The arterial anatomy of the Achilles tendon: Anatomical study and clinical implications

The Achilles tendon is the most frequently ruptured tendon in the lower limb and accounts for almost 20% of all large tendon injuries. Despite numerous published studies describing its blood supply, there has been no uniformity in describing its topography. The current study comprises a detailed anatomical study of both the intrinsic and extrinsic arterial supply of the Achilles tendon, providing the detail sought from studies calling for improved planning of surgical procedures where damage to the vascularity of the Achilles tendon is likely. A dissection, microdissection, histological, and angiographic study was undertaken on 20 cadaveric lower limbs from 16 fresh and four embalmed cadavers. The Achilles tendon is supplied by two arteries, the posterior tibial and peroneal arteries. Three vascular territories were identified, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. The midsection of the Achilles tendon was markedly more hypovascular that the rest of the tendon. The Achilles tendon is at highest risk of rupture and surgical complications at its midsection. Individuals with particularly poor supply of the midsection may be at increased risk of tendon rupture, and approaches to the tendon operatively should consider the route of supply by the peroneal artery to this susceptible part of the tendon. Clin. Anat. 22:377–385, 2009. © 2009 Wiley‐Liss, Inc.     

The arterial supply of the long head of biceps tendon: Anatomical study with implications for tendon rupture

Zones of hypovascularity are thought to exist in several tendons of the shoulder, contributing to localized tendon weakness and subsequent rupture in clinical practice. Although these zones have been demonstrated in many frequently ruptured tendons, the existence of a similar area in the often ruptured long head of biceps (LHB) tendon is largely unknown. Twenty cadaveric upper limb specimens were dissected after injection with either a radio‐opaque lead oxide/milk mixture or India ink, followed by histological sectioning of the tendons. The LHB tendon was consistently supplied via its osteotendinous and musculotendinous junctions by branches of the thoracoacromial and brachial arteries respectively. In two specimens, additional branches from the anterior circumflex humeral artery travelling in a mesotenon vascularized the midsection of tendon. These source arteries divided the LHB tendon into either two or three vascular territories, depending upon the presence of the mesotenon‐derived vascular supply. A zone of hypovascularity was consistently found in the region of the LHB tendon most frequently prone to rupture. This zone covered an area 1.2–3 cm from the tendon origin, extending from midway through the glenohumeral joint to the proximal inter‐tubercular groove. This hypovascular region occurred on the border of two adjacent vascular territories, where reduced caliber choke vessels provide limited arterial supply. While it is probable that the limited arterial supply contributes to the susceptibility of this area to rupture, similar to other tendons the true pathogenesis is likely to be a combination of both vascular and mechanical factors. Clin. Anat. 23:683–692, 2010. © 2010 Wiley‐Liss, Inc.     

Correlation between patella and patellar tendon width: An anatomic study

Anterior cruciate ligament (ACL) rupture is a common injury among orthopaedic patients with many different treatment modalities including bone-patella-bone autograft (BPBA) ACL reconstruction. Patella tendon width has been reported to be a predictor of recovery speed and success following BPBA repair. This study reports on the strength of the relationship between patella width and patella tendon width. Twenty fresh frozen cadavers were included in the study. Patella and patellar tendon measurements were recorded at the midpoint of the patellar tendon. Pearson correlation and linear regression were used to determine the relationship between patella width and patellar tendon width. Bivariate correlations with 95% confidence intervals and coefficients of determination (R(2) ) are reported. The study used 20 cadavers, 12 men and 8 women with a mean age of 72 (standard deviation [SD] = 12; range = 44 to 87). The mean patella width was 49.24mm (SD = 4.11; range 42.33mm-56.33mm) while the mean patellar tendon width was 26.10mm (SD = 3.31; range 18.33mm-33.33mm). The correlation between patella width and patellar tendon width was 0.67 (95% confidence interval = 0.45 - 0.81). R(2), the percent of variance in patellar tendon width accounted for by patella width, was 0.45. The regression equation for predicting patellar tendon width (y) yielded a formula of y = 0.536 + -0.316 × patella width. A moderate correlation exists between patella width and patellar tendon width. Our data suggests that this correlation is strongest with wider patellas and is more loosely associated with smaller patellas.     

The natural history of anterior cruciate ligament reconstruction using patellar tendon autograft

The purpose of this study was to review the results of ACL reconstruction using a patellar tendon graft placed ‘over the top’ plus a Macintosh lateral tenodesis, examining changes in knee laxity and functional status with increasing time. There were 74 patients operated on over an 11 year period, and divided into four groups for analysis according to postoperative time. There was a significant and progressive increase in side-to-side laxity difference with time, although functional status did not change significantly, indicating a lack of correlation between objective clinical tests and subjective findings. The highest Lysholm, Tegner and IKDC scores were at 4–5 years after operation, when 60% of patients were at their pre-injury level of sports activity. However, there was always a very significant difference between actual and desired Tegner activity levels for the group as a whole. While there was a significant correlation between degenerative changes and the time between injury and reconstruction, there was no correlation with postoperative time: this provides evidence that ACL reconstruction can protect the knee from later degeneration.     

保留止点自体肌腱移植治疗陈旧性髌韧带断裂

背景：髌韧带在膝关节的运动中起着非常重要的的作用,因其断裂比较少见,临床上误诊率较高。目前重建髌韧带的方法较多,疗效报道不一,治疗不当容易出现髌骨位置不良,会严重影响膝关节的功能。 目的：探讨保留止点自体肌腱移植治疗陈旧性髌韧带断裂的临床疗效。 方法：对8例单侧陈旧性髌韧带断裂的患者行保留止点的半肌腱、股薄肌重建髌韧带,髌韧带重建后行半环形石膏后托固定屈膝15°1周,髌韧带重建后2周拆除切口缝线,3周去除石膏行股四头肌等长等张练习,6周时佩戴可调节膝关节护具进行膝关节活动度锻炼,3次/d,每周增加10°。髌韧带重建3个月后允许完全负重行走。 结果与结论：所有患者髌韧带重建后无并发症,X射线示髌骨恢复正常高度。膝关节功能恢复良好。所有患者髌韧带重建后24个月行走2 km以上膝关节无不适。与髌韧带重建前相比,髌韧带重建后24个月患者的Lysholm评分明显增加(P < 0.05),说明保留止点的半腱肌、股薄肌重建髌韧带可重建治疗陈旧性髌韧带断裂。     

Anterior knee symptoms after reconstruction of the anterior cruciate ligament using patellar tendon as a graft

We have reviewed 74 patients, at an average follow-up of nearly 3 years, following anterior cruciate ligament reconstruction with the central third of the patellar tendon to assess the incidence and severity of anterior knee symptoms, not only pain but also other symptoms related to the front of the knee. Sixty-two percent of patients had some degree of pain. In addition, there was numbness in 85%, patello-femoral crepitus in 47% and swelling in 26% of patients. Only one patient felt that the front of the knee was normal. Eleven percent felt that these symptoms were a significant problem.     

髌韧带与膝交叉韧带的血供及其在交叉韧带损伤重建中的意义

目的　探讨髌韧带和膝交叉韧带的血供特点,为临床韧带重建提供形态学依据。 方法　通过成人和胎儿股动脉红色乳胶灌注并解剖剥离、胎儿墨汁灌注组织透明和组织切片等方法,观察髌韧带和膝交叉韧带的动脉分布特点并测量胎儿韧带内微血管密度。 结果　髌韧带的动脉来自膝下外动脉、胫前返动脉、膝降动脉和膝下内动脉的分支;胎儿髌韧带不同区域微血管密度不同,且以韧带中心部为最低。前、后交叉韧带的动脉分别来源于膝中动脉、髌下脂肪垫以及膝下外动脉的分支。多数韧带内血管沿长轴走行,同时也有横向交通的小血管,血管网呈梯状或平行的丛状。近侧端和远侧端较密而中间部相对稀疏。 结论　①髌韧带和膝交叉韧带均存在中心部乏血管区;②韧带两端血供最丰富,且近侧段好于远侧段;③髌韧带血供优于膝交叉韧带,髌韧带重建交叉韧带具有血供基础。     

The arterial supply of the cervical and thoracic spinal muscles and overlying skin: Anatomical study with implications for surgical wound complications

Postoperative spinal wound dehiscence is a significant complication following the posterior midline approach. It is postulated that this approach disrupts the vasculature supplying the paraspinal muscles and overlying skin. Although the spinal vasculature has been investigated previously, the smaller arterioles have not been described in the context of the posterior midline approach. Eight cadaveric neck and posterior torso specimens were dissected after injection with a radio‐opaque lead oxide mixture and subsequent radiographs taken were analyzed. The deep cervical, vertebral, superficial cervical, and occipital arteries consistently supplied the cervical paraspinal muscles. The latter two arteries also vascularized the overlying skin. The deep cervical arteries were found to be located lateral to the C3 to C6 vertebrae, vulnerable to damage with the posterior approach. In the thoracic region, the superior and posterior intercostal arteries consistently supplied the spinal muscles. In all specimens, two small anastomotic vessels posterior to the laminae were found connecting the intercostal artery perforators. Both the arterial perforators and their anastomotic channels were situated in the surgical field and susceptible to damage with the posterior approach. It is likely that the disruption in spinal vasculature contributes to the multifactorial problem of wound dehiscence with the posterior midline approach. Clin. Anat. 26:584–591, 2013. © 2012 Wiley Periodicals, Inc.     

Reconstruction of patellar tendon rupture after anterior cruciate ligament reconstruction: a case report

Patellar tendon rupture following use of its central third for anterior cruciate ligament (ACL) reconstruction is a rare disabling injury that is technically difficult to repair. We report one case of patellar tendon rupture after harvesting the mid-third for ACL reconstruction. A number of different surgical methods exist for reconstructing patellar tendon ruptures. Here we report a case using a bone-tendon-bone (BTB) allograft, followed by a multiple-wire loop reinforcement with no postoperative immobilisation. One year after operation, our patient had regained full knee extension and flexion. Insall Salvati index on the operated side was identical to the uninjured side. The patient had good quadriceps strength, and isokinetic muscle testing showed no deficit in his right leg. He was able to return to professional handball without limitation.     

Anatomical study of the plantaris tendon: reliability as a tendo-osseous graft

Purpose  The purpose of this study was to investigate the insertion of the plantaris tendon in terms of shape, length, width and size, to define if there is available bony insertion for future use as reconstructive procedure in secondary tendon graft in hand surgery. Methods  In 30 limbs, the plantaris tendon was anatomically dissected to investigate its bony attachments to the calcaneus. Results  The plantaris was present in 29 of 30 dissections and regularly inserted in the calcaneus. Conclusions  The tendo-osseous plantaris graft is, according to this research, amenable to be used as a viable choice in reconstruction of secondary flexor tendon injuries related to its length shape and size and especially due to the bone stock adequate to strong phalanx fixation.     

Distal patellar tendon avulsion in association with high-energy knee trauma: A case series and review of the literature

Background

Patellar tendon rupture is rare in the general population. Typically, failure occurs proximally or at the mid-substance. Distal avulsion from the tibial tubercle in adults is rare and not well described in the orthopedic literature.

关节镜下同种异体肌腱重建膝关节前后交叉韧带的临床观察

目的比较关节镜下同种异体肌腱移植和自体肌腱移植重建膝关节前后交叉韧带的临床效果。方法将130例膝关节前后交叉韧带断裂的患者按手术方式的不同分为2组,观察组采用同种异体肌腱移植,对照组采用自体肌腱移植,观察患者临床疗效。结果观察组手术时间明显少于对照组(P0.05);观察组IKDC评定与对照组比较差异无统计学意义(P0.05);2组患者术后Lysholm及Tengner评分均明显高于术前,2组差异有统计学意义(P0.05),观察组及对照组术后Lysholm及Tegner评分比较无明显差异(P0.05)。结论同种异体与自体肌腱重建ACL及PCL的疗效相近,是重建ACL及PCL良好的移植物。     

The role of the patellar tendon angle and patellar flexion angle in the interpretation of sagittal plane kinematics of the knee after knee arthroplasty: A modelling analysis

Background

Many different measures have been used to describe knee kinematics. This study investigated the changes of two measures, the patellar tendon angle and the patellar flexion angle, in response to variations in the geometry of the knee due to surgical technique or implant design.

Reconstruction of a patellar tendon with Achilles tendon allograft for severe patellar infera — A case report

Severe patellar infera accompanied by pathologic shortening and fibrosis of the patellar tendon is relatively an uncommmon condition but can cause recalcitrant joint stiffness and limited range of motion after knee surgery or injury. This report presents a case of a 49-year-old male with severe patellar infera and limping due to joint stiffness after three-time knee surgeries. We report a successful outcome along with a finding of the well-healed allograft after the reconstruction of a patellar tendon using Achilles tendon-bone allograft.     

The conjoint junction of the triceps surae: implications for gastrocnemius tendon lengthening

Forty embalmed cadaver lower limbs were dissected to identify the morphology of the conjoint junction of the tendons of gastrocnemius and soleus and the location of the gastrocnemius tendon relative to bony landmarks. Five patterns of conjoint junction morphology were found: transverse (25%), oblique passing distally and medially (45%), oblique passing distally and laterally (5%) and arcuate as an inverted U (17.5%) and a U-shape (7.5%). Left-right asymmetry of the junction was observed in 31.6% of 19 paired cadaver legs. On the medial side of the calf the gastrocnemius tendon could be located between 38 and 46% of the proportion of the distance between the upper border of the calcaneus and the fibular head. Corresponding values for the midline and lateral side of the calf were 45-58% and 48-51%. The location of the gastrocnemius tendon relative to bony landmarks may help to guide incision planning for open or endoscopic division of the tendon.     

指深屈肌腱及指伸肌腱止点的解剖研究

目的　通过解剖研究指深屈肌腱及指伸肌腱在远节指骨基底掌侧和背侧止点平面的差别,为西摩骨折发生机制提供解剖学依据。 方法　手部残肢10具,其中左手3例,右手7例,均为男性患者,年龄24~58岁。2~5指分别有10指,全部手指无外伤手术史、无畸形。自远节指间关节水平掌侧及背侧分别切开,于末节指骨水平分离各指的指深屈肌腱及指伸肌腱,记录其与末节指骨掌侧及背侧关节面的距离,比较指深屈肌腱及指伸肌腱在末节指骨掌、背侧的止点水平。 结果　指深屈肌腱止点近端至关节面距离：示指（2.19±0.27）mm,中指（2.50±0.14）mm,环指（2.23±0.16）mm,小指（1.83±0.19）mm;指伸肌腱止点近端至关节面距离：示指（0.12±0.02）mm,中指（0.18±0.02）mm,环指（0.12±0.05）mm,小指（0.06±0.01）mm;各指差异有统计学意义（P＜0.05）。指深屈肌腱止点中点至关节面距离：示指（3.73±0.45）mm,中指（4.33±0.45）mm,环指（3.53±0.46）mm,小指（3.16±0.41）mm;指伸肌腱止点中点至关节面距离：示指（1.77±0.06）mm,中指（1.76±0.20）mm,环指（1.77±0.06）mm,小指（1.47±0.10）mm;各指差异有统计学意义（P＜0.05）。 结论　指伸肌腱在末节指骨基底的止点较指深屈肌腱的止点距关节面更近,为西摩骨折的发生机制提供了解剖依据。     

指深屈肌腱及指伸肌腱止点的解剖研究

目的　通过解剖研究指深屈肌腱及指伸肌腱在远节指骨基底掌侧和背侧止点平面的差别,为西摩骨折发生机制提供解剖学依据。 方法　手部残肢10具,其中左手3例,右手7例,均为男性患者,年龄24~58岁。2~5指分别有10指,全部手指无外伤手术史、无畸形。自远节指间关节水平掌侧及背侧分别切开,于末节指骨水平分离各指的指深屈肌腱及指伸肌腱,记录其与末节指骨掌侧及背侧关节面的距离,比较指深屈肌腱及指伸肌腱在末节指骨掌、背侧的止点水平。 结果　指深屈肌腱止点近端至关节面距离：示指（2.19±0.27）mm,中指（2.50±0.14）mm,环指（2.23±0.16）mm,小指（1.83±0.19）mm;指伸肌腱止点近端至关节面距离：示指（0.12±0.02）mm,中指（0.18±0.02）mm,环指（0.12±0.05）mm,小指（0.06±0.01）mm;各指差异有统计学意义（P＜0.05）。指深屈肌腱止点中点至关节面距离：示指（3.73±0.45）mm,中指（4.33±0.45）mm,环指（3.53±0.46）mm,小指（3.16±0.41）mm;指伸肌腱止点中点至关节面距离：示指（1.77±0.06）mm,中指（1.76±0.20）mm,环指（1.77±0.06）mm,小指（1.47±0.10）mm;各指差异有统计学意义（P＜0.05）。 结论　指伸肌腱在末节指骨基底的止点较指深屈肌腱的止点距关节面更近,为西摩骨折的发生机制提供了解剖依据。     

Reconstruction of patellar tendon rupture after total knee arthroplasty using polyethylene cable

BackgroundPatellar tendon rupture is a devastating complication after total knee arthroplasty (TKA). Different strategies have been used to reconstruct or augment direct repairs.MethodsAcute patellar tendon ruptures after TKA were treated using ultra-high molecular weight polyethylene cable (Nesplon cable) for augmentation in four patients. Nesplon cables were inserted anteriorly through the quadriceps just above the patella, and drill holes were placed in the tibial tubercle with one in figure-of-eight fashion and the other in cerclage configuration. Clinical evaluations were performed using range of motion and Knee Society Score at the time of last follow-up. Mean follow-up was 3.5 years.ResultsPostoperatively, mean flexion was 119° and mean extension was 0° in all cases. No knees showed extension lag. Mean knee score was 93.8 and mean function score was 63.8. Infection occurred in one case.ConclusionPatellar tendon reconstruction with Nesplon cable was favorable with good clinical outcomes.     

冈上肌腱血液供应的研究

采用明胶墨汁注入和 ABS 血管铸型法研究22侧成人肩关节肌腱袖的血供来源,结合扫描电镜观察冈上肌腱的微血管结构。冈上肌腱的血供主要来源于旋肱前动脉和肩胛上动脉,在该腱表面肉眼可见有缺血区(即临界区)存在,该区外侧缘距骨止点平均7.8mm,该区的范围随年龄增长而扩大。