Surgical management of chronic Achilles tendon ruptures using less invasive techniques.

BACKGROUND: Surgical management of chronic Tendo Achillis (TA) ruptures usually requires tendon grafting procedures. Several techniques have been described. We examined the outcome of three different less invasive (incisions length less than 3 cm) tendon transfer techniques in the management of patients with a chronic rupture of the TA. METHODS: Of 62 patients (39 males and 23 females; mean age 44.8 years; range 29.3-62 years) with chronic TA ruptures managed operatively, 21 patients had a ≥6cm gap and underwent free ipsilateral semitendinosus (ST) graft (21 patients), whereas patients with smaller gaps had either ipsilateral peroneus brevis (PB) (20 patients) or ipsilateral flexor hallucis longus (FHL) transfer (21 patients). Outcome measures included maximum calf circumference, isometric plantar flexion strength, and the Achilles tendon total rupture score (ATRS), preoperatively and at the last follow up. We also recorded the time to return to activities of daily living (ADL) and sports, and the number of single-leg heel lifts on the affected leg at the last follow up, at an average of 35.4 months. RESULTS: Patient characteristics between groups were similar. All outcome measures significantly improved after surgery (p<0.001), without differences between the three groups. Return to ADL was possible at an average of 4.5 months. Patients undergoing PB transfer had a slower return to sports compared to the other groups, at 6.9±0.5months versus 6.1±0.8 for the FHL and 5.8±0.6 for the ST groups (t-test p=0.005 and p<0.001, respectively). However, 13/14 patients (90%) in the PB group returned to high impact sports, compared to 9/12 (75%) in the FHL and 6/11 (55%) in the ST groups (Fisher's test, p=0.31 and p=0.056, respectively). CONCLUSION: All three techniques produced significant functional improvement, and return to sports was possible in most patients. This study does not demonstrate a clear advantage of one technique over the others.

Conservative, minimally invasive and open surgical repair for management of acute ruptures of the Achilles tendon: a clinical and functional retrospective study.

BACKGROUND: At present, it is unclear which is the best management for Achilles tendon rupture. PURPOSE: We assess the clinical, functional and imaging outcomes of active patients undergoing 3 different types of management for acute subcutaneous rupture of the Achilles tendon, including conservative cast immobilization, traditional open surgery and percutaneous repair. METHODS: 26 active patients were managed for a rupture of the Achilles Tendon from January 2007 to March 2008. Anthropometric measurements, Functional assessment, Isometric strength, Ultrasonographic assessment, Patient satisfaction, Working life, Physical activity, Functional score and Complications were recorded retrospectively. RESULTS: All 23 (21 men, 2 women) patients were reviewed at a minimum follow-up of 24 months (average 25.7, range 24 to 32 months, SD: 6.3) from the index injury. Thermann scores and patient satisfaction were significantly higher following surgery than conservative management with no significance between open and minimally invasive operated patients. Sensitive disturbances occur in up to 12% of open repairs and 1.8% of patients managed nonsurgically. CONCLUSIONS: Clinical and functional outcomes following surgical repair, percutaneous and open, of the Achilles tendon are significantly improved than following conservative management. LEVEL OF EVIDENCE: Level III.

Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures: surgical technique.

BACKGROUND: Patellar tendon chronic ruptures are more debated to manage that acute injuries as the patella tends to retract proximally (after 2 weeks), and surrounding soft tissues may make the repair more complicate. PURPOSE: We propose a novel technique in which the patellar tendon is reconstructed using ipsilateral hamstring tendons. This surgical procedure implies to drill a single tunnel through the patella and another through the tibia to reduce the risk of bony breakage. In addition, the tendon is secured to the bone, at the tunnel exit points, by periostium sutures without requiring any additional surgery for hardware removal. METHODS: We assessed 19 patients (16 men and 3 women) who underwent PT reconstruction at an average of 5.8 years (range, 4 to 7.8 years, SD: 3.5) from the index surgery. The mean age at surgery was 46 ± 9.2 years (range, 38-59 years). RESULTS: All patients had a complete tear of the patellar tendon. CONCLUSIONS: The main indication for this procedure is the reconstruction of the PT in patients with chronic rupture (>6 weeks) in which the tendon gap is greater than 2 centimeters and the scar tissues and degenerated tendon ends do not allow to juxtapose the tendon stumps to each other. LEVEL OF EVIDENCE: Level IV.

Pulsed electromagnetic fields after rotator cuff repair: a randomized, controlled study.

The current study tested the hypothesis that the use of pulsed electromagnetic fields after rotator cuff repair is effective in the short term as an adjuvant treatment to reduce local inflammation, postoperative joint swelling, and recovery time, as well as to induce pain relief. Sixty-six patients who underwent shoulder arthroscopy for repair of small to medium rotator cuff tears were randomly divided into 2 groups with a block randomization procedure. Thirty-two patients underwent arthroscopic rotator cuff repair and application of pulsed electromagnetic fields postoperatively; 34 patients underwent rotator cuff repair and placebo treatment (placebo group). All patients had the same postoperative rehabilitation protocol. At 3 months from the index procedure, visual analog scale, range of motion, and University of California at Los Angeles and Constant scores were significantly better in the pulsed electromagnetic fields group than in the placebo group (P<.05). Three patients in the pulsed electromagnetic fields group and 7 patients in the placebo group had mild to moderate capsulitis (P=.2). Severe capsulitis occurred in 1 patient in the pulsed electromagnetic fields group and 2 patients in the placebo group (P=.6). At the last follow-up (minimum, 2 years), clinical and functional outcomes were further improved in both groups, with no significant intergroup differences. Application of pulsed electromagnetic fields after rotator cuff repair is safe and reduces postoperative pain, analgesic use, and stiffness in the short term. At 2 years, no difference was seen in outcomes in patients who did or did not undergo treatment with pulsed electromagnetic fields.

I.S.Mu.L.T - Rotator Cuff Tears Guidelines.

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.

Clinical evidence in the treatment of rotator cuff tears with hyaluronic acid.

PURPOSE: the aim of this quantitative review is to document potential benefit and adverse effects of hyaluronic acid (HA) injection into the shoulder with rotator cuff tears. METHODS: a systematic literature search was performed in english PubMed, Medline, Ovid, Google Scholar and Embase databases using the combined key words "hyaluronic acid", "rotator cuff tear", "hyaluronate", "shoulder", "viscosupplementation", with no limit regarding the year of publication. Articles were included if they reported data on clinical and functional outcomes, complications in series of patients who had undergone HA injection for management of rotator cuff tears. Two Authors screened the selected articles for title, abstract and full text in accordance with predefined inclusion and exclusion criteria. The papers were accurately analyzed focusing on objective rating scores reported. RESULTS: a total of 11 studies, prospective, 7 were randomized were included by full text. A total of 1102 patients were evaluated clinically after different HA injection compare with corticosteroid injection, physically therapies, saline solution injection and control groups. The use of HA in patients with rotator cuff tears improve VAS and functional score in all trials that we have analyzed. CONCLUSION: intra-articular injection with HA is effective in reducing pain and improving function in shoulder with rotator cuff tears and without severe adverse reaction. LEVEL OF EVIDENCE: Level I.

Arthroscopic repair of the subscapularis tendon: indications, limits and technical features.

The rationale to anatomically repair this tendon is to restore the functional biomechanics of the shoulder. Clinical and imaging assessment are required before undertaking arthroscopy. In this way, associated pathologies of the biceps and labrum may be successfully addressed. The arthroscopic repair of the tendon implies to use suture anchors and reinsert the tendon itself over the footprint. Results after arthroscopy are comparable to those observed after open procedures.