Lateral Tendon Research Articles

Defining a Safe Zone for All-Inside Lateral Meniscal Repairs in Pediatric Patients: A Magnetic Resonance Imaging Study

To establish a safe zone for all-inside meniscal fixation in pediatric patients by use of magnetic resonance imaging (MRI) measurements between the popliteal tendon (PT) and popliteal neurovascular bundle (PNVB). Patients aged 5 to 16years with normal or nearly normal knee MRI scans were included. They were grouped by age: group I, 5 to 7years (n= 61); group II, 8 to 10years (n= 59); group III, 11 to 13years (n= 60); and group IV, 14 to 16years (n= 70). At the level of the lateral meniscus, 2 lines starting at the lateral patellar tendon border and ending at the medial edge of the PT (D1) and the lateral edge of the PNVB (D2) were made on an axial knee MRI scan. A third line (D3) connected D1 to D2 at the meniscocapsular junction of the posterior horn of the lateral meniscus (PHLM). A fourth line (D4), derived geometrically, was parallel and 8mm anterior to D3, simulating the anterior edge of the PHLM. Axial MRI scans of 250 pediatric patients (aged 5-16years) were retrospectively reviewed. Analysis showed significant correlation between age and sex for D3 (P < .0001). For D3, there were significant differences among all age groups, except between groups III and IV. The average D3 by age group was 14.1mm (standard deviation [SD], 3.1mm) for group I, 15.8mm (SD, 2.5mm) for group II, 17.0mm (SD, 3.3mm) for group III, and 17.2mm (SD, 3.1mm) for group IV. The average D4 was 11.39mm (SD, 2.6mm), 13.24mm (SD, 2.24mm), 14.59mm (SD, 2.89mm), and 14.80mm (SD, 2.79mm), respectively. There were significant differences in D3 and D4 in male versus female patients (17.6mm vs 15.7mm, P < .001, and 14.9mm vs 13.2mm, P < .001, respectively), particularly in groups III and IV (17.0mm vs 13.8mm and 16.8mm vs 13.9mm, respectively). This study provides normative data of the distance between the PNVB and PT at the meniscocapsular junction (D3) and anterior edge of the PHLM (D4) with the knee in full extension. Combined with previous studies showing that the addition of knee flexion increases the distance between the meniscus and the neurovascular bundle, these data can be used by surgeons to improve the safety of PHLM repair in pediatric patients. Level III, diagnostic study of nonconsecutive patients.

Isolated rupture of the vastus lateralis tendon: Case report

We report a patient with a history of bariatric surgery who have an isolated rupture of the unilateral vastus lateralis tendon from the adhesion site on the patella. The diagnosis was missed in this case and was placed with magnetic resonance (MR) investigation of the patient during follow-up. A 40-year-old male patient felt pain in his knee after an awkward movement. Initially, because of his bariatric surgery, he had some other complaints, the diagnosis was missed, and the patient had conservative treatment and physical therapy applied. When complaints did not improve, MR was taken, and the vastus lateralis tendon was identified to have ruptured from the patella in isolation. Treated surgically, the patient had no new rupture on check-up performed 1 year later. The patient is fully healed. After the bariatric surgery, some metabolic changes and weakness at the osteotendinous junction of muscles may occur. Isolated vastus lateralis rupture is rarely observed, and diagnosis may be missed. In these patients, surgical treatment is required and other accompanying pathologies of the knee should also be treated at the same time.

A rare muscle variation – accessory piriformis muscle

During routine anatomical dissection of the right lower limb of a 68-year-old male cadaver, a rare muscle variation was revealed and identified as an accessory piriformis muscle. This variant muscle started from the anterior surface of the sacrum below the usual piriformis muscle and extended in a well-identifiable lateral tendon also inserting to the greater trochanter of the femur. In the case described, the accessory piriformis pierced through the proximal part of the sciatic nerve. The length of the additional small muscle was 85 mm with the broadest part of the muscle belly as 9 mm. The course of the variant muscle, especially its tendinous part, might irritate the sciatic nerve and cause piriformis syndrome and other sciatica-like symptoms. The neurologists who diagnose piriformis syndrome and surgeons performing nerve releasing surgery should be well aware of the described rare muscle variation.

Optical Coherence Tomography Thickness Measurements of the Extraocular Rectus Muscle Tendons in Graves' Ophthalmopathy.

To examine extraocular rectus muscle tendons in patients with Graves' ophthalmopathy using optical coherence tomography (OCT). This was a cross-sectional observational study conducted with 55 healthy controls, 45 patients with clinically inactive Graves' ophthalmopathy, and 12 patients with clinically active Graves' ophthalmopathy. Scanning was performed at the 3- and 9-o'clock positions. The medial rectus tendon thickness was measured at 7.2 and 9.2 mm from the limbus and the lateral rectus tendon thickness was measured at 8.5 and 10.5 mm from the limbus. The 9.2-mm medial rectus, 8.5-mm lateral rectus, and 10.5-mm lateral rectus tendons were thicker in the inactive Graves' ophthalmopathy group than the control group (240 ± 70, 231 ± 63, and 228 ± 54 µm vs 201 ± 71, 199 ± 53, and 200 ± 32 µm, respectively; P ≤ .011), whereas the 8.5-mm lateral rectus and 9.2-mm medial rectus tendons were thicker in patients with active Graves' ophthalmopathy than patients with inactive Graves' ophthalmopathy (274 ± 77 and 283 ± 68 µm vs 231 ± 63 and 240 ± 70 µm, respectively; P ≤ .048). A correlation was detected between lateral rectus and medial rectus tendon thicknesses and the Graves' ophthalmopathy clinical activity score (R = 0.252, P = .035; and R = 0.291, P = .013, respectively). OCT emerged as an accurate method for measuring medial rectus and lateral rectus tendon thicknesses in patients with Graves' ophthalmopathy. The imaging tool was able to detect thicker horizontal rectus tendons in patients with inactive Graves' ophthalmopathy than in controls, and in patients with active compared to inactive disease. [J Pediatr Ophthalmol Strabismus. 2018;55(6):356-362.].

Accessory Belly of the Plantaris Muscle and its Clinical Relevance

The plantaris muscle is accessory flexor group muscle of the lower leg. The muscle originates from the lower part of the lateral supracondylar line of the femur and the oblique popliteal ligament, inserted medial to calcaneal tuberosity. During the routine dissection for the undergraduate medical students we encountered accessory plantaris muscle originating medial side of the femoral condyle and capsular ligament. Both the normal lateral and accessory medial tendons fused to form long slender tendon and inserted medial to calcaneal tuberosity. Knowledge of variable origin, course and the insertion of the plantaris muscle is important for surgeons performing various reconstructive surgeries.

Distal triceps transosseous cruciate versus suture anchor repair using equal constructs: a biomechanical comparison

Suture anchor-based repair has been advocated for repair of distal triceps avulsion, but previous models have used an unequal number of sutures across the repair site. We hypothesized that there would be no difference in triceps tendon displacement between gold standard repair with transosseous cruciate bone tunnels and suture anchor repair with an equal number of sutures in the constructs. The triceps tendon footprint was measured in 20 cadaveric elbows (10 matched pairs), and a distal triceps tendon rupture was created. The specimens in each pair were randomly assigned to transosseous cruciate repair or knotless, double-row, anatomic footprint, suture anchor repair. Specimens underwent cyclic loading to 1500 cycles and then load to failure. Footprint uncoverage was measured at 1500 cycles. Data for medial and lateral triceps tendon displacement, footprint uncoverage, and failure load were obtained. Triceps displacement did not differ significantly between the transosseous cruciate and the suture anchor repair group at 1500 cycles on the medial (3.6 ± 0.9 mm vs. 4.3 ± 1.6 mm [mean ± standard deviation], respectively; P = .27) and lateral side (3.1 ± 1.2 mm vs. 2.0 ± 1.2 mm, respectively; P = .06). No other differences were found between the constructs. Transosseous cruciate distal triceps repair and knotless double-row suture anchor repair using constructs with an equal number of sutures showed no significant difference in tendon displacement at 1500 loading cycles. These findings suggest that the biomechanical strength of an all-suture construct is not different from that of suture anchors for repair of distal triceps avulsions.

Ultrasound diagnosis of lateral digital extensor muscle, tendon, and synovial sheath alterations in Colombian creole horses with clinical signs of tarsus hyperflexion.

Background: Tarsus hyperflexion alters locomotion biomechanics in horses. This alteration is of frequent presentation in the Colombian creole horse (CCH). Objective: To determine the echographic alterations of lateral digital extensor (LDE) muscle, tendon, and synovial sheath in CCH with clinical signs of tarsus hyperflexion. Methods: Thirty horses were divided into two groups: 15 healthy horses with no history of locomotion defects (Group 1; control), and 15 horses with clinical signs of tarsus hyperflexion (Group 2). A cross-sectional and a longitudinal echocardiographic examination of the LDE muscle and tendon was performed in all horses, and a histopathological study was performed only to Group 2. Results: 86.7% of the horses showed echographic alterations, with 53.4% showing signs of adhesions in the LDE muscle and tendon in the lateral surface of the hock, where it crosses the tarsus. 33.3% presented increased tendon sinovial sheath fluid. 13.3% showed no echographic alterations and 53.3% presented histopathological alterations. Conclusion: These findings may be related to the presentation of tarsus hyperflexion that could characterize the classic stringhalt in CCH. Keywords: Equine, hock hyperflexion, locomotion, mechanical claudication, stenosing tenosynovitis. Resumen Antecedentes: la hiperflexion del tarso (corvejon) altera la biomecanica del desplazamiento en los caballos. Esta alteracion es de presentacion frecuente en el caballo criollo colombiano (CCC). Objetivo: determinar las alteraciones ecograficas del musculo extensor digital lateral (EDL), tendon y vaina sinovial en CCC con signos clinicos de hiperflexion del corvejon. Metodos: treinta caballos fueron divididos en dos grupos: 15 equinos clinicamente sanos, sin historia de defectos de locomocion (Grupo 1; considerado como control), y 15 equinos con signos clinicos de hiperflexion del corvejon (Grupo 2). Se realizo un examen ecografico transversal y longitudinal del musculo y tendon del EDL en todos los animales, y un estudio histopatologico solo al Grupo 2. Resultados: el 86,7% de los caballos mostraron alteraciones ecograficas. El 53,4% mostro signos de adherencias en el musculo y tendon del EDL, en donde la superficie lateral del corvejon se cruza con el tarso. El 33,3% presento un aumento en el liquido de la vaina sinovial del tendon. El 13,3% no presento ninguna alteracion ecografica, y el 53,3% mostro alteraciones histopatologicas. Conclusion: estos hallazgos podrian estar relacionados con la presentacion de hiperflexion del tarso que puede caracterizar el arpeo clasico en el CCC. Palabras clave: claudicacion mecanica, equino, hiperflexion del corvejon, locomocion, tenosinovitis estenosante. Resumo Antecedentes: a hiperflexao do tarso altera a biomecânica da locomocao dos cavalos. Esta alteracao e de frequente apresentacao no cavalo crioulo colombiano (CCC). Objetivo: determinar as alteracoes no ultrassom do musculo extensor digital lateral (EDL), o tendao e a bainha sinovial em CCC com sinais clinicos de hiperflexao do jarrete. Metodos: trinta cavalos foram divididos em dois grupos: 15 cavalos clinicamente saudaveis sem historico de alteracoes em locomocao (Grupo 1; considerada como controlo), e 15 cavalos com sinais clinicos de hiperflexao do jarrete (Grupo 2). Se realizaram avaliacoes ultrassonograficas transversais e longitudinais do musculo e do tendao do EDL na totalidade dos animais e estudo histopatologico so ao Grupo 2. Resultados: o 86.7% dos equinos mostraram alteracoes no ultrassom, o 53.4% mostrou aderencias no tendao do EDL na proximidade onde cruza a superficie lateral do jarrete, o 33.3% apresentou aumento do liquido da bainha sinovial do tendao, o 13.3% nao apresentou nenhuma alteracao ultrassonografica e o 53.3% mostrou alteracoes histopatologicas. Conclusao: esses achados podem estar relacionados a apresentacao da hiperflexao do tarso que poderiam caracterizar o arpejamento classico no CCC. Palavras-chave: claudicacao mecânica, equino, hiperflexao do jarrete, locomocao, tenossinovite estenosante.

The V-Shaped Distal Triceps Tendon Repair: A Comparative Biomechanical Analysis

Background: Restoring footprint anatomy, minimizing gap formation, and maximizing the strength of distal triceps tendon repairs are essential factors for a successful healing process and return to sport. Hypothesis: The novel V-shaped distal triceps tendon repair technique with unicortical button fixation closely restores footprint anatomy, provides minimal gap formation and high ultimate failure load, and minimizes iatrogenic fracture risk in acute/subacute distal triceps tendon tears. Study Design: Controlled laboratory study. Methods: Twenty-four cadaveric elbows (mean ± SD age, 66 ± 5 years) were randomly assigned to 1 of 3 repair groups: the transosseous cruciate repair technique (gold standard), the knotless suture-bridge repair technique, and the V-shaped distal triceps tendon repair technique. Anatomic measurements of the central triceps tendon footprint were obtained in all specimens with a 3-dimensional digitizer before and after the repair. Cyclic loading was performed for a total of 1500 cycles at a rate of 0.25 Hz, pulling in the direction of the triceps. Displacements were measured on the medial and lateral tendon sites with 2 differential variable reluctance transducers. Load to failure and construct failure mode were recorded. Results: The mean triceps bony insertion area was 399.05 ± 81.23 mm2. The transosseous cruciate repair technique restored 36.6% ± 16.8% of the native tendon insertion area, which was significantly different when compared with the knotless suture-bridge repair technique (85.2% ± 14.8%, P = .001) and the V-shaped distal triceps tendon repair technique (88.9% ± 14.8%, P = .002). Mean displacement showed no significant difference between the V-shaped distal triceps tendon repair technique (medial side, 0.75 ± 0.56 mm; lateral side, 0.99 ± 0.59 mm) and the knotless suture-bridge repair technique (1.61 ± 0.97 mm and 1.29 ± 0.8 mm) but significance between the V-shaped distal triceps tendon repair technique and the transosseous cruciate repair technique (4.91 ± 1.12 mm and 5.78 ± 0.9 mm, P < .001). Mean peak failure load of the V-shaped distal triceps tendon repair technique (732.1 ± 156.0 N) was significantly higher than that of the knotless suture-bridge repair technique (505.4 ± 173.9 N, P = .011) and the transosseous cruciate repair technique (281.1 ± 74.8 N, P < .001). Mechanism of failure differed among the 3 repairs, with the only olecranon fracture occurring in the knotless suture-bridge repair technique at the level of the lateral row suture anchors. Conclusion: At time zero, the V-shaped distal triceps tendon repair technique and the knotless suture-bridge repair technique both provided anatomic footprint coverage. Ultimate load to failure was highest for the V-shaped distal triceps tendon repair technique, while gap formation was different only in comparison with the transosseous cruciate repair technique. Clinical Relevance: The V-shaped distal triceps tendon repair technique provides an alternative procedure to other established repairs for acute/subacute distal triceps tendon ruptures. The reduced repair site motion of the V-shaped distal triceps tendon repair technique and the knotless suture-bridge repair technique at the time of surgery may allow a more aggressive rehabilitation program in the early postoperative period.

Evaluation of pain threshold upon palpation of the masticatory muscles in women with temporomandibular disorder according to the Research Diagnostic Criteria of Temporomandibular Disorders

ABSTRACT Purpose: to evaluate the pain threshold upon palpation of the masticatory muscles in women with temporomandibular disorder (TMD) according to the Research Diagnostic Criteria of Temporomandibular Disorders (RDC/TMD). Methods: a cross-sectional study was conducted involving the evaluation of pain threshold upon palpation of the extraoral muscles (temporal, masseter, posterior mandibular region, submandibular region) and intraoral muscles (lateral pterygoid area and temporal tendon) in women using the RDC/TMD clinical examination. Results: 60 women were evaluated. Statistically significant differences were found among the muscles evaluated regarding the pain threshold. The lateral pterygoid area, bilaterally, had the lowest pain threshold, followed by the masseter and temporal muscles. Conclusion: this study suggests that the lateral pterygoid muscle, bilaterally, has the lowest pain threshold upon palpation among the masticatory muscles, followed by masseter and temporal muscles, in women with TMD, according to the RDC/TMD evaluation.

Partial avulsion of the ulnaris lateralis and enthesiopathy of the lateral epicondyle of the humerus in a thoroughbred race horse

BackgroundThere is relatively little literature on elbow disease in the horse. The only published reports on soft tissue conditions describe collateral ligament and biceps brachii injuries.Case presentationA three-year old Thoroughbred gelding presented with a history of acute onset right forelimb lameness of less than one week duration, one month after commencing training in a National Hunt racing yard. Physical examination and peri-neural anaesthesia failed to localise the lesion. Lameness was localised to the distal humerus by nuclear scintigraphy and intra-articular anaesthesia. A partial avulsion of the tendinous origin of the ulnaris lateralis and enthesiopathy of the lateral humeral epicondyle was diagnosed on ultrasonography. Ultrasonographic findings were loss of longitudinal fibre pattern, a discrete hypo-echoic region within the ulnaris lateralis tendon of origin, and remodelling of the lateral epicondyle of the right humerus at the site of the origin of the ulnaris lateralis. No abnormalities were identified on radiography. The lameness did not resolve with rest, but was successfully treated with extra corporal shockwave therapy (ECSWT) and intra-lesional corticosteroid injections.ConclusionThis is the first report of partial avulsion of the ulnaris lateralis and enthesiopathy of the lateral humeral epicondyle in the horse. In contrast to other reported soft tissue conditions of the elbow, this horse had a successful return to work. This case highlights the value of ultrasonography in assessing peri-articular soft tissues, and the importance of pain relief as treatment in some soft tissue injuries.

Ultrasonography, computed tomography and magnetic resonance imaging of the bovine metacarpo/metatarsophalangeal joint

The aims of the present study were to describe the normal ultrasonographic, magnetic resonance imaging (MRI) and computed tomographic (CT) appearances of the bovine metacarpo/metatarsophalangeal (MCP/MTP) joints and to assess the normal cross-sectional dimensions of the superficial (SDFT) and deep (DDFT) digital flexor tendons. A systematic ultrasound examination was performed on the MCP/MTP joints of 22 healthy cattle and two bovine cadavers, and the cross-sectional dimensions of the SDFT and DDFT were recorded. The cadaveric MCP/MTP joints (n=8) were scanned using a 16-slice multi-detector CT scanner and a 1.5 Tesla MRI scanner, injected with green latex and sectioned into transverse (n=4), sagittal (n=2) and dorsal (n=2) slices. Ultrasonographic, CT and MRI images were correlated with corresponding findings in anatomical dissections for the distal aspects of the third and fourth metacarpal/metatarsal bones, proximal aspects of the proximal phalanges, proximal sesamoid bones, lateral, common and medial digital extensor tendons, SDFT, DDFT, axial and abaxial collateral ligaments, suspensory, palmar/plantar, interdigital intersesamoidean and interdigital phalangosesamoidean ligaments, and collateral, cruciate and short sesamoidean ligaments. The axial and collateral sesamoidean ligaments could not be evaluated by ultrasonography. The articular cartilage, and the short and cruciate sesamoidean ligaments, were not identified in CT images. The cross-sectional dimensions of the SDFT and DDFT differed significantly between the forelimbs and hind limbs (P<0.05); there were no significant differences between the contralateral limbs. The annotated ultrasonographic, CT and MRI images are intended as a normal reference that could be useful for interpretation of clinical disease in the bovine MCP/MTP joint.

Variations in distal attachment of muscles of the leg, foot and the hand and their clinical implications in population of central Ethiopia

Anatomical variations in the distal attachment of lower and upper limb muscles are of paramount importance in surgical and clinical practice. Reports show variations in the insertion of the fibularis longus and brevis tendon from the lateral compartment of the leg, extensor hallucis longus and fibularis tertius from the anterior compartment of the leg, flexor digitorium brevis from the sole of the foot and the existence of accessory muscles in the dorsum of the hand. However, reports are scanty from Ethiopia. The present study was aimed at assessing the existence of variation in the distal attachments of muscles of the lower and upper limbs in the central Ethiopia population. Twenty-two formalin fixed cadavers were used. Careful dissection, critical observation and imaging were done accordingly. We have found the presence of two tendons of extensor halluces longus in one cases, absence of the lateral tendon to the 5thdigit of the flexor digitorum brevis of the sole of the foot in another case and the presence of the accessory extensor indicis muscle on the dorsum of the hand in a third case. These variations are important owing to the use of the tendons in tendon transfer surgeries to correct deformities of the hand, foot and ankle joint, and also for radiologists, clinicians, and surgeons in order to prevent adverse surgical events.

Didatic approach of ultrasonographic examination for evaluation of the carpal joint in horses

ABSTRACT: The carpus is a complex articulation, which is often involved in injuries in equine athletes. The objective of this study was to suggest a didactic approach for ultrasonography training for the examination of the carpal joint in horses. Ultrasonograhy examination was performed in a healthy 14-year-old horse. The images were compared with those of a dissected anatomic specimen of the carpal region of a senior horse and with those reported in the literature. Identifiable structures were as follows: (dorsal) tendon of the muscle extensor carpi radialis, tendon of the muscle extensor carpi obliquus, tendon of the muscle commom digital extensor, dorsal synovial outpouchings, joint capsule and fat cushion, (lateral) tendon of the muscle lateral digital extensor, lateral collateral ligament (deep and superficial components), (medial) medial collateral ligament (deep and superficial components) and (palmar) palmar intercarpal ligament, carpal sheath, carpal tunnel, superficial digital flexor tendon, proximal origin of the deep digital flexor tendon, and palmar carpal ligament. Prior knowledge of the anatomy in combination with the study of anatomical specimens is essential for recognizing musculoskeletal structures during ultrasound examination, contributing to the training and learning processes.

Peritendinous injection of platelet-rich plasma to treat tendinopathy: A retrospective review

ObjectiveThe aim of this study was to determine factors associated with the likelihood of a better clinical outcome after the peritendinous injection of PRP for the treatment of chronic tendinopathy and identify whether PRP represents an effective treatment option for chronic tendinopathies. MethodsThe study included 214 patients (86 males and 128 females; mean age: 39.3 (18–75) years) who received PRP injections for tendinopathy refractory to conventional treatments. The mean duration of symptoms at the moment of the PRP treatment was 8.3 months. Primary outcome measurement was perceived improvement in symptoms for each anatomic compartment for upper and lower limbs at 6 months after treatment. Also, a visual analog scale (VAS) score (pain intensity on a 0–10 scale) was used for pain scoring questionnaire before treatment, 6 weeks and 6 months following the PRP injection(s). To identify factors associated with the likelihood of a better clinical outcome, patients were categorized on the basis of their perceived improvement in symptoms 6 months after the PRP injection(s)—that is, as lower (less than 50% global improvement) or higher (more than 50% global improvement). ResultsA visual analogue scale score and perceived improvement in symptoms were significantly lower after peritendinous injection in 6-week and 6-month follow-ups compared with the baseline (P < 0.001) except for peroneal and Achilles tendons. Overall, 83% of patients indicated moderate to complete improvement in symptoms. The most common injection sites were the lateral epicondyle, Achilles, and patellar tendons. Furthermore, 30% of patients received only 1 injection, 30% received 2 injections, and 40% received 3 or more injections. A total of 85% of patients were satisfied (more than 50% global improvement) with the procedure. In addition, upper limb tendons, increase in the age, and female gender were associated with a higher likelihood of perceived improvement in symptoms. ConclusionsIn the present retrospective study assessing PRP injections in the treatment of chronic tendinopathy, a moderate improvement (>50%) in pain symptoms was observed in most of the patients. Our research found that results were most promising with patellar and lateral epicondylar tendinopathy in the short to medium term. Female patients, patients with upper extremity tendinopathy and older patients appeared to benefit more from PRP injection. Level of evidenceLevel IV, Therapeutic study.

Ankle Evaluation in Active Rheumatoid Arthritis by Ultrasound: A Cross-Sectional Study

Ankle joint evaluation is underestimated in many clinical and sonographic scores used for evaluation and follow-up of rheumatoid arthritis (RA) patients. Agreement on examination parameters is poor among sonographic scores that include the ankle joint. More effort is needed to detect the value of ankle joint examination in RA and assessment of ultrasonographic signs according to frequency, disease duration and activity. The objective of this study was to use ultrasound (US) to detect ankle involvement in active RA and to compare findings with disease duration, disease activity and assessment of ankle bone erosion. A total of 63 RA patients with active disease and 20 controls were included in the study. The tibiotalar and talonavicular joints were examined by US for synovitis and/or effusion in gray-scale and power Doppler modes. The anterior, lateral and posterior ankle tendons were examined for tenosynovitis and tendinosis. Mean age was 35.1 ± 8.3 y, mean disease duration was 22.7 ± 9.6 mo and the mean 28-joint Disease Activity Score–erythrocyte sedimentation rate was 3.05 ± 0.66. Ankle involvement was seen in 28 patients (44.4%). The most frequent pathologies detected were tenosynovitis (30.2%), followed by synovitis (18.3%), erosion (8.7%) and tendinosis (4%). The earliest sonographic signs were tenosynovitis, followed by synovitis, erosion and tendinosis. The right ankle exhibited greater involvement than the left ankle, which was significant with respect to erosions (p = 0.009). The most common tendon affected by tenosynovitis was the tibialis anterior (22.2%), followed by the tibialis posterior (20.6%). Tenosynovitis, especially of the tibialis anterior and posterior, tibiotalar synovitis and erosions should be considered in future US ankle scores for the assessment of RA.

The pyramidalis\u2013anterior pubic ligament\u2013adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept

PurposeAdductor longus injuries are complex. The conflict between views in the recent literature and various nineteenth-century anatomy books regarding symphyseal and perisymphyseal anatomy can lead to difficulties in MRI interpretation and treatment decisions. The aim of the study is to systematically investigate the pyramidalis muscle and its anatomical connections with adductor longus and rectus abdominis, to elucidate injury patterns occurring with adductor avulsions.MethodsA layered dissection of the soft tissues of the anterior symphyseal area was performed on seven fresh-frozen male cadavers. The dimensions of the pyramidalis muscle were measured and anatomical connections with adductor longus, rectus abdominis and aponeuroses examined.ResultsThe pyramidalis is the only abdominal muscle anterior to the pubic bone and was found bilaterally in all specimens. It arises from the pubic crest and anterior pubic ligament and attaches to the linea alba on the medial border. The proximal adductor longus attaches to the pubic crest and anterior pubic ligament. The anterior pubic ligament is also a fascial anchor point connecting the lower anterior abdominal aponeurosis and fascia lata. The rectus abdominis, however, is not attached to the adductor longus; its lateral tendon attaches to the cranial border of the pubis; and its slender internal tendon attaches inferiorly to the symphysis with fascia lata and gracilis.ConclusionThe study demonstrates a strong direct connection between the pyramidalis muscle and adductor longus tendon via the anterior pubic ligament, and it introduces the new anatomical concept of the pyramidalis–anterior pubic ligament–adductor longus complex (PLAC). Knowledge of these anatomical relationships should be employed to aid in image interpretation and treatment planning with proximal adductor avulsions. In particular, MRI imaging should be employed for all proximal adductor longus avulsions to assess the integrity of the PLAC.

Comparison of anatomical risk factors for noncontact anterior cruciate ligament injury using magnetic resonance imaging

PurposeTo compare the significance of the tibio-femoral geometrical indices (notch width index, medial and lateral tibial slopes) and patellar tendon- tibial shaft angle in predicting non-contact ACL injuries and to compare these factors between genders. MethodsRetrospective case control study evaluating 66 MRI knee of patients of age group of 18–60 years with 33 cases of noncontact ACL injury and 33 age matched controls. Notch width index, medial and lateral tibial slopes and patellar tendon tibial shaft angles were calculated and compared for statistical significance and was also compared between the genders. ROC curve was for plotted for the significant factors. ResultsStatistically significant difference was seen in notch width index and patellar tendon tibial shaft angles with cases showing a narrow notch width index and an increased patellar tendon tibial shaft angle. Gender comparative results showed no statistically significant differences. ROC curve plotted for NWI showed an optimal cut off value of 0.263 with a sensitivity of 88% and a specificity of 52%. ROC curve plotted for PTTS angle showed a cut off value of 26.7 degrees with a sensitivity of 67% and a specificity of 49%. ConclusionNarrow Notch width index and increased Patellar tendon tibial shaft angle are predictors of ACL injury. PTTS angle which has been studied as a function of knee flexion angle, can itself be an independent predictor of ACL injury (at a constant knee flexion angle).

Surgical Microanatomy of Lower Eyelid Tarsal Ectropion Repair With a Putterman Ptosis Clamp.

To examine the changes in microscopic anatomy of the lower eyelid tarsal ectropion repair with the Putterman ptosis clamp and better understand the anatomical changes associated with the eyelid malposition correction. Ten orbits from 5 fresh frozen cadaver heads, ranging in age from 53 to 77 years, were used for the dissection. For each head, a Putterman clamp tarsal ectropion repair was performed on one side, while the contralateral unoperated orbit served as a control. After performing the procedure, both orbits were exenterated and they, along with the resected specimens, were studied microscopically using Verhoeff-Masson trichrome and hematoxylin-eosin stains. Conjunctiva, capsulopalpebral fascia, and smooth muscle were present on all tissue specimens incarcerated within the ptosis clamp. Tarsus was present in one specimen. There was a shortening of the posterior lamella of the eyelid with advancement of the capsulopalpebral fascia on all operated specimens when compared with controls. The Putterman clamp ectropion repair works by shortening the posterior lamella of the eyelid and advancing the lower eyelid retractors superiorly. This advancement tightens the lower eyelid retractors and thus stabilizes the eyelid in a more vertical position. In addition to a lateral tendon tuck as described in the original article to tighten horizontal eyelid laxity, this procedure addresses both vertical and horizontal laxity of tarsal ectropion.

Anchored Transosseous-Equivalent Versus Anchorless Transosseous Rotator Cuff Repair: A Biomechanical Analysis in a Cadaveric Model

Background: The original approach for the repair of torn rotator cuffs involved an open technique with sutures passing through the greater tuberosity and tendon. The development of suture anchors allowed for an all-arthroscopic approach with anchor configurations attempting to re-create a transosseous fixation pattern. Presently, an arthroscopic approach can be combined with a transosseous suture configuration without using anchors. Purpose: To evaluate cyclic loading, ultimate load to failure, and the failure mechanisms of transosseous-equivalent (TOE) repair with anchors and anchorless transosseous (AT) repair of rotator cuff tears. Study Design: Controlled laboratory study. Methods: Supraspinatus tears (25 mm) were created in 20 fresh-frozen, human cadaveric shoulders, which were randomized to TOE or AT repair (10 in each group, paired experimental design). Biomechanical testing was performed with an initial preload, cyclic loading, and load to failure. Optical markers were used to monitor gap formation in 3 planes, and the failure mode was recorded. Paired t tests were used to make comparisons of biomechanical parameters between the groups. Multinomial logistic regression was used to compare failure modes between the groups. Significance was set to .05. Results: The TOE group had a significantly higher mean (±SD) ultimate failure load (578.5 ± 123.8 N) than the AT group (468.7 ± 150.9 N) (P = .034). The TOE group also had a significantly less mean first-cycle excursion (2.97 ± 1.97 mm) than the AT group (4.70 ± 2.04 mm) (P = .046). There were no significant differences between the groups in cyclic elongation or linear stiffness during cyclic loading. Primary modes of failure were a type 2 tendon tear with medial tendon disruption in the TOE group (7/10) and a type 1 tendon tear with lateral tendon disruption in the AT group (6/10). Conclusion: TOE repair resulted in a significantly higher mean failure load compared with AT repair in a cadaveric model. The most common modes of failure were a type 2 tendon tear in the TOE group and a type 1 tendon tear in the AT group. Clinical Relevance: A higher mean failure load in TOE versus AT constructs may come at the cost of a less favorable failure mode adjacent to medial anchors at the musculotendinous junction, potentially making revision difficult.

Arthroscopy-Assisted Fabella Excision: Surgical Technique

The fabella is an anatomic variant not seen in all individuals and can potentially be a source of chronic knee pain due to chondromalacia, osteoarthritis, fractures, or biomechanical pressure against the lateral femoral condyle. It is situated intra-articular, close to the lateral femoral condyle, the lateral gastrocnemius head tendon, and the fabellofibular ligament. Given its rarity, the diagnosis of a symptomatic fabella is often overlooked when evaluating patients with persistent posterolateral knee pain. However, this diagnosis should always be considered, especially in high-performance runners, bikers, and triathletes. Although nonoperative management can potentially resolve symptoms associated with this condition, fabella excision via arthroscopically assisted surgery is a reliable and safe alternative to treat patients who do not benefit from nonsurgical treatment. We present our technique detailing fabella excision for treatment of posterolateral knee pain, which includes an arthroscopic evaluation of the fabella to assess damage to the femoral condyle and minimize over-resection and potential damage to surrounding structures.