Outcome of Trapeziectomy and Ligament Reconstruction and Tendon Interposition for Patients Aged Less Than 56 Years: A Retrospective Study With a Minimum 5-Year Follow-Up.

PURPOSE: The purpose of this study was to determine the long-term consequences of trapeziectomy and ligament reconstruction and tendon interposition (LRTI) for trapeziometacarpal osteoarthritis in patients aged less than 56 years. METHODS: A retrospective study was performed to investigate the outcome of trapeziectomy and LRTI with a follow-up period of greater than 5 years in patients aged less than 56 years at the time of surgery. Patients completed the Disabilities of Arm, Shoulder, and Hand (DASH), the Patient-Rated Wrist Evaluation (PRWE), and a 10-point visual analog score for pain (VAS). Objective assessments included thumb opposition, palmar and radial abduction angles, and grip, lateral key, and thumb tip pinch strengths. Radiographic assessments of the thumb carpometacarpal joint were performed in three planes, and the trapezial space and trapezial space to metacarpal height ratios were calculated. RESULTS: Between January 2005 and December 2017, 105 patients were treated. Forty-eight patients with 58 thumbs returned for review. The mean patient age at the time of surgery was 52.5 years, and 96% of the patients were women. The mean follow-up period from surgery was 11 years. The mean VAS score was 1. A significant association was found between younger age at the time of surgery and increased proximal migration of the metacarpal, between high VAS pain scores and high PRWE and DASH scores, weak grip, lateral key pinch and thumb tip pinch strength, and Kapandji score, and between the follow-up period and increasing VAS pain, PRWE, and DASH scores. CONCLUSIONS: Trapeziectomy and LRTI are effective procedures for patients aged less than 56 years. The benefits of surgery should be balanced against the deterioration in the outcome measures of DASH and PRWE and increasing VAS scores with increasing intervals from surgery. TYPE OF STUDY/LEVEL EVIDENCE: Therapeutic IV.

Range of Motion Following Flexor Tendon Repair: Comparing Active Flexion and Extension With Passive Flexion Using Rubber Bands Followed by Active Extension.

PURPOSE: This study aimed to compare the outcome in terms of range of motion between early active flexion and extension (early active motion, [EAM]) and passive flexion using rubber bands followed by active extension (sometimes referred to as a Kleinert regimen) after flexor tendon repair in zones 1 and 2. METHODS: Data were collected from the Swedish national health care registry for hand surgery (HAKIR). Rehabilitation regimens were decided by the preference of each caregiver. At 3 months, 828 digits (656 EAM and 172 passive flexion) and at 12 months, 448 digits (373 EAM and 75 passive flexion) were available for analysis. Thumbs were analyzed separately. RESULTS: No notable difference in total active motion was found between the groups at 12 months of follow-up. CONCLUSIONS: This large registry study supports the hypothesis that EAM rehabilitation may not lead to better range of motion long-term than passive motion protocols. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Tendon Lengthening Surgery for Elbow Flexion Contractures in Brachial Plexus Birth Palsy.

PURPOSE: Flexion contracture of the elbow is a common deformity associated with brachial plexus birth palsy and is often managed with preventive night orthoses. For severe cases, however, surgical interventions may become necessary. This study evaluated the effectiveness of surgically releasing elbow flexion contractures exceeding 30° through partial tenotomy of the brachialis and biceps brachii muscles, along with a division of the lacertus fibrosus. METHODS: We performed 36 anterior elbow releases on patients with injury to the upper trunk (C5-C6) of the brachial plexus and elbow flexion contractures between 30° and 80°. All releases involved lacertus fibrosus section and partial lengthening of the distal portion of the brachialis tendon. In severe cases, biceps brachii tenotomy was also performed. All participants had a minimum follow-up of 12 months and preoperative elbow flexion strength of at least grade 4 on the British Medical Research Council scale, with no deformities in the shape of the ulnohumeral joint or radial head subluxation. RESULTS: Following a mean follow-up of 41 months, the average extension gain was 31° (range, 10°-50°). All patients maintained their flexion strength. Except for two participants with weaker triceps, the mean elbow extension gain was sustained throughout the follow-up period. There were no major or minor complications or reinterventions in the study. CONCLUSIONS: Partial tenotomy of the brachialis and biceps brachii muscles, coupled with lacertus fibrosus section, is an effective treatment for elbow contractures exceeding 30° flexion. This method is successful in individuals with a functioning triceps brachii and elbow extension strength of at least grade 3 on the British Medical Research Council scale. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Regional changes in the free Achilles tendon volume in response to repeated submaximal contractions.

INTRODUCTION: The Achilles tendon (AT) may become smaller in volume following acute bouts of heavy and sustained loading likely because of transient fluid exudation to the periphery and this could augment cellular mechanotransduction and tendon adaptation. Given the structure of the AT is distinct across its length, regional changes in the free AT volume may occur in response to loading. This study aimed to investigate whether the change in tendon volume in response to repeated submaximal loading is distinct across the free AT length. METHODS: Sixteen ATs of healthy males and females (age 24.4 ± 9.4 years, body mass 70.9 ± 16.1 kg, height 1.7 ± 0.1 m) were scanned at rest using freehand 3D ultrasound. Scanning was done before and immediately after submaximal (75 %) voluntary isometric plantarflexion contractions (8 s) involving four sets of ten repetitions. Regional volumetric changes were assessed across the free AT length by dividing the tendon into distal, mid, and proximal regions. RESULTS: Significant reduction in the free AT volume occurred across all tendon regions in response to the intervention, however, the mid- region exhibited the greatest reduction in volume compared to the proximal region (P = 0.025). DISCUSSION: The fact that volume reduction was greatest in the mid-region compared to the proximal region of the free AT may suggest greater tendon adaptation, via mechanotransduction pathways, in the mid-region and this may be important for tendon health and injury prevention.

Biomechanical analysis of cadaver rabbit Achilles tendons after full transection and suture: Comparison of U-Tang 4-strand with the cross-locked version of U-Tang 4-strand suture technique.

Introduction: Tendon injures rank as the second most common hand injuries, and unsatisfactory repair can significantly impact a patient's everyday life. Over the years, various suture techniques have been studied in the pursuit of finding the optimal repair method. The ideal tendon repair should achieve maximum strength, while being easy to perform and minimizing tissue trauma. This study aims to compare the mechanical properties of the cross-locked U-Tang 4-strand suture to its unmodified version, the U-Tang 4-strand suture, to assess which technique offers greater repair strength. Methods: Sixteen Achilles tendons from New Zealand White rabbits were randomly assigned to one of two suture technique groups; an original U-Tang 4-strand suture or a cross-locked U-Tang 4-strand suture, both performed using a 4-0 Supramid thread. The specimens were tested in uniaxial tension after a preconditioning phase. Cross-sectional area, load until failure, gap formation, stiffness, elastic modulus, and failure stress were determined. Results: The standard U-Tang 4-strand suture withstood a maximum force of 25.48 ± 6.06 N, while the cross-locked version endured 33.90 ± 6.09 N. This indicates that the modified version demonstrated significantly greater strength (p = 0.021). The elastic modulus of the cross-locked U-Tang 4-strand suture (0.02 ± 0.003 MPa) was significantly higher than that of the original version (0.01 ± 0.006 MPa) (p = 0.028). No significant differences were observed regarding the cross-sectional area, load at 2 mm gap formation, stiffness and failure stress. Conclusion: Employing the cross-locked U-Tang 4-strand suture results in a significantly greater maximum force and elastic modulus compared to the original U-Tang 4-strand suture, utilizing the same thread and number of strands and knots. Therefore, the cross-locking version provides an alternative for achieving more stable initial repair strength.

Spontaneous Bilateral Patellar Tendon Rupture in Patient with Ehlers-Danlos Syndrome: A Case Report.

Introduction: Bilateral spontaneous patellar tendon ruptures are rare, though it is hypothesized to be more common in patients with risk factors such as connective tissue disorders such as Ehlers-Danlos syndrome (EDS), systemic disorders weakening collagen structures, chronic stress around the patellar tendon, medications, and obesity or sedentary lifestyles. Clinicians should maintain a high degree of clinical suspicion for concerning features on clinical examination and radiological investigations to facilitate prompt diagnosis and operative management. This case report describes the first documented case of an adult patient with EDS who sustained bilateral spontaneous patellar tendon ruptures. There is one previously reported acute bilateral patellar tendon rupture occurring in a pediatric patient with EDS. Within the adult literature, two case reports have reported patients with EDS: One acute unilateral patellar tendon rupture who underwent operative management and one chronic patellar tendon tear requiring reconstruction 2.5 years following initial end-to-end repair. Case Report: A 45-year-old male sustained bilateral patellar tendon ruptures after falling onto his knees while pushing a heavy cart. The patient reported a giving-way sensation and was unable to mobilize independently. On presentation to the emergency department, the patient was noted to have an absent straight-leg raise and a palpable gap between the distal pole of the patella and patellar tendon. Plain radiograph and ultrasound investigations confirmed bilateral complete patellar tendon ruptures. The patient underwent operative management 5 days following injury through bilateral direct patellar tendon repair utilizing the Krackow technique with transosseous fixation. Twelve months post-operatively, the patient had returned to pre-injuries activities of daily living, a full active range of motion without extensor lag, and recorded "fair knee function" on the Lysholm Knee Scoring Scale. Conclusion: This case report described the first reported bilateral spontaneous patellar tendon rupture in an adult patient with EDS, who underwent operative management and achieved a return to pre-injury function. Furthermore, this case report summarizes the pre-existing literature on spontaneous bilateral patellar tendon ruptures and patellar tendon ruptures in patients with EDS.

Dorsal Translocation of the Flexor Pollicis Longus Tendon Following Pediatric Both Bone Forearm Fracture.

Tendon entrapment is a rare complication of closed forearm fractures. A 16-year-old boy sustained a type 1 open both bone forearm fracture after falling from a skateboard. The injury was initially managed with irrigation, debridement, and flexible intramedullary nailing. Seven weeks after surgery, a flexion contracture of the ipsilateral thumb interphalangeal joint was noted. Subsequent hardware removal and hand therapy failed to improve thumb extension. The patient was taken to the operating room for planned tenolysis and possible tendon reconstruction. Intraoperatively, the flexor pollicis longus tendon was found to be wrapped around the radial shaft as an apparent complication of the initial procedure, which necessitated division and reconstruction of the tendon. To our knowledge, this is the first pediatric reported case of dorsal flexor pollicis longus tendon entrapment through the fracture site in a both bone forearm fracture requiring tendon reconstruction. This case highlights a unique surgical approach to a novel complication of pediatric both bone forearm fracture.

Locked Posterior Shoulder Dislocation with Accompanying Fracture: A Debilitating Rare Injury for Athletes?

Shoulder dislocation is undoubtedly one of the most common injuries in traumatology. Posterior dislocation of the shoulder is regarded as comparatively rare compared to anterior dislocation, whilst it is strikingly extraordinary for this type of injury to be accompanied by a concomitant fracture. Accurate diagnosis and appropriate treatment can be considerably demanding, while being vitally important in this exceedingly rare condition. These injuries are broadly considered to be under-reported in the existing literature, especially among high-demand athletes. We present a rare case of a high-demand athlete sustaining a traumatic locked posterior shoulder dislocation with an accompanying fracture treated in our Institution. A detailed clinical examination and plain radiography revealed the peculiar condition, and a CT scan was subsequently performed for more thorough evaluation of the injury. The patient underwent surgery on the day following admission for repair of the extensive shoulder damage, and a deltopectoral approach was utilized. Reduction of the metaphyseal fracture and the dislocation was accomplished with gentle manipulations, and stabilization was obtained with an anatomic plate. A modified McLaughlin procedure was carried out to address the reverse Hill-Sachs lesion. The postoperative period was uneventful, followed by a painstaking physical rehabilitation program, and the patient returned successfully to his sporting activities 6 months postoperatively. By presenting this thought-provoking case, we stress the challenging nature of these immensely infrequent injuries while also highlighting the requirement for more sensitive factor-specific studies regarding their optimal treatment.

Brain-body-task co-adaptation can improve autonomous learning and speed of bipedal walking.

Inspired by animals that co-adapt their brain and body to interact with the environment, we present a tendon-driven and over-actuated (i.e., n joint, n+1 actuators) bipedal robot that (i) exploits its backdrivable mechanical properties to manage body-environment interactions without explicit control, and (ii) uses a simple 3-layer neural network to learn to walk after only 2 minutes of 'natural' motor babbling (i.e., an exploration strategy that is compatible with leg and task dynamics; akin to childsplay). This brain-body collaboration first learns to produce feet cyclical movements 'in air' and, without further tuning, can produce locomotion when the biped is lowered to be in slight contact with the ground. In contrast, training with 2 minutes of 'naive' motor babbling (i.e., an exploration strategy that ignores leg task dynamics), does not produce consistent cyclical movements 'in air', and produces erratic movements and no locomotion when in slight contact with the ground. When further lowering the biped and making the desired leg trajectories reach 1cm below ground (causing the desired-vs-obtained trajectories error to be unavoidable), cyclical movements based on either natural or naive babbling presented almost equally persistent trends, and locomotion emerged with naive babbling. Therefore, we show how continual learning of walking in unforeseen circumstances can be driven by continual physical adaptation rooted in the backdrivable properties of the plant and enhanced by exploration strategies that exploit plant dynamics. Our studies also demonstrate that the bio-inspired co-design and co-adaptations of limbs and control strategies can produce locomotion without explicit control of trajectory errors.

Pharmacological antagonism of Ccr2+ cell recruitment to facilitate regenerative tendon healing.

Successful tendon healing requires sufficient deposition and remodeling of new extracellular matrix at the site of injury, with this process mediating in part through fibroblast activation via communication with macrophages. Moreover, resolution of healing requires clearance or reversion of activated cells, with chronic interactions with persistent macrophages impairing resolution and facilitating the conversion to fibrotic healing. As such, modulation of the macrophage environment represents an important translational target to improve the tendon healing process. Circulating monocytes are recruited to sites of tissue injury, including the tendon, via upregulation of cytokines including Ccl2, which facilitates recruitment of Ccr2+ macrophages to the healing tendon. Our prior work has demonstrated that Ccr2-/- can modulate fibroblast activation and myofibroblast differentiation. However, this approach lacked temporal control and resulted in healing impairments. Thus, in the current study we have leveraged a Ccr2 antagonist to blunt macrophage recruitment to the healing tendon in a time-dependent manner. We first tested the effects of Ccr2 antagonism during the acute inflammatory phase and found that this had no effect on the healing process. In contrast, Ccr2 antagonism during the early proliferative/granulation tissue period resulted in significant improvements in mechanical properties of the healing tendon. Collectively, these data demonstrate the temporally distinct impacts of modulating Ccr2+ cell recruitment and Ccr2 antagonism during tendon healing and highlight the translational potential of transient Ccr2 antagonism to improve the tendon healing process.

Pickleball and the Rising Incidence of Achilles Tendon Injuries in the Elderly.

BACKGROUND: With its rising popularity of pickleball, particularly in the aging population, comes concern for potential injuries that previously rarely affected this patient cohort. The purpose of this study was to investigate the trends of pickleball-related Achilles tendon injuries. METHODS: A retrospective case series was performed to determine the trends associated with pickleball-related Achilles tendon injuries over the last 10 years. A database search of all Achilles tendon ruptures (ICD-10 S86.0) presenting to a large, multistate, subspecialty referral orthopaedic clinic between January 2013 and June 2023 were identified and included in the study. Pickleball-related injuries were identified via query and confirmed with manual chart review. The incidence of pickleball-related injuries, as well as patient demographics and rate of surgery was determined and compared with the total population during that time period. RESULTS: A total of 2684 patients who suffered an Achilles tendon injury between January 2013 and June 2023 were identified, with 43 patients meeting the inclusion criteria for pickleball-related Achilles tendon ruptures. The number and overall incidence of pickleball-related Achilles tendon injuries has been increasing since 2016, excluding 2020 where there was a large decrease likely due to the COVID-19 epidemic. Pickleball was associated with older age at time of injury (64.5 vs 48.6, P < .001) as well as a lower BMI (26.6 vs 29.4, P < .001). In addition, patients who sustained a pickleball-related Achilles tendon injury were more likely to undergo surgery (67.4% vs 45.4%, P = .008). CONCLUSION: The rising popularity of pickleball and its associated injuries poses a significant risk to the aging population, with Achilles tendon injuries occurring in older individuals and resulting in a higher likelihood of undergoing surgery. LEVEL OF EVIDENCE: IV; retrospective case-series.

H-Loop Knotless Double-Row Repair Versus Krackow Repair for Achilles Tendon Rupture: A Biomechanical Study in a Cadaveric Model.

Background: Surgery is widely recognized as an effective treatment for Achilles tendon rupture; however, there remains debate regarding the optimal surgical approach. Purpose: To compare the biomechanical properties of 2 techniques, the H-loop knotless double-row (HLDR) suture repair and the Krackow suture repair, for Achilles tendon rupture in a cadaveric model. Study Design: Controlled laboratory study. Methods: Ten matched Achilles tendon specimens from 5 male and 5 female donors were obtained. Each specimen from a matched pair was randomly distributed to 1 of 2 repair groups, the HLDR group or the Krackow group. Tendon elongation was recorded after exposure to 10, 100, 200, 400, 600, 800, and 1000 load cycles. The gap distance after application of a 100-N force, the force needed to produce a 2-mm gap, and the load to failure were measured. All biomechanical properties were compared between the HLDR and Krackow groups using the paired t test. Results: The HLDR group consistently exhibited significantly less elongation than the Krackow group after exposure to the 7 load cycles (P < .01 for all). In addition, the HLDR group exhibited a significantly smaller gap distance after applying a 100-N force (0.30 ± 0.02 vs 8.10 ± 0.46 mm for Krackow group), required significantly more force to generate a 2-mm gap (419.68 ± 39.48 vs 22.29 ± 3.40 N for the Krackow group), and had a significantly higher ultimate failure load (519.91 ± 57.29 vs 220.30 ± 19.27 N for the Krackow group) (P < .01 for all). Conclusion: The study findings demonstrated that the HLDR technique had more advantages compared with the Krackow technique with regard to elongation after different cyclic loadings, gap distance after a 100-N load, force needed to produce a 2-mm gap, and load to failure in a cadaveric model. Clinical Relevance: The HLDR technique could be a viable option for Achilles tendon rupture repair.

Establishing a rabbit model with massive supraspinatus tendon defect for investigating scaffold-assisted tendon repair.

BACKGROUND: Shoulder pain and disability from rotator cuff tears remain challenging clinical problem despite advancements in surgical techniques and materials. To advance our understanding of injury progression and develop effective therapeutics using tissue engineering and regenerative medicine approaches, it is crucial to develop and utilize animal models that closely resemble the anatomy and display the pathophysiology of the human rotator cuff. Among various animal models, the rabbit shoulder defect model is particularly favored due to its similarity to human rotator cuff pathology. However, a standardized protocol for creating a massive rotator cuff defect in the rabbits is not well defined. Therefore, the objective of our study was to establish a robust and reproducible model of a rotator cuff defect to evaluate the regenerative efficacy of scaffolds. RESULTS: In our study, we successfully developed a rabbit model with a massive supraspinatus tendon defect that closely resembles the common rotator cuff injuries observed in humans. This defect involved a complete transection of the tendon, spanning 10 mm in length and encompassing its full thickness and width. To ensure stable scaffolding, we employed an innovative bridging suture technique that utilized a modified Mason-Allen suture as a structural support. Moreover, to assess the therapeutic effectiveness of the model, we utilized different scaffolds, including a bovine tendon extracellular matrix (ECM) scaffold and a commercial acellular dermal matrix (ADM) scaffold. Throughout the observation period, no scaffold damage was observed. Notably, comprehensive histological analysis demonstrated that the regenerative tissue in the tendon ECM scaffold group exhibited an organized and aligned fiber structure, indicating tendon-like tissue regeneration while the tissue in the ADM group showed comparatively less organization. CONCLUSIONS: This study presents a comprehensive description of the implemented procedures for the development of a highly reproducible animal model that induces massive segmental defects in rotator cuff tendons. This protocol can be universally implemented with alternative scaffolds to investigate extensive tendon defects and evaluate the efficacy of regenerative treatments. The application of our animal model offers a standardized and reproducible platform, enabling researchers to systematically evaluate, compare, and optimize scaffold designs. This approach holds significant importance in advancing the development of tissue engineering strategies for effectively repairing extensive tendon defects.

Which tendon graft to choose for anatomical ligament reconstruction in chronic lateral ankle instability? A biomechanical study.

BACKGROUND: The need for anatomic lateral ligament reconstruction of the ankle continues to grow. This procedure usually requires a gracilis autograft or in some cases an allograft. Siegler et al. reported the mechanical characteristics of the collateral lateral ligaments of the human ankle: 231 ± 129 N for the ATFL and 307 ± 142 N for the CFL. The objective of this study was to evaluate the mechanical properties of different tendon grafts available for ATFL and CFL reconstruction. We hypothesized that the properties of the tested grafts are not inferior to the published values of those of the original ligaments on the lateral side of the ankle. METHODS: This was a comparative biomechanical study using 6 cadaver specimens (108 grafts): The biomechanical properties of nine types of grafts were determined using validated tensile testing methods: Gracilis, SemiT, EHL, FHL, Plantaris, Peroneus longus and brevis, TA and TP. The main outcome measure was the comparison of the mechanical properties of each single-stranded tendon with each other and with the known values ​​for the ATFL and CFL, during a uniaxial static rupture test. RESULTS: The mean load to failure for the gracilis was 257.5 ± 52.9 N. The groups had similar mean values in terms of the maximum load that they could withstand before failing except for the plantaris (137.9 ± 33.7 N) which was statistically lower than all other tested tendons (p < 0,01). The mean load to failure values of the grafts tested were equal or higher than that of the ATFL and CFL reported by Siegler et al. [14]: 231 ± 129 N for the ATFL and 307 ± 142 N for the CFL, while the grafts tested here had mean failure load between 258 ± 53 N and 464 ± 136 N. CONCLUSION: The gracilis, peroneus longus/brevis, EHL, FHL, TA, TP and semiT are legitimate grafts for combined ATFL and CFL reconstruction in the ankle. These tendons have mechanical properties (load to failure, maximum strain at failure and stiffness) that are equal to or higher than the native ligaments on the lateral side of the ankle, except the plantaris. CLINICAL RELEVANCE: This study validates the current use of the gracilis autograft for the anatomical reconstruction of the ATFL and CFL, and even provides proof that other tendons would be suitable for this anatomical reconstruction of the lateral ankle ligament by auto or even allograft under certain conditions. LEVEL OF EVIDENCE: Descriptive laboratory study.

Dorsal Scapholunate Ligament Complex Reconstruction Using Suture Tape-Augmented Autologous Free Tendon Graft for Chronic Scapholunate Dissociation.

Background: The treatment of chronic scapholunate dissociation (SLD) can be challenging due to several factors such as poor quality of ligament, malalignment of the carpus, limited surgical options, and risk of recurrent instability. Various surgical techniques have been developed, but there is ongoing debate regarding the optimal surgical technique. This study aimed to report the clinical and radiological outcomes after dorsal scapholunate (SL) ligament complex reconstruction using suture tape-augmented autologous tendon graft. Methods: The study included patients with Garcia-Elias stage 3-4 chronic SLD, SL advanced collapse (SLAC) stage 1, and a follow-up period exceeding 1 year. Pre- and postoperative SL gap, SL angle (SLA), radiolunate angle (RLA), and dorsal scaphoid translation (DST) were measured, and wrist active range of motion, Modified Mayo Wrist Score (MMWS), and visual analog scale (VAS) were evaluated. Results: Nine patients were included in this study with a mean follow-up period of 17 months (range, 15-31 months). All patients were male, with a mean age of 49 years (range, 30-62 years). Eight patients were classified as Garcia-Elias stage 4, while one was classified as SLAC 1. The median (range) of preoperative, immediate postoperative, and final follow-up measurements for SL gap, SLA, RLA, and DST were 5.4 mm (4.5-5.9), 2.1 mm (1.8-2.5), and 2.5 mm (2.0-2.8) (p = 0.008); 76° (69°-88°), 50° (32°-56°), and 54° (50°-64°) (p = 0.008); 22° (11.5°-33°), 2.8° (0.5°-3.8°), and 3.8° (2.2°-5.6°) (p = 0.008); and 2.8 mm (2.0-3.4), 0.8 mm (0.1-1.2), and 1.0 mm (0.1-2.0) (p = 0.008), respectively. Immediately after surgery, all radiological measurements showed significant improvement, which persisted up to 15 months postoperatively. The preoperative and final follow-up measurements of active flexion, extension, radial deviation, and ulnar deviation of the wrist showed significant improvement. The median preoperative and final follow-up values of MMWS were 51.1 (range, 40-60) and 88.3 (range, 85-95) (p = 0.007), respectively, and those of VAS were 7 (range, 6-8) and 2 (range, 1-3) (p = 0.007), respectively. Conclusions: Dorsal SL ligament complex reconstruction using suture tape-augmented autologous free tendon graft could be regarded as a feasible and straightforward technique for addressing irreparable chronic SLD.

Prognosis of Nonconcurrent Bilateral Achilles Tendon Rupture Is Worse Than Unilateral Achilles Tendon Rupture: Patient-Reported Outcomes at Minimum 2-Year Follow-up.

Backgroud: Approximately 5%-7% of patients who have had Achilles tendon rupture (ATR) suffer from contralateral ATR. However, no studies have evaluated the clinical outcomes of contralateral ATR in patients with an existing ATR. Therefore, in this study, we aimed to investigate patient-reported ankle function and activity levels in patients with nonconcurrent bilateral ATR. Methods: We retrospectively reviewed the data of 222 patients with an acute ATR who presented at our 2 institutions between 2005 and 2017. All patients had a minimum 2-year follow-up period, with no other major injuries to the ankle joint. Of these patients, 17 patients had nonconcurrent bilateral ATR. Patient-reported outcomes were assessed by telephone interview, using the Achilles tendon Total Rupture Score (ATRS), the ankle activity score, and a patient satisfaction questionnaire. Telephonic interviews were conducted by 2 authors, using a prepared script to minimize bias owing to individual interviewers. Results: The mean age of the patients was 45.1 ± 9.8 years, and 89% were men. Patients with nonconcurrent bilateral ATR had significantly lower values in terms of ATRS, ankle activity score, and satisfaction with current activity level, compared to patients who had unilateral ATR (p < 0.001, p = 0.027, and p = 0.012, respectively). Conclusions: Patients with nonconcurrent bilateral ATR had poorer ankle function, activity levels, and satisfaction than those with unilateral ATR in terms of patient-reported outcome measures with an intermediate-term result and a 2-year minimum follow-up period. These results emphasize the importance of the impact of contralateral injury on the prognosis of patients with ATR and the need for efforts to prevent contralateral rupture.

Isolated Latissimus Dorsi Transfer versus Combined Latissimus Dorsi and Teres Major Tendon Transfer for Irreparable Anterosuperior Rotator Cuff Tears.

Background: Irreparable anterosuperior rotator cuff tears (IASRCTs) present significant challenges, especially in young, active patients with limited joint-preserving options. Recently, latissimus dorsi (LD) transfer and combined latissimus dorsi and teres major (LDTM) transfer have gained attention as a potential surgical option. We aimed to compare the clinical and radiological outcomes of LD versus combined LDTM transfer in IASRCTs. Methods: In this retrospective comparative study, 53 patients with IASRCTs were analyzed after undergoing either LD transfer attached to lesser tuberosity (LT) (LD group, n = 23) or combined LDTM transfer attached to greater tuberosity (GT) (LDTM group, n = 30). Clinical evaluations included the visual analog scale score for pain, active shoulder range of motion (ROM), University of California Los Angeles Shoulder Score, American Shoulder and Elbow Surgeons score, activities of daily living that require active internal rotation (ADLIR) scores, and subscapularis (SSC)-specific examinations. Radiographic analyses involved assessing acromiohumeral distance (AHD), Hamada grade, the rate of anterior glenohumeral subluxation reduction, and integrity of the transferred tendon. Results: Postoperatively, both groups demonstrated significant improvements in pain and clinical scores (p < 0.001). At the 2-year follow-up, the LDTM group showed superior internal rotation strength (p < 0.001), ADLIR score (p = 0.017), and SSC-specific physical examination results (belly-press, p = 0.027; bear-hug, p = 0.031; lift-off, p = 0.032). No significant changes in AHD or Hamada grade were observed in either group. At final follow-up, no significant differences were found between the 2 groups in terms of AHD (p = 0.539) and Hamada grade (p = 0.974). Although preoperative anterior glenohumeral subluxation was improved in both groups, the LDTM group showed a statistically significantly higher rate of restoration compared to the LD group (p = 0.015). Conclusions: While both LD and combined LDTM transfers for IASRCTs improved postoperative pain relief, clinical scores, and active ROM, the combined LDTM transfer attached to GT was superior to LD transfer attached to LT in terms of internal rotational strength, ADLIR score, and SSC-specific examinations. Neither group showed significant progress in cuff tear arthropathy or decreased AHD at 2-year follow-up; however, the combined LDTM transfer notably improved preoperative anterior glenohumeral subluxation.

Biologically Enhanced Patch in the Healing and Mechanical Stability of Rotator Cuff Tears.

Biological patches have emerged as promising adjuncts in the surgical management of rotator cuff tears, aiming to enhance tissue healing and biomechanical properties of repaired tendons. These patches, derived from human or animal sources such as dermis or small intestinal submucosa, undergo mechanical and pathological changes within the rotator cuff environment post-implantation. These patches provide structural reinforcement to the repair site, distributing forces more evenly across the tendon and promoting a gradual load transfer during the healing process. This redistribution of forces helps alleviate tension on the repaired tendon and surrounding tissues, potentially reducing the risk of re-tears and improving overall repair integrity. Moreover, biological patches serve as scaffolds for cellular infiltration and tissue ingrowth, facilitating the recruitment of cells and promoting collagen synthesis. The integration of these patches into the host tissue involves a cascade of cellular events, including inflammation, angiogenesis, and matrix remodeling. Inflammatory responses triggered by patch implantation contribute to the recruitment of immune cells and the release of cytokines and growth factors, fostering a microenvironment conducive to tissue repair. However, despite their potential benefits, the long-term efficacy and durability of biological patches in rotator cuff repair remain areas of ongoing research and debate. Further studies are needed to elucidate the optimal patch characteristics, surgical techniques, and rehabilitation protocols to maximize clinical outcomes and minimize complications in rotator cuff surgery.

Tibialis anterior and extensor hallucis longus tendon ruptures complicating a closed tibial fracture: A case report.

INTRODUCTION AND IMPORTANCE: Acute rupture of the tibialis anterior tendon and other tendons is an extremely rare injury. It is usually associated with minor trauma in older patients with medical comorbidity. Surgeons must be alert for rupture of these tendons which can complicate a closed tibial fracture. CASE PRESENTATION: A 19-year-old man was transferred to the emergency department with a segmental fracture at the lower third of his tibia. The patient could not actively dorsiflex his right ankle and first toe but was able to dorsiflex other toes actively. The tibialis anterior and extensor hallucis longus tendon were discovered torn at the same point, supposedly by a bone spike. The fracture was reduced and fixed and the tendons were repaired. CLINICAL DISCUSSION: A traumatic rupture of the tibialis anterior and extensor hallucis longus tendons occurs rarely in conjunction with or as a consequence of a bony fracture in closed trauma, with only a few cases documented in the literature. They typically occur as a result of direct blunt or penetrating injury. In three papers, the tibial fracture caused a direct rupture in the tendon. We believe that the tendons rubbing against the fractured edges of the segmental bone of the tibia led to the tendons tearing gradually. CONCLUSION: Further investigation is needed for an evaluation of ankle and first toe dorsiflexion to check for a palpable gap in the soft tissues of a lower third tibial fracture. The tibialis anterior and other tendons can be located between the segment of the tibial fracture and ruptured.

Is Achilles tendon structure associated with functional ability and chronic ankle instability in military recruits?

OBJECTIVE: To determine the relationship between Achilles tendon (AT) structure, functional ability and chronic ankle instability (CAI) in military recruits. METHODS: Three hundred and sixty newly recruited infantry male soldiers recruited in April 2022 were assessed for AT structure by Ultrasound Tissue Characterization (UTC), for functional abilities (included proprioception ability, heel-raise test, dynamic postural balance, and hopping agility ability) and for CAI (recurrent sprains and a positive perceived instability). RESULTS: Soldiers that were identified with disorganized tendon had significantly lower heel-raise and agility scores compared to those with organized tendon structures (33.6 ± 18.1(n) vs. 49.9 ± 28.9(n), p < 0.001; and 5.39 ± 2.12(n) vs. 6.16 ± 1.90(n), p = 0.002, respectively). The best discriminator between soldiers with organized vs. disorganized structure, was heel-raise test (AUC = 0.741). Moreover, soldiers with disorganized AT structure had a higher prevalence of CAI compared with those with organized tendon structures (p < 0.05). CONCLUSION: Recruits with disorganized tendon structures displayed reduced heel-raise score, agility ability and dynamic postural-balance and greater ankle instability. Inferior tendon quality at the onset of military service is an important physical indicator to consider when seeking to manage future injuries and potential for physical performance. Pre-recruitment screening of the AT structure, CAI, and functional abilities, especially in high-intensity infantry programs, needs to be considered.