Symptomatic Thromboembolic Complications After Shoulder Arthroplasty: An Update.

BACKGROUND: Venous thromboembolism (VTE) complications, including deep vein thrombosis and pulmonary embolism, are dreaded complications of orthopaedic surgical procedures that can result in substantial morbidity and mortality. There is a paucity of data examining risk factors for VTE in shoulder arthroplasty. The purpose of the present study was to review the rate of symptomatic VTE, determine patient and operative risk factors for VTE, and report on complications associated with VTE following shoulder arthroplasty. METHODS: Over a 16-year period, 5,906 patients underwent primary anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty. Symptomatic VTE events were identified in 24 shoulders within 90 days of surgery. Patient records were reviewed for surgical indication, patient and operative risk factors, and management of VTE. RESULTS: The rate of symptomatic VTE following shoulder arthroplasty was 0.41%. There were no deaths resulting from VTE events. Compared with patients who did not have VTE, those with symptomatic VTE events were found to be older (74.75 versus 68.51 years; p = 0.0028) and more likely to have had arthroplasty for a traumatic indication (3.31% versus 0.33%; p < 0.001). Age of >70 years and arthroplasty for a traumatic indication were found to be independent risk factors on multivariate nominal logistic regression analysis, whereas body mass index, sex, operative time, and type of arthroplasty performed were not found to be independent risk factors. There were 11 readmissions resulting directly from the VTE events, and patients diagnosed with VTE as inpatients had longer hospital stays than outpatients (13.71 versus 1.94 days; p = 0.0002). CONCLUSIONS: The risk of VTE following shoulder arthroplasty is low, and routine use of pharmacologic VTE prophylaxis may not be necessary. However, VTE complications can lead to substantial morbidity, longer hospital stays, readmission to the hospital, and further complications. Therefore, patients with multiple risk factors for VTE such as prior history of VTE, active malignancy, age of >70 years, or arthroplasty for traumatic indications should be considered for pharmacologic VTE prophylaxis. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Sociodemographic and behavioural correlates of social jetlag in Australian adults: results from the 2016 National Sleep Health Foundation Study.

Social jetlag is a term used to describe misalignment between biological and social time. Measured as the difference in sleep midpoints between work and free days, social jetlag has been associated with unhealthy lifestyle behaviours and adverse health outcomes. This study aimed to identify the prevalence of social jetlag, and its sociodemographic and behavioural correlates in 837 respondents who completed the Sleep Health Foundation Australia 2016 online survey. Binomial logistic regression models determined associations between social jetlag and self-reported lifestyle and work outcomes, excluding night, evening or rotating shift workers. One third (31.1%) of respondents experienced >1h of social jetlag. In analyses adjusted for sociodemographic variables associated with social jetlag (age, marital status, work status and metropolitan living plus the significant interaction term for age by metro living), social jetlag was associated with longer sleep duration on free days (OR = 2.8, CI = 1.9-4.1), evening preference (OR = 2.0, CI = 1.4-2.4), often staying up later than planned on work days (OR 1.9, CI = 1.3-2.9), and having a computer (OR = 1.7, CI = 1.2-2.4) or phone (OR = 1.6, CI = 1.1-2.4) in the bedroom and internet use in the hour before bed (OR = 1.7, CI 1.2-2.5). Almost twice as many working respondents with social jetlag reported going to work when they should have taken sick leave due to their state of health (OR = 1.9, CI = 1.3-3.0). In conclusion, social jetlag is prevalent in the Australian community and associated with bedtime technology use. Work attendance when in poor health is cause for concern in Australian day workers and requires further investigation.

Patient-Reported and Objectively Measured Function Before and After Reverse Shoulder Arthroplasty.

BACKGROUND AND PURPOSE: Documenting functional outcomes after reverse shoulder arthroplasty (RSA) is critical to advancing patient care. The interplay been self-reported and objectively measured outcome measures has not been widely described. The utilization of wearable devices to document upper extremity limb activity is a new approach for objectively measuring outcomes. Therefore, the purpose of this study was to evaluate changes in pain, and self-reported function and objectively measured limb activity after RSA. We also assessed the influence of pain on self-reported function and objectively measured limb activity to determine the impact of pain on outcomes after RSA. MATERIALS: This study implemented a prospective, repeated-measures design. Fourteen patients undergoing RSA underwent testing before surgery, and 2 and 12 months after surgery. Patient-reported instruments included pain, Disabilities of Arm, Shoulder and hands (DASH), and physical component summary (PCS) of the 36-Item Short Form Health Survey. Objective limb activity (mean activity value, m/s/min epoch; inactive time, %; low activity, %; and high activity, %) was captured with triaxial accelerometers worn on the upper and lower arm. A repeated-measures ANOVA tested for differences across time. The Spearman rank-order correlation was calculated to evaluate the influence of pain on DASH, PCS scores, and mean limb activity. RESULTS: Patient-reported measures improved after surgery (pain, P < .01; DASH, P < .01; PCS, P = .01). No change in limb activity was found at 1 year compared with preoperative values for mean (forearm, P = 1.00; arm, P = .36), inactivity (forearm, P = .33; arm, P = .22), low (forearm, P = .77; arm, P = .11) or high (forearm, P = 1.00; arm, P = .20) activity. There was a relationship between pain and DASH scores 1 year after surgery (P = .04) but not before surgery (P = .16), or 2 months after surgery (P = .30). There was no relationship between pain and PCS scores at any time point (preoperative, P = .97; 2 months, P = .21; 1 year, P = .08) nor pain and limb activity (forearm: preoperative, P = .36; 2 months, P = .67; 1 year, P = .16; arm: preoperative, P = .97; 2 months, P = .59; 1 year, P = .51). CONCLUSIONS: RSA reduced pain and enhanced patient-perceived function. Objectively measured upper extremity limb activity is not different 1 year after surgery compared with preoperative levels. LEVEL OF EVIDENCE: III.

Novel approaches to objectively assess shoulder function.

BACKGROUND: The purpose of this study was to evaluate the effectiveness of existing technologies implemented in a novel manner to objectively capture upper extremity function. MATERIALS AND METHODS: Patients scheduled to undergo reverse shoulder arthroplasty were recruited for the study. Functional limb use was measured with triaxial accelerometers worn in the subjects' natural living environment. Functional reach area was captured by 3-dimensional motion analysis testing as subjects were asked to circumduct their limb, reaching as far as possible in a circular manner. Statistical testing (α ≤ .05) was performed by paired t tests to identify differences between limbs. RESULTS: There was no difference in functional limb activity between sides for the lower (P = .497) or upper arm (P = .918) for inactivity time. Mean activity was greater for the uninvolved limb compared with the involved limb (lower arm, P = .045; upper arm, P = .005). Low-intensity activity was greater for the involved arm compared with the uninvolved arm (lower arm, P = .007; upper arm, P = .015), whereas high-intensity activity was greater for the uninvolved arm (lower arm, P = .013; upper arm, P = .005). Radius of the functional reach area was greater for the uninvolved limb compared with the involved limb (P = .006). CONCLUSIONS: Novel methods of capturing function were effective in discerning differences in side-to-side abilities among patients scheduled to undergo reverse shoulder arthroplasty. These testing procedures may be used to capture function across a spectrum of shoulder diseases. These objective data are invaluable in assessing the impact of disease and recovery after intervention and obtaining reimbursement from third-party payers.

The surgical treatment of periprosthetic elbow fractures around the ulnar stem following semiconstrained total elbow arthroplasty.

BACKGROUND: Limited information exists related to the treatment of periprosthetic fractures of the ulna after semiconstrained elbow arthroplasty. Our goals were to characterize the clinical and radiographic features of periprosthetic fractures around the stem of a loose ulnar component and to determine the outcomes after surgical treatment. METHODS: Between 1980 and 2008, thirty consecutive periprosthetic fractures around the ulnar stem were treated surgically at our institution. Eighteen fractures occurred after primary arthroplasty, and twelve occurred after revision arthroplasty. The mean time between the index arthroplasty and the fracture was eight years. All ulnar components were loose. Ulnar bone loss was moderate in fourteen elbows and severe in sixteen. Surgical reconstruction included revision of the ulnar component in all cases. Fracture fixation was achieved with a longer stemmed implant only in two elbows. Strut allografts were used in twenty elbows, with additional impaction graft augmentation in eight of them. Three additional elbows were revised with impaction grafting alone, and five were reconstructed with an allograft ulnar prosthetic composite. Seven patients were lost to follow-up, one died, and one was managed with conversion to a resection arthroplasty following a deep infection. The remaining twenty-one patients were followed for a mean of 4.9 ± 2.6 years. RESULTS: At the time of the most recent follow-up, eighteen patients reported no pain or mild pain and three patients reported moderate pain. The mean arc of elbow flexion and extension was 112°. The Mayo Elbow Performance Score was 82 points (with fifteen good or excellent results and six fair or poor results). Fracture-healing was achieved in the twenty-one followed patients. Complications included three deep infections, one superficial infection, one case of ulnar component loosening, and one case of transient dysfunction of both the median and radial nerves. CONCLUSIONS: Periprosthetic ulnar fractures around the stem of a loose ulnar component after total elbow arthroplasty usually combine implant loosening and severe bone loss. Revision of the ulnar component may require additional strut allografts, allograft-prosthetic composites, or impaction grafting. Satisfactory outcomes were seen after the majority of revisions; however, deep infections and component loosening continue to be serious complications.

Management of the radial head and linked total elbow arthroplasty.

HYPOTHESIS: In properly selected patients, the radial head need not be resected in linked elbow replacement. BACKGROUND: For linked prostheses, whether the radial head is addressed is a function of the specific pathology present. We reviewed our management of the radial head in linked elbow arthroplasty (TEA) to determine the frequency and indication for subsequent surgery if not resected at the time of the primary procedure. MATERIALS AND METHODS: We reviewed indications in 709 patients who underwent TEA to determine how the radial head was managed. Indications for secondary resection as a result of radial head impingement were identified. Significant differences between the rheumatoid and post-traumatic groups were tested with χ(2) analysis. RESULTS: Of 381 rheumatoid patients who underwent TEA, the radial head was addressed surgically in 169 (44%); of which 68 patients (17.8%) in the rheumatoid arthritis group required complete radial head resection and 101 (27%) had a "radiusing" debridement procedure. Post-traumatic disease was present in 328 patients, and 38 (13%) underwent radial head resection, 5 underwent a debridement radiusing. The radial head was addressed surgically more often in the rheumatoid arthritis group (P = .001). Only 4 of the 709 patients (0.6%) required a secondary resection for radial head impingement, all with good results. CONCLUSIONS: Most often the radial head can be preserved with this linked prosthesis. Rheumatoid arthritis carries a higher prevalence of radial head disease, and hence requires attention more commonly, usually with simple debridement. If impingement symptoms of radial head develop, secondary resection yields good results.

Effectiveness of revision following linked versus unlinked total elbow arthroplasty.

PURPOSE: The purpose of this study is to specifically evaluate the implications of unlinked and linked designs on the survivorship of revision surgery. METHODS: Between 1972 and 1990, 352 linked and 151 unlinked prostheses were inserted at our institution. One-hundred and twenty-two elbows (24%) underwent subsequent revision: 55 linked (16%) and 67 unlinked (44%). Survivorship of the initial and revision total elbow replacement was calculated using a Kaplan-Meier analysis. Comparisons were made between revisions done after a failed primary linked or unlinked designs. The unlinked revised to a linked device was more reliable than when revised to another unlinked device: 1 year survival 84% compared to 47%. RESULTS: Initial survival was 56% at 367 months and 84% at 371 months for the unlinked and linked cohorts, respectively (P < .001). A second revision was required in 12 of the 35 elbows (30%) in the linked cohort and 14 of the 50 elbows (28%) in the unlinked. CONCLUSIONS: At our institution, primary linked implants display significantly better long-term survivorship (P < .001) than did the unlinked designs. Unlinked designs are most reliably converted to a linked implant.

Management of acute distal humeral fractures in patients with rheumatoid arthritis. A case series.

BACKGROUND: The best surgical treatment for a patient with rheumatoid arthritis and an acute distal humeral fracture is not well established. Because of the distorted anatomy of the arthritic elbow joint and the adjacent osteoporotic bone, total elbow arthroplasty may be favored over open reduction and internal fixation in these patients. We retrospectively analyzed a series of patients with rheumatoid arthritis in whom an acute distal humeral fracture had been treated with either open reduction and internal fixation or total elbow arthroplasty; our purpose was to evaluate their outcomes and to identify any influence of age, fracture type, or the extent of the rheumatoid involvement of the elbow joint on the choice of procedure. METHODS: Between 1982 and 2002, an acute distal humeral fracture was treated surgically in sixteen elbows in fourteen patients with rheumatoid arthritis, and the results were retrospectively reviewed at a minimum of twenty-four months postoperatively. Six elbows were treated with open reduction and internal fixation (Group 1) and ten elbows, with primary total elbow arthroplasty (Group 2). Postoperatively, the elbows were examined with standard radiographs, and the clinical outcome was assessed with the Mayo Elbow Performance Score (MEPS). RESULTS: Six patients (six elbows) died before the time of the study, but they had been followed for more than twenty-four months and therefore were included in the series. The eight patients (ten elbows) who were still alive were examined. The mean duration of follow-up was forty-nine months in Group 1 and sixty-six months in Group 2. The MEPS averaged 93 points in Group 1 and 96 points in Group 2. Radiographically, all fractures had healed uneventfully in Group 1 and no prosthesis was loose in Group 2. We could not identify any difference between Groups 1 and 2 with respect to patient age, fracture type, or extent of the rheumatoid arthritis. CONCLUSIONS: Distal humeral fractures in patients with rheumatoid arthritis can be treated successfully with immediate open reduction and internal fixation or with total elbow arthroplasty. Our data suggest that open reduction and internal fixation can be successful when there is mild arthritic involvement. We favor total elbow arthroplasty for patients with severe articular involvement. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Reimplantation of a total elbow prosthesis following resection arthroplasty for infection.

BACKGROUND: The best approach for treatment of infection after total elbow arthroplasty is not clearly defined. The purpose of this study was to report our experience with reimplantation of a total elbow prosthesis following a prior resection arthroplasty to treat infection. METHODS: Between 1976 and 2003 at our institution, twenty-nine patients were treated with reimplantation of a total elbow prosthesis after a prior resection arthroplasty following a deep periprosthetic infection. Eleven of the twenty-nine patients had had at least one procedure performed on the elbow prior to the primary arthroplasty. The mean time interval between the resection arthroplasty and the reimplantation was 72.5 weeks. Patients were followed for an average of 7.4 years after the reimplantation. All patients were assessed clinically, and their medical records were retrospectively reviewed. RESULTS: The mean total Mayo Elbow Performance Score (MEPS) was 35.5 points (range, 15 to 60 points) before the reimplantation and 66.3 points (range, 20 to 100 points) postoperatively (p < 0.001). The most common infecting organism was Staphylococcus epidermidis, which was present in thirteen (45%) of the twenty-nine elbows, followed by methicillin-sensitive Staphylococcus aureus, which was present in seven (24%). The infection was not eradicated in eight elbows (28%). CONCLUSIONS: Reimplantation of a total elbow prosthesis after a prior resection arthroplasty is a reasonable option for the treatment of infection. Improvement in function can be expected in most patients. However, the chance of the infection recurring and requiring additional revision surgery is high.

Triceps insufficiency following total elbow arthroplasty.

BACKGROUND: Over the past decade, the indications for total elbow arthroplasty have increased. One complication that is well recognized but is poorly described in the literature is insufficiency of the extensor mechanism involving complete or partial rupture, or avulsion, of the triceps tendon. We therefore reviewed the records of patients who had undergone surgery for the treatment of triceps insufficiency following total elbow arthroplasty to determine the management options and outcomes of intervention for this problem. METHODS: The records on 887 total elbow arthroplasties performed between 1982 and 2001 were assessed to identify patients who had undergone a subsequent procedure on the triceps. Patients in whom triceps insufficiency developed after débridement for infection were excluded, leaving sixteen elbows in fourteen patients. A Mayo Elbow Performance Score was calculated and elbow extension strength against gravity was measured at the time of final follow-up. RESULTS: There were seven male and seven female patients. The mean age was fifty-four years. The mean duration of follow-up after the triceps reconstruction was sixty-seven months. Three basic techniques were used to repair or reconstruct the extensor mechanism; these included direct suture in seven elbows, anconeus rotation in four, and use of an Achilles tendon allograft in four. The capacity to extend against gravity was restored to fifteen of the sixteen elbows. According to the Mayo Elbow Performance Score, eleven elbows had an excellent outcome, three had a good outcome, and two were considered a clinical failure. CONCLUSIONS: In most patients with triceps insufficiency following total elbow arthroplasty, it is possible to reconstruct the triceps mechanism with a procedure appropriately selected on the basis of tissue quality, tendon retraction, and the status of the olecranon.

Polyethylene wear after total elbow arthroplasty.

BACKGROUND: Articular wear is considered to be a possible long-term complication of the use of stemmed, coupled elbow replacements with the capacity to correct deformity and restore function. There have been no reports on this topic, to our knowledge. METHODS: A review of the results of 919 replacements with the semi-constrained linked Coonrad-Morrey total elbow implant, performed between 1981 and 2000, revealed that twelve patients (1.3%) had undergone an isolated exchange of the articular bushings as a result of polyethylene wear. The status of these patients was assessed clinically and radiographically. RESULTS: The mean age of the twelve patients at the time of the initial total elbow replacement was forty-four years compared with a mean age of sixty-two years in the overall group (p < 0.001). Seven of the twelve patients had posttraumatic arthritis, and five had rheumatoid arthritis. Nine patients had extensive deformity. The group consisted of seven women and five men, and ten patients had involvement of the right dominant elbow. The mean age at the bushing revision was fifty-two years, and the bushings were revised at an average of 7.9 years after implantation. All twelve patients reported pain, and five reported crepitus or a squeaking sound. None had extensive osteolysis. The mean duration of follow-up after the bushing exchange was sixty-five months. The mean arc of motion improved from 89 degrees before the surgery to 109 degrees after it. Three of the twelve patients underwent an additional articular revision at fifty-three, fifty-four, and 136 months after the initial bushing exchange. At the time of final follow-up, all twelve patients had functioning elbows. CONCLUSIONS: Isolated bushing exchange can be a successful revision procedure in patients with a semi-constrained linked total elbow prosthesis. Younger patients with a posttraumatic condition and/or severe pre-existing deformity are at greater risk for the development of excessive bushing wear. Patients should be cautioned against exceeding the recommended activity and lifting restrictions.

Post-acute brain injury rehabilitation for patients with stroke.

PRIMARY OBJECTIVE: Conduct an investigation of post-acute brain injury rehabilitation (PABIR) for persons with stroke. RESEARCH DESIGN: Pre-post-treatment observation study. METHODS AND PROCEDURES: Demographic and medical data for 127 persons with stroke admitted for PABIR at a median interval of 87 days post-stroke were abstracted from medical records. Participants' levels of independence and productivity were assessed at admission and discharge. Follow-up data were available for 90 participants at a median interval of 346 days post-discharge. EXPERIMENTAL INTERVENTIONS: Not applicable. MAIN OUTCOMES AND RESULTS: Participants showed improvements in productivity and independence level from admission to discharge and these gains were maintained at follow-up. Predictors of productivity at discharge were gender and level of independence at admission (Model R(2) = 0.28). Predictors of independence at discharge were similar (Model R(2) = 0.37). CONCLUSION: While this investigation has limitations, findings suggest that PABIR is beneficial for some persons with strokes.

Allograft-prosthesis composite for revision of catastrophic failure of total elbow arthroplasty.

BACKGROUND: Revision of a failed total elbow arthroplasty is a challenging procedure, often associated with bone deficiency. The purpose of this investigation was to review our experience with a composite allograft-implant reconstruction for patients with a failed total elbow arthroplasty. METHODS: Thirteen patients (thirteen elbows) in whom a total elbow arthroplasty had failed, primarily as a result of loosening of the humeral or ulnar component, were operated on with use of an allograft-prosthesis composite; the composite was placed on the humeral side in four of these patients and on the ulnar side in nine. The delay between the last total elbow arthroplasty and the allograft-prosthesis-composite procedure averaged eight years. RESULTS: At an average of forty-two months after the revision, the Mayo Elbow Performance Score was excellent for four elbows, good for three, fair for one, and poor for five. Nine of the thirteen patients had no or only slight pain in the elbow. The mean arc of flexion was 97 degrees, with an average of 28 degrees (range, 0 degrees to 60 degrees ) of extension to 125 degrees (range, 100 degrees to 140 degrees ) of flexion. There were seven complications affecting seven elbows, and five of the seven required a revision procedure. Deep infection developed in four elbows, and the allograft-prosthesis composite had to be removed from three. Two nonunions occurred at the allograft-humeral junction. CONCLUSIONS: An allograft-prosthesis composite can be a valuable option in selected patients with a failed total elbow arthroplasty with massive bone loss. The union and implant survival rates are high. Deep infection remains the main complication. Hence, we recommend the pursuit of other revision options, such as strut graft reconstruction, whenever possible before resorting to the use of an allograft-prosthesis composite in the surgical treatment of a failed total elbow arthroplasty with massive bone loss.

Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: long-term outcome and complications.

BACKGROUND: Primary degenerative arthritis of the elbow is an uncommon disorder that recently has been more clearly recognized. The purpose of this study was to analyze the long-term results and complications of ulnohumeral arthroplasty as treatment of primary osteoarthritis of the elbow and to document any tendency for recurrence of the arthritis after the procedure. METHODS: The results of ulnohumeral arthroplasties performed at our institution, between 1986 and 1996, in forty-six elbows (forty-five patients) with primary osteoarthritis were reviewed at an average of eighty months (range, twenty-four to 164 months) after the operation. There were forty-four men and one woman with a mean age of forty-eight years. All patients complained of pain with terminal elbow extension. The pain was associated with locking in fourteen elbows and with ulnar nerve symptoms in twelve. The surgical procedure involved fenestration of the olecranon fossa and excision of olecranon and coronoid osteophytes in all patients, with removal of loose bodies in thirty-six elbows. A capsular release was performed in nineteen elbows, and an ulnar nerve transposition or neurolysis was done in eight. Preoperative and follow-up assessment included evaluation of elbow pain and range of motion with the Mayo Elbow Performance Score. RESULTS: The mean arc of flexion-extension improved from 79 degrees (range, 10 degrees to 135 degrees) preoperatively to 101 degrees (range, 45 degrees to 135 degrees) at the time of follow-up (p < 0.05). At the last follow-up examination, thirty-five elbows (76%) were not painful or were only mildly painful and eleven were moderately or severely painful. According to the Mayo Elbow Performance Score, the result was excellent for twenty-six elbows, good for eight, fair for four, and poor for eight. Thirteen of the forty-five patients reported some degree of ulnar nerve symptoms postoperatively, and six of them required another operation to decompress or translocate the nerve. Two other patients underwent additional surgery because of persistent symptoms. CONCLUSIONS: The data from this study show that ulnohumeral arthroplasty can yield satisfactory long-term pain relief and an increase in the range of motion. Patients with severe preoperative limitation of elbow extension of >60 degrees and flexion of <100 degrees and those who undergo manipulation under anesthesia in the early postoperative period to increase motion are at risk for the development of ulnar nerve dysfunction postoperatively. One should consider prophylactic ulnar nerve decompression or mobilization under these circumstances.

Reconstruction of chronic ruptures of the distal biceps tendon with use of an achilles tendon allograft.

BACKGROUND: Chronic ruptures of the distal biceps tendon are uncommon and are complicated by the retraction and poor quality of the muscle and tendon. Surgical procedures that have been described for the treatment of this injury are limited by the quality and availability of the structures used for augmentation. The purpose of the present study was to describe the surgical technique for reconstruction of the tendon with an Achilles tendon allograft and to report our preliminary experience with this procedure. METHODS: An Achilles tendon allograft was used to reconstruct a chronic rupture of the distal biceps tendon in four patients. The patients were evaluated with regard to subjective satisfaction, pain, range of motion, and strength in flexion and supination. The results were graded with use of the Mayo elbow performance score. RESULTS: After an average duration of follow-up of 2.8 years (range, 2.0 to 3.7 years), all four patients had a satisfactory subjective result, a full range of motion, and an excellent Mayo elbow performance score. The strength of flexion and supination was comparable with that on the contralateral side in two patients and was slightly decreased in the other two. CONCLUSIONS: Reconstruction of chronic disruptions of the distal biceps tendon with an Achilles tendon allograft appears to offer a satisfactory technical solution for this challenging problem and has provided satisfactory clinical results to date.