Tendon Release Research Articles

Hand-Grip Strength and Return to Heavy Manual Work at a Mean 5-Year Follow-up After Arthroscopic Release of Recalcitrant Lateral Epicondylitis

Background:Lateral epicondylitis of the elbow is a common degenerative disorder in middle-aged patients. Surgery is reserved for patients who do not respond to nonoperative treatment.Purpose:To evaluate hand-grip strength and return to heavy manual activities in patients engaged in work requiring heavy lifting after arthroscopic release of refractory lateral epicondylitis.Study Design:Case series; Level of evidence, 4.Methods:The study included consecutive patients who underwent arthroscopic release of the extensor carpi radialis brevis tendon to treat recalcitrant lateral epicondylitis of the elbow, with a minimum 48-month follow-up. Functional outcome measures included assessment of hand-grip strength, visual analog scale for pain, and Mayo elbow performance score. The recorded measurements were compared at postoperative 1 and 6 months and the final assessment. Pre- and postoperative data were compared using the paired t test, and the various postoperative assessments were compared using 1-way analysis of variance.Results:A total of 22 patients (mean ± SD; age, 34.6 ± 5.9 years) with a mean follow-up of 60.5 ± 4.7 months were included in our study. There were highly significant improvements between preoperative and 1-month postoperative results regarding hand-grip strength (17.5 ± 4.1 kg to 34.4 ± 6.8 kg), visual analog scale score for pain (7.86 ± 1.2 to 1.8 ± 1.09), and Mayo score (57.1 ± 7.9 to 89.3 ± 4.9; P < .00001 for all). Significant improvements were found on all 3 functional measures between 1 and 6 months postoperatively (P ≤ .05 was statistically significant), and there were nonsignificant improvements on all measures from 6-month to final follow-up. The patients regained 96.4% of their hand strength as compared with the unaffected side and returned to their previous activities without reporting serious complications.Conclusion:Minimally invasive arthroscopic release of recalcitrant lateral epicondylitis of the elbow provided a satisfactory functional result, as shown by regaining of hand-grip strength in patients engaged in heavy manual occupations without significant morbidities.

Arthroscopic release of the pectoralis minor tendon as an adjunct to acromioplasty in the treatment of subacromial syndrome associated with scapular dyskinesia

IntroductionOne of the causes of scapular dyskinesia is the retraction of the pectoralis minor muscle. It can be the cause of shoulder pain associated with increased anterior tilt and internal rotation of the shoulder. HypothesisArthroscopic release of the pectoralis minor tendon is effective for shoulder pain, linked to a correction of dyskinesia, resulting in the early disappearance of scapulalgia. Patients and methodsThis was a retrospective, monocentric, single-surgeon study on a continuous series of patients with symptomatic shoulder pain, related to subacromial impingement associated with scapular dyskinesia. The series underwent arthroscopic tenotomies of the pectoralis minor between January 2015 and September 2018. Fifty-eight releases were performed to 57 patients (22 males, 35 females), with a mean age of 51.4 years (29–66 years). In all cases, they presented pain on palpation of the upper bundle of the trapezius muscle, and on palpation of the coracoid insertion of the pectoralis minor. ResultsPreoperatively, there were 30 cases of stage 1 scapular dyskinesia and 28 cases of stage 2, with a scapular index measured at 53.84 (41.66–65.78), while the constant score was 41.46 (19–59). Upper trapezius pain was present in 87.7% of cases. The 57 patients were clinically assessed, with a mean follow-up of 8.9 months (6–24 months). Post-operatively, 15 cases (25.8%) of scapulalgia persisted at 2 months of follow-up, while upper trapezius pain was present in only 22.4%. Scapular dyskinesia was no longer present at 2 months in patients without scapulalgia. The scapular index was measured at 60.42 (52.38–70.96), and the constant score at last follow-up was 76.36 (42–92). ConclusionTenotomy of the pectoralis minor improves painful symptomatology and scapular dyskinesia, in cases of subacromial syndrome with retraction of the pectoralis minor muscle. Level of EvidenceIV, retrospective study.

Endoscopic Treatment of Piriformis Syndrome Results in a Significant Improvement in Pain Visual Analog Scale Scores

PurposeTo survey the clinical satisfaction of patients who have had an endoscopic piriformis release with a sciatic nerve neurolysis.MethodsPatients with piriformis syndrome (PS) who were treated with an endoscopic piriformis release combined with a sciatic neurolysis between 2013 and 2018 were identified. All patients had a minimum follow-up of 1 year. Patients were contacted by telephone in 201,9 whereby the rate of satisfaction and pain were evaluated with the Benson surgery scale and the visual analog scale (VAS).ResultsThe average duration of symptoms at first presentation was 34 months (range 16-54 months). Thirty-seven cases (82,2%) had an EMG that showed sciatic compression around the piriformis muscle. The average preoperative VAS pain score was 7.4 (± 0.8). The mean VAS score at the time of the survey was 1.9 (± 2.4). The difference in median preoperative and postoperative VAS was 6. Using the Wilcoxon signed-rank test, we found there was a significant improvement of VAS score (with P < .001). Using the Benson operative scale, we found that outcomes at the time of the survey were excellent in 23 patients (24 cases, 53.4%), good in 10 (22.2%), fair in 3 (6.7%), and poor in 8 (17.7%). Three patients with a poor result had a wrong diagnosis of PS and ended up needing treatment for a different diagnosis. In total, 33 patients answered affirmative on the question if they would undergo the procedure again. Apart from 3 local wound infections, no major complications were observed.ConclusionsOnce a diagnosis is made, the endoscopic release of the piriformis tendon results in significant improvement in Pain VAS scores for patients with refractory symptoms despite conservative treatment.Level of EvidenceLevel IV, therapeutic case series.

Plantar Plating in the Modified Lapidus Procedure: Evaluation of Function and Impairment of the Tibialis Anterior Tendon

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Plantar Plating in the Modified Lapidus Procedure (MLP) to treat severe Hallux Valgus deformities (HVD) or hypermobility of the first ray has become more popular. Due to biomechanical considerations, early weightbearing can be achieved. The surgical procedure and some plate designs make a release of the Tibialis Anterior tendon (TAT) necessary and screws have to be placed through or close to its insertion. We investigate if there are detectable changes of the tibialis anterior tendon or the function of the tibialis anterior muscle (TAM).Methods:We retrospectively reviewed 22 Feet (17 patients) after plantar plating for a modified Lapidus procedure. All patients underwent a MRI at an average of 27 months (range 12-49 months) postoperatively for evaluation of the tendon. Clinical outcome was evaluated using the EFAS score. Dorsiflexion strength was measured and compared to the healthy contralateral extremity.Complications and union rates were assessed.Results:The subjective satisfaction was rated at a mean of 8.2 (range, 5 - 10; SD +-1.5) on a scale from 0 to 10. Fourteen (82%) patients would undergo the same surgical treatment again. MRI images showed signs of tendinopathy of the TAT in 13 feet (59%). There were no ruptures, signs of thinning of the tendon or fatty infiltration detected. Complication rate was low with only on case with performed revision surgery. Regarding the Range of Motion, the force data comparing both feet of the patients is statistically close in comparison to the other side without any statistical differences.Conclusion:The MLP using a plantar-positioned locking plate leads to high patient satisfaction rates and provides significant improvement of preoperative deformity in severe HVD at midterm follow-up. Inversion strength was reduced, and MRI showed signs of tendinopathy in more than half of the cases. However, these findings did not seem to have any effect on the clinical outcome. None of the present patients had a high degree of fatty infiltration of the TAM in accordance with the Goutallier grading. Plantar-positioned locking plates do not seem to impair the TAM or the TAT.

The effect of different doses of vitamin D on the prognosis of patients undergoing carpal tunnel syndrome surgery.

Vitamin D accelerates myelin repair and recovery after nerve damage. This study aimed to evaluate the effect of vitamin D on the prognosis of patients with carpal tunnel syndrome (CTS). A randomized clinical trial was conducted in the orthopedic ward of Golestan and Imam Khomeini hospitals in Ahvaz for 2 years (from October 2018 to October 2020). Patients were divided into three groups: the first group received 1,000 units of vitamin D daily, the second group received 4,000 units of vitamin D per week for the first 4-6 weeks and then 2,000 units per month, and the third group received no vitamin D supplementation. The results were compared before and after 6 months between the study groups. A total of 105 patients were included in the study, who were divided into three groups. The mean age of the patients was 39.24 ± 7.01 years (25-52 years). The mean level of the vitamin D in the control group was 25.40 ± 8.37 ng/mL, the group receiving 1,000 units/day was 26.71 ± 8.70 ng/mL, and the group receiving 50,000 units per week was 26.17 ± 8.63 ng/mL. The mean values of preoperative pain intensity, symptom severity, and functional status were almost the same in the three groups. These values were reduced after surgery in the two groups receiving the drug compared to the control group. The findings of the study showed that the administration of vitamin D supplementation in patients with CTS can significantly improve the postoperative symptoms of patients who underwent tendon release surgery and further improve the severity of symptoms and dysfunction of patients.

A rare case of the complex phenotype of hereditary spastic paraparesis due to a mutation in a novel gene variant

Hereditary spastic paraplegia (HSP), is a heterogeneous group of corticospinal tract disorders leading to progressive lower limb weakness and spasticity. Recessive mutations in DDHD2 characteristically involve early onset delay in motor and cognitive milestones coupled with spasticity. The complex nature of HSP is always confounding for appropriate management. An 11-year-old boy was brought by his parents for developmental delay noticed from 7 months of age and was diagnosed to have possible spastic cerebral palsy initially. Due to increasing spasticity, he underwent tendon release surgery for achilles and iliopsoas at 4 years of age. Now, he presented to us with increasing stiffness in his lower limbs even after regular physical therapy and myoclonic jerks. He had severe spasticity in the lower limbs with a power of 4/5. His activities of daily living were restricted due to severe spasticity. The lower limb deep tendon reflexes are exaggerated with positive Babinski sign and Scissoring of gait. He also had a mild intellectual disability. He was started on symptomatic management with muscle relaxants. Clinical exome sequencing showed a novel homozygous nonsense variation in exon 6 of DDHD2 gene. Prenatal genetic counseling was given for the next pregnancy and hence chorionic villus sampling for the variant testing of the developing fetus was done. The reports revealed a heterozygous state and asymptomatic carrier, unlikely to be affected by DDHD2-associated phenotype (spastic paraplegia genes 54). HSP should be considered when there is global developmental delay and increasing spasticity in lower limbs despite rehabilitation therapies.

Influence of biofeedback training time on muscle torque and knee excursion following semitendinosus release in spastic quadriplegic children with cerebral palsy: A randomized controlled trial

Background. Medial hamstring shortening represents a serious common complication in children suffering from spastic quadriplegic cerebral palsy. Objective. The purpose of the study was to examine the efficacy of biofeedback training timing following tendon release in spastic quadriplegic cerebral palsied children. Design. a prospective, single-blind, randomized controlled trial. Setting: several hospitals across Giza and Cairo, where children were operated. Methods. Thirty spastic quadriplegic cerebral palsied children of both genders, with their ages ranged from 7 to 9 years (x ̅ = 8.2 ± 0.86 yr.) were randomly assigned into two equal groups (A and B). The control group (A) was trained using electromyographic biofeedback daily for two weeks after removal of plaster cast, in addition to an hour/ day of a designed physical therapy program, while the study group (B) was trained by electromyographic biofeedback during the immobilization period and for two weeks after removal of the cast along with the same physical therapy program as the group (A). The knee extensors’ peak torque and knee excursion angle were measured immediately and two weeks following cast removal by MERAC isokinetic system and electro-goniometer, respectively. Results. The findings exhibited a significant increase (P &lt; 0.05) in the peak torque of knee extensors and an increase in knee excursion in the group (B) immediately and after two weeks of the cast removal when compared with the results of the group (A) after the same period. Conclusion. Applying electromyographic biofeedback training at the two-week immobilization period resulted in a strengthening of the quadriceps and maintaining the obtained range of knee extension following semitendinosus muscle release in spastic quadriplegic children with cerebral palsy.

Endoscopic gluteus maximus tendon release for external snapping hip syndrome: a functional assessment

PurposeThe aim of this retrospective study was to investigate the clinical follow-up of patients with external snapping hip syndrome (ESHS) treated with endoscopic gluteus maximus tendon release and to compare the residual muscular strength and thigh circumference as an indirect outcome measure.MethodsPatients of all ages with external snapping hip syndrome were treated with endoscopic gluteus maximus tendon release. Outcome measures evaluated included: visual analog scale (VAS), modified Harris Hip Score (mHHS), and Non-Arthritic Hip Score (NAHS). The gluteus maximus strength and the circumference of the thigh were also evaluated.ResultsAmong 25 patients, 23 fulfilled the inclusion criteria and one patient was lost to follow-up. The series included 22 patients, 6 males and 16 females with a mean age of 27.9 ± 13.4 years (range 16–76 years). All patients had resolution of the snapping symptoms after the procedure. The mean follow-up was 18 ± 9.3 months. All outcomes improved in a statistically significant manner: VAS value decreased from 6.8 (range 6–8) to 0.6 (range 0–4) (p < 0.001), mHHS increased from 48.6 (range 17.6–67) to 88.2 (range 67–94.6) (p < 0.001), NAHS increased from 49.0 (range 21.5–66) to 90.8 (range 66–98.75) (p < 0.001). A statistically significant reduction of operated limb thigh circumference compared to the contralateral side (3.7%) was also found, while there were no statistical differences regarding the strength of gluteus maximus muscles.ConclusionsEndoscopic gluteus maximus tendon release is an excellent surgical option to treat snapping hip syndrome. The evaluated muscle strength revealed no functional impairment. The significance of the limb circumference reduction has yet to be determined.Level of evidenceIV: retrospective comparative trial.

Transplant of Autologous Mesenchymal Stem Cells Halts Fatty Atrophy of Detached Rotator Cuff Muscle After Tendon Repair: Molecular, Microscopic, and Macroscopic Results From an Ovine Model

Background: The injection of mesenchymal stem cells (MSCs) mitigates fat accumulation in released rotator cuff muscle after tendon repair in rodents. Purpose: To investigate whether the injection of autologous MSCs halts muscle-to-fat conversion after tendon repair in a large animal model for rotator cuff tendon release via regional effects on extracellular fat tissue and muscle fiber regeneration. Study Design: Controlled laboratory study. Methods: Infraspinatus (ISP) muscles of the right shoulder of Swiss Alpine sheep (n = 14) were released by osteotomy and reattached 16 weeks later without (group T; n = 6) or with (group T-MSC; n = 8) electropulse-assisted injection of 0.9 Mio fluorescently labeled MSCs as microtissues with media in demarcated regions; animals were allowed 6 weeks of recovery. ISP volume and composition were documented with computed tomography and magnetic resonance imaging. Area percentages of muscle fiber types, fat, extracellular ground substance, and fluorescence-positive tissue; mean cross-sectional area (MCSA) of muscle fibers; and expression of myogenic (myogenin), regeneration (tenascin-C), and adipogenic markers (peroxisome proliferator-activated receptor gamma [PPARG2]) were quantified in injected and noninjected regions after recovery. Results: At 16 weeks after tendon release, the ISP volume was reduced and the fat fraction of ISP muscle was increased in group T (137 vs 185 mL; 49% vs 7%) and group T-MSC (130 vs 166 mL; 53% vs 10%). In group T-MSC versus group T, changes during recovery after tendon reattachment were abrogated for fat-free mass (–5% vs –29%, respectively; P = .018) and fat fraction (+1% vs +24%, respectively; P = .009%). The area percentage of fat was lower (9% vs 20%; P = .018) and the percentage of the extracellular ground substance was higher (26% vs 20%; P = .007) in the noninjected ISP region for group T-MSC versus group T, respectively. Regionally, MCS injection increased tenascin-C levels (+59%) and the water fraction, maintaining the reduced PPARG2 levels but not the 29% increased fiber MCSA, with media injection. Conclusion: In a sheep model, injection of autologous MSCs in degenerated rotator cuff muscle halted muscle-to-fat conversion during recovery from tendon repair by preserving fat-free mass in association with extracellular reactions and stopping adjuvant-induced muscle fiber hypertrophy. Clinical Relevance: A relatively small dose of MSCs is therapeutically effective to halt fatty atrophy in a large animal model.

Effect of different forearm positions on fragment rotation in extra-articular distal radius fractures: A cadaveric study.

The aim of the study was to investigate the effect of different arm positions (hand pronation/supination and elbow flexion/extension) on fragment rotation in extra-articular distal radius fractures in a cadaveric model. In this study, ten fresh-frozen cadaveric upper extremities from five donors with a mean age of 69 ± 12 years were used. Two cortical pins were inserted in the radius and the ulna. In a custom-made device, different forearm (30°, 60°, and 90° of pronation and supination) and elbow positions (full extension) were tested, using a fluoroscopic analysis. The degree of malrotation between the two pins was measured in these positions. At the last test sequence, the tendon of the brachioradialis muscle was released. A significant difference was found in concerns of the rotational angle between the distal fragment and the radial shaft at different degrees of pronation and supination if the elbow joint was in an extended and flexed position. The release of the brachioradialis tendon did not show any effect. The results of this study supported that rotational malpositions in distal radius fractures can be decreased if the forearm is in a neutral position. Accordingly, the forearm should be in a neutral position while initially immobilization in a plaster splint is performed.

Limited effects on patient outcomes of conjoint tendon release in anterolateral muscle-sparing total hip arthroplasty

BackgroundThe anterolateral muscle-sparing total hip arthroplasty (THA) in the supine position is advantageous owing to the very low-dislocation rate and excellent leg length discrepancy control. However, femur exposure is challenging. Although the conjoined external rotators tendon (CERT) release is effective in improving femoral access, the effects on clinical outcomes remain unclear. The purpose of this study was to evaluate the clinical and radiographic results of CERT release in the anterolateral muscle-sparing THA approach.MethodsThe study was performed as a retrospective cohort study and included 85 hips in 85 patients who underwent primary anterolateral THA. Clinical and radiographic outcomes were investigated 6 months and 1 year after THA (CERT-preserved and non-released patients). The Japanese Orthopaedic Association (JOA) hip score, JOA Hip-disease Evaluation Questionnaire (JHEQ), forgotten joint score (FJS), and the 36 short-form questionnaires (SF-36 mental and physical) were evaluated. The leg length discrepancy, cup inclination and stem orientation were evaluated with radiographs.ResultsAmong all the included hips, 37 patients (43.5%) retained the CERT, and 48 patients (56.5%) included the released CERT. There were no significant differences in the JOA hip scores, JHEQ, FJF-12 and SF-36 between the released and non-released groups. There were significant differences in sagittal stem alignments between groups.ConclusionThe CERT release in anterolateral muscle-sparing THA has a limited effect on post-operative clinical outcomes. The CERT release improved the femur exposure and is more invasive than the preserved CERT. We infer that the CERT should be maintained in patients with a wide range of motions, and release the CERT in inadequate femur canal preparation cases.

Role of abductor hallucis tendon release in treatment of metatarsus adductus in toddlers

Metatarsus adductus is a common congenital foot deformity. Its actual incidence is not well documented and is probably underestimated at one in every 1000 live births.The deformity of pure metatarsus adductus is transverse plane deviation at the tarsometatarsal joint (Lisfranc joint) without other abnormalities of the foot. One of the most widely accepted theories of the etiology of metatarsus adductus is that of abnormal intrauterine position,as in prima gravida mothers. Heredity has been shown to account for only two to four percent of all cases of metatarsus adductus.Aim of the workTo evaluate the role of abductor hallucis release in the treatment of moderate and severe cases of metatarsus adductus in children below the age of three years.PatientsThis study included 60 feet, half of which were treated by abductor hallucis tendon release, the other half by serial casting and the results were compared. All patients were managed at the Orthopaedic Department at El-Hadra University Hospital or Sporting Students Hospital, Alexandria.

Percutaneous, intra-articular, chevron osteotomy (PeICO) for the treatment of mild-to-moderate hallux valgus: a case series.

Treatment for hallux valgus (HV) remains challenging. Third-generation percutaneous procedures try to reproduce chevron-type osteotomies to replicate their benefits, such as intrinsic stability and reproducibility. We report the first results using a percutaneous, intra-articular, chevron osteotomy (PeICO) technique that mimics the classic intra-articular open chevron procedure, associated with a percutaneous adductor tendon release (PATR) for the treatment of mild-to-moderate HV. From May 2015 to October 2018, a total of consecutive 114 feet (74 patients) were included. Primary outcome measures included radiographic (hallux valgus and intermetatarsal angles) and clinical parameters such as visual analog scale (VAS), FAAM Activities of Daily Living (ADL), and FAAM Sport, AOFAS Score, and MOXFQ, preoperatively and at final follow-up (Minimum 18months). A patient satisfaction survey was also performed. Pronation and length of the first metatarsal were also assessed. Secondary outcomes included fluoroscopic time, length of surgery, complications, recurrence, and re-operation rates. At 24.09months on average, the AOFAS score improved from 52.1 points preoperatively to 91.1 (p < 0.001) at the latest follow-up. VAS decreased from 6.3 to 1. Also, FAAM ALD, FAAM Sport, and MOXFQ showed statistically significant differences (p < 0.001) when comparing pre-operative and post-operative periods. Patients found the procedure to be excellent in 82% and very good in 13.5% of cases. Our global complication and re-operation rates were 5.26% and 3.5% (screw removal), respectively. PeICO combined with PATR proved to be a safe, reliable, and effective technique for the correction of mild-to-moderate HV deformity.

Muscle Degeneration Induced by Sequential Release and Denervation of the Rotator Cuff Tendon in Sheep.

Background:In a sheep rotator cuff model, tenotomy predominantly induces fatty infiltration, and denervation induces mostly muscle atrophy. In clinical practice, myotendinous retraction after tendon tear or lateralization after tendon repair tear may lead to traction injury of the nerve.Purpose/Hypothesis:To analyze whether an additional nerve lesion during rotator cuff repair leads to further degeneration of the rotator cuff muscle in the clinical setting. We hypothesized that neurectomy after tendon tear would increase atrophy as well as fatty infiltration and that muscle paralysis after neurectomy would prevent myotendinous retraction after secondary tendon release.Study Design:Controlled laboratory study.Methods:Twelve Swiss alpine sheep were used for this study. For the 6 sheep in the tenotomy/neurectomy (T/N) group, the infraspinatus tendon was released; 8 weeks later, the suprascapular nerve was transected. For the 6 sheep in the neurectomy/tenotomy (N/T) group, neurectomy was performed, and the infraspinatus was tenotomized 8 weeks later. All sheep were sacrificed after 16 weeks. Magnetic resonance imaging (MRI) was performed before the first surgery (baseline) and then after 8 and 16 weeks. The MRI data were used to assess muscle volume, fat fraction, musculotendinous retraction, pennation angle, and muscle fiber length of the infraspinatus muscle.Results:Three sheep (2 in the T/N and 1 in the N/T group) had to be excluded because the neurectomy was incomplete. After 8 weeks, muscle volume decreased significantly less in the T/N group (73% ± 2% of initial volume vs 52% ± 7% in the N/T group; P < .001). After 16 weeks, the mean intramuscular fat increase was higher in the T/N group (36% ± 9%) than in the N/T group (23% ± 6%), without reaching significance (P = .060). After 16 weeks, the muscle volumes of the N/T (52% ± 8%) and T/N (49% ± 3%) groups were the same (P = .732).Conclusion:Secondary neurectomy after tenotomy of a musculotendinous unit increases muscle atrophy. Tenotomy of a denervated muscle is associated with substantial myotendinous retraction but not with an increase of fatty infiltration to the level of the tenotomy first group.Clinical Relevance:Substantial retraction, which is associated with hitherto irrecoverable fatty infiltration, should be prevented, and additional neurogenic injury during repair should be avoided to limit the development of further atrophy.

The Use of the Comma Sign and Tissue for Recognition, Reduction, and Stability During Arthroscopic Repair of Combined Anterosuperior Cuff Tears

Background: The comma sign is a useful marker for combined retracted supraspinatus and subscapularis tears. It was first described by the group of Burkhart as a “composite ligamentous structure” of the rotator interval attached to the retracted subscapularis. However, Neyton and coworkers suggested that the ruptured superior part of subscapularis is pulled upward by supraspinatus retraction. This video illustrates the value of “comma” recognition for reduction and repair stability. We feel that the comma tissue can be a composition of rotator interval ligaments with or without superior subscapularis contribution depending on an associated cleavage tear. Indications: Patients with retracted anterosuperior tears, unless muscle quality is poor (Goutallier classification ≥3). Understanding of the comma tissue is difficult but of crucial importance to assess complex anterosuperior cuff tears for reduction and repair with stability by maintaining and integrating this comma link into the repair construct. Technique Description: Arthroscopic setup includes beach chair position, armholder, cerebral saturation monitoring (target mean arterial blood pressure of about 70 mm Hg). Previously described circumferential portals were used for a repair with a double row construct (4 medial anchors: 2.5 for subscapularis; 1.5 for supraspinatus) and 2 lateral anchors. The superior boarder of subscapularis as well as the retracted capsular layer of supraspinatus was reduced and fixed using a lasso loop technique. Key stages are (1) tendon manipulation with 2 traction sutures; (2) tendon release; (3) comma reduction; (4) footprint preparation (burr, microfracture); (5) retrograde suture passing; (6) knot tying, knotless lateral row; and (7) a close surgeon to physiotherapist rehabilitation link (6 weeks passive to 90°, no resistance training for 3-6 months). Results: Senior author’s (S.B.) series: 32 anterosuperior tears over 4 years (mean age: 62 years, 48-73 years), minimum follow-up 1 year showed good results (mean SSV: 85% [preop. 35%], range: 40%-95%; mean Constant: 82 [preop. 30], range: 40-90). One major complication (cutibacterium infection; brick layer; workers compensation; invalidity demand; Constant/Subjective Shoulder Value both 40) and minor temporary stiffness at 3 months (8 patients; 22%). Conclusion: Adequate reduction and comma integration into a solid repair construct, as well as responsible rehabilitation surveillance, deliver successful results after technically intricate anterosuperior repairs.

Correction of Crossover Toe Deformity by Plantar Plate Tenodesis and Arthroscopic Release of Lumbrical

Plantar plate deficiency is the major cause of instability of the metatarsophalangeal joint. As the joint subluxates dorsally, the lumbrical is tethered on the medial side of the joint by the deep metatarsal ligament and becomes a deforming force for the development of crossover toe deformity. Release of the lumbrical is needed to achieve adequate medial soft-tissue release. Plantar plate tenodesis has been described to correct the deformity by suturing the plantar plate to the extensor digitorum longus tendon. The purpose of this Technical Note is to incorporate the technique of arthroscopic release of the lumbrical tendon into the technique of plantar plate tenodesis.

Treatment for Flexible Flatfoot in Children With Subtalar Arthroereisis and Soft Tissue Procedures.

Background: Children with flexible flatfoot is common in clinics and there is no unified conclusion on surgical treatment. And for some patients with severe deformities, the correction of the subtalar joint arthroereisis combine the release of the Achilles tendon or gastrocnemius muscle release is still not satisfactory. The main aim of the present study was to investigate the therapeutic outcomes of subtalar arthroereisis combined with Achilles tendon or gastrocnemius recession and medial soft tissue (spring ligament, talonavicular joint capsule, tibionavicular ligaments and tibiospring ligaments) tightening for treating flexible flatfoot with severe deformities.Methods: Thirty patients (32 feet) with pediatric flexible flatfoot who underwent subtalar arthroereisis and soft tissue procedures during January 2016 to January 2018. There were 18 males (20 feet) and 12 females (12 feet) with an average age of 9.5 years (range, 8–12 years). We used the AOFAS scores and VAS scores combined with angles measure to evaluate the pre-operative and post-operative status.Results: Thirty patients (32 feet) were followed up for 25.3 months on average (range, 18–36 months). There was no infection. Post-operative foot pain, arch collapse, and other symptoms improved. At last follow-up, the Meary angle was decreased from 17.5° ± 4.4° to 4.1° ± 1.2° (P < 0.05), the talar-first metatarsal (AP) was decreased from 15.3° ± 3.1° to 4.8° ± 1.3°(P < 0.05), The mean AOFAS score was rose from 66.6 ± 5.8 to 88.6 ± 7.9 (P < 0.05), the mean VAS score was decreased from 6.6 ± 0.6 to 1.7 ± 0.3 (P < 0.05).Conclusion: The subtalar arthroereisis combined with soft tissue procedures can effectively correct flexible flatfoot in children and it is a significant method for severe forefoot abduction reconstruction.Level of Evidence: IV

Gouty flexor tenosynovitis – Case report and review of the literature

Gout is a rare cause of tenosynovitis and is difficult to diagnose based on clinical symptoms and imaging modalities. We present a case of gouty tenosynovitis of the proximal interphalangeal joint. A 32-year old male patient presented with a swollen, painful proximal interphalangeal joint of the 3rd digit on his right hand for 2 weeks with flexion contracture. Surgical exploration of the affected joint revealed a gouty tophus with extensive infiltration of the underlying flexor tendon. A tenosynovectomy and flexor tendon release was performed to treat the flexion contracture. Pathology disclosed urate crystals deposited within the tendon. Gouty infiltration of the flexor tendons of the hand can lead to extensive damage and compromised function. A high level of clinical suspicion is required as gouty tenosynovitis is a rare presentation and can often mimic an infectious etiology. Keywords: Gout; Tenosynovitis; Flexor tendon; Hand; Tophi.

Effects of Tendon Release Surgery on Inter-Limb Leg Stiffness Control in Children with Spastic Diplegic Cerebral Palsy during Gait

Impaired motor control and musculotendon tightness in the lower extremities are characteristic features of patients with diplegic cerebral palsy (CP). Tendon release surgery (TRS) helps improve joint and leg stiffness, but the effects of TRS on inter-limb coordination in terms of the total leg stiffness, and the bilateral symmetry in leg stiffness during gait, remain unknown. Ten children with spastic diplegic CP scheduled for TRS and ten healthy controls participated in this study. The inter-limb sharing of total leg stiffness during double-limb support phase and bilateral leg stiffness symmetry during stance phase of gait were calculated using the kinematic and ground reaction force data measured by a motion analysis system. Before TRS, the patients with diplegic CP walked with a decreased share of total leg stiffness during weight-acceptance (p &lt; 0.05) and with increased bilateral leg stiffness asymmetry during single-limb support and weight-transfer during gait (p &lt; 0.05) when compared to healthy controls. After TRS, the bilateral leg stiffness asymmetry was significantly reduced in the CP group, especially in the terminal stance phase, with inter-limb sharing of total leg stiffness becoming similar to that in controls (p &gt; 0.05). The surgery seemed to improve the lower limb control and increased the bilateral limb symmetry during gait.

Clinical application of Wide-awake technique in flexor tendon tenolysis

To discuss the method and effectiveness of Wide-awake technique in flexor tendon tenolysis. The clinical data of 16 patients (22 fingers) with flexor tendon adhesion treated by Wide-awake technique for flexor tendon tenolysis between May 2019 and December 2019 were retrospectively analyzed. The patients were all male, aged from 18 to 55 years old, with an average of 35 years old. Among them, 4 cases (7 fingers) after replantation of severed fingers, 4 cases (7 fingers) after flexor tendon rupture repair, and 8 cases (8 fingers) after open reduction and internal fixation of proximal fractures. The time from the original operation to this operation was 6-18 months, with an average of 8 months. The visual analogue scale (VAS) score was used to evaluate the patient's pain during local anesthesia (when the first needle penetrated the skin), intraoperative, and 24 hours postoperatively; and the recovery of finger movement was evaluated by total finger joint active range of motion (TAM) evaluation system and Strickland (1980) standard after operation. Intraoperative hemostasis and anesthesia were satisfactory, and the patient could fully cooperate with the surgeon in active finger movements. There were different degrees of pain during local anesthesia (VAS score was 2-4), no pain during operation (VAS score was 0), and different degrees of pain after operation (VAS score was 1-8, 9 patients needed analgesics). All incisions healed by first intention after operation. All 16 cases were followed up 9-15 months with an average of 12 months. Finger function was significantly improved, no tendon rupture occurred. At last follow-up, the patients after proximal fracture open reduction and internal fixation were rated as excellent in 4 fingers and good in 4 fingers according to the TAM standard, and both were excellent according to the Strickland (1980) standard; and the patients after replantation of severed fingers and flexor tendon rupture repair were rated as excellent in 4 fingers and good in 10 fingers according to TAM standard, and as excellent in 6 fingers and good in 8 fingers according to Strickland (1980) standard. Wide-awake technique applied in flexor tendon tenolysis can accurately judge the tendon adhesion and release degree through the patient's active activity, achieve the purpose of complete release, and the effectiveness is satisfactory; the effectiveness of tendon adhesion release surgery after fracture internal fixation is better than that of patients after tendon rupture suture and replantation.