Differential elongation of the gastrocnemius after Achilles tendon rupture: a novel technique of selective shortening to treat push-off weakness with case series and literature review.

PURPOSE: Differential elongation of the gastrocnemius after Achilles tendon rupture (ATR) may compromise the ability of athletes to return to competition. Recognition of this differential elongation of the gastrocnemius relative to the soleus is vital to treat patients with weakness in push-off. This paper describes a novel technique performed for selective shortening of the gastrocnemius to treat push-off weakness. METHODS: Three patients with differential proximal retraction of the gastrocnemius greater than 20 mm after treatment for ATR with inability to run and jump underwent surgical correction with this novel technique and were followed-up for 2 years. A novel selective shortening of the gastrocnemius with autologous hamstring graft was performed in these patients. The Achilles Tendon Total Rupture Score (ATRS) and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were recorded preoperatively and at the final follow-up. RESULTS: All three patients were able to return to running and jumping at final follow-up. The ATRS improved significantly in the strength, fatigue, running and jumping domains but there appeared to be a less notable improvement in activities of daily living domain. The AOFAS score showed improvement with the greatest margin in the domain of activity limitation. CONCLUSION: This procedure is the first described selective shortening method of the gastrocnemius tendons after differential elongation following ATR. It is a safe and reliable technique providing improved ATRS and AOFAS scores in three patients who were all able to return to running and jumping sports at 2-year follow-up. LEVEL OF EVIDENCE: IV.

Combined anterior cruciate ligament revision with reconstruction of the antero-lateral ligament does not improve outcome at 2-year follow-up compared to isolated acl revision; a randomized controlled trial.

PURPOSE: It is essential to obtain rotational stability of the knee after anterior cruciate ligament reconstruction (ACL-R) and it is suggested that a supplementary reconstruction of the antero-lateral ligament (ALL-R) may supports this. Theoretically, ALL-R may be particularly advantageous to support revision of failed ACL-Rs. It was hypothesized that ACL revision combined with ALL-R will result in superior outcome compared to isolated ACL revision. METHODS: The study was designed as a randomized controlled trial. Patients eligible for first time ACL revision were randomized to either isolated ACL revision (- ALL group) or ACL revision combined with a single-stranded allograft ALL-reconstruction (+ ALL group). Patient reported outcomes and function were evaluated at two-year follow-up by KNEES-ACL, KOOS, and Tegner activity scale. Objective knee laxity was evaluated at one-year follow-up using an instrumented Rolimeter test, the pivot shift test, and a manual Lachman test. RESULTS: A total of 103 patients were enrolled with 49 patients randomized to the + ALL group and 54 patients in the - ALL group. There were no differences at baseline between groups regarding age, gender, body mass index, preoperative patient reported outcome scores and concomitant meniscus or cartilage injury. The ACL revision was performed with an allograft in 10 patients (20%) in the + ALL group and 8 patients (15%) in the -ALL group. At follow-up there was no significant difference between the groups in patient reported outcome scores and clinical knee laxity. CONCLUSION: Supplementary ALL-R does not improve subjective outcome of first time ACL revision at two-years and clinical knee stability at one-year follow-up compared to isolated ACL revision. LEVEL OF EVIDENCE: Level I.

Loss of the knee-ankle coupling and unrecognized elongation in Achilles tendon rupture: effects of differential elongation of the gastrocnemius tendon.

PURPOSE: The biarticular anatomy of the gastrocnemii is an important mechanism of knee-ankle coupling and differential elongation may affect this function leading to weakness of the push-off phase during the gait. Achilles tendon ruptures may cause detachment of the gastrocnemius tendon from the soleus aponeurosis with subsequent differential elongation of the individual subtendons. This study investigated the effects of such detachment by investigating tendon fusion levels of the two muscle groups, and the effect of sequential differential elongation of the gastrocnemius on the Achilles tendon resting angle (ATRA) and to the knee-ankle coupling. METHODS: Conjoined tendon length (CTL) was measured in 23 cadavers. ATRA in knee extension (ATRA 0) and 90-degree knee flexion (ATRA 90) was measured with the gastrocnemius tendons (GT) intact, transected and with the gap reduced in 5-mm increments. In 15 specimens, knee-ankle coupling was examined. RESULTS: Considerable anatomical variation was present with CTL ranging from 2 to 40% of fibular length. In the intact triceps, surae ATRA 0 differed from ATRA 90 by 6 degrees (p < 0.001). Cutting the gastrocnemius caused an immediate separation of the tendon ends by 19 mm. ATRA 0 and ATRA 90 increased 8 and 4 degrees (p < 0.001), significantly larger increase for ATRA 0 (p < 0.001). Lengthening the gastrocnemius 10 mm altered the coupling point 10 degrees towards dorsiflexion. Transfixing the gastrocnemius at the level of the gap where the Achilles was sectioned, decoupled the knee-ankle coupling in all but two specimens. A moderate correlation between CTL and length of the medial gastrocnemius tendon was found. CONCLUSIONS: A greater relative ATRA 0 than relative ATRA 90 indicates differential elongation of the gastrocnemius. By elongating the gastrocnemius the knee-ankle coupling point shifts dorsally, and 20 mm elongation completely decouples the knee-ankle coupling. Independent lengthening of the gastrocnemius may explain the loss of power experienced by some patients following acute Achilles tendon rupture despite what would appear to be appropriate approximation of the ruptured tendon ends. Recognizing this occurrence is crucial when treating Achilles tendon ruptures and such patients require surgical correction in order to avoid long-term weakness of push-off strength.

Surgical Repair of Complete Plantar Fascia Ruptures in High-Demand Power Athletes: An Alternative Treatment Option.

Surgical repair of complete plantar fascia ruptures has not yet been reported in the literature. Operative technique and outcome are described in 2 gymnasts with heavy plyometric demands who received surgical repair compared with 3 athletes treated nonoperatively. Biomechanics and clinical implications are discussed. In the last 8 years, we have seen 5 high-demand athletes with total rupture of the plantar fascia. This is a retrospective clinical evaluation 1.5 to 8 years postinjury of all 5 patients using dynamic ultrasound, Foot Function Index, sports-specific questions, Foot Posture Index, and foot length. The operated gymnasts returned to the same level of performance within 12 months. None of the conservatively treated athletes returned to preinjury plyometric sports levels but reached a foot load capacity of distance running with the injured foot as limiting factor. Ultrasound with simultaneous dorsiflexion of the toes showed a normal fascia in the operated patients, but a slack fascia that tightened up only at terminal toe dorsiflexion in the conservatively treated group. According to the Foot Function Index, the operated patients reported no complaints, whereas the nonoperative group had clinical relevant impairments in activities of daily life. The Foot Posture Index in all nonoperated patients showed a relative shift toward pronation with increased foot length compared with the noninjured foot. The operated patients showed no difference in foot length but minimal shift into supination with a slightly altered arch contour. Surgical repair of plantar fascia ruptures is technically feasible to restore normal foot load capability with return to high-demand plyometric sports within 12 months.

The Danish Stroke Registry.

AIM OF DATABASE: The aim of the Danish Stroke Registry is to monitor and improve the quality of care among all patients with acute stroke and transient ischemic attack (TIA) treated at Danish hospitals. STUDY POPULATION: All patients with acute stroke (from 2003) or TIA (from 2013) treated at Danish hospitals. Reporting is mandatory by law for all hospital departments treating these patients. The registry included >130,000 events by the end of 2014, including 10,822 strokes and 4,227 TIAs registered in 2014. MAIN VARIABLES: The registry holds prospectively collected data on key processes of care, mainly covering the early phase after stroke, including data on time of delivery of the processes and the eligibility of the individual patients for each process. The data are used for assessing 18 process indicators reflecting recommendations in the national clinical guidelines for patients with acute stroke and TIA. Patient outcomes are currently monitored using 30-day mortality, unplanned readmission, and for patients receiving revascularization therapy, also functional level at 3 months poststroke. DESCRIPTIVE DATA: Sociodemographic, clinical, and lifestyle factors with potential prognostic impact are registered. CONCLUSION: The Danish Stroke Registry is a well-established clinical registry which plays a key role for monitoring and improving stroke and TIA care in Denmark. In addition, the registry is increasingly used for research.