Neglected patellar tendon ruptures—a simple modified reconstruction using hamstrings tendon graft

Purpose

We hereby describe a cost effective and simple anatomical reconstruction without requirement for allograft or implants for neglected chronic patellar tendon injuries. This has been validated in seven patients with an average follow up of greater than three years resulting in good outcome.

Methods

Seven patients (six males, one female) of mean age 41.8 years (range up to 57 years) presented with neglected patellar tendon injury. The time since injury ranged between three months and three years (average nine months). Active extension was not possible in three patients, and four patients had an extensor lag between 40° and 80° (average 62.5°). Four patients had quadriceps strength of grade 2/5 and three patients had grade 3/5. All patients had severe functional limitation with an average IKDC score of 46.8 (range 39–57). They all underwent patellar tendon reconstruction using hamstrings tendon autograft.

Results

Postoperatively with a mean follow up of 40.7 months (range 31–52 months), all patients had a stable knee with mean flexion of 125° (range 120°–130°) and without any extension lag. Quadriceps power was regained in five cases to 5/5 and in two cases to 4/5. With an improvement in the IKDC score to 86.8 (range 80–92), excellent outcome was noted in five patients and good outcome in two patients. The average postoperative Lysholm score was 92.4 (range 89–95) and the average Kujala score was 94.5 (range 92–97).

Conclusion

Patellar tendon reconstruction using hamstrings autograft for neglected patellar tendon injuries provides good stability and excellent outcome. Compared to previous techniques described, our technique is unique in being cost effective and a simple anatomical reconstruction without the requirement for allograft or implants.     

Severe extensor tendon attrition and multiple tendon ruptures resulting from Kienböck's disease

Kienb?ck's disease is a rare but recognized cause of chronic wrist pain. Occasionally, complications arise leading to tendon rupture. The authors present the first reported case of attrition to all extensors of the hand, and extensor tendon rupture to the little finger in a patient with a 45-year history of Kienb?ck's disease. This is also the first reported incidence of this complication in whites. Clinical features, surgical management, and the successful outcome are discussed.     

Achilles tendon suture deteriorates tendon capillary blood flow with sustained tissue oxygen saturation – an animal study

Background  

Treatment of ruptured Achilles tendons currently constitutes of conservative early functional treatment or surgical treatment either by open or minimal invasive techniques. We hypothesize that an experimental Achilles tendon suture in an animal model significantly deteriorates Achilles tendon microcirculation immediately following suturing.     

Medial Achilles tendon island flap—a novel technique to treat reruptures and neglected ruptures of the Achilles tendon

Purpose

There is a strong consensus for surgical treatment of reruptures and neglected ruptures of the Achilles tendon. A number of different surgical techniques have been described and several of these methods include extensive surgical exposure to the calf and technically demanding tendon transfers. The overall risk of complications is high and in particular the risk for wound healing problems, which are triggered by an increased tension in the skin when inserting a bulky graft to cover the rupture. In order to reduce the risk for wound healing problems a new, less complicated surgical technique was developed, as described in this study.

Methods

Nine consecutive patients (including six chronic ruptures and three reruptures) with complicating co-morbidities and with a tendon defect between three and eight centimetres were operated upon using the described novel technique. Patient-reported functional outcome was reported after two to eight years.

Results

All tendon defects were successfully repaired. Neither early nor late surgical complications occurred. High patient satisfaction was reported for all patients.

Conclusions

The new surgical technique with a medial Achilles tendon island flap seems to be safe and results in a good patient reported outcome.     

Extensor tendon repair: mobilise or splint?

OBJECTIVES: The aim of this study was to assess the static and dynamic hand therapy regimes used at Mount Vernon Hospital, following extensor tendon injury during 1995-2000 and compare them to the early active regimes published. METHODS: Sixty-five patients were included and their hand function recorded by calculating total active motion (TAM), percentage combined motion and extensor lag at 4-6 weeks and at 10 weeks postinjury. RESULTS: The results in two groups were good, with mean TAMs of 202 and 258 at 4-6 weeks and at 10 weeks, respectively, for the static regime and 214 and 245, respectively, for the dynamic regime, during the same time periods. CONCLUSION: The results from each group compare favourably with the published series of patients undergoing early active motion, where mobilisation is commenced almost immediately. The authors' preference is the static regime as it is simple, effective and particularly useful in poorly compliant patients.     

The use of Vicryl™ in extensor tendon repairs

Conventionally, tendons are repaired with the strongest possible suture material, usually nonabsorbable in a variety of techniques using two or more strands between the tendon ends. In the initial phase of tendon healing, the repair is almost entirely dependent on the strength of the suture used and sound tendon suturing techniques. While this holds true for the strong flexor tendon system, we question the validity of this approach in the case of extensor tendons. Many of these are flat, and anecdotal evidence suggests that nonabsorbable sutures tend to promote a foreign-body reaction and cause increased tendon tethering. In this article, we seek to confirm that absorbable sutures such as Vicryl™ constitute a superior repair material for extensor tendons.     

Integra® dermal regenerative template application on exposed tendon

Background

Tendon without paratenon presents the reconstructive surgeon with a tissue coverage challenge. Integra® dermal regenerative template has been shown to initiate a stable, vascularized bed for skin grafting over tendon. However, histological processes that occur during incorporation have not been described. The purpose of this study is to characterize the pattern of changes that occur when Integra® is applied to an avascular tendon. We hypothesize that vascular incorporation will originate from the wound periphery and proceed toward the tendon center.

Methods

A full-thickness defect was created over a denuded Achilles tendon in a single hind limb in eight New Zealand white rabbits. Integra was placed over the avascular tendon, and the limb was dressed and splinted. Two animals were euthanized at each timepoint (weeks 1, 2, 3, and 4), and hematoxylin and eosin (H&E)-stained tissue specimens were microscopically evaluated.

Results

Week 1 specimens demonstrated limited adherence between Integra and the tendon, while myofibroblasts were found encircling the tendon. No cellularity was noted centrally. At week 2, the dermis–Integra junction had increasing vascularity and the central portion developed increasing cellularity. By week 3, Integra was completely revascularized. At week 4, Integra had the histological appearance of normal dermis.

Conclusion

Neovascularization of Integra® over exposed tendon occurs from the peripheral tissue. Ingrowth proceeds from the dermis–Integra interface toward the center of the graft. Four weeks after application to the denuded tendon, Integra has the histological appearance of native dermis.     

Management of chronic Achilles tendon ruptures—A review

Achilles tendon ruptures are increasingly common yet up to a fifth of them are undiagnosed after medical consultation. Those undiagnosed will become chronic ruptures causing considerable functional morbidity and represent a challenge to the treating doctor.The purpose of this article is to discuss the presentation and management of chronic Achilles tendon ruptures. Due to the paucity of data, evidence-based recommendations are unavailable. A number of different surgical techniques are presented and a working algorithm is described to aid in the treatment of these lesions.     

Patellar tendon rupture 3 years after anterior cruciate ligament reconstruction with a central one third bone–patellar tendon–bone graft

Use of the central one third bone–patellar tendon–bone autograft is an accepted technique for anterior cruciate ligament (ACL) reconstruction. Patellar tendon rupture following ACL reconstruction is an acknowledged, although rarely reported, complication of this procedure. Of the limited patellar tendon rupture cases reported in the literature, most are described early in the postoperative period. We present a case of late patellar tendon rupture more than 3 years after uneventful ACL reconstruction in a 32-year-old man.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 6 (July-August), 2001: pp 648–652     

Quadriceps tendon ruptures-is there a complete functional restitution?

From January 1986 to November 1999, 35 patients with 36 traumatic ruptures of the quadriceps tendon, all without medical risk factors, were treated (33 men, 2 women; mean age 55 years). Thirty patients were operated within 14 days after trauma. With an average follow up of 55.4 months (7-168) 29 of 30 still living patients (96.7%) were studied retrospectively. Questionnaire (Lysholm score), physical examination, X-ray of both knees and isokinetic testing were performed. The outcome was significantly (P < 0.001) dependent on the time of operative procedure. Twenty-four patients treated within the first 14 days had 20 excellent and 4 good results, the other 5 one good, 1 satisfying and 3 poor results. Twenty-one of 23 patients (91%) could return to work. The type of repair (direct or transosseous suture with or without augmentation), the kind of postoperative physiotherapy, the age and the body mass index had no influence on the final outcome.     

Conservative treatment of tibialis posterior tendon dysfunction—A review

BackgroundAppropriate conservative treatment is considered essential to address symptoms associated with tibialis posterior tendon dysfunction (TPTD) and prevent its potential long-term disabling consequences. The main aim of this review, undertaken in 2007, was to evaluate the evidence from studies for the effects of conservative treatment modalities in the management of TPTD. This evidence could then be used as a basis for the development of a clinical guideline for the management of the condition.MethodologyStudies were selected according to specific criteria and evaluated for methodological quality. As preliminary literature searches had identified no randomised controlled trials at the time of the review, studies of lower hierarchy were included.ResultsFive uncontrolled observational studies evaluating the outcomes of various orthotic treatments alone or in combination with other therapies were included in the review. Different study designs, methodological quality, population characteristics, interventions and outcome measures were found.DiscussionLimited and poor quality evidence was found in this review regarding the conservative treatment of TPTD. Thus a cause–effect relationship between intervention and outcome could not be established nor an optimal conservative treatment regime for the condition. Further better quality research is warranted in this area to inform practice, particularly as there is no consensus in the literature regarding treatment of this condition.     

Multiple extensor tendon ruptures with advanced Kienböck's disease

We describe a patient with spontaneous multiple extensor tendon ruptures that were caused by a displaced fragment of the lunate in advanced Kienb?ck's disease. Complete excision of the lunate, limited carpal fusion, and extensor tendon reconstructions relieved the patient's symptom and restored function.     

How would you treat the partially torn biceps tendon?

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 6 (July-August), 2001: pp 636–639     

Posterior tibial tendon insufficiency: which ligaments are involved?

BACKGROUND: The pathology manifested in posterior tibial tendon insufficiency (PTTI) is not limited to the posterior tibial tendon. The association of ligament failure with deformity has been discussed in numerous publications, but extensive documentation of the structures involved has not been performed. The purpose of this observational study was to identify the pattern of ligament involvement using standardized, high-resolution magnetic resonance imaging (MRI) in a series of 31 consecutive patients diagnosed with PTTI compared to an age matched control group without PTTI. METHOD: The structures evaluated by MRI were the posterior tibial tendon, superomedial and inferomedial components of the spring ligament complex, talocalcaneal interosseous ligament, long and short plantar ligaments, plantar fascia, deltoid ligament, plantar naviculocuneiform ligament, and tarsometatarsal ligaments. Structural derangement was graded on a five-part scale (0 to IV) with level 0 being normal and level IV indicating a tear of more than 50% of the cross-sectional area of the ligament. Standard flatfoot measurements taken from preoperative plain standing radiographs were correlated with the MRI grading system. RESULTS: Statistically significant differences in frequency of pathology in the PTTI group and controls were found for the superomedial calcaneonavicular ligament (p < 0.0001), inferomedial calcaneonavicular ligament (p < 0.0001), interosseous ligament (p = 0.0009), anterior component of the superficial deltoid (p < 0.0001), plantar metatarsal ligaments (p = 0.0002) and plantar naviculocuneiform ligament (p = 0.0006). The ligaments with the most severe involvement were the spring ligament complex (superomedial and inferomedial calcaneonavicular ligaments) and the talocalcaneal interosseous ligament. CONCLUSION: Ligament involvement is extensive in PTTI, and the spring ligament complex is the most frequently affected. Because ligament pathology in PTTI is nearly as common as posterior tibial tendinopathy, treatment should seek to protect or prevent progressive failure of these ligaments.     

How can one platelet injection after tendon injury lead to a stronger tendon after 4 weeks? Interplay between early regeneration and mechanical stimulation

BACKGROUND: Mechanical stimulation improves the repair of ruptured tendons. Injection of a platelet concentrate (platelet-rich plasma, PRP) can also improve repair in several animal models. In a rat Achilles tendon transection model, 1 postoperative injection resulted in increased strength after 4 weeks. Considering the short half-lives of factors released by platelets, this very late effect calls for an explanation. METHODS: We studied the effects of platelets on Achilles tendon regenerates in rats 3, 5 and 14 days after transection. The tendons were either unloaded by Botulinum toxin A (Botox) injections into the calf muscles, or mechanically stimulated in activity cages. No Botox injections and ordinary cages, respectively, served as controls. Repair was evaluated by tensile testing. RESULTS: At 14 days, unloading (with Botox) abolished any effect of the platelets and reduced the mechanical properties of the repair tissue to less than half of normal. Thus, some mechanical stimulation is a prerequisite for the effect of platelets at 14 days. Without Botox, both activity and platelets increased repair independently of each other. However, at 3 and 5 days, platelets improved the mechanical properties in Botox-treated rats. INTERPRETATION: Platelets influence only the early phases of regeneration, but this allows mechanical stimulation to start driving neo-tendon development at an earlier time point, which kept it constantly ahead of the controls.