Tendon Group Research Articles

“Snake Sign” Secondary Sign of Achilles Tendon Rupture

Objective: We describe a secondary sign (Snake sign) due to lax plantar fascia in full-thickness rupture of Achilles tendon. Materials and Methods: A 100 consecutive magnetic resonance images with intact Achilles tendon and second group of 17 patients with Achilles tendon rupture (ATR) were analyzed for Snake sign and angle between the achilles tendon and plantar fascia (APA) was calculated. Results: Significant decrease in the APA (P < 0.0001) with ATR and Snake sign was present in 8 of the 17 cases in the second cohort. Conclusion: Snake sign and APA are useful secondary signs for ATR.

Patellar tendon morphology in trans-tibial amputees utilizing a prosthesis with a patellar-tendon-bearing feature

A patellar-tendon-bearing (PTB) bar is a common design feature used in the socket of trans-tibial prostheses to place load on the pressure-tolerant tissue. As the patellar tendon in the residual limb is subjected to the perpendicular compressive force not commonly experienced in normal tendons, it is possible for tendon degeneration to occur over time. The purpose of this study was to compare patellar tendon morphology and neovascularity between the residual and intact limbs in trans-tibial amputees and healthy controls. Fifteen unilateral trans-tibial amputees who utilized a prosthesis with a PTB feature and 15 age- and sex- matched controls participated. Sonography was performed at the proximal, mid-, and distal portions of each patellar tendon. One-way ANOVAs were conducted to compare thickness and collagen fiber organization and a chi-square analysis was used to compare the presence of neovascularity between the three tendon groups. Compared to healthy controls, both tendons in the amputees exhibited increased thickness at the mid- and distal portions and a higher degree of collagen fiber disorganization. Furthermore, neovascularity was more common in the tendon of the residual limb. Our results suggest that the use of a prosthesis with a PTB feature contributes to morphological changes in bilateral patellar tendons.

Transphyseal Anterior Cruciate Ligament Reconstruction in the Skeletally Immature: Quadriceps Tendon Autograft Versus Hamstring Tendon Autograft.

Background:It is unclear what the optimal graft choice is for performing anterior cruciate ligament (ACL) reconstruction in a skeletally immature patient.Purpose:To evaluate outcomes and complications of skeletally immature patients undergoing transphyseal ACL reconstruction with a hamstring tendon autograft versus a quadriceps tendon autograft.Study Design:Cohort study; Level of evidence, 3.Methods:Between 2012 and 2016, 90 skeletally immature patients from a single institution underwent primary transphyseal ACL reconstruction with either a quadriceps tendon autograft or a hamstring tendon autograft based on surgeon preference (n = 3). Patient demographic, injury, radiographic, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation (SANE), Tegner activity score, pain, satisfaction, and complications such as graft tears and physeal abnormalities.Results:A total of 83 patients (56 hamstring tendon, 27 quadriceps tendon) were available for a minimum follow-up of 2 years or sustained graft failure. The mean age of the patients was 14.8 ± 1.4 years at the time of ACL reconstruction. No differences in chronological age, bone age, sex, patient size, or mechanism of injury were noted between groups. There were no differences in surgical variables, except that the quadriceps tendon grafts were larger than the hamstring tendon grafts (9.6 ± 0.6 mm vs 7.8 ± 0.7 mm, respectively; P < .001). Patient outcomes at a mean follow-up of 2.8 ± 0.9 years revealed no differences based on graft type, with mean Lysholm, SANE, pain, satisfaction, and Tegner scores of 96, 93, 0.6, 9.6, and 6.6, respectively, for the quadriceps tendon group and 94, 89, 0.9, 9.2, and 7.1, respectively, for the hamstring tendon group. While there were no physeal complications in either group, patients undergoing ACL reconstruction with a hamstring tendon autograft were more likely to tear their graft (21% vs 4%, respectively; P = .037).Conclusion:Skeletally immature patients undergoing ACL reconstruction can be successfully managed with either a quadriceps tendon autograft or a hamstring tendon autograft with good short-term outcomes, high rates of return to sport, and low rates of physeal abnormalities. The primary differences between grafts were that the quadriceps tendon grafts were larger and were associated with a lower retear rate. ACL reconstruction performed with a quadriceps tendon autograft may reduce early graft failure in skeletally immature patients.

Nonabsorbable Suture Knot on the Tendon Affects Rotator Cuff Healing: A Comparative Study of the Knots on Tendon and Bone in a Rat Model of Rotator Cuff Tear

Background: Nonabsorbable suture knots are usually used to link the tendon and bone during rotator cuff repair surgery. There are many variations in the arthroscopic knot-tying technique; however, the location of suture knot placement for rotator cuff healing has rarely been studied. Hypothesis: The authors compared the rotator cuff healing between knots tied on tendon and bone in a rotator cuff tear rat model. It has been hypothesized that knots can cause chronic inflammation and create the weakest link between tendon and bone, thus affecting rotator cuff healing. Study Design: Controlled laboratory study. Methods: Bilateral supraspinatus tenotomy and rotator cuff repair at the greater tuberosity were performed on 24 Wistar rats. Nonabsorbable surgical suture knots were made on the right supraspinatus tendon tissue and left humerus inferior to the greater tuberosity, respectively. Twelve rats each were sacrificed at 3 and 9 weeks. Six of the 12 rats were used for biomechanical testing and the remaining 6 for histologic evaluation. Results: The surgical knots placed on the bursal side of the tendon migrated to the articular side, as noted on gross observation in 22 of 24 samples. The knots on the tendon group showed significantly inferior tendon-bone integration and significantly inferior biomechanical results in terms of maximum load to failure and stiffness. An obvious chronic foreign body inflammatory reaction was found in the knots on the tendon group at 3 and 9 weeks. Furthermore, inferior bone-tendon interface regeneration and weakest link formation were obtained in the knots on the tendon group compared with those on the bone group. Conclusion: Nonabsorbable suture knots placed on the tendon migrate to the articular side, causing chronic inflammation and weakening tendon-bone healing, which may explain some retears after rotator cuff repair. Clinical Relevance: The present animal study suggests that it is not recommended in clinical practice to make several bulky nonabsorbable suture knots on the rotator cuff tendon during rotator cuff repair surgery. It may be better to tie the knots at the bone side or do knotless repair.

Complications After Anterior Cruciate Ligament Reconstruction and Their Relation to the Type of Graft: A Prospective Study of 958 Cases

Background: Complications and adverse events after anterior cruciate ligament (ACL) reconstruction are well known, but they have been underestimated in previous studies. Purpose: To describe the complications and adverse events after ACL reconstruction within a 2-year follow-up and analyze them in relation to the type of graft. Study Design: Cohort study; Level of evidence, 3. Methods: From 2000 to 2012, 958 patients with an isolated ACL injury underwent surgery by a single knee surgeon. ACL reconstruction was performed with the medial portal technique for the femoral tunnel and the use of bone–patellar tendon–bone (BPTB) or hamstring tendon graft. Patients were reviewed at 6 weeks and 3, 6, 12, and 24 months after surgery with the International Knee Documentation Committee score, plain radiographs, and the KT-1000 arthrometer. Results: Of 958 patients enrolled, 147 (15%) were lost at last follow-up. The 2 groups (bone–patellar tendon–bone [n = 257] and hamstring [n = 554]) were similar regarding the mean age at the time of surgery and preoperative anterior laxity. The main complications were as follows: anterior knee pain (n = 130 of 811, 16%), stiffness (n = 72, 8.8%), secondary meniscal lesions (n = 59, 7.2%), pain attributed to fixation (n = 79, 9.7%), ACL rerupture (n = 47, 5.7%), contralateral ACL ruptures (n = 24, 3%), patellar fractures (n = 3, 0.3%), infections (n = 9, 1%), and thromboembolic complications (n = 5, 0.6%). There was no significant difference between the grafts with respect to the frequency of joint stiffness, secondary meniscal lesions, or anterior knee pain. During the first 2 postoperative years, the percentage of patients with anterior knee pain was higher in the patellar tendon group (23.3% vs 12.6%, P < .001); however, this difference was not significant after the 2-year interval (3.1% vs 2.5%, P = .63). The percentage of patients with a rerupture of the graft was significantly lower in the patellar tendon group than in the hamstring group (25 of 811 [3.1%] vs 57 of 811 [7%], P = .023). Similar results were recorded regarding the pain related to the hardware material (7 of 811 [0.8%] in the BPTB group vs 113 of 811 [13.9%] in the hamstring group, P = .001). The percentage of ACL ruptures contralateral to the repair was higher in the patellar tendon group (41 of 811 [5%] vs 17 of 811 [2%], P = .016). Conclusion: The total rate of complications after an ACL reconstruction was 39%, and the surgical revision rate for any reason was 28%. Problems with the hardware material were more frequent in the hamstring group, leading to an increased rate of surgical revision. Anterior knee pain was initially higher in the patellar tendon group, but there was no significant difference in a 2-year interval. The rerupture rate was statistically higher in the hamstring group.

DOES THE GRAFT USED FOR ACL RECONSTRUCTION AFFECT THE KNEE MUSCULAR STRENGTH RATIO AT SIX MONTHS POSTOPERATIVELY?

Restoring knee muscle strength after an anterior cruciate ligament (ACL) reconstruction remains challenging. Improvement of rehabilitation program specificity demands additional knowledge on knee muscle strength deficits associated with the graft used for ACL reconstruction. This study aimed to investigate the effects of graft used for ACL reconstruction on the knee muscle strength and balance assessed at six months postoperatively, based on comparisons of the isokinetic strength curves measured throughout knee extension. Cross-sectional study. One-hundred-and-forty-four patients were assigned into three groups according to the graft used for a primary ACL reconstruction: semitendinosus (n=47), semitendinosus+gracilis (n = 75) and patellar (n=22) tendon graft. Normalized hamstring eccentric and quadriceps concentric torques, and hamstrings-to-quadriceps torque ratio (defined as the dynamic functional ratio) were bilaterally assessed during knee extension. Statistical parametric mapping was used to compare the curves of torques and ratio from 90 ° to 30 °of knee flexion between groups. The uninvolved knees presented similar strength and ratio curves in the three groups. When compared involved to uninvolved knees, hamstring strength deficit was found in hamstring tendon groups throughout knee extension (p<0.001), and quadriceps strength deficit in the three groups throughout knee extension (p<0.001). Hamstrings-to-quadriceps torque ratio was unaltered when using hamstring tendon grafts, while increased ratio was observed up to knee mid-extension when using patellar tendon graft (p<0.001). These findings suggest exercises with specific range of motion and contraction type in relation to graft may be considered for implementation into postoperative rehabilitation program in order to eliminate the regional strength deficits observed after ACL reconstruction. 3.

Comparison of knee sonography and pressure pain threshold after anterior cruciate ligament reconstruction with quadriceps tendon versus hamstring tendon autografts in soccer players

ObjectiveThe aim of this study was to compare the pressure pain threshold and muscle architecture after an anatomic single bundle reconstruction with quadriceps tendon and hamstring tendon autografts of the anterior cruciate ligament in competitive soccer players. We hypothesized that both procedures will obtain similar outcomes. MethodsFifty-one participants were enrolled in this secondary analysis of a randomized controlled trial and were categorised into two groups: quadriceps tendon (QT) group (23 men and 3 women; mean age 18.7 ± 3.6; BMI 23.0 ± 2.2) or hamstring tendon (HT) group (16 men and 9 women; mean age 19.2 ± 3.6 BMI 23.5 ± 3.5). Both groups followed the same rehabilitation staged protocol. Pressure pain threshold (PPT), as a measure of perceived pain, was obtained in several points of quadriceps and hamstring muscles. Ultrasound imaging measurements were obtained in quadriceps tendon and knee cartilage thickness. Four measurements were taken in this study: baseline, 1, 3, 6, and 12 months after the anterior cruciate ligament (ACL) reconstruction. ResultsThe analysis of PPT did not find significant differences in both groups × interaction time in the points evaluated: epicondyle (QT = 421.1 ± 184.1 vs HT = 384.7 ± 154.1 kPa), vastus lateralis (QT = 576.2 ± 221.3 vs HT = 560.1 ± 167.7 kPa), vastus medialis (QT = 544.7 ± 198.8 vs HT = 541.1.1 ± 181.77 kPa), patellar tendon (QT = 626.3 ± 221.1 vs HT = 665.0 ± 205.5 kPa), QT (QT = 651.1 ± 276.9 vs HT = 660.0 ± 195.2 kPa).(QT = 667.8 ± 284.7 vs HT = 648.2 ± 193.4 kPa) injured knee (all P > 0.05). The results of ultrasound imaging did not show significant differences in both groups × interaction time in the thickness of the QT (QT = 9.9 ± 2.4 vs HT = 9.4 ± 1.7 kPa) and patellar cartilage (QT = 3.2 ± 0.6 vs HT = 3.2 ± 0.4 kPa) (P > 0.05). ConclusionA QT autograft produces similar results to a HT autograft in ACL reconstructions in terms of pressure pain threshold and ultrasound muscle architecture during the 1-year follow-up. Level of EvidenceLevel I, Therapeutic Study.

A Randomized Clinical Trial Comparing Patellar Tendon, Hamstring Tendon, and Double-Bundle ACL Reconstructions: Patient-Reported and Clinical Outcomes at 5-Year Follow-up.

This randomized clinical trial evaluated the 5-year, disease-specific quality-of-life outcomes of patients treated for anterior cruciate ligament (ACL) deficiency with use of a patellar tendon, single-bundle quadruple-stranded hamstring, or double-bundle hamstring reconstruction. Patients (n = 110 per group; 183 male; 14 to 50 years of age) were randomly allocated to anatomically positioned ACL reconstruction with use of a patellar tendon graft (patellar tendon group; mean age, 28.7 years), quadruple-stranded hamstring tendon construct (hamstring tendon group; mean age, 28.5 years), or double-bundle hamstring tendon construct (double-bundle group; mean age, 28.3 years). Computer-generated allocation with varied block randomization was performed intraoperatively. The 5-year primary outcome measure was the Anterior Cruciate Ligament-Quality of Life (ACL-QOL) score, and secondary outcome measures included the International Knee Documentation Committee (IKDC) subjective score and objective grades, pivot shift assessment, range of motion, kneeling pain, Tegner activity scale, Cincinnati Occupational Rating Scale, complete traumatic reruptures, partial traumatic tears, total traumatic reinjuries, and atraumatic graft failures. Three hundred and fifteen patients (95%) completed the 5-year follow-up (4 withdrawals, and 11 lost to follow-up). ACL-QOL scores increased significantly from baseline for all groups (p < 0.0001), but mean scores at 5 years did not differ among the groups (p = 0.548): mean (and standard deviation) of 82.5 ± 17.9 (95% confidence interval [CI], 79.0 to 86.0) for patellar tendon, 83.9 ± 18.2 (95% CI, 80.3 to 87.4) for hamstring tendon, and 81.1 ± 19.3 (95% CI, 77.4 to 84.8) for double-bundle. The proportions of patients at 5 years with a pivot shift grade of ≥2 (12% for patellar tendon, 16% for hamstring tendon, and 22% for double-bundle; p = 0.149) and with normal and nearly normal knees per IKDC grade (87%, 82%, and 75% for the 3 groups, respectively; p = 0.093) trended in favor of patellar tendon reconstruction. No differences were seen for the IKDC subjective scores, knee range of motion including passive extension deficits, the single leg hop test, Cincinnati Occupational Rating scores, and Tegner activity levels. Kneeling pain was more common with patellar tendon reconstruction (10% of patients compared with 4% for hamstring tendon and 2% for double-bundle; p = 0.029). For hamstring tendon and double-bundle reconstructions, there were trends toward more complete traumatic reruptures (4% for patellar tendon, 10% for hamstring tendon, and 10% for double-bundle; p = 0.145) and partial traumatic tears (0%, 5%, and 6%, respectively; p = 0.059), with significantly fewer combined traumatic reinjuries in the patellar tendon group (4 patients compared with 16 for hamstring tendon and 17 for double-bundle; p = 0.010). Atraumatic graft failure (pivot shift grade of ≥2) was found for 10% of the patients. At 5 years, we found no significant difference in the quality-of-life outcome among the patellar tendon, hamstring tendon, and double-bundle techniques for ACL reconstruction. Significantly more patients in the hamstring tendon and double-bundle groups experienced traumatic graft reinjury compared with the patellar tendon group. There was a trend toward a higher percentage with normal and nearly normal IKDC grades in the patellar tendon group compared with hamstring tendon and double-bundle groups. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Comparison of clinical effect between autogenous semitendinosus and allogenic tendons for anatomical reconstruction of anterior talofibular ligament and calcaneofibular ligament under arthroscopy

Objective To compare the clinical effects of autologous semitendinosus tendon and allogenic tendon arthroscopic anatomical reconstruction of anterior talofibular ligament (ATFL) combined with calcaneofibular ligament (CFL) in the treatment of chronic lateral ankle instability. Methods A retrospective analysis was made of 55 patients with chronic lateral ankle instability who underwent arthroscopic reconstruction of ATFL combined with CFL from January 2012 to June 2017. A total of 28 cases were treated with autologous semitendinosus tendon (autologous group), including 19 males and 9 females, with an average age of 28.5±8.03 years (range, 16-46 years). A total of 27 cases were treated with allogenic tendon (allogenic group), including 17 males and 10 females, with an average age of 27.48±7.89 years (range, 16-46 years). ATFL/CFL was reconstructed by the same method in both groups. The reconstruction methods were the same between the groups. The talus and calcaneus were fixed with absorbable compression nails. Results The operation duration in the autologous group was 94.07±7.83 min, which was longer than that in the allogeneic group 63.56±7.96 min (t=14.51, P<0.001). Fever days 5.26±0.90 days in allogeneic group were longer than 2.46±0.74 days in autologous group (t=-12.55, P<0.001). Wound healing duration in allogeneic group was 13.44±3.33 days longer than that in autologous group 10.32±2.34 days (t=-4.01, P<0.001). In the autologous group, 28 cases were followed up for 34.54±16.04 months, and 27 cases in the allograft group were followed up for 42.74±17.79 months. The mean AOFAS score improved from 63.64±11.20 before operation to 90.21±4.48 after operation in the autologous group, and that improved from 63.93±10.59 before operation to 89.56±5.15 after operation in the allogeneic group with no significant difference between the two groups after operation (t=0.506, P=0.615). The mean VAS score decreased from 5.79±1.79 before operation to 1.54±1.35 after operation in the autologous group, and from 5.89±1.78 before operation to 2.04±1.32 after operation in the allogeneic group. There was no significant difference between the two groups after operation (t=-1.396, P=0.168). Tegner score increased from 4.07±1.39 to 6.43±1.14 in the autologous group and from 3.85±1.06 to 6.52±0.85 in the allogeneic group with no significant difference between the two groups after operation (t=-0.333, P=0.740). Stress radiographic showed that the talar tilt angle decreased from 15.60°±3.86° to 6.01°±2.64° in the autologous group, 16.99°±3.78° to 7.14°±3.34° in the allogeneic group, and there was no significant difference between the two groups after operation (t=-1.382, P=0.171). Anterior talar displacement reduced from 10.82±3.12 mm to 4.03±1.69 mm in the autologous group, from 10.10±2.02 mm to 4.17±1.52 mm in the allogeneic group, and there was no significant difference between the two groups after operation (t=-0.326, P=0.746). No donor tendon dysfunction was found in the autologous group. At the end of follow-up, there was no difference in ankle dorsiflexion, plantar flexion and hind foot mobility between autologous group and allogeneic group. Conclusion Arthroscopic autologous tendon and allogeneic tendon reconstruction of AFTL combined with CFL can obtain satisfactory short-term results. The autologous tendon group was superior to the allogeneic group in terms of fever, wound healing time. However, there was no significant difference in clinical effects between the two groups. Key words: Arthroscopy; Lateral ligament, ankle; Transplantation, homologous

Sternoclavicular Joint Reconstruction Fracture Risk Is Reduced With Straight Drill Tunnels and Optimized With Tendon Graft Suture Augmentation.

Background:Despite the rare entity of sternoclavicular joint (SCJ) instability, a variety of different reconstruction techniques for SCJ dislocations have been described. A technique with oblique drilling has been proposed to reduce intraoperative risks.Purpose:To biomechanically investigate different cerclage reconstruction techniques and the benefit of additional reinforcement using suture tape.Study Design:Controlled laboratory study.Methods:Reconstructed artificial bone specimens were mounted on a mechanical testing machine. They were subjected to anterior and posterior translation, analyzing ultimate strength, displacement, stiffness, and elongation. For stage 1, different angulations of the drill tunnels through the sternum and clavicle were compared. Straight drill tunnels from anterior to posterior were compared with 45° oblique drill tunnels. For stage 2, three different materials for cerclage reconstruction were compared: (1) suture tape alone (FT group), (2) tendon graft alone (tendon group), and (3) tendon graft with suture tape augmentation (tendon+FT group).Results:For the FT group, in the anterior and posterior directions, straight drill holes resulted in a significantly higher load to failure (936.9 ± 122.5 N) compared with oblique ones (434.5 ± 20.2 N) (P < .0001). During cyclic testing, all specimens with straight drill holes survived the 5- to 550-N step, while all specimens with oblique ones failed during the 5- to 450-N step. Analyzing the graft material choice, the mean load to failure was 556.6 ± 174.3 N for the tendon group, 936.9 ± 122.5 N for the FT group, and 767.0 ± 110.7 N for the tendon+FT group (P = .089). The stiffness of the tendon+FT group was significantly lower than that of the FT group and significantly higher than that of the tendon group.Conclusion:Oblique tunnel placement during SCJ reconstruction, while reducing the intraoperative risk, results in decreased primary stability of the construct. Tendon graft reconstruction with suture tape augmentation leads to enhanced stability and optimizes biomechanical properties of the construct.Clinical Relevance:The surgical technique with straight drill holes has superior initial biomechanical properties and may likewise produce superior clinical outcomes in the treatment of SCJ instability. Suture tape augmentation can provide additional stability to reconstruction procedures.

Ultrasound Diagnosis of Complete Rotator Cuff Tear

Pain is the most common complaint in patients with rotator cuff injuries. The rotator cuff is a group of muscles and tendons that surround the shoulder joint, keeping the head of your upper arm bone firmly within the shallow sock-et of the shoulder.

Tensile strength comparison between hamstring tendon, patellar tendon, quadriceps tendon and peroneus longus tendon: A cadaver research

Knee ligament injury is a frequent occurrence. Ligament reconstruction using tendon graft is the best therapy recommendation in the case of severe knee ligament injury. Tendon graft that is oftenly used are hamstring tendon, patellar tendon (BPTB), quadriceps tendon and peroneus longus tendon have been proposed as tendon graft donor. Biomechanically, tensile strength from tendon graft is the main factor that greatly contributes to the success of ligament reconstruction procedure. Numerous researches have been done to calculate tensile strengths of hamstring and patellar tendon, but there has not been a research done yet on the comparison of the tensile strengths of peroneus longus tendon, hamstring, patellar tendon and quadriceps tendon. This research will strive to record the tensile strengths of peroneus longus tendon, hamstring, patellar tendon and quadriceps tendon as well as their comparison. Population of this research is 6 cadavers that have met the exclusion and inclusion criterias. From population above, 48 samples are retrieved and further divided into 4 groups. 12 samples for quadriceps tendon group, 12 samples for hamstring group, 12 samples for peroneus longus tendon group and 12 samples for patellar tendon group. Tensile strength measurement will then be done on each tendon by clamping both ends of examined tendon, then pulled on one side until tendon ruptures. Results are then read with a tensile tester. Tensile strength of peroneus longus tendon is not significantly different in comparison to hamstring tendon (p > 0,05). Whereas when compared to patellar and quadriceps tendons, peroneus longus and hamstring tendons have tensile strengths that are significantly higher (p < 0,05). Peroneus longus tendon have the highest tensile strength in comparison to the other three, followed by hamstring, quadriceps, and patellar tendons respectively.

Efficacy comparison between clavicular hook plate combined with coracoclavicular ligament reconstruction and simple hook plate for acute acromioclavicular joint dislocation

Objective To compare the efficacy between hook plate combined with coracoclavicular ligament functional reconstruction by conjoined tendon transfer and single hook plate surgery in the treatment of Rockwood type III and type V acute acromioclavicular joint dislocations. Methods A prospective cohort study was conducted to analyze the clinical data of 37 patients with Rockwood type III and V acute acromioclavicular dislocations admitted to Jiangning Hospital Affiliated to Nanjing Medical University from October 2011 to April 2016. According to the random number method, the patients were divided into combined tendon and ligament reconstruction group (ligament reconstruction group, 19 patients) and clavicular hook plate group (single plate group, 18 patients). In the ligament reconstruction group, there were 14 males and five females, aged (47.0±11.4)years, and there were 10 patients with type III and nine with type V. In the simple plate group, there were 12 males and six females, aged (45.0±11.2)years, and there were 11 patients with type III and seven with type V. In the ligament reconstruction group, the acromioclavicular joint was reduced by clavicular hook plate, and the oblique ligament and the conical ligament were reconstructed by lateral half-inversion of the short head tendon of biceps brachii combined with tendon. The double-bundle functional reconstruction of coracoclavicular ligament was performed. In single plate group, hook plate was used to reduce acromioclavicular joint. The intraoperative blood loss, incision length, operation time, and visual analogue score (VAS) before operation and after 1 year follow-up were compared. Constant-Murley score and Karlsson score were used to evaluate the effect of operation. X-ray films were taken regularly to observe the reduction and maintenance of acromioclavicular joint dislocation. The complications were recorded. Results All patients were followed up for 17-24 months [(20.0±1.7)months]. There was no significant difference in intraoperative blood loss between the two groups (P>0.05). In the ligament reconstruction group and single plate group, the incision length was (13.4±0.8)cm and (6.6±0.7)cm (P 0.05); the VAS at 1 year after operation was (2.1±0.9)points and (3.8±1.4)points (P<0.05). X-ray showed good reduction of acromioclavicular joint in ligament reconstruction group, with no loss of reduction occurred after removal of hook plate. In the simple plate group, loss of reduction, resorption of distal clavicle bone and bone fusion occurred after removal of hook plate. The Constant-Murley scores in the ligament reconstruction group and the single plate group were (89.5±2.9)points and (79.6±5.0)points respectively; the excellent and good rates of Karlsson score were 89.5% (17/19) and 61.1% (11/18) (bothP<0.05), respectively. In the ligament reconstruction group, one patient complained of pain and swelling at the tendon. In the single plate group, loss of reduction occurred in three patients after removal of internal fixator; obvious subacromial osteolysis was seen in seven patients at 1 year after operation; and impingement sign was positive in nine patients at 1 year after operation. Conclusion The overall surgical effect of hook plate combined with coracoclavicular ligament functional reconstruction by conjoined tendon transfer is superior to single hook plate surgery in the treatment of type Rockwood III and Rockwood V acute acromioclavicular joint dislocations, though with longer operation time and bigger incision. Key words: Acromioclavicular joint; Dislocations; Coracoclavicular ligament

Proximal Hamstring Repair: A Biomechanical Analysis of Variable Suture Anchor Constructs

Background:Despite an abundance of literature regarding construct strength for a myriad of anchors and anchor configurations in the shoulder, there remains a paucity of biomechanical studies detailing the efficacy of these implants for proximal hamstring repair.Purpose:To biomechanically evaluate the ultimate failure load and failure mechanism of knotless and knotted anchor configurations for hamstring repair.Study Design:Controlled laboratory study.Methods:A total of 17 cadaveric specimens divided into 3 groups composed of intact hamstring tendons as well as 2 different anchor configurations (all-knotted and all-knotless) underwent first cyclic loading and subsequent maximal loading to failure. This protocol entailed a 10-N preload, followed by 100 cycles incrementally applied from 20 to 200 N at a frequency of 0.5 Hz, and ultimately followed by a load to failure with a loading rate of 33 mm/s. The ultimate failure load and mechanism of failure were recorded for each specimen, as was the maximal displacement of each bone-tendon interface subsequent to maximal loading. Analysis of variance was employed to calculate differences in the maximal load to failure as well as the maximal displacement between the 3 study groups. Holm-Sidak post hoc analysis was applied when necessary.Results:The all-knotless suture anchor construct failed at the highest maximal load of the 3 groups (767.18 ± 93.50 N), including that for the intact tendon group (750.58 ± 172.22 N). There was no statistically significant difference between the all-knotless and intact tendon groups; however, there was a statistically significant difference in load to failure when the all-knotless construct was compared with the all-knotted technique (549.56 ± 20.74 N) (P = .024). The most common mode of failure in both repair groups was at the suture-tendon interface, whereas the intact tendon group most frequently failed via avulsion of the tendon from its insertion site.Conclusion:Under biomechanical laboratory testing conditions, proximal hamstring repair using all-knotless suture anchors outperformed the all-knotted suture anchor configuration with regard to elongation during cyclic loading and maximal load to failure. Failure in the all-knotted repair group was at the suture-tendon interface in most cases, whereas the all-knotless construct failed most frequently at the musculotendinous junction.Clinical Relevance:No biomechanical studies have clearly identified the optimal anchor configuration to avert proximal hamstring repair failure. Delineating this ideal suture anchor construct and its strength compared with an intact hamstring tendon may alter the current standards for postoperative rehabilitation, which remain extremely conservative and onerous for these patients.

La réparation des ruptures aiguës du tendon quadricipital procure une meilleure fonction que celle des ruptures du tendon patellaire

IntroductionThe purpose of this study was to determine if there is a difference in knee function between patients with quadriceps tendon rupture and patellar tendon rupture after acute surgical repair. Our hypothesis was that knee function would be similar between the two groups. MethodsThe study population included 24 patients; 13 patients suffered from quadriceps tendon rupture and 11 patients from patellar tendon rupture. All patients underwent acute surgical repair using heavy non-absorbable transosseous sutures; another non-absorbable suture, passed through both retinaculum and around the repaired tendon to augment the repair. Clinical evaluation was performed using the Lysholm, Kujala, and VAS scoring systems. In addition, radiographic evaluation to evaluate patellar height and patello-femoral joint arthritis using Iwano's classification was performed. ResultsThe average follow-up time was 70.5 months. All patients in the quadriceps tendon group had full range of knee motion while 3 patients (27 %) in the patellar tendon group had reduced knee flexion. Patients in the quadriceps tendon group had a significantly higher Kujala score in comparison to the patellar tendon group (88 vs 73 p=0.033). No significant differences were identified between the two groups according to the Lysholm scoring system. Patients in the quadriceps tendon group had significantly less pain according to VAS scale (1.2 vs 3.5 p=0.012). Radiographic evaluation revealed that, two patients from each group showed signs of grade II patello-femoral joint arthritis according to Iwano's classification. ConclusionAcute surgical repair of quadriceps tendon ruptures provides better knee function, in comparison to the surgical restoration of patellar tendon rupture. Level of evidenceLevel III, retrospective comparative study.

Better knee function after surgical repair of acute quadriceps tendon rupture in comparison to acute patellar tendon rupture

IntroductionThe purpose of this study was to determine if there is a difference in knee function between patients with quadriceps tendon rupture and patellar tendon rupture after acute surgical repair. Our hypothesis was that knee function would be similar between the two groups. MethodsThe study population included 24 patients; 13 patients suffered from quadriceps tendon rupture and 11 patients from patellar tendon rupture. All patients underwent acute surgical repair using heavy non-absorbable trans-osseous sutures; another non-absorbable suture, passed through both retinaculum and around the repaired tendon to augment the repair. Clinical evaluation was performed using the Lysholm, Kujala, and VAS scoring systems. In addition, radiographic evaluation to evaluate patellar height and patello-femoral joint arthritis using Iwano's classification was performed. ResultsThe average follow-up time was 70.5 months. All patients in the quadriceps tendon group had full range of knee motion while 3 patients (27%) in the patellar tendon group had reduced knee flexion. Patients in the quadriceps tendon group had a significantly higher Kujala score in comparison to the patellar tendon group (88 vs. 73 p=0.033). No significant differences were identified between the two groups according to the Lysholm scoring system. Patients in the quadriceps tendon group had significantly less pain according to VAS scale (1.2 vs. 3.5 p=0.012). Radiographic evaluation revealed that two patients from each group showed signs of grade II patello-femoral joint arthritis according to Iwano's classification. ConclusionAcute surgical repair of quadriceps tendon ruptures provides better knee function, in comparison to the surgical restoration of patellar tendon rupture. Level of evidenceLevel III, retrospective comparative study.

A comparative study on functional outcome of ACL reconstruction: Quadriceps versus hamstring tendon autograft

IntroductionThere are various soft tissue graft options available for anterior cruciate ligament reconstruction. This study aims to compare the functional outcome following anterior cruciate ligament reconstruction between quadriceps tendon and hamstring tendon autografts. HypothesisThere was no significant difference in functional outcome of anterior cruciate ligament reconstruction between quadriceps and hamstring tendon autografts at two years follow up. MethodsOut of total 96 patients in our study, 48 patients included in quadriceps tendon autograft group and remaining 48 patients included in hamstring tendon group. Both group of patients were treated by same surgeon, with similar fixation methods and criteria for functional outcomes includes IKDC scores and clinical assessment of stability at 2 years follow up. ResultsPreoperative IKDC scores in quadriceps and hamstring tendon group are 56 and 58 respectively. Out of 48 patients in quadriceps tendon group 4 patients lost for follow up and out of 48 patients in hamstring tendon group 6 patients lost for follow up at 12 weeks. At 2 year follow up IKDC scores in quadriceps tendon group is 114 in 40 patients and 100 in 4 patients(mean IKDC score 113), in hamstring tendon group is 119 in 38 patients and 113 in 4(mean IKDC score 118) with p value > 0.05(p = 0.97) showing no statistical significance. ConclusionOur study shows no statistical significant difference between quadriceps and hamstring tendon autograft groups at 2 years follow up following anterior cruciate ligament reconstruction. This shows our hypothesis was correct.

Treatment of AC dislocation by reconstructing CC and AC ligaments with allogenic tendons compared with hook plates

BackgroundThe purpose of this study was to compare outcomes between allograft reconstruction and hook plate fixation for acute dislocation of the acromioclavicular joint with a minimum 2-year follow-up.MethodsA retrospective comparative study of patients treated for acute acromioclavicular joint dislocation from February 2010 to December 2014 in our hospital, consisting of 16 patients who were followed-up, was performed.Eight patients were treated for acute AC dislocation and underwent surgical reconstruction as follows: the coracoclavicular and acromioclavicular ligaments were reconstructed with the allogenic tendon. The other eight patients were treated with hook plates to maintain the AC joint reset. At the latest follow-up, radiographic analysis and the Constant and University of California-Los Angeles (UCLA) scores were used to evaluate shoulder function. The satisfaction of the patients in terms of the efficacy and visual analog scale (VAS) data were also recorded.ResultsAfter an average follow-up of 30.3 months (range 24–46 months), no patient had dislocated their joint again at the final follow-up based on X-ray examination. The Constant score was 94.4 for the allogenic tendon group and 93.8 for the hook plate group (P = 0.57). According to the UCLA scale (P = 0.23) or VAS (P = 0.16), we found no significant difference between the two groups. All patients reported that they were very satisfied or satisfied with the outcome of surgery, and no significant difference (P = 0.08) was found between the two groups.ConclusionsThe use of allogenic tendon for reconstruction of the coracoclavicular and acromioclavicular ligaments shows excellent outcomes in terms of the recovery of clinical function or radiographic outcomes for acute AC dislocation. Compared with the hook plate, the hardware did not need to be removed.

Strength recovery after anterior cruciate ligament reconstruction with quadriceps tendon versus hamstring tendon autografts in soccer players: A randomized controlled trial

BackgroundThe comparison between HT and QT grafts in strength recovery and function after an ACLR is scarce in the literature. MethodsA total of 56 participants were enrolled in this randomized controlled trial and placed into two groups: HT or QT. The hamstring/quadriceps (H/Q) ratio was the primary end-point measured with a Genu-3 dynamometer. Peak torque, functional assessment (Lysholm knee scoring scale and Cincinnati Knee Rating System), and anteroposterior laxity (KT-2000™ arthrometer) were also assessed. An intention-to-treat analysis was performed. ResultsThe results of the H/Q ratio analysis of the participants over time revealed significant differences at 60, 180, and 300°/s at three, six, and 12months of follow-up (60°/s: F=5.3, p=0.005; 180°/s: F=5.5, p=0.004; 300°/s: F=5.1, p=0.005). Furthermore, they revealed significant differences at 60°/s, 180°/s, and 300°/s in the participants over time for peak torque in the extensor muscle strength at three and six months of follow-up, with higher values in the hamstring tendon group but not at 12months of follow-up. There were no significant differences in functional endpoints or arthrometer assessments at 24months of follow-up. ConclusionAn ACLR with a QT graft showed similar functional results with a better isokinetic H/Q ratio compared to an ACLR with the HT at 12months of follow-up in soccer players. This higher H/Q ratio observed with the QT could be an advantage of this graft over the HT for an ACLR.

Radiographic Risk Factors and Signs of Abductor Tears in the Hip

The purpose of this study is to identify radiographic risk factors (RRFs) and radiographic signs of abductor tendon tears. Between April 2008 and October 2015, patients with intraoperative diagnosis of partial- or full-thickness abductor tear noted at the time of open or endoscopic treatment were included in this study. Exclusion criteria included lack of preoperative standard supine pelvic radiograph, lack of preoperative magnetic resonance imaging (MRI), or abductor tear not present at the time of operative intervention. Patients were matched by age ±5years, gender, and body mass index ±5 with patients with no abductor pathology by clinical exam and MRI. A standardized supine anterior-posterior pelvis radiograph was performed on all patients. The radiographs were evaluated for RRF (pelvic width, body weight moment arm, abductor moment arm, abductor angle, pelvic height) and signs of abductor tendon pathology (greater trochanteric enthesophyte). Femoral version was measured on MRI when images were available. Statistical analysis was performed and included bivariate and multivariate analyses. There were 152 patients with abductor tears identified at the time of surgery out of 2,838 eligible patients matched with 125 patients without abductor tendon pathology. The study institution was unable to perform a 1:1 match because of the advanced age of the abductor tendon group, which led to a greater age in the abductor group (n= 58) versus the control group (n= 54; P= .01. In abductor group the average age was 58, and 137 of 152 (90%) patients were female; in the control group the average age was 54, with 111 of 125 (89%) patients being female. Abductor tear patients were treated with surgical repair. The RRFs found with bivariate analysis were an increased pelvic width (14.8cm for abductor tears vs 14.3cm for control; P < .001), body weight moment arm (11.1cm vs 10.9cm; P < .001), and abductor moment arm (7.8cm vs 7.6cm; P < .001); decreased femoral anteversion (7.6° vs 10.6°; P= .045); and enthesophyte presence (41% vs 3%; P < .001). Multivariate regression analysis of all variables showed that teardrop distance and enthesophyte presence were the 2 variables most predictive of abductor tears, and other variables did not significantly increase or decrease the likelihood of tear when these 2 variables were considered. The presence of an enthesophyte on the greater trochanter was notable for an odds ratio of 20.7 of having an abductor tear. Patients with abductor tears have a wider pelvis, longer abductor moment arm, and longer body weight moment arm and have greater trochanteric enthesophyte as noted on nearly half of patients with an abductor tear. Presence of an enthesophyte was noted to have an odds ratio of 20.7 and a positive predictive value of 94% for having an abductor tendon tear. The 2 variables predictive of abductor tendon tear when controlling for all variables were enthesophyte presence and teardrop distance, with no other variables significantly increasing or decreasing the likelihood of tear when these 2 variables were considered. Level III, retrospective comparative study.