Erşen, Ali; Ozben, Hakan; Demirhan, Mehmet; Atalar, Ata Can; Kapıcıoğlu, Mehmet
Transfer of the latissimus dorsi tendon to the posterosuperior part of the rotator cuff is an option in active patients with massive rotator cuff tears to restore shoulder elevation and external rotation. However, it is unknown whether this treatment prevents progression of cuff tear arthropathy. The purpose of this study was to determine whether the observed improvement in shoulder function in the early postoperative period with latissimus dorsi tendon transfer for irreparable rotator cuff tears will be permanent or will deteriorate in the midterm period (at 1-5 years after surgery). During a 6-year period, we performed 11 latissimus dorsi tendon transfers in 11 patients for patients with massive, irreparable, chronic tears of the posterosuperior part of the rotator cuff (defined as > 5 cm supraspinatus and infraspinatus tendon tears with Goutallier Grade 3 to 4 fatty infiltration on MRI), for patients who were younger than 65 years of age, and had high functional demands and intact subscapularis function. No patients were lost to followup; minimum followup was 12 months (median, 33 months; range, 12-62 months). The mean patient age was 55 years (median, 53 years; range, 47-65 years). Shoulder forward elevation, external rotation, and Constant-Murley and American Shoulder and Elbow Surgeons scores were assessed. Pain was assessed by a 0- to 10-point visual analog scale. Acromiohumeral distance and cuff tear arthropathy (staged according to the Hamada classification) were evaluated on radiographs. Shoulder forward elevation, external rotation, Constant-Murley scores, and American Shoulder and Elbow Surgeons scores improved at 6 months. However, although shoulder motion values and Constant-Murley scores remained unchanged between the 6-month and latest evaluations, American Shoulder and Elbow Surgeons scores decreased in this period (median, 71; range, 33-88 versus median, 68; range, 33-85; p = 0.009). Visual analog scale scores improved between the
Massive irreparable rotator cuff tears can be reconstructed with latissimus dorsi tendon transfers (LDTT). Although uncommon, the natural length of the latissimus dorsi tendon (LDT) could be insufficient for transfer even after adequate soft tissue releases. Descriptions of cases where grafts were needed to lengthen the LDT are therefore rare. We located only two reports of the use of an acellular dermal matrix to increase effective tendon length in tendon transfers about the shoulder: (1) GraftJacket patch for a pectoralis major tendon reconstruction and (2) ArthroFlex® patch for LDTT. Both of these brands of allograft patches are obtained from human cadavers. These products are usually used to cover soft tissue repairs and offer supplemental support rather than for increasing tendon length. Extending the LDTT with GraftJacket to achieve adequate length, to our knowledge, has not been reported in the literature. We report the case of a 50-year-old male who had a massive, irreparable left shoulder rotator cuff tear that was reconstructed with a LDTT. The natural length of his LDT was insufficient for transfer. This unexpected situation was rectified by sewing two patches of GraftJacket to the LDT. The patient had greatly improved shoulder function at two-year follow-up. PMID:28194290
Henseler, Jan Ferdinand; Nagels, Jochem; Nelissen, Rob G H H; de Groot, Jurriaan H
The purpose of this study is to evaluate the muscle activity with surface electromyography (EMG) and the clinical outcome of the latissimus dorsi transfer. It remains unclear whether the clinical results of the latissimus dorsi transfer for massive posterosuperior rotator cuff tears are achieved either by active muscle contractions or by a passive tenodesis effect of the transfer. Eight patients were evaluated preoperatively and at 1 year (SD, 0.1) after the latissimus dorsi transfer. Clinical evaluation of outcomes included active range of motion, Constant score, and visual analog scale (VAS) for pain and activities of daily living (ADL). Muscle activity was recorded with EMG during directional isometric abduction and adduction tasks. The external rotation in adduction improved from 23° to 51° (P = .03). The external rotation in abduction improved from 10° to 70° (P = .02). The mean Constant score improved from 39 to 62 postoperatively (P = .01). The VAS for pain at rest improved from 3.3 preoperatively to 0.1 (P = .02). The VAS for ADL improved from 4.9 to 2.3 (P = .05). The transferred latissimus dorsi remained active in all cases, as reflected by increased latissimus dorsi EMG activity during abduction tasks. In addition, the latissimus dorsi EMG activity shifted from preoperative antagonistic co-activation in adduction to synergistic activation in abduction. The latissimus dorsi has synergistic muscle activity after transfer. Apart from a tenodesis effect, directional muscle activity seems relevant for improved clinical outcome and pain relief. A specific gain was observed for external rotation in elevated arm positions, a motion essential for ADL tasks. Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
Werner, Clément M L; Ruckstuhl, Thomas; Müller, Roland; Zanetti, Marco; Gerber, Christian
This investigation was performed to analyze the influence of innervation and psychomotor skills on the outcome of latissimus dorsi transfer. Patients with the 10 best and 10 worst results after latissimus dorsi transfer for irreparable rotator cuff tears were selected. All patients meeting the inclusion criteria (n = 12) were subject to a psychomotor test battery (Motorische Leistungsserie) and electromyographic innervation assessment. There was no statistical difference between the 2 groups preoperatively in terms of the commonly tested factors known to influence the results of this procedure adversely. There was a significant difference in both the pattern and selectivity of innervation in the group that had better clinical results. The psychomotor findings were negatively correlated with the range of motion and the strength of the operative shoulder. Function of the operative shoulder could also be predicted by psychomotor function of the uninjured contralateral side. Psychomotor skills testing appears to be a new, potential method by which to predict the outcome of latissimus dorsi transfer.
Bargoin, K; Boissard, M; Kany, J; Grimberg, J
Latissimus dorsi tendon transfer is a surgical option for treating irreparable posterosuperior rotator cuff tears, notably when attempting to reconstruct active external rotation. We hypothesized that the positioning of the transfer's point of fixation would differ depending on the desired elbow-to-body external rotation or external rotation with the elbow abducted. Seven shoulders from four whole frozen cadavers were used. We created two systems to install the subject in a semi-seated position to allow external rotation elbow to body and the arm abducted 90°. Traction sutures were positioned on the latissimus dorsi muscle and a massive tear of the rotator cuff was created. We tested six different transfer positions. Muscle contraction of the latissimus dorsi was stimulated using 10-N and 20-N suspended weights. The point of fixation of the latissimus dorsi on the humeral head had an influence on the elbow-to-body external rotation and with 90° abduction (P<0.001). The fixation point for a maximum external rotation with the elbow to the body was the anterolateral position (P<0.016). The fixation point for a maximum external rotation at 90° abduction was the position centered on the infraspinatus footprint (P<0.078). The optimal point of fixation differs depending on whether external rotation is restored at 0° or 90° abduction. Fundamental study, anatomic study. Copyright Â© 2016 Elsevier Masson SAS. All rights reserved.
Wey, Aaron; Dunn, John C; Kusnezov, Nicholas; Waterman, Brian R; Kilcoyne, Kelly G
In conjunction with reverse total shoulder arthroplasty (RSA), latissimus dorsi and teres major (LD-TM) transfer has been advocated in the setting of combined loss of elevation and external rotation. The purpose of this systematic review is to summarize the clinical outcomes following RSA with LD-TM transfer. A search of PubMed, EMBASE, CINAHL, Medline, and Cochrane databases was performed between January 1, 1990 and March 1, 2016 and included articles related to outcomes following RSA with LD-TM transfer. Primary outcomes of interest were constant score, shoulder range of motion, and patient satisfaction. Secondary outcomes of interest included subjective shoulder value, simple shoulder test, activities of daily living requiring external rotation, and visual analog pain score. Additional outcomes evaluated included complications and reoperations. Frequency-weighted values of outcome data were utilized. Five level IV studies involving 98 shoulders met the inclusion criteria. The mean age of the cohort was 69.1 ± 5.19 years (range 47-85). RSA with LD-TM transfer was performed for rotator cuff arthropathy (94%) or proximal humerus fracture (6%). The average follow-up was 44.5 ± 10.38 months (range 12-105 months). The constant score improved from 28 to 65 ( p < 0.0005). Active external rotation improved from -7.4° to 22.9° ( p < 0.0005). There was a 22.4% overall complication rate, including dislocation (5.1%), infection (5.1%), and transient nerve palsy (3.4%). Patients undergoing RSA with LD-TM transfer in the setting of loss of external rotation demonstrate reliable clinical improvements in shoulder function with complication rates which are comparable to RSA alone.
Ippolito, Giorgio; Serrao, Mariano; Napoli, Francesco; Conte, Carmela; Miscusi, Massimo; Coppola, Gianluca; Pierelli, Francesco; Costanzo, Giuseppe; De Cupis, Vincenzo
Latissimus dorsi tendon transfer (LDT) is a recent method for surgical treatment of massive, irreparable posterosuperior cuff tears (MIPCT). So far, there are no studies on the quantitative motion analysis of the shoulder and latissimus dorsi (LD) muscle activation after LDT. The changes in shoulder movements after LDT can be objectively assessed by the 3-D motion analysis. These changes may not be due to an increased activity of the LD muscle as external rotator. The shoulder kinematics of nine patients with MIPCT were recorded through a 3-D motion analysis system, before LTD (T0), and after 3 (T1) and 6 (T2) months post-LDT. Maximal shoulder flexion-extension, abduction-adduction, and horizontal abduction-adduction, and the internal and external circumduction of the shoulder joint were measured during upright standing posture. Surface EMG activity of the LD muscle was recorded during both internal rotation (IR) and external rotation (ER) tasks in three different postures. A significant increase of shoulder movements was observed at T2 compared with T0 for almost all motor tasks. A significant effect of LDT was also found on LD-IR/ER ratio in posture 1 at T2 compared with T0 and T1. No significant effects were found for the LD-IR/ER ratio in the other postures. Our study indicates that LDT is effective in shoulder motion recovery. Such improvement is not associated with a change in function of the LD muscle, which may be induced by a depression of the humeral head into the glenoid cavity instead.
Anastasopoulos, Panagiotis P.; Alexiadis, George; Spyridonos, Sarantis; Fandridis, Emmanouil
Background: Massive rotator cuff tears pose a difficult and complex challenge even for the experienced surgeon; inability to repair these tears by conventional means designates them as irreparable, while management becomes quite taxing. Several operative options have been suggested for the management of such lesions with varying degrees of success, while it is imperative to match patient demands and expectations to the predicted outcome. Methods: Research articles are examined and key concepts are discussed, in order to provide an evidence based review of the available literature. The anatomy and pathomechanics along with the indications, contraindications and surgical techniques are reported. Results: Transfer of the Latissimus dorsi has been used with success to restore shoulder function in deficits of the posterior rotator cuff. Although it can be used in a variety of settings, the ideal patient for a Latissimus dorsi tendon transfer is a young and active individual, with no glenohumeral osteoarthritis that has a severe disability and weakness related to an irreparable posterior cuff tear. Conclusion: Tendon transfers have proved to be a successful treatment option in salvaging this difficult problem, providing pain relief and restoring shoulder function. Despite the excellent functional outcomes and pain suppression following operation, a variety of factors may affect the outcome; thus making indications and preoperative assessment a valuable component. PMID:28400877
Plath, Johannes E; Seiberl, Wolfgang; Beitzel, Knut; Minzlaff, Philipp; Schwirtz, Ansgar; Imhoff, Andreas B; Buchmann, Stefan
The purpose of this study was to investigate coactivation (CoA) testing as a clinical tool to monitor motor learning after latissimus dorsi tendon transfer. We evaluated 20 patients clinically with the American Shoulder and Elbow Surgeons (ASES) and University of California-Los Angeles (UCLA) outcomes scores, visual analog scale, active external rotation (aER), and isometric strength testing in abduction and external rotation. Measurements of aER were performed while the latissimus dorsi was activated in its new function of external rotation with concomitant activation (coactivation) of its native functions (adduction and extension). Bilateral surface electromyographic (EMG) activity was recorded during aER measurements and the strength testing procedure (EMG activity ratio: with/without CoA). Patients were divided into two groups (excellent/good vs fair/poor) according to the results of the ASES and UCLA scores. The mean follow-up was 57.8 ± 25.2 months. Subdivided by clinical scores, the superior outcome group lost aER with CoA, whereas the inferior outcome group gained aER (UCLA score: -2.2° ± 7.4° vs +4.3° ± 4.1°; P = .031). Patients with inferior outcomes in the ASES score showed higher latissimus dorsi EMG activity ratios (P = .027), suggesting an inadequate motor learning process. Isometric strength testing revealed that the latissimus dorsi transfer had significantly greater activity compared with the contralateral side (external rotation, P = .008; abduction, P = .006) but did not have comparable strength (external rotation, P = .017; abduction, P = .009). Patients with inferior clinical results were more likely to be dependent on CoA to gain external rotation. Therefore, CoA testing may be used as a tool to evaluate the status of postoperative motor learning after latissimus dorsi transfer. Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
Nazerani, Shahram; Motamedi, Mohammad Hosein Kalantar
Objective: The latissimus dorsi muscle transfer finger and wrist extension is a well-known procedure for patients needing replantation or in brachial plexus injuries. To increase the length of the transferred muscle to reach to the finger and wrist extensors, the other authors suggest extending the muscle length by incorporating the iliac crest fascia, which not only prolongs the operation time but also minimizes the chances of a healthy and viable muscle-tendon junction. We present a modification of the standard latissimus dorsi transfer whereby the whole muscle (not partial harvest) is transferred and extended by tendon graft to minimize the distal muscle-tendon problems and inefficient muscle excursion commonly encountered with the thus far reported techniques. Methods: In a 12-year period (1996–2008), 5 patients were treated. Guidelines for patient selection were (1) complete high radial nerve palsy with no simpler solution to address the problem, (2) supple joints and gliding tendons, (3) good patient motivation, and (4) free muscle transfer not feasible or risky. Results: Five male patients aged 18 to 45 were treated for the absence of wrist and finger extension due to radial nerve damage or extensor group destruction. They were able to use the transferred muscle for extension with minimal training and physiotherapy. Conclusion: (1) Transferring the whole muscle ensures a complete neural arborization and better excursion. (2) It ensures a safe tendon suture wherein the muscle-tendon unit is far from the distal end of the skin flap (less possibility of necrosis). PMID:19165312
Veljkovic, Andrea; Lansang, Edward; Lau, Johnny
Flexible forefoot deformities, such as hallux varus, clawed hallux, hammer toes, and angular lesser toe deformities, can be treated effectively with tendon transfers. Based on the presentation of the flexible forefoot deformities, tendon transfers can be used as the primary treatment or as adjuncts to bony procedures when there are components of fixed deformities.
Greenspoon, Joshua A.; Millett, Peter J.; Moulton, Samuel G.; Petri, Maximilian
Background: Tendon transfers can be a surgical treatment option in managing younger, active patients with massive irreparable rotator cuff tears. The purpose of this article is to provide an overview of the use of tendon transfers to treat massive irreparable rotator cuff tears and to summarize clinical outcomes. Methods: A selective literature search was performed and personal surgical experiences are reported. Results: Latissimus dorsi transfers have been used for many years in the management of posterosuperior rotator cuff tears with good reported clinical outcomes. It can be transferred without or with the teres major (L’Episcopo technique). Many surgical techniques have been described for latissimus dorsi transfer including single incision, double incision, and arthroscopically assisted transfer. Transfer of the pectoralis major tendon is the most common tendon transfer procedure performed for anterosuperior rotator cuff deficiencies. Several surgical techniques have been described, however transfer of the pectoralis major beneath the coracoid process has been found to most closely replicate the force vector that is normally provided by the intact subscapularis. Conclusion: Tendon transfers can be used successfully in the management of younger patients with massive irreparable rotator cuff tears and minimal glenohumeral arthritis. Improvements in clinical outcomes scores and range of motion have been demonstrated. This can delay arthroplasty, which is of particular importance for younger patients with high functional demands. PMID:27708730
Greenspoon, Joshua A; Millett, Peter J; Moulton, Samuel G; Petri, Maximilian
Tendon transfers can be a surgical treatment option in managing younger, active patients with massive irreparable rotator cuff tears. The purpose of this article is to provide an overview of the use of tendon transfers to treat massive irreparable rotator cuff tears and to summarize clinical outcomes. A selective literature search was performed and personal surgical experiences are reported. Latissimus dorsi transfers have been used for many years in the management of posterosuperior rotator cuff tears with good reported clinical outcomes. It can be transferred without or with the teres major (L'Episcopo technique). Many surgical techniques have been described for latissimus dorsi transfer including single incision, double incision, and arthroscopically assisted transfer. Transfer of the pectoralis major tendon is the most common tendon transfer procedure performed for anterosuperior rotator cuff deficiencies. Several surgical techniques have been described, however transfer of the pectoralis major beneath the coracoid process has been found to most closely replicate the force vector that is normally provided by the intact subscapularis. Tendon transfers can be used successfully in the management of younger patients with massive irreparable rotator cuff tears and minimal glenohumeral arthritis. Improvements in clinical outcomes scores and range of motion have been demonstrated. This can delay arthroplasty, which is of particular importance for younger patients with high functional demands.
Miyazaki, Alberto Naoki; Checchia, Caio Santos; Checchia, Sergio Luiz; Fregoneze, Marcelo; Santos, Pedro Doneux; do Val Sella, Guilherme
Description of a new surgical technique for treating the shoulders of patients with sequelae of obstetric paralysis. Preliminary analysis on the results obtained from this technique. Five consecutive patients underwent the proposed surgical procedure, consisting of arthroscopic anterior joint release followed by transfer of the latissimus dorsi tendon (elongated and reinforced with a homologous tendon graft) to the posterosuperior portion of the greater tubercle, using a single deltopectoral approach. All the patients were reevaluated after a minimum postoperative period of twelve months. The functional assessment was based on the range of motion and the modified Mallet classification system. Statistical analyses were not possible because of the small sample. Overall, passive and active lateral rotations increased, while medial rotation decreased. The other movements (elevation, capacity to place a hand in the mouth and capacity to place a hand behind the neck) had less consistent evolution. The mean modified Mallet score improved by 4.2 points (from 11.4 to 15.6). The latissimus dorsi tendon can be transferred to the posterosuperior portion of the greater tubercle through a single deltopectoral approach when elongated and reinforced with a homologous tendinous graft.
Chung, U S; Kim, J H; Seo, W S; Lee, K H
We evaluated the clinical outcome of tendon reconstruction using tendon graft or tendon transfer and the parameters related to clinical outcome in 51 wrists of 46 patients with rheumatoid arthritis with finger extensor tendon ruptures. At a mean follow-up of 5.6 years, the mean metacarpophalangeal (MP) joint extension lag was 8 degrees (range, 0-45) and the mean visual analogue satisfaction scale was 74 (range, 10-100). Clinical outcome did not differ significantly between tendon grafting and tendon transfer. The MP joint extension lag correlated with the patient's satisfaction score, but the pulp-to-palm distance did not correlate with patient satisfaction. We conclude that both tendon grafting and tendon transfer are reliable reconstruction methods for ruptured finger extensor tendons in rheumatoid hands.
Buchanan, Patrick; Leyngold, Mark; Mast, Bruce A
Poland syndrome typically presents as a unilateral congenital complete or partial absence of the pectoralis major muscle, variably with other associated anomalies. Reconstruction of the defect typically concentrates on aesthetic restoration with functional outcomes being unsuccessful or limited. We present an innovative means of true muscle transfer that provided functional benefit to increase upper extremity strength. A 16-year-old adolescent boy with Poland syndrome manifesting as left pectoralis major muscle agenesis wished to undergo functional reconstruction. He wanted to play on his high school football team, but could not meet the minimum weightlifting requirements. An ipsilateral latissimus dorsi muscle bipolar functional transfer was done with bone-anchored inset into the sternum and humerus so that muscle flexion would replace the absent pectoralis major. A progressive weight training program was then instituted postoperatively. At 9 months, a significant increase in left upper extremity strength was confirmed. The patient ultimately was able to surpass the weightlifting requirements for his high school football team, and joined the team. Our highlighted procedure restored functional outcome using both plastic surgical principles and orthopedic techniques for muscle and tendon repair: bipolar muscle transfer and load-bearing muscle inset. Heretofore, transfer of the latissimus for provision of pectoralis major function has not been reported. Functional reconstruction was possible due to stable, bipolar muscle transfer with load-bearing muscle attachments into cortical bone of the anterior sternum and anteromedial aspect of the humerus. The techniques described should be within the skill set of most plastic surgeons, so that functional restoration for those with Poland syndrome is possible and accessible.
Watfa, William; di Summa, Pietro G; Raffoul, Wassim
Poland syndrome is a rare congenital anomaly characterized by a unilateral congenital absence of the sternocostal head of the pectoralis major muscle. The absence of the pectoralis major does not only result in chest asymmetry but also in a missing anterior axillary fold, which is essential for natural anatomical appearance in both male and female patients. In Poland syndrome patients, we perform bipolar latissimus dorsi flap transfer, which can be associated with a sublatissimus implant in women. All procedures are performed through a single short midaxillary incision, and tendon translocation in this technique allows the creation of the anterior axillary fold and thus a natural chest appearance. Moreover, this technique can be performed by any plastic surgeon operating under a basic operating room setting.
di Summa, Pietro G.; Raffoul, Wassim
Summary: Poland syndrome is a rare congenital anomaly characterized by a unilateral congenital absence of the sternocostal head of the pectoralis major muscle. The absence of the pectoralis major does not only result in chest asymmetry but also in a missing anterior axillary fold, which is essential for natural anatomical appearance in both male and female patients. In Poland syndrome patients, we perform bipolar latissimus dorsi flap transfer, which can be associated with a sublatissimus implant in women. All procedures are performed through a single short midaxillary incision, and tendon translocation in this technique allows the creation of the anterior axillary fold and thus a natural chest appearance. Moreover, this technique can be performed by any plastic surgeon operating under a basic operating room setting. PMID:27622115
Walton, Laura; Villani, Matthew F
Whether performed as a primary procedure or used to augment and support osseous reconstruction, tendon transfers are a key skill for the foot and ankle surgeon. Understanding the biomechanics preoperative and postoperatively is essential in performing appropriate procedures and in supporting patients through the rehabilitation process. Often the complexity of tendon transfer surgery is lost because it is deemed a soft tissue procedure and in theory should be less complex than osseous procedures. However, the dynamic nature of musculature and tendons require a deeper understanding of surgical and biomechanical concepts. Copyright © 2016 Elsevier Inc. All rights reserved.
Ghosh, S; Singh, V K; Jeyaseelan, L; Sinisi, M; Fox, M
In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5). A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity.
Muiño, José María Silberberg; Gimenez, Martín Alejandro; Salvucci, Mauro Gabriel Maroa; Ferro, Diego; Rullan, Ramón Muiña
Objective: To evaluate subjective and functional mid term results of patients treated by a lattisimus dorsi tendón transfer arthroscopically assisted for massive irreparable posterolateral injuries of the Rotator Cuff. Methods: Between 2009 and 2012, 17 Lattisimus Dorsi transfers (Paribelli technique) for irreparable posterolateral rotator cuff tears were performed. Distribution by sex: 12 men and 5 women with a mean age of 53 years old (range, 40-63). Thirteen right shoulders and 4 left shoulders. Average duration of symptoms prior to surgery was 8 months (range, 6-13 months). Mean follow-up was 28 months (range, 18-44). Patients were evaluated by the VAS, satisfaction rate, the Constant Modified Scale, postoperative range of motion and strength. Postoperative radiological studies included simple AP radiographs and MRI in order to measure AC distance and asses the integrity of the plasty. Results: Postoperative Constant Modified score averaged 63.54 points. (average increase of 13 points compared to preoperative score. (P ..05)). Active Mobility: a) Mean elevation: 142° postop vs. 119° preop (p <.001). b) Mean abduction: 138.24º postop vs. 112.35º preop (p <.001). c) Mean external rotation 40° postop vs. 20.29º preop (p <.004). Insert text. Conclusion: Lattisimus Dorsi transfer in patients with posterolateral massive irreparable injuries of the RC, is a highly demanding and palliative procedure for those cases with loss of active mobility, especially lifting and shoulder abduction.
Panchbhavi, Vinod Kumar
Tendon transfer procedures are useful for replacing a dysfunctional or diseased tendon or for restoring muscle imbalance. The tendon to be transferred is harvested as distal as is necessary to provide adequate length for rerouting and attachment at the different site. The harvesting of tendon itself can be attained using an open surgical approach or minimally invasive percutaneous techniques that limit surgical exposure. This article describes percutaneous techniques for tendon transfer procedures used to address foot and ankle disorders.
Therattil, Paul J.; Russo, Gerardo; Lee, Edward S.
Objective: The latissimus dorsi flap is a workhorse for plastic surgeons, being used for many years for soft-tissue coverage of the upper extremity as well as for functional reconstruction to restore motion to the elbow and shoulder. The authors present a case of functional latissimus dorsi transfer for restoration of elbow flexion and review the literature on technique and outcomes. Methods: A literature review was performed using MEDLINE and the Cochrane Collaboration Library for primary research articles on functional latissimus dorsi flap transfer. Data related to surgical techniques and outcomes were extracted. Results: The literature search yielded 13 relevant studies, with a total of 52 patients who received pedicled, functional latissimus dorsi flaps for upper-extremity reconstruction. The most common etiology requiring reconstruction was closed brachial plexus injury (n = 13). After flap transfer, 98% of patients were able to flex the elbow against gravity and 82.3% were able to flex against resistance. In the presented case, a 77-year-old man underwent resection of myxofibrosarcoma of the upper arm with elbow prosthesis placement and functional latissimus dorsi transfer. The patient was able to actively flex against gravity at 3-month follow-up. Conclusions: A review of the literature shows that nearly all patients undergoing functional latissimus dorsi transfer for upper-extremity reconstruction regain at least motion against gravity whereas a large proportion regain motion against resistance. Considerations when planning for functional latissimus dorsi transfer include patient positioning, appropriate tensioning of the muscle, safe inset, polarity, management of other affected upper-extremity joints, and educating patients on the expected outcomes. PMID:28293330
Hartzler, Robert U; Barlow, Jonathan D; An, Kai-Nan; Elhassan, Bassem T
Our purpose was to determine and compare the external rotation moment arm (ERMA) of the latissimus dorsi (LD), teres major (TM), and lower trapezius (LT) when transferred to selected locations on the proximal humerus. We hypothesize that the LT transfer has a higher ERMA compared with LD or TM. Six fresh frozen cadaveric hemithoraces were used in a novel experimental design. The tendon and joint displacement method was used to calculate ERMA for 6 transfer pairs: LD to superolateral humeral head (SHH), LD to proximal-lateral humeral diaphysis (LHD), TM to SHH, TM to LHD, LT to infraspinatus insertion (ISI), and LT to teres minor insertion (TMI). Tendon transfer pair had a significant effect on ERMA (P < .001), with a significant interaction effect between tendon transfer and position of the humerus (P < .0001). With the humerus at 0° abduction, the ERMAs of the LT-ISI (28.1 mm) or LT-TMI (22.3 mm) transfers were significantly higher than the ERMAs of LD-SHH (10.6 mm; P = .0001, P = .04) or LD-LHD (6.5 mm; P < .0001, P < .001). Also, ERMAs of LT-ISI and LT-TMI transfers were significantly higher than ERMA of TM-LHD (10.4 mm; P = .0001, P = .03). Shoulder external rotation tendon transfers differ in effectiveness and may be affected by arm position. LT potentially results in superior restoration of shoulder external rotation with the arm at the side compared with LD and should be considered as a potential tendon transfer to restore external rotation in selected patients. Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
Tsiampa, Vassiliki A; Ignatiadis, Ioannis; Papalois, Apostolos; Givissis, Panayiotis; Christodoulou, Anastasios; Fridén, Jan
Improved tendon-to-tendon suturing techniques allow for consistent and immediate activation of transferred muscle after surgery. A pre-requisite for early training after tendon transfer surgery is sufficient mechanical integrity of the tendon-to-tendon attachment. This in vitro study compared the mechanisms and magnitudes of load-to-failure response of two different repair techniques (side-to-side running, n = 7) and weave sutures (n = 8) in sheep front foot tendons. Tensile tests were performed by placing pre-conditioned tendons in a testing machine and stretching at a constant speed to failure. The length of the tendons overlap was the same (50 mm) for both repair techniques. The results of the load to failure tests showed that the side-to-side repairs were significantly stronger than the weave repairs. The failure mechanisms were also different. While the side-to-side attachment failed by longitudinal separation of tendon material of the donor tendon but with the fibres locked to the running sutures attached to the recipient tendon, the weave repairs failed by knot slipping or by suture pullout from the tendon substance. It is concluded that use of the side-to-side repair technique can provide early active training of new motors that not only prevent the formation of adhesions but also facilitate the voluntary recruitment of motors powering new functions before immobilisation-related swelling and stiffness restrain muscle contractions.
Castricini, Roberto; De Benedetto, Massimo; Familiari, Filippo; De Gori, Marco; De Nardo, Pasquale; Orlando, Nicola; Gasparini, Giorgio; Galasso, Olimpio
Arthroscopic-assisted latissimus dorsi tendon transfer (LDTT) has been recently introduced for treatment of irreparable, posterosuperior massive rotator cuff tears. We sought to evaluate the functional outcomes of this technique and to check for possible outcome predictors. The study reviewed 86 patients (aged 59.8 ± 5.9 years) who underwent an arthroscopic-assisted latissimus dorsi tendon transfer after 36.4 ± 9 months of follow-up. Of these, 14 patients (16.3%) sustained an irreparable massive rotator cuff tear after a failed arthroscopic rotator cuff repair. The Constant and Murley score (CMS) was used to assess patients' functionality preoperatively and at follow-up. As a group, the CMS improved with surgery from 35.5 ± 6.1 to 69.5 ± 12.3 (P < .001). A lower preoperative CMS and a previous failed rotator cuff repair resulted in lower postoperative range of motion (P = .044 and P = .007, respectively) and CMS (P = .042 and P = .018, respectively). A previous rotator cuff repair resulted in lower satisfaction with surgery (P = .009). Gender and age did not affect the clinical outcomes. Our results support the effectiveness of arthroscopic-assisted LDTT in the treatment of patients with an irreparable, posterosuperior massive rotator cuff tears in pain relief, functional recovery, and postoperative satisfaction. Patients with lower preoperative CMS and a history of failed rotator cuff repair have a greater likelihood of having a lower clinical result. However, the favorable values of summary postoperative scores do not exclude these patients as candidates for arthroscopic-assisted LDTT. Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
Cavadas, P C; Pérez-García, A; Thione, A; Lorca-García, C
The reconstruction of finger flexor tendons with vascularized flexor digitorum superficialis (FDS) tendon grafts (flaps) based on the ulnar vessels as a single stage is not a popular technique. We reviewed 40 flexor tendon reconstructions (four flexor pollicis longus and 36 finger flexors) with vascularized FDS tendon grafts in 38 consecutive patients. The donor tendons were transferred based on the ulnar vessels as a single-stage procedure (37 pedicled flaps, three free flaps). Four patients required composite tendon and skin island transfer. Minimum follow-up was 12 months, and functional results were evaluated using a total active range of motion score. Multiple linear regression analysis was performed to evaluate the factors that could be associated with the postoperative total active range of motion. The average postoperative total active range of motion (excluding the thumbs) was 178.05° (SD 50°). The total active range of motion was significantly lower for patients who were reconstructed with free flaps and for those who required composite tendon and skin island flap. Age, right or left hand, donor/motor tendon and pulley reconstruction had no linear effect on total active range of motion. Overall results were comparable with a published series on staged tendon grafting but with a lower complication rate. Vascularized pedicled tendon grafts/flaps are useful in the reconstruction of defects of finger flexor tendons in a single stage, although its role in the reconstructive armamentarium remains to be clearly established.
Kondratko-Mittnacht, Jaclyn; Duenwald-Kuehl, Sarah; Lakes, Roderic; Vanderby, Ray
Background Tendon is an integral part of joint movement and stability, as it functions to transmit load from muscle to bone. It has an anisotropic, fibrous hierarchical structure that is generally loaded in the direction of its fibers/fascicles. Internal load distributions are altered when joint motion rotates an insertion site or when local damage disrupts fibers/fascicles, potentially causing inter-fiber (or inter-fascicular) shear. Tendons with different microstructure (helical versus linear) may redistribute loads differently. Method of Approach This study explored how shear redistributes axial loads in rat tail tendon (low stress tendons with linear microstructure) and porcine flexor tendon (high stress with helical microstructure) by creating lacerations on opposite sides of the tendon, ranging from about 20-60% of the tendon width, to create various magnitudes of shear. Differences in fascicular orientation were quantified using polarized light microscopy. Results and Conclusions Unexpectedly, both tendon types maintained about 20% of pre-laceration stress values after overlapping cuts of 60% of tendon width (no intact fibers end to end) suggesting that shear stress transfer can contribute more to overall tendon strength and stiffness than previously reported. All structural parameters for both tendon types decreased linearly with increasing laceration depth. The tail tendon had a more rapid decline in post-laceration elastic stress and modulus parameters as well as a more linear and less tightly packed fascicular structure, suggesting that positional tendons may be less well suited to redistribute loads via a shear mechanism. PMID:25700261
Kondratko-Mittnacht, Jaclyn; Duenwald-Kuehl, Sarah; Lakes, Roderic; Vanderby, Ray
Tendon is an integral part of joint movement and stability, as it functions to transmit load from muscle to bone. It has an anisotropic, fibrous hierarchical structure that is generally loaded in the direction of its fibers/fascicles. Internal load distributions are altered when joint motion rotates an insertion site or when local damage disrupts fibers/fascicles, potentially causing inter-fiber (or inter-fascicular) shear. Tendons with different microstructures (helical versus linear) may redistribute loads differently. This study explored how shear redistributes axial loads in rat tail tendon (low stress tendons with linear microstructure) and porcine flexor tendon (high stress with helical microstructure) by creating lacerations on opposite sides of the tendon, ranging from about 20% to 60% of the tendon width, to create various magnitudes of shear. Differences in fascicular orientation were quantified using polarized light microscopy. Unexpectedly, both tendon types maintained about 20% of pre-laceration stress values after overlapping cuts of 60% of tendon width (no intact fibers end to end) suggesting that shear stress transfer can contribute more to overall tendon strength and stiffness than previously reported. All structural parameters for both tendon types decreased linearly with increasing laceration depth. The tail tendon had a more rapid decline in post-laceration elastic stress and modulus parameters as well as a more linear and less tightly packed fascicular structure, suggesting that positional tendons may be less well suited to redistribute loads via a shear mechanism. Copyright © 2015 Elsevier Ltd. All rights reserved.
Kuo, Ken N; Wu, Kuan-Wen; Krzak, Joseph J; Smith, Peter A
Tendon transfers are invaluable in the treatment of severe children's foot deformities. They are often preferable to simple releases, lengthening, or fusion in surgical treatment because they provide an active motor function for deformity correction and, when properly selected, the procedures stabilize the foot against progressive deformity. The authors describe 4 commonly used tendon transfer procedures that are useful in children's foot deformity surgeries.
Background The surgical management of obstetrical brachial plexus palsy can generally be divided into two groups; early reconstructions in which the plexus or affected nerves are addressed and late or palliative reconstructions in which the residual deformities are addressed. Tendon transfers are the mainstay of palliative surgery. Occasionally, surgeons are required to utilise already denervated and subsequently reinnervated muscles as motors. This study aimed to compare the outcomes of tendon transfers for residual shoulder dysfunction in patients who had undergone early nerve surgery to the outcomes in patients who had not. Methods A total of 91 patients with obstetric paralysis-related shoulder abduction and external rotation deficits who underwent a modified Hoffer transfer of the latissimus dorsi/teres major to the greater tubercle of the humerus tendon between 2002 and 2009 were retrospectively analysed. The patients who had undergone neural surgery during infancy were compared to those who had not in terms of their preoperative and postoperative shoulder abduction and external rotation active ranges of motion. Results In the early surgery groups, only the postoperative external rotation angles showed statistically significant differences (25 degrees and 75 degrees for total and upper type palsies, respectively). Within the palliative surgery-only groups, there were no significant differences between the preoperative and postoperative abduction and external rotation angles. The significant differences between the early surgery groups and the palliative surgery groups with total palsy during the preoperative period diminished postoperatively (p < 0.05 and p > 0.05, respectively) for abduction but not for external rotation. Within the upper type palsy groups, there were no significant differences between the preoperative and postoperative abduction and external rotation angles. Conclusions In this study, it was found that in patients with total paralysis
Aydın, Atakan; Biçer, Ahmet; Özkan, Türker; Mersa, Berkan; Özkan, Safiye; Yıldırım, Zeynep Hoşbay
The surgical management of obstetrical brachial plexus palsy can generally be divided into two groups; early reconstructions in which the plexus or affected nerves are addressed and late or palliative reconstructions in which the residual deformities are addressed. Tendon transfers are the mainstay of palliative surgery. Occasionally, surgeons are required to utilise already denervated and subsequently reinnervated muscles as motors. This study aimed to compare the outcomes of tendon transfers for residual shoulder dysfunction in patients who had undergone early nerve surgery to the outcomes in patients who had not. A total of 91 patients with obstetric paralysis-related shoulder abduction and external rotation deficits who underwent a modified Hoffer transfer of the latissimus dorsi/teres major to the greater tubercle of the humerus tendon between 2002 and 2009 were retrospectively analysed. The patients who had undergone neural surgery during infancy were compared to those who had not in terms of their preoperative and postoperative shoulder abduction and external rotation active ranges of motion. In the early surgery groups, only the postoperative external rotation angles showed statistically significant differences (25 degrees and 75 degrees for total and upper type palsies, respectively). Within the palliative surgery-only groups, there were no significant differences between the preoperative and postoperative abduction and external rotation angles. The significant differences between the early surgery groups and the palliative surgery groups with total palsy during the preoperative period diminished postoperatively (p < 0.05 and p > 0.05, respectively) for abduction but not for external rotation. Within the upper type palsy groups, there were no significant differences between the preoperative and postoperative abduction and external rotation angles. In this study, it was found that in patients with total paralysis, satisfactory shoulder abduction values can
Tomonori, Kenmoku; Makoto, Kamegaya; Takashi, Saisu
We describe a new anchoring method for tarsal tendon transfers in myelomeningocele patients to protect the sole of the foot from pressure sores and skin necrosis and to loosen the tension of the transferred tendon.Tendon transfer procedures were performed in 51 feet (33 patients) with myelomeningocele. We transferred tibialis anterior tendons to the second or third cuneiform in 19 with equinovarus deformities, and transferred tibialis anterior tendons to the calcaneus through the interosseous membrane in 32 with talipes calcaneus. Clinical results were evaluated with the muscle power of transferred tendons using manual muscle testing 6 months after surgery. The muscle test result was classified as good, fair, and poor.After passing the tendon through the bony hole, a 2.0-mm Kirschner wire was inserted from the sole to the tibia through the ankle joint at neutral. (It extended from the sole through the posterior cortex of the tibia.) The remaining part of the wire was bent and formed into a loop shaped like the Greek letter "zeta" (zeta). The thread was then tied to the loop of the wire as tightly as possible. In this way, there was no contact with the sole during anchoring, thus avoiding ulcers. In addition, the transferred tendon could be kept stable because the patient's ankle was fixed by the Kirschner wire.No cases of wound infection or skin necrosis of the sole occurred. In 49 of the 51 cases, transferred tendons were firmly anchored to tarsal bones. Muscle strength was good for 83%, fair for 13%, and poor for 4%. Consequently, 45 feet could obtain plantigrade pattern during their walking with shoe inserts or occasional use of ankle-foot orthoses.Our anchoring method has the advantage of protecting the sole of the foot from pressure sores and skin necrosis, as well as maintaining tension on the transferred tendon until it settles down in an anchor hole.
Kozin, Scott H
Paralysis or irreparable injury to the radial or median nerve results in considerable impairment of hand function that directly affects activities of daily living. Radial nerve loss prevents wrist and digit extension, which hinders object acquisition and release. Median nerve loss deprives the hand of thumb function, especially opposition, which impedes prehension. Tendon transfers to restore function are indicated when nerve recovery is no longer expected. Tendon transfer can re-establish active movement and enhance function. The maximum benefit after tendon transfer, however, requires a close working relationship among patient, therapist, and physician. This article will highlight the surgical principles and rehabilitative process to achieve this goal.
Stevanovic, Milan V; Cuéllar, Vanessa G; Ghiassi, Alidad; Sharpe, Frances
In the upper extremity, the latissimus dorsi muscle can be used as an ipsilateral rotational muscle flap for soft-tissue coverage or functional reconstruction of arm and elbow. Patients who have both major soft-tissue loss and functional deficits can be successfully treated with a single-stage functional latissimus dorsi rotational muscle transfer that provides simultaneous soft-tissue coverage and functional reconstruction.
Konarik, Marek; Kachlik, David; Baca, Vaclav
A case of anomalous terminal branching of the axillary artery was encountered and described in a left upper limb of a male cadaver. A series of 214 upper limbs of Caucasian race was dissected. A variant artery, stemming from the very end of the axillary artery followed a superficial course distally. It passed the cubital fossa, ran on the lateral side of the forearm as usual radial artery, crossed ventrally to the palm and terminated in the deep palmar arch. This vessel is a case of the brachioradial artery (incorrectly termed as the “radial artery with high origin”). Moreover, it was associated with another variation, concerning the aberrant posterior humeral circumflex artery passing under the tendon of the latissimus dorsi muscle. The anatomical knowledge of the axillary region is essential for radiodiagnostic, surgical and traumatologic procedures. The superficially located artery brings an elevated danger of heavy bleeding in all unexpected situations, its variant branching can cause problems in radial catheterization procedures and the anomalously coursing other arterial variant poses an elevated danger in surgical procedures concerning the surgical neck of humerus. PMID:25428677
Konarik, Marek; Kachlik, David; Baca, Vaclav
A case of anomalous terminal branching of the axillary artery was encountered and described in a left upper limb of a male cadaver. A series of 214 upper limbs of Caucasian race was dissected. A variant artery, stemming from the very end of the axillary artery followed a superficial course distally. It passed the cubital fossa, ran on the lateral side of the forearm as usual radial artery, crossed ventrally to the palm and terminated in the deep palmar arch. This vessel is a case of the brachioradial artery (incorrectly termed as the "radial artery with high origin"). Moreover, it was associated with another variation, concerning the aberrant posterior humeral circumflex artery passing under the tendon of the latissimus dorsi muscle. The anatomical knowledge of the axillary region is essential for radiodiagnostic, surgical and traumatologic procedures. The superficially located artery brings an elevated danger of heavy bleeding in all unexpected situations, its variant branching can cause problems in radial catheterization procedures and the anomalously coursing other arterial variant poses an elevated danger in surgical procedures concerning the surgical neck of humerus.
Song, S J; Deland, J T
The flexor digitorum longus, the tendon most often used for transfer in posterior tibial tendon insufficiency, is one-half to one-third the size of the posterior tibial tendon. Occasionally it may be particularly small or may have been previously used for transfer. In these cases, the senior author has felt that the addition of a transfer of the Peroneus Brevis (PBr) tendon may be helpful in maintaining sufficient tendon and muscle mass to rebalance the foot. Thirteen patients who underwent this procedure were retrospectively identified and matched by age and length of follow-up to patients who underwent a more standard tendon transfer operation minus the addition of the PBr transfer. Pain and functional status were then assessed by the American Orthopaedic Foot and Ankle Society's ankle/hindfoot rating scale. Each patient was tested by an independent physical therapist to evaluate inversion and eversion strength. The mean duration of follow-up was 20.6 months (12 to 34 months). The average AOFAS score of the PBr group was 75.8 compared to 71.5 for the standard control group. There was no significant difference between the groups when inversion or eversion strengths were compared. Inversion strength and eversion strength was rated good or excellent (4 or 5) in 12 out of 13 of the PBr transfer group patients. No major complications were encountered in either group. Although it does not increase inversion strength, a PBr transfer can be used to augment a small FDL without causing significant eversion weakness. This can be useful when the FDL is particularly small or in revision surgery.
Gray, Kelly; Burns, Joshua; Little, David; Bellemore, Michael; Gibbons, Paul
Tibialis anterior tendon transfer surgery forms a part of Ponseti management for children with congenital talipes equinovarus who, after initial correction, present with residual dynamic supination. Although retrospective studies support good outcomes, prospective longitudinal studies in this population are lacking. We assessed strength, plantar loading, ROM, foot alignment, function, satisfaction, and quality of life in patients with clubfoot that recurred after Ponseti casting who met indications for tibialis anterior tendon transfer surgery, and compared them with a group of patients with clubfoot treated with casting but whose deformity did not recur (therefore who were not indicated for tibialis anterior tendon transfer surgery). Twenty children with idiopathic congenital talipes equinovarus indicated for tibialis anterior tendon transfer surgery were recruited. Assessment at baseline (before surgery), and 3, 6, and 12 months (after surgery) included strength (hand-held dynamometry), plantar loading (capacitance transducer matrix platform), ROM (Dimeglio scale), foot alignment (Foot Posture Index(©)), function and satisfaction (disease-specific instrument for clubfoot), and quality of life (Infant Toddler Quality of Life Questionnaire™). Outcomes were compared with those of 12 age-matched children with congenital talipes equinovarus not indicated for tibialis anterior tendon transfer surgery. Followup was 100% in the control group and 95% (19 of 20) in the tibialis anterior transfer group. At baseline, the tibialis anterior tendon transfer group had a significantly worse eversion-to-inversion strength ratio, plantar loading, ROM, foot alignment, and function and satisfaction. At 3 months after surgery, eversion-to-inversion strength, plantar loading, and function and satisfaction were no longer different between groups. Improvements were maintained at 12 months after surgery (eversion-to-inversion strength mean difference, 8% body weight; 95% CI, -26% to 11
Sarzaeem, Mohammad Mahdi; Lemraski, Mohammad Mahdi Bagherian; Safdari, Farshad
The purpose of this study was to evaluate the outcomes following reconstruction of the chronic Achilles tendon ruptures with large gaps (>6 cm) using free semitendinosus tendon graft transfer. There were 11 consecutive patients underwent the above-mentioned surgical technique for the treatment of chronically ruptured Achilles tendon contributed in current study and were followed up prospectively for a mean of 25 ± 3 months. The intraoperative tendon defect was greater than 6 cm in all of the patients. Functional and clinical assessment was performed using The American Orthopaedic Foot and Ankle Society (AOFAS) and Achilles Tendon Rupture Score (ATRS). The average AOFAS and ATRS improved significantly from 70 ± 5 and 32 ± 6 preoperatively, to 92 ± 5 and 89 ± 4 points post-operatively (P = 0.001). The range of dorsiflexion was significantly limited on the operated side (13 ± 4° vs. 17 ± 4°) (P = 0.04). All patients were able to stand on the tiptoe of injured leg, and no patient walked with a visible limp. Post-operative complications included one patient with symptomatic DVT and 2 patients with superficial infection treated nonoperatively. The technique offers good clinical and functional outcomes and is safe. Reconstruction of the chronic Achilles tendon ruptures with free semitendinosus tendon graft in patients with defects greater than 6 cm is recommended. IV.
Simonson, Devin C; Elliott, Andrew D; Roukis, Thomas S
Deep infection is one of the most devastating complications following repair of an Achilles tendon rupture. Treatment requires not only culture-driven antibiotic therapy, but more importantly, appropriate débridement of some or even all of the Achilles tendon. This may necessitate delayed reconstruction of the Achilles tendon. The authors present a successful case of reconstruction of a chronically infected Achilles tendon in an otherwise healthy 43-year-old man via a multistaged approach using the flexor hallucis longus and peroneus brevis tendons. We also provide a brief review of the literature regarding local tendon transfer used in the reconstruction of Achilles tendon rupture. Copyright © 2016 Elsevier Inc. All rights reserved.
Boahene, Kofi D O
Muscle tendon unit (MTU) transfer is a common procedure performed to restore hand function after peripheral nerve or spinal cord injury. The principles of MTU transfer established for hand surgery can be adopted to optimize the dynamic excursion of the temporalis tendon transfer procedure for facial reanimation. Additionally, the force generating ability of a transferred MTU depends on the ideal length-tension relationship of the donor muscle. There are unclear guideline for selecting the ideal tension at which a transferred MTU will generate maximum force and excursion and current practice often leads to overstretch and suboptimal actin myosin interaction. The use of intraoperative electrical stimulation is an option for determining the ideal tension to optimize excursion of transferred temporalis tendon units in simile restoration. Understanding the biomechanics and principles of MTU and applying it to the temporalis tendon transfer procedure is necessary to improve its use in facial reanimation. Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.
Dunn, Jennifer A; Sinnott, K Anne; Rothwell, Alastair G; Mohammed, Khalid D; Simcock, Jeremy W
After cervical spinal cord injury, the loss of upper limb function is common. This affects an individual's ability to perform activities of daily living and participate in previous life roles. There are surgical procedures that can restore some of the upper limb function lost after cervical spinal cord injury. Tendon transfer surgery has been performed in the tetraplegic population since the early 1970s. The goals of surgery are to provide a person with tetraplegia with active elbow extension, wrist extension (if absent), and sufficient pinch and/or grip strength to perform activities of daily living without the need for adaptive equipment or orthoses. These procedures are suitable for a specific group, usually with spinal cord impairment of C4-8, with explicit components of motor and sensory loss. Comprehensive team assessments of current functioning, environment, and personal circumstances are important to ensure success of any procedure. Rehabilitation after tendon transfer surgery involves immobilization for tendon healing followed by specific, targeted therapy based on motor learning and goal-orientated training. Outcomes of tendon transfer surgery are not limited to the improvements in an individual's strength, function, and performance of activities but have much greater life affects, especially with regard to well-being, employment, and participation. This article will provide an overview of the aims of surgery, preoperative assessment, common procedures, postoperative rehabilitation strategies, and outcomes based on clinical experience and international published literature.
Background Common peroneal nerve palsy leading to foot drop is difficult to manage and has historically been treated with extended bracing with expectant waiting for return of nerve function. Peroneal nerve exploration has traditionally been avoided except in cases of known traumatic or iatrogenic injury, with tendon transfers being performed in a delayed fashion after exhausting conservative treatment. We present a new strategy for management of foot drop with nerve exploration and concomitant tendon transfer. Method We retrospectively reviewed a series of 12 patients with peroneal nerve palsies that were treated with tendon transfer from 2005 to 2011. Of these patients, seven were treated with simultaneous peroneal nerve exploration and repair at the time of tendon transfer. Results Patients with both nerve repair and tendon transfer had superior functional results with active dorsiflexion in all patients, compared to dorsiflexion in 40% of patients treated with tendon transfers alone. Additionally, 57% of patients treated with nerve repair and tendon transfer were able to achieve enough function to return to running, compared to 20% in patients with tendon transfer alone. No patient had full return of native motor function resulting in excessive dorsiflexion strength. Conclusion The results of our limited case series for this rare condition indicate that simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone. PMID:25099247
de Moraes, Frederico Barra; Kwae, Mário Yoshihide; da Silva, Ricardo Pereira; Porto, Celmo Celeno; de Paiva Magalhães, Daniel; Paulino, Matheus Veloso
Objective To compare the gain in elbow flexion in patients with traumatic injury of the brachial plexus following muscle transfer from latissimus dorsi with the gain following free muscle transfer from the medial belly of the gastrocnemius. Methods This was a retrospective study in which the medical files of a convenience sample of 13 patients operated between 2000 and 2010 were reviewed. Group 1 comprised seven patients who underwent transfers from the gastrocnemius and group 2 (controls) comprised six patients who underwent transfers from the latissimus dorsi. The following functions were evaluated: (1) range of motion (ROM) of elbow flexion, in degrees, using manual goniometry and (2) grade of elbow flexion strength, using a muscle strength scale. Satisfactory results were defined as: (1) elbow flexion ROM ≥ 80° and (2) elbow flexion strength ≥ M3. The Fisher exact and Kruskal–Wallis tests were used (p < 0.05). Results The patients’ mean age was 32 years (range: 17–56) and 72% had been involved in motorcycle accidents. Elbow flexion strength ≥ M3 was observed in seven patients (100%) in group 1 and in five patients (83.3%) in group 2 (p = 0.462). None of the patients presented M5, and one patient (16.7%) in group 2 had a poor result (M2). Elbow flexion ROM with a gain ≥ 80° (daily functions) was found in six patients (86%) in group 1 and in three patients (50%) in group 2 (p = 0.1). Conclusion The patients in group 1 had greater gains in strength and ROM than did those in group 2, but without statistical significance. Thus, transfers from the gastrocnemius become a new surgical option, if other techniques cannot be used. PMID:27218077
Elgohary, Hatem Elsayed Ahmed; Elmoghazy, Nabil A; Abd Ellatif, Mohammed Serry
The aim of this study was to assess the functional outcomes after a combined FHL transfer and a gastrocnemius recession for treatment of chronic ruptures of Achilles tendon with a gap and to investigate the patient's satisfaction about the great toe function after transfer. 19 patients with chronic rupture of the Achilles tendon with a gap were treated with a flexor halluces longus tendon transfer combined with a gastrocnemius recession, Clinical diagnosis depends on the presence of gap in the tendon on examination, inability of tip toe walking on the affected side and positive calf-squeeze test, MRI was used to confirm the clinical diagnosis. American Orthopedic Foot & Ankle Society hind foot score was used for assessment of the results. The AOFAS score improved significantly from a mean of 65 preoperatively to 94 at the last follow up (p<0.001), there was no significant difference in the final outcome between patients with FHL tendon weaved through the stump of the Achilles tendon and those with trans osseous tunnels, the mean AOFAS score at the last follow up was 94.2, 93.8 respectively, no patient complained of big toe dysfunction. Management of chronic rupture of the Achilles tendon with a gap with flexor halluces longus tendon transfer combined with a gastrocnemius recession is a safe and reliable method with a significantly improved functional outcome, muscle advancement through gastrocnemius recession decreases the length of the gap without affecting the muscle function, flexor halluces longus tendon transfer doesn't harm the big toe function. Copyright Â© 2016 Elsevier Ltd. All rights reserved.
Deymier-Black, Alix C.; Pasteris, Jill D.; Genin, Guy M.; Thomopoulos, Stavros
Several features of the tendon-to-bone attachment were examined allometrically to determine load transfer mechanisms. The humeral head diameter increased geometrically with animal mass. Area of the attachment site exhibited a near isometric increase with muscle physiological cross section. In contrast, the interfacial roughness as well as the mineral gradient width demonstrated a hypoallometric relationship with physiologic cross-sectional area (PCSA). The isometric increase in attachment area indicates that as muscle forces increase, the attachment area increases accordingly, thus maintaining a constant interfacial stress. Due to the presence of constant stresses at the attachment, the micrometer-scale features may not need to vary with increasing load. PMID:26355607
Nalbantoğlu, Ufuk; Ozkan, Türker; Türkmen, I Metin
The purpose of this study was to evaluate the results of tendon transfers in patients with irreparable radial nerve palsy. The study included 29 patients (5 females, 24 males; mean age 29 years; range 9 to 51 years) who underwent tendon transfers for radial nerve palsy. Four patients had low- and 25 patients had high-level radial nerve palsy. The mean duration of tendon transfer after injury (paralysis time) was 19.7 months (range 1 day to 180 months). Clinical evaluations included joint range of motion and muscle strengths. Functional evaluation was made using the Tajima criteria. The mean follow-up was 56.9 months (range 5 to 90 months). Muscle strengths were measured as follows: 3 (n=3), 4 (n=10), and 5 (n=12) for the wrist extensor muscle; 3 (n=7), 4 (n=10), and 5 (n=12) for the finger extensor muscle; and 3 (n=6), 4 (n=13), and 5 (n=10) for the thumb extensor muscle. The mean wrist range of motion was 67.4 degrees , extension was 48.3 degrees (10 degrees to 70 degrees ), and flexion was 21.5 degrees (10 degrees to 55 degrees ). The mean metacarpophalangeal joint extension was 1.7 degrees (0 degrees to 12 degrees ), thumb abduction was 45.6 degrees (34 degrees to 56 degrees ), and thumb interphalangeal joint extension was 18 degrees (0 degrees to 30 degrees ). According to the Tajima criteria, the results were excellent in 15 patients (51.7%), good in nine patients (31%), and moderate in five patients (17.2%). Eight patients (27.6%) had radial deviation deformity and four patients (13.8%) had 1-level weaker finger extensor muscle strength compared to the other fingers. The flexor carpi ulnaris (FCU) was used in the transfer of patients who developed radial deviation deformity. Treatment of irreparable radial nerve palsy with tendon transfers yields successful results. Radial deviation deformity mostly occurs in patients receiving FCU transfer for finger extension.
Giuffre, Jennifer L; Bishop, Allen T; Spinner, Robert J; Shin, Alexander Y
After reading this article, the participant should be able to: 1. Identify the prerequisite conditions to perform a tendon or a nerve transfer. 2. Detail some of the current nerve and tendon transfer options in upper extremity peripheral nerve injuries. 3. Understand the advantages and disadvantages of tendon and nerve transfers used in isolation and in combination. 4. Appreciate the controversies that surround the nerve/tendon transfers. 5. Realize the treatment outcomes of peripheral nerve injuries. Traditional treatment of a Sunderland fourth- or fifth-degree peripheral nerve injury has been direct neurorrhaphy, nerve grafting, or tendon transfers. With increasing knowledge of nerve pathophysiology, additional treatment options such as nerve transfers have become increasingly popular. With an array of choices for treating peripheral nerve injuries, there is debate as to whether tendon transfers and/or nerve transfers should be performed to restore upper extremity function. Often, tendon and nerve transfers are used in combination as opposed to one in isolation to obtain the most normal functioning extremity without unacceptable donor deficits. The authors tend to prefer reconstructive techniques that have proven long-term efficacy to restore function. Nerve transfers are becoming more common practice, with excellent results; however, the authors are wary of using nerve transfers that sacrifice possible secondary tendon reconstruction should the nerve transfer fail.
Maffulli, N; Oliva, F; Costa, V; Del Buono, A
We hypothesised that a minimally invasive peroneus brevis tendon transfer would be effective for the management of a chronic rupture of the Achilles tendon. In 17 patients (three women, 14 men) who underwent minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum, at a mean follow-up of 4.6 years (2 to 7) the modified Achilles tendon total rupture score (ATRS) was recorded and the maximum circumference of the calf of the operated and contralateral limbs was measured. The strength of isometric plantar flexion of the gastrocsoleus complex and of eversion of the ankle were measured bilaterally. Functional outcomes were classified according to the four-point Boyden scale. At the latest review, the mean maximum circumference of the calf of the operated limb was not significantly different from the pre-operative mean value, (41.4 cm, 32 to 50 vs 40.6 cm, 33 to 46; p = 0.45), and not significantly less than that of the contralateral limb (43.1 cm, 35 to 52; p = 0.16). The mean peak torque (244.6 N, 125 to 367) and the strength of eversion of the operated ankle (149.1 N, 65 to 240) were significantly lower (p < 0.01) than those of the contralateral limb (mean peak torque 289, 145 to 419; strength of eversion: 175.2, 71 to 280). The mean ATRS significantly improved from 58 pre-operatively (35 to 68) to 91 (75 to 97; 95% confidence interval 85.3 to 93.2) at the time of final review. Of 13 patients who practised sport at the time of injury, ten still undertook recreational activities. This procedure may be safely performed, is minimally invasive, and allows most patients to return to pre-injury sport and daily activities. ©2015 The British Editorial Society of Bone & Joint Surgery.
Cuéllar, Vanessa G.; Ghiassi, Alidad; Sharpe, Frances
Introduction: In the upper extremity, the latissimus dorsi muscle can be used as an ipsilateral rotational muscle flap for soft-tissue coverage or functional reconstruction of arm and elbow. Patients who have both major soft-tissue loss and functional deficits can be successfully treated with a single-stage functional latissimus dorsi rotational muscle transfer that provides simultaneous soft-tissue coverage and functional reconstruction. Methods: Our data base was queried for all patients undergoing a rotational latissimus dorsi muscle transfer for simultaneous soft-tissue coverage and functional reconstruction of elbow flexion. Four patients were identified. A chart review documented the mechanism of injury, associated injuries, soft-tissue defect size, number of surgical procedures, length of follow-up, last elbow range of motion, and flexion strength. Results: Four patients with loss of elbow flexion due to traumatic loss of the anterior compartment muscles and the overlying soft tissue underwent simultaneous soft-tissue coverage and elbow flexorplasty using the ipsilateral latissimus dorsi as a bipolar muscle rotational tissue transfer. All flaps survived and had a recovery of Medical Research Council Grade 4/5 elbow flexion strength. No additional procedures were required for elbow flexion. The surgical technique is described and supplemented with surgical technique video and patient outcome. Conclusions: This patient series augments the data provided in other series supporting the safety and efficacy of this procedure which provides both soft-tissue coverage and functional restoration of elbow flexion as a single-stage procedure in the setting of massive traumatic soft-tissue loss of the arm. PMID:27757363
Du, Jun-feng; Zhu, Yang-yi
To explore the clinical effect of interference screw and flexor hallucis longus tendon as augmentation material in repair of chronic Achilles tendon rupture. From September 2010 to June 2012,26 patients with chronic Achilles tendon rupture were treated, including 18 males and 8 females with an average age of 44.2 years old (20 to 66 years old). All patients were unilateral damage. MRI showed the Achilles tendon.ends' distance was 6.0 to 9.0 cm. The postoperative complications were observed. The curative effect was assessed by American Orthopedic Foot and Ankle Society and Leppilahti score. All the 26 patients were followed up for 18 to 68 months (means 30.4 months). No neurological injury and infection of incision occurred, all patients were stage I incision healing. The shape and function of the ankle were recovered well. The average AOFAS score increased from 52.27±12.30 preoperatively to 90.92±6.36 postoperatively. Leppilahti Achilles Tendon Repair score increased from 34.23±12.86 preoperatively to 90.00±5.10 postoperatively. The flexor hallucis tendon transfer with an interference screw technique for repairing the chronic Achilles tendon rupture of type IV of Kuwada had advantages of simple operation, quick recovery, firm tendon fixation, and less complications.
As tendon transfer of the flexor hallucis longus (FHL) and the flexor digitorum longus (FDL) is an established procedure, exact knowledge of the formation of the chiasma plantare is of great interest. Although the quadratus plantae (QP) appears to play a major role, it has been rarely addressed in previous studies. The aim of the present study was to reinvestigate the formation of the chiasma plantare and the composition of the long flexor tendons in order to clarify the inexact and partly contradictory descriptions published from 1865 onward. The chiasma plantare and the long flexor tendons in both feet of 50 formalin-fixed specimens of body donors (25 men and women) were analyzed by gross anatomical dissection. It was composed of one (3%), two (69%) or three layers (28%) which were variably established by the tendinous and muscular fibers of the FHL, the FDL and the QP. In 61% the FHL gave one or more slips to the FDL, and in 39% there was a bidirectional interconnection between the two tendons. The slip from the FHL to the FDL largely reinforces the second (45%), or the second and third tendon (46%). Thus, the FHL is involved in the first tendon in all cases, in the second one in 97% of cases, and in the third tendon in about one half of cases (53%). In all instances, the FDL contributes to the third to fourth, in 98% the second, and in at least 39% to the first tendon. The QP reinforces the second to fourth tendon in nearly all cases, the fifth in about one half of cases, and even the first tendon in 14% of cases. In addition, the individual composition of the five long flexor tendons arising from the chiasma plantare was analyzed in detail. Special emphasis was placed on the evaluation of side and sex differences as well as individual symmetry. Furthermore, biomechanical, developmental and phylogenetic aspects were outlined. In terms of the outcome of this study, the FHL appears to be the better donor for tendon transfer to restore lost function, but
Martínez-Villén, G; Muñoz-Marín, J; Pérez-Barrero, P
There have been very few reports about results of tendon transfers carried out in very old radial palsies affecting the hand. We present two cases of radial palsy operated 52 and 30 years after the original injury, which also had after-effects in pronosupination due to elbow injuries. In the first patient, with high radial-nerve palsy, we made a triple transfer of the pronator teres to the extensor carpi radialis brevis, the flexor carpi ulnaris to the extensor digitorum communis and the palmaris longus to the extensor pollicis longus. In the second case, which had posterior interosseous nerve palsy, we transferred the flexor carpi radialis to the extensor digitorum communis, and the brachiorradialis to the extensor pollicis longus. The surgical findings showed a 'gelatinous degeneration' in some of the receiving tendons, which did not prevent the sutures from being resistant. The first patient, who had a stiff elbow, with pronosupination blocked since childhood, showed disuse atrophy of the pronator teres, which conditioned a late rupture of the tenomuscular junction and required a second surgery for wrist arthrodesis. Results after postoperative period of 30 months after surgery in the first patient, and 14 months after surgery in the second one, showed functional recovery in finger range of extension, grip and key-pinch strength and a significantly higher QuickDASH score, restoring the natural aesthetical appearance of the limb. This facilitated the return to professional and daily activities, re-establishing a fine ability to grab and release objects. Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Schon, Lew C; Shores, Jennifer L; Faro, Frances D; Vora, Anand M; Camire, Lyn M; Guyton, Gregory P
In patients with Achilles tendinosis, Achilles tendon debridement can be supplemented with flexor hallucis longus tendon transfer. Outcomes have not been studied prospectively in older, sedentary, and overweight patients. Fifty-eight consecutive limbs in fifty-six consecutive older, sedentary patients with insertional or midsubstance Achilles tendinosis were enrolled prospectively and underwent the procedure. Ten patients were lost to follow-up, leaving forty-eight limbs in forty-six patients available for evaluation after twenty-four months. The forty-six patients who were included in the study had an average age of 54 ± 10 years with an average body mass index of 33.8 ± 6.8 kg/m². Significant improvement was observed between baseline and twenty-four months in terms of the visual analog scale for overall pain intensity (6.7 ± 2.3 versus 0.8 ± 2.0; p < 0.001), the Short Form-36 physical score (34.3 ± 8.0 versus 49.0 ± 9.3; p < 0.001), the Ankle Osteoarthritis Scale pain (54.4 ± 19.2 versus 1.9 ± 2.7; p < 0.001) and dysfunction (62.6 ± 21.4 versus 11.0 ± 24.2; p < 0.001) subscale scores, and performance of a single-leg heel rise (1.9 ± 3.0 versus 7.3 ± 2.7 cm; p < 0.001). Significant improvement compared with baseline was observed at three or six months except in the single-leg heel rise. Improvements in terms of pain and function occurred over twenty-four months, with the most improvement occurring in the first twelve months. At twenty-four months, maximum gastrocnemius circumference was significantly less in the involved compared with the uninvolved leg (40.2 ± 5.1 versus 41.2 ± 4.8 cm; p < 0.001). The mean passive range of motion of the first metatarsophalangeal joint decreased from 85.1° ± 25.3° preoperatively to 68.1° ± 36.7° (a 20% change) at six months (p = 0.03). Most patients reported no hallux weakness (57%; twenty-six of forty-six patients) and no loss of balance due to hallux weakness (76%; thirty-five of forty-six patients
Rahm, Stefan; Spross, Christian; Gerber, Fabienne; Farshad, Mazda; Buck, Florian M; Espinosa, Norman
Transfer of the flexor hallucis longus (FHL) tendon aims to restore function and relieve pain in chronic Achilles tendon (AT) disease. The goal of the present study was to investigate the clinical and radiographic outcomes of FHL transfer to the AT and to compare the transtendinous technique to the transosseous technique. We hypothesized that the type of technique would have a notable impact on outcome. Forty patients (42 ankles) were retrospectively reviewed and divided into group 1 (transtendinous technique, 22 patients/24 ankles) and group 2 (transosseous technique, 18 patients/18 ankles). Outcome parameters included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Foot Function Index (FFI), and Short Form-36 (SF-36) scores. Magnetic resonance imaging of the lower leg was performed preoperatively to assess muscle quality and fatty infiltration. Postoperatively, isokinetic plantar flexion strength was assessed using a Con-Trex dynamometer. In group 1 (follow-up, 73 months; age, 52 years), the AOFAS score improved from 66 points to 89 points (P < .001) with average values for the VISA-A of 76 points, FFI-D pain 15%, and FFI-D function 22%. In group 2 (follow-up, 35 months; age, 56 years), the AOFAS score increased from 59 points to 85 points (P < .001) with mean values for the VISA-A 76 points, FFI-D pain 25%, and FFI-D function 24%. At follow-up, the average SF-36 score in group 1 was 66% and in group 2 was 77%. Isokinetic testing at 30 deg/s in group 1 revealed notable weakness in the operated ankle averaging 54.7 N·m (75% of normal), and in group 2 the average was 58.2 N·m (77% of normal). No statistically significant differences were found between the groups. The hypothesis was disproved. Both techniques for FHL transfer to AT, intratendinous and transosseous, provided good to excellent clinical and functional outcome in the treatment of irreparable AT disease. Level III
Lui, Tun Hing
Flexor hallucis longus (FHL) tendon transfer is indicated for reconstruction of the Achilles tendon with a gap larger than 5 cm. The tendon can be harvested at zone 2 or zone 3 by minimally invasive techniques with the advantage of minimal soft-tissue dissection. The tendon can be harvested under the sustentaculum tali by zone 2 FHL tendoscopy. It is adequate for FHL transfer to the posterior calcaneal tubercle. If a double-thickness reconstruction of a huge gap of the Achilles tendon is indicated, the tendon can be harvested at the level of the hallux by means of a tendon stripper. However, the interconnection tendon of the master knot of Henry can be split together with the FHL or flexor digitorum longus tendon instead of being cut. Zone 2 FHL tendoscopy can be used to release the split tendon to complete the FHL harvest.
Lyle, Mark A; Nichols, T Richard; Kajtaz, Elma; Maas, Huub
Tendon transfer surgeries are performed to restore lost motor function, but outcomes are variable, particularly those involving agonist-to-antagonist muscles. Here, we evaluated the possibility that lack of proprioceptive feedback reorganization and musculotendon adaptations could influence outcomes. Plantaris-to-tibialis anterior tendon transfer along with resection of the distal third of the tibialis anterior muscle belly was performed in eight cats. Four cats had concurrent transection of the deep peroneal nerve. After 15-20 weeks, intermuscular length and force-dependent sensory feedback were examined between hindlimb muscles, and the integrity of the tendon-to-tendon connection and musculotendon adaptations were evaluated. Three of the transferred tendons tore. A common finding was the formation of new tendinous connections, which often inserted near the original location of insertion on the skeleton (e.g., connections from plantaris toward calcaneus and from tibialis anterior toward first metatarsal). The newly formed tissue connections are expected to compromise the mechanical action of the transferred muscle. We found no evidence of changes in intermuscular reflexes between transferred plantaris muscle and synergists/antagonists whether the tendon-to-tendon connection remained intact or tore, indicating no spinal reflex reorganization. We propose the lack of spinal reflex reorganization could contribute the transferred muscle not adopting the activation patterns of the host muscle. Taken together, these findings suggest that musculotendon plasticity and lack of spinal reflex circuitry reorganization could limit functional outcomes after tendon transfer surgery. Surgical planning and outcomes assessments after tendon transfer surgery should consider potential consequences of the transferred muscle's intermuscular spinal circuit actions. © 2017 The Authors. Physiological Reports published by Wiley Periodicals, Inc. on behalf of The Physiological Society and
Owusu Boahene, Kofi D
Temporalis muscle tendon unit (MTU) transfer may be used as a single-stage procedure for dynamic reanimation of the paralyzed face. Principles and biomechanics of muscle function and tendon transposition are essential in optimizing outcome. Critical steps and pearls for success include minimizing scarring, maintaining glide plains, mobilizing adequate tendon length, insertion of MTU at ideal tension based on intraoperative dynamic tension-excursion relationship, and insertion of tendon as close to the lip margin as possible. Because muscles adapt to tension, load, and task changes by altering their sarcomere arrangement and muscle fiber composition, physiotherapy should be initiated to use the repurposed temporalis MTU for smile restoration.
Oksanen, Maria M; Haapasalo, Heidi H; Elo, Petra P; Laine, Heikki-Jussi
Flexor hallucis longus tendon (FHLT) transfer has become a popular method for reconstructing a chronic Achilles tendon rupture (ATR). The purpose of this study was to evaluate the clinical outcomes and possible hypertrophy of the FHL muscle after FHLT transfer in patients with chronic ATR. Seven patients with chronic ATR underwent an FHLT transfer to heel through single incision. The patients were clinically evaluated 27 (16-39) months after the surgery. The patient satisfaction was assessed with Achilles Tendon Total Rupture Scale (ATRS). Isokinetic strength was measured from both legs. The FHL muscle hypertrophy was evaluated from MRI of both legs. All subjects also performed a gait analysis with an instrumented walkway system (GAITRite(®)). The plantar flexion strength was 16.1% (-45, 7-2, 4%) weaker in the operated leg. ATRS scores averaged 70.3. Marked hypertrophy, +52% (9-104%) of the FHL muscle was seen in the operated leg compared to the non-operated leg. The gait analysis did not show any marked pathology in any of the patients. A mean hypertrophy of 52% of the FHL muscle was found after FHLT transfer for the chronic ATR. This indicates strong adaptation capacity of this muscle after FLHT transfer in situation where the function of the gastro-soleus complex was severely impaired preoperatively. The reconstruction of chronic ATR with FHLT transfer provided a good functional outcome and excellent patient satisfaction. Copyright © 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Kim, J-Young; Lee, Inmook; Seo, Kyungwon; Jung, Woosung; Kim, Byungkwan
In diabetics, although heel ulcers occurring after Achilles tendon lengthening for managing forefoot ulcers are rare, they are a very troublesome complication. The purpose of this study was to evaluate the results of FHL tendon transfer for management of a plantar heel ulcer as a sequelae of insufficiency of the Achilles tendon in diabetic patients. Nine diabetic patients who underwent FHL tendon transfer for treatment of non-healing plantar heel ulcers due to insufficiency of the Achilles tendon for management of forefoot ulcers were treated between October 2005 and April 2007. All of the patients had undergone Achilles tendon lengthening with Hoke's triple hemisection method. The mean age was 55.9 +/- 9.7 years old. The average duration of a plantar heel ulcer was 11.9 +/- 3.8 months. The mean period of followup was 23.9 +/- 8.0 months. Between the occurrence of a heel ulcer and the FHL transfer, five of the patients underwent more than one attempt at direct Achilles tendon repair. The mean size of the wound was 1.2 +/- 0.6 cm2. We assessed the healing time of the heel plantar ulcers and recurrence rates during followup periods. The complication rate and walking ability was also evaluated. All of the plantar heel ulcers healed within 8 weeks after the operation and had not recurred as of the last followup. Two patients had recurrences of previous forefoot ulcers. One patient had a local infection in the FHL tendon transfer area. All of patients could walk without a brace or walking aid device after surgery. We believe that Achilles tendon reconstruction using an FHL transfer for non-healing plantar heel ulcers resulting from a triple Hoke lengthening of the Achilles tendon is a good treatment option for diabetic patients.
Halanski, Matthew A; Abrams, Sam; Lenhart, Rachel; Leiferman, Ellen; Kaiser, Teresa; Pierce, Emily; Franklin, Rachel Rebekah; Opel, Dayton; Noonan, Kenneth J; Crenshaw, Thomas D
Tibialis anterior tendon transfers (TATT) are commonly performed in young children following Ponseti casting for clubfeet. The classic TATT involves advancing the tendon through a hole drilled in the ossified cuneiform. The aim of this study was to determine if tendons transferred through unossified bones have untoward effects on subsequent bone development. Twenty-five piglets underwent one of five surgical procedures. An 18-gauge needle was then used to place a tunnel through the bony or cartilaginous portion of the calcaneus (through direct visualization) and isolated slips of the flexor digitorum superficialis (FDS) were placed through the tunnels, as determined by surgical procedure. Radiographic and/or histologic evaluations of the calcaneal apophyses were then performed. A discrete (1-4) and dichotomous "Normal" or "Abnormal" scoring system was developed and its reliability assessed to grade the appearance of the calcanei. Calcaneal appearances following the surgical procedures were then compared with controls. The average load to failure of a subset of transferred tendons was then compared using an MTS machine. The proposed apophyseal grading system (1-4) demonstrated an intraclass correlational coefficient (ICC) for consistency of 0.92 [95% confidence interval (CI) 0.88 < ICC < 0.95] and ICC for agreement of 0.91 (95% CI 0.86 < ICC < 0.95), indicating strong agreement and consistency. Similarly, Fleiss' kappa for the 1-4 scoring system was found to be 0.67, indicating substantial agreement between reviewers. When the 1-4 system was translated into the dichotomous scheme "Normal" and "Abnormal", the kappa value increased to 0.94, indicating strong agreement. Forty-six apophyses (13 control and 33 operative) were assessed using this scoring scheme. Apophyseal transfers were significantly more abnormal than controls (p < 0.0001), while no difference in abnormalities was found following tunnel placement alone (p = 1). Mechanical testing of the
Huang, Deqing; Balian, Gary; Chhabra, A Bobby
Technologic improvements in the field of tissue engineering are leading to new potential developments in the currently used approaches to treat tendon injuries including difficult clinical scenarios such as zone II flexor tendon injuries of the hand and the mutilated hand with extensive tendon defects. A combination of mesenchymal (adult stem) cells, growth factors, and bioresorbable polymers can provide a solution for the treatment of difficult tendon injuries. Extensive research is needed to show that the extracellular matrix produced in response to the cell/growth factor/polymer composites in vivo is effective and functional as a regenerate tissue. Further exciting advances are foreseen in cell-based genetic engineering with the transfer of DNA to the site of tendon lacerations. These treatment modalities require improved safety precautions to reduce the risks and enhance the benefits of gene therapy.
Shen, Po-Chih; Chou, Shih-Hsiang; Chen, Jian-Chih; Chen, Shu-Jung; Tien, Yin-Chun
Favorable results have been reported for tibialis posterior tendon transfers, which can effectively restore the dorsiflexion of the ankle and normal heel-to-toe gait. However, the commonly used methods for anchoring the transplanted tendon have some drawbacks. Therefore, we developed a new tendon-anchoring method to improve fixation of the transferred tendon and reduce the related complications. The new method entails tying the anchoring suture to the navicular bone instead of the button on the plantar foot to avoid wound complications. It requires no additional skin incisions or special equipment. We retrospectively evaluated 24 feet of 19 pediatric patients (13 [68.4%] females and 6 [31.6%] males) who had undergone anterior transfer of the tibialis posterior tendon with our new method from 2000 to 2013. All patients were clinically followed up. At the final follow-up visit, they were evaluated while standing and walking, and the range of motion of the foot was evaluated. The mean age at surgery was 7.8 (range 2 to 16) years. At the longest follow-up point, all the patients exhibited improved gait, except for 1 patient who required a secondary procedure. All the transferred tibialis posterior tendons could be palpated with certainty during active dorsiflexion or withdrawal of the foot. No tendon displacements, wound infections, or postoperative complications were observed. Fixation of a transferred tibialis posterior tendon by tying the suture to the navicular bone is simple and reliable. This technique can efficiently prevent the plantar ulcers that can develop with the traditional pull-out button method and provides a solution when appropriate-size bioabsorbable interference screws are unavailable. Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Turgut, Gursel; Kayalı, Mahmut Ulvi; Köse, Ozkan; Baş, Lütfü
Composite tissue loss in extremities involving neurovascular structures has been a major challenge for reconstructive surgeons. Reconstruction of large defects can only be achieved with microsurgical procedures. The success of free flap operations depends on the presence of healthy recipient vessels. In cases with no suitable donor artery and vein or in which even the use of vein grafts would not be feasible, the lower limb can be salvaged with a cross-leg free flap procedure. We present a case with a large composite tissue loss that was reconstructed with cross-leg free transfer of a combined latissimus dorsi and serratus anterior muscle flap. This case indicates that this large muscle flap can survive with the cross-leg free flap method and this technique may be a viable alternative for large lower extremity defects that have no reliable recipient artery.
Lui, Tun Hing
Chronic tendinopathy is characterized by pain in the tendon, generally at the start and completion of exercise. However, tendinosis may lead to decreased blood flow, increased stiffness of the tendon and reduced tensile strength, and predispose to rupture. Operative treatment is indicated to restore the function of the Achilles tendon and alleviate the prerupture heel cord pain. A case of acute Achilles tendon rupture with extensive tendinosis that was successfully treated with minimally invasive flexor hallucis longus transfer is reported.
Moussavi, Alia Ayatollahi; Saied, Alireza; Karbalaeikhani, Ali
Tendon transfer for radial nerve paralysis has a 100 years history and any set of tendons that can be considered to be useful has been utilized for the purpose. The pronator tress is used for restoration of wrist dorsiflexion, while the flexor carpi radialis, flexor carpiulnaris, and flexor digitorum superficialis are variably used in each for fingers and thumb movements. The present study was a retrospective analysis, designed to compare three methods of tendon transfer for radial nerve palsy. 41 patients with irreversible radial nerve paralysis, who had underwent three different types of tendon transfers (using different tendons for transfer) between March 2005 and September 2009, included in the study. The pronator teres was transferred for wrist extention. Flexor carpi ulnaris (group 1, n=18), flexor carpi radialis (group 2, n=10) and flexor digitorum superficialis (group 3, n=13) was used to achieve finger extention. Palmaris longus was used to achieve thumb extention and abduction. At the final examination, related ranges of motions were recorded and the patients were asked about their overall satisfaction with the operation, their ability, and time of return to their previous jobs, and in addition, disabilities of the arm, shoulder and hand (DASH) Score was measured and recorded for each patient. The difference between the groups with regard to DASH score, ability, and time of return to job, satisfaction with the operation, and range of motions was not statistically significant (P>0.05). All of the patients had experienced functional improvement and overall satisfaction rate was 95%. No complication directly attributable to the operation was noted, except for proximal interphalangeal joint flexion contracture in three patents. The tendon transfer for irreversible radial nerve palsy is very successful and probably the success is not related to type of tendon used for transfer.
Sowa, Yoshihiro; Morihara, Toru; Kushida, Rie; Sakaguchi, Koichi; Taguchi, Tetsuya; Numajiri, Toshiaki
Several investigators have evaluated the impaired function of the shoulder after removal of the latissimus dorsi muscle for breast reconstruction. However, a few investigators have studied whether including radiotherapy has a negative effect on functional recovery of the shoulder by a long-term follow-up after surgery. In this study, we compared objective measurements of shoulder function preoperatively and postoperatively for 3 years after latissimus dorsi muscle (LDM) flap transfer and postoperative radiotherapy (PRT). Eighteen patients who underwent unilateral transfer of a pedicled LDM flap and PRT within 2 months of breast-conserving surgery were enrolled in this study. Range of motion (ROM) and muscle strength in exhaustive shoulder movements were measured before surgery, and at 3 and 6 months, and 1 and 3 years. The results of ROM measurements at 3months postsurgery showed significant decreases in both flexion and abduction by 7.1 and 9.2 % and at 3 years postsurgery by 4.7 and 5.7 %. The muscle strength measurements at 3 months postsurgery showed statistically significant decreases both in adduction and in the 2nd medial rotation by 30.7 and 25.9 % and at 3 years postsurgery by 36.4 and 20.4 %. A significant improvement in these impairments was not observed for 3 years after surgery compared with that at 3 months after surgery. A combination of the LDM flap procedure and PRT could be associated with a higher incidence of tissue adhesions in both flexion and abduction and muscle deficit both in adduction and in the 2nd medial rotation.
Okazaki, Mutsumi; Mutsumi, Okazaki; Kentaro, Tanaka; Noriko, Uemura; Satoshi, Usami; Tsutomu, Homma; Alisa, Okubo; Mayuko, Hamanaga; Hiroki, Mori
Various types of neurovascular free-muscle transfers have been reported as surgical treatments for long-standing facial paralysis. Among one-stage methods, two approaches, that is, latissimus dorsi transfer with nerve suturing to the contralateral facial nerve and gracilis transfer with nerve suturing to the ipsilateral masseteric nerve, have recently become popular. The former method has the advantage of making spontaneous smiling possible, but the contraction strength of the transferred muscle varies, whereas the latter approach has the advantage of guaranteeing voluntary contraction of the transferred muscle, but makes spontaneous smiling difficult. Recently, dual innervation methods have also been reported, but uncertainty remains about the utility of such approaches. To overcome these drawbacks, we devised a hybrid method combining the two previously established techniques. Two latissimus dorsi muscle flaps containing the thoracodorsal vessels from one side are transferred with a pair of vascular anastomoses. The true trunk of the thoracodorsal nerve, which innervates one of the muscle flaps, is sutured to the contralateral facial nerve, while the short branch of the thoracodorsal nerve, which innervates the other muscle flap, is sutured to the ipsilateral masseteric nerve. From November 2011 to October 2013, we used this method in four patients with long-standing facial paralysis. Smiling was assessed in the three patients who were followed up for more than 1 year, and satisfactory results were obtained (Harii score: 4-5). In one patient, the movement mediated via the contralateral facial nerve was a little weak, but this was compensated for by the muscles controlled by the ipsilateral masseteric nerve. Our novel one-stage method, which involves a combination of two previously established methods, guarantees early voluntary smiling, and spontaneous smiling becomes possible later. In addition, it is free from the uncertainty associated with double innervation
Koulaxouzidis, G; Stark, G B; Lampert, F M
Restoration of active extension of wrist, thumb and digits by muscle-tendon transposition. Radial nerve palsy due to peripheral nerve injury. Peripheral nerve disease. Muscle or tendon injury. Restoration of wrist extension in high radial nerve palsy. Reversible distal radial nerve palsy, absence of suitable donor muscles, spasticity, limited range of motion of affected joints, extensive scarring and inappropriate soft tissue conditions, unjustifiable loss of function at donor site. Reinnervated donor muscles, progressive muscle disease, insufficient patient compliance. Dissection of the flexor carpi ulnaris, palmaris longus and pronator teres tendon insertion. Transposition of the tendons. Interweaving of tendons of the pronator teres and extensor carpi radialis brevis muscles, the extensor digitorum communis and flexor carpi ulnaris muscles, as well as the extensor pollicis longus and palmaris longus muscles using the Pulvertaft technique. 3 Weeks immobilization in forearm splint. Additional immobilization for 2 weeks at night. Subsequently, intensive physical and occupational therapy for another 4-6 weeks is required, starting 3 weeks postoperatively. The procedure was carried out in 12 patients over the past 14 years. We treated proximal radial nerve palsy in nine cases. In accordance with the current medical literature, we consider the described motor replacement surgery a reliable procedure.
Merenda, Lisa A.; Rutter, Laure; Curran, Kimberly; Kozin, Scott H.
Background: Tendon transfer surgery can restore elbow extension in approximately 70% of persons with tetraplegia and often results in antigravity elbow extension strength. However, we have noted an almost 15% rupture/attenuation rate. Objective: This investigation was conducted to analyze potential causes in adolescents/young adults with spinal cord injury (SCI) who experienced tendon rupture or attenuation after biceps-to-triceps transfer. Methods: Medical charts of young adults with SCI who underwent biceps-to-triceps transfer and experienced tendon rupture or attenuation were reviewed. Data collected by retrospective chart review included general demographics, surgical procedure(s), use and duration of antibiotic treatment, time from tendon transfer surgery to rupture/attenuation, and method of diagnosis. Results: Twelve subjects with tetraplegia (mean age, 19 years) who underwent biceps-to-triceps reconstruction with subsequent tendon rupture or attenuation were evaluated. Mean age at time of tendon transfer was 18 years (range, 14-21 years). A fluoroquinolone was prescribed for 42% (n=5) of subjects. Tendon rupture was noted in 67% (n=8), and attenuation was noted in 33% (n=4). Average length of time from surgery to tendon rupture/attenuation was 5.7 months (range, 3-10 months). Conclusion: Potential contributing causes of tendon rupture/attenuation after transfer include surgical technique, rehabilitation, co-contraction of the transfer, poor patient compliance, and medications. In this cohort, 5 subjects were prescribed fluoroquinolones that have a US Food and Drug Administration black box concerning tendon ruptures. Currently, all candidates for upper extremity tendon transfer reconstruction are counseled on the effects of fluoroquinolones and the potential risk for tendon rupture. PMID:23459326
Mardula, Katherine L; Balasubramanian, Ravi; Allan, Christopher H
The purpose of this study was to investigate if a new tendon transfer surgical procedure that uses an implanted passive engineering mechanism for attaching multiple tendons to a single donor muscle in place of directly suturing the tendons to the muscle improves hand function in physical interaction tasks such as grasping. The tendon transfer surgery for high median ulnar palsy was used as an exemplar, where all four flexor digitorum profundus (FDP) tendons are directly sutured to the extensor carpi radialis longus (ECRL) muscle to restore flexion. The new procedure used a passive hierarchical artificial pulley system to connect the muscle to the tendons. Both the suture-based and pulley-based procedures were conducted on N = 6 cadaver hands. The fingers' ability to close around four objects when the ECRL tendon was pulled was tested. Post-surgery hand function was evaluated based on the actuation force required to create a grasp and the slip between the fingers and the object after the grasp was created. When compared with the suture-based procedure, the pulley-based procedure (i) reduced the actuation force required to close all four fingers around the object by 45 % and (ii) improved the fingers' individual adaptation to the object's shape during the grasping process and reduced slip by 52 % after object contact (2.99° ± 0.28° versus 6.22° ± 0.66°). The cadaver study showed that the implanted engineering mechanism for attaching multiple tendons to one muscle significantly improved hand function in grasping tasks when compared with the current procedure.
Mao, Haijiao; Shi, Zengyuan; Xu, Dachuan; Liu, Zhenxin
Neglected Achilles Tendon Ruptures are commonly seen by orthopaedic surgeons. In cases resistant to conservative treatment, a variety of surgical procedures have been utilized in the past. The senior -surgeon at our institution has utilized a technique -employing two turndown fascia flaps fashioned from the proximal Achilles tendon augmented by a tenomyodesis of the flexor hallucis longus and plantaris tendon. The purpose of this study was to assess the clinical outcome of all patients who underwent this procedure. The medical records of 10 cases that underwent this procedure were retrospectively reviewed. We completed data collection sets using the American Orthopaedic Foot and Ankle Society ankle-hind foot scores, isokinetic evaluation, and postoperative magnetic resonance imaging (MRI) at 1 year of follow-up. The mean American Orthopaedic Foot and Ankle Society ankle-hind foot scores improved from 64.4±3.54. Isokinetic testing at 30º/sec and 120º/sec revealed an mean deficits of 24.5%, respectively, in the plantar flexion peak torque of the involved ankle than non-involved ankle. The flexor hallucis longus tendon, gastrocnemius fascia flap and plantaris were well -integrated into the Achilles tendon forming a homogenous tendon, which was confirmed in MRI. Our subjective and objective data indicate that the reconstructive technique using flexor hallucis longus transfer with two turndown gastrocnemius fascia flaps and plantaris tendon is a good option for repairing large gap defect of Achilles tendon.
Föhn, M; Bannasch, H; Stark, G B
A 10-year-old girl from Ghana, Africa, developed chronic osteomyelitis of her right tibia and a large soft tissue defect on the ventral lower leg after a minor injury. She was treated more than 6 months after trauma without any improvement. We report a follow up of 3 years after reconstruction with a single-step pedicled fibula-pro-tibia transfer and wound coverage with a free myocutaneous latissimus dorsi flap.
Kaji, Yoshio; Nakamura, Osamu; Yamaguchi, Konosuke; Tobiume, Sachiko; Yamamoto, Tetsuji
Abstract Rationale: For localized type Volkmann's contracture, in which degeneration of the flexor digitorum profundus (FDP) muscle to one or two fingers and restriction of finger extension occur, dissection or excision of the affected muscle is usually recommended. However, these surgical procedures need relatively wide exposure of the muscle, because the FDP muscle is in the deep portion of the forearm. Patient concerns: In this report, the case of a 35-year-old woman with localized type Volkmann's contracture is presented. Her left forearm had been compressed with an industrial roller 4 months earlier, and severe flexion contracture of the long finger and mild flexion contracture of the ring finger developed gradually. Diagnoses: localized type Volkmann's contracture. Intervention: Five months after the injury, transection of the FDP tendon to the long finger and transfer of the transected tendon to the FDP tendon to the index finger was performed after adjusting the tonus of these two tendons using a small skin incision. This procedure was followed by a tension-reduced early mobilization technique in which a tension-reduced position of the tendon suture site was maintained by taping the long finger to the volar side of the index finger, and then immediate active range of motion (ROM) exercise was started. Outcomes: Within 9 weeks after surgery, full ROM had been regained. Lessons: Using the treatment procedure presented in this case report, a good clinical result was obtained in a minimally invasive manner. PMID:28072735
Lee, Kang; Moon, Jeong Seok; Seo, Jeong Gook; Lee, Woo Chun
We present one-stage treatment of deep infection following repair of Achilles tendon rupture using flexor hallucis longus transfer. Flexor hallucis longus was used not only to connect the defect in Achillles tendon, but also to control the soft tissue infection with its abundant blood supply, simultaneously. The clinical results for the two patients in this report were excellent without major complication.
Wagner, Pablo; Ortiz, Cristian; Vela, Omar; Arias, Paul; Zanolli, Diego; Wagner, Emilio
Tibialis posterior (TP) tendon transfer through the interosseous membrane is commonly performed in Charcot-Marie-Tooth disease. In order to avoid entrapment of this tendon, no clear recommendation relative to the interosseous membrane (IOM) incision size has been made. Analyze the TP size at the transfer level and therefore determine the most adequate IOM window size to avoid muscle entrapment. Eleven lower extremity magnetic resonances were analyzed. TP muscle measurements were made in axial views, obtaining the medial-lateral and antero-posterior diameter at various distances from the medial malleolus tip. The distance from the posterior to anterior compartment was also measured. These measurements were applied to a mathematical model to predict the IOM window size necessary to allow an ample TP passage in an oblique direction. The average tendon diameter (confidence-interval) at 15cm proximal to the medial malleolus tip was 19.47mm (17.47-21.48). The deep posterior compartment to anterior compartment distance was 10.97mm (9.03-12.90). Using a mathematical model, the estimated IOM window size ranges from 4.2 to 4.9cm. The IOM window size is of utmost importance in trans-membrane TP transfers, given that if equal or smaller than the transposed tendon oblique diameter, a high entrapment risk exists. A membrane window of 5cm or 2.5 times the size of the tendon diameter should be performed in order to theoretically diminish this complication. Copyright © 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Watkins, Cynthia; Rivlin, Michael; Beredjiklian, Pedro K
Tendon transfers in hand patients are a commonly performed procedure after extensor tendon rupture. However, the standard side to side technique is not applicable in every patient. We present a case of a musician with unique demands to demonstrate the option to customize surgical technique and therapy regimen to the unique needs of each patient. An extensor indicis proprius to extensor digitorum communis transfer was performed in a 73 year old musician. A controlled active motion therapy protocol was followed. The patients musical practice regimen was incorporated into the therapy. The patient was able to independently extend her ring and small fingers in order to play her instrument and resumed play within one month postoperatively. A patient's functional goals including avocations need to be considered when selecting the appropriate surgical and therapeutic approach.
Lui, Tun Hing
Idiopathic adult hallux varus is a rare deformity. In this report, I present a technique for correction of this condition by extensor hallucis longus tenodesis and extensor digitorum brevis transfer. Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Elhassan, Bassem; Bishop, Alan; Shin, Alexander; Spinner, Robert
Enhancement of upper-extremity function, specifically shoulder function, after brachial plexus injury requires a good understanding of nerve repair and transfer, with their expected outcome, as well as shoulder anatomy and biomechanics enabling the treating surgeon to use available functioning muscles around the shoulder for transfer, to improve shoulder function. Surgical treatment should address painful shoulder subluxation in addition to improvement of function. The literature focuses on improving shoulder abduction, but improving shoulder external rotation should take priority because this function, even if isolated, will allow patients to position their hand in front of their body. With a functional elbow and hand, patients will be able to do most activities of daily living. The lower trapezius has been shown to be a good transfer to restore external rotation of the shoulder. Other parts of the trapezius, levator scapulae, rhomboids, and, when available, the latissimus dorsi, pectoralis major, teres major, biceps, triceps, and serratus anterior muscles can all be used to replace the rotator cuff and deltoid muscle function. To optimize the results, a close working relationship is required between surgeons reconstructing brachial plexus injury and shoulder specialists.
Seybold, Jeffrey D; Campbell, John T; Jeng, Clifford L; Short, Kelly W; Myerson, Mark S
Concomitant tears of the peroneus longus and brevis tendons are rare injuries, with literature limited to case reports and small patient series. Only 1 recent study directly compared the results of single-stage lateral deep flexor transfer, and no previous series objectively evaluated power and balance following transfer. The purpose of this study was to evaluate clinical outcomes, patient satisfaction, and objective power and balance data following single-stage flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon transfers for treatment of concomitant peroneus longus and brevis tears. Over an 8-year period (2005-2012), 9 patients underwent lateral transfer of the FHL or FDL tendon for treatment of concomitant peroneus longus and brevis tears. All but 1 patient underwent additional procedures to address hindfoot malalignment or other contributing deformity at the time of surgery. Mean age was 56.9 years, and average body mass index was 27.9. Lateral transfer of the FHL was performed in 5 patients, and FDL transfer performed in 4 with mean follow-up 35.7 months (range: 11-94). Eight of 9 patients completed SF-12 and Foot Function Index (FFI) scores, and 7 returned for range of motion (ROM) and manual strength testing of the involved and normal extremities. These 7 patients also completed force plate balance tests, in addition to peak force and power testing on a PrimusRS machine with a certified physical therapist. All patients were satisfied with the results of the procedure. Mean SF-12 physical and mental scores were 32 and 55, respectively; mean FFI total score was 56.7. No postoperative infections were noted. Two patients continued to utilize orthotics or braces, and 2 patients reported occasional pain with weightbearing activity. Three patients noted mild paresthesias in the distribution of the sural nerve and 2 demonstrated tibial neuritis. All patients demonstrated 4/5 eversion strength in the involved extremity. Average loss of inversion and
Ma, Shanjun; Zhou, Tianjian
To evaluate the effectiveness of the median nerve constrictive operation combined with tendon transfer to treat the brain paralysis convulsive deformity of the hand. The clinical data from 21 cases with brain paralysis convulsive deformity of the hand were analyzed retrospectively between August 2009 and April 2012. Of them, there were 13 males and 8 females with an average age of 15 years (range, 10-29 years). The causes of the convulsive cerebral palsy included preterm deliveries in 11 cases, hypoxia asphyxia in 7, traumatic brain injury in 2, and encephalitis sequela in 1. The disease duration was 2-26 years (mean, 10.6 years). All the 21 patients had cock waists, crooking fingers, and contracture of adductors pollicis, 12 had the forearm pronation deformity. According to Ashworth criteria, there were 2 cases at level I, 5 cases at level II, 8 cases at level III, 4 cases at level IV, and 2 cases at level V. All patients had no intelligence disturbances. The forearm X-ray film showed no bone architectural changes before operation. The contraction of muscle and innervation was analyzed before operation. The median nerve constrictive operation combined with tendon transfer was performed. The functional activities and deformity improvement were evaluated during follow-up. After operation, all the patients' incision healed by first intension, without muscle atrophy and ischemic spasm. All the 21 cases were followed up 1.5-4.5 years (mean, 2.3 years). No superficial sensory loss occurred. The effectiveness was excellent in 13 cases, good in 6 cases, and poor in 2 cases, with an excellent and good rate of 90.4% at last follow-up. The median nerve constrictive operation combined with tendon transfer to treat brain paralysis convulsive deformity of the hand can remove and prevent the recurrence of spasm, achieve the orthopedic goals, to assure the restoration of motor function and the improvement of the life quality.
Ropars, M; Dréano, T; Siret, P; Belot, N; Langlais, F
Eighteen cases of tendon transfer for isolated radial or posterior interosseous nerve palsy have been carried out in our unit over a period of 21 years. Fifteen patients were reviewed with a mean follow-up of 9.5 years. Nine had sustained high and six low radial nerve injury. We achieved 11 excellent, two good, one fair and one bad result. The main problems were loss of power of gripping and the occurrence of radial deviation, particularly in patients with flexor carpi ulnaris transfer to the extensor digitorum communis. During this time, our technique has evolved, including changes of the tendons transferred. Our final preference is a modified Tsuge procedure, using the pronator teres to restore extension of the wrist, the flexor carpi radialis for extension of the fingers and the palmaris longus for extension of the thumb. Abduction of the thumb is restored by a tenodesis of the abductor pollicis longus to the brachioradialis. This review justifies the final policy, in particular the preservation of flexor carpi ulnaris to maintain wrist stability and flexion.
Mao, Haijiao; Shi, Zengyuan; Wapner, Keith L; Dong, Wenwei; Yin, Weigang; Xu, Dachuan
The purpose of the study was to describe the anatomical variations of the connection between the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons in the knot of Henry in Asians, and quantify the length of FHL tendon graft with different incisions. Sixty-four embalmed feet of 32 cadavers were analyzed anatomically with respect to the individual cross-links in the planta pedis. Single incision technique graft length was measured from the musculotendinous junction of FHL and the point at sustentaculum tali. Double incision technique was measured from musculotendinous junction of FHL and the level of the master knot of Henry. Additionally, minimally invasive incision technique was measured from musculotendinous junction of FHL to the first interphalangeal joint. These three techniques were then combined to determine the total potential tendon graft length obtainable using different approach. Only two different configurations were found. Type 1, a tendinous slip branched from the FHL to the FDL (62 of 64 feet). Type 2, a slip branched from the FHL to the FDL and another slip from the FDL to FHL (2 of 64). The average length of the FHL graft available from a single incision measured 5.08 cm (range 3.32-10.35, SD = 1.09), double incision technique measured 6.72 cm (range 4.69-12.09, SD = 1.03), and minimally invasive incision measured 17.49 cm (range 13.51-20.52, SD = 1.80). The difference between the lengths obtained from these three techniques was statistically significant (p < 0.001). The absence of no attachment and FDL tendon to the FHL between the two tendons in the foot may be more frequent than previously reported. Only two configurations of the anatomical relationship were found in this study. In over 96 % of the feet, a proximal to distal connection from the FHL to the FDL was found, which might contribute to the residual function of the lesser toes after FDL transfer.
Dabas, V; Suri, T; Surapuraju, P K; Sural, S; Dhal, A
We assessed the effect of an early transfer of pronator teres to extensor carpi radialis brevis on hand function in patients with high radial nerve paralysis. Power grip and precision grip were measured preoperatively and postoperatively using a dynamometer. Fifteen patients were operated on, of which ten could be assessed at the end of 6 months. At 6 months after surgery, there was a median increase of 48% in power grip, 162% in tip pinch, 90% in key pinch and 98% in palmar pinch. Decreased palmar flexion was seen in four patients. Fraying of the periosteal extension and rupture of sutures at the junction site were each seen in one patient, leading to unsatisfactory results. Early tendon transfer quickly restored efficient grip while awaiting reinnervation of wrist extensors, avoiding the need for prolonged external splintage.
Lieber, R L
Skeletal muscles have mechanical properties that are well-described by the length-tension relationship (for isometric contractions) and the force-velocity relationship (for isotonic contractions). These two intrinsic properties are scaled for a given muscle based on its architectural properties. Muscle active force-generating range is determined by muscle fiber length, while maximum muscle force is determined by physiologic cross-sectional area. These and other architectural properties should be matched between muscles when planning surgical tendon transfers in order to closely match donor and recipient muscles. Finally, the fiber length/moment arm ratio of a muscle-joint combination must be considered when describing strength because strength is a manifestation of both muscle and joint properties and not either alone. Unfortunately, detailed description of normal musculoskeletal design or optimal transfer strategy cannot be made until more basic science studies of the musculoskeletal system are conducted.
Hahn, Frederik; Meyer, Patrick; Maiwald, Christian; Zanetti, Marco; Vienne, Patrick
In patients with chronic Achilles tendinopathy, augmentation with flexor hallucis longus (FHL) tendon transfer can be performed to improve pain and functional limitations. There are no reports of postoperative imaging for evaluating tendon integration, inflammatory alterations or degeneration of the FHL muscle. The purpose of this study was to evaluate postoperative MR imaging based on clinical outcome and isokinetic strength. 13 patients with chronic Achilles tendinopathy (10 ruptures) underwent augmentation with FHL transfer. Clinical parameters, isokinetic strength and outcome measurements (AOFAS, SF-36) were evaluated at an average followup of 46.5 months. Qualitative and quantitative analyses of postoperative MRI were conducted using the non-operated side for comparison. All patients had a significant reduction of pain. The operated side had a torque deficit of 35% for plantar flexion. Ten patients returned to their former level of activity. MRI showed a complete integration of the FHL tendon in six patients. Fatty atrophy in the triceps surae was found in ten patients. The FHL was free of degeneration in all patients. Hypertrophy of the FHL of more than 15% was observed in eight patients. Augmentation with FHL transfer is a valuable option in the treatment of chronic Achilles tendinopathy with and without rupture. Our results demonstrate high patient satisfaction without donor site morbidity. The FHL tendon is well integrated into the Achilles tendon. Hypertrophy of the FHL muscle suggests functional incorporation into plantar flexion. The primary benefit of the operation is pain relief and increased muscle strength.
Merolla, Giovanni; Chillemi, Claudio; Franceschini, Vincenzo; Cerciello, Simone; Ippolito, Giorgio; Paladini, Paolo; Porcellini, Giuseppe
Summary Background: treatment of symptomatic irreparable rotator cuff tears is extremely challenging because, at present, there are no ideal solutions to this problem. Many patients respond favorably to nonsurgical treatment. However, when conservative measures fail to improve the patient’s pain and disability, surgery should be considered. Methods: different surgical techniques are available and the choice of the most appropriate procedure depends on the presenting symptoms, age of the patient, functional demand, medical comorbidities, joint stability and presence of arthritic changes. The transposition of the surrounding muscles to replace the rotator cuff function represents a viable option in the treatment of younger patients without glenohumeral osteoarthritis and with severe functional limitation. Purpose: aim of this study is to give an overview of the currently available evidence regarding tendon transfer procedures for irreparable rotator cuff tears. PMID:25767779
Georgiadis, G M; Aronson, D D
Posterior transfer of the tendon of the anterior tibial muscle through the interosseous membrane to the calcaneus to prevent or correct a calcaneus deformity was performed in twenty patients (thirty-nine feet) who had a myelomeningocele. The average age of the patients at the time of the operation was 4.6 years, and they were followed for an average of six years. Satisfactory clinical and radiographic results were obtained in thirty-seven (95 per cent) of the thirty-nine feet. Two patients, one who was unable to walk and one who walked at home only, had a mild equinus deformity of the left foot. No patient had a clinical calcaneus deformity, but there was radiographic evidence of talipes calcaneus in one patient (two feet). The anterior tibial muscle functioned more consistently when the operation was performed after the patient was four years old and in patients who had a fifth lumbar or first sacral motor level.
Sillanpää, Petri J; Mäenpää, Heikki M; Mattila, Ville M; Visuri, Tuomo; Pihlajamäki, Harri
Patellar dislocations are associated with injuries to the medial patellofemoral ligament (MPFL). Several techniques for MPFL reconstruction have been recently published with some disadvantages involved, including large skin incisions and donor site morbidity. Arthroscopic stabilizing techniques carry the potential of inadequate restoration of MPFL function. We present a minimally invasive technique for MPFL reconstruction using adductor magnus tendon autograft. This technique is easily performed, safe, and provides a stabilizing effect equal to current MPFL reconstructions. Skin incision of only 3-4 cm is located at the level of the proximal half of the patella. After identifying the distal insertion of the adductor magnus tendon, a tendon harvester is introduced to harvest the medial two-thirds of the tendon, while the distal insertion is left intact. The adductor magnus tendon is cut at 12-14 cm from its distal insertion and transferred into the patellar medial margin. Two suture anchors are inserted through the same incision at the superomedial aspect of the patella in the anatomic MPFL origin. The graft is tightened at 30 degrees knee flexion. Aftercare includes 4 weeks of brace treatment with restricted range of motion.
Dreher, T; Wolf, S I; Heitzmann, D; Fremd, C; Klotz, M C; Wenz, W
The foot drop component of cavovarus foot deformity in patients with Charcot-Marie-Tooth disease is commonly treated by tendon transfer to provide substitute foot dorsiflexion or by tenodesis to prevent the foot from dropping. Our goals were to use three-dimensional foot analysis to evaluate the outcome of tibialis posterior tendon transfer to the dorsum of the foot and to investigate whether the transfer works as an active substitution or as a tenodesis. We prospectively studied fourteen patients with Charcot-Marie-Tooth disease and cavovarus foot deformity in whom twenty-three feet were treated with tibialis posterior tendon transfer to correct the foot drop component as part of a foot deformity correction procedure. Five patients underwent unilateral treatment and nine underwent bilateral treatment; only one foot was analyzed in each of the latter patients. Standardized clinical examinations and three-dimensional gait analysis with a special foot model (Heidelberg Foot Measurement Method) were performed before and at a mean of 28.8 months after surgery. The three-dimensional gait analysis revealed significant increases in tibiotalar and foot-tibia dorsiflexion during the swing phase after surgery. These increases were accompanied by a significant reduction in maximum plantar flexion at the stance-swing transition but without a reduction in active range of motion. Passive ankle dorsiflexion measured in knee flexion and extension increased significantly without any relevant decrease in passive plantar flexion. The AOFAS (American Orthopaedic Foot & Ankle Society) score improved significantly. Tibialis posterior tendon transfer was effective at correcting the foot drop component of cavovarus foot deformity in patients with Charcot-Marie-Tooth disease, with the transfer apparently working as an active substitution. Although passive plantar flexion was not limited after surgery, active plantar flexion at push-off was significantly reduced and it is unknown whether
Jeans, Kelly A; Tulchin-Francis, Kirsten; Crawford, Lindsay; Karol, Lori A
Relapses following nonoperative treatment for clubfoot occur in 29% to 37% of feet after initial correction. One common gait abnormality is supination and inversion of the foot caused by an imbalance of the anterior tibialis tendon muscle. The purpose of this study was to determine if plantar pressures are normalized following an anterior tibialis tendon transfer (ATTT). Thirty children (37 clubfeet) who underwent an ATTT, were seen for plantar pressure testing preoperatively and postoperatively. Each foot was subdivided into 7 regions: medial/lateral hindfoot and midfoot, and the forefoot (first, second, and third to fifth metatarsal heads). Variables included: contact time as a percentage of stance time (CT%), contact area as a percentage of the total foot (CA%), peak pressure (PP), hindfoot-forefoot angle (H-F), location of initial contact, and deviation of the center-of-pressure line (COP). Paired t tests were used for group comparisons, whereas multiple comparisons were assessed with ANOVA (α set to 0.05 with Bonferroni correction). Significant changes were seen in preoperative to postoperative comparison. PP, CT%, and CA% had significant increases in the medial hindfoot, midfoot, and first metatarsal regions, whereas the involvement of the lateral midfoot and forefoot were reduced. Compared with controls, postoperative results following ATTT continue to show increased PP, CA%, and CT% in the lateral midfoot, increased CA% and CT% in the lateral forefoot, whereas CA% was decreased in the first metatarsal region. Compared with controls, the COP line continues to move laterally and the H-F angle continues to show forefoot adductus following ATTT. No differences were found between patients treated with an isolated ATTT and those treated with concomitant procedures. The changes seen in plantar pressures following ATTT would suggest that the foot is better aligned for a more even distribution of pressure throughout the foot, but is not fully normalized
Stark, D.; Tofield, J.J.; Terranova, W.; Hurley, D.; Kenney, J.
Ambulatory patients with large sacral ulcers can represent extremely challenging coverage problems. Technical options become fewer when sacral ulcers are coupled with radiation dermatitis. Latissimus dorsi free flap transfer, with direct anastomoses to sacral vessels, is described in 2 patients.
Jeong, Ji Hun; Ahn, Dong Heun; Kim, Yong Rok; Hong, Mi Jin; Lee, Yung Jin; Park, Chang-il; Heo, Youn Moo
In tetraplegia patients, activities of daily living are highly dependent on the remaining upper limb functions. In other countries, upper limb reconstruction surgery to improve function has been applied to diverse cases, but few cases have been reported in Korea. The current authors experienced a case of posterior deltoid-to-triceps tendon transfer and rehabilitation in a complete spinal cord injury with a C6 neurologic level, and we introduce the case—a 36-year-old man—with a literature review. The patient's muscle strength in C5 C6 muscles were normal, but C7 muscles were trace, and the Spinal Cord Independence Measure III (SCIM III) score was 24. The tendon of the posterior deltoid was transferred to the triceps brachii muscle, and then the patient received comprehensive rehabilitative treatment. His C7 muscle strength in the right upper extremity was enhanced from trace to fair, and his SCIM III score improved to 29. PMID:27152287
Szczesny, Spencer E; Fetchko, Kristen L; Dodge, George R; Elliott, Dawn M
Collagen fibrils in tendon are believed to be discontinuous and transfer tensile loads through shear forces generated during interfibrillar sliding. However, the structures that transmit these interfibrillar forces are unknown. Various extrafibrillar tissue components (e.g., glycosaminoglycans, collagens XII and XIV) have been suggested to transmit interfibrillar loads by bridging collagen fibrils. Alternatively, collagen fibrils may interact directly through physical fusions and interfibrillar branching. The objective of this study was to test whether extrafibrillar proteins are necessary to transmit load between collagen fibrils or if interfibrillar load transfer is accomplished directly by the fibrils themselves. Trypsin digestions were used to remove a broad spectrum of extrafibrillar proteins and measure their contribution to the multiscale mechanics of rat tail tendon fascicles. Additionally, images obtained from serial block-face scanning electron microscopy were used to determine the three-dimensional fibrillar organization in tendon fascicles and identify any potential interfibrillar interactions. While trypsin successfully removed several extrafibrillar tissue components, there was no change in the macroscale fascicle mechanics or fibril:tissue strain ratio. Furthermore, the imaging data suggested that a network of smaller diameter fibrils (<150 nm) wind around and fuse with their neighboring larger diameter fibrils. These findings demonstrate that interfibrillar load transfer is not supported by extrafibrillar tissue components and support the hypothesis that collagen fibrils are capable of transmitting loads themselves. Conclusively determining how fibrils bear load within tendon is critical for identifying the mechanisms that impair tissue function with degeneration and for restoring tissue properties via cell-mediated regeneration or engineered tissue replacements. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop
Bincaz, L E; Cherifi, H; Alnot, J Y
This retrospective study is based on 23 males and one female, of an average age of 36.2 years that presented to us between 1982 and 2000 with an average follow up of 61 months, with fully established paralysis of wrist and fingers extension. Fourteen patients had isolated radial nerve palsy, while ten patients had brachial plexus lesions. 1) The tendon transfer for radial nerve palsy was: PT to ECRB, FCU to ED + EPL and PL to APL + EPB; 2) for brachial plexus injury, the tendon transfer was: PT (n = 4) or FDS III or IV (n = 5) to ECRB, FCU (n = 8) or FDS IV (n = 1) to ED + EPL, PL to APL + EPB and wrist arthrodesis with transfer of FDS IV to ED + EPL and PL to APL + EPB. The results were evaluated according to the degree of wrist movement, MP extension of long fingers, opening of first commissure, thumb opposition, grip power and the subjective evaluation of results. Concerning the radial nerve palsy: results are excellent in nine cases and good in one case. An active extension of the wrist of 38 degrees was obtained as well as MP extension of 0 degree with the wrist straightened. Thumb oppositioned was conserved (Kapandji = 8.2), opening of the first commissure 40 degrees and grip power was 20 kg. Concerning the brachial plexus lesions: results are excellent in five cases and good in the other five. An active wrist extension of 32 degrees was obtained, as well as MP extension deficit of 16 degrees with wrist straightened. Opposition was concerned (Kapandji = 7.2), opening of first commissure of 38 degrees and grip power of 13 kg. The functional results are satisfactory, but the analytic study shows some effect of tenodesis of MP extension.
Weinfeld, Steven B
Achilles tendon disorders include tendinosis, paratenonitis, insertional tendinitis, retrocalcaneal bursitis, and frank rupture. Patients present with pain and swelling in the posterior aspect of the ankle. Magnetic resonance imaging and ultrasound are helpful in confirming the diagnosis and guiding treatment. Nonsurgical management of Achilles tendon disorders includes nonsteroidal anti-inflammatory drugs, physical therapy, bracing, and footwear modification. Surgical treatment includes debridement of the diseased area of the tendon with direct repair. Tendon transfer may be necessary to augment the strength of the Achilles tendon. Copyright © 2014 Elsevier Inc. All rights reserved.
Sasi, P. Kiran; Mahapatra, Swagath; Raj Pallapati, Samuel C.; Thomas, Binu P.
Traumatic musculotendinous junction avulsions are rare injuries except in avulsion amputations. They pose a significant challenge to the treating surgeon. We present a 24-year-old male who sustained an open musculotendinous avulsion of the flexor pollicis longus tendon. He was treated with primary tendon transfer using the flexor digitorum superficialis of ring finger, in flexor zone 3. The functional result at 10 months following surgery was excellent. PMID:27019757
Sakabe, Tomoya; Sakai, Takao
Introduction Tendons establish specific connections between muscles and the skeleton by transferring contraction forces from skeletal muscle to bone thereby allowing body movement. Tendon physiology and pathology are heavily dependent on mechanical stimuli. Tendon injuries clinically represent a serious and still unresolved problem since damaged tendon tissues heal very slowly and no surgical treatment can restore a damaged tendon to its normal structural integrity and mechanical strength. Understanding how mechanical stimuli regulate tendon tissue homeostasis and regeneration will improve the treatment of adult tendon injuries that still pose a great challenge in today's medicine. Source of data This review summarizes the current status of tendon treatment and discusses new directions from the point of view of cell-based therapy and regenerative medicine approach. We searched the available literature using PubMed for relevant original articles and reviews. Growing points Identification of tendon cell markers has enabled us to study precisely tendon healing and homeostasis. Clinically, tissue engineering for tendon injuries is an emerging technology comprising elements from the fields of cellular source, scaffold materials, growth factors/cytokines and gene delivering systems. Areas timely for developing research The clinical settings to establish appropriate microenvironment for injured tendons with the combination of these novel cellular- and molecular-based scaffolds will be critical for the treatment. PMID:21729872
Abolhoda, Amir; Bui, Trung D.; Milliken, Jeffrey C.; Wirth, Garrett A.
Bronchopleural fistula and empyema are serious complications after thoracic surgical procedures, and their prevention is paramount. Herein, we review our experience with routine prophylactic use of the pedicled ipsilateral latissimus dorsi muscle flap. From January 2004 through February 2006, 10 surgically high-risk patients underwent intrathoracic transposition of this muscle flap for reinforcement of bronchial-stump closure or obliteration of empyema cavities. Seven of the patients were chronically immunosuppressed, 5 were severely malnourished (median preoperative serum albumin level, 2.4 g/dL), and 5 had severe underlying obstructive pulmonary disease (median forced expiratory volume in 1 second, 44% of predicted level). Three upper lobectomies and 1 completion pneumonectomy were performed in order to treat massive hemoptysis that was secondary to complex aspergilloma. One patient underwent left pneumonectomy due to ruptured-cavitary primary lung lymphoma. One upper lobectomy was performed because of necrotizing, localized Mycobacterium avium-intracellulare infection. One patient underwent right upper lobectomy and main-stem bronchoplasty for carcinoma after chemoradiation therapy. In 3 patients, the pedicled latissimus dorsi muscle was used to obliterate chronic empyema cavities and to buttress the closure of underlying bronchopleural fistulas. No operative deaths or recurrent empyemas resulted. Two patients retained peri-flap air that required no surgical intervention. We conclude that the use of transposed pedicled latissimus dorsi muscle flap effectively and reliably prevents clinically overt bronchopleural fistula and recurrent empyema. We advocate its routine use in first-time and selected reoperative thoracotomies in patients who are undergoing high-risk lung resection or reparative procedures. PMID:19693302
Wallace, Juanita; White, Hank; Xi, Jing; Kryscio, Richard; Augsburger, Sam; Milbrandt, Todd; Talwalkar, Vishwas; Iwinski, Henry; Walker, Janet
The aim of this study was to identify significant changes in pedobarographic parameters attributed to growth versus growth and surgical intervention for uninvolved feet, clubfeet (CF) subjected to anterior tibialis tendon transfer surgery, and unilateral nonsurgical CF. Participants underwent foot-pressure analysis preoperatively and 3 years postoperatively. Six parameters related to the lateral midfoot showed increases for uninvolved and nonsurgical CF, whereas CF subjected to surgery decreased. Transferring the anterior tibialis tendon resulted in improvements beyond typical growth and in a more balanced foot postoperatively. These changes are not simply changes in the peak pressure, but changes in force/pressure over time in the lateral foot.
Latheef, L; Bhardwaj, P; Sankaran, A; Sabapathy, S R
This study reports an objective assessment of postoperative function of 11 triple transfers for high radial palsies, using pronator teres for wrist extension, flexor carpi ulnaris for finger extension and palmaris longus for thumb extension. The mean follow-up was 3.3 years. Assessment was done by recording the active ranges of wrist motion, grip strength, wrist and finger strength and work simulation. The mean strength and range of wrist extension were 42% and 86%, respectively, of the contralateral wrist. Other measured movements were within the functional range and work simulation confirmed good restoration of function. The mean DASH score was 3.45, with no patient reporting any specific functional complaints. This study shows that even though the range of wrist motion and the strength of the wrist and fingers are less than normal, hand function remains good. We conclude that the flexor carpi ulnaris set of tendon transfer works well. 3.
Johanson, M Elise; Jaramillo, Jeffrey P; Dairaghi, Christine A; Murray, Wendy M; Hentz, Vincent R
To identify key components of conventional therapy after brachioradialis (BR) to flexor pollicis longus (FPL) transfer, a common procedure to restore pinch strength, and evaluate whether any of the key components of therapy were associated with pinch strength outcomes. Rehabilitation protocols were surveyed in 7 spinal cord injury (SCI) centers after BR to FPL tendon transfer. Key components of therapy, including duration of immobilization, participation, and date of initiating therapy activities (mobilization, strengthening, muscle reeducation, functional activities, and home exercise), were recorded by the patient's therapist. Pinch outcomes were recorded with identical equipment at 1-year follow-up. Seven SCI rehabilitation centers where the BR to FPL surgery is performed on a routine basis. Thirty-eight arms from individuals with C5-7 level SCI injury who underwent BR to FPL transfer surgery (N=34). Conventional therapy according to established protocol in each center. The frequency of specific activities and their time of initiation (relative to surgery) were expressed as means and 95% confidence intervals. Outcome measures included pinch strength and the Canadian Occupational Performance Measure (COPM). Spearman rank-order correlations determined significant relations between pinch strength and components of therapy. There was similarity in the key components of therapy and in the progression of activities. Early cast removal was associated with pinch force (Spearman ρ=-.40, P=.0269). Pinch force was associated with improved COPM performance (Spearman ρ=.48, P=.0048) and satisfaction (Spearman ρ=.45, P=.0083) scores. Initiating therapy early after surgery is beneficial after BR to FPL surgery. Postoperative therapy protocols have the potential to significantly influence the outcome of tendon transfers after tetraplegia. Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Study Design Case report. Background Multifocal motor neuropathy is a progressive motor nerve disorder characterized by muscle weakness in the extremities. Muscle imbalance and weakness can become so severe that the involved extremity can be rendered nonfunctional. The purpose of this case report is to describe the physical therapy postoperative management of a patient who underwent a multiple tendon transfer to correct the loss of digital/wrist extension of the right upper extremity. Case Description A 38-year-old woman with a medical diagnosis of multifocal motor neuropathy, which caused muscle imbalance and weakness in the right hand, underwent a multiple tendon transfer to correct the loss of digit and wrist extension. The pronator teres was transferred and attached to the extensor carpi radialis longus and brevis. The palmaris longus was transferred and attached to the extensor pollicis longus. The flexor carpi radialis was transferred and attached to the extensor digitorum communis. The patient underwent static and dynamic splinting and a modified tendon transfer protocol starting at 3 weeks and ending at 16 weeks postsurgery. The patient attended therapy 1 to 3 times a week, depending on protocol stage and need for skilled therapy intervention. Outcomes Patient-reported outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) survey to monitor the return of function and the numeric pain-rating scale to assess pain. At the initial evaluation (3 weeks postsurgery), the patient's DASH score was 87.5 and her pain score was 7/10. At discharge (16 weeks postsurgery), the patient's DASH score was 37.5 and her pain score was 0/10. Strength impairment was monitored with hydraulic hand dynamometers and manual muscle testing. At discharge, her hand grip strength was 4.5 kg, her key pinch strength was 4.1 kg, and her 3-jaw pinch strength was 2.3 kg. Manual muscle testing grades were 5/5 for elbow extension/flexion, 4/5 for forearm pronation
Hunt, Kenneth J; Cohen, Bruce E; Davis, W Hodges; Anderson, Robert B; Jones, Carroll P
Chronic insertional Achilles tendinopathy is a common pathology that can be difficult to manage. Some experts have advocated augmentation with the flexor hallucis longus (FHL) tendon in patients over age 50 and those with more severe tendon disease. We hypothesized that FHL augmentation would be associated with superior clinical outcome scores and greater ankle plantar flexion strength compared with Achilles debridement alone. Consecutive patients older than 50 years who had failed nonoperative treatment for chronic insertional Achilles tendinopathy were randomly assigned to Achilles decompression and debridement alone (control group) or Achilles decompression and debridement augmented with FHL transfer (FHL group). Outcome measures included American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot score, visual analog scale (VAS) for pain, ankle and hallux plantar flexion strength, and a patient satisfaction survey. A total of 39 enrolled patients had a minimum 1-year follow-up, 18 in the control group and 21 in the FHL transfer group. The average patient age was 60.5 years. AOFAS and VAS scores improved in both groups at 6 months and 1 year with no difference between groups. There was greater ankle plantar flexion strength in the FHL group at 6 months and at 1 year compared with the control group (P < .05). There was no difference between the 2 groups in hallux plantar flexion strength preoperatively and at 1 year after surgery. Some 87% of patients were satisfied with the outcome of their procedure. There was no significant increase in wound complications in the FHL group (P < .05). We found no differences in pain, functional outcome (as measured by the AOFAS ankle/hindfoot scale), and patient satisfaction when comparing patients treated with Achilles debridement alone versus FHL augmentation for chronic Achilles tendinopathy. Ankle plantar flexion strength appeared to be improved with FHL transfer, with no loss of hallux plantar flexion strength
... tendon. It can occur as a result of injury, overuse, or with aging as the tendon loses elasticity. Any action that places prolonged repetitive strain on the forearm muscles can cause tendonitis. The ...
Takahashi, Mitsuhiko; Ward, Samuel R; Fridén, Jan; Lieber, Richard L
Chronic skeletal muscle stretch typically increases serial muscle fiber sarcomere number. Since serial sarcomere number correlates with functional excursion in normal muscle, observed changes in sarcomere number are often extrapolated to their new assumed function. However, this has not been well demonstrated experimentally. Thus, we measured the functional properties of muscles stretched due to tendon transfer surgery. Muscle active and passive length-tension curves were measured 1 week and 4 weeks after surgery, and then each muscle was further examined to determine structural adaptation as well as single fiber and fiber bundle passive mechanical properties. We found a disconnect between the functional and structural muscle properties. Specifically, muscle excursion was significantly lower in the transferred muscle compared to controls, even though serial sarcomere number had increased. Furthermore, maximum tetanic tension was significantly reduced, though the two groups had similar physiological cross sectional areas. Passive tension increased in the transferred muscle, which was deemed to be due to proliferation of extracellular matrix. These data are the first to report that muscle morphological adaptation after chronic stretch does not accurately predict the muscle's functional properties. These data have significant implications for examining muscle physiological properties under surgical interventions.
Lalonde, Donald H; Kozin, Scott
After reading this article, the participant should be able to: 1. Make decisions on flexor tendon repair based on current evidence. 2. Perform some important tendon transfers after viewing Dr. Kozin's videos. 3. Inject local anesthesia for wide-awake flexor tendon repair after viewing the appropriate videos in the article. 4. Use relative motion extension splints for the postoperative management of extensor tendon injuries. This article provides a practical, clinically useful overview of some of the current best techniques and evidence available to the plastic surgeon in the treatment of flexor and extensor tendon injuries, tendon transfers, trigger fingers, mallet fingers, boutonniere deformities, and De Quervain tenosynovitis. Twelve short movies and drawings emphasize important points of diagnosis and treatment of tendon disorders.
Wu, Fan; Nerlich, Michael; Docheva, Denitsa
Tendons connect muscles to bones, ensuring joint movement. With advanced age, tendons become more prone to degeneration followed by injuries. Tendon repair often requires lengthy periods of rehabilitation, especially in elderly patients. Existing medical and surgical treatments often fail to regain full tendon function. The development of novel treatment methods has been hampered due to limited understanding of basic tendon biology. Recently, it was discovered that tendons, similar to other mesenchymal tissues, contain tendon stem/progenitor cells (TSPCs) which possess the common stem cell properties. The current strategies for enhancing tendon repair consist mainly of applying stem cells, growth factors, natural and artificial biomaterials alone or in combination. In this review, we summarise the basic biology of tendon tissues and provide an update on the latest repair proposals for tendon tears. Cite this article: EFORT Open Rev 2017;2:332-342. DOI: 10.1302/2058-5241.2.160075 PMID:28828182
Bogduk, Nikolai; Johnson, Garth; Spalding, Deborah
OBJECTIVE: To determine the morphology of the latissimus dorsi in order to assess its actions on the shoulder, the lumbar spine and the sacroiliac joint. DESIGN: A dissection study accompanied by an analysis of the force vectors of the muscle and its parts. BACKGROUND: Although recognised as a muscle of the shoulder, latissimus dorsi has been accorded a role as an extensor of the lumbar spine, and is said to brace the sacroiliac joint. Consideration of the anatomy of the latissimus dorsi suggests that the magnitude of these actions has been overstated. METHODS: The fascicular anatomy of the latissimus dorsi was determined by dissection in five adult cadavers. The size, attachments, and orientation of each fascicle were determined. By applying a force coefficient the maximum force of each fascicle was estimated from its physiological cross-sectional area. By summing the forces and moments of each fascicle the maximum force exerted by latissimus dorsi was calculated for its actions on the shoulder, the lumbar spine, and the sacroiliac joint. RESULTS: The latissimus dorsi was found to consist of a series of fascicles with segmental attachments to the lower six thoracic spinous processes, the L1 and L2 spinous processes, the lateral raphe of the thoracolumbar fascia, the iliac crest and the lower three ribs. These fascicles were uniform in size across a given muscle but varied from specimen to specimen. The maximum total force exerted by the latissimus dorsi on the shoulder was estimated to range between 162 and 529 N, but in view of the attachments of the muscle, only a portion of that force can be exerted on the lumbar spine. The maximum extensor moment exerted on the lumbar spine was calculated to be 6.3 N m. The maximum force exerted across the sacroiliac joint was calculated to be 30 N. CONCLUSIONS: The latissimus dorsi is designed to move the upper limb or to raise the entire trunk in brachiation. Its possible contribution to extension of the lumbar spine is
Sakaki, Marcos Hideyo; Godoy-Santos, Alexandre Leme; Ortiz, Rafael Trevisan; Araújo, Antônio; Fernandes, Túlio Diniz
OBJECTIVE: To quantify the FHL length difference obtained through a single approach and by a double combined approach. METHODS: 16 fresh cadavers, a total of 32 feet, were used to measure the FHL graft length. With the cadaver positioned in ventral decubitus, a posteromedial incision in the ankle and a second incision in the plantar cavus were performed. RESULTS: The average gain of tendon's length (GTL) was of 42.43 mm, the lowest value being 32 mm and the largest 48 mm. The comparative analysis of the GTL on the right and left sides through the paired "t" Test does not show statistical differences, with a p-value = 0.463 and a statistical power of 0.1443. The height analysis of the sample and the right and left GTL performed through linear regression do not show statistically significant differences, with a p-value of 0.38311 and 0.82640, respectively. CONCLUSION: Harvesting the FHL graft using a double combined approach yields a 42.43 mm length gain in comparison to harvesting using the single approach. Level of Evidence III, Case Control Study. PMID:25061420
Danoff, J R; Birman, M V; Rosenwasser, M P
In patients with severe thenar atrophy secondary to carpal tunnel syndrome, we hypothesize that following open carpal tunnel release, concomitant transfer of the abductor pollicis brevis (APB) origin to the flexor carpi radialis (FCR) tendon will lead to improved patient function restoring palmar abduction and thumb opposition. We evaluated 14 patients through questionnaires and seven patients through additional physical examination (thumb range of motion, ability to tip pinch, grip/pinch strength) for a mean follow-up of 2.8 years. All patients showed evidence of palmar abduction with 71% demonstrating the ability to oppose the thumb to the tip and base of the small finger. The transfer of the APB origin to the FCR tendon can restore thumb abduction and opposition for thenar paralysis secondary to severe carpal tunnel syndrome. Patients experience good functional outcomes with the majority experiencing restored thumb opposition.
Swierstra, Bart A.; Verheyen, Cees C. P. M.
A neglected Achilles tendon rupture is often characterized by muscle weakness and an overlengthened repair by scar tissue. Reconstructive surgery is usually performed taking into account the patient’s required level of function. Two surgical cases of neglected Achilles tendon rupture are presented in this article. In both instances it was expected that central fibrosis, possibly after neglected tendon rupture, would be found. However, after longitudinal opening of the tendons, a thickened plantaris tendon was evident at the insertion on the calcaneus in both cases. This hypertrophic tendon occupied most of the diameter of the Achilles tendon. Due to partial or complete rupture of the Achilles tendon, there was notable weakening and tendon transfer-augmentation was performed. A thickened plantaris tendon as a reaction to a neglected rupture of the Achilles tendon is a rare presentation. It can be detected preoperatively by MRI and subsequently preoperative planning can be optimized. PMID:19277842
... You Prevent Achilles Tendonitis? Take these steps to reduce your risk of Achilles tendonitis: Stay in good shape year-round and try to keep your muscles as strong as they can be. Strong, flexible muscles work more efficiently and put less stress on your tendon. Increase the intensity and length ...
Kadel, Nancy J; Donaldson-Fletcher, Emily A; Hansen, Sigvard T; Sangeorzan, Bruce J
The modified Jones procedure is the traditional operative procedure for correction of a clawed hallux, although the deformity may be caused by overpull of one of three different muscles. In this study we present the radiographic and functional outcomes of flexor hallucis longus (FHL) tendon transfer as treatment for clawed hallux. The transfer is performed by drawing two thirds of the FHL tendon up through a drill hole in the proximal phalanx and then suturing it medially back to the remaining third. We retrospectively identified 19 patients (22 feet) who had FHL tendon transfer for correction of clawed hallux over a period of 5 years. Followup was an average of 51.0 (range 6 to 74; +/- 3.8) months after the procedure. Outcome and patient satisfaction were determined using the Long-Form Musculoskeletal Function Assessment (MFA) score. Patients were asked whether they were satisfied, somewhat satisfied, or dissatisfied with the overall outcome and were asked about shoewear limitations. Preoperative and postoperative radiographs were evaluated in 15 patients (17 feet). We measured the hallux valgus and interphalangeal (IP) angles on the anteroposterior (AP) radiographs. On the lateral view we measured the angle of the IP joint, the metatarsophalangeal (MTP) joint, and the talometatarsal angle. Statistical analysis was done using a repeated measures ANOVA (p < 0.05). On the lateral radiographs, the hallux IP joint angle (p < 0.0012; n = 15) and hallux MTP joint angle (p < 0.0265; n = 15) were significantly reduced postoperatively. On AP radiographs, the hallux valgus angle (p < 0.0334) was significantly reduced; however, the IP angle and the talometatarsal angle were not significantly different after surgery. Patients had an average MFA score of 14.6 (+/-3.8 standard error, range 1 to 35; n = 19). Thirteen patients were fully satisfied and six were somewhat satisfied with the overall result of the surgery. Four patients thought that their hallux limited the types of
El-Gammal, Tarek Abdalla; Saleh, Waleed Riad; El-Sayed, Amr; Kotb, Mohammed M; Imam, Hesham Mostafa; Fathi, Nihal Ahmad
One hundred nine obstetrical palsy patients with defective shoulder abduction and external rotation had subscapularis release and transfer of teres major to infraspinatus with or without pedicle transfer of the clavicular head of pectoralis major to deltoid. The age at surgery averaged 67 months (11-192) and follow-up averaged 36 months (12-80). Thirty-nine cases had follow-up CT scan of both shoulders. Improvement of abduction averaged 64 degrees and that of external rotation 50 degrees, 100% and 290% gain, respectively. Both negatively correlated with the age at surgery (P < 0.001), and were significantly higher in patients operated younger than 4 years. On computed tomographic scans, the degree of glenoid retroversion positively correlated (P < 0.001) with the age at surgery, and was significantly higher in patients operated older than 4 years. The degree of posterior subluxation showed no significant difference between different ages. There was no significant difference between the operated and normal sides in patients operated younger than 4years with regard to glenoid retroversion and in those operated younger than 2 years with regard to posterior subluxation. The operation is useful for correction of defective shoulder abduction and external rotation in obstetric palsy. It is best performed before the age of 2 to get maximal improvement in motion and prevent secondary bone changes. Between the ages of 2 and 4, it also resulted in significant improvement in motion and prevented glenoid retroversion, but not posterior subluxation. After the age of 4, the improvement in motion was not significant and secondary bone changes were not prevented.
Tresoldi, Ilaria; Oliva, Francesco; Benvenuto, Monica; Fantini, Massimo; Masuelli, Laura; Bei, Roberto; Modesti, Andrea
The structure of a tendon is an important example of complexity of ECM three-dimensional organization. The extracellular matrix (ECM) is a macromolecular network with both structural and regulatory functions. ECM components belong to four major types of macromolecules: the collagens, elastin, proteoglycans, and noncollagenous glycoproteins. Tendons are made by a fibrous, compact connective tissue that connect muscle to bone designed to transmit forces and withstand tension during muscle contraction. Here we show the ultrastructural features of tendon's components.
Bibbo, Christopher; Baronofsky, Hyim J; Jaffe, Leland
In recent years, total ankle replacement has become a reasonable option for many patients with end-stage ankle arthrosis. In order to be successful, total ankle replacement requires a relatively balanced alignment of the foot in relation to the leg. Such alignment is traditionally achieved surgically by means of stabilization of the hindfoot in conjunction with relocation osteotomy of the calcaneus and/or tibia. In this report, we describe the unconventional combination of total ankle replacement in an adult patient with concomitant paralysis that was addressed by means of tendon transfer.
Dual innervation method using one-stage reconstruction with free latissimus dorsi muscle transfer for re-animation of established facial paralysis: simultaneous reinnervation of the ipsilateral masseter motor nerve and the contralateral facial nerve to improve the quality of smile and emotional facial expressions.
Watanabe, Yorikatsu; Akizuki, Tanetaka; Ozawa, Tsuyoshi; Yoshimura, Kei; Agawa, Kaori; Ota, Tomoyuki
One-stage microneurovascular free muscle transfer is a common surgical procedure for re-animation of established facial paralysis. However, innervation of the transferred muscle by the contralateral facial nerve prevents smile and other facial expressions on one side, and reinnervation requires about 7 months. To overcome these drawbacks, we report a dual innervation method using one-stage reconstruction with free latissimus dorsi muscle transfer. Three patients were treated with the dual innervation method, which is based on the one-stage method with some modifications: the soft tissue present over the ipsilateral masseter muscle and the hilum where the thoracodorsal nerve proceeds into the muscle segment is removed; the muscle is harvested to locate the hilum in the cranial one-third of the segment; and the muscle is transferred to the malar pocket of the paralysed face such that the hilum contacts the masseter muscle. On average, muscle movement was recognised on voluntary biting at 3.4 months and on spontaneous smiling at 5.9 months after surgery. A dual innervation sign was recorded on electromyographs 6.4 months after surgery. The patients developed a spontaneous symmetrical smile and facial expressions on one side with minimum synkinesis after postoperative mirror rehabilitation. The advantages of the dual innervation method include faster reinnervation of the transferred muscle compared to one-stage options; achievement of spontaneous smile and voluntary smile on each side; augmentation of neural signals to the muscle for more symmetrical smiling; minimum synkinesis of the transferred muscle on biting for eyelid closure and emotional facial re-animation through a learning program to enhance cerebral cortical reorganisation.
... up. Tight calf muscles or muscles that lack flexibility decrease a person's range of motion and put an extra strain on the tendon. Running or exercising on a hard or uneven surface or doing lunges or plyometrics without adequate training. A traumatic injury to the Achilles tendon. How ...
... Gardening Safety Turkey Carving Removing a Ring Español Artritis de la base del pulgar Dedo en gatillo ... Gardening Safety Turkey Carving Removing a Ring Español Artritis de la base del pulgar Dedo en gatillo ...
Rath, Santosh; Schreuders, Ton A R; Selles, Ruud W
After tibialis posterior tendon transfer surgery for foot-drop correction, the foot is traditionally immobilised for several weeks. To test the feasibility of early mobilisation after this procedure in patients with Hansen's disease, 21 consecutive patients received active mobilisation of the transfer starting on the 5th postoperative day. Transfer insertion strength was enhanced by Pulvertaft weave. The results were compared with a historical cohort of 21 patients receiving 4 weeks of immobilisation. The primary outcomes were active dorsiflexion, active plantar flexion and total active motion at the ankle, tendon-insertion pullout and time until discharge from rehabilitation with independent walking without aid. Assessments at discharge from rehabilitation and the last clinical follow-up at more than 1 year were compared between both groups. The Student's t-test was used to compare data between the groups, and 95% confidence interval of the difference between groups was determined. A p-value of 0.05 was considered statistically significant. The average follow-up was 22 months for both groups. There was no incidence of insertion pullout of the tendon transfer in either group. In addition, there was no difference in active dorsiflexion angle between the groups at discharge (mean difference: 2.2 degrees, p=0.22) and final assessment (mean difference: 2.3 degrees, p=0.42). The plantar flexion angles were similar in both groups at discharge (mean difference: 0.5 degrees, p=0.86) and final assessment (mean difference: 0.5 degrees, p=0.57). In addition, there was no difference in total active motion between the groups at discharge (mean difference: 2 degrees, p=0.54) and final assessment (mean difference: 1 degrees, p=0.49). The patients were discharged from rehabilitation with independent walking at 44.04+/-7.9 days after surgery in the mobilisation group compared to 57.07+/-2.3 days in the immobilisation group. This indicates a significant difference in morbidity (mean
Nourissat, Geoffroy; Berenbaum, Francis; Duprez, Delphine
Tendon is a crucial component of the musculoskeletal system. Tendons connect muscle to bone and transmit forces to produce motion. Chronic and acute tendon injuries are very common and result in considerable pain and disability. The management of tendon injuries remains a challenge for clinicians. Effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Animal and cellular models have been developed to study tendon-cell differentiation and tendon repair following injury. These studies have highlighted specific growth factors and transcription factors involved in tenogenesis during developmental and repair processes. Mechanical factors also seem to be essential for tendon development, homeostasis and repair. Mechanical signals are transduced via molecular signalling pathways that trigger adaptive responses in the tendon. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis and repair is prerequisite for the identification of effective treatments for chronic and acute tendon injuries.
Novati, Federico Cesare; Franchi, Alberto; Papa, Giovanni; Arnež, Zoran Marij
Elastofibroma is a rare benign lesion that typically arises on the posterior chest wall beneath the scapula. The etiopathogenesis is still unclear and the knowledge about its diagnosis and management mainly comes from small case series. We collected all the data related to 11 Elastofibroma Dorsi treated at our institution between January 2003 and July 2014. The definitive diagnosis was made by histological examination of the mass. We analyzed the characteristic of the patients, (i.e. age, sex, dominant hand, and occupation), the presenting symptoms and signs, the preoperative investigations, surgical management and complications comparing our findings with the current medical literature on the subject. We found that preoperative investigations are of limited value and when clinical presentation is typical the diagnosis could be made presumptively. Surgery should be performed under general anaesthesia since local anaesthetic infiltration and sedation are often inadequate to reduce intraoperative discomfort.
Cavallasca, Javier A; Sohn, Debora I; Borgia, Ariel R; Maliandi, María Del Rosario; Musuruana, Jorge L
Elastofibroma dorsi is a benign, uncommon fibroelastic tissue condition, more common in women after the fifth decade of life. It is usually located in the subscapular region, and can sometimes be bilateral. We present 4 patients, between 53 and 73 years of age, with this disease. It is often an asymptomatic lesion that can manifest, even at its apex, with mild pain when moving the scapula. All our patients had pain.The diagnosis is based on clinical findings and imaging studies, especially ultrasound, computed tomography, and nuclear magnetic resonance. The biopsy is reserved for patients who have no characteristic signs on imaging. In our series, surgical excision was necessary in one of the patients, and in the others, clinical and imaging studies allowed us to arrive at a definitive diagnosis.
Coen, Michael J; Chen, Shin-Tai; Rundle, Charles H; Wergedal, Jon E; Lau, Kin-Hing William
The present study aimed to develop a rat model of biceps tenodesis and to assess the feasibility of a lentiviral (LV)-based bone morphogenetic protein (BMP) 4 in vivo gene transfer strategy for healing of biceps tenodesis. A rat model of biceps tenodesis was developed with an interference-fit open surgical technique. A LV vector expressing a BMP4 gene or β-galactosidase (β-gal) control gene was applied to the bone tunnel and the tendon graft before its insertion into the bone tunnel. Osteointegration was assessed by histology and pull-out tensile strength was measured by a biomechanical test suitable for small rat biceps tendon grafts. Neo-chondrogenesis was seen at the tendon-bone interface of LV-BMP4-treated but not control rats. The LV-BMP4-treated rats showed 32% (p < 0.05) more newly-formed trabecular bone at the tendon-bone junction than the LV-β-gal-treated controls after 3 weeks. However, the sites of neo-chondrogenesis and new bone formation in the LV-BMP4-treated tenodesis were highly spotty. Although the LV-BMP4 strategy did not promote bony integration of the tendon graft, it yielded a 29.5 ± 11.8% (p = 0.066) increase in improvement the pull-out strength of rat biceps tendons compared to the LV-β-gal treatment after 5 weeks. Although the LV-BMP4 in vivo gene transfer strategy did not enhance osteointegration of the tendon graft, it yielded a marked improvement in the return of the pull-out strength of the tendon graft. This presumably was largely a result of the bone formation effect of BMP4 that traps or anchors the tendon graft onto the bony tunnel. Published 2011. This article is a US Government work and is in the public domain in the USA.
Söyüncü, Yetkin; Bigat, Zekiye; Söyüncü, İlkay; Özkan, Ömer
Conventional procedures can usually prevent cerebrospinal fluid (CSF) leakages, but they may not work for complicated cases. In this case presentation, we demonstrated the effectiveness of combined omental and latissimus dorsi musculocutaneous flaps for management of difficult CSF fistula. A reverse turnover latissimus dorsi musculocutaneous flap and omental flap were transferred for reconstruction of the posterior wound and CSF leakage. The omental flap component was used for CSF absorption, and the latissimus dorsi muscle component was used for obliteration of the dead space, covering of the exposed bone, and tension-free closure of the wound. The wound healed dramatically, with no observed severe donor site morbidity. The patient has been followed for 30 months with no evidence of CSF leakage and no pseudomeningocele formation, which was confirmed by magnetic resonance imaging (MRI). Although this is a case presentation, we can say that the combination of the omental and musculocutaneous flaps allow effective treatment and prevention of CSF fistulas in selected high-risk patients and provide durable coverage of complex spinal wounds.
Gregory, C R; Gourley, I M; Koblik, P D; Patz, J D
Dissection and injection studies in canine cadavers and in anesthetized dogs were conducted to determine the feasibility of using the latissimus dorsi, gracilis, and rectus abdominus muscles as musculocutaneous free flaps. Lengths of vascular pedicles for the latissimus dorsi (2 +/- 0.8 cm), gracilis (1.8 +/- 0.8 cm), and rectus abdominus (1.9 +/- 0.9-cm cranial deep epigastric, 1.7 +/- 0.5-cm caudal deep epigastric), as well as arterial diameters (1.28 +/- 0.31-mm thoracodorsal for the latissimus dorsi, 1.10 +/- 0.33-mm muscular branch for the gracilis, 1.25 +/- 0.25-mm cranial deep epigastric and 1.26 +/- 0.32-mm caudal deep epigastric for the rectus abdominus) were considered satisfactory for microvascular transfer. Fluorometry demonstrated overlying cutaneous perfusion in all flaps based on their muscle vascular pedicles, with the exception of the rectus abdominus flap based on the caudal deep epigastric artery. In this instance, up to 20% of the cutaneous element had questionable or no perfusion.
Woo, Evan; Tan, Bien-Keem; Lim, Chong-Hee
Pleural space problems after lung resection and persistent air leaks are among the commonest challenges posed to thoracic surgeons. Surgical repair of air leaks are indicated when conventional tube thoracostomy has failed to solve the problem. We would like to propose the novel application of the combined latissimus dorsi-serratus anterior transposition flap for selected cases of air leaks that are recalcitrant to conventional treatment. We discuss its indications and the surgical technique. Five patients underwent the procedure between 2004 and 2007. They were male patients aged between 32 and 70 years. Four patients had alveolar-pleural fistulas resulting in persistent air leaks while the fifth patient had, in addition, a space problem following lung volume reduction surgery. All patients had prolonged treatment with chest drains without success. With the patient in a lateral decubitus position, a lazy-S incision was used to expose the entire latissimus dorsi and the proximal slips of the serratus anterior muscles. They were raised as pedicled flaps and transferred in tandem. The latissimus dorsi was introduced into the pleural cavity via a thoracic window and used to reinforce the fistula repair. The serratus anterior muscle closed the rib window. In all cases, the lungs reexpanded and chest drains were removed within 5 days post surgery. There were no recurrent air leaks at 1-year follow-up with all patients. Conservative treatment in all our patients was unsuccessful. The dual flap technique has the advantage of allowing normal ventilation while providing a seal over the alveolar-pleural fistula. The muscle bulk of the latissimus dorsi fills the pleural dead space and the serratus anterior muscle seals the axilla preventing subcutaneous emphysema. There was minimal morbidity associated with the use of this dual muscle flap technique. This technique is an effective treatment option for recalcitrant air leaks.
... the area to see if there are any injuries to nerves and blood vessels. When the repair is complete, the wound is closed. If the tendon damage is too severe, the repair and reconstruction ... to repair part of the injury. Another surgery will be done at a later ...
Bevilacqua, Nicholas J
Achilles tendon ruptures are best managed acutely. Neglected Achilles tendon ruptures are debilitating injuries and the increased complexity of the situation must be appreciated. Surgical management is recommended, and only in the poorest surgical candidate is conservative treatment entertained. Numerous treatment algorithms and surgical techniques have been described. A V-Y advancement flap and flexor halluces longus tendon transfer have been found to be reliable and achieve good clinical outcomes for defects ranging from 2 cm to 8 cm. This article focuses on the treatment options for the neglected Achilles tendon rupture. Copyright Â© 2012 Elsevier Inc. All rights reserved.
Monticciolo, D L; Ross, D; Bostwick, J; Eaves, F; Styblo, T
The objective of this study was to define and evaluate mammographic changes in patients treated with breast-conserving therapy and a new reconstructive technique that uses autologous tissue from a latissimus dorsi musculosubcutaneous flap. Of 20 patients who underwent either immediate or delayed endoscopic latissimus dorsi muscle flap reconstruction after lumpectomy, 13 also had postsurgery mammograms available for review. Radiographic findings assessed included skin thickening, density or radiolucency at the reconstruction site, density around the flap, fat necrosis, calcifications, and the presence of surgical clips. Mammograms for three patients (23%) revealed thickening that we believed was attributable to radiation therapy. No patient had increased density in the flap itself; all flaps were relatively radiolucent centrally (13/13; 100%). Mammograms revealed density around the rim of the flap in four patients (31%). This density was most likely secondary to latissimus dorsi muscle fibers and did not limit radiographic evaluation. One patient had calcifications, probably secondary to fat necrosis. No oil cysts were seen. In the majority of patients (11/13; 85%), surgical clips were visible. Endoscopic latissimus dorsi muscle flap reconstruction, previously used only for mastectomy patients, is now being used for improved esthetic outcome in selected patients who desire breast conservation. Our results indicate that the mammographic findings are predictable. The most common findings are relative radiolucency centrally, with or without density from muscle fibers around the edges of the area of tissue transfer. The transplanted musculosubcutaneous flap does not interfere with mammographic evaluation.
Takushima, Akihiko; Harii, Kiyonori; Okazaki, Mutsumi; Ohura, Norihiko; Asato, Hirotaka
Acute unilateral facial paralysis, such as occurs in Bell palsy and Hunt syndrome, is mostly a benign neurologic morbidity that resolves within a few months. However, incomplete or misdirected return of the affected nerve results in unfavorable cosmetic sequelae in some patients. Although functional problems such as lagophthalmos are rare, facial asymmetry on smiling resulting from a lack of mimetic muscle strength in the cheek is often psychologically annoying to patients. To obtain a more natural smile, the authors transfer latissimus dorsi muscle to assist in cheek movement. A small, thinned muscle (mini-latissimus dorsi) is sufficient for transplant in this situation. In this study, 96 patients with incomplete facial paralysis who underwent mini-latissimus dorsi transfer were examined. In this series, along with evaluation using the grading scale used in previous reports, preoperative and postoperative videos of 30 patients were analyzed for quantitative assessment using newly developed computer software. Temporary deterioration of paralysis was recognized in three cases but did not last more than a few months. Signs of transferred muscle contraction were recorded after 4 to 12 months among 91 patients. No apparent clinical signs of contraction were recognized in one patient, and four patients could not be followed postoperatively. The synchronized ratio of vertical movement and the symmetrical ratio of horizontal movement both in the cheek and in the lower lip between healthy and paralyzed sides among 30 patients were statistically improved. Statistical analysis using newly developed computer software revealed that a more symmetrical smile can be achieved by muscle transfer among patients with incomplete facial paralysis. Mini-latissimus dorsi transfer can avoid postoperative muscle bulkiness of the cheek and can achieve more natural cheek movement.
Magnusson, S Peter; Narici, Marco V; Maganaris, Constantinos N; Kjaer, Michael
Tendon properties contribute to the complex interaction of the central nervous system, muscle–tendon unit and bony structures to produce joint movement. Until recently limited information on human tendon behaviour in vivo was available; however, novel methodological advancements have enabled new insights to be gained in this area. The present review summarizes the progress made with respect to human tendon and aponeurosis function in vivo, and how tendons adapt to ageing, loading and unloading conditions. During low tensile loading or with passive lengthening not only the muscle is elongated, but also the tendon undergoes significant length changes, which may have implications for reflex responses. During active loading, the length change of the tendon far exceeds that of the aponeurosis, indicating that the aponeurosis may more effectively transfer force onto the tendon, which lengthens and stores elastic energy subsequently released during unloading, in a spring-like manner. In fact, data recently obtained in vivo confirm that, during walking, the human Achilles tendon provides elastic strain energy that can decrease the energy cost of locomotion. Also, new experimental evidence shows that, contrary to earlier beliefs, the metabolic activity in human tendon is remarkably high and this affords the tendon the ability to adapt to changing demands. With ageing and disuse there is a reduction in tendon stiffness, which can be mitigated with resistance exercises. Such adaptations seem advantageous for maintaining movement rapidity, reducing tendon stress and risk of injury, and possibly, for enabling muscles to operate closer to the optimum region of the length–tension relationship. PMID:17855761
Mazurek, Tomasz; Strankowski, Michał; Ceynowa, Marcin; Rocławski, Marek
This study compared the maximum load, stress, elongation at failure and the mode of failure of three kinds of tendons most frequently used for tendon grafting and tendon transfers, using the Pulvertaft weave suture. Sixty tendons were used from fresh human cadaver upper and lower extremities. The performed repairs included: 9 specimens of flexor digitorum superficialis or profundus tendon with flexor digitorum superficialis or profundus tendon (thick-thick suture), 10 specimens of flexor digitorum superficialis or profundus tendon with palmaris longus tendon (thick-medium thin suture), and 10 specimens of flexor digitorum superficialis or profundus tendon with plantaris tendon (thick-thin suture). Material testing machine was used to test repairs to failure. The mean maximum load at failure increased with the thickness of donor tendon. For the thick-thick specimen, the maximum load at failure was 125 newtons (N), for the thick-medium thin specimen it was 86,8N, and for the thick-thin it was 65,2N. These differences were all statistically significant. The active rehabilitation protocol is possible only with thick-thick connections used, the strength of the thick-medium thin connection is on the border of indications for the active rehabilitation protocol, and the thick-thin connection strength is sufficient only for the passive rehabilitation protocol. Copyright © 2010. Published by Elsevier Ltd.
... Basic types of peroneal tendon injuries are tendonitis, tears and subluxation. Tendonitis is an inflammation of one ... include: Pain Swelling Warm to the touch Acute tears are caused by repetitive activity or trauma. Immediate ...
Achilles tendon rupture Overview By Mayo Clinic Staff Achilles (uh-KILL-eez) tendon rupture is an injury that affects the back ... but it can happen to anyone. The Achilles tendon is a strong fibrous cord that connects the ...
Achilles tendon rupture-surgery; Percutaneous Achilles tendon rupture repair ... To fix your torn Achilles tendon, the surgeon will: Make a cut down the back of your heel Make several small cuts rather than one large cut ...
Schoeller, Thomas; Wechselberger, Gottfried; Hussl, Heribert; Huemer, Georg M
Major upper arm amputations are often accompanied by different levels of soft-tissue divisions involving crushing, traction, and avulsion injuries to various structures. In these cases the goal is not only the re-establishment of circulation, but also functional outcome. Some patients require further reconstruction for functional restoration of elbow flexion and additional soft tissue coverage. Five patients underwent functional latissimus dorsi transfer for restoration of elbow flexion after successful upper arm replantation at our institution. The transfer was unipolar in four patients and bipolar in one. The patients' ages ranged from seven to 55 years. The time period between replantation and transfer ranged from two weeks to 12 months. All flaps healed well with minimal donor site morbidity. At mean 43-month follow-up (range: 22-65 months), functional results were good with M4 in three patients and M3 in two patients for elbow flexion. The pedicled latissimus dorsi muscle flap is a valuable tool to restore elbow flexion and provide coverage of soft tissue defects after major upper arm replantations.
Thorpe, Chavaunne T; Karunaseelan, Kabelan J; Ng Chieng Hin, Jade; Riley, Graham P; Birch, Helen L; Clegg, Peter D; Screen, Hazel R C
Although the predominant function of all tendons is to transfer force from muscle to bone and position the limbs, some tendons additionally function as energy stores, reducing the energetic cost of locomotion. To maximise energy storage and return, energy-storing tendons need to be more extensible and elastic than tendons with a purely positional function. These properties are conferred in part by a specialisation of a specific compartment of the tendon, the interfascicular matrix, which enables sliding and recoil between adjacent fascicles. However, the composition of the interfascicular matrix is poorly characterised and we therefore tested the hypothesis that the distribution of elastin and proteoglycans differs between energy-storing and positional tendons, and that protein distribution varies between the fascicular matrix and the interfascicular matrix, with localisation of elastin and lubricin to the interfascicular matrix. Protein distribution in the energy-storing equine superficial digital flexor tendon and positional common digital extensor tendon was assessed using histology and immunohistochemistry. The results support the hypothesis, demonstrating enrichment of lubricin in the interfascicular matrix in both tendon types, where it is likely to facilitate interfascicular sliding. Elastin was also localised to the interfascicular matrix, specifically in the energy-storing superficial digital flexor tendon, which may account for the greater elasticity of the interfascicular matrix in this tendon. A differential distribution of proteoglycans was identified between tendon types and regions, which may indicate a distinct role for each of these proteins in tendon. These data provide important advances into fully characterising structure-function relationships within tendon. © 2016 The Authors. Journal of Anatomy published by John Wiley & Sons Ltd on behalf of Anatomical Society.
Shadwick, Robert E; Rapoport, H Scott; Fenger, Joelle M
The caudal tendons in tunas and other scombrid fish link myotomal muscle directly to the caudal fin rays, and thus serve to transfer muscle power to the hydrofoil-like tail during swimming. These robust collagenous tendons have structural and mechanical similarity to tendons found in other vertebrates, notably the leg tendons of terrestrial mammals. Biochemical studies indicate that tuna tendon collagen is composed of the (alpha1)(2),alpha2 heterotrimer that is typical of vertebrate Type I collagen, while tuna skin collagen has the unusual alpha1,alpha2,alpha3 trimer previously described in the skin of some other teleost species. Tuna collagen, like that of other fish, has high solubility due to the presence of an acid-labile intermolecular cross-link. Unlike collagen in mammalian tendons, no differences related to cross-link maturation were detected among tendons in tuna ranging from 0.05 to 72 kg (approx. 0.25-6 years). Tendons excised post-mortem were subjected to load cycling to determine the modulus of elasticity and resilience (mean of 1.3 GPa and 90%, respectively). These material properties compare closely to those of leg tendons from adult mammals that can function as effective biological springs in terrestrial locomotion, but the breaking strength is substantially lower. Peak tendon forces recorded during steady swimming appear to impose strains of much less than 1% of tendon length, and no more than 1.5% during bursts. Thus, the caudal tendons in tunas do not appear to function as elastic storage elements, even at maximal swimming effort.
Thorpe, Chavaunne T.; Udeze, Chineye P.; Birch, Helen L.; Clegg, Peter D.; Screen, Hazel R. C.
Tendons transfer force from muscle to bone. Specific tendons, including the equine superficial digital flexor tendon (SDFT), also store and return energy. For efficient function, energy-storing tendons need to be more extensible than positional tendons such as the common digital extensor tendon (CDET), and when tested in vitro have a lower modulus and failure stress, but a higher failure strain. It is not known how differences in matrix organization contribute to distinct mechanical properties in functionally different tendons. We investigated the properties of whole tendons, tendon fascicles and the fascicular interface in the high-strain energy-storing SDFT and low-strain positional CDET. Fascicles failed at lower stresses and strains than tendons. The SDFT was more extensible than the CDET, but SDFT fascicles failed at lower strains than CDET fascicles, resulting in large differences between tendon and fascicle failure strain in the SDFT. At physiological loads, the stiffness at the fascicular interface was lower in the SDFT samples, enabling a greater fascicle sliding that could account for differences in tendon and fascicle failure strain. Sliding between fascicles prior to fascicle extension in the SDFT may allow the large extensions required in energy-storing tendons while protecting fascicles from damage. PMID:22764132
Thorpe, Chavaunne T; Udeze, Chineye P; Birch, Helen L; Clegg, Peter D; Screen, Hazel R C
Tendons transfer force from muscle to bone. Specific tendons, including the equine superficial digital flexor tendon (SDFT), also store and return energy. For efficient function, energy-storing tendons need to be more extensible than positional tendons such as the common digital extensor tendon (CDET), and when tested in vitro have a lower modulus and failure stress, but a higher failure strain. It is not known how differences in matrix organization contribute to distinct mechanical properties in functionally different tendons. We investigated the properties of whole tendons, tendon fascicles and the fascicular interface in the high-strain energy-storing SDFT and low-strain positional CDET. Fascicles failed at lower stresses and strains than tendons. The SDFT was more extensible than the CDET, but SDFT fascicles failed at lower strains than CDET fascicles, resulting in large differences between tendon and fascicle failure strain in the SDFT. At physiological loads, the stiffness at the fascicular interface was lower in the SDFT samples, enabling a greater fascicle sliding that could account for differences in tendon and fascicle failure strain. Sliding between fascicles prior to fascicle extension in the SDFT may allow the large extensions required in energy-storing tendons while protecting fascicles from damage.
Friedman, Michael V.; Stensby, J. Derek; Hillen, Travis J.; Demertzis, Jennifer L.; Keener, Jay D.
A case of a latissimus dorsi myotendinous junction strain in an avid CrossFit athlete is presented. The patient developed acute onset right axillary burning and swelling and subsequent palpable pop with weakness while performing a “muscle up.” Magnetic resonance imaging examination demonstrated a high-grade tear of the right latissimus dorsi myotendinous junction approximately 9 cm proximal to its intact humeral insertion. There were no other injuries to the adjacent shoulder girdle structures. Isolated strain of the latissimus dorsi myotendinous junction is a very rare injury with a scarcity of information available regarding its imaging appearance and preferred treatment. This patient was treated conservatively and was able to resume active CrossFit training within 3 months. At 6 months postinjury, he had only a mild residual functional deficit compared with his preinjury level. PMID:26502450
Piontek, Tomasz; Bąkowski, Paweł; Ciemniewska-Gorzela, Kinga; Grygorowicz, Monika
Plantaris tendon, peronus brevis tendon and flexor hallucis longus tendon augmentation, commonly used in Achilles tendon rupture, often lead to weakening of injured foot and they require the immobilization after the surgery. It is essential to develop the technique, which gives no such limitation and allows for immediate functional improvement. We present our method of minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization. Posterolateral and posteromedial portals were made approximately 3 cm above the posterosuperior part of the calcaneus to clean the area of the Achilles tendon endoscopically. Then the hamstrings are harvested and prepared for the "Endobutton" system. A midline incision of the skin is performed approximately 1 cm above the posterosuperior part of the calcaneus to approach to the posterosuperior part of the calcaneus. Then under fluoroscopy the calcaneus was drilled through using K-wire. The distal end of the graft equipped with an Endobutton loop was entered into the drilled tunnel in the calcaneus. Later, 8 consecutive skin incisions are performed. Proximal ends of the graft were brought out through the native Achilles tendon reaching medial and lateral skin incisions. The final step was to transfer and tie the graft ends through the most proximal skin incision. This minimally invasive, endoscopic technique allows reconstruction of the Achilles tendon using semitendinosus and gracilis tendons with Endobutton stabilization and can be used in so-called "difficult", resistant cases as a "salvage procedure".
Chang, David W; Youssef, Adel; Cha, Sumi; Reece, Gregory P
The extended latissimus dorsi myocutaneous flap can provide autogenous tissue replacement of breast volume without an implant. Nevertheless, experience with the extended latissimus dorsi flap for breast reconstruction is relatively limited. In this study, the authors evaluated their experience with the extended latissimus dorsi flap for breast reconstruction to better understand its indications, limitations, complications, and clinical outcomes. All patients who underwent breast reconstruction with extended latissimus dorsi flaps at the authors' institution between January of 1990 and December of 2000 were reviewed. During the study period, 75 extended latissimus dorsi flap breast reconstructions were performed in 67 patients. Bilateral breast reconstructions were performed in eight patients, and 59 patients underwent unilateral breast reconstruction. There were 45 immediate and 30 delayed reconstructions. Mean patient age was 51.5 years. Mean body mass index was 31.8 kg/m2. Flap complications developed in 21 of 75 flaps (28.0 percent), and donor-site complications developed in 29 of 75 donor sites (38.7 percent). Mastectomy skin flap necrosis (17.3 percent) and donor-site seroma (25.3 percent) were found to be the most common complications. There were no flap losses. Patients aged 65 years or older had higher odds of developing flap complications compared with those 45 years or younger (p = 0.03). Patients with size D reconstructed breasts had significantly higher odds of flap complications compared with those with size A or B reconstructed breasts (p = 0.05). Obesity (body mass index greater than or equal to 30 kg/m2) was associated with a 2.15-fold increase in the odds of developing donor-site complications compared with patients with a body mass index less than 30 kg/m2 (p = 0.01). No other studied factors had a significant relationship with flap or donor-site complications. In most patients, the extended latissimus dorsi flap alone, without an implant, can
Lui, Tun Hing
Tendon adhesion is one of the most common causes of disability following tendon surgery. A case of extensive peritendinous adhesions of the Achilles tendon and tibialis posterior tendon after compound rupture of the tendons was reported. This was managed by endoscopic adhesiolysis of both tendons. The endoscopic approach allows early postoperative mobilisation which can relieve the tendon adhesion. PMID:24045762
Sirasanagandla, Srinivasa Rao; Nayak, Satheesha B.; Somayaji, Nagabhooshana S.; Rao, Mohandas K. G.; Bhat, Kumar M. R.
The extensor digitorum brevis muscle (EDB) is a practical option for use as an island flap or free flap when reconstructing soft tissue defects in the ankle as well as in the entire lower limb. It is frequently used to correct crossover toe deformity and other painful toe disorders. We evaluated the morphometry of the EDB in 44 formalin-fixed limbs. Length and width of the muscles were measured. Surface area was calculated as the product of length and width of the muscle. The length of each tendon was also measured from its origin to the point of distal attachment. Presence of any additional tendons was noted. Mean length, width, and surface area of the muscle were 7.39±0.71 cm, 4.1±0.37 cm, and 30.5±4.78 cm2 on the right side and 7.2±0.84 cm, 3.9±0.37 cm, and 28.4±5.35 cm2 on the left side, respectively. Morphometry of the tendons revealed that the tendon of the great toe had the highest mean length (9.5 cm) and the tendon of the fourth toe had the lowest mean length (6.3 cm). Four of the limbs studied (9.09%) had only three tendons. Three of the limbs studied (6.81%) had five tendons, and in one exceptional case (2.27%), six tendons were detected. These observations have significant value and are applicable to plastic and orthopedic surgery. PMID:24179695
Kubo, Keitaro; Kanehisa, Hiroaki; Fukunaga, Tetsuo
Cooling and heating have been shown to affect the contractile properties of muscles. However, the reasons for these changes remain unclear. The present study aimed to quantify the mechanical properties of muscle and tendon during passive stretch and active contraction, and to investigate the effects of cooling and heating on the mechanical properties of muscle and tendon. Before and after these conditions, the elongation of the muscle fascicle, tendon and aponeurosis of the medial gastrocnemius muscle was directly measured by ultrasonography, while the ankle joint was passively moved within the joint range of +15 to -30 deg (0 deg = neutral anatomic position; positive values for plantar flexion) and subjects performed ramp isometric plantar flexion up to the voluntary maximum. While the muscle fascicle, tendon and aponeurosis stretched during passive dorsi-flexion, the elongation of the tendon was significantly greater than that of the aponeurosis. During isometric contraction, the maximal elongation of the tendon was significantly greater than that of the aponeurosis. After cooling and heating, no significant changes in the elongation of muscle fascicle, tendon and aponeurosis were found during passive stretch. Similarly, after both the immersions there were no changes in the relationship between the estimated muscle force and elongation of each structure (tendon-aponeurosis complex, tendon) during isometric contraction. These results implied that the general application of icing and hot pack did not change the mechanical properties of muscle and tendon.
Chong, Alphonsus K S; Riboh, Jonathan; Smith, R Lane; Lindsey, Derek P; Pham, Hung M; Chang, James
Tissue engineering of flexor tendons requires scaffolds with adequate strength and biocompatibility. The biomechanical properties of acellularized and reseeded flexor tendon scaffolds are unknown. Acellularized tendons and reseeded constructs were tested to determine whether the treatment process had altered their biomechanical properties. Rabbit flexor tendons were acellularized using a freeze-thaw cycle followed by trypsin and Triton-X treatment. Complete acellularization of the tendon samples was confirmed by histology and by attempting to obtain viable cells by trypsin treatment of acellularized tendon. Reseeded constructs were obtained by incubating acellularized tendons in a tenocyte suspension. Tensile testing was performed to compare the ultimate tensile stress and elastic modulus of acellularized tendons and reseeded flexor tendon constructs to control flexor tendons. The treatment protocol successfully acellularized flexor tendons. No cells were seen within the tendon on histologic assessment, and no viable cells could be obtained from acellularized tendon. Acellularized tendon was successfully reseeded with tenocytes, although cell adhesion was limited to the surface of the tendon scaffold. Tensile testing showed that acellularized tendon had the same ultimate stress and elastic modulus as normal tendons. Reseeded tendons had the same elastic modulus as normal tendons, but hind-paw tendon constructs showed a decrease in ultimate stress compared with normal tendons (50.09 MPa versus 66.01 MPa, p = 0.026). Acellularized flexor tendons are a potential high-strength scaffold for flexor tendon tissue engineering. This approach of acellularization and reseeding of flexor tendons may provide additional intrasynovial graft material for hand reconstruction.
Zacharia, Balaji; Puthezhath, Kishore
Swan neck thumb deformity can be caused by osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, tendon transfers and paralytic diseases. Abductor pollicis longus is one of the major stabilizing tendon of the carpometacarpal joint of thumb. To the best of our knowledge, swan neck thumb deformity owing to division of abductor pollicis longus tendon is rare. In this article, we describe a case of isolated division of abductor pollicis longus tendon presenting with swan-neck deformity of thumb and discuss the mechanism, management and outcome. The patient was treated by repair of the divided tendon using palmaris longus tendon graft. At approximately 107 weeks following treatment, the patient was having full range of thumb movement and the deformity completely disappeared. We also describe the unusual mechanism whereby an isolated division of abductor pollicis longus tendon results in swan neck thumb deformity. Level of clinical evidence IV.
Netscher, David T; Badal, Justin J
We review different causes, diagnoses, and treatment options of closed flexor tendon disruptions in the hand. A classification of closed tendon ruptures based on their mechanism includes traumatic tendon avulsion, spontaneous midsubstance rupture, attrition rupture, infiltrative tenosynovial rupture, and iatrogenic. Certain conditions result in tendon disruption inflicted by more than 1 of these etiologies. In rheumatoid arthritis, tendon rupture may result from attrition on an exposed rough surface, proliferative tenosynovial tendon infiltration, or steroid use. Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Nagda, Sameer H; Cohen, Steven B; Noonan, Thomas J; Raasch, William G; Ciccotti, Michael G; Yocum, Lewis A
Very little data exist on latissimus dorsi (LD) and teres major (TM) injuries in professional baseball pitchers. This review was undertaken to report on the management and outcomes of baseball pitchers with injury to 1 or both of these muscles. Case series; Level of evidence, 4. A retrospective review of 16 professional baseball pitchers diagnosed and treated for an LD and/or TM tear between 2002 and 2008 was performed. Magnetic resonance imaging confirmed the diagnosis in all cases. The mean age was 28.1 years. All were treated nonoperatively with rest, rehabilitation, and return to pitching after a throwing program. The injuries included tendon avulsions in 6 athletes and strains in 10. Length of disabled time, return to prior level of pitching, and recurrences were noted. Fifteen of 16 pitchers (94%) returned to the same or higher level of play. The mean time to throwing was 35.6 days. Mean time to pitching was 61.9 days. Nine of 16 injuries (56%) were season-ending. Mean total time lost for athletes returning the same season was 82.4 days. Two of 16 pitchers (13%) sustained recurrent injuries. Prior shoulder and elbow injuries were noted in 75% (12 of 16). Injury of the LD and/or TM can occur in pitchers. Nonoperative treatment is successful in allowing a return to high-level pitching.
Kim, Sang Wha; Jeon, Seung Bae; Hwang, Kyu Tae; Kim, Youn Hwan
Amputation of the extremities is a definitive reconstructive option, and surgeons should aim to preserve maximum overall function. If the exposed bone cannot be adequately covered using local tissues, the stump can be reconstructed using a number of well-described free flap transfer techniques. Between January 2002 and December 2011, 31 patients with severe injuries to the lower extremities underwent above-the-knee, below-the-knee, and Chopart and Ray amputations. Bony stumps were covered using latissimus dorsi myocutaneous flaps alone (group 1), or together with serratus anterior muscle flaps (group 2). The groups were compared with respect to age, flap survival, skin flap size, immediate complications, wound sloughing, deep ulceration, need for bone amputation, limb visual analog scale score, time to prosthesis, and follow-up duration. The mean area of the latissimus dorsi skin flap was 255.9 cm, and immediate complications occurred in 8 (25.8%) patients. In the double-padding group, there were fewer cases of deep ulceration than in the single-flap group, and prostheses could be worn sooner. There were no statistically significant differences in other parameters. Successful reconstruction of amputation stumps requires an adequate, durable, weight-bearing, and well-contoured soft tissue cover. A latissimus dorsi musculocutaneous flap together with a serratus anterior muscle flap provides well-vascularized muscle tissue and a durable skin paddle, leading to less ulceration than conventional flap techniques.
Steiner, Adrian; Anderson, David E; Desrochers, André
Contracted flexor tendon leading to flexural deformity is a common congenital defect in cattle. Arthrogryposis is a congenital syndrome of persistent joint contracture that occurs frequently in Europe as a consequence of Schmallenberg virus infection of the dam. Spastic paresis has a hereditary component, and affected cattle should not be used for breeding purposes. The most common tendon avulsion involves the deep digital flexor tendon. Tendon disruptions may be successfully managed by tenorrhaphy and external coaptation or by external coaptation alone. Medical management alone is unlikely to be effective for purulent tenosynovitis.
Salisbury, S T Samuel; Buckley, C Paul; Zavatsky, Amy B
A study was made of the deformation of tendons when compressed transverse to the fiber-aligned axis. Bovine digital extensor tendons were compression tested between flat rigid plates. The methods included: in situ image-based measurement of tendon cross-sectional shapes, after preconditioning but immediately prior to testing; multiple constant-load creep/recovery tests applied to each tendon at increasing loads; and measurements of the resulting tendon displacements in both transverse directions. In these tests, friction resisted axial stretch of the tendon during compression, giving approximately plane-strain conditions. This, together with the assumption of a form of anisotropic hyperelastic constitutive model proposed previously for tendon, justified modeling the isochronal response of tendon as that of an isotropic, slightly compressible, neo-Hookean solid. Inverse analysis, using finite-element (FE) simulations of the experiments and 10 s isochronal creep displacement data, gave values for Young's modulus and Poisson's ratio of this solid of 0.31 MPa and 0.49, respectively, for an idealized tendon shape and averaged data for all the tendons and E = 0.14 and 0.10 MPa for two specific tendons using their actual measured geometry. The compression load versus displacement curves, as measured and as simulated, showed varying degrees of stiffening with increasing load. This can be attributed mostly to geometrical changes in tendon cross section under load, varying according to the initial 3D shape of the tendon.
Real-time ultrasonography (US) using linear-array probes and a stand-off pad as a ''waterpath'' was performed to evaluate the Achilles tendon in 67 patients (including 24 athletes) believed to have acute or chronic traumatic or inflammatory pathologic conditions. Tendons in 23 patients appeared normal on US scans. The 44 abnormal tendons comprised five complete and four partial ruptures, seven instances of postoperative change, and 28 cases of tendonitis. US depiction of the inner structure of the tendon resulted in the diagnosis of focal abnormalities, including partial ruptures, nodules, and calcifications. Tendonitis was characterized by enlargement and decreased echogenicity of the tendon. The normal US appearance of the Achilles tendon is described.
Docheva, Denitsa; Müller, Sebastian A.; Majewski, Martin; Evans, Christopher H.
Tendon injuries are common and present a clinical challenge to orthopedic surgery mainly because these injuries often respond poorly to treatment and require prolonged rehabilitation. Therapeutic options used to repair ruptured tendons have consisted of suture, autografts, allografts, and synthetic prostheses. To date, none of these alternatives has provided a successful long-term solution, and often the restored tendons do not recover their complete strength and functionality. Unfortunately, our understanding of tendon biology lags far behind that of other musculoskeletal tissues, thus impeding the development of new treatment options for tendon conditions. Hence, in this review, after introducing the clinical significance of tendon diseases and the present understanding of tendon biology, we describe and critically assess the current strategies for enhancing tendon repair by biological means. These consist mainly of applying growth factors, stem cells, natural biomaterials and genes, alone or in combination, to the site of tendon damage. A deeper understanding of how tendon tissue and cells operate, combined with practical applications of modern molecular and cellular tools could provide the long awaited breakthrough in designing effective tendon-specific therapeutics and overall improvement of tendon disease management. PMID:25446135
Komura, Shingo; Yokoi, Tatsuo; Nonomura, Hidehiko
This report describes two cases of traumatic closed index extensor tendon rupture at the musclotendinous junction. Both patients were injured when their work gloves were caught in the revolving parts of machines, and both were treated surgically. One of the patients completely ruptured the index extensor digitorum communis (EDC) and the extensor indicis proprius (EIP) tendons at the musclotendinous junction of dorsal forearm. In this patient, the distal stump of the index EDC tendon was sutured to the middle EDC tendon in an end-to-side juncture. The other patient completely ruptured the EIP tendon and partially ruptured the index EDC tendon at the musclotendinous junction. In this patient, tendon transfer of the extensor digiti minimi (EDM) to the EIP tendon and plication of the index EDC tendon were performed. In both cases, surgical intervention enabled the patients to extend their index fingers almost normally; however, the former complained of inability to extend his index finger independently. Tendon transfer of the EDM in cases of index extensor tendon rupture at the musclotendinous junction is a good method to restore ability to independently extend the index finger. However, consideration should be given to anatomical variation in the little finger. The EDC tendon is sometimes absent leaving the EDM tendon as the only extensor tendon to the little finger.
Luini, J; Chaouat, M; Uzzan, C; Boccara, D; Mimoun, M
One of the most frequently used flap in breast reconstruction after mastectomy is the latissimus dorsi musculocutaneous flap. We present a novel method of sampling by extending the mastectomy scar back until the skin paddle. On the one hand, this technique facilitates the transfer of the flap in thoracic region, on the other hand, it allows for larger skin paddle and maximize new breast contour reintegrating the ear skin during the modeling. The data of 37 patients operated by this technique between 2006 and 2009 were reviewed retrospectively. Cosmetic results were analyzed from photographs by a plastic surgeon who was not the operator. The results were highly satisfactory in 45% cases, satisfactory in 40% of cases, fair in 12% of cases and inadequate in 3% of cases. The main advantage of this technique is to collect large skin paddle with a larger width at the ends through increasing opportunities for modeling. Copyright © 2012. Published by Elsevier SAS.
Giusti, Betti; Pepe, Guglielmina
Tendons among connective tissue, mainly collagen, contain also elastic fibers (EF) made of fibrillin 1, fibrillin 2 and elastin that are broadly distributed in tendons and represent 1–2% of the dried mass of the tendon. Only in the last years, studies on structure and function of EF in tendons have been performed. Aim of this review is to revise data on the organization of EF in tendons, in particular fibrillin structure and function, and on the clinical manifestations associated to alterations of EF in tendons. Indeed, microfibrils may contribute to tendon mechanics; therefore, their alterations may cause joint hypermobility and contractures which have been found to be clinical features in patients with Marfan syndrome (MFS) and Beals syndrome. The two diseases are caused by mutations in genes FBN1 and FBN2 encoding fibrillin 1 and fibrillin 2, respectively. PMID:27812333
Yamazaki, H; Kato, H; Hata, Y; Nakatsuchi, Y; Tsuchikane, A
We analysed 21 patients with closed rupture of the flexor tendons caused by carpal bone and joint disorders. The tendon that ruptured depended on the location of the bone perforation into the carpal tunnel. Radiocarpal arthrography was performed in 13 patients and capsular perforation was demonstrated by contrast medium leakage into the carpal canal in 11 patients. This proved a useful diagnostic test. The flexor tendon(s) were reconstructed with free tendon graft in 17 patients, cross-over transfer of flexor tendons from adjacent digits in two and buddying to an adjacent flexor tendon in one patient. Postoperative total active range of motion in the fingers after 13 free tendon graft reconstructions averaged 213 degrees (range 170-265 degrees ). The active range of motion of the thumb-interphalangeal joint after free tendon graft reconstruction in three cases improved from 0 degrees to 33 degrees on average (range 10 degrees -40 degrees ).
Gatt, Ruben; Vella Wood, Michelle; Gatt, Alfred; Zarb, Francis; Formosa, Cynthia; Azzopardi, Keith M; Casha, Aaron; Agius, Tonio P; Schembri-Wismayer, Pierre; Attard, Lucienne; Chockalingam, Nachiappan; Grima, Joseph N
Tendons are visco-elastic structures that connect bones to muscles and perform the basic function of force transfer to and from the skeleton. They are essential for positioning as well as energy storing when involved in more abrupt movements such as jumping. Unfortunately, they are also prone to damage, and when injuries occur, they may have dilapidating consequences. For instance, there is consensus that injuries of tendons such as Achilles tendinopathies, which are common in athletes, are difficult to treat. Here we show, through in vivo and ex vivo tests, that healthy tendons are highly anisotropic and behave in a very unconventional manner when stretched, and exhibit a negative Poisson's ratio (auxeticity) in some planes when stretched up to 2% along their length, i.e. within their normal range of motion. Furthermore, since the Poisson's ratio is highly dependent on the material's microstructure, which may be lost if tendons are damaged or diseased, this property may provide a suitable diagnostic tool to assess tendon health. We report that human tendons including the Achilles tendons exhibits the very unusual mechanical property of a negative Poisson's ratio (auxetic) meaning that they get fatter rather than thinner when stretched. This report is backed by in vivo and ex vivo experiments we performed which clearly confirm auxeticity in this living material for strains which correspond to those experienced during most normal everyday activities. We also show that this property is not limited to the human Achilles tendon, as it was also found in tendons taken from sheep and pigs. This new information about tendons can form the scientific basis for a test for tendon health as well as enable the design of better tendon prosthesis which could replace damaged tendons. Copyright © 2015 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.
Szychta, Pawel; Butterworth, Mark; Dixon, Mike; Kulkarni, Dhananjay; Stewart, Ken; Raine, Cameron
To analyze clinical implications of the thoracodorsal nerve division in the latissimus dorsi musculocutaneous flap breast reconstruction. Prospective cohort study was conducted on 29 patients. Breast reconstruction with latissimus dorsi musculocutaneous flap was performed unilaterally in 20 patients or bilaterally in 9 women (38 breasts). Thoracodorsal nerve was divided during reconstruction of 20 breasts (group 1) and was preserved for 18 breasts (group 2). Height, width, projection, area of the covering skin and volume of the reconstructed and healthy breasts were measured on the 3D images of the anterior chest wall, taken 6 weeks and 6 months postoperatively with the Di3D 3D camera. Data regarding tissue consistency, painfulness and animation of the reconstructed breast, symmetry of both breasts and overall satisfaction after the surgery were collected at 6 months. The reconstructed and healthy breasts decreased in volume in group 1 (-45.85 cm(3) ± 48.41 cm(3), p = 0.0004; -29.13 cm(3) ± 14.98 cm(3), p = 0.0009) and in group 2 (-31.5 cm(3) ± 25.35 cm(3), p = 0.0001; -15.4 cm(3) ± 21.96 cm(3), p = 0.0537). There were no differences in decrease in volume between groups 1 and 2 (p > 0.05). Respondents in group 1 in comparison to group 2 showed similar satisfaction of the tissue consistency of the reconstructed breast (p > 0.05) and the level of symmetry between both breasts (p > 0.05), gave lower scores for painfulness (p < 0.0001), animation (p < 0.0001) and higher scores for the overall satisfaction about the reconstructed breast (p = 0.0001). We suggest that division of the thoracodorsal nerve during latissimus dorsi musculocutaneous flap breast reconstruction is a useful undertaking to minimize unnatural animation of the reconstructed breast. Copyright © 2013 Elsevier Ltd. All rights reserved.
Hodgson, R J; O'Connor, P J; Grainger, A J
MRI and ultrasound are now widely used for the assessment of tendon and ligament abnormalities. Healthy tendons and ligaments contain high levels of collagen with a structured orientation, which gives rise to their characteristic normal imaging appearances as well as causing particular imaging artefacts. Changes to ligaments and tendons as a result of disease and injury can be demonstrated using both ultrasound and MRI. These have been validated against surgical and histological findings. Novel imaging techniques are being developed that may improve the ability of MRI and ultrasound to assess tendon and ligament disease. PMID:22553301
Dumont, C E; Kessler, J
The surgical management of infected necrosis of the Achilles' tendon and overlying skin is very demanding, and reconstruction with vascularized tendon and skin flaps is considered the benchmark procedure. The authors report a 65-year-old man who sustained a chronic wound after operative repair of a chronic rupture of the Achilles' tendon. A pedicled medial plantar flap including the surrounding vascularized plantar aponeurosis was elevated. The plantar aponeurosis was split and used to bridge the 4-cm-long tendon defect. The flap donor site was covered with a thin skin graft. The flap survived completely without recurrence of the infection. At the 7-month follow-up, the reconstructed Achilles' tendon showed a good functional result and a normal range of dorsi- and plantar flexion of the foot. This technique is of great interest in comparison with free flaps because it does not require vascular anastomosis in a septic environment or a secondary debulking operation, yet it still provides both vascularized tendon and skin graft.
Genin, Guy M.; Thomopoulos, Stavros
High-resolution imaging, composition analysis and mechanical testing reveal a disordered transitional material within the Achilles tendon-to-bone attachment, structured as a fibrous network to enable force transfer and maximize structural integrity.
Perdikis, Galen; Koonce, Stephanie; Collis, George; Eck, Dustin
Objective: This article serves to review latissimus dorsi myocutaneous flap as an option for breast reconstruction postmastectomy. Since the introduction of the latissimus dorsi myocutaneous flap in the late 1970s, its use has always been as a secondary technique, particularly after the development of the transverse rectus abdominus myocutaneous flap in the 1980s. Methods: A literature review of the history of latissimus dorsi myocutaneous flap utilized for breast reconstruction as well as a review of our institution's experience with latissimus dorsi myocutaneous flap and tissue expander placement was performed. Results: There remains a paucity of published studies investigating latissimus dorsi myocutaneous flap for breast reconstruction. Most studies have small numbers and do not utilize tissue expanders. More recently several small studies have been published that show acceptably low complication rates with aesthetically pleasing outcomes when latissimus dorsi myocutaneous flap is employed with a tissue expander. At our institution, we have employed latissimus dorsi myocutaneous flap with tissue expander placement for both delayed and immediate reconstruction with subsequent replacement with a permanent implant with a capsular contraction rate of 10.5%. Our data and others more recently published demonstrate very acceptable capsular contracture rates and aesthetic outcomes, particularly when an expander is utilized. Conclusion: The latissimus dorsi myocutaneous flap remains an excellent choice for breast reconstruction with a low risk of complications. PMID:22031843
Phan, Truong Q V; Spilker, Gerald; Theodorou, Panagiotis; Gossmann, Andreas; Heiss, Michael; Weinand, Christian
In recurrent pressure sores, adjacent tissue has already been consumed by multiple surgeries. Additional problems are several co-morbidities of patients. Especially, severe atherosclerosis would be a contraindication for using free flaps. However, microsurgical techniques allow circumventing these limitations and preparing even severely atherosclerotic vessels. We performed a total of eight sacral pressure sore coverage in our standardized fashion, using the free combined latissimus dorsi and serratus anterior free flaps. All patients had severe atherosclerosis and needed large soft tissue coverage of the sacral defects. Five patients presented after bowel resection, three with recurrent sacral pressure sores. The average follow-up was 12 months. Postoperatively, all patients were allowed to be prone on the operated area. One minor wound dehiscence was sutured in local anesthesia. CT imaging analysis of the pelvis showed complete void space coverage. The combined latissimus dorsi and serratus anterior flaps are a valuable tool for pelvic reconstruction in our hands. In addition, severe atherosclerosis should not be considered an obstacle to microsurgery and the use of free flaps.
Thorpe, Chavaunne T.; Godinho, Marta S.C.; Riley, Graham P.; Birch, Helen L.; Clegg, Peter D.; Screen, Hazel R.C.
While the predominant function of all tendons is to transfer force from muscle to bone and position the limbs, some tendons additionally function as energy stores, reducing the cost of locomotion. Energy storing tendons experience extremely high strains and need to be able to recoil efficiently for maximum energy storage and return. In the equine forelimb, the energy storing superficial digital flexor tendon (SDFT) has much higher failure strains than the positional common digital extensor tendon (CDET). However, we have previously shown that this is not due to differences in the properties of the SDFT and CDET fascicles (the largest tendon subunits). Instead, there is a greater capacity for interfascicular sliding in the SDFT which facilitates the greater extensions in this particular tendon (Thorpe et al., 2012). In the current study, we exposed fascicles and interfascicular matrix (IFM) from the SDFT and CDET to cyclic loading followed by a test to failure. The results show that IFM mechanical behaviour is not a result of irreversible deformation, but the IFM is able to withstand cyclic loading, and is more elastic in the SDFT than in the CDET. We also assessed the effect of ageing on IFM properties, demonstrating that the IFM is less able to resist repetitive loading as it ages, becoming stiffer with increasing age in the SDFT. These results provide further indications that the IFM is important for efficient function in energy storing tendons, and age-related alterations to the IFM may compromise function and predispose older tendons to injury. PMID:25958330
Thorpe, Chavaunne T; Godinho, Marta S C; Riley, Graham P; Birch, Helen L; Clegg, Peter D; Screen, Hazel R C
While the predominant function of all tendons is to transfer force from muscle to bone and position the limbs, some tendons additionally function as energy stores, reducing the cost of locomotion. Energy storing tendons experience extremely high strains and need to be able to recoil efficiently for maximum energy storage and return. In the equine forelimb, the energy storing superficial digital flexor tendon (SDFT) has much higher failure strains than the positional common digital extensor tendon (CDET). However, we have previously shown that this is not due to differences in the properties of the SDFT and CDET fascicles (the largest tendon subunits). Instead, there is a greater capacity for interfascicular sliding in the SDFT which facilitates the greater extensions in this particular tendon (Thorpe et al., 2012). In the current study, we exposed fascicles and interfascicular matrix (IFM) from the SDFT and CDET to cyclic loading followed by a test to failure. The results show that IFM mechanical behaviour is not a result of irreversible deformation, but the IFM is able to withstand cyclic loading, and is more elastic in the SDFT than in the CDET. We also assessed the effect of ageing on IFM properties, demonstrating that the IFM is less able to resist repetitive loading as it ages, becoming stiffer with increasing age in the SDFT. These results provide further indications that the IFM is important for efficient function in energy storing tendons, and age-related alterations to the IFM may compromise function and predispose older tendons to injury.
The tibialis posterior tendon is the largest and anteriormost tendon in the medial ankle. It produces plantar flexion and supination of the ankle and stabilizes the plantar vault. Sonographic assessment of this tendon is done with high-frequency, linear-array transducers; an optimal examination requires transverse retromalleolar, longitudinal retromalleolar, and distal longitudinal scans, as well as dynamic studies. Disorders of the posterior tibial tendon include chronic tendinopathy with progressive rupture, tenosynovitis, acute rupture, dislocation and instability, enthesopathies. The most common lesion is a progressive "chewing gum" lesion that develops in a setting of chronic tendinopathy; it is usually seen in overweight women over 50 years of age with valgus flat feet. Medial ankle pain must also be carefully investigated, and the presence of instability assessed with dynamic maneuvers (forced inversion, or dorsiflexion) of the foot. Sonography plays an important role in the investigation of disorders involving the posterior tibial tendon.
Drake, David B; Tilt, Alexandra C; DeGeorge, Brent R
Flexor tendon injuries continue to pose a significant challenge to the hand surgeon. In particular, chronic tendon ruptures with adhesions of the tendons and sheath, damage or loss of the intrasynovial flexor tendons in zone II, and combined soft tissue and bone injuries present especially difficult problems for restoring satisfactory digital function. This challenge in flexor tendon reconstruction has motivated hand surgeons to explore and develop novel solutions for nearly a century. Recent advances and techniques in processing and decellularizing allograft human flexor tendon constructs may prove to be a new horizon for tendon reconstruction. Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Buda, Roberto; Castagnini, Francesco; Pagliazzi, Gherardo; Giannini, Sandro
Chronic Achilles tendon lesions (CATLs) ensue from a neglected acute rupture or a degenerated tendon. Surgical treatment is usually required. The current English literature (PubMed) about CATLs was revised, and particular emphasis was given to articles depicting CATL classification. The available treatment algorithms are based on defect size. We propose the inclusion of other parameters, such as tendon degeneration, etiology, and time from injury to surgery. Partial lesions affecting less than (I stage) or more than (II stage) half of the tendon should be treated conservatively for healthy tendons, within 12 weeks of injury. In II stage complex cases, an end-to-end anastomosis is required. Complete lesions inferior to 2 cm should be addressed by an end-to-end anastomosis, with a tendon transfer in the case of tendon degeneration. Lesions measuring 2 to 5 cm require a turndown flap and a V-Y tendinous flap in the case of a good-quality tendon; degenerated tendons may require a tendon transfer. Lesions larger than 5 cm should be treated using two tendon transfers and V-Y tendinous flaps. A proper algorithm should be introduced to calibrate the surgical procedures. In addition to tendon defect size, tendon degeneration, etiology of the lesion, and time from injury to surgery are crucial factors that should be considered in the surgical planning.
Qu, Jin; Thoreson, Andrew R.; Chen, Qingshan; An, Kai-Nan; Amadio, Peter C.; Zhao, Chunfeng
Tendon-to-bone integration is a great challenge for tendon or ligament reconstruction regardless of use of autograft or allograft tendons. We mineralized the tendon, thus transforming the tendon-to-bone into a “bone-to-bone” interface for healing. Sixty dog flexor digitorum profundus (FDP) tendons were divided randomly into 5 groups: 1) normal FDP tendon, 2) CaP (Non-extraction and mineralization without fetuin), 3) CaPEXT (Extraction by Na2HPO4 and mineralization without fetuin), 4) CaPFetuin (Non-extraction and mineralization with fetuin), and 5) CaPEXTFetuin (Extraction and mineralization with fetuin). The calcium and phosphate content significantly increased in tendons treated with combination of extraction and fetuin compared to the other treatments. Histology also revealed a dense mineral deposition throughout the tendon outer layers and penetrated into the tendon to a depth of 200 μm in a graded manner. Compressive moduli were significantly lower in the four mineralized groups compared with normal control group. No significant differences in maximum failure strength or stiffness were found in the suture pull-out test among all groups. Mineralization of tendon alters the interface from tendon to bone into mineralized tendon to bone, which may facilitate tendon-to-bone junction healing following tendon or ligament reconstruction. PMID:23939935
Qu, Jin; Thoreson, Andrew R; Chen, Qingshan; An, Kai-Nan; Amadio, Peter C; Zhao, Chunfeng
Tendon-to-bone integration is a great challenge for tendon or ligament reconstruction regardless of use of autograft or allograft tendons. We mineralized the tendon, thus transforming the tendon-to-bone into a "bone-to-bone" interface for healing. Sixty dog flexor digitorum profundus (FDP) tendons were divided randomly into five groups: (1) normal FDP tendon, (2) CaP (non-extraction and mineralization without fetuin), (3) CaPEXT (Extraction by Na2 HPO4 and mineralization without fetuin), (4) CaPFetuin (non-extraction and mineralization with fetuin), and (5) CaPEXTFetuin (extraction and mineralization with fetuin). The calcium and phosphate content significantly increased in tendons treated with combination of extraction and fetuin compared to the other treatments. Histology also revealed a dense mineral deposition throughout the tendon outer layers and penetrated into the tendon to a depth of 200 µm in a graded manner. Compressive moduli were significantly lower in the four mineralized groups compared with normal control group. No significant differences in maximum failure strength or stiffness were found in the suture pull-out test among all groups. Mineralization of tendon alters the interface from tendon to bone into mineralized tendon to bone, which may facilitate tendon-to-bone junction healing following tendon or ligament reconstruction.
Abate, Michele; Salini, Vincenzo; Andia, Isabel
Several epidemiological and clinical observations have definitely demonstrated that obesity has harmful effects on tendons. The pathogenesis of tendon damage is multi-factorial. In addition to overload, attributable to the increased body weight, which significantly affects load-bearing tendons, systemic factors play a relevant role. Several bioactive peptides (chemerin, leptin, adiponectin and others) are released by adipocytes, and influence tendon structure by means of negative activities on mesenchymal cells. The ensuing systemic state of chronic, sub-clinic, low-grade inflammation can damage tendon structure. Metabolic disorders (diabetes, impaired glucose tolerance, and dislipidemia), frequently associated with visceral adiposity, are concurrent pathogenetic factors. Indeed, high glucose levels increase the formation of Advanced Glycation End-products, which in turn form stable covalent cross-links within collagen fibers, modifying their structure and functionality.Sport activities, so useful for preventing important cardiovascular complications, may be detrimental for tendons if they are submitted to intense acute or chronic overload. Therefore, two caution rules are mandatory: first, to engage in personalized soft training program, and secondly to follow regular check-up for tendon pathology.
Davda, Kinner; Malhotra, Karan; O’Donnell, Paul; Singh, Dishan; Cullen, Nicholas
Pathological abnormality of the peroneal tendons is an under-appreciated source of lateral hindfoot pain and dysfunction that can be difficult to distinguish from lateral ankle ligament injuries. Enclosed within the lateral compartment of the leg, the peroneal tendons are the primary evertors of the foot and function as lateral ankle stabilisers. Pathology of the tendons falls into three broad categories: tendinitis and tenosynovitis, tendon subluxation and dislocation, and tendon splits and tears. These can be associated with ankle instability, hindfoot deformity and anomalous anatomy such as a low lying peroneus brevis or peroneus quartus. A thorough clinical examination should include an assessment of foot type (cavus or planovalgus), palpation of the peronei in the retromalleolar groove on resisted ankle dorsiflexion and eversion as well as testing of lateral ankle ligaments. Imaging including radiographs, ultrasound and MRI will help determine the diagnosis. Treatment recommendations for these disorders are primarily based on case series and expert opinion. The aim of this review is to summarise the current understanding of the anatomy and diagnostic evaluation of the peroneal tendons, and to present both conservative and operative management options of peroneal tendon lesions. Cite this article: EFORT Open Rev 2017;2:281-292. DOI: 10.1302/2058-5241.2.160047 PMID:28736620
Lee, G J; Kwak, S; Kim, H K; Ha, S H; Lee, H J; Baek, G H
Spontaneous flexor tendon rupture is a rare condition and the aetiology is not clear. We report 12 elderly Korean farmers with spontaneous flexor tendon ruptures. We found the rupture in the dominant hand in ten patients. A rupture in the little finger was found in all 12 patients (seven with both flexor tendons ruptured and five with only the profundus ruptured), in the ring finger in four patients (the profundus ruptured in all and both flexor tendons in two patients), and in the middle finger a partial rupture of the profundus in one patient. The tendons were ruptured close to the hook of the hamate. Repetitive friction between the flexor tendons and the hamate hook may cause the ruptures. The hamate hook was excised and the ruptured profundus tendons were reconstructed with tendon transfers with quite favourable functional recovery at follow-up of 1 to 2 years. The ruptured superficialis tendons were not reconstructed. Level of Evidence IV.
Fang, Fei; Lake, Spencer P.
Tendon exhibits anisotropic, inhomogeneous and viscoelastic mechanical properties that are determined by its complicated hierarchical structure and varying amounts/organization of different tissue constituents. Although extensive research has been conducted to use modelling approaches to interpret tendon structure–function relationships in combination with experimental data, many issues remain unclear (i.e. the role of minor components such as decorin, aggrecan and elastin), and the integration of mechanical analysis across different length scales has not been well applied to explore stress or strain transfer from macro- to microscale. This review outlines mathematical and computational models that have been used to understand tendon mechanics at different scales of the hierarchical organization. Model representations at the molecular, fibril and tissue levels are discussed, including formulations that follow phenomenological and microstructural approaches (which include evaluations of crimp, helical structure and the interaction between collagen fibrils and proteoglycans). Multiscale modelling approaches incorporating tendon features are suggested to be an advantageous methodology to understand further the physiological mechanical response of tendon and corresponding adaptation of properties owing to unique in vivo loading environments. PMID:26855747
Flury, Matthias; Rickenbacher, Dominik; Jung, Christian; Schneider, Marco M; Endell, David; Audigé, Laurent
To investigate the 2-year postoperative clinical and subjective outcomes after arthroscopic rotator cuff repair (ARCR) with xenologous porcine dermal patch augmentation compared with ARCR alone. Patients aged 60 years or older with a complete supraspinatus (SSP) tendon tear underwent primary ARCR with a transosseous-equivalent technique. By use of a matched-pair comparative trial design, a consecutive series of 20 patients receiving additional xenologous porcine dermal patch augmentation (patch group) was matched by tear location with 20 patients who received ARCR only (control group). Prior conservative treatment failed in all patients. Patients with concomitant pathologies precluding accurate repair assessment, partial or open reconstruction, or a latissimus dorsi and/or pectoralis major muscle transfer were excluded. Patients reported daily pain levels for 10 days after surgery. Clinical parameters and various patient-reported outcome scores were documented preoperatively and at 3, 6, and 24 months after surgery. Repair integrity was determined by magnetic resonance imaging or ultrasound at 24 months. Adverse events were recorded. Group outcome differences were analyzed with t tests, Fisher exact tests, and mixed models. Patients in both groups were aged 67 years on average (range, 60-74 years), and 70% of patients were men. Patients in the patch group had slightly more SSP fatty infiltration preoperatively. Patch surgical procedures were on average 22 minutes longer than control interventions (P = .003). At 24 months, 4 patients and 9 patients were diagnosed with a recurrent SSP tendon defect in the control group (n = 20) and patch group (n = 19), respectively (relative risk, 2.4; P = .096). Of 11 defects (85%) identified as medial cuff failure, 8 occurred in the patch group. Pain rated by all patients decreased from postoperative day 1 to day 10 without any significant group difference (P = .348). No significant group differences were noted for
Yang, Liu; Yin, Li
Background. Chronic Achilles tendon rupture is usually misdiagnosed and treated improperly. This study aims to better understand the treatment of chronic Achilles tendon rupture. Methods. Patients who were not able to perform a single-limb heel rise were chosen. Pre- and postoperative magnetic resonance imaging (MRI) were conducted. By evaluating the presence or absence of Achilles tendon stumps and the gap length of rupture, V-Y advancement, gastrocnemius fascial turndown flap, or flexor halluces longus tendon transfer were selected for tendon repair. The function of ankle and foot was assessed by American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores and Achilles Tendon Total Rupture Score (ATRS). Results. Twenty-nine patients were followed up. One patient had superficial incision infection, which was healed after debridement and oral antibiotics. Three months postoperatively, MRI showed some signs of inflammation, which disappeared at one or two years postoperatively. All patients were able to perform a single-limb heel rise. Mean AOFAS scores and ATRS scores were increased at the latest follow-up. Conclusion. Surgical options can be determined by evaluating the presence of the Achilles tendon stumps and the gap length, which can avoid using the nearby tendon and yield satisfactory functional results. PMID:27847806
LaCroix, Andrew S.; Duenwald-Kuehl, Sarah E.; Lakes, Roderic S.
Tendon is a highly specialized, hierarchical tissue designed to transfer forces from muscle to bone; complex viscoelastic and anisotropic behaviors have been extensively characterized for specific subsets of tendons. Reported mechanical data consistently show a pseudoelastic, stress-vs.-strain behavior with a linear slope after an initial toe region. Many studies report a linear, elastic modulus, or Young's modulus (hereafter called elastic modulus) and ultimate stress for their tendon specimens. Individually, these studies are unable to provide a broader, interstudy understanding of tendon mechanical behavior. Herein we present a metaanalysis of pooled mechanical data from a representative sample of tendons from different species. These data include healthy tendons and those altered by injury and healing, genetic modification, allograft preparation, mechanical environment, and age. Fifty studies were selected and analyzed. Despite a wide range of mechanical properties between and within species, elastic modulus and ultimate stress are highly correlated (R2 = 0.785), suggesting that tendon failure is highly strain-dependent. Furthermore, this relationship was observed to be predictable over controlled ranges of elastic moduli, as would be typical of any individual species. With the knowledge gained through this metaanalysis, noninvasive tools could measure elastic modulus in vivo and reasonably predict ultimate stress (or structural compromise) for diseased or injured tendon. PMID:23599401
LaCroix, Andrew S; Duenwald-Kuehl, Sarah E; Lakes, Roderic S; Vanderby, Ray
Tendon is a highly specialized, hierarchical tissue designed to transfer forces from muscle to bone; complex viscoelastic and anisotropic behaviors have been extensively characterized for specific subsets of tendons. Reported mechanical data consistently show a pseudoelastic, stress-vs.-strain behavior with a linear slope after an initial toe region. Many studies report a linear, elastic modulus, or Young's modulus (hereafter called elastic modulus) and ultimate stress for their tendon specimens. Individually, these studies are unable to provide a broader, interstudy understanding of tendon mechanical behavior. Herein we present a metaanalysis of pooled mechanical data from a representative sample of tendons from different species. These data include healthy tendons and those altered by injury and healing, genetic modification, allograft preparation, mechanical environment, and age. Fifty studies were selected and analyzed. Despite a wide range of mechanical properties between and within species, elastic modulus and ultimate stress are highly correlated (R(2) = 0.785), suggesting that tendon failure is highly strain-dependent. Furthermore, this relationship was observed to be predictable over controlled ranges of elastic moduli, as would be typical of any individual species. With the knowledge gained through this metaanalysis, noninvasive tools could measure elastic modulus in vivo and reasonably predict ultimate stress (or structural compromise) for diseased or injured tendon.
Lin, Yangjing; Yang, Liu; Yin, Li; Duan, Xiaojun
Background. Chronic Achilles tendon rupture is usually misdiagnosed and treated improperly. This study aims to better understand the treatment of chronic Achilles tendon rupture. Methods. Patients who were not able to perform a single-limb heel rise were chosen. Pre- and postoperative magnetic resonance imaging (MRI) were conducted. By evaluating the presence or absence of Achilles tendon stumps and the gap length of rupture, V-Y advancement, gastrocnemius fascial turndown flap, or flexor halluces longus tendon transfer were selected for tendon repair. The function of ankle and foot was assessed by American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores and Achilles Tendon Total Rupture Score (ATRS). Results. Twenty-nine patients were followed up. One patient had superficial incision infection, which was healed after debridement and oral antibiotics. Three months postoperatively, MRI showed some signs of inflammation, which disappeared at one or two years postoperatively. All patients were able to perform a single-limb heel rise. Mean AOFAS scores and ATRS scores were increased at the latest follow-up. Conclusion. Surgical options can be determined by evaluating the presence of the Achilles tendon stumps and the gap length, which can avoid using the nearby tendon and yield satisfactory functional results.
Jakubietz, Michael G; Jakubietz, Danni F; Gruenert, Joerg G; Zahn, Robert; Meffert, Rainer H; Jakubietz, Rafael G
The reconstruction of tendon defects is challenging. The palmaris longus and plantaris tendon are generally considered best for tendon grafting. Only a few studies have examined whether these tendons, when present, meet criteria for successful grafting. The purpose of this study was to evaluate these tendons in regard to adequacy as tendon grafts. To evaluate adequacy for grafting, the palmaris longus and plantaris tendons were harvested from 92 arms and legs of 46 cadavers. Macroscopic evaluation and measurements concerning presence, length, and diameter of the tendons were obtained. Criteria for adequacy were a minimum length of 15 cm with diameter of 3 mm or, alternatively, 30 cm with a diameter of 1.5 mm. The palmaris longus tendon was present bilaterally in 36 cases and was absent bilaterally in 4 cases. The plantaris tendon was present bilaterally in 38 cases and absent bilaterally in 4 cases. In 29 cadavers, the palmaris longus tendon did not meet the criteria to be used as a tendon graft. Only in 8 cases were the tendons satisfactory for grafting bilaterally. The plantaris tendon met criteria for grafting in 20 cases bilaterally. In 17 cases, the tendons were considered inadequate bilaterally. Despite their presence, the palmaris longus and plantaris tendons are adequate for grafting less often than previously thought. In less than 50%, the tendons, although present, would serve as useful grafts. Our findings underscore the importance of choosing a second donor site before surgery in case the primarily selected tendon is not found to be suitable. Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Tanaka, Toshikazu; Moran, Steven L; Zhao, Chunfeng; Zobitz, Mark E; An, Kai-Nan; Amadio, Peter C
Anatomic variation within the 5th extensor compartment may contribute to the development of tenosynovitis and limit the usefulness of the extensor digiti minimi (EDM) for tendon transfer. The purpose of this study was to assess the anatomic variation of the EDM tendon and its surrounding retinaculum, with particular attention to anatomical variation between specimens. Forty-one fresh cadaver hands were dissected. The length of the 5th compartment retinaculum was noted. The incidence of an intercompartmental septum was noted in each specimen as well as the type of tendinous attachments present between the EDM and extensor digitorum communis (EDC) tendons. The presence and length of any accessory retinacular bands distal to the edge of proper extensor retinaculum was also noted. Only one specimen contained a single EDM tendon, while 71% (n = 29) of specimens contained two slips and 23% (n = 9) had three slips; 24% (n = 10) of EDC tendons had no slip to the small finger, while 61% (n = 25) of specimens had a single slip to the small finger. The EDC's contribution to the small finger was found to be an independent tendon in 42% of cases (n = 17), while 34% (n = 14) of specimens were found to have a common EDC slip, which branched to both the ring and small finger. Three EDM tendons divided distal to the extensor retinaculum, while the remaining EDM tendons divided beneath or proximal to the extensor retinaculum. Seventy-three percent (n = 30) of the specimens had an accessory retinacular band surrounding the EDM tendon identified at the base of the 5th metacarpal. Eighty-eight percent (n = 36) of hands had a septum between the EDM slips. The surgeon should be aware of variability within the 5th dorsal compartment in cases of trauma and in cases of tendon transfer. In our series 30 of 41 specimens were noted to contain an accessory dorsal retinacular band surrounding the EDM and 36 specimens were noted to contain a septum within the 5th compartment. The presence of an
... the eyeball. A tendon serves to move the bone or structure. A ligament is a fibrous connective tissue which attaches bone to bone, and usually serves to hold structures together and keep them stable.
Tearing and inflammation of the tendons of the shoulder muscles can occur in sports which require the ... pitching, swimming, and lifting weights. Most often the shoulder will heal if a break is taken from ...
... teens, biceps tendonitis is usually an overuse injury. Baseball pitchers, swimmers, tennis players, and people who have ... But if you swim or play tennis or baseball, that might not be an option! If your ...
... shoes with proper cushioning in the heels. Increase training intensity slowly. Achilles tendon injuries commonly occur after abruptly increasing training intensity. Increase the distance, duration and frequency of your ...
... your primary doctor. Treatments of the Ankle Achilles Tendinosis Surgery Achilles Tendon Rupture Surgery Ankle Arthrodesis Ankle ... for Osteochondral Lesions of the Talus Insertional Achilles Tendinosis Surgery Lateral Ankle Ligament Reconstruction Lateral Ankle Stabilization ...
Basamania CJ: Incidence of major tendon ruptures and anterior cruciate ligament tears in US Army soldiers, Am J Sports Med2007; 35(8):1308-1314. 2... ligament or meniscus in is measurement is relatively independent of knee flex o of less than 0.80 indicates patella alta (Fig. Fig. 4: MRI of left...risk of tendon rupture after fluoroquinolone therapy , and requested that pharmaceutical manufacturers include boxed warnings. In healthy adults
Anderson, David E; Desrochers, André; St Jean, Guy
This article describes tendon disorders in cattle and treatments for such disorders. Tendon injuries causing loss of a production animal or a decreased level of production result in significant economic loss to the cattle producer. Tendon disorders may be congenital or acquired. Congenital abnormalities may include tendon laxity, contracted tendons, or tendon displacement. Acquired tendon disorders may include tendon laxity, contracture, luxation, tendinitis, laceration, avulsion, rupture, and tenosynovitis.
Homma, Tsutomu; Okazaki, Mutsumi; Tanaka, Kentaro; Uemura, Noriko
Paralytic lagophthalmos and smile dysfunction are serious complications of facial paralysis and various reconstructive procedures have been developed to treat them. Among these procedures, there is no doubt that dynamic procedures are more effective than static ones. The 1-stage simultaneous surgical treatment of these 2 dysfunctions with a dynamic procedure involving a single muscle would be ideal, but no such methods have been reported. In this article, we present a 1-stage method for the simultaneous surgical treatment involving the use of a dual latissimus dorsi muscle flap. In this method, 2 muscle flaps based on the descending and transverse branches of the thoracodorsal vessels are transferred to the face. The descending and transverse branches of the thoracodorsal nerve are sutured to separate branches of the masseteric nerve. Using this method, complete eyelid closure during strong clenching and voluntary smiling during weak clenching without eyelid closure were achieved. Although our method does not result in spontaneous smiling, we believe that it is a good option for some patients with long-standing facial paralysis.
Okazaki, Mutsumi; Tanaka, Kentaro; Uemura, Noriko
Summary: Paralytic lagophthalmos and smile dysfunction are serious complications of facial paralysis and various reconstructive procedures have been developed to treat them. Among these procedures, there is no doubt that dynamic procedures are more effective than static ones. The 1-stage simultaneous surgical treatment of these 2 dysfunctions with a dynamic procedure involving a single muscle would be ideal, but no such methods have been reported. In this article, we present a 1-stage method for the simultaneous surgical treatment involving the use of a dual latissimus dorsi muscle flap. In this method, 2 muscle flaps based on the descending and transverse branches of the thoracodorsal vessels are transferred to the face. The descending and transverse branches of the thoracodorsal nerve are sutured to separate branches of the masseteric nerve. Using this method, complete eyelid closure during strong clenching and voluntary smiling during weak clenching without eyelid closure were achieved. Although our method does not result in spontaneous smiling, we believe that it is a good option for some patients with long-standing facial paralysis. PMID:28831334
Wilkman, Tommy; Suominen, Sinikka; Back, Leif; Vuola, Jyrki; Lassus, Patrik
In head and neck cancer patients with significant comorbidities, the reconstructive options are limited, and there is a need for a safe alternative for microvascular flaps without compromising flap size. During the study period, 331 head and neck cancer patients were reconstructed with microvascular tissue flaps. Ten patients requiring large resections were considered to have high risks for long surgery and to be poor candidates for free tissue transfer and thus were reconstructed with a subpectorally tunneled pedicled latissimus dorsi (SP-LD) flap. The flap was raised simultaneously with the tumor resection and tunneled to the head and neck region. The flap was used for reconstruction of oral, mandibular, pharyngeal, or neck defects. Median follow-up was 3.6 years. Median duration of surgery was 7 hours and 17 minutes, and total hospital stay was 20 days. During the follow-up, four patients died of their disease and one from another cause (median of 329 days). We were able to perform large tumor resections with a curative intent and reconstruct major defects in high-risk head and neck cancer patients with a SP-LD flap. It possesses many of the characteristics of a free flap with the benefits of a shorter operation time and less perioperative risk.
Murchison, Nicholas D; Price, Brian A; Conner, David A; Keene, Douglas R; Olson, Eric N; Tabin, Clifford J; Schweitzer, Ronen
The scleraxis (Scx) gene, encoding a bHLH transcription factor, is expressed in the progenitors and cells of all tendon tissues. To determine Scx function, we produced a mutant null allele. Scx-/- mice were viable, but showed severe tendon defects, which manifested in a drastically limited use of all paws and back muscles and a complete inability to move the tail. Interestingly, although the differentiation of all force-transmitting and intermuscular tendons was disrupted, other categories of tendons, the function of which is mainly to anchor muscles to the skeleton, were less affected and remained functional, enabling the viability of Scx-/- mutants. The force-transmitting tendons of the limbs and tail varied in the severity to which they were affected, ranging from dramatic failure of progenitor differentiation resulting in the loss of segments or complete tendons, to the formation of small and poorly organized tendons. Tendon progenitors appeared normal in Scx-/- embryos and a phenotype resulting from a failure in the condensation of tendon progenitors to give rise to distinct tendons was first detected at embryonic day (E)13.5. In the tendons that persisted in Scx-/- mutants, we found a reduced and less organized tendon matrix and disorganization at the cellular level that led to intermixing of tenocytes and endotenon cells. The phenotype of Scx-/- mutants emphasizes the diversity of tendon tissues and represents the first molecular insight into the important process of tendon differentiation.
Marturano, Joseph E.; Arena, Jeffrey D.; Schiller, Zachary A.; Georgakoudi, Irene; Kuo, Catherine K.
Tendons have uniquely high tensile strength, critical to their function to transfer force from muscle to bone. When injured, their innate healing response results in aberrant matrix organization and functional properties. Efforts to regenerate tendon are challenged by limited understanding of its normal development. Consequently, there are few known markers to assess tendon formation and parameters to design tissue engineering scaffolds. We profiled mechanical and biological properties of embryonic tendon and demonstrated functional properties of developing tendon are not wholly reflected by protein expression and tissue morphology. Using force volume-atomic force microscopy, we found that nano- and microscale tendon elastic moduli increase nonlinearly and become increasingly spatially heterogeneous during embryonic development. When we analyzed potential biochemical contributors to modulus, we found statistically significant but weak correlation between elastic modulus and collagen content, and no correlation with DNA or glycosaminoglycan content, indicating there are additional contributors to mechanical properties. To investigate collagen cross-linking as a potential contributor, we inhibited lysyl oxidase-mediated collagen cross-linking, which significantly reduced tendon elastic modulus without affecting collagen morphology or DNA, glycosaminoglycan, and collagen content. This suggests that lysyl oxidase-mediated cross-linking plays a significant role in the development of embryonic tendon functional properties and demonstrates that changes in cross-links alter mechanical properties without affecting matrix content and organization. Taken together, these data demonstrate the importance of functional markers to assess tendon development and provide a profile of tenogenic mechanical properties that may be implemented in tissue engineering scaffold design to mechanoregulate new tendon regeneration. PMID:23576745
Marturano, Joseph E; Arena, Jeffrey D; Schiller, Zachary A; Georgakoudi, Irene; Kuo, Catherine K
Tendons have uniquely high tensile strength, critical to their function to transfer force from muscle to bone. When injured, their innate healing response results in aberrant matrix organization and functional properties. Efforts to regenerate tendon are challenged by limited understanding of its normal development. Consequently, there are few known markers to assess tendon formation and parameters to design tissue engineering scaffolds. We profiled mechanical and biological properties of embryonic tendon and demonstrated functional properties of developing tendon are not wholly reflected by protein expression and tissue morphology. Using force volume-atomic force microscopy, we found that nano- and microscale tendon elastic moduli increase nonlinearly and become increasingly spatially heterogeneous during embryonic development. When we analyzed potential biochemical contributors to modulus, we found statistically significant but weak correlation between elastic modulus and collagen content, and no correlation with DNA or glycosaminoglycan content, indicating there are additional contributors to mechanical properties. To investigate collagen cross-linking as a potential contributor, we inhibited lysyl oxidase-mediated collagen cross-linking, which significantly reduced tendon elastic modulus without affecting collagen morphology or DNA, glycosaminoglycan, and collagen content. This suggests that lysyl oxidase-mediated cross-linking plays a significant role in the development of embryonic tendon functional properties and demonstrates that changes in cross-links alter mechanical properties without affecting matrix content and organization. Taken together, these data demonstrate the importance of functional markers to assess tendon development and provide a profile of tenogenic mechanical properties that may be implemented in tissue engineering scaffold design to mechanoregulate new tendon regeneration.
Landvater, S J; Renström, P A
Achilles tendon ruptures can be treated nonsurgically in the nonathletic or low-end recreational athletic patient, particularly those more than 50 years of age, provided the treating physician does not delay in the diagnosis and treatment (preferably less than 48 hrs and possibly less than 1 week). The patient should be advised of the higher incidence of re-rupture of the tendon when treated nonsurgically. Surgical treatment is recommended for patients who are young and athletic. This is particularly true because the major criticism of surgical treatment has been the complication rate, which has decreased to a low level and to a mild degree, usually not significantly affecting the repair over time. Surgical treatment in these individuals seems to be superior not only in regard to re-rupture but also in assuring the correct apposition of the tendon ends and in placing the necessary tension on the tendon to secure appropriate orientation of the collagen fibers. This in turn allows them to regain full strength, power, endurance, and an early return to sports. Surgery is also recommended for late diagnosed ruptures where there is significant lengthening of the tendon. Surgical technique should involve a medial incision to avoid the sural nerve, absorbable suture, and augmentation with fascia or tendon where there is a gap or late rupture. Postoperatively, the immobilization should be 7 to 10 days in a splint. A walking boot with early motion in plantar flexion or a short leg cast with the tendon under slight tension should thereafter be used for 4 to 5 weeks. An early and well-supervised rehabilitation program should be initiated to restore the patient to the preinjury activity level.
Gomes Júnior, Nelson Pelozo; Andreoli, Carlos Vicente; Pochini, Alberto de Castro; Raduan, Fernando Cipolini; Ejnisman, Benno; Cohen, Moisés
The presence of accessory tendons in the foot and ankle needs to be recognized, given that depending on their location, they may cause disorders relating either to pain processes or to handling of the surgical findings. We describe the presence of an accessory flexor tendon of the toes, seen in surgical exposure for transferring the long flexor tendon of the hallux to the calcaneus, due to the presence of a disorder of tendinopathy of the insertion of the calcaneal tendon in association with Haglund's syndrome.
Gomes Júnior, Nelson Pelozo; Andreoli, Carlos Vicente; Pochini, Alberto de Castro; Raduan, Fernando Cipolini; Ejnisman, Benno; Cohen, Moisés
The presence of accessory tendons in the foot and ankle needs to be recognized, given that depending on their location, they may cause disorders relating either to pain processes or to handling of the surgical findings. We describe the presence of an accessory flexor tendon of the toes, seen in surgical exposure for transferring the long flexor tendon of the hallux to the calcaneus, due to the presence of a disorder of tendinopathy of the insertion of the calcaneal tendon in association with Haglund's syndrome. PMID:26962495
Cordts, Tomke; Bigdeli, Amir K.; Harhaus, Leila; Hirche, Christoph; Kremer, Thomas; Kneser, Ulrich; Schmidt, Volker J.
A female patient with a critical soft tissue defect after elective knee replacement surgery was transferred to our department for reconstruction. As wounds were rapidly progressing, necrotizing fasciitis was initially suspected but eventually ruled out by histopathological analysis. A 50 × 15 cm defect was then reconstructed by means of a combined Parascapular and latissimus dorsi flap before, a couple days later, the patient developed tender pustules and ulcers involving the flap as well as the donor site. Attempts of excising necrotic areas not only continued to fail but seemed to worsen the patient's wound and overall condition. Eventually, pyoderma gangrenosum (PG) was diagnosed and local and systemic therapy was initiated but treatment proved to be challenging and insufficient at first. Being an extremely aggressive disease, early diagnosis is crucial and PG should always be suspected when rapidly progressive ulceration on surgical sites is observed. PMID:28096323
Hollawell, Shane; Baione, William
More than 20% of acute Achilles tendon injuries are misdiagnosed, leading to chronic or neglected ruptures. Some controversy exists regarding how to best manage an acute Achilles tendon rupture. However, a general consensus has been reached that chronic rupture with ≥3 cm of separation is associated with functional morbidity and, therefore, should be managed operatively. It has been demonstrated that the functional outcomes of surgically treated Achilles ruptures are superior to the nonoperative outcomes in a chronic setting. In the present report, we reviewed 4 patients with chronic Achilles tendon ruptures that were successfully treated with an Achilles tendon interposition allograft and simultaneous augmentation with a xenograft. The median duration of rupture was 11 (range 8 to 16) weeks, the median gap between the proximal and distal segments of the tendon was 4.75 (range 3.5 to 6) cm, and the patients were able to return pain-free to all preinjury activities at a median of 14.5 (range 13.8 to 15.5) weeks, without the need for tendon transfer, lengthening, or additional intervention. The median duration of follow up was 37.25 (range 15.25 to 51.5) months, at which point the mean Foot and Ankle Outcomes Instrument core scale score was 97 ± 1 (mean normative score 53 ± 1), and the Foot and Ankle Outcomes Instrument shoe comfort core scale score was 100 ± 0 (mean normative score 59 ± 0). The combined Achilles allograft plus xenograft augmentation technique appears to be a reasonable option for the surgical treatment of chronic Achilles tendon rupture. Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
... ency/article/007678.htm Steroid injections - tendon, bursa, joint To use the sharing features on this page, ... often painful. It can be injected into a joint, tendon, or bursa. Description Your health care provider ...
Ihrke, Chris A. (Inventor); Reich, David M. (Inventor); Bridgwater, Lyndon (Inventor); Linn, Douglas Martin (Inventor); Askew, Scott R. (Inventor); Diftler, Myron A. (Inventor); Platt, Robert (Inventor); Hargrave, Brian (Inventor); Valvo, Michael C. (Inventor); Abdallah, Muhammad E. (Inventor); Permenter, Frank Noble (Inventor); Mehling, Joshua S. (Inventor)
A humanoid robot includes a robotic hand having at least one finger. An actuation system for the robotic finger includes an actuator assembly which is supported by the robot and is spaced apart from the finger. A tendon extends from the actuator assembly to the at least one finger and ends in a tendon terminator. The actuator assembly is operable to actuate the tendon to move the tendon terminator and, thus, the finger.
Watson, Alan H.D.; Williams, Caitlin; James, Buddug V.
Summary Objectives The aim of this study was to investigate and compare the roles of the accessory respiratory muscles, latissimus dorsi (LD), and sternocleidomastoid, in classical singing. Methods Electromyography was used to record the activity of these muscles in six classically trained female singers carrying out a number of singing and nonsinging tasks. Movements of the chest and abdominal walls were monitored simultaneously using inductive plethysmography, and the sound of the phonations was recorded. Results In normal breathing, LD is active transiently during very deep inhalations and in inhalation against resistance. During exhalation it becomes active again as residual capacity is approached or when air is expelled with great force. Sternocleidomastoid (SCM) supports inhalation when lung volume nears 100% vital capacity or when this is very rapid. All singers engaged LD in supported singing where it was associated with maintaining an expanded thorax. In coloratura singing, pulses of activity of increasing amplitude were often seen in LD toward the end of the breath. These were synchronized with each note. During a short phrase typical of the end of an aria, which was sung at full volume with the projected voice, both LD and SCM were active simultaneously. Spectral analysis of muscle activity demonstrated that in some singers, activity in LD and more rarely SCM, fluctuated in phase with vibrato. Conclusions LD appears to play a significant role in maintaining chest expansion and the dynamic processes underlying vibrato and coloratura singing in classically trained singers. PMID:21724365
Watson, Alan H D; Williams, Caitlin; James, Buddug V
The aim of this study was to investigate and compare the roles of the accessory respiratory muscles, latissimus dorsi (LD), and sternocleidomastoid, in classical singing. Electromyography was used to record the activity of these muscles in six classically trained female singers carrying out a number of singing and nonsinging tasks. Movements of the chest and abdominal walls were monitored simultaneously using inductive plethysmography, and the sound of the phonations was recorded. In normal breathing, LD is active transiently during very deep inhalations and in inhalation against resistance. During exhalation it becomes active again as residual capacity is approached or when air is expelled with great force. Sternocleidomastoid (SCM) supports inhalation when lung volume nears 100% vital capacity or when this is very rapid. All singers engaged LD in supported singing where it was associated with maintaining an expanded thorax. In coloratura singing, pulses of activity of increasing amplitude were often seen in LD toward the end of the breath. These were synchronized with each note. During a short phrase typical of the end of an aria, which was sung at full volume with the projected voice, both LD and SCM were active simultaneously. Spectral analysis of muscle activity demonstrated that in some singers, activity in LD and more rarely SCM, fluctuated in phase with vibrato. LD appears to play a significant role in maintaining chest expansion and the dynamic processes underlying vibrato and coloratura singing in classically trained singers. Copyright © 2012 The Voice Foundation. Published by Mosby, Inc. All rights reserved.
Ackermann, Paul W
The regulation of tendon homoeostasis, including adaptation to loading, is still not fully understood. Accumulating data, however, demonstrates that in addition to afferent (sensory) functions, the nervous system, via efferent pathways which are associated with through specific neuronal mediators plays an active role in regulating pain, inflammation and tendon homeostasis. This neuronal regulation of intact-, healing- and tendinopathic tendons has been shown to be mediated by three major groups of molecules including opioid, autonomic and excitatory glutamatergic neuroregulators. In intact healthy tendons the neuromediators are found in the surrounding structures: paratenon, endotenon and epitenon, whereas the proper tendon itself is practically devoid of neurovascular supply. This neuroanatomy reflects that normal tendon homoeostasis is regulated from the tendon surroundings. After injury and during tendon repair, however, there is extensive nerve ingrowth into the tendon proper, followed by a time-dependent emergence of sensory, autonomic and glutamatergic mediators, which amplify and fine-tune inflammation and regulate tendon regeneration. In tendinopathic condition, excessive and protracted presence of sensory and glutamatergic neuromediators has been identified, suggesting involvement in inflammatory, nociceptive and hypertrophic (degenerative) tissue responses. Under experimental and clinical conditions of impaired (e.g. diabetes) as well as excessive (e.g. tendinopathy) neuromediator release, dysfunctional tendon homoeostasis develops resulting in chronic pain and gradual degeneration. Thus there is a prospect that in the future pharmacotherapy and tissue engineering approaches targeting neuronal mediators and their receptors may prove to be effective therapies for painful, degenerative and traumatic tendon disorders. PMID:23718724
Jensen, Nina Vendel; Dahlin, Lars B; Bojsen-Møller, Finn; Søe-Nielsen, Niels H
We describe a patient in whom the motor branch to the first dorsal interosseous muscle was injured by the pins of an fixator used to treat an unstable fracture of the distal radius. She was successfully treated by extensor indicis proprius transfer to the base of the proximal phalanx of the index finger.
Laudner, Kevin G; Williams, Jeffrey G
To determine the strength of the relationship between latissimus dorsi stiffness and altered scapular kinematics among swimmers. Cross sectional. Laboratory. Nineteen NCAA Division III swimmers (7 male, 12 female) (age = 18.8 ± 0.9 years, height = 174.7 ± 8.9 cm, mass = 71.6 ± 11.9 kg) volunteered to participate. Subjects had no recent history of upper extremity pathology or any previous surgery. We measured latissimus dorsi stiffness of the dominant arm while in a lengthened position with a myotonometer. We used an electromagnetic tracking device with specialized software to measure scapular kinematics at humeral elevation angles of 30°, 60°, 90°, and 110° within the scapular plane. Latissimus dorsi stiffness and scapular upward/downward rotation, internal/external rotation, and anterior/posterior tilt. Latissimus dorsi stiffness showed moderate-to-good relationships with increased scapular upward rotation (r > -0.63, P < 0.002) and posterior tilt (r > -0.62, P < 0.004) at all four angles of humeral elevation. Increased latissimus dorsi stiffness also showed moderate-to-good relationships with decreased scapular internal rotation at humeral elevation angles of 60° (r = 0.47, P = 0.03) and 90° (r = 0.54, P = 0.01). Our results suggest there are several moderate-to-good relationships between increased latissimus dorsi stiffness in swimmers and altered scapular upward rotation, internal rotation, and posterior tilt at various angles of humeral elevation. If latissimus dorsi stiffness is not addressed subsequent scapular alterations, which have been associated with shoulder dysfunction, may occur. Published by Elsevier Ltd.
Said, M Nader; Al Ateeq Al Dosari, Mohamed; Al Subaii, Nasser; Kawas, Alaa; Al Mas, Ali; Al Ser, Yaser; Abuodeh, Yousef; Shakil, Malik; Habash, Ali; Mukhter, Khalid
In contrast to closed Achilles tendon ruptures, open injuries are rarely reported in the literature. This paper provides information about open Achilles tendon wounds that are eventually seen in the Middle East. The reporting unit, Hamad Medical Corporation, is one of the biggest trauma centers in the Gulf area and the major health provider in Qatar. This is a retrospective study including patients admitted and operated for open Achilles tendon injuries between January 2011 and December 2013. Two hundred and five cases of open Achilles tendon lacerations were operated in Hamad General Hospital in this period. Forty-eight cases showed partial injuries, and the remaining are complete tendons cut. In the same period, fifty-one closed ruptured Achilles tendons were operated in the same trauma unit. In the majority of cases, the open injury resulted from a slip in the floor-leveled traditional toilette seats. Local damage to the toilette seats resulted in sharp edges causing the laceration of the heel if the patient was slipping over the wet floor. This occurrence is the cause in the vast majority of the cases. Wounds were located 1-5 cm proximal to tendon insertion. Standard treatment principles were applied. This included thorough irrigation in the emergency room, intravenous antibiotics, surgical debridement and primary repair within 24 h. Patients were kept in the hospital 1-7 days for intravenous antibiotics and possible dressing changes. Postoperatively below knee slabs were applied in the majority of patients and were kept for about 4 weeks followed by gradual weight bearing and range of motion exercises. Outpatients follow up in 1-2 weeks. Further follow-up visits at around 2-, 4-, 8- and 12-week intervals until complete wound healing and satisfactory rehabilitation outcome. Sixteen cases needed a second procedure. A high incidence of Achilles tendon open injuries is reported. This seems to be related to partially damaged floor-level toilettes in the
Singh, Amarjeet; Nag, Kushal; Roy, Shuvendu P; Gupta, Ramesh Chandra; Gulati, Vaibhav; Agrawal, Nikunj
To report 22 patients who underwent repair of compound Achilles tendon ruptures with peroneus brevis tendon augmentation. Records of 6 women and 19 men aged 21 to 42 (mean, 28) years who underwent repair of compound Achilles tendon ruptures with peroneus brevis tendon augmentation were reviewed. All the wounds were transverse/oblique, minimally contaminated, and could be closed primarily. Patients were evaluated at months 3, 9, and 12, using the Foot and Ankle Outcome Score (FAOS) questionnaire. Of the 22 patients, 3 developed superficial skin complications that healed gradually, and 2 developed a superficial discharging sinus and underwent minor debridement. No patient had a re-rupture of the Achilles tendon. At the one-year follow-up, all patients achieved good functional outcome in terms of the FAOS. Repair of Achilles tendon ruptures with peroneus brevis tendon augmentation achieved good functional outcome.
Trumble, Dennis R; Melvin, David B; Magovern, James A
Reliable tissue fixation is of fundamental importance to the successful development of muscle powered motor prostheses. This report describes a series of canine implant trials used to develop stable tissue-device interface mechanisms. Muscle pumps were fitted with prototype tendon and chest wall anchoring schemes and secured to the ribs and humeral insertion of latissimus dorsi (LD) muscles. LD stimulation was initiated 1 week postimplantation and continued throughout the implant period to stress these fixation sites. Design modification and implant testing were continued until both muscle and chest wall attachment points were found to be stable. Chest wall fixation was best achieved using perforated metallic plates wired to the ribs, as opposed to bone screws or wire mesh, which were subject to degradation. Direct attachment of the native tendon by means of spiked clamping plates proved ineffective. Stable muscle attachment was ultimately achieved by replacing the humeral tendon with an artificial substitute formed from fine polyester fibers gathered into 6-8 bundles and sewn into the LD insertion. Braided into a single cord, these fibers were fixed to the device by means of spiked clamping plates. Based on these findings, we conclude that perforated anchor plates and multifibrous artificial tendons can function as effective tissue-device interface mechanisms.
Kondratko-Mittnacht, Jaclyn; Lakes, Roderic; Vanderby, Ray
Tendon is vital to musculoskeletal function, transferring loads from muscle to bone for joint motion and stability. It is an anisotropic, highly organized, fibrous structure containing primarily type I collagen in addition to tenocytes and other extracellular matrix components contributing to maintenance and function. Tendon is generally loaded via normal stress in a longitudinal direction. However, certain situations, including fiber breakage, enzymatic remodeling, or tendon pathology may introduce various degrees of other loading modalities, such as shear-lag at the fiber level, potentially affecting cellular response and subsequent function. Fascicles from rat tail tendon were dissected and placed in one of three paired groups: intact, single laceration, or double laceration. Each pair had a mechanically tested and control specimen. Single laceration fascicles contained one transverse laceration to mimic a partial tear. Double laceration fascicles had overlapping, longitudinally separated lacerations on opposite sides to cause intra-fascicular shear transfer to be the primary mechanism of loading. Elastic properties of the fascicle, e.g. peak load, steady state load, and stiffness, decreased from intact to single laceration to double laceration groups. Surprisingly, 45% of the intact strength was maintained when shear was the primary internal load transfer mechanism. Cellular viability decreased after mechanical testing in both laceration groups; cell death appeared primarily in a longitudinal plane where high shear load transfer occurred. This cell death extended far from the injury site and may further compromise an already damaged tendon via enzymatic factors and subsequent remodeling associated with cell necrosis. PMID:26162546
Carmont, Michael R; Maffulli, Nicola
The optimal management of chronic ruptures of the Achilles tendon is surgical reconstruction. Reconstruction of the Achilles tendon using peroneus brevis has been widely reported. Classically, these procedures involve relatively long surgical wounds in a relatively hypovascular area which is susceptible to wound breakdown. We describe our current method of peroneus brevis reconstruction for the Achilles tendon using two para-midline incisions. This technique allows reconstruction of the Achilles tendon using peroneus brevis preserving skin integrity over the site most prone to wound breakdown, and can be especially used to reconstruct the Achilles tendon in the presence of previous surgery.
Carmont, Michael R; Maffulli, Nicola
Background The optimal management of chronic ruptures of the Achilles tendon is surgical reconstruction. Reconstruction of the Achilles tendon using peroneus brevis has been widely reported. Classically, these procedures involve relatively long surgical wounds in a relatively hypovascular area which is susceptible to wound breakdown. Results We describe our current method of peroneus brevis reconstruction for the Achilles tendon using two para-midline incisions. Conclusion This technique allows reconstruction of the Achilles tendon using peroneus brevis preserving skin integrity over the site most prone to wound breakdown, and can be especially used to reconstruct the Achilles tendon in the presence of previous surgery. PMID:17963499
Gerling, Michael E; Brown, Stephen H M
The latissimus dorsi is primarily considered a muscle with actions at the shoulder, despite its widespread attachments at the spine. There is some dispute regarding the potential contribution of this muscle to lumbar spine function. The architectural design of a muscle is one of the most accurate predictors of muscle function; however, detailed architectural data on the latissimus dorsi muscle are limited. Therefore, the aim of this study was to quantify the architectural properties of the latissimus dorsi muscle and model mechanical function in light of these new data. One latissimus dorsi muscle was removed from each of 12 human cadavers, separated into regions, and micro-dissected for quantification of fascicle length, sarcomere length, and physiological cross-sectional area. From these data, sarcomere length operating ranges were modelled to determine the force–length characteristics of latissimus dorsi across the spine and shoulder ranges of motion. The physiological cross-sectional area of latissimus dorsi was 5.6 ± 0.5 cm2 and normalized fascicle length was 26.4 ± 1.0 cm, indicating that this muscle is designed to produce a moderate amount of force over a large range of lengths. Measured sarcomere length in the post-mortem neutral spine posture was nearly optimal at 2.69 ± 0.06 μm. Across spine range of motion, biomechanical modelling predicted latissimus dorsi acts across both the ascending and descending limbs of the force–length curve during lateral bend, and primarily at or near the plateau region (where maximum force generation is possible) during flexion/extension and axial twist. Across shoulder range of motion, latissimus dorsi acts primarily on the plateau region and descending limbs of the force length curve during both flexion/extension and abduction/adduction. These data provide novel insights into the ability of the latissimus dorsi muscle to generate force and change length throughout the spine and shoulder ranges of motion. In addition
Gerling, Michael E; Brown, Stephen H M
The latissimus dorsi is primarily considered a muscle with actions at the shoulder, despite its widespread attachments at the spine. There is some dispute regarding the potential contribution of this muscle to lumbar spine function. The architectural design of a muscle is one of the most accurate predictors of muscle function; however, detailed architectural data on the latissimus dorsi muscle are limited. Therefore, the aim of this study was to quantify the architectural properties of the latissimus dorsi muscle and model mechanical function in light of these new data. One latissimus dorsi muscle was removed from each of 12 human cadavers, separated into regions, and micro-dissected for quantification of fascicle length, sarcomere length, and physiological cross-sectional area. From these data, sarcomere length operating ranges were modelled to determine the force-length characteristics of latissimus dorsi across the spine and shoulder ranges of motion. The physiological cross-sectional area of latissimus dorsi was 5.6±0.5 cm2 and normalized fascicle length was 26.4±1.0 cm, indicating that this muscle is designed to produce a moderate amount of force over a large range of lengths. Measured sarcomere length in the post-mortem neutral spine posture was nearly optimal at 2.69±0.06 μm. Across spine range of motion, biomechanical modelling predicted latissimus dorsi acts across both the ascending and descending limbs of the force-length curve during lateral bend, and primarily at or near the plateau region (where maximum force generation is possible) during flexion/extension and axial twist. Across shoulder range of motion, latissimus dorsi acts primarily on the plateau region and descending limbs of the force length curve during both flexion/extension and abduction/adduction. These data provide novel insights into the ability of the latissimus dorsi muscle to generate force and change length throughout the spine and shoulder ranges of motion. In addition, these
Ultrasound (US) plays an essential role in the follow-up of operated tendons. The US operator must keep in mind three main elements: healing of traumatic injuries of the tendons seems to follow the biological model of histologic healing, surgical repair of a tendon rupture improves the structural parameters of the operated tendon, but it does not grant restitutio ad integrum, and US findings therefore seem poorly correlated with the functional evolution.Before examination, the US operator should be familiar with the nature of the tendon injury that has led to surgery including location, severity, time elapsed between tendon injury and surgical repair, surgical technique, postoperative course and possible complications. US findings in operated as well as non-operated tendons depend on several factors: morphology, structure, vascularization of the tendon, mobility of the tendon and mobility of the peritendinous tissues. Particular features are therefore considered according to the location: shoulder, elbow, wrist, hand, knee, ankle and foot. Interpretation of the US image requires knowledge of the surgical technique and "normal" postoperative appearance of the operated tendon in order to detect pathological findings such as thinning, persistent fluid collections within or around the tendon, persistent hypervascularization, intratendinous calcifications and adhesions.
Berrino, P; Galli, A; Santi, P L
Transposition of the latissimus dorsi musculocutaneous flap is still considered by most authors a first-choice technique for breast reconstruction. However, the aesthetic drawbacks of the technique are significant: In our experience the posterior scar and the "patchlike" skin island are of concern to more than 30% of patients. Recent alternatives have sharply reduced the use of the latissimus dorsi myocutaneous flap as our first-choice technique. The utilization of a latissimus dorsi muscular flap in association with submuscular placement of a tissue expander is now our favorite technique for the majority of patients: Residual scarring is insignificant since the whole muscle can be raised through a 5-7-cm-long, S-shaped incision placed along the anterior border of the latissimus dorsi. The results obtained in a group of 35 patients demonstrate that the final results of the procedure in terms of shape and projection of the reconstructed breasts are absolutely similar to those obtained using the latissimus dorsi musculocutaneous flap. However, in patients with heavy body structure and large contralateral breast, satisfactory symmetry and a natural-looking reconstructed breast are obtained more effectively by transposition of a rectus abdominis myocutaneous flap. The precautions to be taken in order to make the procedure suitable for over-weight patients are described and the results are discussed.
Taş, Süleyman; Balta, Serkan; Benlier, Erol
Background: The etiology of spontaneous rupture of the extensor pollicis longus tendon includes systemic or local steroid injections, wrist fracture, tenosynovitis, synovitis, rheumatoid arthritis, and repetitive wrist motions. Case Report: We encountered a case of extensor pollicis longus tendon rupture with an unusual etiology, cow milking. In this case, transfer of the extensor indicis proprius tendon was performed successfully. At 1 year after surgery, extension of the thumb was sufficient. Conclusion: It appears that patients with occupations involving repetitive motions are at a high risk of closed tendon ruptures. PMID:25207178
Zhang, Cheng-Gang; Dong, Zhen; Gu, Yu-Dong
Brachial plexus palsies of C7-T1 result in the complete loss of hand function, including finger and thumb flexion and extension as well as intrinsic muscle function. The task of reanimating such a hand remains challenging, and so far there has been no reliable neurological reconstructive method for restoring hand function. The authors aimed to establish a reliable strategy to reanimate the paralyzed hand. Two patients had sustained C7-T1 complete lesions. In the first stage of the operative procedure, a supinator motor branch to posterior interosseous nerve transfer was performed with brachialis motor branch transfer to the median nerve to restore finger and thumb extension and flexion. In the second stage, the intact brachioradialis muscle was used for abductorplasty to restore thumb opposition. Both patients regained good finger extension and flexion. Thumb opposition was also attained, and overall hand function was satisfactory. The described strategy proved effective and reliable in restoring hand function after C7-T1 brachial plexus palsies.
Pardes, A M; Freedman, B R; Fryhofer, G W; Salka, N S; Bhatt, P R; Soslowsky, L J
The Achilles tendon is the most commonly ruptured tendon in the human body. Numerous studies have reported incidence of these injuries to be upwards of five times as common in men than women. Therefore, the objective of this study was to investigate the sex- and hormone-specific differences between Achilles tendon and muscle between female, ovariectomized female (ovarian hormone deficient), and male rats. Uninjured tissues were collected from all groups for mechanical, structural, and histological analysis. Our results showed that while cross-sectional area and failure load were increased in male tendons, female tendons exhibited superior tendon material properties and decreased muscle fiber size. Specifically, linear and dynamic moduli were increased while viscoelastic properties (e.g., hysteresis, percent relaxation) were decreased in female tendons, suggesting greater resistance to deformation under load and more efficient energy transfer, respectively. No differences were identified in tendon organization, cell shape, cellularity, or proteoglycan content. Additionally, no differences in muscle fiber type distribution were observed between groups. In conclusion, inferior tendon mechanical properties and increased muscle fiber size may explain the increased susceptibility for Achilles tendon injury observed clinically in men compared to women.
Dumbre Patil, Sampat Shivajirao; Dumbre Patil, Vaishali Sampat; Basa, Vikas Rajeshwarrao; Dombale, Ajay Birappa
Chronic Achilles tendon ruptures are associated with considerable functional morbidity. When treated operatively, debridement of degenerated tendon ends may create large defects. Various procedures to reconstruct large defects have been described. We present a simple technique in which an autologous semitendinosus tendon graft is used to reconstruct defects larger than 5 cm in chronic Achilles tendon ruptures. The purpose of this study was to describe our operative technique and its functional outcome. Achilles ruptures of more than 6 weeks duration were considered for the study. We treated 35 patients (20 males, 15 females) with symptomatic chronic Achilles tendon ruptures. The mean age was 47.4 years (range, 30 to 59). The smallest defect that we had reconstructed was 5 cm, and the largest was 9 cm in length. The average follow-up duration was 30.7 months (range, 20 to 42). Postoperatively, the strength of gastrocsoleus was measured by manual muscle testing (MMT) in non-weight-bearing and weight-bearing positions. All operated patients showed satisfactory functional outcome, good soft tissue healing, and no reruptures. The preoperative weight-bearing MMT of 2/5 improved to 4/5 or 5/5 postoperatively. In all patients, postoperative non-weight-bearing MMT was 5/5. All patients returned to their prerupture daily activity. We present a technique that is simple, with low morbidity. We believe it is a valuable option especially when allografts are not available. It is inexpensive as suture anchors or tenodesis screws are not used. This can be a useful option if other tendons (flexor hallucis longus, peroneus brevis, etc) are not available for transfer. Level IV, retrospective case series. © The Author(s) 2014.
Monaco, Nathan A.; Dwyer, C. Liam; Ferikes, Alex J.; Lubahn, John D.
Background: Volar plate fixation with locked screws has become the preferred treatment of displaced distal radius fractures that cannot be managed nonoperatively. This treatment, however, is not without complication. The purpose of this study was to determine what percentage of hand surgeons, over a 12-month period, have experienced a tendon complication when using volar plates for the treatment of distal radius fractures. Methods: A total of 3022 hand surgeons were e-mailed a link to an online questionnaire regarding their observation and treatment of tendon injuries associated with volar plating of distal radius fractures. Responses were reported using descriptive statistics. Results: Of the 596 (20%) respondents, 199 (33%) surgeons reported encountering at least one flexor tendon injury after distal radius volar plating over the past year of practice. The flexor pollicis longus was the most commonly reported tendon injury (254, 75%). Palmaris longus grafting (118, 37%) and tendon transfer (114, 36%) were the most often reported treatments following this complication. A total of 216 respondents (36%) also encountered 324 cases of extensor tendon rupture after volar plating of distal radius fractures, with tendon transfer (88%) being the preferred treatment option. Conclusions: Both flexor and extensor tendon ruptures can be seen after volar plating of distal radius fractures. Surgeons should be aware of these complications. Critical assessment of hardware position at the time of index procedure is recommended to avoid complications. Long-term studies are needed to standardize approaches to managing tendon rupture following volar plating of distal radius fractures. PMID:27698628
Schöffl, Volker; Heid, Andreas; Küpper, Thomas
Tendon injuries are the second most common injuries of the hand and therefore an important topic in trauma and orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons, but less frequent injuries, e.g., damage to the functional system tendon sheath and pulley or dull avulsions, also need to be considered. After clinical examination, ultrasound and magnetic resonance imaging have proved to be important diagnostic tools. Tendon injuries mostly require surgical repair, dull avulsions of the distal phalanges extensor tendon can receive conservative therapy. Injuries of the flexor tendon sheath or single pulley injuries are treated conservatively and multiple pulley injuries receive surgical repair. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger an “intrinsic” tendon healing to guarantee a good outcome. Many substances were evaluated to see if they improved tendon healing; however, little evidence was found. Nevertheless, hyaluronic acid may improve intrinsic tendon healing. PMID:22720265
Lorenzetti, Fulvio; Giordano, Salvatore; Tukiainen, Erkki
The aim of this study was to assess intraoperatively the hemodynamic changes in the donor vessel of free latissimus dorsi (LD) flap before and after denervation and to analyze flow changes after flap transfer. Twenty-seven patients underwent LD muscle microvascular reconstruction for lower-limb soft tissue defects. Measurements of blood flow were performed intraoperatively by using a 2- to 5-mm probe ultrasonic transit-time flowmeter around the dissected vessels. Registrations were made in the thoracodorsal artery before and after harvesting the flap, after compressing and cutting the motor nerve, and after anastomosis. Mean blood flow of in situ harvested thoracodorsal artery as measured intraoperatively by transit-time flowmeter was (mean ± standard deviation) 16.6 ± 11 mL/min and was significantly increased after raising the flap to 24.0 ± 22 mL/min (p <0.05); it was 25.6 ± 23 mL/min after compressing the motor nerve and was significantly increased after cutting the motor nerve to 32.5 ± 26 mL/min (p <0.05). A significant increase of blood flow to 28.1 ± 19 mL/min was also detected in the thoracodorsal artery after flap transplantation with end-to-side anastomosis (p <0.05). Vascular resistance in the thoracodorsal artery significantly decreased after flap raising and anastomosis (from 7.5 ± 3.4 to 4.0 ± 1.9 and to 4.5 ± 2.4, respectively, p <0.05). LD flap harvesting increases blood flow and decreases resistance in the thoracodorsal artery, especially after denervation.
Bodin, Frédéric; Dissaux, Caroline; Steib, Jean-Paul; Massard, Gilbert
Radical resection of an extended malignant sarcoma of the chest wall requires full-thickness thoracic chest wall reconstruction. Reconstruction is tedious in the case of posteriorly located tumours, because the ipsilateral pedicled myocutaneous latissimus dorsi flap is involved and hence not usable for soft tissue coverage. We report an original case of a left giant dorsal chondrosarcoma originating from the 11th costovertebral joint. After extended resection and skeletal reconstruction, soft tissue coverage was achieved with an original contralateral free flap encompassing both latissimus dorsi and serratus anterior muscles. The flap pedicle was anastomosed to the ipsilateral thoracodorsal vessels.
Çelebi, Mehmet Mesut; Ergen, Emin; Üstüner, Evren
Soft tissue injuries constitute 30-50% of all sports related injuries; however, injury to the latissimus dorsi muscle is quite rare with only a few cases reported in the literature. Herein, we describe an acute traumatic tear of the latissimus dorsi muscle in an elite track athlete, which has not been reported in the track and field sports before. The injury was caused by forceful resisted arm adduction that took place at hurdling and starting from the block. A pseudotumor appearance in the axillary region was misdiagnosed as a mass. The diagnosis was made by ultrasound alone and the patient was managed conservatively. PMID:24765503
Celebi, Mehmet Mesut; Ergen, Emin; Ustüner, Evren
Soft tissue injuries constitute 30-50% of all sports related injuries; however, injury to the latissimus dorsi muscle is quite rare with only a few cases reported in the literature. Herein, we describe an acute traumatic tear of the latissimus dorsi muscle in an elite track athlete, which has not been reported in the track and field sports before. The injury was caused by forceful resisted arm adduction that took place at hurdling and starting from the block. A pseudotumor appearance in the axillary region was misdiagnosed as a mass. The diagnosis was made by ultrasound alone and the patient was managed conservatively.
Delay, E; Foyatier, J L; el Kollali, R; Comparin, J P; Weil, E; Latarjet, J
Very deep burns of the arm and elbow lead to soft tissue necrosis and infection with exposure of important structures. Aggressive debridement should be performed as early as possible to cut the vicious circle, and the defect, which may be extensive, should be covered by well-vascularized tissues. The reliability and versatility of the pedicled latissimus dorsi muscle or musculocutaneous flap make it our first choice in the management of this problem. A retrospective study of three patients for whom salvage of the upper limb has been achieved by the use of a pedicled latissimus dorsi flap is presented, illustrating the advantages of this technique.
Kontor, J. A.
Due to their superficial course, the extensor tendons are frequently lacerated over the dorsum of the hand and fingers. Excellent functional results are obtained in repairs of simple tendon lacerations. ‘Open’ mallet lacerations over the distal IP joint or involving the central extensor slip over the proximal IP joint require more precise suturing methods. More proximal extensor tendon divisions near the wrist involve dissection of the retracted finger extensors or long thumb extensor in the distal forearm and more formal tendon repairs, including a possible tendon transfer to the thumb. ‘Closed injuries’, with varying degrees of extensor tendon disruption, occur at three main sites. The mallet injury at the DIP joint and the boutonnière deformity over the PIP joint are sometimes recognized late, but respond to conservative splinting for a minimum of four weeks with guarded motion avoiding secondary stiffening of the remaining small joints of the hand. Surgery of closed injuries most frequently involves the intra-articular traction fracture type of mallet deformities in which the DIP joint has taken the brunt of the injury. PMID:21286174
Longo, Umile Giuseppe; Lamberti, Alfredo; Petrillo, Stefano; Maffulli, Nicola; Denaro, Vincenzo
Tissue engineering techniques using novel scaffold materials offer potential alternatives for managing tendon disorders. Tissue engineering strategies to improve tendon repair healing include the use of scaffolds, growth factors, cell seeding, or a combination of these approaches. Scaffolds have been the most common strategy investigated to date. Available scaffolds for tendon repair include both biological scaffolds, obtained from mammalian tissues, and synthetic scaffolds, manufactured from chemical compounds. Preliminary studies support the idea that scaffolds can provide an alternative for tendon augmentation with an enormous therapeutic potential. However, available data are lacking to allow definitive conclusion on the use of scaffolds for tendon augmentation. We review the current basic science and clinical understanding in the field of scaffolds and tissue engineering for tendon repair. PMID:22190961
Rodriguez, Mary; Patnaik, Soumya; Wang, Peter
Hip pain is one of the most common reasons for the elderly to present to the emergency department, and the differential diagnosis spectrum is vast. Iliopsoas injury is a relatively uncommon condition that may present with hip or groin pain. It is usually seen in athletes due to trauma, particularly flexion injuries. However, spontaneous iliopsoas tendon tear is extremely rare, and only a small number of cases have been reported; it has an estimated prevalence of 0.66% in individuals from 7 to 95 years. Risk factors include aging, use of steroids, and chronic diseases. Magnetic resonance imaging (MRI) using its high soft-tissue contrast resolution remains the most valuable imaging modality. A prompt diagnosis and treatment, which is usually conservative, is important to improve the quality of life in this group of patients. We describe a case of spontaneous iliopsoas tendon tear in an elderly woman. PMID:26929854
Seitz, Iris A; Adler, Neta; Odessey, Eric; Reid, Russell R; Gottlieb, Lawrence J
Adequate coverage of complex, composite scalp defects in previously radiated, infected, or otherwise compromised tissue represents a challenge in reconstructive surgery. To provide wound closure with bony protection to the brain, improve cranial contour, and prevent or seal cerebrospinal fluid (CSF) leaks, composite free tissue transfer is a reliable and safe option. We report our experience with the latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap in the reconstruction of bony and soft tissue defects of the cranium and overlying scalp. The surgical technique, design, and outcomes of the latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap reconstruction in five patients with cranial defects between 2003 and 2007 were retrospectively evaluated. Patient characteristics, defect size, underlying cause, reconstructive details, and complications were analyzed. All patients (age 43 to 81) had composite defects ranging from 36 to 750 cm2 (mean size 230 cm2) for the bony component and from 16 to 400 cm2 (mean size 170 cm2) for the soft tissue defect. All patients had a history of prior or current infection of the affected area, and two patients had a CSF leak. Defects were due to malignancy and infection (n = 2), infiltrative cutaneous mucormycosis with osteomyelitis (n = 1), and hemorrhagic stroke requiring craniectomy (n = 2), complicated by infection and failed cranioplasty in one patient and continuous CSF leak in the other. The latissimus dorsi composite free flap consisting of skin, muscle, and vascularized rib can successfully cover large complex cranial defects, provide skeletal support, improve contour, and significantly enhance functional outcome with limited donor site morbidity. Copyright Thieme Medical Publishers.
Ackermann, Paul W
The regulation of tendon homoeostasis, including adaptation to loading, is still not fully understood. Accumulating data, however, demonstrates that in addition to afferent (sensory) functions, the nervous system, via efferent pathways which are associated with through specific neuronal mediators plays an active role in regulating pain, inflammation and tendon homeostasis. This neuronal regulation of intact-, healing- and tendinopathic tendons has been shown to be mediated by three major groups of molecules including opioid, autonomic and excitatory glutamatergic neuroregulators. In intact healthy tendons the neuromediators are found in the surrounding structures: paratenon, endotenon and epitenon, whereas the proper tendon itself is practically devoid of neurovascular supply. This neuroanatomy reflects that normal tendon homoeostasis is regulated from the tendon surroundings. After injury and during tendon repair, however, there is extensive nerve ingrowth into the tendon proper, followed by a time-dependent emergence of sensory, autonomic and glutamatergic mediators, which amplify and fine-tune inflammation and regulate tendon regeneration. In tendinopathic condition, excessive and protracted presence of sensory and glutamatergic neuromediators has been identified, suggesting involvement in inflammatory, nociceptive and hypertrophic (degenerative) tissue responses. Under experimental and clinical conditions of impaired (e.g. diabetes) as well as excessive (e.g. tendinopathy) neuromediator release, dysfunctional tendon homoeostasis develops resulting in chronic pain and gradual degeneration. Thus there is a prospect that in the future pharmacotherapy and tissue engineering approaches targeting neuronal mediators and their receptors may prove to be effective therapies for painful, degenerative and traumatic tendon disorders. © 2013 The Authors. International Journal of Experimental Pathology © 2013 International Journal of Experimental Pathology.
Jackson, Lyle T; Dunaway, Linda J; Lundeen, Gregory A
Traumatic tears of the tibialis posterior (TP) tendon following an ankle sprain are rare. The purpose of this study was to report our case series of TP tendon tears following an ankle sprain. Patients with persistent TP tendon pain after an ankle sprain were retrospectively identified over a 4-year period and reviewed. A comparison of magnetic resonance imaging (MRI) interpretations by a radiologist and surgeon was made. Patients failing conservative management underwent operative repair of the TP tendon tear and concomitant pathology. Failure of the index surgery was defined as TP tendinosis, which was treated with excision and flexor digitorum longus tendon transfer. Outcomes were measured with the Foot Function Index (FFI) and American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scores. Thirteen patients were found to have a TP tendon tear following an ankle sprain. The incidence for TP tears with sprains presented to our clinic was 1.04%. MRI identified TP tendon pathology in 4 patients by a radiologist review and in 11 patients by a surgeon review. The most common concomitant pathology was a talar osteochondral defect in 13 of 13 patients and ligament instability in 12 of 13 patients (5/13 lateral, 3/13 medial, 4/13 multidirectional instability). Four of 13 patients failed the index surgery. Of the 9 remaining patients, 4 had clinical follow-up at an average of 4.6 years postoperatively. The average FFI subscale scores were the following: pain, 40.4; disability, 28.9; and activity, 23.6. The average AOFAS hindfoot score was 68.8. Despite being rare, a TP tendon tear should be included in the differential diagnosis for persistent medial-sided pain following an ankle sprain. MRI findings can be subtle. Associated pathology was very common and likely confounded the diagnosis and outcomes. Patients should be counseled on the possibility of poor outcomes and long-term pain. Level IV, case series.
Two-thirds of Achilles tendon injuries in competitive athletes are paratenonitis and one-fifth are insertional complaints (bursitis and insertion tendinitis). The remaining afflictions consist of pain syndromes of the myotendineal junction and tendinopathies. The majority of Achilles tendon injuries from sport occur in males, mainly because of their higher rates of participation in sport, but also with tendinopathies a gender difference is probably indicated. Athletes in running sports have a high incidence of Achilles tendon overuse injuries. About 75% of total and the majority of partial tendon ruptures are related to sports activities usually involving abrupt repetitive jumping and sprinting movements. Mechanical factors and a sedentary lifestyle play a role in the pathology of these injuries. Achilles tendon overuse injuries occur at a higher rate in older athletes than most other typical overuse injuries. Recreational athletes with a complete Achilles tendon rupture are about 15 years younger than those with other spontaneous tendon ruptures. Following surgery, about 70 to 90% of athletes have a successful comeback after Achilles tendon injury. Surgery is required in about 25% of athletes with Achilles tendon overuse injuries and the frequency of surgery increases with patient age and duration of symptoms as well as occurrence of tendinopathic changes. However, about 20% of injured athletes require a re-operation for Achilles tendon overuse injuries, and about 3 to 5% are compelled to abandon their sports career because of these injuries. Myotendineal junction pain should be treated conservatively. Partial Achilles tendon ruptures are primarily treated conservatively, although the best treatment method of chronic partial rupture seems to be surgery. Complete Achilles tendon ruptures of athletes are treated surgically, because this increases the likelihood of athletes reaching preinjury activity levels and minimises the risk of re-ruptures. Marked forefoot
Beef cattle require dietary minerals to maintain their health, production and reproduction. Concentrations of minerals in tissues are at least partially genetically determined. Mapping genomic regions related to the mineral content of the bovine longissimus dorsi muscle may help in the identificatio...
Vidal, Luciano; Hersant, Barbara; Meningaud, Jean Paul
Background: Latissimus dorsi flap is one of the best options for immediate and delayed breast reconstruction. However, this technique is limited by the tissue volume provided by the flap. To improve breast volume while reducing complications, fat grafting is now very often used in addition to latissimus dorsi flap. To the best of our knowledge, fat grafting was always performed as a second-line surgery, at least a few months after the flap procedure. We aimed to report our experience with an associated breast reconstruction technique combining musculocutaneous latissimus dorsi flap with intrapectoral lipofilling for totally autologous breast reconstruction. Methods: Between September 2014 and January 2015, 20 patients underwent this technique for unilateral autologous breast reconstruction (14 delayed and 6 immediate breast reconstructions). A mean harvested fat volume of 278 ml (range: 190–350 ml) and a mean injected fat volume of 228 ml (range: 170–280 ml) were used. Results: None of the patients experienced complications, such as flap necrosis, breast skin necrosis, hematomas, or infection. One of the patients developed a seroma, which was treated with 3 drainage punctions. Only 2 patients underwent delayed fat grafting procedure. Conclusion: Totally autologous breast reconstruction combining latissimus dorsi flap and intrapectoral fat grafting in the same procedure is a new technique allowing increased breast volume in a single surgery. PMID:27975006
Melvin, Alan; Litsky, Alan; Mayerson, Joel; Witte, David; Melvin, David; Juncosa-Melvin, Natalia
A coupling mechanism that can permanently fix a forcefully contracting muscle to a bone anchor or any totally inert prosthesis would meet a serious need in orthopaedics. Our group developed the OrthoCoupler™ device to satisfy these demands. The objective of this study was to test OrthoCoupler’s performance in vitro and in vivo in the goat semitendinosus tendon model. For in vitro evaluation, 40 samples were fatigue-tested, cycling at 10 load levels, n=4 each. For in vivo evaluation, the semitendinosus tendon was removed bilaterally in 8 goats. Left sides were reattached with an OrthoCoupler, and right sides were reattached using the Krackow stitch with #5 braided polyester sutures. Specimens were harvested 60 days post-surgery and assigned for biomechanics and histology. Fatigue strength of the devices in vitro was several times the contractile force of the semitendinosus muscle. The in vivo devices were built equivalent to two of the in vitro devices, providing an additional safety factor. In strength testing at necropsy, suture controls pulled out at 120.5 ± 68.3 N, whereas each OrthoCoupler was still holding after the muscle tore, remotely, at 298±111.3N (mean ± SD)(p<0.0003). Muscle tear strength was reached with the fiber-muscle composite produced in healing still soundly intact. This technology may be of value for orthopaedic challenges in oncology, revision arthroplasty, tendon transfer, and sports-injury reconstruction. PMID:19639642
Yang, Ying; Rupani, Asha; Bagnaninchi, Pierre; Wimpenny, Ian; Weightman, Alan
The highly orientated collagen fibers in tendons play a critical role for transferring tensile stress, and they demonstrate birefringent optical properties. However, the influence that proteoglycans (PGs) have on the optical properties of tendons is yet to be fully elucidated. PGs are the essential components of the tendon extracellular matrix; the changes in their quantities and compositions have been associated with tendinopathies. In this study, polarization sensitive optical coherence tomography (PS-OCT) has been used to reveal the relationship between PG content/location and birefringence properties of tendons. Fresh chicken tendons were imaged at regular intervals by PS-OCT and polarization light microscopy during the extraction of PGs, using guanidine hydrochloride (GuHCl). Complementary time-lapsed images taken from the two modalities mutually demonstrated that the extraction of PGs disturbed the local organization of collagen bundles. This corresponded with a decrease in birefringence and associated banding pattern observed by PS-OCT. Furthermore, this study revealed there was a higher concentration of PGs in the outer sheath region than in the fascicles, and therefore the change in birefringence was reduced when extraction was performed on unsheathed tendons. The results provide new insights of tendon structure and the role of PGs on the structural stability of tendons, which also demonstrates the great potential for using PS-OCT as a diagnostic tool to examine tendon pathology.
Vacher, C; Ben Hadj Yahia, S; Braun, M; Journeau, P
Comparing to other primates, one of the most important specificities of the human anatomy are consequences of bipedalism. Although bone consequences are well known (lumbar lordosis, horizontal position of the foramen magnum, lengthening of the lower limbs, reduction of the pelvis, specialization of the foot), consequences of our locomotion on the Latissimus dorsi are still unclear. One dissection of a chimpanzee Latissimus dorsi (Pan troglodytes) has been performed and compared to 30 human Latissimus dorsi dissections (10 fresh cadavers and 20 formoled cadavers). In each dissection, the existence of direct muscular insertions on the iliac crest has been investigated and the constitution of the thoracolumbar fascia has been described. In chimpanzee dissection, a muscular direct insertion of the Latissimus dorsi was present on the iliac crest of 9 cm long. The TLF was made of the superficial and the deep fascias of the Latissimus dorsi and the superficial fascia of the erector spinae muscles which was deeper. In man, there was no direct muscular insertion of the Latissimus dorsi in 90 % of cases, the TLF was constituted the same way. This study suggests that the Latissimus dorsi has been separated from the iliac crest in man during the evolution because of the permanent bipedalism and that it stayed inserted on the iliac crest in chimpanzee because of the brachiation. Copyright © 2013 Elsevier Masson SAS. All rights reserved.
Kim, S J; Shin, S J; Choi, C H; Kim, H C
We present a biceps rerouting technique for posterolateral rotatory instability using a modification of the biceps femoris tendon tenodesis of Clancy. The distinguishing features of this technique are the approach to the lateral femoral epicondyle through the interval between the iliotibial band and biceps femoris muscle, and fixation of the transferred biceps tendon at the isometric point. Reconstruction for posterolateral rotatory instability by modified biceps tendon rerouting can result in objectively and functionally acceptable knee function.
Yu, JaeHo; Lee, SoYeon; Kim, HyongJo; Seo, DongKwon; Hong, JiHeon; Lee, DongYeop
The application of transcutaneous electrical nerve stimulation (TENS) enhances muscle weakness and static balance by muscle fatigue. It was said that TENS affects decrease of the postural sway. On the other hand, the applications of TENS to separate dorsi-plantar flexor and the comparison with and without visual input have not been studied. Thus, the aim of this study was to compare the effects of TENS on fatigued dorsi-plantar flexor with and without visual input. 13 healthy adult males and 12 females were recruited and agreed to participate as the subject (mean age 20.5 ± 1.4, total 25) in this study after a preliminary research. This experiment was a single group repeated measurements design in three days. The first day, after exercise-induced fatigue, the standing position was maintained for 30 minutes and then the postural sway was measured on eyes open(EO) and eyes closed(EC). The second, TENS was applied to dorsi flexor in standing position for 30 minutes after conducting exercise-induced fatigue. On the last day, plantar flexor applied by TENS was measured to the postural sway on EO and EC after same exercise-induced fatigue. The visual input was not statistically difference between the groups. However, when compared of dorsi-plantar flexor after applied to TENS without visual input, the postural sway of plantar flexor was lower than the dorsi flexor (p< 0.05). As the result, the application of TENS in GCM clinically decreases the postural sway with visual input it helps to stable posture control and prevent to falling down.
Rajabi, Hamid; Sheikhani Shahin, Homa; Norouzian, Manijeh; Mehrabani, Davood; Dehghani Nazhvani, Seifollah
Clinical tendon injuries represent serious and unresolved issues of the case on how the injured tendons could be improved based on natural structure and mechanical strength. The aim of this studies the effect of aquatic activities and alogenic platelet rich plasma (PRP) injection in healing Achilles tendons of rats. Forty rats were randomly divided into 5 equal groups. Seventy two hours after a crush lesion on Achilles tendon, group 1 underwent aquatic activity for 8 weeks (five sessions per week), group 2 received intra-articular PRP (1 ml), group 3 had aquatic activity together with injection PRP injection after an experimental tendon injury, group 4 did not receive any treatment after tendon injury and the control group with no tendon injuries. of 32 rats. After 8 weeks, the animals were sacrificed and the tendons were transferred in 10% formalin for histological evaluation. There was a significant increase in number of fibroblast and cellular density, and collagen deposition in group 3 comparing to other groups denoting to an effective healing in injured tendons. However, there was no significant difference among the studied groups based on their tendons diameter. Based on our findings on the number of fibroblast, cellular density, collagen deposition, and tendon diameter, it was shown that aquatic activity together with PRP injection was the therapeutic measure of choice enhance healing in tendon injuries that can open a window in treatment of damages to tendons.
Rajabi, Hamid; Sheikhani Shahin, Homa; Norouzian, Manijeh; Mehrabani, Davood; Dehghani Nazhvani, Seifollah
BACKGROUND Clinical tendon injuries represent serious and unresolved issues of the case on how the injured tendons could be improved based on natural structure and mechanical strength. The aim of this studies the effect of aquatic activities and alogenic platelet rich plasma (PRP) injection in healing Achilles tendons of rats. METHODS Forty rats were randomly divided into 5 equal groups. Seventy two hours after a crush lesion on Achilles tendon, group 1 underwent aquatic activity for 8 weeks (five sessions per week), group 2 received intra-articular PRP (1 ml), group 3 had aquatic activity together with injection PRP injection after an experimental tendon injury, group 4 did not receive any treatment after tendon injury and the control group with no tendon injuries. of 32 rats. After 8 weeks, the animals were sacrificed and the tendons were transferred in 10% formalin for histological evaluation. RESULTS There was a significant increase in number of fibroblast and cellular density, and collagen deposition in group 3 comparing to other groups denoting to an effective healing in injured tendons. However, there was no significant difference among the studied groups based on their tendons diameter. CONCLUSION Based on our findings on the number of fibroblast, cellular density, collagen deposition, and tendon diameter, it was shown that aquatic activity together with PRP injection was the therapeutic measure of choice enhance healing in tendon injuries that can open a window in treatment of damages to tendons. PMID:25606479
Strom, Adam C; Casillas, Mark M
The operative management of acute Achilles tendon rupture marks the beginning of a comprehensive rehabilitation program. The goals of the rehabilitation program start with the reduction of pain and swelling and the recovery of ankle motion and power. They conclude with the restoration of coordinated activity and safe return to athletic activity. The rehabilitation protocol is directed by the injury and the quality of the repair, along with the patient's age, medical and social history, and athletic inclination. The protocol is dynamic and responsive to changing clinical findings.
Danino, A. M.; Hariss, P. G.; Servant, J. M.
Objective: Severe ballistic injuries to the face create complex, composite defects of 2 facial subunits. These injuries have an extremely high economic impact for the Medicare system. The surgical goal with these patients is to restore basic functions of the face with a rapid morphological improvement. Our hypothesis is as follows: Early restoration of facial segments with a single free multiple island latissimus dorsi flap without primary bone reconstruction can significantly reduce hospitalization time and allow earlier psychiatric therapy with good morphological results. Surgical method: (1) Large debridement, bony stabilization with external fixation, and tracheotomy. (2) Definitive early reconstruction of soft tissue with composite free latissimus dorsi-scapular musculocutaneous flap. (3) Several refinements will optimize the results. Study design: Retrospective case series of lower- and middle-face composite facial close-range high-energy gunshot wound patients were evaluated. Age, gender, mechanism of injury, anatomic subsites involved, surgical procedures, flaps utilized, complications, functional outcomes, time of tracheotomy closure, hospitalization duration, and beginning of psychiatric treatment were analyzed. Results: Twelve defects were gunshot wounds, 12 free latissimus dorsi flaps, and no flap losses. Patients received psychiatric treatment after 22 days (7–29); the tracheotomy was removed in 10 patients with normal alimentation in all cases. Mean hospitalization duration was 21 days. Conclusions: Free tissue transfer techniques allow early reconstruction of the soft tissue framework of the face with a single multiple-island flap. Rapid restitution of facial compartments at a soft tissue level can dramatically reduce duration of hospitalization. PMID:19587777
Wertz, Jess; Galli, Melissa; Borchers, James R.
Context: Achilles tendon (AT) rupture in athletes is increasing in incidence and accounts for one of the most devastating sports injuries because of the threat to alter or end a career. Despite the magnitude of this injury, reliable risk assessment has not been clearly defined, and prevention strategies have been limited. The purpose of this review is to identify potential intrinsic and extrinsic risk factors for AT rupture in aerial and ground athletes stated in the current literature. Evidence Acquisition: A MEDLINE search was conducted on AT rupture, or “injury” and “risk factors” and “athletes” from 1980 to 2011. Emphasis was placed on epidemiology, etiology, and review articles focusing on the risk for lower extremity injury in runners and gymnasts. Thirty articles were reviewed, and 22 were included in this assessment. Results: Aerial and ground athletes share many intrinsic risk factors for AT rupture, including overuse and degeneration of the tendon as well as anatomical variations that mechanically put an athlete at risk. Older athletes, athletes atypical in size for their sport, high tensile loads, leg dominance, and fatigue also may increase risk. Aerial athletes tend to have more extrinsic factors that play a role in this injury due to the varying landing surfaces from heights and technical maneuvers performed at various skill levels. Conclusion: Risk assessment for AT rupture in aerial and ground athletes is multivariable and difficult in terms of developing prevention strategies. Quantitative measures of individual risk factors may help identify major contributors to injury. PMID:24427410
Witvrouw, E; Mahieu, N; Roosen, P; McNair, P
The function of tendons can be classified into two categories: tensile force transmission, and storage and release of elastic energy during locomotion. The action of tendons in storing and releasing energy is mainly seen in sports activities with stretch-shortening cycles (SSCs). The more intense the SSC movements are (jumping-like activities), the more frequently tendon problems are observed. High SSC movements impose high loads on tendons. Consequently, tendons that frequently deal with high SSC motion require a high energy-absorbing capacity to store and release this large amount of elastic energy. As the elasticity of tendon structures is a leading factor in the amount of stored energy, prevention and rehabilitation programmes for tendon injuries should focus on increasing this tendon elasticity in athletes performing high SSC movements. Recently, it has been shown that ballistic stretching can significantly increase tendon elasticity. These findings have important clinical implications for treatment and prevention of tendon injuries.
Bernhard, Andrew; Miller, Josh; Keeler, Jason; Siesel, Kathy; Bridges, Evan
This study was undertaken to help confirm the percentages concerning the presence or absence of the flexor digitorum brevis muscle tendon to the fifth toe. We also hope to be able to determine the presence based on gender and nationality. It is known to be absent occasionally; however, there is no definitive study dedicated to its prevalence. Using a pool of 60 cadavers, 97 total feet were included in our analysis. Of these feet, 47 (48%) lacked a flexor digitorum brevis tendon to the fifth toe at all. Furthermore, 25 (26%) had notably small tendons to the fifth toe. The final 25 (26%) had what the researchers deemed present tendons. This information could be helpful in surgical planning, including tendon transfer techniques, and biomechanical evaluations. Further research would need to be conducted as this was a cadaveric study. Cadaver/anatomy research, Level V.
Miranda, B. H.; Cerovac, S.
Background Spontaneous flexor tendon rupture is considered to be invariably associated with previous hand/wrist injury or systemic disease such as rheumatoid arthritis. Case Description A 54-year-old man presented with a 4-month history of mild ulnar wrist pain and spontaneous left little finger flexion loss in the absence of distant/recent trauma and systemic arthropathy. Surgical exploration confirmed a zone IV left little finger flexor digitorum profundus (FDP5) attritional rupture (100%), ring finger flexor digitorum profundus (FDP4) attenuation (40%) and a disrupted lunotriquetral ligament and volar-ulnar wrist capsule. Volar subluxation of the narrowed carpal tunnel resulted in flexor tendon attrition against the hamate hook. A side-to-side tendon transfer was performed along with a lunotriquetral ligament repair and temporary Kirschner wire fixation. At 6 months the patient had full active, synchronous flexion of the ring and little fingers and reduced wrist pain. Literature Review Traumatic flexor tendon ruptures have been reported following distal radius/hamate hook fractures, from carpal bone osteophytes, accessory carpal bones and intraosseous ganglia. Attritional ruptures caused by chronic, degenerative carpal pathology are less common. Clinical Relevance This case highlights an unusual cause of flexor tendon rupture due to chronic carpal instability. PMID:25032080
Kondratko-Mittnacht, Jaclyn; Lakes, Roderic; Vanderby, Ray
Tendon is vital to musculoskeletal function, transferring loads from muscle to bone for joint motion and stability. It is an anisotropic, highly organized, fibrous structure containing primarily type I collagen in addition to tenocytes and other extracellular matrix components contributing to maintenance and function. Tendon is generally loaded via normal stress in a longitudinal direction. However, certain situations, including fiber breakage, enzymatic remodeling, or tendon pathology may introduce various degrees of other loading modalities, such as shear-lag at the fiber level, potentially affecting cellular response and subsequent function. Fascicles from rat tail tendon were dissected and placed in one of three paired groups: intact, single laceration, or double laceration. Each pair had a mechanically tested and control specimen. Single laceration fascicles contained one transverse laceration to mimic a partial tear. Double laceration fascicles had overlapping, longitudinally separated lacerations on opposite sides to cause intra-fascicular shear transfer to be the primary mechanism of loading. Elastic properties of the fascicle, e.g. peak load, steady state load, and stiffness, decreased from intact to single laceration to double laceration groups. Surprisingly, 45% of the intact strength was maintained when shear was the primary internal load transfer mechanism. Cellular viability decreased after mechanical testing in both laceration groups; cell death appeared primarily in a longitudinal plane where high shear load transfer occurred. This cell death extended far from the injury site and may further compromise an already damaged tendon via enzymatic factors and subsequent remodeling associated with cell necrosis. Copyright © 2015 Elsevier Ltd. All rights reserved.
Qi, Jin; Xia, Yayi; Wang, Yuliang; Zhao, Lin; Yao, Changjiang
To evaluate the effectiveness of hamstring tendon and flexor hallucis longus (FHL) tendon autograft for Achilles tendon defects reconstruction. Between February 2009 and October 2011, 9 patients (9 feet) with Achilles tendon defect were treated with hamstring tendon and FHL tendon autograft. Of 9 cases, 6 were male and 3 were female with an average age of 43 years (range, 21-65 years), including 5 cases of chronic Achilles tendon ruptures caused by sport injury and 4 cases of Achilles tendon defects caused by resection of tendon lesion (2 cases of hyaline degeneration with necrosis, 1 case of giant cell tumor, and 1 case of chronic inflammation with hyaline degeneration). The disease duration ranged from 31 to 387 days (mean, 137.6 days). The defect length was 5 to 18 cm (mean, 8.6 cm). Functional exercise of the ankle began at 6 weeks after plaster fixation. Dehiscence and effusion occurred in 2 cases and plantar pain caused by injury of tibial nerve in 1 case; primary healing of wound was obtained in the other patients without complication. Nine patients were followed up 19.7 months on average (range, 13-25 months); no re-rupture was observed. There was no significant difference in the dorsal extension between at preoperation and at 1 year and last follow-up after operation (P > 0.05); the ankle plantar flexion at 1 year and last follow-up after operation was significantly larger than that at preoperation (P < 0.05). The ankle plantar flexion and dorsal extension at 1 year and last follow-up after operation were significantly larger than those at 3 months after operation (P < 0.05), but no significant difference was found between at 1 year and last follow-up (P > 0.05). American Orthopaedic Foot and Ankle Society (AOFAS) and short-form 36 health survey scale (SF-36) scores were significantly increased at postoperation when compared with scores at preoperation (P < 0.05), and the scores at last follow-up were significantly higher than those at 3 months after
Moura, Diogo Lino; Marques, José Pedro; Lucas, Francisco Manuel; Fonseca, Fernando Pereira
Bilateral patellar tendon rupture is a rare entity, often associated with systemic diseases and patellar tendinopathy. The authors report a rare case of a 34-year-old man with simultaneous bilateral rupture of the patellar tendon caused by minor trauma. The patient is a retired basketball player with no past complaints of chronic knee pain and a history of steroid use. Surgical management consisted in primary end-to-end tendon repair protected temporarily with cerclage wiring, followed by a short immobilization period and intensive rehabilitation program. Five months after surgery, the patient was able to fully participate in sport activities.
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Seybold, Jeffrey D; Campbell, John T; Jeng, Clifford L; Myerson, Mark S
Lateral transfers of the flexor hallucis longus (FHL) or flexor digitorum longus (FDL) tendons have been described for treatment of concomitant, irreparable peroneal tears. This study evaluated the anatomic benefits and constraints of lateral FHL and FDL tendon transfers with regard to available tendon length, diameter, and proximity to the posterior neurovascular bundle. In 9 cadaveric specimens, the FHL and FDL tendons were transected through a medial approach distal to the knot of Henry. Each tendon was transferred into a lateral incision, passing the FDL tendon both posterior and anterior to the tibial neurovascular bundle. The tendons were individually secured to the base of the fifth metatarsal with the foot in maximal eversion and dorsiflexion. The length of donor tendon available for fixation at the fifth metatarsal was measured. After the FDL tendon transfer was secured, the posterior neurovascular bundle was examined for signs of compression. Average FHL tendon diameter measured 5.1 mm; the FDL measured 4.5 mm. After passage through a bone tunnel, an additional 4.9 cm of FHL tendon remained to suture to itself; only 0.5 cm remained for the posterior and anterior FDL transfers. Transfer of the FHL did not increase muscle bulk within the retrofibular groove. Every FDL transfer posterior to the neurovascular bundle produced obvious visual compression of the tibial nerve with plantar flexion and inversion of the foot. Use of the FHL tendon for lateral transfer consistently provided sufficient length of tendon for multiple fixation options and a stronger muscle for transfer. Fixation options for the FDL were limited due to its shorter length. Lateral transfer of the FDL tendon posterior to the neurovascular bundle caused visible compression on the tibial nerve with ankle and hindfoot range of motion. This anatomic study confirmed several advantages for the use of the FHL tendon transfer in cases of concomitant peroneal tears.
Zini, Raul; Panascì, Manlio; Papalia, Rocco; Franceschi, Francesco; Vasta, Sebastiano; Denaro, Vincenzo
Background: Since it was developed, hip arthroscopy has become the favored treatment for femoroacetabular impingement. Due to recent considerable improvements, the indications for this technique have been widely extended. Injuries of the rectus femoris tendon origin, after an acute phase, could result in a chronic tendinopathy with calcium hydroxyapatite crystal deposition, leading to pain and loss of function. Traditionally, this condition is addressed by local injection of anesthetic and corticosteroids or, when conservative measures fail, by open excision of the calcific lesion by an anterior approach. Purpose: To assess whether arthroscopic excision of calcification of the proximal rectus is a safe and effective treatment. Study Design: Case series; Level of evidence, 4. Methods: Outcomes were studied from 6 top amateur athletes (age range, 30-43 years; mean, 32.6 years) affected by calcification of the proximal rectus who underwent arthroscopic excision of the calcification. Patients were preoperatively assessed radiographically, and diagnosis was confirmed by a 3-dimensional computed tomography scan. To evaluate the outcome, standardized hip rating scores were used pre- and postoperatively (at 6 and 12 months): the Hip disability and Osteoarthritis Outcome Score, Oxford Hip Score, and Modified Harris Hip Score. Moreover, visual analog scales (VAS) for pain, sport activity level (SAL), and activities of daily living (ADL) were also used. Results: One year after surgery, all patients reported satisfactory outcomes, with 3 of 6 rating their return-to-sport level as high as preinjury level, and the remaining 3 with a percentage higher than 80%. Five patients ranked their ability to carry on daily activities at 100%. Statistical analysis showed significant improvement of the Oxford Hip Score, the Modified Harris Hip Score, and all 3 VAS subscales (pain, SAL, and ADL) from pre- to latest postoperative assessment (P < .05). Conclusion: Arthroscopic excision of
Janus, Jeffrey R; Carlson, Matthew L; Moore, Eric J
Complex composite defects of the oral cavity are often created due to en bloc resection of malignant tumors. These defects can involve bone, soft tissue, oral mucosa, and external skin, posing a reconstructive challenge to the microvascular surgeon. Though advances have been made in free tissue transfer via piggybacking techniques and double free-flaps, increases in operative time and morbidity remain limiting factors. Likewise, advancements in single composite flaps (e.g., double-skin paddle fibular free-flap) allow for a single donor site, but limit workable tissue. This report describes our experience with the scapular, parascapular, and latissimus dorsi (SPLD) as a combined single unit osteomyocutaneous flap for composite reconstruction of complex oral defects. A case example is subsequently reviewed for clinical correlation. This is an operative techniques article describing the use of the SPLD single multi-tissue flap for repair of complex oral defects. Cadaveric dissection was performed for instructional purposes. Case example was given for clinical correlation. Relevant history, anatomy, procedural details, and possible complications are presented and subsequently correlated to the case example. A SPLD free-flap as a single multi-tissue flap is a viable and beneficial option for reconstruction of complex oral defects. It provides the volume of tissue necessary to fill composite defects and exists as an alternative to multi-flap procedures, which carry a longer operative time and multiple donor site morbidity.
Lomax, Mitch; Tasker, Louise; Bostanci, Ozgur
The purpose of this study was to determine whether inspiratory muscle fatigue (IMF) affects the muscle activity of the latissimus dorsi and pectoralis major during maximal arms only front crawl swimming. Eight collegiate swimmers were recruited to perform 2 maximal 20-second arms only front crawl sprints in a swimming flume. Both sprints were performed on the same day, and IMF was induced 30 minutes after the first (control) sprint. Maximal inspiratory and expiratory mouth pressures (PImax and PEmax, respectively) were measured before and after each sprint. The median frequency (MDF) of the electromyographic signal burst was recorded from the latissimus dorsi and pectoralis major during each 20-second sprint along with stroke rate and breathing frequency. Median frequency was assessed in absolute units (Hz) and then referenced to the start of the control sprint for normalization. After IMF inducement, stroke rate increased from 56 ± 4 to 59 ± 5 cycles per minute, and latissimus dorsi MDF fell from 67 ± 11 Hz at the start of the sprint to 61 ± 9 Hz at the end. No change was observed in the MDF of the latissimus dorsi during the control sprint. Conversely, the MDF of the pectoralis major shifted to lower frequencies during both sprints but was unaffected by IMF. As the latter induced fatigue in the latissimus dorsi, which was not otherwise apparent during maximal arms only control sprinting, the presence of IMF affects the activity of the latissimus dorsi during front crawl sprinting.
Cadenelli, Pierfrancesco; Bordoni, Daniele; Ornelli, Matteo; Radaelli, Stefano
Reconstruction of large soft tissue defects in the upper arm represents a challenge for the reconstructive surgeon. The latissimus dorsi flap is widely used and preferred for this latter type of reconstruction due to its reliability and versatility, although sacrificing the entire muscle can lead to higher incidences of postoperative seroma and functional disability. The recent introduction of the perforator-based flap concept has led to an evolution in upper extremity reconstruction by significantly reducing donor-site morbidity and simultaneously ensuring optimal soft tissues coverage. We report a case of a large soft tissue defect of the posterolateral part of the upper arm, consequent to a sarcoma resection, in which a muscle-sparing latissimus dorsi technique was used to obtain total soft tissue coverage. A 2-year follow-up showed a satisfactory functional result and no evidence of recurrence.
Dave, V; Gandhi, S; Mehta, V; Kumar, A; Arora, J; Suri, R K; Rath, G
Extensor tendon injury is a frequent finding in clinical practice. During a routine dissection class of undergraduate medical students examining the extensor aspect of the right hand, they found an interesting pattern of extensor tendons. The extensor digitorum (ED) exhibited three tendons for the middle and ring fingers. The intermediate tendon of the ED was found to pass to the junctura connecting the tendons of the ring and middle fingers. Additionally the Extensor carpi ulnaris displayed two tendinus slips. The lateral slip was inserted on the base of fifth metacarpal as usual, whereas the medial slip divided into two strands- proximal and distal. Apart from the above findings in the current case specimen, there was an accessory muscle belly for the index finger and the extensor digiti minimi bifurcated into two tendinus slips which gained attachment to the dorsal digital expansion of the little finger. These accessory muscle bellies and tendons could possibly be utilized for tendon reconstructions such as repairs, tenoplasties or tendon transfers.
Tang, Jin Bo; Wu, Ya Fang; Cao, Yi; Chen, Chuan Hao; Zhou, You Lang; Avanessian, Bella; Shimada, Masaru; Wang, Xiao Tian; Liu, Paul Y.
Tendon injury during limb motion is common. Damaged tendons heal poorly and frequently undergo unpredictable ruptures or impaired motion due to insufficient innate healing capacity. By basic fibroblast growth factor (bFGF) or vascular endothelial growth factor (VEGF) gene therapy via adeno-associated viral type-2 (AAV2) vector to produce supernormal amount of bFGF or VEGF intrinsically in the tendon, we effectively corrected the insufficiency of the tendon healing capacity. This therapeutic approach (1) resulted in substantial amelioration of the low growth factor activity with significant increases in bFGF or VEGF from weeks 4 to 6 in the treated tendons (p < 0.05 or p < 0.01), (2) significantly promoted production of type I collagen and other extracellular molecules (p < 0.01) and accelerated cellular proliferation, and (3) significantly increased tendon strength by 68–91% from week 2 after AAV2-bFGF treatment and by 82–210% from week 3 after AAV2-VEGF compared with that of the controls (p < 0.05 or p < 0.01). Moreover, the transgene expression dissipated after healing was complete. These findings show that the gene transfers provide an optimistic solution to the insufficiencies of the intrinsic healing capacity of the tendon and offers an effective therapeutic possibility for patients with tendon disunion. PMID:26865366
Tang, Jin Bo; Wu, Ya Fang; Cao, Yi; Chen, Chuan Hao; Zhou, You Lang; Avanessian, Bella; Shimada, Masaru; Wang, Xiao Tian; Liu, Paul Y
Tendon injury during limb motion is common. Damaged tendons heal poorly and frequently undergo unpredictable ruptures or impaired motion due to insufficient innate healing capacity. By basic fibroblast growth factor (bFGF) or vascular endothelial growth factor (VEGF) gene therapy via adeno-associated viral type-2 (AAV2) vector to produce supernormal amount of bFGF or VEGF intrinsically in the tendon, we effectively corrected the insufficiency of the tendon healing capacity. This therapeutic approach (1) resulted in substantial amelioration of the low growth factor activity with significant increases in bFGF or VEGF from weeks 4 to 6 in the treated tendons (p < 0.05 or p < 0.01), (2) significantly promoted production of type I collagen and other extracellular molecules (p < 0.01) and accelerated cellular proliferation, and (3) significantly increased tendon strength by 68-91% from week 2 after AAV2-bFGF treatment and by 82-210% from week 3 after AAV2-VEGF compared with that of the controls (p < 0.05 or p < 0.01). Moreover, the transgene expression dissipated after healing was complete. These findings show that the gene transfers provide an optimistic solution to the insufficiencies of the intrinsic healing capacity of the tendon and offers an effective therapeutic possibility for patients with tendon disunion.
Freeman, Joseph W; Silver, Frederick H
During limb movement and locomotion, animals store elastic energy in the tendons of the feet, legs, and other limbs. In the turkey, much of the force generated by the gastrocnemius muscle during locomotion is stored as elastic energy through deformation of the tendon. During growth and development, the leg tendons in some avians, including turkeys, mineralize and result in an increase in tensile strength and modulus. The purpose of our study was to evaluate the effects of mineralization on elastic energy storage and transmission in turkey tendons. Elastic and viscous stress-strain curves and elastic energy storage behavior were used to compare the behavior of mineralized turkey gastrocnemius tendons and mineralized self-assembled type I collagen fibers. Based on analysis of these two systems, we concluded that a simple mineralized fibrillar collagenous substrate can mimic the behavior of a more complex fibrillar collagenous substrate such as mineralized turkey tendon; however, the exact mechanism of mineralization may be different between the two substrates. Changes in mechanical properties of turkey tendon were consistent with a model in which mineralization appears to increase the effective collagen fibril length by efficiently transferring stress between neighboring collagen fibrils. Mineralization in self-assembled collagen fibers increased elastic energy storage less efficiently as compared with turkey tendon suggesting that the noncollagenous components of mineralizing tissue may act to promote collagen fibril to collagen fibril interactions.
Kim, Sang Wha; Lee, Ho Jun; Kim, Jeong Tae; Kim, Youn Hwan
Traumatic digit defects of high complexity and with inadequate local tissue represent challenging surgical problems. Recently, perforator flaps have been proposed for reconstructing large defects of the hand because of their thinness and pliability and minimal donor site morbidity. Here, we illustrate the use of thin latissimus dorsi perforator flaps for resurfacing multiple defects of distal digits. We describe the cases of seven patients with large defects, including digits, circumferential defects and multiple-digit defects, who underwent reconstruction with thin latissimus dorsi perforator flaps between January 2008 and March 2012. Single-digit resurfacing procedures were excluded. The mean age was 56.3 years and the mean flap size was 160.4 cm(2). All the flaps survived completely. Two patients had minor complications including partial flap loss and scar contracture. The mean follow-up period was 11.7 months. The ideal flap for digit resurfacing should be thin and amenable to moulding, have a long pedicle for microanastomosis and have minimal donor site morbidity. Thin flaps can be harvested by excluding the deep adipose layer, and their high pliability enables resurfacing without multiple debulking procedures. The latissimus dorsi perforator flap may be the best flap for reconstructing complex defects of the digits, such as large, multiple-digit or circumferential defects, which require complete wrapping of volar and dorsal surfaces.
Karaaltin, Mehmet Veli; Erdem, Adnan; Canter, Ibrahim; Cavdar, Günay; Baghaki, Semih
The Latissimus dorsi musculocutaneous flap is a valuable workhorse of the microsurgeon, especially in closing large body defects. One of the pitfalls in harvesting the flap, is particularly in its inferior aspect which may be unreliable. Here we report a series of 53 patients who were undergone bipedicled free latissimus dorsi musculocutaneous free flaps for extensive tissue defects. The age of patients were between 5 and 64 and all of them were males. The wound sizes in these patients ranged between 31-35 x 10-12 cm and flap dimensions were between 38-48 x 6-8 cm. Perforator branches of the 10th intercostal vessels were dissected and supercharged to the flaps to reduce the risk of ischemia of the inferior cutaneous extensions. The secondary pedicles were anastomosed to recipient vessels other than the primary pedicles. Recipient areas were consisted of lower extremities. Four patients suffered of early arterial failure in the major pedicle and all revisions were successfully attempted. Neither sign of venous congestion nor arterial insufficiency were observed at the inferior cutaneous extensions of the flaps, and all defects were reconstructed successfully. All donor sites were primarily closed, only two patients suffered from a minor area of superficial epidermal loss at the donor site, without suffering any adjunct complications. In conclusion coverage of large defects can be safely performed with extending the skin paddle of latissimus dorsi flap as a bipedicled free flap.
Hata, Yoshinobu; Otsuka, Hajime; Makino, Takashi; Koezuka, Satoshi; Sugino, Keishi; Shiraga, Nobuyuki; Tochigi, Naobumi; Shibuya, Kazutoshi; Homma, Sakae; Iyoda, Akira
Surgery for chronic pulmonary aspergillosis is often technically risky. The choice of immediate thoracoplasty or muscle flap plombage to prevent postoperative space problems remains controversial. This study focused on the use of muscle flaps to prevent postoperative complications. During an 8-year period (2004 to 2012), all patients surgically treated for chronic pulmonary aspergillosis were enrolled in this retrospective study. Concomitant intrathoracic transposition of the latissimus dorsi muscle flap has been performed since 2011. The clinical records of these patients were reviewed retrospectively. From 2004 to 2012, 16 patients were treated for chronic pulmonary aspergillosis. Fifteen patients received lobectomies and one had a partial resection. A preventive latissimus dorsi muscle flap was used in 6 patients (37 %). No postoperative deaths occurred. Prolonged air leaks appeared in 2 patients without muscle flaps, resulting in empyema in both. None of the patients with preventive muscle flaps suffered prolonged air leaks and subsequent empyema. In the outpatient clinic, late onset air leaks developed in 2 patients, one of whom had a lobectomy with muscle flap while the other had a lobectomy without muscle flap. Residual pleural space persisted in these two patients and Aspergillus infection later recurred. Concomitant latissimus dorsi muscle flaps may be effective for the prevention of prolonged air leaks and subsequent empyema. Late onset air leaks are problematic.
Schade, Valerie L; Harsha, Wayne; Rodman, Caitlin; Roukis, Thomas S
Septic peroneal tenosynovitis is a rare and significant challenge. A search of peer-reviewed published studies revealed only 5 case reports to guide treatment, none of which resulted in significant loss of both peroneal tendons necessitating reconstruction. No clear guidance is available regarding how to provide reliable reconstruction of both peroneal tendons after a significant loss secondary to septic tenosynovitis. In the present report, we describe the case of a young, active-duty soldier who underwent lateral ankle ligament reconstruction with a tendon allograft whose postoperative course was complicated by septic peroneal tenosynovitis resulting in significant loss of both peroneal tendons. Reconstruction was achieved in a staged fashion with the use of silicone rods and external fixation to maintain physiologic tension and preserve peroneal tendon function, followed by reconstruction of both peroneal tendons and the superior peroneal retinaculum with a tensor fascia lata autograft. Soft tissue coverage was obtained with an anterolateral thigh free tissue transfer and a split-thickness skin graft. The patient returned to full activity as an active-duty soldier with minimal pain and no instability of the right lower extremity. The muscle strength of both peroneal tendons remained at 5 of 5, and no objective findings of ankle instability were seen at 3.5 years postoperatively. Published by Elsevier Inc.
Griffin, M; Hindocha, S; Jordan, D; Saleh, M; Khan, W
Extensor tendon injuries are very common injuries, which inappropriately treated can cause severe lasting impairment for the patient. Assessment and management of flexor tendon injuries has been widely reviewed, unlike extensor injuries. It is clear from the literature that extensor tendon repair should be undertaken immediately but the exact approach depends on the extensor zone. Zone I injuries otherwise known as mallet injuries are often closed and treated with immobilisaton and conservative management where possible. Zone II injuries are again conservatively managed with splinting. Closed Zone III or ‘boutonniere’ injuries are managed conservatively unless there is evidence of displaced avulsion fractures at the base of the middle phalanx, axial and lateral instability of the PIPJ associated with loss of active or passive extension of the joint or failed non-operative treatment. Open zone III injuries are often treated surgically unless splinting enable the tendons to come together. Zone V injuries, are human bites until proven otherwise requires primary tendon repair after irrigation. Zone VI injuries are close to the thin paratendon and thin subcutaneous tissue which strong core type sutures and then splinting should be placed in extension for 4-6 weeks. Complete lacerations to zone IV and VII involve surgical primary repair followed by 6 weeks of splinting in extension. Zone VIII require multiple figure of eight sutures to repair the muscle bellies and static immobilisation of the wrist in 45 degrees of extension. To date there is little literature documenting the quality of repairing extensor tendon injuries however loss of flexion due to extensor tendon shortening, loss of flexion and extension resulting from adhesions and weakened grip can occur after surgery. This review aims to provide a systematic examination method for assessing extensor injuries, presentation and management of all type of extensor tendon injuries as well as guidance on
Kaux, Jean-François; Samson, Antoine; Crielaard, Jean-Michel
Summary Introduction recently, the viscoelastic properties of hyaluronic acid (HA) on liquid connective tissue have been proposed for the treatment of tendinopathies. Some fundamental studies show encouraging results on hyaluronic acid’s ability to promote tendon gliding and reduce adhesion as well as to improve tendon architectural organisation. Some observations also support its use in a clinical setting to improve pain and function. This literature review analyses studies relating to the use of hyaluronic acid in the treatment of tendinopathies. Methods this review was constructed using the Medline database via Pubmed, Scopus and Google Scholar. The key words hyaluronic acid, tendon and tendinopathy were used for the research. Results in total, 28 articles (in English and French) on the application of hyaluronic acid to tendons were selected for their relevance and scientific quality, including 13 for the in vitro part, 7 for the in vivo animal part and 8 for the human section. Conclusions preclinical studies demonstrate encouraging results: HA permits tendon gliding, reduces adhesions, creates better tendon architectural organisation and limits inflammation. These laboratory observations appear to be supported by limited but encouraging short-term clinical results on pain and function. However, controlled randomised studies are still needed. PMID:26958533
Pietschmann, Matthias F.; Gülecyüz, Mehmet F.; Ficklscherer, Andreas; Jansson, Volkmar; Müller, Peter E.
Introduction Tendon tissue engineering (TTE) tries to produce tendinous tissue of high quality to replace dysfunctional tissue. One possible application of TTE might be the replacement of ruptured tissue of the rotator cuff. Autologous tenocytes seem to be most suitable as no differentiation in vitro is necessary. Today it is still uncertain if there is a difference between tendon-derived cells (TDC) of different native tissues. Moreover, the search for suitable scaffolds is another important issue in TTE. Material and methods This study compared TDC of the long head of the biceps tendon (LHB), the anterior cruciate ligament (ACL) and the tendon of the musculus semitendinosus (TMS). The TDC were isolated using the cell migration method. Cell morphology was assessed using light microscopy and gene expression was performed using polymerase chain reaction (PCR). Afterwards, cell seeding efficiency and proliferation were tested on a collagen I scaffold using the WST-1 assay. Results were confirmed using H + E staining. Results The TDC of the LHB showed higher expression levels of collagen type I and decorin (p < 0.01) compared to TDC of other origin. Results showed efficient cell seeding and proliferation within the scaffold. Proliferation within the scaffold was not as high as when cells were cultivated without a scaffold. Conclusions The TDC of the LHB seems to be the most suitable cell source. Further research is necessary to find out if the results can be transferred to an in vivo model. The new collagen I scaffold seems to offer an opportunity to combine good biocompatibility and mechanical strength. PMID:25097592
Axibal, Derek P; Anderson, John G
Tendon ruptures are common findings in foot and ankle practice. The etiology of tendon ruptures tends to be multifactorial-usually due to a combination of trauma, effects of systemic diseases, adverse effects of medications, and obesity. We present an unusual case of right Achilles tendinitis, left Achilles tendon rupture, bilateral peroneus longus tendon rupture, and left peroneus brevis tendon rupture of unknown etiology. This case report highlights the need for research for other possible, lesser known etiologies of tendon pathology. Therapeutic, Level IV, Case Study.
Takushima, Akihiko; Harii, Kiyonori; Asato, Hirotaka; Ueda, Kazuki; Yamada, Atsushi
Neurovascular free-muscle transfer for facial reanimation was performed as a secondary reconstructive procedure for 45 patients with facial paralysis resulting from ablative surgery in the parotid region. This intervention differs from neurovascular free-muscle transfer for treatment of established facial paralysis resulting from conditions such as congenital dysfunction, unresolved Bell palsy, Hunt syndrome, or intracranial morbidity, with difficulties including selection of recipient vessels and nerves, and requirements for soft-tissue augmentation. This article describes the authors' operative procedure for neurovascular free-muscle transfer after ablative surgery in the parotid region. Gracilis muscle (n = 24) or latissimus dorsi muscle (n = 21) was used for transfer. With gracilis transfer, recipient vessels comprised the superficial temporal vessels in 12 patients and the facial vessels in 12. For latissimus dorsi transfer, recipient vessels comprised the facial vessels in 16 patients and the superior thyroid artery and superior thyroid or internal jugular vein in four. Facial vessels on the contralateral side were used with interpositional graft of radial vessels in the remaining patient with latissimus dorsi transfer. Cross-face nerve grafting was performed before muscle transfer in 22 patients undergoing gracilis transfer. In the remaining two gracilis patients, the ipsilateral facial nerve stump was used as the primary recipient nerve. Dermal fat flap overlying the gracilis muscle was used for cheek augmentation in one patient. In the other 23 patients, only the gracilis muscle was used. With latissimus dorsi transfer, the ipsilateral facial nerve stump was used as the recipient nerve in three patients, and a cross-face nerve graft was selected as the recipient nerve in six. The contralateral facial nerve was selected as the recipient nerve in 12 patients, and a thoracodorsal nerve from the latissimus dorsi muscle segment was crossed through the upper lip
Huh, Jeannie; Boyette, Deanna M; Parekh, Selene G; Nunley, James A
Chronic ruptures of the tibialis anterior tendon are often associated with tendon retraction and poor-quality tissue, resulting in large segmental defects that make end-to-end repair impossible. Interpositional allograft reconstruction has previously been described as an operative option in these cases; however, there are no reports of the clinical outcomes of this technique in the literature. Eleven patients with chronic tibialis anterior tendon ruptures underwent intercalary allograft recon-struction between 2006 and 2013. Patient demographics, injury presentation, and details of surgery were reviewed. Postoperative outcomes at a mean follow-up of 43.8 (range, 6-105) months included the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, Short Form-12 (SF-12) physical health score, Lower Extremity Functional Score (LEFS), visual analog scale (VAS) pain rating, dorsiflexion strength, gait analysis, and complications. The average postoperative dorsiflexion strength, as categorized by the Medical Council grading scale, was 4.8 ± 0.45. The average postoperative VAS score was 0.8 ± 1.1. The average LEFS was 66.9 ± 17.2, SF-12 physical health score was 40.1 ± 14.4, and AOFAS score was 84.3 ± 7.7. One complication occurred, consisting of transient neuritic pain in the superficial peroneal nerve distribution. There were no postoperative infections, tendon reruptures, reoperations, or allograft-associated complications. Allograft reconstruction of chronic irreparable tibialis anterior tendon ruptures yielded satisfactory strength, pain, and patient-reported functional outcomes. This technique offers a safe and reliable alternative, without the donor site morbidity associated with tendon transfer or autograft harvest. Level IV, retrospective case series. © The Author(s) 2015.
Yang, Ying; Rupani, Asha; Weightman, Alan; Wimpenny, Ian; Bagnaninchi, Pierre; Ahearne, Mark
Tendons are load-bearing collagenous tissues consisting mainly of type I collagen and various proteoglycans (PGs) including decorin and versican. It is widely accepted that highly orientated collagen fibers in tendons a play critical role for transferring tensile stress and demonstrate birefringent optical properties. However, the influence that proteoglycans have on the optical properties of tendons is yet to be fully elucidated. Tendinopathy (defined as a syndrome of tendon pain, tenderness and swelling that affects the normal function of the tissue) is a common disease associated with sporting injuries or degeneration. PG's are the essential components of the tendon extracellular matrix; changes in their quantities and compositions have been associated with tendinopathy. In this study, polarization sensitive optical coherence tomography (PS-OCT) has been used to reveal the relationship between proteoglycan content/location and birefringent properties of tendons. Tendons dissected from freshly slaughtered chickens were imaged at regular intervals by PS-OCT and polarizing light microscope during the extraction of PGs or glycosaminoglycans using established protocols (guanidine hydrochloride (GuHCl) or proteinase K solution). The macroscopic and microscopic time lapsed images are complimentary; mutually demonstrating that there was a higher concentration of PG's in the outer sheath region than in the fascicles; and the integrity of the sheath affected extraction process and the OCT birefringence bands. Extraction of PGs using GuHCl disturbed the organization of local collagen bundles, which corresponded to a reduction in the frequency of birefringence bands and the band width by PS-OCT. The feature of OCT penetration depth helped us to define the heterogeneous distribution of PG's in tendon, which was complimented by polarizing light microscopy. The results provide new insight of tendon structure and also demonstrate a great potential for using PS-OCT as a
Background Zone 2 flexor tendon injuries still represent a challenging problem to hand surgeons despite the well developed surgical techniques and suture materials. Meticulous surgical repair with atraumatic handling of the severed tendon stumps and minimal damage to the tendon sheath are particularly important to prevent postoperative adhesions and ruptures in this area. In zone 2 flexor tendon injuries proximal to the vinculas, the cut ends of the flexor tendons retract to the palm with muscle contraction. To retrieve the severed proximal flexor tendon under tendon sheath and pulley system is very difficult without damaging these structures. Many techniques are described in the literature for the delivery of the retracted proximal tendon stump to the repair site. Methods In this report we would like to present a simple and relatively atraumatic technique that facilitates passing of the retracted flexor tendon through the pulleys in zone 2. We sutured the proximal tendon stump at the distal palmar crease with 3–0 polypropylene suture and used a 14 gauge plastic feeding tube, acting like a conduit for the passage of straightened needle to the finger. Results We have used this technique 21 times without any complication in our clinic. We have not seen any suture breakage during the passage or needle breakage due to the bending of the needle. Conclusions We have found this technique is very simple and very effective in retrieving the retracted tendon stump without causing undue damage to the tendon stump or tendon sheath. PMID:24040913
Sollender, J L; Rayan, G M; Barden, G A
Triceps tendon avulsion injuries are rare. We report four weight lifters with triceps tendon raptures, two of whom had received local steroid injections for pain in the triceps. All four patients had taken oral anabolic steroids before injury. All patients had closed avulsion of the triceps tendon from its insertion into the olecranon. Three patients were injured while bench pressing heavy weights, and one patient was injured while swinging a baseball bat. Satisfactory results were achieved after surgical reinsertion of the tendon.
The objective of the two-staged flexor tendon method is to improve the predictability of final results in difficult problems dealing with tendon reconstruction. This article reviews the evolution and benefits of this procedure. It also considers the use of the technique to help deal with problems requiring pulley and skin reconstruction simultaneously with re-constituting the flexor tendon system.
When re-operating patients with midportion Achilles tendinosis, having had a poor effect of ultrasound (US) and Doppler-guided scraping, the author found the involvement of the plantaris tendon to be a likely reason for the poor result. The aim of this study was to investigate the occurrence of a plantaris tendon in close relation to the Achilles tendon in consecutive patients with midportion Achilles tendinosis undergoing treatment with US and Doppler-guided scraping. This study includes 73 consecutive tendons with chronic painful midportion Achilles tendinosis, where US+Doppler examination showed thickening, irregular tendon structure, hypo-echoic regions, and localised high blood flow outside and inside the ventral Achilles midportion. The tendons were treated with US+Doppler-guided scraping, via a medial incision. If there was a plantaris tendon located in close relation to the medial Achilles, it was extirpated. An invaginated, or 'close by located', enlarged plantaris tendon was found in 58 of 73 (80%) tendons. Preliminary clinical results of the combined procedure, US + Doppler-guided surgical scraping and extirpation of the plantaris tendon, are very promising. A thickened plantaris tendon located in close relation to the medial Achilles seems common in patients with chronic painful midportion tendinosis. The role of the plantaris tendon in midportion Achilles tendinosis needs to be further evaluated and should be kept in mind when treating this condition.
Szebeszczyk, Janina; Straszecka, Joanna
The examination of Achilles tendon reflex is widely used as a simple, noninvasive clinical test in diagnosis and pharmacological therapy monitoring in such diseases as: hypothyroidism, hyperthyroidism, diabetic neuropathy, the lower limbs obstructive angiopathies and intermittent claudication. Presented Achilles tendon reflect measuring system is based on the piezoresistive sensor connected with the cylinder-piston system. To determinate the moment of Achilles tendon stimulation a detecting circuit was used. The outputs of the measuring system are connected to the PC-based data acquisition board. Experimental results showed that the measurement accuracy and repeatability is good enough for diagnostics and therapy monitoring purposes. A user friendly, easy-to-operate measurement system fulfills all the requirements related to recording, presentation and storing of the patients' reflexograms.
Tan, Jun; Wang, Bin; Xu, Yan; Tang, Jin Bo
We compared the tensile strength of different repair configurations on tendons with oblique and transverse lacerations. Seventy-two fresh pig flexor tendons were divided randomly and repaired using the modified Kessler, the cruciate, or the 4-strand Massachusetts General Hospital (MGH) repair methods. The tendons were lacerated either transversely or obliquely. They were repaired with conventional and oblique suture repairs. The 2-mm gap formation force and ultimate strength were determined as biomechanical performance for each repair. The gap formation and ultimate strength of the tendons vary with orientations of tendon lacerations and suture methods. In the tendons repaired with the modified Kessler or the cruciate methods, the 2-mm gap formation and ultimate strength of obliquely cut tendons were significantly lower than those of transversely cut tendons. The obliquely placed modified Kessler or cruciate sutures significantly improved the repair strength in the tendons with an oblique laceration. In the tendons repaired with the MGH method, no statistical differences were found in the repair strength of obliquely and transversely lacerated tendons. The direction of tendon lacerations affects strength of certain repair configurations. The nonlocking modified Kessler or the cruciate tendon repairs are weakened considerably when the tendon laceration is oblique but their mechanical performance is strengthened by re-orienting the repair strands to lie parallel to the laceration. The cross-locked configuration of the MGH repair is not affected by the obliquity of the tendon laceration.
Hayashida, Kenji; Endo, Yoshie; Kamebuchi, Katsuhiko
Objective: It is difficult to cover a large skin and soft tissue defect with exposure of the ilium. We therefore performed a new reconstruction technique, using a reverse latissimus dorsi muscle flap fed by perforating branches of only the 10th intercostal artery. Methods: A 45-year-old man had a large traumatic defect located on the hip with exposure of the iliac crest. After confirming and preserving perforating branches of the 10th intercostal artery, the latissimus dorsi muscle flap was turned over just proximal to the perforating branch, and a split-thickness skin graft was performed over the flap. Results: The skin graft took place well and there were no circulation problems. Conclusions: This flap covered a larger area on the hip than the musculocutaneous flap. Furthermore, this is easier to perform and is less invasive than a vascularized free flap. Skin and soft tissue defects that expose bones of the lumbar or hip region can be reconstructed with a local flap; however, the deficit is small for this coverage and usually there is little skin and soft tissue to cover the wound defect in the surrounding area. Thus, it is often difficult to deal with large defects. We performed a reconstruction, using a reverse latissimus dorsi flap fed by perforating branches of the 10th intercostal artery for a large skin and soft tissue defect of the hip with exposure of the iliac crest, resulting in a good outcome. This technique is thought to be useful for reconstruction when the ilium is exposed, and we report the case and surgical procedure. PMID:21559059
Cha, Han Gyu; Shin, Ho Seong; Kang, Moon Seok; Nam, Seung Min
Background The most common complication of latissimus dorsi myocutaneous flap in breast reconstruction is seroma formation in the back. Many clinical studies have shown that fibrin sealant reduces seroma formation. We investigated any statistically significant differences in postoperative drainage and seroma formation when utilizing the fibrin sealant on the site of the latissimus dorsi myocutaneous flap harvested for immediate breast reconstruction after skin-sparing partial mastectomy. Methods A total of 46 patients underwent immediate breast reconstruction utilizing a latissimus dorsi myocutaneous island flap. Of those, 23 patients underwent the procedure without fibrin sealant and the other 23 were administered the fibrin sealant. All flaps were elevated with manual dissection by the same surgeon and were analyzed to evaluate the potential benefits of the fibrin sealant. The correlation analysis and Mann-Whitney U test were used for analyzing the drainage volume according to age, weight of the breast specimen, and body mass index. Results Although not statistically significant, the cumulative drainage fluid volume was higher in the control group until postoperative day 2 (530.1 mL compared to 502.3 mL), but the fibrin sealant group showed more drainage beginning on postoperative day 3. The donor site comparisons showed the fibrin sealant group had more drainage beginning on postoperative day 3 and the drain was removed 1 day earlier in the control group. Conclusions The use of fibrin sealant resulted in no reduction of seroma formation. Because the benefits of the fibrin sealant are not clear, the use of fibrin sealant must be fully discussed with patients before its use as a part of informed consent. PMID:23094246
Williams, J G
Achillodynia (Achilles tendon pain) is a significant source of disability to many people taking part in sports. Papers in the English language published since 1986 are reviewed here, grouped into specific subject areas including biomechanics, pathology, general clinical presentations, experimental treatments, steroids, podiatry and surgery. While there has been no dramatic breakthrough in the field, there have been various interesting advances with particular reference to imaging and conservative management, which will hopefully stimulate further studies. Many problems of Achilles tendon lesions in athletes remain unsolved, however, and much is yet to be done to provide adequate and generally effective methods of prevention and conservative treatment.
Yarmand, M S; Nikmaram, P; Djomeh, Z Emam; Homayouni, A
This study was conducted to investigate the effects of various heating methods, including roasting, braising and microwave heating, on mechanical properties and microstructure of longissimus dorsi (LD) muscle of the camel. Shear value and compression force increased during microwave heating more than roasting and braising. Results obtained from scanning electron microscopy (SEM) showed more damage from roasting than in either braising or microwave heating. Granulation and fragmentation were clear in muscle fibers after roasting. The perimysium membrane of connective tissue was damaged during braising, while roasting left the perimysium membrane largely intact. The mechanical properties and microstructure of muscle can be affected by changes in water content during cooking.
Abolhoda, Amir; Wirth, Garrett A; Bui, Trung D; Milliken, Jeffrey C
Transposition of extrathoracic muscle flaps has been the cornerstone of treatment of a number of complex intrathoracic pathologies such as bronchopleural fistulas and residual infected pleural spaces. We present a simple step-wise technique for preservation and harvesting of the most common muscle flap employed by thoracic surgeons, namely latissimus dorsi, just prior to performing a standard posterolateral thoracotomy. Since 2004, we have successfully utilized pedicled latissimus muscle as our preferred prophylactic flap against development of postoperative bronchopleural fistulas or recurrent empyemas. This technique should be part of every thoracic surgeon's surgical armamentarium.
Allevi, Fabiana; Motta, Gloria; Colombo, Valeria; Biglioli, Federico
A 45-year-old woman with left facial palsy presented to our department. She developed the condition after radical resection of a neurinoma of the homolateral VIII cranial nerve 2 years prior. On physical examination, a complete palsy of the lower third of the face was reported. Electromyographic examination showed no fibrillation potentials in mimic muscles. A latissimus dorsi muscle free flap (6 cm × 3 cm), split into two bellies linked by their own neurovascular pedicle, was used to restore full-mouth smile. Ten years after surgery, the patient showed a near-natural smile without need of any ancillary procedure. 2015 BMJ Publishing Group Ltd.
Miao, Xudong; Wu, Yongping; Tao, Huimin; Yang, Disheng; Huang, Lu
Background: Transfer of a flexor hallucis longus (FHL) tendon can not only reconstruct the Achilles tendon but also provide ischemic tendinous tissues with a rich blood supply to enhance wound healing. This retrospective study aims to investigate clinical outcomes in patients who underwent repair of Kuwada grade IV chronic Achilles tendon rupture with long hallucis longus tendons harvested using a minimally invasive technique. Materials and Methods: 35 patients who were treated for Kuwada grade IV Achilles tendon injuries from July 2006 to June 2011 were included in this retrospective study. The age ranged between 23 and 71 years. The duration from primary injury to surgery ranged from 29 days to 34 months (mean value, 137.6 days). All 35 patients had difficulties in lifting their calves. Thirty two were followed up for a mean 32.2 months (range 18–72 months), whereas three were lost to followup. Magnetic resonance imaging (MRI) showed that the tendon rupture gap ranged from 6.0 to 9.2 cm. During surgery, a 2.0 cm minor incision was made vertically in the medial plantar side of the midfoot, and a 1.5 cm minor transverse incision was made in the plantar side of the interphalangeal articulation of the great toe to harvest the FHL tendon, and the tendon was fixed to the calcaneus with suture anchors. Postoperative appearance and function were evaluated by physiotherapists based American Orthopedic Foot and Ankle Society-ankle and hindfoot score (AOFAS-AH), and Leppilahti Achilles tendon ratings. Results: Results were assessed in 32 patients. Except for one patient who suffered complications because of wound disruption 10 days after the operation, all other patients had primary wound healing, with 28 of 32 able to go up on their toes at last followup. The AOFAS-AH score was increased from preoperative (51.92 ± 7.08) points to (92.56 ± 6.71) points; Leppilahti Achilles tendon score was increased from preoperative (72.56 ± 7.43) to (92.58 ± 5.1). There were
Forootan, Kamal S; Karimi, Hamid; Forootan, Nazilla-Sadat S
Precise and tension-free approximation of two tendon endings is the key predictor of outcomes following tendon lacerations and repairs. We evaluate the efficacy of a new tendon approximator device in tendon laceration repairs. In a comparative study, we used our new tendon approximator device in 99 consecutive patients with laceration of 266 tendons who attend a university hospital and evaluated the operative time to repair the tendons, surgeons' satisfaction as well as patient's outcomes in a long-term follow-up. Data were compared with the data of control patients undergoing tendon repair by conventional method. Totally 266 tendons were repaired by approximator device and 199 tendons by conventional technique. 78.7% of patients in first group were male and 21.2% were female. In approximator group 38% of patients had secondary repair of cut tendons and 62% had primary repair. Patients were followed for a mean period of 3years (14-60 months). Time required for repair of each tendon was significantly reduced with the approximator device (2 min vs. 5.5 min, p<0.0001). After 3-4 weeks of immobilization, passive and active physiotherapy was started. Functional Results of tendon repair were identical in the two groups and were not significantly different. 1% of tendons in group A and 1.2% in group B had rupture that was not significantly different. The new nerve approximator device is cheap, feasible to use and reduces the time of tendon repair with sustained outcomes comparable to the conventional methods.
Cury, Diego Pulzatto; Dias, Fernando José; Miglino, Maria Angélica; Watanabe, Ii-sei
Tendons are transition tissues that transfer the contractile forces generated by the muscles to the bones, allowing movement. The region where the tendon attaches to the bone is called bone-tendon junction or enthesis and may be classified as fibrous or fibrocartilaginous. This study aims to analyze the collagen fibers and the cells present in the bone-tendon junction using light microscopy and ultrastructural techniques as scanning electron microscopy and transmission electron microscopy. Forty male Wistar rats were used in the experiment, being 20 adult rats at 4 months-old and 20 elderly rats at 20 months-old. The hind limbs of the rats were removed, dissected and prepared to light microscopy, transmission electron microscopy and scanning electron microscopy. The aging process showed changes in the collagen fibrils, with a predominance of type III fibers in the elderly group, in addition to a decrease in the amount of the fibrocartilage cells, fewer and shorter cytoplasmic processes and a decreased synthetic capacity due to degradation of the organelles involved in synthesis. PMID:27078690
Overgoor, Max L E; Carroll, Sean M; Papanicolau, George; Carroll, Camilla M A; Ustüner, Tuncay E T; Stremel, Richard W; Anderson, Gary L; Franken, Ralph J P M; Kon, Moshe; Barker, John H
In cardiomyoplasty, the latissimus dorsi muscle is lifted on its primary neurovascular pedicle and wrapped around a failing heart. After 2 weeks, it is trained for 6 weeks using chronic electrical stimulation, which transforms the latissimus dorsi muscle into a fatigue-resistant muscle that can contract in synchrony with the beating heart without tiring. In over 600 cardiomyoplasty procedures performed clinically to date, the outcomes have varied. Given the data obtained in animal experiments, the authors believe these variable outcomes are attributable to distal latissimus dorsi muscle flap necrosis. The aim of the present study was to investigate whether the chronic electrical stimulation training used to transform the latissimus dorsi muscle into fatigue-resistant muscle could also be used to induce angiogenesis, increase perfusion, and thus protect the latissimus dorsi muscle flap from distal necrosis. After 14 days of chronic electrical stimulation (10 Hz, 330 microsec, 4 to 6 V continuous, 8 hours/day) of the right or left latissimus dorsi muscle (randomly selected) in 11 rats, both latissimus dorsi muscles were lifted on their thoracodorsal pedicles and returned to their anatomical beds. Four days later, the resulting amount of distal flap necrosis was measured. Also, at predetermined time intervals throughout the experiment, muscle surface blood perfusion was measured using scanning laser Doppler flowmetry. Finally, latissimus dorsi muscles were excised in four additional stimulated rats, to measure angiogenesis (capillary-to-fiber ratio), fiber type (oxidative or glycolytic), and fiber size using histologic specimens. The authors found that chronic electrical stimulation (1) significantly (p < 0.05) increased angiogenesis (mean capillary-to-fiber ratio) by 82 percent and blood perfusion by 36 percent; (2) did not reduce the amount of distal flap necrosis compared with nonchronic electrical stimulation controls (29 +/- 5.3 percent versus 26.6 +/- 5
Friedman, Michael V; Stensby, J Derek; Hillen, Travis J; Demertzis, Jennifer L; Keener, Jay D
A case of a latissimus dorsi myotendinous junction strain in an avid CrossFit athlete is presented. The patient developed acute onset right axillary burning and swelling and subsequent palpable pop with weakness while performing a "muscle up." Magnetic resonance imaging examination demonstrated a high-grade tear of the right latissimus dorsi myotendinous junction approximately 9 cm proximal to its intact humeral insertion. There were no other injuries to the adjacent shoulder girdle structures. Isolated strain of the latissimus dorsi myotendinous junction is a very rare injury with a scarcity of information available regarding its imaging appearance and preferred treatment. This patient was treated conservatively and was able to resume active CrossFit training within 3 months. At 6 months postinjury, he had only a mild residual functional deficit compared with his preinjury level. © 2015 The Author(s).
Lu, Hui; Yang, Hu; Shen, Hui; Ye, Ganmin; Lin, Xiang-Jin
Abstract Corticosteroid injections for hand tendinitis can lead to a rare significant complication of tendon spontaneous rupture. However, only sporadic cases were reported in the literature before. This study was designed to gauge the clinical effect of tendon repair in patients of tendon spontaneous rupture after corticosteroid injection and analyze our experience. This was a retrospective observational study of 13 patients (8 women and 5 men) operated between July 2011 and December 2015 for tendon spontaneous rupture after corticosteroid injection. Demographic data, clinical features, imaging data, and surgical treatments were carefully reviewed. The average age was 52.308 ± 15.381 years (range 29–71). The average injection times were 2.538 ± 1.664 times (range 1–6). The average rupture time (after last injection) was 10.923 ± 9.500 weeks (range 3–32). Nine patients were treated by tendon suture (69% of cases), and 4 patients were treated by tendon grafting (31% of cases). All patients received follow-up in our outpatient clinic. The sites of the tendon rupture (15 tendons of 13 patients had involved) include extensor pollicis longus (6 tendons, 40% of cases), extensor digiti quinti and extensor digiti minimi (4 tendons, 27% of cases), ring finger of extensor digitorum communis (3 tendons, 20% of cases), and middle finger of extensor digitorum communis (2 tendons, 13% of cases). Two patients who had tendon adhesion (15% of cases) were treated by tendon release. One patient who had tendon rerupture (8% of cases) was treated by tendon grafting. No patient had complications of infections, vascular, or nerve injury. Tendon spontaneous rupture is a serious complication after corticosteroid injection for tendinitis. Rigid standard of corticosteroid injection is very important. Magnetic resonance imaging was contributory to preoperative assess tendon defect and can be used to monitor healing quality of tendons during the follow-up. PMID:27741145
Ellison, Philip; Mason, Lyndon William; Molloy, Andrew
Chronic rupture of the Achilles tendon (delayed diagnosis of more than 4 weeks) can result in retraction of the tendon and inadequate healing. Direct repair may not be possible and augmentation methods are challenging when the defect exceeds 5-6 cm, especially if the distal stump is grossly tendinopathic. We describe our method of Achilles tendon reconstruction with ipsilateral semitendinosis autograft and interference screw fixation in a patient with chronic rupture, a 9 cm defect and gross distal tendinopathy. Patient reported outcome measures consistently demonstrated improved health status at 12 months post surgery: MOXFQ-Index 38-25, EQ5D-5L 18-9, EQ VAS 70-90 and VISA-A 1-64. The patient was back to full daily function, could single leg heel raise and was gradually returning to sport. No complications or adverse events were recorded. Reconstruction of chronic tears of the Achilles tendon with large defects and gross tendinopathy using an ipsilateral semitendinosis autograft and interference screw fixation can achieve satisfactory improvements in patient reported outcomes up to 1 year post-surgery. Copyright © 2015 Elsevier Ltd. All rights reserved.
Zhu, Guiquan; Li, Chunhua; Chen, Jin; Cai, Yongcong; Li, Ling; Wang, Zhaohui
Abstract Oncological resection of advanced carcinoma in the head and neck region results in vast defects. The free latissimus dorsi musculocutaneous flap (FLDMF) is one of the most commonly used flaps for the repair of complex head and neck defects. We tried to modify FLDMF to multiple segments or combine it with acellular dermis to fit through-and-through defects in the oral-facial region during the last decade. A retrospective review of patients with FLDMF reconstruction between 2004 and 2012 was undertaken. Demographics, histology, surgical management, disease control and overall survival, complications, radiotherapy, aesthetic outcome, as well as economic results were analyzed. The majority of the patients (66.7%) had recurrent tumors, and the rest of the patients had primary tumor with stage IV. Fourteen patients (38.9%) had a history of prior radiation therapy, whereas 27.8% of the patients had postoperative radiation therapy. The areas of the defects vary from 52 cm2 to 180 cm2 (mean, 86.4 cm2). The flap failed in 1 of the 37 patients. The complications at the recipient site include hematoma (n = 6, 16.7%), venous insufficiency (n = 4, 11.1%), infection (n = 3, 8.3), and partial flap necrosis (n = 2, 5.5%). The donor-site complications include delayed healing, necrosis of skin graft, and limited shoulder function. The 5-year overall survival rate was 39.1%, and the 5-year disease-free survival rate was 22.1%. In conclusion, the FLDMF could be modified to fit vast defects where voluminous tissue is needed to be transferred in the head and neck region. PMID:25723665
Dai, Xiaoshu; Xu, Qiaobing
This paper describes an efficient and versatile method for the fabrication of nanostructured substrates from a piece of tendon which comprises aligned collagen nanofibers. We used a microtome to generate the tendon slices (10-50 µm thick), which were used as a scaffold for guiding directional cell growth. Highly aligned and uniform monolayer cells sheets were obtained. The tendon slices were used as a master, and the nanostructures outlined by the bundles of collagen nanofibers were successfully transferred onto a polystyrene film using standard soft lithography. The cell growing on the nanostructured polystyrene substrate showed good adhesion and alignment. The technique developed here enables one to fabricate nanostructured substrates without using any traditional micro/nanofabrication tools. The nanostructured substrate, e.g. a slice of tendon, has excellent biocompatibility and relatively good mechanical stability, which makes this technique useful in constructing complicated 3D tissues.
Aydin, Atakan; Ozkan, Turker; Onel, Defne
Background Obstetric palsy is the injury of the brachial plexus during delivery. Although many infants with plexopathy recover with minor or no residual functional deficits, some children don't regain sufficient limb function because of functional limitations, bony deformities and joint contractures. Shoulder is the most frequently affected joint with internal rotation contracture causing limitation of abduction, external rotation. The treatment comprises muscle release procedures such as posterior subscapularis sliding or anterior subscapularis tendon lengtening and muscle transfers to restore the missing external rotation and abduction function. Methods We evaluated whether the preoperative abduction degree affects functional outcome. Between 1998 and 2002, 46 children were operated on to restore shoulder abduction and external rotation. The average age at surgery was 7.6 years and average follow up was 40.8 months. We compared the postoperative results of the patients who had preoperative abduction less than 90° (Group I: n = 37) with the patients who had preoperative abduction greater than 90° (Group II: n = 9), in terms of abduction and external rotation function with angle measurements and Mallet classification. We inquired whether patients in Group I needed another muscle transfer along with latissimus dorsi and teres major transfers. Results In Group I the average abduction improved from 62.5° to 131.4° (a 68.9° ± 22.9°gain) and the average external rotation improved from 21.4° to 82.6° (a 61.1° ± 23°gain). In Group II the average abduction improved from 99.4°to 140°(a40.5° ± 16°gain) and the average external rotation improved from 33.2°to 82.7° (a 49.5° ± 23.9° gain). Although there was a significant difference between Group I and II for preoperative abduction (p = 0.000) and abduction gain in degrees (p = 0.001), the difference between postoperative values of both groups was not significant (p = 0.268). There was also no significant
van Geel, Albertus N; Lans, Titia E; Haen, Roel; Tjong Joe Wai, Rudi; Menke-Pluijmers, Marian B E
Patients with severe complaints of radiation-induced fibrosis after breast-conserving therapy and not responding to conservative therapy, were treated by partial mastectomy and m. latissimus dorsi reconstruction. To determine the feasibility and outcome of this approach, a retrospective study of nine patients was carried out. After a mean follow-up of 46 months, eight of the nine patients experienced improvement of their complaints and shape of the breast. In only one case did the procedure fail, as evidenced by continuation of all complaints. Partial mastectomy and m. latissimus dorsi reconstruction is the ultimate option in the treatment of radiation fibrosis. The procedure is safe with satisfying results.
Gott, Michael; Ast, Michael; Lane, Lewis B; Schwartz, John A; Catanzano, Anthony; Razzano, Pasquale; Grande, Daniel A
Advancements in the technical aspects of tendon repair have significantly improved the treatment of tendon injuries. Arthroscopic techniques, suture material, and improved rehabilitation have all been contributing factors. Biological augmentation and tissue engineering appear to have the potential to improve clinical outcomes as well. After review of the physiology of tendon repair, three critical components of tissue engineering can be discerned: the cellular component, the carrier vehicle (matrix or scaffold), and the bioactive component (growth factors, platelet rich plasma). These three components are discussed with regard to each of three tendon types: Intra-synovial (flexor tendon), extra-synovial (Achilles tendon), and extra-synovial tendon under compression (rotator cuff). Scaffolds, biologically enhanced scaffolds, growth factors, platelet rich plasma, gene therapy, mesenchymal stem cells, and local environment factors in combination or alone may contribute to tendon healing. In the future it may be beneficial to differentiate these modes of healing augmentation with regard to tendon subtype.
Magne, D; Bougault, C
Tendons are the structures that attach muscles to bones and transmit mechanical forces. Tendon cells are composed of mature tenocytes and a rare population of tendon stem cells. Both cell types ensure homeostasis and repair of tendon extracellular matrix to guarantee its specific mechanical properties. Moreover, tendon cells seem to present a marked potential for trans-differentiation, predominantly into the chondrocyte and osteoblast lineages. In this review article, we first present chronic tendon pathologies associated with abnormal ossification, such as spondyloarthritis and calcifying tendinopathy, and discuss how tendon cell differentiation and trans-differentiation may participate in these diseases. We moreover present the factors known to influence tendon cell differentiation and trans-differentiation, with a particular emphasis on extracellular environment, mechanical stimulation and several soluble factors that can tip the balance toward one or another lineage. A better understanding of the neglected tendon cell biology may be extremely useful to understand the pathological mechanisms of spondyloarthritis and calcifying tendinopathy.
Wang, Tao; Gardiner, Bruce S.; Lin, Zhen; Rubenson, Jonas; Kirk, Thomas B.; Wang, Allan; Xu, Jiake
Tendon and ligament injury is a worldwide health problem, but the treatment options remain limited. Tendon and ligament engineering might provide an alternative tissue source for the surgical replacement of injured tendon. A bioreactor provides a controllable environment enabling the systematic study of specific biological, biochemical, and biomechanical requirements to design and manufacture engineered tendon/ligament tissue. Furthermore, the tendon/ligament bioreactor system can provide a suitable culture environment, which mimics the dynamics of the in vivo environment for tendon/ligament maturation. For clinical settings, bioreactors also have the advantages of less-contamination risk, high reproducibility of cell propagation by minimizing manual operation, and a consistent end product. In this review, we identify the key components, design preferences, and criteria that are required for the development of an ideal bioreactor for engineering tendons and ligaments. PMID:23072472
Wang, Tao; Gardiner, Bruce S; Lin, Zhen; Rubenson, Jonas; Kirk, Thomas B; Wang, Allan; Xu, Jiake; Smith, David W; Lloyd, David G; Zheng, Ming H
Tendon and ligament injury is a worldwide health problem, but the treatment options remain limited. Tendon and ligament engineering might provide an alternative tissue source for the surgical replacement of injured tendon. A bioreactor provides a controllable environment enabling the systematic study of specific biological, biochemical, and biomechanical requirements to design and manufacture engineered tendon/ligament tissue. Furthermore, the tendon/ligament bioreactor system can provide a suitable culture environment, which mimics the dynamics of the in vivo environment for tendon/ligament maturation. For clinical settings, bioreactors also have the advantages of less-contamination risk, high reproducibility of cell propagation by minimizing manual operation, and a consistent end product. In this review, we identify the key components, design preferences, and criteria that are required for the development of an ideal bioreactor for engineering tendons and ligaments.
Filan, P; Hart, R
To verify, in cadaver specimens, the precise anatomic structure of cross-connection between the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons and to identify its position in relation to orientation points in the foot in view of the surgical technique for tendon transfer, including the necessity of subsequent tendon suture. A hundred cadaver legs (50 cadavers of 29 men and 21 women, all Caucasians) were dissected by an extensive medio-plantar approach. The anatomical relationship of the FHL and FDL tendons was studied. The distances measured were as follows: between the first metatarsophalangeal joint line and the FHL origin of a tendinous slip; between the slip and the calcaneal tubercle; and the total distance between the first metatarsophalangeal joint line and the calcaneal tubercle. In all cadaver legs, a cross-connection between the FHL and FDL tendons was present in the plantar midfoot. There was always a tendinous slip branching from the FHL tendon and running lateral and distal to the FDL tendon. The slip was attached to the FDL tendon distal to its branching for the toes; it either attached to only the FDL tendon for the second toe or it split to attach to the FDL tendon branches for the second and the third toe. The two configurations were referred to as type II and type II,III, respectively. Type II was found in both legs of 31 cadavers (62 %), and type II,III in 14 cadavers (28 %). In five cadavers (10 %) attachment was different in the right and the left foot. Expressed in absolute numbers, there were 67 type II attachments (two-thirds of the findings) and 33 type II,III attachments (one-third of the findings). The average distance between the first metatarsophalangeal joint line and the origin of an FHL tendinous slip was 7.3 (± 0.9 ) cm, the average distance between the origin of an FHL tendinous slip and the calcaneal tubercle was 9.2 (± 1.1) cm and the average distance between the first metatarsophalangeal joint line and
Guerquin, Marie-Justine; Charvet, Benjamin; Nourissat, Geoffroy; Havis, Emmanuelle; Ronsin, Olivier; Bonnin, Marie-Ange; Ruggiu, Mathilde; Olivera-Martinez, Isabel; Robert, Nicolas; Lu, Yinhui; Kadler, Karl E.; Baumberger, Tristan; Doursounian, Levon; Berenbaum, Francis; Duprez, Delphine
Tendon formation and repair rely on specific combinations of transcription factors, growth factors, and mechanical parameters that regulate the production and spatial organization of type I collagen. Here, we investigated the function of the zinc finger transcription factor EGR1 in tendon formation, healing, and repair using rodent animal models and mesenchymal stem cells (MSCs). Adult tendons of Egr1–/– mice displayed a deficiency in the expression of tendon genes, including Scx, Col1a1, and Col1a2, and were mechanically weaker compared with their WT littermates. EGR1 was recruited to the Col1a1 and Col2a1 promoters in postnatal mouse tendons in vivo. Egr1 was required for the normal gene response following tendon injury in a mouse model of Achilles tendon healing. Forced Egr1 expression programmed MSCs toward the tendon lineage and promoted the formation of in vitro–engineered tendons from MSCs. The application of EGR1-producing MSCs increased the formation of tendon-like tissues in a rat model of Achilles tendon injury. We provide evidence that the ability of EGR1 to promote tendon differentiation is partially mediated by TGF-β2. This study demonstrates EGR1 involvement in adult tendon formation, healing, and repair and identifies Egr1 as a putative target in tendon repair strategies. PMID:23863709
Eekhoff, Jeremy D; Fang, Fei; Kahan, Lindsey G; Espinosa, Gabriela; Cocciolone, Austin J; Wagenseil, Jessica E; Mecham, Robert P; Lake, Spencer P
Elastic fibers are present in low quantities in tendon, where they are located both within fascicles near tenocytes and more broadly in the interfascicular matrix (IFM). While elastic fibers have long been known to be significant in the mechanics of elastin-rich tissue (i.e., vasculature, skin, lungs), recent studies have suggested a mechanical role for elastic fibers in tendons that is dependent on specific tendon function. However, the exact contribution of elastin to properties of different types of tendons (e.g., positional, energy-storing) remains unknown. Therefore, this study purposed to evaluate the role of elastin in the mechanical properties and collagen alignment of functionally distinct supraspinatus tendons (SSTs) and Achilles tendons (ATs) from elastin haploinsufficient (HET) and wild type (WT) mice. Despite the significant decrease in elastin in HET tendons, a slight increase in linear stiffness of both tendons was the only significant mechanical effect of elastin haploinsufficiency. Additionally, there were significant changes in collagen nanostructure and subtle alteration to collagen alignment in the AT but not the SST. Hence, elastin may play only a minor role in tendon mechanical properties. Alternatively, larger changes to tendon mechanics may have been mitigated by developmental compensation of HET tendons and/or the role of elastic fibers may be less prominent in smaller mouse tendons compared to the larger bovine and human tendons evaluated in previous studies. Further research will be necessary to fully elucidate the influence of various elastic fiber components on structure-function relationships in functionally distinct tendons.
To study the status quo of the methods and materials for accelerating the tendon healing and preventing the tendon adhesion as to provide an essential reference for future research and clinical application. The recent articles on methods of accelerating tendon healing and preventing tendon adhesion were extensively reviewed. Tendon healing was decided by the co-effects of both endogenous and exogenous ways, and the former was more important. It was affected by the tendon sheath, vincula tendinum and synovial fluid as well. Tendon adhesion was mostly caused by excessive participation of exogenous healing factors and serious damage of the situations around the tendon. Tendon healing was accelerated by methods like repairing, reconstruction of peri-tendon tissues, electric stimulation, physiotherapy, adding herbs or growth factors, and gene intervention. Tendon adhesion was reduced or prevented by methods like the restoration of tendon sheath, using substitutions, adding herbs/drugs, and improving suturing techniques. Via the appropriate methods and techniques combining the Chinese traditional and modern medicine, tendon healing can be accelerated and the quality of tendon healing can be improved.
Kulig, Kornelia; Oki, Kari C; Chang, Yu-Jen; Bashford, Gregory R
To examine Achilles and patellar tendon morphology in dancers with and without tendon pain. Fifty-three dancers with and without Achilles and/or patellar tendon pain participated. Eleven age-matched non-dancers served as controls. Longitudinal ultrasound images of the middle and distal Achilles and proximal and distal patellar tendons were acquired. To assess macromorphology, the thickness of the middle and distal Achilles and proximal and distal patellar tendons were measured. Micromorphology was analyzed by selecting 2 x 2-mm2 regions of interest in the tendons; spectral analysis using the fast Fourier transform was run for several kernels (2 x 2-mm2 subimages) within each image, and the peak spatial frequency (PSF) was extracted. A one-way ANOVA compared asymptomatic, symptomatic, and control tendon thickness and PSF. Macromorphology: There was no significant difference between asymptomatic and symptomatic dancers in middle or distal Achilles tendon thickness and distal patellar tendon thickness. Proximal patellar tendons in control subjects were thinner than those in asymptomatic (p=0.036) and symptomatic (p=0.003) dancers. Micromorphology: There was no significant difference in PSF between asymptomatic and symptomatic dancers and controls in the Achilles or patellar tendon. Increased proximal patellar tendon thickness without changes in tendon micromorphology suggests that tendon adaptations are more likely activity-related and less likely influenced by degeneration.
Green, Jennifer B; Skaife, Tyler L; Leslie, Bruce M
To determine the incidence of bilateral distal biceps tendon ruptures. A retrospective review of 321 patients who underwent operative repair of a distal biceps tendon rupture between 1988 and 2010 identified 26 patients with bilateral ruptures. We recorded patient age, mechanism of injury, time between symptom onset before the first surgery and subsequent contralateral symptoms, and time between surgeries. Twenty-two bilateral ruptures were confirmed intra-operatively, 3 by MRI, and 1 was lost to follow up. A total of 23 bilateral ruptures (92%) occurred in men. The average age at the initial rupture was 44 years (range, 29-74 y). The average age at subsequent rupture was 48 years (range, 36-79 y). Excluding the 2 women (age 72 and 79 y), the average age at the initial rupture was 42 years and the average age at subsequent rupture was 46 years. The average interval between ruptures was 4.1 years (range, 0.8-13.9 y). The initial rupture occurred in the dominant extremity in 12 cases (50%) and in the nondominant extremity in 10 cases (42%); in 3 patients (8%) the dominance was not documented or ambidextrous. Thirty-three percent were heavy laborers, 3 patients had a smoking history, and 1 patient reported a history of steroid use. Twenty-two patients (88%) had the second side repaired, where we noted that 12 (55%) of the second tendon ruptures were partial tears. The 8% cumulative incidence of bilateral biceps tendon ruptures in a consecutive series of biceps tendon repairs may be higher because not all patients were contacted, which introduced a sampling bias. This 8% rate is markedly higher than the reported rate of 1.2 per 100,000 for an isolated distal biceps tendon rupture. This implies that patients with a distal biceps tendon rupture are at risk for a rupture on the contralateral side. Prognostic III. Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Sturdivant, C A; Lunt, D K; Smith, G C; Smith, S B
Three experiments were conducted to document the fatty acid composition of tissues from purebred Wagyu cattle from Japan and North American crossbred Wagyu. In experiment 1, subcutaneous (s.c.) adipose tissues (n = 23) were obtained from Japanese cattle representing the five Japanese fat quality grades. The monounsaturated:saturated fatty acid ratio (MUFA:SFA) was greatest in fat quality grade 5 samples (2·57) and least in the fat quality grade 3 samples (2·08; P < 0·05). In experiment 2, M. longissimus dorsi and the associated intramuscular (i.m.) and s.c. adipose tissues were obtained from carcasses of Wagyu crossbred steers (1/2-7/8) raised in the USA. Fatty acid composition varied among depots, but the MUFA:SFA ratio in s.c. adipose tissue (1·46) was not different from values reported for other breeds of cattle. In experiment 3, samples of M. longissimus dorsi ribsteaks were obtained from three regions in Japan. Samples from the Gunma region had the greatest (P < 0·05) MUFA:SFA ratio (2·10), relative to samples from the Kagoshima (1·82) and Miyazaki (1·65) regions. The data indicate that beef from purebred Wagyu cattle raised in Japan is enriched in monounsaturated fatty acids, and that the degree of enrichment depends upon the region of Japan from which the samples were obtained.
Kim, Ho-Kyoung; Lee, Sang-Hoon
The aim of this study was to investigate the effects of aqueous extract from Sarcodon aspratus on tenderization of the bovine longissimus dorsi muscles in comparison with commercial proteolytic enzymes. Furthermore, meat quality and muscle protein degradation were examined. We marinated meat with 2% Sarcodon aspratus extract, 2% kiwi extract, and 0.2% papain. Beef chunks (3×3×3 cm3) were marinated with distilled water (control), Sarcodon aspratus extract (T1), kiwi extract (T2) or papain (T3) for 48 h at 4℃. There were no significant differences in muscle pH and lightness between control and treated samples. T1 had the lowest redness (p<0.01), and higher cooking loss and water holding capacity than control and T2 (p<0.05). T1 and T3 exhibited lower shear force values than control (p<0.05). Total protein solubility did not differ significantly between T1 and control, but T1 had less myofibrillar protein solubility than control and T2 (p<0.001). The degradation of myosin heavy chain in T1 and T3 was observed. This degradation of myofibrillar protein suggests that Sarcodon aspratus extract could influence tenderization. These results show that aqueous extract of Sarcodon aspratus extract actively affect the tenderness of the bovine longissimus dorsi muscle. PMID:26761876
Direct Lentiviral-Cyclooxygenase 2 Application to the Tendon-Bone Interface Promotes Osteointegration and Enhances Return of the Pull-Out Tensile Strength of the Tendon Graft in a Rat Model of Biceps Tenodesis
Wergedal, Jon E.; Stiffel, Virginia; Lau, Kin-Hing William
This study sought to determine if direct application of the lentiviral (LV)-cyclooxygenase 2 (COX2) vector to the tendon-bone interface would promote osteointegration of the tendon graft in a rat model of biceps tenodesis. The LV-COX2 gene transfer strategy was chosen for investigation because a similar COX2 gene transfer strategy promoted bony bridging of the fracture gap during bone repair, which involves similar histologic transitions that occur in osteointegration. Briefly, a 1.14-mm diameter tunnel was drilled in the mid-groove of the humerus of adult Fischer 344 rats. The LV-COX2 or βgal control vector was applied directly into the bone tunnel and onto the end of the tendon graft, which was then pulled into the bone tunnel. A poly-L-lactide pin was press-fitted into the tunnel as interference fixation. Animals were sacrificed at 3, 5, or 8 weeks for histology analysis of osteointegration. The LV-COX2 gene transfer strategy enhanced neo-chondrogenesis at the tendon-bone interface but with only marginal effect on de novo bone formation. The tendon-bone interface of the LV-COX2-treated tenodesis showed the well-defined tendon-to-fibrocartilage-to-bone histologic transitions that are indicative of osteointegration of the tendon graft. The LV-COX2 in vivo gene transfer strategy also significantly enhanced angiogenesis at the tendon-bone interface. To determine if the increased osteointegration was translated into an improved pull-out mechanical strength property, the pull-out tensile strength of the LV-COX2-treated tendon grafts was determined with a pull-out mechanical testing assay. The LV-COX2 strategy yielded a significant improvement in the return of the pull-out strength of the tendon graft after 8 weeks. In conclusion, the COX2-based in vivo gene transfer strategy enhanced angiogenesis, osteointegration and improved return of the pull-out strength of the tendon graft. Thus, this strategy has great potential to be developed into an effective therapy to
Direct lentiviral-cyclooxygenase 2 application to the tendon-bone interface promotes osteointegration and enhances return of the pull-out tensile strength of the tendon graft in a rat model of biceps tenodesis.
Rundle, Charles H; Chen, Shin-Tai; Coen, Michael J; Wergedal, Jon E; Stiffel, Virginia; Lau, Kin-Hing William
This study sought to determine if direct application of the lentiviral (LV)-cyclooxygenase 2 (COX2) vector to the tendon-bone interface would promote osteointegration of the tendon graft in a rat model of biceps tenodesis. The LV-COX2 gene transfer strategy was chosen for investigation because a similar COX2 gene transfer strategy promoted bony bridging of the fracture gap during bone repair, which involves similar histologic transitions that occur in osteointegration. Briefly, a 1.14-mm diameter tunnel was drilled in the mid-groove of the humerus of adult Fischer 344 rats. The LV-COX2 or βgal control vector was applied directly into the bone tunnel and onto the end of the tendon graft, which was then pulled into the bone tunnel. A poly-L-lactide pin was press-fitted into the tunnel as interference fixation. Animals were sacrificed at 3, 5, or 8 weeks for histology analysis of osteointegration. The LV-COX2 gene transfer strategy enhanced neo-chondrogenesis at the tendon-bone interface but with only marginal effect on de novo bone formation. The tendon-bone interface of the LV-COX2-treated tenodesis showed the well-defined tendon-to-fibrocartilage-to-bone histologic transitions that are indicative of osteointegration of the tendon graft. The LV-COX2 in vivo gene transfer strategy also significantly enhanced angiogenesis at the tendon-bone interface. To determine if the increased osteointegration was translated into an improved pull-out mechanical strength property, the pull-out tensile strength of the LV-COX2-treated tendon grafts was determined with a pull-out mechanical testing assay. The LV-COX2 strategy yielded a significant improvement in the return of the pull-out strength of the tendon graft after 8 weeks. In conclusion, the COX2-based in vivo gene transfer strategy enhanced angiogenesis, osteointegration and improved return of the pull-out strength of the tendon graft. Thus, this strategy has great potential to be developed into an effective therapy to
Chen, Hua; Hao, Ming; Zhang, Wei; Gao, Yuan; Liang, Xiangdang; Zhang, Qun; Guo, Yizhu; Zhang, Lihai; Tang, Peifu
To evaluate the effectiveness of channel-assisted minimally invasive repair (CAMIR) for acute closed Achilles tendon ruptures. Between January 2011 and June 2012, 30 patients (30 sides) with acute closed Achilles tendon ruptures were treated with CAMIR technique. Among 30 patients, 18 were male and 12 were female with an average age of 30.4 years (range, 22-50 years); the locations were left side in 10 cases and right side in 20 cases. All the causes were sports injury. B-ultrasound was used to confirm the diagnosis, with the average distance from the rupture site to the Achilles tendon insertion of 4.4 cm (range, 2-8 cm). The time from injury to operation was 3 hours to 9 days (median, 4 days). All injuries were repaired by CAMIR technique. The average operation time was 17.0 minutes (range, 10-25 minutes), and the mean incision length was 2.0 cm (range, 1.5-2.5 cm). All the incisions healed by first intention. There was no complication of wound problem, deep vein thrombosis, re-rupture, or sural nerve injury. All cases were followed up 12-24 months with an average of 16 months. At last follow-up, the patients could walk normally with powerful raising heels and restored to normal activity level. MRI imaging suggested the continuity and healing of ruptured tendon. The circumference difference between affected leg and normal leg was less than 1 cm, and the ankle dorsi-extension was 20-30°, plantar flexion was 20-30°. Arner Lindholm score showed that the surgical results were excellent in 28 cases and good in 2 cases, with an excellent and good rate of 100%. CAMIR is a safe and reliable method to repair acute closed Achilles tendon rupture, with many advantages of minimal injury, low re-rupture and infection. Sural nerve injury can be minimized using CAMIR by carefully placing the suture channel with a stab incision and special trocar based on a modified Bunnel suture technique.
Xue, H.; Mercier, R.S.
This paper presents a general procedure for analyzing the second-order wave effects on the tendon tension responses of a TLP. The approach solves both first- and second-order equation of motions for a TLP system in frequency domain. Viscous effects are included in the form of statistically linearized damping coefficients. An efficient algorithm has been devised for reducing the burden of second-order wave diffraction analysis, which selects the interacting frequency pairs according to springing frequency of interest to minimize the cost of computing quadratic transfer functions (QTFs) and allow accurate interpolation of QTFs. Moment statistics of the tension process are computed through an eigenvalue analysis. The developed method is applied to analyze the tendon tension responses of a TLP design in water depth of 3,000 ft.
Glass, Zachary A.; Schiele, Nathan R.; Kuo, Catherine K.
Tendon is a strong connective tissue that transduces muscle-generated forces into skeletal motion. In fulfilling this role, tendons are subjected to repeated mechanical loading and high stress, which may result in injury. Tissue engineering with stem cells offers the potential to replace injured/damaged tissue with healthy, new living tissue. Critical to tendon tissue engineering is the induction and guidance of stem cells towards the tendon phenotype. Typical strategies have relied on adult tissue homeostatic and healing factors to influence stem cell differentiation, but have yet to achieve tissue regeneration. A novel paradigm is to use embryonic developmental factors as cues to promote tendon regeneration. Embryonic tendon progenitor cell differentiation in vivo is regulated by a combination of mechanical and chemical factors. We propose that these cues will guide stem cells to recapitulate critical aspects of tenogenesis and effectively direct the cells to differentiate and regenerate new tendon. Here, we review recent efforts to identify mechanical and chemical factors of embryonic tendon development to guide stem/progenitor cell differentiation toward new tendon formation, and discuss the role this work may have in the future of tendon tissue engineering. PMID:24484642
Glass, Zachary A; Schiele, Nathan R; Kuo, Catherine K
Tendon is a strong connective tissue that transduces muscle-generated forces into skeletal motion. In fulfilling this role, tendons are subjected to repeated mechanical loading and high stress, which may result in injury. Tissue engineering with stem cells offers the potential to replace injured/damaged tissue with healthy, new living tissue. Critical to tendon tissue engineering is the induction and guidance of stem cells towards the tendon phenotype. Typical strategies have relied on adult tissue homeostatic and healing factors to influence stem cell differentiation, but have yet to achieve tissue regeneration. A novel paradigm is to use embryonic developmental factors as cues to promote tendon regeneration. Embryonic tendon progenitor cell differentiation in vivo is regulated by a combination of mechanical and chemical factors. We propose that these cues will guide stem cells to recapitulate critical aspects of tenogenesis and effectively direct the cells to differentiate and regenerate new tendon. Here, we review recent efforts to identify mechanical and chemical factors of embryonic tendon development to guide stem/progenitor cell differentiation toward new tendon formation, and discuss the role this work may have in the future of tendon tissue engineering.
Maffulli, Nicola; Del Buono, Angelo; Spiezia, Filippo; Longo, Umile Giuseppe; Denaro, Vincenzo
To assess histological changes and possible differences in the quadriceps of patients undergoing open repair of the tendon after spontaneous rupture, and subjects with no history of tendon pathology. Biopsies were harvested from the quadriceps tendon of 46 patients (34 men, 12 women) who had reported unilateral atraumatic quadriceps tendon rupture and had undergone surgical repair of the tendon. Samples were also harvested from both the tendons in 11 (N = 11 × 2) patients, nine males and two females, dying from cardiovascular disorders. For each tendon, three slides were randomly selected and examined under light microscopy, and assessed using a semiquantitative grading scale (range 0-21) which considers fibre structure, fibre arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinisation. The pathological sum-score averaged 19.2 ± 3.7 in ruptured tendons and 5.6 ± 2.0 in controls, and all variables considered were significantly different between the two groups, showing an association between tendon abnormalities and rupture (0.05 < P < 0.001). This study confirms that the presence of histological degenerative changes in torn quadriceps tendons increases the risk of rupture.
Background Ankle strength is often impaired in some of the most common neuromuscular disorders. Consequently, strength generated around this joint is important to assess, because it has a great impact on balance and gait. The objectives of this study were to establish normative data and predictive equations for both ankle dorsi- and plantar-flexion strength from a population of healthy subjects (children and adults), to assess the reliability of the measurements and to study the feasibility of using a novel dynamometer on a group of patients with a neuromuscular disorder. Methods Measurements of maximal isometric torque for dorsi- and plantar-flexion were performed on 345 healthy subjects from 5 to 80 years of age. The feasibility of the method was tested on nine patients diagnosed with type 2A limb girdle muscular dystrophy. Results The results documented normal strength values depending on gender and age on ankle dorsi- and plantar-flexion. The reliability of the technique was good with no evaluator effect and a small learning effect. The dynamometer was found suitable in the group of patients, even very weak. Conclusions The device developed was both reliable and accurate in assessing both ankle dorsi-flexion and plantar-flexion torque measurements from weak patients and children to strong healthy adults. Norms and predictive equations are provided for these two muscle functions. PMID:23522186
Seckel, B R; Upton, J; Freidberg, S R; Gilbert, K P; Murray, J E
Three cases are presented demonstrating the use of a pedicled myocutaneous flap of latissimus dorsi muscle to reconstruct large defects of the anterior and middle skull after ablative surgery for carcinoma. This method is proposed as an alternative to reconstruction with a free myocutaneous flap in selected patients.
Corradino, B; Di Lorenzo, S; Calamia, C; Moschella, F
Achilles tendon ruptures are becoming more common. Complications after open or minimally invasive surgery are: recurrent rupture (2-8%), wound breakdown, deep infections, granuloma, and fistulas. The authors expose their experience with a personal technique. In 8 patients with acute rupture of Achilles tendon the surgery was performed at least 25 days after trauma. Clinical exam and MR demonstrated in all case a total lesion of tendon. After a posterolateral skin incision the tendon stumps were debrided and suture in end-to-end fashion. A tendon flap was harvested from the proximal part of the tendon, in order to protect and reinforce the suture itself. A plaster cast was applied for 3 weeks and the patients started the rehabilitation protocol. After 4 months all patients returned to pre-injury daily activities. The mean follow up was 13 months (ranged between 6 and 24 months). No major complications occurred. The posterolateral skin incision, not above the tendon, preserves the vascularity of the soft tissues, allows identifying and not accidentally injuring the sural nerve, and prevents the cutaneous scar is overlapped the tendon. In this way is favoured physiological tendon sliding. The preparation of the flap tendon does not weaken the overall strength of the tendon and protects the tendon suture. The tension on sutured stumps is less than being spread over a larger area. In our sample of 8 patients the absence of short-and long-term complications and the rapid functional recovery after surgery suggest that the technique used is safe and effective. Copyright © 2015 Elsevier Ltd. All rights reserved.
Jielile, Jiasharete; Aibai, Minawa; Sabirhazi, Gulnur; Shawutali, Nuerai; Tangkejie, Wulanbai; Badelhan, Aynaz; Nuerduola, Yeermike; Satewalede, Turde; Buranbai, Darehan; Hunapia, Beicen; Jialihasi, Ayidaer; Bai, Jingping; Kizaibek, Murat
Active Achilles tendon kinesitherapy facilitates the functional recovery of a ruptured Achilles tendon. However, protein expression during the healing process remains a controversial issue. New Zealand rabbits, aged 14 weeks, underwent tenotomy followed immediately by Achilles tendon microsurgery to repair the Achilles tendon rupture. The tendon was then immobilized or subjected to postoperative early motion treatment (kinesitherapy). Mass spectrography results showed that after 14 days of motion treatment, 18 protein spots were differentially expressed, among which, 12 were up-regulated, consisting of gelsolin isoform b and neurite growth-related protein collapsing response mediator protein 2. Western blot analysis showed that gelsolin isoform b was up-regulated at days 7–21 of motion treatment. These findings suggest that active Achilles tendon kinesitherapy promotes the neurite regeneration of a ruptured Achilles tendon and gelsolin isoform b can be used as a biomarker for Achilles tendon healing after kinesitherapy. PMID:25317130
Zhang, Qiang; Cheng, Biao
Tendon injuries are very common in occupational and athletic settings, and the elderly population. Tendons repair and regenerate slowly and inefficiently in vivo after injury. The limited ability of tendons to self-repair and the general inefficiency of current treatment strategies have intensified the need for an effective therapeutic approach. Tendon-derived stem cells (TDSCs) have recently been identified within tendon tissues. TDSCs exhibit universal stem cell characteristics, such as clonogenicity, a high proliferative capacity, multi-differentiation potential, non-immunogenicity, and immunosuppression. As a result, implanting TDSCs at damaged sites within tendons may be an effective way for tendon regeneration. This review summarizes the properties of TDSCs and discusses the advantages of its use in tendon tissue engineering.
Olszewski, Katarzyna; Dick, Taylor J M; Wakeling, James M
Achilles tendon moment arms are commonly measured using the tendon-excursion technique and ultrasound imaging of the muscle-tendon junction. The tendon-excursion technique relies on the assumption that the tendon load is constant and thus it does not stretch. However, previous studies have not enforced this constraint and thus it is not known how sensitive the estimated Achilles tendon moment arms are to varying load during the measurement process. The aim of this study was to compare estimates of Achilles tendon moment arms when calculated using the different constraints of constant force (and thus tendon stretch), constant joint torque, or contraction effort. Achilles tendon moment arms were measured for the medial and lateral gastrocnemii in 8 healthy male subjects across five different ankle angles (-5° dorsiflexion to 35° plantarflexion), and a range of contraction levels. Moment arms were calculated for three different constraints of constant force, torque, or effort. Moment arms were significantly greater for the lateral gastrocnemius than for the medial gastrocnemius. At low contraction levels, including the passive condition, the moment arms increased with plantarflexion, whereas the moment arms decreased with plantarflexion at higher contraction levels. There was no difference between the calculated moment arms using the constant force and the constant torque methods; however both these methods yielded significantly different moment arms when compared to the commonly used constant effort method. Copyright © 2015 Elsevier Ltd. All rights reserved.
Nicoli, Fabio; Orfaniotis, Georgios; Lazzeri, Davide; Lim, Seong Yoon; Kiranantawat, Kidakorn; Chen, Pei-Yu; Ciudad, Pedro; Chilgar, Ram M; Sapountzis, Stamatis; Sacak, Bulent; Chen, Hung-Chi
Reconstruction of complex upper extremity defects requires a need for multiple tissue components. The supercharged latissimus dorsi (LD)-groin compound flap is an option that can provide a large skin paddle with simultaneous functional muscle transfer. It is necessary to supercharge the flap with the superficial circumflex iliac pedicle to ensure the viability of its groin extension. In this report, we present a case of a supercharged LD-groin flap in combination with vascularized inguinal lymph nodes, which was used for upper limb reconstruction in a young male patient, following excision of high-grade liposarcoma. Resection resulted in a 28 cm × 15 cm skin defect extending from the upper arm to the proximal forearm, also involving the triceps muscle, a segment of the ulnar nerve and the axillary lymph nodes. Restoration of triceps function was achieved with transfer of the innervated LD muscle. Part of the ulnar nerve was resected and repaired with sural nerve grafts. Post-operatively, the flap survived fully with no partial necrosis, and no complications at both the recipient and donor sites. At 1-year follow up, the patient had a well-healed wound with good elbow extension (against resistance), no tumor recurrence, and no signs of lymphedema. We believe this comprehensive approach may represent a valuable technique, for not only the oncological reconstruction of upper extremity, but also for the prevention of lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:689-694, 2016. © 2015 Wiley Periodicals, Inc.
Mazzone, Michael F; McCue, Timothy
The Achilles tendon, the largest tendon in the body, is vulnerable to injury because of its limited blood supply and the combination of forces to which it is subjected. Aging and increased activity (particularly velocity sports) increase the chance of injury to the Achilles tendon. Although conditions of the Achilles tendon are occurring with increasing frequency because the aging U.S. population is remaining active, the diagnosis is missed in about one fourth of cases. Injury onset can be gradual or sudden, and the course of healing is often lengthy. A thorough history and specific physical examination are essential to make the appropriate diagnosis and facilitate a specific treatment plan. The mainstay of treatment for tendonitis, peritendonitis, tendinosis, and retrocalcaneobursitis is ice, rest, and nonsteroidal anti-inflammatory drugs, but physical therapy, orthoties, and surgery may be necessary in recalcitrant cases. In patients with tendon rupture, casting or surgery is required. Appropriate treatment often leads to full recovery.
Summary Tendons are often subject to age related degenerative changes that coincide with a diminished regenerative capacity. Torn tendons often heal by forming scar tissue that is structurally weaker than healthy native tendon tissue, predisposing to mechanical failure. There is increasing interest in providing biological stimuli to increase the tendon reparative response. Stem cells in particular are an exciting and promising prospect as they have the potential to provide appropriate cellular signals to encourage neotendon formation during repair rather than scar tissue. Currently, a number of issues need to be investigated further before it can be determined whether stem cells are an effective and safe therapeutic option for encouraging tendon repair. This review explores the in-vitro and invivo evidence assessing the effect of stem cells on tendon healing, as well as the potential clinical applications. PMID:23738300
Bellemère, P; Ardouin, L
Primary flexor tendon repair is still challenging even in the most experienced hands. With atraumatic surgery, the goal is to suture the tendon in a way that it will be strong enough to allow for tendon gliding without the risk of rupture or adhesions during the 12 weeks needed for the tendon to heal. After reviewing the zone 2 anatomy, the authors describe the state of art for flexor tendon repair along with their personal preferences. Although suture methods and postoperative rehabilitation programs are not universal, most specialized teams now use multistrand suturing techniques with at least 4 stands along with protected and controlled early active mobilization. Although the published rates of failure of the repair or postoperative adhesions with stiffness have decreased, these complications are still a concern. They will continue to pose a challenge for scientists performing research into the mechanics and biology of flexor tendon repairs, especially in zone 2.
Ginés-Cespedosa, Albert; Monllau, Joan C.
The objective of this study was to confirm the presence and frequency of a bifurcation of the popliteus tendon. The popliteus tendon has received attention due to its important function as a knee stabiliser. Several anatomical variants have recently been reported, one of them being a bifurcated tendon. However, the actual frequency as well as the possible role of this particular variant is still unknown. We prospectively analysed a series of 1,569 arthroscopies between January 2005 to December 2007. Six asymptomatic bifurcated popliteus tendons were found. No alterations in the magnetic resonance imaging were seen and no clinical signs (related to the popliteus tendon) were observed in these patients before surgery. In all cases the morphological variant was found by chance. Our results suggest that the presence of a bifurcated popliteus tendon is a fact and that its frequency, not previously reported, should not be ignored. PMID:18998130
Agabalyan, Natacha A; Evans, Darrell J R; Stanley, Rachael L
Mineralisation of the tendon tissue has been described in various models of injury, ageing and disease. Often resulting in painful and debilitating conditions, the processes underlying this mechanism are poorly understood. To elucidate the progression from healthy tendon to mineralised tendon, an appropriate model is required. In this study, we describe the spontaneous and non-pathological ossification and calcification of tendons of the hindlimb of the domestic chicken (Gallus gallus domesticus). The appearance of the ossified avian tendon has been described previously, although there have been no studies investigating the developmental processes and underlying mechanisms leading to the ossified avian tendon. The tissue and cells from three tendons – the ossifying extensor and flexor digitorum longus tendons and the non-ossifying Achilles tendon – were analysed for markers of ageing and mineralisation using histology, immunohistochemistry, cytochemistry and molecular analysis. Histologically, the adult tissue showed a loss of healthy tendon crimp morphology as well as markers of calcium deposits and mineralisation. The tissue showed a lowered expression of collagens inherent to the tendon extracellular matrix and presented proteins expressed by bone. The cells from the ossified tendons showed a chondrogenic and osteogenic phenotype as well as tenogenic phenotype and expressed the same markers of ossification and calcification as the tissue. A molecular analysis of the gene expression of the cells confirmed these results. Tendon ossification within the ossified avian tendon seems to be the result of an endochondral process driven by its cells, although the roles of the different cell populations have yet to be elucidated. Understanding the role of the tenocyte within this tissue and the process behind tendon ossification may help us prevent or treat ossification that occurs in injured, ageing or diseased tendon. PMID:23826786
Mabe, Isaac; Hunter, Shawn
Quadriceps tendon with a patellar bone block may be a viable alternative to Achilles tendon for anterior cruciate ligament reconstruction (ACL-R) if it is, at a minimum, a biomechanically equivalent graft. The objective of this study was to directly compare the biomechanical properties of quadriceps tendon and Achilles tendon allografts. Quadriceps and Achilles tendon pairs from nine research-consented donors were tested. All specimens were processed to reduce bioburden and terminally sterilized by gamma irradiation. Specimens were subjected to a three phase uniaxial tension test performed in a custom environmental chamber to maintain the specimens at a physiologic temperature (37 ± 2 °C) and misted with a 0.9 % NaCl solution. There were no statistical differences in seven of eight structural and mechanical between the two tendon types. Quadriceps tendons exhibited a significantly higher displacement at maximum load and significantly lower stiffness than Achilles tendons. The results of this study indicated a biomechanical equivalence of aseptically processed, terminally sterilized quadriceps tendon grafts with bone block to Achilles tendon grafts with bone block. The significantly higher displacement at maximum load, and lower stiffness observed for quadriceps tendons may be related to the failure mode. Achilles tendons had a higher bone avulsion rate than quadriceps tendons (86 % compared to 12 %, respectively). This was likely due to observed differences in bone block density between the two tendon types. This research supports the use of quadriceps tendon allografts in lieu of Achilles tendon allografts for ACL-R.
Agabalyan, Natacha A; Evans, Darrell J R; Stanley, Rachael L
Mineralisation of the tendon tissue has been described in various models of injury, ageing and disease. Often resulting in painful and debilitating conditions, the processes underlying this mechanism are poorly understood. To elucidate the progression from healthy tendon to mineralised tendon, an appropriate model is required. In this study, we describe the spontaneous and non-pathological ossification and calcification of tendons of the hindlimb of the domestic chicken (Gallus gallus domesticus). The appearance of the ossified avian tendon has been described previously, although there have been no studies investigating the developmental processes and underlying mechanisms leading to the ossified avian tendon. The tissue and cells from three tendons - the ossifying extensor and flexor digitorum longus tendons and the non-ossifying Achilles tendon - were analysed for markers of ageing and mineralisation using histology, immunohistochemistry, cytochemistry and molecular analysis. Histologically, the adult tissue showed a loss of healthy tendon crimp morphology as well as markers of calcium deposits and mineralisation. The tissue showed a lowered expression of collagens inherent to the tendon extracellular matrix and presented proteins expressed by bone. The cells from the ossified tendons showed a chondrogenic and osteogenic phenotype as well as tenogenic phenotype and expressed the same markers of ossification and calcification as the tissue. A molecular analysis of the gene expression of the cells confirmed these results. Tendon ossification within the ossified avian tendon seems to be the result of an endochondral process driven by its cells, although the roles of the different cell populations have yet to be elucidated. Understanding the role of the tenocyte within this tissue and the process behind tendon ossification may help us prevent or treat ossification that occurs in injured, ageing or diseased tendon. © 2013 Anatomical Society.
Battery, Lucy; Maffulli, Nicola
Overuse tendon injuries present with pain and swelling of the affected tendon with associated decrease in exercise tolerance and function of the limb. After early inflammatory and degenerative hypotheses, the term "tendinopathy" is now deemed a more appropriate reflection of the mixed histopathological picture seen in operative biopsies from affected patients. The condition presents histopathological evidence of "failed healing response," but its etiology remains unclear. The incidence of tendinopathy is increased in individuals with obesity and decreased insulin sensitivity (as seen in type 1 and type 2 diabetes mellitus). These groups of patients also exhibit an increased risk of developing a state of chronic low-grade, systemic inflammation. This paper considers the theoretical bases to discuss whether these conditions may predispose to the development of tendinopathy and the implication that such a relationship may have on its management.
Kaalund, S; Lass, P; Høgsaa, B; Nøhr, M
The typical badminton player with an Achilles tendon rupture is 36 years old and, despite limbering up, is injured at the rear line in a sudden forward movement. He resumes work within three months and has a slight lack of dorsiflexion in the ankle as the main complication. Most patients resume badminton within one year, but some finish their sports career, mainly due to fear of a new injury. The investigation discusses predisposing factors and prophylactic measures. PMID:2605439
Kaalund, S; Lass, P; Høgsaa, B; Nøhr, M
The typical badminton player with an Achilles tendon rupture is 36 years old and, despite limbering up, is injured at the rear line in a sudden forward movement. He resumes work within three months and has a slight lack of dorsiflexion in the ankle as the main complication. Most patients resume badminton within one year, but some finish their sports career, mainly due to fear of a new injury. The investigation discusses predisposing factors and prophylactic measures.
AD-A172 279 TENDON FIEROPLASIA INDUCTION BY EXOGENOUS ELECTRICAL 1/ FIELDS(U) MEDICAL COLL OF VIRGINIA RICHMOND DEPT OF PHYSIOLOGY AND BIOPHYSICS S...Security Classification) Tendon Fibroplasia Induction by Exogenous Electrical Fields l2dAL 9I F.; Liu, Li-Ming. 134. TYPE PF REPORT 13b. TIME COVERED 14... tendon explant fibroplasia, collagen synthesis and oriented migration. Independent variables are: pulse repetition rate, pulse duration, peak current
Carmont, Michael R; Silbernagel, Karin Grävare; Nilsson-Helander, Katarina; Mei-Dan, Omer; Karlsson, Jon; Maffulli, Nicola
The Achilles tendon Total Rupture Score (ATRS) was developed because of the need for a reliable, valid and sensitive instrument to evaluate symptoms and their effects on physical activity in patients following either conservative or surgical management of an Achilles tendon rupture. Prior to using the score in larger randomized trial in an English-speaking population, we decided to perform reliability, validity and responsiveness evaluations of the English version of the ATRS. Even though the score was published in English, the actual English version has not be validated and compared to the results of the Swedish version. From 2009 to 2010, all patients who received treatment for Achilles tendon rupture were followed up using the English version of the ATRS. Patients were asked to complete the score at 3, 6 and 12 months following treatment for Achilles tendon rupture. The ATRS was completed on arrival in the outpatient clinic and again following consultation. The outcomes of 49 (13 female and 36 male) patients were assessed. The mean (SD) age was 49 (12) years, and 27 patients had treatment for a left-sided rupture, 22 the right. All patients received treatment for ruptured Achilles tendons: 38 acute percutaneous repair, 1 open repair, 5 an Achilles tendon reconstruction using a Peroneus Brevis tendon transfer for delayed presentation, 1 gracilis augmented repair for re-rupture and 4 non-operative treatment for mid-portion rupture. The English version of ATRS was shown to have overall excellent reliability (ICC = 0.986). There was no significant difference between the results with the English version and the Swedish version when compared at the 6-month- or 12-month (n.s.) follow-up appointments. The effect size was 0.93. The minimal detectable change was 6.75 points. The ATRS was culturally adapted to English and shown to be a reliable, valid and responsive method of testing functional outcome following an Achilles tendon rupture.
Liu, Huanhuan; Zhu, Shouan; Zhang, Can; Lu, Ping; Hu, Jiajie; Yin, Zi; Ma, Yue; Chen, Xiao; OuYang, Hongwei
Tendons that connect muscles to bone are often the targets of sports injuries. The currently unsatisfactory state of tendon repair is largely attributable to the limited understanding of basic tendon biology. A number of tendon lineage-related transcription factors have recently been uncovered and provide clues for the better understanding of tendon development. Scleraxis and Mohawk have been identified as critical transcription factors in tendon development and differentiation. Other transcription factors, such as Sox9 and Egr1/2, have also been recently reported to be involved in tendon development. However, the molecular mechanisms and application of these transcription factors remain largely unclear and this prohibits their use in tendon therapy. Here, we systematically review and analyze recent findings and our own data concerning tendon transcription factors and tendon regeneration. Based on these findings, we provide interaction and temporal programming maps of transcription factors, as a basis for future tendon therapy. Finally, we discuss future directions for tendon regeneration with differentiation and trans-differentiation approaches based on transcription factors.
Murrell, George A C
Nitric oxide is a small free radical generated by a family of enzymes, the nitric oxide synthases (NOSs). In a series of experiments performed over the last 15 years, we showed that nitric oxide is induced by all 3 isoforms of NOS during tendon healing and that it plays a crucial beneficial role in restoring tendon function. In normal tendons, very little NOS activity was found, whereas in injured rat and human tendons, NOS activity was expressed in healing fibroblasts in a temporal fashion. In healing rat Achilles tendon fibroblasts, the first isoform to be expressed was endothelial NOS, followed by inducible NOS and then brain or neuronal NOS. Systemic inhibition of NOS activity decreased the cross-sectional area and mechanical properties of the healing rodent Achilles tendons. The addition of nitric oxide via nitric oxide-flurbiprofen enhanced rat Achilles tendon healing. The addition of nitric oxide to cultured human tendon cells via chemical means and via adenoviral transfection enhanced collagen synthesis, suggesting that one mechanism for the beneficial effect of nitric oxide on tendon healing might be via matrix synthesis. Most recently, 3 randomized, double-blind clinical trials evaluated the efficacy of nitric oxide donation via a patch in the management of the tendinopathy. In all 3 clinical trials, there was a significant positive beneficial effect of nitric oxide donation to the clinical symptoms and function of patients with Achilles tendinopathy, tennis elbow, and supraspinatus tendinitis.
Bakri, Karim; Mardini, Samir; Evans, Karen K.; Carlsen, Brian T.; Arnold, Phillip G.
Large and life-threatening thoracic cage defects can result from the treatment of traumatic injuries, tumors, infection, congenital anomalies, and radiation injury and require prompt reconstruction to restore respiratory function and soft tissue closure. Important factors for consideration are coverage with healthy tissue to heal a wound, the potential alteration in respiratory mechanics created by large extirpations or nonhealing thoracic wounds, and the need for immediate coverage for vital structures. The choice of technique depends on the size and extent of the defect, its location, and donor site availability with consideration to previous thoracic or abdominal operations. The focus of this article is specifically to describe the use of the pectoralis major, latissimus dorsi, and rectus abdominis muscle flaps for reconstruction of thoracic defects, as these are the workhorse flaps commonly used for chest wall reconstruction. PMID:22294942
Swain, M V; Gigiel, A J; Limpens, G
This paper covers the work carried out on the textural effects of chilling hot boned meat using solid carbon dioxide (CO(2)). The purpose was to measure the texture of beef Longissimus dorsi (LD) chilled in boxes with solid CO(2) and to compare this with conventionally chilled meat. The results showed that CO(2) chilled meat were tougher than the controls. Shear force (SF) and work done (WD) results indicated that 63% of the CO(2) chilled meat were above 50N compared to 32% of the controls, taste panel would judge this as slightly tough. 22% of the CO(2) chilled meat was SF>100N which overall would be judged as extremely tough as compared to 2% of the controls. The work also showed that the laser diffraction technique was unable to distinguish between active and passive shortening giving only an average or overall length for the area viewed.
Qi, Jun; Li, Chunbao; Chen, Yinji; Gao, Feifei; Xu, Xinglian; Zhou, Guanghong
Changes in eating and technological quality attributes of ovine longissimus dorsi muscle during repeated freeze and thaw were investigated. Shear force value, L* value, a* value and fiber diameter decreased (P<0.05) but lipid oxidation increased (P<0.05) with repeated freeze-thaw cycles. Sarcomere length and pH decreased (P<0.05) within the first 10 freeze-thaw cycles but increased (P<0.05) after 5 further cycles. Total and myofibrillar protein solubility, and intramuscular free fatty acids concentration decreased (P<0.05) after 1 cycle of freeze and thaw but then increased (P<0.05) gradually with further cycles. Hardness, chewiness, cohesiveness and resilience of comminuted lamb products decreased (P<0.05) with increased freeze-thaw cycles. And therefore, repeated freeze and thaw should be minimized in terms of meat color for commercial value and water holding capacity for further processing.
Lampert, Joshua A; Harmaty, Marco; Thompson, Elizabeth Chabner; Sett, Suvro; Koch, R Michael
Ectopia cordis is a rare congenital defect characterized by complete or partial displacement of the heart outside the thoracic cavity. Repair of ectopia cordis can present a reconstructive challenge often requiring a staged approach. Ideally, structural integrity and protection of the heart are restored using autologous tissues capable of growth. In addition, reconstruction of the thorax must proceed without compromise to pulmonary or cardiovascular stability. The following article describes repair of thoracoabdominal ectopia cordis in a patient with pentalogy of Cantrell. Reconstruction of the chest wall was accomplished using a musculoosseus composite flap involving segments of the 9th and 10th ribs and overlying pedicled latissimus dorsi muscle. This is the first report known to the authors of such a repair.
Antonopoulos, Dimitrios; Tsiliboti, Dimitra; Skarpetas, Dimitrios; Masmanidis, Aris
Reconstruction of enormous composite defects of the face in the presence of meningitis is a difficult problem. We present a case of a 29-year-old man with a huge, posttraumatic bone and soft tissue defect of the upper half of the left side of the face (orbit-zygoma-frontal-partial temporal bones), frontal lobe of the brain, and enucleated eye with intact facial skin. An initial reconstruction using cement was complicated by multiple episodes of meningitis. In a multiple-stage procedure, we used a free latissimus dorsi muscle flap to re-construct the soft tissue defect and control the infection, a complete left orbit and frontal MEDPOR implant for the bone defect, and also an orbital sphere MEDPOR implant for the eyeball. In a 2-year follow-up, no infection was observed, and the cosmetic result is satisfactory. The combination of free flap and MEDPOR implants demonstrates an alternative method for reconstruction of complicated facial defects.
Tizioto, Polyana C; Taylor, Jeremy F; Decker, Jared E; Gromboni, Caio F; Mudadu, Mauricio A; Schnabel, Robert D; Coutinho, Luiz L; Mourão, Gerson B; Oliveira, Priscila S N; Souza, Marcela M; Reecy, James M; Nassu, Renata T; Bressani, Flavia A; Tholon, Patricia; Sonstegard, Tad S; Alencar, Mauricio M; Tullio, Rymer R; Nogueira, Ana R A; Regitano, Luciana C A
Beef cattle require dietary minerals for optimal health, production and reproduction. Concentrations of minerals in tissues are at least partly genetically determined. Mapping genomic regions that affect the mineral content of bovine longissimus dorsi muscle can contribute to the identification of genes that control mineral balance, transportation, absorption and excretion and that could be associated to metabolic disorders. We applied a genome-wide association strategy and genotyped 373 Nelore steers from 34 half-sib families with the Illumina BovineHD BeadChip. Genome-wide association analysis was performed for mineral content of longissimus dorsi muscle using a Bayesian approach implemented in the GenSel software. Muscle mineral content in Bos indicus cattle was moderately heritable, with estimates ranging from 0.29 to 0.36. Our results suggest that variation in mineral content is influenced by numerous small-effect QTL (quantitative trait loci) but a large-effect QTL that explained 6.5% of the additive genetic variance in iron content was detected at 72 Mb on bovine chromosome 12. Most of the candidate genes present in the QTL regions for mineral content were involved in signal transduction, signaling pathways via integral (also called intrinsic) membrane proteins, transcription regulation or metal ion binding. This study identified QTL and candidate genes that affect the mineral content of skeletal muscle. Our findings provide the first step towards understanding the molecular basis of mineral balance in bovine muscle and can also serve as a basis for the study of mineral balance in other organisms.
Ahmadzadeh, Hossein; Connizzo, Brianne K.; Freedman, Benjamin R.; Soslowsky, Louis J.; Shenoy, Vivek B.
Tendon has a complex hierarchical structure composed of both a collagenous and a non-collagenous matrix. Despite several studies that have aimed to elucidate the mechanism of load transfer between matrix components, the roles of glycosaminoglycans (GAGs) remain controversial. Thus, this study investigated the elastic properties of tendon using a modified shear-lag model that accounts for the structure and non-linear mechanical response of the GAGs. Unlike prior shear-lag models that are solved either in two dimensions or in axially symmetric geometries, we present a closed-form analytical model for three-dimensional periodic lattices of fibrils linked by GAGs. Using this approach, we show that the non-linear mechanical response of the GAGs leads to a distinct toe region in the stress-strain response of the tendon. The critical strain of the toe region is shown to decrease inversely with fibril length. Furthermore, we identify a characteristic length scale, related to microstructural parameters (e.g. GAG spacing, stiffness, and geometry) over which load is transferred from the GAGs to the fibrils. We show that when the fibril lengths are significantly larger than this length scale, the mechanical properties of the tendon are relatively insensitive to deletion of GAGs. Our results provide a physical explanation for the insensitivity for the mechanical response of tendon to the deletion of GAGs in mature tendons, underscore the importance of fibril length in determining the elastic properties of the tendon, and are in excellent agreement with computationally intensive simulations. PMID:23932185
Ahmadzadeh, Hossein; Connizzo, Brianne K; Freedman, Benjamin R; Soslowsky, Louis J; Shenoy, Vivek B
Tendon has a complex hierarchical structure composed of both a collagenous and a non-collagenous matrix. Despite several studies that have aimed to elucidate the mechanism of load transfer between matrix components, the roles of glycosaminoglycans (GAGs) remain controversial. Thus, this study investigated the elastic properties of tendon using a modified shear-lag model that accounts for the structure and non-linear mechanical response of the GAGs. Unlike prior shear-lag models that are solved either in two dimensions or in axially symmetric geometries, we present a closed-form analytical model for three-dimensional periodic lattices of fibrils linked by GAGs. Using this approach, we show that the non-linear mechanical response of the GAGs leads to a distinct toe region in the stress-strain response of the tendon. The critical strain of the toe region is shown to decrease inversely with fibril length. Furthermore, we identify a characteristic length scale, related to microstructural parameters (e.g. GAG spacing, stiffness, and geometry) over which load is transferred from the GAGs to the fibrils. We show that when the fibril lengths are significantly larger than this length scale, the mechanical properties of the tendon are relatively insensitive to deletion of GAGs. Our results provide a physical explanation for the insensitivity for the mechanical response of tendon to the deletion of GAGs in mature tendons, underscore the importance of fibril length in determining the elastic properties of the tendon, and are in excellent agreement with computationally intensive simulations. Copyright © 2013 Elsevier Ltd. All rights reserved.
Hoang, P D; Herbert, R D; Todd, G; Gorman, R B; Gandevia, S C
This study provides the first in vivo measures of the passive length-tension properties of relaxed human muscle fascicles and their tendons. A new method was used to derive passive length-tension properties of human gastrocnemius muscle-tendon units from measures of ankle stiffness obtained at a range of knee angles. Passive length-tension curves of the muscle-tendon unit were then combined with ultrasonographic measures of muscle fascicle length and pennation to determine passive length-tension curves of the muscle fascicles and tendons. Mean slack lengths of the fascicles, tendons and whole muscle-tendon units were 3.3+/-0.5 cm, 39.5+/-1.6 cm and 42.3+/-1.5 cm, respectively (means +/- s.d., N=6). On average, the muscle-tendon units were slack (i.e. their passive tension was zero) over the shortest 2.3+/-1.2 cm of their range. With combined changes of knee and ankle angles, the maximal increase in length of the gastrocnemius muscle-tendon unit above slack length was 6.7+/-1.9 cm, of which 52.4+/-11.7% was due to elongation of the tendon. Muscle fascicles and tendons underwent strains of 86.4+/-26.8% and 9.2+/-4.1%, respectively, across the physiological range of lengths. We conclude that the relaxed human gastrocnemius muscle-tendon unit falls slack over about one-quarter of its in vivo length and that muscle fascicle strains are much greater than tendon strains. Nonetheless, because the tendons are much longer than the muscle fascicles, tendons contribute more than half of the total compliance of the muscle-tendon unit.
Furnas, H.; Lineaweaver, W.C.; Alpert, B.S. )
We report on a series of patients with scalp defects who have been treated with a variety of free flaps, spanning the era of microvascular free tissue transfer from its incipient stages to the present. Between 1971 and 1987, 18 patients underwent scalp reconstruction with 21 free flaps: 11 latissimus dorsi, 3 scalp transfers between identical twins, 3 groin, one combined latissimus dorsi and serratus anterior, two serratus anterior, and one omentum. These flaps were used to cover scalp defects resulting from burns, trauma, radiation, and tumors in patients ranging from 7 to 79 years of age. Follow-up has ranged from 3 weeks to 7 years. All of our flaps survived and covered complex defects, many of which had failed more conservative attempts at cover. One patient received radiation therapy to his flap without unfavorable sequelae. This experience began with a pioneering omental flap and includes cutaneous and muscle flaps. The latissimus dorsi is our first choice for free flap reconstruction of extensive, complicated scalp wounds because of its large size, predictable blood supply, ease of harvesting, and provision of excellent vascularity to compromised beds.
O'Brien, Etienne John Ogilvy; Shrive, Nigel G; Rosvold, Joshua M; Thornton, Gail M; Frank, Cyril B; Hart, David A
Heterotopic mineralization may result in tendon weakness, but effects on other biomechanical responses have not been reported. We used a needle injury, which accelerates spontaneous mineralization of murine Achilles tendons, to test two hypotheses: that injured tendons would demonstrate altered biomechanical responses; and that unilateral injury would accelerate mineralization bilaterally. Mice underwent left hind (LH) injury (I; n = 11) and were euthanized after 20 weeks along with non-injured controls (C; n = 9). All hind limbs were examined by micro computed tomography followed by biomechanical testing (I = 7 and C = 6). No differences were found in the biomechanical responses of injured tendons compared with controls. However, the right hind (RH) tendons contralateral to the LH injury exhibited greater static creep strain and total creep strain compared with those LH tendons (p ≤ 0.045) and RH tendons from controls (p ≤ 0.043). RH limb lesions of injured mice were three times larger compared with controls (p = 0.030). Therefore, despite extensive mineralization, changes to the responses we measured were limited or absent 20 weeks postinjury. These results also suggest that bilateral occurrence should be considered where tendon mineralization is identified clinically. This experimental system may be useful to study the mechanisms of bilateral new bone formation in tendinopathy and other conditions.
Sato, T; Hori, N; Nakamoto, N; Akita, M; Yoda, T
Masticatory muscle tendon-aponeurosis hyperplasia is a new disease entity associated with limited mouth opening. In this study, we analyzed the microstructural characteristics of muscles and tendons in masticatory muscle tendon-aponeurosis hyperplasia by electron microscopy and energy-dispersive X-ray analysis to determine the elemental composition. Histological analysis was performed to detect the calcification. Transmission electron microscopy and scanning electron microscopy were conducted to clarify the microstructural characteristics of muscles and tendons. Energy-dispersive X-ray microanalysis was performed to identify the distribution of elements. Mineralized nodules were observed in tendon tissues of masticatory muscle tendon-aponeurosis hyperplasia as compared with facial deformity. Electron microscopy revealed that the muscle and tendon tissues in masticatory muscle tendon-aponeurosis hyperplasia showed degenerative changes and distinctive histological findings as compared with tissues in facial deformity. We found that Ca, P, and Si were detected only in masticatory muscle tendon-aponeurosis hyperplasia. We demonstrated that masticatory muscle tendon-aponeurosis hyperplasia exhibits heterotopic calcification in tendon tissues. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Maffulli, Nicola; Spiezia, Filippo; Testa, Vittorino; Capasso, Giovanni; Longo, Umile Giuseppe; Denaro, Vincenzo
Chronic tears of the Achilles tendon with a tendon gap exceeding 6 cm are a surgical challenge. The purpose of this study is to report the long-term results of reconstruction of such chronic Achilles tendon ruptures with use of a free autologous gracilis tendon graft. Twenty-one patients underwent reconstruction of a chronic rupture of the Achilles tendon. Fifteen patients were available for clinical and functional assessment on the basis of anthropometric measurements, isometric strength testing, and the Achilles Tendon Total Rupture Score after a mean duration of follow-up of 10.9 years (range, eight to twelve years). All fifteen patients were able to walk on the tiptoes, and no patient used a heel lift or walked with a visible limp. At an average of 10.9 years of follow-up, the maximum calf circumference of the operatively treated leg remained substantially decreased and the operatively treated limb was significantly weaker than the contralateral, normal limb. Two patients had developed tendinopathy of the contralateral Achilles tendon, one had developed tendinopathy of the reconstructed tendon, and one had ruptured the contralateral Achilles tendon eight years after the index tear. The long-term results of treatment of chronic tears of the Achilles tendon with free gracilis tendon grafting showed that patients retained good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference.
Kennedy, J A; Dias, J J
The optimal management of partial flexor tendon laceration is controversial and remains a clinical challenge. Abnormal tendon gliding (triggering and entrapment) was assessed at the A2 pulley in 40 turkey tendons in three groups: intact, partially divided (palmar or lateral), and trimmed. Testing was of gliding resistance and friction coefficient at 30° and 70° of flexion, loaded with 2 and 4 N. We observed for triggering and entrapment. The changes in gliding properties were compared and analysed using Wilcoxon matched pair testing. A significant difference was found in the change in gliding properties of intact to lacerated and lacerated to trimmed tendons and between tendons that glided normally compared with those exhibiting triggering or entrapment. This suggests that palmar and lateral lacerations which, through clinical examination and visualization, are found to glide normally should be treated with early mobilization. However, partial lacerations that exhibit triggering or entrapment should be trimmed. © The Author(s) 2013.
Paredes, J.J.; Andarawis-Puri, Nelly
Tendon injuries, known as tendinopathies, are common musculoskeletal injuries that affect a wide range of the population. Canonical tendon healing is characterized by fibrosis, scar formation, and the loss of tissue mechanical and structural properties. Understanding the regenerative tendon environment is an area of increasing interest in the field of musculoskeletal research. Previous studies have focused on utilizing individual elements from the fields of biomechanics, developmental biology, cell and growth factor therapy, and tissue engineering in an attempt to develop regenerative tendon therapeutics. Still, the specific mechanism for regenerative healing remains unknown. In this review, we highlight some of the current approaches of tendon therapeutics and elucidate the differences along the tendon midsubstance and enthesis, exhibiting the necessity of location-specific tendon therapeutics. Furthermore, we emphasize the necessity of further interdisciplinary research in order to reach the desired goal of fully understanding the mechanisms underlying regenerative healing. PMID:27768813
Harries, Luke; Kempson, Susan; Watura, Roland
Calcific tendinosis (tendonosis/tendonitis) is a condition which results from the deposition of calcium hydroxyapatite crystals in any tendon of the body. Calcific tendonitis usually presents with pain, which can be exacerbated by prolonged use of the affected tendon. We report a case of calcific tendinosis in the posterior tibialis tendon at the navicular insertion. The pathology is rare in the foot, and extremely rare in the tibialis posterior tendon, indeed there are only 2 reported in the published literature. This case report highlights the need to consider calcific tendinosis in the foot despite its rarity. If this diagnosis is considered early, appropriate investigations can then be requested and unnecessary biopsies, use of antibiotics and surgery can be avoided. We also discuss possible causes of calcific tendinosis in the tibialis posterior tendon, the role of imaging modalities and review treatment methods. PMID:22470798
Paredes, J J; Andarawis-Puri, Nelly
Tendon injuries, known as tendinopathies, are common musculoskeletal injuries that affect a wide range of the population. Canonical tendon healing is characterized by fibrosis, scar formation, and the loss of tissue mechanical and structural properties. Understanding the regenerative tendon environment is an area of increasing interest in the field of musculoskeletal research. Previous studies have focused on utilizing individual elements from the fields of biomechanics, developmental biology, cell and growth factor therapy, and tissue engineering in an attempt to develop regenerative tendon therapeutics. Still, the specific mechanism for regenerative healing remains unknown. In this review, we highlight some of the current approaches of tendon therapeutics and elucidate the differences along the tendon midsubstance and enthesis, exhibiting the necessity of location-specific tendon therapeutics. Furthermore, we emphasize the necessity of further interdisciplinary research in order to reach the desired goal of fully understanding the mechanisms underlying regenerative healing.
Ahmad, Jamal; Jones, Kennis; Raikin, Steven M
Background When Achilles tendon ruptures become chronic, a defect often forms at the rupture site. There is scant literature regarding the treatment of chronic Achilles ruptures with defects of 6 cm or larger. We examined outcomes from combining a turndown of the proximal, central Achilles with a flexor hallucis longus (FHL) tendon transfer to treat this condition. Materials Between September 2002 and December 2013, 32 patients presented with a chronic Achilles rupture and a defect of 6 cm or more. Twenty patients were male and 12 were female. Patient age was between 20 and 74 years, with a mean of 53.3 years. Eighteen and 14 patients had their right and left Achilles tendon affected, respectively. The number of days between injury and surgery ranged from 30 to 315 days, with a mean of 102 days. Reconstruction of the Achilles involved a turndown of the proximal, central tendon and FHL augmentation. Final patient follow-up ranged from 18 to 150 months, with a mean of 62.3 months. At surgery, the gap between the ruptured ends of the Achilles ranged from 6 to 12 cm, with a mean gap of 7.5 cm. Full healing was achieved in all 32 patients (100%) by 5 months postoperatively. Mean Foot and Ankle Ability Measures scores increased from 36.3% to 90.2% between initial and latest follow-up (P < .05). Mean visual analogue scales of pain decreased from 6.6 to 1.8 of 10 between first and last encounter (P < .05). Postoperative complications occurred in 5 patients (15.6%), including 3 (9.4%) superficial wound problems, 1 (3.1%) deep wound infection, and 1 (3.1%) deep vein thrombosis. Discussion Outcomes from treating chronic Achilles ruptures with large defects are scant within the orthopaedic literature. Our method of Achilles reconstruction results in a high rate of improved function and pain relief. Therapeutic, Level IV: Case series. © 2016 The Author(s).
Koch, Horst; Tomaselli, F; Pierer, G; Schwarzl, F; Haas, F; Smolle-Jüttner, F M; Scharnagl, E
Besides other factors, the choice of reconstructive method for full thickness thoracic wall defects depends on the morbidity of preceding surgical procedures. The pedicled latissimus dorsi flap is a reliable and safe option for reconstruction of the thorax. A posterolateral thoracotomy, however, results in division of the muscle. Both parts of the muscle can be employed to close full thickness defects of the chest wall. The proximal part can be pedicled on the thoracodorsal vessels or the serratus branch; the distal part can be pedicled on paravertebral or intercostal perforators. This retrospective study was undertaken to evaluate the reconstructive potential of both parts of the latissimus dorsi in thoracic wall reconstruction after posterolateral thoracotomy. Between 1987 and 1999, 36 consecutive patients underwent reconstruction of full-thickness thoracic wall defects with latissimus dorsi-flaps after posterolateral thoracotomies. The defects resulted from infection and open window thoracostomy (n=31), trauma (n=3) and resection of tumours (n=2). The patients' average age was 57 years (range 22-76 years). Twenty-five patients were male, 11 were female. In 31 cases the split latissimus dorsi alone was employed; in five cases additional flaps had to be used due to the size of the defects, additional intrathoracic problems or neighbouring defects. In 34 cases defect closure could be achieved without major complications. Empyema recurred in the pleural cavity in one case and one patient died of septicaemia. The 15 patients who had required a respirator in the preoperative phase could be extubated 4.8 days (average) after thoracic wall reconstruction. Postoperative hospital stay averaged 16 days. Different methods are available for reconstruction of full thickness defects of the thoracic wall. After posterolateral thoracotomy in the surgical treatment of empyema, oncologic surgery and traumatology, the latissimus dorsi muscle still retains some reconstructive
Andarawis-Puri, Nelly; Kuntz, Andrew F.; Kim, Soung-Yon
Background Rotator cuff tears are common shoulder problems whose propagation is difficult to predict because of the structural and mechanical inhomogeneity of the supraspinatus tendon. We have previously shown that the supraspinatus and the infraspinatus tendons mechanically interact when the supraspinatus tendon is intact or exhibits a full-thickness tear so that an increase in supraspinatus tendon strain is paralleled by an increase in infraspinatus tendon strain. Such interaction is critical and suggests that an increase in infraspinatus tendon strain that accompanies an increase in supraspinatus tendon strain may shield the supraspinatus tendon from further injury but increase the risk of injury to the infraspinatus tendon. In this study, the mechanical interactions between the supraspinatus and infraspinatus tendons were evaluated for the commonly occurring supraspinatus tendon partial-thickness tears through a range of rotation angles. Methods For each joint rotation and supraspinatus tendon tear size evaluated, the supraspinatus tendon was loaded, and images corresponding to 5N, 30N, 60N and 90N of supraspinatus tendon load were isolated for the speckle painted supraspinatus and infraspinatus tendons. A region of interest outlining the insertion site was isolated and displacements between the 5N loaded image and each of the others were measured, from which normalized average principal strains were quantified in both tendons. Results The observed effect on infraspinatus tendon strain paralleled that observed on strain in the supraspinatus tendon. Introducing a supraspinatus tendon partial-thickness tear and increasing load caused an increase in normalized average maximum and a decrease in normalized average minimum principal strain in the infraspinatus tendon. Increasing rotation angle from internal to external rotation caused a general decrease in normalized average maximum and increase in normalized average minimum principal strain in both tendons
Jiang, Dapeng; Xu, Bo; Yang, Mowen; Zhao, Zheng; Zhang, Yubo; Li, Zhaozhu
After injury, tendons often heal with poor tissue quality and inferior mechanical properties. Tissue engineering using tendon stem cells (TSCs) is a promising approach in the repair of injured tendon. Tenogenic differentiation of TSCs needs an appropriate environment. More recently, the acellular extracellular matrix (ECM) generated from fibroblasts has been used to construct various engineering tissues. In this study, we successfully developed an engineered tendon tissue formed by seeding TSCs in de-cellularized fibroblast-derived matrix (dFM). Patellar TSCs and dermal fibroblast were isolated and cultured. Using the method of osmotic shock, dFM was obtained from dermal fibroblast. ECM proteins in dFM were examined. TSCs at passage 3 were seeded in dFM for 1 week. Proliferative capacity and characterization of TSCs cultured in dFM were determined by population doubling time, immunofluorescence staining and quantitative reverse transcriptase polymerase chain reaction. Engineered tendon tissue was prepared with dFM and TSCs. Its potentials for neo-tendon formation and promoting tendon healing were investigated. dFM is suitable for growth and tenogenic differentiation of TSCs in vitro. Neo-tendon tissue was formed with tendon-specific protein expression when TSCs were implanted together with dFM. In a patellar tendon injury model, implantation of engineered tendon tissue significantly improved the histologic and mechanical properties of injured tendon. The findings obtained from our study provide a basis for potential use of engineered tendon tissue containing dFM and TSCs in tendon repair and regeneration. Copyright © 2014 International Society for Cellular Therapy. Published by Elsevier Inc. All rights reserved.
Padaliya, N. R.; Ranpariya, J. J.; Kumar, Dharmendra; Javia, C. B.; Barvalia, D. R.
Aim: The present study was conducted to evaluate the equine palmar tendon by ultrasonography (USG) in standing the position. Materials and Methods: USG of palmar tendons was performed in 40 adult horses using linear transducer having frequency of 10-18 MHz (e-soate, My Lab FIVE) and L52 linear array transducer (Titan, SonoSite) with frequencies ranging from 8 to 10 MHz. Palmar tendon was divided into 7 levels from distal to accessory carpal bone up to ergot in transverse scanning and 3 levels in longitudinal scanning. Results: The USG evaluation was very useful for diagnosis of affections of the conditions such as chronic bowed tendon, suspensory ligament desmitis, carpal sheath tenosynovitis and digital sheath effusions. The mean cross-sectional area (cm2) of affected tendons was significantly increased in affected than normal tendons. The echogenicity was also found reduced in affected tendons and ligaments along with disorganization of fiber alignment depending on the severity of lesion and injury. Conclusion: USG proved ideal diagnostic tool for diagnosis and post-treatment healing assessment of tendon injuries in horses. PMID:27047074
Spiesz, Ewa M; Zysset, Philippe K
In this paper, we review the hierarchical structure and the resulting elastic properties of mineralized tendons as obtained by various multiscale experimental and computational methods spanning from nano- to macroscale. The mechanical properties of mineralized collagen fibres are important to understand the mechanics of hard tissues constituted by complex arrangements of these fibres, like in human lamellar bone. The uniaxial mineralized collagen fibre array naturally occurring in avian tendons is a well studied model tissue for investigating various stages of tissue mineralization and the corresponding elastic properties. Some avian tendons mineralize with maturation, which results in a graded structure containing two zones of distinct morphology, circumferential and interstitial. These zones exhibit different amounts of mineral, collagen, pores and a different mineral distribution between collagen fibrillar and extrafibrillar space that lead to distinct elastic properties. Mineralized tendon cells have two phenotypes: elongated tenocytes placed between fibres in the circumferential zone and cuboidal cells with lower aspect ratios in the interstitial zone. Interestingly some regions of avian tendons seem to be predestined to mineralization, which is exhibited as specific collagen cross-linking patterns as well as distribution of minor tendon constituents (like proteoglycans) and loss of collagen crimp. Results of investigations in naturally mineralizing avian tendons may be useful in understanding the pathological mineralization occurring in some human tendons.
Barfred, T; Adamsen, S
Three cases are presented, in which an anomalous tendon slip between the extensor carpi ulnaris tendon and the extensor apparatus of the fifth finger was found. One of the patients was a violinist, who had serious impairment of the left wrist joint and the small finger due to the anomaly. The symptoms disappeared after excision.
Frisch, Catherine Kayt Vincent
Mechanical properties of tendon predict tendon health and function, but measuring these properties in vivo is difficult. An ultrasound-based (US) analysis technique called acoustoelastography (AE) uses load-dependent changes in the reflected US signal to estimate tissue stiffness non-invasively. This thesis explores whether AE can provide information about stiffness alteration resulting from tendon tears both ex vivo and in vivo. An ex vivo ovine infraspinatus tendon model suggests that the relative load transmitted by the different tendon layers transmit different fractions of the load and that ultrasound echo intensity change during cyclic loading decreases, becoming less consistent once the tendon is torn. An in vivo human tibialis anterior tendon model using electrically stimulated twitch contractions investigated the feasibility of measuring the effect in vivo. Four of the five subjects showed the expected change and that the muscle contraction times calculated using the average grayscale echo intensity change compared favorably with the times calculated based on the force data. Finally an AE pilot study with patients who had rotator cuff tendon tears found that controlling the applied load and the US view of the system will be crucial to a successful in vivo study.
Fuentes, Christina T; Gomi, Hiroaki; Haggard, Patrick
Muscle spindles provide information about the position and movement of our bodies. One method for investigating spindle signals is tendon vibration. Vibration of flexor tendons can produce illusions of extension, and vibration of extensor tendons can produce illusions of flexion. Here we estimate the temporal resolution and persistence of these illusions. In Experiments 1 and 2, sequences of alternating vibration of wrist flexor and extensor tendons produced position illusions that varied with alternation period. When vibrations alternated at 1 Hz or slower, perceived position at the end of the sequence depended on the last vibration. When vibrations alternated every 0.3 s, perceived position was independent of the last vibration. Experiment 2 verified and extended these results using more trials and concurrent electromyographic recording. Although tendon vibrations sometimes induce reflexive muscle activity, we found no evidence that such activity contributed to these effects. Experiment 3 investigated how long position sense is retained when not updated by current information from spindles. Our first experiments suggested that vibrating antagonistic tendons simultaneously could produce conflicting inputs, leaving position sense reliant on memory of position prior to vibration onset. We compared variability in position sense after different durations of such double vibration. After 12 s of double vibration, variability across trials exceeded levels predicted from vibrations of flexor or extensor tendons alone. This suggests that position sense memory had decayed too much to substitute for the current conflicting sensory information. Together, our results provide novel, quantitative insight into the temporal properties of tendon vibration illusions.
Hüfner, T; Gaulke, R; Imrecke, J; Krettek, C; Stübig, T
The conservative functional treatment of Achilles tendon ruptures has developed further over the last 20 years and is basically possible for 60-80% of patients. The treatment leads to success if the indications obtained by dynamic sonography are correctly interpreted (adaptation of the tendon ends up to 20 degrees plantar flexion), if the patient presents sufficient compliance and the physiotherapy is increasingly intensified depending on tendon healing. Modern ortheses allow an increased equinus position and therefore improved protection of the healing tendon. If these factors are present a relatively low re-rupture rate of only 7% can be achieved. The decisive advantage of conservative functional therapy is the avoidance of specific operative risks, such as infection and injury to the sural nerve. After removal of the orthesis the tendon should continue to be modeled using shoe insoles and raised heels.
Thomas, G.; Brown, A.
Our water resources infrastructure is susceptible to aging degradation just like the rest of this country`s infrastructure. A critical component of the water supply system is the flood gate that controls the outflow from dams.Long steel rods called tendons attach these radial gates to the concrete in the dam. The tendons are typically forty feet long and over one inch in diameter. Moisture may seep into the grout around the tendons and cause corrosion. Lawrence Livermore National Laboratory is working with the California Department of Water Resources to develop advanced ultrasonic techniques for nondestructively inspecting their tendons. A unique transducer was designed and fabricated to interrogate the entire tendon. A robust,portable unit was assembled that included a computer controlled data acquisition system and specialized data processing software to analyze the ultrasonic signals. This system was tested on laboratory specimens and is presently being fielded at two dam sites.
Tempfer, Herbert; Traweger, Andreas
Tendons represent a bradytrophic tissue which is poorly vascularized and, compared to bone or skin, heal poorly. Usually, a vascularized connective scar tissue with inferior functional properties forms at the injury site. Whether the increased vascularization is the root cause of tissue impairments such as loss of collagen fiber orientation, ectopic formation of bone, fat or cartilage, or is a consequence of these pathological changes remains unclear. This review provides an overview of the role of tendon vasculature in healthy and chronically diseased tendon tissue as well as its relevance for tendon repair. Further, the nature and the role of perivascular tendon stem/progenitor cells residing in the vascular niche will be discussed and compared to multipotent stromal cells in other tissues. PMID:26635616
Frizziero, Antonio; Salamanna, Francesca; Della Bella, Elena; Vittadini, Filippo; Gasparre, Giuseppe; Nicoli Aldini, Nicolò; Masiero, Stefano; Fini, Milena
Introduction: Several conditions such as training, aging, estrogen deficiency and drugs could affect the biological and anatomo-physiological characteristics of the tendon. Additionally, recent preclinical and clinical studies examined the effect of detraining on tendon, showing alterations in its structure and morphology and in tenocyte mechanobiology. However, few data evaluated the importance that cessation of training might have on tendon. Basically, we do not fully understand how tendons react to a phase of training followed by sudden detraining. Therefore, within this review, we summarize the studies where tendon detraining was examined. Materials and Methods: A descriptive systematic literature review was carried out by searching three databases (PubMed, Scopus and Web of Knowledge) on tendon detraining. Original articles in English from 2000 to 2015 were included. In addition, the search was extended to the reference lists of the selected articles. A public reference manager (www.mendeley.com) was adopted to remove duplicate articles. Results: An initial literature search yielded 134 references (www.pubmed.org: 53; www.scopus.com: 11; www.webofknowledge.com: 70). Fifteen publications were extracted based on the title for further analysis by two independent reviewers. Abstracts and complete articles were after that reviewed to evaluate if they met inclusion criteria. Conclusions: The revised literature comprised four clinical studies and an in vitro and three in vivo reports. Overall, the results showed that tendon structure and properties after detraining are compromised, with an alteration in the tissue structural organization and mechanical properties. Clinical studies usually showed a lesser extent of tendon alterations, probably because preclinical studies permit an in-depth evaluation of tendon modifications, which is hard to perform in human subjects. In conclusion, after a period of sudden detraining (e.g., after an injury), physical activity should
Blackburn, N E; Mc Veigh, J G; Mc Caughan, E; Wilson, I M
Breast reconstruction using the latissimus dorsi (LD) flap following mastectomy is an important management option in breast cancer. However, one common, but often ignored, complication following LD flap is shoulder dysfunction. The aim of this critical review was to comprehensively assess the musculoskeletal impact of LD breast reconstruction and evaluate the functional outcome following surgery. Five electronic databases were searched including; Medline, Embase, CINAHL Plus (Cumulative Index to Nursing and Allied Health), PubMed and Web of Science. Databases were searched from 2006 to 2016, and only full text, English language articles were included. Twenty-two observational studies and two surveys were reviewed with sample sizes ranging from six to 206 participants. The majority of studies had small sample sizes and were retrospective in nature. Nevertheless, there is evidence to suggest that there is some degree of weakness and reduced mobility at the shoulder following LD muscle transfer. The literature demonstrates that there is considerable morbidity in the immediate post-operative period with functional recovery varying between studies. The majority of work tends to be limited and often gives conflicting results; therefore, further investigation is required in order to determine underlying factors that contribute to a reduction in function and activities of daily living.
Horn, Dominik; Jonas, Rene; Engel, Michael; Freier, Kolja; Hoffmann, Jürgen; Freudlsperger, Christian
Tailoring the most suitable reconstructive approach to each patient remains challenging especially in the head and neck region. To compare the applicability of the latissimus dorsi (LD) and anterolateral thigh (ALT) flap, we retrospectively analyzed patients who had reconstruction of extensive and/or bulky composite tissue defects in the head and neck area. We performed 85 free tissue transfers (44 LD and 41 ALT flaps). LD mean flap surface was 115.8 cm(2). ALT mean flap surface was 67.0 cm(2). Pedicle length ranged from 8 to 16 cm in LD and 11-16 cm in ALT flaps. The survival rate was 93% in ALT and 91% in LD flaps. Donor site morbidity occurred in 5% (ALT) and 7% (LD). A Two-team-approach was possible in 24% of the LD group, whereas all ALT flaps were raised in a Two-team-approach. Both flaps present excellent opportunities for the reconstruction of extensive and/or bulky defects. They largely meet the requirements of an ideal soft tissue flap in terms of versatility, skin texture and tissue stock. Both flaps can be raised with a double skin paddle. The advantages and disadvantages of each flap have to be weighed up against each other and both flaps should be in the repertoire of every microvascular surgeon.
de Oliveira, Riza Rute; do Nascimento, Simony Lira; Derchain, Sophie F M; Sarian, Luís Otávio
Mastectomy negatively affects scapulothoracic and glenohumeral kinematics. Breast reconstructive methods such as the latissimus dorsi flap can result in anatomical modifications that may in theory further affect the shoulder apparatus. The purpose of this study was to examine the effects of latissimus dorsi flap reconstruction on the recovery of shoulder motion and other postsurgical problems during the first year after mastectomy. This was a prospective cohort study of 104 consecutive mastectomies (47 with immediate latissimus dorsi flaps). Shoulder range of motion was assessed before and at 1, 3, 6, and 12 months after surgery. Pain, tissue adhesion, scar enlargement, and web syndrome were assessed during follow-up. There was a 30 percent decrease of shoulder range of motion 1 month after surgery, with gradual recovery over time. However, mean abduction and flexion capacities did not reach baseline levels and were on average 5 to 10 percent lower than baseline, even after 1 year. Over time, the latissimus dorsi flap was not associated with restriction of flexion or abduction. Scar enlargement (at the first month, p = 0.009) and tissue adhesion (at month 12, p = 0.032) were significantly less common in the latissimus dorsi flap group. The authors' study clearly suggests that the additional anatomical manipulation required for the latissimus dorsi flap procedure does not further affect shoulder kinematics and is associated with a lower incidence of tissue adhesion. Therapeutic, II.
Parmaksizoglu, F; Beyzadeoglu, T
Two total and one subtotal above-elbow amputations had replantation or revascularization for their severely damaged upper extremities followed by functional latissimus dorsi island pedicle musculocutaneous flap to restore elbow flexion. The mean follow-up was 68 months (range: 14 to 121 months). At final follow-up examinations, the patients had sufficient range-of-motion of their elbows with good strength. Restoring elbow function eliminates one of the most important limiting factors for above-elbow replantations. Functional latissimus dorsi island pedicle musculocutaneous flap is very reliable, has minimal donor-site morbidity and offers a wider choice when deciding about arm replantation in the upper arm region by providing a chance of restoring functions.
Paradol, P-O; Toussoun, G; Delbaere, M; Delaporte, T; Delay, E
Tumefaction arising lately after latissimus dorsi flap harvest are rare and observed in 1 or 2% of the cases. These lesions are frequently related to kystic sero-hematoma and are easily and efficiently treated with surgical excision. In some rare circumstances, a tumoral evolution can mimic a kystic sero-hematoma. We will discuss one case of desmoid tumor arising from a latissimus dorsi flap donor-site scar. The subject was a 45 years old woman who had a breast reconstruction following mastectomy. A dorsal tumefaction, with a benign aspect, was observed during the follow-up period. The biopsy showed an extra-abdominal desmoid tumor. The patient was treated with a large excision of the lesion and reconstructed using two opposing local cutaneous advancing flaps. No radicalization was necessary. No sign of recurrence has been observed at 4 years follow-up.
Tilley, Benjamin J; Cook, Jill L; Docking, Sean I; Gaida, James E
Tendon pain occurs in individuals with extreme cholesterol levels (familial hypercholesterolaemia). It is unclear whether the association with tendon pain is strong with less extreme elevations of cholesterol. To determine whether lipid levels are associated with abnormal tendon structure or the presence of tendon pain. We conducted a systematic review and meta-analysis. Relevant articles were found through an electronic search of 6 medical databases-MEDLINE, Cochrane, AMED, EMBASE, Web of Science and Scopus. We included all case-control or cross-sectional studies with data describing (1) lipid levels or use of lipid-lowering drugs and (2) tendon structure or tendon pain. 17 studies (2612 participants) were eligible for inclusion in the review. People with altered tendon structure or tendon pain had significantly higher total cholesterol, low-density lipoprotein cholesterol and triglycerides, as well as lower high-density lipoprotein cholesterol; with mean difference values of 0.66, 1.00, 0.33, and -0.19 mmol/L, respectively. The results of this review indicate that a relationship exists between an individual's lipid profile and tendon health. However, further longitudinal studies are required to determine whether a cause and effect relationship exists between tendon structure and lipid levels. This could lead to advancement in the understanding of the pathoaetiology and thus treatment of tendinopathy. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Gulick, Dawn T.; Yoder, Heather N.
An injury to the ACL can result in significant functional impairment. It has been estimated that more than 100,000 new ACL injuries occur each year. Surgeons employ numerous techniques for reconstruction of the ACL. Of critical importance is the source of the graft to replace the damaged ACL. The graft choices include autografts (the patient's own tissue), allografts (donor tendon), and synthetic/prosthetic ligaments. Tissue harvest sites for autografting include the middle third of the patella tendon, the quadriceps tendon, semitendinosus tendon, gracilis tendon, iliotibial band, tensor fascia lata, and the Achilles tendon. Selection of the type of graft material is predicated upon the tissue's ability to tolerate high levels of stress. Likewise, the clinical presentation and functional outcome is related to the graft material selected. This manuscript specifically examined the patella tendon and hamstring tendon grafts. Numerous manuscripts that studied the outcomes of these graft materials were compiled to help the clinician appreciate the advantages and disadvantages of each of the graft materials. Outcome measures such as thigh circumference, knee range of motion, isokinetic strength, knee stability, pain, and vertical jump/1-leg hop were incorporated. The purpose of this manuscript was to compare and contrast the clinical presentation of patients who underwent an ACL reconstruction using the patella tendon versus the hamstring tendons. This information can be valuable to the clinician when considering the rehabilitation protocol after ACL reconstruction. PMID:24701126
Breidenbach, Andrew P; Gilday, Steven D; Lalley, Andrea L; Dyment, Nathaniel A; Gooch, Cynthia; Shearn, Jason T; Butler, David L
Improving tendon repair using Functional Tissue Engineering (FTE) principles has been the focus of our laboratory over the last decade. Although our primary goals were initially focused only on mechanical outcomes, we are now carefully assessing the biological properties of our tissue-engineered tendon repairs so as to link biological influences with mechanics. However, given the complexities of tendon development and healing, it remains challenging to determine which aspects of tendon biology are the most important to focus on in the context of tissue engineering. To address this problem, we have formalized a strategy to identify, prioritize, and evaluate potential biological success criteria for tendon repair. We have defined numerous biological properties of normal tendon relative to cellular phenotype, extracellular matrix and tissue ultra-structure that we would like to reproduce in our tissue-engineered repairs and prioritized these biological criteria by examining their relative importance during both normal development and natural tendon healing. Here, we propose three specific biological criteria which we believe are essential for normal tendon function: (1) scleraxis-expressing cells; (2) well-organized and axially-aligned collagen fibrils having bimodal diameter distribution; and (3) a specialized tendon-to-bone insertion site. Moving forward, these biological success criteria will be used in conjunction with our already established mechanical success criteria to evaluate the effectiveness of our tissue-engineered tendon repairs. © 2013 Published by Elsevier Ltd.
The Andrew J. Weiland Medal is presented each year by the American Society for Surgery of the Hand and the American Foundation for Surgery of the Hand for a body of work related to hand surgery research. This essay, awarded the Weiland Medal in 2011, focuses on the clinical need for flexor tendon reconstruction and on investigations into flexor tendon biology. Reconstruction of the upper extremity is limited by 2 major problems after injury or degeneration of the flexor tendons. First, adhesions formed after flexor tendon repair can cause decreased postoperative range of motion and hand function. Second, tendon losses can result from trauma and degenerative diseases, necessitating additional tendon graft material. Tendon adhesions are even more prevalent after tendon grafting; therefore these 2 problems are interrelated and lead to considerable disability. The total costs in terms of disability and inability to return to work are enormous. In this essay, published work from the past 12 years in our basic science laboratory is summarized and presented with the common theme of using molecular techniques to understand the cellular process of flexor tendon wound healing and to create substances and materials to improve tendon repair and regeneration. These are efforts to address 2 interrelated and clinically relevant problems that all hand surgeons face in their practice. Copyright Â© 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Ning, Liang-Ju; Zhang, Yi; Chen, Xiao-He; Luo, Jing-Cong; Li, Xiu-Qun; Yang, Zhi-Ming; Qin, Ting-Wu
To develop a naturally derived tendon tissue engineering scaffold with the preservation of the native ultrastructure, tensile strength, and biochemical composition of the tendon extracellular matrix (ECM), decellularized tendon slices (DTSs) were prepared using repetitive freeze/thaw of the intact Achilles tendons, frozen section, and nuclease treatment. The DTSs were characterized in the native ultrastructure, mechanical properties, biochemical composition, and cytocompatibility. Histological examination and DNA quantification analysis confirmed that cells were completely removed from tendon tissue by repetitive freeze/thaw in combination with nuclease treatment 12 h. The intrinsic ultrastructure of tendon tissue was well preserved based on scanning electron microscopy examination. The tensile strength of the DTSs was retained 85.62% of native tendon slice. More than 93% of proteoglycans (fibromodulin, biglycan) and growth factors (TGF-β1, IGF-1, VEGF, and CTGF) inherent in tendon ECM were preserved in the DTSs according to ELISA analysis. Furthermore, the DTSs facilitated attachment and repopulation of NIH-3T3 fibroblasts in vitro. Overall, the DTSs are sheet scaffolds with a combination of elemental mechanical strength and tendon ECM bioactive factors that may have many potential applications in tendon tissue engineering. Copyright © 2012 Wiley Periodicals, Inc.
Breidenbach, Andrew P; Gilday, Steven D; Lalley, Andrea L; Dyment, Nathaniel A; Gooch, Cynthia; Shearn, Jason T; Butler, David L
Improving tendon repair using Functional Tissue Engineering (FTE) principles has been the focus of our laboratory over the last decade. Although our primary goals were initially focused only on mechanical outcomes, we are now carefully assessing the biological properties of our tissue-engineered tendon repairs so as to link biological influences with mechanics. However, given the complexities of tendon development and healing, it remains challenging to determine which aspects of tendon biology are the most important to focus on in the context of tissue engineering. To address this problem, we have formalized a strategy to identify, prioritize, and evaluate potential biological success criteria for tendon repair. We have defined numerous biological properties of normal tendon relative to cellular phenotype, extracellular matrix and tissue ultra-structure that we would like to reproduce in our tissue-engineered repairs and prioritized these biological criteria by examining their relative importance during both normal development and natural tendon healing. Here, we propose three specific biological criteria which we believe are essential for normal tendon function: 1) scleraxis-expressing cells; 2) well-organized and axially-aligned collagen fibrils having bimodal diameter distribution; and 3) a specialized tendon-to-bone insertion site. Moving forward, these biological success criteria will be used in conjunction with our already established mechanical success criteria to evaluate the effectiveness of our tissue-engineered tendon repairs. PMID:24200342
Tilley, Benjamin J; Cook, Jill L; Docking, Sean I; Gaida, James E
Background Tendon pain occurs in individuals with extreme cholesterol levels (familial hypercholesterolaemia). It is unclear whether the association with tendon pain is strong with less extreme elevations of cholesterol. Objective To determine whether lipid levels are associated with abnormal tendon structure or the presence of tendon pain. Methods We conducted a systematic review and meta-analysis. Relevant articles were found through an electronic search of 6 medical databases—MEDLINE, Cochrane, AMED, EMBASE, Web of Science and Scopus. We included all case–control or cross-sectional studies with data describing (1) lipid levels or use of lipid-lowering drugs and (2) tendon structure or tendon pain. Results 17 studies (2612 participants) were eligible for inclusion in the review. People with altered tendon structure or tendon pain had significantly higher total cholesterol, low-density lipoprotein cholesterol and triglycerides, as well as lower high-density lipoprotein cholesterol; with mean difference values of 0.66, 1.00, 0.33, and −0.19 mmol/L, respectively. Conclusions The results of this review indicate that a relationship exists between an individual’s lipid profile and tendon health. However, further longitudinal studies are required to determine whether a cause and effect relationship exists between tendon structure and lipid levels. This could lead to advancement in the understanding of the pathoaetiology and thus treatment of tendinopathy. PMID:26474596
Blei, C.L.; Nirschl, R.P.; Grant, E.G.
Twenty-three patients were prospectively examined with ultra-sound (US) for acute or recurrent Achilles tendon symptoms. Three types of pathologic conditions of the Achilles tendon were found: tendinitis/tenosynovitis, acute tendon trauma, and postoperative changes. US appears to enable differentiation of these conditions and to contribute to the diagnosis of a broad range of Achilles tendon disorders.
Mirzoev, Timur; Blottner, Dieter; Shenkman, Boris; Lomonosova, Yulia; Vilchinskaya, Natalia; Nemirovskaya, Tatiana; Salanova, Michele
The aim of the study was to analyze some of the key markers regulating anabolic and catabolic processes in mouse m. longissimus dorsi, an important back muscle system for trunk stabilization, following 30-day spaceflight and 8-day recovery period. C57/black mice were divided into 3 groups: 1) Vivarium Control (n=7), 2) Flight (n=5), 3) Recovery (n=5). The experiment was carried out in accordance with the rules of biomedical ethics certified by the Russian Academy of Sciences Committee on Bioethics. Using Western-blotting analysis we determined the content of IRS-1, p-AMPK, MURF-1 and eEF2 in m. longissimus dorsi. The content of IRS-1 in mice m. longissimus dorsi after the 30-day flight did not differ from the control group, however, in the Recovery group IRS-1 level was 80% higher (p<0.05) as compared to Control. Phospho-AMPK content remained unchanged. In the Recovery group there was an increase of eEF2 by 75% compared to the Control (p<0.05). After spaceflight MuRF-1 content was increased more than 2 times compared to the control animals. Thus, our findings showed that the work of the IRS-1 - dependent signaling pathway is only active in the recovery period. The content of the ubiquitin-ligase MURF-1 that takes parts in degrading myosin heavy chain was increased after the spaceflight, however, after 8-day recovery period MURF-1 level did not exceed the control indicating normalization of protein degradation in m. longissimus dorsi. The work was supported by the program of basic research of RAS and Federal Space Program of Russia for the period of 2006-2015.
Kusmia, Slawomir; Eliav, Uzi; Navon, Gil; Guillot, Geneviève
The sequence combining DQF (double quantum filtering) with magnetisation transfer (DQF-MT) was tested as an alternative to the DQF sequence for characterising tendon and muscle by MR imaging. DQF-MT images of tendon-muscle phantoms were obtained at 4.7 T using ultra-short time to echo (UTE) methods in order to alleviate the loss of SNR due to the short T2 of the tissues. Two different sampling schemes of the k-space, Cartesian or radial, were employed. In vivo images of the human ankle on a clinical 1.5 T scanner are also presented. Parameters providing optimal tendon signal as well as optimal contrast between this tissue and muscle were determined. Two sets of parameters resulting in different contrasts between the tissues were found. For the first set (short creation time τ = 10 μs and magnetisation exchange time t LM = 100 ms), DQF-MT signals in muscle and tendon were detected, with that of the tendon being the larger one. For the second set (long creation time τ = 750 μs and magnetisation exchange time 10 μs < t LM < 100 ms), the DQF-MT signal was detected only in the tendon, and the decay of the double quantum coherence was slower than that observed for the first one, which allowed us to acquire DQF-MT MR images on a clinical 1.5 T MR scanner with minimal software interventions. In favourable conditions, the DQF-MT signal in the tendon could represent up to 10 % of the single-quantum signal. Dipolar interaction within macromolecules such as collagen and myosin is at the origin of the DQF-MT signal observed in the first parameter set. This should enable the detection of muscle fibrosis.
Szczesny, Spencer E; Elliott, Dawn M
Despite the critical role tendons play in transmitting loads throughout the musculoskeletal system, little is known about the microstructural mechanisms underlying their mechanical function. Of particular interest is whether collagen fibrils in tendon fascicles bear load independently or if load is transferred between fibrils through interfibrillar shear forces. We conducted multiscale experimental testing and developed a microstructural shear lag model to explicitly test whether interfibrillar shear load transfer is indeed the fibrillar loading mechanism in tendon. Experimental correlations between fascicle macroscale mechanics and microscale interfibrillar sliding suggest that fibrils are discontinuous and share load. Moreover, for the first time, we demonstrate that a shear lag model can replicate the fascicle macroscale mechanics as well as predict the microscale fibrillar deformations. Since interfibrillar shear stress is the fundamental loading mechanism assumed in the model, this result provides strong evidence that load is transferred between fibrils in tendon and possibly other aligned collagenous tissues. Conclusively establishing this fibrillar loading mechanism and identifying the involved structural components should help develop repair strategies for tissue degeneration and guide the design of tissue engineered replacements. Copyright © 2014 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.
Szczesny, Spencer E.; Elliott, Dawn M.
Despite the critical role tendons play in transmitting loads throughout the musculoskeletal system, little is known about the microstructural mechanisms underlying their mechanical function. Of particular interest is whether collagen fibrils in tendon fascicles bear load independently or if load is transferred between fibrils through interfibrillar shear forces. We conducted multiscale experimental testing and developed a microstructural shear lag model to explicitly test whether interfibrillar shear load transfer is indeed the fibrillar loading mechanism in tendon. Experimental correlations between fascicle macroscale mechanics and microscale interfibrillar sliding suggest that fibrils are discontinuous and share load. Moreover, for the first time, we demonstrate that a shear lag model can replicate the fascicle macroscale mechanics as well as predict the microscale fibrillar deformations. Since interfibrillar shear stress is the fundamental loading mechanism assumed in the model, this result provides strong evidence that load is transferred between fibrils in tendon and possibly other aligned collagenous tissues. Conclusively establishing this fibrillar loading mechanism and identifying the involved structural components should help develop repair strategies for tissue degeneration and guide the design of tissue engineered replacements. PMID:24530560
Qi, Y X; Zhang, X H; Wang, Y Q; Pang, Y Z; Zhang, Z B; Zhang, T L; Zhang, Z X
The extracellular matrix (ECM) is the major macromolecule in skeletal muscle, which affects meat quality greatly. The remodeling of the ECM is mainly regulated by matrix metalloproteinases (MMPs). The expression patterns of MMP-1, -2, and -8 in longissimus dorsi muscle were explored using quantitative real-time polymerase chain reaction. The results show that the expression of MMP-1, -2, and -8 decreased significantly from 135 days of pregnancy to postnatal 30 months. While the expression of MMP-1, -2, and -8 showed no significant relationships with intramuscular fat contents, MMP-1 and -2 showed significant negative correlations with the shearing force of the longissimus dorsi muscle in cattle. The expression of MMP-1 also showed a significant negative correlation with cooking loss and a positive correlation with water holding capacity. The expression levels of MMP-1 and -2 were usually higher in fat than in skeletal muscle tissue. The expression of MMP-8 was significantly higher in the mammary fat pad and the longissimus dorsi muscle than in all other tissues. This study indicates that the remodeling of the ECM has important effects both on the development of postnatal skeletal muscle and on meat quality.
Simões, Ricardo; Machado, Eduardo Luis Guimarães; Freitas, Odilon Gariglio de Alvarenga; Moreira, Maria da Consolação Vieira; Gomes, Otoni Moreira
To study the effect of propafenone on the contractile function of latissimus dorsi muscle isolated from rats in an organ chamber. We studied 20 latissimus dorsi muscles of Wistar rats and divided them into 2 groups: group I (n=10), or control group - we studied the feasibility of muscle contractility; group II (n=10), in which the contralateral muscles were grouped - we analyzed the effect of propafenone on muscle contractility. After building a muscle ring, 8 periods of sequential 2-minute baths were performed, with intervals of preprogrammed electrical stimulation using a pacemaker of 50 stimuli/min. In group II, propafenone, at the concentration of 9.8 microgram/mL, was added to the bath in period 2 and withdrawn in period 4. In group I, no significant depression in muscle contraction occurred up to period 5 (p>0.05). In group II, a significant depression occurred in all periods, except between the last 2 periods (p<0.05). Comparing groups I and II only in period 1, which was a standard period for both groups, we found no significant difference (p>0.05). Propafenone had a depressing effect on the contractile function of latissimus dorsi muscle isolated from rats and studied in an organ chamber.
Lloyd, T W; Tyler, M P; Roberts, A H
A 23 year old male kick boxer presented with a 24 hour history of pain and being unable to extend the interphalangeal joint of the left thumb. There was no history of trauma or any other risk factor for spontaneous rupture of the extensor pollicis longus tendon. On the previous day, he had been doing reverse press ups on the dorsum of his hands with his wrists hyperflexed as part of his training for kick boxing. At operation the extensor pollicis longus tendon was found to be divided at the level of the dorsal tubercle of the radius and was not directly repairable. The treatment was an extensor indicis proprius transfer. We suggest that the cause of the tendon rupture was direct pressure on the dorsal tubercle of the radius sustained while performing reverse press ups.
Lloyd, T. W.; Tyler, M. P.; Roberts, A. H.
A 23 year old male kick boxer presented with a 24 hour history of pain and being unable to extend the interphalangeal joint of the left thumb. There was no history of trauma or any other risk factor for spontaneous rupture of the extensor pollicis longus tendon. On the previous day, he had been doing reverse press ups on the dorsum of his hands with his wrists hyperflexed as part of his training for kick boxing. At operation the extensor pollicis longus tendon was found to be divided at the level of the dorsal tubercle of the radius and was not directly repairable. The treatment was an extensor indicis proprius transfer. We suggest that the cause of the tendon rupture was direct pressure on the dorsal tubercle of the radius sustained while performing reverse press ups. PMID:9631230
Evans, Roslyn B
Despite advances in understanding of the mechanical aspects of tendon management with improved suture technique and early stress application with postoperative therapy, clinical results remain inconsistent after repair, especially within the synovial regions. Complementary research to enhance the intrinsic pathway of healing, suppress the extrinsic pathway of healing, and manipulate frictional resistance to tendon gliding is now the focus of current basic science research on tendons. In the future, application of these new biologic therapies may increase the "safety zone" (or tolerance for load and excursion without dysfunctional gapping) as therapists apply stress to healing tendons and may alter future rehabilitation protocols by allowing greater angles of motion (and thus tendon excursion), increased external load, and decreased time in protective orthoses (splints). However, at this time, the stronger repair techniques and the application of controlled stress remain the best and most well-supported intervention after tendon injury and repair in the recovery of functional tendon excursion and joint range of motion. The hand therapist's role in this process remains a critical component contributing to satisfactory outcomes. Copyright © 2012 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.
A histologically normal insertion site does not regenerate following rotator cuff tendon-to-bone repair, which is likely due to abnormal or insufficient gene expression and/or cell differentiation at the repair site. Techniques to manipulate the biologic events following tendon repair may improve healing. We used a sheep infraspinatus repair model to evaluate the effect of osteoinductive growth factors and BMP-12 on tendon-to-bone healing. Magnetic resonance imaging and histology showed increased formation of new bone and fibrocartilage at the healing tendon attachment site in the treated animals, and biomechanical testing showed improved load-to-failure. Other techniques with potential to augment repair site biology include use of platelets isolated from autologous blood to deliver growth factors to a tendon repair site. Modalities that improve local vascularity, such as pulsed ultrasound, have the potential to augment rotator cuff healing. Important information about the biology of tendon healing can also be gained from studies of substances that inhibit healing, such as nicotine and antiinflammatory medications. Future approaches may include the use of stem cells and transcription factors to induce formation of the native tendon-bone insertion site after rotator cuff repair surgery. PMID:18264850
Burrus, M Tyrrell; Werner, Brian C; Park, Joseph S; Perumal, Venkat; Cooper, M Truit
Objective The objective of the present study is to utilize a national database to examine the association between obesity and postoperative complications after primary Achilles tendon repair. Methods The PearlDiver database was queried for patients undergoing primary Achilles repair using CPT 27650. Excision of a Haglund's deformity or tendon transfer were exclusion criteria. Patients were then divided into obese (body mass index [BMI] > 30 kg/m(2)) and nonobese (BMI < 30 kg/m(2)) cohorts using ICD-9 codes. Complications within 90 days postoperatively were assessed using ICD-9 and CPT codes. Results In all, 18 948 patients who underwent primary Achilles tendon repair were identified from 2005 to 2012. Overall, 2962 patients (15.6%) were coded as obese or morbidly obese. Obese patients had significantly higher rates of postoperative wound complications (odds ratio [OR] = 2.1; P < .0001), infection (OR = 1.8; P < .0001), venous thromboembolism (VTE; OR = 1.8; P = .001), and medical complications (OR = 3.9; P < .0001) compared with nonobese patients after primary Achilles tendon repair. Additionally, obese patients had a significantly lower rate of ankle stiffnesassociated with a significantly higher risk of s (OR = 0.4; P < .0001) compared with nonobese patients. Conclusion Obesity is associated with a significantly higher risk of wound complications, infection, VTE, and medical complications after primary Achilles tendon repair. Prognostic, Level II: Retrospective study. © 2015 The Author(s).
Font Tellado, Sònia; Bonani, Walter; Balmayor, Elizabeth R; Foehr, Peter; Motta, Antonella; Migliaresi, Claudio; van Griensven, Martijn
Tissue engineering is an attractive strategy for tendon/ligament-to-bone interface repair. The structure and extracellular matrix composition of the interface are complex and allow for a gradual mechanical stress transfer between tendons/ligaments and bone. Thus, scaffolds mimicking the structural features of the native interface may be able to better support functional tissue regeneration. In this study, we fabricated biphasic silk fibroin scaffolds designed to mimic the gradient in collagen molecule alignment present at the interface. The scaffolds had two different pore alignments: anisotropic at the tendon/ligament side and isotropic at the bone side. Total porosity ranged from 50% to 80% and the majority of pores (80-90%) were <100-300 μm. Young's modulus varied from 689 to 1322 kPa depending on the type of construct. In addition, human adipose-derived mesenchymal stem cells were cultured on the scaffolds to evaluate the effect of pore morphology on cell proliferation and gene expression. Biphasic scaffolds supported cell attachment and influenced cytoskeleton organization depending on pore alignment. In addition, the gene expression of tendon/ligament, enthesis, and cartilage markers significantly changed depending on pore alignment in each region of the scaffolds. In conclusion, the biphasic scaffolds fabricated in this study show promising features for tendon/ligament-to-bone tissue engineering.
Ramsey, M L
Rupture of the distal biceps tendon occurs most commonly in the dominant extremity of men between 40 and 60 years of age when an unexpected extension force is applied to the flexed arm. Although previously thought to be an uncommon injury, distal biceps tendon ruptures are being reported with increasing frequency. The rupture typically occurs at the tendon insertion into the radial tuberosity in an area of preexisting tendon degeneration. The diagnosis is made on the basis of a history of a painful, tearing sensation in the antecubital region. Physical examination demonstrates a palpable and visible deformity of the distal biceps muscle belly with weakness in flexion and supination. The ability to palpate the tendon in the antecubital fossa may indicate partial tearing of the biceps tendon. Plain radiographs may show hypertrophic bone formation at the radial tuberosity. Magnetic resonance imaging is generally not required to diagnose a complete rupture but may be useful in the case of a partial rupture. Early surgical reattachment to the radial tuberosity is recommended for optimal results. A modified two-incision technique is the most widely used method of repair, but anterior single-incision techniques may be equally effective provided the radial nerve is protected. The patient with a chronic rupture may benefit from surgical reattachment, but proximal retraction and scarring of the muscle belly can make tendon mobilization difficult, and inadequate length of the distal biceps tendon may necessitate tendon augmentation. Postoperative rehabilitation must emphasize protected return of motion for the first 8 weeks after repair. Formal strengthening may begin as early as 8 weeks, with a return to unrestricted activities, including lifting, by 5 months.
Sharma, Pankaj; Maffulli, Nicola
Tendon disorders are frequent and are responsible for substantial morbidity both in sports and in the workplace. Tendinopathy, as opposed to tendinitis or tendinosis, is the best generic descriptive term for the clinical conditions in and around tendons arising from overuse. Tendinopathy is a difficult problem requiring lengthy management, and patients often respond poorly to treatment. Preexisting degeneration has been implicated as a risk factor for acute tendon rupture. Several physical modalities have been developed to treat tendinopathy. There is limited and mixed high-level evidence to support the, albeit common, clinical use of these modalities. Further research and scientific evaluation are required before biological solutions become realistic options.
Gulotta, Lawrence V.; Chaudhury, Salma; Wiznia, Daniel
Tendon healing is fraught with complications such as reruptures and adhesion formation due to the formation of scar tissue at the injury site as opposed to the regeneration of native tissue. Stem cells are an attractive option in developing cell-based therapies to improve tendon healing. However, several questions remain to be answered before stem cells can be used clinically. Specifically, the type of stem cell, the amount of cells, and the proper combination of growth factors or mechanical stimuli to induce differentiation all remain to be seen. This paper outlines the current literature on the use of stem cells for tendon augmentation. PMID:22190960
Murray, G A; Semple, J C
Work done to date on artificial tendons by many authors is described in chronological order. A brief description of the techniques and materials is given in each case, with a summary of the results. The overall implications of the work are discussed in terms of prosthesis durability, the attachment to bone and tendon, mechanical properties and the volume of scar tissue generated. It is concluded that construction of a permanent artificial tendon is a realistic and worthwhile aim; further experimental work ought to include long term in vivo testing with means provided for monitoring any drift of the attachment points.
Manske, Mary Claire; McKeon, Kathleen E; Johnson, Jeffrey E; McCormick, Jeremy J; Klein, Sandra E
Tibialis posterior tendon dysfunction is a common disorder leading to pain, deformity, and disability, although its pathogenesis is unclear. A vascular etiology has been proposed, but there is controversy regarding the existence of a hypovascular region that may render the tendon vulnerable. The purpose of this study was to provide a description of the arterial anatomy supplying the tibialis posterior tendon. Sixty adult cadaveric lower extremities were obtained from a university-affiliated body donation program. Thirty specimens obtained within 72 hours of death were used for microscopic analysis. Thirty specimens were previously frozen and used for macroscopic analysis. The tibialis anterior, tibialis posterior, and peroneal arteries were injected with India Ink and Ward's Blue Latex. The specimens used for macroscopic analysis were debrided with sodium hypochlorite to expose the extratendinous anatomy. For the microscopic analysis, the tendon was cleared using a modified Spälteholz technique to expose the intratendinous vascular anatomy. Macroscopically, an average of 2.5 ± 0.7 vessels entered the tendon proximal to the navicular insertion. In all, 28/30 (93.3%) specimens had a vessel entering 4.1 ± 0.6 cm proximal to the medial malleolus and 24/30 (80.0%) specimens had a vessel entering 1.7 ± 0.9 cm distal to the medial malleolus. Microscopically, an average of 1.9 ± 0.3 vessels entered each tendon proximal to the navicular insertion. In total, 27/30 (90%) specimens had a vessel entering the tendon 4.8 ± 0.8 cm proximal to the medial malleolus and 30/30 (100%) specimens had a vessel entering the tendon 1.9 ± 0.8 cm distal to the medial malleolus. In all specimens, a hypovascular region was observed, starting 2.2 ± 0.8 cm proximal to the medial malleolus and ending 0.6 ± 0.6 cm proximal to the medial malleolus with an average length of 1.5 ± 1.0 cm. The insertion of the tendon was well vascularized both on microscopic and macroscopic specimens. The
Washer, Glenn A.; Green, Robert E.
The goal of this research was to examine ultrasonic stress measurement techniques for the condition assessment of prestressing tendons. Acoustoelastic measurements were made in prestressing rods and strands, and constants are reported that relate the change in ultrasonic velocity to the change in stress. The effects of dispersion in prestressing tendons, which act as circular wave guides for ultrasonic waves, were measured and evaluated. For this research, narrow-band, noncontact Electromagnetic Acoustic Transducers (EMATs) were designed to launch and receive ultrasonic waves propagating within the tendons.
Damkat-Thomas, L; Black, CE; Herbert, K
An unusual case of fibromatosis of the dominant left flexor pollicus longus (FPL) in a thirteen year old schoolboy. Initially presenting with pain in the thenar eminence and difficulty flexing the metacarpal phalangeal joint (MPJ), other symptoms include locking, triggering and difficulty writing. MRI showed a 4cm segment of thickened abnormal tendon. Intra-operatively three 1cm nodules were excised from the FPL while preserving the tendon. Histopathology reported the nodules as fibromatosis. A literature search revealed that this has not previously been reported although symptomatic tendon sheath fibromas have. Our patient achieved a good result following surgical intervention and the two year review has shown no complications. PMID:24946359
Virk, Mandeep S; Cole, Brian J
The long head of biceps tendon (LHBT) is frequently involved in rotator cuff tears and can cause anterior shoulder pain. Tendon hypertrophy, hourglass contracture, delamination, tears, and tendon instability in the bicipital groove are common macroscopic pathologic findings affecting the LHBT in the presence of rotator cuff tears. Failure to address LHBT disorders in the setting of rotator cuff tear can result in persistent shoulder pain and poor satisfaction after rotator cuff repair. Tenotomy or tenodesis of the LHBT are effective options for relieving pain arising from the LHBT in the setting of reparable and selected irreparable rotator cuff tears.
Background: Some intractable cases of postcraniotomy infection, which can involve compromised skin, an open frontal air sinus, and residual epidural dead space, have been reported. In such cases, reconstructing the scalp and skull is challenging. Methods: Between 2009 and 2016, the author treated 12 patients with recalcitrant postcraniotomy surgical site infections with latissimus dorsi (LD) free flaps. The patients’ ages ranged from 37 to 79 years (mean, 63.5 years), and their underlying diseases included subarachnoid hemorrhaging (n = 5), brain tumors (n = 4), and cerebral arteriovenous malformations (n = 3). Results: The LD free flap was used for scalp reconstruction in 3 cases, scalp reconstruction and separation of the intracranial and nasal cavities in 5 cases, and the obliteration of epidural dead space in 4 cases. Debridement followed by staged cranial reconstruction was carried out in 8 cases, and single-stage cranial reconstruction was conducted in 2 cases. The bone defects of the other 2 cases, which were small, were filled with LD musculo-adipose free flaps. The postoperative local appearance of the wounds was acceptable in every case, and no complications occurred. Conclusions: The LD free flap is a versatile tool for the treatment of complex postcraniotomy surgical site infections. This vascularized muscle flap is useful for controlling local infections because of its abundant vascularity. Moreover, its variety of uses means that it can resolve several problems in cases involving complex cranial wounds. PMID:28740770
Ma, Ji; Sun, Da-Wen; Pu, Hongbin
Spectral absorption index was proposed to extract the morphological features of the spectral curves in pork meat samples (longissimus dorsi) under the conditions including fresh, frozen-thawed, heated-dehydrated and brined-dehydrated. Savitzky-Golay (SG) smoothing and multiplicative scatter correction (MSC) were used for calibrating both the spectral reflectance and absorbance values. The absorption values were better than the reflectance values and the calibrated spectra by MSC were better than the raw and SG smoothing corrected spectra in building moisture content predictive models. The optimized partial least square regression (PLSR) model attained good results with the MSC calibrated spectral absorption values based on the spectral absorption index features (R(2)P=0.952, RMSEP=1.396) and the optimal wavelengths selected by regression coefficients (R(2)P=0.966, RMSEP=0.855), respectively. The models proved spectral absorption index was promising in spectral analysis to predict moisture content in pork samples using HSI techniques for the first time.
Xu, Shuman; Tang, Peng; Chen, Xianchun; Yang, Xi; Pan, Qinwen; Gui, Yu; Chen, Li
Abstract Backgroud: An important drawback of the traditional technique for harvesting latissimus dorsi (LD) myocutaneous flap is a long, posterior donor-site incision. Current techniques involve endoscopic or robotic harvesting via a combined approach of open and closed surgery, which necessitates an open axillary incision and the use of special retractors. In this paper, we introduce a fully enclosed laparoscopic technique for harvesting LD flap (LDF) using only 3 small trocar ports. This technique eliminates the need for axillary and donor-site incisions and specialized retractors and considerably reduces the incision size. Methods: We performed laparoscopic harvesting of LDF with prosthesis implantation for immediate breast reconstruction (IBR) after nipple-sparing mastectomy in 2 patients with malignant breast neoplasm who wished to avoid a long scar on the back. Results: IBR using this technique was uneventful in both cases, without any donor-site complications or flap failure. Both patients were satisfied with the esthetic results of the procedure, especially the absence of a visible scar on the back. Conclusion: Enclosed laparoscopic harvesting of LDF is simpler and less invasive than the traditional methods. These preliminary results warrant further evaluation in a larger population to validate the benefits of this technique. PMID:27861385
Kaur, N; Gupta, A; Saini, S
Breast reconstruction (BR) plays a significant role in the woman's physical, emotional and psychological recovery from breast cancer. However, the current most accepted methods of reconstruction are expensive, may require microsurgical skills and can be offered to a very small number of patients seeking treatment in tertiary care centers. For the large majority of women seeking treatment in public hospitals, solution lies in finding a method of reconstruction, which is autologous, produces a reasonable match to the contralateral breast in size, shape and symmetry and produces minimal donor site morbidity. It should also be a technique, which is cost effective and can withstand the effects of radiotherapy (RT). The autologous latissimus dorsi (LD) flap is one such versatile technique, which can serve as an ideal reconstructive option for the majority of patients. During a period of 6 years, 19 patients underwent immediate BR using this flap in the Department of General Surgery. Patients who were young (mean age 37.4 years), had small to medium sized breasts, with operable breast cancer (Stage II and IIIa) were selected for the procedure. Satisfactory cosmetic results as rated by patients as well as surgeons were achieved in the majority. Donor site morbidities were seroma formation (78%) and donor site wound breakdown (21%). Post-operative RT was well-tolerated by the reconstructed breast. Autologous LD flap reconstruction is a safe and economical option for BR in low resource settings and is suitable for women with small and medium sized breasts.
Goh, Terence; Tan, Bien-Keem; Ong, Yee-Siang; Chew, Winston
The latissimus dorsi (LD) flap is a large and reliable myocutaneous flap with a consistently long vascular pedicle. However, the limitation of the thoracodorsal pedicle is that it has only one draining vein for anastomosis. We describe a simple technique of recruiting the tributary vein to the serratus anterior and using it as a second draining vein to alleviate congestion in lower limb reconstruction. The serratus anterior venous tributary segment is cut back to an avalvular segment which averages 5 mm in length. Provision of an additional venous outflow to the flap enabled a second venous anastomosis to the short saphenous vein (N = 1), the long saphenous vein (N = 2), a deep vein (N= 1), and to a deep vein via a vein graft (N = 1), respectively. Five patients with degloving injury of the lower extremity of sizes 150 cm(2) (10 × 15 cm) to 260 cm(2) (10 × 26 cm) underwent successful reconstruction using the LD muscle flap with the serratus anterior tributary vein as a second outflow vein. This serratus anterior venous tributary serves as a useful second outflow channel for alleviating venous congestion during lower limb reconstructive surgery and should be routinely preserved as a lifeboat.
Bak, Kathrine Holmgaard; Lindahl, Gunilla; Karlsson, Anders H; Orlien, Vibeke
The color of pork longissimus dorsi high pressure (HP) treated at 200 to 800 MPa at 5 and 20 °C for 10 min was determined to a high degree by pressure level and to a lesser degree by temperature. Severe color changes appeared up to a threshold pressure at 400 MPa. HP treatment at 20 °C compared to 5 °C resulted in meat, which was less red and slightly lighter. Storage at 2 °C for 6 days had no effect on lightness due to no further protein denaturation, but meat HP treated above 300 MPa became significantly less red and more yellow within the first day of storage. Reflectance spectra showed that a short-lived ferrohemochrome myoglobin species was formed during HP treatment at 300 to 800, but transformed into a brown, ferric form of the pigment within the first day of storage. This explains the observed changes in the redness and yellowness after one day of storage.
Legrand, Anais; Kaufman, Yoav; Long, Chao; Fox, Paige M
Tendon injuries are encountered after major and minor hand trauma. Despite meticulous repair technique, adhesion formation can occur, limiting recovery. Although a great deal of progress has been made toward understanding the mechanism of tendon healing and adhesions, clinically applicable solutions to prevent adhesions remain elusive. The goal of this paper is to review the most recent literature relating to the tendon healing and adhesion prevention. Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Okech, William; Kuo, Catherine K
Adult tendons fail to regenerate normal tissue after injury, and instead form dysfunctional scar tissue with abnormal mechanical properties. Surgical repair with grafts is the current standard to treat injuries, but faces significant limitations including pain and high rates of re-injury. To address this, we aim to regenerate new, normal tendons to replace dysfunctional tendons. A common approach to tendon tissue engineering is to design scaffolds and bioreactors based on adult tendon properties that can direct adult stem cell tenogenesis. Despite significant progress, advances have been limited due, in part, to a need for markers and potent induction cues. Our goal is to develop novel tendon tissue engineering approaches informed by embryonic tendon development. We are characterizing structure-property relationships of embryonic tendon to identify design parameters for three-dimensional scaffolds and bioreactor mechanical loading systems to direct adult stem cell tenogenesis. We will review studies in which we quantified changes in the mechanical and biochemical properties of tendon during embryonic development and elucidated specific mechanisms of functional property elaboration. We then examined the effects of these mechanical and biochemical factors on embryonic tendon cell behavior. Using custom-designed bioreactors, we also examined the effects of dynamic mechanical loading and growth factor treatment on embryonic tendon cells. Our findings have established cues to induce tenogenesis as well as metrics to evaluate differentiation. We finish by discussing how we have evaluated the tenogenic differentiation potential of adult stem cells by comparing their responses to that of embryonic tendon cells in these culture systems.
Mechchat, Atif; Elidrissi, Mohammed; Mardy, Abdelhak; Elayoubi, Abdelghni; Shimi, Mohammed; Elibrahimi, Abdelhalim; Elmrini, Abdelmajid
Les plaies du tendon patellaire sont peu fréquentes et sont peu rapportés dans la littérature, contrairement aux ruptures sous cutanées. Les sections du tendon patellaire nécessitent une réparation immédiate afin de rétablir l'appareil extenseur et de permettre une récupération fonctionnelle précoce. A travers ce travail rétrospectif sur 13 cas, nous analysons les aspects épidémiologiques, thérapeutiques et pronostiques de ce type de pathologie en comparant différents scores. L’âge moyen est de 25 ans avec une prédominance masculine. Les étiologies sont dominées par les accidents de la voie publique (68%) et les agressions par agent tranchant (26%) et contendant (6 %). Tous nos patients ont bénéficié d'un parage chirurgical avec suture tendineuse direct protégée par un laçage au fils d'aciers en légère flexion. La rééducation est débutée après sédation des phénomènes inflammatoires. Au dernier recul les résultats sont excellents et bon à 92%. Nous n'avons pas noté de différence de force musculaire et d'amplitude articulaire entre le genou sain et le genou lésé. Les lésions ouvertes du tendon patellaire est relativement rare. La prise en charge chirurgicale rapide donne des résultats assez satisfaisants. La réparation est généralement renforcée par un semi-tendineux, synthétique ou métallique en forme de cadre de renfort pour faciliter la réadaptation et réduire le risque de récidive après la fin de l'immobilisation. PMID:25170379
Cystic fibrosis transmembrane conductance regulator mediates tenogenic differentiation of tendon-derived stem cells and tendon repair: accelerating tendon injury healing by intervening in its downstream signaling.
Liu, Yang; Xu, Jia; Xu, Liangliang; Wu, Tianyi; Sun, Yuxin; Lee, Yuk-Wai; Wang, Bin; Chan, Hsiao-Chang; Jiang, Xiaohua; Zhang, Jinfang; Li, Gang
Tendons are a mechanosensitive tissue, which enables them to transmit to bone forces that are derived from muscle. Patients with tendon injuries, such as tendinopathy or tendon rupture, were often observed with matrix degeneration, and the healing of tendon injuries remains a challenge as a result of the limited understanding of tendon biology. Our study demonstrates that the stretch-mediated activation channel, cystic fibrosis transmembrane conductance regulator (CFTR), was up-regulated in tendon-derived stem cells (TDSCs) during tenogenic differentiation under mechanical stretching. Tendon tissues in CFTR-dysfunctional DF508 mice exhibited irregular cell arrangement, uneven fibril diameter distribution, weak mechanical properties, and less matrix formation in a tendon defect model. Moreover, both tendon tissues and TDSCs isolated from DF508 mice showed significantly decreased levels of tendon markers, such as scleraxis, tenomodulin, Col1A1 (collagen type I α 1 chain), and decorin Furthermore, by RNA sequencing analysis, we demonstrated that Wnt/β-catenin signaling was abnormally activated in TDSCs from DF508 mice, thereby further activating the pERK1/2 signaling pathway. Of most importance, we found that intervention in pERK1/2 signaling could promote tenogenic differentiation and tendon regeneration both in vitro and in vivo Taken together, our study demonstrates that CFTR plays an important role in tenogenic differentiation and tendon regeneration by inhibiting the β-catinin/pERK1/2 signaling pathway. The therapeutic strategy of intervening in the CFTR/β-catenin/pERK1/2 regulatory axis may be helpful for accelerating tendon injury healing, which has implications for tendon injury management.-Liu, Y., Xu, J., Xu, L., Wu, T., Sun, Y., Lee, Y.-W., Wang, B., Chan, H.-C., Jiang, X., Zhang, J., Li, G. Cystic fibrosis transmembrane conductance regulator mediates tenogenic differentiation of tendon-derived stem cells and tendon repair: accelerating tendon injury
Kontogeorgakos, Vasileios; Koutalos, Antonios; Hantes, Michael; Manoudis, Gregory; Badras, Leonidas; Malizos, Konstantinos
A novel technique for managing ruptured tibialis anterior tendon complicated by infection and tendon substance loss in a young adult is described. A two-stage reconstruction technique with a silicon tube and tendon autograft was performed. At first, after local control of the infection, scar excision and placement of a silicone tube was performed. Ten weeks later, ipsilateral hamstrings tendons were harvested and bridged the 7 cm tendon gap. Eighteen months later, the patient has excellent clinical and functional outcome.
Yamamoto, Kenichi; Hojo, Hironori; Koshima, Isao; Chung, Ung-il; Ohba, Shinsuke
Heterotopic ossification or calcification follows any type of musculoskeletal trauma and is known to occur after arthroplasties of hip, knee, shoulder, or elbow; fractures; joint dislocations; or tendon ruptures. Histamine receptor H2 (Hrh2) has been shown to be effective for reducing pain and decreasing calcification in patients with calcifying tendinitis, which suggested that H2 blockers were effective for the treatment of tendon ossification or calcification. However, the detailed mechanisms of its action on tendon remain to be clarified. We investigated the mechanisms underlying H2 blocker-mediated suppression of tendon calcification, with a focus on the direct action of the drug on tendon cells. Famotidine treatment suppressed the mRNA expressions of Col10a1 and osteocalcin, ossification markers, in a tendon-derived cell line TT-D6, as well as a preosteoblastic one MC3T3-E1. Both of the cell lines expressed Hrh2; histamine treatment induced osteocalcin expression in these cells. Famotidine administration suppressed calcification in the Achilles tendon of ttw mice, a mouse model of ectopic ossification. These data suggest that famotidine inhibits osteogenic differentiation of tendon cells in vitro, and this inhibition may underlie the anti-calcification effects of the drug in vivo. This study points to the use of H2 blockers as a promising strategy for treating heterotopic ossification or calcification in tendon, and provides evidence in support of the clinical use of famotidine.
Gelberman, Richard H; Linderman, Stephen W; Jayaram, Rohith; Dikina, Anna D; Sakiyama-Elbert, Shelly; Alsberg, Eben; Thomopoulos, Stavros; Shen, Hua
formation. Quantitative assessment of gene and protein expression showed effects of treatment: ASC-sheet treatment modulated the postrepair inflammatory response and facilitated healing by increasing regenerative M2 macrophages (M2 marker CD204, twofold of normal, p = 0.030), inflammatory inhibitor (prostaglandin reductase 1 [PTRG1], 1.6-fold of normal, p = 0.026), and proteins involved in tendon formation (periostin [POSTN], 1.9-fold of normal, p = 0.035). Consistently, semiquantitative and qualitative evaluations of repaired tissue showed that ASC-sheet treatment reduced mononuclear cell infiltration (12% less than nontreated tendons, p = 0.021) and introduced CD146+ stem or progenitor cells to the repair site. The combined administration of ASCs and rBMP-12 further stimulated M2 macrophages by increasing IL-4 (116-fold of normal, p = 0.002) and led to the increase of M2 effector matrix metalloproteinase-12 involved in matrix remodeling (twofold of normal, p = 0.016) and reduction of a negative regulator of angiogenesis and cell migration (StAR-related lipid transfer domain protein13 [STARD13]; 84% of normal, p = 0.000), thus facilitating the proliferative stage of tendon repair. ASCs and BMP-12 accelerated the progression of healing in the proliferative stage of tendon repair. The effects of ASCs and BMP-12 on tendon functional recovery should be evaluated in future studies. The cell sheet approach is an effective, biocompatible, and surgeon-friendly approach for cell and growth factor delivery during tendon repair. Combined application of ASCs and BMP-12 may accelerate intrasynovial tendon healing while suppressing the adverse inflammatory response.
Sarman, Hakan; Atmaca, Halil; Cakir, Ozgur; Muezzinoglu, Umit Sefa; Anik, Yonca; Memisoglu, Kaya; Baran, Tuncay; Isik, Cengiz
Although pre- and postoperative imaging of Achilles tendon rupture (ATR) has been well documented, radiographic evaluations of postoperative intratendinous healing and microstructure are still lacking. Diffusion tensor imaging (DTI) is an innovative technique that offers a noninvasive method for describing the microstructure characteristics and organization of tissues. DTI was used in the present study for quantitative assessment of fiber continuity postoperatively in patients with acute ATR. The data from 16 patients with ATR from 2005 to 2012 were retrospectively analyzed. The microstructure of ART was evaluated using tendon fiber tracking, tendon continuity, fractional anisotropy, and apparent diffusion coefficient values by way of DTI. The distal and proximal portions were measured separately in both the ruptured and the healthy extremities of each patient. The mean patient age was 41.56 ± 8.49 (range 26 to 56) years. The median duration of follow-up was 21 (range 6 to 80) months. The tendon fractional anisotropy values of the ruptured Achilles tendon were significantly lower statistically than those of the normal side (p = .001). However, none of the differences between the 2 groups with respect to the distal and proximal apparent diffusion coefficient were statistically significant (p = .358 and p = .899, respectively). In addition, the fractional anisotropy and apparent diffusion coefficient measurements were not significantly different in the proximal and distal regions of the ruptured tendons compared with the healthy tendons. The present study used DTI and fiber tracking to demonstrate the radiologic properties of postoperative Achilles tendons with respect to trajectory and tendinous fiber continuity. Quantifying DTI and fiber tractography offers an innovative and effective tool that might be able to detect microstructural abnormalities not appreciable using conventional radiologic techniques.
Domnick, C; Herbort, M; Raschke, M J; Schliemann, B; Siebold, R; Śmigielski, R; Fink, C
The structural properties of hamstring tendon grafts were evaluated in a porcine model, after processing it to a flat shape, to better replace or augment anatomic flat structures (e.g. ACL, MPFL or MCL). In this biomechanical study, porcine flexor tendons were used which have a comparable shape to semitendinosus and gracilis tendons. One part of the tendon was prepared to a flat tendon construct by splitting the tendon longitudinally with a knife to half of the diameter of the tendon. The semi-split tendon was scratched out to a flat shape. The other matched part was tested in its original round shape. The tendons (n = 40) have been fixed in a uniaxial testing machine (Zwick/Roell) by cryo-clamps after preparing the fixed ends by 2-0 polyester sutures (2-0 Ethibond(®) EXCEL, Ethicon, Somerville, NJ). In every specimen, there was a free 60-mm tendon part between both clamps. The tendons have been loaded to failure to evaluate typical biomechanical parameters such as stiffness, yield load and maximum load. No statistically significant differences (n.s.) regarding stiffness, yield load and maximum load between natively round and processed flat tendons could be detected. A prepared flat-shaped tendon does not show any different structural properties compared with an original round tendon. Therefore, a flat tendon seems to be a biomechanical stable graft option for anatomic reconstruction or augmentation of injured natively flat-shaped structures such as MCL, MPFL or ACL.
Common sports, involving raising the arms above the head, i.e., throwing, racquet games and swimming, often result in rotator cuff tendinitis. During the throwing motion, the humeral head and its overlying biceps tendon and rotator cuff must pass rapidly under the coraco-acromial arch. Damage to these structures can occur by several mechanism. First, an increase in the size of the structures passing underneath the arch may lead to impingement. This can occur either by way of hypertrophy of the musculotendinous cuff or by way of inflammation of the cuff. Second, a decreased space available underneath the arch secondary to osteophyte formation of the acromion and fibrosis of the subacromial space may lead to impingement. Third, weakness or incompetence of the rotator cuff allows the humerus to ride up and impinge on the coracoacromial arch with motion of the shoulder. Tendinitis can be combined with increased laxity of the glenohumeral joint and/or acquired instability due to a labral tear. Prevention of overuse injuries is a cornerstone of our treatment concept. The muscle tendon unit requires passive and neuromuscular facilitated streching after warming-up exercises. Muscular imbalance and weakness are prevented by balanced eccentric strenthening with particular attention to the external rotators and scapular muscles. Knowledge of the mechanics of the pitching motion, tennis serve, swimming stroke, etc. is of paramount importance in the prevention of injuries. As the onset of shoulder problems contributes to a particularly fatiguing situation, extreme fatique performance severity should be avoided. Every effort must be made to apply conservative treatment when overuse problems arise in the athlete's shoulder.(ABSTRACT TRUNCATED AT 250 WORDS)
Abdallah, Muhammad E.; Platt, Robert, Jr.; Hargrave, B.; Pementer, Frank
Conventionally, tendon-driven manipulators implement some force control scheme based on tension feedback. This feedback allows the system to ensure that the tendons are maintained taut with proper levels of tensioning at all times. Occasionally, whether it is due to the lack of tension feedback or the inability to implement sufficiently high stiffnesses, a position control scheme is needed. This work compares three position controllers for tendon-driven manipulators. A new controller is introduced that achieves the best overall performance with regards to speed, accuracy, and transient behavior. To compensate for the lack of tension feedback, the controller nominally maintains the internal tension on the tendons by implementing a two-tier architecture with a range-space constraint. These control laws are validated experimentally on the Robonaut-2 humanoid hand. I
Ryan, Christina N M; Sorushanova, Anna; Lomas, Alex J; Mullen, Anne Maria; Pandit, Abhay; Zeugolis, Dimitrios I
Although glycosaminoglycans constitute a minor portion of native tissues, they play a crucial role in various physiological processes, while their abnormal expression is associated with numerous pathophysiologies. Glycosaminoglycans have become increasingly prevalent in biomaterial design for tendon repair, given their low immunogenicity and their inherent capacity to stimulate the regenerative processes, while maintaining resident cell phenotype and function. Further, their incorporation into three-dimensional scaffold conformations significantly improves their mechanical properties, while reducing the formation of peritendinous adhesions. Herein, we discuss the role of glycosaminoglycans in tendon physiology and pathophysiology and the advancements achieved to date using glycosaminoglycan-functionalized scaffolds for tendon repair and regeneration. It is evidenced that glycosaminoglycan functionalization has led to many improvements in tendon tissue engineering and it is anticipated to play a pivotal role in future reparative therapies.
Al-Qattan, Mohammad M
There is a paucity of the literature on the outcome of zone III flexor tendon injuries. In this paper, we report on the results of zone III flexor tendon repair in 35 consecutive adult patients with clean cut lacerations of both flexor tendons in 42 fingers. There were 25 men and 10 women with an average age of 32 years. Repair of both flexor tendons was performed using 'figure of eight' core sutures and a continuous epitendinous suture. Postoperatively, an immediate active range of motion protocol was applied to ensure full active extension of the interphalangeal joints. The results were assessed using the Strickland-Glogovac grading system. There were no ruptures. One patient with two injured fingers developed complex regional pain syndrome and the final outcome was fair in both fingers. In the remaining 34 patients (40 fingers), 33 patients (38 fingers) had an excellent outcome and the remaining patient (two fingers) had a good outcome.
Amlang, M H; Zwipp, H
Tendinosis of the Achilles tendon is a degenerative-reparative structural change of the tendon with microdefects, increases in cross-section due to cicatricial tendon regeneration, neoangiogenesis and reduction of elasticity. The previously used term tendinitis is only rarely used for the chronic form since signs of inflammation such as redness and hyperthermia or elevated levels of inflammatory parameters on laboratory testing are generally absent. Duplex sonography with visualization of the neovascularization has become a valuable supplement not only for diagnostics but also for therapy planning. The classic, conservative therapy for painful tendinosis consists of oral anti-inflammatory drugs, pain-adapted load reduction, raising the heel, stretching the calf musculature, and various physiotherapeutic interventions. When conservative treatment over a period of 4 - 6 months fails to produce any or non-adequate pain relief, an indication for surgical treatment should be considered. In the therapy for fresh ruptures of the Achilles tendon further developments in minimally invasive techniques have led to a worldwide paradigm change over the past 10 years. The decisive advantage of minimally invasive surgical techniques is the lower risk of wound infection as compared to the sutures of the open technique. When compared with conservative functional therapy the minimally invasive repair has the advantage of being less dependent on the compliance of the patient since, in the early phase of tendon healing the suture prevents a separation of the tendon ends upon controlled movements. However, not every patient with a ruptured Achilles tendon should be treated with a minimally invasive repair. Open tendon reconstruction and functional conservative therapy are still justified when the correct indication is given. © Georg Thieme Verlag KG Stuttgart · New York.
Lui, Tun Hing
Peroneal tenosynovitis usually responds to conservative therapy. Early diagnosis and management are imperative because improper or delayed diagnosis and treatment of peroneal tenosynovitis may lead to progression of the tenosynovitis to peroneal tendon rupture, ultimately limiting the benefit of nonoperative treatment. For refractory cases, endoscopic tenosynovectomy is indicated. The purpose of this Technical Note is to report a minimally invasive approach to perform a synovectomy of zones 1 and 2 of the peroneal tendon sheath.
White, Eric A; Omid, Reza; Matcuk, George R; Domzalski, Jerome T; Fedenko, Alexander N; Gottsegen, Christopher J; Forrester, Deborah M; Patel, Dakshesh B
Lipoma arborescens, described as lipomatous infiltration and distention of synovial villi resulting in a frond-like appearance, most frequently affects the suprapatellar recess of the knee. While there have been reports of this entity involving the upper extremity joints, bursa, and tendon sheaths, we present the first reported case of lipoma arborescens isolated to the biceps tendon sheath. We describe imaging and histologic findings with clinical correlation.
Maffulli, Nicola; Oliva, Francesco; Del Buono, Angelo; Florio, Antonietta; Maffulli, Gayle
The purpose of this study was to compare outcomes of different minimally invasive techniques for reconstruction of Achilles tendon re-ruptures. We prospectively enrolled 21 patients undergoing minimally invasive reconstruction using a transfer of the ipsilateral peroneus brevis (PB) (five patients) or the free ipsilateral semitendinosus tendon (ST) graft with or without interference screw fixation (ten and six patients, respectively). We assessed the maximum calf circumference and isometric plantar flexion strength before surgery and at the last follow up. The Achilles tendon total rupture score (ATRS) and number of single-leg heel lifts on the affected leg were evaluated at the last follow up. The median follow up was 39 months. The outcome of surgery was excellent/good in 17 (81 %) of 21 patients. In the operated leg, the maximum calf circumference and isometric plantar flexion strength were significantly improved after surgery (P < 0.0001). The average ATRS was 86 (range 79-92), and the average number of single-legged heel lifts was 33 (range 11-48). No further re-ruptures were recorded. Minimally invasive ipsilateral PB transfer and free ipsilateral ST graft with or without interference screw fixation are safe and effective procedures to reconstruct the Achilles tendon after a re-rupture, providing a significant improvement of the symptoms and function in the mid term.
Abdallah, Muhammad E. (Inventor); Platt, Robert (Inventor); Wampler, II, Charles W. (Inventor)
A method is provided for distributing tension among tendons of a tendon-driven finger in a robotic system, wherein the finger characterized by n degrees of freedom and n+1 tendons. The method includes determining a maximum functional tension and a minimum functional tension of each tendon of the finger, and then using a controller to distribute tension among the tendons, such that each tendon is assigned a tension value less than the maximum functional tension and greater than or equal to the minimum functional tension. The method satisfies the minimum functional tension while minimizing the internal tension in the robotic system, and satisfies the maximum functional tension without introducing a coupled disturbance to the joint torques. A robotic system includes a robot having at least one tendon-driven finger characterized by n degrees of freedom and n+1 tendons, and a controller having an algorithm for controlling the tendons as set forth above.
Ihrke, Chris A. (Inventor); Bergelin, Bryan J. (Inventor); Bridgwater, Lyndon (Inventor)
A grasp assist device includes a glove with first and second tendon-driven fingers, a tendon, and a sleeve with a shared tendon actuator assembly. Tendon ends are connected to the respective first and second fingers. The actuator assembly includes a drive assembly having a drive axis and a tendon hook. The tendon hook, which defines an arcuate surface slot, is linearly translatable along the drive axis via the drive assembly, e.g., a servo motor thereof. The flexible tendon is routed through the surface slot such that the surface slot divides the flexible tendon into two portions each terminating in a respective one of the first and second ends. The drive assembly may include a ball screw and nut. An end cap of the actuator assembly may define two channels through which the respective tendon portions pass. The servo motor may be positioned off-axis with respect to the drive axis.
Kraemer, Robert; Lorenzen, Johan; Rotter, Robert; Vogt, Peter M; Knobloch, Karsten
Treatment of ruptured Achilles tendons currently constitutes of conservative early functional treatment or surgical treatment either by open or minimal invasive techniques. We hypothesize that an experimental Achilles tendon suture in an animal model significantly deteriorates Achilles tendon microcirculation immediately following suturing. Fifteen Achilles tendons of eight male Wistar rats (275-325 g) were included. After preparation of the Achilles tendon with a medial paratendinous approach, Achilles tendon microcirculation was assessed using combined Laser-Doppler and spectrophotometry (Oxygen-to-see) regarding:- tendinous capillary blood flow [arbitrary units AU]- tendinous tissue oxygen saturation [%]- tendinous venous filling pressure [rAU]The main body of the Achilles tendon was measured in the center of the suture with 50 Hz. 10 minutes after Achilles tendon suture (6-0 Prolene), a second assessment of microcirculatory parameters was performed. Achilles tendon capillary blood flow decreased by 57% following the suture (70 +/- 30 AU vs. 31 +/- 16 AU; p < 0.001). Tendinous tissue oxygen saturation remained at the same level before and after suture (78 +/- 17% vs. 77 +/- 22%; p = 0.904). Tendinous venous filling pressure increased by 33% (54 +/- 16 AU vs. 72 +/- 20 AU; p = 0.019) after suture. Achilles tendon suture in anaesthetised rats causes an acute loss of capillary perfusion and increases postcapillary venous filling pressures indicating venous stasis. The primary hypothesis of this study was confirmed. In contrast, tendinous tissue oxygen saturation remains unchanged excluding acute intratendinous hypoxia within the first 10 minutes after suture. Further changes of oxygen saturation remain unclear. Furthermore, it remains to be determined to what extent reduced capillary blood flow as well as increased postcapillary stasis might influence tendon healing from a microcirculatory point of view in this animal setting.
Hansen, Mette; Kongsgaard, Mads; Holm, Lars; Skovgaard, Dorthe; Magnusson, S Peter; Qvortrup, Klaus; Larsen, Jytte O; Aagaard, Per; Dahl, Morten; Serup, Annette; Frystyk, Jan; Flyvbjerg, Allan; Langberg, Henning; Kjaer, Michael
The knowledge about the effect of estradiol on tendon connective tissue is limited. Therefore, we studied the influence of estradiol on tendon synthesis, structure, and biomechanical properties in postmenopausal women. Nonusers (control, n = 10) or habitual users of oral estradiol replacement therapy (ERT, n = 10) were studied at rest and in response to one-legged resistance exercise. Synthesis of tendon collagen was determined by stable isotope incorporation [fractional synthesis rate (FSR)] and microdialysis technique (NH(2)-terminal propeptide of type I collagen synthesis). Tendon area and fibril characteristics were determined by MRI and transmission electron microscopy, whereas tendon biomechanical properties were measured during isometric maximal voluntary contraction by ultrasound recording. Tendon FSR was markedly higher in ERT users (P < 0.001), whereas no group difference was seen in tendon NH(2)-terminal propeptide of type I collagen synthesis (P = 0.32). In ERT users, positive correlations between serum estradiol (s-estradiol) and tendon synthesis were observed, whereas change in tendon synthesis from rest to exercise was negatively correlated to s-estradiol. Tendon area, fibril density, fibril volume fraction, and fibril mean area did not differ between groups. However, the percentage of medium-sized fibrils was higher in ERT users (P < 0.05), whereas the percentage of large fibrils tended to be greater in control (P = 0.10). A lower Young's modulus (GPa/%) was found in ERT users (P < 0.05). In conclusion, estradiol administration was associated with higher tendon FSR and a higher relative number of smaller fibrils. Whereas this indicates stimulated collagen turnover in the resting state, collagen responses to exercise were negatively associated with s-estradiol. These results indicate a pivotal role for estradiol in maintaining homeostasis of female connective tissue.
Svensson, René B; Hansen, Philip; Hassenkam, Tue; Haraldsson, Bjarki T; Aagaard, Per; Kovanen, Vuokko; Krogsgaard, Michael; Kjaer, Michael; Magnusson, S Peter
Tendons are strong hierarchical structures, but how tensile forces are transmitted between different levels remains incompletely understood. Collagen fibrils are thought to be primary determinants of whole tendon properties, and therefore we hypothesized that the whole human patellar tendon and its distinct collagen fibrils would display similar mechanical properties. Human patellar tendons (n = 5) were mechanically tested in vivo by ultrasonography. Biopsies were obtained from each tendon, and individual collagen fibrils were dissected and tested mechanically by atomic force microscopy. The Young's modulus was 2.0 ± 0.5 GPa, and the toe region reached 3.3 ± 1.9% strain in whole patellar tendons. Based on dry cross-sectional area, the Young's modulus of isolated collagen fibrils was 2.8 ± 0.3 GPa, and the toe region reached 0.86 ± 0.08% strain. The measured fibril modulus was insufficient to account for the modulus of the tendon in vivo when fibril content in the tendon was accounted for. Thus, our original hypothesis was not supported, although the in vitro fibril modulus corresponded well with reported in vitro tendon values. This correspondence together with the fibril modulus not being greater than that of tendon supports that fibrillar rather than interfibrillar properties govern the subfailure tendon response, making the fibrillar level a meaningful target of intervention. The lower modulus found in vitro suggests a possible adverse effect of removing the tissue from its natural environment. In addition to the primary work comparing the two hierarchical levels, we also verified the existence of viscoelastic behavior in isolated human collagen fibrils.
Yin, Nai-Hao; Chen, Wen-Shiang; Wu, Ying-Tai; Shih, Tiffany Tingfang; Rolf, Christer; Wang, Hsing-Kuo
Controlled laboratory study. To measure and compare patellar tendon stiffness and microcirculation in college tennis players and nonathletic students when performing eccentric knee extension exercises that do and do not reduce tendon stiffness. Previous studies suggest that tendon microcirculation response during exercises may vary based on the tendon's plastic properties. Methods The study included 3 groups of college-age male students: tennis players who performed 4 sets of either 40 (n = 12) or 80 (n = 13) repetitions of eccentric knee extension exercise and nonathletic students (n = 14) who performed 4 sets of 40 repetitions. Tendon stiffness was measured before and after exercise completion. Changes in total hemoglobin and oxygen saturation (OSat) were analyzed while performing the 4 sets. Comparisons were made within and between the groups. The level of association between tendon microcirculation and stiffness reduction was assessed. The 2 groups (player/4 × 80 and student/4 × 40) exhibiting patellar tendon stiffness reductions (P<.008) showed higher total hemoglobin and OSat levels, above the pre-exercise levels, in the fourth set compared to the first set of exercises (P<.004). The tennis players who performed 4 sets of 40 repetitions exhibited higher OSat levels in the fourth set than in the first set (P = .004) but had no reduction in tendon stiffness. Changes in OSat levels in the fourth set were correlated with patellar tendon stiffness reductions (r = -0.381, P = .02). We conclude that there was increased patellar tendon microcirculation after performing knee extension eccentric exercises that resulted in a reduction in tendon stiffness.
Woon, Colin Y L; Pridgen, Brian C; Kraus, Armin; Bari, Sina; Pham, Hung; Chang, James
Tissue engineering of human flexor tendons combines tendon scaffolds with recipient cells to create complete cell-tendon constructs. Allogenic acellularized human flexor tendon has been shown to be a useful natural scaffold. However, there is difficulty repopulating acellularized tendon with recipient cells, as cell penetration is restricted by a tightly woven tendon matrix. The authors evaluated peracetic acid treatment in optimizing intratendinous cell penetration. Cadaveric human flexor tendons were harvested, acellularized, and divided into experimental groups. These groups were treated with peracetic acid in varying concentrations (2%, 5%, and 10%) and for varying time periods (4 and 20 hours) to determine the optimal treatment protocol. Experimental tendons were analyzed for differences in tendon microarchitecture. Additional specimens were reseeded by incubation in a fibroblast cell suspension at 1 × 10(6) cells/ml. This group was then analyzed for reseeding efficacy. A final group underwent biomechanical studies for strength. The optimal treatment protocol comprising peracetic acid at 5% concentration for 4 hours produced increased scaffold porosity, improving cell penetration and migration. Treated scaffolds did not show reduced collagen or glycosaminoglycan content compared with controls (p = 0.37 and p = 0.65, respectively). Treated scaffolds were cytotoxic to neither attached cells nor the surrounding cell suspension. Treated scaffolds also did not show inferior ultimate tensile stress or elastic modulus compared with controls (p = 0.26 and p = 0.28, respectively). Peracetic acid treatment of acellularized tendon scaffolds increases matrix porosity, leading to greater reseeding. It may prove to be an important step in tissue engineering of human flexor tendon using natural scaffolds.
Screen, H R C; Toorani, S; Shelton, J C
Tendons experience widely varying loading conditions in vivo. They may be categorised by their function as either positional tendons, which are used for intricate movements and experience lower stress, or as energy storage tendons which act as highly stressed springs during locomotion. Structural and compositional differences between tendons are thought to enable an optimisation of their properties to suit their functional environment. However, little is known about structure-function relationships in tendon. This study adopts porcine flexor and extensor tendon fascicles as examples of high stress and low stress tendons, comparing their mechanical behaviour at the micro-level in order to understand their stress relaxation response. Stress-relaxation was shown to occur predominantly through sliding between collagen fibres. However, in the more highly stressed flexor tendon fascicles, more fibre reorganisation was evident when the tissue was exposed to low strains. By contrast, the low load extensor tendon fascicles appears to have less capacity for fibre reorganisation or shearing than the energy storage tendon, relying more heavily on fibril level relaxation. The extensor fascicles were also unable to sustain loads without rapid and complete stress relaxation. These findings highlight the need to optimise tendon repair solutions for specific tendons, and match tendon properties when using grafts in tendon repairs.
Alberti, Kyle A.; Sun, Jeong-Yun; Illeperuma, Widusha R.; Suo, Zhigang; Xu, Qiaobing
Purpose A strong isotropic material that is both biocompatible and biodegradable is desired for many biomedical applications, including rotator cuff repair, tendon and ligament repair, vascular grafting, among others. Recently, we developed a technique, called “bioskiving” to create novel 2D and 3D constructs from decellularized tendon, using a combination of mechanical sectioning, and layered stacking and rolling. The unidirectionally aligned collagen nanofibers (derived from sections of decellularized tendon) offer good mechanical properties to the constructs compared with those fabricated from reconstituted collagen. Methods In this paper, we studied the effect that several variables have on the mechanical properties of structures fabricated from tendon slices, including crosslinking density and the orientation in which the fibers are stacked. Results We observed that following stacking and crosslinking, the strength of the constructs is significantly improved, with crosslinked sections having an ultimate tens ile strength over 20 times greater than non-crosslinked samples, and a modulus nearly 50 times higher. The mechanism of the mechanical failure mode of the tendon constructs with or without crosslinking was also investigated. Conclusions The strength and fiber organization, combined with the ability to introduce transversely isotropic mechanical properties makes the laminar tendon composites a biocompatiable material that may find future use in a number of biomedical and tissue engineering applications. PMID:25691802
Hadraba, Daniel; Janacek, Jiri; Filova, Eva; Lopot, Frantisek; Paesen, Rik; Fanta, Ondrej; Jarman, Anneliese; Necas, Alois; Ameloot, Marcel; Jelen, Karel
Fibrillar collagen in tendons and its natural development in rabbits are discussed in this paper. Achilles tendons from newborn (~7 days) to elderly (~38 months) rabbits were monitored in intact (n tendons=24) and microtome sectioned (n tendons=11) states with label-free second harmonic generation microscopy. After sectioning, the collagen fiber pattern was irregular for the younger animals and remained oriented parallel to the load axis of the tendon for the older animals. In contrast, the collagen fiber pattern in the intact samples followed the load axis for all the age groups. However, there was a significant difference in the tendon crimp pattern appearance between the age groups. The crimp amplitude (A) and wavelength (Λ) started at very low values (A=2.0±0.6 µm, Λ=19±4 µm) for the newborn animals. Both parameters increased for the sexually mature animals (>5 months old). When the animals were fully mature the amplitude decreased but the wavelength kept increasing. The results revealed that the microtome sectioning artifacts depend on the age of animals and that the collagen crimp pattern reflects the physical growth and development.
Longo, Umile Giuseppe; Franceschi, Francesco; Ruzzini, Laura; Rabitti, Carla; Morini, Sergio; Maffulli, Nicola; Forriol, Francisco; Denaro, Vincenzo
We analysed the morphological features of the human surgical specimens of supraspinatus tendon from patients with rotator cuff tears. Tendon samples were harvested from 31 subjects (21 men and 10 women; mean age 51 years, range 38-64) who underwent arthroscopic repair of a rotator cuff tear, and from five male patients who died of cardiovascular events (mean age, 69.6 years). Histological examination was performed using Haematoxylin and Eosin, Masson's Trichrome and Van Gieson's connective tissue stain. The specimens were examined twice by the same examiner under white light and polarized light microscopy. Particular effort was made to assess any evidence of the changes associated with tendinopathy. Within each specific category of tendon abnormalities, the chi-square test showed significant differences between the control and ruptured tendons (P < 0.05). Using the kappa statistics, the agreement between the two readings ranged from 0.57 to 0.84. We found thinning and disorientation of collagen fibres and chondroid metaplasia to be more pronounced on the articular side of the specimens from patients with rotator cuff tear (P < 0.05). The present study provides a description of the histological architecture of human surgical specimens of normal supraspinatus tendon from patients with rotator cuff tears and demonstrates more frequent tendon changes on the articular side of the rotator cuff.
Wong, J.K.F.; Alyouha, S.; Kadler, K.E.; Ferguson, M.W.J.; McGrouther, D.A.
Trauma by suturing tendon form areas devoid of cells termed “acellular zones” in the matrix. This study aimed to characterise the cellular insult of suturing and acellular zone formation in mouse tendon. Acellular zone formation was evaluated using single grasping sutures placed using flexor tendons with time lapse cell viability imaging for a period of 12 h. Both tension and injury were required to induce cell death and cell movement in the formation of the acellular zone. DNA fragmentation studies and transmission electron microscopy indicated that cells necrosed. Parallel in vivo studies showed that cell-to-cell contacts were disrupted following grasping by the suture in tensioned tendon. Without tension, cell death was lessened and cell-to-cell contacts remained intact. Quantitative immunohistochemistry and 3D cellular profile mapping of wound healing markers over a one year time course showed that acellular zones arise rapidly and showed no evidence of healing whilst the wound healing response occurred in the surrounding tissues. The acellular zones were also evident in a standard modified “Kessler” clinical repair. In conclusion, the suture repair of injured tendons produces acellular zones, which may potentially cause early tendon failure. PMID:20600895
Malvankar, S; Khan, W S
The Achilles tendon is believed to have first developed two million years ago enabling humans to run twice as fast. However if the Achilles tendon is so important in terms of evolution, then why is this tendon so prone to injury - especially for those more active like athletes. The Achilles tendon had an integral role in evolving apes from a herbivorous diet to early humans who started hunting for food over longer distances, resulting in bipedal locomotion. Evolutionary advantages of the Achilles tendon includes it being the strongest tendon in the body, having an energy-saving mechanism for fast locomotion, allows humans to jump and run, and additionally is a spring and shock absorber during gait. Considering these benefits it is therefore not surprising that studies have shown athletes have thicker Achilles tendons than subjects who are less active. However, contradictory to these findings that show the importance of the Achilles tendon for athletes, it is well known that obtaining an Achilles tendon injury for an athlete can be career-altering. A disadvantage of the Achilles tendon is that the aetiology of its pathology is complicated. Achilles tendon ruptures are believed to be caused by overloading the tensed tendon, like during sports. However studies have also shown athlete Achilles tendon ruptures to have degenerative changes in the tendon. Other flaws of the Achilles tendon are its non-uniform vascularity and incomplete repair system which may suggest the Achilles tendon is on the edge of evolution. Research has shown that there is a genetic influence on the predisposition a person has towards Achilles tendon injuries. So if this tendon is here to stay in our anatomy, and it probably is due to the slow rate of evolution in humans, research in genetic modification could be used to decrease athletes' predisposition to Achilles tendinopathy.
Hao, Zi-Chen; Wang, Shan-Zheng; Zhang, Xue-Jun; Lu, Jun
Tendon-bone healing after anterior cruciate ligament (ACL) reconstruction is a complex process, impacting significantly on patients' prognosis. Natural tendon-bone healing usually results in fibrous scar tissue, which is of inferior quality compared to native attachment. In addition, the early formed fibrous attachment after surgery is often not reliable to support functional rehabilitation, which may lead to graft failure or unsatisfied function of the knee joint. Thus, strategies to promote tendon-bone healing are crucial for prompt and satisfactory functional recovery. Recently, a variety of biological approaches, including active substances, gene transfer, tissue engineering and stem cells, have been proposed and applied to enhance tendon-bone healing. Among these, stem cell therapy has been shown to have promising prospects and draws increasing attention. From commonly investigated bone marrow-derived mesenchymal stem cells (bMSCs) to emerging ACL-derived CD34+ stem cells, multiple stem cell types have been proven to be effective in accelerating tendon-bone healing. This review describes the current understanding of tendon-bone healing and summarizes the current status of related stem cell therapy. Future limitations and perspectives are also discussed.
Yu, Kaifan; Shu, Gang; Yuan, Fangfang; Zhu, Xiaotong; Gao, Ping; Wang, Songbo; Wang, Lina; Xi, Qianyun; Zhang, Shouquan; Zhang, Yongliang; Li, Yan; Wu, Tongshan; Yuan, Li; Jiang, Qingyan
Fat and lean pig breeds show obvious differences in meat quality characteristics including the fatty acid composition of muscle. However, the molecular mechanism underlying these phenotypes differences remains unknown. This study compared meat quality traits between Lantang (a Chinese indigenous breed) and Landrace (a typical lean breed). The Lantang pigs showed higher L* values and intramuscular fat content, lower pH(45min), pH(24h) and shear force in longissimus dorsi (LD) muscle than Landrace (P < 0.05). Fatty acid analysis demonstrated the lower monounsaturated fatty acids (MUFA) and higher polyunsaturated fatty acids (PUFA) percentage in Lantang LD than that in Landrace LD (P < 0.05). To further identify candidate genes for fatty acid composition, the transcriptome of LD muscle from the two breeds were measured by microarrays. There were 586 transcripts differentially expressed, of which 267 transcripts were highly expressed in Lantang pigs. After the validation by real-time quantitative PCR, 13 genes were determined as candidate genes for fatty acid composition of muscle, including Stearoyl-CoA desaturase (SCD). Then, a SCD over-expression plasmid was transfected into C2C12 cells to reveal the effect of SCD on the fatty acid composition in vitro. The results showed that SCD over-expression significantly increased PUFA proportion, while reduced that of saturated fatty acids (SFA) in C2C12 cells (P < 0.05). In summary, this study compared the differences of fatty acid composition and transcriptome in two breeds differing in meat quality, and further identified the novel role of SCD in the regulation of PUFA deposition.
Longo, Benedetto; Laporta, Rosaria; Pagnoni, Marco; Campanale, Antonella; Grippaudo, Francesca Romana; Santanelli Di Pompeo, Fabio
Reconstruction of large defects of the lateral region of the face is rather challenging due to the unique color, texture, and thickness of soft tissues in this area. Microsurgical free flaps represent the gold standard, providing superior functional and aesthetic restoration. Purpose of this study was to assess reliability of skin-grafted latissimus dorsi (LD) flap, for a pleasant and symmetric reconstruction of the lateral aesthetic units of the face compared to a control group of patients addressed to perforator flaps. From November 2008 to June 2012, 5 patients underwent skin-grafted LD flap reconstruction of defects involving the lateral aesthetic units of the face, with 8.1 ± 0.5 × 9.7 ± 1.3 cm mean size. A 1-to-4 Likert scale was used to assess skin color, texture, shape, and bulkiness. Using the Pressure-Specified Sensory Device epicritic, proprioceptive, and protopathic sensitivities were tested. Outcomes were compared with those of a control group of 5 patients addressed to reconstruction with perforator flaps (3 anterolateral thigh flap, 2 vertical deep inferior perforator flap). At mean 21-month follow-up all flaps healed uneventfully without need for revisions, all developing more satisfactory results in terms of skin color (P = 0.028) and texture (P = 0.021) match, shape (P = 0.047) and bulkiness (P = 0.012) compared with perforator flaps. No differences in epicritic, proprioceptive, and protopathic sensitivities were observed (P > 0.05) between the two groups. Skin-grafted LD flap may be a suitable option for reconstruction of wide defects of the lateral aesthetic units of the face.
Feng, Jiajun; Pardoe, Cleone I; Mota, Ashley Manuel; Chui, Christopher Hoe Kong; Tan, Bien-Keem
The aim of unilateral breast reconstruction after mastectomy is to craft a natural-looking breast with symmetry. The latissimus dorsi (LD) flap with implant is an established technique for this purpose. However, it is challenging to obtain adequate volume and satisfactory aesthetic results using a one-stage operation when considering factors such as muscle atrophy, wound dehiscence and excessive scarring. The two-stage reconstruction addresses these difficulties by using a tissue expander to gradually enlarge the skin pocket which eventually holds an appropriately sized implant. We analyzed nine patients who underwent unilateral two-stage LD reconstruction. In the first stage, an expander was placed along with the LD flap to reconstruct the mastectomy defect, followed by gradual tissue expansion to achieve overexpansion of the skin pocket. The final implant volume was determined by measuring the residual expander volume after aspirating the excess saline. Finally, the expander was replaced with the chosen implant. The average volume of tissue expansion was 460 mL. The resultant expansion allowed an implant ranging in volume from 255 to 420 mL to be placed alongside the LD muscle. Seven patients scored less than six on the relative breast retraction assessment formula for breast symmetry, indicating excellent breast symmetry. The remaining two patients scored between six and eight, indicating good symmetry. This approach allows the size of the eventual implant to be estimated after the skin pocket has healed completely and the LD muscle has undergone natural atrophy. Optimal reconstruction results were achieved using this approach.
van Huizum, Martine A; Hoornweg, Marije J; de Ruiter, Noor; Oudenhoven, Erik; Hage, J Joris; Veeger, Dirk Jan
Dissection of the latissimus dorsi (LD) flap may have a distinct impact on upper extremity function and strength. To date, insufficient differentiation has been made between loss of muscular strength and shoulder function by dissection of the LD muscle per se and loss of function resulting from all excisional surgery, radiation therapy, and reconstructive procedures at the donor site and the recipient site that may have been combined near the shoulder region. This study determines the long-term effect of the LD breast reconstruction on the strength profiles of the upper extremity by measuring the isometric torque strength both in seven synergistic- and two contra-movement directions. The Biodex System 3 Pro (Biodex Medical Systems, New York, NY) was used in 12 patients at a mean of 3.5 years after surgery, and in 20 matched controls. Because loss of LD muscle may not result in significant impairment of activities of daily live (ADL) even in cases where objective measurements are decreased, this study simultaneously assessed the subjective function by use of the standardised Disability of Arm, Shoulder and Hand (DASH) questionnaire. This study observed a significant long-term loss of 8.8 Nm or 19% LD torque strength in synergistic movement directions after transplantation of the LD muscle. This loss correlated significantly with an increase of the mean DASH score among the patients. Because no significant loss of contra-movement torque strength was observed, it was concluded that the loss of synergistic torque strength appears to result from the loss of LD function per se.
Kachrimanis, G; Papadopoulou, O
Rupture of the common extensor tendon is the most common acute tendon injury of the elbow. The authors describe a case of a patient with a clinical history of tendinopathy caused by functional overload of the common extensor tendon, treated also with infiltrations of steroids, and subsequent partial rupture of the tendon during sport activity. The diagnosis was made clinically and at ultrasound (US) examination; US follow-up after some time showed the healing of the lesion. This case confirms that injections of steroids may be a contributory cause of tendon rupture, and emphasizes the sensitivity and specificity of US in the study of pathologies of the elbow tendons.
Plotkin, Benjamin; Sampath, Srihari C; Sampath, Srinath C; Motamedi, Kambiz
The tendons of the wrist are commonly symptomatic. They can be injured, infected, or inflamed. Magnetic resonance imaging and ultrasonography are useful tools for evaluating the wrist. Pathologic conditions of the wrist tendons include de Quervain tenosynovitis, extensor carpi ulnaris tendinopathy, rheumatoid tenosynovitis, infectious synovitis, tendon tears, hydroxyapatite deposition disease, intersection syndrome, tenosynovial giant cell tumor, and fibroma of the tendon sheath. In this article, we review the normal appearance of the wrist tendons, discuss relevant anatomy, and give an overview of common pathologic conditions affecting the wrist tendons. Online supplemental material is available for this article. (©)RSNA, 2016.
Sammer, Douglas M; Chung, Kevin C
The intrasynovial flexor tendons of the hand are critical for normal hand function. Injury to these tendons can result in absent finger flexion, and a subsequent loss of overall hand function. The surgical techniques used to repair these tendons have improved in the past few decades, as have the postoperative rehabilitation protocols. In spite of these advances, intrasynovial flexor tendon repairs continue to be plagued by postoperative scar formation, which limits tendon gliding and prevents a full functional recovery. This paper describes the current challenges of flexor tendon repair, and evaluates the most recent advances and strategies for achieving an excellent functional outcome. © 2014 by the Wound Healing Society.
Estrada-Malacón, C A; García-Estrada, G A
The patellar tendon lesion is very important due to the role of this tendon on the conformation of the extensor mechanism of the quadriceps. When the terminal end of this mechanism is injured, the extensor function of the knee is completely lost and thus the functional capability of the involved limb is completely disrupted.
Kulig, Kornelia; Chang, Yu-Jen; Winiarski, Slawomir; Bashford, Gregory R
The purpose of this study was to explore the relationship between tendon micro-morphology quantified from a sonogram and tendon mechanical characteristics measured in vivo. Nineteen adults (nine with unilateral Achilles tendinosis) participated. A commercial ultrasound scanner was used to capture longitudinal B-mode ultrasound images from the mid-portion of bilateral Achilles tendons and a custom image analysis program was used to analyze the spatial frequency content of manually defined regions of interest; in particular, the average peak spatial frequency of the regions of interest was acquired. In addition, a dynamometer and a motion analysis system indirectly measured the tendon mechanical (stiffness) and material (elastic modulus) properties. The peak spatial frequency correlated with tendon stiffness (r = 0.74, p = 0.02) and elastic modulus (r = 0.65, p = 0.05) in degenerated tendons, but not healthy tendons. This is the first study relating the mechanical characteristics of degenerated human Achilles tendon using a non-invasive micro-morphology analysis approach.
Omae, Hiromichi; Zhao, Chunfeng; Sun, Yu Long; An, Kai-Nan; Amadio, Peter C
The ideal scaffold for tendon engineering would possess the basic structure of the tendon, native extracellular matrix, and capability of cell seeding. The purpose of this study was to assess the tissue engineering potential of a novel composite consisting of a decellularized multilayer sliced tendon (MST) scaffold seeded with bone marrow stromal cells (BMSC). BMSC and infraspinatus tendons were harvested from 20 dogs. The tendons were sectioned in longitudinal slices with a thickness of 50 microm. The slices were decellularized, seeded with BMSC, and then bundled into one composite. The composite was incubated in culture media for 14 days. The resulting BMSC-seeded MST was evaluated by qRT-PCR and histology. The BMSC viability was assessed by a fluorescent tracking marker. Histology showed that the seeded cells aligned between the collagen fibers of the tendon slices. Analysis by qRT-PCR showed higher tenomodulin and MMP13 expression and lower collagen type I expression in the composite than in the BMSC before seeding. BMSC labeled with fluorescent tracking marker were observed in the composite after culture. Mechanical testing showed no differences between scaffolds with or without BMSC. BMSC can survive in a MST scaffold. The increased tenomodulin expression suggests that BMSC might express a tendon phenotype in this environment. This new composite might be useful as a model of tendon tissue engineering.
Pridgen, Brian C; Woon, Colin Y L; Kim, Maxwell; Thorfinn, Johan; Lindsey, Derek; Pham, Hung; Chang, James
Acellular human tendons are a candidate scaffold for tissue engineering flexor tendons of the hand. This study compared acellularization methods and their compatibility with allogeneic human cells. Human flexor tendons were pretreated with 0.1% ethylenediaminetetracetic acid (EDTA) for 4 h followed by 24 h treatments of 1% Triton X-100, 1% tri(n-butyl)phosphate, or 0.1% or 1% sodium dodecyl sulfate (SDS) in 0.1% EDTA. Outcomes were assessed histologically by hematoxylin and eosin and SYTO green fluorescent nucleic acid stains and biochemically by a QIAGEN DNeasy kit, Sircol collagen assay, and 1,9 dimethylmethylene blue glycosaminoglycan assay. Mechanical data were collected using a Materials Testing System to pull to failure tendons acellularized with 0.1% SDS. Acellularized tendons were re-seeded in a suspension of human dermal fibroblasts. Attachment of viable cells to acellularized tendon was assessed biochemically by a cell viability assay and histologically by a live/dead stain. Data are reported as mean±standard deviation. Compared with the DNA content of fresh tendons (551±212 ng DNA/mg tendon), only SDS treatments significantly decreased DNA content (1% SDS [202.8±37.4 ng DNA/mg dry weight tendon]; 0.1% SDS [189±104 ng DNA/mg tendon]). These findings were confirmed by histology. There was no decrease in glycosaminoglycans or collagen following acellularization with SDS. There was no difference in the ultimate tensile stress (55.3±19.2 [fresh] vs. 51.5±6.9 [0.1% SDS] MPa). Re-seeded tendons demonstrated attachment of viable cells to the tendon surface using a viability assay and histology. Human flexor tendons were acellularized with 0.1% SDS in 0.1% EDTA for 24 h with preservation of mechanical properties. Preservation of collagen and glycoaminoglycans and re-seeding with human cells suggest that this scaffold is biocompatible. This will provide a promising scaffold for future human flexor tendon tissue engineering studies to
Yin, Zi; Chen, Xiao; Zhu, Ting; Hu, Jia-jie; Song, Hai-xin; Shen, Wei-liang; Jiang, Liu-yun; Heng, Boon Chin; Ji, Jun-feng; Ouyang, Hong-Wei
It is reported that decellularized collagen matrices derived from dermal skin and bone have been clinically used for tendon repair. However, the varying biological and physical properties of matrices originating from different tissues may influence the differentiation of tendon stem cells, which has not been systematically evaluated. In this study, the effects of collagenous matrices derived from different tissues (tendon, bone and dermis) on the cell differentiation of human tendon stem/progenitor cells (hTSPCs) were investigated, in the context of tendon repair. It was found that all three matrices supported the adhesion and proliferation of hTSPCs despite differences in topography. Interestingly, tendon-derived decellularized matrix promoted the tendinous phenotype in hTSPCs and inhibited their osteogenesis, even under osteogenic induction conditions, through modulation of the teno- and osteolineage-specific transcription factors Scleraxis and Runx2. Bone-derived decellularized matrix robustly induced osteogenic differentiation of hTSPCs, whereas dermal skin-derived collagen matrix had no apparent effect on hTSPC differentiation. Based on the specific biological function of the tendon-derived decellularized matrix, a tissue-engineered tendon comprising TSPCs and tendon-derived matrix was successfully fabricated for Achilles tendon reconstruction. Implantation of this cell-scaffold construct led to a more mature structure (histology score: 4.08 ± 0.61 vs. 8.51 ± 1.66), larger collagen fibrils (52.2 ± 1.6 nm vs. 47.5 ± 2.8 nm) and stronger mechanical properties (stiffness: 21.68 ± 7.1 Nm m(-1) vs.13.2 ± 5.9 Nm m(-1)) of repaired tendons compared to the control group. The results suggest that stem cells promote the rate of repair of Achilles tendon in the presence of a tendinous matrix. This study thus highlights the potential of decellularized matrix for future tissue engineering applications, as well as developing a practical strategy for functional tendon
Archambeault, Mark; de Bruin, Hubert; McComas, Alan; Fu, Winnie
We present a novel instrumentation system for studying tendon and spinal reflexes using a commercial linear servo-motor as a precisely controlled tendon hammer. The system uses a LabVIEW-based program to both control electrical or mechanical stimuli and record and measure the resulting M and H waves. The hammer can deliver tendon taps with selected velocities, durations, frequencies and excursions. Preliminary results for both soleus and flexor carpi radialis muscles show that impact velocity is an important variable in eliciting tendon reflexes. As expected, the tendon reflex amplitude was also found to be dependent on excursion depth, but not as significantly as hammer velocity. Other stimulus paradigms are also presently being investigated.
Howell, Kristen; Chien, Chun; Bell, Rebecca; Laudier, Damien; Tufa, Sara F.; Keene, Douglas R.; Andarawis-Puri, Nelly; Huang, Alice H.
To date, the cell and molecular mechanisms regulating tendon healing are poorly understood. Here, we establish a novel model of tendon regeneration using neonatal mice and show that neonates heal via formation of a ‘neo-tendon’ that differentiates along the tendon specific lineage with functional restoration of gait and mechanical properties. In contrast, adults heal via fibrovascular scar, aberrant differentiation toward cartilage and bone, with persistently impaired function. Lineage tracing identified intrinsic recruitment of Scx-lineage cells as a key cellular mechanism of neonatal healing that is absent in adults. Instead, adult Scx-lineage tenocytes are not recruited into the defect but transdifferentiate into ectopic cartilage; in the absence of tenogenic cells, extrinsic αSMA-expressing cells persist to form a permanent scar. Collectively, these results establish an exciting model of tendon regeneration and uncover a novel cellular mechanism underlying regenerative vs non-regenerative tendon healing. PMID:28332620
Zhang, Minghua; Cui, Xu; Zeng, Jizhang; Liu, Xiong; Huang, Mitao; Zhang, Pihong; Huang, Xiaoyuan
To investigate the clinical efficacy of free latissimus dorsi musculocutaneous flaps in repairing large and deep skin and soft tissue defects around the knee joints. Twenty-five patients with large and deep skin and soft tissue defects around the knee joints were hospitalized from March 2005 to March 2014. The area of defects around the knee joints ranged from 10 cm × 8 cm to 43 cm × 23 cm. The free latissimus dorsi musculocutaneous flaps were used to repair the defects, with the area ranging from 12 cm × 10 cm to 45 cm × 25 cm. The thoracodorsal artery and its concomitant vein of the musculocutaneous flap were anastomosed to the descending branch of the lateral circumflex femoral artery and its concomitant vein respectively to reconstruct blood supply. Split-thickness skin grafts around the flap donor sites were harvested to cover the muscle surface of the musculocutaneous flaps. The flap donor sites were closed directly with suture, and the skin donor sites were healed by dressing change. All the 25 flaps survived without vascular crisis. The flaps were in satisfactory appearance. The flap donor sites were healed with linear scar. All the patients were followed up for 3 to 6 months. At last, they were able to stand up and walk. The free latissimus dorsi musculocutaneous flap transplantation is an effective treatment for the repair of large and deep soft tissue defects around the knee joints, and the descending branch of lateral circumflex femoral artery and its concomitant vein are the appropriate recipient vessels.
Gorin, Michael A; Marashdeh, Wael; Ross, Ashley E; Allaf, Mohammad E; Pienta, Kenneth J; Pomper, Martin G; Rowe, Steven P
PET imaging using radiotracers that target prostate-specific membrane antigen (PSMA) are increasingly being used in the evaluation of men with prostate cancer (PCa). It is therefore of increasing importance for imaging specialists to recognize potential pitfalls of this novel imaging technique. In this report, we describe a series of benign elastofibroma dorsi with uptake of the PSMA-targeted PET radiotracer F-DCFPyL. We retrospectively analyzed the imaging data of 75 men with PCa who were consecutively imaged with F-DCFPyL PET/CT. Acquired images were reviewed for the presence of radiotracer uptake in the region of the scapular tip adjacent to the chest wall. Only those lesions with discrete radiotracer uptake corresponding to an area on CT with the characteristic appearance of an elastofibroma were considered positive. In total, 18/75 (24.0%) patients had evidence of at least one elastofibroma dorsi on F-DCFPyL PET/CT. Eight (44.4%) of these patients had unilateral lesions, all of which were right sided. Detected lesions had a median maximal diameter of 2.3 cm (range: 1.3-8.4 cm) and a median perpendicular thickness to the chest wall of 0.9 cm (range: 0.6-2.5 cm). The median maximum standardized uptake value of detected lesions was 1.4 (range: 1.1-2.4) and the median maximum standardized uptake value corrected to lean body mass was 1.1 (range: 0.8-1.7). This study is the first to report uptake of a PSMA-targeted PET radiotracer in elastofibroma dorsi. Radiotracer uptake in these benign lesions should not be falsely mistaken as sites of metastatic PCa.
Zhang, S G; Liu, T; Brown, M A; Wu, J P
Fatty acid (FA) composition of longissimus dorsi intramuscular fat in Black Yak and Chinese Yellow Cattle were evaluated in 44 Black Yak and 41 Chinese Yellow Cattle of both genders. Interactions of species with gender were observed for total saturated fatty acid (SFA), unsaturated fatty acid (UFA), monounsaturated fatty acid (MUFA), polyunsaturated fatty acid (PUFA), palmitic acid, stearic acid, oleic acid, linolenic acid, arachidonic acid, EPA, and DHA concentrations, as well as PUFA/SFA ratio in the longissimus dorsi (p<0.05). The SFA percentage was greater in yellow cattle than yak in both genders but the species difference in heifers was greater than in steers (p<0.05). Yak had greater UFA, MUFA and PUFA percentages than yellow cattle in both steers and heifers (p<0.05) but the difference between yak and yellow cattle heifers was greater than yak and yellow cattle steers. The percentages of inolenic acid, arachidonic acid, eicosapentaenoic acid, and docosahexaenoic acid; and PUFA/SFA were greater in yak than yellow cattle in both steers and heifers (p<0.05). In addition, the ratio of n-6/n-3 PUFA in yak was lesser than in yellow cattle (p<0.05). These results indicated that FA composition generally differed between yak and yellow cattle but the differences were not the same in heifers as compared to steers. Results also suggested that species differences in FA composition tended to favor Black Yak over Chinese Yellow Cattle, indicating that the longissimus dorsi of Black Yak may have a higher nutritive value than that of Chinese Yellow Cattle and potential for development as a desirable natural product.
Li, Chun-Guang; Li, Bing; Yang, Yun-Feng
Objective * These authors contributed equally to this work. To explore tendon-bundle technique for treating Achilles tendon rupture with no defects. Methods Patients with full unilateral Achilles tendon rupture with no defects were included. The Achilles tendon medial edge surgical repair approach was used, revealing horsetail-like rupture bundles. Tendon bundles were anatomically realigned and repaired end-to-end using 5-0 sutures. Patients were followed-up for 1 year, and assessed for differences between the repaired versus healthy limb. Results Out of 24 patients (18 male, 6 female; aged 19-56 years) at 1 year following surgery, mean American Orthopaedic Foot and Ankle Society score was 92.4 ± 5.9; mean differences between the surgically repaired versus contralateral side in dorsiflexion and plantarflexion angle were 3.5 ± 2.3° and 5.6 ± 3.2°, respectively; mean difference in calf circumference between the two sides was 0.9 ± 0.5 cm; and mean increase in Achilles tendon width versus the healthy side was 0.8 ± 0.2 cm. By 1 year post-surgery, there were no significant between-side differences in dorsiflexion and plantarflexion angle, or calf circumference. Conclusions Tendon-bundle surgery resulted in good ankle function restoration and low complication rates. Tendon-bundle surgery may reduce blood supply destruction and maximally preserve Achilles tendon length, and may be effective for treating Achilles tendon rupture with no defects.
Handsfield, Geoffrey G; Inouye, Joshua M; Slane, Laura C; Thelen, Darryl G; Miller, G Wilson; Blemker, Silvia S
The Achilles is the thickest tendon in the body and is the primary elastic energy-storing component during running. The form and function of the human Achilles is complex: twisted structure, intratendinous interactions, and differential motor control from the triceps surae muscles make Achilles behavior difficult to intuit. Recent in vivo imaging of the Achilles has revealed nonuniform displacement patterns that are not fully understood and may result from complex architecture and musculotendon interactions. In order to understand which features of the Achilles tendon give rise to the nonuniform deformations observed in vivo, we used computational modeling to predict the mechanical contributions from different features of the tendon. The aims of this study are to: (i) build a novel computational model of the Achilles tendon based on ultrashort echo time MRI, (ii) compare simulated displacements with published in vivo ultrasound measures of displacement, and (iii) use the model to elucidate the effects of tendon twisting, intratendon sliding, retrocalcaneal insertion, and differential muscle forces on tendon deformation. Intratendon sliding and differential muscle forces were found to be the largest factors contributing to displacement nonuniformity between tendon regions. Elimination of intratendon sliding or muscle forces reduced displacement nonuniformity by 96% and 85%, respectively, while elimination of tendon twist and the retrocalcaneal insertion reduced displacement nonuniformity by only 35% and 3%. These results suggest that changes in the complex internal structure of the tendon alter the interaction between muscle forces and tendon behavior and therefore may have important implications on muscle function during movement. Copyright © 2016 Elsevier Ltd. All rights reserved.
Chu, Po-Jung; Lee, Hung-Maan; Hou, Yao-Tung; Hung, Sheng-Tsai; Chen, Jung-Kuei; Shih, Jui-Tien
Background The purpose of the study is to retrospectively review the clinical outcome of our study population of middle-aged RA patients who had suffered extensor-tendon rupture. We reported the outcome of autogenous palmaris tendon grafting of multiple extensor tendons at wrist level in 14 middle-aged rheumatoid patients. Methods Between Feb. 2000 to Feb. 2004, thirty-six ruptured wrist level extensor tendons were reconstructed in fourteen rheumatoid patients (11 women and three men) using autogenous palmaris longus tendon as a free interposition graft. In each case, the evaluation was based on both subjective and objective criteria, including the range of MCP joint flexion after surgery, the extension lag at the metacarpophalangeal joint before and after surgery, and the ability of the patient to work. Results and Discussion The average of follow-up was 54.1 months (range, 40 to 72 months). The average range of MCP joint flexion after reconstruction was 66°. The extension lag at the metacarpophalangeal joint significantly improved from a preoperative mean of 38° (range, 25°–60°) to a postoperative mean of 16° (range, 0°–30°). Subjectively all patients were satisfied with the clinical results, and achieved a return to their level of ability before tendon rupture. We found good functional results in our series of interposition grafting using palmaris longus to reconstruct extensor tendon defects in the rheumatoid patients. Conclusion Reconstruction for multiple tendon ruptures is a salvage procedure that is often associated with extensor lag and impairment of overall function. Early aggressive treatment of extensor tendon reconstruction using autogenous palmaris longus tendon as a free interposition graft in the rheumatoid wrist is another viable option to achieve good clinical functional result. PMID:18435845
Lustgarten, Meghann; Redding, W Rich; Labens, Raphael; Morgan, Michel; Davis, Weston; Seiler, Gabriela S
Tendon and ligament injuries are common causes of impaired performance in equine athletes. Gray-scale ultrasonography is the current standard method for diagnosing and monitoring these injuries, however this modality only provides morphologic information. Elastography is an ultrasound technique that allows detection and measurement of tissue strain, and may provide valuable mechanical information about equine tendon and ligament injuries. The purpose of this study was to determine the feasibility, reproducibility, and repeatability of elastography; and to describe elastographic characteristics of metacarpal tendons in sound horses. Nineteen legs for 17 clinically sound horses without evidence of musculoskeletal pathology were included. Elastographic images of the superficial and deep digital flexor tendons and the branches of the suspensory ligament (tendon of the interosseous muscle) were described quantitatively and qualitatively. There was no statistically significant difference between operators (P = 0.86) nor within operators (P = 0.93). For qualitative assessments, reproducibility (0.46) was moderate and repeatability (0.78) was good. Similar to human Achilles tendons, equine tendons were classified as predominantly hard using elastography. There was no statistically significant difference in stiffness of the flexor tendons (P = 0.96). No significant difference in stiffness was found with altered leg position during standing (P = 0.84) and while nonweight bearing (P = 0.61). The flexor tendons were softer when imaged in longitud