Die Rekonstruktion von langstreckigen Achillessehnendefekten durch einen Transfer des Musculus flexor hallucis longus

Objective

The aim of flexor hallucis longus (FHL) transfer is to bridge long defects of the Achilles tendon. In addition to the substitution of the Achilles tendon by the tendon graft, the flexor hallucis longus muscle changes its function to plantar flexion of the ankle. A part of the muscle belly is placed into the paratendon sheath which supports healing even in patients with critical soft tissue injuries.

Indications

Extended Achilles tendon defects, extended degenerative disease of the Achilles tendon, and reruptures, especially in patients with significant soft tissue injuries.

Contraindications

Ruptures of the Achilles tendon which can be treated by direct reconstruction.

Surgical technique

The patient is placed in a prone position. After a central longitudinal approach to the Achilles tendon and debridement of the diseased tendon material, the deep fascia is split. After identification of the flexor hallucis longus tendon, the tendon is retracted with a plantiflexed hallux and dissected at the entrance point to the tarsal tunnel. The tendon is fixed to the calcaneus via a 6?mm drill hole using an interference screw in the press-fit technique.

Postoperative management

A lower limb orthosis is used for the first 8?weeks: the first 4?weeks plantar flexion of 30° with partial weight bearing of 20?kg, then full weight bearing for 2?weeks with 15° plantar flexion, and another 2?weeks with neutral position of the ankle. After removal of the orthosis, a heel lift of 1.5?cm (e.g., silicon heel cushion) is recommended for 3?months. Running activities are restricted for 6?months.

Results

In a series of 25 consecutive patients (15?men, 10?women) with an average age of 61?years (range 37?C79?years), it was possible in all cases to reconstruct the Achilles tendon function. The AOFAS Hindfoot Score improved from 62 to 89 points. Especially in the category pain, the patients reached 38?of a maximum of 40?points. Compared to the healthy leg, a limitation in maximum strength in plantar flexion was found (42?of a maximum of 50?points).     

Efficacy and complications of open and minimally invasive surgery in acute Achilles tendon rupture: a prospective randomised clinical study—preliminary report

Purpose

Surgical treatment of an acute Achilles tendon rupture can effectively reduce the risk of re-rupture, but it increases the probability of surgical complications. We postulated that a minimally invasive surgical treatment might reduce the number of complications related to open surgery and improve the functional results.

Method

We enrolled 47 patients with acute Achilles tendon ruptures in a prospective, randomised trial to compare clinical results and complications between a minimally invasive procedure with the Achillon® device and traditional open surgery with Krackow-type sutures. The average patient age was 46 years. The follow up time was 24 months.

Results

No Achilles tendon re-rupture or nerve injury occurred in treated patients. There were two cases of wound infections in the open surgery group, and one superficial wound infection occurred in the minimally invasive group. The groups were not significantly different in the amount of pain, range of ankle movements, the single heel-rise test, calf circumference, or time to return to work and sports.

Conclusion

After a two year follow-up period, we found no significant differences in clinical outcomes between groups treated with traditional open surgery or minimally invasive surgery.     

Reconstruction of soft tissue defects in the Achilles tendon region with perforator-based fasciocutaneous flaps

Background

Reconstruction of soft tissue defects in the Achilles tendon region can be technically demanding. Perforator-based flaps can be an effective local solution, replacing like-for-like skin. We report our experience with perforator-based flap reconstruction of the Achilles tendon region with or without rupture of the Achilles tendon.

Methods

Between January 1999 and 2011, 11 patients had perforator-based flaps based on peroneal and posterior tibial perforators. There were six V-Y advancement flaps, four propeller flaps and one peninsular flap. The mean defect size was 19.3 (range 9–36)?cm². One patient had reconstruction of a composite Achilles tendon defect.

Results

There were no flap failures. Mean follow-up was 26.4 (range 3–120)?months. Post-operative complications included haematoma in one patient and dehiscence of wound because of further sloughing of the tendon—at the distal edge of a V-Y advancement flap. This patient needed a second local flap. There were no wound breakdowns, painful sensitivity or difficulty with walking. All patients who had skin and soft tissue reconstruction only were partially weight bearing by 2 weeks and gradually increased weight bearing and fully weight bearing by 4 weeks.

Conclusions

Perforator-based flaps are a robust method of covering small- to medium-sized defects in the Achilles tendon region. Presence of multiple perforators on either side of the Achilles tendon invites a number of flap designs, tailored to the defect. Level of Evidence: Level IV, Therapeutic study.     

Results of operative treatment for recalcitrant retrocalcaneal bursitis and midportion Achilles tendinopathy in athletes

Background

The results of operative treatment for recalcitrant midportion Achilles tendinopathy and recalcitrant retrocalcaneal bursitis were evaluated using the patient administered, disease specific, and validated VISA-A-G questionnaire.

Methods

A cohort of 89 patients was prospectively followed. These patients underwent operations for sport induced midportion Achilles tendinopathy (39 procedures) or retrocalcaneal bursitis (55 procedures). Depending on the individual intraoperative findings the patients of either disease were treated with two respective operative modifications (tendon repair or no tendon repair). Preoperative and follow-up status (3, 6, and 12 months) were investigated using the VISA-A-G questionnaire.

Results

Preoperatively, the four groups scored from 37.0 ± 17.6 to 45.9 ± 15.2 (p = 0.376–0.993) on the VISA-A-G questionnaire. Six and 12 months postoperatively, the VISA-A-G scores improved significantly (p < 0.001). Twelve months postoperatively, the groups’ scores were not different (p = 0.100–0.952) and ranged from 80.8 ± 17.9 to 90.3 ± 10.6.

Conclusion

Retrocalcaneal bursitis and midportion Achilles tendinopathy responded equally well to operative treatment. When repaired, additional tendon lesions did not influence this result. We demand to differentiate not only between midportion Achilles tendinopathy and retrocalcaneal bursitis but also to identify additional Achilles tendon lesions to specifically address these lesions during operative procedures.

Level of evidence

Prospective mixed cohort study.     

Z-shortening of healed, elongated Achilles tendon rupture

Purpose

A rupture of the Achilles tendon may heal in continuity, resulting in a lengthened Achilles tendon. The elongated structure must be shortened to restore effective push off. We report the results of a longitudinal study using Z-shortening of ruptured Achilles tendons that healed in continuity but were elongated.

Methods

Nine patients underwent surgery for elongation of a healed Achilles tendon rupture. All participants were prospectively followed up for two to five?years, and final review was performed at 32?±?14?months from operation. Clinical and functional assessment (anthropometric measurements, isometric strength, postoperative total rupture score) was performed.

Results

All patients were able to walk on tiptoes, and no patient used a heel lift or walked with a visible limp. No patient developed clinically evident deep-vein thrombosis or sustained a rerupture. Two patients were managed conservatively following a superficial surgical wound infection. At final review, maximum calf circumference remained significantly decreased in the operated leg. The operated limb was significantly weaker than the nonoperated one.

Conclusions

Managing a healed Achilles tendon rupture using Z-shortening is safe and effective, providing good recovery and early weight bearing and active ankle mobilisation. Such patients should be warned that they are at risk for postoperative complications and that their ankle–plantar flexion strength is likely to be permanently reduced.     

Arthroscopic excision of separated ossicles of the lateral malleolus

Background

We have conducted a retrospective review of 19 patients for whom 20 separated ossicles of the lateral malleolus were excised arthroscopically. We examined the operating methods, findings, and overall results.

Methods

The patients’ indications for this procedure were as follows. The main complaints were pain alone; ossicle sizes were small and ankle instability was minimal. There were 12 ankles of 12 males and eight ankles of seven females. The patients’ average age was 17.6 years. A 2.7-mm, 30° arthroscope was inserted into the ankle joint through the anterolateral portal. Instruments were inserted through the accessory anterolateral portal, and ossicles were removed piece by piece. Talar tilt angles and anterior displacements were examined and compared before and after surgery by use of stress radiographs. Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scales were assessed pre and postoperatively.

Results

All patients recovered their original levels of activity. The mean talar tilt angle changed from 6.1° ± 2.4° preoperatively to 6.0° ± 1.8° postoperatively (p = 0.93), and the mean anterior displacement changed from 5.9 ± 1.7 mm preoperatively to 6.1 ± 2.0 mm postoperatively (p = 0.42). Average JSSF ankle/hindfoot scale improved from 77.6 ± 2.6 points preoperatively to 97.2 ± 5.2 points postoperatively (p < 0.01).

Conclusions

Arthroscopic excision of separated ossicles of the lateral malleolus achieved good results with minimum incisions, and relatively early resumption of daily and sports activity was possible. However, when the ossicles were embedded within the fibers of the anterior talofibular ligament, it was impossible to avoid cutting of ligament fibers. To reduce the possibility of ligament dysfunction, we believe postoperative treatment should conform to the accepted method for treatment of acute ankle sprains.     

Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle?

Purpose

The purpose of the study is to explain the cause–effect relationship in three patients who reported combined ruptures of the Achilles tendon and the gastrosoleus complex 6 months after they had received corticosteroids injections for the management of retrocalcaneal bursitis.

Methods

Three cryopreserved cadavers (three men, three left legs) were examined to assess the anatomic connection between the retrocalcaneal bursa and the Achilles tendon (distal and anterior fibers). Blue triptan medium contrast was injected.

Results

An unexpected connection between the retrocalcaneal bursa and the anterior fibers of the Achilles tendon was found in all instances.

Conclusions

Local corticosteroid injection of the retrocalcaneal bursa may help the symptoms of retrocalcanear bursitis, but pose a risk of Achilles tendon rupture. This risk–benefit has to be taken into account when corticosteroid injections are prescribed to professional and high-level athletes.     

The Intact Posterior Cruciate Ligament Not Only Controls Posterior Displacement but Also Maintains the Flexion Gap

Background

The PCL is a strong stabilizer of the knee and provides posterior stability to the tibia. However, sagittal alignment of the PCL with the knee at 90° flexion suggests the PCL might play a role not only in posterior stabilization but also in maintaining the flexion gap.

Questions/purposes

We determined whether the intact PCL helps maintain the flexion gap.

Methods

We examined axial radiographs and gravity sag views of 17 patients with chronic isolated unilateral PCL injury. The flexion gap was defined as the mean value of the medial and lateral distances between the femoral and tibial bones on the axial radiograph. Increase in the flexion gap and posterior laxity were determined by comparing the patients’ injured and contralateral uninjured knees.

Results

The flexion gap of PCL injured knees (median, 7.5 mm; range, 5.3–11.5 mm; medial median, 6.2 mm; medial range, 3.7–8.3 mm; lateral median, 7.9 mm; lateral range, 5.3–11.5 mm) was larger than that seen in uninjured knees (median, 5.0 mm; range, 4.0–7.6 mm; medial median, 4.6 mm; medial range 3.4–7.1 mm; lateral median, 5.6; lateral range, 4.5–11.2 mm). The increment in the medial distance was similar to that in the lateral distance. Posterior laxity of injured knees was 9.1 (median); 5.4 to 15.2 (range) mm greater than that of uninjured knees. We found no correlation between posterior laxity and the flexion gap increment.

Conclusions

Our data suggest the intact PCL controls posterior displacement and maintains the flexion gap.     

Percutaneous versus open repair of acute Achilles tendon ruptures

Background

Controversy exists regarding the optimal treatment for acute Achilles tendon ruptures. Conservative and surgical treatments have been reported with variable results and complications rates. The purpose of this study is to compare the postoperative clinical and functional results of percutaneous versus open repair of acute Achilles tendon ruptures.

Materials and methods

We present 34 patients with acute Achilles tendon ruptures treated with open and percutaneous surgical repair. There were 15 patients who had open surgical repair and 19 patients who had percutaneous repair. The mean follow-up was 22 months (range 10–24 months) for the open repair group and 20 months (range 9–24 months) for the percutaneous repair group; no patient was lost to follow-up. Postoperative rehabilitation was the same for both groups. Wound healing, complications, ankle range of motion, and patients’ return to work, activity level, weight-bearing, and subjective assessment of their treatment were recorded.

Results

No significant difference was observed with respect to any of the examined variables between the open and percutaneous repair groups. Tendon healing was observed in all patients of both groups by 7–9 weeks. The mean time of patients’ return to work was 7 weeks for the open repair group and 9 weeks for the percutaneous repair group. All patients were capable of full weight bearing by the 8th postoperative week time; the time to return to previous activities including non-contact sports was 5 months for both groups. All patients expressed satisfaction and graded their treatment as good. As expected, cosmetic appearance was significantly better in the percutaneous repair group. One patient who had open repair experienced skin incision pain and dysesthesia and graded his operation as fair. No patient experienced other complications such as re-rupture, infection, sural neuroma, or Achilles tendinitis within the period of this study.

Conclusions

The present study showed similarly successful clinical and functional results after both open and percutaneous repair of acute Achilles tendon ruptures are similar. Cosmetic appearance is superior in the group of patients who had a percutaneous treatment.     

Rerouting des Musculus brachioradialis zur Verbesserung der Unterarmsupination oder -pronation

Objective

Improvement of active forearm supination or pronation. Reduction of paralytic pronation or supination posture.

Indications

Disability or impairment of active supination or pronation due to cerebral palsy, obstetric palsy or traumatic brachial plexus palsy, quadriplegia or paralysis from other causes.

Contraindications

Inadequate passive range of motion of forearm supination or pronation. Insufficient power of brachioradialis muscle < M4. Insufficient rehabilitation after conservative treatment or neurosurgical intervention with possible improvement of supination or pronation. Lack of patient’s cooperation and compliance.

Surgical technique

Exposure and mobilisation of brachioradialis muscle. Division of brachioradialis tendon distally with Z-plasty. Passing distal tendon through the interosseus space in dorsal to palmar direction for restoration of supination respectively in palmar to dorsal direction for restoration of pronation. Suturing both tendon ends.

Postoperative management

Management includes an above elbow cast with the elbow in 70° flexion for 4 weeks. Then active physiotherapy to learn new brachioradialis muscle function for supination or pronation over 1–1.5 years. If needed dynamic orthesis.

Results

Özkan et al. performed brachioradialis rerouting to restore supination in 5 children between 4 and 14 years with pronation deformity and to restore pronation in 4 children aged 5–9 years with supination deformity. Mean active gain for supination was 81° (40–140°). Active pronation improved from 28 to 49° (30–75°; Özkan et al., J Hand Surg Br 29:263–268, 2004; Özkan et al., J Hand Surg Am 29:22–27, 2004). Between April 2006 and January 2011 we used this technique in 4 patients aged 7–26 years (mean 14 years). Three patients could be followed up. One patient had preoperative a fixed pronation deformity of the forearm in 80° pronation. In this case active range of motion could be improved to 80/30/0° pronation/supination. One patient improved from preoperative 0/0/90° pronation/supination to 30/0/90° postoperatively. In one case no functional improvement of forearm rotation could be achieved in long-term follow-up. No functional loss in forearm rotation to the opposite direction or of the elbow function was observed. Mean follow-up time was 51 months (21–77 months).     

Incidence and effect of calcifications after open-augmented Achilles tendon repair

Background and aims

The objective of this study was to analyse the incidence and effect on clinical outcome of post-operative Achilles tendon calcifications after open-augmented repair according to the Silfverskjöld technique.

Patients/methods

This retrospective study presents the results of follow-up examinations on 104 patients with Achilles tendon rupture who were treated according to the Silfverskjöld technique. Post-operative calcifications were identified by means of sonography, and clinical outcome was evaluated using the 100 points Thermann score. The average follow-up examination period was 3.7 years with an average patient age of 42.9 years. Two groups were identified and included those with (Group I) and those without (Group II) calcifications. Clinical outcome was evaluated using the Thermann score for both groups and was compared statistically by means of the two random sample t-test.

Results

Fifteen patients (Group I) developed tendon calcifications (14.4%) and 89 none (Group II). Group I scored 88.0 points and Group II 88.1 (good to very good outcome). There were no negative effects on clinical outcome (t = 0.98).

Conclusions

The incidence of tendon calcification after open-augmented repair of Achilles tendon rupture was 14.4% with no negative effects on clinical outcome as measured by the Thermann score.     

Simulated Ankle Equinus Affects Knee Kinematics During Gait

Background

It is critical to distinguish gait compensations from true abnormalities when planning interventions to improve gait in individuals with neuromuscular disorders.

Questions/Purposes

The aim of this study was to determine the effect of isolated ankle equinus on knee kinematics during the initial contact phase of gait.

Methods

Ten healthy subjects (29?+?4.3 years) participated, and testing occurred in a motion analysis laboratory. This cross-sectional study investigated five gait conditions in each subject: shoe alone, shoe with unilateral ankle foot orthosis locked at neutral, 10°, 20°, and 30° of fixed ankle plantar flexion. Gait kinematics were recorded and calculated with 3D motion analysis. The difference between the shoe and each brace condition was analyzed by repeated-measures ANOVA. The primary outcome was knee flexion at initial contact.

Results

With greater than 10° simulated ankle equinus, the primary gait compensation pattern was increased knee flexion at initial contact. A significant degree of knee flexion occurred ranging from 7° to 22°.

Conclusion

Our data suggests that observed knee flexion at initial contact may be a compensation pattern in individuals with >10° ankle equinus. However, in individuals with ≤10° ankle equinus, observed knee flexion may represent a true gait deviation. This has clinical significance in the realm of cerebral palsy for treatment planning to improve gait.

     

Z-lengthening of the Achilles Tendon with Transverse Skin Incision

Background

The risk of various complications after Achilles tendon lengthening is mainly related to the length of surgical exposure and the lengthening method. A comprehensive technique to minimize the complications is required.

Methods

The treatment of Achilles tendon tightness in 57 patients (95 ankles) were performed by using a short transverse incision on a skin crease of the heel and by Z-lengthening of the tendon. In the severe cases, two or three transverse incisions were required for greater lengthening of the tendon, and a serial cast or Ilizarov apparatus was applied for the gradual correction. The results of these 95 ankles were compared to those of 18 ankles, which underwent percutaneous sliding lengthening, and to the 19 ankles, which received Z-lengthening with a medial longitudinal incision.

Results

The functional and cosmetic satisfaction was achieved among those who underwent the tendon lengthening with the new technique. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score improved from 56.1 to 81.8. The second operations to correct recurrence were performed in the two cerebral palsy patients.

Conclusions

The new technique has a low rate of complications such as scarring, adhesion, total transection, excessive lengthening, and recurrence of shortening. The excellent cosmesis and the short operation time are the additional advantages.     

Distal radius fractures and the volar lunate facet fragment: Kirschner wire fixation in addition to volar-locked plating

Background

The volar lunate facet fragment of a distal radius fracture may not be stabilized with volar-locked plating alone due to the small size and distal location of the fragment. Identification and stabilization of this small fragment is critical as unstable fixation may result in radiocarpal and radioulnar joint subluxation. The addition of spring wire fixation with volar plating can provide stable internal fixation of this critical fracture fragment.

Methods

A retrospective review (2006–2011) identified nine patients with distal radius fractures with an associated volar lunate facet fragment that were treated with volar-locked plating and spring wire fixation of the volar lunate facet fragment. Radiographic indices, range of motion, grip strength, and postoperative Patient-related wrist evaluation (PRWE) scores were obtained to assess pain and function.

Results

All distal radius fractures healed, and the volar lunate facet fragment reduction was maintained. The mean follow-up was 54 weeks. Mean active range of motion was 46° wrist flexion, 51° wrist extension, 80° pronation, and 68° supination. The mean grip strength was 21 Kg, achieving 66 % of the uninjured limb. The average PRWE score was 17. No patient required removal of hardware or had evidence of tendon irritation.

Conclusions

The addition of spring wire fixation to volar-locked plating provided stable fixation of the volar lunate facet fragment of distal radius fractures without complication. This technique addresses a limitation of volar-locked plating to control the small volar lunate facet fragment in distal radius fractures otherwise amenable to volar plating.

Level of Evidence

A retrospective case series, Level IV.     

Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: a matched pair analysis

Objective

In Achilles tendon injuries, it is suggested that a pathological continuum might be evident from the healthy Achilles tendon to Achilles tendinopathy to Achilles tendon rupture. As such, risk factors for both tendinopathy and rupture should be the same.

Hypothesis

Hereditary and medical risk factors for Achilles tendinopathy and Achilles tendon rupture are the same to a similar extent in a matched pair analysis.

Design

Matched pair study; level of evidence: 3.

Setting

Recreational sportsmen as well as athletes on national level.

Patients

566 questionnaires were analysed. 310 subjects were allocated to 3 groups (A, B, C) after matching the pairs for age, weight, height and gender: (A) healthy Achilles tendons (n?=?89, age 39?±?11?years, BMI 25.1?±?3.9, females 36%), (B) chronic Achilles tendinopathy (n?=?161, age 41?±?11?years, BMI 24.4?±?3.7, females 34%), (C) acute Achilles tendon rupture (n?=?60, age 40?±?9?years, BMI 25.2?±?3.2, females 27%).

Results

We found a positive family history of Achilles tendinopathy as a risk factor for Achilles tendinopathy (OR: 4.8, 95% CI: 1.1–21.4; p?=?0.023), but not for Achilles tendon rupture (OR: 4.0, 95% CI 0.7–21.1, p?=?0.118). Smoking and cardiac diseases had a lower incidence in Achilles tendinopathy than in healthy subjects (both p?=?0.001), while cardiovascular medication did not change the risk profile.

Conclusion

Identifying risk factors associated with Achilles tendon disorders has a high clinical relevance regarding the development and implementation of prevention strategies and programs. This cross-sectional study identified a positive family history as a significant solitary risk factor for Achilles tendinopathy, increasing the risk fivefold. However, in this matched pair analysis excluding age, weight, height and gender as risk factors no further factor necessarily increases the risk for either Achilles tendinopathy or Achilles tendon rupture.     

Wiederherstellung der Daumenendgelenkbeugung durch Transposition der oberflächlichen Beugesehne des Ringfingers

Objective

Restoration of active thumb flexion at the distal joint.

Indications

Loss of active flexion of the interphalangeal (IP) joint of the thumb if there is a transection of the flexor pollicis longus (FPL) tendon at the tendon channel of the thumb or thenar and direct suture is not possible but the tendon channel is intact, as alternative procedure to a free tendon graft if the transection is proximal to the tendon channel and the muscle of the FPL is contracted/injured or the FPL tendon is unharmed but the FPL muscle is partially or complete paralyzed.

Contraindications

Insufficiency of the FPL tendon channel, impairment of the superficial or deep flexor tendon of the ring finger, limited passive motion of the proximal and distal thumb joints, acute local general infection and non-compliance or incapacity of the patient.

Surgical technique

The surgical technique depends on the necessity of transosseous refixation of the FDS IV at the base of the distal phalanx of the thumb or the possibility of woven sutures through the FPL proximal to the tendon channel. If the tendon channel is intact the distal part of the FPL tendon is shortened to 1 cm, the FDS IV tendon is cut distal to the chiasma of Camper, pulled through the carpal tunnel and moved into the channel of the FPL tendon and fixed transosseously through the base of the distal phalanx of the thumb. If the transection of the FPL tendon is located proximal to the tendon channel and muscle of the FPL is injured, FDS IV tendon will be woven using the Pulvertaft technique through the FPL tendon at the distal forearm.

Postoperative management

Postoperative 6 weeks motion of thumb flexion without resistance in relieved position of the thumb through a thermoplast splint and 6 weeks of functional use of the hand with increasing weight bearing.

Results

In this study 10 patients with FDS IV transposition to reconstruct an isolated rupture of the FPL tendon could be followed for an average of 4.1 years postoperatively. The active range of motion of the IP joint of the thumb averaged 65° (10–100°), 8/10 patients achieved an equal active and passive range of motion of the IP joint of the thumb, in 2 patients some flexion insufficiency remained, 9 patients could reach the fingertip of the small finger with the thumb and 1 patient lacked 3 mm. Contracture of the proximal thumb joint developed in two patients. After removal of the FDS IV tendon two patients developed contracture of the PIP joint of the ring finger. The grip force was reduced to 81?%, lateral grip to 83?% and pinch grip to 77?%. The DASH score averaged 18 (0–31) and 8/10 patients would choose to undergo this surgery again.     

Lesser Tuberosity Avulsions in Adolescents

Background

Subscapularis tendon avulsions of the lesser tuberosity are relatively rare and often missed acutely and their characteristic appearance is frequently not recognized or is misinterpreted for an osteochondroma or a neoplastic process.

Questions/Purposes

This report reviews our experience with six adolescents who had subscapularis tendon avulsions of the lesser tuberosity.

Methods

Six male adolescents (12–15 years) presented with shoulder pain following history of trauma during amateur sport. Clinical notes including range of motion, strength tests, and pain assessment were reviewed along with imaging studies pre- and post treatment. Treatment consisted of either surgical or conservative measures.

Results

Two of the six patients had a large avulsion that simulated an exostosis of the proximal humerus that was misdiagnosed as an osteochondroma at two different outside institutions. All six cases were diagnosed with subscapularis tendon avulsion of the lesser tuberosity following clinical and imaging evaluation at our institution. Five of the patients underwent surgical repair and fixation of the tendon and the lesser tuberosity with suture anchors. One patient was treated conservatively. All patients had a good outcome with recovery of full shoulder strength and motion upon follow-up.

Conclusion

Clinicians should have a high index of suspicion of lesser tuberosity avulsions in adolescents who present with loss of internal rotation and anterior shoulder pain following traumatic injuries. In addition, an osseous fragment or exostosis along the inferomedial humeral head should suggest a subscapularis tendon avulsion and also should not be confused with an osteochondroma or a neoplastic process.     

Die Transposition des Musculus biceps femoris zum Ersatz des Kniegelenkstreckers nach Resektion des Musculus quadriceps

Objective

Improvement of gait and ability to stand by reconstruction of functional knee extension.

Indications

Loss of function of the quadriceps femoris muscle due to tumour resection or traumatic damage of the muscle with loss of active knee extension.

Contraindications

Inadequate strength of the biceps femoris muscle. Recurrent tumour or ankylosis of the knee joint.

Surgical technique

The tendon of the biceps femoris is dissected near the knee at the head of the fibula and is mobilized proximally. The underlying common peroneal nerve and the neurovascular supply of the biceps muscle must be spared. Through a ventral approach at the thigh the lateral intermuscular septum is opened and the biceps tendon is pulled through and sutured to the quadriceps tendon and periost of the patella.

Postoperative management

The knee is immobilized in extension with a cast followed by a knee orthosis for 6 weeks, which is followed by intensive physiotherapy; however, the patient should not be forced to flex the knee extensively. The orthosis can be worn for another 3–4 weeks to stabilize the knee joint, while the muscles are intensively trained.

Results

Reliable reconstruction of functionally useful, active knee extension without an orthosis of a previously unstable knee joint in the sagittal plane, even if full extension is not to be expected.