The impact of competitive level of high school and collegiate athletes on outcomes of thoracic outlet syndrome.

OBJECTIVE: Thoracic outlet syndrome (TOS) has life-changing impacts on young athletes. As the level of competition increases between the high school (HS) and collegiate (CO) stage of athletics, the impact of TOS may differ. Our objective is to compare surgical outcomes of TOS in HS and CO athletes. METHODS: This was a retrospective review of HS and CO athletes within a prospective surgical TOS database. The primary outcome was postoperative return to sport. Secondary outcomes were resolution of symptoms assessed with somatic pain scale (SPS), QuickDASH, and Derkash scores. Categorical and continuous variables were compared using χ2 and analysis of variance, respectively. Significance was defined as P < .05. RESULTS: Thirty-two HS and 52 CO athletes were identified. Females comprised 82.9% HS and 61.5% CO athletes (P = .08). Primary diagnoses were similar between groups (venous TOS: HS 50.0% vs CO 42.3%; neurogenic TOS: 43.9% vs 57.7%; pectoralis minor syndrome: 6.3% vs 0.0%) (P = .12). Pectoralis minor syndrome was a secondary diagnosis in 3.1% and 3.8% of HS and CO athletes, respectively (P = 1.00). The most common sports were those with overhead motion, specifically baseball/softball (39.3%), volleyball (12.4%), and water polo (10.1%), and did not differ between groups (P = .145). Distribution of TOS operations were similar in HS and CO (First rib resection: 94.3% vs 98.1%; scalenectomy: 0.0% vs 1.9%, pectoralis minor tenotomy: 6.3% vs 0.0%) (P = .15). Operating room time was 90.0 vs 105.3 minutes for HS and CO athletes, respectively (P = .14). Mean length of stay was 2.0 vs 1.9 days for HS and CO athletes (P = .91). Mean follow-up was 6.9 months for HS athletes and 10.5 months for CO athletes (P = .39). The majority of patients experienced symptom resolution (HS 80.0% vs CO 77.8%; P = 1.00), as well as improvement in SPS, QuickDASH, and Derkash scores. Return to sport was similar between HS and CO athletes (72.4% vs 73.3%; P = .93). Medical disability was reported in 100% HS athletes and 58.3% CO athletes who did not return to sport (P = .035). CONCLUSIONS: Despite increased level of competition, HS and CO athletes demonstrate similar rates of symptom resolution and return to competition. Of those that did not return to their sport, HS athletes reported higher rates of medical disability as a reason for not returning to sport compared with CO athletes.

Roles of Plasminogen Activator Inhibitor-1 in Heterotopic Ossification Induced by Achilles Tenotomy in Thermal Injured Mice.

Heterotopic ossification (HO) is the process by which ectopic bone forms at an extraskeletal site. Inflammatory conditions induce plasminogen activator inhibitor 1 (PAI-1), an inhibitor of fibrinolysis, which regulates osteogenesis. In the present study, we investigated the roles of PAI-1 in the pathophysiology of HO induced by trauma/burn treatment using PAI-1-deficient mice. PAI-1 deficiency significantly promoted HO and increased the number of alkaline phosphatase (ALP)-positive cells in Achilles tendons after trauma/burn treatment. The mRNA levels of inflammation markers were elevated in Achilles tendons of both wild-type and PAI-1-deficient mice after trauma/burn treatment and PAI-1 mRNA levels were elevated in Achilles tendons of wild-type mice. PAI-1 deficiency significantly up-regulated the expression of Runx2, Osterix, and type 1 collagen in Achilles tendons 9 weeks after trauma/burn treatment in mice. In in vitro experiments, PAI-1 deficiency significantly increased ALP activity and mineralization in mouse osteoblasts. Moreover, PAI-1 deficiency significantly increased ALP activity and up-regulated osteocalcin expression during osteoblastic differentiation from mouse adipose-tissue-derived stem cells, but suppressed the chondrogenic differentiation of these cells. In conclusion, the present study showed that PAI-1 deficiency promoted HO in Achilles tendons after trauma/burn treatment partly by enhancing osteoblast differentiation and ALP activity in mice. Endogenous PAI-1 may play protective roles against HO after injury and inflammation.

Zigzag tenotomy of the extensor hallucis longus through minimally invasive surgery in cadaveric specimens: description of a new technique.

BACKGROUND: Lengthening of the extensor hallucis longus (EHL) is performed to address various forefoot pathologies. The retraction of this tendon is strongly associated with the Hallux Abductus Valgus (HAV) deformity. Minimally Invasive Surgery (MIS) lengthening of the EHL is carried out in combination with other surgical techniques for HAV bone realignment. It is performed without ischemia, using local anesthesia and sedation if required by the patient. One of the advantages of this technique is immediate ambulation with a postoperative shoe without the need for a cast. The objective of the research was to demonstrate the efficacy and safety of the minimally invasive technique for lengthening the tendon in patients with HAV. MATERIALS AND METHODS: The procedures were performed on 11 fresh cryopreserved cadaveric feet. HAV surgery was performed through dorsomedial and dorsolateral portals for Reverdin-Isham, Akin and adductor tenotomy. In addition, EHL tendon elongation was performed using the Beaver 67 MIS scalpel through an incomplete zigzag tenotomy. The specimens used did not present any type of disease nor had they undergone previous surgeries that could affect the technique. First, the plantar flexion of the metatarsophalangeal joint was measured with a goniometer to establish the degrees of this joint before proceeding with the technique, the tenotomy was performed and remeasured and finally the osteotomy was performed. In addition, an anatomical dissection of cadaveric specimens was performed and various anatomical and surgical relationships were analyzed and measured. RESULTS: The data indicate that, after performing zigzag tenotomy, there is an average improvement of 13.91 degrees in plantar flexion. CONCLUSIONS: The study confirms the effectiveness and safety of elongating the extensor hallucis longus tendon of the hallux using minimally invasive surgery. The zigzag technique for tendon elongation may be considered a viable minimally invasive treatment option for addressing tendon hyperextension in patients with HAV.

Duration and outcome of orthotic treatment in children with clubfoot - a four-year follow-up national register study of Swedish children born between 2015 and 2017.

BACKGROUND: The Ponseti method for treating clubfoot consists of initial treatment with serial casting accompanied by achillotenotomy if needed, followed by the maintenance phase including treatment with a foot abduction orthosis (FAO) for at least four years. This study aimed to examine the duration, course, and outcome of orthotic treatment in children with clubfoot. METHODS: 321 children with clubfoot, born between 2015 and 2017, registered in the Swedish Pediatric Orthopedic Quality Register (SPOQ), were included in this prospective cohort study. Data on deformity characteristics and orthotic treatment were extracted. For children with bilateral clubfoot, one foot was included in the analysis. RESULTS: Of the 288 children with isolated clubfoot, 274 children (95.5%) were prescribed an FAO, and 100 children (35%) changed orthosis type before 4 years of age. Of the 33 children with non-isolated clubfoot, 25 children (76%) were prescribed an FAO, and 21 children (64%) changed orthosis type before 4 years of age. 220 children with isolated clubfoot (76%), and 28 children with non-isolated clubfoot (84%) continued orthotic treatment until 4 years of age or longer. Among children with isolated clubfoot, children ending orthotic treatment before 4 years of age (n = 63) had lower Pirani scores at birth compared to children ending orthotic treatment at/after 4 years of age (n = 219) (p = 0.01). It was more common to change orthosis type among children ending orthotic treatment before 4 years of age (p = 0.031). CONCLUSIONS: The majority of children with clubfoot in Sweden are treated with an FAO during the maintenance phase. The proportion of children changing orthosis type was significantly greater and the Pirani score at diagnosis was lower significantly among children ending orthotic treatment before 4 years of age. Long-term follow-up studies are warranted to fully understand how to optimize, and individualize, orthotic treatment with respect to foot involvement and severity of deformity. LEVEL OF EVIDENCE: II.

Endoscopic Tendon Release for Iliopsoas Impingement After Total Hip Arthroplasty-Excellent Clinical Outcomes and Low Failure Rates at Short-Term Follow-Up.

PURPOSE: To investigate the clinical effectiveness of endoscopic iliopsoas tendon release (IPR) at the lesser trochanter (LT) in patients with iliopsoas impingement (IPI) after total hip arthroplasty (THA). METHODS: Between November 2017 and March 2021, a consecutive series of 36 patients were treated with endoscopic IPR for diagnosed IPI. Patients included had acetabular cup position confirmed by functional imaging (OPS, Corin, Pymble, NSW), typical clinical symptoms of IPI, and a positive response to diagnostic injection. Clinical assessment included validated patient-reported outcome measures (PROMs) along with hip flexion strength and active range of motion at different time marks up to 2-year follow-up, as well as surgical complications. RESULTS: Overall, 36 consecutive patients (11 males) with a mean age of 62 ± 12 years were included. All patients had failed nonoperative management. Dynamic computed tomography assessment was available in 89% of the patients, edge loading was reported in 10%, and variable cup overhang was reported in 50%. Clinically, PROMs were significantly improved at every time mark when compared with preoperative values (P < .001), showing the biggest improvement within the first 4 weeks after surgery. At the 6-month follow-up, peak isometric hip flexion strength on the operated side was 20% lower than the contralateral side (P < .001). Failure rate of the procedure was 2.8% (1 case). Linear regression showed no association between cup overhang and clinical outcomes. CONCLUSIONS: Endoscopic IPR at the LT is a safe and reproducible technique associated with significant and immediate improvement in pain, functional outcomes, and high patient satisfaction. With minimal short-term weakness, no complications, and only a single revision, even in cases with cup malposition and/or edge loading, we believe that endoscopic IPR can be considered as one of the first-line operative options in patients with symptomatic IPI, irrespective of component position. LEVEL OF EVIDENCE: Level IV, case series.

Editorial Commentary: Shoulder Long Head of the Biceps Tendon Transposition Without Tenotomy May Be a Beneficial Augment for Massive Rotator Cuff Tear Repair.

Although many surgeons discard the long head of the biceps (LHB) tendon during arthroscopic rotator cuff repairs, several authors have argued that the LHB tendon may serve as a biologic and structural augment for massive repairs. There are multiple benefits of incorporating the LHB tendon autograft in difficult-to-repair massive rotator cuff tears. First, by maintaining the glenoid origin, the tendon likely retains a significant native blood supply, as well as tenocytes, which may support the healing process. In addition, there are several biomechanical benefits. The LHB may act as a dynamic humeral head depressor since it is still attached to the muscular unit distally. The tendon could also serve as a convergence post, while proving robust tissue for the repair. Also, the LHB tendon may decrease undue tension on the repair, bringing us closer to a tension-free repair. Finally, this may be a cost-conscious technique. One concern, requiring additional investigation, is that some surgeons believe the LHB may be a pain generator in patients with rotator cuff tears. One surgeon's trash is another surgeon's treasure.

Editorial Commentary: For Post-Hip Arthroplasty Iliopsoas Tendonitis, Psoas Tenotomy Is the Preferred First-Line Treatment, Even in Cases of Cup Overhang.

Iliopsoas impingement pathology is one of the causes of persistent pain after total hip arthroplasty. It is reported as occurring in approximately 4% of cases; this may be significantly greater (in cases of postarthroplasty pain of unknown etiology). Inflammation is a result of impingement of the tendon against the acetabular component. This may occur with anteroinferior prominence when the cup is properly positioned in anteversion or when the cup is oversized. Other causes of impingement include a cup-reinforcement ring or acetabular cage, a collared femoral component, screws penetrating through the ilium, cement extrusion, anterior wall hypoplasia, or increased femoral offset. When conservative treatment does not achieve the best outcome, the 2 main therapeutic options are psoas tenotomy or revision of the cup component. Tenotomy can be performed either arthroscopically or by an open approach and may be considered the best option for many patients, even in cases with anterior component prominence, as it is less invasive, presents fewer complications, and has faster recovery. The debate is open. The level of tenotomy remains controversial, with risks and benefits of both a lesser trochanter and transcapsular approach.

Augmentation of Massive Rotator Cuff Repairs Using Biceps Transposition Without Tenotomy Improves Clinical and Patient-Reported Outcomes: The Biological Superior Capsular Reconstruction Technique.

PURPOSE: To evaluate the outcomes of a consecutive series of patients after transposition of the biceps without tenotomy (biological superior capsular reconstruction [bio-SCR] technique) to augment massive rotator cuff repairs. METHODS: Thirty massive rotator cuff tears repaired and augmented using the bio-SCR technique between June 2018 and July 2021 were identified and retrospectively reviewed. American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale pain scores, supraspinatus and infraspinatus strength, and range of motion were collected preoperatively and postoperatively. RESULTS: The average age of patients undergoing bio-SCR augmentation was 67.0 years (range, 28.4-81.9 years), and the mean clinical follow-up period was 2.9 years (range, 1.8-4.5 years). The average ASES score improved from 33.2 preoperatively to 80.8 at 6 months postoperatively, 92.0 at 1 year, and 87.0 at 2 years (P < .001). The minimal clinically important difference for the ASES score was exceeded at all postoperative intervals. Active forward flexion improved from 120.6° to 156.8° (P < .001). The pain score improved from 7.1 to 0.9 (P < .001). Postoperatively, 1 complication (3.3%) occurred: a proximal biceps rupture. CONCLUSIONS: Incorporating a transposed biceps tendon into the repair of a massive rotator cuff tear using the bio-SCR technique resulted in significant clinical improvements with a low complication rate. LEVEL OF EVIDENCE: Level IV, case series.

Satisfactory mid-term clinical outcomes of endoscopic tenotomy for iliopsoas tendinopathy following total hip arthroplasty.

PURPOSE: To report 5-year outcomes of endoscopic iliopsoas tenotomy in patients with iliopsoas tendinopathy following total hip arthroplasty (THA) and determine whether clinical scores are associated with cup position. METHODS: Patients who underwent endoscopic iliopsoas tenotomy for iliopsoas tendinopathy following THA (2014-2017) were contacted. Indications for endoscopic iliopsoas tenotomy after THA were groin pain during active hip flexion, exclusion of other causes of groin pain, and no pain relief after 6 months of conservative treatment. Pretenotomy cup inclination and anteversion were measured on radiographs; axial and sagittal cup overhang were measured on computed tomography (CT) scans. Oxford hip score (OHS), modified Harris hip score (mHHS), and groin pain were assessed. RESULTS: The initial cohort comprised 16 men (17 hips) and 31 women (32 hips), aged 60.7 ± 10.6 years. Cup inclination and anteversion were, respectively, 46.2 ± 6.2° and 14.6 ± 8.4°, while axial and sagittal cup overhang were, respectively, 4.4 ± 4.0 mm and 6.9 ± 4.5 mm. At ≥5 years follow-up, four hips underwent cup and stem revision, two underwent isolated cup revision and one underwent secondary iliopsoas tenotomy. OHS improved by 23 ± 10 and mHHS improved by 31 ± 16. Posttenotomy groin pain was slight in 20.0%, mild in 17.5% and moderate in 12.5%. Regression analyses revealed that net change in mHHS decreased with sagittal cup overhang (ß = -3.1; 95% confidence interval [CI] = -4.6 to -1.7; p < 0.001), but that there were no associations between cup position and net change in OHS. CONCLUSIONS: Endoscopic iliopsoas tenotomy provides good mid-term clinical outcomes in patients with iliopsoas tendinopathy following THA. Furthermore, improvements in mHHS were found to decrease with increasing sagittal cup overhang, in cases for which adequate preoperative imaging was available. LEVEL OF EVIDENCE: Level IV.

Modified arthroscopic tenotomy of the extensor carpi radialis brevis for refractory lateral epicondylitis: a cohort study.

BACKGROUND: Different arthroscopic techniques exist for managing the extensor carpi radials brevis (ECRB) when treating refractory lateral epicondylitis. The purpose of this study is to compare the outcomes of a standard arthroscopic débridement with ECRB tendon release to an arthroscopic ECRB tenotomy distal to its insertion without débridement using a retrospective cohort study design. METHODS: This study included patients underwent arthroscopic treatment of lateral epicondylitis during 2 different time periods: 2016-2019 (débridement) and 2019-2021 (modified tenotomy without débridement). Patients were assessed preoperatively and at the last follow-up with Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analog Scale of pain. RESULTS: A total of 69 patients completed the follow-up (38 in the débridement group and 31 in the tenotomy group). Patients in both groups showed significant improvements were found in MEPS, DASH, and Visual Analog Scale after surgery. Patients in the tenotomy group had higher MEPSs and reported less pain with a minimum 2 year follow-up after surgery. DASH scores between groups were similar at all time periods. CONCLUSION: Arthroscopic modified tenotomy of the ECRB without débridement improves function and pain significantly for patients with refractory lateral epicondylitis, which is not inferior to arthroscopic débridement technique.

Biomechanics of subscapularis V-shaped tenotomy compared to standard tenotomy.

BACKGROUND: Subscapularis function is critical after anatomic total shoulder arthroplasty (aTSA). Recently, however, a technique has been described that features a chevron or V-shaped subscapularis tendon cut (VT). This biomechanical study compared repair of the standard tenotomy (ST), made perpendicular to the subscapularis fibers, to repair of the novel VT using cyclic displacement, creep, construct stiffness, and load to failure. METHODS: This biomechanical study used 6 pairs of fresh frozen paired cadaveric shoulder specimens. One specimen per each pair underwent VT, the other ST. Subscapularis tenotomy was performed 1 cm from the insertion onto the lesser tuberosity. For VT, the apex of the V was 3 cm from the lesser tuberosity. After tenotomy, each humerus underwent humeral head arthroplasty. Eight figure-of-8 sutures were used to repair the tenotomy (Ethibond Excel; Ethicon, US LLC). Specimens were cyclically loaded from 2 to 100 N at 45 degrees abduction at a rate of 1 Hz for 3000 cycles. Cyclic displacement, creep, and stiffness and load to failure were measured. RESULTS: Cyclic displacement did not differ significantly between the ST and VT from 1 to 3000 cycles. The difference in displacement between the V-shaped and standard tenotomy at 3000 cycles was 1.57 mm (3.66 ± 1.55 mm vs. 5.1 ± 2.8 mm, P = .31, respectively). At no point was the V-shape tenotomy (VT) >3 mm of average displacement, whereas the standard tenotomy (ST) averaged 3 mm of displacement after 3 cycles. Creep was significantly lower for VT in cycles 1 through 3. For all cycles, stiffness was not significantly different in the VT group compared with the ST group. Load to failure was not statistically significant in the VT compared to the standard tenotomy throughout all cycles (253.2 ± 27.7 N vs. 213.3 ± 76.04 N; P = .25, respectively). The range of load to failure varied from 100 to 301 N for standard tenotomy compared with 216 to 308 N for VT. CONCLUSION: This study showed that VT and ST demonstrated equivalent stiffness, displacement, and load to failure. VT had the benefit of less creep throughout the first 3 cycles, although there was no difference from cycle 4 to 3000. The VT had equivalent biomechanical properties to the ST at time zero, an important first step in our understanding of the technique. The VT technique warrants further clinical study to determine if the technique has clinical benefits over ST following aTSA.

Reliability of Percutaneous Achilles Tenotomy in the Treatment of Idiopathic Clubfoot.

BACKGROUND: Talipesequinovarus is a congenital ankle/foot malformation that commonly affects newborns. In its treatment using the Ponseti method, an Achilles tenotomy is frequently needed to correct residual equinus deformity. Percutaneous (PC) tenotomy is the most commonly used technique and needs to be thoroughly evaluated. The question we needed to answer was: "Does PC Achilles tenotomy result in complete tendon sectioning"? METHODS: This clinical study included 56 idiopathic clubfeet in 36 patients who presented during the first 6 months of life and were treated with Ponseti manipulation and casting followed by PC Achilles tenotomy. PC tenotomy was done under general anesthesia, and Thompson's calf squeeze test was performed intraoperatively just after tenotomy. In case of a negative test (ie, ankle plantar flexion with calf squeeze), the percutaneous incision was extended to assess the cause of the negative test. RESULTS: Forty-nine feet (87.5%) had a complete tenotomy, as evidenced by a positive Thompson's calf squeeze test. While 7 feet (12.5%) showed a negative test, and therefore the percutaneous incision was extended and all were found to have an incompletely divided Achilles tendon. The tendons were then completely divided, after which Thompson's test became positive in all. CONCLUSION: Percutaneous Achilles tenotomy is a reliable procedure, but was found to result in incomplete tendon sectioning in 12.5% of cases, affecting the range of ankle dorsiflexion. Thompson's squeeze test is reliable in picking up cases of incomplete tenotomy after the PC technique, and in these cases the incision should be extended for complete sectioning. LEVEL OF EVIDENCE: Level I.

Assessment of Gross Motor Skills in Ponseti-treated Children With Idiopathic Clubfoot at 3 Years Old: Insights from the Peabody Developmental Motor Scale 2.

BACKGROUND: Congenital talipes equinovarus, or clubfoot, can lead to lifelong functional impairments, including diminished gross motor skills (GMS), if left untreated. The Ponseti method corrects idiopathic clubfoot through casting and bracing. Given the importance of GMS in childhood development, this technique must be optimized to support childhood and long-term health outcomes. This study examined immediate posttreatment GMS in 3-year-old children treated with Ponseti, hypothesizing that they would perform on par with their nonclubfoot peers. METHODS: Data from 45 children (33 to 46 mo of age) treated for idiopathic clubfoot were analyzed. The Peabody Developmental Motor Scales, 2nd edition, was used to assess GMS, and logistic regression identified factors influencing Gross Motor Quotient (GMQ) scores. RESULTS: Approximately half (n=22) of the patients exhibited below-average GMS (11th to 25th percentile), with 11 scoring below the 10th percentile. Initial deformity severity, gender, and cast numbers did not impact GMQ. Repeat percutaneous tenotomy was associated with lower GMQs. Brace compliance significantly reduced odds of low GMQs by up to 80%. Age at testing and additional surgery were also linked to below-average and poor GMQs. CONCLUSIONS: GMS appeared to be impaired in almost half of the 3-year-old patients treated for idiopathic clubfoot, so our hypothesis was disproven. Repeat percutaneous tenotomy was associated with lower GMS, necessitating future recognition of patients who might be at risk of relapse. Brace noncompliance emerged as a significant risk factor, emphasizing early identification of these patients and education for their parents. This study offers a benchmark for clinicians and parents, but research on long-term outcomes is needed. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Outcomes of Ponseti Method for the Treatment of Clubfeet in Children With Arthrogryposis.

INTRODUCTION: The Ponseti serial casting method is the method of choice in treating children with congenital clubfeet. The arthrogrypotic clubfoot has traditionally been considered challenging to treat, with higher rates of recurrence and the need for more corrective surgeries. However, initial reports have found promising results in using the Ponseti method to treat arthrogrypotic feet. This study aims to compare the outcomes of idiopathic versus arthrogrypotic clubfeet following initial treatment with the Ponseti serial casting method. METHODS: A retrospective review of medical records from a single institution was conducted. Data was collected from children ages 0 to 18 with idiopathic or arthrogrypotic clubfoot treated from 2002 to 2022 with Ponseti-style serial casting with a minimum 2-year follow-up. Recurrence was defined as the need for additional casting or subsequent surgeries following initial correction. Data was collected on relevant patient demographics, previous treatment, casting records, Achilles tenotomies, and surgical treatments. RESULTS: A total of 352 patients (546 feet) met inclusion criteria. In all, 334 idiopathic and 18 arthrogrypotic patients were analyzed with an average follow-up duration of 3.4 and 4.2 years, respectively. Twelve patients had distal arthrogryposis, and 6 had amyoplasia. In all, 93.4% of idiopathic and 72.2% of arthrogrypotic patients successfully achieved correction with Ponseti casting and Achilles tenotomy. Recurrence rates were significantly higher in the arthrogrypotic group at 83.3% compared with 44.6% in the idiopathic group ( P =0.001). A posterior or posterior medial release was performed in 35.0% of idiopathic and 66.7% arthrogrypotic feet. CONCLUSIONS: We report the largest series of arthrogrypotic clubfeet treated by Ponseti casting to the best of our knowledge. In contrast to earlier reports, our investigation underscores that while the Ponseti method may be able to secure initial correction in arthrogrypotic clubfeet, on average, at a 3-year follow-up, the prognosis is less favorable. These patients exhibit higher recurrence and often require operative treatment. Notably, a posterior medial release may eventually be needed in up to 6 of 10 patients. LEVEL OF EVIDENCE: Level III-therapeutic studies-investigating the results of treatment.

Assessment of function and muscle strength after endoscopic iliopsoas tenotomy to treat iliopsoas impingement after total hip arthroplasty.

PURPOSE: The objective of this study was to evaluate the functional outcome during follow-up (FU) after endoscopic tenotomy for iliopsoas (IP)-cup impingement and to quantitatively analyze the hip flexion strength. METHODS: This was a monocentric, retrospective cohort study of a single surgeon series. Functional assessment was based on the modified Harris score, the Oxford score and the visual analog scale score. Strength was measured with a handheld dynamometer in the sitting and lying position. RESULTS: Thirty-six IP tenotomies for cup impingement were performed between May 2013 and November 2021. Seven (19%) patients were lost to FU. At the time of tenotomy, the mean (standard deviation) age was 62,6 (12,2) and BMI was 26,5 (4,1). The mean FU time after tenotomy to the last FU was 3,6 (0,8) years. All three outcome scores improved from preoperatively to six months postoperatively (p < 0.001). There were no significant change from six months to last FU. The minimal clinically important difference (MCID) of the modified Harris score was set at 25. 20 (69%) patients had values that exceeded the threshold at one month and six months and neutral 19 (65.5%) had values that exceeded the threshold at the last FU. The limp symmetry index concerning hip flexion strength was 63% at 90° and 40% at 30° at the last FU. CONCLUSION: Most patients significantly improved their outcome scores after endoscopic iliopsoas tenotomy, with results remaining consistently stable over time. Despite a significant loss in hip flexion strength, the majority of patients did not report any impairment of their quality of life. STUDY DESIGN: Level III, Retrospective cohort study.

Can the Achilles tendon regenerate completely following percutaneous tenotomy in older children with clubfoot?

PURPOSE: The aims of the study were to document the outcomes of percutaneous Achilles tenotomy (pAT) performed in older children with clubfoot, by assessing the clinical, functional and ultrasonographic evidence of Achilles tendon regeneration. METHODS: A retrospective case series of older children with clubfoot treated between August 2011 and July 2020 was studied. Clinical assessment of ankle range of motion and calf strength, functional assessment of triceps surae muscle endurance by single leg heel-rise test, and ultrasonographic assessment of Achilles tendon echotexture and dimensions to assess tendon regeneration were performed. RESULTS: Percutaneous Achilles tenotomy was performed on 31 children (48 clubfeet) at a mean age of 5.24 ± 2.14 years (1-10.2 years). At a mean follow-up of 4.86 ± 1.97 years, all children demonstrated normal calf strength with mean dorsiflexion range of 13.64° (0-25°) and mean plantarflexion range of 37.95° (10-40°). The heel-rise endurance test was completed by 27 children with mean 25.85 heel rises/minute (range 17-30) and mean height of heel rise of 6.29 cm (range 4-10 cm). Normal fibrillar tendinous echotexture with homogenous echogenicity was seen on ultrasonography in 41 feet (85.4%) with mean tendon width of 9.7 mm (3.3-16 mm) and thickness of 5.1 mm (1.8-15 mm), comparable with unaffected feet. CONCLUSIONS: Clinical, functional and ultrasonographic parameters unequivocally demonstrate complete regeneration of the Achilles tendon, when pAT is performed in older children with delayed-presenting idiopathic clubfoot treated using Ponseti principles.

Minimally invasive ultrasound-assisted cutting thread tenotomy of the deep digital flexor tendon in horses: An ex vivo study.

OBJECTIVE: To evaluate the feasibility and limitations associated with a minimally invasive ultrasound-assisted cutting thread technique for tenotomy of the deep digital flexor tendon (DDFT) in horses. STUDY DESIGN: Ex vivo study. SAMPLE POPULATION: Twenty cadaveric forelimbs. METHODS: Forelimbs were placed on a jig to mimic a standing semiflexed position and the midmetacarpal region was prepared to perform tenotomy of the DDFT using a percutaneous technique with a cutting thread. For that purpose, the thread was placed percutaneously around the DDFT (first dorsally and then palmarly) with the aid of a curved 20 gauge spinal needle. Tendon palpation/manipulation and ultrasonographic assessment assisted thread placement. Procedure time and skin puncture size were recorded. Limbs were then dissected to evaluate the degree of DDFT transection and the presence of any iatrogenic lesions. RESULTS: The DDFT was completely transected in all cases. Minor lesions of the superficial digital flexor tendon were found in 11/20 limbs and considered clinically irrelevant. However, the neurovascular bundle was damaged in 6/20 limbs (four limbs had nerve damage and two limbs had a nerve and either a palmar artery or vein damaged). The skin puncture hole sizes ranged from undetectable to 5 mm long. The average duration of the procedure was 7 min and 38 s (range: 4 min 56 s to 10 min 19 s). CONCLUSION: A DDFT tenotomy can be performed reliably with a percutaneous cutting thread technique. However, refinement of the technique is required to minimize iatrogenic damage. CLINICAL SIGNIFICANCE: The reported technique allows a DDFT tenotomy to be performed in a minimally invasive manner and has the potential to be clinically applicable.

Complications of Percutaneous Tendo-Achilles Lengthening for Treatment and Prevention of Diabetic Foot Ulcers: A Systematic Review.

Percutaneous Achilles tendon lengthening is an effective surgical procedure to treat and prevent forefoot and midfoot ulcerations in patients with diabetes. Patients with diabetes are prone to plantar ulcerations due to a combination of factors, such as peripheral neuropathy, decreased tendon elasticity, peripheral vascular disease, and hyperglycemia. Complications such as re-ulceration and transfer lesion to the heel, associated with a calcaneal gait secondary to over-lengthening, are possible with percutaneous Achilles tendon lengthening. Although percutaneous Achilles tendon lengthening is well accepted, the overall incidence of complication has not been well described. A systematic review of the reported data was performed to determine the incidence of complication for percutaneous tendo-Achilles lengthening when used for the treatment and prevention of diabetic plantar ulcerations. Nine studies involving 490 percutaneous lengthening procedures met the inclusion criteria. The overall complication rate was 27.8% (8% with transfer heel ulcerations). Given the high rate of complications associated with a percutaneous Achilles tendon lengthening, careful patient selection and consideration of these risks should be considered prior to proceeding with this procedure. Additional prospective comparative analyses with standardization of surgical technique, degrees of lengthening achieved, and post-operative weightbearing and immobilization modalities are needed to decrease incidence of complication and achieve higher healing rates.

Staying in the Game: Interventions for Managing Achilles Tendinopathy in the In-Season Athlete.

ABSTRACT: Achilles tendinopathy is a common overuse injury that is traditionally managed with activity modification and a progressive eccentric strengthening program. This narrative review describes the available evidence for adjunctive procedural interventions in the management of midportion and insertional AT, specifically in the athletic population. Safety and efficacy data from available literature on extracorporeal shockwave therapy, platelet-rich plasma, high-volume injectate with or without tendon scraping, and percutaneous needle tenotomy are used to propose an algorithm for treatment of Achilles tendinopathy for the in-season athlete.

Comparison of decrease in elbow flexion strength in patients after tenotomy and tenodesis of the long head of the biceps brachii.

NTRODUCTION: The last two decades have been leading to the development of several types of surgical techniques and procedures to manage the LHB lesions. This paper analyses and compares the difference in muscle strength pre- and post-operatively in two most commonly used surgical procedures - LHB tenotomy and tenodesis. METHOD: The study includes 68 patients who underwent surgery between 2016 and 2020. The patients who had met the prospective study inclusion criteria were divided into two groups based on type of surgery they had undergone (LHB tenotomy or tenodesis); each group consisted of 34. The muscle strength during elbow flexion was measured preoperatively and postoperatively using the Commander Echo Console ultrasound muscle testing device. All patients enrolled in the study had been assessed for elbow flexion strength preoperatively. The muscle strength was measured preoperatively and then 3 years postoperatively (12 to 60 months) on average. CONCLUSION: The study confirmed that the patients who had undergone LHB tenodesis show a significantly lower decrease in elbow flexion strength and a significantly lower incidence of "Popeye" deformity than the patients after LHB tenotomy. Moreover, in the tenodesis group, it was possible to initiate rehabilitation earlier. The incidence of postoperative complications was almost identical in both groups of patients (Tab. 10, Fig. 6, Ref. 40).