Assessment of Functional Conservative Treatment of Acute Complete Achilles Tendon Rupture.

BACKGROUND: In recent years, treatment for Achilles tendon rupture (ATR) went through radical changes: from the conservative non-weight bearing approach to a functional protocol. This functional protocol allows complete weight bearing after only 2 weeks by placing the foot in a plastic boot in tapered down equines and using interchangeable wedges under the heel. This change of approach has dramatically lowered the rate of re-rupture. OBJECTIVES: To describe our preliminary results with this functional protocol and to assess outcome measures in the functional conservative treatment. METHODS: The study comprised 15 people who were evaluated clinically and by sonograph. We measured calf circumference, ankle joint range of motion (ROM), and single-leg heel-rise test (SLHRT). In addition, standard scoring methods (Achilles Tendon Rupture Score and Physical Activity Scale) were examined. RESULTS: In our cohort 14 people successfully gained SLHRT. The mean Achilles Tendon Rupture Score functional questionnaire and Physical Activity Scale physical activity questionnaire score was 85.6 of 100, and 4.7 of 6, respectively. There were no significant differences in ankle ROM compared to the uninjured limb. There was statistically significant reduction in the calf circumference and soleus muscle thickness sonographically. CONCLUSIONS: It seems that the conservative functional treatment of ATR demonstrates good functional outcomes, with the patients returning to close to normal activity, although noted muscle wasting and weakness. This protocol presents a true alternative to surgery and should be considered for most non-insertional Achilles tendon tears.

Distal radius fractures: an evidence-based approach to assessment and management.

Distal radius fractures account for one in five bony injuries in both primary and secondary care. These are commonly the result of a fall on outstretched hands or high-energy trauma. On assessment, clinicians should determine the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms. Investigations should always include radiographs to evaluate for intra-articular involvement and fracture displacement. Owing to the heterogeneous injury patterns and patient profiles, the preferred management should consider the severity of the fracture, desired functional outcome and patient comorbidities. Non-operative management in select patients can give good results, especially in older adults. Immobilisation with or without reduction forms the mainstay of non-operative treatment. Surgical management options include closed reduction and application of a cast, percutaneous K-wires, open reduction and internal fixation with plates, or external fixation. Patients should be encouraged to mobilise as soon as it is safe to do so, to prevent stiffness. Median nerve compression is the most common complication followed by tendon rupture, arthrosis and malunion. This article outlines the British Orthopaedic Association Standards for Trauma and Orthopaedics for the management of distal radius fractures.

The recovery after Achilles tendon rupture: a protocol for a multicenter prospective cohort study.

BACKGROUND: Achilles tendon rupture (ATR) is a common sports injury, with a rising incidence and significant impairments. Due to the lack of treatment guidelines, there is no consensus about diagnostic methods, primary treatment (non-surgical or surgical) and rehabilitation. It is hypothesized that this lack of consensus and guidelines leads to sub-optimal recovery and higher societal costs. The primary aim of this study is to give a broad insight into the recovery after ATR. Secondarily this study aims to explore factors contributing to recovery and gain insight into the cost-effectiveness of ATR management. METHODS: This multicenter prospective cohort study will include all adult (≥ 18 years) patients with an ATR treated at the three main hospitals in the Northern Netherlands: University Medical Center Groningen, Martini Hospital Groningen and Medical Center Leeuwarden. All subjects will be invited for three visits at 3, 6 and 12 months post-injury. The following data will be collected: patient-reported outcome measures (PROMs), physical tests, imaging and economic questionnaires. At 3 months post-injury personal, injury, and treatment data will be collected through a baseline questionnaire and assessment of the medical file. The PROMs concern the Dutch version of the Achilles Tendon Total Rupture Score, EQ-5D-5 L, Oslo Sport Trauma Research Center Overuse Injury Questionnaire, Injury Psychological Readiness Return to Sport Scale, Tampa Scale of Kinesiophobia, Expectations, Motivation and Satisfaction questionnaire and a ranking of reasons for not returning to sport. The administered physical tests are the heel-rise test, standing dorsiflexion range of motion, resting tendon length and single leg hop for distance. Ultrasound Tissue Characterization will be used for imaging. Finally, economic data will be collected using the Productivity Cost Questionnaire and Medical Consumption Questionnaire. DISCUSSION: This prospective cohort study will contribute to optimal decision making in the primary treatment and rehabilitation of ATRs by providing insight into (1) ATR recovery (2) novel imaging for monitoring recovery (3) (barriers to) return to sport and (4) cost-effectiveness of management. The analysis of these data strives to give a broad insight into the recovery after ATR as well as provide data on novel imaging and costs, contributing to individualized ATR management. TRIAL REGISTRATION: Trialregister.nl. NTR6484 . 20/06/2017. 20/07/2017.

A comparative clinical and functional assessment of cortical button versus suture anchor in distal biceps brachii tendon repair.

PURPOSE: The studies comparing the fixation methods being used for the ruptured distal biceps brachii tendon reinsertion show similar outcomes of cortical button and suture anchors usage, however, longer follow-up studies remain necessary. The goal of this study was to compare the clinical and functional three-year outcomes of the cortical button in contrast to the suture anchor fixation. METHODS: A retrospective cohort study comprised of 28 males on average 3 years after surgical reinsertion of the distal biceps brachii tendon with the use of a cortical button (Group I, n = 11) or a suture anchor (Group II, n = 17). The outcomes assessed were range of elbow joint and forearm motion (ROM), arm circumferences, visual analogue scale (VAS), Mayo Elbow Performance Index (MEPI), Quick Disability of the Arm, Shoulder, and Hand (Quick DASH) and forearm flexor and supinator muscle torques measured under isometric and isokinetic conditions. RESULTS: The comparison between the two studied groups revealed no statistically significant differences in ROM (p = 0.24-1.00), circumferences (p = 0.15-0.50), VAS (p = 0.71), MEPI (p = 0.23), Quick DASH (p = 0.61) or in the obtained muscle torque values (p = 0.07-1.00). However, differences in supination ROM between the surgical and non-surgical side were found in both groups (p = 0.01-0.02), and differences in pronation (p = 0.02) were found in Group II. The muscle torque values obtained in the surgical, dominant limb were lower than those in the nonsurgical, nondominant limb. CONCLUSION: The comprehensive comparison of three-year outcomes of cortical button versus suture anchor fixations did not favour one fixation method over the other, and the results justify the clinical usage of both methods.

Mapping functions in health-related quality of life: mapping from the Achilles Tendon Rupture Score to the EQ-5D.

PURPOSE: Health state utility values are derived from preference-based measurements and are useful in calculating quality-adjusted life years (QALYs), which is a metric commonly used in cost-effectiveness studies. The purpose of this study was to convert the Achilles Tendon Rupture Score (ATRS) to the preference-based European Quality of Life-5 Dimension Questionnaire (EQ-5D) by estimating the relationship between the two scores using mapping. METHODS: Data were collected from a randomised controlled trial, where 100 patients were treated either surgically or non-surgically for Achilles tendon rupture. Forty-three and forty-four patients in surgical group and non-surgical group completed the ATRS and the EQ-5D alongside each other during follow-up at three time points. Different models of the relationship between the ATRS and the EQ-5D were developed and analysed based on direct mapping and cross-validation. The model with the lowest mean absolute error was observed as the one with the best fit. RESULTS: Among the competing models, mapping based on using a combination of the ATRS items four, five, and six associated with limitation due to pain, during activities of daily living and when walking on uneven ground, produced the best predictor of the EQ-5D score. CONCLUSIONS: The present study provides a mapping algorithm to enable the derivation of utility values directly from the ATRS. This approach makes it feasible for researchers, as well as medical practitioners, to obtain preference-based values in clinical studies or settings where only the ATRS is being administered. The algorithm allows for the calculation of QALYs for use in cost-effectiveness analyses, making it valuable in the study of acute Achilles tendon ruptures. LEVEL OF EVIDENCE: II.

Short-term functional assessment of gait, plantarflexor strength, and tendon properties after Achilles tendon rupture.

BACKGROUND: Although early functional rehabilitation (EFR) has been suggested to yield rapid functional recovery after Achilles tendon rupture (ATR) compared to conventional rehabilitation (CR), most quantitative assessments occur long after rehabilitation has been completed. Few data exist regarding the short-term functional gains during the healing period post-ATR. It remains unclear if EFR allows for an objectively faster return to function. The aim of this study was to examine EFR's effect on gait, plantarflexor strength, and tendon properties in early post-operative follow-ups. METHODS: Fourteen patients received either EFR (n = 6) or CR (n = 8) after percutaneous ATR repair. Functional gait analysis, maximal voluntary isometric contractions (MVICs), and Achilles tendon properties were assessed at 8 and 12 weeks post-op. RESULTS: Comparison of EFR against CR yielded no statistically significant differences in ankle kinematics or kinetics, Achilles tendon properties or MVICs on the injured (INJ) ankle at either time point. During gait, only CR patients demonstrated significantly lower plantarflexion moments on INJ at 8 weeks (0.817 ±â€¯0.151 N·m/kg vs. 1.172 ±â€¯0.177 N·m/kg, p = 0.002). All patients exhibited deficits in plantarflexor moment at 8 weeks and eversion moment at 12 weeks on INJ during gait that had effect sizes of note when compared to CON. SIGNIFICANCE: ATR patients, regardless of rehabilitation, exhibit deficits in gait, AT properties, and single-limb strength at 8 weeks. Though AT properties and single-limb plantarflexor isometric strength remain at a deficit at 12 weeks, bipedal plantarflexion moments are comparable between INJ and CON. Though effect size calculations suggested clinically significant differences, clear benefits of EFR compared to CR were not found.

Reliability of Sonographic Assessment of Biceps Femoris Distal Tendon Strain during Passive Stretching.

The purpose of this study was to determine the intra-rater, inter-examiner and inter-observer reliability of biceps femoris long head (BFlh) tendon strain using ultrasound imaging. Nineteen patients (age: 20.4 ± 0.35 y) were tested twice with a 1-wk interval. Each session included passive stretching from three different hip positions. Tests were performed independently by two examiners while BFlh tendon displacement (mm) and strain (%) were manually extracted from ultrasound video footages by two observers. Intra-rater comparisons revealed an intra-class correlation coefficient (ICC2,1) range of 0.87 to 0.98 and a variability less than 4.74%. Inter-examiner comparisons revealed an ICC2,1 range of 0.83 to 0.99 and less than 4.69% variability. Inter-observer ICCs ranged from 0.93 to 0.97 with variability less than 4.89%. Using a well-defined scanning protocol, two experienced examiners attained high levels of intra-rater agreement, with similarly excellent results for inter-rater and inter-observer reliability for BFlh tendon displacement and strain.

Assessment of Kinematics and Electromyography Following Arthroscopic Single-Tendon Rotator Cuff Repair.

BACKGROUND: The increasing demand for rotator cuff (RC) repair patients to return to work as soon as they are physically able has led to exploration of when this is feasible. Current guidelines from our orthopedic surgery clinic recommend a return to work at 9 weeks postoperation. To more fully define capacity to return to work, the current study was conducted using a unique series of quantitative tools. To date, no study has combined 3-dimensional (3D) motion analysis with electromyography (EMG) assessment during activities of daily living (ADLs), including desk tasks, and commonly prescribed rehabilitation exercise. OBJECTIVE: To apply a quantitative, validated upper extremity model to assess the kinematics and muscle activity of the shoulder following repair of the supraspinatus RC tendon compared to that in healthy shoulders. DESIGN: A prospective, cross-sectional comparison study. SETTING: All participants were evaluated during a single session at the Medical College of Wisconsin Department of Orthopaedic Surgery's Motion Analysis Laboratory. PARTICIPANTS: Ten participants who were 9-12 weeks post-operative repair of a supraspinatus RC tendon tear and 10 participants with healthy shoulders (HS) were evaluated. METHODS: All participants were evaluated with 3D motion analysis using a validated upper extremity model and synchronized EMG. Data from the 2 groups were compared using multivariate Hotelling T2 tests with post hoc analyses based on Welch t-tests. MAIN OUTCOME MEASUREMENTS: Participants' thoracic and thoracohumeral joint kinematics, temporal-spatial parameters, and RC muscle activity were measured by applying a quantitative upper extremity model during 10 ADLs and 3 rehabilitation exercises. These included tasks of hair combing, drinking, writing, computer mouse use, typing, calling, reaching to back pocket, pushing a door open, pulling a door closed, external rotation, internal rotation, and rowing. RESULTS: There were significant differences of the thoracohumeral joint motion in only a few of the tested tasks: comb maximal flexion angle (P = .004), pull door internal/external rotation range of motion (P = .020), reach abduction/adduction range of motion (P = .001), reach flexion/extension range of motion (P = .001), reach extension minimal angle (P = .025), active external rotation maximal angle (P = .012), and active external rotation minimal angle (P = .004). The thorax showed significantly different kinematics of maximal flexion angle during the call (P = .011), mouse (P = .007), and drink tasks (P = .005) between the 2 groups. The EMG data analysis showed significantly increased subscapularis activity in the RC repair group during active external rotation. CONCLUSIONS: Although limited abduction was expected due to repair of the supraspinatus tendon, only a single ADL (reaching to back pocket) had a significantly reduced abduction range of motion. Thoracic motion was shown to be used as a compensatory strategy during seated ADLs. Less flexion of the thorax may create passive shoulder flexion at the thoracohumeral joint in efforts to avoid active flexion. The RC repair group participants were able to accomplish the ADLs within the same time frame and through thoracohumeral joint kinematics similar to those in the healthy shoulder group participants. In summary, this study presents a quantification of the effects of RC repair and rehabilitation on the ability to perform ADLs. It may also point to a need for increased rehabilitation focus on either regaining external rotation strength or range of motion following RC repair to enhance recovery and return to the workforce. LEVEL OF EVIDENCE: III.

Outcomes assessment in rotator cuff pathology: what are we measuring?

BACKGROUND: Assessments used to measure outcomes associated with rotator cuff pathology and after repair are varied. This lack of standardization leads to difficulty drawing comparisons across studies. We hypothesize that this variability in patient-reported outcome measures and objective metrics used in rotator cuff studies persists even in high-impact, peer reviewed journals. METHODS: All studies assessing rotator cuff tear and repair outcomes in 6 orthopedic journals with a high impact factor from January 2010 to December 2014 were reviewed. Cadaveric and animal studies and those without outcomes were excluded. Outcome measures included range of motion (forward elevation, abduction, external rotation, and internal rotation), strength (in the same 4 planes), tendon integrity imaging, patient satisfaction, and functional assessment scores. RESULTS: Of the 156 included studies, 63% documented range of motion measurements, with 18% reporting range of motion in all 4 planes. Only 38% of studies reported quantitative strength measurements. In 65% of studies, tendon integrity was documented with imaging (38% magnetic resonance imaging/magnetic resonance anrhrogram, 31% ultrasound, and 8% computed tomography arthrogram). Finally, functional score reporting varied significantly, with the 5 most frequently reported scores ranging from 16% to 61% in studies, and 15 of the least reported outcomes were each reported in ≤6% of studies. CONCLUSIONS: Significant variability exists in outcomes reporting after rotator cuff tear and repair, making comparisons between clinical studies difficult. Creating a uniformly accepted, validated outcomes tool that assesses pain, function, patient satisfaction, and anatomic integrity would enable consistent outcomes assessment after operative and nonoperative management and allow comparisons across the literature.

What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears?

BACKGROUND: Few studies define the clinical signs to evaluate the integrity of teres minor in patients with massive rotator cuff tears. CT and MRI, with or without an arthrogram, can be limited by image quality, soft tissue density, motion artifact, and interobserver reliability. Additionally, the ill-defined junction between the infraspinatus and teres minor and the larger muscle-to-tendon ratio of the teres minor can contribute to error. Therefore, we wished to determine the validity of clinical testing for teres minor tears. QUESTION/PURPOSES: The aim of this study was to determine the accuracy of commonly used clinical signs (external rotation lag sign, drop sign, and the Patte test) for diagnosing the teres minor's integrity. METHODS: We performed a prospective evaluation of patients referred to our shoulder clinic for massive rotator cuff tears determined by CT arthrograms. The posterosuperior rotator cuff was examined clinically and correlated with CT arthrograms. We assessed interobserver reliability for CT assessment and used three different clinical tests of teres minor function (the external rotation lag sign, drop sign, and the Patte test). One hundred patients with a mean age of 68 years were available for the analysis. RESULTS: The most accurate test for teres minor dysfunction was an external rotation lag sign greater than 40°, which had a sensitivity of 100% (95% CI, 80%-100%) and a specificity of 92% (95% CI, 84%-96%). External rotation lag signs greater than 10° had a sensitivity of 100% (95% CI, 80%-100%) and a specificity of 51% (95% CI, 40%-61%). The Patte sign had a sensitivity of 93% (95% CI, 70%-99%) and a specificity of 72% (95% CI, 61%-80%). The drop sign had a sensitivity of 87% (95% CI, 62%-96%) and a specificity of 88% (95% CI, 80%-93%). An external rotation lag sign greater than 40° was more specific than an external rotation lag sign greater than 10° (p < 0.001), and a Patte sign (p < 0.001), but was not more specific than the drop sign (p < 0.47). There was poor correlation between involvement of the teres minor and loss of active external rotation. CONCLUSIONS: Clinical signs can predict anatomic patterns of teres minor dysfunction with good accuracy in patients with massive rotator cuff tears. This study showed that the most accurate test for teres minor dysfunction is an external rotation lag sign and that most patients' posterior rotator cuff tears do not lose active external rotation. Because imaging is not always accurate, examination for integrity of the teres minor is important because it may be one of the most important variables affecting the outcome of reverse shoulder arthroplasty for massive rotator cuff tears, and the functional effects of tears in this muscle on day to day activities can be significant. Additionally, teres minor integrity affects the outcomes of tendon transfers, therefore knowledge of its condition is important in planning repairs. LEVEL OF EVIDENCE: Level III, diagnostic study.

A comparison of conventional ultrasonography and arthrosonography in the assessment of cuff integrity after rotator cuff repair.

BACKGROUND: This study was designed to perform conventional ultrasonography, magnetic resonance arthrography (MRA) and arthrosonography exams after rotator cuff repair to compare the results of conventional ultrasonography and arthrosonography with those of MRA as the gold standard. METHODS: We prospectively studied 42 consecutive patients (14 males, 28 females; average age, 59.4 years) who received arthroscopic rotator cuff repair due to full-thickness tears of the supraspinatus tendon from 2008 to 2010. The integrity assessment of the repaired rotator cuff was performed 6 months postoperatively using conventional ultrasonography, MRA, and arthrosonography. RESULTS: The diagnostic accuracy of the conventional ultrasonography compared to MRA was 78.6% and the McNemar test results were 0.016 in full-thickness tear and 0.077 in partial-thickness tear. The diagnostic accuracy of arthrosonography compared to MRA was 92.9% and the McNemar test results were 0.998 in full-thickness tear and 0.875 in partial-thickness tear. CONCLUSIONS: It was found that the integrity assessment of the repaired rotator cuff by ultrasonography must be guarded against and that arthrosonography is an effective alternative method in the postoperative integrity assessment. Also, an arthrosonography seems to be a suitable modality to replace the conventional ultrasonography.

Psychological distress negatively affects self-assessment of shoulder function in patients with rotator cuff tears.

BACKGROUND: In many areas of orthopaedics, patients with greater levels of psychological distress report inferior self-assessments of pain and function. This effect can lead to lower-than-expected baseline scores on common patient-reported outcome scales, even those not traditionally considered to have a psychological component. QUESTIONS/PURPOSES: This study attempts to answer the following questions: (1) Are higher levels of psychological distress associated with clinically important differences in baseline scores on the VAS for pain, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons score in patients undergoing arthroscopic rotator cuff repair? (2) Does psychological distress remain a negative predictor of baseline shoulder scores when other clinical variables are controlled? METHODS: Eighty-five patients with full-thickness rotator cuff tears were prospectively enrolled. Psychological distress was quantified using the Distress Risk Assessment Method questionnaire. Patients completed baseline self-assessments including the VAS for pain, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons score. Age, sex, BMI, smoking status, American Society of Anesthesiologists classification, tear size, and tear retraction were recorded for each patient. Bivariate correlations and multivariate regression models were used to assess the effect of psychological distress on patient self-assessment of shoulder pain and function. RESULTS: Distressed patients reported higher baseline VAS scores (6.7 [95% CI, 4.4-9.0] versus 2.9 [95% CI, 2.3-3.6], p = 0.001) and lower baseline Simple Shoulder Test (3.7 [95% CI, 2.9-4.5] versus 5.7 [95% CI 5.0-6.4], p = 0.001) and American Shoulder and Elbow Surgeons scores (39 [95% CI, 34-45] versus 58 [95% CI, 53-63], p < 0.001). Distress remained associated with higher VAS scores (p = 0.001) and lower Simple Shoulder Test (p < 0.001) and American Shoulder and Elbow Surgeons scores (p < 0.001) when age, sex, BMI, American Society of Anesthesiologists classification, smoking status, tear size, and tear retraction were controlled. CONCLUSIONS: Higher levels of psychological distress are associated with inferior baseline patient self-assessment of shoulder pain and function using the VAS, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons score. Longitudinal followup is warranted to clarify the relationship between distress and self-perceived disability and the effect of distress on postoperative outcomes after arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: Level I, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Living with a symptomatic rotator cuff tear 'bad days, bad nights': a qualitative study.

BACKGROUND: Rotator cuff tears are a common cause of shoulder pain. There is an absence of information about symptomatic rotator cuffs from the patients' perspective; this limits the information clinicians can share with patients and the information that patients can access via sources such as the internet. This study describes the experiences of people with a symptomatic rotator cuff, their symptoms, the impact upon their daily lives and the coping strategies utilised by study participants. METHODS: An interpretive phenomenological analysis approach was used. 20 participants of the UKUFF trial (The United Kingdom Rotator Cuff Surgery Trial) agreed to participate in in-depth semi-structured interviews about their experiences about living with a symptomatic rotator cuff tear. Interviews were digitally recorded and fully transcribed. Field notes, memos and a reflexive diary were used. Data was coded in accordance with interpretive phenomenological analysis. Peer review, code-recode audits and constant comparison of data, codes and categories occurred throughout. RESULTS: The majority of patients described intense pain and severely disturbed sleep. Limited movement and reduced muscle strength were described by some participants. The predominantly adverse impact that a symptomatic rotator cuff tear had upon activities of daily living, leisure activities and occupation was described. The emotional and financial impact and impact upon caring roles were detailed. Coping strategies included attempting to carry on as normally as possible, accepting their condition, using their other arm, using analgesics, aids and adaptions. CONCLUSIONS: Clinicians need to appreciate and understand the intensity and shocking nature of pain that may be experienced by participants with known rotator cuff tears and understand the detrimental impact tears can have upon all areas of patient's lives. Clinicians also need to be aware of the potential emotional impact caused by cuff tears and to ensure that patients needing help for conditions such as depression are speedily identified and provided with support, explanation and appropriate treatment.

"Soft, hard, or just right?" Applications and limitations of axial-strain sonoelastography and shear-wave elastography in the assessment of tendon injuries.

Injury to a tendon leads to alterations in the mechanical properties of the tendon. Axial-strain sonoelastography and shear-wave elastography are relatively new, real-time imaging techniques that evaluate the mechanical properties of tendons in addition to the existing morphological and vascular information that is obtained with traditional imaging tools. Axial-strain sonoelastography displays the subjective distribution of strain data on an elastogram caused by tissue compression, whereas shear-wave elastography provides a more objective, quantitative measure of the intrinsic tissue elasticity using the acoustic push-pulse. Recent studies suggest that axial-strain sonoelastography is able to distinguish between asymptomatic and diseased tendons, and is potentially more sensitive than conventional ultrasound in detecting early tendinopathy. Shear-wave elastography seems to be a feasible tool for depicting elasticity and functional recovery of tendons after surgical management. While initial results have been promising, axial-strain sonoelastography and shear-wave elastography have not yet found routine use in wider clinical practice. Possible barriers to the dissemination of axial-strain sonoelastography technique include operator dependency, technical limitations such as artefacts and lack of reproducibility and quantification of sonoelastography data. Shear-wave elastography may improve the reproducibility of elastography data, although there is only one published study on the topic to date. Large-scale longitudinal studies are needed to further elucidate the clinical relevance and potential applications of axial-strain sonoelastography and shear-wave elastography in diagnosing, predicting, and monitoring the progress of tendon healing before they can be widely adopted into routine clinical practice.

The AutoQual ultrasound elastography method for quantitative assessment of lateral strain in post-rupture Achilles tendons.

This paper presents the AutoQual elastography method: a novel algorithm that improves the quality of 2D displacement field calculation from ultrasound radio frequency (RF) sequences of acutely ruptured Achilles tendons to determine image-lateral strain fields and has potential use for ligaments and muscles. This method uses 2D bicubic spline interpolation of the RF signal, Quality Determined Search, Automatic Search Range and Adaptive Block Size components as a novel combination that is designed to improve continuity and decrease displacement field noise, especially in areas of low signal strength. We present a simple experiment for quantitatively comparing the AutoQual method to a multiscale (MS) elastography method from ultrasound RF sequences of a 5% agar phantom for rigid body motion and known lateral strain loads with speeds up to 5mm/s. We finally present examples of four in vivo Achilles tendons in various damage states and with manual or artificially controlled passive flexion of the foot. Results show that the AutoQual method offers a substantial improvement on the MS method, achieving similar performance for rigid body tracking at all speeds, a lower normalized square error at all strains induced and a more continuous strain field at higher compression rates. AutoQual also showed a greater average normalized cross correlation for image blocks in the area of interest, a lower standard deviation of the strain field and a visually more acceptable point tracking for in vivo examples. This work demonstrates lateral ultrasound elastography which is robust to the complex passive motion of the Achilles and to various imaging artifacts associated with imaging tendon rupture. This method potentially has a wide clinical application for assessing in vivo strains in and hence mechanical function of any near skin surface tissues that are longitudinally loaded.

Single incision power optimizing cost-effective (SPOC) distal biceps repair.

BACKGROUND: The purpose of this study was to review the results of a single anterior incision distal biceps tendon repair that reattaches the tendon to its posterior anatomic insertion site. We hypothesize this repair maximizes the supination torque of the biceps muscle throughout the full arc of forearm rotation. METHODS: A consecutive series of patients with distal biceps tears were treated using a technique that reattaches the distal biceps tendon to the posterior radial surface similar to a 2-incision repair, which optimizes the biceps moment arm in all forearm positions including maximum supination. This method of distal biceps reattachment has been utilized in our practice since December 2008 on 40 distal biceps tendon repairs. Biodex testing was used to quantify the peak supination torque, the supination work, and the power of supination at each degree of forearm rotation and included on patients with a minimum clinical follow up of 12 months. Range of motion was also recorded. RESULTS: Thirty patients met the inclusion criteria. Three patients, 2 of whom were lost to follow-up and 1 with bilateral repairs, were not included in this study. Seventeen of the remaining 27 patients completed strength testing using a Biodex Isokinetic Testing machine. Supination strength averaged 91% and 91% of the uninjured side at 60 and 120 deg/sec, respectively. Twenty-five (93%) patients reported no pain and had returned to work or normal activities. CONCLUSION: A single anterior incision distal biceps tendon repair that maximizes supination torque throughout full forearm rotation has been utilized. No specialized anchors or equipment are required. LEVEL OF EVIDENCE: Level IV, Case Series, Treatment Study.

A biomechanical assessment of tendon repair after radiofrequency treatment.

After acute tendon injury, rapid mobilization prevents adhesions and improves the ultimate strength of the repair. Radiofrequency (RF) ablation is proposed to enhance angiogenesis in the early stages of healing. The mechanism and effect of RF have not yet been described in an animal model of tendon injury. To investigate the biomechanical effect of bipolar RF on acute injury in a rabbit model of partial Achilles tendon transection and suture repair, RF-treated tendon repairs were compared to untreated tendons. Cross-sectional area, Young's modulus, and ultimate tensile strength were determined. At 6 and 12 weeks after repair, RF-treated tendons had significant increases in cross-sectional area (P<.001; P< .0001) and ultimate tensile strength (P<.0001; P<.01). Young modulus of RF-treated tendons was increased at 6 weeks but not at 12 weeks (P<.01) Compared with untreated tendons, RF-treated tendons showed faster return to mechanical integrity. This may allow earlier rehabilitation.

Systematic review of rotator cuff tears in workers' compensation patients.

BACKGROUND: The burden imposed by workplace rotator cuff (RC) injuries has been reasonably defined. However, literature associated with the demographic characteristics and 'best practices' to manage such injuries among workers' compensation (WC) patients is scant. AIMS: To consolidate the existing literature on full-thickness RC tears among WC patients. Subject, shoulder and injury characteristics were examined to determine if and how WC recipients may differ from their non-compensable counterparts. METHODS: A systematic search (databases, clinical practice guideline web resources, conference proceedings and reference lists) revealed 450 abstracts. Two blinded reviewers independently assessed abstracts for inclusion. Sixty abstracts were subsequently included in a blinded full manuscript review. Seventeen of these manuscripts (3.8% of sample; 11 intervention and 6 determinant) were included in the present review. RESULTS: Previous studies demonstrate that operative interventions are appropriate for full-thickness RC tears as substantial gains in range of motion, strength and quality of life were witnessed within the first post-operative year. Non-operative interventions, including workplace-based work hardening, physical therapy and the use of an early referral system, were shown to improve outcomes. Conflicting results exist with respect to determinants such as age and sex. Importantly, WC patients had consistently poorer outcomes than non-WC patients. CONCLUSIONS: Our results show that although WC patients experience substantial benefits from various treatments for full-thickness RC tears, disparities exist between them and their non-WC counterparts. The lack of WC-specific literature limited our results. Larger studies, particularly ones comparing WC patients with their non-compensable counterparts, are crucial to allow for future evidence-based recommendations.

Scoring systems for the functional assessment of patients with rotator cuff pathology.

Ideally, an outcome instrument measures phenomena that are directly relevant to the patient and provides a comprehensive assessment of the impact of a condition on the patient's daily life. During the past decades, several rating scales have been developed to assess the functional status of patients with shoulder pain. Several scoring systems are currently available for the evaluation of patients with rotator cuff pathology. Each of them evaluates shoulder function using specific variables. The main features of these scoring systems are presented in this review. Although many scoring systems are commonly used to evaluate shoulder function, we are still far from a single outcome evaluation system, which is reliable, valid, and sensitive to clinically relevant changes, takes into account both patient's and physician's perspective, and is short and practical to use.

The biomechanical assessment of gap formation after flexor tendon repair using partial interlocking cross-stitch peripheral sutures.

The gap formation of five core plus peripheral suture techniques for flexor tendon repair was evaluated by cyclic load testing. Fifty pairs of dental roll tendon models were sutured using six-strand Pennington modified Kessler core suture with 4-0 Polypropylene. One-half or three-fourths circumferential interlocking cross-stitch, or three complete circumferential peripheral suture techniques were performed using 6-0 Polypropylene. An initial cyclic load of 10 N for 500 cycles was applied and increased by 5 N for an additional 500 cycles at each new load until rupture. The complete circumferential interlocking cross-stitch had the greatest fatigue strength. The partial circumferential cross-stitches resulted in significantly larger gap formations at both the repaired and unrepaired sides than the complete circumferential sutures, and were also associated with early rupture. The full circumference of the cut tendon must be sutured using an interlocking cross-stitch peripheral suture to improve strength and avoid gap formation.