Tendon Release Research Articles

Outcomes of the Ponseti Method for Untreated Clubfeet in Nepalese Patients Seen Between the Ages of One and Five Years and Followed for at Least 10 Years.

To our knowledge, there are no reports of the Ponseti method initiated after walking age and with >10 years of follow-up. Our goal was to report the clinical findings and patient-reported outcomes for children with a previously untreated idiopathic clubfoot who were seen when they were between 1 and 5 years old, were treated with the Ponseti method, and had a minimum follow-up of 10 years. A retrospective review of medical records was supplemented by a follow-up evaluation of physical findings (alignment and range of motion) and patient-reported outcomes using the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C). The initial treatment was graded as successful if a plantigrade foot was achieved without the need for an extensive soft-tissue release and/or osseous procedure. We located 145 (91%) of 159 patients (220 clubfeet). The average age at treatment was 3 years (range, 1 to 5 years), and the average duration of follow-up was 11 years (range, 10 to 12 years). The initial scores according to the systems of Pirani et al. and Diméglio et al. averaged 5 and 17, respectively, and an average of 8 casts were required. Surgical treatment, most commonly a percutaneous Achilles tendon release (197 feet; 90%), was required in 96% of the feet. A plantigrade foot was achieved in 95% of the feet. Complete relapse was rare (3%), although residual deformities were common. Patient-reported outcomes were favorable. A plantigrade foot was achieved in 95% of the feet initially and was maintained in most of the patients, although residual deformities were common. Patient-reported outcomes were satisfactory, and longer-term follow-up with age-appropriate outcome measures will be required to evaluate function in adulthood. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic treatment of internal snapping hip

Introduction:Internal snapping hip syndrome (ISHS) is caused by the iliopsoas tendon snapping over either the iliopectineal ridge or the anterior femoral head. Excellent results are achieved only with activity modification, rest, and stretching the iliopsoas muscle. The literature favors iliopsoas tendon release if conservative therapy fails. There is little evidence about the gold standard of this condition.Objective:Describe clinical results, complicactions and recurrence rate of arthroscopic treatment of ISHS.Methods:We included all patients who failed conservative treatment and were treated with arthroscopy for ISHS between March 2012 and March 2018. Patients with less than 2 years of follow up and previous surgery on the hip were excluded.We performed Ilizariturri´s technique with a transcapsular endoscopic release in central compartment.We registered modified Harris hip score (MHHS), Hip outcome score activity of daily living (EHOSDL), patients satisfaction, recurrence rate and complications.Results:Eight patients were included. Average follow up was 36 months (range 24-60 months). MMHS improved from preoperative average score of 70 (range 62-72) to postoperative average of 93 (range 92 to 96). Average EHOSDL improvement was 30% (from 55% preoperative to 85% postoperative). All patients had excellent results. Average patient satisfaction was 8 (range 7-9). We had no recurrence or complications.Conclusion:Arthroscopic treatment of ISHS allowed us to obtain very good clinical results with no complications or recurrences with a minimum 2 years follow up.

The effect of conjoint tendon release on gait after direct anterior total hip arthroplasty.

There has been considerable interest in the direct anterior (DA) approach to total hip arthroplasty (THA) recently. To facilitate exposure of the proximal femur it is sometimes necessary to release the conjoint tendon. To prospectively investigate whether release of the conjoint tendon has an impact on gait in the early postoperative period. We measured gait velocity, stride length, single-limb support and single-limb support symmetry preoperatively, at discharge from the hospital, and 2, 6 and 12 weeks and postoperatively. Participants also completed the Timed Up and Go and a series of questionnaires (WOMAC, SF-12, Harris Hip Score, and pain VAS) at each visit. 36 participants undergoing a DA THA with a single surgeon were enrolled in this study. 22 participants had a release of the conjoint tendon during their surgery. We found no differences between the groups for any gait, patient-reported or surgical outcomes (p < 0.05). There was a total of 3 complications reported in the release group, and 1 complication in the group that did not have a release. Although the conjoint tendon has an important role in the biomechanics of the hip, we found release of the conjoint tendon during the DA approach for THA to have no impact on gait or patient reported outcomes within 12 weeks post-surgery. Therefore, if the exposure of the proximal femur is limited, a low threshold for release of the conjoint tendon is recommended to improve visualisation.

Inhibition of calpain delays early muscle atrophy after rotator cuff tendon release in sheep.

Chronic rotator cuff (RC) tears are characterized by retraction, fat accumulation, and atrophy of the affected muscle. These features pose an intractable problem for surgical repair and subsequent recovery, and their prevention may be easier than reversal. Using an established ovine model, we tested the hypothesis that inhibition of the protease calpain mitigates m. infraspinatus atrophy by preservation of the myofibers’ structural anchors in the sarcolemma (the costameres). Already 2 weeks of distal tendon release led to a reduction in muscle volume (−11.6 ± 9.1 cm3, P = 0.038) and a 8.3% slow‐to‐fast shift of the fiber area (P = 0.046), which were both entirely abolished by chronic local administration of the calpain inhibitor calpeptin alone, and in combination with sildenafil. Calpain inhibition blunted the retraction of the muscle‐tendon unit by 0.8–1.0 cm (P = 0.020) compared with the control group, and prevented cleavage of the costameric protein talin. Calpain 1 and 2 protein levels increased in the medicated groups after 4 weeks, counteracting the efficacy of calpeptin. Hence atrophic changes emerged after 4 weeks despite ongoing treatment. These findings suggest that the early muscular adaptations in the specific case of RC tear in the ovine model are indistinguishable from the atrophy and slow‐to‐fast fiber transformation observed with conventional unloading and can be prevented for 2 weeks. Concluding, calpain is a potential target to extend the temporal window for reconstruction of the ruptured RC tendon before recovery turns impossible.

Effect of Achilles tendon lengthening on ankle and subtalar joint orientation and load distribution utilizing a novel cadaveric model to simulate weight bearing

Category: Basic Sciences/Biologics Introduction/Purpose: Ankle arthroplasties are increasingly performed to address ankle arthritis. Patients with long standing ankle arthritis often present with an associated achilles tendon contracture. An open or percutaneous lengthening of the Achilles is commonly performed at the same time as the ankle arthroplasty to improve range of motion. Current ankle arthroplasty implants include mobile bearing and fixed bearing systems. Lengthening the achilles tendon improves dorsiflexion, however the effect of the lengthening on the ankle and subtalar joint is not well documented in the literature. Using a novel system to simulate weight bearing in a cadaveric model, we evaluated achilles tendon lengthening and its effect on ankle and subtalar joint orientation and load distribution. This may have potential implications to polyethylene implant longevity in total ankle arthroplasties. Methods: Five fresh frozen lower limb cadaveric specimens without known skeletal condition were used. The femoral head was potted with PMMA and TekScan pressure sensors were inserted into the ankle and subtalar joint. The specimens were placed on a custom jig, which allowed for load cell modulated loading of the leg; 75 lb load (half body weight)(4) was applied at the femoral head while the foot was supported against a fixed plate keeping the ankle in neutral position. Mean pressure (MP), peak pressure (PP), contact area (CA), and center of force (COF) were measured in both joints under two conditions; baseline (BASE), and following Achilles tendon release (TENDON) to simulate lengthening. Each condition was tested three times per specimen; the results were averaged per specimen and used for final analysis. Displacement of COF was calculated relative to its location at baseline. Results: The Mean Pressure (MP), Peak Pressure (PP) and Contact Area (CA) did not show a statistical difference in the ankle and subtalar joints between baseline (BASE) and TENDON (Achilles tendon release) conditions. (Table 1). Further, the displacement of the COF from the BASE to TENDON was 0.5 mm. In our model, the contracture of the muscle was not fully simulated. Further hindfoot kinetic studies with active achilles contracture may demonstrate a difference in contact forces in the ankle and subtalar joint as compared to normal. Conclusion: Ankle arthroplasty is becoming an effective treatment option for ankle joint arthritis. Our novel study demonstrates that Achilles tendon lengthening did not change the mean pressure, peak pressure, contact area center of force in the ankle and subtalar joint. This model provides validation for further studies evaluating tendon release and contact pressure changes in a cadaver with an implanted fixed bearing versus mobile bearing total ankle prosthesis. Difference in polyethylene wear may effect the longevity of ankle replacements. This study will provide clinicians additional information when evaluating the benefit/risks associated with lengthening the Achilles tendon for ankle arthroplasty patients.

Endoscopic Release of the Piriformis Tendon and Sciatic Nerve Exploration by the Lateral Decubitus Approach Through an Incision on the Iliotibial Band

Entrapment of the sciatic nerve is considered a challenging problem for orthopaedic surgeons. Many surgical interventions (open or endoscopic) have been described as treatments. We describe an endoscopic technique for release of the piriformis tendon and sciatic nerve exploration by the lateral approach through an incision on the iliotibial band.

Endoscopic release of the piriformis tendon and sciatic nerve exploration.

ABSTRACTRobinson, in 1947 introduced for the first time the term ‘piriformis syndrome’. More recently, many etiologies of sciatic nerve entrapment around the gluteal region or the non-discogenic area have been identified, resulting in the use of a new term ‘The Deep Gluteal Syndrome’. The purpose of this study was to assess the outcomes following the endoscopic release of sciatic nerve entrapment. Type of study is a consecutive case series. Fifteen patients were diagnosed with sciatic nerve entrapment from January 2012 to December 2015, all of them were treated with endoscopic release of the piriformis tendon and sciatic nerve exploration on lateral decubitus position. Every patient had a minimum follow-up to 2 years. The patient-reported outcome scores used included the modified Harris Hip Score (mHHS), pain was estimated on a visual analog scale (VAS) and the Benson outcomes questionnaire. The patient’s mean age was 40.2 years (range, 28–50 years). The score improvement from pre-operative to 24-month follow-up was 46.8–84.9 for mHHS (P <0.05). The VAS decreased from pre-operative to 24-month follow-up was 7.4–1.86 (P < 0.05). The Benson outcome ratings were excellent for 11 patients, good for 3 and fair for 1. The Endoscopic Release of the Piriformis Tendon and Sciatic Nerve Exploration showed an improvement of functions, diminishing pain and allowing patients to return to daily activities without symptoms (Level of Evidence: IV).

Does endoscopic piriformis tenotomy provide safe and complete tendon release? A cadaver study

BackgroundEndoscopic piriformis release (EPR) is among the available treatments for piriformis syndrome. This procedure typically involves dividing the muscle near the sciatic nerve in the sub-gluteal space, which contains numerous blood vessels and nerves. The objectives of this prospective cadaver study were: 1) to assess the reproducibility and quality of endoscopic piriformis tenotomy near the greater trochanter; 2) to detect iatrogenic injuries to the lateral hip rotators, nerves, and vessels; 3) and to define the surgical safety margins relative to the sciatic nerve and inferior gluteal bundle. HypothesisEPR at the greater trochanter ensures full release of the muscle with a limited risk of neuro-vascular injury. Material and methodsEPR was performed via two portals on 10 cadaver hips preserved in zinc chloride and placed in the prone position. A third, ancillary portal was required in 7 cases. The area was then dissected with the Kocher-Langenbeck approach to allow an assessment of the tenotomy, detect iatrogenic injuries, and measure the distances separating the tenotomy site from the sciatic nerve and inferior gluteal artery. ResultsComplete tenotomy was achieved in 9 (90%) cases. The tendon adhered to the capsule in 2 (20%) cases and showed acquired avulsion in 1 case. No injuries to the sciatic nerve or inferior gluteal artery occurred. Mean distances from the tenotomy site were 5.21±0.59cm (range, 4.5–6.6cm) for the sciatic nerve and 7.1±0.89cm (range, 5.4–8.5cm) for the inferior gluteal artery. DiscussionEPR by a tenotomy at the greater trochanter without sciatic nerve release provides full release of the muscle with satisfactory safety margins and a short learning curve. Level of evidenceIII, prospective cadaver case-control study.

Arthroscopic patellar release allows timely return to performance in professional and amateur athletes with chronic patellar tendinopathy.

Return to sports rates in amateur and professional athletes with chronic patellar tendinopathy following arthroscopic patellar release are unpredictable. The present study aims to analyse the effectiveness of arthroscopic patellar release in professional compared to amateur athletes. A total of 34 amateur and 20 professional athletes with chronic patellar tendinopathy, refractory to conservative treatment, were studied prospectively and underwent arthroscopic tendon release at the inferior patellar pole. Impact of grouped sports on clinical and functional outcome, subjective patient satisfaction and return to sports rates were assessed. Additionally, preoperative MRI-scans of the knee were evaluated and correlated with clinical outcome. In 40 patients (74.1%) arthroscopic patellar release resulted in complete recovery and return to preinjury exercise levels. Full return to sports was achieved after a median of 3.0 (range 0.5-12.0) months. Functional outcome measures VISA-P (Victorian Institute of sport assessment for patella) and modified Blazina scores improved significantly from pre- to postoperatively (VISA-P: 48.8 vs. 94.0 pts., respectively, p < 0.0001; Blazina: 4.47 vs. 0.5, respectively, p < 0.0001). As rapid recovery and timely return to sports are crucial for professional athletes, arthroscopic patellar release should be considered after failed conservative treatment. IV.

PC084. Serious Complications From Embolosclerotherapy of Upper Extremity High- and Low-Flow Vascular Malformations From a Specialist Single Center

Minimally invasive, embolosclerotherapy (EST) for upper extremity vascular malformations (VMs) carries significant risk of serious complications, such as ischemia, infarction, amputation, nerve injury, contracture, and ulceration, with as high as 61% rates for hand treatments most recently reported. Despite improved care in specialist centers, up-to-date estimates of complication risk for audit and informed consent are scarce; recent literature focuses on high-flow VMs (HFVM) with a paucity of data for low-flow VMs (LFVM). This study reviews the 5-year serious complications following EST of all upper extremity VM in our tertiary referral center for vascular anomalies. All VM patients underwent multidisciplinary review directed intervention, and demographic, procedural, follow-up, and complication data collected prospectively in a dedicated database. Treatment outcomes for upper extremity VM from January 1, 2013, to December 31, 2017, were analyzed (Figures 1 and 2). EST interventions were performed under fluoroscopic guidance. All ESTs of HFVM were performed under selective catheter angiography and direct injection, but LFVM with direct injection only. Serious complications were defined as any tissue or functional damage caused by direct injection, distal embolization, or tissue reaction. There were 70 patients who had a total of 150 EST procedures for upper extremity VMs (median age, 24.5 years; range, 1-73 years; 44 male, 26 female). Of these, 28 (40%) had EST for HFVM and 42 (60%) for LFVM (total 78 and 72 procedures, respectively). Most used agents were foam sclerosant (STD 3% mixed in ratio 2:8 with air), dehydrated absolute ethanol, and coils. Serious complications as follows: HFVM in five patients (17.9%) or 6.4% of total procedures; three ischemia of fingers and/or hand requiring amputation (Figs 1 and 2), and two skin ulcerations. Serious complication in LFVM occurred in five patients (11.9%) or 6.9% of total procedures: one median nerve injury causing wrist drop requiring nerve grafting and hand therapy, one hand contracture requiring tendon release, and three skin ulcerations. All ulcerations resolved without significant long-term disability. However, the nerve and tendon injuries carried degrees of long-term functional disability. Current EST is relatively safe for upper extremity HFVM where our complication rate of 17.9% compares favorably with the recent literature, possibly owing to the selective use of foam versus alcohol, and improved classification and targeted treatment. For LFVM, significant complications resulted in 11.9% of patients from local toxicity after direct injection. These outcomes will direct treatment strategies to avoid local toxic complications in the hand for both HFVM and LFVM, and to informed consent.Fig 2After amputations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Arthroscopic double-row reconstruction of high-grade subscapularis tendon tears

Reconstruction of tendon integrity to maintain glenohumeral joint centration and hence to restore shoulder functional range of motion and to reduce pain. Isolated or combined full-thickness subscapularis tendon tears (≥upper two-thirds of the tendon) without both substantial soft tissue degeneration and cranialization of the humeral head. Chronic tears of the subscapularis tendon with higher grade muscle atrophy, fatty infiltration, and static decentration of the humeral head. After arthroscopic three-sided subscapularis tendon release, two double-loaded suture anchors are placed medially to the humeral footprint. Next to the suture passage, the suture limbs are tied and secured laterally with up to two knotless anchors creating atransosseous-equivalent repair. The affected arm is placed in ashoulder brace with 20° of abduction and slight internal rotation for 6weeks postoperatively. Rehabilitation protocol including progressive physical therapy from amaximum protection phase to aminimum protection phase is required. Overhead activities are permitted after 6months. While previous studies have demonstrated superior biomechanical properties and clinical results after double-row compared to single-row and transosseous fixation techniques, further mid- to long-term clinical investigations are needed to confirm these findings.

Arthroscopic Identification and Management of Recurrent Iliopsoas Impingement After Total Hip Arthroplasty

Arthroscopic release of the iliopsoas tendon for iliopsoas impingement (IPI) after total hip arthroplasty (THA) at the lesser trochanter gives good results. However, where IPI then recurs, due to adhesions between the healing iliopsoas tendon and the surrounding soft tissue, and nonoperative measures have failed, a revision THA procedure is usually considered. We propose a technique of arthroscopic visualization of the recurrent IPI and a subsequent psoas tenotomy at the level of the hip joint using an outside-in capsulotomy approach. This secondary tenotomy, located proximally directly at the level of the recurrent impingement, allows relief of the painful symptoms without compromising the muscle function of the iliopsoas and precludes the need for a complex THA revision.

A Comparison of Radiofrequency-Based Microtenotomy and Arthroscopic Release of the Extensor Carpi Radialis Brevis Tendon in Recalcitrant Lateral Epicondylitis: A Prospective Randomized Controlled Study

To compare the clinical effects of radiofrequency (RF)-based microtenotomy and arthroscopic release of the extensor carpi radialis brevis (ECRB) tendon in patients with recalcitrant lateral epicondylitis through a prospective randomized controlled study. A total of 46 patients were randomly assigned to receive arthroscopic release (group A, 24 patients) or RF-based microtenotomy (group B, 22 patients). The visual analog scale (VAS) score for pain, flexion-extension arc, operation time, Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), Mayo Elbow Performance Score (MEPS), and grip power of groups A and B were compared during the recovery phases for up to 2 postoperative years. Both groups showed statistically significant functional improvement compared with their preoperative grip strength and DASH, VAS, and MEPS scores at 2years after surgery (P < .05). There were no differences in postoperative pain relief or functional restoration between the 2 groups during the recovery phases, however the mean operation time for group B (41.4 ± 5.2minutes) was significantly shorter than that for group A (15.6 ± 3.6minutes, P < .001). In group B, 1 patient underwent revision surgery due to postoperative ECRB rupture, and 1 patient in group A underwent open release for persistent postoperative discomfort. RF-based microtenotomy for treating recalcitrant lateral epicondylitis provided clinical outcomes comparable with those from arthroscopic release of ECRB tendon during the recovery phase. RF-based microtenotomy is considered as one of the surgical procedures for treating recalcitrant lateral epicondylitis, with the advantages of reliable elbow functional restoration and significantly shorter operation time. Level I, prospective randomized trial.

Calcaneofibular Ligament Transfer for Recurrent Peroneal Tendon Subluxation in Pediatric and Young Adult Patients.

Peroneal tendon subluxation is an uncommon cause of lateral ankle pain and instability but can be disabling for some young patients. Surgical management may be required to restore function for patients who fail nonoperative management. The purpose of this study was to determine the functional outcomes after surgical management of peroneal tendon subluxation in pediatric and adolescent patients. A retrospective review of patients presenting to our institution over a 10-year period yielded 18 cases of recurrent subluxation refractory to nonoperative management in 14 children or young adults (mean age 15.0 y). All patients failed nonoperative management and were treated operatively with isolated calcaneofibular ligament transfer to construct a new soft tissue restraint for the peroneal tendons. Patients were evaluated clinically and sent validated questionnaires, including the Foot and Ankle Ability Measure (FAAM) and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. All 18 ankles of 14 patients had minimum 2-year follow-up. Ten of 18 ankles (55.6%) returned the outcome surveys at an average of 5.7 years after the index procedure (range, 2. 0 to 9.7 y). The average FAAM activities of daily living score was 93.5 (±2.9) and the sports subscale was 77.8 (±6.1). The mean AOFAS subjective scaled score was 84.3 (±4.5). All patients returned to sports and recreational activity. Complications included 1 case of recurrent subluxation (1/18, 5.5%) treated with revision to a Chrisman-Snook procedure and 4 ankles (4/18, 22.2%) with stiffness or arthrofibrosis treated with a secondary procedure of peroneal tendon release or lysis of adhesions. Surgical management with rerouting of the peroneal tendons under the calcaneofibular ligament appears to be safe and effective for young patients with chronic peroneal tendon subluxation. It provides a low rate of recurrent subluxation, excellent stability, and good long-term functional outcomes. However, the potential for postoperative stiffness appears to be a limitation to the procedure and necessitates aggressive physical therapy to maintain ankle motion. Level IV- retrospective case series.

ARTHROSCOPIC TREATMENT OF PATIENTS WITH LATERAL HUMERAL EPICONDYLITIS (TENNIS ELBOW)

In the past decade the clinical and anatomical studies proved that lateral humeral epicondylitis can be successfully treated arthroscopically.Purpose of the study is to identify the optimal method of surgical treatment for patients with lateral humeral epicondylitis.Material and methods. The authors conducted an integral study consisting of two sections: clinical and anatomical. Anatomical section included precision preparation of extensor muscles of the forearm. Clinical section was dedicated to comparative analysis of statistically valid and matched by lesion severity groups of patients who underwent open and arthroscopic procedures. All patients were divided into three groups. Patients of Group I underwent arthroscopic release of extensor carpi radialis brevis tendon (ECRB) without decorticating of the lateral humeral epicondyle. Patients of Group II underwent arthroscopic release of ECRB in combination with decortication of the lateral humeral epicondyle. Patients in Group III underwent an open release of ECRB.Results. Patients who underwent arthroscopic release of ECRB demonstrated less pronounced pain syndrome as compared to patients after ECRB release along with decortication of epicondyle or after open release (р0,05). VAS pain score in Group I decreased from 7 to 1 point, in Group II — from 7 to 3 points, in Group III — from 7 to 4 points. Mean time until full recovery after the surgery was 24,2±7,8 days in Group I, 39,4±5,6 days in Group II and 60,2±15,6 days in Group III (р0,05). Functional outcomes were assessed by Mayo Elbow Performance Score (MEPS) in 9 weeks postoperatively: Group I — improvement from 60 to 79 points, Group II — from 62 to 75 points, Group III — from 60 to 75 points.Conclusion. Drilling or removal of periosteum of the damaged epicondyle does not provide a positive effect. Decortication also has certain disadvantages like postoperative pain intensification leading to lesser range of motion in elbow and increased bleeding of the wound. Patients after simple release of ECRB demonstrated minimal postoperative pain which allows early rehabilitation and return to daily and professional activities.

Wound repair and functional reconstruction of high-voltage electrical burns in wrists

Objective: To explore the methods and effects of wound repair and functional reconstruction of high-voltage electrical burns in wrists. Methods: From January 2009 to June 2016, 71 patients with high-voltage electrical burns in wrists were hospitalized, with 118 wrist wounds including 21 of type Ⅰ, 69 of type Ⅱ, 9 of type Ⅲ, and 19 of type Ⅳ. According to the wrist injuries, different surgical operations were performed. Forearm amputation was conducted in 20 wrists with necrosis in the distal end. On the basis of fasciotomy for decompression, early debridement was performed on the other 98 wrist wounds. After debridement, wounds with area ranging from 10 cm×7 cm to 30 cm×18 cm were repaired with tissue flaps with abundant blood supply. Thirty-two wounds were repaired with pedicled groin flaps, 11 wounds with pedicled paraumbilical flaps, 3 wounds with pedicled anterolateral thigh island flaps, 9 wounds with combined abdominal axial pattern flaps, 37 wounds with free skin flaps or myocutaneous flaps, and 6 wounds with flow-through descending branch of lateral femoral circumflex artery flaps, with tissue flap area ranging from 12 cm×8 cm to 34 cm×20 cm. Ulnar artery or radial artery vascular reconstruction was performed in 20 wrist wounds. Forty-one donor sites were sutured directly, while 14 were closed by thin split-thickness skin grafts from same-side thighs, and 43 were closed by thin split-thickness skin grafts from opposite-side thighs. Fifty-three wrist wounds were performed with tendon and nerve repair surgery, of which 20 were performed with simple tendon and nerve release surgery. Flexor digitorum profundus tendons and (or) flexor pollicis longus tendons were reconstructed with autologous or allogeneic tendon transplantation in 33 wrist wounds, and the median nerve was repaired with sural nerve graft in 21 wrist wounds. In 6 to 24 months after the last operation, tendon function of 53 wrist wounds which had tendon repair was evaluated with finger total active motion (TAM) method, while median nerve function of 21 wrist wounds which had median nerve repair was evaluated with integrate estimation method. Results: (1) After forearm amputation, the incisions of 20 wrists with necrosis in the distal end were healed. (2) Among the 98 tissue flaps, 90 had good blood flow, while 8 had distal necrosis, of which 6 were healed after necrotic tissue removal and skin grafting, and two were sutured directly after debridement. Infection occurred under 7 flaps, of which 3 were healed by dressing change, and 4 were healed after second debridement. Twenty wrist wounds which had radial artery or ulnar artery repair had good blood supply of hand and amputation was avoided. During follow-up of 1 to 3 years, the incisions and flaps of patients who had tissue flap repair surgery healed well. (3) The excellent and good rate of TAM in each finger of the corresponding affected limbs of 53 wrist wounds which had tendon and nerve repair surgery was 51%. (4) Twenty wrists which had simple tendon and nerve release surgery were followed up for 1 to 2 years. The strength of muscle dominated by the median nerve was restored to grade Ⅴ in 1 wrist, grade Ⅳ in 3 wrists, and grade Ⅲ in 2 wrists. The strength of muscle dominated by the ulnar nerve was restored to grade Ⅳ in 3 wrists, with no recovery in other wrists. Sensory function examination showed grade S0 in 4 wrists, grade S1 in 2 wrists, grade S2 in 3 wrists, grade S3 in 8 wrists, and grade S4 in 3 wrists. Twenty-one wrists which had median nerve repair were followed up for 1 to 2 years. There was no recovery in muscle strength dominated by the median nerve. Sensory function examination showed grade S0 in 3 wrists, grade S1 in 5 wrists, grade S2 in 8 wrists, and grade S3 in 5 wrists. Conclusions: It is a good method to sequentially conduct early fasciotomy for decompression, early debridement, vascular reconstruction, transplant of tissue flap with abundant blood supply, tendon and nerve repair in repairing electrical burn wounds of wrists, avoiding amputation, and reconstructing hand function according to the condition of electrical burns of wrists.

Conjoint Tendon Release in Direct Anterior Total Hip Arthroplasty: No Impact on Patient Outcomes.

The direct anterior (DA) approach for total hip arthroplasty (THA) has become increasingly popular. However, femoral access can be more technically challenging in difficult cases as compared with other approaches. Conjoint tendon release can improve proximal femoral exposure, but its effect on patient function and pain has not been studied. This study evaluated the effect of conjoint tendon release on length of stay (LOS), inpatient pain medication requirements, and functional outcomes of patients undergoing DA THA. The authors retrospectively reviewed charts of all primary DA THAs conducted by a single surgeon between August 2012 and July 2015. Patient demographics, bilateral THA cases, intraoperative conjoint tendon or other soft tissue releases, intraoperative complications, LOS, and inpatient pain medication data were evaluated. One-year functional outcome scores, including the Western Ontario and McMaster Universities Osteoarthritis Index and the Harris Hip Scores, were also reviewed. The authors identified 312 primary DA THAs, with 29 concurrent bilateral THAs. The conjoint tendon was released in 180 cases, whereas a tensor fascia lata (TFL) was released for 29 cases. Mean LOS was 1.3±1.1 days, with patient age (P=.002), bilateral THA (P<.001), TFL release (P=.005), and intraoperative complications (P=.002) predictive of LOS. Mean daily morphine equivalent dose narcotic use was 43.2±48.2 mg, with age being a negative predictor of narcotic use (P=.019). Conjoint tendon release was not predictive of LOS, inpatient pain medication requirements, or outcome scores. Given that conjoint release improves femoral exposure but does not affect LOS or 1-year patient-reported outcomes, intraoperative thresholds for conjoint release should be low. [Orthopedics. 2017; 40(6):e971-e974.].

Costamere protein expression and tissue composition of rotator cuff muscle after tendon release in sheep.

ABSTRACTPrevious studies suggested that degradation of contractile tissue requires cleavage of the costamere, a structural protein complex that holds sarcomeres in place. This study examined if costamere turnover is affected by a rotator cuff tear in a previously established ovine model. We found the activity of focal adhesion kinase (FAK), a main regulator of costamere turnover, was unchanged at 2 weeks but decreased by 27% 16 weeks after surgical release of the infraspinatus tendon. This was accompanied by cleavage of the costamere protein talin into a 190 kDa fragment while full length talin remained unchanged. At 2 weeks after tendon release, muscle volume decreased by 17 cm3 from an initial 185 cm3, the fatty tissue volume was halved, and the contractile tissue volume remained unchanged. After 16 weeks, the muscle volume decreased by 36 cm3, contractile tissue was quantitatively lost, and the fat content increased by 184%. Nandrolone administration mitigated the loss of contractile tissue by 26% and prevented fat accumulation, alterations in FAK activity, and talin cleavage. Taken together, these findings imply that muscle remodeling after tendon release occurs in two stages. The early decrease of muscle volume is associated with reduction of fat; while, the second stage is characterized by substantial loss of contractile tissue accompanied by massive fat accumulation. Regulation of costamere turnover is associated with the loss of contractile tissue and seems to be impacted by nandrolone treatment. Clinically, the costamere may represent a potential intervention target to mitigate muscle loss after a rotator cuff tear. © 2017 The Authors. Journal of Orthopaedic Research® published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 36:272–281, 2018.

Arthroscopic Iliopsoas Release at the Level of the Lesser Trochanter Following Total Hip Arthroplasty

Iliopsoas impingement is an uncommon cause of pain after total hip arthroplasty. If pain persists after a trial of conservative treatment, surgical intervention can alleviate the patient's symptoms. Multiple advantages exist to release the iliopsoas tendon at the level of the lesser trochanter. The purpose of this Technical Note is to demonstrate a technique for arthroscopic release of the iliopsoas tendon at the lesser trochanter after total hip arthroplasty.

Transient Changes in Brain Metabolites after Transcranial Direct Current Stimulation in Spastic Cerebral Palsy: A Pilot Study.

Muscle spasticity is a disability caused by damage to the pyramidal system. Standard treatments for spasticity include muscle stretching, antispastic medications, and tendon release surgeries, but treatment outcomes remain unsatisfactory. Anodal transcranial direct current stimulation (tDCS) in patients with muscle spasticity is known to result in significant improvement in spastic tone (p < 0.001). However, the mechanism of action by which tDCS treatment affects spasticity remains unclear. This pilot study aimed to investigate the effect of anodal tDCS upon brain metabolites in the left basal ganglia and ipsilateral primary motor cortex (M1) in children with spastic cerebral palsy (CP). This study consisted of three steps: a baseline evaluation, a treatment period, and a follow-up period. During the treatment period, patients were given 20 min of 1 mA anodal tDCS over the left M1 for five consecutive days. Outcomes were compared between pre- and immediate posttreatment in terms of brain metabolites, Tardieu scales, and the quality of upper extremity skills test. Ten patients with spastic CP were enrolled. Following tDCS, there were significant increases in the ratio of N-acetylaspartate (NAA)/creatine (Cr) (p = 0.030), choline (Cho)/Cr (p = 0.043), and myoinositol (mI)/Cr (p = 0.035) in the basal ganglia. Moreover, increased glutamine-glutamate (Glx)/Cr ratio in the left M1 (p = 0.008) was found. In addition, we also observed improvements in the extent of spasticity and hand function (p = 0.028). Five consecutive days of anodal tDCS over the left M1 appeared statistically to reduce the degree of spasticity and increase NAA, Cho, mI, and Glx. Future research studies, involving a larger sample size of spastic CP patients undergoing tDCS is now warranted.