Tendon Insertion Research Articles

P1237 Musculoskeletal involvement is frequent in bio-naïve patients with IBD initiating biological treatment– a prospective cohort study

Abstract Background Musculoskeletal (MSK) involvement in IBD patients contributes to poorer outcomes and reduced quality of life (QoL). Recognising MSK involvement is important before initiating biologics, as their effects can differ between the gut, peripheral joints and spine. We aimed to describe the prevalence and distribution of peripheral and axial MSK symptoms and clinical findings in IBD patients starting biological treatment. Methods Bio-naïve IBD patients were consecutively recruited. Musculoskeletal symptoms were assessed using questionnaires and a structured interview. A rheumatologist conducted a clinical evaluation of peripheral joints, entheses, and spine mobility and considered various differential diagnoses. Results Of 82 patients (ulcerative colitis (UC): 33, Crohn’s disease (CD): 49), 51(62%) had musculoskeletal symptoms and 51(62%) had clinical findings (Table 1). Peripheral joint pain was reported by 39(48%) patients, usually affecting the hands, followed by the knees and ankles. Entheseal pain was present in 15(18%) patients, most often affecting the lateral hips, followed by the Achilles and patella tendons. Back pain was reported by 33(40%) patients. In 16 of these patients, the assessing rheumatologist could attribute the symptoms to competing differential diagnoses, such as degenerative spine disease (n=15), osteoarthritis (n=3) and overuse injury (n=2). Patients with CD suffered from significantly more MSK symptoms, particularly joint pain, compared to UC patients (67% vs. 40%, and 65% vs. 30%, respectively, p-values=0.01). Clinical evaluation revealed arthritis in 24(29%) patients and enthesitis in 50(61%). The small peripheral joints were predominantly involved in an oligo- and polyarticular pattern. Achilles tendon insertions were the most frequently affected entheses; enthesitis was asymptomatic in 72% of the cases. The Assessment of Spondyloarthritis international Society (ASAS) classification criteria for peripheral spondyloarthritis were met in 44% of patients; and for fibromyalgia in 8.5% of patients, all with clinically active IBD. Being female was associated with more frequent musculoskeletal symptoms and clinical findings. No other differences in clinical findings were observed between UC and CD, nor between those with active and inactive IBD. Patients with MSK involvement had significantly lower EQ-5D scores than those without. Conclusion Two-thirds of IBD patients scheduled for their first biological treatment exhibited musculoskeletal involvement, sometimes asymptomatically. Axial and peripheral symptoms were equally common. A multidisciplinary approach is crucial for early detection and integrated treatment aiming for remission in all disease domains to improve patients’ QoL.

The Study of the Skeletal Remains of the 16th Century Italian Commander Alessandro Farnese and His Wife, Maria D'Aviz

ABSTRACTEntheseal changes are indicators of persistent and long‐term changes induced by occupational activity and refer to marks on the skeleton where a muscle, tendon, or ligament inserts into the periosteum. Their study makes it possible to deduce further information about the person to whom the human bone remains belong. The authors present here the analysis of these markers on the bone remains of two Italian historical figures who lived in the 16th century. In 2021, the exhumation of the remains of Alessandro Farnese and Maria D'Aviz was authorized for study purposes and the skeletal remains were examined. The data collected from the examination of the mortal remains of Alessandro Farnese are compatible with historical data about his biography. As a skilled leader and assiduous sportsman, he showed signs of entheseal changes in his bone tissue attributable to physical activities. On the other hand, the case of Maria D'Aviz differs significantly from that of Alessandro Farnese in that her bone segments show no signs of entheseal changes. The analysis carried out on the remains results to be very useful in verifying the comparison with the elements present in their biography. The possibility of confirming the connection between entheseal changes and lifestyle habits is fundamental to increasing credibility in the application of these elements in the process of identifying nameless bodies in the forensic context.

Achilles tendon morphology adaptations in chronic post-stroke hemiparesis: a comparative analysis with neurologically intact controls.

In individuals with chronic post-stroke hemiparesis, slow walking speed is a significant concern related to inadequate propulsion of the paretic limb. However, an overlooked factor is this population's altered morphology of the Achilles tendon, which may compromise the propulsive forces by the paretic limb. This study aimed to explore changes in Achilles tendon morphology, including gross thickness and intra-tendinous collagen fiber bundle organization, following stroke-induced brain lesions. Fifteen individuals with chronic post-stroke hemiparesis (at least 6 months post-stroke) and 19 neurologically intact controls participated. Ultrasound imaging was used to evaluate Achilles tendon thickness and collagen organization in the paretic and non-paretic limbs of post-stroke participants, as well as in the right limb (control limb) of the neurologically intact control group. Compared to control individuals, the paretic limb in individuals post-stroke showed increased tendon thickness at the Achilles tendon insertion and 2 cm above it. The collagen fiber bundle at the Achilles tendon insertion of the paretic limb showed reduced organization compared to that in the control limb. Individuals post-stroke also exhibited slower walking speed, and increased plantarflexor muscle tone in the paretic limb compared to controls. In conclusion, individuals with chronic post-stroke hemiparesis demonstrated tendon thickening and collagen disorganization in the paretic limb, particularly at the insertion site of the Achilles tendon, likely due to an abnormal loading environment influenced by increased plantarflexor muscle tone, muscle co-activation, and muscle disuse and atrophy. These changes may increase tendon compliance, impair force transmission and propulsion, and contribute to slower walking speed. Addressing Achilles tendon integrity should be incorporated as a component of strategies to improve neuromuscular control in this population.

The rectus abdominis tendon insertion to the pubic bone and its clinical implications: A cadaveric study.

The primary aim of this study is to determine the rectus abdominis tendon (RAT) insertional anatomy and consequently clarify the extension of secure mobilization of the tendon from the pubic bone in the setting of anterior approaches in pelvic and acetabular reconstruction surgery. Elevenfreshfrozencadavericpelvisesweredissectedbytwo fellowship-trainedorthopaedic trauma surgeons utilizing the anteriorintrapelvicapproach (AIP). The RAT at the pubic body was dissected, and its footprint on the pubic bone was defined, marked, and measured. Nineteen (19) RAT insertions were analyzed. The average total medial vertical length was 33mm (range 26-42mm), and the average total lateral vertical length was 36.5mm (range 26-46mm). The total width of the proximal insertion on both sides was measured at an average of 20.42mm (range 14-24mm). The average width of the tendon at the transition area between the cranial and caudal areas of the pubic bone was 16.45mm (range 12-22mm). The average distal insertion width of the RAT was less than the proximal and middle widths, measuring 10.45mm (range 8-13mm). The tendon can be safely mobilized up to an average total medial vertical length of 33mm (and in no case more than 42mm) and to an average total lateral vertical length of 36.5mm (and in no case more than 46mm). This piece of anatomical information will equip orthopaedic surgeons with a better understanding of the insertional anatomy of the RAT and subsequent safer surgical release when performing anterior approaches to the pelvic ring.

Lower Limb Osteochondrosis and Apophysitis in Young Athletes—A Comprehensive Review

Osteochondrosis and apophysitis are common causes of pain in the growing skeleton, each with different causes and treatment approaches. Osteochondrosis involves degenerative processes affecting the epiphyseal ossification centers of the developing bones, while apophysitis results from repetitive traction injuries to the tendon insertions and affects both the cartilage and the underlying bone. Raising awareness of these conditions is crucial to facilitate the recovery of young athletes and prevent their sporting careers from being jeopardized early on. This review presents six known lower limb conditions that occur in young athletes, including three apophysitis such as Osgood–Schlatter disease, Sinding–Larsen–Johansson syndrome, and Sever’s disease, and three osteochondroses, including Perthes’ disease, Köhler’s disease, and Freiberg’s disease. The aim of this review is to outline the pathophysiology, clinical presentation, and treatment strategies for each of these conditions to provide a comprehensive understanding of their impact on young athletes. This review will provide clinicians, coaches, and physiotherapists with essential, evidence-based insights to increase their awareness of these conditions and refine treatment strategies for young athletes.

Vanderbilt University Rehabilitation Approach to Zone 2 Tendon Repairs in the Hand.

Zone 2 of the hand, which stretches from the region between the A1 pulley at the distal palmar crease to the insertion of the FDS tendon at the end of the A4 pulley, is notable for its high complication rate following surgery. Many of these complications, such as adhesions, contractures, and tendon rupture, can be avoided through adequate rehabilitation. We document the rehabilitation protocol at Vanderbilt University Medical center, which is characterized by 4 phases. An initial postoperative phase emphasizes shielding the flexor tendons with little motion, a second phase focuses on an orthosis to keep the metacarpophalangeal joints flexed at 45 degrees, a third phase focuses on strengthening exercises, and a fourth phase that focuses on transitioning to normal activities without restriction.

Advances and Challenges in Zone 2 Flexor Tendon Repairs.

Flexor zone 2 is the area between the A1 pulley at the distal palmar crease to the insertion of the flexor digitorum superficialis tendon at A4 pulley. Termed "no man's land," primary repair at zone 2 had notoriously high rate of complications such as adhesions, contractures, and tendon rupture. Improved understanding of tendon healing, stronger suture materials, novel operative techniques, judicious pulley venting, and early active rehabilitation have helped improve outcomes. This review examines current methodologies and postoperative considerations for zone 2 flexor tendon repair.

Arthroscopic evaluation of anatomical variations of the oblique popliteal ligament and their association with popliteal cyst formation.

The posteromedial compartment of the knee houses several important anatomical structures, including the oblique popliteal ligament (OPL), an accessory insertion tendon of the semimembranosus muscle. Popliteal cysts develop from the synovial bursa located between the medial gastrocnemius and the semimembranosus, typically secondary to intra-articular pathologies causing effusion. This study aimed to describe the normal anatomy of the postero-medial capsule of the knee and its anatomical variations, particularly in the presence of popliteal cysts. This was a prospective descriptive study conducted over four consecutive months, including 96 knees from 96 patients who underwent arthroscopy for various intra-articular pathologies. The anatomy of the oblique popliteal ligament was categorized into four types: integrated OPL (Type 1), prominent "cord-like" OPL (Type 2A), normally prominent OPL (Type 2B), and bulging OPL (Type 3). The presence of popliteal cysts was evaluated preoperatively using magnetic resonance imaging (MRI). Type 1 OPL was observed in 13 knees (13.5%), Type 2A in 22 (22.9%), Type 2B in 40 (41.7%), and Type 3 in 21 (21.9%). MRI revealed popliteal cysts in 20 knees (20.8%), of which 8 (8.3%) were symptomatic. No popliteal cysts were identified in Type 1 knees. Cysts were present in 2 of 22 Type 2A knees (9.1%), 6 of 40 Type 2B knees (15%), and 12 of 21 Type 3 knees (57.1%). A statistically significant relationship was found between the anatomical type of the postero-medial capsule and the presence of a popliteal cyst (p < 0.001). Arthroscopic anatomy of the postero-medial capsule appears altered in the presence of a popliteal cyst. This alteration is characterized by a bulging OPL within the joint, creating a communication orifice at its superior margin leading to the cyst. Posteromedial synovectomies aimed at disrupting the unidirectional flow mechanism into the cyst should target a triangular area defined by the medial gastrocnemius, the semimembranosus, and the oblique popliteal ligament. IV; observational study.

Assessment of tibialis anterior tendon insertion variations in relation to hallux valgus utilizing magnetic resonance imaging

BackgroundHallux valgus is a deformity characterized by lateral deviation of the big toe and medial deviation of the first metatarsal, causing difficulty in walking and requiring various treatments. Despite its multifactorial etiology, the role of the tibialis anterior tendon in hallux valgus and its variations in the morphology of tibialis anterior tendon distal insertion sites have not been fully explored. This study aimed to evaluate the effect of such variations on hallux valgus using magnetic resonance imaging.MethodsThis was a retrospective study and included 115 individuals aged 18 years and older who underwent foot radiographs and MRI. The participants were divided into a hallux valgus group of 53 patients and a control group of 62 people based on radiographic measurements. Tibialis anterior tendon distal attachment was classified into five types according to the attachment morphology. Statistical analyses were performed to evaluate the relationship between the tibialis anterior tendon types and hallux valgus severity.ResultsAmong the participants, patients who underwent foot radiography and MRI due to any medical indication 70.4% were female, with a mean age of 43.83 ± 15.25 years. In terms of tibialis anterior tendon distal attachment, the most common type was Type 5 (40.9%), followed by Type 2 (34.8%). Type 4 was not observed in any case. In all participants, the mean hallux valgus angle was 20.63 ± 8.42o, and the mean intermetatarsal angle was 9.69 ± 2.68o. Tibialis anterior tendon distal attachment Type 5 was significantly associated with an increased hallux valgus angle but not with the intermetatarsal angle. We found a significant relationship between the diameter of the tibialis anterior tendon and hallux valgus angle.ConclusionsThis study revealed a significant association between hallux valgus and Type 5 tibialis anterior tendon distal attachment, suggesting that tibialis anterior tendon morphology influences hallux valgus severity. The findings underscore the importance of considering variations in tibialis anterior tendon distal attachment sites in the etiopathogenesis and treatment planning of hallux valgus.

Anatomical research of positional relationship between protective channel and sural nerve during Achilles tendon repair using channel assisted minimally invasive repair technique

To evaluate the positional relationship between protective channel and sural nerve while treating acute Achilles tendon rupture with channel assisted minimally invasive repair (CAMIR) technique based on anatomical observations of cadaver specimens. Twelve adult cadaveric lower limb specimens (6 left, 6 right) were utilized. A CAMIR device was implanted at a distance of 4 cm from the proximal end of the specimen to the Achilles tendon insertion. The skin was incised along the tendon's medial side, the sural nerve was dissected, and the positional relationship with the protective channel was observed. The distance from the sural nerve-Achilles tendon intersection to the calcaneal insertion, the vertical distance between protective channel and the calcaneal insertion, and the horizontal distance between the sural nerve and protective channel were measured by using vernier caliper. Anatomical examination demonstrated a variable positional relationship between the sural nerve and protective channel, with the sural nerve positioned above (8 specimens) or below (4 specimens) the protective channel. The distance from the sural nerve-Achilles tendon intersection to the calcaneal insertion was (105.67±14.94) mm, the vertical distance between protective channel and the calcaneal insertion was (93.20±9.57) mm, and the horizontal distance between the sural nerve and protective channel was (0.31±0.14) mm. The use of CAMIR technique for the treatment of acute Achilles tendon rupture can effectively avoid iatrogenic injury to the sural nerve.

Associated Reconstruction Technique for the Posterolateral Corner and the Anterior Cruciate Ligament with Double Femoral Tunnel

Objectives The constant study evolution of the structures and biomechanical functioning of the posterolateral complex (PLC) of the knee show that this structure plays an extremely important role in joint stability, especially when associated with injury to the anterior cruciate ligament (ACL). Failure to detect the PLC lesion causes posterolateral rotational instability in the knee, generating an overload on the reconstructed ACL, increasing its potential for failure. Surgical treatment is the gold standard for patients with combined injuries of the PLC and ACL. However, despite the numerous reconstruction techniques described, the best technique is still controversial. This study presents a less invasive technique with fewer bone tunnels, lower cost and less surgical complexity, using four bone tunnels with a single tunnel for the ACL and lateral collateral ligament (LCL) in the lateral femoral condyle and only 04 interference screws for the anatomical reconstruction of the ACL / PLC and restoration of stability of the injured knee. Surgical technique Patient in supine position. A graft is prepared with 2 semitendinosus tendons (1 from each knee) and 1 gracilis tendon (from the knee with ligament injury). The tendons must be at least 24 cm long. The graft is prepared in quadruple for the ACL (gracilis tendon duplicated and 2 simple semitendinosus tendons) and double for the PLC (continuation of the 2 simple semitendinosus tendons). An incision is made on the lateral aspect of the knee over the lateral epicondyle, towards the head of the fibula, approximately 12cm long. The femoral insertion site of the lateral collateral ligament (LCL) is identified slightly proximal and posterior to the femoral epicondyle. The unique femoral tunnel for the ACL and LCL is performed using the outside-in technique. The guidewire must be inserted in the origin of the LCL anatomical point at the external lateral cortex towards the origin of the ACL anatomical on the medial wall of the lateral fêmur condyle. The fibular head tunnel is performed, positioned from anterolateral to posteromedial, approximately 0.5 cm below the tip of the fibular head. The fourth and last tunnel is performed l at the popliteal tendon femoral insertion. It should be directed anteriorly and proximally to avoid confluence with the ACL tunnel. The graft is passed through the tibial tunnel towards the femoral tunnel. Both semitendinosus legs exit the LCL insertion at the lateral aspect of the femur. Graft fixation at the femoral tunnel lateral cortex is performed with an interference screw. The graft is tensioned at its tibial exit with knee flexed at 20° and fixed with an interference screw, reconstructing the ACL. For PLC reconstruction, the two semitendinosus legs are passed under the iliotibial tract through the fibular head tunnel from anterolateral to posteromedial. The graft is tensioned with knee at 30° of flexion and valgus and fixed with an interference screw at the fibular tunnel, reconstructing the LCL. The remaining portion of the graft is passed below the iliotibial tract and LCL, being inserted into the femoral tunnel corresponding to the insertion of the popliteal tendon. The graft is then tensioned with knee flexed at 60° and valgus and fixed with an interference screw. Conclusion We believe that the described technique for ACL reconstruction associated with PLC injury is able to restore knee stability through a minimally invasive, reproducible and less technically challenging approach, with a lower learning curve than those currently available.

Paratenon-Sparing Quad Tendon Graft Harvest

Background: In recent years, the quadriceps tendon has gained popularity for primary anterior cruciate ligament (ACL) reconstruction surgery due to its robustness, easy access, and ability to be tailor-made to each patient. However, concerns remain regarding potential complications associated with quadriceps tendon harvest, including impaired healing and damage to the extensor mechanism. Indications: Preserving the quadriceps paratenon, which is a source of blood supply, nutrients, and therapeutic cells during ACL reconstruction surgery, may improve postoperative outcomes by mitigating potential adverse effects associated with quadriceps harvest. As a result, it may also facilitate the quadriceps healing process and postoperative rehabilitation. Technique Description: The incision area is marked approximately 1 cm below to 3 cm above the proximal patellar pole, and the skin is dissected from the underlying tendon, exposing both the quadriceps and its paratenon. Once the tendon insertion to the patella's proximal pole is visualized, a double-blade knife is used to make a full-thickness 2-cm longitudinal cut, taking care not to cut over 2 cm of the overlying paratenon. Then, the distal end of the tendon is safely detached from the patella followed by placing continuous whip sutures, which are then loaded on a graft harvesting system and cannula. The cannula is gently plunged underneath the paratenon while applying tension on the whip sutures with the knee flexed to 90°. Then, the cannula is twisted repeatedly under the paratenon until the desired length of 61/2 to 7 cm is reached. Again, care is taken not to lever the tendon and to harvest it along its anatomic course. Finally, the quad tendon cutter is used to transect the quad at its proximal end. During the procedure, knee extension and flexion are used to aid visualization and access to the tendon's ends. Results: Preservation of the quadriceps paratenon during its harvest for ACL reconstruction surgery can potentially improve postoperative outcomes by facilitating healing and reducing friction between the tendon and neighboring tissue. Discussion/Conclusions: Preserving the quadriceps paratenon during ACL reconstruction surgery is a technique that can be easily performed and has the potential to improve postoperative outcomes. By preserving the paratenon, surgeons can reduce potential adverse effects associated with quadriceps harvest, such as impaired healing and damage to the extensor mechanism. Based on our experience and the available literature, we believe that preserving the paratenon during quadriceps tendon harvest is a valuable technique that surgeons should consider when performing ACL reconstruction surgery. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Relationship Between Ultrasound and Physical Examination in the Assessment of Enthesitis in Patients With Spondyloarthritis: Results From the DEUS Multicenter Study.

The study objectives were (i) to explore the agreement between the Outcome Measures in Rheumatology (OMERACT) ultrasound lesions of enthesitis and physical examination in assessing enthesitis in patients with spondyloarthritis (SpA) and (ii) to investigate the prevalence and clinical relevance of subclinical enthesitis in this population. Twenty rheumatology centers participated in this cross-sectional study. Patients with SpA, including axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA), underwent both ultrasound scan and physical examination of large lower limb entheses. The OMERACT ultrasound lesions of enthesitis were considered, along with a recently proposed definition for "active enthesitis" by our group. Subclinical enthesitis was defined as the presence of "active enthesitis" in ≥1 enthesis in patients with SpA without clinical enthesitis (ie, number of positive entheses on physical examination and Leeds Enthesitis Index score = 0). A total of 4,130 entheses in 413 patients with SpA (224 with axSpA and 189 with PsA) were evaluated through ultrasound and physical examination. Agreement between ultrasound and physical examination ranged from moderate (ie, enthesophytes) to almost perfect (ie, power Doppler and "active enthesitis"). Patellar tendon entheses demonstrated the highest agreement, whereas Achilles tendon insertion showed the lowest. Among 158 (38.3%) of 413 patients with SpA with clinical enthesitis, 108 (68.4%) exhibited no "active enthesitis" on ultrasound. Conversely, of those 255 without clinical enthesitis, 39 (15.3%) showed subclinical enthesitis. Subclinical enthesitis was strongly associated with local structural damage. However, no differences were observed regarding the demographic and clinical profiles of patients with SpA with and without subclinical enthesitis. Our study underscores the need for a comprehensive tool integrating ultrasound and physical examination for assessing enthesitis in patients with SpA.

Biomechanical Changes to the Hindfoot After Zadek Osteotomy.

Insertional Achilles tendinopathy (IAT) is a common source of heel pain in active adults and athletes. The Zadek osteotomy (ZO) is a calcaneal dorsal closing wedge osteotomy that has demonstrated clinical success as a treatment for IAT, purported to favorably improve tendon mechanics, decrease impingement, and decrease pressure within the retrocalcaneal bursa. The present study aims to evaluate the biomechanical effects of ZO on Achilles strain, position of the Haglund prominence relative to the Achilles insertion, and retrocalcaneal pressure. The ZO was performed on 10 fresh-frozen foot and ankle mid tibia-fibula cadaveric specimens. An osteotomy was performed using a 1-cm dorsal closing wedge procedure secured with a 7.0 mm cannulated screw. Point pressure sensor catheters and differential variable reluctance transducers were used to measure the retrocalcaneal pressure and Achilles strain, respectively, pre- and postosteotomy. Paired t-tests were utilized to detect statistical differences (P < .05). After the ZO, the Haglund prominence was translated 9.9 mm anteriorly with respect to the insertion of the Achilles (P < .05) and the Achilles tendon insertion was translated 3.4 mm proximally (P < .05). The ratio of calcaneal length to greater tuberosity length, the X/Y ratio, increased from 2.56 to 3.52 with the osteotomy (P < .05). At maximum dorsiflexion, retrocalcaneal pressure decreased from 117 to 66 mm Hg (44%, P = .018). The Achilles strain changed from 0.00362 to 0.00436 in the anterior fibers (P = .484) and changed from 0.00467 to 0.00283 in the posterior fibers (P = .088). Biomechanical testing in a cadaveric model demonstrates that the ZO decreased retrocalcaneal pressure, shifted the Achilles tendon insertion proximally, increased the X/Y ratio of the calcaneus, and did not significantly change the strain of the Achilles tendon. Despite the clinical success demonstrated in recent literature, there are no biomechanical studies describing the effect of the ZO on the biomechanics of the hindfoot, and the mechanism of symptom relief of the ZO for IAT is not well understood. The present study measures two potential ZO effects relative to Haglund prominence by measuring retrocalcaneal pressure and displacement of the Achilles tendon with respect to the Haglund prominence, and measures one ZO effect relative to calcification of the tendon by measuring the Achilles tendon strain.

Validation of Fixed Ultrasonography for Achilles Tendon Assessment: A Reliability Study

Background: It is important to highlight the advantages of ultrasound in assessing muscular and tendinous behavior due to its non-invasive nature and capacity for dynamic studies. However, evaluating tendons via ultrasound can be challenging given the complexity of anisotropic phenomena related to collagen fiber arrangement. This study aims to validate the reliability of fixed ultrasound compared to manual acquisition in measuring Achilles tendon thickness. Method: Twenty participants, six men and fourteen women, were recruited. Ultrasound was used to measure the Achilles tendon’s thickness at two specific points (4 and 6 cm from the calcaneal insertion of the Achilles tendon). The measurements were conducted by two examiners, one with previous experience and another without. Results: The measurements at 6 cm from the calcaneal insertion showed α = 0.996, α = 0.998 for measurements at 4 cm using manual acquisition, and α = 0.997 for measurements with fixed ultrasound at rest. For the weight-bearing and ankle dorsiflexion measurements, the reliability was excellent (α = 0.999 and α = 1.000). Conclusions: The findings demonstrated excellent reliability in the ultrasound measurements of the Achilles tendon’s thickness, even when performed by different evaluators and under load-bearing conditions. This study suggests the clinical utility of assessing anatomical structures under load, enhancing ultrasound’s applicability beyond the examination table. It is concluded that fixed ultrasound acquisition exhibits excellent reliability in measuring the Achilles tendon’s thickness, offering potential benefits for precise diagnosis of pathologies, planning surgical interventions, and reducing possible errors related to operator variability.

Biomechanical Changes to the Ankle After Zadek Osteotomy

Category: Hindfoot; Sports Introduction/Purpose: Insertional Achilles tendinopathy is a common source of heel pain in active adults and athletes. This may occur in conjunction with Haglund’s deformity, a calcaneal prominence that can be associated with inflammation of the retrocalcaneal bursa. Corrective surgery may be indicated after failed nonoperative treatment. One option includes the Zadek osteotomy, a calcaneal dorsal closing wedge osteotomy, which may relieve retrocalcaneal pressure, resulting in improved clinical outcomes. However, a gap in the knowledge base exists regarding the postoperative effects of the procedure on the biomechanics of the calcaneus and Achilles tendon. This study aims to evaluate the biomechanical changes of the Zadek osteotomy on retrocalcaneal pressure, position of the Haglund’s prominence relative to the Achilles insertion, and Achilles strain. Methods: Ten fresh-frozen foot and ankle cadaveric specimens underwent dissection for exposure of the Achilles tendon and retrocalcaneal space. The Zadek osteotomy was performed by making a 1-cm dorsal closing wedge osteotomy fixed by a single threaded 7.0-mm cannulated screw. Radiographic markers were placed on the Haglund’s prominence and the Achilles tendon insertion. Pre- and post-procedure simulated weightbearing, perfect lateral radiographs were taken to measure displacement in the superior-inferior and anterior-posterior axes. The Achilles tendon was loaded with 170 N to simulate weightbearing. The ankle was then maximally dorsiflexed for 3 cycles at 0.25 Hz. Catheter pressure sensors and voltage transducer linear displacement sensors were placed on the specimens to measure retrocalcaneal pressure and Achilles strain respectively at maximum dorsiflexion. The testing protocol was completed before and after the osteotomy, and paired student’s t-tests were done to detect statistical differences (p &lt; 0.05). Statistical outliers were removed from analysis. Results: After the Zadek osteotomy, the Haglund’s prominence was displaced by 9.9 mm anteriorly (N = 10, p &lt; 0.0001) and the Achilles insertion was displaced by 3.4 mm superiorly (N = 10, p &lt; 0.001) with respect to each other. The calcaneal X/Y ratio increased from 2.56 to 3.52 (N = 10, p &lt; 0.0001). At maximum dorsiflexion, retrocalcaneal pressure dropped from 117 mmHg to 66 mmHg (N = 7, -44%, p = 0.018) after the procedure. Our study did not find significant changes in the anterior or posterior Achilles strain secondary to the osteotomy. The strain increased in the anterior fibers by 20% (N = 9, p = 0.484) and decreased in the posterior fibers by 39% (N = 9, p = 0.088). Conclusion: Biomechanical testing in a cadaveric model demonstrates that the Zadek osteotomy significantly decreased retrocalcaneal pressure, shifted the Haglund's prominence anteriorly, shifted the Achilles tendon insertion superiorly, increased the X/Y ratio of the calcaneus, and did not significantly change the strain on the Achilles tendon. These results may explain the improvements in pain and function seen in clinical studies. However, nonpathological foot and ankle specimens were used in this study, which should affect interpretation. Overall, the current results support the Zadek osteotomy can be a viable treatment option for relieving pressure within the retrocalcaneal bursa for insertional Achilles tendinopathy. Zadek Osteotomy and Mechanical Testing Setup i-iii) Illustration of the Zadek Osteotomy technique performed. A &amp; B) Illustration depicting cadaveric foot and ankle specimen in testing rig before and after dorsiflexion respectively

Effect of Glenohumeral Abduction on Supraspinatus Tendon Strain: A Cadaveric Study

Objectives Rotator cuff tears are among the most common causes of shoulder pain and loss of function in adults. The supraspinatus tendon plays a crucial role in shoulder abduction, where a better understanding of the mechanical environment could lead to more informed clinical decisions. This study aimed to examine the heterogeneous nature of the supraspinatus tendon to understand the differences in regional strain patterns. Methods Five fresh frozen cadaveric shoulders were abducted from 60° to 90°. The supraspinatus tendon was loaded at 30 newtons to simulate motion in a subject operating at roughly 26% of the maximum glenohumeral abduction force. The surface strain at the supraspinatus tendon insertion, where tears most commonly occur, was evaluated in the tendon’s anterior, middle, and posterior regions to identify the heterogeneous deformation during abduction. Results Surface strain increased with increasing abduction angle (R2 = 0.697, P &lt; 0.001). The posterior regions exhibited larger strains compared to the anterior regions at 70° (P = 0.037), 75° (P = 0.028), and 90° (P = 0.011) of abduction. Conclusion During abduction, the strain on the bursal surface of the supraspinatus tendon insertion increases with increasing abduction angle, and the posterior region experiences the largest strains.

Evaluation of Shampakadi Basti and Kshar Basti along with Pristha Basti in Trik Grah (Ankylosing Spondylitis)

Basti is considered the most effective treatment for Vata, as well as for Pitta, Kapha, and Rakta (blood) in Samsarga, and Sannipata Doshaas. Within the 'Nanatmaja vyadhi' of Vata, Charaka sutra 20/10 mentions a total of eighty types of Vata Rogas, known as Ashiti Roga. Trik-Asthi is sacrum bone. Sacroiliitis is often the earliest manifestation of ankylosing spondylitis. Ankylosing spondylitis is a complex, and systemic inflammatory rheumatic disease mainly affecting the axial skeleton, with the potential to cause severe debilitation. Fibrosis and ossification of tendon, ligament and capsule insertion at the area of sacroiliac and intervertebral discs are the main characteristics of ankylosing spondylitis. Eighty types of Nanatmaja Vata Vikara caused by Vata. Trik Grah one of the Vata Nanatamaja Vyadhi. Vata-Vyadhies can be considered as a group of such diseases, which Modern Science has given different names. Methods: This clinical study was done to “Evaluation of Shampakadi Basti and Kshar Basti along with Pristha Basti in Trik Grah (ankylosing spondylitis)”. Basti Karma is known to be the best for Vata disorders thus for this research, open labelled clinical study was done wherein 50 patients were taken in random manner having symptoms of Trik Grah and were divided into two groups, Group A received Shampakadi Basti along with Pristha Basti and Group B received Kshar Basti along with Pristha Basti daily for 8 days. Results: Evaluation and the result of both the group exhibited that the improvement provided by group B was better in both sign &amp; symptoms like Sandhi Shool (pain), Sandhi Jadyata (stiffness), Angamarda (fatigue), quality of sleep in comparison to group A. Conclusion: As Vata vitiation is a cause Trik Grah, no other treatment modality act as good as Basti. As Ama involvement was there, which was obstructing or vitiating the Samanya Vata action, thus Shampakadi Basti and Kshar Basti along with Pristha Basti showed encouraging results in this disease.

Olecranon fractures: An old fixation device for a new surgical technique

IntroductionInternal fixation in not-comminuted oblique and transverse olecranon fractures is commonly performed with tension band wiring. However, despite its high healing rate, this technique is associated with a high rate of complications, often requiring the removal of fixation devices in up to 80 % of cases. The aim of our study was to describe a surgical technique using eyelet pins that maintains the effectiveness of the classic tension band wiring while reducing intolerance or displacement of the fixation devices. MethodsFifteen patients with surgically treated Mayo type II A or II B olecranon fractures, meeting the inclusion criteria, were enrolled. Clinical and functional assessments were conducted using MEPS and DASH scores at the 12 month follow-up. Additionally, complications and the duration of the operation were documented. ResultsFifteen patients were enrolled, with eight having type II A and seven having type II B olecranon fractures. The mean patient age was 46.8 years, including ten males and five females. Nine cases involved the right side, while six involved the left. At the 12-month follow-up, the mean MEPS score was 98/100, and the DASH score was 9. Two patients (13.3 %) experienced superficial wound infections, and two (13.3 %) had persistent pain at the triceps tendon insertion site. No cases required removal of fixation devices. ConclusionThe eyelet pin system was found to be a safe and effective method for reducing and fixing olecranon fractures. Based on a limited series, this new technique exhibits the same reliability and reproducibility as tension band wiring but with a lower rate of complications.

Omega Plate Fixation of Comminuted Olecranon Fractures: Technique and Case Series.

Fixation of olecranon fractures, especially those with minimal proximal bone and those that present with significant comminution, can be technically challenging. Current open reduction and internal fixation (ORIF) methods, such as tension band wire (TBW) constructs, plate fixation (PF), and intramedullary screws (IMSF), have demonstrated high rates of reoperation and symptomatic implants. We present the omega plate technique, which utilizes a mini-fragment plate passed under the triceps tendon insertion, allowing maximal implant surface area contact with small, proximal olecranon fracture fragments. The mini-fragment plate is not placed on the dorsal subcutaneous border of the ulna, which allows it to capture medial and lateral fragments of cortical comminution and may contribute to less soft tissue irritation.