Tendon Defect Research Articles

Reconstruction of the extensor apparatus with advanced structural defects in knee revision arthroplasty

Restoration of the extensor apparatus in the case of advanced tendon defects as part of revision total knee arthroplasty (TKA). Reconstruction and augmentation using vascularized gastrocnemius muscle and tendon. Advanced degeneration of the extensor apparatus (patella tendon; quadriceps tendon) with or without discontinuity, following revision arthroplasty. Persistent infection or pending TKA revision. Damaged gastrocnemius or soleus muscle or Achilles tendon. Extension of the surgical TKA-access medial-distally. Separation of the medial gastrocnemius muscle along the raphe and preparation of the distal tendon from the soleus portion. Transposition into the defect site, augmentation or reconstruction of the defect by double turn of the gastrocnemius tendon. The muscle belly serves to adequately cover the tendon as well as the ventral knee joint. Mesh coverage of the muscle. Immobilization of the knee and ankle for 10days until mesh graft healing. Stepwise increasing flection of the knee with 30°/60°/90° every 2weeks. Total weight bearing with secured full extended knee, no weight bearing with flexed knee for 6weeks. In 9patients, 3with complete rupture of the patellar tendon, 5with destruction of the extensor apparatus, and 1patient with rupture of the quadriceps tendon following TKA revision, good functional results were achieved with active extension of the knee joint and standing/gait stability 6months after surgery.

Three-Dimensional Tendon Scaffold Loaded with TGF-β1 Gene Silencing Plasmid Prevents Tendon Adhesion and Promotes Tendon Repair.

Tendon adhesion formation is associated with the aberrant expression of many genes, and interfering with the expression of these genes can prevent adhesion and promote tendon repair. Recent studies have found that silencing the transforming growth factor β-1 (TGF-β1) gene can reduce the occurrence of tendon adhesions. The development of tissue engineering and three-dimensional (3D) printing technology have provided new solutions for tendon repair. In this study, TGF-β1 gene silencing microRNA (miRNA) based RNAi plasmid was loaded on a 3D tendon scaffold using 3D printing technology. In vitro experiments confirmed the sustained release of plasmid and the good biocompatibility of the printed tendon scaffold. Subsequently, the TGF-β1 gene silencing plasmid loaded tendon scaffold was implanted in a chicken tendon defect model to evaluate the effect of the scaffold in vivo. The results from biomechanical tests and histological examinations showed that the scaffold not only promoted tendon regeneration but also prevented tendon adhesion, which was conducive to the recovery of biofunction. Evaluation of protein expression showed that the loaded plasmids prevented tendon adhesion and promoted tendon functional repair via silencing of the TGF-β1 gene.

EP.FRI.194 Patellar height after Anterior Cruciate Ligament rupture reconstruction using the autologous bone-patellar tendon-bone graft technique in the Maltese population

Abstract Aim The primary aim of this study is to determine whether there is a change in patellar height after closure of the patellar tendon defect after a bone-patellar tendon-bone graft harvesting. The secondary aim is to evaluate clinical and functional outcomes. Method A retrospective observational study was conducted. Patients who were diagnosed with ACL injury and underwent reconstruction of ACL using the bone- patellar tendon- bone graft technique from 2015 to 2020 were included (56 patients). All patients underwent the same procedural steps. All patients had pre- and post-operative knee radiographs (antero-posterior and lateral views). The Caton- Deschamps Index was used to measure patellar height pre- and post-operatively. The International Knee Documentation Committee-Subjective Knee Evaluation Form was used to assess functional outcome. Clinical outcome was assessed by reviewing patient records. Results There was a change from the pre-op index 0.995 +/− 0.144 (mean +/- SD) to the post-op index 0.948 +/− 0.150. With a statistically significant decrease in index of 0.048 +/− 0.131 (p value 0.009) was found. The null hypothesis (that there is no change) is rejected and therefore the alternative hypothesis (a decrease in patellar height) is accepted. The mean IKDC-SKF score was 76.851 +/− 15.015 (SD) ranging from 40.2 to 100. Conclusion Performing ACL reconstruction using the B-pT-B technique, although predisposing to a decreased patellar height, it does not increase the incidence of patella baja. An overall good functional outcome was achieved, mean IKDC-SKF 76.85. However, no clear association between change in patellar height and PF symptoms could be demonstrated.

What's New in Musculoskeletal Basic Science.

What's New in Musculoskeletal Basic Science.

328 Patellar Height After Anterior Cruciate Ligament Rupture Reconstruction Using the Autologous Bone-Patellar Tendon-Bone Graft Technique in The Maltese Population

Abstract Aim The primary aim of this study is to determine whether there is a change in patellar height after closure of the patellar tendon defect after a bone-patellar tendon-bone graft harvesting. The secondary aim is to evaluate clinical and functional outcomes. Method A retrospective observational study was conducted. Patients who were diagnosed with ACL injury and underwent reconstruction of ACL using the B-p-T-B graft technique from 2015 to 2020 were included (56 patients). All patients underwent the same procedural steps in the same centre. All patients had pre- and post-operative knee radiographs (antero-posterior and lateral views). The Caton- Deschamps Index was used to measure patellar height pre- and post-operatively. The International Knee Documentation Committee-Subjective Knee Evaluation Form was used to assess functional outcome. Clinical outcome was assessed by reviewing patient records. Results There was a change from the pre-op index 0.995 +/- 0.144 (mean +/- SD) to the post-op index 0.948 +/- 0.150. With a statistically significant decrease in index of 0.048 +/- 0.131 (p value 0.009) was found. The null hypothesis (that there is no change) is rejected and therefore the alternative hypothesis (a decrease in patellar height) is accepted. The mean IKDC-SKF score was 76.851 +/- 15.015 (SD) ranging from 40.2 to 100 Conclusions Performing ACL reconstruction using the B-pT-B technique, although predisposing to a decreased patellar height, it does not increase the incidence of patella baja. An overall good functional outcome was achieved, mean IKDC-SKF 76.85. However, no clear association between change in patellar height and PF symptoms could be demonstrated.

Knotless Reconstruction of Chronic Achilles Tendon Ruptures With

Chronic Achilles tendon ruptures can result in tendon lengthening and significant functional deficits including gait abnormalities and diminished push-off strength. Surgical intervention is typically required to restore Achilles tension and improve ankle plantarflexion strength. A variety of surgical reconstruction techniques exist depending on the size of the defect and amount of associated tendinosis. For smaller tendon defects 2 to 3 cm in size, primary end-to-end repair using an open incision and multiple locking sutures is an established technique. However, a longer skin incision and increased soft tissue dissection is required, and failure at the suture-tendon interface has been reported that can result in postoperative tendon elongation and persistent weakness. In this report, we describe a novel technique to reconstruct chronic midsubstance Achilles tendon ruptures using a small incision with knotless repair of the tendon secured directly to the calcaneus. This technique minimizes wound healing complications, increases construct fixation strength, and allows for early range of motion and rehabilitation.Level of Evidence: Level V, Expert Opinion.

Histologic changes during healing with autologous fascia lata graft after superior capsule reconstruction in rabbit model.

Superior capsule reconstruction (SCR) has been developed to improve shoulder function and relieve pain in the treatment of irreparable rotator cuff tears. Previous studies have reported that graft healing can enhance favorable outcomes after SCR. On the other hand, graft tears often lead to less desirable outcomes and sometimes require additional surgical procedures. However, the healing process underlying this remains unclear. In this study, we aimed to investigate histologic changes occurring during the healing process associated with autologous fascia lata graft after SCR invivo. We hypothesized that (1) autologous fascia lata graft can regenerate the fibrocartilaginous insertion into both the greater tuberosity and superior glenoid and (2) the midsubstance of the grafted fascia gradually remodels into tendon- and/or ligament-like tissue after SCR. Irreparable supraspinatus tendon defects were created in 24 mature Japanese white rabbits (age, 6 months; mean weight, 3.2 kg). Four weeks after creation of the defects, the right shoulders were subjected to SCR using autologous fascia lata grafts. The left shoulders were left untreated. Samples from the shoulders were harvested at 4, 8, 12, and 16 weeks after surgery to undergo histologic and immunohistochemical examinations. Macroscopically, we did not observe graft tears after SCR in our experiments. Histologically, the number of chondrocyte-like cells gradually increased, and the extracellular matrices around those cells contained glycosaminoglycan at the fascia-bone junction after SCR. The unmineralized fibrocartilage, mineralized fibrocartilage, and tidemark were observed 16 weeks after SCR. The distribution of type II collagen presented a pattern similar to that of a normal tendon and ligament insertion. The cells and collagen fiber gradually oriented parallelly to the long axis in the midsubstance of the grafted fascia lata. Additionally, type III collagen was replaced with type I collagen in the midsubstance of the grafted fascia lata after SCR. SCR using fascia lata autograft regenerated the fibrocartilaginous insertion at both the greater tuberosity and superior glenoid. The midsubstance of the grafted fascia gradually remodeled into tendon- and/or ligament-like tissue. These results suggest that the fascia lata autograft has the capacity for graft-to-bone healing and remodeling after SCR.

Reconstruction of Achilles region defects: A single-centre experience.

Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to the use of free flaps. The aim of this study was to discuss reconstruction options and to help the surgeon to select reliable approach to achieve favourable outcomes. In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single centre. Reconstructions were performed with secondary healing (n=2), negative pressure wound therapy and skin grafting (n=2), free flaps (n=6) and local and distant flaps (n=4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting. Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. The use of special digital imaging techniques facilitates flap surgery and helps minimise the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Super-thin free flaps offer a distinct advantage in skillful hands. The use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favourable outcomes.

Effects of hypoxia on Achilles tendon repair using adipose tissue-derived mesenchymal stem cells seeded small intestinal submucosa

BackgroundThe study was performed to evaluate the feasibility of utilizing small intestinal submucosa (SIS) scaffolds seeded with adipose-derived mesenchymal stem cells (ADMSCs) for engineered tendon repairing rat Achilles tendon defects and to compare the effects of preconditioning treatments (hypoxic vs. normoxic) on the tendon healing.MethodsFifty SD rats were randomized into five groups. Group A received sham operation (blank control). In other groups, the Achilles tendon was resected and filled with the original tendon (Group B, autograft), cell-free SIS (Group C), or SIS seeded with ADMSCs preconditioned under normoxic conditions (Group D) or hypoxic conditions (Group E). Samples were collected 4 weeks after operation and analyzed by histology, immunohistochemistry, and tensile testing.ResultsHistologically, compared with Groups C and D, Group E showed a significant improvement in extracellular matrix production and a higher compactness of collagen fibers. Group E also exhibited a significantly higher peak tensile load than Groups D and C. Additionally, Group D had a significantly higher peak load than Group C. Immunohistochemically, Group E exhibited a significantly higher percentage of MKX + cells than Group D. The proportion of ADMSCs simultaneously positive for both MKX and CM-Dil observed from Group E was also greater than that in Group D.ConclusionsIn this animal model, the engineered tendon grafts created by seeding ADMSCs on SIS were superior to cell-free SIS. The hypoxic precondition further improved the expression of tendon-related genes in the seeded cells and increased the rupture load after grafting in the Achilles tendon defects.

Clinical and Structural Results of Rotator Cuff Repair Compared With Rotator Cuff Debridement in Arthroscopic Treatment of Calcifying Tendinitis of the Shoulder

Background: Arthroscopic treatment of calcifying tendinitis of the shoulder reveals good to excellent results. However, whether the tendon needs to be repaired after removal of the calcific deposit or simply debrided remains unclear. Purpose: To evaluate the structural and clinical results after arthroscopic calcific deposit removal with additional rotator cuff repair or rotator cuff debridement. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 44 patients (46 shoulders) were enrolled in this retrospective cohort study with a mean follow-up of 58.4 months. Patients underwent arthroscopic removal of a calcific deposit and bursectomy after failed nonoperative treatment. A total of 22 patients received additional rotator cuff repair irrespective of the degree of debridement (the repair group), whereas 22 patients received a simple rotator cuff debridement without additional repair (the debridement group). Groups were comparable in sex, age, and size and consistency of the deposits according to the Gärtner and Bosworth classifications. Clinical evaluation was performed by the Constant score, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES) score, and numerical rating scales for pain, function, and satisfaction. In 29 patients (14 in the debridement group and 15 in the repair group), additional magnetic resonance imaging at follow-up was performed to evaluate the structural results using the Sugaya classification. Results: All patients were satisfied with the results of surgery; 100% of the repair group and 95.7% of the debridement group reported they would undergo the surgical procedure again. Comparison of the clinical results showed significantly better results in the repair group versus the debridement group for the Constant score (86.2 vs 80.6, respectively; P = .04), the ASES score (98.3 vs 88.9; P = .004), the Simple Shoulder Test (11.6 vs 10; P = .005), and the numerical rating scales for pain (0.1 vs 0.8; P = .007), function (9.6 vs 8.8; P = .008), and satisfaction (9.8 vs 9.1; P = .036). Comparison of the postoperative tendon integrity showed 80% Sugaya grade I in the rotator cuff repair group and 64% Sugaya grade II in the debridement group, with a statistically significant difference in favor of the repair group (P = .004). Postoperative clinical evaluation revealed no positive O’Brien tests in the repair group, whereas approximately one-third of the debridement group showed a positive O’Brien test during examination. Conclusion: Arthroscopic removal of calcific deposits with rotator cuff debridement or cuff repair showed good to excellent clinical and structural midterm results. However, patients who underwent additional repair of the tendon defect had significantly better clinical results as well as better structural results in terms of tendon integrity.

Clinical application of dorsal digital cutaneous branch flap with partial extensor tendon in repairing compound tissue defects of the dorsal finger.

Purpose: To investigate the clinical efficacy of using dorsal digital cutaneous branch flap with partial extensor tendon in repairing compound tissue defects of the dorsal digits of the hand. Methods: Between January 2018 and January 2020, ten patients with skin and soft tissue defects of the digits accompanied by extensor tendon defects underwent surgical repair using dorsal digital cutaneous branch flap with partial extensor tendon. The donor site was repaired with dorsal metacarpal artery flap. The smallest skin defect area was 2.0 × 1.5cm, while the largest skin defect area was 4.0 × 3.0cm. The length of tendon defect ranged from 1.5 to 3.0cm. Sensation within the flap, aesthetic appearance of both the donor and recipient sites, functional recovery, and return-to-work time were measured. Results: All 10 flaps survived after surgery. All patients were followed up for 12-18 months, with an average follow-up period of 15.4 months. After flap repair, the digits had satisfactory shape and appearance along with a soft texture. Hand function was excellent in eight cases and good in two cases. Two-point discrimination was 6-9mm with an average of 8mm. No patient experience cold intolerance. The donor sites healed well with satisfactory appearance. Conclusion: Dorsal digital cutaneous branch flap with partial extensor tendon could be used to repair skin and tendon defects simultaneously. The advantages of this method include simple donor tissue harvesting; less donor-site morbidity; reliable blood supply; and satisfactory recovery of appearance, sensation, and function of the flap. Therefore, this method could be suitable for repairing soft tissue defects of the dorsal digits with extensor tendon defects.

Application of channel-assisted minimally invasive repair system in Myerson types Ⅰand Ⅱ chronic Achilles tendon rupture

To investigate the effectiveness of channel-assisted minimally invasive repair system (CAMIR) in treatment of the Myerson types Ⅰ and Ⅱchronic Achilles tendon rupture. Between May 2016 and August 2017, 19 patients with Myerson types Ⅰ and Ⅱchronic Achilles tendon ruptures were treated with CAMIR. There were 14 males and 5 females, aged from 21 to 48 years, with an average age of 34.5 years. The disease duration was 5-9 weeks (mean, 7.5 weeks). The preoperative Thompson tests of affected ankles showed positive. There were 11 cases of Myerson type Ⅰwith the gaps of Achilles tendon defect of 1-2 cm (mean, 1.58 cm), and 8 cases of Myerson type Ⅱwith the gaps of Achilles tendon defect of 2.5-4.0 cm (mean, 3.16 cm). The ankle dorsiflexion and plantarflexion range of motion were measured before and after operation; the American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was used to assess the patients' ankle joint function. No major blood vessels, nerves, and other tissue structures were damaged during the operation; 3 cases of Myerson type Ⅰ were converted to Myerson type Ⅱ according to the gaps of the defect after the scar tissue was removed during the operation. After operation, the depressed part of the Achilles tendon disappeared, the continuity of the tendon was restored, and the Thompson tests were negative. All 19 patients were followed up 12-25 months, with an average of 14 months. All incisions healed by first intention, and no infection and skin necrosis occurred; all the pre-injury activities and exercise were restored at 6 months after operation. During the follow-up period, no heel pain or re-rupture occurred. At last follow-up, except that there was no significant difference in ankle dorsiflexion range of motion of Myerson type Ⅰ patients ( t=2.118, P=0.071), the AOFAS ankle and hindfoot score, ankle plantarflexion range of motion of Myerson types Ⅰ and Ⅱ patients, and ankle dorsiflexion range of motion of Myerson type Ⅱ patients were significantly improved when compared with preoperative values ( P<0.05). According to AOFAS ankle and hindfoot function score, the ankle joint function of type Ⅰ patients was excellent in 7 cases and good in 1 case, and of type Ⅱ patients were excellent in 8 cases, good in 2 cases, and fair in 1 case. CAMIR is safe and effective in the treatment of Myerson types Ⅰ and Ⅱ chronic Achilles tendon rupture with fewer complications and better functional recovery of ankle joint.

Treatment options for chronic ruptures of Achilles tendon - case series.

Chronic Achilles tendon ruptures arise as a result of acute ruptures unrecognized during primary examination or due to non-compliance of the patient. In the treatment, surgical revision is often used, with the possibility of static or dynamic plasties, together with augmentation techniques. This paper presents two cases where static plasty was used to bridge a tendon defect of up to 10 cm, resulting in full restoration of tendon function.

Improved Healing of Rabbit Patellar Tendon Defects After an Atelocollagen Injection

Background: Patellar tendinopathy is a common cause of limitations in daily life activities in young and/or active people. The patellar tendon consists of a complex of collagen fibers; therefore, collagen could be used as a scaffold in the treatment of patellar tendinopathy. Purpose: To evaluate the healing capacity of injected atelocollagen as a treatment scaffold for patellar tendon defect and, hence, its potential for the treatment of patellar tendinopathy. Study Design: Controlled laboratory study. Methods: After receiving a full-thickness patellar tendon defect, 24 New Zealand White rabbits were divided into a control group (without treatment) and an experimental group that received an atelocollagen injection into the defect. Six rabbits from each group were subsequently used for either histologic scoring or biomechanical testing. The Mann-Whitney U test was used to compare histologic evaluation scores and load to failure between the 2 groups. Statistical significance was set at P < .05. Results: The experimental group showed excellent repair of the damaged patellar tendon and good remodeling of the defective area. In contrast, the control group showed defective healing with loose, irregular matrix fibers and adipose tissue formation. A statistically significant difference was found between the 2 groups in both histologic scores and biomechanical tests at postoperative week 12. Conclusion: Injection of atelocollagen significantly improved the regeneration of damaged patellar tendons. Clinical Relevance: Atelocollagen gel injections could be used to treat patellar tendinopathy in outpatient clinic settings.

Microscopic characterisation of local strain field in healing tissue in the central third defect of mouse patellar tendon at early-phase of healing

Tendons exhibit a hierarchical collagen structure, wherein higher-level components, such as collagen fibres and fascicles, are elongated, slid, and rotated during macroscopic stretching. These mechanical behaviours of collagen fibres play important roles in stimulating tenocytes, imposing stretching, compression, and shear deformation. It was hypothesised that a lack of local fibre behaviours in healing tendon tissue may result in a limited application of mechanical stimuli to cells within the tissue, leading to incomplete recovery of tissue structure and functions in regenerated tendons. Therefore, the present study aimed to measure the microscopic strain field in the healing tendon tissue. A central third defect was created in the patellar tendon of mice, and the regenerated tissue in the defect was examined by tensile testing, collagen fibre analysis, and local strain measurement using confocal microscopy at 3 and 6 weeks after surgery. Healing tissue at 3 weeks exhibited a significantly lower strength and disorganised collagen fibre structure compared with the normal tendon. These characteristics at 6 weeks remained significantly different from those of the normal tendon. Moreover, the magnitude of local shear strain in the healing tissue under 4% tissue strain was significantly smaller than that in the normal tendon. Differences in the local strain field may be reflected in the cell nuclear shape and possibly the amount of mechanical stimuli applied to the cells during tendon deformation. Accordingly, restoration of a normal local mechanical environment in the healing tissue may be key to a better healing outcome of tendon injury.

Outcomes of Tibialis Anterior Tendon Reconstruction with Autograft or Allograft.

In cases of tibialis anterior tendon (TAT) ruptures associated with significant tendon defect, an interposition graft is often needed for reconstruction. Both auto- and allograft reconstructions have been described in the literature. Our hypothesis was that both graft types would have a good integrity and provide comparable outcomes. Patients who underwent TAT reconstruction using either an auto- or allograft were identified. Patient-reported outcomes (PROs) were collected using the 12-Item Short Form Health Survey (SF-12) questionnaire, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the Foot Function Index (FFI), and the Karlsson-Peterson score. Functional outcome was assessed by isokinetic strength measurement. Outcomes were further assessed with magnetic resonance imaging (MRI) evaluation of graft integrity. All measurements were also performed for the contralateral foot. Twenty-one patients with an average follow-up of 82 months (20-262 months), comprising 12 allograft and 9 autograft TAT reconstructions, were recruited. There were no significant differences in patient-reported outcomes between allograft reconstructions and autografts: SF-12 (30.7 vs 31.1, P = .77); AOFAS (83 vs 91.2, P = .19); FFI (20.7% vs 9.5%, P = .22); and Karlsson-Peterson (78.9 vs 87.1, P = .23). All grafts (100%) were intact on MRI with a well-preserved integrity and no signs of new rupture. There were no major differences in range of motion and functional outcomes as measured by strength testing between the operative and nonoperative side. Reconstructions of TAT achieved good PROs, as well as functional and imaging results with a preserved graft integrity in all cases. There were no substantial differences between allograft and autograft reconstructions. Level IV, retrospective case series.

Application of lateral circumflex femoral artery chimeric flap to repair complex wounds of foot and ankle

To investigate the effectiveness of lateral circumflex femoral artery chimeric flap transplantation in repair of complex wounds of foot and ankle. A retrospective study was conducted to analyze the clinical data of 20 patients with complex wounds of foot and ankle treated with lateral circumflex femoral artery chimeric flap between June 2017 and June 2020. There were 14 males and 6 females with an average age of 42.8 years (range, 21-65 years). Among them, 8 cases had dorsalis pedis tendon defect with or without bone exposure, 4 cases had partial or total Achilles tendon defect without bone exposure, and 8 cases had deep cavity and bone exposure. The wound area ranged from 10 cm×6 cm to 21 cm×11 cm. The time from injury to operation ranged from 6 to 22 days, with an average of 9.4 days. The lateral femoral circumflex artery flap was used in 6 cases with fascia lata flap, 6 cases with rectus femoris aponeurosis flap, and 8 cases with lateral femoral muscle flap. The flap area ranged from 12.0 cm×6.5 cm to 35.0 cm×7.5 cm. All flap donor sites were sutured directly. The survival, appearance, texture, sensation of the flap, and complications of the donor site were observed. The foot and ankle function was evaluated by Kofoed score. All patients were followed up 8-24 months (mean, 14.2 months). On the 3rd day after operation, 1 case had partial necrosis of 1 flap with fascia lata flap and healed after dressing change; 1 case of chimeric muscle flap developed venous crisis at 12 hours after operation; the chimeric flaps survived successfully in the other 18 patients and the wounds were primary healing. The color and texture of the flaps were good, the flaps recovered protective sensation. Only linear scar remained in the donor site of thigh. There was no sensory disturbance around the incision or walking disturbance. The Kofoed score of the foot and ankle function at last follow-up was 75-96, with an average of 89.8. Among them, 15 cases were excellent, 4 cases were good, and 1 case was qualified. The excellent and good rate was 95.0%. The application of lateral circumflex femoral artery chimeric flap can accurately and stereoscopically repair the complex wounds of foot and ankle and achieve satisfactory effectiveness.

Predictive factor for failure of conservative management in the treatment of calcific tendinitis of the shoulder

Objectives:Calcific tendinitis of the shoulder is a painful condition characterized by the presence of calcium deposits within the tendons of the rotator cuff (RTC) and accounts for up to 7% of all presentations of shoulder pain. Conservative treatment with physical therapy (PT) and corticosteroid injection is often the first line treatment. When conservative management fails, arthroscopic surgery for removal of the calcium may be considered. Surgical removal is often followed by rotator cuff repair to address the resulting tendon defect. This study was performed to assess predictive factors for failure of conservative management as well as to characterize the rate of rotator cuff repair in the setting of calcific tendinitis. We hypothesize that larger calcific lesion would have a higher likelihood to fail conservative treatment and the majority of patients requiring surgery will require a concomitant rotator cuff repair.Methods:A retrospective review of patients who were diagnosed with calcific tendinitis at our institution between 2009 and 2019 was performed. Demographics, comorbidities, pain score (VAS), ASES, ROM and patient-reported quality of life measures were recorded and analyzed. All patients underwent a radiograph and MRI. Size of the calcific lesion was measured based on its largest diameter on radiograph. Statistical analysis included chi-square, independent t test and ANOVA. Descriptive statistics were used to report data. p<0.05 was considered to be statistically significant.Results:239 patients were identified in the study period; 127 (53.1%) were female. Mean age was 54 years and BMI 29.2 with mean follow up of 6 months. Preoperative pain score was 6.3 and ASES score was 47.9. 160 had an intact RTC (67.2%) and 78 had a partial RTC tear (32.8%). The calcific lesion was located in the supraspinatus in 148 patients (63.8%), infraspinatus in 32 patients (13.8%), subscapularis in 9 patients (3.9%), teres minor in 1 patient (0.4%) and combined tendons in 42 patients (18.1%). 93/239 (38.9%) patients failed conservative treatment after an average of 4.4 months necessitating surgical management. Failure rate for PT was 36.6% (24/71), for subacromial corticosteroid injection was 31.6% (25/79) and 33.8% (24/71) for ultrasound guided aspiration. Among patients who underwent surgery the majority of patients, 77/93 (82.8%) required a concomitant rotator cuff repair. Sub-analysis demonstrates that calcific lesions > 1 cm was significantly associated with failure of conservative treatment (odds ratio=2.81, 95% CI 1.25-6.29, p<0.05). All patients who underwent surgery demonstrated significant improvements in pain scores (6.3 to 2.3 VAS), ASES (47.9 to 90.49), forward flexion (133° to 146.8°) and external rotation (49.2° to 57.6°) (p<0.05) postoperatively.Conclusions:Patients with calcific lesions >1 cm have a 2.8x-increased likelihood of failing conservative treatment in the setting of calcific tendinitis of the shoulder. The majority of patients who undergo surgical management for removal of the calcific deposit will require a concomitant rotator cuff repair and have significant improvements in shoulder pain and function. While conservative management is often considered a first-line treatment, the size of the lesion may play a significant role regarding whether conservative treatment will be successful, and patients should be counseled accordingly. Once surgery is decided, orthopedic surgeons should also be aware of the high likelihood of concomitant rotator cuff repair for preoperative planning and discussion.

Molecular Mechanisms of Fetal Tendon Regeneration Versus Adult Fibrous Repair.

Tendinopathies are painful, disabling conditions that afflict 25% of the adult human population. Filling an unmet need for realistic large-animal models, we here present an ovine model of tendon injury for the comparative study of adult scarring repair and fetal regeneration. Complete regeneration of the fetal tendon within 28 days is demonstrated, while adult tendon defects remained macroscopically and histologically evident five months post-injury. In addition to a comprehensive histological assessment, proteome analyses of secretomes were performed. Confirming histological data, a specific and pronounced inflammation accompanied by activation of neutrophils in adult tendon defects was observed, corroborated by the significant up-regulation of pro-inflammatory factors, neutrophil attracting chemokines, the release of potentially tissue-damaging antimicrobial and extracellular matrix-degrading enzymes, and a response to oxidative stress. In contrast, secreted proteins of injured fetal tendons included proteins initiating the resolution of inflammation or promoting functional extracellular matrix production. These results demonstrate the power and relevance of our novel ovine fetal tendon regeneration model, which thus promises to accelerate research in the field. First insights from the model already support our molecular understanding of successful fetal tendon healing processes and may guide improved therapeutic strategies.

ADIPOFASCIAL FLAP FOR BONE DEFECTS COVERAGE IN COMPLEX HAND INJURIES: A CASE REPORT AND LITERATURE REVIEW

Abstract INTRODUCTION Hand injuries are often accompanied by defects in bone, tendon, and neurovascular structures that require complex repairs and an adequate skin coverage. Occasionally, this requires using different reconstructive techniques. Reverse flow adipofascial flaps are an option for the coverage of dorsal defects of the hand and fingers, basically. Its vascular supply allows to prevent, in case of fractures or bone defects, subsequent complications (osteomyelitis, pseudoarthrosis or adhesions). MATERIAL AND METHODS We present a patient with complex saw wounds in hand with extensor tendons injuries of the 4th and 5th fingers and an intercalary bone defect measuring 1.3cm x 0.9cm at the base of the proximal phalanx of the 4th finger, which is stabilized with Kirschner wires and cement. This structure is covered by an adipofascial flap based on 2nd, 3rd and 4th intermetacarpal dorsal perforators. Additionally, literature review was conducted in PubMed database with the search terms "Adipofascial flap AND ostheosynthesis". RESULTS Bone stabilization and coverage is achieved without any problems. Subsequently, bone cement and wires are replaced by an autologous radial graft and by plate and screws. Six articles are reviewed that reported the capability of these flaps to prevent bone infections, adhesions and nonunions. CONCLUSION Adipofascial flaps are a safe, low-morbidity and versatile reconstructive option to take into account for urgent or delayed reconstruction of complex dorsal hand defects. These dońt require microsurgical techniques and resources that may not be available in many centers and dońt sacrifice main vascular axis or future reconstructive options.