There is a correlation between histopathological findings of joint capsule and synovium, and postoperative clinical outcomes and treatment in patients with isolated type II superior labrum anterior posterior lesions.

OBJECTIVES: This study aims to histologically examine the joint capsule and synovium to determine the correlation between histopathological findings and postoperative clinical outcomes in patients with isolated type II superior labrum anterior posterior (SLAP) lesions. PATIENTS AND METHODS: Thirty-eight patients (24 males, 14 females; mean age 53.2±6.6 years; range, 45 to 67 years) who underwent arthroscopic treatment of type II SLAP lesions between June 2017 and September 2018 were evaluated prospectively. Visual analog scale (VAS), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) scores of all patients were recorded preoperatively, and at 6th and 12th months postoperatively. Biceps tenotomy was applied as arthroscopic surgical treatment in all patients. Biopsy materials obtained from rotator interval joint capsule and synovium during the arthroscopy were evaluated histopathologically. The density of the vessels in the specimens was defined as low, medium, and high by the pathologist. The patients with medium or low vessel density in specimens were group 1 (n=14) and those with high vessel density group 2 (n=24). RESULTS: In group 2, preoperative VAS score was significantly higher. There was no difference between the scores of the groups except for the sixth month SST score which was significantly higher in group 1. Histopathological evaluation revealed that the number of lymphocytes, fibroblasts, mast cells, myofibroblast, synovial lining cells, macrophages, and amount of collagen in connective tissue were significantly higher in group 2. In five patients of group 2, the rehabilitation program was interrupted due to pain and difficulty in gaining a range of motion during the first four weeks postoperatively. Four of these patients recovered with medication and long-duration physiotherapy. Shoulder stiffness developed in one patient who required arthroscopic release and further rehabilitation. CONCLUSION: There is a correlation between histopathological findings of joint capsule and synovium, and postoperative clinical outcomes and treatment in patients with isolated type II SLAP lesions. Almost 20% of patients who had pathologic histological findings in joint capsule and synovium needed pain control and long-duration rehabilitation program after arthroscopic surgery for better shoulder function recovery and prevention of shoulder stiffness.

Activity gains after upper limb surgery for spasticity in patients with spinal cord injury.

Spasticity is a common and increasingly prevalent secondary complication of spinal cord injury. The aim of the study was to evaluate patient-experienced gains in prioritized activities after surgery to reduce the effects of spasticity in upper limbs in tetraplegia. The study includes evaluation of 30 operations for 27 patients performed on hypertonic tetraplegic hands during 2007-2015 using the Canadian Occupational Performance Measure. Activity performance increased at both 6 months and 12 months by a mean of 3.0 and 2.9 points, respectively. Satisfaction increased by 3.3 and 3.4, respectively. All types of activities improved, with wheelchair manoeuvring as one of the highest rated. The intervention increased prioritized activity performance and persisted at least 12 months after surgery. Patients with mild upper limb impairment showed greater improvement after surgery. After operation, patients were able to perform 71% of their prioritized activities, which they could not perform before. Patients' satisfaction with the performance was high. LEVEL OF EVIDENCE: IV.

Chronic Boutonniere Deformities, Supple, or Stiff: A New Surgical Technique With Early Mobilization in 11 Cases.

Injuries to the central slip of the extensor mechanism can lead to a Boutonniere deformity with important functional consequences. We report a series of 11 patients treated by lengthening-dorsalizing the lateral bands and tightening the central slip with early mobilization. The average age of the patients was 42 years (14;52). The extension defect of the proximal interphalangeal (PIP) joint was 64 degrees (80;55) and the hyperextension of the distal interphalangeal joint was 10 degrees (15;5). The surgery was performed with peripheral nerve block (sensitive), allowing dynamic adjustment of the tendinous sutures. With a dorsal incision, a tenolysis of the extensor was performed. The central slip was tightened and the lateral bands dorsalized by cross-stitches over the PIP joint. The active flexion/extension was tested, and then lengthening of the lateral bands by "mesh graft" tenotomy was performed over the second phalange. There was no immobilization. The deformity was improved in 10 patients with a total flexion of the finger. The mean lack of extension in the PIP was 8 degrees (0;20) and the active flexion of the distal interphalangeal joint was 80 degrees (70;85). There was 1 failure. The majority of techniques necessitate an immobilization of 3 to 6 weeks. Our procedure uses the elastic properties of the elongation and allows immediate mobilization. The result can be compromised in case of insufficient tendinous surface or if postoperative instructions are not followed.

Primary surgical repair of acute Achilles tendon rupture: comparative results of three surgical techniques.

PURPOSE: To determine which of the three surgical techniques for acute unilateral complete rupture of Achilles tendons in use at the University Clinical Centre Maribor gives the best short-term functional results. METHODS: In the retrospective analysis of the results of 3 surgical techniques, 262 patients of which 244 (93.1%) were men (mean age 41.6 ± 10.0 years, range 21.5-83.0 years) operated on during the period from 2000 to 2008 were included. Group A (open technique with fascial augmentation) included 42 (16%) patients, group B (original modification of percutaneous suturing according to Cretnik and Kosanovic) included 159 (60.7%) patients, and group C (original percutaneous fixation with two embracing and crossed loops according to Kruscic) included 61 (23.3%) patients. The rehabilitation protocol for group C included use of individually manufactured closed ankle functional orthosis, which replaced the plaster cast after 2 weeks of immobilization and permits early ankle range-of-motion exercising and full weight bearing. The functional outcome and incidence of postsurgical complications were analysed from medical records covering the period of 6 months. RESULTS: Patients from group C achieved the best functional results in the shortest time. The duration of immobilization (5.3 ± 0.1 weeks) and use of crutches (5.3 ± 0.5 weeks) were the shortest. The ability to rise up on toes on the affected leg, to walk on toes and heels, and duration of restriction of physical activities including sports were shorter than in the other two groups (p < 0.001 for all variables). Two reruptures were experienced in group B, one in group C, and none in group A. CONCLUSIONS: Good functional results and a relatively small number of postsurgical complications advocate the use of percutaneous suturing techniques. The best and fastest functional recovery was attained in the group treated with the original technique of percutaneous fixation with two embracing and crossed thread loops according to Kruscic.

[Achilles tendon rupture : Current diagnostic and therapeutic standards]. / Achillessehnenruptur : Aktuelle Standards in Diagnostik und Therapie.

A superior life expectancy and an increased activity in the population result in an increase in degenerative diseases, such as Achilles tendon ruptures. The medical history and physical examinations are the methods of choice to diagnose Achilles tendon ruptures. Ultrasound and radiography represent reasonable extended diagnostic procedures. In order to decide on the medical indications for the therapy concept, the advantages and disadvantages of conservative and surgical treatment options have to be weighed up on an indivdual basis. There are explicit contraindications for both treatment options. For the surgical treatment concept open suture techniques, minimally invasive methods and reconstructive procedures are available. The postoperative management of the patient is as important as the choice of surgical technique. With the correct medical indications and supervision of the patient it is possible to achieve extremely satisfying results for the patient with both conservative and surgical treatment options.

[Pulley reconstruction in the hand]. / Ringbandrekonstruktion an der Hand.

BACKGROUND: To ensure proper function of the flexor tendons, pulleys are extremely important. Pulleys can be impaired by injury, infection, but also sometimes iatrogenically. The consequences of this failure are often poorly understood. OBJECTIVES: What is the impact of pulley insufficiency, what are the clinical signs, and what are the reconstruction options? METHODS: The experiences of 64 patients with different forms of pulley insufficiency are presented. RESULTS: All patients benefit from a ring ligament reconstruction. A phalanx fracture can be one complication. CONCLUSIONS: Pulley reconstructions are very beneficial operations.

[Flexor tendon transplantation]. / Beugesehnentransplantation.

BACKGROUND: Insufficiency of both flexor tendons of a finger considerably disrupts the function of the whole hand. Flexor tendon transplantation represents the best way to reconstruct or improv function in many cases. OBJECTIVES: Based on the literature and our own results, not only the current state of the surgical technique, but also the opportunities and dangers of this sophisticated operation, are represented. Knowledge of alternative methods is important. METHODS: With a follow-up of between 2 to 12 years, a total of 272 patients who underwent flexor tendon transplantation in the hand during several periods from 1974 to 2000 were investigated. RESULTS: Similar to the international literature, our long-term results did not specify the exact surgical technique (pedicled or free). According to the Buck-Gramcko score, 32 % had very good results, 26.4 % good, 15.1 % satisfactory, and 26.5 % poor. CONCLUSIONS: Numerous details need to be considered before, during, and after surgery. For the patient, the procedure has tremendous significance in many ways; thus, this operation should only be performed by an experienced hand surgeon.

[Rehabilitation after flexor tendon injuries of the hand]. / Rehabilitation nach Beugesehnenverletzungen an der Hand.

BACKGROUND: Advances in basic research evaluating suture material, techniques, and maximum tendon load with regard to repair site failure help to decide between rehabilitation protocols after the repair of flexor tendon injuries. OBJECTIVES: The presentation and choice of rehabilitation protocols depending on the mechanism of injury and knowledge of the influencing factors concerning tendon load. Expected outcome after flexor tendon repair. METHODS: Evaluating recent literature and basic research investigations, and presenting expert opinions. RESULTS: Based on the mechanism of injury, the suture technique, the compliance of the patient, and the latest knowledge on tendon capacity help to choose from the basic principles of rehabilitation protocols: passive or early motion protocols, such as those described by Duran-Houser and Kleinert, in the majority of cases lead to good and fair results according to the Hand Functional Score of the American Society for Surgery of the Hand. A larger number of excellent functional results are seen after the rehabilitation of flexor tendon injuries using combined passive/active or completely active motion protocols, e.g., according to Small. In addition to choosing a specific protocol and considering different zones of injury, it is essential to thoroughly supervise therapy and to monitor the adjustment of splints. It is widely recommended that patients should be provided with additional scar treatment and physical therapy throughout their entire rehabilitation. CONCLUSIONS: Flexor tendon injuries, especially in zone 2, are still a challenge with regard to operative treatment and rehabilitation, with an unpredictable outcome. Further knowledge and advances in suture techniques and material will support the use of active motion protocols and improve functional results in the future.

[Tenolysis of the flexor tendons in the hand]. / Tenolyse der Beugesehnen an der Hand.

BACKGROUND: Properly gliding flexor tendons is mandatory for the normal functioning of the finger and thumb. Any damage to tendons, tendon sheath or adjacent tissue can lead to the formation of adhesions that inhibit the normal gliding function. If adhesions limit the digital function and adequate hand therapy does not provide further progress, then surgical intervention should be considered. AIM: The authors' strategy and treatment algorithm for flexor tenolysis are presented in the context of the current literature. METHODS: There is no absolute indication for flexor tenolysis. The decision should be made in a motivated patient who has access to adequate postoperative hand therapy. It should be based on healed fractures and osteotomies, mature soft tissue coverage, intact tendons and gliding tissues, and a full range of passive flexion, and preferably extension of the affected joints. The principle of flexor tenolysis is the consequent resection of all adhesive tissue around the tendon inside and outside the tendon sheath, with preservation of as many pulley sections as possible. Therefore, extensive approaches are frequently necessary. Arthrolysis and the resolution of unfavorable scars, the resection of scarred lumbricals, and pulley reconstruction are additional procedures that are frequently performed. RESULTS: In the literature, improvement in the range of motion is between 59 and 84 %. Good and excellent functional results are reported in 60-80 % of the cases. Nevertheless, in selected cases, functional deterioration occurs. Flexor tendon ruptures after tenolysis were observed in 0-8 % of the patients. DISCUSSION: With regard to complications such as secondary tendon ruptures, loss of pulleys, and scar formation, flexor tenolysis is part of a reconstructive ladder that includes further procedures. In the case of failure or complications, salvage procedures such as arthrodesis, amputation, and ray resection or staged flexor tendon reconstruction including tendon grafting are recommended. After successful flexor tenolysis long-term hand therapy for at least 3-6 months is mandatory to maintain the intraoperative gain of function.

The functional effect of a distal rectus femoris tenotomy in adults with cerebral palsy.

The purpose of this study was to determine the effect of a distal rectus femoris tenotomy on function and gait in adults with cerebral palsy who had diminished knee flexion during swing. A stiff knee gait pattern is commonly seen in individuals with cerebral palsy and frequently leads to tripping and falling. Five subjects, 25-51 years, (34.6±10.3 years) participated in the study; each individual had the surgery after the age of 18. Four of the five subjects underwent bilateral distal rectus femoris tenotomies for a total of nine limbs being studied. Four of the five subjects had a single procedure of a distal rectus femoris tenotomy and one subject also had bilateral adductor tenotomies. All individuals underwent a pre-operative and post-operative, (3.28±1.6 years) three-dimensional gait analysis. Pre-operative gait revealed diminished peak knee flexion and out of phase rectus femoris activity with a quiet vastus lateralis during swing in all subjects. Significant findings after a distal rectus femoris tenotomy included: improved peak swing knee flexion, improved peak stance hip extension, and increased total knee excursion without loss in knee extension strength. During swing, knee flexion angle improved on average 11° which correlated with subjective report of less shoe wear, tripping, and falling due to improved clearance. In conclusion, a distal rectus femoris tenotomy should be considered a surgical option for adults with cerebral palsy and a stiff knee gait pattern to improve mobility, function, and quality of life.

[Avulsion of the proximal hamstring origin - report of 6 cases]. / Proximale Ausrissverletzungen der ischiokruralen Muskulatur - Ergebnisse nach 6 Fällen.

Proximal hamstring origin avulsions are rare injuries. A common cause for this kind of injury is a trauma with the hamstring in overextension and simultaneously forced hip flexion and knee extension. We report on 6 cases, 5 with an acute rupture of the hamstring origin and one case with a delayed presentation in our emergency room. In 3 cases the injury was related to sport activity, the other 3 are related to accidents during work. None of these patients took part in competitive sports. One case was reported 8 weeks after trauma with an MRI performed one week before. Due to the low functional deficits conservative treatment was preferred. In all of the acute injuries open refixation was done within the first two weeks after trauma using 2-3 suture anchors. Postoperative mobilisation was done with partial weight bearing. Active knee flexion against gravity was not started until six weeks postoperative. All patients who had surgery achieved good results 3-28 months after surgery. They suffered from only little pain (VAS1-2) and had good movement ability. Sport activities were reduced in 3 cases, 2 patients returned to pre-injury sport levels. All patients were able to perform one-legged squats. In the evaluated LEFS (Lower Extremity Functional Scale) 75.6/80 points were achieved (72-79). There were no severe complications within this case study. It is important to distinguish proximal hamstring origin avulsions from the majority of hamstring muscle injuries. If the avulsion is treated with surgery, refixation should be performed within the first weeks to prevent the sciatic nerve from being bound in scar tissue with a consecutive high risk of injury during mobilisation of the tendon.

[Percutaneous tenotomy and aponeurotomy (PTA) for knee flexor contracture in children with spastic cerebral palsy]. / Tenotomía y aponeurotomía percutánea (TAP) para la contractura de los flexores de rodilla en niños con parálisis cerebral espástica.

UNLABELLED: Knee flexor muscle contracture is frequent in patients with spastic cerebral palsy. The purpose of the study was to determine whether percutaneous tenotomy and aponeurotomy may decrease knee flexor contracture in children with spastic cerebral palsy. MATERIAL AND METHODS: A prospective study of consecutive cases was conducted from January to December 2009 in 24 children with a diagnosis of moderate to severe spastic cerebral palsy who had knee flexor contracture with a popliteal angle > or = 45 degrees and a gross motor function classification scale of 4 or 5; they underwent percutaneous tenotomy and aponeurotomy surgery and were followed-up for 24 months. Variance analysis with a factorial design was used for data analysis. RESULTS: The mean popliteal angle was 83.48 degrees preoperatively and 27.30 degrees by the end of the follow-up, with an improvement of 56.18 degrees (p < 0.01). Statistically significant differences were found in all measurements comparing them with the baseline values. DISCUSSION: Percutaneous aponeurotomy of knee flexor muscles is described. Compared to other procedures it provides the benefits of minimally invasive surgery, mild postoperative pain, short hospital stay -without using immobilization during the entire process- and children returned to their therapy program within five days. CONCLUSION: Percutaneous tenotomy and aponeurotomy of knee flexors was shown to be a good alternative for the treatment of knee flexor contracture in patients with spastic cerebral palsy.

Selective plantar fascia release for nonhealing diabetic plantar ulcerations.

BACKGROUND: Achilles tendon lengthening can decrease plantar pressures, leading to resolution of forefoot ulceration in patients with diabetes mellitus. However, this procedure has been reported to have a complication rate of 10% to 30% and can require a long period of postoperative immobilization. We have developed a new technique, selective plantar fascia release, as an alternative to Achilles tendon lengthening for managing these forefoot ulcers. METHODS: We evaluated sixty patients with diabetes for a mean of 23.5 months after selective plantar fascia release for the treatment of nonhealing diabetic neuropathic ulcers in the forefoot. Preoperative and postoperative dorsiflexion range of motion of the affected metatarsophalangeal joint and wound-healing data were used to evaluate the effectiveness of the procedure and to determine the relationship between plantar fascia release and ulcer healing. Complications were recorded. RESULTS: Thirty-six (56%) of the ulcers healed within six weeks, including twenty-nine (60%) of the plantar toe ulcers and seven (44%) of the metatarsophalangeal joint ulcers. The mean range of motion of the affected metatarsophalangeal joint increased from 15.3° ± 7.8° to 30.6° ± 14.1° postoperatively (p < 0.05). All patients in whom the preoperative dorsiflexion of the affected metatarsophalangeal joint was between 5° and 30° and in whom the range of motion of that joint increased by ≥13° after the procedure experienced healing of the ulcer. No ulcer recurrence in the original location was identified during follow-up. No patients experienced any complications associated with the selective plantar fascia release. CONCLUSIONS: Our results suggest that selective plantar fascia release can lead to healing of neuropathic plantar forefoot ulcers in diabetic patients. Ulcers in patients in whom the preoperative dorsiflexion angle of the affected metatarsophalangeal joint is between 5° and 30° and in whom the increase in range of motion is ≥13° postoperatively have the greatest chance of being cured. LEVEL OF EVIDENCE: Therapeutic level IV. See Instructions for Authors for a complete description of the levels of evidence.

Extensor tendon release in tennis elbow: results and prognostic factors in 80 elbows.

PURPOSE: The objectives of this study were to evaluate the results in the outpatient treatment of recalcitrant lateral epicondylitis with release of the common extensor origin according to Hohmann and to determine any prognostic factors. METHODS: Eighty tennis elbows in 77 patients with a characteristic history of activity-related pain at the lateral epicondyle interfering with the activities of daily living refractory to conservative care for at least 6 months and a confirmatory physical examination were included. Clinical outcome was evaluated using the QuickDASH score system. Data were collected before the operation and at the medians of 18 months (range 6-36 months; short term) and 4 years (range 3-6 years; medium term) postoperatively. RESULTS: The mean QuickDASH was improved both at the short- and the medium-term follow-ups and did not change significantly between the follow-ups. At the final follow-up, the QuickDASH was improved in 78 out of 80 elbows and 81% was rated as excellent or good (QuickDASH<40 points). We found a weak correlation between residual symptoms (a high QuickDASH score) at the final follow-up and high level of baseline symptoms (r=0.388), acute occurrence of symptoms (r=0.362), long duration of symptoms (r=0.276), female gender (r=0.269) and young age (r=0.203), whereas occurrence in dominant arm, a work-related cause or strenuous work did not correlate significantly with the outcome. CONCLUSION: Open lateral extensor release performed as outpatient surgery results in improved clinical outcome at both short- and medium-term follow-ups with few complications. High baseline disability, sudden occurrence of symptoms, long duration of symptoms, female gender and young age were found to be weak predictors of poor outcome. LEVEL OF EVIDENCE: Case series, Level IV.