Absent Tendon Research Articles

Functional Considerations in Bilateral, Simultaneous Tendon Injuries of the Upper Extremity

» Bilateral, simultaneous same-tendon injuries of the upper extremity are rarely encountered, yet their unique complexity poses a substantial challenge for treating orthopaedic surgeons.» In general, extremities with more tendon retraction should be repaired acutely while contralateral injuries can be treated in a staged or simultaneous manner depending on injury morphology, location, and anticipated functional impairment.» Combinations of accelerated and conventional rehabilitation protocols can be used for individual extremities to minimize the length of functional impairment.

Risk Factors for Rotator Cuff Repair Failure and Reliability of the Rotator Cuff Healing Index (RoHI) in Thai Patients: Comparison of the RoHI With a Modified Scoring System

Background: The success rate of surgical treatment for rotator cuff (RC) tear ranges from 16% to 94%. The Rotator Cuff Healing Index (RoHI) is a system for predicting failure after RC repair and is based on a combined score of factors, including age, anteroposterior (AP) tear size, tendon retraction, fatty infiltration of the infraspinatus muscle, bone mineral density (BMD), and level of work activity. Purpose: To determine the factors leading to RC repair failure in a Thai population, to test the reliability of the RoHI in this population, and to compare the RoHI with a modified RoHI (m-RoHI) based on the factors for repair failure as determined. Study Design: Case-control study; Level of evidence, 3. Methods: This study included 133 Thai patients who underwent arthroscopic RC repair between February 2012 and February 2021. Postoperative magnetic resonance imaging was performed at 6 to 24 months to evaluate RC healing. Variables that might affect failure rates were evaluated, including demographic characteristics, AP tear size and retraction, radiographic measurements, and magnetic resonance imaging findings. The m-RoHI was created using factors that significantly predicted repair failure on multivariate analysis. The area under the receiver operating characteristic curve was calculated to determine the reliability of the RoHI and to compare the reliability of the RoHI and m-RoHI to predict failure rates. Results: Multivariate logistic regression analysis revealed that body mass index ≥23 (adjusted odds ratio [OR], 9.02; P = .034), high work activity (adjusted OR, 19.53; P = .008), AP tear size ≥2.5 cm (adjusted OR, 19.04; P = .001), and a retraction size of 2 to <3 cm (adjusted OR, 20.36; P = .013) were the independent factors that predicted repair failure in our population. BMD was not independently predictive of repair failure. We used these 4 significant independent factors to generate the m-RoHI. The area under the curve of the final adjusted m-RoHI was slightly improved as compared with the original RoHI, but this difference was not significant (0.827 [95% CI, 0.741-0.913] vs 0.780 [95% CI, 0.686-0.875], respectively; P = .447). Conclusion: The m-RoHI had a similar predictive value for repair failure to the original RoHI in our study population, but it did not require obtaining BMD. The m-RoHI may be useful in populations where BMD is not routinely obtained.

The Extensor Indicis Proprius Transposition for the Ulnar Collateral Ligament Stabilization in Thumb Hypoplasia Grades II-IIIa.

Congenital upper extremity deformities are rare, the reported incidence is from 0.15% to 0.2%. The thumb is very important for a hand's functionality, as it provides up to 50% of its total performance. Proper pinch grip formation at the age of 12 to 16 months is part of normal development; however, no functional development can affect a child's psychoemotional development. Well-described techniques such as third or fourth superficial flexor transposition can be found in the literature. There is a paucity of studies on using the extensor indicis proprius (EIP) transposition for stabilization of the ulnar collateral ligament for the first metacarpophalangeal joint (MCPJ). Techniques for the usage of EIP tendon for the reconstruction of absent extensor pollicis longus tendon are more commonly practiced as they create abduction and extension for the thumb hypoplasia grade II-IIIa. We performed EIP transposition with subperiosteally fixation for the ulnar collateral ligament stabilization for thumb hypoplasia patients with a mean age of 38 months (11 to 128) and grade II (n=9), grade IIIa (n=4), and grade IIIb (n=1). Long-term follow-up (2 to 10y) for the esthetical and functional study was performed. Patients and parents are satisfied with functional and esthetic outcomes. We believe that the EIP tendon transposition can be an alternative method for thumb hypoplasia patients grade II-IIIa reconstruction.

Walking Difficulties and Brainstem Dysfunction: a Case Report of Adult Onset Leigh Syndrome

Leigh syndrome (LS) or subacute necrotizing encephalomyelopathy is a progressive, lethal, mitochondrial disease mostly presenting in childhood. We report a 36-year-old African male presenting to the Emergency Department with a 6-month history of progressive dysarthria. Examination also showed oculomotor limitations for downgaze and convergence, mild right hemiparesis with Babinski sign, and absent lower limb tendon reflexes. He revealed he was presenting mild walking difficulties since the age of 25. Family history was unremarkable. A brain magnetic resonance showed diffuse white matter lesions without enhancing around the third ventricle, in the medulla oblongata, and bilaterally to the caudate and the putamen. Polymerase-chain-reaction amplification of the mitochondrial genes, followed by direct sequencing, found a 10191T>C variant related to LS. To now, only 8 late-onset patients share the same pathogenic variant.

Assessment of the Tendon Retraction Classification Systems for Predicting Reparability and Rotator Cuff Integrity in Arthroscopic Rotator Cuff Repair

Assessment of the Tendon Retraction Classification Systems for Predicting Reparability and Rotator Cuff Integrity in Arthroscopic Rotator Cuff Repair

Developing a patient decision aid for Achilles tendon rupture management: a mixed-methods study

ObjectiveTo develop and user-test a patient decision aid portraying the benefits and harms of non-surgical management and surgery for Achilles tendon ruptures.DesignMixed methods.SettingA draft decision aid was developed using guidance...

Clinical outcomes and tendon lengthening after arthroscopic rotator cuff repair.

There is a phenomenon in which the tendon appears to increase the length after rotator cuff repair. However, it is unclear in which cases tendon lengthening occurs and how the degree of lengthening affects the surgical outcome. This study aimed to evaluate preoperative and postoperative musculotendinous junction (MTJ) and tendon length on magnetic resonance imaging and assess the postoperative tendon lengthening and its impact on postoperative outcomes. We reviewed 109 patients with good repair integrity after arthroscopic rotator cuff repair. Patients whose supraspinatus tendons were simply pulled out laterally without any additional procedures were included. They underwent serial magnetic resonance imaging before surgery and at 3, 6, and 24months after surgery. The location of the MTJ in relation to the line of the glenoid fossa and the supraspinatus tendon length were measured. Clinical evaluation was conducted 2years after surgery, including the range of shoulder motion, shoulder strength index (affected/unaffected strength), Constant score, University of California, Los Angeles score, and pain numeric rating scale. The characteristics of the preoperative tendon, change in tendon length over time, amount of the lateral shift of MTJ location and tendon length, and impact of tendon lengthening on postoperative clinical outcomes were analyzed. The preoperative tendon retraction significantly correlated with the MTJ location (r=-0.75; P<.0001) and preoperative tendon length (r=-0.46; P<.0001). The tendon length at 3, 6, and 24months after surgery was significantly longer than those before surgery (26.7±5.8mm, 27.9±6.6mm, 28.5±5.6mm, and 21.5±5.1mm, respectively). From before surgery to 24months after surgery, the MTJ location moved 8.4±8.6mm laterally and the tendon length increased 7.0±6.1mm. A significant and weak negative correlation was found between tendon lengthening and the abduction strength index (r=-0.22; P=.03); however, no significant correlation with pain, range of shoulder motion, external rotation strength index, Constant score, and University of California, Los Angeles score was found. Multiple linear regression analysis also showed that tendon lengthening was only associated with the abduction strength index (standardized coefficient=-0.20, P=.03). Tendon lengthening and lateral shift of MTJ location were observed after arthroscopic rotator cuff repair, and they correlated with preoperative tendon retraction. Although the amount of tendon lengthening had negative weak correlation with abduction strength index, it did not affect other postoperative outcomes.

Minimum 5-Year Clinical Outcomes of Arthroscopically Repaired Massive Rotator Cuff Tears: Effect of Age on Clinical Outcomes

Background: Massive rotator cuff tears (MRCTs) can be challenging to treat, and the efficacy of repair of MRCTs in older patients has been debated. Purpose: To report minimum 5-year outcomes after primary arthroscopic rotator cuff repair of MRCT and determine whether age affects outcomes. Study Design: Case series; Level of evidence 4. Methods: The study included consecutive patients with MRCTs who were treated with arthroscopic rotator cuff repair by a single surgeon between February 2006 and October 2016. MRCTs were defined as ≥2 affected tendons with tendon retraction to the glenoid rim and/or a minimum exposed greater tuberosity of ≥67. Patient-reported outcome (PRO) data collected preoperatively and at a minimum of 5 years included the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numeric Evaluation (SANE) score; the shortened version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH); the 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS); and patient satisfaction. Surgical failure was defined as subsequent revision rotator cuff surgery or conversion to reverse total shoulder arthroplasty. Regression analysis was performed to determine whether age had an effect on clinical outcomes. Results: A total of 53 shoulders in 51 patients (mean age, 59.7 years; range, 39.6-73.8 years; 34 male, 19 female) met inclusion criteria with a mean follow-up of 8.1 years (range, 5.0-12.1 years). Three shoulders (5.7%) failed at 2.4, 6.0, and 7.1 years. Minimum 5-year follow-up was obtained in 45 of the remaining 50 shoulders (90%). Mean PROs improved as follows: ASES from 58.8 to 96.9 (P < .001), SANE from 60.5 to 88.5 (P < .001), QuickDASH from 34.2 to 6.8 (P < .001), and SF-12 PCS from 41.1 to 52.2 (P < .001). Patient satisfaction was a median of 10 (on a scale of 1-10). Age was not associated with any PRO measures postoperatively (P > .05). Conclusion: This study demonstrated significantly improved clinical scores, decreased pain, and increased return to activity for patients with MRCT at midterm follow-up (mean, 8.1 years; range, 5.0-12.1 years). In this patient cohort, no association was found between age and clinical outcomes.

An objective assessment of the impact of tendon retraction on sleep efficiency in patients with full-thickness rotator cuff tears: a prospective cohort study.

Sleep quality, quantity, and efficiency have all been demonstrated to be adversely affected by rotator cuff pathology. Previous measures of assessing the impact of rotator cuff pathology on sleep have been largely subjective in nature. This study was undertaken to objectively analyze this relationship through the use of activity monitors. Patients with full-thickness rotator cuff tears at a single institution were prospectively enrolled between 2018 and 2020. Waistworn accelerometers were provided for the patients to use each night for 14 days. Sleep efficiency was calculated using the ratio of the time spent sleeping to the total amount of time that was spent in bed. Retraction of the rotator cuff tear was classified using the Patte staging system. This study included 36 patients: 18 with Patte stage 1 disease, 14 with Patte stage 2 disease, and 4 patients with Patte stage 3 disease. During the study, 25 participants wore the monitor on multiple nights, and ultimately their data was used for the analysis. No difference in the median sleep efficiency was appreciated amongst these groups (P&gt;0.1), with each cohort of patients demonstrating a generally high sleep efficiency. The severity of retraction of the rotator cuff tear did not appear to correlate with changes in sleep efficiency for patients (P&gt;0.1). These findings can better inform providers on how to counsel their patients who present with complaints of poor sleep in the setting of full-thickness rotator cuff tears. Level of evidence: Level II.

Progression of symptomatic bilateral rotator cuff disease

Prior studies have demonstrated that conservatively treated rotator cuff tears and rotator cuff tendinopathy may continue to progress. It is unclear whether that rate of progression differs between sides in patients with bilateral disease. This study evaluated the likelihood of progression of rotator cuff disease as confirmed via magnetic resonance imaging (MRI) in individuals with symptomatic bilateral pathology, treated conservatively for a minimum of 1 year. We identified patients with bilateral rotator cuff disease confirmed via MRI within the Veteran's Health Administration electronic database. A retrospective chart review via the Veteran's Affairs electronic medical record was performed. Progression was determined using 2 separate MRIs with a minimum of 1 year apart. We defined progression as (1) a progression from tendinopathy to tearing, (2) an increase from partial-thickness to full-thickness tearing, or (3) an increase in tear retraction or tear width of at least 5 mm. Four hundred eighty MRI studies from 120 Veteran's Affair patients with bilateral, conservatively treated rotator cuff disease were evaluated. Overall, 42% (100/240) of rotator cuff disease had progressed. No significant difference was found between progression of right vs. left rotator cuff pathology, with right shoulder pathology progressing at a rate of 39% (47/120), while left shoulder disease progressed at a rate of 44% (53/120). The likelihood of disease progression was associated with less initial tendon retraction (P value=.016) and older age (P value=.025). Rotator cuff tears are no more likely to progress on the right, as compared to the left side. Older age and less initial tendon retraction were found to be predictors of disease progression. These suggest that higher activity level may not associate with greater progression of rotator cuff disease. Future prospective studies evaluating progression rates between dominant vs. nondominant shoulders are warranted.

Chronic quadriceps tendon rupture: quadriceps tendon reconstruction using ipsilateral semitendinosus tendon graft

Ruptures of the quadriceps tendon (QTRs) are uncommon. If the rupture is not diagnosed, chronic ruptures may develop. Re-ruptures of the quadriceps tendon are rare. Surgery is challenging because of tendon retraction, atrophy and poor quality of the remaining tissue. Multiple surgical techniques have been described. We propose a novel technique in which the quadriceps tendon is reconstructed using the ipsilateral semitendinosus tendon.

GVHD in its sclerodermiform form revealing type 1 diabetes: A case report

Sclerodermiform syndrome is Common in diabetic, it encompasses a set of manifestations that preferentially affect the hands and back, but the association of type 1 diabetes with systemic sclerosis is a rare entity. We report the case of 18-year-old patient from a consanguineous marriage, with a history of acute myeloid leukemia which he was treated by an allograft in France associated with chemotherapy 9 session and immunosuppressants currently in complete remission, diabetic type 1 for 4 years, hypothyroidism under levothyrox 50ug / d. At the interrogation the patient reported the consequences of the graft were marked by stage I cutaneous GVHD confirmed by skin biopsy of which he received corticosteroid therapy at a dose of 10mg / day in addition to neoral or slightly atrophic hyperpigmented macules not sclerotic at the level of the back and the lateral surface of the left foot. The patient also had corticosteroid-induced complications, including diabetes and osteoporosis. On physical examination tendon retraction, elbows and finger, Amyotrophy of the hands, palpable thyroid not increased volume allowed for glycemic imbalance. At TSH biology = 6uui / ml, HBA1C = 8%, anti-GAD antibody negative to cervical ultrasound: thyroid hypotrophy with thyroid nodules classified EUTIRADS 2. The patient is referred for follow-up in dermatology. The association of sweet diabetes and sclerodermiform lesions is frequently linked to the glycemic imbalance responsible for an accumulation of extracellar matrix and excessive glycation of collagen. The search for signs of scleroderma should be evoked in front of a diabetic hand syndrome to Watch for and treat associated pathologies.

Clinical and radiologic outcomes after tendon insertion medialized repair of large-to-massive rotator cuff tears

To evaluate the effectiveness of tendon insertion medialized repair in treatment of large-to-massive rotator cuff tears (L/MRCT). The clinical and imaging data of 46 L/MRCT patients who underwent arthroscopic insertion medialized repair between October 2015 and June 2019 were retrospectively analyzed. There were 26 males and 20 females with an average age of 57.7 years (range, 40-75 years). There were 20 cases of large rotator cuff tears and 26 cases of massive rotator cuff tears. Preoperative imaging evaluation included fatty infiltration (Goutallier grade), tendon retraction (modified Patte grade), supraspinatus tangent sign, acromiohumeral distance (AHD), and postoperative medializaiton length and tendon integrity. The clinical outcome was evaluated by visual analogue scale (VAS) score, American Society for Shoulder and Elbow Surgery (ASES) score, shoulder range of motion (including anteflexion and elevation, lateral external, and internal rotation) and anteflexion and elevation muscle strength before and after operation. The patients were divided into two groups (the intact tendon group and the re-teared group) according to the integrity of the tendon after operation. According to the medializaiton length, the patients were divided into group A (medialization length ≤10 mm) and group B (medialization length >10 mm). The clinical function and imaging indexes of the patients were compared. All patients were followed up 24-56 months, with an average of 31.8 months. At 1 year after operation, MRI showed that the medializaiton length of supraspinatus tendon was 5-15 mm, with an average of 10.26 mm, 33 cases in group A and 13 cases in group B. Eleven cases (23.91%) had re-teared, including 5 cases (45.45%) of Sugaya type Ⅳ and 6 cases (54.55%) of Sugaya type Ⅴ. At last follow-up, the VAS score, ASES score, shoulder anteflexion and elevation range of motion, lateral external rotation range of motion, and anteflexion and elevation muscle strength significantly improved when compared with those before operation ( P<0.05); there was no significant difference in internal rotation range of motion between pre- and post-operation ( P>0.05). The Goutallier grade and modified Patte grade of supraspinatus muscle in the re-teared group were significantly higher than those in the intact tendon group, and the AHD was significantly lower than that in the intact tendon group ( P<0.05). There was no significant difference in other baseline data between the two groups ( P>0.05). Except that the ASES score of the intact tendon group was significantly higher than that of the re-teared group ( P<0.05), there was no significant difference in the other postoperative clinical functional indicators between the two groups ( P>0.05). There was no significant difference in the incidence of re-tear, VAS score, ASES score, range of motion of shoulder joint, and anteflexion and elevation muscle strength between group A and group B ( P>0.05). Tendon insertion medialized repair may be useful in cases with L/MRCT, and shows good postoperative shoulder function. Neither tendon integrity nor medialization length shows apparent correlations with postoperative shoulder function.

No difference in clinical outcomes between operative and nonoperative management of minimally retracted proximal hamstring ruptures.

The indications for surgical treatment of proximal hamstring ruptures are continuing to be refined. The purpose of this study was to compare patient-reported outcomes (PROs) between patients who underwent operative or nonoperative management of proximal hamstring ruptures. A retrospective review of the electronic medical record identified all patients who were treated for a proximal hamstring rupture at our institution from 2013 to 2020. Patients were stratified into two groups, nonoperative or operative management, which were matched in a 2:1 ratio based on demographics (age, gender, and body mass index), chronicity of the injury, tendon retraction, and number of tendons torn. All patients completed a series of PROs including the Perth Hamstring Assessment Tool (PHAT), Visual Analogue Scale for pain (VAS), and the Tegner Activity Scale. Statistical analysis was performed using multi-variable linear regression and Mann-Whitney testing to compare nonparametric groups. Fifty-four patients (mean age = 49.6 ± 12.9years; median: 49.1; range: 19-73) with proximal hamstring ruptures treated nonoperatively were successfully matched 2:1 to 27 patients who had underwent primary surgical repair. There were no differences in PROs between the nonoperative and operative cohorts (n.s.). Chronicity of the injury and older age correlated with significantly worse PROs across the entire cohort (p < 0.05). In this cohort of primarily middle-aged patients with proximal hamstring ruptures with less than three centimeters of tendon retraction, there was no difference in patient-reported outcome scores between matched cohorts of operatively and nonoperatively managed injuries. Level III.

Anatomic restoration of the articular deep layer is a definitive factor for repair status in delaminated rotator cuff tear.

Recent studies have focused on the deep layer in delaminated rotator cuff tears. However, no studies have discussed the relationship between repair success and the properties of the deep layer. Herein, we aimed to analyze the intraoperative repair tension of the deep layer with respect to clinical outcomes and repair integrity and to evaluate the clinical results of delaminated rotator cuff tears after dual layer-specific repair. A total of 202 patients with delaminated rotator cuff tears had undergone dual layer-specific suture bridge repair; the mean follow-up duration was 28.6 (24-72) months. Intraoperatively, the repair tension of the deep layer was measured using a tensiometer, and mobility was ranked as easy or tight. After repair of the deep layer, the superficial layer tension was measured and ranked in a similar fashion. Clinical outcomes were evaluated using the Constant score, American Shoulder and Elbow Surgeons score, and subjective shoulder values. The relationship between retear and intraoperative qualitative factors of tendons was investigated. Prognostic factors for retear were analyzed using multiple logistic regression analyses. Postoperative retears occurred in 11 (5.4%) patients. With regard to the deep layer, the tight mobility group had greater tear size, tendon retraction, and fatty infiltration of the supraspinatus and infraspinatus than the easy mobility group. No intergroup difference in postoperative retear rate was observed between the tight and easy deep-layer groups. Logistic regression analysis showed that fatty infiltration of the infraspinatus (odds ratio, 3.1; 95% confidence interval, 1.3-7.7; P=.013) and mobility of the superficial layer after deep layer repair (odds ratio, 8.1; 95% confidence interval, 1.7-38.1; P=.008) were predictors of retear. Intraoperative mobility in the deep layer was not directly related to postoperative retear. Conversely, the quality of the infraspinatus concomitant with mobility of the superficial layer after deep layer repair significantly influenced repair integrity. Good clinical results were obtained even in cases with high repair tension of the deep layer.

A Case of Childhood Onset of Extended Sensory Ataxic Neuropathy, Dysarthria, and Ophthalmoparesis Phenotype with Pathogenic Polymerase Gamma Variation

Background: Ataxia neuropathy spectrum, including sensory ataxia neuropathy, dysarthria, and ophthalmoparesis (SANDO), is a part of polymerase gamma (POLG) gene-related disorder, a heterogeneous group of mitochondrial disorders. Childhood onset of the SANDO phenotype is rare, and we describe such a case here, probably the first from India. Clinical Description: A 17-year-old girl presented with progressive gait abnormality since 5 years of age, later associated with ptosis and seizures. On examination, she had atrophy of distal small muscles and absent tendon reflexes in addition to ataxia and ptosis. Differentials for a neurodegenerative disorder with cognitive sparing and ophthalmoplegia were suspected. Management: Investigations revealed a mild elevation in serum lactate, transaminases, and creatine phosphokinase, with abnormal neurophysiology showing primary muscle disease with symmetrical sensorimotor polyneuropathy, and a normal neuroimaging. Gene sequencing analysis for the mitochondrial disorder was done, which revealed a pathogenic variation in the POLG gene. The child was kept on supportive management, including antiepileptics. Conclusion: This case shows that the SANDO phenotype of POLG-related disorders, classically seen in adults, may rarely be seen in children. Our case highlights the fact that although many of the progressive neurodegenerative disorders have a nonspecific clinical presentation, biomarkers, and neurophysiologic abnormalities, a few important phenotypic clues and awareness of POLG-related disorders may enable a pediatrician to order focused genetic testing to delineate the etiology.

Reconstruction of delayed distal biceps ruptures with a dermal matrix

ObjectivesDistal biceps tear is uncommon, with well-recognized risk factors and typical clinical presentation. Delays in surgical treatment lead to several challenges, such as tendon retraction and tendon degeneration. We present a surgical technique using a sterilized acellular dermal matrix, which provides a solution for a challenging pathology. Material and MethodsWe present a detailed surgical technique of distal biceps reconstruction with acellular dermal matrix, performed in 4 patients, with an average time to diagnosis of 36 days (range, 28–45 days). Demographics, clinical data, range of motion and subjective satisfaction were collected. ResultsAt a mean follow-up of 18 months, all 4 patients showed full range of motion and strength, complete recovery and previous work resumed without pain. No complications appeared during this time. ConclusionsDelayed distal biceps tear reconstruction by acellular dermal matrix showed promising results. Meticulous surgical technique using this matrix provided excellent reconstruction, with very solid anatomical repair and exceptionally good fixation, good clinical outcome and satisfied patients. Level of evidenceIV

Paper 17: Minimum 5-year Clinical Outcomes of Arthroscopically Repaired Massive Rotator Cuff Tears – Effect of Age on Clinical Outcomes

Objectives: Massive rotator cuff tears (MRCTs) are a frequent and challenging entity encountered by for orthopedic surgeons, accounting for up to 40% of all rotator cuff tears (RCT). Furthermore, the efficacy of repair of MRCTs in older patients is questioned by some. The purpose of this study is to report minimum 5-year outcomes after primary arthroscopic rotator cuff repair (ARCR) of MRCT and the effect that age has on outcomes. We hypothesized that there would be low rates of revision and a high patient satisfaction in a mid-term follow up in those patients treated with a primary ARCR independent of age. Methods: Data was collected prospectively and retrospectively reviewed for this IRB approved study. Inclusion criteria was that patients were a minimum of 5 years out from an ARCR of a MRCT by a single surgeon from February 2006 to November 2016. Patients were excluded if they had glenohumeral osteoarthritis (Hamada &gt;2), fatty infiltration (Goutallier &gt;3), or if they had concomitant pathologies such as labral lesions or chondromalacia that led to additional surgical procedures except for biceps tenodesis/tenotomy and subacromial decompression. MRCTs were defined by the Neer Circle’s Delphi consensus statement as tendon retraction to the glenoid rim and/or a minimum exposed greater tuberosity of at least 67 percent in combination with the Gerber classification of at least two affected tendons. Patient reported outcome (PRO) data was collected preoperatively and evaluated at a minimum follow-up of 5 years postoperatively using the American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numeric Evaluation Score (SANE), Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the Short Form 12 physical component summary (SF-12 PCS), and patient satisfaction to assess surgical outcomes at final follow-up. Linear and LOESS regression in addition to correlation was analyzed to assess the effect of age on clinical outcomes. Further, a sub-group analysis of patients over and under 65 was performed. Retears, revision surgery, and surgical complications were recorded. Surgical failure was defined as revision surgery. Results: In total, 188 patients with ≥ 2 tendon RCTs who were at least 5 years out from surgery were identified. After application of exclusion criteria and the Neer Circle’s MRCT definition, 61 patients (mean age: 59.5 years, range: 39.6-73.8; 38 males, 23 females) with a mean follow up of 7.9 years (range 5.0-12.1) included in this study. Final follow-up was obtained in 44 patients (76%). At final follow-up, the mean PROs were significantly improved over preoperative levels for all PROs. The ASES scores improved from 59.4 to 95.0 (p&lt;.001), SANE improved from 66.3 to 89.9 (p&gt;.001), QuickDASH improved from 34.2 to 8.3 (p&lt;.001) and SF-12 PCS improved from 41.5 to 51.3 (p&lt;.001). Median postoperative satisfaction was 10 (range 1-10). Linear and LOESS regression analysis as well as correlation analysis showed that no PRO measures (ASES, SANE, QuickDASH, SF12-PCS, or patient satisfaction) were significantly associated with age at time of surgery. In the subgroup analysis of over and under 65, no significant differences between groups were demonstrated for PROs with the exception of postoperative SF-12 PCS (53.6 vs. 49.1; p=.041). Conclusions: The most important finding in this study is that patients undergoing ARCR of MRCTs experience significant improvements in shoulder function irrespective of patient age.

Distal Biceps Tendon Repair Using a Single Incision, Dual Anchor Technique

Background: Distal biceps tendon ruptures commonly present in the middle-aged population resulting in deficits of strength and endurance. Operative management has shown improved functional outcome; however, there is not a clear consensus on an ideal surgical method. Indications: Distal biceps tendon repair is indicated for patients with clinical evidence and supporting magnetic resonance imaging confirmation of complete or partial rupture of the biceps tendon. Ideally, surgery is performed within 1 to 2 weeks of the injury to minimize the amount of scar tissue that is formed and the severity of the tendon retraction. Technique Description: A single incision is created on the volar surface of the forearm approximately 15 mm distal to the main flexor crease. After dissection to and retrieval of the biceps tendon, a #2 FiberTag stitch is placed distally and secured in a standard looped, locking fashion. An anchor is then placed in the most proximal aspect of the radial tuberosity and preliminarily placed around the tendon. An all-suture intramedullary cortical button is then placed in the distal aspect of the radial tuberosity. The FiberTag sutures are then shuttled through the button and tightened to anatomically reduce the distal biceps. The sutures on the proximal anchor are then used as supplemental fixation. Results: An anterior, single incision technique provides exposure necessary for dual anchor fixation and anatomic restoration of the distal biceps tendon. Utilizing this approach, patients are found to have improved flexion and pronation at 1 year, lower rates of heterotopic ossification, and lower rates of reoperation. Conclusion: Distal biceps tendon repair through an anterior, single incision provides excellent exposure for surgical repair. Utilizing a dual anchor technique, the distal button allows for anatomic fixation while the proximal suture anchor provides secondary fixation and increases the bone-tendon interface. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Degree of Tendon Retraction and Younger Age Are Associated With Functional Decline Following Nonoperative Management of Complete Proximal Hamstring Ruptures

To characterize functional outcomes of patients with complete proximal hamstring tendon ruptures who were treated nonoperatively and determine whether there are patient characteristics associated with unfavorable outcomes. We retrospectively identified patients aged 18-80 (treated 1/2000-12/2019) who received nonoperative management of complete rupture of the hamstring tendon origin. Participants completed the Lower Extremity Functional Scale (LEFS), as well as Tegner Activity Scale (TAS), and a chart review was conducted to obtain demographic and medical information. Preinjury and postinjury TAS scores were compared, and additional models quantified associations between LEFS scores or changes in TAS scores (ΔTAS) and patient characteristics. Twenty-eight subjects (mean age: 61.5 ± 1.5 years; 10 male) were included. The mean follow-up time was 5.8 ± 0.8 years (range: 2-22 years). Mean preinjury and postinjury TAS scores were 5.3 ± 0.4 and 3.7 ± 0.4, respectively, with a change of 1.5 ± 0.3 (P= .0002). Degree of tendon retraction showed a negative correlation with LEFS score (P= .003) and ΔTAS (P= .005). Increased follow-up time (P= .015) and body mass index (P= .018) were associated with lower LEFS scores. Moreover, increased follow-up time (P= .002) and younger age at injury (P= .035) were associated with more negative ΔTAS. Patients classified with an American Society of Anesthesiologists (ASA) score of 2 had a median LEFS score that was 20 points (95% CI: 6.9-33.6) lower than those classified as ASA 1 (P= .015). In this study, we found that increased degree of tendon retraction, increased follow-up time, and younger age at initial injury were associated with significantly worse self-reported functional outcomes. Level IV, prognostic case series.