Primary augmentation of percutaneous repair with flexor hallucis longus tendon for Achilles tendon ruptures reduces tendon elongation and may improve functional outcome.

PURPOSE: Achilles tendon ruptures (ATR) result in loss of strength and function of the gastrosoleus-Achilles tendon complex, probably because of gradual tendon elongation and calf muscle atrophy, even after surgical repair. Flexor hallucis longus (FHL) augmentation not only reinforces the repair and provides new blood supply to the tendon, but also protects the repair, internally splinting the repaired Achilles tendon, maintaining optimal tension. We prospectively compared the clinical outcomes of patients with acute ATR, managed with either percutaneous repair only or percutaneous repair and FHL augmentation. METHODS: Patients with acute ATR undergoing operative management were divided into two groups. Thirty patients underwent percutaneous repair under local anesthesia, and 32 patients underwent percutaneous repair augmented by FHL tendon, harvested through a 3 cm longitudinal posteromedial incision, and transferred to the calcaneus, under epidural anesthesia. All patients were treated by a single surgeon between 2015 and 2019 and were followed prospectively for 24 months. RESULTS: The percutaneous only group was younger than the augmented one (35.4 ± 8.0 vs 40.4 ± 6.6 years, p = 0.01). In the augmented group, 25 patients stayed overnight and only 5 were day cases, whereas in the percutaneous only group 4 patients stayed overnight and 28 of them were day cases (p < 0.001). The duration of the procedure was significantly longer in the augmented group (38.9 ± 5.2 vs 13.2 ± 2.2 min, p < 0.001). At 24 months after repair, the Achilles tendon resting angle (ATRA) was better in the augmented group (-0.5 ± 1.7 vs -4.0 ± 2.7, p < 0.001), as was Achilles tendon rupture score (ATRS) (91.7 ± 2.2 vs 89.9 ± 2.4, p = 0.004). Calf circumference of the injured and the non-injured leg did not differ between the groups, as did the time interval to single toe raise and the time interval to walking in tiptoes. Although plantarflexion strength of the operated leg was significantly weaker than the non-operated leg in both groups, the difference in isometric strength of the operated leg between the groups was not significant at 24 months (435 ± 37.9 vs 436 ± 39.7 N, n.s.). CONCLUSION: Percutaneous repair and FHL tendon augmentation may have a place in the management of acute Achilles tendon ruptures, reducing tendon elongation and improving functional outcome. LEVEL OF EVIDENCE: Level II.

The Cincinnati incision is safe and effective for revision surgery for insertional tendinopathy of the Achilles tendon.

The present study reports the outcomes of revision surgery using a Cincinnati incision with tendon debridement and calcaneoplasty for insertional Achilles tendinopathy (IAT) in a cohort of patients at 24-month follow-up. Patients undergoing revision surgery following failed previous surgery for IAT were prospectively recruited. Patients were assessed pre-operatively and at 3, 6,12 and 24 months. The Victorian Institute of Sport Assessment Scale for Achilles Tendinopathy (VISA-A), the EQ5D questionnaire and the visual analogue scale (VAS) were used for evaluation. Data from 33 patients with a mean age of 43.9 years old are reported. 27% (9 of 33 patients) were female. The left side was involved in 58% (19/33) of patients. No clinically relevant complications were reported in any of the patients. Most of subscales of EQ5D improved at last follow-up: Usual Activities (P = 0.01), Mobility (P = 0.03), Pain/Discomfort (P = 0.001), Thermometer (P = 0.04). No statistically significant change for the subscales Self-Care (P = 0.08) and Anxiety-Depression (P = 0.1) was evidenced. The VISA-A score improved significantly at last follow-up (P < 0.0001), as did the VAS score (P < 0.0001). These results indicated that a Cincinnati incision followed by tendon debridement and calcaneoplasty for revision surgery for IAT is feasible and reliable, achieving clinically relevant improvement in the VISA-A, EQ5D and VAS at 24 months follow-up.

Slowed-Down Rehabilitation Following Percutaneous Repair of Achilles Tendon Rupture.

BACKGROUND: Following percutaneous repair of acute Achilles tendon (AT) ruptures, early postoperative weightbearing is advocated; however, it is debatable how aggressive rehabilitation should be. We compared the clinical and functional outcomes in 2 groups of patients who followed either our "traditional" or a "slowed down" rehabilitation after percutaneous surgical repair. METHODS: Sixty patients were prospectively recruited to a slowed down (29 patients) or a traditional (31 patients) rehabilitation program. Both groups were allowed immediate weightbearing postoperatively; a removable brace with 5 heel wedges was applied at 2 weeks. In the slowed-down group, 1 wedge was removed after 4 weeks. Gradual removal of the boot took place after 4 wedges were kept for 4 weeks. In the traditional group, 1 wedge was removed every 2 weeks, with removal of the boot after 2 wedges had been kept for 2 weeks. The AT Resting Angle (ATRA) evaluated tendon elongation. Patient reported functional outcomes were assessed using the AT Rupture Score (ATRS). Calf circumference difference and the isometric plantarflexion strength of the gastro-soleus complex were evaluated. RESULTS: At the 12-month follow-up, both ATRA and ATRS were more favorable in the slowed-down group. The isometric strength and the calf circumference were more similar to the contralateral leg in the slowed-down group than in the traditional one. CONCLUSION: Following percutaneous repair of acute Achilles tendon patients undergoing slowed down rehabilitation performed better than the traditional one. These conclusions must be considered within the limitations of the present study. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Failed Surgery for Patellar Tendinopathy in Athletes: Midterm Results of Further Surgical Management.

BACKGROUND: Tendon injuries are commonly seen in sports medicine practice. Many elite players involved in high-impact activities develop patellar tendinopathy (PT) symptoms. Of them, a small percentage will develop refractory PT and need to undergo surgery. In some of these patients, surgery does not resolve these symptoms. PURPOSE: To report the clinical results in a cohort of athletes who underwent further surgery after failure of primary surgery for PT. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 22 athletes who had undergone revision surgery for failed surgical management of PT were enrolled in the present study. Symptom severity was assessed through the Victorian Institute of Sport Assessment Scale for Patellar Tendinopathy (VISA-P) upon admission and at the final follow-up. Time to return to training, time to return to competition, and complications were also recorded. RESULTS: The mean age of the athletes was 25.4 years, and the mean symptom duration from the index intervention was 15.3 months. At a mean follow-up of 30.0 ± 4.9 months, the VISA-P score improved 27.8 points (P < .0001). The patients returned to training within a mean of 9.2 months. Fifteen patients (68.2%) returned to competition within a mean of 11.6 months. Of these 15 patients, a further 2 had decreased their performance, and 2 more had abandoned sports participation by the final follow-up. The overall rate of complications was 18.2%. One patient (4.5%) had a further revision procedure. CONCLUSION: Revision surgery was feasible and effective in patients in whom PT symptoms persisted after previous surgery for PT, achieving a statistically significant and clinically relevant improvement of the VISA-P score as well as an acceptable rate of return to sport at a follow-up of 30 months.

Isolated medial patellofemoral ligament reconstruction for recurrent patellofemoral instability: analysis of outcomes and risk factors.

BACKGROUND: The medial patellofemoral ligament (MPFL) is always damaged after patellar dislocation. In selected patients, MPFL reconstruction is necessary to restore a correct patellar tracking. Despite the large number of different techniques reported to reconstruct the MPFL, there is no consensus concerning the optimal procedure, and debates is still ongoing. The present study analysed the results after isolated MPFL reconstruction in patients with patellofemoral instability. Furthermore, a subgroup analysis of patients presenting pathoanatomical risk factors was made. METHODS: In November 2020, the main electronic databases were accessed. All articles reporting the results of primary isolated MPFL reconstruction for recurrent patellofemoral instability were considered for inclusion. Only articles reporting a minimum 12-month follow-up were eligible. RESULTS: Data from a total of 1777 knees were collected. The mean age of the patients involved was 22.8 ± 3.4 years. The mean follow-up was 40.7 ± 25.8 months. Overall, the range of motion (+ 27.74; P < 0.0001) and all the other scores of interests improved at last follow-up: Kujala (+ 12.76; P = 0.0003), Lysholm (+ 15.69; P < 0.0001), Tegner score (+ 2.86; P = 0.006). Seventy-three of 1780 patients (4.1%) showed a positive apprehension test. Thirty of 1765 patients (1.7%) experienced re-dislocations, while 56 of 1778 patients (3.2%) showed persisting joint instability. Twenty-five of 1786 patients (1.4%) underwent revision surgeries. CONCLUSION: Isolated MPFL reconstruction for recurrent patellofemoral instability provides reliable surgical outcomes. Patients with pathoanatomical predisposing factors reported worse surgical outcomes.

Modified Zadek osteotomy without excision of the intratendinous calcific deposit is effective for the surgical treatment of calcific insertional Achilles tendinopathy.

INTRODUCTION: Nonoperative management of calcific insertional Achilles tendinopathy (CIAT) may fail in 10-30% of patients, and various operative procedures have been described to manage those. METHODS: A modified Zadek (dorsal closing wedge) calcaneal osteotomy, without removing the calcific deposits and without detaching the insertion of the Achilles tendon, was performed between November 2016 and December 2017 in 25 consecutive patients (mean age 53.5 years), who were followed for at least 2 years. RESULTS: The osteotomies had united at an average of 5 weeks. Two superficial wound infections (8%) were documented. Patients had returned to their normal activities at an average time of 23 ± 7.7 weeks. Three out of four patients, who practised recreational sport activity, returned to their pre-injury level. VAS and VISA-A scores had significantly improved at 3 months postoperatively (p < .001) and continued to improve for 24 months. CONCLUSION: The modified Zadek osteotomy, without excision of the intra-tendinous calcification, was safe, and significantly improved clinical outcome in patients with CIAT at 2 years after surgery. Level of evidence IV.

Better outcomes and reduced failures for arthroplasty over osteotomy for advanced compartmental knee osteoarthritis in patients older than 50 years.

BACKGROUND: Both compartmental knee arthroplasty (CKA) and open-wedge high tibial osteotomy (HTO) may be used to treat patients older than 50 years of age with advanced compartmental osteoarthritis (OA) secondary to leg axis deformities. A meta-analysis was conducted to clarify the role of open-wedge HTO versus CKA for patients older than 50 years with advanced compartmental knee OA. The present investigation aimed to analyse the clinical outcomes, implant failure and survivorship. METHODS: This meta-analysis was performed in accordance with the PRISMA guidelines. In September 2020, the main online databases were accessed. All clinical trials comparing the outcomes of open-wedge HTO versus CKA for compartmental knee OA were considered. Data analysis was performed through the Review Manager Software 5.3 (the Nordic Cochrane Collaboration, Copenhagen). Implant survivorship was analysed with a Kaplan-Meier (KM) curve that was performed using the STATA/MP software (StataCorp, College Station, TX). RESULTS: Data from 618 (HTO, 307; CKA, 311) patients were collected. Good baseline comparability among patient age, BMI and gender was detected. The Tegner Activity Scale was higher in the CKA group (P = 0.04), as were the Lysholm score (P = 0.001), the International Knee Documentation Committee (P = 0.0001) and the Knee injury and Osteoarthritis Outcome Score (P = 0.05). At a mean follow-up of 5 years, revisions were less in the CKA cohort (OR, 2.27; P = 0.004). The Kaplan-Meier curve evidenced longer implant survivorship in favour of the CKA group (P = 0.01). CONCLUSION: In patients older than 50 years of age with compartmental knee OA secondary to frontal axis leg deformities, CKA performed better than open-wedge HTO.

Dorsally Based Closing Wedge Osteotomy of the Calcaneus for Insertional Achilles Tendinopathy.

BACKGROUND: Surgical management may be indicated for patients with insertional Achilles tendinopathy (IAT) after failure of nonoperative management, and various surgical techniques have been described. HYPOTHESIS: We present the technique and results of modified dorsal closing wedge calcaneal osteotomy, performed in a cohort of 28 consecutive patients. We hypothesized that this will be a safe procedure that can improve hindfoot pain and function for most patients who will return to preoperative daily life and sports activities. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A modified dorsal closing wedge osteotomy was performed in 28 patients (mean age, 54.7 years) from November 2015 to December 2016. All patients were followed for at least 2 years postoperatively. RESULTS: All osteotomies united at a mean of 5 weeks. The mean anatomic change in calcaneal length was 4 mm (range, 3-6 mm). The overall complication rate was 10.7%. There were 2 superficial wound infections (7.1%) and 1 instance of sural nerve-related paresthesia (3.5%) reported. All patients returned to their presurgical level of activities at a mean of 23 ± 8.0 weeks. Further, 3 of 4 patients who participated in recreational sports activities returned to their preinjury level. Visual analog scale and Victorian Institute of Sports of Australia-Achilles scores significantly improved postoperatively (P < .001) and continued to improve for 24 months. CONCLUSION: The modified dorsal closing wedge calcaneal osteotomy is a safe procedure and significantly improved pain and function in patients with IAT at 2 years after surgery.

Participation to Leisure Activities and Well-Being in a Group of Residents of Naples-Italy: The Role of Resilience.

We explored the relationship between cultural and social participation, physical activity, and well-being in a group of residents of the metropolitan area of Naples, Italy and the role that resilience plays in this relationship. Naples offers a remarkable urban environment with the potentially beneficial psychological effects of outstanding natural beauty, and one of the world's most impressive repositories of tangible and intangible cultural heritage. However, Naples was also, and still is, heavily affected by the 2008 economic crisis, in addition to preexisting social and economic issues. The major finding of this study is that, despite this highly contrasting urban environment, the combination of physical activity and engagement in social and cultural activities has a positive effect on subjective (self-reported) psychological well-being (SPWB) in a group of residents, and that resilience mediates this relationship.

Delayed (14-30 Days) Percutaneous Repair of Achilles Tendon Ruptures Offers Equally Good Results As Compared With Acute Repair.

BACKGROUND: Minimally invasive repair of acute Achilles tendon ruptures has been performed for several years, resulting in reduced morbidity as compared with open repair. HYPOTHESIS: A minimally invasive technique can be used to manage Achilles tendon ruptures in patients presenting between 14 and 30 days from injury. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We prospectively recruited 21 consecutive patients who presented between 14 and 30 days after the index injury, and we compared them with 21 patients who were matched according to sex, age (±2 years), and level of activity, who presented within 14 days of the index injury. All patients underwent the same minimally invasive procedure under local anesthesia: a core suture repair consisting of a modified Bunnell suture in the proximal stump and a modified Kessler suture in the distal stump. RESULTS: At 12 months after minimally invasive repair, patients with delayed treatment had a median Achilles tendon rupture score of 91 (SD, 2.4; range, 87-96) as compared with 91 (SD, 2.2; range, 86-96) in patients treated acutely, who presented at a median 2.4 days (range 1-6 days) from the injury. There were no significant differences between groups in terms of mean (SD) Achilles tendon resting angle: delayed repair group, -3.9° (2.0); acute repair group, -3.7° (1.9) (P = .69). No patient in either group developed a wound infection. One patient in the acute group experienced an iatrogenic sural nerve injury. CONCLUSION: Patients with Achilles tendon rupture treated by percutaneous repair 14 to 30 days after injury achieved similar results at 1 year as patient treated <14 after injury.

Ipsilateral free semitendinosus graft with interference screw fixation for surgical management of insertional acute Achilles tendon tears.

INTRODUCTION: Very distal tears of the Achilles tendon are uncommon, and poor quality tendinous tissue of the calcaneal stump can compromise healing. Little has been published about the characteristics and surgical management of such injuries. We present a surgical technique, developed by the senior author, to restore continuity of the gastrosoleus-Achilles tendon-calcaneus complex using a free ipsilateral semitendinosus graft, and clinical outcomes of a case series of 28 consecutive patients. Our hypothesis was that this is a safe technique, and patients can return to pre-injury occupation and athletic activities. PATIENTS AND METHODS: A total of 28 patients (mean age 46 years) underwent minimally invasive reconstruction using a free ipsilateral semitendinosus graft for acute insertional rupture of tendo Achillis. The procedure required two small incisions along the course of the Achilles tendon, and one posteromedial incision at level of the ipsilateral knee to harvest the semitendinosus tendon. Patients were assessed at minimum 2 years (range, 2-2.5 years) following the index procedure. RESULTS: The median Achilles tendon Rupture Score (ATRS) at the latest follow-up was 88. Two patients developed a superficial wound infection. All patients returned to their preinjury occupation, whilst 22 out of 28 patients (79%), returned to their preinjury level of physical activity at a mean of 6.7 months after surgery, reporting good or excellent overall satisfaction in 88.5% of cases. CONCLUSION: This minimally invasive technique was safe, and allowed most of patients to return to preinjury daily and sport activities within 9 months from surgery.

Surgical management of chronic Achilles tendon ruptures using less invasive techniques.

BACKGROUND: Surgical management of chronic Tendo Achillis (TA) ruptures usually requires tendon grafting procedures. Several techniques have been described. We examined the outcome of three different less invasive (incisions length less than 3 cm) tendon transfer techniques in the management of patients with a chronic rupture of the TA. METHODS: Of 62 patients (39 males and 23 females; mean age 44.8 years; range 29.3-62 years) with chronic TA ruptures managed operatively, 21 patients had a ≥6cm gap and underwent free ipsilateral semitendinosus (ST) graft (21 patients), whereas patients with smaller gaps had either ipsilateral peroneus brevis (PB) (20 patients) or ipsilateral flexor hallucis longus (FHL) transfer (21 patients). Outcome measures included maximum calf circumference, isometric plantar flexion strength, and the Achilles tendon total rupture score (ATRS), preoperatively and at the last follow up. We also recorded the time to return to activities of daily living (ADL) and sports, and the number of single-leg heel lifts on the affected leg at the last follow up, at an average of 35.4 months. RESULTS: Patient characteristics between groups were similar. All outcome measures significantly improved after surgery (p<0.001), without differences between the three groups. Return to ADL was possible at an average of 4.5 months. Patients undergoing PB transfer had a slower return to sports compared to the other groups, at 6.9±0.5months versus 6.1±0.8 for the FHL and 5.8±0.6 for the ST groups (t-test p=0.005 and p<0.001, respectively). However, 13/14 patients (90%) in the PB group returned to high impact sports, compared to 9/12 (75%) in the FHL and 6/11 (55%) in the ST groups (Fisher's test, p=0.31 and p=0.056, respectively). CONCLUSION: All three techniques produced significant functional improvement, and return to sports was possible in most patients. This study does not demonstrate a clear advantage of one technique over the others.

Minimally Invasive Achilles Tendon Stripping for the Management of Tendinopathy of the Main Body of the Achilles Tendon.

Achilles tendinopathy is a common cause of disability. New nerves fibers grow from the paratenon into the Achilles tendon, and they could play a central role in the development of pain. We report the results of minimally invasive Achilles tendon stripping for Achilles tendinopathy in 47 active patients. The Victorian Institute of Sports Assessment-Achilles questionnaire score improved from 53.8 preoperatively to 85.3 postoperatively (p < .001). After a mean follow-up period of 40.5 months, 41 patients had resumed sporting activities at an average of 3.5 months postoperatively. A sural nerve injury was recorded in 5 patients (10.6%), and all 5 complications occurred during the first 12 cases. As a result, the technique was slightly modified, and no sural nerve neuropathy was observed subsequently. One superficial infection (2.1%) was recorded. Minimally invasive Achilles tendon stripping seems to be an effective, technically simple, and inexpensive treatment of Achilles tendinopathy. Further randomized controlled trials involving more patients are needed to confirm these outcomes.

Single minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg.

BACKGROUND: Chronic exertional compartment syndrome (CECS) involves a painful increase in compartment pressure caused by exercise and relieved by rest, common in athletes. The most common site for CECS in the lower limbs is the anterior leg compartment. The aim of this study is to evaluate the outcomes of a single minimal incision fasciotomy in athletes and their capability to return to high level sport activity. METHODS: The study reports mid-term results in a series of 18 consecutive athletes with chronic exertional compartment syndrome of the leg who had undergone minimally invasive fasciotomy. Between 2000 and 2007, we prospectively enrolled 18 consecutive athletes (12 males and six females, median age 27 years) with unilateral or bilateral chronic exertional compartment syndrome undergoing unilateral or bilateral minimally invasive fasciotomy. Clinical outcomes were assessed with Short-Form Health Survey-36 (SF-36) and European Quality of Life-5 Dimension (EQ-5D) scale. The ability to participate in sport before and after surgery and the time to return to training (RTT) and to sport (RTS) were recorded. RESULTS: The median follow-up after surgery was 36 months. Both questionnaires showed a statistically significant improvement (P < 0.0001) after surgery. At the time of the latest follow-up, 17 of 18 patients (94 %) had returned to pre-injury or higher levels of sport. Only one patient (6 %) returned to sport at lower levels than those of pre-injury status. The median time to return to training and to return to sport was 8 and 13 weeks, respectively. No severe complications or recurrence of the symptoms were recorded. CONCLUSIONS: Minimally invasive fasciotomy is effective and safe for athletes suffering from unilateral or bilateral chronic exertional compartment syndrome of the anterior and lateral compartments of the leg with good results in the mid-term.

Early signs of osteoarthritis in professional ballet dancers: a preliminary study.

OBJECTIVE: To investigate a cohort of professional ballet dancers for evidence of early signs of osteoarthritis (OA). DESIGN: One radiologist and 1 orthopedic surgeon specialized in musculoskeletal disorders analyzed magnetic resonance imaging scans independently. SETTING: University Teaching Hospital. PARTICIPANTS: Fifteen professional ballet dancers (4 males and 11 females; age range, 19-36 years) experiencing chronic pain in the hip, knee, spine, ankle, or foot joints. MAIN OUTCOME MEASURES: Presence of osteophytes, subchondral sclerosis, joint space narrowing, cysts, and bone marrow changes; the Kellgren and Lawrence scale was used to quantify the knee OA. RESULTS: In the knee, there was thinning and irregularity of the articular cartilage over the medial femoral condyle and bone marrow changes within the lateral femoral condyle. In the hip, there was a loss of joint space and a frayed labrum with deep recess. The first metatarsophalangeal joint showed evidence of osteophytic development. CONCLUSIONS: Early signs of OA, in different joints, were present in a small but highly selected cohort of professional ballet dancers. In future, prospective studies among a number of ballet companies should control for medical and natural history alongside the visual analysis of images and plain radiographs to confirm these preliminary results.

Minimally invasive reconstruction of chronic achilles tendon ruptures using the ipsilateral free semitendinosus tendon graft and interference screw fixation.

BACKGROUND: Achilles tendon ruptures represent more than 40% of all tendon ruptures requiring surgical management. About 20% of acute Achilles tendon tears are not diagnosed at the time of injury and become chronic, necessitating more complicated management than fresh injuries. Several techniques for the reconstruction of chronic tears of the Achilles tendon have been described, but the superiority of one technique over the others has not been demonstrated. HYPOTHESIS: Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft will result in improvement of the overall function with a low rate of complications. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 2008 and 2010, the authors prospectively enrolled 28 consecutive patients (21 men and 7 women; median age, 46 years) with chronic closed ruptures of the Achilles tendon who had undergone reconstruction with a free semitendinosus tendon graft. They assessed the Achilles tendon Total Rupture Score (ATRS), maximum calf circumference, and isometric plantarflexion strength before surgery and at the last follow-up. Outcome of surgery and rate of complications were also recorded. The median follow-up after surgery was 31.4 months. RESULTS: The overall result of surgery was excellent/good in 26 (93%) of 28 patients. The ATRS improved from 42 (range, 29-55) to 86 (range, 78-95) (P < .0001). In the operated leg, the maximum calf circumference and isometric plantarflexion strength were significantly improved after surgery (P < .0001); however, their values remained significantly lower than those of the opposite side (P < .0001). All patients were able to walk on tiptoes and returned to their preinjury working occupation. No infections were recorded. CONCLUSION: Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft provides a significant improvement of symptoms and function, although calf circumference and ankle plantarflexion strength do not recover fully.

Less-invasive semitendinosus tendon graft augmentation for the reconstruction of chronic tears of the Achilles tendon.

BACKGROUND: Less-extensive and gentler exposure and dissection of deep soft tissues could reduce the times of recovery and rehabilitation after Achilles tendon reconstruction. HYPOTHESIS: A minimally invasive semitendinosus autologous graft reconstruction of the Achilles tendon preserves skin integrity and reduces wound breakdown. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 26 patients underwent minimally invasive semitendinosus autologous graft reconstruction for chronic ruptures to the Achilles tendon. Patients underwent a comparison of preoperative versus postoperative maximum calf circumference and isometric plantarflexion strength and evaluation of postoperative complications. The Achilles Tendon Total Rupture Score (ATRS) was administered at the final follow-up appointment. RESULTS: All patients were reviewed at an average of 8.2 years (range, 7-10 years) from surgery. No patient was lost to follow-up. At final follow-up, the maximum calf circumference was significantly higher than preoperatively but significantly lower than the contralateral side. The isometric plantarflexion strength in the operated leg was lower than in the uninjured one. The mean ATRS was 88. Two patients developed a superficial wound infection, both healing within 2 months from the index surgery after systemic antibiotics and local dressings. One patient developed scar adhesion to the distal wound. All patients returned to their preinjury working occupation; 22 patients returned to their preinjury level of activity at a mean of 6.7 months after surgery. CONCLUSION: This technique is minimally invasive, is safe, and allows most of the patients to return to preinjury daily and sport activities within 9 months from surgery.

Isolated anterior talofibular ligament Broström repair for chronic lateral ankle instability: 9-year follow-up.

BACKGROUND: Lateral ankle sprains may result in pain and disability in the short term, decreased sport activity and early retirement from sports in the mid term, and secondary injuries and development of early osteoarthritis to the ankle in the long term. HYPOTHESIS: This combined approach to chronic lateral instability and intra-articular lesions of the ankle is safe and in the long term maintains mechanical stability, functional ability, and a good level of sport activity. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We present the long-term outcomes of 42 athletes who underwent ankle arthroscopy and anterior talofibular Broström repair for management of chronic lateral ankle instability. We assessed in all patients preoperative and postoperative anterior drawer test and side-to-side differences, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Kaikkonen grading scales. Patients were asked about return to sport and level of activity. Patients were also assessed for development of degenerative changes to the ankle, and preoperative versus postoperative findings were compared. RESULTS: Thirty-eight patients were reviewed at an average of 8.7 years (range, 5-13 years) after surgery; 4 patients were lost to follow-up. At the last follow-up, patients were significantly improved for ankle laxity, AOFAS scores, and Kaikkonen scales. The mean AOFAS score improved from 51 (range, 32-71) to 90 (range, 67-100), and the mean Kaikkonen score improved from 45 (range, 30-70) to 90 (range, 65-100). According to outcome criteria set preoperatively, there were 8 failures by the AOFAS score and 9 by the Kaikkonen score. Twenty-two (58%) patients practiced sport at the preinjury level, 6 (16%) had changed to lower levels but were still active in less demanding sports (cycling and tennis), and 10 (26%) had abandoned active sport participation although they still were physically active. Six of these patients did not feel safe with their ankle because of the occurrence of new episodes of ankle instability. Of the 27 patients who had no evidence of degenerative changes preoperatively, 8 patients (30%) had radiographic signs of degenerative changes (5 grade I and 3 grade II) of the ankle; 4 of the 11 patients (11%) with preexisting grade I changes remained unchanged, and 7 patients (18%) had progressed to grade II. No correlation was found between osteoarthritis and status of sport activity (P = .72). CONCLUSION: Combined Broström repair and ankle arthroscopy are safe and allow most patients to return to preinjury daily and sport activities.

High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon.

OBJECTIVES: Several substances are routinely injected in and around tendons. The present study evaluated the long term effects of high volume image guided injection (HVIGI) of normal saline, local anaesthetic and aprotinin in athletic patients with resistant tendinopathy of the main body of the Achilles tendon. DESIGN: Case series. METHODS: The study included a series of 94 athletes (69 men and 25 women; average age 37.5 years, range 22-63) with ultrasound confirmed tendinopathy of the main body of the Achilles tendon. All the patients had not improved after at least three months of conservative management. Patients were injected with 10 mL of 0.5% Bupivacaine Hydrochloride, 25 mg aprotinin, and up to 40 mL of injectable normal saline. We prospectively administered the Victorian Institute of Sport Assessment-Achilles tendon (VISA-A) to assess the short- and long-term pain and functional improvement. RESULTS: At baseline (n = 94), the VISA-A score was 41.7 ± 23.2 (range 11-60), and had improved to 74.6 ± 21.4 (range 71-100) by 12 months (n = 87) (p = 0.003), with no significant difference between sexes. CONCLUSION: HVIGI with aprotinin significantly reduces pain and improves function in patients with chronic Achilles tendinopathy in the short- and long-term follow up.