Subacromial Surgery for Irreparable Posterosuperior Rotator Cuff Tears.

The irreparable posterosuperior rotator cuff tear describes a tear of the supraspinatus and/or infraspinatus tendon that is massive, contracted, and immobile in both the anterior-posterior and medial-lateral directions. Patients with an intact subscapularis and preserved forward elevation are challenging to treat because there is not a consensus treatment algorithm. For low-demand, elderly patients, several subacromial surgical options are available that can provide pain relief without the risks or burden of rehabilitation posed by reverse total shoulder arthroplasty or a complex soft-tissue reconstruction (e.g., superior capsular reconstruction, tendon transfer, bridging grafts). Debridement, more specifically the "smooth-and-move" procedure, offers a reliable outcome with documented improvements in pain and function at long-term follow-up. Similarly, the biodegradable subacromial balloon spacer (InSpace; Stryker, Kalamazoo, MI) has been shown to significantly improve pain and function in patients who are not responsive to nonoperative treatment. Disease progression with these options is possible, with a small percentage of patients progressing to rotator cuff arthropathy. Biologic tuberoplasty and bursal acromial reconstruction are conceptually similar to the balloon spacer but instead use biologic grafts to prevent bone-to-bone contact between the humeral head and the acromion. Although there is no single gold standard treatment, the variety of surgical techniques allows patients and surgeons to effectively manage these challenging situations.

[Acquired foot drop]. / Verworven klapvoet.

A dropping foot is the consequence of a variety of debilitating conditions and is oftentimes treated conservatively by general practitioners and other specialists. Typically, it is caused by peroneal nerve palsy secondary to compression or a hernia nucleosipulpei at the level L4-L5. Identifying the underlying pathology requires a neurological work-up oftentimes including ultrasound and electromyographic investigation. When a peroneal nerve compression is found, decompression can be achieved operatively. Should the underlying cause of the dropping foot have been treated adequately without an effect on the foot itself, then a posterior tibial tendon transfer may be considered. Generally, a posterior tibial tendon transfer has good outcomes for the treatment of dropping foot although it is partly dependent on the physiotherapy that accompanies it.

Drop Foot With Posterior Tibialis Weakness Treated With Peroneus Longus Transfer in a Child: A Case Report.

CASE: An 8-year-old girl with a history of acute flaccid paralysis presented with chronic valgus drop foot causing tripping and falling. Traditionally surgical correction of this deformity is accomplished by transferring the posterior tibialis tendon to enhance dorsiflexion. The authors describe a new technique which transfers the peroneus longus tendon to the dorsum of the foot in a patient with weakness of the posterior tibialis muscle. The patient's drop foot and gait were improved at the 22-month follow-up. CONCLUSION: Successful transfer of the peroneus longus was accomplished with improved limb clearance during gait and coronal alignment in stance.

Electromyographic biofeedback training in a cerebral palsy patient undergoing pronator teres rerouting and brachioradialis to extensor carpi radialis brevis tendon transfer surgery: A case report.

Several surgical procedures are used to treat dynamic pronation position of the forearm and flexion deformity of the wrist in cerebral palsy. Postoperative results of pronator teres rerouting were explored, while specially designed postoperative physiotherapy and its outcomes were limited. Herein, we present a case in whom the outcomes of electromyographic biofeedback (EMG-BF) training were assessed after pronator teres rerouting and brachioradialis tendon to extensor carpi radialis brevis tendon transfer combined with derotation osteotomy. The peak value increased, while the resting value decreased for the muscles after the intervention. Range of motion, hand function, manual ability, functional independence, and quality of life levels were improved. In conclusion, EMG biofeedback training may have a positive effect on neuromuscular control of pronator teres and brachioradialis. Free use of the upper extremity and improved manual ability positively affect the activity and quality of life of the patients.

[The current status and challenges of surgical treatment for chronic Achilles tendon rupture].

With the growing demand for physical activity, an increasing number of individuals with chronic Achilles tendon ruptures are opting for surgical intervention. Surgical approaches encompass end-to end anastomosis, tendon flap techniques, tendon transfer procedures, and free tendon grafting, among others. When selecting the appropriate surgical method and determining the surgical indications, it is imperative to consider factors like the length of the Achilles tendon defect, patient age, aesthetic preferences, functional requirements, and local tissue conditions. As medical devices evolve and surgical techniques advance, the criteria for surgical intervention are also evolving. Drawing from existing literature evidence, it becomes crucial to define reasonable parameters for addressing Achilles tendon defects with each surgical technique, aligning more closely with clinical needs. Additionally, auxiliary technologies such as biologic therapy and innovative biomaterials have demonstrated promising results in laboratory or animal models. The focal point of advancing these auxiliary technologies lies in facilitating the translation of pertinent clinical outcomes in the future.

Up to date diagnosis and treatment of massive irreparable cuff tears: Results of the survey of the U45 ESSKA Committee.

PURPOSE: Irreparable rotator cuff tears are disabling and can severely affect daily life activities, especially when young and active patients are involved. The definition is still debated, and they can have several clinical presentations. The treatment depends on the clinical presentation and the patient's age. METHODS: The survey was developed by the ESSKA U45 Committee and was uploaded on the ESSKA website. Fifty-seven questionnaires were returned. Several aspects of the diagnosis and treatment of massive irreparable cuff tears were investigated. Moreover, treatment options for specific clinical scenarios were given for posterior-superior and anterior-superior cuff tears in young and old patients. RESULTS: Fatty degeneration of the muscles was the most common criterion to define an irreparable tear (59.7%). In young patients with external rotation with the arm at side lag, partial repair of the cuff was the most common option (41.8%); in case of external rotation with the arm at side + external rotation at 90° of abduction lag without pseudoparalysis, the most common option was partial repair of the cuff + latissimus dorsi or lower trapezius transfer (39.3%), and in case of external rotation with the arm at side + external rotation at 90° of abduction lag with pseudoparalysis, partial repair of the cuff + latissimus dorsi or lower trapezius transfer was still the most common option (25.5%). The same scenarios in old patients yielded the following results: reverse prosthesis (49.1%), reverse prosthesis (44.6%) and reverse prosthesis ± latissimus dorsi or lower trapezius transfer (44.6%), respectively. CONCLUSIONS: The present survey clearly confirms that biological options (partial cuff repairs and tendon transfers) are the reference in the case of young patients with deficient cuffs (both posterior and anterior). Reverse shoulder prosthesis is the most common treatment option in old patients in all clinical scenarios. LEVEL OF EVIDENCE: Level IV.

Biomechanical Comparison Between Superior Capsular Reconstruction and Lower Trapezius Tendon Transfer in Irreparable Posterosuperior Rotator Cuff Tears.

BACKGROUND: Superior capsular reconstruction (SCR) and lower trapezius tendon transfer (LTT) have recently been used to manage irreparable posterosuperior rotator cuff tears (PSRCTs). There has been a paucity of comparative biomechanical considerations between the 2 procedures. PURPOSE: To compare the glenohumeral stability and biomechanical properties between SCR and LTT in PSRCTs involving the entire infraspinatus tendon region. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen cadaveric shoulders were tested at 0°, 20°, and 40° of shoulder abduction. Maximum internal, external, and total humeral range of motion (ROM), superior translation of the humeral head, and subacromial contact characteristics were compared among 4 conditions: (1) intact rotator cuff, (2) PSRCTs involving the entire infraspinatus tendon region, (3) LTT using Achilles allograft (12 N and 24 N of loading), and (4) SCR using fascia lata allograft. RESULTS: Although a decrease in total ROM was noted in LTT with 12 N compared with the tear condition, LTT with both 12 N and 24 N as well as SCR did not restrict total rotational ROM compared with the intact condition. LTT had decreased total ROM compared with tear condition at 20° of abduction (P = .042), while no significant decrease was confirmed at all abduction angles after SCR. SCR and LTT with 24 N decreased superior translation compared with the PSRCT condition at 0° and 20° of abduction (P < .037) but not significantly at 40° of abduction, whereas LTT with a 24-N load decreased glenohumeral superior translation at all abduction angles (P < .039). Both SCR and LTT decreased subacromial contact pressure compared with the tear condition (P < .014) at all abduction angles. SCR decreased subacromial contact pressure at 0° and 40° of abduction (P = .019 and P = .048, respectively) compared with LTT with 12 N of loading, while there was no difference between SCR and LTT with 24 N of loading in all abduction angles. SCR increased the contact area compared with the PSRCT condition at all abduction angles (P < .023), whereas LTT did not increase the contact area. CONCLUSION: SCR and LTT decreased glenohumeral superior translation and contact pressure compared with PSRCT conditions. The LTT was superior to SCR in terms of superior translation of the humeral head at a higher shoulder abduction angle, whereas the SCR showed more advantageous subacromial contact characteristics compared with LTT. CLINICAL RELEVANCE: These biomechanical findings provide insights into these 2 fundamentally different procedures for the treatment of young and active patients with PSRCTs involving the entire infraspinatus tendon region.

Increased latissimus dorsi and teres major muscle volume after anterior transfer for irreparable anterior superior rotator cuff tear: correlation with improved internal rotation strength.

INTRODUCTION: While the well-established correlation between increased muscle volume and enhanced muscle strength is widely recognized, there have been no studies assessing volumetric muscle changes in transfer surgery in the shoulder. This study aimed to evaluate changes in transferred muscle volume and their clinical implications in anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with anterior superior irreparable rotator cuff tears (ASIRCTs). MATERIALS AND METHODS: The study retrospectively examined 40 patients who underwent aLDTM tendon transfers for ASIRCTs between August 2018 and January 2022. Using ImageJ software, the LDTM muscle was segmented in T2-weighted oblique axial images, and total muscle volume (tLDTMV) of both immediate and postoperative 1-year were calculated. Pearson correlation analysis was used to determine the correlation between ΔtLDTMV and ΔASES scores, Δactive-ROM, and Δstrength. RESULTS: The current study revealed an 11.4% increase in tLDTMV at 1-year postoperative. Patients were grouped based on postoperative ASES score: Group 1 (Optimal, n = 17) and Group 2 (Suboptimal, n = 23). Although tLDTMVimmediate postoperative values were similar between groups (P = 0.954), tLDTMV1-year postoperative value was significantly higher in Group 1 compared to Group 2 (P = 0.021). In correlation analysis, ΔtLDTMV showed significant correlations with ΔASES score (r = 0.525, P < 0.001), ΔaROM of forward elevation (FE) (r = 0.476, P = 0.002), ΔaROM of internal rotation (IR) at back (r = 0.398, P = 0.011), Δstrength of FE (r = 0.328, P = 0.039), Δ strength of IR at 90° abduction (r = 0.331, P = 0.037), and IR at side (r = 0.346, P = 0.029). CONCLUSIONS: Significant increase in tLDTMV was observed at 1-year postoperative for ASIRCT patients. Notably, greater ΔtLDTMV exhibited a correlation with better ASES scores, increased aROM and strength in both FE and IR. Nevertheless, further research is required by employing more robust standardized measurement tools and a larger sample size.

Surgical Technique: Brachioradialis to Extensor Carpi Radialis Longus and Brevis Nerve Transfers for Tetraplegia.

Improving upper extremity function in high cervical spinal cord injury (SCI) patients with tetraplegia is a challenging task owing to the limited expendable donor muscles and nerves that are available. Restoring active wrist extension for these patients is critical because it allows for tenodesis grasp. This is classically achieved with brachioradialis (BR) to extensor carpi radialis brevis (ECRB) tendon transfer, but outcomes are suboptimal because BR excursion is insufficient and its origin proximal to the elbow further limits the functionality of the tendon transfer, particularly in the absence of elbow extension. As an alternative approach to restore wrist extension in patients with ICSHT group 1 SCI, we present the first clinical report of the BR to extensor carpi radialis longus (ECRL) and BR to ECRB nerve transfers.

Adult traumatic brachial plexus injuries: advances and current updates.

Nerve grafting, tendon transfer and joint fusion are routinely used to improve the upper limb function in patients with brachial plexus palsies. Newer techniques have been developed that provide additional options for reconstruction. Nerve transfer is a tool for restoring upper limb function in total root avulsions where nerve grafting is not possible. In partial brachial plexus injuries, nerve transfers can greatly improve shoulder, elbow, wrist and hand function. Intraoperative electrical stimulation can be used to diagnose precisely which nerve is injured and to choose which nerve fascicles should be transferred. Finally, measuring the postoperative outcome can improve the evaluation of our techniques. The aim of this article was to present the current techniques used to treat patients with brachial plexus injury.

Endoscopic peroneus brevis tendon transfer for chronic ruptures of the Achilles tendon: surgical technique.

Chronic Achilles tendon rupture is usually defined as a rupture diagnosed 4-6 weeks after injury. The management of chronic Achilles tendon rupture (CATR) is a topic of hot debate, and no consensus has been achieved. Surgical management of CATR is recommended. Several approaches, techniques, and grafts have been described. Open techniques carry a high risk of wound breakdown, infection, and necessitate long rehabilitation times. Surgical techniques with smaller incisions to reduce the risk of scar fibrosis, pain, and infection are becoming common. The ipsilateral tendon of the hallux flexor longus and the peroneus brevis is commonly used. Endoscopic transfer of the peroneus brevis tendon is an innovative alternative to other procedures, with comparable results of other autografts even in elite athletes. The tendon of the peroneus brevis is harvested by tendoscopy before performing a calcaneal tendon endoscopy and fixing the graft in a calcaneal tunnel using an interference screw. After surgery, an anterior splint is placed for 3 weeks with immediate forefoot weight bearing. The rehabilitation starts on the 15th postoperative day.

Injury of flexor halluics longus tendon in amateur marathon runners results in abnormal plantar pressure distribution: observational study.

OBJECTIVE: To analyze the changes of plantar pressure in amateur marathon runners with flexor halluics longus (FHL) tendon injury using the Medtrack-Gait plantar pressure measurement system, and to explore whether the plantar pressure data can be used as an index for the diagnosis of injury. METHODS: A total of 39 healthy amateur marathon runners without any ankle joint symptoms were recruited. Dynamic and static plantar pressure data were measured using the pressure plate of Medtrack-Gait. According to MRI imaging findings, whether the FHL tendon was injured or not was judged, and the dynamic and static data were divided into the injury group and control group. The data with statistically significant differences between the two groups were used to make the receiver operating characteristic (ROC) curve. RESULT: The maximum contact area (PA) of the first metatarsal(M1) region, the maximum load-bearing peak value (PW) and the time pressure integral (PMPTI) of the second metatarsal(M2) region in the injury group were lower than those in the control group, respectively (P < 0.05). The maximum contact area (PA) of the fifth metatarsal(M5) region was higher than that in the control group (P < 0.05). The area under curve (AUC) value of the ROC curve of the PA of M1 region, the PW and PMPTI of M2 region were statistically (P < 0.05). CONCLUSION: FHL tendon injury resulted in decreased PA in M1, decreased PW and PMPTI in M2, and increased PA in the M5 region, suggesting that FHL tendon injury resulted in a force shift from the medial to the lateral side of the foot. The PA of M1, PW and PMPTI of M2 have certain diagnostic value for early FHL injury in amateur marathon runners.

Evaluation of the ankle function after Achilles tendon resection: a retrospective clinical study.

INTRODUCTION: The Achilles tendon is the strongest tendon in the human body and has the function of plantar ankle flexion. When the tendon is exposed, the peritendineum has been breached and the thick avascular tendon colonized with bacteria, a complete resection of the tendon may be indicated to achieve infection control and facilitate wound closure. The Achilles tendon reconstruction is not mandatory, as the plantar flexion of the ankle joint is assumed by the remaining flexor hallucis longus, flexor digitorum longus and tibialis posterior muscles. Our study aimed to evaluate the impact of Achilles tendon resection without reconstruction on leg function and quality of life. MATERIAL AND METHODS: We retrospectively evaluated all patients who were treated with an Achilles tendon resection between January 2017 and June 2022 in our quaternary institution. After evaluating the data, the patients who survived and were not amputated were contacted for re-evaluation, which included isokinetic strength measurement of both ankle joints, evaluation of the ankle range of motion and collection of several functional scores. RESULTS: Thirty patients were included in the retrospective study, with a mean age of 70.3 years, including 11 women and 19 men. The most frequent cause of the infection was leg ulcer (43.3%), followed by open tendon suture (23.3%). No tendon reconstruction was performed. Fifteen patients could be gained for reevaluation. The average difference in ankle flexion torque on the injured side compared to the healthy side at 30 degrees/second was 57.49% (p = 0.003) and at 120 degrees/second was 53.13% (p = 0.050) while the difference in power was 45.77% (p = 0.025) at 30 degrees/second and 38.08% (p = 0.423) at 120 degrees/second. The follow-up time was between 4 and 49 months and a positive correlation could be determined between the time elapsed from surgery and the ankle joint strength. There was a significant loss of range of motion on the operated side compared to the healthy side: 37.30% for plantar flexion, 24.56% for dorsal extension, 27.79% for pronation and 24.99% for supination. The average Lepillhati Score was 68.33, while the average American Orthopedic Foot and Ankle Score was 74.53. CONCLUSION: The complete Achilles tendon resection leaves the patient with satisfactory leg function and an almost normal gait. Especially in elderly, multimorbid patients, straightforward tendon resection and wound closure provide fast infection control with acceptable long-term results. Further prospective studies should compare the ankle function and gait in patients with and without Achilles tendon reconstruction after complete resection.

Editorial Commentary: Lower Trapezius Transfer May Be Indicated for Surgical Management of Massive Irreparable Rotator Cuff Tears in Younger, Non-Arthritic Patients.

Although shoulder rotator cuff repair fixation constructs and suture anchor design have evolved, repair of massive or functionally irreparable tears historically has relied on tendon mobilization and compression, optimizing footprint biology, and attempting a tension-free repair. However, despite these efforts, rates of failure of complete healing may be high, ranging from 20% to 94%. This has led to a search for alternative approaches, including bridging grafts, subacromial balloons, superior capsular reconstructions, biologic tuberoplasties, bursal acromial grafts, and, ultimately, renewed interest in tendon transfers. The latissimus dorsi transfer was traditionally a preferred tendon-transfer technique for posterosuperior massive cuff tears, but inconsistent outcomes have resulted in declining popularity. Recently, the lower trapezius transfer (LTT) has gained acceptance for the treatment of posterosuperior tears, particularly with external rotation weakness and lag signs. The LTT is biomechanically superior to the latissimus dorsi transfer, offering a more native vector of pull and in-phase activation. LTT could be indicated for younger patients with massive cuff tears. However, LTT is relatively contraindicated in patients with cuff tear arthropathy; combined loss of elevation and external rotation; irreparable subscapularis tear; teres minor involvement; and/or those of advanced age or unable to comply with rigid rehabilitation guidelines.

Outcomes after arthroscopically assisted lower trapezius transfer with Achilles tendon allograft.

BACKGROUND: Lower trapezius tendon transfer is 1 option to improve pain and function with massive irreparable rotator cuff tears. Magnetic resonance imaging (MRI) evaluation of tendon healing with the procedure has not yet been reported. The purpose of this study was to evaluate early tendon transfer healing using postoperative MRI scans and to assess early clinical outcomes in patients after arthroscopically assisted lower trapezius tendon transfer (AALTT) for massive irreparable rotator cuff tears. METHODS: This was a single institution retrospective review of consecutive patients with massive irreparable rotator cuff tears who underwent AALTT with a single surgeon from January 2017 to July 2020 with a minimum 6-month follow-up. Patient information including age, sex, follow-up, prior surgical history, and type of work (sedentary or labor-intensive) was recorded. Preoperative and postoperative range of motion, external rotation strength, presence of a lag sign, and pain visual analog scale data were extracted from medical records. Patient-reported outcomes were extracted from patient charts. Six-month postoperative MRIs were reviewed for tendon transfer healing at both the greater tuberosity and the trapezius-allograft interface. RESULTS: A total of 19 patients met inclusion criteria with average age 56.7 (range, 29-72 years). Of these patients, 17 (89.5%) were male. The average follow-up was 14.6 (range, 6-45) months. Fifteen (78.9%) patients had unsuccessful previous rotator cuff repair. Six-month MRI demonstrated complete healing of the transferred tendon in 17 of 19 patients (89.5%). There were significant improvements in postoperative pain visual analog scale (5.9 ± 2 vs. 1.8 ± 2), ASES score (44.6 ± 18 vs. 71.2 ± 24), and Patient Reported Outcomes Measurement Information System Physical (46.3 ± 6 vs. 51.3 ± 11) and in external rotation motion (10.5 ± 17° vs. 40.5 ± 13°) and strength (2.8/5 ± 1 vs. 4.7/5 ± 0.5) at final follow-up. All patients with a preoperative external rotation lag sign had reversal of their lag sign at final follow-up (15/15). Of 17 work-eligible patients, 13 (76.4%) were able to return to work. CONCLUSION: In this series, AALTT showed a high rate of healing of the transferred tendon on MRI by 6 months postoperatively. The current findings of a high rate of early tendon transfer healing are consistent with the good early and mid-term outcomes that have been observed in AALTT and provide support for surgeon and patient expectations, postoperative rehabilitation, and return to work following AALTT for massive posterior superior rotator cuff tears.

Comparison of nerve versus tendon transfer for radial nerve palsy.

OBJECTIVE: This study aims to investigate the choice of intervention time and operation mode between nerve and tendon transfer for the treatment of radial nerve palsy (RNP). METHODS: 46 RNP patients underwent nerve transfer (n = 22) and tendon transfer (n = 24). The intraoperative blood loss, main incision length, operation duration, and length of hospital stay and follow-up period of patients in these two groups were recorded and compared. The range of motion (ROM) of the elbow, wrist, fingers, and thumb, the hand grip and pinch strength, the Disabilities of Arm, Shoulder, and Hand (DASH) and the 36-Item Short Form Health Survey (SF-36) scores were measured and compared preoperatively and postoperatively between the two groups. RESULTS: The ROM of thumb and the hand grip strength of patients in the nerve transfer group were greater than that in the tendon transfer (P < 0.05). Both of the two groups indicated significant improvements in the ROM of elbow, wrist, finger, thumb and the hand grip and pinch strength (P < 0.05) postoperatively. The DASH scores decreased significantly at 6 months (P < 0.05) and 12 months (P < 0.05) after surgery in both groups, while the postoperative SF-36 scores significantly increased (P < 0.05). There was no significant difference in postoperative DASH and SF-36 scores between the two groups (P > 0.05). CONCLUSION: In summary, both nerve and tendon transfer techniques are effective treatments for RNP. Nerve transfer is particularly advantageous for early RNP, while tendon transfer is suitable for patients with radial nerve injury more than one year.

"Biological Fixation" of Flexor Digitorum Longus: A New Modification of Tendon Transfer for Treatment of Posterior Tibialis Tendon Dysfunction.

Numerous surgical procedures for the treatment of posterior tibialis tendon (PTT) dysfunction have been developed, including tendon transfers, osteotomies, and arthrodesis. Among these methods, foot and ankle surgeons most frequently use flexor digitorum longus (FDL) tendon transfer in conjunction with medial translational osteotomy of the calcaneus. Formerly, some less invasive techniques have been described to reduce surgical-related complications after FDL tendon transfer. Herein, we introduced a new modification of short-stump FDL tendon fixation to the navicular bone and reported the functional outcomes of the current technique in a patient with PTT dysfunction. In the current technique, the FDL tendon was fixed to the navicular bone via a trans-osseous tunnel using a split PTT stump. This method does not require any kind of fixation devices, such as an interference screw or anchor suture.Level of Evidence: V.

Management of irreparable subscapularis tears: Current concepts.

Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC. When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.

Tendon transfers in cerebral palsy: art or science?

Tendon transfers in cerebral palsy are commonly described as a method to improve function in the upper limb. The field can be considered by some to be more of an art than science due to the unique challenges involved, which include poor volitional control and spasticity. Surgical outcomes can be uncertain and, in certain circumstances, worsened. This presentation looks at the rationale behind tendon transfers for patients with cerebral palsy and the application of this rationale (science vs. art) to a philosophy of treatment.

Endoscopic assisted flexor digitorum longus transfer in flexible flatfoot.

BACKGROUND: Posterior tibial tendon insufficiency is the commonest cause of adult flexible flatfoot. Transfer of the flexor digitorum longus (FDL) has been described a therapeutic arsenal in flexible flat feet and posterior tibial tendon disorders. It is often combined with bony procedure (open or percutaneous calcaneal osteotomy). METHODS: We describe a technique and the steps endoscopic approach of FDL transfer. RESULTS: The procedure is able to be performed safely and reproducible under perfect viewing CONCLUSION: In the future with a clinical study investigating, we purpose the results of such surgery in a cohort of patients with flexible flatfoot. Level IV Therapeutic study: case serie. No funding was received for this research project.