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PubMed2004

Retroviral delivery of Noggin inhibits the formation of heterotopic ossification induced by BMP-4, demineralized bone matrix, and trauma in an animal model.

BACKGROUND: The heterotopic ossification of muscles, tendons, and ligaments is a common problem faced by orthopaedic surgeons. We investigated the ability of Noggin (a BMP [bone morphogenetic protein] antagonist) to inhibit heterotopic ossification. METHODS: Part 1: A retroviral vector carrying the gene encoding human Noggin was developed and used to transduce muscle-derived stem cells. Part 2: Cells transduced with BMP-4 were implanted into both hind limbs of mice along with either an equal number, twice the number, or three times the number of Noggin-expressing muscle-derived stem cells (treated limb) or with nontransduced muscle-derived stem cells (control limb). At four weeks, the mice were killed and radiographs were made to look for evidence of heterotopic ossification. Part 3: Eighty milligrams of human demineralized bone matrix was implanted into the hind limbs of SCID (severe combined immunodeficiency strain) mice along with 100,000, 500,000, or 1,000,000 Noggin-expressing muscle-derived stem cells (treated limbs) or nontransduced muscle-derived stem cells (control limbs). At eight weeks, the mice were killed and radiographs were made. Part 4: Immunocompetent mice underwent bilateral Achilles tenotomy along with the implantation of 1,000,000 Noggin-expressing muscle-derived stem cells (treated limbs) or nontransduced muscle-derived stem cells (control limbs). At ten weeks, the mice were killed and radiographs were made. RESULTS: Part 1: An in vitro BMP inhibition assay demonstrated that Noggin was expressed by muscle-derived stem cells at a level of 280 ng per million cells per twenty-four hours. Part 2: Three varying doses of Noggin-expressing muscle-derived stem cells inhibited the heterotopic ossification elicited by BMP-4-expressing muscle-derived stem cells. Heterotopic ossification was reduced in a dose-dependent manner by 53%, 74%, and 99%, respectively (p < 0.05). Part 3: Each of three varying doses of Noggin-expressing muscle-derived stem cells significantly inhibited the heterotopic ossification elicited by demineralized bone matrix. Heterotopic ossification was reduced by 91%, 99%, and 99%, respectively (p < 0.05). Part 4: All eleven animals that underwent Achilles tenotomy developed heterotopic ossification at the site of the injury in the control limbs. In contrast, the limbs treated with the Noggin-expressing muscle-derived stem cells had a reduction in the formation of heterotopic ossification of 83% and eight of the eleven animals had no radiographic evidence of heterotopic ossification (p < 0.05). CONCLUSIONS: The delivery of Noggin mediated by muscle-derived stem cells can inhibit heterotopic ossification caused by BMP-4, demineralized bone matrix, and trauma in an animal model. CLINICAL RELEVANCE: Gene therapy to deliver Noggin may become a powerful method to inhibit heterotopic ossification in targeted areas of the body.

Achilles Tendon↗
PubMed2005

Soft-tissue releases to treat spastic hip subluxation in children with cerebral palsy.

BACKGROUND: Spastic hip subluxation and dislocation are common problems in children with cerebral palsy. Soft-tissue releases have proved to be beneficial in the prevention of spastic hip dislocation. A protocol for treatment based on patient age, hip abduction, and hip migration percentage was established in 1988. The purpose of this study was to assess the outcome in sixty-five children treated according to this protocol and followed for a minimum of eight years. METHODS: The medical records and radiographs of sixty-five children, from an original series of seventy-four patients, who met the inclusion criteria were available for review. Forty-seven children had spastic quadriplegia and were unable to walk; eighteen children had spastic diplegia and were able to walk independently or with assistive devices. The mean age at the time of the surgery was 4.4 years. Open adductor tenotomy and psoas muscle recession or iliopsoas tenotomy were performed on 129 hips, which were followed for a mean of 10.8 years. The mean age at the time of follow-up was fifteen years. Hips were grouped according to the hip migration percentage preoperatively, at one year postoperatively, and at the time of final follow-up. The final outcome for the patient was defined according to the worse hip. An analysis was performed to identify potential factors influencing outcome. RESULTS: Thirty-two patients (49%) had a good result, eleven (17%) had a fair result, three (4%) had a poor result, and nineteen (30%) had a failure. The mean hip migration percentage was 34% preoperatively and 18% at the time of final follow-up. Nineteen patients required subsequent osseous reconstructive procedures, and eleven required repeat soft-tissue releases. The migration percentage at one year postoperatively was the most predictive of the final outcome (p = 0.001). Patients who had been able to walk preoperatively had a better long-term outcome (p = 0.01). Neither the preoperative hip migration percentage nor the age at surgery significantly affected the outcome. CONCLUSIONS: Soft-tissue release was effective for long-term prevention of hip dislocation in 67% (forty-three) of sixty-five children with spastic hip subluxation. Two preoperative factors that were related to a favorable outcome were a spastic diplegic pattern of involvement and the ability to walk. The hip migration percentage at one year postoperatively was a good predictor of final outcome.

Cerebral Palsy↗
PubMed2006

Surgical technique and anatomic study of latissimus dorsi and teres major transfers.

BACKGROUND: Combined latissimus dorsi and teres major musculotendinous transfer has been described for the treatment of massive rotator cuff deficits. The procedure is technically complex because of the proximity of the radial nerve, the axillary nerve and its posterior branches, and the neurovascular bundles to the muscles. The purpose of the present cadaveric study was to examine surgically relevant relationships for latissimus dorsi and teres major tendon transfers. METHODS: Twelve cadaveric shoulder girdles were dissected, and the latissimus dorsi, the teres major, and the posterior cord of the brachial plexus and its branches were identified. The relationships between the tendons and local neurologic structures were measured during various steps of the latissimus dorsi/teres major transfer procedure. The effect of humeral rotation on the exposure of the latissimus dorsi and teres major tendons through the posterior approach was quantified, and relevant surgical landmarks were described. RESULTS: The radial nerve passed directly anterior to the tendons at an average of 2.9 cm medial to the superior aspect and 2.3 cm medial to the inferior aspect of the humeral insertions. From the posterior axillary approach, maximal internal rotation facilitated exposure for tenotomy by delivering the tendon insertions on the humerus into the surgical field. During axial mobilization of the musculotendinous units, the neurovascular pedicles to the latissimus dorsi and teres major were identified at an average of 13.1 and 7.4 cm axial to the humeral insertions, respectively. The posterior branch of the axillary nerve was noted to cross superficially over the transferred tendons as they were tunneled under the posterior deltoid. CONCLUSIONS: Multiple steps of the combined latissimus dorsi and teres major musculotendinous transfer place local neurologic structures at risk. These steps include tendon release, musculotendinous axial mobilization, and tendon tunneling in the plane between the infraspinatus-teres minor and the posterior deltoid. We have quantified and described the relationship of the axillary and radial nerves to the tendons during tenotomy, the distance from the tendons' insertions to their neurovascular bundle that must be identified during axial mobilization, and the course of the posterior branch of the axillary nerve in relation to the tunneled path of the tendons. CLINICAL RELEVANCE: The present study provides important anatomic findings for the safe mobilization and transfer of the latissimus dorsi and teres major tendons during the surgical treatment of irreparable rotator cuff tears.

Back↗
PubMed2006

Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper's Knee). A randomized, controlled trial.

BACKGROUND: Although the surgical treatment of patellar tendinopathy (jumper's knee) is a common procedure, there have been no randomized, controlled trials comparing this treatment with forms of nonoperative treatment. The purpose of the present study was to compare the outcome of open patellar tenotomy with that of eccentric strength training in patients with patellar tendinopathy. METHODS: Thirty-five patients (forty knees) who had been referred for the treatment of grade-IIIB patellar tendinopathy were randomized to surgical treatment (twenty knees) or eccentric strength training (twenty knees). The eccentric training group performed squats on a 25 degrees decline board as a home exercise program (with three sets of fifteen repetitions being performed twice daily) for a twelve-week intervention period. In the surgical treatment group, the abnormal tissue was removed by means of a wedge-shaped full-thickness excision, followed by a structured rehabilitation program with gradual progression to eccentric training. The primary outcome measure was the VISA (Victorian Institute of Sport Assessment) score (possible range, 0 to 100), which was calculated on the basis of answers to a symptom-based questionnaire that was developed specifically for patellar tendinopathy. The patients were evaluated after three, six, and twelve months of follow-up. RESULTS: There was no difference between the groups with regard to the VISA score during the twelve-month follow-up period, but both groups had improvement (p < 0.001). The mean combined VISA score for the two groups increased from 30 (95% confidence interval, 25 to 35) before the start of treatment to 49 (95% confidence interval, 42 to 55) at three months, 58 (95% confidence interval, 51 to 65) at six months, and 70 (95% confidence interval, 62 to 78) at twelve months. In the surgical treatment group, five knees had no symptoms, twelve had improvement but were still symptomatic, two were unchanged, and one was worse after twelve months (p = 0.49 compared with the eccentric training group). In the eccentric training group, five knees did not respond to treatment and underwent secondary surgery after three to six months. Of the remaining fifteen knees in the eccentric training group, seven had no symptoms and eight had improvement but were still symptomatic after twelve months. CONCLUSIONS: No advantage was demonstrated for surgical treatment compared with eccentric strength training. Eccentric training should be tried for twelve weeks before open tenotomy is considered for the treatment of patellar tendinopathy.

Adult↗
PubMed1983

Features resisting primary treatment of congenital club foot.

The aims of this study were: (1) to see whether the number of relapses of hindfoot deformity in congenital club foot in the first year of life could be reduced by operative treatment, and (2) to try by surgery to pinpoint features of congenital club feet that make them resistant to treatment. As compared to treatment of 95 feet with manipulation and plaster cast only or with heel cord tenotomy added, early tenotomy of both the heel cord and the tibialis posterior tendon in 23 feet markedly reduced the number of relapses of hindfoot deformity, and the need for additional treatment. The results indicate that the achilles and the tibialis posterior tendons, and their corresponding muscles, are the main dynamic features that need to be dealt with when treating the hindfoot deformity in congenital club foot.

Achilles Tendon↗
PubMed1986

Dynamic post-surgical hallux varus after lateral sesamoidectomy: treatment and prevention.

Hallux varus and clawing are occasionally seen after a McBride procedure, due to the severance of the flexor hallucis brevis, when the lateral sesamoid is removed. The present study includes six patients, (involving ten feet), who developed hallux varus and great toe clawing after McBride procedures were performed by various orthopedic surgeons. Treatment utilized partial proximal phalangeal resection, with and without silicone single-stem implants, extensor hallucis longus tendon transfer to the great toe metatarsal, and interphalangeal joint arthrodesis, or tenodesis of the great toe to correct clawing. One patient eventually required a great toe metatarsophalangeal joint fusion. This reconstructive surgery is generally effective by correcting capsular malalignment, the "bowstringing" tendency of the extensor hallucis longus, and great toe clawing that develops simultaneously with hallux varus. Lateral sesamoidectomy is risky, and believed unnecessary as adductor hallucis tenotomy is effective in relieving hallux valgus. Although, it can occur with excessive excision of the medial emminence and distal advancement of the abductor hallucis. The author is unaware of hallux varus developing after adductor hallucis tenotomies.

Adult↗
PubMedDate not supplied

Efficacy of different techniques of superior oblique weakening in the correction of the "A" anisotropia.

The authors present the results of 118 operations in which five different techniques for superior oblique weakening were employed for the correction of "A" pattern: recession of the tendon, split-lengthening, posterior fiber tenectomy near the scleral insertion, full tenectomy near the scleral insertion and marginal tenotomy (Z lengthening). In all the techniques but one, the marginal tenotomy, a high percentage of correction and a good coefficient of correlation between initial incomitance and obtained correction were found. We propose a new technique of superior oblique weakening, the full tenectomy of the tendon near the scleral insertion, and an easy, safe and effective technique.

Analysis of Variance↗
PubMedDate not supplied

Management of superior oblique palsy after surgery for true Brown's syndrome.

Thirty patients requiring surgery for true Brown's syndrome were examined postoperatively. Follow-up ranged from three months to 20 years. Eight-five percent of patients demonstrated some degree of superior oblique palsy, with 54% having a decompensated condition and 30% requiring a second surgical procedure. Patients with marked preoperative restriction appear to be at increased risk for developing a decompensated superior oblique palsy postoperatively. Solutions to this problem are suggested: 1) perform tenotomy at insertion and preserve the adjacent intermuscular septum so a less crippling effect is seen; 2) combine tenotomy with inferior oblique weakening initially in those patients with marked preoperative restriction.

Child↗
PubMed2000

[Prevalence and morbidity of hip excentration in cerebral palsy: review of the literature].

PURPOSE OF THE STUDY: Excentration of the hip is one of the main orthopedic complications of ante and perinatal cerebral palsy. Excentration can progress to dislocation even if tenotomy is performed. What is the prevalence and morbidity of hip excentration? METHODS: We reviewed the pertinent literature on the prevalence and morbidity of hip excentration in patients with cerebral palsy based on the Medline and Reedoc databases. RESULTS: Data presented in the literature vary greatly. Populations are representative of the referral network of the teams reporting the study rather than the cerebral palsy population in general. Signs reported were pain, difficult nursing procedures, difficult sitting position, pressure sores and fractures, but only one sign can be taken fully into account: 50 p. cent of the dislocated hip joints were painful. DISCUSSION: No one study gives a precise assessment of the prevalence of hip excentration and displacement and its consequences in patients with cerebral palsy. In a population of quadriplegic patients who do not walk, the question is whether complementary tenotomy should be performed, knowking the difficult operative and postoperative situation of such procedures. In this population, walking is an exceptional goal of bone surgery, pain relief and patient comfort are more common goals. Data in this literature (50 p. 100 of the dislocated hips are painful) suggest a prudent approach. However, there is no known marker which can be used to distinguish hips which will become painful from those which will remain pain free. In addition, irreversible cartilage degeneration can cause pain contraindicating reconstructive surgery.

Cerebral Palsy↗
PubMedDate not supplied

The effect of prereduction traction on the results of closed reduction of developmental dislocation of the hip.

A group of 86 developmentally dislocated hips in children aged 6-48 months was treated by closed reduction before 1957 without preliminary traction, and another group of 176 hips was treated after 1957 with prereduction traction. The results in these two groups were compared to clarify the effect of prereduction traction. During the treatment of these cases, subcutaneous adductor tenotomy was performed when obviously indicated. Otherwise preliminary traction was the only variable between the two groups. To rule out tenotomy as a factor influencing the result, the hips of children aged 6-36 months who had prereduction traction as the single variable were taken out of the group and the results analyzed. It is concluded that prereduction traction decreases the incidence of avascular necrosis of the femoral head when developmentally dislocated hips of children aged 6-36 months are treated with closed reduction with traction as the single variable.

Child, Preschool↗
PubMed2001

Outcome of surgery for congenital fibrosis of the inferior rectus muscle.

PURPOSE: To report clinical findings and surgical outcome in a large series of patients with fibrosis of the inferior rectus muscle. MATERIALS AND METHODS: Subject Cases: A total of 17 cases were diagnosed with unilateral fibrosis of the inferior rectus muscle during the past 27 years at our institution. They were aged from 5 months to 17 years, with 15 cases under 10 years of age. No differences were present regarding the laterality or gender. FINDINGS: All the cases showed hypotropia with restricted eye elevation. Forced duction test showed resistance to upward eye movement. A horizontal deviation in primary eye position was also present in 10 cases (59%). The affected eye was amblyopic in the majority of cases. Binocular vision was absent in 15 of the 17 cases. RESULTS: Surgical Outcome: All the cases received either recession or free tenotomy of the inferior rectus muscle. Resection of the ipsilateral superior rectus muscle was additionally performed to correct residual hypotropia. Fibrosis of the inferior rectus was present as intraoperative finding in all the 17 cases. Hypotropia disappeared in 10 cases and decreased in 7 cases. Restoration of satisfactory binocular alignment was obtained in all the 17 cases. CONCLUSION: Recession of the inferior rectus muscle was effective treatment for fibrosis of the inferior rectus. Additional resection of the ipsilateral superior rectus muscle was useful to correct residual hypotropia. Free tenotomy is not recommended.

Adolescent↗
PubMedDate not supplied

Sonographic healing stages of Achilles tendon after tenomuscular lengthening in children with cerebral palsy.

Long-term follow-up of a tenotomized Achilles tendon reveals healing with formation of a tendonlike structure between the cut tendon ends. A prospective study to show sonographic healing stages was designed. Twelve patients (21 Achilles tendons) with the diagnosis of cerebral palsy, spastic diplegia, and shortening of their Achilles tendons underwent a tenomuscular release. The healing process was documented by monthly ultrasound studies. Overall, 102 examinations were done, with a mean follow-up of 5.3 months. The authors found six distinct healing stages, with no significant change occurring in the length of the primary gap at the tenotomy site throughout healing. Based on these results, the authors conclude that sonographic healing stages of the cut Achilles tendon can be defined and staged. They also suggest that transverse tenotomy at the tenomuscular junction is a safe method, with no risk of overlengthening.

Achilles Tendon↗
PubMed2001

Conservative treatment of developmental dysplasia of the hip in Kuwait.

This paper evaluates the results of conservative treatment for developmental dysplasia of the hip after an average follow-up of 3 years in 69 patients and 99 hips: 31 bilateral, 23 left side, and 14 right. They were treated at the Al-Razi Hospital, Kuwait, between January 1995 and December 1996. There were 59 girls and 10 boys aged between 5 months and 24 months (average age 12 months). The treatment consisted of traction for 1 or 2 weeks, followed by manipulation in 36 hips and manipulation with adductor longus tenotomy in 45 hips and with adductor longus and psoas tenotomy in 18 hips. Avascular necrosis of the femoral head developed in 16 hips (16%): 14 hips on the affected side and 2 hips on the unaffected side. Persistent acetabular dysplasia was present in 13 hips, subluxation in 9 hips and dislocation in 13 hips. Open reduction was later required in 5 hips, open reduction and innominate osteotomy in 8 hips, and hip extracapsular innominate osteotomy in 1 hip. The results were evaluated according to the age groups with highest rate of complications after the age of 15 months. The treatment protocol was changed to limit conservative treatment until the age of 14 months.

Female↗
PubMed2003

Biomechanical effects of dissecting flexor carpi ulnaris.

Our aim was to determine whether the length and function of the flexor carpi ulnaris muscle were affected by separating it from its soft tissue connections. We measured the length of flexor carpi ulnaris before and after its dissection in ten patients with cerebral palsy. After tenotomy, tetanic contraction shortened the muscle by a mean of 8 mm. Subsequent dissection to separate it from all soft tissue connections, resulted in a further mean shortening of 17 mm (p < 0.001). This indicated that the dissected connective tissue had been strong enough to maintain the length of the contracting muscle. Passive extension of the wrist still lengthened the muscle after tenotomy, whereas this excursion significantly decreased after subsequent dissection. We conclude that the connective tissue envelope, which may be dissected during tendon transfer of flexor carpi ulnaris may act as a myofascial pathway for the transmission of force. This may have clinical implications for the outcome after tendon transfer.

Adolescent↗
PubMed1976

[Responses of the muscle spindles of tenotomized and hypertrophied muscles to stretch and vibration].

Responses of primary and secondary endings of muscle spindles were studied after tenotomy and hypertrophy in the cat soleus muscles. Under constant load (100 g) background activity of primary endings in a control muscle was 17 +/- 1.5 imp/s. It did not change in hypertrophic muscle and increased after tenotomy to 26 +/- 1.5 imp/s. Responses of secondary endings did not change under the same conditions. The frequency of a response from primary and secondary endings of tenotomized and hypertrophic muscles were higher during dynamic and static phase of stretching as compared to response of normal muscle spindles. Primary endings of tenotomized and hypertrophic muscles were able to repeat vibration up to 200 Hz, while secondary endings responded only with some increase in the discharge frequency.

Animals↗
PubMed2003

Ultrastructural determinants of murine achilles tendon strength during healing.

The mechanisms by which tendon strength is established during growth and development and restored following injury are not completely understood and are likely to be complex, multifactorial processes. Several studies examining the relationship between mechanical behavior and ultrastructural characteristics of tendons and ligaments during growth and maturation suggest that collagen fibril diameter is strongly correlated with tendon strength. Because of the similarities between development and repair processes of musculoskeletal tissues, increases in tendon strength during healing may be related to increases in fibril ultrastructural parameters such as fibril size, numerical density, and area fraction. In this study, we compared murine Achilles tendons at various time points after tenotomy with sham-operated controls in tensile tests to failure and examined tendons using electron microscopy to assess collagen fibril ultrastructure. We found that in the 6-week period following Achilles tenotomy, fibril mean diameter remained significantly smaller than sham-side diameter by a factor of 2-3. Despite the persistently small fibril size, increasing numerical density resulted in a gradual increase in fibril area fraction. Biomechanical strength did not reach that of intact tendons until some time between 5 and 7 weeks, approximately the same time period when fibril area fraction began to approach sham values. These data suggest that parameters other than collagen fibril size are most responsible for increased tendon strength during healing.

Achilles Tendon↗
PubMed2004

Is the absence of the ossific nucleus prognostic for avascular necrosis after closed reduction of developmental dysplasia of the hip?

The presence of the ossific nucleus before reduction of developmental dysplasia of the hip may reduce the rate of avascular necrosis. Forty-eight hips in 45 children who underwent successful closed reduction had at least a 2-year follow-up. Medical records were reviewed for sex, side, Pavlik harness, traction, age at reduction, adductor tenotomy, cast duration, length of follow-up, and subsequent surgery. Prereduction radiographs were reviewed for presence or absence of the ossific nucleus. Avascular necrosis was noted as present if there was evidence of Bucholz and Ogden type II, III, or IV on the postreduction radiographs. Avascular necrosis was noted postreduction in 17 hips. Adductor tenotomy may reduce the rate of avascular necrosis following closed reduction. Delaying closed reduction until the presence of the ossific nucleus can be detected radiographically may reduce the rate of avascular necrosis. The presence of avascular necrosis increases the need for subsequent surgery.

Female↗
PubMed1978

Achilles tendon injury. II. Structure of tenotomized rabbit crural muscles after primary and delayed tendon suture.

This investigation was designed to study the long-term effects of surgical treatment, as recommended and followed in clinical practice, on the fine structure of rabbit crural muscles after Achilles tenotomy. Two main results were made: (A) Even after 12 weeks of mobilization a number of morphological changes were found, especially in the soleus muscles. These abnormalities were similar to those found in human soleus muscles after surgically treated Achilles tendon rupture. (B) There were a large number of small heavily stained (for myofibrillar ATPase at pH 9.4) fibres in the experimental soleus muscles, such that the normal ratio of fibre types was reversed. This was apparent if tendon suture had been performed after a delay of 3 weeks. The results suggested that as a consequence of the de- and regenerative events, induced by immobilization or tenotomy plus immobilization, a number of new fibres had been formed. Some of these were so short that they were out of reach of nerve terminals and remained non-innervated. Furthermore, from the point of view of clinical practice, the extensive long-term effects of suture delay make themselves manifest not until at least a delay of one week.

Achilles Tendon↗