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Loss of the knee–ankle coupling and unrecognized elongation in Achilles tendon rupture: effects of differential elongation of the gastrocnemius tendon

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The biarticular anatomy of the gastrocnemii is an important mechanism of knee–ankle coupling and differential elongation may affect this function leading to weakness of the push-off phase during the gait. Achilles tendon ruptures may cause detachment of the gastrocnemius tendon from the soleus aponeurosis with subsequent differential elongation of the individual subtendons. This study investigated the effects of such detachment by investigating tendon fusion levels of the two muscle groups, and the effect of sequential differential elongation of the gastrocnemius on the Achilles tendon resting angle (ATRA) and to the knee–ankle coupling.

Methods

Conjoined tendon length (CTL) was measured in 23 cadavers. ATRA in knee extension (ATRA 0) and 90-degree knee flexion (ATRA 90) was measured with the gastrocnemius tendons (GT) intact, transected and with the gap reduced in 5-mm increments. In 15 specimens, knee–ankle coupling was examined.

Results

Considerable anatomical variation was present with CTL ranging from 2 to 40% of fibular length. In the intact triceps, surae ATRA 0 differed from ATRA 90 by 6 degrees (p < 0.001). Cutting the gastrocnemius caused an immediate separation of the tendon ends by 19 mm. ATRA 0 and ATRA 90 increased 8 and 4 degrees (p < 0.001), significantly larger increase for ATRA 0 (p < 0.001). Lengthening the gastrocnemius 10 mm altered the coupling point 10 degrees towards dorsiflexion. Transfixing the gastrocnemius at the level of the gap where the Achilles was sectioned, decoupled the knee–ankle coupling in all but two specimens. A moderate correlation between CTL and length of the medial gastrocnemius tendon was found.

Conclusions

A greater relative ATRA 0 than relative ATRA 90 indicates differential elongation of the gastrocnemius. By elongating the gastrocnemius the knee–ankle coupling point shifts dorsally, and 20 mm elongation completely decouples the knee–ankle coupling. Independent lengthening of the gastrocnemius may explain the loss of power experienced by some patients following acute Achilles tendon rupture despite what would appear to be appropriate approximation of the ruptured tendon ends. Recognizing this occurrence is crucial when treating Achilles tendon ruptures and such patients require surgical correction in order to avoid long-term weakness of push-off strength.

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Abbreviations

ATRA:

Achilles tendon resting angle of the ankle

ATRA 0:

Achilles tendon resting angle of the ankle with the knee in full extension (0 degrees of flexion)

ATRA 90:

Achilles tendon resting angle of the ankle with the knee in 90 degrees of flexion

GT:

Gastrocnemius tendons

CTL:

Conjoined tendon length

AT:

Achilles tendon

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Acknowledgements

Thanks to Professor Anatomist Joergen Tranum Jensen Head of Institute of Anatomy University of Copenhagen and his employees for free access to the facilities, availability and preparation of specimens and great support and service at his Institute. Thanks to Dr Michael Moelmer, SAKS and Institute of Anatomy for providing excess cadavers from different courses for our study. Thanks to Jesper Velbak, Arthrex for conveyance of funding.

Funding

Arthrex Islands Brygge 43, 2300 Copenhagen, Denmark sponsored 10 of the 23 specimens.

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Authors and Affiliations

  1. Department of Orthopaedics, Naestved Hospital, Ringstedgade 61, 4700, Naestved, Denmark

    Susanne Olesen Schaarup

  2. Department of Orthopaedics, Zealand University Hospital Koege, Lykkebaekvej 1, 4600, Koege, Denmark

    Eva Wetke

  3. Department of Orthopaedics, IOC Centre of Bispebjerg Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark

    Lars Aage Glud Konradsen

  4. Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK

    James David Forbes Calder

  5. Department of Bioengineering, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BU, UK

    James David Forbes Calder

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  1. Susanne Olesen Schaarup
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Contributions

SOS conceived of the study, design and protocol, coordinated the practical arrangements, participated in the testing of all cadavers, dissection, data collection and processing and the statistical analysis. She drafted the manuscript and constructed the figures and drawings. EW participated in the dissection and testing of cadavers, and helped to draft the manuscript and to process the data and graphs. She carried out the statistical analysis. LK participated in the dissection and testing of cadavers, manuscript drafting and critical review. He conceived the uncoupling test and helped to design its performance. JC contributed to the idea and design of the study, manuscript drafting and performed the linguistics and thoroughly critical review of the manuscript. The final manuscript has been read and approved by all four authors.

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Correspondence to Susanne Olesen Schaarup.

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Schaarup, S.O., Wetke, E., Konradsen, L.A.G. et al. Loss of the knee–ankle coupling and unrecognized elongation in Achilles tendon rupture: effects of differential elongation of the gastrocnemius tendon. Knee Surg Sports Traumatol Arthrosc 29, 2535–2544 (2021). https://doi.org/10.1007/s00167-021-06580-1

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