Achilles tendon rupture

NewsBot · Nov 4, 2024

Mini-open versus percutaneous surgical repair for acute Achilles tendon rupture: a systematic review and meta-analysis
Marian Andrei Melinte et al
Int Orthop. 2024 Oct 28

Purpose: To compare the clinical outcomes and complications of mini-open (MOT) and percutaneous techniques (PT) in the surgical repair of acute Achilles tendon rupture (AATR).

Methods: We systematically searched PubMed, Scopus, Web of Science, Clinical Trials, and the Cochrane Library for studies comparing MOT with PT for AATR. We assessed functional outcomes, complication rates, and operation time. Statistical analyses were performed using RevMan Web. Odds ratios (ORs) and mean difference (MD) with 95% confidence intervals (CIs) were pooled with a fixed-effects model for dichotomous and continuous endpoints, respectively. Heterogeneity was evaluated with I2 statistics.

Results: Eight studies, comprising 484 patients, were included, of whom 226 (46%) underwent MOT. MOT was associated with a significantly lower re-rupture rate (1.48% vs. 6.11%; OR 0.28; 95% CI 0.09-0.86; p = 0.03; I2 = 6%) and sural nerve injury rate (0.57% vs. 5.64%; OR 0.24; 95% CI 0.07-0.81; p = 0.02; I2 = 0%). No significant differences were observed in venous thrombosis (OR 0.81; 95% CI 0.17-3.94; p = 0.33; I2 = 0%), wound infection (OR 0.56; 95% CI 0.12-2.62; p = 0.46; I2 = 0%), or operation time (MD 1.83 min; 95% CI -1.13-4.79; p = 0.23; I2 = 88%). Functional outcomes showed higher American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores in the MOT group (MD 1.52 points; 95% CI 0.62-2.42; p = 0.001; I2 = 3%), while (Achilles Tendon Total Rupture Score) ATRS, time to return to activities, and ankle plantar and dorsiflexion were comparable.

Conclusions: MOT for AATR repair seems to reduce re-ruptures and sural nerve injuries while improving AOFAS scores, with no significant differences in other complications compared to PT. These findings suggest that the MOT may offer a safer and equally effective alternative to PT for AATR.
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NewsBot · Nov 4, 2024

Ultrasound assessment of acute Achilles tendon
rupture and measurement of the tendon gap
Michelle Fenech et al
Source

Achilles tendon rupture is a common sports-related injury which can carry significant morbidity to patients. Ultrasound remains the
workhorse of imaging as it can confirm and localise the extent of Achilles tendon injury. The sonographic anatomy, both normal
and ruptured sonographic appearances, as well as sonographic technique must be appreciated to accurately image and report findings, critical to patient management. Particular attention should be applied to the measurement of the diastasis between acutely
ruptured tendon ends as this information can assist with informing the decision of conservative vs. operative management. Further
work is necessary to standardise the measurement technique including correlating the degree of plantarflexion of the foot with
the sonographic tendon gap measures.
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NewsBot · Nov 4, 2024

Females present larger deficit in heel-rise height at 3 months following an Achilles tendon rupture compared with males
Elin Larsson et al
Knee Surg Sports Traumatol Arthrosc. 2024 Oct;32(10):2581-2588

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.
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NewsBot · Nov 5, 2024

Fear of reinjury after acute Achilles tendon rupture is related to poorer recovery and lower physical activity postinjury
Elin Larsson et al
J Exp Orthop. 2024 Oct 31;11(4):e70077. doi: 10.1002/jeo2.70077

Purpose
The aim of this study was to investigate how fear of reinjury to the Achilles tendon affects return to previous levels of physical activity and self‐reported Achilles tendon Total Rupture Score (ATRS) outcomes.

Methods
Data were collected from a large cohort of patients treated for an acute Achilles tendon rupture at Sahlgrenska University Hospital Mölndal between 2015 and 2020. The ATRS and additional questions concerning fear of reinjury, treatment modality, satisfaction of treatment and recovery were analyzed 1–6 years postinjury. Analysis was performed to determine the impact of fear of reinjury on patient‐reported recovery and physical activity.

Results
Of a total of 856 eligible patients, 550 (64%) answered the self‐reported questionnaire and participated in the follow‐up. Of the participants, 425 (77%) were men and 125 (23%) were women. ATRS, recovery in percentage, satisfaction of treatment, recovery on a 5‐point scale and physical activity level post‐ versus preinjury were significantly related to fear of reinjury (p < 0.001). Of the nonsurgically treated patients, 59% reported fear of reinjury compared to 48% of the surgically treated patients (p = 0.024) Patients that reported fear of reinjury had a 15‐point lower median ATRS score than those who did not (p < 0.001).

Conclusion
More than half of patients who have suffered an Achilles tendon rupture are afraid of reinjuring their tendon. Patients who reported fear of reinjury exhibited a significantly lower ATRS score. This indicates the importance of addressing psychological aspects in the treatment after this injury.
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NewsBot · Nov 5, 2024

The current status and challenges of surgical treatment for chronic Achilles tendon rupture
S M Feng
Zhonghua Wai Ke Za Zhi. 2024 Jun 1;62(6):520-524

With the growing demand for physical activity, an increasing number of individuals with chronic Achilles tendon ruptures are opting for surgical intervention. Surgical approaches encompass end-to end anastomosis, tendon flap techniques, tendon transfer procedures, and free tendon grafting, among others. When selecting the appropriate surgical method and determining the surgical indications, it is imperative to consider factors like the length of the Achilles tendon defect, patient age, aesthetic preferences, functional requirements, and local tissue conditions. As medical devices evolve and surgical techniques advance, the criteria for surgical intervention are also evolving. Drawing from existing literature evidence, it becomes crucial to define reasonable parameters for addressing Achilles tendon defects with each surgical technique, aligning more closely with clinical needs. Additionally, auxiliary technologies such as biologic therapy and innovative biomaterials have demonstrated promising results in laboratory or animal models. The focal point of advancing these auxiliary technologies lies in facilitating the translation of pertinent clinical outcomes in the future.
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NewsBot · Nov 5, 2024

Modified Minimally Invasive Bunnell Suture Surgery with Channel-assisted Minimally Invasive Reconstruction Device for Treating Achilles Tendon Rupture
Chao Li , Fu-chun Li
Z Orthop Unfall

Objective
The aim of this study was to improve the process of microincision and endoscopic surgery for the treatment of Achilles tendon (AT) rupture using the modified minimally invasive Bunnell suture (MIBS) technique.

Methods
From December 2019 to December 2021, 20 patients with AT rupture who visited the First Affiliated Hospital of Harbin Medical University (Harbin, China) underwent MIBS surgery.

Results
A total of 20 patients were included, of whom 18 (90.0%) were male and 2 (10.0%) were female. The mean age of the patients was 37.75 ± 9.94 years. In terms of the site of the AT, two (10.0%) had surgery on their left AT. The mean duration of surgery was 23.00 ± 2.47 minutes, and the mean bleeding volume was 5.00 ± 1.12 mL. All 20 patients (100%) showed complete incisional healing (stage I healing) and normal functional recovery (3–6 months postoperatively). There were no cases of abnormal functional recovery or postoperative recurrence within the 3–6 month follow-up period. The Achilles tendon Total Rupture Score (ATRS) significantly improved post-surgery (83.6 ± 5.59) compared to pretreatment (0.3 ± 0.92, p < 0.0001), indicating successful patient recovery.

Conclusions
After the modified MIBS surgical process, the operation steps were simplified, the surgical difficulty was reduced, and the surgical trauma was alleviated, resulting in good postoperative recovery and patient satisfaction with the outcome. Therefore, the MIBS surgery has high promotability.
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NewsBot · Nov 6, 2024

PLATELET-RICH PLASMA FOR ACUTE ACHILLES TENDON RUPTURE: RESULTS OF THE PATH-2 STUDY, A DOUBLE-BLIND MULTICENTRE RANDOMIZED PLACEBO-CONTROLLED TRIAL
The British Orthopaedic Foot & Ankle Society (BOFAS) Annual Congress 2018, Edinburgh, Scotland, 7–9 November 2018.

Background
Disability and slow return to sport and work after tendon rupture are major challenges. Platelet Rich Plasma (PRP) is an autologous supraphysiological concentration of platelets from whole blood that has demonstrated positive cellular and physiological effects on healing in laboratory conditions but evidence from adequately powered robust clinical trials is lacking. We aimed to determine the clinical efficacy of PRP for treatment of acute Achilles tendon rupture.

Methods
In a placebo-controlled, participant- and assessor-blinded, trial at 19 NHS hospitals we randomly assigned 230 adults starting acute Achilles rupture non-surgical management to PRP injection or dry-needle insertion (placebo) to the rupture gap under local anaesthetic. Patients with confounding or contraindicated concurrent medical conditions were excluded. The primary outcome was muscle-tendon function, assessed by the limb symmetry index (LSI, uninjured limb/injured limb × 100, higher scores better) of the work (Joules) performed during the heel-rise endurance test at 24 weeks. Secondary outcomes were: Achilles Tendon Rupture Score (ATRS, 0–100, higher scores better), quality of life (SF-12), pain, and goal attainment. Trial registration: ISRCTN54992179

Results
Participants were aged mean 46 years and 57 (25%) were female. 103/114 (90%) of the PRP group and all (n=116) in the placebo group received allocated treatment. At 24 weeks, mean LSI was 34.4 for the PRP group and 38.8 for placebo (adjusted mean difference −4.4 95% CI −11.2 to 2.5, n=201) and ATRS was mean 65.2 PRP vs 65.8 (adjusted mean difference −0.6, 95% CI −4.9 to 3.7, n=224). There were no differences between groups in the other secondary outcomes.

Conclusion
We found no evidence of PRP efficacy for improving muscle-tendon function or patient-reported recovery after acute Achilles tendon rupture. Our findings challenge the increasing global use of PRP for acute tendon injury and indicate that robust evaluations are required in other applications.
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NewsBot · Nov 6, 2024

Transverse small incision intrathecal "loop" minimally invasive suture for treatment of acute Achilles tendon rupture
Aikeremu Aierken et al
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2024 Sep 15;38(9):1055-1058

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.
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NewsBot · Nov 10, 2024

Achilles tendon rupture treated with open versus percutaneous repair: A Narrative review
Anderson Lee et al
Journal of Orthopaedic Reports; Volume 3, Issue 4, December 2024, 100357

Highlights
•Achilles tendon repair usually classifies nonoperative and operative techniques which include percutaneous or open repair.
•The operative techniques are more desirable, compared to nonoperative techniques.
•The percutaneous repair offers a safer and quicker return-to-work timeline while yielding comparable functional outcomes.
•The primary disadvantage of percutaneous repair is an increased rate of sural nerve injury.
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Background
The purpose of this study is to highlight the differences in functional outcomes and complication rates between percutaneous and open repair of Achilles tendon ruptures.
Methods
A comprehensive database search of PubMed, Cochrane, Google Scholar, and MEDLINE was implemented to find literature that compared the two techniques up from 2000 until 2022. Inclusion criteria included randomized controlled trials and retrospective/prospective comparison studies of two types of techniques. Primary measurements of interest included functional outcome scores, time to return to work, and complication rates.
Results
12 comparative papers were selected for analysis. A total of 1047 ankles were included with 496 of them being the percutaneous technique and 551 the open technique. Percutaneous repair was found to be associated with a statistically significant increase in sural nerve injury occurrences and an earlier time to return to work. Open repair was linked to a statistically significant increase in delayed wound healing and wound infection. Differences in AOFAS function scores were found to be statistically insignificant between the two groups.
Conclusions
Although there is an increased risk of sural nerve injury, the percutaneous repair technique is still the most desirable method in repairing Achilles tendon ruptures injury as it is associated with similar functional outcome, an earlier time to return to work, and a lower rate of wound infection and breakdown.
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NewsBot · Nov 11, 2024

Recent developments in Achilles tendon risk-analyzing rupture factors for enhanced injury prevention and clinical guidance: Current implications of regenerative medicine
Maria V. Sankova, et al
Journal of Orthopaedic Translation Volume 49, November 2024, Pages 289-307

Background
In recent years, many countries have actively implemented programs and strategies to promote physical education and sports. Despite these efforts, the increase in physical activity has been accompanied by a significant rise in muscle and tendon-ligament injuries, with Achilles tendon rupture being the most prevalent, accounting for 47 % of such injuries. This review aims to summarize all significant factors determining the predisposition of the Achilles tendon to rupture, to develop effective personalized prevention measures.
Objective
To identify and evaluate the risk factors contributing to Achilles tendon rupture and to develop strategies for personalized prevention.
Methods
This review utilized data from several databases, including Elsevier, Global Health, PubMed-NCBI, Embase, Medline, Scopus, ResearchGate, RSCI, Cochrane Library, Google Scholar, eLibrary.ru, and CyberLeninka. Both non-modifiable and modifiable risk factors for Achilles tendon injuries and ruptures were analyzed.
Results
The analysis identified several non-modifiable risk factors, such as genetic predisposition, anatomical and functional features of the Achilles tendon, sex, and age. These factors should be considered when selecting sports activities and designing training programs. Modifiable risk factors included imbalanced nutrition, improper exercise regimens, and inadequate monitoring of Achilles tendon conditions in athletes. Early treatment of musculoskeletal injuries, Achilles tendon diseases, foot deformities, and metabolic disorders is crucial. Long-term drug use and its risk assessment were also highlighted as important considerations. Furthermore, recent clinical advancements in both conventional and surgical methods to treat Achilles tendon injuries were described. The efficacy of these therapies in enhancing functional outcomes in individuals with Achilles injuries was compared. Advancements in cell-based and scaffold-based therapies aimed at enhancing cell regeneration and repairing Achilles injuries were also discussed.
Discussion
The combination of several established factors significantly increases the risk of Achilles tendon rupture. Addressing these factors through personalized prevention strategies can effectively reduce the incidence of these injuries. Proper nutrition, regular monitoring, timely treatment, and the correction of metabolic disorders are essential components of a comprehensive prevention plan.
Conclusion
Early identification of Achilles tendon risk factors allows for the timely development of effective personalized prevention strategies. These measures can contribute significantly to public health preservation by reducing the incidence of Achilles tendon ruptures associated with physical activity and sports. Continued research and clinical advancements in treatment methods will further enhance the ability to prevent and manage Achilles tendon injuries.
The translational potential of this article
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This study identifies key modifiable and non-modifiable risk factors for Achilles tendon injuries, paving the way for personalized prevention strategies. Emphasizing nutrition, exercise, and early treatment of musculoskeletal issues, along with advancements in cell-based therapies, offers promising avenues for improving recovery and outcomes. These findings can guide clinical practices in prevention and rehabilitation, ultimately reducing Achilles injuries and enhancing public health.

NewsBot · Nov 11, 2024

Surgical versus nonoperative treatment for acute Achilles' tendon rupture:A meta-analysis
Source

Background:Acute Achilles tendon rupture(AATR) is common among young individuals.There are various management options available, including conservative treatment, open surgical repair, and minimally invasive treatments. However, the optimal treatment approach remains controversial.Purpose:In this study, we conducted a thorough analysis of the existing literature to compare the clinical outcomes of surgical and nonoperative treatments for patients with AATR by conducting a meta-analysis of randomized controlled trials.Study Design:Meta analysis; Level of evidence, 1.Methods:Eligible trials randomly assigned adults with AATR to surgical or conservative treatment and assessed by three independent reviewers.We searched in PubMed, Embase,and The Cochrane Library.The assessment of risk of bias was conducted by entering the data from each included study into the Revman computer program.Extracted data were meta-analyzed.Heterogeneity was evaluated using the I2 test. Pooled results were expressed as odds ratios, risk ratios(OR), and mean differences(MD).Results:The meta-analysis included a total of 14 studies and 1399 patients, with 696 patients receiving surgical intervention and 703 patients undergoing non-surgical treatment. The follow-up duration ranged from 12 to 30 months.The surgical group was found to have a significantly lower re-rupture rate (OR 0.30, 95% CI 0.18-0.54; P < 0.00001), but also had a higher risk of other complications(OR 3.28, 95% CI 1.56-6.93, P = 0.002). The surgical group also had significantly abnormal calf (OR 0.45, 95% CI 0.26-0.76, P = 0.03). There was no statistically significant difference between the two groups in terms of returning to sports, ATRS , abnormal motion of foot and ankle,unable heel-rise,and torque for plantar flexion.The meta-analysis results indicate that surgical intervention for AATR is associated with a lower re-rupture rate, but a higher risk of other complications.Our assessment of life-quality and functional outcomes also suggests that surgery leads to significantly better outcomes in terms of sick leave, abnormal calf, and torque for plantar flexion. Based on these findings, we recommend that surgery is a preferable option for patients who have a higher risk of re-rupture and require a quick rehabilitation.
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NewsBot · Nov 11, 2024

Peritendinous Submembrane Access Technique for Management of Acute Ruptures of the Achilles Tendon: A Retrospective Study of 249 Cases
Xin Huang et al
Orthop Surg. 2024 Jul;16(7):1648-1656

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.
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NewsBot · Nov 13, 2024

Current Update in Achilles Tendon Rupture Management: Operative or Nonoperative?
Farrell Hartoyo et al
Source

The Achilles tendon is the most commonly ruptured tendon in the foot and ankle region. The peak incidence of Achilles tendon rupture occurs in the age range of 30-49 years, with a higher prevalence among males. Various risk factors, including aging, obesity, episodic athletic activity, engagement in high-impact sports, antibiotic use, and systemic factors, contribute to the occurrence of Achilles tendon rupture. Beyond the injury mechanism, it is crucial to assess any history of minor or repetitive trauma to the Achilles tendon and identify associated risk factors. Thorough examination and comparison of both the affected and unaffected sides are essential. While the diagnosis of Achilles Tendon Rupture is primarily clinical, radiological imaging can aid in visualizing the tendon gap. Treatment options for Achilles tendon rupture include conservative and surgical approaches. Despite a lower re-rupture rate associated with surgical treatment, recent evidence suggests that conservative treatment provides comparable results. However, return to activity was found to be better in surgical treatment with early rehabilitation
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NewsBot · Nov 14, 2024

Prevalence and risk factors for Achilles tendon rupture in the military population from 2006 to 2015: a retrospective cohort study
John J Fraser et al
BMJ Mil Health. 2024 Nov 12:e002759

Introduction: Achilles tendon rupture (ATR) is a serious musculoskeletal injury that results in substantial functional decline, especially in highly physically demanding occupations such as service in the military. The purpose of this retrospective cohort study was to evaluate the prevalence and associated factors of ATR in US military service members.

Methods: The Defence Medical Epidemiology Database was used to identify all diagnosed ATR in military personnel from 2006 to 2015. The prevalence of ATR was calculated and compared by year, service branch and military rank. Unadjusted and adjusted assessments of risk were calculated.

Results: Officers incurred 15 978 episodes at a prevalence of 7.43/1000 (male: 8.11/1000; female: 3.89/1000). Among enlisted personnel, there were 59 242 episodes of ATR that occurred at a prevalence of 6.23 episodes per 1000 (male enlisted: 6.49/1000; female enlisted: 4.48/1000). Apart from enlisted aviation specialists (where there was no significant difference in risk between men and women), both female officers and enlisted service members had significantly lower risk of ATR compared with their male counterparts in all occupations (prevalence ratio (PR): 0.26-0.73). Aviation and service officers demonstrated significantly lower risk of ATR episodes (PR: 0.87-0.91) and administration, operations, intelligence and logistic officers demonstrated increased risk (PR: 1.16-1.31) compared with ground and naval gunfire officers. Among enlisted specialties, all but mechanised/armour and combat engineers had significantly higher risk of ATR risk compared with infantry (PR: 1.14-2.13), with the highest risk observed in the administration, intelligence and communication fields.

Conclusions: ATR was ubiquitous in the US military, with multiple risk factors identified, including male sex, older age, rank, military occupation and service branch. These findings highlight the populations that can most greatly benefit from preventive screening and care.
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NewsBot · Nov 15, 2024

Percutaneous repair of achilles tendon ruptures: short-term results of 41 patients
İbrahim Bozkurt
Source

Aims: Despite the current popularity of surgical treatment of Achilles tendon ruptures, there is no clear consensus about which technique should be applied. The aim of this study is to evaluate the short- to mid-term results of acute Achilles tendon ruptures treated with the percutaneous method and to discuss these results in light of the literature.
Methods: In this study, 41 patients who were operated on percutaneously with the diagnosis of acute Achilles tendon rupture between 2016 and 2019, whose treatment was completed, and who had a follow-up period of at least 1 year were included. At the patients’ final follow-up visits, the range of motion of the ankle joint, time to return to work and sports, and complications were evaluated. For functional evaluations, the scoring system of the American Orthopaedic Foot & Ankle Society (AOFAS) for the ankle joint was used.
Results: The mean age of the patients was 29.3 (18-50) years and the mean follow-up duration was 23 (12-38) months. The mean dorsiflexion angle was 32.27° (20-45°) and the mean plantar flexion angle was 34.58° (20-45°). The time to return to work was 14.2 (8-21) weeks, while time to return to sports was 30.4 (17-49) weeks. The mean AOFAS score of the patients was 91.63 (74-100). The complications included infection in 2 (4.8%) patients, wound necrosis in 1 (2.4%) patient, re-rupture in 1 (2.4%) patient, and sural nerve neuropraxia in 1 (2.4%) patient.
Conclusion: The findings of this study suggest that percutaneous repair is an effective method in the treatment of acute Achilles tendon ruptures, like other surgical methods that offer good functional results with low complication rates.
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NewsBot · Nov 16, 2024

No detectable loss of myonuclei from human muscle fibers after six weeks of immobilization following an Achilles tendon rupture
Oscar Horwath et al
Am J Physiol Cell Physiol. 2024 Nov 15

Muscle disuse has rapid and debilitating effects on muscle mass and overall health, making it an important issue from both scientific and clinical perspectives. However, the myocellular adaptations to muscle disuse are not yet fully understood, particularly those related to the myonuclear permanence hypothesis. Therefore, in this study, we assessed fiber size, number of myonuclei, satellite cells, and capillaries in human gastrocnemius muscle after a period of immobilization following an Achilles tendon rupture. Six physically active patients (5M/1F, 43 {plus minus} 15 years) were recruited to participate after sustaining an acute unilateral Achilles tendon rupture. Muscle biopsies were obtained from the lateral part of the gastrocnemius before and after six weeks of immobilization using a plaster cast and orthosis. Muscle fiber characteristics were analyzed in tissue cross-sections and isolated single fibers using immunofluorescence and high-resolution microscopy. Immobilization did not change muscle fiber type composition nor cross-sectional area of type I or type II fibers, but muscle fiber volume tended to decline by 13% (p=0.077). After immobilization, the volume per myonucleus was significantly reduced by 20% (p=0.008). Myonuclei were not lost in response to immobilization but tended to increase in single fibers and type II fibers. No significant changes were observed for satellite cells or capillaries. Myonuclei were not lost in the gastrocnemius muscle after a prolonged period of immobilization, which may provide support to the myonuclear permanence hypothesis in human muscle. Capillaries remained stable throughout the immobilization period, whereas the response was variable for satellite cells, particularly in type II fibers.
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NewsBot · Nov 17, 2024

Economic and Performance Analysis of
Achilles Tendon Rupture in the National
Basketball Association
Kristopher Meadows et al
Source

Background: Achilles tendon ruptures are common and potentially career-ending injuries for National Basketball Association
(NBA) players. Many studies have reviewed the impact of Achilles tendon ruptures on return to play (RTP) and performance,
but there are no studies on their economic significance.
Purpose/Hypothesis: This study aimed to analyze the economic and performance consequences of Achilles tendon ruptures
usingthe cost of recovery (COR) for NBA franchises as well as preinjury salary/career success. It was hypothesized that players
with higher preinjury salaries or performance would have an increased COR, higher rates of RTP, and more career success after
their injury.
Study Design: Descriptive epidemiology study.
Methods: Publicly available data of NBA players who sustained an Achilles tendon rupture between 1990 and 2023 were analyzed. Data were retrospectively gathered by R software code to include players’ ages, positions, salaries, pre- and postinjury
player efficiency rating, time missed after injury, and RTP. Performance impact was measured by advanced statistics: player efficiency rating, Win Shares per 48 Minutes, and Value Over Replacement Player. Two groups of 3 cohorts were created: All-Star,
Starter, and Reserve versus group A (\$3,999,999), group B ($3,999,999 to $8,999,999), and group C (.$8,999,999). Analysis
of variance with post hoc Tukey tests for continuous data and Fisher exact tests for categorical data was used. Significance levels
were set at P \ .05.
Results: A total of 37 players met the inclusion criteria and played between the years of 1992 through 2019. The mean COR that
NBA teams faced was $4 million per player. The cumulative economic loss from Achilles tendon ruptures in the NBA between
1992 and 2019 was $117,578,851. Overall RTP was 78.38%, and 31.03% of players who returned to play were out of the
NBA within 3 years. RTP to the highest playing level was highest in group B (45.5%), followed by group A (40%) then group C
(12.5%). The COR of All-Star players, Starter players, and Reserve players averaged $5.7 million, $3.4 million, and $3 million,
respectively.
Conclusion: This study investigated the financial and performance implications of Achilles tendon ruptures among NBA athletes.
Most players struggled to restore their preinjury performance, except for Reserve players. The findings provide valuable insights
into the complexities of COR and postinjury performance.
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NewsBot · Nov 17, 2024

Prevalence and risk factors for Achilles tendon rupture in the military population from 2006 to 2015: a retrospective cohort study
John J Fraser et al
Source

Introduction Achilles tendon rupture (ATR) is a serious musculoskeletal injury that results in substantial functional decline, especially in highly physically demanding occupations such as service in the military. The purpose of this retrospective cohort study was to evaluate the prevalence and associated factors of ATR in US military service members.

Methods The Defence Medical Epidemiology Database was used to identify all diagnosed ATR in military personnel from 2006 to 2015. The prevalence of ATR was calculated and compared by year, service branch and military rank. Unadjusted and adjusted assessments of risk were calculated.

Results Officers incurred 15 978 episodes at a prevalence of 7.43/1000 (male: 8.11/1000; female: 3.89/1000). Among enlisted personnel, there were 59 242 episodes of ATR that occurred at a prevalence of 6.23 episodes per 1000 (male enlisted: 6.49/1000; female enlisted: 4.48/1000). Apart from enlisted aviation specialists (where there was no significant difference in risk between men and women), both female officers and enlisted service members had significantly lower risk of ATR compared with their male counterparts in all occupations (prevalence ratio (PR): 0.26–0.73). Aviation and service officers demonstrated significantly lower risk of ATR episodes (PR: 0.87–0.91) and administration, operations, intelligence and logistic officers demonstrated increased risk (PR: 1.16–1.31) compared with ground and naval gunfire officers. Among enlisted specialties, all but mechanised/armour and combat engineers had significantly higher risk of ATR risk compared with infantry (PR: 1.14–2.13), with the highest risk observed in the administration, intelligence and communication fields.

Conclusions ATR was ubiquitous in the US military, with multiple risk factors identified, including male sex, older age, rank, military occupation and service branch. These findings highlight the populations that can most greatly benefit from preventive screening and care.
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NewsBot · Nov 17, 2024

Long-term patient outcome is affected by deep venous thrombosis after Achilles tendon rupture repair
Susanna Aufwerber, Simon Svedman, Karin Grävare Silbernagel, Paul W. Ackermann
26 May 2024

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.
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NewsBot · Nov 19, 2024

Recent developments in Achilles tendon risk-analyzing rupture factors for enhanced injury prevention and clinical guidance: Current implications of regenerative medicine
Maria V Sankova et al
J Orthop Translat. 2024 Nov 4:49:289-307

Background: In recent years, many countries have actively implemented programs and strategies to promote physical education and sports. Despite these efforts, the increase in physical activity has been accompanied by a significant rise in muscle and tendon-ligament injuries, with Achilles tendon rupture being the most prevalent, accounting for 47 % of such injuries. This review aims to summarize all significant factors determining the predisposition of the Achilles tendon to rupture, to develop effective personalized prevention measures.

Objective: To identify and evaluate the risk factors contributing to Achilles tendon rupture and to develop strategies for personalized prevention.

Methods: This review utilized data from several databases, including Elsevier, Global Health, PubMed-NCBI, Embase, Medline, Scopus, ResearchGate, RSCI, Cochrane Library, Google Scholar, eLibrary.ru, and CyberLeninka. Both non-modifiable and modifiable risk factors for Achilles tendon injuries and ruptures were analyzed.

Results: The analysis identified several non-modifiable risk factors, such as genetic predisposition, anatomical and functional features of the Achilles tendon, sex, and age. These factors should be considered when selecting sports activities and designing training programs. Modifiable risk factors included imbalanced nutrition, improper exercise regimens, and inadequate monitoring of Achilles tendon conditions in athletes. Early treatment of musculoskeletal injuries, Achilles tendon diseases, foot deformities, and metabolic disorders is crucial. Long-term drug use and its risk assessment were also highlighted as important considerations. Furthermore, recent clinical advancements in both conventional and surgical methods to treat Achilles tendon injuries were described. The efficacy of these therapies in enhancing functional outcomes in individuals with Achilles injuries was compared. Advancements in cell-based and scaffold-based therapies aimed at enhancing cell regeneration and repairing Achilles injuries were also discussed.

Discussion: The combination of several established factors significantly increases the risk of Achilles tendon rupture. Addressing these factors through personalized prevention strategies can effectively reduce the incidence of these injuries. Proper nutrition, regular monitoring, timely treatment, and the correction of metabolic disorders are essential components of a comprehensive prevention plan.

Conclusion: Early identification of Achilles tendon risk factors allows for the timely development of effective personalized prevention strategies. These measures can contribute significantly to public health preservation by reducing the incidence of Achilles tendon ruptures associated with physical activity and sports. Continued research and clinical advancements in treatment methods will further enhance the ability to prevent and manage Achilles tendon injuries.

The translational potential of this article: This study identifies key modifiable and non-modifiable risk factors for Achilles tendon injuries, paving the way for personalized prevention strategies. Emphasizing nutrition, exercise, and early treatment of musculoskeletal issues, along with advancements in cell-based therapies, offers promising avenues for improving recovery and outcomes. These findings can guide clinical practices in prevention and rehabilitation, ultimately reducing Achilles injuries and enhancing public health.
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NewsBot · Nov 23, 2024

Long-term muscular performance and functional outcomes following Achilles tendon rupture: A systematic review of surgical vs non-surgical management
K. Moss et al
Source

Purpose: Achilles tendons are the most ruptured tendon with incidences of up to 31.17 per 100,000 person-years, resulting in long-term impairments. Traditionally, surgical repair has been associated with lower re-rupture rates but greater costs and risk of surgical complications, when compared to non-surgical treatment. However, recent research suggests equivalent re-rupture rates when non-surgical treatment is combined with accelerated rehabilitation. With fewer risks and costs, a growing number of health services are transitioning to non-surgical, therapist-led pathways. However, no systematic review has evaluated the long-term functional and muscular performance outcomes following surgical and non-surgical treatment, to date. Therefore, the aim of this systematic review was to determine the long-term functional and muscle performance outcomes following surgical and non-surgical management of Achilles tendon rupture (ATR).
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NewsBot · Nov 26, 2024

Incidence, demographics, characteristics and management of acute Achilles tendon rupture: An epidemiological study
Samuel Briggs-Price ,Jitendra Mangwani,Linzy Houchen-Wolloff,Gayatri Modha,Emma Fitzpatrick,Murtaza Faizi,Jenna Shepherd,Seth O’Neill
June 21, 2024

Background
Achilles tendon rupture (ATR) account for 10.7% of all tendon and ligament injuries and causes lasting muscular deficits and have a profound impact on patients’ quality of life. The incidence, characteristics and management of ATR in the United Kingdom (UK) is poorly understood. This investigation aims to understand the incidence of ATR in the UK.

Methods
Prospective data collection of ATR incidence from a United Kingdom Emergency department. Retrospective review of management protocols and immobilisation duration from electronic medical records.

Results
ATR incidence is 8 per 100,000 people per annum. Participants were predominately male (79.2%) and primarily reported a sporting mechanism of injury (65.2%). Mean immobilisation duration was 63.1 days. 97.1% were non-surgically managed post ATR. 46.2% of participants had experienced a previous ATR or Achilles tendinopathy prior to their current ATR.

Conclusion
The incidence of ATR found was 8. cases per 100,000 people per annum. Most ATR were managed non-surgically in this cohort. The majority of ruptures occurred during sporting activity. Almost one quarter (23.3%) of individuals report Achilles pain prior to ATR.
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NewsBot · Nov 27, 2024

Direct Anatomical Reconstruction of the Achilles Tendon and Its Application for Surgical Treatment of Acute Achilles Tendon Ruptures
Alessandro Pisano andGaetano Caruso et al
Surg. Tech. Dev. 2024, 13(4), 382-392; https://doi.org/10.3390/std13040030

Background/Objectives: Acute ruptures of the Achilles Tendon (AT) are common injuries in the active population, in particular among men aged 30 to 50. Full functional recovery after this kind of injury is long and challenging and nowadays there is no universal “gold standard” strategy when dealing with them. Methods: When it comes to surgical treatment, various techniques have been described: in case of a typical lesion at the midportion of the tendon (which is the most common type), the basic principle of surgical repair is the end-to-end suture of the tendon stumps. The AT (“calcaneal tendon” according to the International Anatomical Terminology) is the strongest tendon of the human body, it is the conjunct tendon of the two Gastrocnemii Muscles and the Soleus Muscle and has a well-recognizable twisted structure: the subtendon from the Medial Head of the Gastrocnemius attaches postero-laterally on the calcaneal tendon footprint, the subtendon from the Lateral Head of the Gastrocnemius attaches antero-laterally and the subtendon from the Soleus attaches medially, therefore creating a 90° twist of the tendon structure. Results: the twisted structure of the human AT is of central importance to its biomechanics, since it gives the tendon a higher resistance to deformation and concurs in supination of the subtalar joint during gait. Conclusions: given the abovementioned anatomical and biomechanical premises, we believe that the restoration of the subtendons anatomy can lead to a better functional recovery of the Triceps Surae—Achilles Tendon complex, therefore we recently decided to adopt for open surgical repair the Direct Anatomical Reconstruction of the Achilles Tendon, which we describe in the present article.
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NewsBot · Nov 28, 2024

Neuromechanical adaptations in the gastrocnemius muscle after Achilles tendon rupture during walking
Raad M. Khair et al
Journal of Electromyography and Kinesiology
Volume 80, February 2025

Although some Achilles tendon rupture (ATR) patients regain function in low-force levels activities, it is not yet well known how neuromuscular and structural alterations after ATR manifest during everyday-locomotion. This study assessed medial gastrocnemius (MG) fascicle shortening during walking 1-year after ATR. Additionally, we explored neuromuscular alterations in lateral gastrocnemius (LG), soleus and flexor hallucis longus (FHL) muscles.
We observed 3.1 pp (95 %CI 0.8–5.4 pp) higher average and 14.5 pp (95 %CI 0.5–28.5 pp) higher peak LG surface electromyography amplitude in the injured compared to the un-injured during walking, but no differences were observed in soleus or FHL. The injured limb fascicles were 12.9 mm shorter while standing compared to the un-injured limb. In absolute terms, MG shortening in the injured limb was 2.8 mm (95 %CI 0.96–4.6 mm) smaller compared to the un-injured limb. However, when normalized to standing fascicle length, the amount of shortening was not different between the limbs.
Our results showed that 1-year after ATR, MG muscle had remodelled, which manifested as shorter fascicle length during standing. During walking, injured and un-injured MG fascicles showed similar shortening relative to the standing fascicle length, suggesting that MG could function effectively at the new mechanical settings during everyday locomotion.
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NewsBot · Nov 29, 2024

iTRAQ-Based Proteomic Analysis of Spontaneous Achilles Tendon Rupture
Bayixiati Qianman et al
J Proteome Res. 2024 Nov 27

Spontaneous Achilles tendon rupture (SATR) predominantly affects middle-aged and elderly individuals with chronic injuries. However, the exact cause and mechanism of SATR remain elusive, and potential therapeutic intervention or prevention is still insufficient. The present study aimed to uncover the key pathological molecules by using iTRAQ proteomics. The results identified 2432 candidate proteins in SATR patients using iTRAQ proteomic analysis. A total of 307 differentially expressed proteins (DEPs) were identified and linked to 211 KEGG signaling pathways including Coronavirus disease (COVID-19), focal adhesion, and ribosomes. GO enrichment analysis highlighted significant enrichment in processes such as biological adhesion, ossification, lipid (APOA4) processes, and extracellular matrix (ECM) organization (collagen). PPI network analysis identified hub genes such as serum albumin (ALB), fibronectin (FN1), and actin cytoplasmic 1. The WB analysis confirmed that FN1 and the receptor for activated C kinase (RACK1) were downregulated in the SATR tendon. Immunohistochemical staining revealed that collagen I and III were suppressed, while collagen II and APOA4 expression were higher in the SATR pathological tissue (P < 0.05). However, the primary cultured tenocytes (PCTs) from SATR patients showed enhanced proliferation and, consistent with tissue staining, reduced collagen I and III and increased collagen II. Our findings reveal vital targets and pathways in SATR's etiological progression, offering a new perspective on the diagnosis, treatment, and prognosis of this complex disorder.
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NewsBot · Dec 3, 2024 at 7:52 PM

Long-term effects of functional recovery based on emergency and late repair with Achilles tendon rupture: A retrospective study
Hyunsik Chu, Yongchul Choi et al
Source

Background
Repair for total Achilles tendon ruptures is sometimes delayed, despite the recommendation for early repair.
Objective
To investigate patient recovery scores, and ankle strength and function according to the timing of Achilles tendon rupture repair.
Methods
We conducted a retrospective analysis by categorizing repair: emergency (ER, n = 38), late (LR, n = 16), and very late (VLR, n = 13). Patients were evaluated based on the Achilles Tendon Total Rupture Score (ATRS), dorsiflexion range of motion, ankle strength, hop tests, and balance.
Results
All groups showed consistent improvement in the ATRS, heel-raise, plantarflexion strength, hop tests, and balance up to 6 and 9 months post-surgery. At 3 months, the ER and LR groups had significantly better values in the ATRS, heel raise, plantarflexion strength, and single-hop test compared with the VLR group (p < 0.05); by 12 months, there were no significant between-group differences (p > 0.05). The ER group outperformed the VLR group in the crossover hop test, and in posteromedial and lateral balance at 12 months (p < 0.05).
Conclusion
Twelve months after Achilles tendon rupture repair, VLR induced similar improvement in the ATRS, and ankle strength and function compared to ER and LR. Therefore, despite being very late, the repair was significantly effective in improving ankle function.
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NewsBot · Dec 4, 2024 at 7:54 PM

Traction Sural Neuropathy Following
Nonoperative Management of Acute Achilles
Tendon Rupture: A Case Report
Katherine J. Kim , Isabella V. Cuturrufo , Kenneth Vitale
Source

Achilles tendon ruptures are prevalent among physically active adults and can lead to sural nerve injuries
(SNIs) due to the anatomical proximity of the sural nerve to the Achilles tendon. While SNIs are wellrecognized in surgical contexts, their occurrence following nonoperative treatments, which are often
preferred for their lower risk of surgical complications, remains less documented and poorly understood.
This report describes a case of a 30-year-old active male who developed chronic traction sural neuropathy
after opting for nonoperative treatment of an acute complete Achilles tendon rupture. Despite adhering to a
rehabilitation protocol, he experienced persistent symptoms of sural nerve damage, which were confirmed
as chronic sensory neuropathy through nerve conduction studies. Here, we discuss the proposed
pathophysiology and review the literature on SNIs in Achilles injuries. This case highlights the importance
for clinicians to accurately diagnose and remain aware of the potential for SNIs in the nonoperative
management of Achilles tendon ruptures.
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NewsBot · Dec 7, 2024 at 10:50 PM

Surgical vs. nonoperative treatment for acute Achilles' tendon rupture: a meta-analysis of randomized controlled trials
Lei Fan et al
Front Surg. 2024 Nov 21:11:1483584

Background: Acute Achilles tendon rupture (AATR) is common among young individuals. There are various management options available, including conservative treatment, open surgical repair, and minimally invasive treatments. However, the optimal treatment approach remains controversial.

Purpose: In this study, we conducted a thorough analysis of the existing literature to compare the clinical outcomes of surgical and nonoperative treatments for patients with AATR by conducting a meta-analysis of randomized controlled trials.

Study design: Meta analysis; Level of evidence, 1.

Methods: Eligible trials randomly assigned adults with AATR to surgical or conservative treatment and assessed by three independent reviewers. We searched in PubMed, Embase, and The Cochrane Library. The assessment of risk of bias was conducted by entering the data from each included study into the Revman computer program. Extracted data were meta-analyzed. Heterogeneity was evaluated using the I2 test. Pooled results were expressed as odds ratios, risk ratios (OR), and mean differences (MD).

Results: The meta-analysis included a total of 14 studies and 1,399 patients, with 696 patients receiving surgical intervention and 703 patients undergoing non-surgical treatment. The follow- up duration ranged from 12 to 30 months. The surgical group was found to have a significantly lower re-rupture rate (OR: 0.30, 95% CI: 0.18-0.54; P < 0.00001), but also had a higher risk of other complications (OR: 3.28, 95% CI: 1.56-6.93, P = 0.002). The surgical group also had significantly abnormal calf (OR: 0.45, 95% CI: 0.26-0.76, P = 0.03). There was no statistically significant difference between the two groups in terms of returning to sports, ATRS, abnormal motion of foot and ankle, unable heel-rise, and torque for plantar flexion.

Conclusion: The meta-analysis results indicate that surgical intervention for AATR is associated with a lower re-rupture rate, but a higher risk of other complications. Our assessment of life-quality and functional outcomes also suggests that surgery leads to significantly better outcomes in terms of sick leave, abnormal calf, and torque for plantar flexion. Based on these findings, we recommend that surgery is a preferable option for patients who have a higher risk of re-rupture and require a quick rehabilitation.
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Achilles tendon rupture

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Depression folowing surgery for an achilles tendon rupture

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Past ruptured achilles tendon

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The most frequent heel lift height to treat Achilles tendonitis

Testosterone replacement therapy is associated with increased odds of Achilles tendon injury

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Achilles tendon rupture

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Depression folowing surgery for an achilles tendon rupture

Are bacteria involved in achilles tendon ruptures?

Past ruptured achilles tendon

Achilles Tendon rupture and Plantar Fasciitis

The most frequent heel lift height to treat Achilles tendonitis

Testosterone replacement therapy is associated with increased odds of Achilles tendon injury

Achilles Tendon and Femoral Cartilage Thickness in Flatfoot

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