Perineorrhaphy Compared With Pelvic Floor Muscle Therapy in Women With Late Consequences of a Poorly Healed Second-Degree Perineal Tear: A Randomized Controlled Trial.

OBJECTIVE: To evaluate outcomes after pelvic floor muscle therapy, as compared with perineorrhaphy and distal posterior colporrhaphy, in the treatment of women with a poorly healed second-degree obstetric injury diagnosed at least 6 months postpartum. METHODS: We performed a single center, open-label, randomized controlled trial. After informed consent, patients with a poorly healed second-degree perineal tear at minimum 6 months postpartum were randomized to either surgery or physical therapy. The primary outcome was treatment success, as defined by Patient Global Impression of Improvement, at 6 months. Secondary outcomes included the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and the Hospital Anxiety and Depression Scale. Assuming a 60% treatment success in the surgery group and 20% in the physical therapy group, plus anticipating a 20% loss to follow-up, a total of 70 patients needed to be recruited. RESULTS: From October 2015 to June 2018, 70 of 109 eligible patients were randomized, half into surgery and half into tutored pelvic floor muscle therapy. The median age of the study group was 35 years, and the median duration postpartum at enrollment in the study was 10 months. There were three dropouts in the surgery group postrandomization. In an intention-to-treat analysis, with worst case imputation of missing outcomes, subjective global improvement was reported by 25 of 35 patients (71%) in the surgery group compared with 4 of 35 patients (11%) in the physical therapy group (treatment effect in percentage points 60% [95% CI 42-78%], odds ratio 19 [95% CI 5-69]). The surgery group was superior to physical therapy regarding all secondary endpoints. CONCLUSION: Surgical treatment is effective and superior to pelvic floor muscle training in relieving symptoms related to a poorly healed second-degree perineal tear in women presenting at least 6 months postpartum. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02545218.

Obstetrical Anal Sphincter Injuries and the Need for Adequate Care.

BACKGROUND: An estimated 4% to 6.6% of women delivering vaginally sustain obstetrical anal sphincter injuries (OASI). Despite this, a gap exists in the provision of postpartum care to women globally. Given the negative impact of OASI, action is needed, and multidisciplinary perineal clinics can help. Consequently, such a clinic was established in 2011 at the Royal Alexandra Hospital (RAH), a tertiary care center in Edmonton, Alberta. OBJECTIVE: This study assesses the state of perineal clinics specializing in OASI internationally and locally by investigating the literature for descriptions of specialized perineal clinics for women with OASI, describing the RAH perineal clinic, and assessing the prevalence of OASI at the RAH in the context of the clinic. METHODS: A search of peer-reviewed literature was conducted on Medline and observations and interviews of RAH perineal clinic staff were conducted, as was a medical chart review. RESULTS: Articles describing only 10 perineal clinics specializing in OASI were found, with varying structures. The multidisciplinary RAH clinic, like one other clinic, has a strong physiotherapy focus, with education and Pilates classes and one-on-one appointments offered by pelvic floor physiotherapists. In 2016, of the 326 (6.9%) vaginal deliveries that resulted in OASI at the RAH, only 66.0% (215) were referred to the clinic. CONCLUSIONS: Multidisciplinary perineal clinics are needed globally. Despite the creation of the perineal clinic at the RAH, women continue to lack specialized care after OASI. It is crucial that healthcare professionals specializing in OASI share their experiences to establish best practices and create new, and improve existing, perineal clinics.

Relative Motion Flexion Splinting for Flexor Tendon Lacerations: Proof of Concept.

BACKGROUND: The principle of relative motion has allowed patients to regain a higher degree of hand function, while protecting extensor tendon repairs. The purpose of this study was to determine whether the principle of relative motion could be a viable method to protect a flexor tendon repair. METHODS: Four fresh-frozen cadaver arms were each mounted on a testing apparatus (wrist in 30° of extension, metacarpophalangeal [MCP] joints blocked to 70°-80°). A minimum of 11 N was used to cyclically load the flexor digitorum profundus and extensor digitorum communis tendons to maximum allowable flexion and extension for 25 cycles. Measurements of elongation of the tendons were obtained through the use of differential variable reluctance transducers. Testing was performed in both intact and repaired (single 6-0 nylon suture) middle finger tendons (zone 3) with and without a relative motion flexion splint (RMFS), which placed the affected finger in 15° to 25° of relative flexion at the MCP joint. RESULTS: In all 4 hands, elongation was restricted to less than 1.3 mm in repaired tendon in the RMFS compared with elongation >2 mm in the nonsplinted condition. Average elongation was 0.86 mm (SD = 0.45). Visual examination of the tendons demonstrated no gapping with the use of the RMFS in any of the hands. All repairs had suture breakage and repair rupture without the RMFS. CONCLUSIONS: This study demonstrates that the RMFS decreases elongation and eliminates tendon-repair gapping after flexion/extension cycling in a cadaver model. It provides proof of concept that the RMFS may be a viable protective mechanism for flexor tendon repairs in zone 3.

A Special Tear Pattern of Anterior Horn of the Lateral Meniscus: Macerated Tear.

BACKGROUND: We describe a special, interesting phenomenon found in the anterior horn of the lateral meniscus (AHLM): most tear patterns in the AHLM are distinctive, with loose fibers in injured region and circumferential fiber bundles were separated. We name it as macerated tear. The goal of this study was to bring forward a new type of meniscal tear in the AHLM and investigate its clinical value. MATERIALS AND METHODS: AHLM tears underwent arthroscopic surgery from January 2012 to December 2014 were included. Data regarding the integrity of AHLM were prospectively recorded in a data registry. Tear morphology and treatment received were subsequently extracted by 2 independent reviewers from operative notes and arthroscopic surgical photos. RESULTS: A total of 60 AHLM tears in 60 patients (mean age 27.1 years) were grouped into horizontal tears (n = 15, 25%), vertical tears (n = 14, 23%), complex tears (n = 6, 10%), and macerated tears (n = 25, 42%). There were 6 patients with AHLM cysts in macerated tear group and one patient in vertical tear group. 60 patients were performed arthroscopic meniscus repairs and were followed-up with averaged 18.7 months. Each group had significant postoperative improvement in Lysholm and IKDC scores (p < 0.05). However, the macerated tear group showed least functional recovery of Lysholm and IKDC scores compared to other groups (p < 0.05). In addition, there were no differences in postoperative range of motion, return to work, or return to sport/other baseline activities between the four groups (p > 0.05). CONCLUSIONS: This study demonstrated that the macerated tear is common in the tear pattern of AHLM. However, feasibility of the treatment of this type of meniscal tear, especially the meniscus repairs still requires further study.

Impact of Pelvic Floor Physical Therapy on Quality of Life and Function After Obstetric Anal Sphincter Injury: A Randomized Controlled Trial.

OBJECTIVES: There is no standard of care for women sustaining an obstetric anal sphincter injury (OASIS). We sought to determine whether pelvic floor physical therapy (PFPT) would improve the quality of life and function in women 12 weeks after OASIS. METHODS: This institutional review board-approved randomized trial enrolled primiparous women 2 weeks after delivery complicated by OASIS. After informed consent, all subjects underwent vaginal electromyography and anorectal manometry and completed validated questionnaires; measures were repeated for all subjects at 12 weeks after delivery. The intervention arm completed 4 PFPT sessions. The primary outcome was a change in the Fecal Incontinence Quality of Life. RESULTS: Three hundred four women were screened; 250 were excluded, and 54 were randomized. After four were lost to follow-up, analysis included 27 in the intervention arm and 23 in the control arm. Overall, mean age was 29.8 ± 4.7 years, and there were no demographic differences between groups.Fecal Incontinence Quality of Life domain scores showed improvement for both groups from baseline to 12 weeks for coping (P = 0.006) and depression (P = 0.009); however, there was no difference in domain scores between groups. For the secondary outcome of anorectal manometry, squeezing pressure improved for all subjects (P = 0.035) from baseline to 12 weeks. Vaginal EMG strength (microvolts) increased for all subjects in measures of rest average (P < 0.000), rapid peak (P = 0.006), and work average (P < 0.000), with no difference based on therapeutic arm. CONCLUSIONS: All women showed improvements in quality of life and function at 12 weeks after delivery, regardless of treatment allocation. Further study is needed to determine whether PFPT provides a significant benefit to women having OASIS.

Primary repair of the acetabular labrum: outcomes with 2 years' follow-up.

PURPOSE: The purpose of this study was to assess the results and outcomes of primary repair of the torn acetabular labrum. METHODS: All patients undergoing hip arthroscopy are prospectively assessed solely with the modified Harris Hip Score, which is an outcomes tool. Over a 4-year period, 37 patients (38 hips) underwent primary repair of a torn acetabular labrum and had reached 2 years' follow-up. No cases were excluded. For perspective on the frequency of this procedure, the ratio of labral refixations after pincer femoroacetabular impingement correction to primary repairs was evaluated. RESULTS: The mean age was 26 years (range, 11 to 44 years). There were 26 female and 11 male patients, with 20 right and 18 left hips. The mean improvement in the modified Harris Hip Score was 18.9 points (70.5 points preoperatively and 89.4 points postoperatively), with 35 hips (92%) showing improvement, including good and excellent results in 35 hips (92%). Associated pathology included articular damage (21 hips), ligamentum teres (14 hips), cam femoroacetabular impingement (11 hips), borderline dysplasia (center-edge angle, 20° to 25°) (3 hips), dysplasia (center-edge angle <20°) (2 hips), and iliopsoas (2 hips). Four patients underwent repeat arthroscopy at a mean of 10 months (range, 5 to 15 months) postoperatively. The labral repair site was fully healed in each of these cases. There were no complications. During the study period, a total of 1,574 arthroscopic hip procedures were performed, including 439 labral refixations, representing an 11.6:1 ratio of refixation to repair. CONCLUSIONS: This study showed good clinical results of primary repair with favorable outcomes and evidence of good healing, even among the 11% of patients who required repeat arthroscopy. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Results of arthroscopic partial repair of large retracted rotator cuff tears.

PURPOSE: To evaluate the midterm results of partial rotator cuff repair using the Constant score and the acromiohumeral radiographic measurement. METHODS: Thirty-eight patients with a mean age of 65 years and a large retracted rotator cuff tear (at least 2 tendons) were included in the study. Patients underwent clinical examination, standard radiography, and isometric strength testing at a mean follow-up of 47 months. The rotator cuff tears were classified as posterosuperior, anterosuperior, or global tears (≥3 tendons), and an arthroscopic partial repair was performed. RESULTS: The mean Constant score significantly increased from 56 points before surgery to 71 points after surgery (P = .041); the mean age- and sex-adjusted Constant score significantly improved from 63% to 90% at a mean follow-up of 47 months after arthroscopic partial rotator cuff repair (P = .003); and the subcategories pain and activity significantly improved (P = .001, P = .014, respectively). The active range of motion improved from 133° of flexion and 111° of abduction before surgery to 163° of forward flexion and 156° of abduction after surgery (P < .001). However, the active range of external rotation decreased from 44° before surgery to 36° after surgery. Further, there was a trend toward a decrease in the mean acromiohumeral distance from 7.0 mm before surgery to 5.6 mm after surgery. The abduction strength did not significantly improve after surgery (4.2 kg before surgery and 4.8 kg after surgery; P = .116). CONCLUSIONS: An arthroscopic partial repair of the rotator cuff is an effective tool to improve the Constant score by restoring active forward flexion and abduction and through pain relief. Further, we found that a pathologically decreased acromiohumeral distance cannot be reversed by a partial rotator cuff repair. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Morphology of large rotator cuff tears and of the rotator cable and long-term shoulder disability in conservatively treated elderly patients.

OBJECTIVE: The objective of this study was to describe the morphology of the rotator cuff tendon tears and long-term shoulder disability in conservatively treated elderly patients and determine if an association exists between these factors. METHODS: Assessment of the rotator cuff tendon tear dimensions and depth, rotator interval involvement, rotator cable morphology and location, and rotator cuff muscle status was carried out on magnetic resonance studies of 24 elderly patients treated nonoperatively for rotator cuff tendon tears. Long-term shoulder function was measured using the Western Ontario Rotator Cuff (WORC) index; Disabilities of the Shoulder, Arm, and Hand questionnaire; and the American Shoulder Elbow Self-assessment form, and a correlation between the outcome scores and morphologic magnetic resonance findings was carried out. RESULTS: The majority of large rotator cuff tendon tears are limited to the rotator cuff crescent. Medial rotator interval involvement (isolated or in association with lateral rotator interval involvement) was significantly associated with WORC physical symptoms total (P = 0.01), WORC lifestyle total (P = 0.04), percentage of all WORC domains (P = 0.03), and American Shoulder Elbow Self-assessment total (P = 0.01), with medial rotator interval involvement associated with an inferior outcome. CONCLUSIONS: Medial rotator interval tears are associated with long-term inferior outcome scores in conservatively treated elderly patients with large rotator cuff tendon tears.

Long-term results after SLAP repair: a 5-year follow-up study of 107 patients with comparison of patients aged over and under 40 years.

PURPOSE: The aims of this prospective cohort study were to assess the long-term results after isolated superior labral repair and to determine whether the results were associated with age. METHODS: One hundred seven patients underwent repair of isolated SLAP tears. There were 36 women and 71 men with a mean age of 43.8 years (range, 20 to 68 years). Mean follow-up was 5.3 years (range, 4 to 8 years). Of the patients, 62 (57.9%) were aged 40 years or older. Follow-up examinations were performed by an independent examiner; 102 patients (95.3%) had a 5-year follow-up. RESULTS: The Rowe score improved from 62.8 (SD, 11.4) preoperatively to 92.1 (SD, 13.5) at follow-up (P < .001). Satisfaction was rated excellent/good for 90 patients (88%) at 5 years. There was no significant difference in the results for patients aged 40 years or older and those aged under 40 years. Difficulty with postoperative stiffness and pain was reported by 14 patients (13.1%). CONCLUSIONS: Our results suggest that long-term outcomes after isolated labral repair for SLAP lesions are good and independent of age. Postoperative stiffness was registered in 13.1% of the patients. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

[Functional reeducation of flexor tendons with associated lesions in zone II--comparative study]. / Reeducarea functionala a tendoanelor flexoare cu leziuni asociate în zona II--studiu comparativ.

UNLABELLED: Regaining satisfactory digital function after flexor tendon laceration and repair has long been one of the most important problems in hand surgery. But optimal therapy is often difficult to ascertain, given the plethora of immediat postoperative protocols published in the scientific literature. AIM: The purpose of this study is to compare the functional results between Kleinert, Silfverkiöld, Gratton and Strickland protocol towards evaluate them by interconnection and with the literature. MATERIAL AND METHODS: The prospective study enorolled 75 patients who presented in our cabinet consecutives during 1.05.2008-1.12.2010. The subjects were evaluated regarding Total active motion test and Grip strenght test at 12 weeks postoperative. RESULTS: We found the best results to Gratton group, followed by Strickland, Silfverkiöld-May and Kleinert groups. CONCLUSIONS: We conclude that, for the tendinous lessions with associated injury (nervs and vessels) in zone II, our first therapeutical indication is to use the Gratton protocol.

Parachute technique: a complimentary method in zone II tendon repair.

Flexor tendon lacerations still represent a challenging problem for the hand and the plastic surgeon, particularly in zone II. Many techniques have been devised accordingly to make the surgery of this zone easier. Hence, we too have devised an added complementary technique (ie, the parachute technique) to the common surgical techniques of the tendon repair to ease the repairing process and improve the outcomes. In this study, 79 patients, from whom 21 patients had 2 injured fingers, with flexor tendon injury in zone II (ie, 100 fingers) underwent this new technique. Finally, the results were hopeful. Thus, this complementary parachute technique combined with an early active mobilization with almost full range of flexion and extension, starting on the first postoperative day, resulted in improved outcomes compared with both passive mobilization and gentle active mobilization with a limited range of motion (ie, "controlled"). The Strickland formula (total active motion) system was used to evaluate the functional results of the flexor tendon repair. Finally, this technique is applicable for tendon repairs, and is shown to produce good results in their hands.

Technique for and an anatomic guide to forearm tendon repair.

Forearm lacerations involving muscle bellies are usually treated by repairing muscle fascia. Repair of tendons themselves is stronger and restores normal muscle anatomy better. Tendon repair requires good knowledge of forearm muscle and tendon anatomy. We have made cadaver measurements to produce graphical maps of locations of individual muscles tendons of origin and insertion, some practical guides for finding tendon ends and a simple grasping stitch for intramuscular tendons.

Repair of complete nerve lacerations at the forearm: an outcome study using Rosén-Lundborg protocol.

A comparison of outcomes based on a scoring system for assessments, described by Rosén and Lundborg, after sharp complete laceration of median and/or ulnar nerves at various levels in the forearm was carried out. There were 66 males (90.4%) and 7 females (9.6%), with a mean age of 31 years (range: 14-62 years). The patients were categorized into three groups according to the type of nerve injury. The median nerve was injured in 25 cases (group M, 34.3%), the ulnar in 27 (group U, 36.9%), and both the nerves in 21 (group MU, 28.8%). The demographic data of the patients and the mechanism of injury were recorded. We also examined the employment status at the time of the injury and we estimated the percentage of patients who returned to their work after trauma. In all cases, a primary epineural repair was performed. Concomitant injuries were repaired in the same setting. The mean period of time between injury and surgery was 5.3 hours (range: 2-120 hours). A rehabilitation protocol and a reeducation program were followed in all cases. The mean follow-up was 3 years (range: 2-6 years), with more distal injuries having a shorter follow-up period. The total score was 2.71 in group M (range: 0.79-2.99) and 2.63 in group U (range: 0.63-3), with no significant differences observed. There was a significant difference between these two groups and group MU (total score 2.03, range: 0.49-2.76, P = 0.02). Up to the last follow-up, 61 patients (83.5%) had returned to their previous work. The Rosén-Lundborg model can be a useful and simple tool for the evaluation of the functional outcome after nerve injury and repair temporally reflecting the processes of regeneration and reinnervation.

An evidence-based approach to flexor tendon laceration repair.

The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.

Finger zone II flexor tendon repair in children (5-10 years of age) using three 'figure of eight' sutures followed by immediate active mobilization.

For children between 5-10 years of age with zone II flexor tendon lacerations, the literature recommends a modified early mobilization programme under the supervision of a hand therapist but the fingers are immobilized between physiotherapy sessions. We report on a series of children between 5-10 years of age with flexor tendon lacerations (n = 54 fingers) in zone II repaired with a six-strand core suture (three separate 'figure of eight' sutures) and actively mobilized immediately after surgery similar to adult rehabilitation programmes with no immobilization between the physiotherapy sessions. The average follow-up for the study group was 13 months (range 7-25 months). There were no ruptures. The final outcome was excellent in 46 fingers (85%) and good in the remaining eight fingers (15%) using the Strickland-Glogovac criteria.