Early active mobilization of tendon grafts using mesh reinforced suture techniques

The flexor digitorum profundus tendon in 11 digits with division of both flexor tendons in zone 2 was reconstructed with a palmaris longus tendon graft in a two-stage procedure. The distal and proximal fixation of the graft was reinforced with a polyester mesh sleeve placed around the ends of the graft during stage 1. All digits were mobilized with a combination of active extension and active and passive flexion within 3 days of the second stage. There were three ruptures, one due to faulty technique and two due to falls on outstretched hands during alcohol intoxication and football. Excluding the ruptures, the mean active composite distal and proximal interphalangeal joint range of motion 6 weeks and 6 months post-operatively was 141 degrees and 136 degrees respectively. The results indicate that palmaris longus tendon grafts can survive and heal during early active mobilization, with few or no adhesions of functional significance. The techniques described here represent one possible approach to the safe implementation of early active mobilization after tendon grafting procedures.     

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.     

Treatment of distal biceps tendon injuries using the Boyd and Anderson method

Boyd and Anderson method for treatment of injury to the distal part of the biceps tendon has been recalled. The method has been used in 5 males aged 38-47 (mean 41) with good final functional results.     

Histopathological findings in chronic tendon disorders

Tendon injuries and other tendon disorders represent a common diagnostic and therapeutic challenge in sports medicine, resulting in chronic and long-lasting problems. Tissue degeneration is a common finding in many sports-related tendon complaints. In the great majority of spontaneous tendon ruptures, chronic degenerative changes are seen at the rupture site of the tendon (1). Systemic diseases and diseases specifically deteriorating the normal structure of the tendon (i.e. foreign bodies, and metabolic, inherited and infectious tendon diseases) are only rarely the cause of tendon pathology. Inherited diseases, such as various hereditary diseases with disturbed collagen metabolism and characteristic pathological structural alterations (Ehlers-Danlos syndrome, Marfani syndrome, homocystinuria (ochronosis)), represent approximately 1% of the causes of chronic tendon complaints (2), whereas foreign bodies are somewhat more common and are found in less than 10% of all chronic tendon problems (1). Rheumatoid arthritis and sarcoidosis are typical systemic diseases that cause chronic inflammation in tendon and peritendinous tissues. Altogether, these 'specific' disorders represented less than 2% of the pathological alterations found in the histological analysis of more than 1000 spontaneously ruptured tendons (1, 3, 4). In this material, degenerative changes were seen in a great majority of the tendons, indicating that a spontaneous tendon rupture is a typical clinical end-state manifestation of a degenerative process in the tendon tissue. The role of overuse in the pathogenesis of chronic tendon injuries and disorders is not completely understood. It has been speculated that when tendon is overused it becomes fatigued and loses its basal reparative ability, the repetitive microtraumatic processes thus overwhelming the ability of the tendon cells to repair the fiber damage. The intensive repetitive activity, which often is eccentric by nature, may lead to cumulative microtrauma which further weakens the collagen cross-linking, non-collagenous matrix, and vascular elements of the tendon. Overuse has also been speculated to cause chronic tendon problems, by disturbing the micro- and macrovasculature of the tendon and resulting in insufficiency in the local blood circulation. Decreased blood flow simultaneous with an increased activity may result in local tissue hypoxia, impaired nutrition and energy metabolism, and together these factors are likely to play an important role in the sequence of events leading to tendon degeneration (4). A sedentary lifestyle has been proposed as a main reason for poor basal circulation of the tendon, and presumably is at least partly responsible for the high number of tendon problems in people with a sedentary lifestyle who occasionally take part in high physical activity sports events.     

Suppression of alloreactivity with gamma delta T-cells: relevance to increased gamma delta T-cells following bone marrow transplantation

Morphologic changes in the long head of the biceps brachii (LHB) and bicipital groove associated with cuff tears were studied in 170 cadavers. In specimens with minimum or moderate cuff tears, the primary finding was relative stenosis at the bicipital groove induced by enlargement of the LHB. However, this stenosis was not apparent in specimens with massive cuff tears and in these specimens, the medial wall of the groove exhibited wear and tear, a potential cause of LHB instability. We suggest that the long head of the biceps brachii muscle can potentially compensate for inadequate rotator cuff function. This increasing activity could lead to enlargement of the tendon and cause deterioration of the bicipital gliding mechanism.     

Complete rupture of the distal semimembranosus complex in a professional athlete

Complete ruptures of the distal hamstring tendons rarely cause functional disability significant enough to warrant surgical intervention. Isolated ruptures of the distal semimembranosus tendon complex have not been reported previously in the literature. A case of a complete rupture of the distal semimembranosus tendon complex occurring in a professional football player with resultant functional disability is reported here. The magnetic resonance imaging scan was essential for an accurate diagnosis. Subsequent surgical repair and postoperative rehabilitation is described. Strict attention to recreating the multiple attachments of the semimembranosus tendon complex is recommended.     

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.     

Anterior tibialis tendon ruptures: an outcome analysis of operative versus nonoperative treatment

Ruptures of the anterior tibialis tendon are a rare clinical entity. Case reports in the literature reveal a total of 28 cases. Unfortunately, because of the limited discourse in the orthopaedic literature, there are few guidelines regarding the treatment for these injuries. This study analyzes the treatment of 16 anterior tibialis tendon ruptures. Eight patients in this group had operative treatment of their ruptures, and eight patients had nonsurgical treatment of their ruptures. The average follow-up for the operative and nonoperative patients were 6.68 years and 3.86 years, respectively. The Foot and Ankle Outcome questionnaire provided by the American Academy of Orthopaedic Surgeons and an outcome-based foot score described by Kitaoka et al. were used as the methods of analysis. Our outcome results show no statistically significant difference between operative and nonoperative treatment in anterior tibialis tendon ruptures. The lack of statistical difference between operative and nonoperative groups may be a reflection of the age bimodality present in this study. Elderly low demand patients were treated nonsurgically and young active patients were treated operatively. Therefore, despite a lack of statistical difference present in the outcome of both groups, we still maintain the need to repair/reconstruct anterior tibialis tendon ruptures in young active patients with high functional demands. The deficits present in the nonoperative group, we believe, would not be well tolerated in a young high functional demand patient. Nonsurgical management is an appropriate alternative in low demand elderly patients.     

The growth inhibitory effect of N1,N12-bis(ethyl)spermine in small cell lung cancer cells is maintained in cells expressing the c-myc and Ha-ras oncogenes

OBJECTIVE: The purpose of this study was to assess the diagnostic role of MR arthrography in patients with tendinopathy or rupture of the long biceps tendon. MATERIALS AND METHODS: MR arthrograms of 42 consecutive patients with arthroscopic or surgical confirmation of diagnosis (16 normal biceps tendons, 19 with tendinopathy, and seven with ruptures) were analyzed independently by two radiologists. Visibility of the biceps tendon, caliber changes, contour irregularities, and signal intensities were assessed separately in the parasagittal and axial planes. In addition, the two radiologists made an overall evaluation of abnormalities of the biceps tendon using both MR imaging planes. RESULTS: The most reliable MR findings for tendinopathy were caliber changes (sensitivity was 59% for observer 1 and 82% for observer 2; specificity was 88% and 64%, respectively) and signal abnormalities (sensitivity, 77% and 88%, respectively; specificity, 75% and 43%, respectively) in the parasagittal plane. Absence of visualization of the tendon in the parasagittal plane was a reliable sign for rupture (sensitivity, 86% and 86%, respectively; specificity, 94% and 87%, respectively). The overall sensitivity for detecting abnormalities (tendinopathy or rupture) was 92% for observer 1 and 89% for observer 2. Specificity was 56% and 81%, respectively. CONCLUSION: MR findings of tendinopathy and rupture of the biceps tendon are subtle. However, the combination of several MR criteria in two imaging planes makes a reasonably accurate diagnosis possible. The biceps tendon should not only be assessed in the bicipital sulcus on axial images but also on parasagittal images.     

Proprioceptive consequences of tendon vibration during movement

1. Previous studies have used tendon vibration to investigate kinesthetic illusions in the isometric limb and end point control in the moving limb. These previous studies have shown that vibration distorts the perceptions of static joint angle and movement and causes systematic errors in the end point of movement. In this paper we describe the effects of tendon vibration during movement while human subjects performed a proprioceptively coordinated motor task. In an earlier study we showed that the CNS coordinates this motor task-a movement sequence-with proprioceptive information related to the dynamic position and velocity of the limb. 2. When performing this movement sequence, each subject sat at a table and opened the right hand as the right elbow was passively rotated in the extension direction through a prescribed target angle. Vision of the arm was prevented, and the movement velocity was changed randomly from trial to trial, leaving proprioception as the only useful source of kinematic information with which to perform the task. 3. In randomly occurring trials, vibration was applied to the tendon of the biceps brachii, a muscle that lengthens during elbow extension. In some experiments the timing of tendon vibration was varied with respect to the onset of elbow rotation, and in other experiments the frequency of vibration was varied. In each experiment we compared the accuracy of the subject's response (i.e., the elbow angle at which the subject opened the hand) in trials with tendon vibration with the accuracy in trials without tendon vibration. 4. The effect of tendon vibration depended on the frequency of vibration. When the biceps tendon was vibrated at 20 Hz, subjects opened the hand after the elbow passed through the target angle ("overshooting"). Overshooting is consistent with an underestimate of the actual displacement or velocity of the elbow. Vibration at 30 Hz had little or no effect on the elbow angle at hand opening. Vibration at 40 Hz caused subjects to open the hand before the elbow reached the target angle ("undershooting"). Undershooting is consistent with an overestimate of the actual displacement or velocity of the elbow. The size of the error depended on the velocity of the passively imposed elbow rotation. 5. The effect of tendon vibration also depended on the timing of vibration. If 40-Hz vibration began at the onset of movement, the subject undershot the target. If 40-Hz vibration started 5 s before movement onset and continued throughout the movement, the undershoot error increased in magnitude. However, if 40-Hz vibration started 5 s before movement onset and then stopped at movement onset, the subject overshot the target. When vibration was shut off during movement, a transition occurred from an over-shooting error to an undershooting error at a time that depended on the velocity of elbow rotation. 6. In a separate experiment, subjects were instructed to match either the perceived dynamic position or the perceived velocity of rotation imposed on the right elbow by actively rotating the left elbow. In both matching tasks, tendon vibration produced oppositely directed errors depending on the frequency of vibration. Vibration at 20 Hz produced a perception of decreased elbow velocity and a bias in dynamic position in the flexion direction, and vibration at 40 Hz produced the opposite perceptions. 7. We conclude that muscle spindle afferents, which are activated by tendon vibration, are an important source of the dynamic position and velocity information that the CNS uses to coordinate this movement sequence task. The observed effects of vibration timing and frequency suggest that perceptual changes evoked by vibration cannot be explained by the simple summation of sensory input evoked by movement and by vibration. Rather, the bias in perception produced by vibration appears to be related to the difference between vibration- and movement-evoked activity in muscle spindle afferents.     

Diseases of the Achilles tendon in dogs and cats

Dogs and cats rarely have problems with the Achilles tendon and if so, it usually results from a direct trauma. Prime area for injuries is the insertion on the tuber calcanei or directly proximal. One defers between complete and partial ruptures, acute and chronic injuries as well as displacement of the tendon of the superficial digital flexor muscle. In 38 cases (33 dogs and five cats) the clinical examination, radiology, ultrasonography and therapy are shown. Usually the clinical examination is sufficient for a diagnosis (hyperflexion of the hock and weight-bearing on the plantar surface of the metatarsus). The radiology primarily shows up abnormalities on the calcaneus, mineralisations of the tendon and allows the assessment of implants. Ultrasonography is the diagnostic imaging of choice for judgement of tendon diseases as well as the progress of their healing. Tendon suture is advisable if the rupture is open, fresh and/or complete and in cases of luxation of the superficial digital flexor muscle. Immobilisation of the tarsus in hyperextension seems to be of utmost importance no matter if an operative or conservative therapy is chosen.     

Are complications in cruciate ligament replacement operations with patellar tendon transplantation dependent on surgical technique and surgical timing?

HYPOTHESIS: In a retrospective study we analyzed our results of ACL reconstructions with a patellar tendon graft. We wanted to know if the complications were dependent upon timing and technique of surgery. METHOD: We reviewed 283 patients after ACL-reconstruction, who underwent an operation with bone patellar tendon graft between 1984-1993. In our study we particularly looked for complications. The overall rate of complications was 21.6% dependent on the applied technique. Infections, DVTs, limitations of movement and graft failures were the most common complications. Furthermore we analyzed the timing of operation. Arthrofribrosis was less common in the group with delayed reconstruction (6.1%) whereas in the primary reconstruction group the rate was 17.6%. For this reason we changed our management with regard to the timing of operation. Meniscal injuries were the most common additional injuries in both groups. Conservatively treated ACL-ruptures showed a high rate of mensical ruptures in combination with cartilage injuries. CONCLUSION: Because of these results we put more emphasis on patient information to achieve the optimal result and to meet the individual needs for every patient.     

Acute attenuation of the extensor pollicis longus tendon. A case report

The current understanding of tendon biomechanics indicates that indirect injury to the tendon midsubstance requires the presence of preexisting disease during mechanical overload. This belief has been substantiated by the association of extensor pollicis longus rupture with chronic tenosynovitis caused by repetitive activity, inflammatory conditions such as rheumatoid arthritis, and minimally displaced distal radius fractures. This case of acute, traumatic, intratendinous attenuation of the extensor pollicis longus tendon offers a contradiction to the view that midsubstance tendon failure requires preexisting disease.     

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.     

Indications for and results with the Swanson distal ulnar prosthesis

Classically, wrist synovectomy, when the distal radioulnar joint is involved, includes excision of the distal ulna (the classical Darrach procedure). Orthopedists and rheumatologists are well aware of the propensity for extensor tendon rupture, particularly of the ring and little finger, in this area. Dr. Alfred Swanson has presented his results with a silastic interposition to substitute for the excision of the distal ulna. This paper presents a surgical technic, indications, and results in five cases of rheumatoid arthritis in which wrist synovectomy and repair of extensor tendon ruptures were done as appropriate. This distal ulnar prosthesis is recommended for routine use in wrist synovectomy when excision of the distal ulna is performed.     

Experimental study on the effects of tension-reduced early mobilization on extensor tendon healing

Numerous clinical and experimental studies have been reported on early postoperative mobilization after flexor tendon repair. However, there have been only a few experimental studies reported on extensor tendon repair. In 1989, Ishiguro reported the usefulness of tension-reduced early mobilization in clinical cases of extensor tendon ruptures. The purpose of this experimental study was to examine the in vivo effect of tension-reduced early mobilization on extensor tendon healing in chicken. An experiment was performed on the extensor tendons of 218 chickens in an attempt to examine the effects of tension-reduced early mobilization on tendon healing and adhesion. The extensor tendon of the fourth toe was cut and the distal stump of the tendon was transferred to the extensor tendon of the third toe. Postoperatively two protocols were employed. In the immobilization group, a cast was applied for three weeks. In the early-mobilization group, immediate active motion of the digits was allowed. A tension-reduced position was maintained by taping the fourth toe to the dorsum of the third. The findings from the early mobilization group and from the immobilization group were as follows: 1. Macroscopically, sutures at the repair site of the early-mobilized tendon were not evident after three weeks because of fibrous connective tissue growth. Despite this abundant connective tissue, tendon gliding was observed to be smooth. Between the suture site and the gliding floor, loose connective tissue, similar to normal paratenon, was observed. Histology confirmed this observation. 2. The tensile strength required to extend the MP joint was significantly lower for the early-mobilization group than for the immobilization group, suggesting minimal adhesion between the sutured tendon and the gliding floor in the early-mobilization group. 3. No significant difference in tensile strength among the various tendon repair techniques employed was observed at the suture site.     

Achilles tendon injuries

Massive haemorrhage is an uncommon complication in pancreatitis. Most affected patients suffer from chronic disease with associated pseudocyst. We present five patients (four male) with a mean age of 41 years (range 34-48 years). All patients had alcohol-induced pancreatitis complicated either by haematemesis (3), intraperitoneal haemorrhage (1) or both haematemesis and intraperitoneal haemorrhage (1). Source of bleeding was pseudocyst wall (2), splenic artery pseudoaneurysm (2) and splenic artery rupture (1). Distal pancreatectomy and splenectomy was performed in two patients, intracystic ligation and drainage in two, and packing with subsequent external drainage in one. Rebleeding occurred in two patients and required subsequent distal pancreatectomy and splenectomy in one; the other patient died of splenic rupture. No rebleeding and no mortality occurred after resection. Primary pancreatic resection is recommended whenever possible. Other management options include embolisation and ligation.     

Magnetic resonance imaging scanning in the diagnosis of zone II flexor tendon rupture

This study was undertaken to determine the usefulness of magnetic resonance imaging (MRI) in the diagnosis of flexor tendon rupture in patients who had prior surgery. Magnetic resonance imaging scans were performed on 11 digits (16 tendons) with the clinical diagnosis of flexor tendon rupture. Clinical suspicion correlated with MRI and surgical findings. Clinical examination yielded a 60% accuracy in diagnosis. MRI differentiated rupture from adhesions with a 100% accuracy rate. The MRI scan is a valuable tool in diagnosing tendon ruptures and may help reduce the incidence of unnecessary tendon explorations.     

Arthroscopic anterior cruciate ligament reconstruction using autogenous hamstring tendon graft without detachment of the tibial insertion

This article describes a modified arthroscopic technique of anterior cruciate ligament reconstruction using quadrupled hamstring tendon graft. The autogenous semitendinosus and gracilis grafts are harvested without detachment of the tibial insertion. To obtain longer grafts, the accessory tibial insertions of the hamstring tendons are dissected. The EndoButton (Acufex Microsurgical, Andover, MA) is used for femoral fixation and two spiked staples are used for tibial fixation in a belt buckle fashion. Then the residual anterior laxity is restored by additional absorbable interference screw fixations. In this technique, more viable graft is obtained and more firm distal fixation is achieved by preservation of the tibial insertion of hamstring tendons.     

Early motion after repair of Achilles tendon ruptures

The purpose of this study was to evaluate the clinical outcome of patients treated with limited immobilization and early motion after repair of acute Achilles tendon ruptures. Thirteen consecutive patients with complete ruptures of the Achilles tendon were identified, repaired, and rehabilitated with early motion starting an average of 10 days after surgery. Active range of motion was begun at an average of 23 days and weightbearing in a walking boot was started at an average of 3.5 weeks after surgery. The average length of follow-up was 27 months. Twelve of 13 patients returned to running activities in an average of 3 months. All 12 patients who participated in lateral motion activities before their injury returned to similar activities in an average of 7 months. The patients rated their overall status at an average of 93% of their preinjury level. Follow-up Cybex testing demonstrated plantarflexion strength averaging 92%, plantarflexion power averaging 88%, and plantarflexion endurance averaging 88% of the nonindexed extremity. Early range of motion after Achilles repair is safe and there is no increased risk of rerupture in compliant patients. The patients achieved good return of plantarflexion strength, power, and endurance.