A clinical study on reconstruction of small and medium sized defects of tendo Achilles and heel regions with fascio cutaneous flaps

Background: Soft tissue defects of tendo Achillis and heel regions are difficult to reconstruct because of less vascularity and limited mobility of the skin. Most of these defects result from trauma, infection and excision of malignancy. Well vascularized tissues with sensation are needed to cover these defects as these regions are more prone for repeated friction and weight bearing. Aim was to study the versatility and applications of various flaps in the reconstruction of soft tissue defects of tendo Achillis and heel regionsMethods: This retrospective study was conducted in the Department of Plastic and Reconstructive Surgery, Thanjavur Medical College, Tamil Nadu, India from 2015-2019. About 22 patients with soft tissue defects of tendo Achillis and heel regions were studied. The aetiology of the defect, size of the defect and the outcome of treatment with various flaps were evaluated.Results: Of the 22 patients 20 patients were males and 2 patients were females. The age group ranged from 12 years to 68 years. Most of the defects were due to road traffic accidents. The soft tissue defects were classified into small, medium and large sized defects based on the area of the defects. Reverse sural artery flap extended lateral calcaneal artery flap, posterior tibial artery perforator flap and lateral supra malleolar flap were the various flaps used to cover these defects.Conclusions: Fascio cutaneous flaps play a major role in the reconstruction of tendo Achillis exposed defects and heel defects. Long term follow-up with physiotherapy is essential to achieve excellent function of tendo Achillis.

Case Series: Management of Foot Drop

Aim: To highlight the functional outcome of surgical management of foot drop in patients with Hansen disease. Case Presentation: We present three cases of foot drop following Hansen’s disease that were managed surgically by Tibialis posterior transfer. The patients had preoperative physiotherapy for ten days and postoperative physiotherapy for four weeks. Their post-operative periods were uneventful and the corrections were satisfactory. Discussion: Involvement of common peroneal nerve in Hansen’s disease usually results in paralysis of the anterior tibial and/or peroneal muscles. Hansen’s disease patients with foot-drop walk with a ‘high-stepping gait’, lifting the leg high as if climbing steps even while walking on level ground. When the paralysis has been present for more than six months to one year without recovery, the best option of treatment at this stage is corrective surgery and the main aim of the corrective surgery is to restore active dorsiflexion of the foot so that the gait becomes normal. This is achieved by re-routing the tendon of Tibialis posterior muscle, brings that tendon to lie in front of the ankle and is anchored distally. If the tendo-achillis tendon is found to be tight, it should be lengthened as the first step of the Tibialis posterior transfer operation. Conclusion: Surgical correction of foot drop usually leads to restoration of active dorsiflexion of the foot thereby preventing development of secondary deformities and ulceration. Our patients were able to dorsiflex their feet after the surgical correction.

A Two-Stage Foot Repair in a 55-Year-Old Man with Poliomyelitis

A 55-year-old man with poliomyelitis presented with a plantarflexed foot and painful ulceration of the sub–first metatarsophalangeal joint present for many years. A two-stage procedure was performed to bring the foot to 90°, perpendicular to the leg, and resolve the ulceration. The first stage corrected only soft-tissue components. It involved using a hydrosurgery system to debride and prepare the ulcer, a unilobed rotational skin plasty to close the ulcer, and a tendo Achillis lengthening to decrease forefoot pressure. The second stage corrected the osseous deformity with a dorsiflexory wedge osteotomy of the first metatarsal. The ulceration has remained closed since the procedures, with complete resolution of pain.

Zdravljenje idiopatskega in kompleksnega prirojenega talipes ekvinovarusa z metodo po Ponsetiju

Congenital idiopathic clubfoot is a deformity typically occurring in an otherwise healthy child which occurs in 11,4 in 10.000 live births. Approximately one-half of cases present with bilateral deformity and affects boys and girls equally. Clubfoot is characterized by adduction, supination and cavus deformity of the forefoot and midfoot, varus of the heel, and a fixed plantar flexion (equinus) of the ankle. Treatment od idiopathic type of clubfoot consists of corrective manipulation and casting by the Ponseti method, where usually four to six casts are needed. Equinus is corrected with tendo Achillis tenotomy followed by foot abduction brace application.Complex type of clubfoot, which has more severe rigid deformation, is present in 6,5% of all clubfeet and is refractory to the usual corrective manipulation and casting by the Ponsetti method. Clinically, complex clubfoot is characterized as short, stubby foot, having rigid equinus, severe adduction and plantar flexion of all metatarsals, a deep crease above the heel and a transverse crease in the sole of the foot. Modified Ponsetti method for treatment of complex clubfoot consists of simultaneus correction of adduction and heel varus and subsequent cavus and rigid equinus correction. After the Achillis tendon tenotomy, modified foot abduction brace is applied, where foot is in 40° outer rotation in contrast to 70° abduction used in less rigid congenital idiopathic clubfoot. Relapse occurs in 14% and is ussually related to problems with shoe fit and patient coplience.

Percutaneous needle tenotomy for Ponseti technique in the management of Congenital Talipes Equinovarus (CTEV)

Background: The Ponseti method has become established treatment of choice in the management of clubfoot i.e. congenital talipes equinovarus (CTEV). Tenotomy of Tendo-achillis often is required as last step of ponseti method of treatment. This procedural note describes a simple method of doing a percutaneous tenotomy of Tendo-achilles. Methods: In Orthopedics OPD of Dhaka Medical College Hospital, Dhaka, percutaneous needle tenotomy was done in 70 feet of 52 patients from September 2013 to May 2014 by the same orthopedic surgeons for the management of CTEV by Ponseti technique. Results: We have found this technique is very effective than the commonly practiced percutaneous blade tenotomy or open tenotomy. Conclusion: This simple method of tenotomy using a wide bore needle during treatment of clubfoot in children can be a good surgical option. DOI: http://dx.doi.org/10.3329/jdmc.v23i1.22695 J Dhaka Medical College, Vol. 23, No.1, April, 2014, Page 55-59

Achilles tendinopathy

The two main categories of tendo Achillis tendon disorder are broadly classified by anatomical location to include non-insertional and insertional conditions. Non-insertional Achilles tendinopathy is often managed conservatively, and many rehabilitation protocols have been adapted and modified, with excellent clinical results. Emerging and popular alternative therapies, including a variety of injections and extracorporeal shockwave therapy, are often combined with rehabilitation protocols. Surgical approaches have developed, with minimally invasive procedures proving popular. The management of insertional Achilles tendinopathy is improved by recognising coexisting pathologies around the insertion. Conservative rehabilitation protocols as used in non-insertional disorders are thought to prove less successful, but such methods are being modified, with improving results. Treatment such as shockwave therapy is also proving successful. Surgical approaches specific to the diagnosis are constantly evolving, and good results have been achieved.