{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T05:19:45Z","timestamp":1777612785707,"version":"3.51.4"},"reference-count":45,"publisher":"SAGE Publications","issue":"2","license":[{"start":{"date-parts":[[2026,1,26]],"date-time":"2026-01-26T00:00:00Z","timestamp":1769385600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Foot Ankle Int."],"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>Percutaneous Achilles tendon repair has become increasingly favored because of its lower rate of wound complications compared with open techniques. However, its success rates are limited and rely on precise tendon capture, which can be challenging because of limited intraoperative visualization. Previous clinical and cadaveric studies have reported frequent cases of incomplete or eccentric suture placement with this approach. Although not the only factor in improving the results of percutaneous Achilles repair, understanding the positional anatomy of the Achilles could be helpful in improving capture of the tendon. This study aimed to characterize the level-dependent axial orientation of the distal Achilles tendon using magnetic resonance imaging (MRI), focusing on levels relevant to percutaneous needle passage to improve the accuracy of repair.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>A retrospective review of MRI scans from 82 individuals without Achilles pathology was performed. The axial orientation of the tendon was measured at 3, 5, 7, 9, and 11\u2009cm proximal to its calcaneal insertion, relative to both the transmalleolar (TM) axis and the insertional tendon axis. Tendon width was also measured at each level. All measurements were performed using multiplanar reconstructed images, and differences across levels were analyzed using a linear mixed effects model with Bonferroni correction for multiple comparisons. A separate age-matched cohort of patients with acute Achilles rupture (n\u2009=\u200982) was also analyzed to compare orientation patterns between normal and ruptured tendons.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>\n                      The Achilles tendon orientation exhibited level-dependent variation in external rotation proximally when measured relative to the TM axis, increasing from 2.1 degrees (95% CI, 0.8-3.4) at 3\u2009cm to a peak of 11.2 degrees at 7\u2009cm (95% CI, 9.3-13.1) and 9\u2009cm (95% CI, 9.6-12.8), with a slight decrease at 11\u2009cm. When referenced to the insertional axis, a transition from internal to external rotation was observed between 5 and 7\u2009cm (\u0394\u2009=\u2009+6.6 degrees,\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      \u2009&lt;\u2009.001). The narrowest tendon width was also noted at 5\u2009cm (13.3\u2009mm), with greater width observed both proximally and distally. In the ruptured cohort, the tendon demonstrated a more externally rotated configuration at the rupture zone compared with normal tendons.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion:<\/jats:title>\n                    <jats:p>The Achilles tendon demonstrates level-dependent variation in axial orientation along its length, with a general tendency toward external rotation at more proximal levels. Although there are currently no established guidelines regarding needle trajectory during percutaneous repair, these findings suggest that a uniform axial needle path may not align with native tendon anatomy at all levels. Adjusting the direction of suture passage based on the specific level of repair may enhance procedural accuracy during percutaneous Achilles repair. Notably, these MRI-based recommendations have not been validated with cadaveric or other biomechanical testing.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence:<\/jats:title>\n                    <jats:p>Level III, diagnostic retrospective study.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/10711007251398000","type":"journal-article","created":{"date-parts":[[2026,1,27]],"date-time":"2026-01-27T05:17:15Z","timestamp":1769491035000},"page":"260-268","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["MRI Analysis of the Axial Plane Orientation of the Achilles Tendon: Implications for Level-Specific Percutaneous Repair Trajectories"],"prefix":"10.1177","volume":"47","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3040-3858","authenticated-orcid":false,"given":"Jaeyoung","family":"Kim","sequence":"first","affiliation":[{"name":"Foot and ankle service, Hospital for Special Surgery, New York, NY, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jaden","family":"Sacks","sequence":"additional","affiliation":[{"name":"Foot and ankle service, Hospital for Special Surgery, New York, NY, USA"},{"name":"Duke University, Durham, NC, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5252-3629","authenticated-orcid":false,"given":"Seif El","family":"Masry","sequence":"additional","affiliation":[{"name":"Foot and ankle service, Hospital for Special Surgery, New York, NY, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-4126-4107","authenticated-orcid":false,"given":"Lance","family":"Ward","sequence":"additional","affiliation":[{"name":"Foot and ankle service, Hospital for Special Surgery, New York, NY, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4304-7445","authenticated-orcid":false,"given":"Scott","family":"Ellis","sequence":"additional","affiliation":[{"name":"Foot and ankle service, Hospital for Special Surgery, New York, NY, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4482-5114","authenticated-orcid":false,"given":"Jonathan","family":"Deland","sequence":"additional","affiliation":[{"name":"Foot and ankle service, Hospital for Special Surgery, New York, NY, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2026,1,26]]},"reference":[{"key":"e_1_3_2_2_2","doi-asserted-by":"publisher","DOI":"10.1177\/107110079201300610"},{"key":"e_1_3_2_3_2","doi-asserted-by":"publisher","DOI":"10.1177\/03635465211053619"},{"key":"e_1_3_2_4_2","doi-asserted-by":"publisher","DOI":"10.1097\/00003086-200207000-00024"},{"key":"e_1_3_2_5_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0304197"},{"key":"e_1_3_2_6_2","doi-asserted-by":"publisher","DOI":"10.1097\/01.blo.0000144475.05543.e7"},{"key":"e_1_3_2_7_2","doi-asserted-by":"publisher","DOI":"10.1097\/00003086-199708000-00018"},{"key":"e_1_3_2_8_2","doi-asserted-by":"publisher","DOI":"10.1002\/ca.20758"},{"key":"e_1_3_2_9_2","doi-asserted-by":"publisher","DOI":"10.1177\/0363546515587082"},{"key":"e_1_3_2_10_2","doi-asserted-by":"publisher","DOI":"10.1186\/s12893-024-02333-2"},{"issue":"12","key":"e_1_3_2_11_2","article-title":"Morphometric analysis of Achilles tendon structure and its significance: a cadaveric study","volume":"14","author":"Francis YM","year":"2022","unstructured":"Francis YM, Taj S, Karunakaran B, et al. Morphometric analysis of Achilles tendon structure and its significance: a cadaveric study. Cureus. 2022;14(12):e32172.","journal-title":"Cureus"},{"key":"e_1_3_2_12_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00167-007-0448-z"},{"key":"e_1_3_2_13_2","doi-asserted-by":"publisher","DOI":"10.1002\/jor.26041"},{"key":"e_1_3_2_14_2","doi-asserted-by":"publisher","DOI":"10.3113\/FAI.2011.0879"},{"key":"e_1_3_2_15_2","doi-asserted-by":"publisher","DOI":"10.1177\/2473011418814004"},{"key":"e_1_3_2_16_2","doi-asserted-by":"publisher","DOI":"10.1177\/107110070602701116"},{"key":"e_1_3_2_17_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0020-1383(98)00147-8"},{"key":"e_1_3_2_18_2","doi-asserted-by":"publisher","DOI":"10.1177\/1071100715589632"},{"key":"e_1_3_2_19_2","doi-asserted-by":"publisher","DOI":"10.1177\/0363546506293255"},{"issue":"3","key":"e_1_3_2_20_2","first-page":"223","article-title":"The use of the Ma-Griffith technique for percutaneous repair of fresh ruptured tendo Achillis","volume":"76","author":"Klein W","year":"1991","unstructured":"Klein W, Lang D, Saleh M. The use of the Ma-Griffith technique for percutaneous repair of fresh ruptured tendo Achillis. Chir Organi Mov. 1991;76(3):223-228.","journal-title":"Chir Organi Mov"},{"key":"e_1_3_2_21_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.asmr.2024.100924"},{"key":"e_1_3_2_22_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jorep.2024.100357"},{"key":"e_1_3_2_23_2","doi-asserted-by":"publisher","DOI":"10.1177\/107110070102200705"},{"key":"e_1_3_2_24_2","doi-asserted-by":"publisher","DOI":"10.1177\/1071100716628915"},{"issue":"2","key":"e_1_3_2_25_2","first-page":"179","article-title":"Is percutaneous repair of the Achilles tendon a safe technique? A study of 124 cases","volume":"72","author":"Maes R","year":"2006","unstructured":"Maes R, Copin G, Averous C. Is percutaneous repair of the Achilles tendon a safe technique? A study of 124 cases. Acta Orthop Belg. 2006;72(2):179.","journal-title":"Acta Orthop Belg"},{"key":"e_1_3_2_26_2","doi-asserted-by":"publisher","DOI":"10.1007\/s11999-009-0944-1"},{"key":"e_1_3_2_27_2","doi-asserted-by":"publisher","DOI":"10.1097\/00042752-199907000-00007"},{"key":"e_1_3_2_28_2","doi-asserted-by":"publisher","DOI":"10.1177\/0363546505283266"},{"key":"e_1_3_2_29_2","doi-asserted-by":"publisher","DOI":"10.3109\/17453679608996672"},{"issue":"4","key":"e_1_3_2_30_2","first-page":"295","article-title":"Torsion of the Achilles tendon in man and its anatomical and surgical significance","volume":"43","author":"Morimoto I","year":"1968","unstructured":"Morimoto I, Ogata T. Torsion of the Achilles tendon in man and its anatomical and surgical significance. Kaibogaku Zasshi. 1968;43(4):295-302. In Japanese","journal-title":"Kaibogaku Zasshi"},{"key":"e_1_3_2_31_2","doi-asserted-by":"publisher","DOI":"10.3109\/17453677608998983"},{"key":"e_1_3_2_32_2","doi-asserted-by":"publisher","DOI":"10.1177\/145749690809700312"},{"key":"e_1_3_2_33_2","article-title":"Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis","volume":"364","author":"Ochen Y","year":"2019","unstructured":"Ochen Y, Beks RB, Van Heijl M, et al. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019;364:k5120.","journal-title":"BMJ"},{"key":"e_1_3_2_34_2","doi-asserted-by":"publisher","DOI":"10.4055\/cios.2020.12.1.1"},{"key":"e_1_3_2_35_2","doi-asserted-by":"publisher","DOI":"10.1177\/0363546519858990"},{"key":"e_1_3_2_36_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.fas.2013.11.005"},{"key":"e_1_3_2_37_2","doi-asserted-by":"publisher","DOI":"10.1002\/ca.23247"},{"key":"e_1_3_2_38_2","doi-asserted-by":"publisher","DOI":"10.1177\/03635465020300022501"},{"key":"e_1_3_2_39_2","doi-asserted-by":"publisher","DOI":"10.2214\/ajr.173.2.10430128"},{"key":"e_1_3_2_40_2","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.K.00917"},{"key":"e_1_3_2_41_2","doi-asserted-by":"publisher","DOI":"10.3113\/FAI.2010.1069"},{"key":"e_1_3_2_42_2","doi-asserted-by":"publisher","DOI":"10.1177\/107110070502601106"},{"key":"e_1_3_2_43_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.injury.2005.02.012"},{"key":"e_1_3_2_44_2","doi-asserted-by":"publisher","DOI":"10.1177\/0363546512453293"},{"key":"e_1_3_2_45_2","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.I.01401"},{"key":"e_1_3_2_46_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijsu.2017.03.021"}],"container-title":["Foot &amp; Ankle International"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/10711007251398000","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/10711007251398000","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/10711007251398000","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T21:23:58Z","timestamp":1777411438000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/10711007251398000"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,26]]},"references-count":45,"journal-issue":{"issue":"2","published-print":{"date-parts":[[2026,2]]}},"alternative-id":["10.1177\/10711007251398000"],"URL":"https:\/\/doi.org\/10.1177\/10711007251398000","relation":{},"ISSN":["1071-1007","1944-7876"],"issn-type":[{"value":"1071-1007","type":"print"},{"value":"1944-7876","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,26]]}}}