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We report the results of 23 soft-tissue release procedures in 15 patients who had juvenile chronic arthritis. The operation, which includes hamstring tenotomies and posterior capsulotomy, is a safe and effective way of eliminating contracture, relieving pain and improving function.
The effect of storage at sub-zero temperatures and subsequent thawing was investigated in dissected muscles, tendons, limbs and spines. Freezing caused a noticeable shortening of muscles which when thawed could easily be elongated; the same effects, though less pronounced, were observed with tendons. During freezing, myotomy or tenotomy led to the development of a striking deformity owing to unopposed shortening of the opposing muscles. After thawing, all frozen specimens containing muscles and joints showed an increased range of passive movements, easily demonstrable by mild tensile forces.
We studied the pathogenesis, incidence and consequences of avascular necrosis in 184 children treated for congenital dislocation of the hip. Of 210 hips, 99 (47%) had some evidence of avascular necrosis (total 81, partial 18). The incidence was not influenced by the age at reduction, the duration of traction or the use of adductor tenotomy. Patients treated by closed reduction without preliminary traction did not have a higher incidence of avascular necrosis. At long-term clinical and radiological review of 81 hips, early avascular necrosis significantly increased the chance of a poor outcome but did not predispose to acetabular dysplasia. If review includes minor forms of avascular necrosis, then this condition is common after closed reduction. Its presence is an important determinant of long-term radiological and clinical outcome.
Sixty-one patients with 68 osteonecrotic femoral heads, at different stages of development, were treated surgically; their average age was 36 years. Necrosis followed a fracture in 43 hips and traumatic dislocation in three. It was idiopathic in 14, cortisone-induced in seven and associated with gout in one. The operation of multiple drilling, curettage of the necrotic bone and muscle pedicle bone grafting was performed in all. Cheilectomy of the superolateral part of the femoral head and adductor tenotomy were added in cases of advanced necrosis. Of the several types of muscle pedicle used, tensor fasciae latae anteriorly and quadratus femoris posteriorly were preferred. Full weight-bearing was not permitted for five to six months. The follow-up period varied from three to 12 years. Hip pain was regularly relieved and abduction and rotation of the joints were improved. Those with post-traumatic or idiopathic necrosis did better than those with cortisone-induced necrosis.
In 20 skeletally mature female merino sheep, divided into four groups, we performed total medial meniscectomy, removal of the middle third of the patellar tendon, and tenotomy of the calcaneal tendon of the right hind leg. Group I (control) had no additional procedures. In the other three groups the medial meniscus was replaced by the middle third of the patellar tendon from the ipsilateral knee. The animals were killed at three (group II), six (group III), or 12 months (group IV) and the tendon-meniscus examined macroscopically, by light and scanning electron microscopy, and biomechanically. Remodelling of the tissue had taken place by 12 months but the failure stress and tensile modulus for the tendon-meniscus were lower than for the normal meniscus. Our evidence suggests that, in sheep, replacement of a meniscus by a tendon autograft may decrease the severity of the degenerative changes that occur after meniscectomy.
We assessed the outcome after simultaneous multiple operations performed on 18 children with spastic diplegia, with emphasis on the changes in the physiological cost index (PCI) of walking. Fourteen patients had a measurable reduction at one year, but the more severely affected patients took up to two years to reach a new functional plateau. The level of the preoperative PCI allows prediction of the outcome of surgery in terms of reducing the effort of walking, or improving its appearance only. Intrapelvic intramuscular psoas tenotomy produced an improvement of hip flexion deformity in 15 of 17 patients without the loss of muscle power to initiate the swing phase. Fractional lengthening corrected hamstring tightness in 17 cases, and the mean popliteal angle was reduced from 63 degrees preoperatively to 30.2 degrees, with almost complete resolution of the fixed knee flexion deformity present in ten patients. Distal transfer of the rectus femoris, when it was shown to be contracting inappropriately, improved the knee flexion arc during walking from a mean of 28.3 degrees to 45.2 degrees.
Conventional methods of imaging in the investigation of developmental dysplasia of the hip all have disadvantages, either in definition or in exposure to radiation. We describe a new open-configuration MR scanner which is unique in that it allows anaesthesia and access to the patient within the imaging volume for surgical procedures and application of casts. We performed 13 scans in eight anaesthetised infants. Dynamic imaging revealed two dislocated hips which were then visualised during reduction. Hip spicas were applied without removing the patient from the scanner. In one hip, an adductor tenotomy was carried out. In all patients, stressing the hips during dynamic imaging allowed an assessment of stability. This was particularly useful in two hips in which an analysis of stability in different positions facilitated the planning of femoral osteotomies. This method of imaging provides new and important information. It has great potential in the investigation of developmental dysplasia of the hip and, with ultrasound, may allow management without the need for radiography.
We have studied the formation of collagen fibrils in 'activated fibroblasts' of tendo Achillis of rabbits. The tendon was in the process of regeneration after experimental partial tenotomy. Samples were taken from the peri-incisional region and analysed by transmission electron microscopy. Ultrastructural examination showed the presence of a 'fine dense granular substance' inside the rough endoplasmic reticulum and procollagen filaments. These come together to form collagen fibrils in the dilated vacuoles of the rough endoplasmic reticulum. The possible intra- and extracellular origin of collagen fibrils is suggested. Within the cell biosynthesis of collagen fibrils take place with the formation of collagen substance which gives rise to procollagen filaments. These make contact in parallel apposition to produce striated 'spindle-shaped bodies' which elongate by the longitudinal attachment of more procollagen filaments and form intracellular nascent collagen fibrils.
We conducted a prospective, randomised, controlled trial of 45 patients (47 elbows), with tennis elbow, who underwent either a formal open release or a percutaneous tenotomy. All patients had pre- and post-operative assessment using the Disability of Arm, Shoulder and Hand (DASH) scoring system. Both groups were followed up for a minimum of 12 months. Statistical analyses using the Mann-Whitney U test and repeated measured ANOVA showed significant improvements for patient satisfaction (p = 0.012), time to return to work (p = 0.0001), improvements in DASH score (p = 0.001) and improvement in sporting activities (p = 0.046) in the percutaneous group. Those patients undergoing a percutaneous release returned to work on average three weeks earlier and improved significantly more quickly than those undergoing an open procedure. The percutaneous procedure is a quicker and simpler procedure to undertake and produces significantly better results.
This study was performed to test the hypothesis that attaching a tendon to a trough in cancellous bone results in tendon-healing that is biomechanically superior to that after direct fixation of a tendon to cortical bone. Twenty adult female goats were treated with a bilateral tenotomy of the infraspinatus tendon with subsequent reattachment of the tendon. In shoulders randomized to the cancellous-fixation group, a cancellous bed was prepared with a motorized burr and a template measuring twenty by five by five millimeters. The repair in the shoulders randomized to the cortical-fixation group was performed in the same manner, except that the tendon was attached to cortical bone. Three outcome measures were assessed, six and twelve weeks after the repair, with the Student paired t test and analysis of variance: load to failure, energy to failure, and stiffness. The types of repair were not significantly different with regard to any of the three outcomes. When the six and twelve-week data were combined, an average difference in load to failure of 3.9 per cent in favor of cancellous repair was observed but it was not significant (p = 0.78). The associated 95 per cent confidence interval for the difference ranged from 10.5 per cent in favor of cortical repair to 18.3 per cent in favor of cancellous repair. Histological analysis at six and twelve weeks revealed progressive maturation and reorganization of the bone-tendon interface with re-establishment of collagen-fiber continuity between the tendon and bone. This process was indistinguishable between the cortical and cancellous specimens. This study demonstrated no significant benefit from the creation of a trough to expose the tendon to cancellous bone. In this model, at both six and twelve weeks, the tendon-to-bone healing process of the two groups appeared similar and the biomechanical properties were approximately equal.
One hundred and forty-four boys who had Duchenne muscular dystrophy were managed at a single center between 1953 and 1994 and were followed for a mean of 8.9 years. The long duration of follow-up provided an opportunity to examine the effects of physical therapy and orthopaedic treatment on contractures of the lower extremities and on the duration of the ability to walk. Contractures of the lower extremities were controlled best when patients were managed with a combination of daily passive stretching exercises, prescribed periods of standing and walking, tenotomy of the Achilles tendon, posterior tibial-tendon transfer, and application of knee-ankle-foot orthoses. Approximately two years after bracing, the severity of the contracture of the heel cords was similar in the patients who had had an operation and those who had not. By the fourth year after bracing, however, the patients who had had an operation had less severe contractures than those who had had bracing alone. Five to seven years after the operation and bracing, control of contractures was still good, especially for the patients who had had posterior tibial-tendon transfer. Contracture of the knee was well controlled five to seven years after bracing in all patients who had had bracing, with or without an operation. The program enabled the patients who had been managed with bracing to walk until a mean age of 13.6 years. After loss of the ability to walk with bracing, the ability to stand continued for an additional two years with use of orthoses. The findings of the present study demonstrate the value of traditional methods of operative treatment and bracing for controlling contractures of the lower extremities in patients who have Duchenne muscular dystrophy and for prolonging their ability to walk.
BACKGROUND: Joint angular velocity (the rate of flexion and extension of a joint) is related to the dynamics of muscle activation and force generation during walking. Therefore, the goal of this research was to examine the joint angular velocity in normal and spastic gait and changes resulting from muscle-tendon lengthening (recession and tenotomy) in patients who have spastic cerebral palsy. METHODS: The gait patterns of forty patients who had been diagnosed with spastic cerebral palsy (mean age, 8.3 years; range, 3.7 to 14.8 years) and of seventy-three age-matched, normally developing subjects were evaluated with three-dimensional motion analysis and electromyography. The patients who had cerebral palsy were evaluated before muscle-tendon lengthening and nine months after treatment. RESULTS: The gait patterns of the patients who had cerebral palsy were characterized by increased flexion of the knee in the stance phase, premature plantar flexion of the ankle, and reduced joint angular velocities compared with the patterns of the normally developing subjects. Even though muscle-tendon lengthening altered sagittal joint angles in gait, the joint angular velocities were generally unchanged at the hip and knee. Only the ankle demonstrated modified angular velocities, including reduced dorsiflexion velocity at foot-strike and improved dorsiflexion velocity through mid-stance, after treatment. Electromyographic changes included reduced amplitude of the gastrocnemius-soleus during the loading phase and decreased knee coactivity (the ratio of quadriceps and hamstring activation) at toe-off. Principal component analyses showed that, compared with joint-angle data, joint angular velocity was better able to discriminate between the gait patterns of the normal and cerebral palsy groups. CONCLUSIONS: This study showed that muscle-tendon lengthening corrects biomechanical alignment as reflected by changes in sagittal joint angles. However, joint angular velocity and electromyographic data suggest that the underlying neural input remains largely unchanged at the hip and knee. Conversely, electromyographic changes and changes in velocity in the ankle indicate that the activation pattern of the gastrocnemius-soleus complex in response to stretch was altered by recession of the complex.
BACKGROUND: Diastrophic dysplasia results in severe disproportionate growth failure, multiple joint deformities, and early osteoarthritis of the hips. Mortality is increased in early childhood, but thereafter life expectancy is normal. Because of severe flexion deformities, resting pain, and diminished movements of the hip joints, total hip arthroplasty is indicated at an early age. The purpose of our study was to evaluate prospectively the midterm results of total hip arthroplasty in a consecutive series of patients with diastrophic dysplasia. METHODS: Between 1982 and 1996, forty-one total hip replacements were performed in twenty-four consecutive patients with diastrophic dysplasia (mean age, forty-one years) at our hospital. The patients were followed prospectively for a minimum of five years with clinical examination, determination of Harris hip scores, and radiographs. Twenty-two patients (thirty-eight hips) were examined clinically and radiographically at the time of follow-up, and the remaining two patients (three hips) were contacted only by telephone. The mean duration of follow-up was 7.8 years. RESULTS: The mean Harris hip score increased from 44 points (range, 25 to 66 points) before the operation to 70 points (range, 37 to 89 points) at the final follow-up examination (p < 0.001). Ten complications (24%) were recorded. Five (12%) of the forty-one hips required revision because of aseptic loosening of the acetabular component at a mean of 9.4 years after the primary operation. No revisions were due to aseptic failure of the femoral component. CONCLUSIONS: Implant survival was good and the Harris hip scores increased significantly after total hip arthroplasty in patients with diastrophic dysplasia. However, shortening femoral osteotomy and transposition of the greater trochanter, adductor and flexor tenotomies, and modification of the femoral stem were frequently needed. Total hip arthroplasty is recommended for patients with diastrophic dysplasia and severe degeneration of the hip joints, even for those who are relatively young. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.
BACKGROUND: Recent studies have suggested that tenotomy and repair of the subscapularis tendon carried out for anterior approaches to the shoulder can be followed by failure of the tendon repair and by changes resulting in permanent loss of subscapularis function. We hypothesized that release of the subscapularis with use of a superficial osteotomy of the lesser tuberosity followed by repair of the two opposing bone surfaces would lead to consistent bone-to-bone healing, which would be possible to monitor radiographically, and would lead to satisfactory clinical and structural outcomes. METHODS: Thirty-nine shoulders in thirty-six consecutive patients who, at an average age of fifty-seven years, had undergone total shoulder replacement through an anterior approach involving an osteotomy of the lesser tuberosity were evaluated at an average of thirty-nine months. Assessment included a standardized interview and physical examination, scoring according to the system described by Constant and Murley, and imaging with conventional radiography and computed tomography to assess healing of the osteotomy site and changes in the subscapularis. RESULTS: The osteotomized tuberosity fragment healed in an anatomical position in all shoulders, and no cuff tendon ruptures were observed. At the time of follow-up, thirty-three (89%) of thirty-seven shoulders evaluated with a belly-press test had a negative result and twenty-seven (75%) of thirty-six shoulders evaluated with a lift-off test had an unequivocally normal result. Fatty infiltration of the subscapularis muscle increased after the operation (p < 0.0001) and was at least stage two in eleven (32%) of thirty-four shoulders. The fatty infiltration had progressed by one stage in eight (24%) of the thirty-four shoulders, by two stages in five shoulders (15%), and by three stages in two shoulders (6%). CONCLUSIONS: Osteotomy of the lesser tuberosity provides an easy anterior approach for total shoulder replacement and is followed by consistent bone-to-bone healing, which can be monitored, and good subscapularis function. In the presence of documented anatomical healing of the osteotomy site, postoperative fatty infiltration of the subscapularis muscle remains unexplained and needs to be investigated further as it is associated with a poorer clinical outcome.
BACKGROUND: Recent studies have suggested that tenotomy and repair of the subscapularis tendon carried out for anterior approaches to the shoulder can be followed by failure of the tendon repair and by changes resulting in permanent loss of subscapularis function. We hypothesized that release of the subscapularis with use of a superficial osteotomy of the lesser tuberosity followed by repair of the two opposing bone surfaces would lead to consistent bone-to-bone healing, which would be possible to monitor radiographically, and would lead to satisfactory clinical and structural outcomes. METHODS: Thirty-nine shoulders in thirty-six consecutive patients who, at an average age of fifty-seven years, had undergone total shoulder replacement through an anterior approach involving an osteotomy of the lesser tuberosity were evaluated at an average of thirty-nine months. Assessment included a standardized interview and physical examination, scoring according to the system described by Constant and Murley, and imaging with conventional radiography and computed tomography to assess healing of the osteotomy site and changes in the subscapularis. RESULTS: The osteotomized tuberosity fragment healed in an anatomical position in all shoulders, and no cuff tendon ruptures were observed. At the time of follow-up, thirty-three (89%) of thirty-seven shoulders evaluated with a belly-press test had a negative result and twenty-seven (75%) of thirty-six shoulders evaluated with a lift-off test had an unequivocally normal result. Fatty infiltration of the subscapularis muscle increased after the operation (p < 0.0001) and was at least stage two in eleven (32%) of thirty-four shoulders. The fatty infiltration had progressed by one stage in eight (24%) of the thirty-four shoulders, by two stages in five shoulders (15%), and by three stages in two shoulders (6%). CONCLUSIONS: Osteotomy of the lesser tuberosity provides an easy anterior approach for total shoulder replacement and is followed by consistent bone-to-bone healing, which can be monitored, and good subscapularis function. In the presence of documented anatomical healing of the osteotomy site, postoperative fatty infiltration of the subscapularis muscle remains unexplained and needs to be investigated further as it is associated with a poorer clinical outcome.
Chronic muscle and tendon injuries to the groin are common sports injuries. The symptoms of groin injuries are often uncharacteristic which can result in a delay in the correct and specific diagnosis being reached. The most common injury is the overuse strain resulting in chronic tendinitis of the adductor muscle/tendon units, especially the adductor longus. The rectus femoris and rectus abdominous muscles and tendons are also commonly affected. Computed tomography, magnetic resonance imaging and ultrasonography have been widely adopted to diagnose muscle/tendon injuries to the groin. Ultrasonography has been shown to be accurate and sensitive in diagnosing tendon injuries in the groin region, especially small partial ruptures of the muscle/tendon unit. Ultrasonography has the advantage of being fast, inexpensive and widely available. Normal findings are readily distinguished from pathological findings providing valuable pre-operative information, such as location and extent of the injury. The differential diagnoses are many and often difficult to reach. The most commonly overlooked differential diagnoses are chronic prostatitis and hernias. A multidisciplinary approach is valuable in many cases. The recommended treatment is well planned and gradually increased rehabilitation programme during the first stages. Surgery for acute injuries is rarely indicated. Surgery, for example tenotomy of the adductor longus, has given satisfactory results in many athletes when nonsurgical treatment has failed.
An in-season adductor muscle strain may be debilitating for the athlete. Furthermore, an adductor strain that is treated improperly could become chronic and career threatening. Any one of the six muscles of the adductor group could be involved. The degree of injury can range from a minor strain (Grade I), where minimal playing time is lost, to a severe strain (Grade III) in which there is complete loss of muscle function. Ice hockey and soccer players seem particularly susceptible to adductor muscle strains. In professional ice hockey players throughout the world, approximately 10% of all injuries are groin strains. These injuries, which have been linked to hip muscle weakness, previous injuries to that area, preseason practice sessions and level of experience, may be preventable if such risk factors can be addressed before each season. Hip-strengthening exercises were shown to be an effective method of reducing the incidence of adductor strains in one closely followed National Hockey League ice hockey team. Despite the identification of risk factors and strengthening intervention for ice hockey players, adductor strains continue to occur throughout sport. Clinicians feel an active training programme, along with completely restoring the strength of the adductor muscle group, is the key to successful rehabilitation. Surgical intervention is available if nonoperative treatment fails for 6 months or longer. Adductor release and tenotomy was reported to have limited success in athletes.
Effects of denervation and deafferentation on mass and enzyme activity of soleus and plantaris muscles were studied when the synergistic gastrocnemius was either intact or tenotomized in adult male Wistar rats. Denervation of the sciatic nerve at L4 and L5 induced a severe atrophy (approximately 50%) in both soleus and plantaris within 2 weeks. Deafferentation at L4 and L5 also caused a decrease in muscle weight for soleus and plantaris (approximately 11 and 24%, respectively). No compensatory response to the tenotomy was induced either for muscle weight or enzyme activity in both denervated and deafferentated muscles. It is suggested that the efferent information(s) through the nerve fibers has an important effect of the regulation of both muscle mass and enzyme activity. Its effect on the activities was greater in mitochondrial than cytoplasmic enzymes. The data also suggest that the afferent information(s) plays a significant role for the regulation of muscle mass, including an induction of compensatory hypertrophy, but not for enzyme activity.