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Orthopaedic Knowledge Update ® 7 OKU ® Foot and Ankle

Orthopaedic Knowledge Update ® OKU ® Foot and Ankle 7

EDITOR Loretta B. Chou, MD, FAAOS Professor and Chief of Foot and Ankle Surgery Department of Orthopaedic Surgery

Stanford University Stanford, California

Board of Directors, 2023-2024 Kevin J. Bozic, MD, MBA, FAAOS President Paul Tornetta III, MD, PhD, FAAOS First Vice President Annunziato Amendola, MD, FAAOS Second Vice President Michael L. Parks, MD, FAAOS Treasurer Felix H. Savoie III, MD, FAAOS Past President Alfonso Mejia, MD, MPH, FAAOS Chair, Board of Councilors Joel L. Mayerson, MD, FAAOS Chair-Elect, Board of Councilors Michael J. Leddy III, MD, FAAOS Secretary, Board of Councilors Armando F. Vidal, MD, FAAOS Chair, Board of Specialty Societies Adolph J. Yates, Jr, MD, FAAOS Chair-Elect, Board of Specialty Societies Michael P. Bolognesi, MD, FAAOS Secretary, Board of Specialty Societies Lisa N. Masters Lay Member Evalina L. Burger, MD, FAAOS Member at Large Chad A. Krueger, MD, FAAOS Member at Large Toni M. McLaurin, MD, FAAOS Member at Large Monica M. Payares, MD, FAAOS Member at Large Thomas E. Arend, Jr, Esq, CAE Chief Executive Officer (ex-officio)

Wolters Kluwer Health Brian Brown, Director, Medical Practice Tulie McKay, Senior Content Editor, Acquisitions Stacey Sebring, Senior Development Editor Sean Hanrahan, Lead Editorial Coordinator Marisa Solorzano-Taylor, Editorial Coordinator Kristen Watrud, Product Marketing Manager Catherine Ott, Production Project Manager Stephen Druding, Manager, Graphic Arts & Design Margie Orzech-Zeranko, Manufacturing Coordinator TNQ Technologies, Prepress Vendor

The material presented in the Orthopaedic Knowledge Update ® : Foot and Ankle 7 has been made available by the American Academy of Orthopaedic Surgeons (AAOS) for educational purposes only. This material is not intended to present the only, or necessarily best, methods or procedures for the medical situations discussed, but rather it is intended to represent an approach, view, statement, or opinion of the author(s) or producer(s), which may be helpful to others who face similar situations. Medical providers should use their own, independent medical judgment, in addition to open discussion with patients, when developing patient care recommendations and treatment plans. Medical care should always be based on a medical provider’s expertise that is individually tailored to a patient’s circumstances, preferences and rights. Some drugs or medical devices demonstrated in AAOS courses or described in AAOS print or electronic publications have not been cleared by the US Food and Drug Administration (FDA) or have been cleared for specific uses only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or device he or she wishes to use in clinical practice and to use the products with appropriate patient consent and in compliance with applicable law. Furthermore, any statements about commercial products are solely the opin ion(s) of the author(s) and do not represent an AAOS endorsement or evaluation of these products. These statements may not be used in advertising or for any commercial purpose. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written per mission from the publisher. ISBN: 978-1-9752-1343-5 Library of Congress Control Number: Cataloging in Publication data available on request from publisher. Printed in the United States of America Published 2025 by the American Academy of Orthopaedic Surgeons

Staff American Academy of Orthopaedic Surgeons Anna Salt Troise, MBA, Chief Commercial Officer Hans Koelsch, PhD, Director, Publishing Lisa Claxton Moore, Senior Manager, Editorial Steven Kellert, Senior Editor 9400 West Higgins Road Rosemont, Illinois 60018 Copyright 2025 by the American Academy of Orthopaedic Surgeons Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

Acknowledgments

Editorial Board, Orthopaedic Knowledge Update ® : Foot and Ankle 7 Editor Loretta B. Chou, MD, FAAOS Professor and Chief of Foot and Ankle Surgery Department of Orthopaedic Surgery Stanford University Stanford, California Section Editors Gregory C. Berlet, MD, FRCS(C), FAAOS, FAOA Attending Surgeon Rebecca A. Cerrato, MD, FAAOS Chairman, Orthopedic Surgeon Mercy Medical Center Institute of Foot and Ankle Reconstruction Baltimore, Maryland Christopher P. Chiodo, MD, FAAOS Chairman, Department of Orthopedic Surgery Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts Andrew Haskell, MD, FAAOS Department of Molecular and Cellular Medicine Department of Orthopaedics Orthopaedic Surgery Specialist Orthopaedic Foot and Ankle Center Worthington, Ohio

MaCalus Vinson Hogan, MD, MBA, FAAOS Chief, Department of Orthopedic Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Kenneth J. Hunt, MD, FAAOS Associate Professor Department of Orthopaedics University of Colorado School of Medicine Aurora, Colorado Sheldon S. Lin, MD, FAAOS Associate Professor Department of Orthopaedics Rutgers New Jersey Medical School Newark, New Jersey Elizabeth A. Martin, MD, MSc, FAAOS Attending Orthopaedic Surgeon Department of Orthopedic Surgery Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts Ariel A. Palanca, MD, FAAOS Assistant Professor Department of Orthopaedic Surgery Orthopedic Surgeon Palomar Health Medical Center Redwood City, California Robert D. Santrock, MD, FAAOS Physician, Department of Foot and Ankle Orthopaedic Foot and Ankle Center Worthington, Ohio

Institute for Regenerative Medicine Texas A&M Health Science Center Bryan, Texas

Orthopaedic Knowledge Update ® : Foot and Ankle 7

Contributors

Samuel B. Adams, MD, FAAOS, FAOA Associate Residency Program Director Director of Foot and Ankle Research Associate Professor Department of Orthopaedic Surgery Foot and Ankle Orthopaedic Surgeon Duke University Medical Center Morrisville, North Carolina Amiethab Aiyer, MD, FAAOS, FAOA Associate Professor Department of Orthopaedics Division Chief of Foot and Ankle Surgery Johns Hopkins University School of Medicine Baltimore, Maryland Lara C. Atwater, MD, FAAOS Assistant Professor Department of Orthopaedic Surgery and Rehabilitation Orthopedist Oregon Health and Science University Portland, Oregon Joseph Benevenia, MD, FAAOS Chair, Department of Orthopaedics Orthopaedic Surgeon Rutgers New Jersey Medical School Newark, New Jersey Gregory C. Berlet, MD, FRCS(C), FAAOS, FAOA Attending Surgeon Department of Orthopaedics Orthopaedic Surgery Specialist Orthopaedic Foot and Ankle Center Worthington, Ohio Matthew M. Buchanan, MD, FAAOS Orthopaedic Foot and Ankle Surgeon Nirschl Orthopaedic Center Arlington, Virginia Bopha Chrea, MD Assistant Professor Department of Orthopaedics and Rehabilitation Orthopedist Oregon Health and Science University Portland, Oregon

David J. Ciufo, MD Assistant Professor Department of Orthopaedics

Orthopaedic Surgeon University of Rochester Rochester, New York

Justin Daigre, MD, FAAOS Foot and Ankle Specialist Department of Orthopaedic Surgery Decatur Orthopaedic Clinic Decatur, Alabama David J. Dalstrom, MD, FAAOS Associate Professor Chief, Division of Foot and Ankle Surgery Department of Orthopaedics Orthopedic Surgeon University of California San Diego La Jolla, California Richard J. de Asla, MD, FAAOS Orthopedic Surgeon Department of Orthopaedic Surgery Division of Foot and Ankle Surgery Naples Community Hospital Naples, Florida Malcolm R. DeBaun, MD Assistant Professor Department of Orthopaedic Trauma Surgery Duke University School of Medicine Durham, North Carolina Benedict F. DiGiovanni, MD, FAAOS, FAOA Professor of Orthopaedics Department of Orthopaedics and Rehabilitation

Orthopaedic Surgeon University of Rochester Rochester, New York Jesse F. Doty, MD, FAAOS

Director of Foot and Ankle Surgery Department of Orthopaedic Surgery Erlanger Health System Chattanooga, Tennessee Eric I. Ferkel, MD, FAAOS Attending Orthopaedic Surgeon Department of Orthopedic Surgery Foot and Ankle Surgeon Southern California Orthopedic Institute Los Angeles, California Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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Contributors

A. Samuel Flemister Jr, MD, FAAOS Professor, Department of Orthopaedics and Rehabilitation Orthopedic Surgery Specialist University of Rochester School of Medicine and Dentistry Rochester, New York

Nigel Hsu, MD, FAAOS Assistant Professor Department of Orthopaedics Foot and Ankle Orthopaedic Surgeon Johns Hopkins University School of Medicine Baltimore, Maryland Yazan Kadkoy, MS Rutgers New Jersey Medical School Newark, New Jersey Meghan Kelly, MD, PhD Assistant Professor of Foot and Ankle Surgery Department of Orthopaedics Mount Sinai Icahn School of Medicine New York, New York Trapper Lalli, MD, FAAOS Assistant Professor Department of Orthopaedics University of North Carolina at Chapel Hill Chapel Hill, North Carolina

Ian M. Foran, MD Assistant Professor Department of Orthopaedics Orthopedic Surgeon University of California San Diego La Jolla, California Daniel J. Fuchs, MD, FAAOS Assistant Professor

Department of Orthopaedic Surgery Foot and Ankle Orthopaedic Surgeon Rothman Institute at Thomas Jefferson University Philadelphia, Pennsylvania Daniel J. Garcia, BS Rutgers New Jersey Medical School Newark, New Jersey Michael J. Gardner, MD, FAAOS Professor Department of Orthopaedic Surgery Stanford University School of Medicine Redwood City, California Lauren E. Geaney, MD, FAAOS Assistant Professor, Program Director Department of Orthopaedics Orthopaedic Surgeon University of Connecticut Farmington, Connecticut Christopher E. Gross, MD, FAAOS Associate Professor Director, Foot and Ankle Division Deparment of Orthopaedics Medical University of South Carolina Charleston, South Carolina Ajay N. Gurbani, MD Assistant Professor Department of Orthopaedic Surgery Orthopedic Foot and Ankle Surgery Specialist University of California, Los Angeles Santa Monica, California Department of Orthopaedic Surgery Foot and Ankle Orthopaedic Surgeon University of Chicago Pritzker School of Medicine Chicago, Illinois Extremity Medical Parsippany, New Jersey Steven L. Haddad, MD, FAAOS Professor, Chief Clinical Officer

Brian C. Lau, MD Assistant Professor Division of Sports Medicine

Department of Orthopaedic Surgery Duke University School of Medicine Durham, North Carolina Frederick R. Lemley, MD, FAAOS Orthopedic Foot and Ankle Surgeon Syracuse Orthopedic Specialists Syracuse, New York Kshitij Manchanda, MD Assistant Professor

Department of Orthopaedic Surgery UT Southwestern Medical Center Frisco, Texas Sara Lyn Miniaci-Coxhead, MD, MEd, FAAOS Assistant Professor Department of Orthopaedics Orthopaedic Surgeon Cleveland Clinic Foundation Cleveland, Ohio Daniel K. Moon, MD, MS, MBA, FAAOS Assistant Professor Department of Orthopedic Surgery University of Colorado School of Medicine Aurora, Colorado Robert F. Murphy, MD, FAAOS Associate Professor Department of Orthopaedics and Physical Medicine Pediatric Orthopaedic Surgeon

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Contributors

David E. Oji, MD, FAAOS Clinical Assistant Professor Foot and Ankle Surgery, Orthopedic Sports Medicine

Michael S. Pinzur, MD, FAAOS Professor of Orthopaedic Surgery and Rehabilitation Department of Orthopaedic Surgery Loyola University Health System Maywood, Illinois Steven M. Raikin, MD, FAAOS Professor, Department of Orthopaedic Surgery Director of Foot and Ankle Services Orthopaedic Surgeon Rothman Institute and Thomas Jefferson University Philadelphia, Pennsylvania Christopher L. Ruland, MD, MS Resident Physician Department of Orthopedic Surgery Orthopedic Sports Medicine Stony Brook University Hospital Stony Brook, New York Robert D. Santrock, MD, FAAOS Physician, Department of Foot and Ankle Orthopaedic Foot and Ankle Center Worthington, Ohio Adam P. Schiff, MD, FAAOS Assistant Professor Department of Orthopaedic Surgery Orthopaedist Loyola University Medical Center Maywood, Illinois

Department of Orthopaedic Surgery Stanford University School of Medicine Los Gatos, California

Joseph T. O’Neil, MD Assistant Professor of Orthopaedic Surgery Division of Foot and Ankle Surgery Orthopaedic Surgeon Sidney Kimmel Medical College at Thomas Jefferson University Rothman Orthopaedic Institute Philadelphia, Pennsylvania

Ariel A. Palanca, MD, FAAOS Assistant Professor Department of Orthopaedic Surgery Orthopaedic Surgeon Palomar Health Medical Center Redwood City, California

Chirag S. Patel, MD, FAAOS Orthopedic Surgeon Department of Orthopedics OrthoCollier Naples, Florida

Megan C. Paulus, MD, FAAOS Assistant Clinical Professor Department of Orthopaedic Surgery Stony Brook University Hospital Stony Brook Orthopaedics Associates Stony Brook, New York David I. Pedowitz, MD, MS, FAAOS Professor of Orthopaedics Department of Orthopaedic Surgery Chief, Division of Foot and Ankle Surgery Director, Foot and Ankle Fellowship Sidney Kimmel Medical College Thomas Jefferson University Rothman Orthopaedic Institute Philadelphia, Pennsylvania W. Bret Smith, DO, FAAOS Clinical Assistant Professor Department of Orthopedic Surgery Orthopedic Surgery Specialist University of South Carolina School of Medicine Columbia, South Carolina Niall Smyth, MD Orthopedist, Department of Orthopaedics Cleveland Clinic Weston Weston, Florida Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

Orthopaedic Knowledge Update ® : Foot and Ankle 7

Preface

Orthopaedic Knowledge Update ® : Foot and Ankle con tinues to be an excellent resource for the prevailing body of literature. OKU ® is renowned to offer reviews and summaries of the most relevant and critical studies for the reader. Recent information can be easily accessed, and the annotated references allow for perusal. OKU ® Foot and Ankle 7 will be helpful to residents, fellows, and practicing orthopaedic surgeons. This seventh volume contains 29 chapters contributed by more than 40 authors, all of whom are leaders in foot and ankle surgery. Like prior volumes, the chapters focus on significant discoveries, materials, methods, and studies that are new since the sixth volume was published in 2019. We are excited to include a new section titled Contemporary Surgical Techniques. This section includes chapters on surgical management of Charcot neuroarthropathy, min imally invasive surgery of the foot and ankle, and revision total ankle arthroplasty. All chapters have been updated to include the latest treatment guidelines, surgical techniques, and literature reviews, along with illustrations. I thank the authors for completing the enormous task of reviewing and researching an immense amount of up-to-date literature. The authors have done a first-rate job of summing up these articles and adding to estab lished knowledge. Also, I thank the section editors of OKU ® Foot and Ankle . They are indeed leaders in the

field. They, too, have expended a great deal of time and exercised their expertise to ensure the quality and com prehensiveness of the chapters. The result is chapters that are thorough and up to the rigors of OKU ® . It is a privilege to have edited the fifth and sixth volumes, and now the seventh volume, of OKU ® Foot and Ankle . I am grateful to the American Academy of Orthopaedic Surgeons for their support and confidence in me to prepare this new volume. Special thanks to Lisa Claxton Moore, Senior Manager, Editorial, publishing team of AAOS. Her expertise and guidance were much needed and appreciated every step of the way. This acknowledgment includes Marisa Solorzano-Taylor, Editorial Coordinator, Health Learning, Research & Practice, and Stacey Sebring, Senior Development Editor, Medicine and Advanced Practice at Wolters Kluwer. I am indebted to their steady availability to answer many ques tions, as well as their know-how of OKU ® production. We hope this new volume of Orthopaedic Knowledge Update ® : Foot and Ankle with up-to-date information on clinical, imaging, and surgical procedures aids the physician to evaluate, diagnose, and treat patients with disorders of the foot and ankle.

Loretta B. Chou, MD, FAAOS Editor

Orthopaedic Knowledge Update ® : Foot and Ankle 7

Table of Contents

Section 1: General Foot and Ankle Topics

Chapter 6 Diabetic Foot Disease . . . . . . . .67 Bopha Chrea, MD Lara C. Atwater, MD, FAAOS Chapter 7 Peripheral Nerve Disorders . . . . .85 David E. Oji, MD, FAAOS Section 3: Arthritis of the Foot and Ankle SECTION EDITORS: Robert D. Santrock, MD, FAAOS Gregory C. Berlet, MD, FRCS(C), FAAOS, FAOA Chapter 8 Ankle Arthritis: Part I. Joint Preservation Techniques and Arthrodesis . . . . . . . . . . . 109 Adam P. Schiff, MD, FAAOS Samuel B. Adams, MD, FAAOS, FAOA Chapter 9 Ankle Arthritis: Part II. Total Ankle Arthroplasty . . . . . . . . . . .133 Steven L. Haddad, MD, FAAOS Justin Daigre, MD, FAAOS Chapter 10 Midfoot and Hindfoot Arthrodesis . .151 Kshitij Manchanda, MD W. Bret Smith, DO, FAAOS Trapper Lalli, MD, FAAOS Chapter 11 Adult-Acquired Flatfoot Deformity . .167

SECTION EDITOR: Christopher P. Chiodo, MD, FAAOS

Chapter 1 Biomechanics of the Foot and Ankle . .3 Richard J. de Asla, MD, FAAOS Chapter 2 Shoes and Orthoses . . . . . . . . 13 Jesse F. Doty, MD, FAAOS Chapter 3 Imaging Studies of the Foot andAnkle.............23 Daniel J. Fuchs, MD, FAAOS Steven M. Raikin, MD, FAAOS Chapter 4 Foot and Ankle Conditions in Children and Adolescents . . . . . .37 Robert F. Murphy, MD, FAAOS

Section 2: Neuromuscular Disease

SECTION EDITOR: Rebecca A. Cerrato, MD, FAAOS

Chapter 5 Cavovarus Deformity . . . . . . . .51 Amiethab Aiyer, MD, FAAOS, FAOA Nigel Hsu, MD, FAAOS Niall Smyth, MD Matthew M. Buchanan, MD, FAAOS Frederick R. Lemley, MD, FAAOS Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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Table of Contents

Section 4: The Forefoot SECTION EDITOR: Elizabeth A. Martin, MD, MSc, FAAOS

Section 6: Foot and Ankle Trauma

SECTION EDITOR: Andrew Haskell, MD, FAAOS

Chapter 12 Disorders of the Hallux . . . . . . 185 Sara Lyn Miniaci-Coxhead, MD, MEd, FAAOS Chapter 13 Lesser Toe Deformities and Metatarsalgia . . . . . . . . . .203 Lauren E. Geaney, MD, FAAOS

Chapter 18 Ankle and Pilon Fractures . . . . . 283 Brian C. Lau, MD Malcolm R. DeBaun, MD Michael J. Gardner, MD, FAAOS Chapter 19 Talar Fractures . . . . . . . . . 299 Samuel B. Adams, MD, FAAOS, FAOA Chapter 20 Calcaneal Fractures . . . . . . . .311 Jesse F. Doty, MD, FAAOS Chapter 21 Midfoot and Forefoot Trauma . . . 327 Joseph T. O’Neil, MD David I. Pedowitz, MD, MS, FAAOS Chapter 22 Amputations of the Foot and Ankle . 351 Michael S. Pinzur, MD, FAAOS Section 7: Tendon Disorders and Sports-Related Foot and Ankle Injuries

Section 5: Special Problems of the Foot and Ankle

SECTION EDITOR: Sheldon S. Lin, MD, FAAOS

Chapter 14 Nondiabetic Foot Infections . . . . 225 Meghan Kelly, MD, PhD A. Samuel Flemister Jr, MD, FAAOS Chapter 15 Plantar Heel Pain . . . . . . . . 237 David J. Ciufo, MD Benedict F. DiGiovanni, MD, FAAOS, FAOA Chapter 16 Foot and Ankle Tumors . . . . . . 249 Yazan Kadkoy, MS Daniel J. Garcia, BS Joseph Benevenia, MD, FAAOS Chapter 17 Osteonecrosis of the Talus . . . . .267 Daniel K. Moon, MD, MS, MBA, FAAOS

SECTION EDITORS: MaCalus Vinson Hogan, MD, MBA, FAAOS Kenneth J. Hunt, MD, FAAOS

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Table of Contents

Chapter 24 Sports-Related Injuries of the FootandAnkle . . . . . . . . . .371 Christopher E. Gross, MD, FAAOS Chapter 25 Ankle Ligament Injuries . . . . . . 385 Chirag S. Patel, MD, FAAOS Chapter 26 Arthroscopy of the Foot and Ankle and Osteochondral Lesions of the Talus . 403 Eric I. Ferkel, MD, FAAOS Christopher L. Ruland, MD, MS

Chapter 28 Minimally Invasive Surgery of the FootandAnkle . . . . . . . . . 439 Ariel A. Palanca, MD, FAAOS Megan C. Paulus, MD, FAAOS Chapter 29 Revision Total Ankle Arthroplasty . 449 Gregory C. Berlet, MD, FRCS(C), FAAOS, FAOA Robert D. Santrock, MD, FAAOS

Index..............461

Section 8: Contemporary Surgical Techniques

SECTION EDITOR: Ariel A. Palanca, MD, FAAOS

Chapter 27 Surgical Management of Charcot Neuroarthropathy . . . . . . . .429 Ian M. Foran, MD David J. Dalstrom, MD, FAAOS

Orthopaedic Knowledge Update ® : Foot and Ankle 7

7 SECTION

Tendon Disorders and Sports-Related Foot and Ankle Injuries

Section Editors: MaCalus Vinson Hogan, MD, MBA, FAAOS Kenneth J. Hunt, MD, FAAOS

CHAPTER

Disorders of the Achilles Tendon

AJAY N. GURBANI, MD

medial to midline insertion allows the tendon to provide some inversion in addition to its primary role of plantar flexion of the ankle. The tendon does not have a true synovial sheath; instead, it is surrounded by a paratenon, a thin gliding membrane continuous proximally with the fascial envelope of the muscle. The paratenon is a highly vascular structure that, along with the surrounding mus cle complex, provides blood flow to the tendon. An area that is relatively hypovascular within the tendon 2 to 6 cm from the calcaneal insertion may be predisposed to degenerative changes and rupture. The Achilles tendon is subjected to forces as high as 6 to 10 times the body weight during activities such as running. These factors, combined with the function of the gastrocnemius-soleus complex in crossing the knee, ankle, and subtalar joint, may help explain the high incidence of degenerative changes and injuries to the Achilles tendon. ACUTE ACHILLES TENDON RUPTURES Achilles tendon rupture is most common in men between the ages of 30 to 50 years. A retrospective review of 331 patients with Achilles tendon rupture found that 83% of injuries were sustained by men with an average age of 46.4 years. The same study noted that 68% of the sustained injuries were due to sports-related activities. 1 Most Achilles tendon ruptures occur 2 to 6 cm from the insertion of the tendon, with proximal ruptures account ing for only 10% to 15% of all Achilles tendon ruptures. 2 Ruptures at the insertion are rare and are associated with factors such as a Haglund deformity, a history of insertional Achilles tendinosis, or prior steroid therapy in the area. The common mechanism of rupture is a forced eccentric loading of the plantarflexed foot. The exact cause of Achilles tendon rupture remains unclear, but it

ABSTRACT The Achilles tendon is the strongest tendon in the body and plays a significant functional role. Anatomic characteristics of the Achilles tendon contribute to the development of varied pathol ogy, including rupture and tendinopathy. The treatment of acute Achilles tendon ruptures remains controversial. It is important to review surgical and nonsurgical options for both Achilles tendon rupture and Achilles tendinopathy, along with rehabilitation protocols. Chronic Achilles tendon ruptures represent a challenging clinical entity, with most of the literature focused on var ied surgical approaches.

Section 7: Tendon Disorders and Sports-Related Foot and Ankle Injuries

Keywords: Achilles tendinopathy; Achilles tendon; Achilles tendon rupture

INTRODUCTION The functional importance of the Achilles tendon is sug gested by its status as the strongest and thickest tendon in the body. The Achilles tendon is formed by the two heads of the gastrocnemius and the soleus and inserts into the posterior aspect of the calcaneus. The slightly

Neither Dr. Gurbani nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter. This chapter is adapted from Padanilam TG: Disorders of the anterior tibial, peroneal, and Achilles tendons, in Chou LB, ed: Orthopaedic Knowledge Update ® : Foot and Ankle 6 . American Academy of Orthopaedic Surgeons, 2020, pp 377-391. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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Section 7: Tendon Disorders and Sports-Related Foot and Ankle Injuries

has been associated with inflammatory or autoimmune disorders, systemic or injectable steroid use, collagen abnormality, exposure to fluoroquinolones, repetitive microtrauma, metabolic disorders, and overpronation of the foot. An acute rupture usually can be diagnosed on the basis of the patient’s history and physical examination. Most patients have a history of a traumatic event and describe a feeling of being kicked in the heel. Walking and climbing or descending stairs may be difficult. Examination reveals decreased plantar flexion strength, swelling around the tendon and loss of tendon contour, a palpable gap, lack of ankle movement when the calf is squeezed (the Thompson test), and an increased dorsiflex ion position of the ankle when the patient is prone and the knee is bent to 90° ( Figure 1 ). Imaging is rarely needed to confirm diagnosis of an acute Achilles tendon rupture. In fact, a retrospective study comparing patients with confirmed intraoperative Achilles tendon ruptures who had undergone preoperative MRI with those who did not undergo preoperative MRI found that a positive physical examination was more sensitive in diagnosing Achilles tendon rupture than radiologists’ interpretation of MRI. The authors suggest that MRI evaluation be reserved for patients with equivocal examination findings, or in the setting of chronic injuries for preoperative planning. 3 The treatment of an acute Achilles tendon rupture remains controversial. Nonsurgical treatment traditionally

has consisted of prolonged immobilization in plantar flexion, with avoidance of weight bearing. Advocates of nonsurgical treatment emphasize the complications of sur gical treatment, including wound healing–related issues. Surgical treatment traditionally has been recommended for active patients because of the belief that rerupture rates are higher after nonsurgical treatment. Many studies have attempted to answer the question of whether surgical or nonsurgical treatment is superior. In a retrospective study of 945 patients with a nonsur gically treated Achilles tendon rupture, the decision for nonsurgical treatment was based on a palpation finding that the tendon ends were well approximated. 4 Patients were treated with an equinus cast for 4 weeks, a walker boot for the subsequent 4 weeks, and finally physical therapy. All patients were able to return to work and a preinjury level of sports activity. The rerupture rate was 2.8%. Almost all of the patients (99.4%) reported a good or excellent result. A historical control group of surgically treated patients was studied for comparison. A retrospective study of 363 patients who underwent an identical functional rehabilitation program after sur gical or nonsurgical treatment found a rerupture rate of 1.4% after surgical treatment and 8.6% after nonsurgical treatment. 2 The study was limited by the absence of stan dardized criteria for assignment to a treatment group. The patients who were surgically treated tended to be younger and have higher physical demands than those who were nonsurgically treated, or they had sought treatment more than 24 hours after injury. The study findings included no functional or outcome measures. Another study evaluated the functional outcomes of 80 patients who were randomly assigned to surgical or nonsurgical treatment. 5 No signif icant between-group difference was found in peak torque or total work at 1-year follow-up. Patients in both groups had decreased peak torque in the injured leg, however, in comparison with the uninjured leg. Cast immobilization was used for 6 weeks after surgery and for 10 weeks in nonsurgical treatment. The rerupture rates (5.4% in the patients who were surgically treated and 10.3% in those who were nonsurgically treated) were not considered to be statistically significantly different. Early mobilization has been emphasized in the treat ment of Achilles tendon ruptures. A randomized study of 97 patients evaluated functional outcomes when early mobilization was used after surgical or nonsurgical treat ment. 6 All treatment was initiated within 72 hours of injury, and patients in both groups used a removable boot after 2 weeks of immobilization in a short leg equinus cast. The rerupture rate was 4% in patients who were surgically treated and 12% in those who were nonsurgically treated. Functional testing at 6-month follow-up revealed much better results in the patients who were surgically treated, but at 12-month follow-up

Section 7: Tendon Disorders and Sports Related Foot and Ankle Injuries

FIGURE 1 Clinical photograph showing the Matles test, in which the leg with an Achilles tendon rupture has greater dorsiflexion than the normal leg in the background. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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Chapter 23: Disorders of the Achilles Tendon

the only significant between-group difference was that patients in the surgical group performed better in the heel-rise test. A study reported results on the first 45 of these 97 patients in whom an ultrasonography was per formed before the initiation of treatment. Nonsurgical management of ruptures with more than 10 mm of dias tasis between the tendon ends led to significantly higher rerupture rates than with surgical management. 7 Another randomized study of surgical and nonsurgical treatment in 144 patients evaluated functional outcomes after an accelerated functional rehabilitation program that began 2 weeks after injury. 8 No significant between-group difference was found in range of motion, strength, or rerupture rate. A meta-analysis of 10 randomized studies concluded that the risk of rerupture was equivalent after surgical or nonsurgical treatment of an Achilles tendon rupture if early motion was used during nonsurgical treatment. 9 If early motion was not used, the risk reduc tion with surgery was 8.8%. No significant difference was found in range of motion, strength, calf circumfer ence, or functional outcome. A 2021 network meta- analysis of 19 randomized controlled trials compared outcomes of treatment with primary immobilization, function rehabilitation, minimally invasive repair, and open repair. No difference in rerupture risk was found between modern treatment techniques (functional reha bilitation, minimally invasive repair, and open repair), whereas traditional primary immobilization was asso ciated with higher rerupture risk compared with open repair (odds ratio, 4.06). Minimally invasive surgery was associated with a lower risk of complication that resulted in additional procedures. 10 This is a different result than was previously reported in a meta-analysis of level I and level II studies compar ing surgical and nonsurgical treatment of acute Achilles tendon ruptures. 11 A 3.7% rerupture rate in the surgical group and 9.8% in the nonsurgical group were noted. No significant difference was found in return to sport, incidence of deep vein thrombosis, or physical activity scale. These results were similar to those found in a 2022 multicenter randomized controlled trial of 526 patients who were assigned to nonsurgical treatment, open repair, or minimally invasive repair. Although no difference in functional outcomes was reported between groups at 12 months, nonsurgical management was associated with a higher rate of rerupture (6.2% versus 0.6% in each of the surgical groups). 12 With regard to trends in choice of treatment method, there may be geographic variability. A review of a large healthcare database suggested that surgical management is the preferred method of treatment for acute Achilles tendon ruptures in the United States. 13 A review of a Denmark national registry from 1994 to 2013 showed a statistically significant increase in incidence of Achilles

tendon ruptures and a noticeable decline in surgical treat ment from 2009 to 2013. 14 Recent research on the surgical treatment of Achilles tendon ruptures has focused on the use of minimally invasive repair techniques and early mobilization ( Figure 2 ). Historically, minimally invasive and percutaneous techniques have been criticized as leading to relatively high rates of rerupture and sural nerve injury. 15-17 A ret rospective study evaluated the use of immediate weight bearing in 52 patients. 15 After surgery using a modified percutaneous approach, the limb was placed in a cast, and immediate weight bearing was allowed. A boot with a heel lift was substituted after 2 weeks, and exercises were started. At an average 28-month final follow-up, 47 patients (90%) were able to return to their desired level of activity, and the average American Orthopaedic Foot and Ankle Society score was 90. Four patients had sural neuritis, which resolved within 6 months. No reruptures were observed. A study of 15 elite athletes found that all were able to return to their sport after a minimally invasive repair. 17 Thirteen patients had no pain but did have a subjective perception of reduction in calf strength, two had wound-healing difficulty, and none had sural nerve injuries. The study concluded that percutaneous repair is safe and effective for treating Achilles tendon rupture in elite athletes. In a randomized prospective study comparing open repair with the use of a commer cially available percutaneous repair device, all 40 patients regained Achilles tendon function. 16 No between-group difference was found in maximal calf circumference, ankle dorsiflexion, or the ability to perform heel rises. The complication rate was 5% in the patients treated with a percutaneous repair and 35% in those treated with an open repair. No reruptures or sural nerve injuries were found in either group of patients. There were fewer incidences of local tenderness, skin adhesion, and tendon

Section 7: Tendon Disorders and Sports Related Foot and Ankle Injuries

A FIGURE 2 A , Intraoperative photograph showing a mini mally invasive Achilles tendon repair. B , Photograph showing resting tension of the Achilles tendon restored after repair. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023 B

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Section 7: Tendon Disorders and Sports-Related Foot and Ankle Injuries

thickening in the patients who received a percutaneous repair. A retrospective study of 270 patients compared open repair with percutaneous repair and found no statis tically significant difference between the two approaches with regard to complications. 18 Early motion was evaluated after open repair in a retro spective study of 107 patients, 96 of whom (90%) received no immobilization and started exercise 3 to 5 days after surgical repair. 19 Patients were able to resume heavy labor and sports activity 13 weeks after surgery on average. No rerupture, gap formation, or tendon elongation was noted. The study concluded that early motion may facilitate the proliferation, transportation, and alignment of tendon cells, thereby leading to an improvement in the overall reconstruction of the tendon. However, those results are somewhat contradictory to the results found in a separate 2022 prospective study of 60 patients who underwent percutaneous Achilles tendon repair that compared the outcomes of a traditional accelerated rehabilitation pro gram to a slower rehabilitation protocol. In this study, both groups were allowed immediate weight bearing; however, the patients with the slower rehabilitation protocol were immobilized for a longer period and started eccentric exercises at a later time (approximately 12 weeks after surgery). The slower rehabilitation group was found to have improved patient-reported functional outcomes, calf circumference, isometric strength, and Achilles tendon ten sion as measured by resting angle at a 12-month follow-up. These results suggest that the added benefits of earlier mobilization may potentially be offset by an increased risk of tendon elongation during the healing process. 20 In addition to tendon elongation, another marker that has been identified as a potential correlate to functional outcomes is the Achilles tendon cross-sectional area. A 2020 prospective study of 22 patients evaluated tendon structure using ultrasonography and patient functional outcomes at multiple time points up to 1 year after Achilles tendon rupture. In this study, which did not control for treatment provided, tendon cross-sectional area at 12 weeks was found to be the strongest predictor of improved performance on heel-rise testing at 1 year. 21 The effect of various rehabilitation protocols on Achilles tendon cross-sectional area after rupture continues to be explored. CHRONIC ACHILLES TENDON RUPTURES An estimated 10% to 25% of Achilles tendon ruptures are neglected or not immediately identified. 22 The patient risk factors for delayed diagnosis include age older than 55 years, a high body mass index, and injury unrelated to sports activity. 1 Although there is no clear demarcation between acute and chronic rupture, a rupture estimated to have been present for 4 to 6 weeks is likely to have

characteristics consistent with chronic rupture. Chronic rupture is more challenging to treat than acute rupture because of the presence of a gap between the tendon ends, retraction and scarring of the calf muscle, and loss of muscle contractility. The patient may have vague symptoms that are not specific to the Achilles tendon region. There may be a sense of weakness or unsteadiness in gait, rather than pain. Difficulty in stair climbing and walking uphill is common. Loss of tendon contour is seen on examination. Some patients have sufficient reparative tissue to make palpation of a gap difficult. The Thompson test usually is positive but is less reliable than with acute rupture. The Matles test also usually is positive. Most patients are unable to perform a single-leg heel rise. Retraction and scarring of the tendon ends means that nonsurgical restoration of the physiologic tension of the gastrocnemius-soleus complex is difficult. The use of an ankle-foot orthosis should be considered for a patient who is a poor surgical candidate because of significant comorbidities. A patient with minimal functional deficits also may benefit from nonsurgical treatment. The benefit of physical therapy is in recruiting other muscle groups to compensate for the loss of Achilles tendon function. There is limited evidence regarding the outcomes of non surgical management of chronic Achilles tendon ruptures in the literature. 23

Surgical treatment of a chronic rupture involves the restoration of continuity to tendon ends that have retracted and created irreducible gaps. The available surgical techniques include tendon mobilization, turn down flaps, tendon advancement, tendon transfer, free tissue transfer, and synthetic graft. 22 A 2- to 3-cm gap can be effectively treated using tendon mobilization and stretching of the proximal musculature, followed by end- to-end repair. The use of turndown flaps involves freeing a strip of tendon from the proximal residual tendon and weaving it through the distal and proximal tendon ends. A study reported on the treatment of chronic ruptures with removal of a section of scar tissue and direct pri mary repair of the remaining scar tissue without the use of any graft in 30 patients. 24 At 33 months average follow-up, there were no reruptures and all patients were able to use stairs. Fourteen patients who were involved in sports were able to return to their sport. Histologic evaluation of the interposed scar tissue showed the bio logic potential for healing. A V-Y tendon advancement can be used for gaps smaller than 5 cm and patients have reported satisfactory outcomes; however, the cosmetic results may be unsatisfactory and persistent plantar flex ion weakness is seen. 25 Tendon transfers are an option for the treatment of chronic ruptures. Tendon transfer provides not only material to fill gaps between rupture ends but also additional strength with its associated Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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Chapter 23: Disorders of the Achilles Tendon

musculotendinous unit. The most common donor sites are the flexor hallucis longus (FHL), peroneal tendons, and flexor digitorum longus. Peroneus brevis tendon transfers were performed through a limited approach in 32 patients and all were able to work and participate in leisure activities. 26 Six were rated as having an excellent outcome, and 24 had a good outcome. Loss of eversion strength was found objectively on examination but was not subjectively reported by patients. The FHL tendon transfer has several reported advantages including limited donor morbidity, greater strength than a peroneus brevis transfer, an axis of pull similar to that of the Achilles tendon, and improved vascularity of the reconstruction with presence of the low-lying muscle belly 27 ( Figure 3 ). The use of a free tissue transfer such as a semitendino sus graft has had good results for the treatment of ten don gaps larger than 6 cm. 28 A study reported excellent results in 62 of 72 patients with a chronic rupture at the insertion of the Achilles tendon when the gastrocnemius aponeurosis was used to reconstruct the insertion. 29 Most studies of synthetic grafts have been small, and com parative evaluation therefore is difficult. Although sur gical treatment of chronic ruptures has led to improved outcomes, patients continue to have strength deficits in comparison with the contralateral limb. A variety of techniques have been studied, but the small numbers of patients, combined with variations in patient selection, gap measurements, postoperative regimens, and outcome measurements, create difficulty in comparing data and making firm recommendations. ACHILLES TENDINOPATHY Achilles tendinopathy is described as insertional or nonin sertional. Noninsertional tendinopathy is further classified as peritendinitis, peritendinitis with tendinosis, or tendino sis. Tendinosis is a chronic, noninflammatory, degenerative process of the tendon that is associated with decreased vascularity, repetitive microtrauma, and aging. The asso ciated etiologic factors can include diabetes, hypertension, steroid use, obesity, and estrogen exposure. Patients range from relatively young and active patients with peritendi nitis caused by overuse to patients older than 50 years with tendinosis combined with peritendinitis of varying severity. Patients with peritendinitis have diffuse swelling and tenderness along the course of the tendon. Patients with tendinosis typically have pain and swelling along a nodular area within the tendon. Tenderness to palpation often is present along the area of tendon thickening. The patient may have difficulty performing a single-leg heel rise. MRI and ultrasonography can be useful for defining the location and extent of disease. Nonsurgical management is effective in 70% to 75% of patients. 30,31 Modalities including rest, NSAIDs,

Section 7: Tendon Disorders and Sports Related Foot and Ankle Injuries

activity modification, and eccentric strengthening fre quently are used. Immobilization in a short leg cast or boot may be beneficial if the condition is recalcitrant. Injectable therapies are gaining popularity for treating Achilles tendinosis, using agents such as platelet-rich plasma, autologous blood, sclerosing agents, protease inhibitors, hemodialysate, corticosteroids, and prolother apy. A systematic review of nine randomized controlled studies involving the use of injectable therapies found only one study meeting the quality criteria. 31 Most patients treated with an injectable therapy were found FIGURE 3 Intraoperative photograph showing the use of a harvested flexor hallucis longus tendon to treat a chronic Achilles tendon rupture. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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Section 7: Tendon Disorders and Sports-Related Foot and Ankle Injuries

to have mild to moderate clinical benefit, but patients in placebo and control groups had similar improvements. In regard to platelet-rich plasma, a 2021 meta-analysis of four randomized controlled trials with 170 patients found no specific added benefit of platelet-rich plasma compared with saline injections when combined with an eccentric training program for the treatment of chronic midsubstance Achilles tendinopathy. 32 The effectiveness of extracorporeal shock wave ther apy was evaluated in a systematic meta-analysis of four randomized controlled studies and two pre-post stud ies. 33 The studies were inconsistent in participant char acteristics as well as dosages and impulses per session. Four studies found statistically significant improvement in functional outcomes, and the meta-analysis concluded that the evidence was satisfactory to show the effective ness of extracorporeal shock wave therapy for treating chronic Achilles tendinopathy. Surgical treatment may be indicated for refractory Achilles tendinosis after 6 months of unsuccessful non surgical treatment. The traditional surgical treatment consists of removing diseased portions of the tendon. Augmentation with FHL tendon transfer may be needed if more than 50% of the tendon is removed. A prospective study of 56 patients who had FHL transfer for insertional or noninsertional Achilles tendinopathy found significant improvement in functional outcome scores at 24-month follow-up, and 32 patients (57%) had no hallux weak ness. 34 Most of the patients in this study were described as sedentary. The study authors expressed concern that relatively young, active patients might notice functional deficits associated with great toe weakness. Minimally invasive paratenon release also has been suggested for treating Achilles tendinopathy. In a retro spective case study of 26 patients, percutaneous release of adhesions between the paratenon and tendon was followed by instillation of methylprednisolone and bupivacaine into the paratenon. 35 At an average 13-month follow-up, 73% of tendons were pain free or had significant improvement in pain. The study authors suggested that the release of adhesions in this procedure disrupts the neovascular ization process and allows tendon healing. A retrospec tive review of the outcomes of 39 runners found that 30 runners (77%) reported a good or excellent outcome an average 17 years after ultrasound-guided multiple per cutaneous tenotomies for Achilles tendinosis. 36 Several studies of isolated gastrocnemius lengthening for Achilles tendinopathy found clinical improvement in all patients without loss of plantar flexion strength. 37-39 Comparison with other studies is difficult, however, because of the lim ited characterization of the extent of tendon involvement. Insertional Achilles tendinopathy ranges from peri tendinitis to tendinosis. Isolated peritendinitis tends to

occur in relatively young and athletic individuals and can be caused by overuse, hill running, an interval training program, or a training error. Insertional tendinosis is more common in individuals older than 50 years with varying levels of activity. Patients often have concomi tant symptoms from retrocalcaneal bursitis and Haglund deformity. Inflammatory arthropathies may contribute to the etiology and especially should be considered in a younger patient with bilateral symptoms. The initial symptoms usually are morning stiffness, posterior heel pain, and swelling with activity, progressing to constant pain. Often the patient has swelling along the posterior heel. Active and passive limitation of dorsiflexion may be present. The location of the tenderness can help dis tinguish among retrocalcaneal bursitis, Haglund defor mity, and insertional tendinosis; all three sometimes are present. Radiographs may show calcification within the insertion of the tendon. Traditionally, a Haglund defor mity was considered to be most common in patients with insertional tendinopathy, but a recent retrospective radiographic study challenged this belief. 40 No significant difference was found in the radiographic parameters of Haglund deformity between patients with or without insertional Achilles tendinosis. Calcification of the ten don insertion was present in 73% of patients. The initial treatment, often including rest, NSAIDs, and activity modification, is effective in most patients. 30 Eccentric exercises are less effective for treating insertional tendinopathy than noninsertional tendinopathy. 33 A ran domized controlled study found a 28% improvement in patients treated with eccentric exercise, compared with a 64% improvement in those treated with extracorporeal shock wave therapy. 41 A prospective study of 103 patients treated using an ankle-foot orthosis and a home stretching program found improvement in 91 patients (88%). The average duration of treatment was 163 days. 42

Surgical treatment may be indicated if symptoms are not relieved after 6 to 12 months of nonsurgical manage ment. Surgical treatment is directed toward the underlying pathologic changes. The techniques include débridement of the Achilles tendon insertion, débridement of the ret rocalcaneal bursa, and posterosuperior calcaneal ostec tomy ( Figure 4 ). Several approaches have been described, including medial, lateral, combined medial and lateral, endoscopic, J-shaped, transverse, and central tendon split ting; there are insufficient data that suggest the superiority of one approach over another. A study reported on the results of dorsal closing wedge osteotomy in a group of recreational and professional athletes. 43 This was per formed on 52 patients who showed signs of a Haglund deformity and less than 50% degenerative tendinopathy at the Achilles tendon insertion on magnetic resonance images. All professional athletes returned to the same Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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