Tendon Attachment Research Articles

Tibial bone defect prediction based on preoperative artefact-reduced CT imaging is superior to standard radiograph assessment

PurposeThe purpose of this study was to evaluate the accuracy of preoperative CT-based Anderson Orthopaedic Research Institute (AORI)-grading and to correlate Computed tomography (CT)-based volumetric defect measurements with intraoperative AORI findings.Methods99 patients undergoing revision total knee arthroplasty (rTKA) with preoperative CT-images were identified in an institutional revision registry. CT-image segmentation with 3D-Slicer Software was used to create 3D tibial bone defects which were then graded according to the AORI-classification. The AORI classification categorizes tibial defects into three types: Type I has healthy cortical and cancellous bone near the joint line, Type II involves metaphyseal bone loss affecting one or both condyles, and Type III indicates deficient metaphyseal bone with distal defects and potential damage to the patellar tendon and collateral ligament attachments. These 3D-CT gradings were compared to preoperative X-ray and intraoperative AORI grading. The Friedman test was used to investigate differences between AORI values of each measurement method. Volumetric 3D-bone defect measurements were used to investigate the relationship between AORI classification and volumetric defect size in the three anatomic zones of the tibia.ResultsSubstantial agreements between preoperative 3D-CT AORI and intraoperative AORI (kappa = 0.663; P < 0.01) and fair agreements between preoperative X-ray AORI and intraoperative AORI grading (kappa = 0.304; P < 0.01) were found. Moderate correlations between volume of remaining bone and intraoperative AORI grading were found in epiphysis (rS = – 0.529; P < 0.001), metaphysis (rS = – 0.557; P < 0.001) and diaphysis (rS = – 0.421; P < 0.001). Small volumetric differences between AORI I vs. AORI II defects and relatively large differences between AORI II and AORI III defects in each zone were detected.ConclusionTibial bone defect prediction based on preoperative 3D-CT segmentation showed a substantial agreement with intraoperative findings and is superior to standard radiograph assessment. The relatively small difference in defect volume between AORI I, IIa and IIb suggests that updated CT-based classifications might hold benefits for the planning of rTKA.Level of evidenceRetrospective Cohort Study; III

Occurrence of calcaneal spurs on skeletal remains of historical populations in the context of footwear development.

This communication is focused on monitoring the occurrence of plantar and dorsal exostoses (spurs) on the calcanei of skeletons from various dated historical periods. A total of 361 calcanei from 268 individuals were evaluated (prehistoric sites - Podivín, Modřice, Mikulovice; mediaeval sites - Olomouc-Nemilany, Trutmanice; modern age sites - the former Municipal Cemetery in Brno in Malá Nová Street, collections of the Department of Anatomy, Masaryk University, Brno). Differences in period footwear for individual population samples were taken into account when interpreting the findings. Health defects were sought for individual types of historical footwear, which could have a causal connection with the occurrence of exostoses on the calcanei. Plantar calcaneal spur occurred most frequently in the mediaeval population (23.5 %; N = 51), less frequently in prehistory (14.1 %; N = 85) and least in modern times (9.8%; N = 132). Similar results were observed for dorsal calcaneal spur in the attachment of the Achilles tendon, but with higher values. In the Middle Ages, its incidence was highest (47.0 %; N = 51), followed by prehistoric times (32.9 %; N = 85), with the least found from the modern age (19.9 %; N = 132). However, the results obtained correspond only to a certain extent to the defects in footwear in the relevant historical period.

Structural and functional heterogeneity of mineralized fibrocartilage at the Achilles tendon-bone insertion.

A demanding task of the musculoskeletal system is the attachment of tendon to bone at entheses. This region often presents a thin layer of fibrocartilage (FC), mineralized close to the bone and unmineralized close to the tendon. Mineralized FC deserves increased attention, owing to its crucial anchoring task and involvement in enthesis pathologies. Here, we analyzed mineralized FC and subchondral bone at the Achilles tendon-bone insertion of rats. This location features enthesis FC anchoring tendon to bone and sustaining tensile loads, and periosteal FC facilitating bone-tendon sliding with accompanying compressive and shear forces. Using a correlative multimodal investigation, we evaluated potential specificities in mineral content, fiber organization and mechanical properties of enthesis and periosteal FC. Both tissues had a lower degree of mineralization than subchondral bone, yet used the available mineral very efficiently: for the same local mineral content, they had higher stiffness and hardness than bone. We found that enthesis FC was characterized by highly aligned mineralized collagen fibers even far away from the attachment region, whereas periosteal FC had a rich variety of fiber arrangements. Except for an initial steep spatial gradient between unmineralized and mineralized FC, local mechanical properties were surprisingly uniform inside enthesis FC while a modulation in stiffness, independent from mineral content, was observed in periosteal FC. We interpreted these different structure-property relationships as a demonstration of the high versatility of FC, providing high strength at the insertion (to resist tensile loading) and a gradual compliance at the periosteal surface (to resist contact stresses). STATEMENT OF SIGNIFICANCE: Mineralized fibrocartilage (FC) at entheses facilitates the integration of tendon in bone, two strongly dissimilar tissues. We focus on the structure-function relationships of two types of mineralized FC, enthesis and periosteal, which have clearly distinct mechanical demands. By investigating them with multiple high-resolution methods in a correlative manner, we demonstrate differences in fiber architecture and mechanical properties between the two tissues, indicative of their mechanical roles. Our results are relevant both from a medical viewpoint, targeting a clinically relevant location, as well as from a material science perspective, identifying FC as high-performance versatile composite.

The unilateral muscular slip of the two-bellied Serratus Posterior Inferior muscle: a case report and a review of literature.

The two-bellied serratus posterior inferior (SPI) muscle with a muscular slip is a rare variation of the back region, which can cause significant discomfort to patients. Patients typically present with symptoms of chronic pain syndrome, radiating back pain, myofascial pain, or lower back pain. This report describes a case of a female cadaver with a two-headed SPI muscle and a right muscular slip, along with a literature review. A case of an unusual back muscle was observed in a female cadaver during advanced cadaver dissection of the back region. The SPI muscle was found deep to the latissimus dorsi muscle and superficial to the erector spinae and thoracolumbar fascia. Its oblique arrangement and insertion onto the 8th-11th costae were consistent with its known anatomy, but the presence of two separate fibrotendinous heads and an uncommon variance between the erector spinae and latissimus dorsi muscles was observed. The SPI muscle fibers were found to be attached to the 8th costa on the right side and displayed two heads on both sides. In our study, the presence of muscular and tendinous digitations towards the twelfth rib was not detected, which aligns with the characteristics described for types D and E. However, we observed a separation between the digitations. Therefore, it is appropriate to classify our findings as type E according to the established categorization. Simultaneously, an anomalous muscular slip, which did not conform to any of the aforementioned classifications, was identified as extending towards the 8th rib. The underlying cause of unilateral oblique muscular fiber extension is thought to result from aberrant muscle migration during embryonic development or alterations in tendon attachment sites. Differential diagnosis of unidentified lower back pain should consider the various types and alterations of the SPI muscle.

Loss of Fgfr1 and Fgfr2 in Scleraxis-lineage cells leads to enlarged bone eminences and attachment cell death.

Tendons and ligaments attach to bone are essential for joint mobility and stability in vertebrates. Tendon and ligament attachments (ie, entheses) are found at bony protrusions (ie, eminences), and the shape and size of these protrusions depend on both mechanical forces and cellular cues during growth. Tendon eminences also contribute to mechanical leverage for skeletal muscle. Fibroblast growth factor receptor (FGFR) signaling plays a critical role in bone development, and Fgfr1 and Fgfr2 are highly expressed in the perichondrium and periosteum of bone where entheses can be found. We used transgenic mice for combinatorial knockout of Fgfr1 and/or Fgfr2 in tendon/attachment progenitors (ScxCre) and measured eminence size and shape. Conditional deletion of both, but not individual, Fgfr1 and Fgfr2 in Scx progenitors led to enlarged eminences in the postnatal skeleton and shortening of long bones. In addition, Fgfr1/Fgfr2 double conditional knockout mice had more variation collagen fibril size in tendon, decreased tibial slope, and increased cell death at ligament attachments. These findings identify a role for FGFR signaling in regulating growth and maintenance of tendon/ligament attachments and the size and shape of bony eminences.

In Vivo Length Changes Between the Attachments of the Medial Patellofemoral Complex Fibers in Knees With Anatomic Risk Factors for Patellar Instability

Background: Medial patellofemoral complex (MPFC) reconstruction plays an important role in the surgical treatment of patellar instability. Anatomic reconstruction is critical in re-creating the native function of the ligament, which includes minimizing length changes that occur in early flexion. Anatomic risk factors for patellar instability such as trochlear dysplasia, patella alta, and increased tibial tuberosity to trochlear groove (TT-TG) distance have been shown to influence the function of the MPFC graft in cadaveric studies, but the native length change patterns of the MPFC fibers in knees with anatomic risk factors have not been described. Purpose: To describe the in vivo length changes of the MPFC fibers in knees with anatomic risk factors for patellar instability and identify the optimal attachment sites for MPFC reconstruction. Study Design: Controlled laboratory study. Methods: Dynamic computed tomography imaging was performed on the asymptomatic knee in patients with contralateral patellar instability. Three-dimensional digital knee models were created to assess knees between 0° and 50° of flexion in 10° increments. MPFC fiber lengths were calculated at each flexion angle between known anatomic attachment points on the extensor mechanism (quadriceps tendon, MPFC midpoint [M], and patella) and femur (1, 2, and 3, representing the proximal to distal femoral footprint). Changes in MPFC fiber length were compared for each condition and assessed for their relationships to morphologic risk factors (trochlear depth, Caton Deschamps Index [CDI], and TT-TG distance). Results: In 22 knees, native MPFC fibers were found to be longer at 0° than at 20° to 50° of flexion. Length changes observed between 0° and 50° increased with the number of risk factors present. In the central fibers of the MPFC (M-2), 1.7% ± 3.1% length change was noted in knees with no anatomic risk factors, which increased to 5.6% ± 4.6%, 17.0% ± 6.4%, and 26.7% ± 6.8% in the setting of 1, 2, and 3 risk factors, respectively. Nonanatomic patella-based attachments were more likely to demonstrate unfavorable length change patterns, in which length was greater at 50° than 0°. In patellar attachments, an independent relationship was found between increasing length changes and TT-TG distance, while in quadriceps tendon attachments, a trend toward a negative relationship between length changes and CDI was noted. All configurations demonstrated a strong relationship between percentage change in length and number of morphologic risk factors present, with the greatest influence found in patella-based attachments. Conclusion: The MPFC fibers demonstrated increased length changes in knees when a greater number of morphological risk factors for patellar instability were present, which worsened in the setting of nonanatomic configurations. This suggests that the function of the intact MPFC in patients with anatomic risk factors may not reflect previously described findings in anatomically normal knees. Further studies are needed to understand the pathoanatomy related to these changes, as well as the implications for graft placement and assessment of length changes during MPFC reconstruction techniques. Clinical Relevance: MPFC length change patterns vary based on the number of morphologic risk factors for patellar instability present and should be considered during reconstructive procedures.

At mid- to long-term follow-up after proximal hamstring tendon avulsion; there was greater fatty infiltration, muscle atrophy and strength deficit in the hamstring muscles of the injured leg than in the uninjured leg

BackgroundProximal hamstring tendon avulsions (PHAs) may be treated nonoperatively or operatively. Little is known about the result of the injury, and its treatment, on the quality and function of the hamstring muscle after healing and rehabilitation. We hypothesized that the injured leg would have greater fatty infiltration and atrophy than the uninjured leg at follow-up and that these findings would correlate to muscle weakness.MethodsIn a cross-sectional cohort study, 48 patients treated for PHA, either operatively or nonoperatively, were re-examined 2–11 years post-treatment. We measured muscle strength with isokinetic strength tests, and muscle volume and fatty infiltration with MRI.Primary outcomes were hamstring muscle quality, quantified by outlining the cross-sectional area slice-by-slice, and the degree of fatty infiltration estimated using the Goutallier grading method. Secondary outcome was concentric isokinetic hamstring muscle strength measured using BioDex at 60°/sec and tendon attachment assessed on MRI. Comparisons with the outcomes of the uninjured leg were made.ResultsThe total hamstring muscle volume was on average reduced by 9% (SD ± 11%, p < 0.001) compared to that of the uninjured leg. Fatty infiltration was significantly more severe in the injured hamstrings than in the uninjured hamstrings (p < 0.001). This was also true when only analyzing operatively treated patients. The reduction in muscle volume and increase in fatty infiltration correlated significantly (r = 0.357, p = 0.013), and there was also a statistically significant correlation with muscle atrophy and reduction in isokinetic strength (r = 494, p < 0.001).ConclusionPHA injuries result in fatty infiltration and muscle atrophy and the muscle quality impairment correlates with residual muscle weakness.

Functional and Structural Outcomes After Arthroscopic Rotator Cuff Repair With or Without Preoperative Corticosteroid Injections

Background: Corticosteroid injections (CSIs) are effective in alleviating pain in patients with rotator cuff tears, but controversy still exists regarding their potential adverse effects on clinical outcomes after rotator cuff repair. Purpose: To compare both the functional and the structural outcomes in patients who underwent arthroscopic rotator cuff repair with or without preoperative CSIs. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort study was carried out among patients who underwent arthroscopic rotator cuff repair for partial- and full-thickness tears between 2015 and 2019. The patients who received preoperative CSIs were included in the CSI group and compared with a group without preoperative CSIs (non-CSI group), matched at a ratio of 1:2 based on tear size, age, and follow-up time. Both functional evaluation and structural assessments using magnetic resonance imaging (MRI) were performed at the final follow-up. Clinical outcomes—including retear rate as the primary outcome; pain; functional scores including the Constant-Murley score, American Shoulder and Elbow Surgeons score, and Fudan University Shoulder Score; range of motion (ROM); tendon integrity; tendon healing type; and cartilage thickness—were compared between the 2 groups with a statistical significance of P < .05 and power of 0.9. Results: Thirty-one patients were included in the CSI group, and 62 were included in the non-CSI group. After a mean 3-year follow-up, the 2 groups demonstrated no significant differences in retear rate; visual analog scale for pain; shoulder functional scores; and active ROM including forward flexion, abduction, external rotation, and internal rotation. No significant differences were observed on postoperative MRI scans of the rotator cuff tendon (tendon integrity, healing type, residual tendon attachment area, etc), cartilage thickness, and muscle atrophy. Conclusion: No significant differences were found at a mean 3-year follow-up in the retear rates, pain, ROM, and glenohumeral structure on postoperative MRI scans after arthroscopic rotator cuff repair with or without preoperative CSIs.

Climbing influences entheseal morphology in the humerus of mice: An experimental application of the VERA methodology

AbstractObjectivesWhen studying hominin skeletal remains, anthropologists commonly assume that the morphology of entheses (muscle and tendon attachment sites) is influenced by physical activity patterns during life. Here, we use samples of mice from a prior experiment (Siegel &amp; Jones [1975] American Journal of Physical Anthropology 42:141–144) to test this assumption. Specifically, we investigate the effects of habitual climbing on entheses of the humerus using a recently developed protocol for analyzing entheseal morphology called the “Validated Entheses‐based Reconstruction of Activity” (VERA) method.Materials and MethodsIn the original experiment, young mice were raised for approximately 9 weeks in one of two experimental conditions: a cage designed to limit locomotion to terrestrial quadrupedalism over a flat surface (n = 22), or a cage designed to impel animals to cling to a suspended wire mesh apparatus and limit their locomotion to climbing (n = 21). We μCT‐scanned the humeri of these mice and used the VERA method to assess the morphology of the deltoid tuberosity, greater tubercle, lesser tubercle, and supinator crest.ResultsSignificant differences in entheseal morphology were detected between climbers and non‐climbers when using both multivariate statistics to assess all entheses simultaneously and univariate statistics to assess each enthesis individually.DiscussionOur results provide new support for the general use of entheseal morphology for inferring hominin physical activity patterns in the past. Furthermore, based on our results, we propose that analyzing entheseal morphology using the VERA method may be a promising strategy for future research on the importance of climbing in hominin locomotor evolution.

Radiographic Description of Soft Tissue Attachments around the Elbow.

Quantitatively define the radiographic locations of the major soft-tissue attachments about the elbow. In 10 cadaveric elbows, the attachments of the medial ulnar collateral ligament, lateral ulnar collateral ligament, annular ligament, triceps, and biceps were marked with radiopaque spheres. Measurements were made on calibrated AP and lateral fluoroscopic images from known osseous landmarks. On AP radiographs; the anterior bundle of the MUCL (aMUCL) measured 28.6mm (95% CI, 27. 5-29.8mm) from the humeral attachment to the midpoint of the MUCL ridge on the ulna and 14.3mm, (95% CI 13.0-15.5) to the olecranon. The LUCL was 39.9mm (95% CI, 38.6 - 41.1mm) from the humeral attachment to the supinator crest attachment and 8.9mm (95% CI, 8.1-9.8mm) to the lateral epicondyle. On the lateral radiographs, the humeral attachment of the aMUCL to the medial coronoid was 27.1mm (95% CI, 25.9-28.2mm) and 9.3mm (95%CI, 17.5 -21.2mm) to the tip. The LUCL humeral attachment to the supinator crest was 45.4mm (95%CI, 44.1-46.8mm). The LUCL humeral attachment was located 8.9mm (95%CI, 8.0-9.7mm) posterior from the anterior humeral line. The soft-tissue attachments about the elbow were reproducibly demonstrated on radiographs in relation to osseous landmarks and radiographic lines. The radiographic relationships will allow for improved identification of the ligament and tendon attachment sites of the elbow for intraoperative assessment and postoperative evaluation following reconstruction.

Acupotomy relieves pain and improves motor function by regulating autophagy and apoptosis of cartilage in rabbits with knee osteoarthritis apoptosis

To observe the effect of acupotomy on the expression of Beclin-1, Bcl-2 and Caspase-3 in the cartilage tissue in rabbits with knee osteoarthritis (KOA), so as to explore its mechanism underling improvement of KOA. Twenty-four healthy male New Zealand rabbits were randomly and equally divided into blank control, model and acupotomy groups, with 8 rabbits in each group. By using the modified Videman's methods, the KOA model was established by left hind limb immobilization with a plaster cast for 6 weeks. The severity of KOA (knee pain, swelling and motor function) was assessed using Lequesne score, and the rabbits with a score below 4 were excluded. The acupotomy was applied to "Hedingci" (the attachment of the quadriceps tendon to the patella at the upper edge), "Binneixia" (the medial patellar supporting band attachment of medial inferior patellar margin), "Binwaixia" (the lateral patellar supporting band attachment of the lower lateral patellar margin), "Chengfeijian" (the lateral collateral ligament of the knee passes over the lateral joint space), "Weiyangci" (the medial margin of biceps femoris at the lateral end of popliteus), "Yinlingci" (the medial tibial attachment of anserinus tendon) on the left hind limb once a week for 4 weeks. One week after the last intervention, the left knee joint dysfunction severity(pain, maximum walking distance, and some activities of daily living) was evaluated by using modified Lequesne score. Histopathological changes of the cartilage were observed under light microscope after H.E. staining. The apoptosis of chondrocytes was observed after terminal deoxynucleotidyl transferase-mediated fluorescein-dUTP nick-end labeling (TUNEL) staining. The autophagolysosomes of chondrocytes were observed using transmission electron microscopy. The expression levels of Beclin-1, Bcl-2 and Caspase-3 (related factors of autophagy and apoptosis) were detected using Real-time PCR and Western blot separately. In comparison with the blank control group, the Lequesne score, apoptosis rate, expression levels of Caspase-3 mRNA and protein were significantly increased (P<0.001), and the number of autophagolysosomes, expression levels of Beclin-1 and Bcl-2 mRNAs and proteins considerably decreased (P<0.001) in the model group. Relevant to the model group, the acupotomy group had an obvious decrease in Lequesne score, rate of apoptosis, and expression levels of Caspase-3 mRNA and protein (P<0.001) and an apparent increase in the number of autophagolysosomes and expression levels of Beclin-1 and Bcl-2 mRNAs and proteins (P<0.001). Findings of H.E. staining showed severe damaged cartilage surface, with a large number of exfoliation defects, few chondrocytes on the surface and disordered arrangement of transitional cells in the model group, which was relatively milder in the acupotomy group. Acupotomy can mitigate knee-joint pain and improve functional activity in KOA rabbits, which may be associated with its functions in promoting autophagy and suppressing apoptosis by up-regulating expressions of Beclin-1 and Bcl-2 mRNAs and proteins and down-regulation of Caspase-3 mRNA and protein.

Classic Versus Congruent-Arc Latarjet Procedures

Glenohumeral instability remains a frequent pathology, specifically in athletes and active patients. As such, several treatment options have been described. In the setting of significant glenoid bone loss (i.e., >20%), off-track Hill–Sachs lesions, and failed previous soft-tissue–based repairs, glenoid bone–augmentation techniques must be considered. These techniques restore stability by a triple blocking effect of the bony graft, the capsulolabral complex repair, and the dynamic sling effect of the conjoined tendon. The classic Latarjet procedure consists in performing a coracoid osteotomy along with the conjoined tendon attachment followed by transfer and fixation to the anterior glenoid, positioning the lateral surface of the coracoid to be flush with the articular side. Then, a modification of this technique defined as “congruent-arc Latarjet” (CAL) was described. This approach involves rotating the coracoid process 90° along its longitudinal axis using the inferior surface to recreate the native glenoid arc. Biomechanical studies have discussed advantages and disadvantages of these techniques. The CAL allows a greater glenoid surface area, which may be relevant in patients with increased glenoid bone loss. However, the bone contact area is reduced, which increases the technical difficulty of screw positioning with an increased risk of graft fragmentation. The classic Latarjet technique has a greater initial fixation strength between the graft and the glenoid and a greater potential for bone consolidation due to the broader contact bone area. Excellent clinical and sports outcomes with low recurrence rates have been observed in both techniques. Imaging findings have exhibited high bone block healing and no difference in graft placement, but CAL demonstrated a greater incidence of fibrous or nonunion rates and errors in screw fixation. Finally, while similar early complications have been reported, long-term outcomes are still needed in CAL for comparing osteoarthritis progression. These results emphasize that either technique can be considered to manage glenohumeral instability when appropriately indicated.

Evaluating the Efficacy of Low Dose Radiotherapy in the Treatment of Painful, Benign Musculoskeletal Conditions

Introduction: Inflammatory diseases of the locomotor system are a very heterogeneous group of ailments, including enthesopathies. They arise as a result of long-term overload in the area of tendon attachments, which may lead to chronic inflammation and then, degeneration, which are the cause of chronic pain. The main methods of treatment are physiotherapy, physical agents treatment, pharmacological and orthopaedic treatment, i.e. manual therapy, the use of appropriate insoles correcting posture defects, cryotherapy, shock waves, iontophoresis, non-steroidal anti-inflammatory drugs, steroid injections, surgery and platelet-rich plasma therapy. Another, lesser-known method of treatment is low-dose radiation therapy (LDRT). Research objective: To evaluate the efficacy, time to improvement and analgesic effect duration after low dose radiotherapy (LDRT) in patients with enthesopathies. Materials and methods: A retrospective analysis included a group of 90 patients (51 women, 39 men) with a diagnosis of enthesopathy and treated with conformal radiotherapy using photon radiation at the NIO in Kraków from July 2018 to April 2021. The treated group included patients with heel, elbow, knee, shoulder and wrist problems. In each case, the total dose of radiation was 6 Gy, divided into 6 fractions administered on subsequent working days, given in a vacuum form to the patient immobilised. Pain was assessed with the use of an 11-point numerical rating scale (NRS). Pain was assessed by implementing the above mentioned scale prior to the commencement of radiotherapy, during the treatment, and then 1 month and 6 months following the completion of treatment. Results: In the vast majority of patients (92%), with a mean age of 51 years, at least temporary, partial improvement of pain has been demonstrated in the irradiated joints. The median time to treatment response was 30 days. Median pain intensity, as measured via the NRS scale, was 8.0 (IQR 7.0-10.0) before the treatment, 5.0 (IQR 3.0-7.0) after 1 month, and 2.0 (IQR 0-4.0) after 6 months from treatment completion. Persistent improvement in pain control after LDRT was shown in 85% of patients, with a mean follow-up period of 522 days (range: 55-952 days). The best response was observed in patients with heel spurs (a decrease of median NRS score by 7.0). Conclusions: Low dose RT is a very effective method of pain reduction in enthesopathies, particularly among patients with heel spurs. Most patients experienced pain reduction as early as 1 month after LDRT. Continuous pain reduction was observed during the follow-up period up to the 6th month and in most cases, the analgesic effect was long-lasting.

Anatomical Study of Sites and Surface Area of the Attachment Region of Tibial Posterior Tendon Attachment.

The purpose of this study was not only to examine the attachment site but also to quantify the effect of the tibialis posterior tendon (TPT) on each attachment site by examining the surface area of the attachment region. We examined 100 feet from 50 Japanese cadavers. The TPT attachment to the navicular bone (NB), medial cuneiform bone (MCB), and lateral cuneiform bone (LCB) were set as the main attachment sites (Type I). The attachment seen in Type I with the addition of one additional site of attachment was defined as Type II. Furthermore, surface area was measured using a three-dimensional scanner. Attachment to the NB, MCB, and LCB was present in all specimens. The TPT attachment to the NB, MCB, and LCB comprised 75.1% of total attachment surface area. The ratio of the NB, MCB, and LCB in each type was about 90% in Types II and III, and 70-80% in Types IV-VII. The quantitative results demonstrated the NB, MCB, and LCB to be the main sites of TPT attachment, although individual differences in attachment sites exist, further developing the findings of previous studies.

Efficacy of Fu's Subcutaneous Needling in Treating Soft Tissue Pain of Knee Osteoarthritis: A Randomized Clinical Trial.

Fu's subcutaneous needling (FSN) is a new acupuncture technique that produces a long-lasting effect in soft-tissue injuries. In patients with degenerative knee osteoarthritis (OA), myofascial trigger points (MTrPs) are common in the lower-limb muscles. In this randomized clinical trial, we evaluated the immediate, 1-week and 2-week effectiveness of FSN therapy in the treatment of degenerative knee OA. We randomly divided 32 patients with knee OA into the FSN group (mean age: 65.73 ± 6.79 years) or the transcutaneous electrical nerve stimulation (TENS) group (mean age: 62.81 ± 5.72 years). The pressure pain threshold (PPT) and tissue hardness (TH) of the muscle and tendon attachment sites, knee range of motion, and physical ability (average walking speed) were measured. The subjective pain intensity index, Western Ontario and McMaster Universities OA Index (WOMAC), and Lequesne index were used to determine the efficacy of FSN on MTrP-induced soft-tissue pain compared with that of TENS. A significantly greater improvement in pain qualities in the VAS (p &lt; 0.05) was found in the FSN group. Moreover, in muscle and tendon qualities (including PPT and TH), a significant difference in the PPT of the quadriceps muscle (p &lt; 0.05) was also observed among the immediate treatments in the FSN group. As for the functional index questionnaire assessment, the FSN group exhibited significant improvements among the immediate, 1-week and 2-week efficacies in terms of WOMAC (p &lt; 0.05) and Lequesne index scores (p &lt; 0.05). FSN was effective in treating soft-tissue pain in degenerative knee OA in terms of alleviating pain, strengthening walking ability, and improving overall functional performance. Pain relief was the primary benefit of FSN and a significant correlation between pain relief and knee joint mobility improvement was found. ClinicalTrials.gov Protocol Registration and Results System (registration number: NCT04356651).

Revision Anterior Cruciate Ligament Reconstruction Using Semitendinosus Tendon With Bone Fragment

After anterior cruciate ligament (ACL) reconstruction, the tibial tunnel becomes widened over time. A revision surgery of the ACL reconstruction is required to fill the widened tunnels. Bone–patellar tendon–bone grafts often are used to fill enlarged bone tunnels. However, due to the variation in tendon length, it is often difficult to adjust the position of the bone fragment to the enlarged part of the bone tunnel. This study describes an arthroscopic ACL reconstruction technique using the semitendinosus tendon as well as a bone fragment which is placed in the enlarged tibial tunnel. The tendon and cortical bone were collected together at the tendon attachment using a flat chisel. The bone fragment was inserted through the tendon in a controlled manner and ultimately placed at the posterior wall of the tibial foramen. This technique was determined to be less invasive than using bone–patellar tendon–bone in a 2-stage revision ACL reconstruction. In addition, this technique can be easily performed by any surgeon who is accustomed to conventional ACL reconstruction using the semitendinosus tendon and does not require any special equipment. Our findings suggest that this technique may be useful for revision ACL reconstruction.

Scaffold-based tissue engineering strategies for soft-hard interface regeneration.

Repairing injured tendon or ligament attachments to bones (enthesis) remains costly and challenging. Despite superb surgical management, the disorganized enthesis newly formed after surgery accounts for high recurrence rates after operations. Tissue engineering offers efficient alternatives to promote healing and regeneration of the specialized enthesis tissue. Load-transmitting functions thus can be restored with appropriate biomaterials and engineering strategies. Interestingly, recent studies have focused more on microstructure especially the arrangement of fibers since Rossetti successfully demonstrated the variability of fiber underspecific external force. In this review, we provide an important update on the current strategies for scaffold-based tissue engineering of enthesis when natural structure and properties are equally emphasized. We firstly described compositions, structures and features of natural enthesis with their special mechanical properties highlighted. Stimuli for growth, development and healing of enthesis widely used in popular strategies are systematically summarized. We discuss the fabrication of engineering scaffolds from the aspects of biomaterials, techniques and design strategies and comprehensively evaluate the advantages and disadvantages of each strategy. At last, this review pinpoints the remaining challenges and research directions to make breakthroughs in further studies.

Paleopathology, Entheseal Changes, and Cross-Sectional Geometry: The Zooarchaeology of Working Animals

Morphological changes in the skeletons of working animals such as reindeer, horse, and cattle have long been observed and documented in the archaeological record. Activities such as riding, carrying cargo on their backs, and pulling vehicles like sleds and ploughs throughout an animal’s life history cause alterations and variations to skeletal tissue. Such alterations include paleopatho­logical lesions, entheseal changes (EC)—alterations in muscle, tendon, and ligament attachment sites on bone—and variations in cross-sectional bone geometry (CSBG). These clues are helpful for reconstructing human-animal relationships in faunal remains of our archaeological past. However, other factors influence the morphological appearance of skeletal tissue besides working activities, such as age, sex, body size, nutrition, genetics, environmental factors, and management by human caretakers. This article explores how paleopathological lesions, EC, and CSBG in faunal skeletal remains are examined to reconstruct working activity and changes to human-animal rela­tionships in the archaeological record. In particular, we discuss two primary topics of inquiry: (1) a review of paleopathological identifiers in working animals such as cattle, horse, camel, and rein­deer; and (2) how EC and CSBG are understood in terms of bone functional adaptation, and their application in working and non-working animals such as reindeer and horse. Next, we analyze each topic highlighting their benefits and limitations, including how they contribute to archeolog­ical understandings of human-animal relationships in the past, as well as their implications for future research.

A case report: anatomical translocation in tibial insertion of semitendinosus tendon after tibial lengthening

BackgroundThere is the most common method for arthroscopic anterior cruciate ligament (ACL) reconstruction by using the semitendinosus and gracilis tendons and single-tunnel technique. However, anatomic translocation of hamstring tendon attachment is very rare.Case presentationA 45-year-old male who need to receive right knee ACL reconstruction due to sprain injury while playing table tennis was found to have a translocation at tibial attachment of semitendinosus tendon. The tibial insertion of left semitendinosus was then explored by ultrasound and found to be identical to the contralateral limb. The patient has a history of bilateral tibial lengthening.ConclusionsThis is the first case as far as we know that reported anatomic translocation of the tibial attachment of the hamstring tendon after tibial lengthening. Surgeons should be aware of this specific situation when hamstring tendon need to be harvested to avoid unnecessary complications.

Outcomes of Functioning Free Gracilis Muscle Transplantation to Restore Elbow Flexion in Late Brachial Plexus Birth Injury.

Restoring elbow function is challenging after late presenting brachial plexus birth injury (BPBI). Free functioning muscle transplantation (FFMT) using the gracilis muscle is a reliable procedure to restore elbow flexion in patients with impaired function after spontaneous recovery or failed surgical reconstruction. A retrospective review was performed on BPBI patients more than 2 years of age who received a FFMT between January 1993 and January 2018, with the aim of improving elbow flexion as the primary or secondary functional goal. Patients with preoperative elbow flexion Medical Research Council (MRC) grades less than 3 with more than or equal to 18 months of follow-up duration were included in the analysis. Patient demographic information and pre/postoperative clinical parameters including elbow flexion MRC scale, passive elbow range of motion, and complications were recorded. Surgical data including donor nerve choice, site of the FFMT tendon attachment, and necessity of concomitant procedures or reoperation were also analyzed. Fifty-six FFMTs were performed for the primary (29 patients) or secondary (26 patients) objective of restoring elbow flexion. The mean age at the time of the procedure was 9.6 years (standard deviation [SD] = 6.29, R = 3-35). Mean follow-up was 7.9 years (SD = 5.2). Elbow flexion improved from a median MRC grade 2 to 4 after a FFMT (p < 0.05). Patients who had a FFMT to restore two functions had 86% lower elbow flexion MRC grades than those who had a FFMT to restore flexion only (p < 0.05). Patients less than 12 years old at the time of surgery had more complications, reoperations, and rates of a flexion contracture more than or equal to 30 degrees than those aged more than 12 years (p < 0.05). FFMT is a reliable option for upper extremity reanimation. Patients aged less than 12 years old at the time of FFMT had significantly more complications, reoperations, and rates of postoperative elbow flexion contracture more than or equal to 30 degrees, but equivalent elbow flexion MRC grades. III.