Musculotendinous architecture of pathological supraspinatus: A pilot in vivo ultrasonography study

Architectural changes associated with tendon tears of the supraspinatus muscle (SP) have not been thoroughly investigated in vivo with the muscle in relaxed and contracted states. The purpose of this study was to quantify the geometric properties within the distinct regions of SP in subjects with full‐thickness tendon tears using an ultrasound protocol previously developed in our laboratory, and to compare findings with age/gender matched normal controls. Twelve SP from eight participants (6 male/2 female), mean age 57 ± 6.0 years, were investigated. Muscle geometric properties of the anterior region (middle and deep parts) and posterior region (deep part) were measured using image analysis software. Along with whole muscle thickness, fiber bundle length (FBL) and pennation angle (PA) were computed for architecturally distinct regions and/or parts. Pathologic SP was categorized according to the extent of the tear in the tendon (with or without retraction). In the anterior region, mean FBL of the pathologic SP was similar with normal controls; however, mean PA was significantly smaller in pathologic SP with retraction compared with normal controls, in the contracted state (P < 0.05). Mean FBL in the posterior region in both relaxed and contracted states was significantly shorter in the pathologic SP with retraction compared with normal controls (P < 0.05). Findings suggest FBL changes associated with tendon pathology vary between the distinct regions, and PA changes are related to whether there is retraction of the tendon. The ultrasound protocol may provide important information on architectural changes that may assist in decision making and surgical planning. Clin. Anat., 2013. © 2012 Wiley Periodicals, Inc.     

Approach and treatment of the adult acquired flatfoot deformity

Adult acquired flatfoot deformity (AAFD), embraces a wide spectrum of deformities. AAFD is a complex pathology consisting both of posterior tibial tendon insufficiency and failure of the capsular and ligamentous structures of the foot. Each patient presents with characteristic deformities across the involved joints, requiring individualized treatment. Early stages may respond well to aggressive conservative management, yet more severe AAFD necessitates prompt surgical therapy to halt the progression of the disease to stages requiring more complex procedures. We present the most current diagnostic and therapeutic approaches to AAFD, based on the most pertinent literature and our own experience and investigations.     

The Physiologic Basis of Surgery

Four methods of allograft tendon-to-muscle anastomosis were tested in single cycle distraction to failure using 10 anastomosed ovine calcaneal tendon-biceps brachii units. The tendon-muscle units were compared to intact ovine biceps brachii muscle units. Methods of tendon-to-muscle anastomosis were derived from modifications of existing muscle tendon repair and tenorrhaphy techniques. Load to failure (N), stiffness (N/cm), distraction (cm), and modes of failure were recorded. Of the four methods tested, the side-to-side technique demonstrated the highest load to failure (152.1 N), the greatest stiffness (17.6 N/cm), the least distraction (2.99 cm) before failure, and the least amount of muscle tissue trauma at failure. Results indicate that, of the methods tested, the side-to-side technique offers the greatest initial stability and should therefore allow adequate revascularization and healing of the anastomosis site.     

Rotura del tendón de Aquiles asociada al uso de fluoroquinolonas en pacientes mayores de 60 años: experiencia de un centro de tercer nivel

BackgroundFluoroquinolones have been associated with increased risk of tendinopathy and Achilles tendon rupture (ATR), especially in patients over 60 years of age.MethodsA retrospective study was carried out including patients over 60 years of age with ATR attended in our centre over the period 2000-2017.ResultsWe identified 44 patients with RTA, of whom 18% (8/44) had been previously treated with fluoroquinolones, with a mean age at diagnosis of ATR of 77.37 years and concomitant corticotherapy in 4 of them. In 7 patients, the rupture was spontaneous and all required surgical management. A significantly higher frequency of smoking, concomitant corticotherapy and spontaneous ruptures were found in the group treated with fluoroquinolones.ConclusionsATR is an adverse event that can occur in patients over 60 years of age treated with fluoroquinolones, so an adequate risk-benefit assessment should be carried out in this population, especially in the presence of associated risk factors.     

Extensor Mechanism Reconstruction Using Marlex Mesh: Is Postoperative Casting Mandatory?

BackgroundExtensor mechanism (EM) disruption after total knee arthroplasty is a catastrophic complication. Reconstruction using monofilament polypropylene mesh (Marlex Mesh; CR Bard, Franklin Lakes, NJ) has emerged as the preferred treatment, but reports are limited to the designing institution. This study describes a nondesigner experience and compares 2 postoperative immobilization strategies: long leg cast vs knee immobilizer.MethodsA retrospective review of consecutive EM reconstructions between 2012 and 2019 was performed. Primary repairs and allograft reconstructions were excluded, leaving 33 knees (30 patients) who underwent Marlex reconstruction. Mean time from disruption to reconstruction was 14 months, and 14 of 33 (42%) had previous repair or reconstruction attempts. The mean age was 69 years, and mean body mass index was 35 kg/m². Postoperatively, extension was maintained using a knee immobilizer in 19 of 33 (58%) patients, whereas 14 of 33 (42%) patients were long leg casted. Kaplan-Meier analysis determined all-cause survivorship free of mesh failure.ResultsAt mean 25-month follow-up, 19 of 33 (58%) EM reconstructions were functioning. Excluding explanted infections (5 recurrent and 2 new), 19 of 26 (73%) EM reconstructions were in situ. Six-year survivorship was 69% and not influenced by immobilization type (cast: 67%, immobilizer: 71%; P = .74). Extensor lag was not associated with immobilization type, improving from a mean preoperative lag of 43° to a mean postoperative lag of 9°. Among successes, University of California at Los Angeles activity and Knee Injury and Osteoarthritis Outcome Score - Joint Replacement score improvements exceeded minimal clinically important difference (2.2-3.3 and 52.5-64.0, respectively).ConclusionMarlex mesh EM reconstruction is a durable and reliable treatment with acceptable clinical results achievable outside the designer institution. Provided sufficient duration and compliance with postoperative immobilization, similar outcomes can be obtained with either a cast immobilizer or a knee immobilizer.