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

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

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

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

Determining the Optimal Treatment for Idiopathic Clubfoot: A Network Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Clubfoot, or congenital talipes equinovarus deformity, is a common anomaly affecting the foot in infants. However, clinical equipoise remains between different interventions, especially those based on the Ponseti method. The aim of this study was to examine the clinical outcomes of the various interventions for treating idiopathic clubfoot. METHODS: Searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Scopus, and CINAHL were conducted. Randomized controlled trials comparing different interventions, including the Ponseti method, accelerated Ponseti method, Ponseti method with botulinum toxin type A (Botox) injection, Ponseti method with early tibialis anterior tendon transfer (TATT), Kite method, and surgical treatment, were included. Network meta-analyses (NMAs) were conducted according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) reporting guidelines. The primary outcomes were the change in total Pirani score and maximal ankle dorsiflexion. Secondary outcomes were the number of casts, time in casts, and rates of tenotomy, total complications, relapse, adverse events, and additional required major surgery. RESULTS: Eleven randomized controlled trials involving 740 feet were included. According to the SUCRA (surface under the cumulative ranking curve)-based relative ranking, the Ponseti method was associated with the best outcomes in terms of Pirani score changes, maximal ankle dorsiflexion, number of casts, adverse events, and total complications, whereas the accelerated Ponseti method was associated with the best outcomes in terms of time in casts and tenotomy rate. Early TATT ranked best in terms of relapse rate. The Ponseti method with Botox injection was associated with the best outcomes in terms of the need for additional major surgery. CONCLUSIONS: The NMAs suggest that the Ponseti method is the optimal treatment overall, despite potential drawbacks such as longer time in casts and higher rates of tenotomy, relapse, and the need for additional surgery compared with other modified approaches. Therefore, clinicians should consider how treatments can be tailored individually. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Optimised return to play: high treatment success rate in core muscle injury with surgical release of the anterior tendon of the rectus abdominis muscle and proximal tenotomy of the adductor longus muscle.

OBJECTIVES: Core muscle injury is a debilitating condition that causes chronic groin pain in athletes, particularly common in soccer players. The condition is characterised by pain in the inguinal region and can lead to a significant number of absences from high-intensity physical activity. It is caused by repetitive overload without proper counterbalance from the abdominal muscles, hip flexors, and adductors in susceptible athletes. Surgical indications for core muscle injury consider cases where non-surgical treatments have not provided sufficient relief. The aim of this study was to assess the results of surgical intervention for core muscle injury using the technique employed by the Sports Medicine Group of (Institute of Orthopedics and Traumatology of Hospital das Clínicas - Universidade de São Paulo). The procedure involves releasing the anterior portion of the tendon of the rectus abdominis muscle near the pubic symphysis, along with proximal tenotomy of the adductor longus muscle tendon. METHODS: This study utilised a consecutive historical cohort analysis of the medical records of 45 male athletes, of which, 75.6% were professional soccer players, who underwent surgical treatment between January 1, 2002, and December 31, 2021. The participants included active athletes aged between 18 and 40 years, with a mean age of 23.9 years, and were diagnosed with myotendinous core muscle injury. These athletes experienced pain in the pubic symphysis and adductor tendon region and had previously undergone medical treatment and physical therapy for a duration of three to six months without significant improvement. RESULTS: The average time for athletes to return to sport after surgery was 135 days, with a majority of participants being soccer and futsal players. The surgical intervention yielded promising results, with a positive correlation between unilateral injuries and the time taken to return to sport. The complication rate was low, at 6.7%. Notably, the rate of symptom resolution was high, at 93.3%. Furthermore, the analysis indicated that the player's position on the field significantly influenced the discharge period, suggesting that the game position plays a role in the recovery process. CONCLUSION: The combined surgical procedure involving the release of the rectus abdominis tendon and adductor longus muscle tenotomy demonstrates favourable outcomes for athletes with core muscle injury. This study provides strong support for the effectiveness of this surgical approach in managing the condition and offers a potential path to recovery and return to sports activities. STUDY DESIGN: Cross-sectional study.

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

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

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

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

The Impact of Operative Correction of Equinus in Cerebral Palsy on Gait Patterns.

BACKGROUND: This study aimed to evaluate gait outcomes and strength following the surgical correction of equinus in cerebral palsy (CP) based on different surgical procedures. We included the Baumann and Strayer procedures, as well as the Achilles tendon lengthening (ATL). METHODS: A retrospective analysis was performed in patients with infantile, bilateral CP who received instrumental 3D gait analysis before and after surgical correction (18.66 months postoperatively). Patients were divided into 3 groups: Strayer surgery, Baumann surgery, and ATL. Gait performance and muscle strengths were compared between studied surgeries. RESULTS: A total population of 204 patients (15.43 years) with 341 operated lower limbs (LLs) was analyzed. Dorsiflexion in swing and stance phases significantly improved in all groups postoperatively. The Strayer and the ATL group showed higher postoperative dorsiflexion than the Baumann group. However, no loss of strength was observed with the Baumann method. Maximum power improved in this group postoperatively. An 8.2% loss in calf muscle strength was recorded in the Strayer group. CONCLUSION: Operative pes equinus treatment successfully improved the gait of children and adults with CP postoperatively. There were differences in postoperative results between studied operative techniques regarding range of motion and power. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

A single-center, single-blinded, randomized, parallel-group, non-inferiority trial to compare the efficacy of a 22-gauge needle versus a 15 blade to perform an Achilles tendon tenotomy in 244 clubfeet-study protocol.

BACKGROUND: Achilles tendon tenotomy is an integral part of the Ponseti method, aimed at correcting residual equinus and lack of dorsiflexion after correction of the adductus deformity in clubfoot. Percutaneous tenotomy using a number 15 scalpel blade is considered the gold standard, resulting in excellent results with minimal complications. The use of a large-bore needle to perform Achilles tendon tenotomies has been described in literature, but a large-scale randomized controlled trial is currently lacking. In this trial, we aim to show the non-inferiority of the needle tenotomy technique compared to the gold standard blade tenotomy technique. METHODS: We will randomize 244 feet into group A: needle tenotomy or group B: blade tenotomy. Randomization will be done using a block randomization with random block sizes and applying a 1:1 allocation to achieve an intervention and control group of the exact same size. Children will be evaluated at 3 weeks and 3 months post-tenotomy for primary and secondary clinical outcomes. The primary clinical outcome will be the range of dorsiflexion obtained the secondary clinical outcomes will be frequency of minor and major complications and Pirani score. The non-inferiority margin was set at 4°, and thus, the null hypothesis of inferiority of the needle technique will be rejected if the mean difference between both techniques is less than 4°. The statistical analysis will use a multi-level mixed effects linear regression model for the primary outcomes and a multi-level mixed effects logistic regression model for the secondary clinical outcomes. The physician performing the evaluations post-tenotomy will be the only one blinded to group allocation. TRIAL REGISTRATION: This trial was registered prospectively with ClinicalTrials.gov registration number: NCT04897100 on 21 May 2021.

What happens to endoscopic/arthroscopic tenotomies with iliopsoas impingement in the medium term? Review of a prospective cohort of 64 patients with a minimum follow-up of 5 years.

INTRODUCTION: The occurrence of iliopsoas impingement (IPI) after total hip arthroplasty (THA) is a proven risk factor for negative outcomes. Endoscopic or arthroscopic tenotomies of the iliopsoas offer a surgical solution with short-term results that have already been validated in prospective multicenter series. We carried out a review of the patients at more than 5 years of follow-up in order to assess the stability of the results over time. HYPOTHESIS: Our main hypothesis was that endoscopic/arthroscopic tenotomies allow stable medium-term resolution of the painful symptoms of IPI. Our secondary hypothesis was that medium-term survival was satisfactory. MATERIAL AND METHOD: This study is a continuation of a multicenter prospective series. Patients were contacted through multiple channels in order to: obtain an Oxford score, assess for satisfaction, psoas irritation, and daily pain on a visual analogue scale (VAS). RESULTS: Of 64 patients in the original study, 57 were contacted. The Oxford score at the last follow-up was 40.7±7.7 [12-48]. There was a significant difference between the Oxford scores preoperatively, at 8 months and at the last follow-up. The mean satisfaction out of 10 was 8.0±2.1 [1-10]. We found 84% satisfaction at 5 years against 83% at 8 months. The VAS was 2.1±2.3 [0-10]. A straight leg psoas sign was present in 19.6% (10/51) of patients at 5 years, compared to 15.6% (8/51) at 8 months. The sign disappeared in four cases, while it reappeared during the interval in six cases. Survival was 91.2% (95% CI: 80.2-96.3) at 5 years. CONCLUSION: Endoscopic/arthroscopic iliopsoas tenotomies represent a permanent medium-term solution to treat IPI after THA. The existence of a force differential or an acetabular overhang does not seem, within a certain limit, to impact the results in the medium term. LEVEL OF EVIDENCE: IV; prospective series without control group.

Tenotomy or tenodesis versus conservation of the long head of the biceps tendon in the repair of isolated supraspinatus tears: A systematic review of the literature.

BACKGROUND: Few studies have directly compared the outcomes of rotator cuff repair (RCR) with or without concomitant LHBT tenotomy or tenodesis. The aim of this literature review was to assess: (i) whether an adjuvant procedure on the LHBT at the time of RCR gives better functional results than RCR alone; and (ii) whether reoperation rates are higher after RCR alone or RCR+tenotomy or tenodesis. METHODS: A literature search was carried out on PubMed, MEDLINE, Embase, Web of Science and the Cochrane database for papers published in English or French between 1st January, 2010, and 31st December, 2021. Included studies compared the results of RCR alone with RCR+concomitant tenotomy or tenodesis in patients with tears of the supraspinatus tendon or rotator cuff. ARTICLES: A total of 626 articles were identified in the literature search and 168 were retained for more detailed examination. Forty-seven articles were read in their entirety and nine articles comparing RCR with or without concomitant tenotomy or tenodesis of the LHBT were retained for the analysis. RESULTS: Nine articles comparing the results of RCR alone versus RCR+LHBT tenotomy or tenodesis were reviewed. The majority of patients were more than 50 years old and male. The rate of lesions to the LHBT in the studies included ranged from 26.8-60.2%. Eight of the nine studies compared the functional results of RCR alone versus RCR+tenotomy or tenodesis, with six reporting no significant difference, one reporting better outcomes after concomitant biceps surgery and one reporting worse outcomes after a biceps procedure. DISCUSSION: This review did not provide a strong answer to our questions, owing to the heterogenicity of clinical evaluation and low level of evidence of the studies. However, it appears that in the absence of biceps pathology or in the presence of small lesions, the LHBT could be preserved. The rate of revision did not seem to be higher and cuff healing lower in this situation. Therefore, further randomized studies are required to identify the role of concomitant procedure of the biceps in case of small isolated supraspinatus repair. LEVEL OF EVIDENCE: III; systematic review.

Modified arthroscopic intra-articular transtendinous looped biceps tenodesis leads to satisfactory functional outcomes and less frequent Popeye deformity compared to biceps tenotomy.

PURPOSE: The present study aimed to propose a modified intra-articular transtendinous looped biceps tenodesis (mTLBT) using a suture anchor and to compare the functional outcomes and incidence of Popeye deformities between biceps tenotomy and mTLBT. METHODS: Medical records of patients who underwent either tenotomy or mTLBT for the long head of the biceps tendon (LHBT) lesion between January 2016 and April 2021 were retrospectively reviewed. The inclusion criteria were patients aged 40-70 years with LHBT pathologies, such as superior labrum anterior to posterior (SLAP) lesions > type II, LHBT pulley system rupture with bicipital instability, and intra-articular LHBT tear. The exclusion criteria were full-thickness supraspinatus tears, frozen shoulder, shoulder fracture, and postoperative traumatic events that affected the operated shoulder. All patients were followed up for at least 1 year. Popeye deformity, bicipital cramping pain, visual analog scale (VAS) pain score, and functional outcome scores (University of California at Los Angeles [UCLA] and American Shoulder and Elbow Surgeons [ASES] scores) were recorded. Fisher's exact test and Chi-square test were used for categorical variables, whereas the Mann-Whitney U test was used for nonparametric variables. RESULTS: The mTLBT and tenotomy groups included 15 and 40 patients, respectively. The incidence of Popeye deformity and biceps cramping pain in the tenotomy group (52.5% and 50%, respectively) was significantly higher than that in the mTLBT group (13.3% and 20%, respectively) (p = 0.009 and p = 0.045, respectively). The postoperative VAS, UCLA, and ASES scores were not significantly different between the two groups. One patient in the tenodesis group experienced metallic-anchor pullout. CONCLUSION: mTLBT is an arthroscopic intra-articular top of the groove tenodesis that can be performed completely in the intra-articular space and is especially suitable for patients with an intact or partially torn rotator cuff. This technique is reliable for treating biceps pathologies as it results in similar functional outcome scores, lesser biceps cramping pain, and less frequent Popeye deformity compared to biceps tenotomy. LEVEL OF EVIDENCE: III.

Exploring Bracing Adherence in Ponseti Treatment of Clubfoot: A Comparative Study of Factors and Outcomes in Uganda.

The Ponseti method of clubfoot treatment involves two phases: initial correction, usually including tenotomy; and bracing, to maintain correction and prevent relapse. Bracing should last up to four years, but in Uganda, approximately 21% of patients drop from clinical oversight within the first two years of using the brace. Our study compared 97 adherent and 66 non-adherent cases to assess the influential factors and effects on functional outcomes. We analyzed qualitative and quantitative data from clinical records, in-person caregiver interviews, and assessments of foot correction and functionality. Children who underwent tenotomy had 74% higher odds of adherence to bracing compared to those who did not undergo tenotomy. Conversely, children from rural households whose caregivers reported longer travel times to the clinic were more likely to be non-adherent to bracing (AOR 1.60 (95% CI: 1.11-2.30)) compared to those without these factors. Adhering to bracing for a minimum of two years was associated with improved outcomes, as non-adherent patients experienced 2.6 times the odds of deformity recurrence compared to adherent patients. Respondents reported transportation/cost issues, family disruptions, and lack of understanding about the treatment method or importance of bracing. These findings highlight the need to address barriers to adherence, including reducing travel/waiting time, providing ongoing education for caregivers on bracing protocol, and additional support targeting transportation barriers and household complexities.

Percutaneous ultrasound-guided needle tenotomy for treatment of chronic tendinopathy and fasciopathy: a meta-analysis.

OBJECTIVES: To systematically assess the efficacy of percutaneous ultrasound-guided needle tenotomy (PUNT) in the treatment of chronic tendinopathy and fasciopathy. METHODS: A comprehensive literature search was performed with the following search terms: tendinopathy, tenotomy, needling, Tenex, fasciotomy, ultrasound-guided, and percutaneous. Inclusion criteria consisted of original studies evaluating pain or function improvement after PUNT. Meta-analyses investigating standard mean differences were performed to assess the pain and function improvement. RESULTS: Thirty-five studies with 1674 participants (1876 tendons) were enrolled in this article. Of which 29 articles were included in meta-analysis and the remaining 9 articles without enough numeric data were included in descriptive analysis. PUNT significantly alleviated pain with the standard mean difference of 2.5 (95% CI: 2.0-3.0; p < 0.05), 2.2 (95% confidence interval (CI): 1.8-2.7; p < 0.05), and 3.6 (95% CI: 2.8-4.5; p < 0.05) points in short-term, intermediate-term, and long-term follow-up intervals, respectively. It was also associated with marked improvement in function with 1.4 (95% CI: 1.1-1.8; p < 0.05), 1.8 (95% CI: 1.3-2.2; p < 0.05), and 2.1 (95% CI: 1.6-2.6; p < 0.05) points, respectively in short-term, intermediate-term, and long-term follow-ups. CONCLUSION: PUNT improved pain and function at short-term intervals with persistent results on intermediate- and long-term follow-ups. PUNT can be considered an appropriate minimally invasive treatment for chronic tendinopathy with a low rate of complications and failures. CLINICAL RELEVANCE: Tendinopathy and fasciopathy are two common musculoskeletal complaints that can cause prolonged pain and disability. PUNT as a treatment option could improve pain intensity and function. KEY POINTS: • The best improvement in pain and function was achieved after the first 3 months following PUNT and was continued to the intermediate- and long-term follow-ups. • No significant difference was found between different tenotomy methods in terms of pain and function improvement. • PUNT is a minimally invasive procedure with promising results and low complication rates for treatments of chronic tendinopathy.

Indication for Achilles Tenotomy in Congenital Clubfoot: Effectiveness of Using the Tibio-Plantar Fascia Angle as a Radiographic Parameter.

Congenital clubfoot is one of the most common deformities in children, and currently, the Ponseti method is used worldwide because of its favorable short-term results. With the Ponseti method, the indication for Achilles tenotomy is traditionally based on only physical examination findings; however, some surgeons have also utilized plain radiographs. Because using physical examinations to determine the degree of hindfoot dorsiflexion for the indication of tenotomy can lead to underestimation. We developed and utilized the effectiveness of the tibio-plantar fascia angle (Ti-P angle) in the lateral maximum dorsiflexion view in determining the need for Achilles tenotomy. A retrospective analysis of consecutive 26 patients with congenital idiopathic clubfeet (37 feet) was performed. Whether Achilles tenotomy was indicated was determined based on physical examination for a former period (Group P). For the latter period, whether tenotomy was indicated was determined by referencing radiographs (Group X). No significant differences were found in any of the background factors or severity between Group P and Group X. Cases with larger tibiocalcaneal and Ti-P angles were more likely to require Achilles tenotomy or additional soft tissue release. An angle of more than 72° of the Ti-P angle demonstrated adequate specificity for the indication of Achilles tenotomy. The radiographic lateral tibio-plantar fascia angle is useful for deciding whether a tenotomy needs to be performed.

Lateral epicondylitis: comparing ultrasound-guided tenotomy with or without amniotic membrane allograft injection.

Aim: To evaluate the clinical response to augmenting ultrasound-guided tenotomy (USGT) with an amniotic membrane (AM) allograft injection. Design: Retrospective study. Materials & methods: Subjects underwent either a USGT (N = 16) or a combined USGT plus AM injection (N = 14). Results: Both groups demonstrated a significant reduction in pain from baseline starting after 2 weeks in the USGT plus AM group (p = 0.036) and after 8 weeks in the USGT group (p = 0.021). The reduction in pain was sustained for the entire duration of the study (52 weeks). There was no significant difference in pain levels at 26- or 52-week follow-up or patient satisfaction between the two groups. Conclusion: USGT with or without AM allograft injections results in a significant reduction in pain with high patient satisfaction.

The goal of this study was to determine if a single injection of an amniotic membrane (AM) tissue improves clinical outcomes for patients with chronic tennis elbow treated with ultrasound-guided tenotomy. Ultrasound-guided tenotomy involves using a cutting device to remove degenerative tissue with ultrasound-guidance to help tendon's healing process. An AM injection is thought to reduce inflammation in the surrounding tissue, provide growth factors that help with the tendon's healing process, and minimize painful scar formation. 30 patients were included in this study (16 ultrasound-guided tenotomy [USGT] and 14 USGT plus AM injection). Both groups showed improvement in pain levels compared with their baseline at the short-term follow-up, and this reduction in pain was sustained for 52 weeks. There were no long-term differences between the two groups at the 52 week follow-up in pain levels or satisfaction. Our findings suggest that USGT, with or without AM injection, is an effective method of treatment for chronic tennis elbow.

Transcanal Endoscopic Stapedial and Tensor Tympani Tenotomy for Middle Ear Myoclonus: A Retrospective Case Series of Surgical Outcomes.

OBJECTIVE: To describe and analyze the surgical outcomes of transcanal endoscopic resection of the stapedial tendon (ST) and tensor tympani tendon (TT) in the management of middle ear myoclonus (MEM). STUDY DESIGN: A retrospective case series. SETTING: Tertiary academic center. PATIENTS: Seven consecutive patients (seven ears) with tinnitus were diagnosed with MEM. INTERVENTION: Transcanal endoscopic resection of both the ST and TT using either microinstruments or a laser. MAIN OUTCOME MEASURES: The symptom of tinnitus, based on visual analog scale and Tinnitus Handicap Inventory scores, was analyzed preoperatively and postoperatively for each patient. The intraoperative findings and postoperative complications were also evaluated. RESULTS: Amelioration of objective tinnitus with significant improvement in visual analog scale and Tinnitus Handicap Inventory scores was noted in all seven patients. The ST and TT were easily identified in the same endoscopic field, with minimal or no removal of the scutum. There was no need to perform an anterior tympanotomy to expose the TT. Resection of both the ST and TT and creating a gap between the cut edges were achieved by using either microinstruments or a laser under an endoscopic field. Conversion to or conjunction with the microscopic approach was unnecessary for any of the seven patients. No hearing loss or hyperacusis occurred postoperatively. CONCLUSIONS: Transcanal endoscopic resection of the ST and TT successfully ameliorated the symptom of tinnitus in patients with MEM. A transcanal endoscopic approach provides an alternative method to manage MEM, providing excellent visualization and minimal invasiveness.

Percutaneous Achilles tendon tenotomy in clubfoot patients with a 22 gauge needle in a low-resource setting.

Ponseti treatment has been well-established as the gold standard for the treatment of idiopathic clubfoot in high-income countries and middle- and low-income countries (LMICs). The tenotomy is usually performed in the clinic using a scalpel blade under local anesthesia. However, we believe that by adapting the technique from Minkowitz et al. to a low-resource setting, we can help address some of the known barriers to Ponseti care. Using a needle instead of a blade makes the procedure less cumbersome easier to learn and easier to understand for the provider, family and the patient. We were able show that the needle tenotomy technique can be implemented in a low-resource setting like Pakistan, and can be performed using only one assistant and materials that are locally and readily available for the same cost This paper and its attached educational videos can help spread the technique among providers in low-resource settings.

Arthroscopic popliteal tenotomy grants satisfactory outcomes in total knee arthroplasty with persistent localised posterolateral pain and popliteus tendon impingement.

PURPOSE: The purpose was to estimate the prevalence of popliteus tendon impingement following TKA, and to describe the characteristics and the differential diagnosis protocol for this rare condition. The hypothesis was that arthroscopic popliteal tenotomy in TKA patients with suspected popliteus tendon impingement would relieve pain and improve satisfaction. METHODS: Of 741 TKAs performed over three years, eight (1.1%, all women) had suspected popliteus tendon impingement, of which seven had severe localised posterolateral knee pain and one global knee pain. Upon confirmation of popliteus tendon impingement, arthroscopic popliteal tenotomy was performed, and outcomes (Pain on visual analogue scale (pVAS; best, 0; worst, 10), Oxford Knee Score (OKS; best, 48; worst, 0) and satisfaction (best, 100%; worst, 0%) assessed at mean 18-month follow-up. RESULTS: At four to 30 months after TKA, arthroscopic exploration revealed popliteus tendon impingement in all eight knees. Six reported complete pain relief (pVAS, 0) the day following arthroscopic popliteal tenotomy, whilst one reported some residual pain (pVAS, 2). The remaining patient with global pain reported no pain relief, and required revision TKA at 12 months. Excluding the revised TKA, OKS was between 19 and 43, and satisfaction was rated ≥ 80% in five of the remaining seven patients. CONCLUSIONS: Arthroscopic popliteal tenotomy relieved symptoms in TKA patients with persistent localised posterolateral pain and a positive popliteus test. These findings suggest that the popliteus test is reliable to diagnose popliteus tendon impingement following TKA, which could be treated by arthroscopic popliteal tenotomy. LEVEL OF EVIDENCE: Level IV, Small case series.

Subgroups of Idiopathic Clubfoot Can Predict Short-term Outcomes.

BACKGROUND: The Pirani scale is used for the assessment of Ponseti-managed clubfoot. Predicting outcomes using the total Pirani scale score has varied results, however, the prognostic value of midfoot and hindfoot components remains unknown. The purpose was to (1) determine the existence of subgroups of Ponseti-managed idiopathic clubfoot based on the trajectory of change in midfoot and hindfoot Pirani scale scores, (2) identify time points, at which subgroups can be distinguished, and (3) determine whether subgroups are associated with the number of casts required for correction and need for Achilles tenotomy. METHODS: Medical records of 226 children with 335 idiopathic clubfeet, over a 12-year period, were reviewed. Group-based trajectory modeling of the Pirani scale midfoot score and hindfoot score identified subgroups of clubfoot that followed statistically distinct patterns of change during initial Ponseti management. Generalized estimating equations determined the time point, at which subgroups could be distinguished. Comparisons between groups were determined using the Kruskal-Wallis test for the number of casts required for correction and binary logistic regression analysis for the need for tenotomy. RESULTS: Four subgroups were identified based on the rate of midfoot-hindfoot change: (1) fast-steady (61%), (2) steady-steady (19%), (3) fast-nil (7%), and (4) steady-nil (14%). The fast-steady subgroup can be distinguished at the removal of the second cast and all other subgroups can be distinguished at the removal of the fourth cast [ H (3) = 228.76, P < 0.001]. There was a significant statistical, not clinical, difference in the total number of casts required for correction across the 4 subgroups [median number of casts 5 to 6 in all groups, H (3) = 43.82, P < 0.001]. Need for tenotomy was significantly less in the fast-steady (51%) subgroup compared with the steady-steady (80%) subgroup [ H (1) = 16.23, P < 0.001]; tenotomy rates did not differ between the fast-nil (91%) and steady-nil (100%) subgroups [ H (1) = 4.13, P = 0.04]. CONCLUSIONS: Four distinct subgroups of idiopathic clubfoot were identified. Tenotomy rate differs between the subgroups highlighting the clinical benefit of subgrouping to predict outcomes in Ponseti-managed idiopathic clubfoot. LEVEL OF EVIDENCE: Level II, prognostic.

The long head of biceps at the shoulder: a scoping review.

BACKGROUND: This review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions. METHODS: PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English. RESULTS: 214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep's role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy's limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation. CONCLUSIONS: The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required. PRE-REGISTRATION: OSF: https://osf.io/erh9m.