Value of ultrasound and magnetic resonance imaging in the assessment of Achilles tendon healing following percutaneous repair with the Dresden instrument.

BACKGROUND: Percutaneous Achilles tendon (AT) repair with the Dresden instrument is a safe and effective treatment for AT rupture within 15 days after injury. Follow-up includes clinical examination and imaging to assess the healing process and detect possible complications. The findings of each control visit determine the progression of the rehabilitation of each patient. METHODS: We assessed the postoperative findings of all patients who underwent AT with the Dresden technique from May 2022 to September 2023, during a follow-up period of 6 months. The study population included 40 male patients between 18 and 59 years of age. Ultrasound (US) and magnetic resonance imaging (MRI) were performed in all patients at day 15 postoperatively and then monthly for 6 months. RESULTS: All patients completed 6 months follow-up and 2 (5%) presented with postoperative wound dehiscence. No sural nerve lesions, reruptures, reoperations or other complications were seen. Both imaging methods showed excellent correlation of findings at all time points. Both methods were effective to assess the hematoma and structural changes of the healing process during the first 3 months. The use of US with Doppler was a useful tool to evaluate blood flow to the tendon stumps. After 3 months no significant morphological changes were observed but the US enabled a dynamic functional assessment of the tendon. After 4 months tissues showed homogenization and decrease of volume without further major changes. CONCLUSION: Both US and MRI proved to be excellent methods to assess the healing process after percutaneous AT repair. The US performed by an experienced investigator showed advantages over MRI in evaluating the gap between the tendon stumps, the possibility of evaluating the vascularity with Doppler US and assessing the functionality of the healing tendon with dynamic examination, besides being a cheap and easily accessible imaging method.

Photobiomodulation and amniotic membrane for treat tendon injury in rats.

Tendons, complex fibrous structures, are subjected to great tensions, which can give rise to the so-called tendinopathies. This study aimed to evaluate photobiomodulation and human Amniotic Membrane applied as single or combined therapies to treat induced Achilles tendon lesions. Seventy-five rats were divided into five groups (n=15): C- control Sham surgery; I- tendon injury; LA- tendon injury treated with photobiomodulation; AM- tendon injury treated with Amniotic Membrane; LAM- tendon injury + photobiomodulation and Amniotic Membrane, subdivided into three groups (n=5) with analysis at 3, 7, and 14 days. The tendon injuries were made with a 20 g weight released from a mini guillotine onto the ankle in dorsiflexion. AM and LAM groups received an Amniotic Membrane fragment while LA and LAM groups received transcutaneous photobiomodulation, using a 660 nm wavelength laser. The inflammatory cells showed statistical differences between groups C and I (p<0.05), I and AM (p<0.01), I and LA (p<0.05), and I and LAM (p<0.01). Both photobiomodulation and Amniotic Membrane were shown to enhance tendon repair, and the association of photobiomodulation plus Amniotic Membrane was the most effective treatment. We conclude that the association of photobiomodulation plus Amniotic Membrane was effective in accelerating and improving the tendon regeneration process.

Effect of cell therapy with adipose-derived stem cells in the treatment of acute rupture of the Achilles tendon in humans.

The aim of this study was to evaluate the effect of adipose-derived stem cells (ADSCs) in the treatment of acute rupture of the Achilles tendon. It was a cross-sectional study involving 15 patients. Patients were randomly divided: group 1-rupture; group 2-suture; group 3-rupture + ADSCs. In the AOFAS score, the score was higher in group 3 with a significant difference. In the ATRS score, the score was higher in groups 2 and 3, also with a significant difference. As for the ultrasound score, there was a significant difference between the experimental groups in relation to this score, however, in the multiple comparisons test, comparing two groups at a time, it was possible to observe a significant difference of the experimental groups. It can be concluded that cell therapy in this condition may be a treatment option due to tissue regeneration and significant recovery of function.

Surgical treatment of distal hamstring tendon injuries yield a higher return-to-sports rate: A systematic review.

PURPOSE: The purpose of this study is to compare the patient-reported outcomes and return to sports of the conservative and surgical treatment of distal hamstring tendon injuries. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two reviewers searched PubMed, Scopus and Virtual Health Library databases in January 2023. Clinical studies evaluating conservative or surgical management outcomes of distal hamstring tendon injuries were considered eligible for this systematic review if predefined criteria were fulfilled: (1) published in English or Spanish; (2) evaluated any of the following: patient-reported outcomes, return-to-sports rate (RTS-R) or return-to-sports time (RTS-T). Data were presented in tables using absolute values from individual studies and derived pooled percentages. RESULTS: Eighteen studies were included for 67 patients and 68 distal hamstring tendon injuries. Initially, 39 patients (58.2%) underwent surgical treatment, whereas 28 (41.8%) were treated conservatively. Among conservative treatment patients, 15 failed and had to be operated on (53.6%), all with distal semitendinosus tendon injuries. Anchor fixation was the technique of choice in 20 lesions (36.4%), tenodesis in 16 (29.1%), tenectomy in 14 (25.5%) and sutures were preferred in five (9%). Thirteen out of 28 patients (46.4%) undergoing initial conservative treatment returned to sports at a mean of 3.6 months (range 1 week to 12 months), in contrast to surgical treatment, in which 36 out of 39 patients (92.3%) returned at a mean of 4.2 months (range 6 weeks to 12 months). Additionally, 14 of 15 patients (93.3%) converted to surgical treatment after failed conservative treatment returned to sports at a mean of 7.6 months after injury. CONCLUSION: Initial surgical treatment of distal hamstring tendon injuries yields a high RTS-R (92.3%) at a mean of 4.2 months. Furthermore, 15 out of 28 patients (53.6%) initially treated conservatively had to be operated on, delaying the RTS-T (mean 7.6 months after injury) without affecting their RTS-R. LEVEL OF EVIDENCE: IV.

Minimally Invasive Suture Technique Pull-out to Repair the Acute Flexor Tendons in Zone II of the Hand / Técnica de sutura minimamente invasiva pull-out para reparar lesões agudas dos tendões flexores da zona II da mão

Abstract Objective: To evaluate the safety and effectiveness of a modified pull-out suture technique in patients undergoing primary repair surgery for injuries to the flexor tendons of the fingers with Total Active Motion (TAM) as the primary outcome. Method: A total of 29 patients (38 fingers) were chosen from both sexes, aged between 18 and 65 years with clean acute tendon laceration occurring within 15 days, in the Verdan's zone II of flexor tendon in the hand, when only the deep flexor tendon was sutured, either associated or not with digital nerve injury. The patients were operated on using the proposed technique and evaluated at 3, 9 and 24-weeks PO. The primary outcome was the assessment of Total Active Movement (TAM) and 3 classifications were employed: Strickland, IFSSH and Buck-Gramcko. Results: We observed a total active motion (TAM) of 209.3 °at the end of 24 weeks; 83.0% of Good and Excellent results by the Modified Strickland Classification, 93% of Excellent results by the IFSSH Classification, and 97% of Good and Excellent results using the Buck-Gramcko Classification. There were no cases of rupture, but tendon adhesion was observed in 3 fingers. Conclusion: The present suture technique proved to be safe and effective with a low rate of complications, obtaining an excellent functional result in terms of total active mobility, according to the evaluations and classifications used.

Resumo Objetivo: Avaliar a segurança e a efetividade da técnica de sutura pull-out modificada nos pacientes submetidos à cirurgia de reparo primário das lesões dos tendões flexores nos dedos, tendo como desfecho primário o movimento ativo total (TAM). Método: Foram escolhidos 29 pacientes (38 dedos), de ambos os sexos, com idade entre 18 e 65 anos, com laceração tendinosa aguda e limpa, ocorrida em até 15 dias, na zona II de Verdan do tendão flexor da mão, quando apenas o tendão flexor profundo foi suturado, associada ou não à lesão do nervo digital. Os pacientes foram operados pela técnica proposta e avaliados em 3, 9 e 24 semanas PO. O desfecho primário foi a avaliação do movimento ativo total (TAM) e foram empregadas 3 classificações: Strickland, IFSSH e Buck-Gramcko. Resultados: Observamos um movimento ativo total (TAM) de 209,3° ao final de 24 semanas; 83,0% de resultados Bons e Excelentes pela Classificação de Strickland Modificada, 93% de resultados Excelentes pela Classificação IFSSH e 97% de resultados Bons e Excelentes pela Classificação Buck-Gramcko. Não houve casos de ruptura, mas foi observada aderência tendínea em 3 dedos. Conclusão: A presente técnica de sutura mostrou-se segura e eficaz com baixo índice de complicações, obtendo excelente resultado funcional em termos de mobilidade ativa total, de acordo com as avaliações e classificações utilizadas.

Quadricipital Tendon Simultaneous Bilateral Tear in a Patient with Type-II Diabetes Mellitus after Low-energy Trauma: Case Report / Ruptura bilateral simultânea do tendão quadricipital em paciente portador de diabetes mellitus do tipo II após trauma de baixa energia: Relato de caso

Abstract Simultaneous bilateral rupture of the quadricipital tendon is an extremely rare lesion. We report a case of this injury after low-energy trauma in a patient with type-II diabetes mellitus. Both knees were surgically approached in the same surgical procedure. Early rehabilitation is essential for the adequate functional recovery of the knee. The aim of the present report was to describe an atypical case of this type of injury after minimal trauma, as well as to detail the surgical technique used to treat it.

Resumo A ruptura bilateral simultânea do tendão do quadríceps é uma lesão extremamente rara. Relatamos um caso desta lesão após trauma de baixa energia em paciente portador de diabetes mellitus do tipo II. O diagnóstico é essencialmente clínico, e requer tratamento precoce. Os dois joelhos foram abordados cirurgicamente no mesmo ato operatório. A reabilitação precoce é fundamental para a recuperação funcional adequada do joelho. O objetivo deste relato foi descrever um caso atípico deste tipo de lesão após trauma mínimo, bem como detalhar a técnica cirúrgica utilizada para o tratamento.

High-grade Pleomorphic Sarcoma Associated with Metallosis in a Patient with Total Hip Arthroplasty / Sarcoma pleomórfico de alto grau associado a metalose em paciente com artroplastia total do quadril

Abstract Although the relationship between hip arthroplasty and the development of sarcoma was first described in the literature about forty years ago, this association is extremely rare. In the present case report, we describe the association between orthopedic implants and soft tissue sarcoma in a 79-year-old man who underwent primary total hip arthroplasty (THA) for coxarthrosis 24 years ago. In the present case report, we describe the clinical evolution and the radiographic and histopathological findings of the lesion. In the intraoperative period of the second revision surgery, loosening of the acetabular and femoral components in association with extensive areas of necrosis and metallosis was evidenced. We performed debridement of the hip and right thigh region and removed the implants. Due to the extent of the lesion and to necrosis, it was not possible to perform a new joint reconstruction. The histopatho-logical diagnosis of high-grade undifferentiated pleomorphic sarcoma associated with extensive areas of metallosis was confirmed in tissue adjacent to the implant. The patient developed pulmonary metastases and died 6 months after the diagnosis. Despite the rarity of this association, sarcomas should be considered in the differential diagnosis of aseptic loosening, especially in the presence of metallosis in the peri-implant tissue. To our knowledge, the 24-year latency period between primary THA and the establishment of a sarcoma diagnosis is one of the longest reported to date.

Resumo Apesar da relação entre artroplastia de quadril e o desenvolvimento de sarcoma ter sido descrita pela primeira vez na literatura há cerca de quarenta anos, esta associação é extremamente rara. No presente relato de caso, descrevemos a associação entre implante ortopédico e sarcoma de partes moles em um homem de 79 anos submetido a artroplastia primária total do quadril (ATQ) por coxartrose há 24 anos. Foram descritas a evolução clínica e os achados radiográficos e histopatológicos da lesão. No intraoperatório da segunda cirurgia de revisão, foi evidenciada soltura dos componentes acetabular e femoral em associação com extensas áreas de necrose e de metalose. Foi realizado desbridamento da região do quadril e da coxa direita e retirada dos implantes. Devido à extensão da lesão e da necrose, não foi possível realizar nova reconstrução articular. O diagnóstico histopatológico de sarcoma pleomórfico indiferenciado de alto grau associado a extensas áreas de metalose foi estabelecido no tecido adjacente ao implante. O paciente evoluiu com metástases pulmonares e faleceu 6 meses após o diagnóstico. Apesar da raridade da associação, os sarcomas devem ser considerados no diagnóstico diferencial das solturas assépticas, particularmente na presença de metalose no tecido peri-implantar. Pelo nosso conhecimento o período de latência de 24 anos entre a ATQ primária e o estabelecimento do diagnóstico de sarcoma é um dos mais longos relatado até o momento.

Alternativa quirúrgica usando autoinjertos de tendón de gracilis y tendón de semitendinoso en re-rotura de tendón rotuliano. Reporte de caso / Surgical alternative using gracilis and semitendinosus tendon autografts in patellar tendon re-rupture. Case report

La rotura del tendón rotuliano es infrecuente y aún más lo es su re-rotura. La integridad de este tendón es fundamental para una adecuada movilidad de la rodilla y una marcha apropiada. El tratamiento se basa en diferentes técnicas quirúrgicas: reparación y aumentación tendinosa usando autoinjertos o aloinjertos. En el presente artículo se describe una alternativa en el posicionamiento de los autoinjertos del tendón de gracilis y tendón de semitendinoso, preservando su inserción en el caso de tener mala calidad de tejidos blandos. A los seis meses postoperatorios se logra un adecuado mecanismo extensor íntegro, con arcos de movilidad en el plano sagital de 0 a 90°, con un buen patrón de marcha sin dolor.

Rupture of the patellar tendon is infrequent and even more infrequent re-rupture; the integrity of this tendon is necessary for an adequate knee mobility and a proper gait. The treatment is based on different surgical techniques performing a tendon repair and augmentation using autografts or allografts. The present article describes an alternative in the positioning of autografts of gracilis tendon and semitendinosus tendon, achieving a complete extensor mechanism after a 6-month follow-up, with ranges of mobility in the sagittal plane from 0 to 90°, with an adequate gait pattern without pain

[Extensor pollicis longus rupture in a pediatric patient: case report and a literature review]. / Rotura del extensor pollicis longus en paciente pediátrico: reporte de caso y revisión de la literatura.

INTRODUCTION: the rupture of the extensor pollicis longus (EPL) tendon is a rare pathology and usually occurs in adult women in relation to distal radius fractures. MATERIAL AND METHODS: we present the case of an adolescent female patient who, after conservative treatment with splinting of a Peterson type I physeal fracture of the radius, suffered an acute extension deficit of the thumb at six weeks, diagnosed with clinical radiological examination as spontaneous rupture of the extensor pollicis longus (EPL). She was treated with extensor pollicis indicis propius (EIP) transfer with satisfactory results and recovering her usual activity one month after surgery. CONCLUSION: this kind of injuries are infrequent in pediatric ages and rarely described in a pediatric patient with immature skeleton, what makes this case something exceptional. It is necessary considering these complications in patients of low ages even with no other risk factors. The most frequent treatment applied in adults as in children is the EIP transference with good results in the long term.

INTRODUCCIÓN: la rotura del tendón extensor pollicis longus (EPL) constituye una patología infrecuente y se presenta normalmente en mujeres adultas en relación con fracturas de radio distal. MATERIAL Y MÉTODOS: se presenta el caso de una paciente adolescente femenino que, tras tratamiento conservador con férula de una fractura fisaria Peterson tipo I en radio, sufre a las seis semanas déficit agudo de extensión del pulgar, diagnosticada mediante examen clínico radiológico de rotura espontánea del extensor pollicis longus. Es tratada por medio de transferencia del extensor propio del índice (EPI) con resultados satisfactorios y recuperación de su actividad habitual al mes postoperatorio. CONCLUSIÓN: este tipo de lesiones son poco frecuentes en edad pediátrica y casi nunca descritas en un paciente pediátrico con inmadurez esquelética, lo cual hace de este caso algo excepcional. Es necesario tener en cuenta este tipo de complicaciones en pacientes de baja edad aún sin otros factores de riesgo asociados. El tratamiento aplicado más frecuentemente, tanto en adultos como en niños, es la transferencia del extensor propio del índice con buenos resultados a largo plazo.

[Hidden posterior tibial tendon dislocation after ankle sprain: case report]. / Luxación del tendón tibial posterior oculta tras un esguince de tobillo: reporte de caso.

INTRODUCTION: traumatic posterior tibial tendon dislocation is a rare entity that can go unnoticed in our usual clinical practice. MATERIAL AND METHODS: a 31-year-old man, with no relevant medical history, suffered a high-energy traffic accident. He presented a dislocation of the posterior tibial tendon that went unnoticed. After an early diagnosis, a primary repair of the flexor retinaculum was performed and the anatomical reduction of the tendon was achieved. RESULTS: the patient was able to resume sports activity three months after the injury with good functional results. CONCLUSIONS: we should suspect this entity after high-energy trauma with ankle sprains. Surgical treatment of this lesion offers good functional results.

INTRODUCCIÓN: la luxación traumática del tendón tibial posterior es una entidad poco frecuente que puede pasar desapercibida en nuestra práctica clínica habitual. MATERIAL Y MÉTODOS: un hombre de 31 años, sin antecedentes médicos de interés, sufrió un accidente de tráfico de alta energía. Presentaba una luxación del tendón tibial posterior que pasó desapercibida. Tras un diagnóstico precoz se consiguió realizar una reparación primaria del retináculo flexor y se logró la reducción anatómica del tendón. RESULTADOS: el paciente pudo retomar la actividad deportiva a los tres meses de la lesión con buen resultado funcional. CONCLUSIONES: debemos sospechar esta entidad tras un traumatismo de alta energía con entorsis de tobillo. El tratamiento quirúrgico de esta lesión ofrece buenos resultados funcionales.

Spontaneous rupture of the extensor pollicis longus tendon after conservative treatment of a non-displaced distal radius fracture in an adolescent.

A spontaneous rupture of the extensor pollicis longus (EPL) tendon after a fracture of the distal radius is a known complication in adults. In contrast, there are a paucity of reports concerning EPL tendon ruptures in children and adolescents. The authors present a case of a spontaneous rupture of the EPL tendon in a 15-year-old girl after a non-displaced distal radius fracture. The patient had no predisposing factors including rheumatoid arthritis or steroid injection. During surgery, the EPL tendon was found to be ruptured at the extensor retinaculum (third compartment). Extensor indicis proprius (EIP) to EPL transfer was performed. At the 18-month follow-up, the patient was asymptomatic and showed satisfactory thumb function, with normal active extension.

La rotura espontánea del tendón del extensor largo del pulgar (EPL) tras una fractura distal del radio es una complicación conocida en adultos. En cambio, son escasos los informes sobre roturas del tendón del EPL en niños y adolescentes. Los autores presentan un caso de rotura espontánea del tendón del EPL en una niña de 15 años tras una fractura distal del radio no desplazada. La paciente no presentaba factores predisponentes como artritis reumatoide o inyección de esteroides. Durante la intervención quirúrgica, se descubrió que el tendón del EPL estaba roto a la altura del retináculo extensor (tercer compartimento). Se realizó una transferencia del extensor indicis proprius (EIP) al EPL. A los 18 meses de seguimiento, el paciente estaba asintomático y mostraba una función satisfactoria del pulgar, con una extensión activa normal.

Acute Distal Biceps Tendon Injury: Diagnosis and Treatment / Lesões agudas do tendão distal do bíceps: Diagnóstico e tratamento

Abstract Acute distal biceps injuries clinically present with sudden pain and acute loss of flexion and supination strength. The main injury mechanism occurs during the eccentric load of the biceps. The hook test is the most significant examination test, presenting the highest sensibility and specificity for this lesion. Magnetic resonance imaging, the gold standard imaging test, can provide information regarding integrity and identify partial and/or complete tears. The surgical treatment uses an anterior or double approach and several reattachment techniques. Although there is no clinical evidence to recommend one fixation method over the other, biomechanical studies show that the cortical button resists better to failure. Although surgical treatment led to an 89% rate of return to work in 14 weeks, the recovery of high sports performance occurred in 1 year, with unsustainable outcomes.

Resumo As lesões agudas do tendão distal do bíceps se apresentam, clinicamente, com uma dor súbita associada a perda aguda de força de flexão e supinação. Seu principal mecanismo de lesão ocorre durante contração excêntrica do bíceps. O "Hook Test" é o principal teste semiológico, sendo o mais sensível e específico. A ressonância magnética, exame padrão ouro para o diagnóstico, pode fornecer informações sobre a integridade, identificando as lesões parciais e/ou completas. O tratamento cirúrgico pode ser realizado por duas vias principais: anterior e por dupla via porém as técnicas de reinserção tendínea são diversas não havendo evidência clínica que recomende um método de fixação em detrimento ao outro; embora o botão cortical apresente maior resistência a falha nos estudos biomecânicos. Com o tratamento cirúrgico o retorno as atividades laborais foi de 89% em 14 semanas (média) porém ao esporte de alto rendimento o prazo foi longo, média de 1 ano, e não duradouro.

Early or Delay? The Most Suitable Rehabilitation Protocol for "No Man's Land" Injury: Meta-Analysis with Trial Sequential Analysis - 20 Years Trends / Precoce ou tardio? O protocolo de reabilitação mais adequado para lesão na região 'terra de ninguém': Metanálise com análise sequencial de ensaios - Tendências de 20 anos

Abstract Objective The aim of this study is to analyze various rehabilitation protocol and determine which methods will yield a better outcome. Methods The database reports were searched within 1990 until 2020, using PubMed, Cochrane library database, Ovid, Medline, and the other several published trials. A statistical analysis was made from Review Manager and Trial Sequential Analysis (TSA). Result The mean of re-rupture rate is 3.3% (n= 8) in the combination protocol until 8% (n= 48) in CAM protocol. Meta-analyses found no significant difference between Kleinert vs CAM in re-rupture rate. Also no significant difference in Duran vs CAM in rerupture rate. In Trial Sequential Analysis (TSA), the z-curve does not cross both of the trial sequential boundaries, a further trial with larger sample will be required. The TSA of flexion contracture CAM vs Kleinert was indicated that CAM protocol may be superior than Kleinert to reduce the incidence of flexion contracture. For the range of mean flexion contracture 6.6% (n= 18) in CAM to 23.6% (n= 76) in Kleinert protocol. Conclusion Current meta-analysis proposed that the combination technique will result less re-rupture incidence and better functional outcome in flexor zone II injuries than other techniques. The CAM method also results less flexion contracture than others. However, a further meta-analyses with larger sample trials will be required to confirm this review's conclusion.

Resumo Objetivo O objetivo deste estudo é analisar vários protocolos de reabilitação e determinar quais métodos produzem um melhor resultado. Métodos Os relatórios dos bancos de dados foram pesquisados entre 1990 e 2020, usando PubMed, banco de dados da biblioteca Cochrane, Ovid, Medline e vários outros ensaios publicados. Uma análise estatística foi feita a partir do Review Manager e Trial Sequential Analysis (TSA). Resultado A taxa média de re-ruptura é de 3,3% (n = 8) no protocolo combinado, e até 8% (n = 48) no protocolo de Movimento Ativo Controlado (MAC). As metanálises não encontraram diferença significativa entre Kleinert vs MAC na taxa de re-ruptura. Também não há diferença significativa entre Duran e MAC na taxa de re-ruptura. Na Trial Sequential Analysis (TSA), a curva z não cruza ambos os limites sequenciais de ensaio, será necessário um ensaio adicional com amostra maior. A TSA de contratura em flexão MAC vs Kleinert indicou que o protocolo MAC pode ser superior ao Kleinert para reduzir a incidência de contratura em flexão. Para a faixa de contratura média em flexão de 6,6% (n = 18) no MAC a 23,6% (n = 76) no protocolo Kleinert. Conclusão A metanálise atual propôs que a técnica combinada resultará em menor incidência de re-ruptura e melhor resultado funcional em lesões da zona flexora II do que outras técnicas. O método MAC também resulta em menos contratura em flexão do que outros. No entanto, serão necessárias mais metanálises com estudos com amostras maiores para confirmar a conclusão desta revisão.

Reliability and Validity of the Hook Test for Diagnosis of Distal Biceps Tendon Ruptures.

PURPOSE: Although the initial description of the distal biceps tendon (DBT) hook test (HT) reported 100% sensitivity (Sn) and specificity (Sp), subsequent retrospective series have demonstrated imperfect validity. The purpose of this investigation was to prospectively assess the validity and reliability of the HT for complete DBT ruptures. We aimed to determine the Sn/Sp and interrater reliability for the HT. METHODS: A consecutive series of adult patients presenting to our outpatient clinics with an elbow complaint was prospectively examined. Patients were included if they had undergone advanced imaging (magnetic resonance imaging or ultrasound) that imaged the DBT and underwent DBT repair. There were four participating surgeons, all of whom were blinded to magnetic resonance imaging/ultrasound prior to performing the HT. To determine the Sn/Sp of the HT and advanced imaging, intraoperative findings served as the primary reference standard. The interrater reliability of the HT was calculated for cases in which a primary examiner (surgeon) and secondary examiner (physician assistant or resident) performed the HT. RESULTS: Of 64 patients who had undergone advanced imaging, 28 (44%) underwent DBT surgery and were included in the assessment of Sn/Sp. The mean age was 49 years, and all patients were men. The Sn and Sp of the HT were 96% and 67%, respectively. Advanced imaging demonstrated 100% Sn and Sp. Twenty-five patients were evaluated by a primary and secondary examiner. The interrater reliability was substantial (Cohen kappa, 0.71). CONCLUSIONS: The Sn and Sp of the HT were 96% and 67%, respectively, when assessed prospectively. Advanced imaging findings (magnetic resonance imaging/ultrasound) demonstrated 100% Sn and Sp. The HT can be performed reliably by examiners with varying experience levels. Considering the imperfect validity of the HT, we caution against the use of this examination alone to diagnose DBT ruptures. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Rotura traumática simultánea y bilateral del tendón del cuádriceps en un paciente fisicoculturista: informe de caso y revisión de la literatura / Simultaneous bilateral traumatic quadriceps tendon rupture in a bodybuilding patient: case report and literature review

La rotura traumática, simultánea y bilateral del tendón cuadricipital es una lesión infrecuente, generalmente asociada a otras enfermedades sistémicas tales como insuficiencia renal o trastornos endocrinos. Presentamos el caso de un varón sano y atleta de 38 años que sufrió esta lesión mientras realizaba una sentadilla en el gimnasio. (AU)

The traumatic bilateral and simultaneous quadriceps tendon rupture is a rare injury, usually associated with other systemic diseases such as renal insufficiency or endocrine disorders. We present the case of a 38-year-old healthy male athlete who sustained this injury while performing a squat at the gym. (AU)

Achilles Tendon Injuries in the Pediatric Population.

BACKGROUND: Achilles tendon injuries are common in adults, and there is extensive literature describing the injury characteristics and treatment of these adult injuries. However, Achilles injuries are rare in the pediatric population and as a result, there is limited research reported on this age group. We therefore sought to characterize the injury presentation, treatment and outcomes for pediatric patients with partial and complete Achilles injuries. METHODS: A retrospective chart review was conducted of patients aged 0-18 treated for Achilles tendon injuries at 2 geographically distinct tertiary institutions between 2008 and 2021. Data collected included demographics, injury characteristics, and treatment course. Injury types were separated into 2 cohorts: traumatic Achilles injuries and ruptures due to muscular contraction. Traumatic injuries were further delineated into 2 injury mechanisms: open injuries related to penetrating trauma and closed injuries related to blunt trauma. Standard descriptive analyses were utilized to summarize findings. RESULTS: Thirty-nine patients (43.6% female, median age 15 years) were identified, 29 (74.4%) of whom had complete tears. Twenty-five patients (64.1%) presented with traumatic injuries; among these, 48.0% (n=12/25) were ≤12 years. All patients ≤12 years sustained a traumatic injury. The most common traumatic mechanism was an open laceration due to penetrating trauma (68.0%), followed by closed ruptures associated with blunt trauma (32.0%). Fourteen patients (35.9%) presented with closed ruptures due to muscular contraction. Four patients (10.2%) had a prior history of clubfoot treated with Achilles tenotomy. Thirty-five patients (89.7%) were surgically treated with an open repair. The median immobilization period across all patients was 11 weeks (interquartile range: 10-12), starting most commonly with a posterior splint (46.2%) and concluding with a CAM boot (94.9%). Of patients with full follow-up data (n=22/39), all resumed normal activities, with a median clearance time of 6 months (interquartile range: 5-7.9). CONCLUSIONS: We found that older adolescents (≥14 y) were more likely to rupture their Achilles tendon through a forceful muscular contraction, whereas younger patients (≤12 y) were more likely to injure their Achilles via a traumatic mechanism. Most patients were treated operatively and returned to sports at a median time of 6 months. A further prospective study is warranted to better characterize treatment protocols and patient outcomes in this population. LEVEL OF EVIDENCE: Level-IV.

Flexor Tendon Repair in Zone II Augmented With an Externalized Detensioning Suture: Protected Flexor Tendon Repair.

Flexor tendon repair in zone II benefits from early finger motion to prevent stiffness. This article presents a technique that serves to augment a zone II flexor tendon repair with an externalized detensioning suture that can be used following any commonly employed repair method. This simple technique enables early active motion and is suited for patients who are less likely to be compliant after surgery or when the soft-tissue injury to the finger and hand is substantial. Although this technique substantially strengthens the repair, a possible drawback is that the tendon excursion distal to the repair is limited until the externalized suture is removed, which may lead to less motion of the distal interphalangeal than what may have occurred without the detensioning suture.

Distal overactivation of gastrocnemius medialis in persistent plantarflexion weakness following Achilles tendon repair.

Structural alterations of the triceps surae and Achilles tendon (AT) can promote plantarflexion weakness one-year following an AT repair, influencing the activation strategies of the Gastrocnemius Medialis (GM) muscle. However, this is yet to be demonstrated. We aimed to determine whether patients with plantar flexion weakness one-year after AT repair show altered GM spatial activation. In this cross-sectional and case-control study, ten middle-aged men (age 34 ± 7 years old, and 12.9 ± 1.1 months post-surgery) with a high AT total rupture score who attended conventional physiotherapy for six months after surgery, and ten healthy control men (age 28 ± 9 years old), performed maximal and submaximal (40, 60 and 90%) voluntary isometric plantarflexion contractions on a dynamometer. The peak plantar flexor torque was determined by isokinetic dynamometry and the GM neuromuscular activation was measured with a linear surface-electromyography (EMG) array. Overall EMG activation (averaged channels) increased when the muscle contraction levels increased for both groups. EMG spatial analysis in AT repaired group showed an increased activation located distally at 85-99%, 75-97%, and 79-97% of the electrode array length for 40%, 60%, and 90% of the maximal voluntary isometric contractions, respectively. In conclusion, patients with persistent plantar flexion weakness after AT rupture showed higher distal overactivation in GM.

Inadequate Purchase in the Proximal Tendon Stump Using the Percutaneous Achilles Repair System: A Technical Tip.

Minimally invasive approaches for the Achilles tendon have emerged as viable alternatives for acute Achilles ruptures, with several potential benefits in comparison to the open approach. Occasionally, proper purchase in the proximal tendon stump is not achieved due to severe degenerative disease of the tendon. In this article, we present a technique in which a small accessory incision is used during percutaneous Achilles repair in order to pass the sutures in a more proximal and healthy area of the tendon. This technique is useful for situations in which adequate tendon grasp is not obtained, avoiding the need of conversion to an open approach.Level of Evidence: Level V: Expert opinion.

Tendones peroneos: una revisión contemporánea / Peroneal tendons. Contemporary update

La patología de peroneos es compleja y frecuentemente subdiagnosticada. El conocimiento detallado de la anatomía, biomecánica y fisiopatología es fundamental para realizar un correcto diagnóstico y tratamiento. El objetivo de este artículo es revisar la información más actualizada sobre la patología de los tendones peroneos (tendinopatía, inestabilidad y rotura).

Pathology of the peroneal tendons is complex and often underdiagnosed. Knowledge of anatomy, biomechanics, and physiopathology is necessary for diagnosing and treating this condition. The objective of this article is to review the most updated information regarding peroneal tendon pathology (tendinopathy, dislocation/subluxation, and tears), which may help managing patients with lateral pain of the foot and ankle.