Biochemistry and biomechanics of healing tendon: Part II. Effects of combined laser therapy and electrical stimulation

Twenty-two closed Achilles tendon ruptures caused by sports injuries in 22 patients (average age, 37.6 years) were repaired with Kirschmayer core suture and cross-stitch epitenon suture, and early active ankle motion with weightbearing was implemented after surgery. This study was undertaken to evaluate the effectiveness of the repair technique and rehabilitation protocol by assessing clinical results and magnetic resonance imaging findings. The follow-up period averaged 24.6 months. Twenty of the tendons (91%) healed without rerupture, and two tendons (9%) suffered a partial rerupture at 23 and 56 days, respectively. Active ankle extension reached from the minus range to 0 degree in an average of 9.7 days, and ankle motion recovered to normal in an average of 6.0 weeks. Full weightbearing without heel raising became possible in an average of 16.4 days, and heel raising with both legs became possible in an average of 7.3 weeks. The patients returned to full sports activity in 13.1 weeks. The interval until the area of high-intensity signal at the tendon repair site on T2-weighted magnetic resonance imaging scans became intermediate-intensity signal averaged 6.9 weeks, and the tendon repair site became low-intensity signal in an average of 12.6 weeks, demonstrating excellent tendon healing. Treatment employing Kirschmayer core suture and cross-stitch epitenon suture may help athletes return to sports activity in a shorter period than that allowed by previous methods of repair for Achilles tendon ruptures.     

Outcome and prognostic factors of achilles rupture repair using a new scoring method

A new clinical scoring system, including subjective assessment of symptoms and evaluation of ankle range of motion and isokinetic measurement of ankle plantar flexion and dorsiflexion strengths, is presented in 101 patients (86 men, 15 women) who had repair of a closed Achilles tendon rupture. Twenty-one patients were competitive athletes and 70 were recreational athletes. Eighty-one percent of the ruptures were related to sports, and 32% occurred while playing volleyball. Twenty-six patients had previous Achilles tendon symptoms. At followup, an average of 3.1 years after repair, the overall result scores were excellent in 34 cases, good in 46, fair in 17, and poor in four. Only age was a predictor of overall results. The isokinetic strength scores were excellent or good in 72 cases, fair in 18, and poor in 11. Presence of systemic diseases, activity level, previous Achilles tendon symptoms, and later return to physical exercise were predictors of strength results. Gender, body weight, height, period between rupture and operation, surgeon, rupture site, operative method, complications, and thickness, width, and area of the Achilles tendon at followup were not related significantly to the outcome.     

Repair of distal biceps tendon ruptures in athletes

Ten athletes with distal biceps tendon ruptures that had been anatomically repaired with a double-incision techniques were reviewed to determine their functional recovery. All of the patients were men, with an average age of 40 years (range, 25 to 49). Eight of the 10 patients were weight lifters or body builders, and 7 had participated on a competitive level at some point in their athletic careers. Six injured their dominant extremity, and 4 their nondominant extremity. Isokinetic muscle testing of supination and flexion was performed in 8 patients and the results were compared to a control group. Followup averaged 50 months (range, 12 to 105). Patients uniformly graded their subjective results as excellent, with a group mean rating of 9.75 on a 10-point scale. All athletes returned to full, unlimited activity. The contour of the biceps muscle was restored in all cases. Isokinetic muscle testing demonstrated that in those patients with a repaired dominant extremity, supination strength and endurance was normal; in flexion, they had normal strength, but averaged 20% less endurance. Testing of the group that had the nondominant extremity repaired revealed a supination strength deficit of 25%, but normal endurance. Flexion strength and endurance were essentially normal in this group. Anatomic repair of a distal biceps tendon rupture gives consistently excellent subjective and good objective results in athletes, particularly for those sports with high strength demands such as weight lifting and body building. Rehabilitation of the operated arm, especially the repaired nondominant extremity, should be emphasized.     

Apoptosis of tubular epithelial cells in familial juvenile gouty nephropathy

Chronic ruptures of the patellar tendon are uncommon injuries. They are technically difficult to repair because of scar formation, poor quality of the remaining tendon, and quadriceps muscle atrophy and contracture. We report the reconstruction of a chronic patellar tendon rupture with an interesting complication, a tibial stress fracture. The reconstruction was performed 3 months after the injury using an Achilles tendon-bone allograft and reinforcing suprapatellar wire. At 2 weeks postoperatively, the patient had attained full extension and 90 degrees of flexion. Ten months after the index procedure, the patient had range of motion 0 degrees to 120 degrees and was diagnosed with a healing tibial stress fracture. At 17 months postoperatively, the patient had attained full extension, 120 degrees of flexion, and 85% quadriceps strength. The preoperative goals of attaining full range of motion, improving quadriceps strength, obtaining anatomic patellar alignment, and restoring function were obtained despite the complication of a tibial stress fracture. Although this reconstructive procedure is technically demanding, with potential complications, the functional results obtained can be excellent.     

Gait analysis and muscle strength in children with surgically treated clubfeet

Twenty-three children who had unilateral surgery for idiopathic clubfeet underwent gait analysis and isokinetic muscle-strength testing at an average of 10 years after surgical release. Ankle sagittal-plane kinematics were disturbed in 20 clubfeet. Fifteen children had an internal foot-progression angle. Genu valgum and knee hyperextension were common. Plantarflexion power was decreased by 23% on the side of surgery (p = 0.00005). Quadriceps weakness (defined as a decrease in strength >10% of the nonoperated-on limb's strength) was seen in nine of 22 operated-on limbs and hamstring weakness in eight of 22. Gastrocsoleus weakness exceeded 10% in 16 of 21 clubfeet. Average weakness of the gastrocsoleus was 27% (p < 0.05). Ten-year analysis of children treated with clubfoot releases revealed disturbances in ankle motion and strength. Loss of plantarflexion power and gastrocsoleus strength can be predicted by Achilles tendon lengthening. Knee kinematic abnormalities and weakness also were seen. These abnormalities produce functional difficulties in gait and may lead to degenerative changes later.     

Propofol bolus facilitates reduction of luxed temporomandibular joints

All patients with badminton-related acute Achilles tendon ruptures registered during 1990 to 1994 at the University Hospital of Ume? were retrospectively followed up using a questionnaire. Thirty-one patients (mean age, 36.0 years), 27 men and 4 women, were included. Thirty patients (97%) described themselves as recreational players or beginners. The majority of the injuries (29 of 31, 94%) happened at the middle or end of the planned game. Previous local symptoms had been noticed by five patients (16%). Long-term results showed that patients treated with surgery had a significantly shorter sick leave absence than patients treated without surgery (50 versus 75 days). There was no obvious selection favoring any treatment modality. None of the surgically treated patients had reruptures, but two reruptures occurred in the nonsurgically treated group. There seemed to be fewer remaining symptoms and a higher sports activity level after the injury in the surgically treated group. Our results indicate that local muscle fatigue may interfere with strength and coordination. Preventive measures such as specific treatment of minor injuries and adequate training of strength, endurance, and coordination are important. Our findings also indicate that surgical treatment and careful postoperative rehabilitation is of great importance among badminton players of any age or sports level with Achilles tendon rupture.     

The treatment of prolactinomas during pregnancy and the lactation period

Thanks to its good long-term results, surgery is the method of choice to treat subcutaneous ruptures of the Achilles tendon. Reconstructed tendons present typical morphological and functional US patterns which depend partly on the kind of surgical reconstruction and partly on the time passed since surgery. The authors report the results of the clinical and US follow-up of a series of 62 surgical patients treated in 7 years for the subcutaneous rupture of the Achilles tendon. The patients were 55 men and 7 women, whose mean age was 36 years (range: 25-65 years). The left-hand side was affected in 38 patients and the right-hand side in 24 patients. All patients were operated on using an end-to-end suture and reinforcement plastic surgery pulling down a gastrocnemius tendon flap. To homogenize the results, all the US exams were performed by the same operator, in the presence of the orthopedic specialist and under the same conditions: both the involved and the contralateral Achilles tendons were studied, longitudinal and transverse scans were performed with the foot in max. plantar and dorsal flexion and, whenever possible, dynamic scans were also performed making the sural triceps contract against resistance. The following parameters were studied clinically: pain (which was absent in 39 patients, occasional in 11, after stress in 9 and on walking in 3 patients), skin scar trophism (which was eutrophic in 53.23% of patients, keloid in 27.42% and hypertrophic in 19.35% of patients), ankle joint excursion (plantar flexion was impaired in 32.3% and dorsal flexion in 36% of patients), walking on tiptoe (in all, 22.6% of patients complained of difficulties walking on tiptoe) and, finally, work activity resumption (which all patients achieved). US depicted the surgical tendons as much bigger than the contralateral ones (3-4 times on the average), which increase in volume lasted throughout the follow-up. In 75% of patients the echo structure of the surgical tendons was inhomogeneous, with scattered hypoechoic and hyperechoic areas. In the extant 25% of patients, nearly all of them followed-up for over 6 years, US depicted a clear-cut hyperechoic area whose size and echo structure were similar to the healthy tendons'. Our results strongly suggest that tenorrhaphy and flap plastic surgery be used to repair subcutaneous ruptures of the Achilles tendon. US proved to be the most reliable and feasible method also in the follow-up. The US images of the patients submitted to surgery more than 6 years earlier revealed fibrillate reorganization patterns and tendon restructuring. These processes involve both ends of the sutured tendon and not the reinforcement flap, which further confirms the exclusively mechanical, and not biological, function of the latter.     

Is apoptosis a "programmed cell death"?]

The purpose of this study was to evaluate the results and complications of anterior cruciate ligament surgery in middle-aged patients. Forty-five consecutive patients over 40 years old (average age, 44.6 years) who had arthroscopically assisted anterior cruciate ligament reconstructions with midthird patellar tendon autografts were evaluated. The patients returned for interviews, physical examinations, radiographs, Biodex dynamometer strength testing, and KT-1000 arthrometer testing at an average of 37 months after their surgeries (range, 24 to 96 months). The mean Lysholm and Gillquist score was 91, which corresponds to symptoms only with vigorous activity. The overall scores from the International Knee Documentation Committee form were 29 (64%) normal or nearly normal and 2 (4%) severely abnormal. Side-to-side differences as determined by the KT-1000 arthrometer were < or = 3 mm in 31 of 40 patients (78%), between 3 and 5 mm in 4 patients (10%), and > 5 mm in 5 patients at 30 pounds of anterior displacement. Seventy-six percent of the patients (N = 34) returned to their preoperative activity levels. Three patients required repeat arthroscopic surgery for persistent knee pain and two patients had graft ruptures. This study shows that when middle-aged patients undergo surgery, their results can be successful and satisfying to a degree similar to those of younger patients.     

Surgical repair of Achilles tendon rupture. Comparison of surgical with conservative treatment

Achilles tendon suture combined with a triceps surae tendon tip-over graft was performed in 314 patients with acute rupture of the Achilles tendon between 1980 and 1991. Analysis of these cases showed a low tissue complication rate compared with that reported in the literature. An average of 8.1 years after repair, 223 patients were examined using Holz's scale of clinical assessment after Achilles tendon repair. The results were 'good' in 87.4%, 'fair' in 11.2% and 'poor' in 1.4%. The re-rupture rate was very low (0.4%). These results are better than the re-rupture rate after surgical repair with solely end-to-end suture or after conservative immobilizing or conservative functional treatment. In conclusion, these data show that the fascial reinforcement is a valuable complement to the tendon suture.     

Conservative functional therapy of closed rupture of the Achilles tendon. Treatment approach and analysis of results

In a prospective study in the period from May 1989 to April 1994, 161 patients at the Unfallchirurgische Klinik in Braunschweig were treated for rupture of the Achilles tendon using a conservative functional method. A follow-up examination was carried out on 132 patients (81%) after an average of 12.6 months. Conservative therapy was indicated if dynamic ultrasonography showed sufficient adaptation of the rupture. Continuous retention of the adapted tendon fragments was guaranteed by means of special footwear that raises the back of the foot (Variostabil). The average age of the patients was 39.5 years. In 97 cases (73.5%) the injury was caused by sports. In 68 ruptures the dehiscence was compensated in plantar flexion. In 48 cases the dehiscence was 1-5 mm, and in 16 cases it was between 6 and 10 mm. The average period of hospitalization was 4.8 days (1/19). The period of inability to work was an average of 4 weeks (27.4 days (0/98)). The rupture healed on an average of 9.5 weeks (5.9/23). Complications included seven cases of re-rupture (5.3%), and, in the course of treatment, four patients (3%) suffered profound leg vein thrombosis that in one case developed into postthrombotic syndrome. In two cases there was tendovaginitis of the Achilles tendon. Early functional conservative therapy using the VARIO-STABIL shoe is a suitable method for treating a newly ruptured Achilles tendon. When there is a precise indication, the method is equally as good as operative therapy and because of the low complication rate, it is even preferable.     

Comparison of ultrasonography and magnetic resonance in the postoperative monitoring of complete subcutaneous rupture of the Achilles tendon]

The diagnostic accuracy of US and MRI in the subcutaneous rupture of the Achilles tendon has already been assessed. We used both techniques to study the Achilles tendon during the postoperative repair process after surgery according to Bosworth. The results were compared and discussed in relation to clinical recovery. Ten patients with complete subcutaneous rupture of the Achilles tendon were followed-up with physical examination and submitted to US and MR studies 40, 60 and 90 days postoperatively. Eighty patients recovered in the expected time, while 2 took longer. At 90 days, the US findings in 7 patients and the MR findings in 8 patients who recovered in the expected time could be considered normal. US poorly distinguished the tendon from the reinforcement flap because of gross tendon echostructure. The tendon and the reinforcement flap were not distinguishable at MRI because they were uniformly hypointense. Clinical recovery appeared as a hyperechoic structure and a gross fibrillar pattern at US and as a hypointense structure with some small hyperintense areas at MRI. US and MRI were in disagreement in one patient with a postoperative algodystrophic syndrome, where US showed some alterations which were considered false positives because of clinical recovery and negative MR findings. US and MR patterns were considered abnormal in the 2 patients with delayed recovery. US showed persistent hyperechoic areas within the tendon, while the MR signal was of intermediate intensity in the tendon and reinforcement flap. To conclude, we believe that US is an appropriate technique for the postoperative follow-up of complex subcutaneous ruptures of the Achilles tendon. Additional MRI should be performed in all the cases where US findings are in disagreement with clinics.     

Reconstruction of chronic rupture of the extensor mechanism after patellectomy

Chronic extensor mechanism ruptures are uncommon but challenging clinical problems. Previously published procedures for treating chronic extensor mechanism ruptures assume an intact patella is available to anchor the repair. A case is presented of a patient who had a previous patellectomy, followed by rupture of the extensor mechanism. After two failed attempts at repair, an Achilles tendon allograft was used successfully to restore function of the extensor mechanism. The described technique offers an alternative for reconstruction of the extensor mechanism after patellectomy.     

Primary repair for posterior cruciate ligament injuries. An eight-year followup of fifty-three patients

We reviewed 53 of 58 patients who had primary repairs of posterior cruciate ligament injuries between 1981 and 1988. Sixteen patients had isolated posterior cruciate ligament ruptures, 16 had complex injuries with capsular and collateral ligament involvement, and 21 had additional anterior cruciate ligament ruptures. Forty-six patients were treated by transosseous multiple-loop sutures and seven with bony avulsions by screw osteosynthesis. The mean follow-up time was 7.5 years (range, 3 to 12). All patients were examined subjectively (questionnaire) and objectively (clinical examination, KT-1000 arthrometer, functional testing, radiographs, and Cybex II isokinetic strength analysis). The results were graded according to the International Knee Documentation Committee evaluation form and the Lysholm score. The average Lysholm score was 82.4 (range, 40 to 100). Thirty-eight patients returned to their preinjury activities at the same intensity level. The patients' subjective assessments were normal or nearly normal in 35 patients. The posterior drawer test was negative or 1+ in 46 patients. Cybex isokinetic strength analysis revealed a decrease in quadriceps muscle strength of the involved limb by 10.5% (P < 0.01). Our data suggest that primary repair of posterior cruciate ligament ruptures provides good results after 8 years in approximately two thirds of the patients. Distal ligamentous ruptures, lack of athletic activity, and temporary olecranization correlated with poor results. Bony avulsions, midsubstance or proximal ruptures, and athletic activity correlated with good results.     

Bilateral Achilles tendon rupture: a report on two cases

Two cases of traumatic bilateral Achilles tendon rupture are reported. One of the patients was a healthy middle-aged man, who had been an active national-level gymnast 20 years earlier. He had not suffered any complaints of Achilles tendons before. The ruptures occurred when, after a sauna, he showed his guests a vault forwards, which he had been able to perform easily. This time the landing took place on the toes, causing a high peak stretch to the calf muscles and Achilles tendons. The total rupture of both Achilles tendons was treated surgically, with an excellent result 2 days after the trauma. End-to-end suturation and a fascial flap plasty were made on both sides. No macroscopic degeneration could be detected on the rupture sites. He was allowed to walk freely 6 weeks after the surgery. The second case was a 54-year-old woman, who had suffered from Achilles tendinitis and peritendinitis for 2 years. Both tendons had been surgically treated, and severe adhesions and local degenerative changes had been found. The tendon rupture occurred when she injured her left ankle while getting out of the car. Two days later she fell at home, because of the weakness of the left side, and consequently the right Achilles tendon was injured. She was treated conservatively for 10 days, before the surgery was performed. Both tendons were ruptured and an extensive degeneration of the area was observed. The right side suffered from a rerupture, which was again treated surgically. After surgery the recovery was slow, but the final result 3 years later was moderate. Neither of the patients had any systemic diseases.     

Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears

The functional outcome after surgery was determined in 21 patients an average of 29 months (range, 24-52 months) after surgery to evaluate the efficacy of arthroscopic repair of triangular fibrocartilage complex (TFCC) tears and ulnar shortening. All of the patients had reparable lesions of the TFCC treated after a delay of more than 6 months from the time of injury. The patients' average age was 32 years and all patients had wrist pain limiting them from work and/or sports prior to surgery. After surgery, there was a significant relief of pain (p < .01). Grip strength and range of motion averaged 83% +/- 18% and 81% +/- 16%, respectively, of that of the uninjured side. At follow-up evaluation, 14 patients with repairs underwent follow-up studies; the TFCC was noted to be intact in 12 patients.     

A comparison of results in acute and chronic anterior cruciate ligament ruptures of arthroscopically assisted autogenous patellar tendon reconstruction

We conducted a prospective study of 94 consecutive patients who received a patellar tendon autograft for anterior cruciate ligament rupture. Eighty-seven patients (93%) returned for followup a mean of 28 months postoperatively; 57 had chronic and 30 had acute or subacute ruptures. There were no significant differences between the subgroups for age, sex, articular cartilage lesions, or months of followup. Forty-six meniscal tears were repaired; 27 of these extended into the central avascular region. Rehabilitation emphasized immediate knee motion, but strenuous activity was delayed for at least 4 months. Only one patient had a knee motion complication, and stability (<3 mm, KT-2000 arthrometer, 134 N) was restored in 85% of knees with chronic ruptures and 92% of knees with acute ruptures. Earlier reconstruction should be considered in active persons as symptoms and limitations continued postoperatively in knees with chronic ruptures, leading to overall less satisfactory results. In patient rating of the overall knee condition, 69% of knees with chronic ruptures and 100% of knees with acute ruptures scored in the normal or very good range. Repair of meniscal tears that extend into the central avascular region should be considered, as 24 of the 27 (89%) menisci repaired showed clinical evidence of healing and did not require reoperation.     

Potency and hourly maintenance requirement of combinations of mivacurium and pancuronium in adults

The purpose of this study was to evaluate retrospectively outcomes of the Mau osteotomy for hallux abducto valgus deformity. Twenty-two patients were evaluated by the senior author on an average of 14 months (range, 3-34 months) following their surgery. Preoperative and postoperative intermetatarsal (IM) and hallux abductus (HA) angles were evaluated as well as range of motion of the first metatarsophalangeal joint and patient satisfaction. The mean preoperative IM and HA angles were 16.1 degrees and 35.8 degrees. The mean reduction in IM and HA angles was 10.5 degrees and 23.5 degrees, respectively. Joint range of motion was 58 degrees of dorsiflexion (range, 42 degrees-80 degrees) and 11 degrees of plantarflexion (range, 0 degree-20 degrees). There were no cases of delayed healing or avascular necrosis. There were two patients (9%) with radiographic values consistent with hallux varus; however, neither patient had a clinical appearance of hallux varus and neither patient was displeased with the outcome. Ninety-one percent of patients returned to a soft shoe or sneakers in an average of 5.1 weeks following surgery. Eighty-two percent of patients had no pain at the time of their evaluation, and 96% of patients stated they were satisfied or very satisfied with the surgery. Comparing the subgroup of patients who underwent a Mau-Reverdin procedure with another subgroup undergoing a Mau-Reverdin fibular sesamoidectomy, there was a 3.7 degrees greater reduction of IM angle and 6.7 degrees greater reduction in HA angle in the subgroup with the fibular sesamoidectomy.     

Methods and rationale for closed treatment of Achilles tendon ruptures

A method of closed treatment of Achilles tendon ruptures by casting, utilizing a long leg cast for 6 weeks and a short leg cast for 4 additional weeks, is presented. An experimental model using rabbits supports the clinical contention that closed approximation and immobilization of Achilles tendons allows tendon healing to progress, at least in the early stages. Observations made on the tendon sheath during early healing attribute a very positive role to it in providing needed blood supply to the tendon. The importance of maintaining a smooth gliding surface as well suggests that the tendon sheath should not be violated by surgical repair on the Achilles tendon.     

Acute skier's thumb repaired with a proximal phalanx suture anchor

The purpose of this study was to determine the functional outcome of a surgical technique for the repair of injuries of the ulnar collateral ligament of the thumb. A 14-point questionnaire was developed to determine functional outcome after surgical repair of acute ulnar collateral ligament rupture. Early ulnar collateral ligament repair was performed on 58 patients with grade III sprains (complete rupture) of the ligament using a new technique that employs a suture anchor for fixation. Forty-five patients were interviewed at a minimum postoperative interval of 12 months and were included in this study. Forty-four patients (98%) believed they had a stable repair, were satisfied with their surgery, and would have it again if necessary. Forty-four patients (98%) were not hindered in their day-to-day activities and had a functional range of motion. Mild discomfort was felt by eight of our patients (17%), but only three patients (7%) had pain with activities. The average time to return to skiing was 1.7 days. The use of a suture anchor provided a strong and stable repair if the surgery was performed early.     

Scapholunate ligament repair and capsulodesis for the treatment of static scapholunate dissociation

Twenty-four patients were treated with scapholunate ligament repair and dorsal capsulodesis for scapholunate dissociation. Seventeen patients were available for follow-up at an average of 30 months. The average interval between injury and surgery was 3 months. At final follow-up, no patients were pain-free. Average total wrist motion was 60% and grip strength 70% of the opposite normal side. The average preoperative scapholunate angle was 78 degrees and was corrected to a normal 47 degrees at surgery. The average final scapholunate angle was 72 degrees, which was not significantly different from the preoperative value. The scapholunate gap likewise was not significantly changed postoperatively. Only two patients had an excellent or good outcome using a clinical grading system, and six out of 17 scored good or excellent using a radiographic grading system. In conclusion, repair of the scapholunate ligament with dorsal capsulodesis failed to provide consistent pain relief and maintain carpal alignment in patients with static scapholunate instability.