Surgical excision of symptomatic mature posttraumatic myositis ossificans: characteristics and outcomes in 32 athletes.

PURPOSE: The purpose of this study was to report characteristics and outcomes of surgical excision of symptomatic mature posttraumatic myositis ossificans in adult athletes. The hypothesis was that surgical excision of the ossified mass in these circumstances can effectively relief symptoms and result in return to high-level sports with minimal postoperative complications. METHODS: All operations involving excision of posttraumatic heterotopic ossifications performed between 1987 and 2015 were reviewed. Included cases had isolated excision of posttraumatic myositis ossificans, whereas excluded cases had: (1) concomitant reattachment of tendon to bone; (2) chronic overuse injuries which preceded the development of the heterotopic mass or large calcifications which were excised from tendon-to-bone insertions; and (3) excision of heterotopic ossification from a ligament, capsule, or tendon insertion following avulsion injury without tendon-to-bone repair. After surgery, return to sports was allowed at 4-6 weeks. RESULTS: Of 57 athletes undergoing excision of heterotopic ossifications, 32 were eligible as isolated excision of posttraumatic myositis ossificans. Twenty-four (75%) were ice hockey or soccer players. Median age was 23 years. Prior to surgery, patients were unable to continue their sports. At surgery, the ossification was excised from a thigh muscle in 27 (84%) cases. Median follow-up was 2 years (range 1-20 years). Outcome was Good/Excellent in 26 (81%) patients, corresponding to return to preinjury sports with minimal symptoms at sports activities. Preinjury Tegner activity level was resumed after surgery in 30 of 32 (94%) athletes, of whom 28 (94%) were involved in high-level sports corresponding to Tegner levels 8-10. No postoperative complications were recorded other than minimal insensitive areas at the periphery of skin incisions. CONCLUSION: In high-level athletes who present chronic disabling mature posttraumatic myositis ossificans that interferes with their sports career, surgical excision of the heterotopic mass results in effective clinical improvement with return to sports and minimal postoperative risks. LEVEL OF EVIDENCE: Case series, Level IV.

Clinical principles in the management of hamstring injuries.

PURPOSE: Hamstring injuries are among the most common muscle injuries seen in sports clinical practice. This narrative review covers essential knowledge of hamstring injuries, ranging from strains to total proximal three-tendon ruptures. The primary aim is to provide basic information for clinicians and sports medicine therapists dealing with hamstring problems. METHODS: In this review, existing literature of hamstring injuries was taken together. Emphasis was given to subjects less well covered in previous reviews, such as preventive measures, as well as the most relevant information needed in the treatment of these injuries. RESULTS: Occasionally, symptoms remain after hamstring injuries which can be successfully treated with surgery. Knowledge of the effectiveness of preventive measures and nonsurgical and surgical treatment is limited by small studies of low evidence level. CONCLUSIONS: Evidence-based treatment algorithms are not available. Larger studies of better quality with more concrete grading of hamstring tears are needed to improve knowledge in prevention and treatment of hamstring injuries. LEVEL OF EVIDENCE: IV.

Triceps tears in athletes: different injury patterns and surgical treatment.

INTRODUCTION: Triceps muscle tears requiring surgical treatment are uncommon injuries. METHOD: We present 10 cases, all of them were athletes. All these patients were treated surgically between 1993 and 2009. Three operations were performed in the acute phase and the rest seven cases an average of 6 months (range 3-12 months) after the primary injury. The mean follow-up period after surgery was 6 years (range 2-9 years). RESULTS: The result was evaluated to be excellent in five cases, good in four, and fair in one patient. All except one patient were able to resume full training. CONCLUSION: Our results show that surgical treatment seems to be beneficial in severe triceps tears even after failed conservative treatment.

Central Tendon Injuries of Hamstring Muscles: Case Series of Operative Treatment.

BACKGROUND: As compared with injuries involving muscle only, those involving the central hamstring tendon have a worse prognosis. Limited information is available regarding the surgical treatment of central tendon injuries of the hamstrings. PURPOSE: To describe the operative treatment and outcomes of central tendon injuries of the hamstrings among athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eight athletes (6 top level, 2 recreational) with central hamstring tendon injuries underwent magnetic resonance imaging and surgical treatment. The indication for surgery was recurrent (n = 6) or acute (n = 2) central hamstring tendon injury. All patients followed the same postoperative rehabilitation protocol, and return to play was monitored. RESULTS: Magnetic resonance imaging found a central tendon injury in all 3 hamstring muscles (long head of the biceps femoris, semimembranosus, and semitendinosus) with disrupted tendon ends. In acute and recurrent central tendon injuries, full return to play was achieved at 2.5 to 4 months. There were no adverse events during follow-up. CONCLUSION: Central tendon injuries of the hamstrings can be successfully repaired surgically after acute and recurrent ruptures.

Distal tears of the hamstring muscles: review of the literature and our results of surgical treatment.

BACKGROUND: Hamstring strains are among the most frequent injuries in sports, especially in events requiring sprinting and running. Distal tears of the hamstring muscles requiring surgical treatment are scarcely reported in the literature. OBJECTIVE: To evaluate the results of surgical treatment for distal hamstring tears. DESIGN: A case series of 18 operatively treated distal hamstring muscle tears combined with a review of previously published cases in the English literature. Retrospective study; level of evidence 4. SETTING: Mehiläinen Sports Trauma Research Center, Mehiläinen Hospital and Sports Clinic, Turku, Finland. PATIENTS: Between 1992 and 2005, a total of 18 athletes with a distal hamstring tear were operated at our centre. MAIN OUTCOME MEASUREMENTS: At follow-up, the patients were asked about possible symptoms (pain, weakness, stiffness) and their return to the pre-injury level of sport. RESULTS: The final results were rated excellent in 13 cases, good in 1 case, fair in 3 cases and poor in 1 case. 14 of the 18 patients were able to return to their former level of sport after an average of 4 months (range 2-6 months). CONCLUSIONS: Surgical treatment seems to be beneficial in distal hamstring tears in selected cases.

Recurrent and chronic complete ruptures of the proximal origin of the hamstring muscles repaired with fascia lata autograft augmentation.

Hamstring injuries are common, especially among athletes. A complete rupture of the proximal hamstring muscles requires surgical intervention. In this report we describe a reconstruction method for a complete proximal hamstring rupture using fascia lata autograft augmentation in addition to suture anchors. This method can be advocated in cases in which the primary repair has failed or in chronic injuries where a large defect between the distally retracted tendons and the ischial tuberosity prevents anatomic reinsertion. In our technique, a muscle-tendon flap is first created from the retracted tendon stump, turned proximally, and fixed to the ischial tuberosity by suture anchors. The fascia lata graft is then fixed from the midpart to the ischial tuberosity via the same sutures. The other sleeve of the graft is folded on the ventral side of the ruptured tendon stump and fixed by use of absorbable sutures. Then the other sleeve is folded on the dorsal side and fixed in the same manner. Finally, the fixation can still be reinforced with additional absorbable sutures passing through both sleeves of the graft, as well as the muscle-tendon bridge and the tendon stump.

Tension-band wiring for fractures of the fifth metatarsal located in the junction of the proximal metaphysis and diaphysis.

BACKGROUND: Fractures of the proximal fifth metatarsal, other than those involving the tuberosity, have a tendency to delayed union or even nonunion. HYPOTHESIS: Tension-band wire technique is a good alternative in treating fractures of the fifth metatarsal located in the proximal junction of the metaphysis and the diaphysis. STUDY DESIGN: Case series; level of evidence, 4. METHODS: Between 1996 and 2001, a total of 27 cases of proximal metaphysial/diaphysial fractures of the fifth metatarsal were treated with tension-band wiring. All of the patients had undergone prior unsuccessful nonoperative or operative treatment. The mean delay from the diagnosis of the fracture to the final operative procedure was 19.5 weeks (range, 6-48 weeks). RESULTS: The mean length of follow-up was 35 months (range, 12-70 months). All patients were able to return to their prior levels of activity. The mean time for union as shown on radiographs was 12.8 weeks, and the return to full activity took 8 to 20 weeks (mean, 14.7 weeks). There were no delayed unions, nonunions, or refractures during the follow-up. CONCLUSION: The tension-band wire technique seems to give good results in the treatment of proximal metaphysial/diaphysial fractures of the fifth metatarsal in cases of primary unsuccessful nonoperative treatment or primary unsuccessful intramedullary screw fixation.

Different distributions of operative diagnoses for Achilles tendon overuse injuries in Italian and Finnish athletes.

BACKGROUND: the origin of chronic Achilles tendinopathy (AT) is currently unclear and epidemiological factors, such as ethnicity, may be associated. METHODS: intraoperative findings from the treatment of 865 Finnish and 156 Italian athletic patients with chronic Achilles tendon related pain were evaluated, retrospectively. The mean age was 34 years (range, 18 to 65 years) in the Finnish and 29 years (range, 17-63 years) in the Italian patients. In total, 786 patients were males and 226 females of which 84 and 87% Finnish, respectively. Data were collected, retrospectively from patient records. The differences in the frequencies of operative findings were assessed for statistical significance. RESULTS: retrocalcaneal bursitis, partial tear and chronic paratenonitis were the most prevalent findings in patients with chronic AT undergoing surgery. Tendinosis and chronic paratenonitis were significantly (p=0.011) more common in Finnish athletes. Italian patients exhibited significantly (p<0.001) more insertional calcific tendinopathy (heel spurs) and prominent posterosuperior calcaneal corners (Haglund's heel). CONCLUSION: ethnicity appears to be associated with specific characteristics of overuse-related Achilles tendon pathology. This is an issue that should be considered in the planning of genetic research on AT.

Surgical excision of posttraumatic ossifications at the proximal hamstrings in young athletes: technique and outcomes.

BACKGROUND: Proximal hamstring tears can be associated with chronic disability related to the unusual formation of heterotopic ossifications. The role for operative intervention in these circumstances has not been clearly defined. PURPOSE/HYPOTHESIS: The purpose of this study was to describe the surgical management of young athletes who had chronic disability related to proximal hamstring ossifications after eccentric load injuries. The hypothesis was that after surgical excision of posttraumatic heterotopic ossifications at the proximal hamstrings with concomitant repair of the tendons to the ischium, significant functional improvement with low risk of postoperative complications can be expected at minimum 2-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The cases of 11 consecutive male athletes who developed chronic disability associated with heterotopic ossifications at the proximal hamstring muscles after sports-related tears were reviewed. During surgery, the ossified mass was meticulously excised, and the tendons were debrided and fixed to the ischium. At minimum 2-year follow-up, self-reported outcome was rated as excellent, good, moderate, or poor. Operative reports and office visits were reviewed. Activity level before the injury and at latest follow-up was graded with the Tegner scale. RESULTS: The median age at injury was 17 years (range, 13-25 years). Sports activities included ice hockey, soccer, track and field athletics, and judo. Mean interval from injury to surgery was 45 months. The smallest ossified mass was 2 × 2 × 4 cm and the largest, 3 × 4 × 9 cm. Median follow-up was 4 years (range, 2-10 years). Six patients had excellent, 1 patient had good, and 4 patients had moderate outcomes; 7 of them were able to return to preinjury activities (Tegner score, 7-10). There were 2 cases of loss of skin sensation at the posterior femoral cutaneous nerve distribution, but neither patient described this as significantly interfering with any activity. All patients had symmetric side-to-side single-legged hop test and a 5 out of 5 on hamstring muscle strength at latest follow-up. CONCLUSION: Heterotopic ossifications that develop at the proximal hamstrings after eccentric load injuries can be associated with significant chronic disability. These cases can be effectively treated by surgical excision of the ossified masses and concomitant debridement with suture fixation of the proximal hamstring tendons to the ischium. Return to preinjury activities is expected in the majority of these cases, with low postoperative risks.

Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy.

BACKGROUND: proximal hamstring tendinopathy (PHT) is a disabilitating disease often causing underperformance in the athletically demanding patients. The main symptom of PHT is lower gluteal pain especially during running or while prolonged sitting. Mainly affecting athletically active individuals, PHT is a considerable challenge for treating health care professionals. PURPOSE: this paper aims to concisely present the literature on PHT to guide health care professionals treating these patients and doing research on the subject. METHODS: we reviewed the literature on PHT through literature search of scientific journal databases. CONCLUSIONS: as a tendinopathic pathology, it is a rather recently discovered exertion injury. As with other chronic tendon overuse injuries, current treatment strategies are unspecific with uncertain outcomes due to the unknown etiology of the tendon degeneration. Diagnostic features as well as both operative and non-operative treatments are evaluated from a clinical perspective, providing up to date information for clinicians and sports medicine therapists dealing with hamstring problems. LEVEL OF EVIDENCE: V.

Comparison of two procedures for meniscal cysts. A report of 35 patients with a mean follow-up of 33 months.

BACKGROUND: The cause, pathogenesis, and appropriate treatment of meniscal cysts remain controversial. PURPOSE: We wanted to evaluate the results of treatment of meniscal cysts with two different operative procedures. STUDY DESIGN: Prospective cohort study. METHODS: Two different operative procedures were compared. Sixteen patients (group 1) had an open excision of the cyst performed in addition to arthroscopic examination of the knee. Nineteen patients (group 2) were treated entirely arthroscopically. The postoperative treatment course was the same for both groups. The mean length of follow-up was 33 months. RESULTS: The results were excellent or good in 86% of the patients (30 of 35) and were equally good for both procedures. Patients with degenerative changes of the knee joint seemed to have a less favorable outcome. CONCLUSIONS: Good or excellent results can be expected from either open or arthroscopic treatment of meniscal cysts.

Observation of anomalous insertion of the medial meniscus on the anterior cruciate ligament.

We wanted to determine the frequency of occurrence and types of anomalous insertions of the medial meniscus to the anterior cruciate ligament (ACL) in Finnish patients. In 987 consecutive arthroscopies from January 1996 to August 1998, the meniscal pathology was mapped using videoprints and drawings. We found 11 anomalous medial meniscus insertions to the ACL. There were 4 female and 6 male patients in the series. In 1 woman, the anomaly was bilateral. The mean age of the patients was 30.6 years (range 14 to 63 years). The anomalous band was excised in all patients. The anomaly usually was not the finding that caused the need for arthroscopy. In 3 knees, the anomaly was the only pathologic finding. The frequency of this anomaly occurring was approximately 1.2%. The anomalous medial meniscus insertion to the ACL is a very rare clinical finding. Arthroscopic surgeons should be aware of its existence as well as of other anterior horn insertion variations of the medial meniscus.

Macroscopic Anomalies and Pathological Findings in and Around the Achilles Tendon: Observations From 1661 Operations During a 40-Year Period.

BACKGROUND: Nonsurgical treatments for chronic Achilles tendinopathy (AT) results in unpredictable success rates. Surgical treatment may be chosen as reports show mostly encouraging but variable success rates depending on the pathology. The distribution of surgically confirmed pathologies in AT is largely unknown. PURPOSE: To ascertain the distributions of macroscopically observed anomalies in participants undergoing surgical treatment for chronic AT. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The main macroscopic pathologies of 1661 chronic Achilles tendon overuse injuries, which were diagnosed and surgically treated by a single surgeon, were reviewed. The surgeries were performed on professional and recreational athletes during the years 1976-1980, 1986-1990, 1996-2000, and 2006-2010. Surgical diagnoses, along with age- and sport-specific characteristics, were collected retrospectively from patient records. RESULTS: The relative proportion of tendinosis increased during the study period from 4.2% to 21%, and paratenonitis decreased from 50% to 26%. Retrocalcaneal pathologies were the most common surgically confirmed lesions at 30%, while the mean age at surgery increased by 11 years over the entire study period. CONCLUSION: Surgically confirmed pathologies in and around the Achilles tendon showed coherent changes, chronic paratenonitis, and retrocalcaneal problems as the most prevalent findings. The classification of midportion and insertional tendinopathy and retrocalcaneal bursitis in AT should strictly be used as a clinical diagnosis. During surgical evaluations, the diagnosis is further clarified as more specific pathologies may be identified.

A combination of Latarjet and Remplissage for treatment of severe glenohumeral instability and bone loss. A case report.

Recurrent glenohumeral instability is challenging to treat when large bony defects are present in the anterior glenoid and there is a large Hill-Sachs lesion. We present a case with extensive glenoid and humeral bone loss treated with open Latarjet procedure combined with posterior arthroscopic Remplissage. 3.5 years after surgery, there have been no dislocations or any subjective signs of instability. After half a year, the patient was able to return to work as an airline pilot. Constant score has improved from 33 to 74 and the Oxford instability score from 8 to 46. We find that in young patients with difficult instability combining the Latarjet and Remplissage is a good and replicable method.

Calcific spurs at the insertion of the Achilles tendon: a clinical and histological study.

In active people, insertional calcific tendinopathy (CT) of the Achilles tendon is rare. We evaluated the results of surgical treatment for Achilles tendon CT and analyzed post-surgery Achilles tendon histological features. The study included 36 operations in 34 patients. Twenty-eight (78%) cases had a resection of a Haglund's deformity performed. The mean age of the patients was 42 years (range=23 to 68). Thirteen of the patients were professional athletes and 20 recreational athletes. In twenty-five (69%) cases, the result of surgery was rated good, in nine cases (25%) moderate and in two (6%) cases poor. The mean age of those with a good result was 10 years lower (40 versus 50 years) than those with a moderate result (p=0.0239). Higher athletic activity was also related to a better outcome (p=0.0205). Histology samples showed fast remodellation and stem-cell activation. Surgery seemed to result in a good outcome in patients with or without a Haglund's deformity which failed conservative treatment.

All-arthroscopic double-bundle coracoclavicular ligament reconstruction using autogenous semitendinosus graft: a new technique.

We present our novel arthroscopic anatomic double-bundle coracoclavicular ligament reconstruction technique using a semitendinosus tendon autograft. The dorsal limb of the graft is positioned around the dorsal edge of the clavicle, re-creating the conoid ligament. The anterior limb proceeds superiorly and re-creates the trapezoid ligament. The solution effectively stabilizes the acromioclavicular joint and prevents anterior posterior translation. This new arthroscopic double-bundle coracoclavicular joint reconstruction is an effective and reliable method in stabilizing the clavicle and neutralizing the anterior-posterior translation, and we find it to be technically practical for the surgeon.

Proximal hamstring tendinopathy: results of surgical management and histopathologic findings.

BACKGROUND: Tendon disorders are common problems in sports and are known to be difficult to treat. Only limited information is available concerning treatment of proximal hamstring tendinopathy. To the authors' knowledge, no histopathologic findings of proximal hamstring tendinosis have been published. HYPOTHESIS: Surgery (semimembranosus tenotomy and exploration of the sciatic nerve) is an effective treatment for proximal hamstring tendinopathy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 103 cases of proximal hamstring tendinopathy in athletes (58 men, 32 women; 13 bilateral operations) with surgical treatment were included. The cases were retrospectively analyzed, and a 4-category rating system was used to evaluate the overall result. At the follow-up, the patients were asked about possible symptoms and their return to sports. Biopsy samples from 15 of the operated tendons were taken and analyzed by a pathologist. RESULTS: The average follow-up was 49 months (range, 12-156 months). The result was evaluated to be excellent in 62 cases, good in 30, fair in 5, and poor in 6. After surgery, 80 of the 90 patients were able to return to the same level of sporting activity as before the onset of the symptoms. This took a mean of 5 months (range, 2-12 months). Typical morphologic findings of tendinosis were found in all biopsy specimens. CONCLUSION: Given the good functional outcome and low complication rate, the authors present surgical treatment as a valuable option in proximal hamstring tendinopathy if conservative treatment fails.

Complete proximal hamstring avulsions: a series of 41 patients with operative treatment.

BACKGROUND: Complete proximal hamstring avulsions can cause considerable morbidity and are often associated with significant functional loss. HYPOTHESIS: Early surgical treatment leads to better results than does surgery in the chronic phase. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Forty-one patients (21 men and 20 women) with a complete proximal hamstring avulsion were included. The cases were retrospectively analyzed, and a 4-category rating system was used to evaluate the overall result of the surgical treatment. RESULTS: The mean follow-up was 37 months (range, 12-72 months). Nineteen patients were rated as having an excellent result and 10 patients a good result. In 5 patients, the result was classified as moderate and in 7 patients poor. In the patients with an excellent or good result, the delay from the injury to surgery averaged 2.4 months, whereas in patients with a moderate or poor result, the delay averaged 11.7 months. The difference was statistically significant (P < .001). CONCLUSION: Excellent or good results can often be expected with surgery, and considerable improvement of symptoms may be achieved even in chronic cases. According to the results, early operative treatment in complete proximal avulsions of the hamstring muscles gives better results than does late surgery and is therefore recommended.

Distal patellar tendinosis: an unusual form of jumper's knee.

Jumper's knee is a common problem in athletes participating in sports that involve running and jumping. Typically activity related pain is felt at the proximal insertion of the patellar tendon. Symptoms and findings in the more distal parts of the patellar tendon are unusual. All of the patients in this retrospective study were active athletes suffering from distal patellar tendinosis. There were 19 men and four women. The mean age of the patients was 24 years (range 12-32). All of the patients were operated on after conservative treatment lasting for an average of 23 months had failed. After a mean postoperative follow-up of 42 months 21 of the knees were rated good meaning that the athlete had returned to the prior level of activity without any symptoms. In three knees the result was fair as the patients benefited from the operation but there were some remaining symptoms. No poor results were reported. All patients were able to return to their previous level of sports 8-12 weeks after surgery. Operative treatment seems to give good results in most cases after unsuccessful conservative treatment of the unusual distal patellar tendinosis in athletes.

Intra-articular cysts and ganglia of the knee: a report of nine patients.

Completely intra-articular cysts and ganglia of the knee are rare. They have been found in various locations such as on the anterior or posterior cruciate ligaments, in the infrapatellar fat pad, on the posterior wall of the posteromedial compartment and (very rarely) in connection to the menisci. We analyzed nine patients with intra-articular cysts or ganglia found in a series of 2,400 consecutive arthroscopies. In four patients, the cyst or ganglion was found attached to the anterior part of the ACL, in two patients it was located between the ACL and the PCL, and in the remaining three cases it was found in connection with the meniscus. In three out of the nine patients there was either no or very minor additional pathology found in the knee besides the cyst or the ganglion. We believe that intra-articular cysts and ganglia of the knee can be symptomatic, and excellent or good results after cyst removal can be expected especially when there is little additional pathology.