Journal of Foot and Ankle Surgery (Asia Pacific)

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2022 | January-March | Volume 9 | Issue 1

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Managing Tendon Problems in the Foot and Ankle

[Year:2022] [Month:January-March] [Volume:9] [Number:1] [Pages:1] [Pages No:1 - 1]

   DOI: 10.5005/jp-journals-10040-1202  |  Open Access |  How to cite  | 


Original Article

Rocco Aicale, Annarita Fraccascia, Nicola Poeta, Nicola Maffulli

Minimally Invasive Stripping for Achilles Tendon: A Novel Option to Treat the Tendinopathy of the Main Body

[Year:2022] [Month:January-March] [Volume:9] [Number:1] [Pages:4] [Pages No:2 - 5]

Keywords: Achilles tendinopathy, Ankle joint, Minimally invasive, Stripping

   DOI: 10.5005/jp-journals-10040-1189  |  Open Access |  How to cite  | 


Achilles tendinopathy (AT) is commonly defined as failed healing response characterized by an increase in noncollagenous matrix and proliferation of altered tenocytes and degradation of collagen fibers. Diagnosis is made by clinical evaluation, and magnetic resonance imaging (MRI) or ultrasonography (US) imaging is used for differential diagnosis or is not a clear case. The first line of management is conservative, while open or minimally invasive techniques are considered in the second line. Generally, after 6 months of nonoperative management, surgery is indicated. Minimally invasive stripping of the Achilles tendon in case of tendinopathy of the main body is effective, inexpensive, and technically simple. However, randomized controlled trials (RCTs) with a control group and more patients are needed to confirm clinical outcomes.


Original Article

Keith Hay-Man Wan, Michael Siu-Hei Tse, Irene Oi-Lam Lo, Simon Chi-Pan Yuen, Richard Hin-Lun Lee, Kam-Kwong Wong

Retrospective Comparative Study between Open and Modified Ultrasound-guided Percutaneous Achilles Tendon Repair

[Year:2022] [Month:January-March] [Volume:9] [Number:1] [Pages:5] [Pages No:7 - 11]

Keywords: Achilles tendon repair, Foot and ankle surgery, Minimal invasive, Surgical technique

   DOI: 10.5005/jp-journals-10040-1178  |  Open Access |  How to cite  | 


Introduction: To compare the outcomes between the percutaneous repair technique of the Achilles tendon rupture with the open repair technique. Materials and methods: A retrospective review of patients with complete Achilles tendon rupture managed surgically in our institution from January 2015 to June 2019. Group I consisted of patients managed with the percutaneous repair technique. Group II consisted of patients managed with the open technique. Clinical outcomes including re-rupture, wound infection, and pain control were compared. Results: Fifty-two patients were included in the study with 22 patients allocated into group I and 30 patients allocated to group II. The mean age of group I was 41.2 (range 21–78, SD 16.097). The mean follow-up time was 38.4 months (range 14–55 months, SDV 12.738). The mean age of group II was 48.8 (range 27–80, SDV 14.938). At postoperative 1 year, there was no statistical difference in the range of motion. Among the patients in group I, the mean numeral pain rating scale (NPRS) was statistically lower than that of the patients in group II. There was no wound infection, sural nerve injury, or re-rupture in group I. Two patients in group II developed postoperative wound infection. One of them had been complicated with the re-rupture of the repaired Achilles tendon. Conclusion: The percutaneous repair technique is a reasonable treatment option for ruptured Achilles tendon, with a satisfactory medium-term outcome comparable, if not better, than the traditional open repair technique.


Original Article

Gideon JW Cheok, Kevin Koo

Minimally Invasive Achilles Tendon Repair Confers Faster Recovery and Reduced Complications Compared to Open Achilles Tendon Repair

[Year:2022] [Month:January-March] [Volume:9] [Number:1] [Pages:6] [Pages No:10 - 15]

Keywords: Achilles tendon repair, Foot and ankle, Functional outcomes, Minimally invasive

   DOI: 10.5005/jp-journals-10040-1190  |  Open Access |  How to cite  | 


Current literature shows that minimally invasive (MIS) tendo-Achilles (TA) repairs carry a lower risk of infection compared to open repairs. Our study aimed to assess whether MIS TA repair also contributed to improved patient outcomes as well as lowered infection and wound complication rates. Between January 2017 and December 2019, 19 patients underwent minimally invasive TA repairs performed by two fellowship-trained foot and ankle surgeons at a tertiary institution. A retrospective review of registry data was performed. Outcomes were measured to include AOFAS Score, RAND36 Scores as well as patient-reported satisfaction scores and visual analog scale (VAS) for pain assessment. Statistical analysis was performed using a Student's t-test for continuous variables and Pearson's Chi-squared test for categorical variables. The overall results showed that patients who underwent MIS TA repair had much faster recovery when compared to traditional open TA repairs. Of the 19 patients who underwent MIS TA repair, there were two cases of superficial wound infection compared to six in the open group (p < 0.05). The MIS TA repair arm of the study also had higher patient-reported satisfaction rates, lower VAS pain scores (p < 0.05), with better AOFAS and SF36 quality of life measures. Overall, the rate of superficial infection, wound complication and length of stay were all reduced in the MIS group with similar deep infection rates. Our study concludes that where possible, TA rupture should be repaired minimally invasively and by an experienced foot and ankle surgeon as this will yield the best outcomes for the patient. Level of evidence: III


Original Article

Pradeep K Meena, Nagaraj Manju Moger, J Pragadeeshwaran

Functional Outcomes of Gastrocnemius Fascial Turn-down Flap with FHL Augmentation in Chronic Achilles Tear: A Short-term Prospective Study

[Year:2022] [Month:January-March] [Volume:9] [Number:1] [Pages:5] [Pages No:16 - 20]

Keywords: Foot and ankle ability measure, Foot and ankle disability index, RUPP score, Tendo-Achilles, Visual analog scale

   DOI: 10.5005/jp-journals-10040-1201  |  Open Access |  How to cite  | 


Introduction: Tendo-Achilles (TA) is one of the main tendons utilized for every movement of the lower limb. Rupture of TA leads to severe disruption of overall mobility and leads to difficulty in doing daily routine activities. The purpose of this prospective study was to observe the functional outcome of gastrocnemius fascial turn down flap with flexor hallucis longus (FHL) augmentation for chronic TA tear. Materials and methods: Tendo-Achilles rupture was diagnosed in all patients either by clinical or radiological means (most of them were type II or type III according to KUWADA classification). Preoperative functional scores (modified RUPP, FADI, FAAM, VAS) were documented. All 13 patients were treated surgically by gastrocnemius fascial turn down flap with FHL augmentation. All surgeries were performed by the same surgeon. The standard postoperative protocol was followed in all patients. Patients were followed up regularly at 3 months, 6 months, 1 year, and 2 years postoperative for functional outcome score. Results: The results were statistically analyzed by paired T-test for evaluating improvement in pre- and post-intervention periods. Functional outcome scores showed a significant improvement with FAAM score was improved from 30.84 ± 2.9 to 76.23 ± 3.98 (p < 0.001), FADI 40.92 ± 3.15 to 85.2 ± 4.04 (p < 0.001), modified RUPP score at 2 weeks postoperatively was 3.07 ± 1.18 which at 2 years of follow-up improved to mean score 22.77 ± 3.45 (p < 0.0001). VAS preoperatively value of 7.77 ± 1.01 improvised to 1.85 ± 0.99 at 2 years’ follow-up (p < 0.01) showing a significant decrease in overall pain. Conclusion: Functional outcomes show turn down flap with FHL augmentation as a good procedure for chronic TA rupture. Proper rehabilitation and wound care is the mainstay for good outcomes. Wound dehiscence is, however, a challenge that needs special care for providing good outcomes. Level of evidence: III


Original Article

Rahul Upadhyay, Jitesh Jain, Divyanshu Goyal

Clinical Experience with Gastrocnemius Recession Surgery in Chronic Plantar Fasciitis

[Year:2022] [Month:January-March] [Volume:9] [Number:1] [Pages:4] [Pages No:21 - 24]

Keywords: American Orthopaedic Foot and Ankle Score Ankle-hindfoot score, Functional, Gastrocnemius recession, Gastrocnemius tightness, Heel pain, Plantar fasciitis, Visual analog pain score, Visual analog score

   DOI: 10.5005/jp-journals-10040-1177  |  Open Access |  How to cite  | 


Aim and objective: In this study, we evaluated functional outcomes in patients treated with gastrocnemius recession for chronic plantar fasciitis due to isolated gastrocnemius tightness. Materials and methods: In this prospective study, 20 patients with chronic plantar fasciitis due to isolated gastrocnemius tightness were included. Non-conservative treatment was given to all patients for 9 months. After the trial of conservative treatment, 20 patients who did not respond well were operated for gastrocnemius (18 open and 2 endoscopic procedures). American Orthopaedic Foot and Ankle Score (AOFAS) was calculated at 6 weeks, 3 months, 6 months, and 9 months. Visual analog score (VAS) was recorded at 9 months. At final follow-up at 9 months, patients were asked to choose satisfaction level in terms of high/partial/low and would they recommend this surgery to their friends and if they would go for the same for the opposite limb. Results: Visual analog score improved from 7.2 to 1.2 (p value < 0.0001). The difference of the AOFAS at final follow-up (9 months) was found to be highly significant with a pre-op score of 49.4 to a final score as high as 93.3 (p value < 0.0001). Patient satisfaction level was calculated with relation to the AOFAS. High satisfaction was observed in 18 patients and partial satisfaction in 2 patients. Conclusion: Gastrocnemius recession done for isolated gastrocnemius tightness causing chronic plantar fasciitis provides statistically significant improvement without any major complications with a short recovery period.


Original Article

Gautam Kumar, Rajesh Simon, Surekh Ravi, Deepu J Punnoose

Repair of Peroneus Brevis Tear with Autologous Gracilis: A Case Report

[Year:2022] [Month:January-March] [Volume:9] [Number:1] [Pages:5] [Pages No:25 - 29]

Keywords: Ankle joint, Gracilis autograft, Peroneal, Peroneus brevis, Peroneus brevis tear, Pulverate weaving technique, Tendon repair

   DOI: 10.5005/jp-journals-10040-1200  |  Open Access |  How to cite  | 


Aim: Gracilis autograft repair for an isolated atraumatic peroneus brevis rupture. Background: Peroneal tendon injuries are one of the causes of lateral ankle pain and instability that can either involve peroneus brevis tendon (PBT) or peroneus longus tendon (PLT). PBT tears are often associated with trauma, leading to forced dorsiflexion of ankle or chronic subluxation. Atraumatic tear of PBT is rare, with only a few cases described. The surgical management for PBT tear includes peroneal tendoscopy, debridement and tubulization of remaining tendon and tenodesis. There is no consensus regarding the optimal surgical intervention for irreparable tears. Case description: A 43-year-old businessman presented to our clinic with complaints of pain and swelling in lateral side of left ankle of 1 week duration. The clinical examination revealed high-arched foot with diffuse swelling over the retrofibular area with tenderness elicited along the line of PBT. The sagittal view of ankle MRI showed completed tear of PBT. A curvilinear lateral incision was made along the posterior border of fibula. The proximal end of donor graft was secured to the proximal end of remaining PBT using pulverate weaving technique, while the distal end graft was looped through the drill hole in 5th metatarsal base and sutured to itself. Conclusion: Autograft is biologically superior to allograft with the advantages of tissue compatibility and faster reincorporation. Clinical significance: Surgical management of PBT tears are advocated for active, symptomatic, or patients who fail to improve with conservative management.



Shobhalakshmi S Holla, Soni Srikantaiah, Ramesh Debur

Single Session of Low-dye Calcaneal Taping as a Viable Alternative to LASER Therapy for the Treatment of Plantar Fasciitis: A Randomized Controlled Trial

[Year:2022] [Month:January-March] [Volume:9] [Number:1] [Pages:5] [Pages No:30 - 34]

Keywords: Physiotherapy, Plantar fasciitis, Plantar heel pain, Rehabilitation

   DOI: 10.5005/jp-journals-10040-1182  |  Open Access |  How to cite  | 


Background: Due to pressures of lifestyle and survival, both the urban and rural sections of society cannot give enough time for follow-up, thereby compelling many individuals to discontinue physiotherapy treatment. Treatment of plantar fasciitis (PF) requires multiple sessions and therefore falls into the scope of this problem. Taping has the advantage that it remains on the patient for multiple days and therefore negates the need for the patient's follow-up. If a single session of taping can deliver outcomes comparable to conventional LASER therapy, it would become a viable alternative solution for this problem. The aim was to compare and analyze the change in ankle muscle strength, flexibility, dorsiflexion, range of motion, and foot function in individuals with PF between the taping and LASER group. Materials and methods: Sixty-one participants diagnosed with PF were randomly allocated into a study and control group. The study group received a single session of low-dye calcaneal taping while the control group received five sessions of LASER therapy. Both the groups received a home exercise program. A pre- and post-intervention assessment of all the variables was done for both groups. Results: A within-group analysis using the Wilcoxon signed-rank test showed a significant difference in all the variables in both the laser and taping group (p < 0.05). A between-group analysis using the Mann–Whitney U test showed no difference in outcomes between the taping and laser groups (p > 0.05). Conclusion: A single session of taping can provide comparable outcomes as a conventional LASER therapy for short-term benefits in individuals with PF. CTRI registration number: CTRI/2018/02/011850



Anjul Verma, Rakesh Parmar, Inder Pawar, Shashank Agarwal

Diagnostic Dilemma of Subungual Glomus Tumor of Great Toe: A Case Report and Review of the Literature

[Year:2022] [Month:January-March] [Volume:9] [Number:1] [Pages:5] [Pages No:35 - 39]

Keywords: Classical triad, En Bloc, Glomus tumor

   DOI: 10.5005/jp-journals-10040-1145  |  Open Access |  How to cite  | 


Background: Glomus tumor is a benign neoplasm also known as angioneuromyoma, arising from glomus bodies which are specialized structures for thermoregulation.1 Solitary benign glomus tumors are small, usually <1.0 cm in size and they pose a diagnostic dilemma.2,3 They usually present with a classical triad of spontaneous pain, pressure tenderness, and cold hypersensitivity. Case description: A 37-year-old woman presented to us with complaints of pain and temperature sensitivity, in left great toe with difficulty in wearing shoes from the last 5 years. X-rays and blood investigations were normal. Magnetic resonance imaging (MRI) was done and showed T1 hypointense, T2 hyperintensity, and subtle bone expansion with the possibility of glomus tumor. En bloc removal of the lesion was done and a histopathological report confirmed it to be a glomus tumor. The patient was asymptomatic after 3 weeks of surgery. Discussion: The purpose of this case report is to make the orthopedic surgeon aware of the possibility of glomus tumor as a differential of chronic toe pain.



Amit Gupta, Ravi Bhadiyadra, Ramesh Deshpande, Aditya Menon, Vikas M Agashe

A Rare Case of Rosai-Dorfman Disease in Calcaneum and Study of Literature

[Year:2022] [Month:January-March] [Volume:9] [Number:1] [Pages:6] [Pages No:40 - 45]

Keywords: Brodie's abscess, Calcaneal osteomyelitis, Case report, Foot tumors, Heel pain, Histiocytosis, Immunohistochemical staining, Lytic, Osteoarticular tuberculosis-foot and ankle tuberculosis

   DOI: 10.5005/jp-journals-10040-1165  |  Open Access |  How to cite  | 


Background: Pain and osteolytic lesions on X-rays with non-specific changes on histopathology and negative culture are common scenarios; patients often treated with empirical antibiotics or anti-tuberculosis therapy (ATT), especially in regions where tuberculosis (TB) is endemic. The policy of “Diagnosis before treatment” should be the dictum in such cases. We report a rare case of Rosai-Dorfman disease (RDD) of calcaneum diagnosed by following these guidelines. Case description: A 17-year-old female presented with left heel pain for 1 year. She was diagnosed with Brodie's abscess of calcaneum at another facility on imaging. Empirical antibiotics were started after debridement, as cultures were negative and histopathology was not done. Symptoms recurred in 2 months. At presentation, careful clinical evaluation, the site of tenderness was found to be 2–3 cm distal to the prior incision. MRI revealed a large lesion with post-contrast enhancement. CT-guided biopsy from an appropriate site at our facility was inconclusive as there were no signs of infection or malignancy. Subsequently, thorough debridement was done using a different incision excising the biopsy scar. Tissue cultures were negative. Histopathology showed areas of dense lymphohistiocytic infiltrate with lymphocytic emperipolesis within their cytoplasm. There were no granulomas. On immunohistochemical staining, the macrophages strongly expressed S100 but not CD1a. Accordingly, a diagnosis of RDD was made. The surgical site healed with an uneventful postoperative period. She was advised protected weight-bearing for 6 weeks. Pain resolved and no further treatment had to be given. The patient was asymptomatic at a 3-year follow-up and the radiograph showed complete consolidation of the cavity with no evidence of recurrence. Conclusion: Primary intraosseous RDD is an unusual manifestation of a rare disease. Careful assessment of clinical details, inputs and help from imaging consultants, sending adequate tissue samples from appropriate sites for both culture and histopathology, and specialized staining techniques helped accurately diagnose this condition. Clinical significance: The case highlights the challenges faced in diagnosing a lytic lesion in the foot and the importance of avoiding empirical medication before obtaining a diagnosis despite negative percutaneous image-guided biopsies.


Rehabilitation Corner

Sidak Dhillon, Bibek Adhya, Rajesh K Rajnish, Himmat Dhillon

Lateral Ankle Sprain: Current Strategies of Management and Rehabilitation Short of Surgery

[Year:2022] [Month:January-March] [Volume:9] [Number:1] [Pages:4] [Pages No:46 - 49]

Keywords: Ankle rehabilitation, Ankle sprain, Recurrent ankle sprains

   DOI: 10.5005/jp-journals-10040-1196  |  Open Access |  How to cite  | 


Lateral ankle sprain is a common injury in physically active individuals; for purposes of adequate recovery, it is important to clinically grade the severity of ankle sprains, and plan appropriate rehabilitation interventions. The risk of subsequent ankle sprains, chronic ankle pain, and ankle instability is significant, especially in elite athletes. Modern methods of rehabilitation are more aggressive; in addition to the rest, ice, compression, and elevation (RICE) protocols, early phased functional support and supervised exercise therapy are considered better for early recovery. This should include graded neuromuscular and proprioceptive exercises over during the recovery phase. Specialized ankle stability programs need to be considered for professional athletes, with special attention to individual risk factors that could predispose them to recurrent lateral ankle sprains. The management protocol for recurrent sprains, although similar, needs to be more aggressive depending on the extent of the injury, duration since the first injury, and the associated instability. Modern methods include computerized documentation and the use of robots to oversee rehabilitation protocols.


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