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Dynamic Ultrasound Assessment of the Effects of Knee and Ankle Position on Achilles Tendon Apposition Following Acute Rupture
Assad A. Qureshi, MSc, MRCS1; Talal Ibrahim, MD, FRCS(Tr&Orth)2; Winston J. Rennie, MSc, FRCR2; Andrew Furlong, FRCS(Tr&Orth)2
1 Division of Orthopaedic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, United Kingdom. E-mail address: qureshi123@doctors.org.uk
2 Division of Orthopaedic Surgery (T.I.), Department of Radiology (W.J.R.), and Department of Orthopaedic Surgery (A.F.), Leicester Royal Infirmary, Leicester LE1 5WW, United Kingdom
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at Leicester Royal Infirmary, Leicester, United Kingdom

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Dec 21;93(24):2265-2270. doi: 10.2106/JBJS.J.01757
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Abstract

Background: 

Previous reports have suggested that knee flexion improves tendon edge apposition following acute rupture of the Achilles tendon. The aim of the present study was to determine, with use of ultrasonography, the effects of knee and ankle position on the Achilles tendon gap distance in patients with an acute rupture.

Methods: 

Twenty-six patients with a unilateral acute complete Achilles tendon rupture that had been confirmed with ultrasonography were recruited within a week after the injury. The mean age at the time of presentation was forty-one years. Ultrasound measurements included the location of the rupture and the gap distance between the superficial tendon edges with the ankle in neutral and the knee extended. The gap distance was sequentially measured with the foot in maximum equinus at the ankle and with 0°, 30°, 60°, and 90° of knee flexion.

Results: 

The mean distance of the rupture from the calcaneal enthesis was 52 mm (range, 40 to 76 mm). The mean gap distance with the ankle in neutral and the knee extended was 12 mm (95% confidence interval, 10 to 13 mm). This distance decreased to 5 mm (95% confidence interval, 4 to 7 mm) when the foot was placed in maximum ankle equinus with 0° of knee flexion and to 4 mm (95% confidence interval, 3 to 5 mm) with 30° of knee flexion, 3 mm (95% confidence interval, 2 to 4 mm) with 60° of knee flexion, and 2 mm (95% confidence interval, 1 to 2 mm) with 90° of knee flexion. Expressing the reduction in gap distance with each successive position as a percentage of the gap distance with the knee extended and the ankle in neutral revealed a mean reduction of 55.7%, 64.4%, 75.4%, and 84.8% with maximum ankle equinus and 0°, 30°, 60°, and 90° of knee flexion, respectively. The difference in gap distance between each of these positions was significant (p < 0.05).

Conclusions: 

Maximum ankle equinus alone significantly reduces the gap distance after acute Achilles tendon rupture. Increasing knee flexion further reduces the gap distance by small increments that, although significant, may not be clinically important.

Clinical Relevance: 

These findings may play an important role in the closed treatment of acute rupture of the Achilles tendon.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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