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Paralytic clawing of the hallux may occur in children with congenital disorders of the neuraxis. Tenodesis of flexor hallucis longus allows correction of this deformity in early childhood. Seventeen of these procedures have been reviewed and good results were obtained in fifteen.
Nine patients have been reviewed at an average period of 22 years after a Watson-Jones tenodesis performed for chronic instability of the ankle. Only three patients had complete relief of symptoms. Two favourable early results deteriorated 7 and 10 years after operation. Radiographic examination revealed full correction of both anterior and lateral instability of the talus in only two cases. Talar tilt was controlled more successfully than increased anterior drawer movement. Long-standing instability was associated with the formation of marginal exostoses, the severity of which appeared proportional to the degree of instability.
We describe a technique of soft-tissue reconstruction which is effective for the treatment of chronic lunotriquetral instability. Part of extensor carpi ulnaris is harvested with its distal attachment preserved. It is passed through two drill holes in the triquetrum and sutured to itself. This stabilises the ulnar side of the wrist. We have reviewed 46 patients who underwent this procedure for post-traumatic lunotriquetral instability with clinical signs suggestive of ulnar-sided carpal instability. Standard radiographs were normal. All patients had pre-operative arthroscopy of the wrist at which dynamic lunotriquetral instability was demonstrated. A clinical rating system for the wrist by the Mayo clinic was used to measure the outcome. In 19 patients the result was excellent, in ten good, in 11 satisfactory and in six poor. On questioning, 40 (87%) patients said that surgery had substantially improved the condition and that they would recommend the operation. However, six (13%) were unhappy with the outcome and would not undergo the procedure again for a similar problem. There were six complications, five of which related to pisotriquetral problems. The mean follow-up was 39.1 months (6 to 100). We believe that tenodesis of extensor carpi ulnaris is a very satisfactory procedure for isolated, chronic post-traumatic lunotriquetral instability in selected patients. In those with associated pathology, the symptoms were improved, but the results were less predictable.
Six fresh-frozen adult cadaveric specimens were mounted in an Instron materials testing machine with use of a cemented intramedullary rod. Angular relationships between the first metatarsal and the talus were recorded with a sonic digitizer. A flatfoot deformity was created by dividing the talonavicular joint capsule (superiorly, medially, and inferiorly), the spring ligament, the anteromedial aspect of the subtalar joint capsule, and the plantar fascia. Angular displacement in the sagittal and transverse planes was recorded at no load and at 100, 350, and 700-newton plantar loads. Each specimen was subjected to four different reconstructions with tenodesis, and the angular relationship between the first metatarsal and the talus was measured at the four levels of load. A reconstruction with use of the peroneus longus tendon was performed by preserving its insertion into the first metatarsal, rerouting the tendon and passing it from medial to lateral through a calcaneal bone tunnel, and anchoring it to the lateral aspect of the calcaneus. A reconstruction with the tibialis tendon was performed by passing the medial third of the tendon from dorsal to plantar through the navicular and from medial to lateral through the calcaneal bone tunnel and securing it to the lateral aspect of the calcaneus. The reconstruction with the tibialis anterior tendon was repeated with the tendon graft routed along the medial aspect of the navicular, directly through the calcaneal bone tunnel. The fourth reconstruction was done with use of an Achilles tendon allograft.(ABSTRACT TRUNCATED AT 250 WORDS)
Thirty-seven chronically unstable ankles in thirty-six patients were operated on with use of a Watson-Jones tenodesis. Thirty-four ankles (thirty-three patients) were followed for a mean duration of thirteen years and eight months (range, ten to eighteen years) after the operation. There were nine male and twenty-four female patients. The mean age of the patients was thirty-one years (range, fourteen to fifty-seven years) at the time of the operation and forty-four years (range, twenty-eight to seventy years) at the time of the latest follow-up. At the time of the most recent follow-up evaluation, twenty-seven patients (twenty-eight ankles) were examined directly by one of us and twenty-five patients (twenty-six ankles) also were evaluated radiographically. The other six patients were interviewed, with use of a questionnaire, by telephone. Of the thirty-four ankles, nineteen had an excellent result (grade 1), eleven had a good result (grade 2), three had a fair result (grade 3), and one had a poor result (grade 4) according to the rating system of Good et al. The mean score (and standard deviation) on the ankle-hindfoot scale of the American Orthopaedic Foot and Ankle Society for the twenty-eight ankles that were examined directly by one of us was 90 +/- 9.3 points (range, 68 to 100 points). Progression of an exostosis at the edge of the joint was detected in eighteen (69 percent) of the twenty-six ankles that were examined radiographically, but narrowing of the joint space was not seen in any ankle. No relationship was detected between the clinical results and radiographic osteoarthrotic changes or the duration of follow-up. The results did not deteriorate over the long term.
Hyperextension of the thumb metacarpophalangeal joint may be congenital or result from an injury to the volar ligamentary system. The usual complaints are local pain, joint instability and weakness of the pinch and grip. The present paper describes a simple method of correcting this instability by using a palmaris longus-tenodesis as a hyperextension checkrein for the joint.
Surgical correction of the footdrop deformity caused by various neuromuscular diseases is a time-honored technique, with most surgical procedures intended to correct the absence of active dorsiflexion and a concomitant cavovarus foot deformity. We describe suspension tenodesis of the tibialis anterior tendon to the distal tibia to correct the footdrop deformity. This technique is simpler to perform and more secure than transferring the distal attachment of a tendon to a new location in the foot itself or using tendon weaving techniques. In addition, compared with an ankle fusion, our technique allows for a certain amount of shock absorption during gait and is much less invasive, and a future ankle fusion could be performed if needed for full stability and definitive correction of the symptomatic footdrop. Finally, the technique we describe is easily reproducible and seems to remain stable over time.
Rupture of the anterior cruciate ligament constitutes a major disability in young athletes and those patients with persistent disabling instability who have failed to respond to conservative treatment. A new method of reconstruction by means of semitendinsous tenodesis was used in five patients with satisfactory end results after an average follow-up of 21.4 months. Limited clinical experience indicates that with this method less anteroposterior instability persists than with other methods.
Treatment of the chronically unstable distal ulna often requires reconstruction using tenodesis techniques. A review of described techniques for distal ulnar stabilization is presented, addressing chronic instability with and without distal radioulnar joint degenerative disease.
Tendoachilles tenodesis to the fibula was performed in postpolio patients to improve their gait. The charts of 48 patients with 52 tenodeses were reviewed. The mean follow-up was 5.5 years. Gait improved in one-third. When the hindfoot was stabilized, gait improved in 40% of the patients, but when it was not stabilized, only 22% improved their gait. Excessive equinus developed in 18 patients, all of whom were less than age 12 years when operated. We conclude that it is reasonable to use this procedure to improve the gait of postpolio children with flail lower extremity, provided the hindfoot is stabilized.
Repair of chronic ankle instability is recommended by a step-to-step approach. Anatomic repair with ligamentoplasty or periosteal flap will result in complete range of motion of the foot, but with less stability (7.1 degrees talar tilt). The more unphysiologic tenodesis procedure should be done in long-standing cases and gross instability, with the risk of loss of motion (10 degrees supination in one third of the cases), but with the advantage of best mechanical stability (3.5 degrees talar tilt).
In the treatment of valgus flat foot in adolescent patients, when growth has nearly ceased (about 13 years in the female and 15 in the male) the operation of choice is varus osteotomy of the calcaneum, stabilised by a homoplastic bone wedge, together with tenodesis of tibialis anterior and posterior. At this age, skeletal growth is not sufficient to guarantee corrective evolution of the deformity after repositioning of the calcaneo-talar joint by any surgical technique. Varising osteotomy of the calcaneum offers the advantage of avoiding sacrifice of the calcaneo-talar joint, as in the Grice-Green arthrodesis, which although indicated for the paralytic valgus flat foot, is not appropriate in the idiopathic variety.
Children with myelomeningocele often develop progressive valgus deformity of the ankle that may be concomitant with, or mistaken for, paralytic hindfoot valgus. The same deformity is encountered in children who sustain lower motor neuron deficits. It is imperative to obtain an anteroposterior weight-bearing radiograph of the ankles to differentiate and document the degree of ankle valgus. To address the ankle deformity, we employed the fibular-Achilles tenodesis described by Westin. We are reporting our experience with 18 patients (32 ankles) who underwent this procedure. We noted improvement in relative fibular length and reduced talar tilt in 26 ankles (81.2%). In addition, there was some improvement in the orientation of the hindfoot; rotational deformity was unaffected.
This article reviews patients with documented anterior cruciate ligament-deficient knees. Historical features are emphasized, and a rating system is provided. A lateral tenodesis is described, with timing of the repair and proper rehabilitation stressed.
Hallux varus is a deformity, either congenital or acquired, of the first metatarsophalangeal joint. It presents as a medical deviation of the hallux in relation to the longitudinal axis of the first metatarsal shaft. The authors discuss the case history of a patient and the surgical technique--a split width tenodesis--which they used to correct the deformity.
Eight patients with tetraplegia at the sixth cervical level had ten flexor pollicis longus tenodeses performed to create a key grip. Two of the patients also had tendon transfers to create active finger flexion; these failed. The remaining six patients were objectively evaluated by the hand-function test of Jebsen et al. to measure gains in hand function. All patients improved postoperatively, the average improvement being 31 per cent. Although these patients did not add many new hand activities to their repertoire, they showed increased speed and ease of pre-existing hand functions. Three patients did gain the ability to self-catheterize, enabling two of them to live totally independent life-styles. Fixation of the thumb interphalangeal joint with Kirschner wires did not provide sufficient long-term stability, and initial arthrodesis of this joint is recommended in conjunction with the flexor pollicis longus tenodesis.
A case of patient with flexor digitorum profundus tenodesis at the site of metaphyseal fracture of the radius is presented. The open fracture occurred when the patient was 11 years old and was treated elsewhere with plaster of paris. Progressive flexion contracture of the middle, ring and little finger was treated surgically 7 years later. Full extension and good hand function has been achieved.
We describe 129 patients with disabling instability of the knee due to deficiency of the anterior cruciate ligament. They were treated by replacement of the ligament with a Leeds-Keio prosthesis supplemented by an extra-articular MacIntosh lateral substitution reconstruction. After an average period of 71 months a satisfactory outcome was found in only 60% of knees. Nine had required revision because of recurrent instability and the pivot-shift sign had become positive in 40% of patients. In our opinion the long-term results are unsatisfactory when compared with those obtained using a graft from the medial third of the patellar tendon supplemented with a MacIntosh extra-articular tenodesis.