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Background: It has been reported that 43.6% of ankle fractures are accompanied by posterior malleolus fractures. The aim of this study is to define a safe zone for posterior malleolus fractures by determining the locations of the important anatomical structures in this region. Additionally, it aims to identify the trans-Achilles passage line for Kirschner wire insertion through a posteroanterior approach for posterior malleolus fragments., Methods: Six below-knee amputee fresh-frozen leg cadavers were used in this study. A trans-Achilles Kirschner wire was applied to the cadavers in the posteroanterior direction under the guidance of fluoroscopy. The areas where the Kirschner wire passed were dissected, and their proximity to vital anatomical structures was measured., Results: In all cadavers, the transverse thickness of the Achilles tendon at the level of the trans-Achilles Kirschner wire was 15.5 mm and the trans-Achilles Kirschner wire application was 18.6 mm from the sural nerve, 16 mm from the posterior tibial tendon, and 12.16 mm from the flexor digitorum longus muscle. It was performed 15.16 and 14.6 mm from the posterior tibial artery and vein, 12.3 mm from the tibial nerve, 13.6 mm from the tibiofibular joint, and 55.5 mm from the insertion site of the Achilles tendon to the calcaneus and at a sufficient distance from vital anatomical structures., Conclusions: The proposed trans-Achilles percutaneous surgical technique is safe from neurovascular structures for fixing posterior malleolar fractures. However, the long-term clinical outcomes of this technique need to be explored., Level of Evidence: Level III, A cadaveric study., (© 2024. The Author(s).)

Aims: Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE., Methods: This was a multicentre, prospective national collaborative audit with data collection over nine months for all patients undergoing foot and ankle surgery in an operating theatre or TA rupture treatment, within participating UK hospitals. The association between VTE and thromboprophylaxis was assessed with a univariable logistic regression model. A multivariable logistic regression model was used to identify key predictors for the risk of VTE., Results: A total of 13,569 patients were included from 68 sites. Overall, 11,363 patients were available for analysis: 44.79% were elective (n = 5,090), 42.16% were trauma excluding TA ruptures (n = 4,791), 3.50% were acute diabetic procedures (n = 398), 2.44% were TA ruptures undergoing surgery (n = 277), and 7.10% were TA ruptures treated nonoperatively (n = 807). In total, 11 chemical anticoagulants were recorded, with the most common agent being low-molecular-weight heparin (n = 6,303; 56.79%). A total of 32.71% received no chemical prophylaxis. There were 99 cases of VTE (incidence 0.87% (95% CI 0.71 to 1.06)). VTE-related mortality was 0.03% (95% CI 0.005 to 0.080). Univariable analysis showed that increased age and American Society of Anesthesiologists (ASA) grade had higher odds of VTE, as did having previous cancer, stroke, or history of VTE. On multivariable analysis, the strongest predictors for VTE were the type of foot and ankle procedure and ASA grade., Conclusion: The 90-day incidence of symptomatic VTE and mortality related to VTE is low in foot and ankle surgery and TA management. There was notable variability in the chemical prophylaxis used. The significant risk factors associated with 90-day symptomatic VTE were TA rupture and high ASA grade., Competing Interests: J. Mangwani reports support from the Leicester Hospitals Charity, related to this study. J. Mangwani reports payment or honoraria for lectures, presentations, educational events from Orthosolutions, and royalties from Meshworks, unrelated to this study. K. Malhotra reports payment or honoraria for lectures, presentations, speaker bureaus, manuscript writing or educational events from NewClip Technics, unrelated to this study. L. W. Mason reports royalties or licenses, consulting fees, and patents planned, issued or pending from Orthosolutions, unrelated to this study., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

In order to evaluate the early radiographic characteristics of the lateral talocalcaneal (L-TC) angle in patients with idiopathic clubfoot (ICF) and to investigate its prognostic significance for relapse after initial treatment with the Ponseti method. We retrospectively included 151 patients (96 males and 55 females; 227 feet) with ICF treated at our Institution between January 2005 and December 2014. The age at initial treatment was less than 6 months, and radiographs were obtained within 3 months of the Achilles tenotomy (mean age: 2.3 months; range: 0.77-6.8). All patients were followed up for at least 7 years (range, 7-18). The participants' feet were classified into 3 groups: relapsed (Group A), not relapsed (Group B), and normal foot groups which consisted of healthy feet in patients with unilateral ICF (Group C). All angle measurements were expressed in degrees. Forty-seven ICF feet in 33 patients relapsed, while 180 feet in 118 patients did not, and the age at relapse was 5.92 ± 1.91 years. Seventy-five normal feet were included in Group C. The average L-TC angle in Group A and B patients was 33.57° ± 12.05° and 39.37° ± 12.55°, respectively, while Group C was 49.61° ± 9.11°. A significant difference was found among the 3 groups of patients (F = 31.48, p < .001). The L-TC angle cut-off value below which a recurrence could be predicted was 36.1° (sensitivity, 74.47%). The L-TC angle of ICF patients treated using the Ponseti method were reduced compared to normal feet. An L-TC angle of <36.1° has relative value in predicting ICF relapse., (Copyright © 2024. Published by Elsevier Inc.)

Background: Alkaptonuria (AKU) is a rare hereditary disease. Ochronotic arthropathy, tendinopathy, and osteopenia/osteoporosis are generally musculoskeletal manifestations in patients with AKU. Because of the ochronotic tendinopathy and osteopenia, the surgical strategy for chronic ochronotic Achilles tendon rupture may be challenging. No studies have reported the surgical treatment of chronic Achilles tendon rupture in patients with AKU., Case Presentation: We report a case of AKU that required surgical treatment for chronic Achilles tendon rupture. A 60-year-old woman was referred to our department for the assessment of left hindfoot pain that persisted for more than nine months after an ankle sprain. Three years prior to the first presentation to our hospital, she was diagnosed with AKU due to pigmented hip cartilage at the time of total hip arthroplasty. The patient was diagnosed as chronic Achilles tendon rupture based on the results of physical examination and magnetic resonance imaging (MRI). The MRI showed enlarged scar tissue of the Achilles tendon with an intrasubstance high signal intensity. We performed resection of the central part of the scar tissue (total length, 24 mm) followed by direct repair using the proximal and distal stumps of the scar tissue. The MRI at 12months after surgery showed continuity of the repaired Achilles tendon. At 18 months after surgery, the Achilles Tendon Total Rupture Score improved from 22 points preoperatively to 84 points postoperatively. The foot and ankle outcome score also improved., Conclusions: We reported a case of AKU with chronic Achilles tendon rupture in which direct repair using scar tissue between the tendon stumps was effective. Careful selection of the surgical procedure for the treatment of chronic ochronotic Achilles tendon rupture is recommended because of concomitant ochronotic tendinopathy and osteopenia/osteoporosis., (© 2024. The Author(s).)

Case: We report the case of a 44-year-old man who sustained an Achilles tendon rupture with an associated trimalleolar fracture and traumatic peroneal dislocation of the left ankle after a snowboarding injury. These injuries have been surgically repaired; the patient has returned to all his activities 18 months after surgery., Conclusion: The possibility of such injuries occurring in combination should be considered. A thorough history, physical examination, and plain radiographs should be performed in higher energy trauma to the ankle. Additional diagnostic tests such as ultrasonography or magnetic resonance imaging may be used to supplement treatment., Levels of Evidence: Level 5., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C446)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The Achilles tendon is the most commonly injured and ruptured tendon in the body and typically occurs during participation in sports or recreational activities in men between 30 and 50 years of age. Treatment options for Achilles tendon rupture include conservative and surgical approaches. Conservative treatment is associated with a higher risk of rerupture, while surgical treatment carries a risk of wound site complications. Generally, both methods result in a prolonged tendon healing time. Studies are ongoing to identify biomolecules that aid tendon repair. The main objective of our study is to investigate the effects of zinc sulfate (ZnSO4) mineral supplementation on Achilles tendon healing in rats., Methods: Forty-eight female Sprague-Dawley rats were divided into four equal groups (C-15, C-30, ZnSO4-15, and ZnSO4-30) after standard Achilles tendon repair surgery. The ZnSO4-15 and ZnSO4-30 groups received an oral zinc sulfate monohydrate solution (50 mg/kg/day) for 15 and 30 days, respectively. The C-15 and C-30 groups were given 1 mL of distilled water per day orally during the experimental periods. Rats were sacrificed on the 15th and 30th day depending on their groups, and the healing of the operated tendons was evaluated using Movin and Bonar histopathologic scoring. For biomechanical analyses, the operated and intact Achilles tendons of all groups were removed, and tensile tests were performed to determine the tensile strength and toughness values for each tendon., Results: Movin and Bonar scores were significantly lower in the ZnSO4-15 group than in the C-15 group and in the ZnSO4-30 group than in the C-30 group (p<0.05). Although we did not find the biomechanical results statistically significant, the intact tendons of the ZnSO4-15 group exhibited higher toughness than those of the C-15 group, and the tensile strength and toughness values of the operated and intact tendons of the ZnSO4-30 group were also higher than those of the C-30 group., Conclusion: Zinc sulfate monohydrate mineral supplementation had histopathologically positive effects on the proliferation and remodeling stages of Achilles tendon healing and may biomechanically benefit both operated and intact tendons.

Achilles tendon injury has been increasing over recent years due to a variety of causes. The injury of the Achilles tendon is a disabling condition, which is difficult to treat if there is a gap or defect between the two ends of the disrupted tendon. Patients with a rupture of the Achilles tendon should be operated without delay. Most of the people in our country use flat pan in the latrine, which are at a same level of the toilet floor. Surface of the toilet pan breaks down and cause sharp cut. Some of the cases of open tendon injuries occur due to road traffic accident, cut by broken glass and also assault. It is generally accepted that surgical repair of fresh ruptures of the Achilles tendon gives excellent results. Objective of the study was to find out the evaluation of the results of primary repair of Open tendo-achilles injury (OTAI). This prospective study was done in the department of Casualty of Mymensingh Medical College Hospital, Bangladesh in the period of Octy 2021 to June 2022. Patients who came with OTAI in casualty department were selected randomly. All cases were selected as OTAI, without associated injury of other leg muscles, posterior tibial artery and nerve within 12 hours. All patients underwent primary end to end repair by Modified Kessler's method. Evaluation of the results of primary repair of OTAI were carried out and were find out the common causes of injury, age and sex incidence, level of injury and to proposed a protocol for treating such cases in comfortable, cheap and convenient way for the patients. Operations were done at Casualty operation theatre (COT). Then 48 patients were followed up at the Department of Casualty. Among them 43(89.58%) of patients were able to stand on tip toes, 4(08.33%) of patients were not stand on tip toes of affected foot unsupported but able to stand on tip toes supported, 1(02.08%) of patients failed to stand on affected foot unsupported due to severe infection and wound gap. Final result were Excellent - 29(60.0%), Good - 14(30.0%), Fair - 4(8.0%), Poor - 1(2.0%). Repair of OTAI is not difficult but early diagnosis, proper surgical toileting, meticulous repair; adequate post-operative management is the key of success. So, the result of this study, treatment protocol can be followed, which is easy for surgeon and convenient and cheap for the patients.

Background: Percutaneous Achilles tendon (AT) repair with the Dresden instrument is a safe and effective treatment for AT rupture within 15 days after injury. Follow-up includes clinical examination and imaging to assess the healing process and detect possible complications. The findings of each control visit determine the progression of the rehabilitation of each patient., Methods: We assessed the postoperative findings of all patients who underwent AT with the Dresden technique from May 2022 to September 2023, during a follow-up period of 6 months. The study population included 40 male patients between 18 and 59 years of age. Ultrasound (US) and magnetic resonance imaging (MRI) were performed in all patients at day 15 postoperatively and then monthly for 6 months., Results: All patients completed 6 months follow-up and 2 (5%) presented with postoperative wound dehiscence. No sural nerve lesions, reruptures, reoperations or other complications were seen. Both imaging methods showed excellent correlation of findings at all time points. Both methods were effective to assess the hematoma and structural changes of the healing process during the first 3 months. The use of US with Doppler was a useful tool to evaluate blood flow to the tendon stumps. After 3 months no significant morphological changes were observed but the US enabled a dynamic functional assessment of the tendon. After 4 months tissues showed homogenization and decrease of volume without further major changes., Conclusion: Both US and MRI proved to be excellent methods to assess the healing process after percutaneous AT repair. The US performed by an experienced investigator showed advantages over MRI in evaluating the gap between the tendon stumps, the possibility of evaluating the vascularity with Doppler US and assessing the functionality of the healing tendon with dynamic examination, besides being a cheap and easily accessible imaging method., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Percutaneous and minimally invasive suturing techniques are very important in the treatment of acute Achilles tendon ruptures because they combine the advantages of surgical treatment (low re-rupture rate) and non-opervative treatment (low risk of complications). In the authors' approach, the percutaneous, peritendineum-preserving technique with the Dresden instrument has proven itself as a standard treatment for 20 years., Dresden Technique: Strict adherence to the original Dresden technique with posteromedial incision and subfascial preparation is crucial for the safe avoidance of the sural lesions regularly reported in percutaneous procedures. The rupture zone and the peritendineum should not be opened. By adding a third suture and using non-absorbable suture material, stability comparable to the open Krackow suture technique is achieved. Functional aftertreatment with protection in a special boot and appropriate supervision of the patient aims at early rehabilitation while minimizing the risk of re-rupture or loss of tension., Outlook: The focus of future efforts should be to further improve treatment results through individualized postoperative treatment adapted to tendon healing., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Achilles tendon ruptures that are older than 4-6 weeks or developed over a more extended period are chronic. Two challenges characterize the treatment. First, defect zones over a length of several centimeters must frequently be bridged. Second, a prolonged loss of function of the muscles leads to an irreversible fatty degeneration of the tissue. So that even if the tendon is restored, significant functional deficits remain. If there are doubts about the ability of the calf muscles to regenerate, regardless of the size of the defect, tendon transfers are recommended to use the power of an additional muscle to support the plantar flexion of the ankle., Treatment: Established concepts are the transposition of the flexor hallucis longus or the peroneus brevis muscle. If the muscle is intact, defects of up to 2 cm can be treated with a direct suture. Defects between 2 and 5 cm can be bridged using a VY-plasty or a turndown flap. For larger defects, free tendon transplants can be considered. The technical alternative for larger defects is a tendon transfer of the flexor hallucis longus or the peroneus brevis muscle. Besides bridging the defect, another advantage of tendon transfer is that vital muscle tissue is placed in the bed of the Achilles tendon. Both tendons are covered with muscle tissue over nearly the full length, which offers advantages, especially in patients with critical soft tissue or after infection., Follow-Up Treatment and Prognosis: Follow-up treatment is analogous to an acute Achilles tendon rupture. However, permanent impairments are possible; 75-80% of athletes regain their original performance level., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: The Achilles tendon is the strongest tendon in humans and is frequently injured, especially in the physically active young to middle-aged population. An increasing frequency of Achilles tendon ruptures (ATR) has been reported in several studies. However, there is no international consensus regarding possible non-operative (N-OP) or operative (surgical) treatment (OP)., Objectives: The aim of this article is to semi-quantitatively compare both treatment options for ATR by analyzing the results reported in the literature., Material and Methods: For this purpose, relevant categories were identified, and the literature was then evaluated in a PubMed analysis. Ten meta-analyses and two cost analyses were included. The data was extracted according to the categories and evaluated comparatively., Results: OP and N‑OP for acute ATR can lead to equally good restitution of clinical function if early functional rehabilitation is applied. The lower re-rupture rate is an advantage of OP, whereas the lower general complications speak in favor of N‑OP. The minimally invasive or percutaneous surgical technique (M-OP) appears to be advantageous over the open surgical technique (O-OP), although studies show an increased rate of lesions of the sural nerve., Conclusion: There is no consensus regarding the superiority of OP or N‑OP for acute ATR, as several studies conducted since the introduction of early mobilization protocols have shown similar results for these two interventions. Results and complications of M‑OP and O‑OP are also comparable. Considering the available data on the various surgical procedures, the authors prefer the M‑OP technique with adequate sural nerve protection for repair of acute ATR, combined with an early mobilization protocol., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Purpose: A persisting gender bias has been recently highlighted in orthopaedics and sports medicine. The aim of this study was to evaluate the volume of gender-specific data and gender-specific results in the treatment of a common tendon disease, Achilles tendinopathy., Methods: Pubmed, Cochrane, and Web of Science were searched to identify all clinical studies focusing on Achilles tendinopathy treatment. The Visual Analogue Scale (VAS) and Victorian Institute of Sport Assessment-Achilles (VISA-A) data of women and men of the studies that disaggregated results by gender were collected, and a meta-analysis was conducted. Treatment response within and in between gender categories was evaluated, focusing on overall gender-disaggregated data, as well as within each of the three treatment categories: conservative treatment, injective treatment and surgical treatment. A formal risk of bias analysis was conducted using Downs and Black's grading system., Results: Out of the 8796 papers screened, 178 were included after the screening. The number of female study participants grew from 20% up to 1990 to 48% in the years 2019-2022. Only 373 out of 3423 (11%) female patients and 685 of 4352 (16%) male patients were found in sex-disaggregated studies. A meta-analysis was conducted on the 14 papers that reported sex-disaggregated data for VAS and VISA-A. The meta-analysis revealed that there was no difference in the overall treatment response between women and men and that both genders showed an overall significant treatment benefit in terms of VAS and VISA-A values. However, significant differences were documented within the treatment categories. While no differences were found in surgical studies, in conservative treatment studies, men experienced lower posttreatment VAS values (p = 0.004). The largest difference was found in injective treatments, with men experiencing a larger change in VAS values (men = -3.0, women = -1.0, p = 0.016) and higher posttreatment VISA-A values (p = 0.032)., Conclusion: This systematic review and meta-analysis showed a lack of awareness of the importance of sex-specific data within Achilles tendinopathy treatment research. The proportion of female study subjects has grown over the years, but there is still a large data gap caused by the absence of sex-disaggregated data. The omission of sex-disaggregated data causes the loss of valuable knowledge on the true effectiveness of current Achilles tendinopathy treatment. The results of this study indicate that women profit less from available treatments, particularly injective approaches, which prompts further research for treatment adaptation by gender., Level of Evidence: Level IV., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: There is a lack of knowledge concerning differences between females and males in the early stages after an acute Achilles tendon rupture. This article aims to explore the different factors affecting early function after an Achilles tendon rupture with a validated test battery that includes functional tests, clinical measurements and patient-reported outcome at a 3-month follow-up analysis of a larger prospective study., Methods: This study was part of the DUSTAR-study (Diagnostic UltraSonography for the choice of Treatment of acute Achilles tendon Rupture) where the main aim was to evaluate if an acute ultrasonography could determine which patients, with an Achilles tendon rupture, should be treated surgically or nonsurgically. At the 3-month follow-up, the results between males and females were compared., Results: One hundred and twenty-seven patients were included at the 3-month follow-up; of these, 102 (80%) were males and 25 (20%) were females. Amongst the females, 11 (44%) were able to perform a single leg heel-rise compared to 48 (47%) of the males; however, the difference was not statistically significant. There was no difference between the sexes in the frequency of completing a single-leg heel-rise at 3 months after injury; however, there were statistically significant differences between the groups when comparing Limb Symmetry Index (LSI) of heel-rise height and heel-rise work. The females had a median heel-rise height LSI/median heel-rise work LSI of 45%/14% compared to males who reached a level of 57%/23% (p = 0.006/p = 0.010). At the 3-month follow-up, the median (range) Achilles tendon Total Rupture Score (ATRS) reported by females was 28.5 (8-51), which had a nonsignificant difference compared to males who reported a median (range) ATRS of 30 (1-86)., Conclusion: The risk of reduced heel-rise height and worse heel-rise work 3 months after an acute Achilles tendon rupture increases by being a female. Through this knowledge, we highlighted the importance of an individualised treatment for acute Achilles tendon ruptures with better outcome for both males and females., Level of Evidence: Level II., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Objective: To evaluate the effectiveness and feasibility of a transverse small incision intrathecal "loop" minimally invasive suture for acute Achilles tendon rupture., Methods: The clinical data of 30 patients with acute Achilles tendon rupture treated with transverse small incision intrathecal "loop" minimally invasive suture between January 2022 and October 2023 was retrospectively analyzed. The patients were all male, aged from 29 to 51 years, with an average of 39.8 years. The cause of injury was acute sports injury, and the time from injury to operation was 1-14 days, with an average of 3.4 days. The operation time, incision length, intraoperative blood loss, intraoperative complications, wound healing, and hospital stay were recorded. Postoperative appearance and function of ankle were evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Vancouver Scar Scale (VSS) score, and Arner-Lindholm score., Results: The operation time ranged from 30 to 90 minutes, with an average of 54.2 minutes; the incision length ranged from 1.3 to 3.5 cm, with an average of 2.2 cm; the intraoperative blood loss ranged from 5 to 70 mL, with an average of 22.3 mL; and the hospital stay ranged from 2 to 6 days, with an average of 3.7 days. All incisions healed by first intention, and there was no incision infection, poor healing, and deep venous thrombosis. All patients were followed up 5.3-22.0 months (mean, 14.7 months). During the follow-up, all the 30 patients had returned to exercise, and there was no complication such as Achilles tendon re-rupture, postoperative infection, and gastrocnemius muscle injury. At last follow-up, the AOFAS ankle-hindfoot score was 82-100, with an average of 95.1; the VSS score was 1-4, with an average of 2.1; according to the Arner-Lindholm score, 24 cases were rated as excellent and 6 cases as good., Conclusion: Transverse small incision intrathecal "loop" minimally invasive suture for the treatment of acute Achilles tendon rupture has the advantages of simple instrument, convenient operation, small trauma, quick recovery, and satisfactory effectiveness.

Tunnel widening is a frequent problem following arthroscopic ligament reconstruction surgery that may primarily arise from a graft-tunnel mismatch caused by errors in surgical instruments and methods. The present study aimed to observe the influence of current surgical instruments and methods on graft-tunnel matching. We established an in vitro model using porcine Achilles tendons and tibias, and compared traditional surgical instruments (control group) with custom instruments (experimental group). Graft measurements, bone-tunnel creation, and measurements of the maximum pullout force of the graft from the bone tunnel were performed. Results indicated that the measuring gauge developed by our research group (capable of accurate measurement of graft diameters) may mitigate errors arising from graft-diameter measurement using traditional measuring cylinders. Therefore, errors caused by current surgical instruments and surgical methods led to an increase in graft-tunnel mismatches. The degree of mismatch was greater at the tibial end than at the femoral end., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Xu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Postoperative tissue adhesion and poor tendon healing are major clinical problems associated with tendon surgery. To avoid postoperative adhesion and promote tendon healing, we developed and synthesized a membrane to wrap the surgical site after tendon suturing. The bilayer-structured porous membrane comprised an outer layer [1,4-butanediol diglycidyl ether cross-linked with carboxymethyl cellulose (CX)] and an inner layer [1,4-butanediol diglycidyl ether cross-linked with Bletilla striata polysaccharides and carboxymethyl cellulose (CXB)]. The morphology, chemical functional groups, and membrane structure were determined. In vitro experiments revealed that the CX/CXB membrane demonstrated good biosafety and biodegradability, promoted tenocyte proliferation and migration, and exhibited low cell attachment and anti-inflammatory effects. Furthermore, in in vivo animal study, the CX/CXB membrane effectively reduced postoperative tendon-peripheral tissue adhesion and improved tendon repair, downregulating inflammatory cytokines in the tendon tissue at the surgical site, which ultimately increased tendon strength by 54% after 4 weeks.

Background: The AGEs levels in tissues of diabetics and elderly tend to be higher than in normal individuals. This study aims to determine the effects of AGEs on Achilles tendon repair., Materials and Methods: Thirty-six male eight-week-old Sprague Dawley rats were selected in this study. The rats were randomly divided into two experimental groups and a control group after the transection of the Achilles tendon. During the tendon repair, the experimental groups were injected around the Achilles tendon with 350mmol/L (low dose group) and 1000mmol/L (high dose group) D-ribose 0.2 ml respectively to increase the AGEs level, while in the control group were given the same amount of PBS. The injections were given twice a week for six weeks. Collagen-I, TNF-α, and IL-6 expression in the healed Achilles tendon was assessed. Additionally, macroscopic, pathological, and biomechanical evaluations of Achilles tendon repair were conducted., Results: The repaired Achilles tendons in the high dose group showed severe swelling and distinctive adhesions. The histological score went up with the increase of the AGEs in the Achilles tendon (p<0.001). TNF- α and IL-6 in the Achilles tendon increased (p<0.001, p<0.001), and the production of collagen-I decreased with the accumulation of AGEs in the repaired Achilles tendon (p<0.001). The tensile strength of Achilles tendon in the high dose group was impaired significantly., Conclusion: In current study, the compromised tendon repair model induced by AGEs was successfully established in rat. The study demonstrated that AGEs significantly impair Achilles tendon repair., (© 2024. The Author(s).)

Background: Surgical treatment of insertional Achilles tendinopathy (IAT) historically consists of Achilles tendon debridement with reattachment and excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. Zadek osteotomy (ZO) is an alternative to an open midline splitting approach. The purpose of this study was to analyze patient-reported outcomes and complications after percutaneously performed ZO with minimum 2 years' follow-up., Methods: One hundred eight cases treated with percutaneous ZO with a minimum 2-year follow-up were retrospectively reviewed. Postoperative complications and patient satisfaction were evaluated. Foot Function Index (FFI) and visual analog scale (VAS) scores were recorded at preoperative and follow-up appointments to measure patients' functional outcomes and pain, respectively., Results: Mean follow-up was 41.2 months (range, 24-65). Mean age was 51.8 years (range, 28-81). The mean FFI score improved from 56.1 (range, 47-88) to 11.0 (range, 7-59) postoperatively ( P < .001). The mean VAS score improved from 7.7 (range, 5-10) to 0.4 (range, 0-7) postoperatively ( P < .001). The overall complication rate was 3.8% (n = 4). Of 104 cases, 98.1% of patients said they were satisfied with their procedure (n = 102) when asked if they were satisfied with their ZO and recovery., Conclusion: We found the percutaneous ZO to be a safe and effective intervention for treatment of IAT. At a minimum of 2-year follow-up, this intervention is associated with minimal complications, improved function, reduced pain, and a high rate of patient satisfaction., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Oliver N. Schiper, MD reports royalties or licenses and consulting fees from Treasce Medical Concepts, Vilex, Exactech, and Enovis. Jonathan R. M. Kaplan, MD, reports royalties or licenses and consulting fees from Artelon, Edge Surgical, Exactech, Surgebright, and Enovis. A. Holly Johnson, MD, reports royalties or licenses from Novastep and Treace Medical Concepts. Tyler A. Gonzalez, MD, MBA, reports royalties or licenses and consulting fees from Treace Medical Concepts, Surgical Fusion Technologies, Vilex; consulting fees from Stryker, Surgebright, and Enovis. Ettore Vulcano, MD, reports royalties or licenses and consulting fees from Novastep, Vilex, and Treace Medical Concepts. Disclosure forms for all authors are available online.

Background: An endoscopic calcaneal SpeedBridge technique was described recently. The primary objective of this study was to report the postoperative complications seen with calcaneal SpeedBridge repair. The secondary objective was to report short- and medium-term functional outcomes., Hypothesis: Postoperative complications are less common with endoscopic vs. open SpeedBridge suturing., Material and Methods: The endoscopic SpeedBridge technique was used in 9 patients who had insertional Achilles tendinopathy refractory to conservative management. The patients were evaluated at least 24 months after the procedure. Infectious and wound-healing complications were recorded. Visual analogue scale (VAS) scores for pain and patient satisfaction, shoeing difficulties, the European Foot and Ankle Society (EFAS) score, and the Victorian Institute of Sport Assessment-Achilles (VISA-A) score were assessed., Results: During the mean follow-up of 25.3 months, no complications were recorded. The EFAS and VISA-A scores were 37/40 and 91/100, respectively. The mean VAS scores for pain and satisfaction were 1.7/10 and 9.3/10, respectively. No patients reported shoeing difficulties., Conclusion: Endoscopic calcaneal SpeedBridge suturing is associated with a lower complication rate compared to the open variant. Clinical outcomes are highly satisfactory in the short and middle terms., Level of Evidence: IV; retrospective observational cohort study., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Calcanectomy and Achilles tendon resection are very hard to repair., Objective: Ilizarov's "calcaneogenesis" is possible with ankle joint preservation. Even after 3.5 years of functio laesa of the triceps surae muscle it can be rebuilt., Material and Methods: A 25-year-old motorcyclist suffered a 3rd degree open calcaneal dislocation fracture (type 5). Osteitis and necrosis required calcanectomy, resection of the Achilles tendon and a latissimus dorsi muscle transfer. A talus corpus osteotomy with Ilizarov distraction created in the 1st step a "neo-calcaneus". In a delayed 2nd step a fresh-frozen Achilles tendon-bone block allograft was transplanted to regain active plantar flexion., Results: The initial AOFAS score of 35 points was significantly improved to 70 points 12 years after step 1. After both operations the patient could walk without an orthosis and regained 88% of normal plantar flexion strength. Quantitative measure of health outcome according to EQ-5D-5L was marked by the patient with 80 out of 100 points., Discussion: "Calcaneogenesis" with preservation of the ankle joint is possible and innovative. Despite 3.5 years of disconnection of the triceps surae muscle, an Achilles tendon-bone block allograft could restore 88% of the push-off force even attached to a neo-calcaneus that is 1/3 smaller than normal, which is also new., (© 2024. The Author(s).)

Objective: The results of surgical versus conservative treatment of acute Achilles tendon ruptures are still controversial. The objective of this study was to compare surgical and conservative treatment at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results., Hypotheses: There is no difference in the complications, clinical results and functional outcomes between the two treatment groups. There is no difference in the occurrence of complications or the clinical results due to the immobilization or rehabilitation protocols., Methods: This was a retrospective comparative, multicenter, non-randomized study of acute Achilles tendon ruptures treated between 01/01/2018 and 31/12/2019 at 21 study sites in France. All patients who received surgical or conservative treatment were included. The demographics, sports participation, nature of treatment, immobilization parameters (type, duration, position) and rehabilitation protocol were collected. Rerupture, general and specific complications, clinical results (heel-rise test, single-leg hop, calf circumference, ankle dorsiflexion) and the functional outcomes (ATRS, VISA-A, EFAS, SF-12) were collected at the final review., Results: Four hundred five patients were reviewed at a mean follow-up of 24 (±7) months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics. There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) (p=0.176). There were more general complications in the conservative group (24%) than in the surgical group (11%) (p=0.04). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects). The ATRS (p=0.017), EFAS Total (p=0.013), EFAS daily living (p=0.008), and SF-12 physical (p=0.01) were better in the surgical group. Strict then relative immobilization provided the best balance between functional recovery (EFAS total of 33, p<0.01) and tendon lengthening (0°, p=0.01) without increasing the occurrence of rerupture (2%, p=0.18). Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days (p=0.082 and p=0.07)., Conclusions: This study found no differences in the number of reruptures between surgical treatment and conservative treatment of acute Achilles tendon ruptures. Surgical treatment led to better clinical results but had a variable effect on improving the functional scores. No matter which treatment is used, in the ideal case, 3 weeks of strict immobilization in equinus should be followed by progressive reduction over the next 3 weeks. Early weightbearing and mobilization within 30 days did not increase the risk of rerupture; it actually optimized the clinical and functional outcomes., Level of Evidence: III; retrospective comparative, non-randomized., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Plantar flexion force in recreational athletes after repair of Achilles tendon tears has rarely been reported, due to the lack of a widely available and fast measurement method. Knowledge of this parameter would allow optimisation of muscular and sports recovery. The main objective of this study was to measure the isometric force of the triceps surae at least 1 year after unilateral Achilles-tendon repair, comparatively to the unaffected side, using a portable device. The secondary objectives were to compare Achilles tendon and calf-muscle trophicity, dorsiflexion, and the single-leg heel-rise test versus the normal side and to assess functional scores at last follow-up., Hypotheses: (i) Plantar flexion force does not differ significantly between the operated and contralateral sides. (ii) Calf-muscle trophicity, dorsiflexion, and the single-leg heel-rise test do not differ significantly between the operated and contralateral sides., Patients and Methods: This single-centre retrospective study included patients aged 18 to 65 years with a history of open repair of an acute unilateral Achilles tear at least 1 year earlier. Plantar flexion force, calf-muscle trophicity, dorsiflexion, and the heel-to-floor distance were measured on both sides and compared. The ATRS, VISA-A score, and EFAS score were determined. All complications were recorded., Results: The study included 30 patients with a mean follow-up of 20.3 months (range, 12-28 months). The operated side had significantly lower values for isometric triceps surae force, calf circumference, and heel-to-floor distance compared to the contralateral side (p<0.0001). Tendon width was significantly greater on the operated side (p<0.0001). Dorsiflexion did not differ significantly between sides (p=0.106). Mean functional score values were 91.5±6 for the ATRS (maximum, 100), 85±12 for the VISA-A score (maximum, 100), and 19.5±4 for the EFAS score (maximum, 24)., Discussion: Isometric triceps-surae force measured using a portable device at least 1 year after open surgical Achilles-tendon repair was significantly decreased compared to the contralateral side. Calf circumference and heel-to-floor distance were also significantly lower. These data indicate a need for improved monitoring of triceps surae recovery to optimise rehabilitation and sports resumption., Level of Evidence: IV, retrospective comparative cohort study., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Objective: The optimal treatment and rehabilitation strategy for acute Achilles tendon rupture (ATR) remain a debate. This study aimed to compare the results of the two postoperative regimens after treatment for ATR with modified closed percutaneous repair under local anesthesia., Methods: In a 4-year study, 72 consecutive patients with acute complete ATR were randomized after percutaneous repair into a functional group (FG), using a modified brace (28 males, three females; mean age 41.9 [29-71] years) and an immobilization group (IG), wearing a rigid plaster (28 males, two females; mean age 42.2 [29-57] years), for a period of 6 weeks. Except for immobilization, they followed the same weight-bearing and rehabilitation protocols. The follow-up period was 3 years. The complication rate, active and passive ankle range of motion, standing heel-rise test, clinical outcome using the American Foot and Ankle Society (AOFAS) hindfoot-ankle score, return to the previous activity level, and subjective assessment were assessed., Results: There was one rerupture in the IG and two transient sural nerve disturbances in the FG and one in the IG, and one suture extrusion in the IG, with no other complications. The average AOFAS scores were 96.9 ± 4.3 and 96.0 ± 4.9 in the FG and IG, respectively. Patients in the FG reached a final range of motion and muscular strength sooner without limping and were more satisfied with the treatment. No significant differences could be detected between groups according to the results in any of the assessed parameters., Conclusion: Early dynamic functional bracing in patients with ATR treated with modified closed percutaneous repair under local anesthesia resulted in earlier functional recovery with similar final results in terms of complications and functional outcomes, such as rigid postoperative immobilization with standardized rehabilitation and weight-bearing protocol., Level of Evidence: I, Prospective randomized study., Competing Interests: Declaration of Competing Interest The authors declare that no benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. The authors received no financial support for the research, autorship, and/or publication of this article., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Achilles tendon ruptures are common injuries typically sustained during sport with higher incidence in men, though little is understood regarding sex-specific risk factors or outcomes following injury management. This cross-sectional clinical study and systematic review aimed to examine sex-specific Achilles tendon rupture incidence and outcomes following intervention. This study included patients who sustained a rupture between 2011-2021, were ≥18 years old, and who had a minimum follow-up of at least six months, and evaluated age, sex, sport involvement, mechanism of injury, and postoperative complications and revision. Separately, a systematic literature review in the PubMed, EMBASE, and Cochrane databases was performed. A total of 705 male and 158 female patients were included in this retrospective study. 71.1% of men and 52.5% of women sustained a sports-related rupture (p < .001), with sport involvement demonstrating a positive correlation with revision rate (coefficient = 0.09, p = .02). A total of 21 studies with 250,907 patients (87,514 male, 35,792 female) were included in the systematic review. All studies revealed an increased incidence of ATR in men. Functional outcomes were worse in women, and female sex was an independent risk factor for postoperative complications and need for revision surgery. This study demonstrated a higher incidence of sports-related ATR in men than women, likely related to their higher ball sport participation. Although the retrospective analysis did not find a significant difference in complication or revision rates, the systematic review demonstrates poorer functional outcomes, with increased likelihood for postoperative complication and revision surgery in women as compared to men., (Copyright © 2024 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Extensor mechanism (EM) disruption after total knee arthroplasty (TKA) is devastating, especially in cases of re-rupture. A 67-year-old man with diabetes had patellar tendon rupture after revision TKA and then had migration of the bone block after Achilles tendon allograft with bone block (ATBB) augmentation with cerclage. A third reconstruction was performed with open reduction and internal fixation and high-strength braided suture augmentation. Five months postoperatively, the patient had regained full range of motion with intact EM and hardware. The risk of re-rupture is high in ATBB, and the primary issues in this case were nonunion and tendinous compromise. A construct that encompasses compression and buttressing of the bone block with tendon augmentation potentially addresses the risks of recurrent EM rupture in more complex cases. [ Orthopedics. 2024;47(5):e273-e276.].

Recent research shows that the functional outcome after an acute Achilles tendon rupture is comparable after conservative versus operative treatment. It is therefore recommended to treat patients conservatively, but strong reasons for surgical treatment exist. In principle, no additional radiographic diagnostic exams are indicated for the diagnosis. An appropriate anamnesis, palpable gap and positive Thompson test have an excellent sensitivity. In case of doubt, an ultrasound should be performed as the first step. A shared decision process should be pursued for establishing treatment plan. However, it is recommended that patients be treated conservatively unless strong arguments for surgical intervention are present. It is important to properly inform patients, and thus manage expectations about the expected rehabilitation process. If there is an increased risk of re-rupture, such as in athletes or during physically demanding work, surgical treatment can be considered. Then a surgical technique in which expertise and experience has been gained should be used as no difference in outcome have been found after open versus minimal invasive techniques.

Background and Objectives : There are numerous techniques for the surgical treatment of Achilles tendon lesions described in the literature, and it is possible to distinguish repair techniques as either open surgery or percutaneous repair techniques. Both approaches have advantages and disadvantages. With this retrospective study, we aim to analyze the incidence of re-ruptures and other complications, return to sport and overall quality of life at a long-term follow-up in the treatment of acute ATRs, comparing the results of percutaneous repair with those of open repair. Materials and Methods : This is a retrospective study on a consecutive series of patients with complete tear of the AT who were managed through a surgical approach by the Operative Unit of Orthopaedics and Traumatology of Sant'Anna University Hospital (Ferrara, Emilia-Romagna, Italy) between April 2014 and December 2021. Patients were treated with a percutaneous or an open technique according to the surgeon's preference without randomization. Results : We considered 155 patients who met the established inclusion criteria. Of these, 103 (66.45%) patients underwent percutaneous treatment with the Tenolig ® system, and 52 (33.55%) underwent open surgery, with an average ATRS in the first group of 92.5 compared to an average ATRS value of 82 in patients treated with the open technique. Conclusions : In our experience, following overlapping rehabilitation protocols in all patients included, we observed that the Tenolig ® repair system led to a better ATRS at long-term follow-up, with comparable complication rates to open surgery.

Background: The Achilles tendon is the body's strongest and largest tendon. It is commonly injured, particularly among athletes, accounting for a significant portion of serious tendon injuries. Several factors play a precipitating role in increasing the risk of these injuries., Objective: Our objective is to derive and validate a risk calculator for the prediction of incidence of any complication following Achilles tendon repair., Methods: We used de-identified data from the American College of Surgeons' National Surgical Quality Improvement Project (NSQIP) database from 2005 to 2021. It comprises 7010 individuals who had undergone Achilles tendon rupture repair. Demographic and risk factors information was collected. To develop the calculator, the sample was divided into a derivation cohort (40%) and a validation cohort (60%). Multivariate logistic regression was used for statistical analysis, and a risk calculator for incidence of any complication was derived from the derivation cohort and validated on the remaining 60% of the sample. Patients with missing data were excluded, and the significance level was set at p < 0.05., Results: We analyzed the derivation cohort of 2245 individuals who underwent Achilles tendon repair surgery between 2005 and 2021, with a 5.5% overall complication. Multivariate logistic regression identified anesthesia type, ASA classification, certain co-morbidities (pre-operative dialysis and medication-requiring hypertension), and wound classification as significant predictors of complications. The developed risk calculator model had an area under the curve (AUC) of 0.685 in the derivation cohort and 0.655 in the validation cohort, surpassing the widely used and validated modified frailty index. A cut-off score threshold of 0.06 was established using Youden's index to dichotomize individuals into low and high risk for developing any postoperative complications., Conclusion: Our risk calculator includes factors that most significantly affect the incidence of any complication following Achilles tendon repair., (© 2024. The Author(s).)

Background: In recent decades, early rehabilitation after Achilles tendon rupture (ATR) repair has been proposed. The aim of this prospective cohort study was to compare different immobilisation durations in order to determine the optimal duration after open surgery for ATR repair., Methods: This study included 1088 patients (mean age, 34.9 ± 5.9 years) who underwent open surgery for acute ATR repair. The patients were categorised into four groups (A, B, C, and D) according to postoperative immobilisation durations of 0, 2, 4, and 6 weeks, respectively. All patients received the same suture technique and a similar rehabilitation protocol after brace removal,; they were clinically examined at 2, 4, 6, 8, 10, 12, 14, and 16 weeks postoperatively, with a final follow-up at a mean of 19.0 months. The primary outcome was the recovery time for the one-leg heel-rise height (OHRH). Secondary outcomes included the time required to return to light exercise (LE) and the recovery times for the range of motion (ROM). Data regarding the surgical duration, complications, the visual analogue scale (VAS) score for pain, the Achilles tendon Total Rupture Score (ATRS), and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score were also collected., Results: The recovery times for OHRH, LE, and ROM were significantly shorter in groups A and B than in groups C and D (P < 0.001). The VAS scores decreased over time, reaching 0 in all groups by 10 weeks. The mean scores in groups A and B were higher than those in the other groups at 2 and 4 weeks (P < 0.001), whereas the opposite was true at 8 weeks (P < 0.001). ATRS and the AOFAS Ankle-Hindfoot scale score increased across all groups over time, showing significant between-group differences from weeks 6 to 16 (P < 0.001) and weeks 6 to 12 (P < 0.001). The mean scores were better in groups A and B than in groups C and D. Thirty-eight complications (3.5%) were observed, including 20 re-ruptures and 18 superficial infections. All complications were resolved at the last follow-up, with no significant between-group differences., Conclusions: Immobilisation for 2 weeks after open surgery for ATR repair may be the optimal strategy for early rehabilitation with relatively minimal pain and other complications., Trial Registration: ClinicalTrials.gov (NCT04663542)., (© 2024. The Author(s).)

Background: Over the past decade, overlapping procedures in orthopaedic surgery have come under increased public scrutiny. Central to this discussion is what should constitute a "critical portion" of any surgical procedure-a definition which may differ between patients and surgeons. This study therefore aimed to assess which components of three common foot and ankle procedures are considered "critical" from both the patient and surgeon perspectives., Methods: For this survey-based study, questionnaires were administered to patients who presented to an orthopaedic foot and ankle clinic and separately administered to foot and ankle surgeons through e-mail. The questionnaires broached all steps involved in three common foot and ankle procedures: open reduction and internal fixation of ankle fracture, Achilles tendon repair, and ankle arthroscopy. Respondents were asked to characterize each step as "always critical," "often critical," sometimes critical," rarely critical," or "never critical." A combined "always critical" and "often critical" response rate of greater than 50% was used to define a step as genuinely critical. Patient and surgeon responses were thereafter compared using Mann-Whitney U and Kruskal-Wallis tests ( P -value <0.05 was considered significant)., Results: Notably, both patients and surgeons considered informed consent, preoperative marking of the surgical site, preoperative time-out, surgical soft-tissue dissection, and certain procedure-specific steps (critical portions) of these procedures. By contrast, only patients considered skin incision and wound closure to be critical steps., Conclusion: Patients and surgeons were largely in agreement as to what should comprise the critical portions of several common foot and ankle procedures. Certain discrepancies did exist, however, such as skin incision and closure, and both groups were also in general agreement regarding what was not considered a critical component of these operations. Such findings highlight a potential opportunity for improved preoperative patient education and patient-physician communication., Level of Evidence: Level IV: Evidence from well-designed case-control or cohort studies., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Objectives: This study aimed to evaluate the biomechanical and histological effects of fluoroquinolones on surgically repaired tendon healing., Materials and Methods: The Achilles tendons of 40 Wistar rats (mean weight: 213.5 g; range 201 to 242 g) were bilaterally surgically cut and repaired. The rats were randomly divided into four groups: the first and third groups were designated as control groups and did not receive drug therapy, whereas the second and fourth groups received 300 mg/kg ciprofloxacin for a week after the surgical procedure. The first and second groups had both tendons dissected at the end of the first week, while the third and fourth groups were dissected at the end of the third week. The left tendons were examined biomechanically, while the right tendons were examined histologically., Results: Statistical analysis revealed that the mean maximum tensile forces of tendons in the first and second groups were 5.2±1.84 N (range, 2.9 to 8.5 N) and 11.1±2.65 N (range, 7.3 to 13.9 N), respectively, which was found to be statistically significant (p< 0.05). At the end of the third week, mean maximum tensile forces of the third and fourth groups were determined to be 20.7±5.0 N (range, 22.1 to 29.8 N) and 28.7±4.6 N (range, 22.1 to 36.8 N), respectively, which was also statistically significant (p< 0.05). Histologically, our results were compatible., Conclusion: This study demonstrated that ciprofloxacin did not exhibit the expected adverse effects on surgically repaired tendon healing in the early stages but likely contributed to healing in the short term by affecting the inflammatory phase.

Background: There are many adhesion barrier materials, cross-linked or non-cross-linked hyaluronic acid (HA), used during surgeries., Purpose: This study investigates the efficacy of cross-linked and non-cross-linked HA in preventing Achilles tendon adhesions. We hypothesized that non-cross-linked HA may be more effective than cross-linked HA in preventing Achilles tendon adhesions following injury and repair., Methods: Twenty male Sprague Dawley rats, totaling 40 legs, underwent Achilles tendon transection and repair. Following the surgery, they were treated simultaneously with cross-linked and non-cross-linked HA formulations. The rats were divided into four groups: a positive control group, a group treated with BMC non-cross-linked HA gel, a group treated with DEFEHERE cross-linked HA gel, and a group treated with ANIKA cross-linked HA gel. Four weeks after surgery, macroscopic evaluation of peritendinous adhesion and histological analysis were conducted to assess the effectiveness of the treatments., Results: Non-cross-linked BMC HA demonstrated superior efficacy in preventing tendon adhesions compared to cross-linked HA and control groups. Histological analysis confirmed reduced adhesion severity in the non-cross-linked HA group (P < 0.05). The findings support the potential of non-cross-linked HA as a treatment to inhibit tendon adhesions. Further research, including clinical trials, is warranted to validate these results in human subjects., Conclusions: Non-cross-linked BMC HA had significantly lower tendon adhesions parameters and better healing scores in histological analysis than cross-linked HA and control group did. Non-cross-linked HA holds promise as a potential treatment to inhibit the formation of such adhesions., (© 2024. The Author(s).)

Aims: The gold standard for percutaneous Achilles tendon tenotomy during the Ponseti treatment for idiopathic clubfoot is a tenotomy with a No. 15 blade. This trial aims to establish the technique where the tenotomy is performed with a large-bore needle as noninferior to the gold standard., Methods: We randomized feet from children aged below 36 months with idiopathic clubfoot on a 1:1 basis in either the blade or needle group. Follow-up was conducted at three weeks and three months postoperatively, where dorsiflexion range, Pirani scores, and complications were recorded. The noninferiority margin was set at 4° difference in dorsiflexion range at three months postoperatively., Results: The blade group had more dorsiflexion at both follow-up consultations: 18.36° versus 18.03° (p = 0.115) at three weeks and 18.96° versus 18.26° (p = 0.001) at three months. The difference of the mean at three months 0.7° is well below the noninferiority margin of 4°. There was no significant difference in Pirani scores. The blade group had more extensive scar marks at three months than the needle group (8 vs 2). No major complications were recorded., Conclusion: The needle tenotomy is noninferior to the blade tenotomy for usage in Ponseti treatment for idiopathic clubfoot in children aged below 36 months., Competing Interests: This work was conducted with support from Harvard Catalyst and The Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health Award UL1 TR002541) and its affiliated academic healthcare centers for the statistical analysis section of this trial. M. Pigeolet is supported by a GRANT of the Belgian Kids’ Fund (BKF) for Pediatric Research., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Background: Insertional Achilles tendinopathy (IAT) is a common pathology with multiple surgical interventions available for treatment. The Zadek, dorsal closing wedge calcaneal osteotomy (ZO) has been demonstrated to be effective treatment of IAT. There have been various recommendations in the literature as to what measurement of wedge removal should be considered ideal to produce greatest postoperative range of motion (ROM), thus postoperative biomechanical potential. Accordingly, the purpose of this cadaveric study was to assess the range of motion achieved after various measurements of wedge removal by ZO., Methods: The ZO was performed on six cadaveric specimens. A 7.5 mm and 15 mm wedge osteotomy was marked and sequentially completed on each specimen. Lateral fluoroscopic imaging was utilized to take preoperative and postoperative ROM measurements for each osteotomy. Dorsiflexion (DF) and plantarflexion (PF) ROM arcs were measured for each wedge size and compared by t-test. Effect sizes were calculated by Cohen's d analysis., Results: Maximal DF was 110.87 ± 12.97 deg in the pre-osteotomy state. Removal of a 7.5 mm wedge improved DF by 8 deg to a mean 102.93 ± 13.81 deg (p = 0.08). Removal of a 15 mm wedge improved DF by 16 deg to a mean 95.96 ± 11.41 deg (p = 0.003). Cohen's d and effect size calculation demonstrated a 7.5 mm wedge to have a small effect on DF, while a 15 mm wedge had a medium effect (0.29, 0.52 respectively). Maximal PF did not change significantly amongst the pre-osteotomy, 7.5 mm wedge, or 15 mm wedge positions. ICC was 0.96., Conclusion: Based on the results presented in this study, removal of a 15 mm wedge with ZO yields significant and greater improvement in ROM than a 7.5 mm wedge. We hope the current study will better inform preoperative planning for ZO., Study Type: Prospective Cadaver Study., Level of Evidence: V., Competing Interests: Declaration of Competing Interest Jonathan R. M. Kaplan MD: royalties or licenses and consulting fees from Surgical Fusion Technologies, Enovis, Treace Medical Concepts, Vilex; consulting fees from Artelon, Edge Surgical, Exactech, and Surgebright. SarahRose Hall BA: none. Padam Kumar MD: none. Rita M. DiTommaso MPAS: none. Stephanie S. Giles BA: none. Tyler Gonzalez MD, MBA: royalties or liceses and consulting fees from Treace Medical Concepts, Surgical Fusion Technologies, Vilex; consulting fees from Stryker, Surgebright and Enovis. Edward Haupt MD: Consultant for Exactech., (Copyright © 2024 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: This study aimed to compare the complications and outcomes of lateral and central Achilles tendon-splitting approaches for the treatment of Haglund syndrome., Methods: Patients who underwent surgery for Haglund syndrome between June 2012 and June 2022 were included in the study. Patients undergoing lateral approach surgery were included in group 1, whereas patients undergoing central Achilles tendon-splitting approach surgery were included in group 2. Surgical outcomes of the patients were evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle hindfoot scale, visual analog pain scale (VAS), and Victorian Institute of Sport Assessment-Achilles (VISAA) scores. In addition, preoperative and final follow-up scores were compared., Results: The study included 66 patients: 32 (14 females, 18 males) underwent surgery using the lateral approach in group 1, whereas in group 2, 34 patients (18 females, 16 males) underwent surgery using the central Achilles tendon-splitting approach. There was a significant statistical difference in the AOFAS, VISAA, and VAS scores between preoperative and final follow-up for both group 1 and group 2 ( P  < .001, P  < .001, P  < .001, P  < .001, respectively). Group 1 had a small (0.76) relative increase in VAS score compared with group 2 ( P  = .033). There was no significant difference between the complication rates of group 1 and group 2., Conclusion: In our study, we found the lateral approach and central Achilles tendon-splitting approaches to be safe and effective in the surgical treatment of Haglund syndrome without clinically meaningful differences in outcomes or complication rates., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Introduction: Paratenon preserving techniques to facilitate acute Achilles tendon rupture repair (AATR) functions by maintaining vascularity and biology for optimal healing response. Therefore, the purpose is to evaluate the outcomes following paratenon preserving repair of the midsubstance AATR. The hypothesis was that paratenon-preserving techniques demonstrate high return to play rates and low complication rates for the repair of the midsubstance AATR., Materials and Methods: A systematic review of the PubMed, Embase, and the Cochrane Library databases was performed by two authors using specific search terms and eligibility criteria. The assessment of the evidence was two-fold: level and quality of evidence. A meta-analysis of proportions for the various complication rates was performed using the restricted maximum likelihood method following the Freeman-Tukey double-arcsine transformation. Fixed effects models were employed if I 2  < 25% (low heterogeneity), and random effects models were employed if I 2  ≥ 25% (moderate to high heterogeneity)., Results: The pooled return to play rate was 90.3%. The pooled rerupture rate as reported was 0.9% (best-case scenario 0.8% and worst-case scenario 6.8%). No meaningful subgroup analysis for rerupture rates could be performed based on the meta-regression. The pooled complication rate other than reruptures was 4.8%. The pooled infection rates were 0.3%, DVT rates were 1.6%, and sural nerve injury rates were 0.3%., Conclusions: Paratenon preserving techniques that are minimally invasive in nature demonstrated safe and favorable outcomes with high return to play rates and low complication rates for the repair of the midsubstance AATR., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The aim of the study was to examine the impact of a deep venous thrombosis (DVT) on patient outcomes 3 years after Achilles tendon rupture (ATR) repair and if there were continued improvements between 1 and 3 years after surgery. A secondary aim was to determine risk factors associated with impaired patient outcomes in the long term., Methods: This cohort study consisted of 181 ATR-repaired patients, from two large randomized clinical trials, who attended a 3-year follow-up evaluation. Patients were postoperatively randomized to two different weight-bearing interventions compared with immobilization in a below-knee plaster cast for 2 weeks. During immobilization, screening for DVT was performed with Doppler ultrasound. At 1 and 3 years postoperatively, functional- and patient-reported outcomes were evaluated by the validated heel-rise test and self-reported questionnaire, Achilles tendon Total Rupture Score (ATRS)., Results: In total, 76 out of 181 (42%) patients exhibited a DVT at the 2- or 6-week screening after ATR surgery. Suffering from a DVT during immobilization resulted at 3 years in a worse limb symmetry index (LSI) of heel-rise total work compared to patients without DVT, adjusted for age (DVT mean LSI 68% vs. no DVT 78%, p = 0.027). At 3 years, patients with a DVT during immobilization displayed lower ATRS (DVT median 88 vs. no DVT 93, p = 0.046), which was not significant after adjustment for age. However, patients with DVT exhibited an improvement in ATRS, LSI total work, and LSI maximum height between 1 and 3 years, which was not seen among patients without DVT. Independent risk factors for reduced patient functional outcomes at 3 years were older age, greater calf muscle hypotrophy, and suffering a DVT., Conclusions: DVT during immobilization affects patients' long-term functional outcomes 3 years after ATR repair. Clinicians should adequately address risk factors contributing to impaired patient outcomes in the long term, including calf muscle hypotrophy, DVT, and older age., Level of Evidence: Level Ⅲ., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Background: The influence of social determinants of health (SDH) on postoperative complications has been investigated in several studies, although correlation with Achilles tendon rupture (ATR) repair remains uninvestigated. SDH encompasses several factors, including insurance status and area-based measurements, including the Area Deprivation Index (ADI) and Social Vulnerability Index (SVI), which ranks neighborhoods by social disadvantage. This study investigated the correlation between patient demographics, SDH, and complications following ATR repair., Methods: A retrospective cohort study was conducted on 521 patients who presented with acute ATR and met the inclusion criteria, including age ≥18 years, a minimum of 30-day follow-up, and repair within 28 days of rupture. We reviewed patient demographics, time to surgery (TTS), and postoperative complications, including venous thromboembolism (VTE), rerupture, surgical site infection (SSI), wound dehiscence, and sural nerve injury. SDH variables included race, smoking status, insurance status, level of education, ADI, and SVI. Univariate regression tested the correlation between complications and SDH indicators. Significant variables ( P  < .05) were included in a multivariate regression., Results: Sixty-eight complications occurred in 59 patients (11.3%). Multivariate regression showed that a higher ADI, that is, socially deprived individuals, was associated with lower rates of VTE (OR = 0.41, P  = .04). Higher body mass index (BMI) was associated with rerupture (OR = 8.73, P  < .01). Male patients had lower rates of wound dehiscence (OR = 0.31, P  = .03) and VTE (OR = 0.32, P  = .02) compared with women. Longer TTS correlated with sural nerve injuries (OR = 2.23, P  < .01) and shorter TTS with reruptures (OR = 0.02, P   =  .02)., Conclusion: Some measures of SDH were associated with postoperative complications. Gender also may have an effect, with male sex associated with lower rates of wound dehiscence and VTE. BMI was associated with higher rates of reruptures and overall general complications., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Achilles tendon reconstruction is an effective method of repairing Achilles tendon rupture defects. We introduce a new approach for Achilles tendon reconstruction using transversal calcaneal anchored autogenous semitendinosus tendon graft. The study aimed to evaluate the clinical role of this new Achilles tendon reconstruction. We retrospectively enrolled patients who underwent Achilles tendon reconstruction using transversal calcaneal anchored autogenous semitendinosus tendon graft for acute Achilles tendon rupture defects from 2016 to 2021. The clinical and radiological results were assessed at the preoperative and the final postoperative follow-up with Visual Analog Score (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores and Achilles tendon Total Rupture Scores (ATRS). Besides, at the last postoperative follow-up, the difference in ankle range of motion between the two side of the patients and the incidence of postoperative complications were recorded. Results revealed patients had significantly lower VAS and higher AOFAS and ATRS (P < 0.01). Compared to the healthy ankle, the operative ankle showed significant deficits in ankle range of motion (P < 0.01). Additionally, radiological results showed no noticeable signs of tunnel enlargement in the calcaneus and no patient had re-rupture. Transversal calcaneal anchored Achilles tendon reconstruction with free semitendinosus tendon autograft is an effective treatment option for patients with acute Achilles tendon rupture with large defects and have high postoperative exercise demands., (© 2024. The Author(s).)

Objective: To examine the feasibility and clinical effect of all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening for Achilles tendon contracture. Methods: This is a retrospective case series study. From February 2021 to February 2023, the clinical data of 24 patients (30 feet) with Achilles tendon contracture treated with all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening were analyzed retrospectively. There were 10 males and 14 females, aged (32.8±16.1) years (range: 9 to 62 years). There were 8 cases of left side only, 10 cases of right side only and 6 cases of bilateral. There were 14 cases (16 feet) of foot varus, 4 cases (6 feet) of foot valgus, and 6 cases (8 feet) without deformity. All patients underwent all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening. The surgical effects were evaluated using the maximum dorsal extension angle of ankle joint in knee extension position, the visual analogue scale (VAS) of pain, the American Orthopedic Foot and Ankle Society ankle-hindfoot score(AOFAS-AH). Paired sample t test was used to compare the scores before and after operation. Results: All patients successfully completed the operation, and the operation time of Achilles tendon lengthening was (22.0±5.7)minutes (range: 15 to 35 minutes) and the intraoperative blood loss was (6.5±2.7)ml (range: 2 to 15 ml). All patients primarily healing without any complications such as sural nerve injury, Achilles tendon rupture, important blood vessel injury, and obvious decrease of lift heel strength of achilles tendon. All 24 patients were followed up for (17.2±4.5) months (range: 12 to 28 months). One patient suffered from lift heel's weakness in one foot after operation, and recovered after repeated lift heel functional exercises. The ankle dorsiflexion function of two patients with calf triceps spasm were not improved after operation, and it was obviously improved after botulinum toxin injection. At the last follow-up, the maximum dorsal extension angle of ankle joint in knee extension position increased from -9.2°±7.6°(range:-25° to 5°) preoperatively to 14.5°±7.0°(range:0° to 28°)( t =24.83, P <0.01); the VAS score was reduced from (4.5±1.7) points (range:1 to 8 points) preoperatively to (1.5±0.9) points (range:0 to 3 points) ( t =9.53, P <0.01), the AOFAS-AH was increased from (60.5±11.4)points (range:38 to 85 points) to (90.8±5.4) points (range:80-100 points)( t =14.21, P <0.01). Conclusions: All-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening for Achilles tendon contracture not only provides Achilles tendon lengthening, but also avoids complications such as Achilles tendon rupture and sural nerve injury. It is an effective method for the treatment of Achilles tendon contracture.

Purpose: Achilles tendon ruptures (ATRs) close to the insertion, in high-level athletes, and in patients at high risk of re-rupture, may be better suited to operative repair. Minimally Invasive Repair (MIR) of the Achilles tendon has excellent outcome and low complication rates. Traditionally MIR has showed lower repair strength, failing due to suture pull-out from the distal tendon stump. The aim of this study was to describe the outcome of ATR patients who received transosseous distal suture placement using a standard technique as a reference., Methods: Following ATR, patients were evaluated for pre-injury activity level, body weight, location of the tear and size of the distal Achilles tendon stump. Patients considered to be at high-risk of re-rupture: Tegner level ≥ 8, body weight ≥ 105Kg and distal ATR, received transosseous (TO) distal suture placement (n = 20) rather than the usual transtendinous (TT) technique (n = 55). Patient reported outcome measures and functional evaluation was performed at 12 months following repair., Results: At 12 months follow up both methods resulted in good median (IQR) Achilles tendon Total Rupture Score TO 83.8 (74-88.3) vs. TT 90 (79-94), low increased relative Achilles Tendon Resting Angle TO -3.5˚ (3.6) vs. TT -3.5˚ (3.3) and mean (SD) Single leg Heel-Rise Height Index TO 88.2% (9.9) vs. TT 85.6% (9.9) (n.s.). There were 4 re-ruptures in the high-risk group and 2 in the group receiving TT distal suture placement. All but one of these were traumatic in nature. The mode of failure following TO distal suture placement was proximal suture pull out., Conclusions: To distal suture placement during minimally-invasive Achilles tendon repair for higher-risk patients can lead to results equivalent to those in lower-risk patients treated with a standard TT MIR technique, except for the re-rupture rate which remained higher. There may be factors that have greater influence on outcome other than suture placement following ATR., (© 2024. The Author(s).)

With up to 50 incidents per 100,000 inhabitants, Achilles tendon ruptures are among the most frequent tendon injuries encountered in orthopedics and trauma surgery. Apart from high-risk forms of sport, degenerative processes are primarily responsible for weakening and ultimately rupture. In addition to assessing the typical clinical signs with inability to perform powerful plantar flexion, the diagnostics include easy to earn examination techniques, such as the Thompson test and ultrasound as the imaging gold standard. Conservative and surgical treatment are available depending on the constitution, age and requirements of the patient. The latter option is divided into conventional open, minimally invasive or percutaneous procedures. Good to very good results can be expected regardless of the form of treatment, provided that early functional rehabilitation is carried out. The average rerupture rate is 5% and the return to sport rate is around 80%., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Acute closed midsubstance Achilles tendon rupture(ACMATR) is common, with various treatment methods developed over time. We retrospectively compared the two mini transverse-incision repair (2MTIR) with percutaneous repair (PR) to determine which method yields better results., Methods: All cases meeting criteria from 2018 to 2021 in our hospital were included and followed up for 1 to 5 years. A final questionnaire with multiple indexes was conducted via phone call. Comparative analysis of these indexes between the two groups was performed using IBM SPSS Statistics (V.26). Continuous variables that passed tests for normality and equal variance were compared using the Student's t-test. Ranked data were compared using the Mann-Whitney U test. Categorical variables were tested with the chi-square test or Fisher's exact test. A p-value of less than 0.05 was considered statistically significant., Results: There was one rerupture in the PR group. The final indexes for "Tightness Feeling", "Heel Rising Strength", and "Foot Numbness" were statistically different (P < 0.05) between the two groups. The "Re-rupture" and "Return to Sports" indexes showed no statistical difference (P > 0.05)., Conclusions: The 2MTIR technique provided a technically straightforward, minimally invasive procedure with well-preserved paratenon and direct end-to-end firm fixation in cases of ACMATR. It resulted in very low complications, easy rehabilitation, and full weight-bearing as early as 5-6 weeks postoperatively, yielding better functional outcomes compared to the PR technique in the 1-5 year follow-up., Trial Registration: The study was preliminarily registered and approved by the University of Hong Kong-Shenzhen Hospital Ethical Board with Project number: hkuszh2023074 on May 4, 2023., (© 2024. The Author(s).)

Case: Traumatic pediatric Achilles ruptures are rare, and few cases have been reported among patients with a history of Achilles tenotomy. A 17-year-old boy with a history of Achilles tenotomies for congenital clubfoot as an infant presented with acute midsubstance Achilles tendon rupture of the right leg. The gastrocnemius fascia was dissected to allow for approximation of the ruptured Achilles tendon segments. Furthermore, the plantaris tendon was harvested and sutured around the Achilles tendon-rupture site to improve strength., Conclusions: Patients with a history of clubfoot and chronic Achilles tendon pain should be alerted to the risk of Achilles tendon rupture., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C399)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background and Purpose: The aim of our study was to assess the regional variations in Achilles tendon rupture incidence and treatment methods in Finland during the period 1997-2019., Methods: The Finnish National Hospital Discharge Register (NHDR) and the Finnish Register of Primary Health Care Visits (PHCR) were searched to identify all adult patients diagnosed with Achilles tendon rupture during our study period. The population-based annual incidence and incidences of surgically and non-surgically treated Achilles tendon ruptures were calculated for each hospital district., Results: Achilles tendon rupture incidence increased from 17.3 per 105 person-years in 1997 to 32.3 per 105 in 2019. The mean incidence of Achilles tendon ruptures ranged from 26.4 per 105 (North Savo) to 37.2 per 105 (Central Ostrobothnia). The incidence of Achilles tendon ruptures increased in all areas. The proportion of non-surgical treatment of Achilles tendon ruptures ranged in 1997 from 7% (Vaasa) to 67% (Åland) and in 2019 from 73% (Southwest Finland) to 100% (East Savo, Kainuu, Länsi-Pohja, Åland). During the study period, a shift towards non-surgical treatment was evident in all hospital districts., Conclusion: Regional variations in Achilles tendon rupture incidence exist in Finland; however, the incidence increased in all areas during the follow-up period. More Achilles tendon rupture patients are currently being treated non-surgically throughout the country.

Xenografts, commonly from porcine or bovine sources, have decades-long documented use in reconstructive surgery, including the repair of Achilles tendons. Despite decellularization processes, the risk of antigenicity with xenografts still poses a threat for graft failure. Allograft tissues reduce the risk of immune response and provide greater likelihood of successful grafting. SteriGraft® Pericardium (BSP) (Bone Bank Allografts, San Antonio, Texas) is a lyophilized allograft obtained from the pericardial sac that has undergone sterilization and processing for use in the surgical repair. The aim of this case study was to highlight the novel use of human pericardium allograft in the repair of an exposed Achilles tendon within a vascular ulceration with the concomitant use of synthetic extracellular matrix, amniotic allografting, dermal allografting, and negative pressure wound therapy to achieve healing of the wound and restoration of limb function.

Objective: Percutaneous repair is an alternative to open surgical repair of the Achilles tendon with comparable, functional results and low re-rupture and infection rates; however, sural nerve injury is a known complication. The purpose of this study is to design a new surgical procedure, the minimally invasive peritendinous submembrane access technique (MIS-PSAT). It offers optimal results, with excellent functional outcomes, and with minimal soft tissue complications and sural nerve injury., Methods: This retrospective study included 249 patients with acute closed Achilles tendon ruptures treated at our institution between 2009 and 2019. All patients underwent MIS-PSAT at our institution and were followed up for 8-48 months. Functional evaluation was based on the Achilles tendon total rupture score (ATRS) and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS), associated with local complications and isokinetic tests., Results: None of the patients had infection, necrosis, or sural nerve injury. Re-rupture occurred in two cases. The average times to return to work and sports was 10.4 and 31.6 weeks, respectively. The average ATRS and AOFAS-AHS scores were 90.2 and 95.7, respectively, with an excellent rate of 99.5%. Isokinetic tests showed that ankle function on the affected side was comparable with that on the healthy side (p > 0.05)., Conclusion: The MIS-PSAT for acute Achilles tendon rupture is easy to perform with few complications. Importantly, the surgical technique reduces the risk of sural nerve injuries. Patients have high postoperative satisfaction, low re-rupture rates, and muscle strength, and endurance can be restored to levels similar to those on the healthy side., (© 2024 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

There are many high-level studies comparing nonoperative treatment, open repair, and minimally invasive repair for Achilles tendon ruptures. This article summarizes the most up-to-date literature comparing these treatment options. The authors' preferred protocol for nonoperative treatment is discussed. Preferred techniques for open repair and chronic Achilles repair are discussed with reference to the literature., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Calcific insertional Achilles tendinopathy(CIAT) with Haglund deformity is a type of recalcitrant tendinopathy. The necessity of concomitant removal of Haglund deformity during CIAT treatment is controversial. The present study aimed to evaluate the functional outcomes between Haglund resection and Haglund non-resection in the treatment of CIAT with Haglund deformity., Methods: A retrospective study included 29 patients who were underwent Achilles tendon debridement, bursal excision, and subsequent tendon reattachment.for CIAT with Haglund deformity. All patients were divided into 2 groups according to Haglund resection (resection group, n = 16) and Haglund non-resection (non-resection group, n = 13) using the parallel line method on lateral calcaneal X ray after surgery. Patients were evaluated in terms of the American Orthopedic Foot and Ankle Society (AOFAS), Visual Analog Scale (VAS) and Victorian Institute of Sports Assessment-Achilles (VISA-A) scores and the mean time of activities of daily living (ADL). Anatomy changes included the Fowler-Philip angle, calcaneal pitch angle and Achilles tendon force arm were measured with radiography preoperatively and postoperatively., Results: Both groups exhibited a significant increase in AOFAS, VAS and VISA-A scores after surgery. There were no significant differences between the resection group and the non-resection group for the AOFAS (92.38 ± 5.7 vs. 93.15 ± 12.17; P = 0.82), VAS (0.5 ± 0.52 vs. 0.61 ± 0.87; P = 0.66) and VISA-A questionnaire (82.56 ± 13.46 vs. 74.92 ± 16.4; P = 0.18) at the latest follow-up. The mean time of ADL in the non-resection group was significantly faster compared to that of the resection group (8.15 ± 2.51 weeks vs. 11.31 ± 4.06 weeks, P = 0.02). The Fowler-Philip angle of the resection group decreased from 55.55° ± 12.34° preoperatively to 44.52° ± 10.24° at the latest follow-up (P = 0.001). The Fowler-Philip angle of the non-resection group decreased from 54.38° ± 8.41° preoperatively to 46.52° ± 8.02° at the latest follow-up (P = 0.016). The calcaneal pitch angle of the resection group increased from 22.76° ± 5.37° preoperatively to 25.98° ± 6. 4° at the latest follow-up (P = 0.018). The Achilles tendon force arm of the resection group decreased from 178.50 mm ± 5.37 mm preoperatively to 173.90 mm ± 8.07 mm at the latest follow-up (P = 0.018)., Conclusion: Resection or non-resection of the posterosuperior calcaneal tuberosity for CIAT with Haglund deformity would both provide satisfactory functional outcomes. Haglund non-resection may expedite patients' return to their daily activities, suggesting a Haglund deformity resection may be unnecessary in the surgical treatment for CIAT with Haglund deformity., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2024 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)