almost all identified a point higher than this region as their highest point for repair. Particular care is advised if an ultrasound reports the location of any rupture relative to the musculotendinous junction.

Key Words: Achilles tendon, rupture, surgical repair, conservative treatment, musculotendinous zone.

Accepted: November, 2009
Published: December, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0212.0004


The most common site for Achilles tendon rupture is 2-6cm from the calcaneal insertion, [1,2] although avulsion fractures of the os calcis have been described. [3] The Achilles tendon rupture is a common injury, affecting approximately 18 in 100,000 people [4,5], typically males between 30 and 50 years of age.

There is considerable debate in the orthopaedic literature about the benefits of surgical versus conservative treatment. However, it is generally accepted that surgical repair offers a lower rate of re-rupture, and conservative treatment avoids wound complications. [4,6,7] Many surgeons would elect to treat a rupture proximal to the musculotendinous junction (i.e. within the muscle belly) conservatively. The aim of this study was to investigate the confusion among surgeons of the exact nature and location of the musculotendinous junction.

Subjects and Methods

Delegates at the 2008 British South West Orthopaedic Club (SWOC) were asked to fill in an anonymous questionnaire, which showed a photograph of an exposed lower leg (male, 177cm tall – age and weight of the subject?). They were firstly asked their level of seniority, and then asked to draw two lines on the photograph; the first (labeled “line 1”) at the level of musculotendinous junction, and the second (labeled “line 2”) at the upper limit of where they thought surgical repair of an Achilles tendon rupture could be beneficial. They were also asked what they understood by the term “musculotendinous junction” for the Achilles tendon, and what they considered as the clinical significance of this junction.

The original photograph included a tape measure which was cropped out of the image shown to the delegates. The exact location of the Achilles tendon insertion was established using ultrasound and a mark on the subjects’ skin, which was digitally removed on the image shown to the delegates. A scaled ruler was used to directly measure the delegates’ markings on the photograph.

Results

Twenty-two (out of 35) surgeons returned a completed form- 7 Consultants (2 with an interest in foot and ankle surgery), thirteen Specialist registrars (SpR), 1 Associate Specialist, 1 ST1 trainee, and 1 respondent not specifying their grade.

The average level at which the musculotendinous junction was identified was 10.1cm (Standard Deviation [SD] 3.9cm) above the calcaneal attachment, with the average for consultants slightly higher than SpRs, at 11.5cm and 8.8cm respectively. The average highest level at which people thought surgery would be beneficial was 8.7cm (SD 2.7cm), with little difference between consultants and SpRs (8.8cm compared to 8.6cm). This meant that overall, those that responded thought that the highest level at which a patient might benefit from surgery was on average 1.4cm (SD 1.4cm) below the level of the musculotendinous junction.

There was a wide disparity in answers, with levels identified for the musculotendinous junction varying between 5.5cm and 24.5cm, with the level identified for considering surgery varying between 5.5cm and 17.5cm. The variation in differences between the two levels was also large, from people identifying the highest level for surgery at 3.5cm below the musculotendinous junction through to 2.5cm above it.

When asked what their understanding of the term “musculotendinous junction” was, virtually all respondents stated that it was where the muscle fibres were replaced by tendon, with a few people identifying it as a zone of transition rather than a discrete “junction”. When asked what they felt its clinical significance was, comments varied from “the muscle enhances healing/vascularity”, “the suture in the muscle belly is less likely to hold”, to “nil”, and “arbitrary”. However, most comments (thirteen out of twenty two) suggested that tears above the musculotendinous junction should be treated non-operatively, with comments such as “ruptures proximal to this don’t benefit from surgery”, and “repair at or above will be difficult due to suture cut out”. The results are summarized in figures 1 and 2.

Figure 1 Survey Results.

Figure 2 Results Key.

Discussion

In 2007 Pichler, et al. [8], directly measured the distance from the soleus musculotendinous junction to the attachment of the tendon to the posterior surface of the calcaneal tuberosity in series of cadavers.

Although they reported a wide anatomical variation, ranging from 0 to 11.75cm, they showed that the overall average distance was 5.51cm, with 70% of their subjects having a musculotendinous junction between 2.54cm and 7.62cm from the attachment to the calcaneus. [8] This is considerably lower than the level identified by the surgeons in our survey (where the average was 10.1cm). This suggests that orthopaedic surgeons consistently overestimate the level of the musculotendinous junction. This disparity is of concern as it may lead to misinterpretation of ultrasound reports that make reference to the musculotendinous junction.

It is interesting to note that the surgeons surveyed are prepared to consider operative repair more proximal than the anatomical musculotendinous junction. It would suggest that there is adequate quality tendon to repair proximally. This is despite the fact that the majority of respondents defined the musculotendinous junction as a level beyond which sutures would not hold.

We would suggest that the term musculotendinous junction should continue to define the point at which the last fibres of soleus attach to the Achilles tendon. Proximal to this there is a ‘musculotendinous zone’. This study has identified an ‘Achilles surgical zone’ which is approximately 0-10cm from the calcaneal insertion. Further research is required to discover the true value of surgery for high Achilles ruptures.

In the light of our findings, and bearing in mind the considerable anatomical variation identified by Pichler, et al., [8] we suggest that, to avoid confusion, any ultrasound scan on a suspected Achilles tendon rupture should identify the level of a rupture relative to the calcaneal insertion.

References

1. Carr AJ, Norris SH: The blood supply of the calcaneal tendon. J Bone Joint Surg 71B:100 – 101, 1989.
2. Lagergren C, Lindholm A: Vascular distribution in the Achilles tendon. Acta Chir Scand 116: 491 – 495, 1958/59.
3. Arner O, Lindholm A: Avulsion fracture of the os calcaneus. Acta Chir Scand 117: 258 – 260, 1959.
4. Khan RJK, Fick D, Keogh A, Crawford J, Brammar T, Parker M: Treatment of acute Achilles tendon ruptures. J Bone Joint Surg 87A (10) 2202 – 2209, 2005.
5. Bhandar M, Guyatt GH, Siddiqui F, Morrow F, Busse J, Leighton RK, Sprague S, Schemitsch EH: Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis. Clin Orthop Relat Res. 400:190-200, 2002.
6. Lea RB, Smith L: Non-Surgical Treatment of Tendo Achilles Rupture. J Bone Joint Surg 54A (7): 1398 – 1407, 1972.
7. Strauss EJ, Ishak C, Jazzrawi L, Sherman O, Rosen J: Operative treatment of acute Achilles tendon ruptures: An institutional review of clinical outcomes. Injury 38: 832 – 838, 2007.
8. Pichler W, Tesch NP, Grechenig W, Leithgoeb O, Windisch, G: Anatomical variations of the musculotendinous junction of the soleus muscle and its clinical implications. Clin Anat 20: 444 – 447, 2007.


Address Correspondence to: Richard Cove FRCS(orth)
Email: richard_cove@yahoo.com

Orthopaedic Registrar, Royal Cornwall Hospital, Truro, UK.
Orthopaedic SHO, Derriford Hospital, Plymouth. UK.
Othopaedic Consultant, Plymouth. UK.

© The Foot and Ankle Online Journal, 2009

Surgical Correction of Subluxing Peroneal Tendons Utilizing a Lateral Slip of the Achilles Tendon: A case report

by Mark Mendeszoon, DPM, FACFAS, FAFAOM,1 , J. Todd McVey, DPM2, Adam MacEvoy, DPM3  

The Foot and Ankle Online Journal 2 (8): 3

Subluxation of the peroneal tendon can be either an acute or chronic condition. As an acute injury, it can quite often be misdiagnosed as a lateral ankle sprain. This case report describes a technique using the lateral slip of the Achilles tendon as a retinacular graft to repair subluxation and dislocation of the peroneal tendons.

Key words: Tubularization, Achilles tendon graft, modified Brostrom repair, subluxation, dislocation, peroneal tendons.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: July, 2009
Published: August, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0208.0003

 


The peroneal tendons course around the lateral ankle at the distal aspect of the fibula. These tendons which include the tendons of the peroneus longus and brevis move through a tunnel created of both fibrous and osseous structures. [2] The borders of this tunnel include the lateral malleolus, posterior talofibular ligament, calcaneal fibular ligament, and superior peroneal retinaculum. Both tendons run together until they are distal to the fibula where they split and enter separate sheaths. Most important to us is the superior peroneal retinaculum (SPR) which is the primary restraint to subluxation and dislocation of the peroneal tendons. [1,8,9]

 

First Described in 1803 by Monteggia, peroneal subluxation and dislocation can be categorized as either acute or chronic injuries. Most acute injuries are caused by a sudden dorsiflexion and inversion of the ankle while the peroneals are contracting. Acute injuries occur most often during sporting activities.

The most common injury occurs during downhill skiing. If the injury is left untreated, it can lead to chronic pain or ankle pain that will require surgical correction. Pain is caused by splitting or fraying of the peroneal tendons which occur when the tendon continues to sublux over the posterior lateral edge of the fibula causing micro tears to the tendon. Chronic injuries are also associated with patients who are prone to multiple ankle sprains. These sprains can lead to lateral ankle weakness which can lead to inflammation of the peroneal tendon sheath. [6,8,9] The sustained inflammation of the sheath can lead to weakening and stretching of superior peroneal retinaculum which will allow the peroneal tendons to leave the peroneal tunnel. Echard and Davis created a classification system for peroneal subluxation.

This system includes for subtypes which are as follows:

I-Periosteum is elevated form underlying malleolus.
II-Superior peroneal retinaculum is torn from the anterior insertion.
III-Superior peritoneal retinaculum is avulsed with a small piece of bone.
IV-Superior peroneal retinaculum is avulsed from posterior attachment and tendon dislocates.

Conservative treatment of this condition can be used however the literature shows there is a high failure rate for this course of action. [2] Most conservative treatment includes casting for 4-6 weeks. Other treatment includes taping which as a lower success rate than casting. Usually primary repair is indicated for tears in the tendon involving 50% or less. [11] Considering the majority of these patients are athletes, most want a speedy return to activity and expect a high success rate. [1,8,9,10]

Case Report

A male patient reported that he was racing his motocross bike when he landed a jump with his foot in an awkward position. He recalls extreme pain at his ankle and noted that a bone was protruding under his skin, which he states that he pushed the bone back in to place and went to the emergency room (ER).

At the ER it was noted that patient had significant swelling, pain on palpation, ecchymosis, popping sensation along with extreme instability. Patient was immobilized, obtained a magnetic resonance image (MRI) and sent to the office the next day for consultation. After educating the patient on conservative and surgical options, the patient chose the latter. MRI showed extreme poster lateral edema, and anterior talofibular ligament (ATFL) tear, avulsion fracture of fibula, with a high suspicion of SPR tear.

Clinical evaluation reveals a 5’11” male who is 195 lbs. The patient’s neurovascular status remains intact. There is significant ecchymosis, positive Mondor sign, pain on palpation of fibula, pain with range of motion and the fibula is mobile at the lateral ankle. Stress films in the operating room while the patient is under general anesthesia reveals a positive anterior drawer and talar tilt.

Surgical Technique

An incision is made over the lateral aspect of the leg following the peroneal tendons, approximately 10-12cm in length. (Fig 1.) Significant hematoma and disruption of the tissue is encountered during blunt dissection. The peroneal tendon sheath is completely ruptured, and the peroneus brevis is lying on top of the lateral aspect of the fibula. The peroneal retinaculum is ruptured with an associated fleck of bone. On closer inspection, the peroneal groove is noted to be disrupted, rough, and shallow.

Figure 1  10-12 cm incision along the peroneal tendons.

The calcaneofibular ligament is intact and stable, and the posterior capsule gapped open. The ATFL is attenuated and the origin is slightly disrupted. The peroneal tendons are intact distally.

The damaged peroneal tendon are then tubularized using #2 fiber wire and placed back onto the fibular groove (Figs. 3,4). Subluxation and popping of the tendon is still noted. Because of this a reconstruction using the lateral 20% of the Achilles tendon is performed. A transverse incision is made into the Achilles tendon approximately 8 cm proximal to the insertion. The tendon is split distally and dissected through blunt means and used to protect the sural nerve and lateral structures. The low-lying muscle belly of the peroneus brevis, which is dissected away from the tendon just enough to pass the Achilles slip through its course. (Fig. 2) The cut end of the Achilles tendon is passed under the muscle belly of the peroneus brevis and over the peroneus longus and brevis tendons. (Figs. 5 and 6)

Figure 2  Resection of low lying muscle belly.

 

Figures 3 and 4 Repair of the peroneal tendons through tubularization.

 

Figures 5 and 6  A tunnel is made through the peroneus brevis muscle belly and the slip of the Achilles tendon is then passed over the peroneal tendons.

This bridge of tendon over the peroneal tendons is then anchored to the lateral malleolus using an Arthrex® bioabsorbable anchor. (Figs. 7,8 and 9) At completion of this reconstruction, there is no sign of subluxation of the peroneal tendons.

The wound is then irrigated and a modified Brostrom technique is used to repair and tighten the ligaments in a pants-over-vest fashion. This greatly increases the tension strength of the repair. The wound is then closed in layers.

  

Figures 7, 8 and 9  Bone anchor is used to anchor the repair.  The procedure is strengthened with a Modified Brostrom repair.

Discussion

There have been many options reported for surgical repair of peroneal subluxation or dislocation. These include direct repair of peroneal retinaculum, reconstruction of peroneal retinaculum, bone block (lateral malleolus, sliding graft), and groove deepening and rerouting procedures. [1,2,4,6,9]   Each of these procedures have their strengths and weaknesses. Acute repair of the superficial peroneal retinaculum is a simple repair however it may not be able to fix the underlying problem if there is a shallow grove, or the superior peroneal retinaculum itself is inherently weak due to prolonged inflammation. Reconstruction of the peroneal tendon can be accomplished using the peroneus brevis, plantaris, and/or Achilles tendons. There have been few studies reported on these techniques. A concomitant soft tissue procedure is a rerouting technique using the calcaneal fibular ligament. Bone block procedures incorporate part of an osteotomy used to deepen the fibular grove. This was first described by Kelly, and then modified by DuVries. [1,6,9,10] Complications associated with these techniques include graft fracture, tendonitis, pain and re-subluxation. Groove deepening procedures are performed by removing bone from the posterior aspect of the fibula. The result of deepening this grove is a more stable tunnel for the peroneus brevis and longus tendon sheath for gliding.

Peroneal tendon subluxation and dislocation is a condition which can be easily misdiagnosed as an ankle sprain and may cause a chronic painful condition requiring surgical intervention. As foot and ankle specialists we need to have a high suspicion, particularly in the younger athletic patients prone to such injuries.  The two most inherent causes of peroneal subluxation are multiple lateral ankle sprains and a shallow peroneal grove at the distal aspect of the tibia. Conservative treatment for this condition does not report a high success rate. The patient healed satisfactorily utilizing a lateral slip of the Achilles tendon in a tissue transfer technique and at the short term 6 month post op visit the patient had no complaints of pain.

References

1. Butler BW, Lanthier J, Wertheimer SJ: Subluxing peroneals: A review of the literature and case report. J Foot Ankle Surg 32: (2):134 – 139, 1993.
2 Oliva F, Ferran N, Maffulli N: Peroneal retinaculoplasty with anchors for peroneal tendon subluxation. Bull Hosp Joint Disease 63: (3 – 4): 113 – 116, 2006.
3. Ferran NA, Maffulli N, Oliva F: Management of recurrent subluxation of the peroneal tendons. Foot Ankle Clinics 11: (3) 465 – 474, 2006.
4. Kollias SL, Ferkel RD: Fibular grooving for recurrent peroneal tendon subluxation. Am J Sports Medicine 25: (3):329 – 335, 1996.
5. Brage ME, Hansen ST Jr: Traumatic subluxation/dislocation of the peroneal tendons. Foot Ankle Online 13: (7): 423 – 431, 1992.
6. Tan V, Lin SS, Okereke E: Superior peroneal retinaculoplasty: a surgical technique for peroneal subluxation. Clinical Ortho Rel Res [serial online] 410: 320 – 325, 2003.
7. Krause JO, Brodsky JW: peroneus brevis tendon tears: Pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int 19: (5): 271 – 279, 1998.
8. Ferran NA, Maffulli N, Oliva F: Management of recurrent subluxation of the peroneal tendons. Foot Ankle Clinics [serial online]11: (3):465 – 474, 2006.
9. Niemi WJ, Savidakis J Jr, DeJesus JM: Peroneal subluxation: a comprehensive review of the literature with case presentations. J Foot Ankle Surg 36: (2): 141 – 145, 1997.
10. Porter D, McCarroll J, Knapp E, Torma J: Peroneal tendon subluxation in athletes: fibular groove deepening and retinacular reconstruction. Foot Ankle Int 26: (6): 436 – 441, 2005.
11. Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG: Operative treatment for peroneal tendon disorders. J Bone Joint Surg 90A: (2): 404 – 418, 2008.
12. Mendicino RW, Orsini RC, Whitman SE, Catanzariti AR: Fibular groove deepening for recurrent peroneal subluxation. J Foot Ankle Surg 40: (4):252 – 263, 2001.


Address correspondence to:Adam MacEvoy, DPM. PGY III, Department Of Veterans Affairs. Louis Stokes Cleveland Medical Center. Podiatry Surgery . Cleveland Ohio 44106. (216) 791-3800 Ext 5891

1 Precision Orthopedics, 150 7th Ave, Chardon , Ohio 44024.
2 Department Of Veterans Affairs. Louis Stokes Cleveland Medical Center
Podiatry Surgery. Cleveland, Ohio 44106.
3 PGY III, Department Of Veterans Affairs. Louis Stokes Cleveland Medical Center. Podiatry Surgery . Cleveland, Ohio 44106.

© The Foot and Ankle Online Journal, 2009