Idiopathic Toe-walking (ITW) is a condition where children persistently walk on their toes in the absence of neurological or orthopaedic structural abnormalities. ITW affects 2% of children at the age of 5.5yr. This may eventually result in fixed ankle equinus. There is a paucity of long-term natural history studies in untreated ITW however persisting equinus contractures are implicated in common adult foot conditions.

The Aim of this study is to show if the percentage of contact pressure through the hindfoot during standing and walking improve following surgical tendoachilles lengthening one year after surgery in children with ITW when compared to a normative cohort

23 patients (46 feet) diagnosed with ITW between 2017-2022; were treated with open zone III Achilles lengthening. We reported patient demographics, clinical resolution, or revision. Passive dorsiflexion range and hindfoot pressure percentage when standing and walking were measured on a baropodometric walkway and compared pre-operatively and at 12-18months postoperatively. We compared this to data from a previously studied normative cohort

87% of children had compete resolution of toe-walking. 3 had recurrence with 1 patient having a revision surgery. Mean pre-operative static heel pressure percentage was 15.7%, this improved to 54.7% (p<0.001). This neared normative average of 70.6%. Mean pre-operative dynamic heel pressure percentage was 5.5%, this improved to 44.6% (p<0.001). This neared the normative mean of 52.0%. Mean Passive dorsiflexion in extension and 90˚ knee flexion was −5.8˚ and 0.5˚ respectively. This improved on average by 17.4˚ and 14.5˚ to a new mean of 11.6˚ and 15.0˚ (p<0.001).

Open Zone III Achilles lengthening for ITW has high resolution rates. Hindfoot contact pressures and passive ankle dorsiflexion show improvement at 1 year post operatively.

Aims & Background. Congenital Talipes Equinovarus (CTEV) is the most common congenital musculoskeletal birth defect affecting 1 in 1000 births per annum. We have compared our surgical results to the British Society of Children's Orthopaedics (BSCOS) published guidelines. Methods. Between, 2006–16, patients who were referred for treatment of pathological CTEV were audited. Data from a combination of Clinical Portal, Orthotic Patient Administration System and Surgical Elogbook were assessed. In addition, the degree of deformity was classified by the Harrold & Walker method at the time of diagnosis (senior author). Most of this information was recorded prospectively and analysed retrospectively. Ponseti technique was the method of treatment. Results. 96 patients assessed (133 feet). There were 78 males and 18 females, 37 patients were affected bilaterally and 11 had associated syndromes. There were 23 Harrold & Walker (H&W) 1, 28 H&W 2 and 82 H&W 3 classification feet. Average time period in Ponseti boots and bars was 14.4 months (95% CI 12.9–15.9), average time in all types of bracing of was 17.1 months (95% CI 14.8–14.8). Number and rate of surgeries performed were as follows: 77 Tendoachilles release (63.1%), 19 Tibialis Anterior Transfer (5.6%), 15 Radical Release (12.3%), revision 25 Surgery (20.5%) & 5 Abductor Hallucis Release (4.1%). Conclusion. The audit confirms that the unit meets most of the current BSCOS guidelines. All surgical procedures apart from radical release surgery fall within accepted limits. This may be due, in part, to the syndromal cases. We do however demonstrate a significantly reduced average time period in bracing compared to that recommended by BSCOS. There are multiple reasons for this discrepancy including non-compliance and poor splint tolerance (child refusing to use). We feel this work demonstrates a reduced period in bracing can be achieved whilst maintaining standards of treatment

Aims

The aim was to compare long-term patient-reported outcome measures (PROMs) after operative and nonoperative treatment of acute Achilles tendon rupture in the context of a randomized controlled trial.

ECSWT has been on the medical horizon for last 30 years mainly in urology for urolithiasis and has found a parallel use in orthopaedics for various chronic soft tissue conditions like Tendoachilles tendinoses and plantar fasciitis etc. ECSWT acts a piezoelectric device releasing acoustic energy and causing micro-trauma activating cytokine mediated response stimulating local angiogenesis and tissue repair. Methodology. 56 patients were recruited for the trial after ethics approval was achieved. The diagnosis was confirmed with ultrasound scan and measuring the width of the swelling and the local hypervascularity. The cohort of the patients was randomised in groups for physiotherapy [n=23] and shockwave therapy [n= 23]. The patient groups with shockwave therapy received a 3-week treatment with typical 2000 impulses per session once a week and physiotherapy group was subjected to eccentric loading exercises. Patients were assessed at 12 week with AOFAS, VISA-A scores and repeat ultrasound scan. Results. The average age of the average age was 51 years [36- 73 years] Mean duration of symptoms prior to treatment was 25 months (range 6-60 months). AOFAS scores increased in both groups: from 64□86 in the ECSWT group and 72□79 in the physiotherapy group. VISA-A scores also increased in both groups from 39□73 in the ECSWT group and from 36□56 in the physiotherapy group. Scores were significantly higher in the ECWST group post treatment. The ultrasound scan findings suggested the tendon girth receding from 10.9 mm□9.9 mm in physiotherapy group while 9.8 mm□8.7 mm in the ECSWT group with hypervascularity decreasing from marked to mild in both groups. Statistical significance was established using SPSS 16 p < 0.001in post treatment group. Conclusion. Clinically significant improvement was found in the patients treated with ECSWT as compared to the physiotherapy sessions while radiological evidence showed parallel improvement in both the groups

Background: Neglected ruptures of the tendoachilles pose a difficult surgical problem. Intervening scar tissue has to be excised which cannot be repaired by end-to-end anastamosis. Several techniques for reconstruction of chronic ruptures have been described. The flexor hallucis longus (FHL) tendon transfer is considered advantageous over other tendon transfers. One disadvantage of FHL is it has limited excursion. There are no data to determine the optimal positioning of the FHL tendon to the calcaneum.

Materials and Methods: Two computer programmes (MSC.visualNastran Desktop 2002™ and Solid Edge® V19 were used to generate a human ankle joint model. This model is able to reproduce dorsi- and plantarflexion. Different attachment points of FHL tendon transfer to the calcaneum were investigated.

Results: The lowest muscle force to produce plantarflexion (single stance heel rise) was 1355N. Plantarflexion increased for a more anterior attachment point. The maximal plantarflexion was 33.4° for anterior attachment and 24.4° for posterior attachment. There was no significant difference in these figures when the attachment point was moved to either a medial or lateral position.

Clinical relevance: Optimal FHL tendon transfer positioning is a compromise between achieving plantarflexion for normal physiological function versus the force generating capacity and limited excursion of FHL. A more posterior attachment point is advantageous in terms of power. The range of motion is 10° less than when attachment is more anterior, the arc of motion (24.4°) is still physiological. We recommend that FHL is transferred to the calcaneum in a posterior position.

Introduction: Management of acute rupture of the Achilles tendon is controversial. Conservative treatment has a higher re-rupture rate while surgery has complications like infection and wound breakdown. We devised a protocol in our hospital to decide between the surgical or non-surgical options. At our institution, a well-documented and structured program of non-operative or opeartive management of Achilles tendon rupture with use of either casts or operation has been devised based on Ultrasound findings of the ‘Gap/distance between the two ends of the Tear’. PURPOSE: The purpose of this study was to compare the incidence of Re-rupture in those treated by cast immobilization where the ends were approximating at ultrasound examination at our institution. METHODS: This study Prospectively assessed the results in 50 consecutive patients with a complete rupture of the Achilles tendon who had been treated with our regimen depending on the findings of the ultrasound examination, between 2003 and 2006. All ruptured Tendoachilles had ultrasound done in Full Equinus position to assess whether the ends are approximating or not. If ends were approximating they were treated in an equinus cast. Patients were evaluated on the basis of the subjective results and functional outcome measure, along with validated visual analogue scores. Re-rupture rates were measured at 06 months after injury. There were 35 Male and 13 females. This was followed by a final questionnaire to assess their return to pre-injury activities. Two patients were lost to follow-up as they moved out of the area. RESULTS: All the 48 re-ruptures available for analysis had their ultrasound done on initial presentation. 25 were treated non-operatively and 23 underwent surgery. The overall complication rate for Non Operative was minimal, with NO re-rupture or documented deep vein thromboses. In operative group there were 2 re-ruptures, 5 postoperative infection and discharge. CONCLUSION: The results of our non-operative treatment were better overall than published results of non operative & operative repair of acute Achilles tendon rupture. In this study the ends are approximating, confirmed on ultrasound before being assigned to Cast Immobilization. SIGNIFICANCE: The previous studies have not assigned patients into operative or non-operative groups based on whether the ends are approximating in full equines position. By assigning only those in whom the ends are approximating, to cast immobilization, re-rupture rates are less, thus resulting in better and stronger healing of TAs’ and avoiding risks of surgery

Chronic ruptures of the tendo-achilles in young individuals pose difficult therapeutic problems. Surgical repair Is necessary to achieve optimum functional results. We present our results using a modified Bosworth technique using a ‘turn-down’ strip of gastrosoleus aponeurosis

Materials and methods: 11 patients (9 Males:2 Females) Age range: 23–51 (average 36) Time since rupture: 9–20 weeks (average 13). All had pain, weak or absent push-off and restricted ADL.

Technique: Posterior midline incision – rupture exposed, ends debrided – 1” strip of gastrosoleus aponeurosis about 2–3” long – detatched proximally ‘turned down’ with fascial surface anterior. This modification was to avoid tissue bulge at proximal end of incision. The fascial strip was approximated with delayed absorbable sutures. The plantaris was used to supplement the repair when possible.

Cast-bracing for 9 weeks. FU – 12–42 months, minimum 12. All patients independently assessed at one year. AOFAS hindfoot scores – Preop and 1 year postop

Results: AOFAS scores: Preop: 49 (40–61) Postop: 82(70–94) 2 minor wound problems-no surgical intervention required. Push-off strength returned to about 70–80% in all patients. 7/11 patients returned to preop recreational activities.

We conclude that this is a safe and predictable repair technique in this group of patients. It is technically easy, restores tendon length and provides excellent functional improvement.

The operative and non-operative treatment options for acute tendo achilles rupture are well documented in the literature. The management of late presenting tendon rupture is usually operative, and can be complicated by acute shortening of the muscle-tendon unit and leave repairs under tension, which may lead to re-rupture. We report the use of the sliding graft technique for reconstruction of late presenting rupture.

A proximal intra muscular Z lengthening through a separate incision facilitates distal translation of the proximal tendon stump, allowing direct repair distally with minimum tension.

Post operatively a below knee cast is applied for six weeks with progressive dorsiflexion at two weekly intervals.

A dorsiflexion restriction splint accompanies early physiotherapy for a further six weeks with unprotected weight bearing commencing at three months.

There were eleven patients in the study group with an average follow up of 13 months. All tendons united. There were no re-ruptures. Two distal wound breakdowns occurred and one of these healed by secondary intention.

Good single stance power returned in patients with smaller separations but greater calf wasting and weakness was observed in those patients with large separations.

We conclude that this technique can be employed for the reconstruction of late presenting tendo achilles ruptures but great care is required with soft tissue dissection distally.

Consideration could be given to deep flexor transfers in the widely separated case.

The diagnosis of painful heel syndrome is quite common in any busy orthopaedics OPD. Though neoplasm and infections are not uncommon in calcaneum, the surgeon does not suspect infection unless there is an obvious history of punctured wound or constitutional symptoms. As such till date there is no series of large number of cases of calcaneal tuberculosis. We present our experience with 39 cases of calcaneal tuberculosis which include 2 cases of simultaneous bilateral symmetric involvement and 13 cases of tubercular lesion at the site of the attachment of Tendoachilles and Plantar Fascia. A classification of calcaneal tuberculosis is proposed. Material & Methods: (n=39) age 6–60 years; male: female – 20:19; duration of symptoms – 2 weeks to 8 years; “Heel up” sign present in 19 cases; X-ray showed erosive lesion at the site of Tendoachilles attachment (enthesitic type lesion) – 8 cases; erosive lesion at the site of Plantar Fascia attachment – 5 cases; Intraosseous lytic lesion(s) without subtalar joint involvment – 23 cases; subtalar joint involvemnet – 3 cases. FNAC was positive in 17 cases and core biopsy revealed tubercular material in 12 cases. All cases except one were treated conservatively. Discussion: The diagnosis and treatment of calcaneal tuberculosis are often delayed because the surgeon is unaware and signs and symptoms of calcaneal osteomyelitis are less dramatic than seen in osteomyelitis of long bones. The diagnostic and radiological features will be discussed