Tendon Involvement Research Articles

Sonographic Findings in Inflammatory Arthritis Secondary to Immune Checkpoint Inhibition: A Case Series.

ObjectiveImmune checkpoint inhibitors (ICI) are transforming the field of oncology, leading to tumor regression in multiple advanced cancers. With this case series, we review the ultrasound imaging findings in a series of patients with ICI‐induced inflammatory arthritis (IA), a novel rheumatic disease that is caused by cancer immunotherapy.MethodsWe identified patients with rheumatologist‐diagnosed, ICI‐induced IA who had musculoskeletal ultrasound performed for clinical care. A retrospective chart review was done to obtain demographics, oncologic history, clinical presentation, imaging, and synovial fluid results. Ultrasound images were reviewed and scored for synovial and tendon pathology, presence of Doppler, and bony erosion.ResultsNine patients were included in this study with a total of 18 joint regions assessed. The knees were the most commonly imaged joint followed by the hands, wrists, feet, and ankles. Synovitis was seen in 12 of the 18 joints with active Doppler in 50% of the cases. Tendon involvement was also frequently seen (13 of 18 joints) with tenosynovitis, tendinitis, and enthesophytes. Erosions were less frequent and seen in only three cases but were also an early finding.ConclusionPatients with ICI‐induced IA had a wide range of pathology affecting the synovium, tendons, and bones on musculoskeletal ultrasound. Further systematic study with imaging is needed for this group of diseases.

Ultrasonographic Evidence of Predominance of Acute Extracapsular and Chronic Intrasynovial Patterns in 100 Cases of Psoriatic Hand Dactylitis.

To use ultrasonography to study whether the duration of psoriatic dactylitis was associated with different patterns of extracapsular and synovial-based involvement. One hundred cases of hand dactylitis from 85 patients with psoriatic arthritis (PsA) were consecutively enrolled in a multicenter cross-sectional study and divided into 2 groups according to dactylitis duration (shorter or longer than the median: 20 weeks). All dactylitis fingers were investigated using high-frequency ultrasound both in greyscale (GS) and power Doppler (PD), evaluating the presence of flexor tenosynovitis, soft tissue edema, subcutaneous PD signal (PDS), extensor tendon involvement, and joint synovitis. Cases with a shorter dactylitis duration (< 20 weeks) had a significantly higher prevalence of GS flexor tenosynovitis of grade > 2, PD flexor tenosynovitis, soft tissue edema, and subcutaneous PDS (p = 0.001, p < 0.001, p < 0.05, and p = 0.001, respectively). However, the presence of synovitis in GS and PD mode (in both cases at proximal interphalangeal level) was more frequent in patients with longer dactylitis duration (p < 0.001). When detected in the chronic form, flexor tenosynovitis was grade 2 or lower. In a large cohort of PsA hand dactylitis, we found a predominant extracapsular inflammation (flexor tenosynovitis and soft tissue edema) in early cases and a high prevalence of joint synovitis at proximal interphalangeal level in the chronic form. However, longitudinal imaging studies are needed to clarify these aspects.

Comparison of Structural Integrity and Functional Outcome Between Delaminated and Nondelaminated Rotator Cuff Tears After En Masse Arthroscopic Repair: A Retrospective Cohort Study With Propensity Score Matching

Background: Arthroscopic repair of delaminated rotator cuff tears (RCTs) has shown poor prognoses. Despite the importance of delaminated tears, only a few studies have compared delaminated and nondelaminated tears. Purpose: This study aimed to compare the clinical outcomes and structural integrity after en masse arthroscopic rotator cuff repair between delaminated and nondelaminated RCTs and to evaluate whether infraspinatus tendon involvement affects the prognosis for delaminated tears after arthroscopic cuff repair, through use of propensity score matching for precise comparison. Study Design: Cohort study; Level of evidence, 3. Methods: This study included 180 consecutive patients with medium- or large-sized RCTs who had an arthroscopic rotator cuff repair with a minimum 2-year follow-up, of whom 57 and 123 had delaminated tears (group 1) and nondelaminated tears (group 2), respectively. The en masse repair technique using a single-row or transosseous-equivalent double-row suture-bridge technique was used for of all the delaminated cases. Preoperative and postoperative visual analog scale pain scores, shoulder active range of motion, American Shoulder and Elbow Surgeons (ASES) scores, and Constant scores were assessed. Magnetic resonance imaging was performed at least 24 months postoperatively to identify retear of the repaired rotator cuffs. After propensity score matching, 32 cases in both groups were successfully matched, and the clinical and radiological results were analyzed. Results: Before propensity score matching, postoperative clinical outcomes were improved, showing no significant differences between the groups, excluding forward elevation (P = .011). Groups 1 and 2 had 17 (29.8%) and 11 retear cases (8.9%), respectively (P < .001). After propensity score matching, only the ASES score (72.5 vs 77.1) showed a significant superiority in group 2 (P = .038). Propensity-matched groups 1 and 2 had 8 (25.0%) and 2 (6.3%) retear cases, respectively (P = .034). No significant difference was found in structural integrity depending on whether the RCT included the infraspinatus tendon (IST). The odds ratio for retear of the delaminated tears, including IST, was 5.5 (95% confidence interval, 1.0-30.0, P = .038). Conclusion: Delaminated RCT was a negative prognostic factor of structural integrity after repair and could affect the functional outcome. However, whether IST tear was involved had no effect on the prognosis after repair.

Finger injury by snap button machine: A case report of an accident with a jeans snap button machine

We present a case report of a 16-year-old male who had an accident with a snap button machine. He was brought to the Emergency Department having pinched his right middle finger between the jeans button. Although first impressions of the accident might have expected a worse injury, fortunately it just showed a nail bed cut. Most accidents of this type cause serious injuries with the involvement of vessels, nerves, tendons, muscles or bones.

Ultrasound in the assessment of musculoskeletal involvement in systemic lupus erythematosus: state of the art and perspectives.

Musculoskeletal manifestations are extremely common in patients with systemic lupus erythematosus. Transient and migratory arthralgia is frequently reported even without clinical signs of joint or tendon inflammation. In less than 15% of patients, joints may be more severely affected by deforming (Jaccoud's arthropathy) and/or erosive arthropathy (Rhupus syndrome). In recent years, ultrasound has emerged as a promising imaging technique for the assessment of musculoskeletal involvement in systemic lupus erythematosus, having demonstrated the ability to detect inflammation and structural damage both at articular and periarticular level. Recent ultrasound studies have also revealed new insights into musculoskeletal involvement in patients with systemic lupus erythematosus, some of them questioning the traditional concepts of systemic lupus erythematosus arthropathy, with potential clinical, prognostic and therapeutic implications. In daily clinical practice, the use of ultrasound in the assessment of joint and tendon involvement in patients with systemic lupus erythematosus is still limited. Several methodological issues encountered in ultrasound studies evaluating musculoskeletal involvement in systemic lupus erythematosus patients need to be addressed in order to improve both the reliability and clinical usefulness of ultrasound findings. This paper reviews ultrasound studies assessing musculoskeletal involvement in patients with systemic lupus erythematosus, highlighting certainty, limits, potential applications and future perspectives of ultrasound use in systemic lupus erythematosus patients.

Sonographic findings from inflammatory arthritis due to antisynthetase syndrome.

Inflammatory arthritis is a common feature of antisynthetase syndrome. Ultrasonography is able to characterize important features of bone and tendon pathology but has not been evaluated in this setting. We review the sonographic findings in a series of patients with antisynthetase syndrome and inflammatory arthritis. A retrospective chart review was performed of patients with antisynthetase syndrome-associated inflammatory arthritis who had undergone ultrasound imaging for joint pathology. Seventeen sonographic assessments of eight patients were included. Synovial hypertrophy was seen in all eight patients, with active Doppler signal present in six patients (13 of 17 ultrasound locations). Tendon involvement was common, with tenosynovitis in seven patients (11 of 17 ultrasound locations). Erosions were present in five patients. Musculoskeletal ultrasound showed significant joint pathology including proliferative synovitis and tenosynovitis. This may be severe and associated with erosive disease. Further systematic studies are needed to better understand the articular involvement of antisynthetase syndrome. Key points • Marked inflammatory change-with proliferative synovitis, tenosynovitis, and erosions-can be seen in selected patients with antisynthetase syndrome (ASyS). • Inflammatory arthritis from ASyS can be severe and erosive in the absence of RF and ACPA and can be refractory to immunosuppressive therapy used to manage the myositis and interstitial lung disease. • Systematic sonographic evaluation of patients with ASyS is needed to further evaluate pathology and treatment response of inflammatory arthritis.

Clinical correlation between serum uric acid level and tophus involmente of tendon: a descriptive study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Clinical correlation between serum uric acid level and tophus involvement of tendon.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This is a non randomised multicetric prospective study carried out from December 2015 to May 2018. This is a descriptive study comprising 108 patients with diagnosis of gout according to the American College of Rheumatology (ACR) criteria. US examination included the quadriceps tendons, the patellar Tendon, peroneus tendon and the Achilles tendon. All tendons were evaluated bilaterally according to the EULAR guidelines for performing US in rheumatology.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; We included the patients aged between 20-60 year. In this study male patients was 86 (79.63% ) and 22 (20.37%) patient were female. In this study 108 patients with serum uric acid level between 5.5 -9.0 mg/dl with age from 20 yr to 60 yr were studied. Uric acid level between 7 - 9 mg/dl found in 68.48% and it was in age between 30–45 yr of age. 73 patiens (67.59%) had pain at enthesis for at least once before inclusion in the study. Intra-tendinous tophi and hyperechoic aggregates were&lt;strong&gt; &lt;/strong&gt;the most frequent lesions at the tendon in US examinations. In our study Patellar tendon is the most frequently involved tendon followed by quadriceps, Achilles and peroneus tendon.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Tophius involvement of tendon in the lower limbs in gout is very frequent, particularly at the patellar tendon, Quadriceps tendon and Achilles tendon.&lt;/p&gt;

Symptomatic psoriatic dactylitis is associated with ultrasound determined extra-synovial inflammatory features and shorter disease duration

To explore the link between ultrasonographic features of dactylitis in psoriatic arthritis (PsA) and symptoms, digital tenderness and duration of dactylitis. Forty-eight cases of PsA dactylitis were investigated using high frequency ultrasound (US) both in grey scale (GS) and Power Doppler (PD), evaluating the presence and the degree of flexor tenosynovitis, peri-tendinous oedema, subcutaneous PD, extensor tendon involvement, GS synovitis and intra-articular PD signal (PDS) of the involved digits. Patients were compared according to the presence of local pain and digital tenderness, the duration of dactylitis and the concomitant treatment. The presence of pain/tenderness was positively associated with US GS flexor tenosynovitis of grade >2 (p < 0.001), PD-flexor tenosynovitis (p < 0.001), peri-tendinous oedema (p < 0.001) and subcutaneous PDS (p < 0.001); moreover, it was negatively associated with GS synovitis (p < 0.001) and intra-articular PD (p < 0.001). The same positive and negative association with US findings were found comparing patients with duration of dactylitis shorter or longer than the median (24weeks) (p < 0.001 for all comparisons). Pain and digital tenderness are linked to dactylitis duration and earlier lesions are associated with extra synovial inflammatory changes. These findings suggest a hitherto unappreciated extra synovial basis for symptoms in PsA dactylitis.

The lever arm ratio of the rotator cuff to deltoid muscle explains and predicts pseudoparalysis of the shoulder: the Shoulder Abduction Moment index.

In patients with a rotator cuff tear, tear pattern and tendon involvement are known risk factors for the development of pseudoparalysis of the shoulder. It remains unclear, however, why similar tears often have very different functional consequences. The present study hypothesizes that individual shoulder anatomy, specifically the moment arms (MAs) of the rotator cuff (RC) and the deltoid muscle, as well as their relative recruitment during shoulder abduction, plays a central role in pseudoparalysis. Biomechanical and clinical analyses of the pseudoparalytic shoulder were conducted based on the ratio of the RC/deltoid MAs, which were used to define a novel anatomical descriptor called the Shoulder Abduction Moment (SAM) index. The SAM index is the ratio of the radii of two concentric spheres based on the centre of rotation of the joint. One sphere captures the humeral head (numerator) and the other the deltoid origin of the acromion (denominator). A computational rigid body simulation was used to establish the functional link between the SAM index and a potential predisposition for pseudoparalysis. A retrospective radiological validation study based on these measures was also undertaken using two cohorts with and without pseudoparalysis and massive RC tears. Decreased RC activity and improved glenohumeral stability was predicted by simulations of SAM indices with larger diameters of the humeral head, being consequently beneficial for joint stability. Clinical investigation of the SAM index showed significant risk of pseudoparalysis in patients with massive tears and a SAM < 0.77 (odds ratio (OR) 11). The SAM index, which represents individual biomechanical characteristics of shoulder morphology, plays a determinant role in the presence or absence of pseudoparalysis in shoulders with massive RC tears.

The Systemic Sclerosis Questionnaire (SySQ): Validation of the Translation of the Original German Version Into Spanish and Its Relationship to the Disease and to Quality of Life

ObjectiveTranslation, transculturation and validity of the self-administered questionnaire for functionality (Systemic Sclerosis Questionnaires [SySQ]) for use in Spanish patients with systemic sclerosis and its relationship to the severity of the disease and to quality of life. Patients and methodsWe conducted an observational analytical study to perform a cross-cultural validation of the self-administered questionnaire on functionality in scleroderma. The validity of the form and content was evaluated by an expert panel. The method included: (a) adaptation into Spanish of the construct for translation and back translation, and transculturation; (b) internal consistency with the SySQ (Cronbach's alpha), and (c) reproducibility was assessed taking into account all occasions in which the test was performed with Cohen's kappa. Additionally, we calculated the Spearman correlation coefficient with the Medsger severity scale, Health Assessment Questionnaire score and SF-36 score. ResultsWe included 70 patients with systemic sclerosis: age 17–78 (51±12) years, 65 (93%) were women, diffuse/limited subtype 64/36%, disease duration of .5–40 years. Optimal internal consistency for all categories of the final version of SySQ (Cronbach's α of .961) and intraobserver reliability in 2 tests over a 2-week interval (Cohen's kappa coefficient .618) and optimal interobserver reliability in 2 tests on the same day (Cohen's kappa coefficient .911). Moderate correlation between functionality by SySQ and by Health Assessment Questionnaire (r=.573, P<.0001). Inverse correlation between SySQ and quality of life mental health domain SF-36 (r=−.435, P<.001) and physical domain SF-36 (r=−.638, P<.001). Medsger severity scale (tendon, heart, lung, vascular) also showed significant correlation with SySQ. ConclusionsSySQ in this validated Spanish version is a suitable instrument to measure functional status in patients with systemic sclerosis. Reduced functionality is related to greater tendon and peripheral vascular involvement and to a poorer quality of life.

The study for the characteristics of secondary acquired cholesteatoma

Objective:Retrospctive analysed the Characteristics and outcomes of surgical treatment of 18 patients who were diagnosed as secondary acquired cholesteatoma (SAC).Method:Patients with SAC accepted operations were enrolled in this study. Then the factors such as sex, age, cource of history, otorrhea before operation, the size of perforation of tympanic membrane, entry site of epithelium, extension direction, ossicular destruction, tympanosclerosis, tympanum tympani tendon involvement, stage of cholesteatoma（JOS, 2015, Japan），degree of gasification of mastoid（JOS，2015，Japan），air conductive threshold, bone conductive threshold, air-bone gap, the healing of tympanic membrane and the auditory improvement were analyzed.Result:Eighteen patients were enrolled in this study, with course of history range from 2 months to 50 years (average: 20.20±16.31) years. There were 14 cases with wet ear before operation. All patients were conformed with perforation of membranal tensa by otoendoscopic photography before operation, with nearly total in 5 ears,large size in 10 ears,medium size in 2 ears and small size in 1 ear. Ossicular erosion were found in 13 patients (malleus involved in 6, incus involved in 12 and stapes involved in 4). Thirteen patients with tendon of tensor tympani involved and 9 patients with tympanosclerosis were conformed during operation. The epithelium entered through the malleus manubrium to the promontory in 13 cases, through the edge of the perforation in 3 cases and through the incus long process to around stapes in 1 case. Cholesteatoma invasion extend to anterosuperior area in 3 cases, posterosuperior area in 3 cases,both in anterosuperior and posterosuperior area in 12 cases. The cholesteatomas classified: stage Ⅰ in 11 cases, stage Ⅱ in 7 cases. Mastoid gasification classified MC0 in 6 cases, MC1 in 10 cases and MC2 in 2 cases. The average air conductive threshold was (56.32±10.15) dB, bone conductive threshold was (20.76±6.22) dB and air-bone gap (35.56±9.84) dB.Tympanic membrane healed in all patients during following up, without recurrent of cholesteatoma, and the post-operative air conductive threshold (43.02±14.96) dB and air-bone gap (21.04±12.90)dB were improved significantly(P<0.05).Conclusion:Most of SAC were secondary to nearly total or large perforation of membranal tensa (83.33%), with relative long history of chronic otitis media (average 20.20 ± 16.31) years and otorrhea before operation. The epithelium entered mainly through the malleus manubrium to the promontory，then through edge of the perforation，by extending anterosuperior and posterosuperior area and usually accompanied with tendon of tensor tympani involved, ossicular destruction, and poor mastoid gasification and tympanosclerosis. The characteristics of SAC were different from other type of cholesteatoma which need further researches.

Weightbearing CT and MRI findings of Stage II Flatfoot Deformity

Category: Hindfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) is a new imaging technique that allows excellent evaluation of the relative three-dimensional positioning of the tarsal bones in dynamic deformities such as AAFD. MRI, on the other hand, provides an accurate evaluation of soft tissue integrity in the unloaded foot. The objective of this study was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that a significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of involvement of ligaments and posterior tibial tendon (PTT). Methods: This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant. Results: We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (p&lt;0.01). Involvement of the talocalcaneal interosseous ligament significantly correlated with increased forefoot abduction as measured by the talonavicular uncoverage angle. Spring ligament degeneration, of both superomedial and inferior components, and talocalcaneal interosseous ligaments significantly correlated to subtalar joint subluxation (p&lt;0.001). Involvement of the talocalcaneal interosseous ligament was the only one to significantly correlate to the presence of subfibular impingement (p=0.02). Degeneration of the PTT was significantly associated with sinus tarsi impingement (p=0.04). Conclusion: This study is the first to evaluate correlation between bone, tendinous and ligamentous involvement in AAFD patients, using WBCT and MR images. Our results demonstrated that progressive bone deformity in WBCT is significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal ligaments. The implications are that WBCT can predict ligamentous injuries and that MRI can predict dynamic bone deformity in AAFD patients. Furthermore, the correlation of bone and soft tissue involvement could impact surgical planning of flatfoot patients, decreasing thresholds for additional soft tissue procedures such as a spring ligament reconstruction.

Use of Autogenous Fascia Lata Graft in the Treatment of Chronic Segmental Defect of the Common Calcaneus Tendon in Domestic Feline

Background: The common calcaneus tendon is formed by the common tendon of the femoral biceps muscle, tendon of the superficial digital flexor muscle and gastrocnemius muscle tendon, and its rupture is related to acute traumas in small animals. Among some applications described, surgical repair can be adopted in the correction of tendon ruptures and theuse of grafts may be indicated in some severe lesions, where it is not possible to perform tenorrhaphy. This study aims to report the case of a feline with rupture of the common calcaneus tendon in which the tenorrafia associated with the autogenous fascia lata graft was performed as adjuvant to the cicatrization of the same.Case: A 24-month-old, undefined male feline with approximately 3 kg was treated at the FCAV Veterinary Hospital, UNESP Jaboticabal, State of São Paulo, Brazil, with a history of falling, for approximately two weeks, and has since plantigrade posture. Upon physical examination, it was possible to identify a discontinuity of the common calcaneus tendon. The radiographs were performed, which did not show any bone changes. A hemogram and biochemical profile were performed, which were within normal limits. The patient underwent surgery, and a complete lesion of the common calcaneus tendon was identified, with a chronic aspect. Approximation of the stumps was impossible, so a flap of fascia lata, about two centimeters long and one centimeter wide, was removed, which was used as a bed and tendon support for tendon growth. After removal all of the present fibrosis, the tendon stumps were approximated by means of modified Kessler suture with mononylon thread, and fascia lata flap of the ipsilateral limb was sutured with separate single points in both tendon endsand in their lateral and medial portion. In the tibiotarsic joint, the external skeletal fixator type II was used for immobilization, during a period of 30 days. In the immediate postoperative period the patient was already able to support the member on the floor, with progressive improvement, and after 60 days of surgery the animal presented complete support of thelimb, without pain or any other alteration coming from the surgery. The animal presented a rapid recovery after surgical treatment with the autogenous fascia lata flap.Discussion: The rupture of the common calcaneus tendon is not commonly reported in felines and its occurrence is related to acute trauma, where the animals will present lameness and plantigrade posture. Depending on the degree of tendon involvement, there are different procedures that may be indicated, such as tenorrhaphy, reimplantation for avulsion cases, and transplantation with grafts when there is segment loss. In the present study, the use of tenorrhaphy associated with the implantation of autogenous lata-fascia graft was chosen, since the grafts generally provide the framework for healing due to its replacement by collagen tissue in the recipient, in addition to providing mechanical protection initially. Fascia lata, due to its antigenic character as being autogenous, has been shown to be a viable and easily obtained surgical option. The use of the fascia lata graft associated with external immobilization with external fixator type II in the tibiotarsal joint allowed an excellent result and is therefore a recommended treatment for cases of rupture of the common calcaneus tendon in felines.Keywords: cats, lameness, plantigrade stance.

Functional outcomes and return to sports after surgical treatment of insertional Achilles tendinopathy: Surgical approach tailored to the degree of tendon involvement.

Insertional Achilles tendinopathy is a generic term that encompasses several types of ailments. While conservative treatment is less effective than for conditions isolated to the tendon body, there is no consensus as to the best type of surgical care. Surgical treatment for insertional Achilles tendinopathy that is tailored to the severity of the tendon involvement will lead to satisfactory functional outcomes. Forty-six patients were included with an average age of 44.1±11.4 years and a mean preoperative AOFAS score of 62.2±11.7. The mean duration of symptoms before the surgery was 33.1±24 months. The inclusion criteria were pain at the tendon insertion and failure of at least 6 months of conservative treatment. Tendon involvement was evaluated preoperatively using MRI and confirmed intraoperatively after debridement. The primary treatment in all patients was resection of the calcaneal abnormality. Depending on the degree of tendon involvement, debridement or detachment/reattachment were also performed. The minimum follow-up was 12 months. The mean follow-up was 33±13.5 months. None of the patients were lost to follow-up. The mean AOFAS score was 93.7±7.3 at the last follow-up. The ATRS and VISA-A scores were 89.2±4.1 and 89±3.2, respectively. The sports participation level was the same or higher in 71.7% of cases. Increased preoperative passive dorsiflexion was statistically correlated with the degree of tendon involvement. Surgery for insertional Achilles tendinopathy led to good functional outcomes and satisfactory return to sports when the surgical care was tailored to the sdegree of tendon involvement. IV.

Prediction of the Irreparability of Rotator Cuff Tears

To determine the influence of preoperative factors on reparability of rotator cuff tears (RCTs) and yield a predictive model for predicting irreparability preoperatively. Among patients with full-thickness RCTs, the reparable group underwent arthroscopic rotator cuff repairs for reparable RCTs whereas the irreparable group underwent alternative surgical procedures for irreparable RCTs. We analyzed age, sex, chronic pseudoparalysis (CPP), mediolateral and anteroposterior tear sizes, acromiohumeral distance (AHD), tangent sign, fatty infiltration (FI) (group 1, Goutallier stage 0 or 1; and group 2, Goutallier stage 2, 3, or 4), and tendon involvement (TI) (type 1, supraspinatus; type 2, supraspinatus and subscapularis; type 3, supraspinatus and infraspinatus; and type 4, all 3 tendons). The irreparability rate was 12.5%. Between the reparable (663 patients) and irreparable (95 patients) groups, significant differences were found in age (58.8 ± 8.3years vs 65.6 ± 8.0years, P < .001); female sex (46.9% vs 63.2%, P= .014); CPP (6.5% vs 36.8%, P < .001); mediolateral tear size (23.7 ± 12.1mm vs 47.4 ± 9.1mm, P < .001); anteroposterior tear size (17.9 ± 11.5mm vs 43.4 ± 16.2mm, P < .001); AHD (9.0 ± 1.7mm vs 5.8 ± 1.6mm, P < .001); tangent sign (2.9% vs 61.1%, P < .001); group 2 FI of the subscapularis (6.9% vs 20.0%, P < .001), supraspinatus (12.1% vs 58.9%, P<.001), infraspinatus (26.8% vs 69.5%, P < .001), and teres minor (4.2% vs 10.5%, P= .008); and type 1, 2, 3, and 4 TI (88.1%, 6.2%, 5.4%, and 0.3%, respectively, vs 29.5%, 21.1%, 28.4%, and 21.1%, respectively; P < .001). Multiple logistic regression analysis showed CPP, mediolateral tear size, AHD, tangent sign, group 2 FI of the supraspinatus, and type 4 TI were significant independent predictors of irreparability, with odds ratios of 3.539 (P= .007), 1.087 (P < .001), 0.624 (P<.001), 6.141 (P < .001), 2.233 (P= .034), and 12.350 (P= .016), respectively. These factors yielded a predictive model for irreparability as follows: Logit P= 1.264× CPP+ 0.084× Mediolateral tear size - 0.472× AHD+ 0.804× Group 2 FI of supraspinatus+ 1.815× Tangent sign+ 2.514× Type 4 TI - 3.460. The irreparability of RCTs is strongly associated with CPP, mediolateral tear size, AHD, tangent sign, group 2 FI of the supraspinatus, and type 4TI and can be preoperatively calculated using the predictive equation. Level III, retrospective comparative study.

A Rotator Cuff Tear Concomitant With Shoulder Stiffness Is Associated With a Lower Retear Rate After 1-Stage Arthroscopic Surgery

Background: Few studies have reported on the radiological characteristics and repair integrity of coexistent rotator cuff tears (RCTs) and shoulder stiffness after simultaneous arthroscopic rotator cuff repair and capsular release. Purpose: To evaluate the radiological characteristics and repair integrity of 1-stage arthroscopic surgery of RCTs concomitant with shoulder stiffness. Study Design: Cohort study; Level of evidence, 3. Methods: Among patients who underwent arthroscopic repair of full-thickness RCTs, the stiff group underwent simultaneous capsular release for shoulder stiffness, and the nonstiff group had no stiffness. Symptom duration, prevalence of diabetes, tear size, tendon involvement (type 1, supraspinatus; type 2, supraspinatus and subscapularis; and type 3, supraspinatus and infraspinatus; type 4, supraspinatus, subscapularis, and infraspinatus), and fatty infiltration (Goutallier stages 0-4) were evaluated. A retear was appraised using magnetic resonance imaging, and clinical outcomes were assessed using range of motion, the Korean Shoulder Scoring System (KSS), and the University of California, Los Angeles (UCLA) shoulder score. Results: The stiff group showed a significantly lower retear rate (1/39, 2.6%) than the nonstiff group (47/320, 14.7%) (P = .043). There were significant differences in symptom duration (7.4 ± 6.6 vs 15.0 ± 23.7 months, respectively; P < .001), mediolateral tear size (18.9 ± 8.9 vs 24.1 ± 12.0 mm, respectively; P = .002), tendon involvement (94.9%, 5.1%, 0.0%, and 0.0% vs 85.3%, 6.9%, 7.8%, and 0.0%, respectively; P = .048), and fatty infiltration of the subscapularis (66.7%, 33.3%, 0.0%, 0.0%, and 0.0% vs 31.9%, 61.3%, 5.6%, 1.3%, and 0.0%, respectively; P < .001) and teres minor (74.4%, 20.5%, 5.1%, 0.0%, and 0.0% vs 47.2%, 48.8%, 3.8%, 0.0%, and 0.3%, respectively; P = .007) between the stiff and nonstiff groups. Preoperatively, the stiff group showed significantly worse forward flexion (95.9° ± 23.6° vs 147.7° ± 4.2°, respectively; P < .001), external rotation (17.4° ± 10.1° vs 51.6° ± 12.1°, respectively; P < .001), and internal rotation (L5 vs L2, respectively; P < .001) and lower KSS (52.1 ± 13.8 vs 66.3 ± 13.5, respectively; P < .001) and UCLA scores (18.7 ± 4.8 vs 22.5 ± 4.5, respectively; P < .001) than the nonstiff group. However, these differences became insignificant from 3 months postoperatively for forward flexion (P > .05) and KSS (P > .05) and UCLA scores (P > .05), from 1 year postoperatively for external rotation (P > .05), and at the last follow-up for internal rotation (P > .05). A multiple logistic regression analysis revealed that only mediolateral tear size (odds ratio, 1.043; P = .014) and type 2 tendon involvement (odds ratio, 4.493; P = .003) were independent predictors of a retear. Conclusion: RCTs concomitant with shoulder stiffness showed a smaller mediolateral tear size, anterosuperior tendon involvement, and less severe fatty infiltration preoperatively and better repair integrity postoperatively than RCTs without stiffness. Furthermore, the clinical outcomes and range of motion at final follow-up were similar between the 2 groups.

Arthroscopic Massive Rotator Cuff Repair and Techniques for Mobilization

Massive rotator cuff tears, as classified by size or tendon involvement, are challenging to repair due to scarring, retraction of the tendons, and difficult visualization. Left untreated, these injuries can lead to fatty infiltration and reduced acromiohumeral distance that precludes future repair. The high rate of failure in these patients often impedes an anatomical repair. However, advanced mobilization techniques of the supraspinatus help facilitate a reduction of an otherwise irreparable tear. By performing this repair, more costly procedures may be avoided, such as a superior capsular reconstruction and reverse total shoulder arthroplasty. This Technical Note presents our preferred technique of an all-arthroscopic, medialized repair with double interval slides for the treatment of a massive rotator cuff tear.

MRI overestimates the full-thickness tear of distal triceps tendon rupture.

Injury to the distal triceps brachii tendon is rare. Imaging radiographs are used to confirm the findings of physical examination, classify the extent of injury, and guide treatment. Magnetic resonance imaging (MRI) is considered the gold standard of diagnostic imaging. However, no previous study has reported on the accuracy of differentiation between partial- and full-thickness triceps tendon tears. Our study's aim was to define the accuracy of MRI in differentiating partial- from full-thickness tear of the distal triceps tendon. We hypothesized that MRI has low accuracy in differentiating partial- from full-thickness tears. A total of eight patients with nine triceps tendon tears underwent surgical repair from 2011 to 2015. MRI of the elbows were retrospectively reviewed for the presence and type of tear, tendon involvement, and location of the tear, and later correlated with surgical findings. Of the three surgically confirmed complete tears, MRI correctly reported a complete tear in all patients. Of the six partial tears confirmed at surgery, MRI correctly identified four tears. In two cases, MRI described a complete tear, but only a partial tear was noted at surgery. False-positive MRI assessment of distal triceps injury is not rare. Surgeons should rely on clinical examination in assessing distal triceps tendon injury, with imaging studies providing an adjunctive role in the diagnosis and decision-making.

Power Doppler Ultrasound Evaluation of Peripheral Joint, Entheses, Tendon, and Bursa Abnormalities in Psoriatic Patients: A Clinical Study.

To evaluate the prevalence rates of peripheral joint, enthesis, tendon, and bursa abnormalities by power Doppler (PD) ultrasonic examination in patients with psoriatic arthritis (PsA), psoriatic patients without clinical signs of arthritis (non-PsA psoriasis group), and healthy individuals, to detect subclinical PsA. A total of 253 healthy volunteers, 242 non-PsA psoriatic patients, and 86 patients with PsA were assessed by 2-dimensional and power Doppler (PD) ultrasound. Peripheral joint, enthesis, tendon, and bursa abnormalities were observed, characterizing abnormal PD. The affected patients and sites with abnormalities in various ages were compared among groups; PD signal grades for the abnormalities were also compared. In the PsA group, significantly higher percentages of sites showing joint effusion/synovitis, enthesitis, and tenosynovitis in all age groups, and markedly higher rates of sites with bursitis were found in young and middle age groups, compared with the non-PsA and control groups (all p < 0.01). Meanwhile, the non-PsA group showed significantly higher rates of joint effusion/synovitis and enthesitis sites, and elevated PD signal grades of synovitis, enthesitis, and tenosynovitis in comparison with the control group, both in young and middle age groups (all p < 0.01). Patients with PsA have high percentages and PD signal grades of peripheral joint, tendon, enthesis, and bursa involvement. Young and middle-aged non-PsA patients have high synovitis and enthesitis percentages, and elevated PD signal grades of synovitis, enthesitis, and tenosynovitis.

Athletic pubalgia: Return to play after targeted surgery.

Surgery for athletic pubalgia usually consists in abdominal wall repair combined with routine bilateral adductor tenotomy. We currently confine the surgical procedure to the injured structure(s) (abdominal wall only, adductor tendon only, or both) to limit morbidity and expedite recovery. Outcomes of this à la carte approach are unclear. The objectives of this retrospective study were to determine the return to play (RTP) time, evaluate the potential influence of injury location, and assess the frequency of recurrence or contralateral involvement. À la carte surgery for athletic pubalgia is associated with similar RTP times as the conventional procedure and is not followed by recurrence. Consecutive adults younger than 40 years of age who underwent surgery for athletic pubalgia with injury to the abdominal wall and/or adductor attachment sites between 2009 and 2015 were included. Patients with intra-articular hip disorders, isolated pubic symphysis involvement, or herniation were not eligible. The diagnosis was established clinically then confirmed by at least one imaging technique (ultrasonography plus either a radiograph of the pelvis or magnetic resonance imaging of the pelvis). The criterion for performing surgery was failure of appropriate conservative therapy followed for at least 3 months. Of the 27 included patients, eight had abdominal wall involvement only, seven adductor tendon involvement only, and 12 both. Overall, 25 (92.6%) patients returned to play at their previous level, after a mean of 112±38 days (range, 53-223 days), and experienced no recurrence during the 1-year follow-up. Mean RTP time was significantly shorter in the group with abdominal wall injury only (91.1±21.0 days) compared to the groups with adductor tendon injury only (101.7±42.0 days) or combined injuries (132.5±39.0) (p=0.02). In patients with athletic pubalgia, à la carte surgery confined to the injured structure(s) produces excellent RTP outcomes. RTP time is shortest in patients with isolated lower abdominal wall injuries. IV, retrospective study with no control group.