Assessment of formalin preserved and fresh frozen quadriceps tendon graft-suture constructs for load to failure testing: a biomechanical cadaveric study.

PURPOSE: Fresh-frozen specimen availability and cost may be a barrier for initiation of biomechanical studies where soft tissue is used in a construct with other medical devices. The impact of soft tissue preservation method on the outcomes of biomechanical studies in the specific case of graft-suture constructs is relatively unexplored. This study aimed to observe peak loads and failure modes in biomechanical testing of fresh-frozen (FF) versus formalin embalmed (FE) quadriceps tendon (QT) graft-suture constructs for soft tissue fixation in ACLR and assess suitability of FE QT graft constructs for load-to-fail testing. METHODS: Twenty QT grafts were harvested from human cadaver specimens. Ten grafts came from fresh-frozen donors and 10 from embalmed donors. All grafts were prepared with the modified Prusik knot using a braided composite suture and subjected to tensile loading. Comparisons between the biomechanical properties of the graft-suture constructs were made with unpaired t tests with α = 0.05. RESULTS: FE and FF constructs displayed similar peak loads and failure modes. FF constructs had greater elongation after pre-tensioning than FE (7.3 vs. 5.5 mm, p = 0.02) and greater elongation after cyclic loading than FE constructs (17.5 vs. 10.5 mm, p = 0.01). Hysteresis was greater for FF constructs at the 50th, 100th, 150th, and 200th cycle (p = 0.02, p = 0.07, p < 0.001, p = 0.004, respectively). FE constructs were stiffer than fresh-frozen (103 vs. 84 N/mm, p < 0.001). CONCLUSION: FE constructs were significantly stiffer but displayed similar peak load and failure mode to FF which was reflective of the strength of the suture material. FE grafts can offer an alternative to FF grafts in graft-suture constructs for biomechanical studies where load at failure and knot security and strength is of main interest.

Achilles tendon complications of fluoroquinolone treatment: a molecule-stratified systematic review and meta-analysis.

Purpose: The association between fluoroquinolone intake and Achilles tendinopathy (AT) or Achilles tendon rupture (ATR) is widely documented. However, it is not clear whether different molecules have the same effect on these complications. The purpose of this study was to document Achilles tendon complications for the most prescribed fluoroquinolones molecules. Methods: A literature search was performed on Pubmed, Cochrane, Embase, and Web of Science databases up to April 2023. Inclusion criteria: studies of any level of evidence, written in English, documenting the prevalence of AT/ATR after fluoroquinolone consumption and stratifying the results for each type of molecule. The Downs and Black's 'Checklist for Measuring Quality' was used to evaluate the risk of bias. Results: Twelve studies investigating 439,299 patients were included (59.7% women, 40.3% men, mean age: 53.0 ± 15.6 years). The expected risk of AT/ATR was 0.17% (95% CI: 0.15-0.19, standard error (s.e.): 0.24) for levofloxacin, 0.17% (95% CI: 0.16-0.19, s.e.: 0.20) for ciprofloxacin, 1.40% (95% CI: 0.88-2.03, s.e.: 2.51) for ofloxacin, and 0.31% (95% CI: 0.23-0.40, s.e.: 0.77) for the other molecules. The comparison between groups documented a significantly higher AT/ATR rate in the ofloxacin group (P < 0.0001 for each comparison). Levofloxacin and ciprofloxacin showed the same risk (P = n.s.). The included studies showed an overall good quality. Conclusion: Ofloxacin demonstrated a significantly higher rate of AT/ATR complications in the adult population, while levofloxacin and ciprofloxacin showed a safer profile compared to all the other molecules. More data are needed to identify other patient and treatment-related factors influencing the risk of musculoskeletal complications.

Recurrent cyclops lesion after primary resection of fibroreactive nodule following anterior cruciate ligament reconstruction.

In this case report featured in World Journal of Orthopedics, Kelmer et al describe a rare finding of a 28-year-old female patient who presented with a recurrent fibroreactive nodule 7 months following the resection of a primary cyclops lesion, suggesting recurrent cyclops syndrome. The patient had undergone an initial anterior cruciate ligament reconstruction for a non-contact right knee injury and reported successful recovery. Two years later, the patient sustained a repeat right knee injury followed by a positive McMurray test and acute pain with terminal extension. Arthroscopic synovectomy confirmed magnetic resonance imaging (MRI) finding of a cyclops lesion, which was surgically removed. Seven months postoperatively, the patient reported stiffness and difficulty with terminal extension. Repeat MRI indicated a recurrent cyclops lesion, which was surgically resected. Following resection of the second lesion, the patient underwent physical therapy and achieved full range of motion, maintaining complete recovery 19 months postoperatively. Recurrent cyclops lesions have rarely been reported in the literature, and this article is novel in its report of recurrent cyclops syndrome following a bone-patellar tendon-bone allograft. The presentation of this unusual finding exposes a need for further investigation of cyclops lesion pathology, which will aid its prevention and treatment.

Collagen-Type Composition in the Semitendinosus, Quadriceps, and Patellar Tendons of a 22-Year-Old Patient: A Case Report.

Graft failure is a common postoperative complication after anterior cruciate ligament (ACL) reconstruction. Recently, a theory has emerged that histological and microstructural factors of autografts may be related to graft failure. We simultaneously collected the semitendinosus tendon (ST), quadriceps tendon (QT), and patellar tendon (PT) from a 22-year-old patient to provide insights into the differences in the collagen-type composition of the three tendons in skeletally mature patients. These findings may serve as a basis for selecting autografts for ACL to reduce graft failure rates. The patient was a 22-year-old female who required the removal of artificial ligament, screws, and washers and medial patellofemoral ligament (MPFL) reconstruction with an ST autograft after two surgeries for recurrent dislocation of the left patella. The ST, QT, and PT obtained during necessary intraoperative procedures were used as samples. The tissues were processed and immunostained; this was followed by confocal microscopy. Evaluation was performed by calculating the percentage of areas positive for collagen types I and III.The percentage of type I collagen in the ST, QT, and PT groups was 88%, 85%, and 88%, respectively.The collagen-type composition was examined following simultaneous collection of the ST, QT, and PT. The results revealed no significant differences in the content of physically strong type I collagen, which supports previous findings showing that the clinical outcomes after ACL reconstruction do not vary with the autograft used.

Peroneus Longus Tendon Autografts have Better Graft Diameter, Less Morbidity, and Enhanced Muscle Recuperation than Hamstring Tendon in ACL Reconstruction.

Background: Recently the peroneus longus tendon (PLT) gained popularity in anterior cruciate ligament (ACL) reconstruction and has been utilized with satisfactory outcomes. However, there are concerns regarding donor site morbidity. This study aims to compare the functional outcome of ACL reconstruction using hamstring (HT) and PLT autografts and evaluate the donor site morbidity. Methods: Patients who underwent ACL reconstruction were allocated to two groups (HT and PLT). Graft diameter was measured intraoperatively. Knee functional outcome was evaluated with IKDC and Tegner-Lysholm scores preoperatively, and postoperatively after 3 months, 6 months, and 1 year. Donor site morbidities were assessed with thigh circumference measurements, subjective evaluation of sensory disturbances, and ankle scoring with AOFAS and FADI scores. Results: At 1-year follow-up, the PLT group showed comparable IKDC (p = 0.925) and Tegner-Lysholm (p = 0.600) scores with those of the HT group. The mean graft diameter in the PLT group (7.93 ± 0.52 mm) was larger compared with the HT group (7.43 ± 0.50 mm) (p < 0.001). The incidence of thigh atrophy (HT-16.7%, PLT-10%) and sensory disturbances (HT-73.3%, PLT-10%) was greater in the HT group. There was no significant ankle donor site morbidity in the PLT group (AOFAS-98.67 ± 3.45, FADI-99.23 ± 1.69). Conclusion: ACL reconstruction with PLT had comparable functional outcome with that of HT at 1 year. However, PLT demonstrated larger graft diameter, less donor site morbidity, and enhanced muscle recovery without significantly affecting the ankle function. PLT can be safely used as an acceptable alternative graft choice harvested from outside the knee for ACL reconstruction.

[Click phenomenon in acquired Jaensch-Brown syndrome and trigger finger/thumb: the Notta syndrome]. / "Klick"-Phänomen beim erworbenen Jaensch-Brown-Syndrom und schnellenden Finger/Daumen: dem Notta-Syndrom.

CLINICAL FEATURES: The click phenomenon occurs when an acquired mechanical restriction of the elevation in adduction of the eye or of the extension of the finger/thumb, is forcefully overcome. The common cause is a nodule either of the superior oblique tendon posterior to the trochlea in the case of a Jaensch-Brown syndrome or of the digital flexor tendon anterior to the A1 annular pulley in the case of a trigger finger. Both locations share similar anatomical conditions for the development of the nodule and the pathomechanism of the click. RESULTS: From these identical findings in the eye and the hand in small children it can be assumed that the results from the studies of the hand in newborns and infants with a trigger thumb/finger are also applicable to the situation of the eye. 1. This motility disorder is not congenital. This is most likely due to an incomplete development at the time of birth of the sliding factors needed for a free passage of the tendon through the trochlea and the A1 annular pulley. 2. A distinction must be made between stages 0-3: stage 0 = no more restriction of the motility and no click phenomenon; stage 1 = forced active extension/elevation possible; stage 2 = only passive extension/elevation, each with a click phenomenon; stage 3 = no extension/elevation possible and no click phenomenon. 3. In most cases in early childhood there is a spontaneous complete recovery (75% after 6-7 years). In the eye this spontaneous course can only limitedly be shortened with motility exercises in combination with segmental occlusion. CONCLUSION: The click phenomenon is a symptom of stages 1 and 2 of an acquired mechanical restriction of the elevation in adduction of the eye or the extension of the finger/thumb. It should not be called a syndrome.

Reconstruction of the extensor tendon on the dorsal pedis with a chimeric skin-aponeurosis flap from the groin region.

BACKGROUND: Complex defects involving the extensor tendon on the dorsal pedis have been reconstructed using multiple procedures. Skin coverage and tendon transfers have also been performed. This study aimed to present our experience using a chimeric skin-aponeurosis flap for one-stage reconstruction of composite soft-tissue defects on the dorsal pedis. METHODS: Between May 2017 and September 2020, 12 patients with these defects received total treatment using a chimeric groin flap. Based on the superficial circumflex iliac vessels, the skin paddle resurfaced the cutaneous defect, and the vascularised external oblique aponeurosis was rolled to form a tendon-like structure to simultaneously replace the absent segment of the extensor tendons. A suitable "Y" bifurcation was dissected to enlarge the vessel diameter. Single-stage reconstruction was performed using a set of vascular anastomoses at the recipient site. RESULTS: Flap survival was achieved without significant complications. The hammertoe deformity was completely removed. The average dimension of the skin paddle was 8.0 × 13.0 cm (range, 6.5 × 11.0-10.0 × 14.0 cm), and the mean size of the aponeurosis was 8.0 × 4.0 cm (range, 6.0 × 3.0-10.0 × 5.0 cm). At the last follow-up visit, no morbidity was observed at the donor site. Natural shapes and walking functions were successfully achieved with a protective sensation. CONCLUSION: The chimeric groin flap with sheets of external oblique aponeurosis is a great candidate for one-stage reconstruction of composite soft tissue loss on the dorsal pedis. This approach provides cosmetic coverage, allowing faster wound healing and reduced tendon adhesions.

Factors determining the short-term clinical outcomes of conservative treatment in patients with supraspinatus tear.

INTRODUCTION: To identify factors influencing the better and worse changes in the Western Ontario Rotator Cuff Index of patients undergoing conservative treatment for supraspinatus tendon tear. METHODS: The study included 30 patients with supraspinatus tendon tear who underwent conservative treatment. The average duration of intervention was 35.4 days. The Western Ontario Rotator Cuff Index, shoulder range of motion, isometric muscle strength, supraspinatus tendon thickness, thickness of the supraspinatus, infraspinatus, and teres minor muscles, and acromiohumeral interval were assessed before and after the intervention. In the statistical analyses, change in the Western Ontario Rotator Cuff Index was the dependent variable, and the amount of change in each measurement variable before and after the intervention was the independent variable. RESULTS: The average Western Ontario Rotator Cuff Index improved from 1067 at pre-treatment to 997 at post-treatment, but without a significant difference (p = 0.29). A multiple regression analysis revealed that supraspinatus tendon thickness and muscle strength in shoulder external rotation at 90° scaption had a significant effect on the change in the Western Ontario Rotator Cuff Index (R2 = 0.44, p < 0.01). CONCLUSION: Supraspinatus tendon thickness and muscle strength in shoulder external rotation at 90° scaption were important factors for the Western Ontario Rotator Cuff Index score in the early stages of conservative treatment for patients with supraspinatus tendon tear.

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: 3-Year Clinical and Patient-Reported Outcomes.

BACKGROUND: The rate of anterior cruciate ligament (ACL) rupture in active, skeletally immature patients is increasing. Although hamstring tendon autograft (HTA) was previously deemed the gold standard, recent studies have shown HTA to have a high failure rate in this high-risk population of young competitive athletes, and quadriceps tendon autograft (QTA) has yielded excellent preliminary outcomes in some studies examining this population. PURPOSE: To evaluate 3-year clinical and patient-reported functional outcomes of primary ACL reconstruction (ACLR) with soft tissue QTA in skeletally immature patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Skeletally immature patients who underwent ACLR with a full-thickness soft tissue QTA were included. Preoperative patient and surgical data were collected. The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal and complete transphyseal techniques. Patients were followed for a minimum of 2 years with successive clinical visits or were contacted via telephone. Patients who did not have minimum 2-year follow-up after 3 contact attempts via telephone were excluded. Information regarding return to sports (RTS) and concomitant or subsequent surgical procedures was collected. Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and Single Assessment Numeric Evaluation (SANE) scores were collected. RESULTS: Of 85 adolescent patients aged 11.1 to 17.6 years (mean age, 14.1 ± 1.2 years), 2 patients were determined to be lost to follow-up after 3 failed contact attempts. Of the patients included in this study (N = 83), 26 patients (31%) underwent all-epiphyseal and 57 patients (69%) underwent complete transphyseal ACLR. Additionally, 48 patients (58%) underwent concomitant lateral extra-articular tenodesis using the iliotibial band with a modified Lemaire technique. The mean follow-up time was 3.7 ± 1.2 years (range, 2-7 years). Twenty (24%) patients had subsequent surgical procedures, of which 3 (4%) were due to graft failures. At a mean 3-year follow-up, the mean Pedi-IKDC, HSS Pedi-FABS, and SANE scores were 90, 23, and 94 respectively; the RTS rate was 100%; and the rate of RTS at the previous level of performance was 93%. CONCLUSION: Use of a soft tissue QTA for ALCR in a high-risk skeletally immature population of athletes resulted in excellent postoperative outcomes with low rates of graft failure and high return to sport rates.

Exploring Ascorbic Acid's Role in Orthopedic Practices: Present Theories, Innovative Approaches, and Prospects.

In the human body, ascorbic acid (AA) is known for its potent antioxidant and reducing properties and also plays a vital role in supporting the growth of bones and cartilage. It has been used extensively in orthopedic surgery. Ongoing studies under the umbrella of ascorbic acid research investigate its impact on bone and tendon physiology, as well as its influence on joint replacement and postoperative pain. The majority of both laboratory and human studies link the usage of ascorbic acid to enhanced bone health and improved tendon healing. Recent literature suggest that ascorbic acid administration may have a positive impact on the outcome of orthopedic procedures. On the other hand, controversy exists regarding the efficacy of ascorbic acid in reducing the incidence of complex regional pain syndrome. In brief, the effectiveness of ascorbic acid in enhancing orthopedic procedure outcomes remains a subject of ongoing investigation. Although certain studies have hinted at the potential positive influence of ascorbic acid on these outcomes, further research is required to validate its effectiveness and ascertain the ideal dosage and method of administration for maximizing its anticipated advantages. To establish the efficacy of ascorbic acid in improving orthopedic procedure outcomes, rigorous human trials of high quality are imperative. The aim of this review was to provide an overview of ascorbic acid's utilization in orthopedic practices and to pinpoint prospective areas for future research.

The anisotropic and region-dependent mechanical response of wrap-around tendons under tensile, compressive and combined multiaxial loads.

The present work reports on the multiaxial region and orientation-dependent mechanical properties of two porcine wrap-around tendons under tensile, compressive and combined loads based on an extensive study with n=175 samples. The results provide a detailed dataset of the anisotropic tensile and compressive longitudinal properties and document a pronounced tension-compression asymmetry. Motivated by the physiological loading conditions of these tendons, which include transversal compression at bony abutments in addition to longitudinal tension, we systematically investigated the change in axial tension when the tendon is compressed transversally along one or both perpendicular directions. The results reveal that the transversal compression can increase axial tension (proximal-distal direction) in both cases to orders of 30%, yet by a larger amount in the first case (transversal compression in anterior-posterior direction), which seems to be more relevant for wrap-around tendons in-vivo. These quantitative measurements are in line with earlier findings on auxetic properties of tendon tissue, but show for the first time the influence of this property on the stress response of the tendon, and may thus reveal an important functional principle within these essential elements of force transmission in the body. STATEMENT OF SIGNIFICANCE: The work reports for the first time on multiaxial region and orientation-dependent mechanical properties of wrap-around tendons under various loads. The results indicate that differences in the mechanical properties exist between zones that are predominantly in a uniaxial tensile state and those that experience complex load states. The observed counterintuitive increase of the axial tension upon lateral compression points at auxetic properties of the tendon tissue which may be pivotal for the function of the tendon as an element of the musculoskeletal system. It suggests that the tendon's performance in transmitting forces is not diminished but enhanced when the action line is deflected by a bony pulley around which the tendon wraps, representing an important functional principle of tendon tissue.

Ultrasound Therapy With High-Pressure Pulses Is Effective to Reduce the Effects of Collagenase-Induced Tendinopathy in Rat's Achilles Tendon.

OBJECTIVE: We propose an ultrasonic treatment for collagenase-induced tendinopathy in rat's Achilles tendon using pulses with a low number of cycles, high acoustic pressure and very low duty cycle. METHODS: Twenty rats were used to perform the experiment. Four experimental groups of calcaneal tendons were studied: control (n = 6), sham (n = 4), collagenase-induced tendinopathy (n = 8) and ultrasound-treated collagenase-induced tendinopathy (n = 8). Surgical intervention was performed to expose the tendons prior to collagenase injection. A 1 MHz ultrasonic tansducer with a focusing lens was used. Ultrasonic treatments were used with an average total treatment time of 2.5 min, 20-cycle pulses, pressure amplitude p = 7 MPa, and 0.02% duty cycle. Histopathology of the samples was performed to evaluate nuclear density, acute inflammation, and signs of neovascularization. Collagen (types I and III), elastic fibers, and glycosaminoglycans were also analyzed. RESULTS: No tendon involvement was found by the surgical process. Ultrasonic treatment is safe, as it does not affect healthy tendons. When collagenase infiltrated animals were treated with US, a clear predominance of type I collagen fibers and a similar collagen ratio profile to that observed in the control and sham groups was observed, with a higher density of elastic fibers compared to the control and sham groups and a significant increase in the density of glycosaminoglycans. CONCLUSION: The ultrasound treatment proposed reduces the effects of the artificial collagenase lesion to reach the basal level after 45 d.

Ultrasound imaging and shear wave elastography for the differential diagnosis of heel pain: a comparative cross-sectional study.

PURPOSE: In correlation with magnetic resonance imaging (MRI), this study attempts to assess the effectiveness of the diagnostic of ultrasonography (US) features and shear wave elastography (SWE) in determining the different causes of heel pain. MATERIALS AND METHODS: 55 heels with a mean age of 38.33 ± 10.8 were included in the study (10 control cases and 41 cases, 4 of which had bilateral heel pain). There were 23 female cases (56.1%) and 18 male cases (43.95%). Examinations using shear wave elastography (SWE) and ultrasound (US) were done in different positions. MRI and the obtained data were correlated. RESULTS: When used to diagnose different heel pain causes, ultrasound demonstrated great sensitivity and specificity. SWE demonstrated a good correlation with MRI findings and enhanced the ultrasound's diagnostic precision in identifying plantar fasciitis early on (increased accuracy from 88.9 to 93.33% with 100% sensitivity and 83.3% specificity) and Achilles tendinopathy (increased accuracy from 88.9 to 97.8 with 94.7% sensitivity and 100% specificity). CONCLUSION: In summary, we concluded that heel pain can be efficiently examined by both ultrasound (US) and shear wave elastography (SWE) with the former being used as the primary effective tool and the latter being done to increase diagnostic accuracy. We also concluded that SWE improved the ultrasound's diagnostic precision in identifying patients with early plantar fasciitis and Achilles tendinopathy and showed a robust relationship with clinical outcomes, enhancing patient evaluation and follow-up.

Saturated fatty acids negatively affect musculoskeletal tissues in vitro and in vivo.

Fish oils rank among the world's most popular nutritional supplements and are purported to have numerous health benefits. Previous work suggested that fish oils increase collagen production; however, the effect of fish oils on musculoskeletal health is poorly understood. Further, the divergent effects of omega-3 (Ω3FA) and saturated fatty acids (SFA) remains poorly understood. We tested the effects of Ω3FA and SFAs on in vitro-engineered human ligament (EHL) function. EHLs were treated with bovine serum albumin (BSA)-conjugated eicosapentaenoic acid (EPA, 20:5(n-3)), palmitic acid (PA, 16:0), or a BSA control for 6 days. EPA did not significantly alter, whereas PA significantly decreased EHL function and collagen content. To determine whether this was an in vitro artifact, mice were fed a control or high-lard diet for 14 weeks and musculoskeletal mass, insulin sensitivity, and the collagen content, and mechanics of tendon and bone were determined. Body weight was 40 % higher on a HFD, but muscle, tendon, and bone mass did not keep up with body weight resulting in relative losses in muscle mass, tendon, and bone collagen, as well as mechanical properties. Importantly, we show that PA acutely decreases collagen synthesis in vitro to a similar extent as the decrease in collagen content with chronic treatment. These data suggest that Ω3FAs have a limited effect on EHLs, whereas SFA exert a negative effect on collagen synthesis resulting in smaller and weaker musculoskeletal tissues both in vitro and in vivo.

Acute Distal Biceps Tendon Repair With Cortical Button Offers Good Functional Outcomes: A Retrospective Study Focusing on Range of Motion, Muscle Strength and Pain.

Background Distal biceps tendon (DBT) rupture is not one of the most common upper limb injuries. Surgical intervention is recommended for these injuries to restore muscular strength and functionality. Multiple different techniques are documented in the literature, however there is no definitive consensus on the most effective surgical treatment. The objective of this study was to assess the functional results of patients who underwent repair of DBT utilizing cortical button fixation procedures. Methods This study is a retrospective single-unit case series consisting of 54 patients who underwent DBT repair at Heartlands Hospital in Birmingham, United Kingdom. The patients' functional outcomes was assessed by the Mayo Elbow Performance Score (MEPS). Results The mean age was 51±11.01 years. Patients were operated on 4.72±7.083 days after the injury. The mean pain Visual Analogue Scale (VAS) 6 months after the surgery was 0.54±0.50. At 6 months follow-up, the average extension deficit was 2.69° (0-10), flexion 132° (120-140), supination76° (50- 85), and 77° for pronation (78-95). Patients were followed up routinely for 6 months. Mayo Elbow Performance (MEP) Score was utilized to assess the functional outcome and the mean MEP score was 91.43±8.26 which showed excellent functional outcomes for the cohort. Conclusion DBT repair with cortical button fixation yielded favorable functional outcomes at 6 months, notably restoring supination strength. This approach offers anatomical reinsertion while minimizing nerve damage risk.

Acute-Onset Quadriplegia Presenting With Hyperreflexia: A Dilemma in Diagnosis.

An autoimmune polyradiculoneuropathy, Guillain-Barré syndrome (GBS) is an acute, rapidly progressive, and fulminant one. Rapidly developing motor weakness along with absent reflexes, with or without sensory impairment, is the hallmark of GBS. GBS is never a hereditary entity; it is always acquired by the individual. Here, we present an interesting case of GBS in a 37-year-old male patient presenting with lower limb weakness for one day which had progressed to upper limb weakness in a day. There was a history of fever and loose stools four days back. On examination, vitals were within normal limits including single breath count. Central nervous system (CNS) examination revealed as follows: bicep jerk, tricep jerk, and supinator jerk were National Institute of Neurological Disorders and Stroke (NINDS) scale grade 2 in bilateral upper limbs. Knee jerk was NINDS scale grade 3 in bilateral lower limbs, which was unusual considering that GBS presents with areflexia or reduced reflexes. Ankle jerk was absent in bilateral lower limbs. Plantars were mute bilaterally. Nerve conduction study was suggestive of axonal and demyelinating motor neuropathy involving all four limbs. The patient was planned for intravenous immunoglobulin at a dose of 2 g/kg/day for five days but developed an allergic reaction to the first dose; hence, the therapy was discontinued, and the option of plasmapheresis was given to which the patient refused. This is a report of a case of GBS with hyperreflexia which is an uncommon entity in the Indian subcontinent.

Outcomes of an All-Soft Tissue Fixation Technique for Reconstruction of the Medial Patellofemoral Complex Using Double-Bundle Quadriceps Tendon Autograft for Recurrent Patellar Dislocation in Skeletally Immature Patients.

Background: Patellar fracture, femoral physis injury, and recurrent instability are concerning complications in medial patellofemoral ligament (MPFL) reconstruction (MPFLR) techniques for recurrent patellar dislocation in children and adolescents. Purpose: To evaluate the outcomes of an anatomic all-soft tissue fixation technique for reconstruction of the medial patellofemoral complex (MPFC) using a double-bundle quadriceps tendon (QT) autograft for recurrent patellar dislocation in skeletally immature patients. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study involved 24 skeletally immature patients (24 knees; 16 women and 8 men; age range, 9.5-15 years) with recurrent patellar dislocation who underwent MPFC reconstruction using a double-bundle QT autograft between September 2018 and January 2021. Only soft tissue suture fixation was used on the femoral and patellar sides of the 2 bundles of the QT. Radiographs, computed tomography, and magnetic resonance imaging were used to evaluate physeal status, lower limb alignment, patellar height and tilt, trochlear morphology, tibial tubercle-trochlear groove distance, and any associated knee pathology. Functional outcomes were assessed with the Kujala score, the visual analog scale (VAS) for pain, and the grading system of Insall et al.22. Results: The mean follow-up time was 40 ± 9.6 months (range, 28-56 months). At the final follow-up, the Kujala and VAS pain scores showed a significant improvement versus preoperative scores (P < .001), and the passive lateral patellar glide showed a significant reduction (P < .001). All patients had negative apprehension and J signs. Of the 24 patients, 23 regained full range of motion, while 1 patient had a knee flexion deficit. The patellar tilt angle improved significantly at the final follow-up (P < .001). There was no patellar fracture, femoral physis injury, or recurrence of patellar dislocation. According to the grading system of Insall et al, the results were excellent in 15 knees (62.5%), good in 8 knees (33.3%), fair in 1 knee (4.2%), and no knees showed poor results. Conclusion: Reconstruction of the MPFC using a double-bundle QT autograft with an all-soft tissue fixation technique was an effective method for treating patellar instability in skeletally immature patients.

Reduced Intratendinous Sliding in Achilles Tendinopathy During Active Plantarflexion Regardless of Horizontal Foot Position.

PURPOSE: The Achilles tendon consists of three subtendons with the ability to slide relative to each other. As optimal intratendinous sliding is thought to reduce the overall stress in the tendon, alterations in sliding behavior could potentially play a role in the development of Achilles tendinopathy. The aims of this study were to investigate the difference in intratendinous sliding within the Achilles tendon during isometric contractions between asymptomatic controls and patients with Achilles tendinopathy and the effect of changing the horizontal foot position on intratendinous sliding in both groups. METHODS: Twenty-nine participants (13 Achilles tendinopathy and 16 controls) performed isometric plantarflexion contractions at 60% of their maximal voluntary contraction (MVC), in toes-neutral, and at 30% MVC in toes-neutral, toes-in, and toes-out positions during which ultrasound images were recorded. Intratendinous sliding was estimated as the superficial-to-middle and middle-to-deep relative displacement. RESULTS: Patients with Achilles tendinopathy present lower intratendinous sliding than asymptomatic controls. Regarding the horizontal foot position in both groups, the toes-out foot position resulted in increased sliding compared with both toes-neutral and toes-out foot position. CONCLUSION: We provided evidence that patients with Achilles tendinopathy show lower intratendinous sliding than asymptomatic controls. Since intratendinous sliding is a physiological feature of the Achilles tendon, the external foot position holds promise to increase sliding in patients with Achilles tendinopathy and promote healthy tendon behavior. Future research should investigate if implementing this external foot position in rehabilitation programs stimulates sliding within the Achilles tendon and improves clinical outcome.

Non-surgical management of posterior tibial tendon dysfunction- a UK survey.

BACKGROUND: Posterior Tibial Tendon Dysfunction (PTTD) is commonly seen within musculoskeletal care. The condition's prevalence and management is poorly understood. This study aims to demonstrate current practice by multi-professional clinicians across the United Kingdom within the National Health Service. METHODS: A national (UK) cross-sectional online survey was conducted among multi-professionals who treat PTTD within their NHS practice. The survey covered assessment, management and evaluation. This was shared via social media and professional groups. RESULTS: Two hundred thirteen surveys were completed, with 153 matching the eligibility criteria. The main respondents were Physiotherapists (48%) and Podiatrists (38%). Ultrasound scanning was used most frequently when considering initial imaging (67%). Many different treatment modalities were used, but a core set of education/advice, foot orthoses, and foot specific as well as general exercise were most commonly chosen. Outcome measures routinely used were pain scale (96/269) and single leg heel raise (84/269), but patient reported outcome measures were not routinely used. The most frequent reason to escalate care was failure to manage symptoms with conservative management (106/123; 86.2%), followed by fixed deformity (10/123; 8.2%). CONCLUSIONS: This survey provides evidence on current non-surgical management for PTTD from UK NHS practice. It provides a valuable marker for clinicians to use to compare their own practice and can be used in further research as a comparator.

Pectoralis Major Transfer For Anterior Recurrent Dislocation of Reverse Total Shoulder Arthroplasty: A Case Report.

Introduction: Reverse total shoulder arthroplasty (RTSA) has revolutionized the treatment landscape for a spectrum of shoulder pathologies, extending its indications from rotator cuff arthropathy to encompass irreparable rotator cuff lesions, fractures, inflammatory arthritis, and tumors. However, the exponential increase in RTSA usage has brought a proportional rise in associated complications, with dislocation being one of the most common early post-operative complications. Case Report: This case report details a 65-year-old right-hand dominant male patient presenting with chronic pain and weakness in the right shoulder, diagnosed with advanced glenohumeral arthritis and massive irreparable rotator cuff tears. The patient underwent a Bony Increased- Offset RTSA (BIO-RTSA) procedure, coupled with subscapularis repair. Postoperatively, the patient experienced pain and instability, culminating in an atraumatic anterior dislocation at 4 months. Despite conservative management, recurrent dislocations persisted. Revision surgery was performed with an increase in the linear component size for containment. About 1 year postoperative of the revision surgery, recurrent dislocation reoccurred. Re-revision surgery was performed with secondary pectoralis major (PM) transfer for subscapularis deficiency due to re-tear from recurrent dislocation, and with an increased humeral tray size for better containment. About 1-year and 6-month post-operative to the re-revision surgery, the patient achieved restored stability, improved range of motion, and reported satisfaction with the outcome. Conclusion: This case report underscores the challenges of managing recurrent anterior dislocation after RTSA. The successful use of secondary PM transfer highlights its efficacy as a salvage procedure in restoring stability for persistent anterior dislocation after RTSA. Yet, further clinical studies are warranted to establish the role of such interventions in the management for RTSA-associated complications. Level of Evidence IV: Case report.