Ankle Cartilage: Chondral and Osteochondral Lesions: A Further Dive into the Incidence, Terminology, and the Cartilage Cascade.

The current concepts thoroughly highlight the ankle cartilage cascade focusing on the different stages and the different etiologic factors that can introduce a patient into the cascade. Moreover, the authors will provide the reader with a comprehensive overview of the types of lesions that may present as symptomatic, asymptomatic, and dangerous for progression into osteoarthritis, and the authors supply the reader with considerations and directions for future clinical implications and scientific endeavors.

[Ligamentous injuries of the ankle joint : Importance of radiological imaging procedures]. / Bandverletzungen des Sprunggelenks : Stellenwert radiologischer bildgebender Verfahren.

Injuries of the ankle joint show lesions of the lateral ligamentous apparatus with an incidence of 1 in 1000 cases. With a range of 0.3-0.7 in 1000 cases, injuries of the medial ligamentous apparatus occur more frequently than previously thought and are often overlooked. Correct imaging diagnostics of the ankle ligaments are mandatory for the prognosis and treatment planning. In cases of clinically strong suspicion of ligamentous injury or osteochondral lesions of the ankle joint, after primary radiographic evaluation magnetic resonance imaging (MRI) is primarily recommended for a more precise assessment. Additionally, the sensitivity for assessment of the ligaments with ultrasonography is good (91% vs. 97% with MRI) but its specificity is inferior compared to MRI (63% vs. 93% with MRI). Supination trauma is the most common ankle injury and attention should be paid to the anterior tibiofibular ligament and calcaneofibular ligament. In approximately 50%, injuries to the superficial layer of the medial collateral ligament complex are associated with lesions of the posterior tibiotalar ligament.

Os supranaviculare and navicular osteochondral lesion contributing to the development of a navicular stress fracture in an adolescent male athlete: Case report.

Stress fractures of the tarsal navicular bone can be problematic in the athlete. This case details the injury and outcome of an adolescent male athlete who experienced one year of intermittent foot pain without acute trauma. Radiographs and computed tomography demonstrated a triad of a navicular stress fracture, an os supranaviculare, and an osteochondral defect of the navicular bone. The patient underwent successful operative fixation and returned to painless full function with imaging demonstrating healing at six months. Diagnosis of a navicular stress fracture in the setting of both an os supranaviculare and osteochondral lesion of the navicular bone have not been reported elsewhere in the literature. While repetitive loading on the navicular bone can independently produce a stress fracture, the patient had an increased risk for this injury; the presumably pre-existing navicular osteochondral lesion and os supranaviculare may have resulted in decreased effective articular surface area, thereby increasing force on the navicular bone and producing a stress fracture. Understanding navicular stress fractures and concomitant bony pathology contributing to injury is crucial to successful diagnosis, management, and prevention of recurrence.

Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis.

OBJECTIVE: To determine and compare the incidence rate of (osteo)chondral lesions of the ankle in patients with acute and chronic isolated syndesmotic injuries. DESIGN: A literature search was conducted in the PubMed (MEDLINE) and EMBASE (Ovid) databases from 2000 to September 2021. Two authors independently screened the search results, and risk of bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Studies on acute and chronic isolated syndesmotic injuries with pre-operative or intra-operative imaging were included. The primary outcome was the incidence rate with corresponding 95% confidence intervals (CIs) of (osteo)chondral lesions of the ankle in combined and separate groups of acute and chronic syndesmotic injuries. Secondary outcomes were anatomic distribution and mean size of the (osteo)chondral lesions. RESULTS: Nine articles (402 syndesmotic injuries) were included in the final analysis. Overall (osteo)chondral lesion incidence was 20.7% (95% CI: 13.7%-29.9%). This rate was 22.0% (95% CI: 17.1-27.7) and 24.1% (95% CI: 15.6-35.2) for acute and chronic syndesmotic injuries, respectively. In the combined acute and chronic syndesmotic injury group, 95.4% of the lesions were located on the talar dome and 4.5% of the lesions were located on the distal tibia. (Osteo)chondral lesion size was not reported in any of the studies. CONCLUSIONS: This meta-analysis shows that (osteo)chondral lesions of the ankle are present in 21% of the patients with isolated syndesmotic injuries. No difference in incidence rate was found between the different syndesmotic injury types and it can be concluded that the majority of lesions are located on the talar dome. PROSPERO REGISTRATION NUMBER: CRD42020176641.

Significant variations in surgical construct and return to sport protocols with syndesmotic injuries: an ISAKOS global perspective.

OBJECTIVES: Although the body of literature on syndesmosis injuries is growing with regard to both the biomechanics and clinical outcomes for various fixation constructs, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavoured to assess the current approaches to managing syndesmotic injuries through a Research Electronic Data Capture survey. METHODS: The survey consisted of 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment and technique, and postoperative management. Responses were generated through six different athlete scenarios: moderate impact, high impact, and very high impact athletes with/without complete deltoid injury. Frequencies and percentages were calculated for all categorical responses. RESULTS: A total of 742 providers responded to the survey, including 457 American surgeons and 285 members of various international societies. Flexible devices were the preferred fixation construct (47.1%), followed by screws (29.6%), hybrid fixation (e.g. combination of flexible device and screw, 18%), and other (5.3%). Sixty-four percent of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated return to full participation, largely dependent on the presence or absence of a deltoid ligament injury. CONCLUSION: The most common elements used as surgical indications were syndesmosis widening > 2 mm on x-ray, an anterior inferior talofibular ligament injury in combination with a posterior inferior talofinular ligament or deltoid ligament involvement on magnetic resonance imaging, and widening of the distal tibiofibular joint during arthroscopic evaluation. Overall, flexible fixation (e.g. suture button) was the preferred device choice for the repair of an injured syndesmosis. Most respondents did not alter their rehab protocol or anticipated return to play timeline based on the injury severity. However, there was considerable variability between respondents on the time to weight-bearing, running, and full participation. Further pragmatic outcomes data are necessary to guide safe return to play protocols for syndesmotic injuries. LEVEL OF EVIDENCE: Level IV.

Posteroinferior tibiofibular ligament - A cadaveric study.

BACKGROUND: Ankle injuries are one of the most common musculoskeletal disorder. The purpose of this study was to analyze and describe the detailed anatomical arrangement and relationship of posterior ligaments of the ankle, especially de posteroinferior tibiofibular ligament (PITFL) and intermalleolar ligament (IML). Controversy exists in the previous literature regarding their morphology and denomination, as well as the relation with ankle injuries including posterior soft tissue impingement syndrome. METHODS: Seventeen fresh-frozen cadaveric feet were used. The origins, insertions, ligament lengths, orientations with respect to relevant bony landmarks of the PITFL were evaluated. RESULTS: PITFL was present in all anatomical specimens. It was formed by two independent components, the superficial and deep fibers. Their dimensions vary widely between specimens. The IML was located between the deep PITFL and posterior talofibular ligament. The shape varied from a thin fibrous band to a thick cordlike structure. The IML was evident in 82.4% of the ankles. In 28.6% of the cases, the posterior intermalleolar ligament was split into two bundles in the fibular insertion. In 14 ankles, three slips were found. CONCLUSION: Given the frequency of injury and increasing necessity for surgical intervention, a more comprehensive anatomic knowledge of the different ligaments is warranted, provide clinically pertinent quantitative data and improve the treatment of these lesions.

Ankle microinstability: arthroscopic findings reveal four types of lesion to the anterior talofibular ligament's superior fascicle.

PURPOSE: ATFL's superior fascicle injury has been considered to be the underlying cause in cases of ankle microinstability. As its clinical diagnosis can be difficult, arthroscopic examination may be the only objective diagnostic tool. The purpose of this study was to determine what types of injuries to the ATFL's superior fascicle are associated with ankle microinstability, and to provide the reader with an arthroscopic classification of the types of microinstability affecting the ankle. METHODS: Ankle arthroscopy video records obtained during a four-year period from 232 patients with the diagnosis of ankle microinstability were reviewed. The characteristics of the ATFL's superior fascicle injury were identified, described and recorded along with any concomitant intra-articular pathology. RESULTS: Four different injury patterns were consistently seen affecting the ATFL's superior fascicle. These ranged from ligament attenuation associated with loss of tension (type I), through to partial detachment (type II) or total detachment (type III) from the fibula. Finally, a total or partial resorption of the ATFL's superior fascicle (type IV) was also observed. There was a statistically significant association between the type of injury identified and the rate of intra-articular pathology observed arthroscopically. Equally, the higher the type in the classification, the higher the rate of loose bodies, lateral talar OCD, deltoid "open book" tears, and anterior soft-tissue formation. CONCLUSION: Different types of ATFL's superior fascicle injury can be observed in patients with ankle microinstability, ranging from ligament attenuation associated with a loss of tension (8.2%) to different degrees of partial (69.1%) and total (16.8%) ligament detachment from the fibula, or ligament remnant resorption (5.9%). As the type of injury progresses along with the proposed classification, the rate of intra-articular injuries also increases. The clinical relevance of this study is that a morphological ATFL's superior fascicle tear is recognized in patients with the diagnosis of ankle microinstability. LEVEL OF EVIDENCE: IV.

Periosteal stripping in high ankle sprains: An association with osteonecrosis.

OBJECTIVE: We present a series of 20 cases of a sleeve-type injury of the distal tibia characterized by traumatic periosteal stripping caused by a high ankle sprain. We characterize the magnetic resonance imaging findings associated with this injury and highlight its association with distal tibial osteonecrosis. MATERIALS AND METHODS: We collected 20 cases of high ankle sprains with periosteal stripping of the distal tibia through teaching files and a search through our PACS database. We recorded the presence and pattern of syndesmotic ligamentous injury and the presence or absence of syndesmotic widening in patients with periosteal stripping. The presence or absence of associated fractures and osteonecrosis was noted and characterized by location. RESULTS: The most commonly torn ligament was the anterior inferior tibiofibular ligament. 25% (5/20) of the patients in our series developed osteonecrosis. Osteonecrosis developed as early as 3-4 weeks following the initial injury. Of the patients with osteonecrosis, 40% (2/5) had fractures of the posterior malleolus. All patients with osteonecrosis had widening of the syndesmosis. Two of the five patients with osteonecrosis were in the pediatric age group. CONCLUSION: In contrast to conventional syndesmotic and interosseous ligamentous tearing, high ankle injuries with tibial periosteal stripping may result in avulsion of the extra-osseous vasculature supplied by the periosteum, leading to osteonecrosis. This pattern of injury has not been emphasized in the literature. Our findings underscore the importance of the integrity of the periosteum for maintaining adequate vascularity of the distal tibia.

Finite Element Analysis of the Effect of Talar Osteochondral Defects of Different Depths on Ankle Joint Stability.

BACKGROUND Talus cartilage injury leads to changes in biomechanics of the ankle joint and ultimately affects ankle joint function, but which talus cartilage defects require surgery is still uncertain. This research used a finite element method to simulate the effect of different depth of talus cartilage defects on the stress and stability of the ankle joint in a certain area. MATERIAL AND METHODS A three-dimensional finite element model with different depths of osteochondral defects was created to simulate and calculate joint stress and displacement of the articular surface of the distal tibia and the proximal talus while the ankle joint was in the push-off, midstance, and heel-strike phases. RESULTS The equivalent stress of the proximal talus did not change significantly at a defect depth of 1 mm, whereas the equivalent stress of the upper talus increased significantly at a defect depth of ≥3 mm or more, reaching a maximum value at a defect depth of 10 mm. The equivalent stress of the tibial cartilage and the equivalent stress and displacement in the corresponding forces in the midstance phase and heel-strike phase were significantly different from those in the normal group, but the difference in stress in each defect group was not obvious. CONCLUSIONS The effect of cartilage defects of the talus on biomechanics of the ankle is clear, especially in the midstance and push-off phases. When the defect reaches the subchondral bone (at a depth of 3 mm), the most obvious change in ankle joint stability occurs, and it does not increase linearly with the increase in depth of the defect.

Characteristics of Osteochondral Lesions of the Talus in Different Age Groups.

We analyzed the characteristics of 112 consecutive patients who were operatively treated for osteochondral lesions of the talus from August 2014 to April 2019 in our hospital. The patients were divided into three age groups: young-adult (<40 years), middle-age (40-60 years) and old-age (>60 years). The basic clinical features, localization and size of the lesions, Hepple stage, and surgical procedures were compared among groups. Several significant differences were found on the characteristics of osteochondral lesions of the talus among age groups. There were more female patients in the old-age group (p<0.01), and old patients had a longer duration of symptoms (p<0.05). The OLTs in middle- and old-age patients were mostly located in the medial part of the talus with larger depth (p<0.01). Hepple stage 5, the cystic type, was very common in the old-age group (p<0.01). With regard to surgical procedures, more osteochondral autograft transplantations were applied in the old-age group (p<0.01). Female and deep medial talar subchondral cyst is the typical characteristics of patients over 60 years old. Age is an important factor that must be considered when choosing surgery procedure for patients with osteochondral lesions of the talus.

Morphology of Anterior Talofibular Ligament After Arthroscopic Lateral Ankle Ligament Repair.

BACKGROUND: Arthroscopic lateral ankle ligament repair for chronic lateral ankle instability (CLAI) yields good clinical results. However, the healing process of the ligament after anatomical repair remains unclear. This study evaluated the functional and patient-based outcomes for CLAI patients who underwent arthroscopic lateral ankle ligament repair and the morphological condition of the repaired anterior talofibular ligament (ATFL). METHODS: We retrospectively reviewed 47 patients (50 ankles) who underwent arthroscopic lateral ankle ligament repair for CLAI (mean follow-up, 14 months). The Japanese Society for Surgery of the Foot Ankle-Hindfoot (JSSF) scale score and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were assessed preoperatively and 12 months postoperatively. Magnetic resonance imaging (MRI) was performed preoperatively and at 6 and 12 months postoperatively to evaluate the ATFL. The functional and patient-based outcomes were compared between the group with repaired ATFLs and high signal intensity and the group with repaired ATFLs and low signal intensity. RESULTS: The mean JSSF score improved significantly from 72.3 ± 11.6 preoperation to 95.3 ± 5.4 at 12 months postoperation. The MRI findings at 12 months postoperation showed that each repaired ATFL had a linear band structure from the talar to the fibular attachment site, and 41 of 50 ankles (82%) had low signal intensity of the ligament. On the SAFE-Q, the social functioning scores at 12 months postoperation were significantly higher in the low signal intensity group than in the high signal intensity group. CONCLUSION: Arthroscopic lateral ankle ligament repair for CLAI yielded good functional and patient-based outcomes and restored the morphological condition of the ATFL. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Lower limb acute joint injuries: when to refer for X-ray?

This article summarises the clinical decision tools available to help decide when acute lower limb joint injuries should be referred for plain film radiography. The Ottawa foot and ankle rules are a tool for deciding whether to refer a patient for X-ray or not. The rules are highly sensitive, gaining National Institute for Health and Care Excellence recommendation in the UK, although they have limited benefit in some patient groups, such as those with peripheral neuropathy. The Ottawa knee rules are highly sensitive but less specific than the Pittsburgh decision rules. Although the Pittsburgh rules are more specific, they have been less extensively investigated and, unlike the Ottawa rules, are not National Institute for Health and Care Excellence recommended. A major barrier to use of these rules in clinical practice is the concern of litigation, although National Institute for Health and Care Excellence recommendation should reassure clinicians and thus reduce the amount of unnecessary radiation exposure.

Syndesmotic malreduction may decrease fixation stability: a biomechanical study.

BACKGROUND: This study aims to investigate the malreduction of syndesmosis and its effects on stability. METHODS: The biomechanical tests, including the three-dimensional (3D) displacement of the syndesmotic incisura, fibular rotation angle, and torque resistance, were performed on six cadaver legs. These specimens were first tested intact (intact group), then cut all the syndesmotic ligaments and fixed in anatomical position (anatomical model group) and test again. After that, syndesmosis was fixed in 1 cm malreduction (anterior and posterior displacement group) to do the same test. RESULTS: In internal or external load, there were significant differences in torque resistance and fibular rotation angle (internal t = 2.412, P = 0.036; external t = 2.412, P = 0.039) between the intact and post-malreduction groups. In internal rotation load, there were significant differences in sagittal displacement between the intact and post-malreduction groups (P = 0.011), and between the anatomical and post-malreduction groups (P = 0.020). In external rotation load, significant differences existed between the intact and ant-malreduction group (P = 0.034) in sagittal (anterior-posterior) displacement. Significant differences also existed between the intact and post-malreduction groups (P = 0.013), and between the anatomical and post-malreduction groups (P = 0.038) in coronal (medial-lateral) displacement. CONCLUSIONS: Malreduction in different conditions does affect the stability of the syndesmotic fixation. The result of the study may reveal the biomechanical mechanism of poor clinical outcome in syndesmosis malreduction patients and pathological displacement patterns of the ankle under syndesmotic malreduction conditions. LEVEL OF EVIDENCE: III.

Effectiveness of the saline load test in diagnosis of simulated traumatic ankle arthrotomies.

BACKGROUND: Limited studies have been conducted to determine the minimum amount and sensitivity of the saline load test of the ankle. Prior studies, only performed in arthroscopic models, have suggested a wide range of volumes necessary to confirm arthrotomy. The purpose of this study was to investigate the amount of fluid required and the sensitivity of the saline load test to identify an intra-articular arthrotomy of the ankle. Using cadavers without prior ankle trauma or surgeries we aim to assess volume needed to detect ankle arthrotomies at varying arthrotomy locations. We hypothesized that the volume needed would vary based on site of arthrotomy. METHODS: Twenty thawed, fresh-frozen below knee cadavers were divided into four groups based on arthrotomy location. An ankle arthrotomy was made using a 4 mm trochar at the four standard ankle portal sites; anteromedial, anterolateral, posteromedial, and posterolateral. To confirm intra-articular location, a arthroscope was inserted for direct visualization of the ankle joint. An 18-gauge needle was then inserted into the ankle joint, and saline mixed with methylene blue was injected. During the injection, the known arthrotomy site was viewed for extravasation. Amount of saline required to diagnose arthrotomy was recorded. All injections were confirmed as intra-articular by demonstrating methylene blue staining of the anterior joint. RESULTS: The saline volume required to achieve extravasation ranged from 3 mL to 11 mL. The mean saline volume required to achieve extravasation was 5.3 mL. A total of 8 mL was required to achieve 90% sensitivity, 10 mL for 95% sensitivity and 11 mL for 99% sensitivity. For the anterolateral, anteromedial, posteromedial, and posterolateral arthrotomy sites the mean saline volume needed to detect a traumatic arthrotomy was 5.2 mL, 6.2 mL, 5 mL, and 4.8 mL respectively. There was no statistically significant difference in volume needed to detect arthrotomies across all four locations (p = 0.69). CONCLUSION: In this cadaveric model, an injection of 10 mL identified 95% of arthrotomies approximately 4 mm in size. No difference in volume needed to detect extravasation was found across all four arthrotomy locations. Prior studies performed in arthroscopic models with patients undergoing ankle arthroscopy may overestimate volume needed to detect arthrotomies. LEVEL OF EVIDENCE: V.

Comparison of autologous osteoperiosteal cylinder and osteochondral graft transplantation in the treatment of large cystic osteochondral lesions of the talus (OLTs): a protocol for a non-inferiority randomised controlled trial.

INTRODUCTION: Large cystic osteochondral lesions of the talus (OLTs) have been shown to have inferior clinical outcomes after reparative techniques such as bone marrow stimulation. Autologous osteochondral transplantation has been viewed as an alternative choice for treating these lesions, but donor-site morbidity has limited its application. Excellent clinical outcomes have been shown in repairing these types of lesions with autologous osteoperiosteal grafts, and these outcomes are achieved at a low cost and without donor-site morbidity in the normal knee joint. This will be the first randomised controlled trial to compare the two surgical techniques, and recommendations for the treatment of patients with large cystic OLTs will be provided. METHODS AND ANALYSIS: A non-inferiority randomised controlled trial will be conducted. A total of 70 participants with clinically diagnosed large cystic OLTs will be randomly allocated to either the experimental group or the control group at a ratio of 1:1. The experimental group will be treated with autologous osteoperiosteal cylinder graft transplantation, while the control group will be treated with autologous osteochondral transplantation. The primary outcome measure will be the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score and the Short Form 12 (SF-12) questionnaire. Secondary outcome measures will include the secondary arthroscopy International Cartilage Repair Society score, the Magnetic Resonance Observation of Cartilage Repair Tissue score, the Tegner activity level score, the visual analogue scale, routine X-rays, CT and complications. These parameters will be evaluated preoperatively, as well as at 3, 6, 12, 24, 36 and 60 months postoperatively. In this trial, we hypothesised that both procedures offer good results for the treatment of patients with large cystic OLTs, and occurrence of donor-site morbidity in autologous osteoperiosteal cylinder graft transplantation group is less than that in autologous osteochondral transplantation group. ETHICS AND DISSEMINATION: The current study was approved by the board of research ethics of Peking University Third Hospital Medical Science Research Ethics Committee. The results of this study will be presented at national and international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03347877.

Internal tibial torsion is related to syndesmosis injury in a large osteological collection.

BACKGROUND: The long-term consequences of tibial torsion remain unclear. This study evaluated whether syndesmotic injuries are associated with tibial torsion. METHODS: A collection of over 3000 cadaveric skeletons was screened for irregular bony prominence along the lateral distal tibia, consistent with previous syndesmosis injury. Tibial torsion was measured and compared to 1034 control cadaveric tibiae. RESULTS: Mean torsion of 236 specimens with syndesmotic injury was 6.2±8.9 degrees, while that of control specimens was 7.9±8.8 degrees (P = 0.008). Multiple regression analysis showed a non-statistically significant trend toward internal torsion and syndesmotic injury (standardized beta=-0.051, P=0.059). Syndesmosis injury was present in 48/200 specimens (24.0%) with internal torsion and 31/199 specimens (15.6%) with external torsion (P=0.035). CONCLUSION: This association between internal tibial torsion and syndesmotic injury suggests that internal tibial torsion might not be an entirely benign condition and merits further study.

[Stingray injury: A case in French Polynesia]. / Piqûre de raie pastenague : un cas en Polynésie française.

INTRODUCTION: Stingray injuries occur when people inadvertently step on these fish. Penetration of the barb results in puncture and/or laceration wounds and lesions related to the venom. PATIENTS AND METHODS: We report the case of a 76-year-old woman in French Polynesia who was stung on her right ankle by a stingray. She initially had a hypertensive episode with encephalopathy and a haemorrhagic wound due to an indwelling fragment of the barb. Necrosis due to the poison required medical-surgical management with debridement, which yielded a favourable outcome. DISCUSSION: Stingray injuries are rare and not well-known by doctors. They can be serious due to injury by the barb and to venom poisoning, leading to enzymatic tissue destruction, ischaemia and intense pain. The initial treatment consists in immersion in hot water, as the venom is thermolabile; antibiotics and surgery may be necessary, depending on the condition of the wound.

Peroneal Tendon Pathology: Treatment and Reconstruction of Peroneal Tears and Instability.

Peroneal tendon pathology is becoming an increasingly recognized source of lateral-sided ankle pain. High clinical suspicion, along with judicious physical examination coupled with confirmatory advanced imaging modalities, are necessary to make an accurate diagnosis and aid in guiding treatment. Peroneal pathology encompasses several distinct conditions. Peroneal tendon tears and injuries to the peroneal retinaculum must be identified to guide treatment. Patients with peroneal pathology report high levels of satisfaction after surgical management with most returning to their preinjury level of function. An early and accurate diagnosis, along with treatment tailored to the individual, is necessary to obtain optimal outcomes.

Reconstruction of Complete Peroneus Longus and Brevis Tendon Ruptures Using a Semitendinosus and Gracilis Tendon Graft.

The patient was a 40-year-old female who had been treated at our hospital for left peroneal tendonitis due to an ankle sprain 2 years earlier. She re-injured that ankle while dancing. The pain in the lateral left foot soon improved, but she had difficulty standing with the left foot in equinus. Complete peroneus longus and brevis tendon ruptures were diagnosed. The ipsilateral semitendinosus and gracilis tendons were harvested and used to reconstruct the tendons. Three months after surgery, the patient was able to stand in equinus, and at 5 months after surgery she resumed her original level of sports activities.