Aims. The gold standard for percutaneous Achilles tendon tenotomy during the Ponseti treatment for idiopathic clubfoot is a tenotomy with a No. 15 blade. This trial aims to establish the technique where the tenotomy is performed with a large-bore needle as noninferior to the gold standard. Methods. We randomized feet from children aged below 36 months with idiopathic clubfoot on a 1:1 basis in either the blade or needle group. Follow-up was conducted at three weeks and three months postoperatively, where dorsiflexion range, Pirani scores, and complications were recorded. The noninferiority margin was set at 4° difference in dorsiflexion range at three months postoperatively. Results. The blade group had more dorsiflexion at both follow-up consultations: 18.36° versus 18.03° (p = 0.115) at three weeks and 18.96° versus 18.26° (p = 0.001) at three months. The difference of the mean at three months 0.7° is well below the noninferiority margin of 4°. There was no significant difference in Pirani scores. The blade group had more extensive scar marks at three months than the needle group (8 vs 2). No major complications were recorded. Conclusion. The needle tenotomy is noninferior to the blade tenotomy for usage in Ponseti treatment for idiopathic clubfoot in children aged below 36 months. Cite this article: Bone Joint J 2024;106-B(8):871–878

Tenotomy of the iliopsoas tendon has been described as an effective procedure to treat refractive groin pain induced by iliopsoas tendinitis. However, the procedure forces the rectus femoris to act as the primary hip flexor and little is known about the long-term effects of this procedure on the peri-articular muscle envelope (PAME). Studies suggest that iliopsoas tenotomy results in atrophy of the iliopsoas and decreased hip flexion strength with poorer outcomes, increasing the susceptibility for secondary tendinopathy. The aim of this study is to describe changes in the PAME following psoas release. All patients who presented for clinical examination at our hospital between 2016 and 2021 were retrospectively reviewed. Patients who presented after psoas tenotomy with groin pain and who were unable to actively lift the leg against gravity, were included. Pelvic MRI was taken. Qualitative muscle evaluation was done with the Quartile classification system. Quantitative muscle evaluation was done by establishing the cross-sectional area (CSA). Two independent observers evaluated the ipsi- and contralateral PAME twice. The muscles were evaluated on the level: iliacus, psoas, gluteus minimus-medius-maximus, rectus femoris, tensor fasciae lata, piriformis, obturator externus and internus. For the qualitative evaluation, the intra- and inter-observer reliability was calculated by using kappastatistics. A Bland-Altman analysis was used to evaluate the intra- and inter-observer reliability for the quantitative evaluation. The Wilcoxon test was used to evaluate the changes between the ipsi- and contra-lateral side. 17 patients were included in the study. Following psoas tenotomy, CSA reduced in the ipsilateral gluteus maximus, if compared with the contralateral side. Fatty degeneration occurred in the tensor fascia latae. Both CSA reduction and fatty degeneration was seen for psoas, iliacus, gluteus minimus, piriformis, obturator externus and internus. No CSA reduction and fatty degeneration was seen for gluteus medius and rectus femoris. Conclusions/Discussion. Following psoas tenotomy, the PAME of the hip shows atrophy and fatty degeneration. These changes can lead to detrimental functional problems and may be associated with debilitating rectus femoris tendinopathy. In patients with psoas tendinopathy, some caution is advised when considering an iliopsoas tenotomy

Percutaneous flexor tenotomy involves cutting the flexor digitorum tendons to correct claw toe deformity to treat apical pressure areas and prevent subsequent infection in patients with peripheral neuropathy. Performing this under ultrasound guidance provides reassurance of complete release of the tendon and increases procedural safety. This study is a retrospective case series evaluating the effectiveness, safety, and patient satisfaction of performing percutaneous ultrasound-guided flexor tenotomy in an outpatient setting. People with loss of protective sensation, a digital flexion deformity, and an apical toe ulcer or pre-ulcerative lesion who presented to our institution between December 2019 and June 2022 were included in this study. Participants were followed-up at a minimum of 3 months. Time to ulcer healing, re-ulceration rate, patient satisfaction, and complications were recorded. An Australian cost analysis was performed comparing this procedure performed in rooms versus theatres. There were 28 ulcers and 41 pre-ulcerative lesions. A total of 69 tenotomy procedures were performed on 38 patients across 52 episodes of care. The mean time to ulcer healing was 22.5 +/- 6.4 days. There were 2 cases of re-ulceration. 1 patient sustained a transfer lesion. There were four toes that went onto require amputation, all in the setting of pre-existing osteomyelitis. 94% of patients strongly agreed that they were satisfied with the outcome of the procedure. Costs saved were estimated to be $1426. Flexor tenotomy is a minimally invasive procedure that can be performed in the outpatient setting, and therefore without delay to treatment, reducing risk of ulcer progression and need for subsequent amputation. This is the first study to report on flexor tenotomy under ultrasound-guidance. Ultrasound-guided percutaneous flexor tenotomy is safe and effective, with high patient satisfaction and low recurrence rates. This performance in the outpatient setting ensures significant time and cost savings for both the practitioner and patient

The objective of this study is to evaluate the effectiveness and safety of percutaneous tenotomy of the iliopsoas tendon with the aid of ultrasound in cadavers. An anatomical and descriptive study of the technique of percutaneous tenotomy of the iliopsoas tendon guided by ultrasound and to share our experience in performing it and its reproducibility in clinical practice. Out of 20 tenotomies, 17 were total, performed at the level of the superior border of the acetabulum. Three tenotomies were partial, with more than 75% of the tendon being sectioned in all three. During one of the tenotomies, there was a partial injury to the femoral nerve. Measurements were made of the distance between the site where the blade was inserted and the femoral nerve, a noble structure that would be at greater risk during the procedure, with an average distance of 8.4 millimeters. Ultrasound-guided iliopsoas tendon release procedures have the ability to be performed in a cadaveric model, consistently achieving complete tendon release, except in cases of obesity, with minimal repercussions on adjacent structures, and require approximately 4 minutes to complete

There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis. This systematic review and meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomized controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and the Jadad score. The primary outcome included patient reported functional outcome measures pooled using standardized mean difference (SMD) and a random effects model. Secondary outcome measures included pain (visual analogue scale VAS), rate of Popeye deformity, and operative time. 860 patients from 11 RCTs (426 tenotomy vs 434 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.14, 95% CI −0.04 to 0.32; p=0.13). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the primary outcome. There was no significant difference for pain (VAS). Tenodesis resulted in a lower rate of Popeye deformity (OR 0.29, 95% CI 0.19 to 0.45, p < 0.00001). Tenotomy demonstrated a shorter operative time (MD 15.21, 95% CI 1.06 to 29.36, p < 0.00001). Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. A large multi-centre clinical effectiveness randomised controlled trial is needed to provide clarity in this area

Introduction and Objective. There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis. Materials and Methods. This systematic review and meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomized controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and the Jadad score. The primary outcome included patient reported functional outcome measures pooled using standardized mean difference (SMD) and a random effects model. Secondary outcome measures included visual analogue scale (VAS), rate of cosmetic deformity (Popeye sign), range of motion, operative time, and elbow flexion strength. Results. 751 patients from 10 RCTs demonstrated (369 tenotomy vs 382 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.17 95% CI −0.02 to 0.36, p=0.09). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the primary outcome. Secondary outcomes including VAS, shoulder external rotation, and elbow flexion strength did not reveal any significant difference. Tenodesis resulted in a lower rate of Popeye deformity (OR 0.27 95% CI 0.16 to 0.45, p<0.00001). Conclusions. Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. This finding was irrespective of the whether the rotator cuff was intact

Aims. There is a lack of high-quality research investigating outcomes of Ponseti-treated idiopathic clubfeet and correlation with relapse. This study assessed clinical and quality of life (QoL) outcomes using a standardized core outcome set (COS), comparing children with and without relapse. Methods. A total of 11 international centres participated in this institutional review board-approved observational study. Data including demographics, information regarding presentation, treatment, and details of subsequent relapse and management were collected between 1 June 2022 and 30 June 2023 from consecutive clinic patients who had a minimum five-year follow-up. The clubfoot COS incorporating 31 parameters was used. A regression model assessed relationships between baseline variables and outcomes (clinical/QoL). Results. Overall, 293 patients (432 feet) with a median age of 89 months (interquartile range 72 to 113) were included. The relapse rate was 37%, with repeated relapse in 14%. Treatment considered a standard part of the Ponseti journey (recasting, repeat tenotomy, and tibialis anterior tendon transfer) was performed in 35% of cases, with soft-tissue release and osteotomies in 5% and 2% of cases, respectively. Predictors of relapse included duration of follow-up, higher initial Pirani score, and poor Evertor muscle activity. Relapse was associated with poorer outcomes. Conclusion. This is the first multicentre study using a standardized COS following clubfoot treatment. It distinguishes patients with and without relapse in terms of clinical outcomes and QoL, with poorer outcomes in the relapse group. This tool allows comparison of treatment methods and outcomes, facilitates information sharing, and sets family expectations. Predictors of relapse encourage us to create appropriate treatment pathways to reduce relapse and improve outcome. Cite this article: Bone Joint J 2024;106-B(7):735–743

Shoulder arthroplasty procedures continue to increase in prevalence and controversy still remains about the optimal method to manage the subscapularis. Scalise et al. performed an analysis of 20 osteotomies and 15 tenotomy procedures, and found the tenotomy group had a higher rate of abnormal subscapularis tendons on ultrasound examination. There was one tendon rupture in the subscapularis tenotomy group and no ruptures in the osteotomy group. Jandhyala et al. retrospectively examined 26 lesser tuberosity osteotomies and 10 subscapularis tenotomies for arthroplasty, and their study demonstrated a significant improvement in the belly press test for the osteotomy group. Lapner et al. performed a randomised controlled trial assigning patients to either a lesser tuberosity osteotomy or a subscapularis peel procedure. They evaluated 36 osteotomies and 37 subscapularis peels. The outcomes evaluated were Dynamometer internal rotation strength, the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) score and American Shoulder and Elbow Surgeons (ASES) score, and in a subsequent paper they evaluated the healing rates and Goutallier grade. Their studies illustrated no difference in the internal rotation strength between groups. Both groups significantly improved WOOS and ASES scores postoperatively, but the difference was not significant between groups. Goutallier grade increased significantly in both groups, but there was no significant difference between the groups. Overall, the different approaches have not demonstrated a meaningful clinical difference. Further studies are needed to help understand issues leading to subscapularis complications after arthroplasty

To our knowledge, we are the only centre in the UK where Achilles tenotomies (TA) for CTEV Ponseti correction are performed in outpatient clinic under local anaesthetic by an Advanced Physiotherapy Practitioner (APP) in orthopaedics. This study aims to present the outcomes and safety of this practice. Retrospective analysis of cases of idiopathic CTEV undergoing Ponseti correction January 2020 to October 2022. Demographic data: Pirani score and number of casts before boots and bar. Patients were divided into five groups: Group 1: TA performed by an Orthopaedic consultant under general anaesthetic (GA) in theatre. Group 2: TA performed by an Orthopaedic consultant under local anaesthetic (LA) in theatre. Group 3: TA performed by APP under GA in theatre. Group 4: TA performed by APP under LA in theatre. Group 5: TA performed by an APP under LA in outpatient clinic. Complications recorded: revision TA, infection, neurovascular injury or need for re-casting. Mean follow up 18 months. 45 feet included. Mean Pirani score 5.5, age started casting 33 days and total number of casts 6. No significant difference in demographic details between groups. 6, 4, 20, 5 and 10 tenotomies were performed in groups 1, 2, 3, 4, and 5 respectively. Complications were 1 revision tenotomy from group 2, one from group 4 and 1 renewal of cast from 3. This study demonstrates that TAs performed in outpatient clinic under LA by an APP is safe and feasible. No increase in complications were observed compared to TAs performed by orthopaedic consultants

Europeam Group of Neuro-orthopaedic (GLAENeO), Caracas, The prevention of a dislocated hip is one of the aims of early surgery in Cerebral Palsy children, specially those severely involved. We performed a retrospective study of those cerebral palsy patients operated of adductor tenotomy between 1975 and 1995 with a total of 1474 patients. We grouped them in those who had a unilateral tenotomy and those who had a bilateral tenotomy as primary surgery. Of these only 8% had an obturator neurectomy, without walking ability, and 92 % had it not. Age at surgery varied from 6 months to 8 years of age with a mean of 4 years and 3 months. Group I: 792 patients (53.7 %) with unilateral adductor contracture, sustained a unilateral adductor tenotomy. Of these patients a total of 619 (78, 2 %) required a contralateral adductor tenotomy at a mean of 3 years and 6 months. Group II: 682 patients (46, 3 %) with bilateral adductor contracture that had a bilateral adductor tenotomy in one stage. Of the 792 patients that sustained a two stage adductor tenotomy, 123 (20%) presented a unilateral dislocated hip and of these 115 (93 %) occurred in the hip operated secondly at a mean of 1 year post tenotomy. Of the 682 patients with bilateral adductor tenotomies only 7 (1 %) had a dislocated hip 2 years post tenotomy. Of the 72 dislocated hips, 12 (59 %) were quadriplegics, 28 (22 %) were diplegic, 21 (18 %) hemiplegics and 1 (1 %) tetraplegic. Of the 619 patients tenotomized in two stages, in 143 the diaphyseal – cervical angle was 155 ° (23,1 %), at a mean of 6 and a half years of age and 3 years post the second tenotomy. In 102 of these patients (71 %) a varus derotation osteotomy was performed in the hip operated in the second act with further dislocation of the hip in 20 cases (20 %). Of the 685 patients with bilateral tenotomy in one stage, varus derotation osteotomy was required in 68 (68 %) at a mean of 6 years of age with only a 3 % of dislocations in this group. In view of these results we recommend a bilateral adductor tenotomy be performd regardless of a difference in the degree of contracture of both sides, thus coordinating the forces and avoid further dislocation the hip

Management of the pathologic long-head biceps tendon remains controversial. Biceps tenotomy is a simple intervention but may result in visible deformity and subjective cramping. Comparatively, biceps tenodesis is technically challenging, and has increased operative times, and a more prolonged recovery. The purpose of this study was to determine the incidence of popeye deformity following biceps tenotomy versus tenodesis, identify predictors for developing a deformity, and compare subjective and objective outcomes between those that have one and those that do not. Data for this study were collected as part of a randomized clinical trial comparing tenodesis versus tenotomy in the treatment of lesions of the long head of biceps tendon. Patients 18 years of age or older with an arthroscopy confirmed biceps lesion were randomized to one of these two techniques. The primary outcome measure for this sub-study was the rate of a popeye deformity at 24-months post-operative as determined by an evaluator blinded to group allocation. Secondary outcomes were patient reported presence/absence of a popeye deformity, satisfaction with the appearance of their arm, as well as pain and cramping on a VAS. Isometric elbow flexion and supination strength were also measured. Interrater reliability (Cohen's kappa) was calculated between patient and evaluator on the presence of a deformity, and logistic regression was used to identify predictors of its occurrence. Linear regression was performed to identify if age, gender, or BMI were predictive of satisfaction in appearance if a deformity was present. Fifty-six participants were randomly assigned to each group of which 42 in the tenodesis group and 45 in the tenotomy group completed a 24-month follow-up. The incidence of popeye deformity was 9.5% (4/42) in the tenodesis group and 33% (15/45) in the tenotomy group (18 male, 1 female) with a relative risk of 3.5 (p=0.016). There was strong interrater agreement between evaluator and patient perceived deformity (kappa=0.636; p<0.001). Gender tended towards being a significant predictor of having a popeye with males having 6.6 greater odds (p=0.090). BMI also tended towards significance with lower BMI predictive of popeye deformity (OR 1.21; p=0.051). Age was not predictive (p=0.191). Mean (SD) satisfaction score regarding the appearance of their popeye deformity was 7.3 (2.6). Age was a significant predictor, with lower age associated with decreased satisfaction (F=14.951, adjusted r2=0.582, p=0.004), but there was no association with gender (p=0.083) or BMI (p=0.949). There were no differences in pain, cramping, or strength between those who had a popeye deformity and those who did not. The risk of developing a popeye deformity was 3.5 times higher after tenotomy compared to tenodesis. Male gender and lower BMI tended towards being predictive of having a deformity; however, those with a high BMI may have had popeye deformities that were not as visually apparent to an examiner as those with a lower BMI. Younger patients were significantly less satisfied with a deformity despite no difference in functional outcomes at 24 months. Thus, biceps tenodesis may be favored in younger patients with low BMI to mitigate the risk of an unsatisfactory popeye deformity

This paper evaluates the ability to predict the need for a tenotomy prior to beginning the Ponseti method. The purpose of this study was to determine how one might predict the need for tenotomy at the initiation of the Ponseti treatment for clubfeet. Fifty clubfeet in thirty-five patients were treated with serial casting. The feet were prospectively rated according to two different scoring systems (Pirani, et. al. and Dimeglio, et. al.). The decision to perform a tenotomy was made when the foot could not be easily dorsiflexed 15 degrees prior to application of the final cast. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required a significantly greater number of casts (p< 0.05). Of 27 feet with an initial Pirani score 5.0, 85.2% required a tenotomy and 14.8% did not. 94.7% of the Dimeglio Type III feet required tenotomies. At the time of the initial evaluation there was a significant difference between those that did and did not require a tenotomy for multiple components of the Pirani hind-foot score. Following removal of the last cast there was no significant difference between those that did and did not have a tenotomy. In conclusion, children with clubfeet who have an initial score of 5.0 by the Pirani system or are rated as Type III feet by the Dimeglio system are very likely to need a tenotomy. Those that needed a tenotomy were more severely deformed with regard to all components of the hindfoot deformity, not just equinus. At the end of treatment feet were equally well corrected whether or not they needed a tenotomy

Achilles tenotomy is a recognised step in the Ponseti technique for the correction of idiopathic congenital talipes equinovarus in most percutaneous cases. Its use has been limited in part by concern that the subsequent natural history of the tendon is unknown. In a study of 11 tendons in eight infants, eight tendons were shown to be clinically intact and ten had ultrasonographic evidence of continuity three weeks after tenotomy. At six weeks after tenotomy all tendons had both clinical and ultrasonographic evidence of continuity

Purpose: The purpose of this paper was to determine how to predict the need for a percutaneous tenotomy at the initiation of the Ponseti method for treatment of a clubfoot. Methods: Fifty clubfeet in 35 patients were treated with serial casting performed at weekly intervals and were rated according to the Pirani and Dimeglio clubfoot scoring systems. Scores for each foot were obtained at each visit, prior to cast application and following removal of the final cast. The final cast was applied with the foot in 15 degrees of dorsiflextion. A percutaneous Achilles tenotomy was performed if the foot could not be dorsiflexed to 15 prior to application of the final cast. Tenotomies were performed as an office procedure under local anesthesia in 36 to 50 feet (72%). Results: The patients that underwent tenotomy required significantly more casts. Of 27 feet with initial Pirani scores of ≥5.0, 85.2% required a tenotomy and 14.8% did not; and 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and those that did not have a tenotomy. Conclusion: Children with clubfeet who have an initial score of ≥5.0 by the Pirani system or who are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy

We performed a prospective ultrasonographic study of tendon healing following Ponseti-type Achilles tenotomy in 27 tendons (20 patients) with idiopathic congenital talipes equinovarus. Serial ultrasound examinations (both static and dynamic) were performed at 3, 6 and 12 weeks post-operatively. Casts were removed routinely 3 weeks post-tenotomy apart from two patients over 24 months of age who remained immobilised for 6 weeks. We observed three differing phases of healing apparent at 3, 6 and 12 weeks post tenotomy. We defined the end point of healing as the observation of tendon homogeneity across the gap zone on ultrasonography. This transition to normal ultra-structure was frequently seen by ultrasonography only at 12 weeks, when the divided ends of the tendon were indistinct. Though there is evidence of continuity of the tendon at the time of cast removal, it remains in the mid-phase of healing. The time taken for complete healing should be considered prior to planning a revision tenotomy. In two children over the age of 2 years, who had repeat tenotomy, the completion of healing by our criteria took longer than 12 weeks. The tendon gap healing does not appear to occur as readily in children over two years and other Methods: may be preferable to percutaneous tenotomy

Purpose of the study: Injury to the long head of the biceps is frequently associated with massive rotator cuff tears leading to pain and functional impotency. Tenotomy of the long biceps is a validated option for unrepairable cuff tears, but can lead to an unsatisfactory aesthetic result (Popeye sign) or functional impairment (loss of strength). The objectives of this study were to confirm the clinical efficacy of intra-articular resection of the long head of the biceps, to study the radiographic evolution, to evaluate aesthetic and functional outcome of tenotomy procedures and to compare them with those of tenodesis with an interference screw, an alternative to tenotomy. Materials and Methods: We conducted a retrospective analysis of 151 patients presenting an unrepairable rotator cuff tear. Tenotomy of the long head of the biceps was performed in 63 patients and tenodesis of the long head of the biceps using an interference screw in 88. Acromioplasty was also performed in 21 shoulders with the resection of the long head of the biceps. All patients were reviewed by an independent investigator at mean 63 months follow-up. Results: Patient satisfaction was good or very good for 92%. The absolute Constant score improved from 47.4±13.8 points preoperatively to 70.8±12.2 points at last followup for the whole series, increasing on average 24.4 points (p< 0.05). There was no statistical difference for the Constant score between tenotomy and tenodesis. The subacromial space decreased 2±2.3 mm on average (p< 0.05). Degeneration of the glenohumeral joint was noted in 12% of shoulders at last follow-up. Retraction of the long head of the biceps (Popeye sign) were noted in 31% of patients with tenotomy and in 10% of those with tenodesis (p< 0.001). There were twice as many cases of brachial biceps cramps in the tenotomy group (24%) than in the tenodesis group (12%). Muscle force for elbow flexion in the supination position was greater in the tenodesis group than in the tenotomy group (p< 0.05). Conclusion: Arthroscopic tenotomy or tenodesis of the long head of the biceps are valid therapeutic options for unrepairable rotator cuff tears. The efficacy of the two techniques is the same in terms of the objective outcome (Constant score) but tenodesis limits the aesthetic sequelae and preserves elbow flexion and supination force

The purpose of this study was to evaluate outcome following arthroscopic biceps tenotomy or tenodesis for massive irreparable rotator cuff tears associated with biceps lesions. This is a retrospective study of sixty-eight consecutive patients (mean age 68 ± 6 years) with seventy-two irreparable rotator cuff tears treated with arthroscopic biceps tenotomy (thirty-nine cases) or tenodesis (thirty-three cases). All patients were evaluated clinically and radiographically at a mean follow-up of thirty-five months (range, 24–52). Fifty-three patients (78%) were satisfied. Constant score improved from forty-six to sixty-seven points (p< 0.001). Presence of a healthy, intact teres minor on preoperative imaging correlated with increased postoperative external rotation (40 vs. 18°, p< 0.05) and higher Constant score (p< 0.05). Three patients with a pseudoparalyzed shoulder did not benefit from the procedure and did not regain active elevation above the horizontal level. By contrast, fifteen patients with painful loss of active elevation recovered active elevation. The acromiohumeral distance decreased 1 mm on average, and only one patient developed glenohumeral osteoarthritis. There was no difference between tenotomy and tenodesis (Constant Score sixty-one vs. seventy-three). A “Popeye” sign was clinically apparent in twenty-four tenotomy patients (61%), but none were bothered by it. Two patients required reoperation with a reverse prosthesis. Arthroscopic biceps tenotomy and tenodesis effectively treats severe pain or dysfunction caused by an irreparable rotator cuff tear associated with biceps pathology. Shoulder function is significantly lower if the teres minor is atrophic or fatty infiltrated. Pseudoparalysis or severe cuff arthropathy are contraindications

Subscapularis tenotomy (SST) has been the preferred approach for shoulder arthroplasty for decades but recent controversy has propelled lesser tuberosity osteotomy (LTO) as a potential alternative. Early work by Gerber suggested improved healing and better outcomes with LTO although subscapularis muscular atrophy occurred in this group as well with unknown long-term implications. However, we previously performed a biomechanical study showing that some of the poor results following tenotomy may have been due to historic non-anatomic repair techniques. Surgical technique is critical to allow anatomic healing – this is true of both SST or LTO techniques. A recent meta-analysis of biomechanical cadaveric studies showed that LTO was stronger to SST at “time-zero” with respect to load to failure but there were no significant differences in cyclic displacement. A recent study evaluated neurodiagnostic, functional, and radiographic outcomes in 30 patients with shoulder arthroplasty who had SST. The authors found that the EMG findings were normal in 15 patients but abnormal in the other 15 and that these abnormalities occurred in 5 muscle groups (not just the subscapularis). In another study, patient outcomes were inferior in those patients who had documented subscapularis dysfunction following SST compared to patients who had LTO (none of whom had subscap dysfunction). The literature is not clear, however, on ultimate outcomes based on subscapularis dysfunction post-arthroplasty with some studies showing no difference and others showing significant differences

Spastic muscles show permanent contraction but also paradoxical muscular weakness. Compartmental muscular pressure in normal subjects oscillates between 0 and 5 mmHg. To study compartmental pressure in the posterior superficial compartment of the leg in children with spastic paralysis, to identify its variations after a percutaneous tenotomy of the Achilles tendon, and to find any possible connection with arterial pressure or weight. Twelve patients who had undergone a percutaneous tenotomy of the Achilles tendon were studied. Six of them were tetraplegic and three hemiplegic, with bilateral and unilateral tenotomies respectively. The following variables were taken into consideration: age, weight, systolic and diastolic arterial pressure and pressure of the superficial compartment of the leg, both pre- and post- tenotomy. The measurement of the compartmental pressure was taken using an automatic calibration monitor with an error of measure of ± 1 mmHg. Statistics: descriptive, non-parametric tests (Wilcoxon, Kruskall- Willis). The average age was 9.3 years old, 11 in men and 7.5 in women. 89.5% of the total population was male and 10.5 % female. The average weight was 27.2 Kilograms, 28.1 Kg. in men and 20.5 Kg. in women. Systolic pressure was 94.1 mmHg and diastolic pressure 41.3 mmHg. Pre-tenotomy compartmental pressure was 12.1 mmHg and 7.9 mmHg post-tenotomy, decreasing 34.5 % (p= 0.08, N.S.). Systolic pressure had no relation to pre-tenotomy (r = −0.16) o post-tenotomy (r = −0.13) compartmental pressure. Diastolic pressure had no relation either (p =0.2 and r=−0.36), respectively. The pressure of the superficial compartment of the leg is higher than normal in spastic patients, decreasing, although not significantly, after a percutaneous tenotomy of the Achilles tendon is performed

Aims. Our aim was to describe the mid-term appearances of the repair process of the Achilles tendon after tenotomy in children with a clubfoot treated using the Ponseti method. Patients and Methods. A total of 15 children (ten boys, five girls) with idiopathic clubfoot were evaluated at a mean of 6.8 years (5.4 to 8.1) after complete percutaneous division of the Achilles tendon. The contour and subjective thickness of the tendon were recorded, and superficial defects and its strength were assessed clinically. The echogenicity, texture, thickness, peritendinous irregularities and potential for deformation of the tendon were evaluated by ultrasonography. Results. The appearance of the Achilles tendon was slightly abnormal, with more thickening and less conspicuous contours than a normal tendon. Its strength was grossly normal, with no insufficiency of the triceps surae. Ultrasonographic findings revealed a mild fusiform thickening in 12 children (80%). The tissue at the site of the repair had a slightly hypoechoic, fibrillar quality with hyperechoic striation and the anterior contour was irregular and blurred. There was a focal narrowing within the healing tissue in two children. Conclusion. This mid-term evaluation of the ability of the Achilles tendon to repair after division suggests a combination of intrinsic and extrinsic mechanisms. There were minor abnormalities which did not appear to affect function. Cite this article: Bone Joint J 2017;99-B:139–44

Percutaneous Achilles tenotomy is an integral part of the Ponseti technique. Though considered as a simple procedure, many authors have reported serious neurovascular complications that include iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation. The authors describe the results of their new tenotomy technique, the ‘Posterior to Anterior Controlled’ (PAC) technique in an attempt to eliminate such complications. This is a prospective study. Infants < 1 year of age with idiopathic clubfoot were taken up for the Ponseti technique of correction. Tenotomy was performed by the ‘PAC’ technique under local anaesthesia if passive dorsiflexion was found to be < 15 degrees. Outcome measures included completeness of the tenotomy (by ultrasonography), improvement in the equinus angle and occurrence of neurovascular complications. 40 clubfeet in 22 patients underwent ‘PAC’ tenotomy. The mean age was 3.5 months. The tenotomy was found to be complete in all cases. The equinus angle improved by an average of 78.5 degrees (range 70–95 degrees), which was statistically significant (p < 0.05, students t test). Mild soakage of the cast with blood was noted in 21 (52.5%) cases. No neurovascular complication was noted. The average follow-up was 12.2 months (range 9–18 months). The ‘PAC’ tenotomy virtually eliminates the possibility of neurovascular damage, maintains the percutaneous nature of the procedure, is easy to learn and can be performed even by relatively inexperienced surgeons safely and effectively as an office procedure under local anaesthesia

The diagnosis and treatment of disorders of the long head of the biceps tendon remains controversial. There is uncertainty as to the role of the long head of biceps and it can be difficult to determine whether the patient's pathology is coming from the biceps or other adjacent structures. In addition, the appropriate type of treatment remains controversial. We retrospectively reviewed the files of the senior author's experience in over 4000 arthroscopic shoulder procedures. We examined cases involving isolated biceps pathology, excluding those patients with rotator cuff tears and labral pathology, involving 92 biceps tenotomies and 103 biceps tenodeses. Our analysis supports the benefit of clinical examination over all types of radiological investigations. The benefits and technique of biceps tenodesis is described including surgical technique. Irritation by PLA interference screw is examined. A paradigm is put forward to help in diagnosis and management of these lesions. Long head of biceps pathology is a significant cause of shoulder pain in association with other shoulder problems and in isolation. Biceps tenodesis and tenotomy is an efficacious way of dealing with this pathology

Introduction: A growing number of pediatric orthopaedic surgeons have adopted the Ponseti method for the treatment of idiopathic congenital clubfeet. Ponseti himself does not recommend the standard use of radiographs but suggests that palpation alone should be used to assess the correction in infant clubfeet. Although ultrasound diagnostic techniques for evaluating the infant foot are on the rise, most orthpaedic surgeon still rely on native radiographs to objectify the course of treatment. The aim of our study was to elucidate the role of radiographs in Ponseti clubfoot treatment. Material and Methods: From the end of 2002 on we have used the treatment regime as originally described by Ponseti. Only infants with idiopathic clubfeet treated within the first three weeks of life were included. Radiographs of infant clubfeet are taken in ap.- view and lateral view in maximum dorsiflexion. Radiographs were taken at presentation mostly for legal documentation, before tenotomy at about 6 to 15 weeks of age, and 1 week after the percutaneous Achilles tenotomy (pAT). The tibiocalcaneal angle (Tib.C.-angle), the ap.- talo-calcaneal angle (TC-angle) and the lateral talo-calcaneal angle (lat. TC- angle) were evaluated. The maximum dorsiflexion was evaluated clinically. Results: Forty-seven feet met the inclusion criteria. The mean gain of the tibiocalcaneal angle after tenotomy was 15,08 degrees. The ap.- talo-calcaneal angle only showed a mean change of 2,57 degrees and the lateral talo-calcaneal angle changed 0,44 degrees. The dorsi-flexion was found to have gained 13,85 degrees after tenotomy. The values of the tibiocalcaneal angle (Tib. C.-angle) and the values for dorsiflexion (DF) before and after pAT showed a significant difference (p< 0.05). No significant difference was found for the ap.- talo-calcaneal angle (TC-angle) and the lateral talo-calcaneal angle (lat. TC- angle) before and after tenotomy. Discussion: The results of our series indicate that the tib-iocalcaneal angle changes about the same amount as the clinical dorsiflexion does. The ap.- talo-calcaneal angle (TC-angle) and the lateral talo-calcaneal angle (lat. TC- angle) were not influenced much by the Achilles tenotomy in our series. This seems reasonable as cutting of the Achilles tendon mostly influences the calcaneous which is the endpoint of the tendon. The dorsal opening of the talocalcaneal joint is coupled with derotation of the talus and calcaneous in the ap.-view and is hardly influenced by pAT. Although the position of the calcaneous in the heel can be palpated and even quantified by the empty heel sign according to Pirani, radiographs are the only way to objectify the true anatomy

The long head of the biceps tendon has been proposed as a source of pain in patients with rotator cuff tears. The purpose of this study is to evaluate the objective, subjective, and radiographic results of arthroscopic biceps tenotomy in selected patients with rotator cuff tears. Three hundred seven arthroscopic biceps tenotomies were performed in patients with full thickness rotator cuff tears. All patients had previously failed appropriate nonoperative management. Patients were selected for arthroscopic tenotomy if the tear was thought to be irreparable or the patient was older and not willing to participate in the rehabilitation required following rotator cuff repair. One hundred eleven shoulders underwent a concomitant acromioplasty. The mean age at surgery was 64.3 years. The mean preoperative radiographic acromiohumeral interval measured 6.6 mm. Patients were evaluated clinically and radiographically at a mean 57 months follow-up (range 24 to 168 months). The mean Constant score increased from 48.4 points preoperatively to 67.6 points postoperatively (p < 0.0001). Eighty-seven percent of patients were satisfied or very satisfied with the result. Nine patients underwent an additional surgical procedure (three for attempt at rotator cuff repair and six for reverse prostheses for cuff tear arthropathy). The acromiohumeral interval decreased by a mean. 1.3 mm during the follow-up period and was associated with longer duration of follow-up (p < 0.0001). Preoperatively, 38% of patients had glenohumeral arthritis; postoperatively, 67% of patients had glenohumeral arthritis. Concomitant acromioplasty was statistically associated with better subjective and objective results only in patients with an acromiohumeral distance greater than 6 mm. Fatty infiltration of the rotator cuff musculature had a negative influence on both the functional and radiographic results (p < 0.0001). Arthroscopic biceps tenotomy in the treatment of rotator cuff tears in selected patients yields good objective improvement and a high degree of patient satisfaction. Despite these improvements, arthroscopic tenotomy does not appear to alter the progressive radiographic changes that occur with long standing rotator cuff tears

Purpose: Appropriate treatment of full-thickness tears of the rotator cuff with subacromial impingement remains a subject of debate. Considering that in most patients, spontaneous tears of the long biceps tendon reduces the pain and that subacromial osteoarthritis is well tolerated by many patients, we proposed arthroscopic tenotomy of the long biceps in this indication with the aim of relieving pain. We report here the long-term outcome. Material and methods: Between 1988 and 1999, 307 arthroscopic tenotomies of the long biceps tendon were performed in patients with unrepairable tears of the rotator cuff tendons (massive full thickness tears, old patients, non-motivated patients). The procedure was isolated in 64% and associated with acromioplasty in 36%. All patients were given prior medical treatment. Mean age at surgery was 64.3 years. The preoperative subacromial height was 6.6 mm. The tendon lesion was an isolated tear of the supraspinatus in 31%, tears of two tendons in 44.6% and tears of three tendons in 21.8%, and isolated tears of the subscapularis in 2.6%. Mean follow-up was 57 months (24–168). Results: The Constant score improved from 48.4 to 67.6 points (p< 0.001). Glenohumeral osteoarthritis (Samilson) increased from 38% to 67% of the shoulders postoperatively. Association with acromioplasty improved the objective and subjective result solely in the group of isolated tears of the supraspinatus. The size of the tear and the degree of fatty degeneration of the rotator cuff muscles had a statistically significant influence on functional and radiographic outcome (p< 0.001) while time since surgery had no effect on radiographic outcome (p< 0.001). Discussion: This simple easy-to-perform procedure yielded pain relief at rest and also nighttime pain. It can be recommended for massive rotator cuff tears with sub-acromial impingement in elderly or poorly-motivated patients whose pain fails to respond to medical treatment. This procedure does not allow recovery of shoulder motion or force

Sixty-two children were reviewed between 3 and 14 years (average 9.8 years) after flexor tenotomy for curly toes or hammer toes. No patients were aware of loss of flexor power in the toes. In only 5% of 188 toes was the operation unsuccessful. When the cause of failure was identifiable it proved to be that the scar crossed one or more flexor creases. None of the operated toes had an abnormally extended posture; only one toe was stiff and this resulted from tethering by a scar. It is concluded that open flexor tenotomy is an effective method for correcting curly toes and hammer toes in childhood. Pre-operative assessment must demonstrate that the resting length of the flexor tendons is unduly short, and that this shortening is the only cause of the deformity

Purpose: The main purpose of the study is to present our experience with the Ponseti casting followed by an Achilles tendon (AT) tenotomy in children with arthrogryposis multiplex congenita (AMC). Methods: 7 children with 14 severe clubfeet were treated by us with a Ponseti manipulations and casting followed by AT tenotomy. 5 children (10 feet) were followed at least 24 months after the AT tenotomy and were selected for the final evaluation. Their mean age at follow up was 38,4 months and average follow up period was 35,8 months. The treatment was begun within first month of life, the AT tenotomy to correct rigid equinus was performed at 14,4 weeks of life on average, after 7–10 cast changes (mean 8,4). Niki H. et al. clinical criteria and standard standing AP and lateral radiographs were analyzed for final evaluation. Results: There were 7 feet with clinically satisfactory results. Among 3 unsatisfactory feet there were two (1 child) with rocker-bottom pseudocorrections after repeated bilateral AT tenotomies and one recurrent clubfoot (1 child). Six feet required in soft tissue releases in 3, 12 and 21 months after the AT tenotomy due moderate equinus and adductus. 3 feet underwent repeated AT tenotomies in 6 and 15 months after the primary procedure. The mean interval between initial AT tenotomies and redo surgical procedures was 10,5 months (range 3–21 months). Two feet (20%) remain without significant deformity after AT tenotomies. Conclusion: Clubfeet in AMC respond initially to the Ponseti method of casting and the deformity may be corrected or diminished. In some children wide surgical treatment can be avoided, in other delayed. Despite necessity for additional surgical intervention, the Ponseti method of casting and Achilles tenotomy does seem to be an alternative for initial treatment in children with AMC

Aim. Two different techniques to release subscapularis during total shoulder replacement (TSR) have been described (tenotomy and osteotomy) with no consensus as to which is superior. In this study we review the clinical outcomes of a sequential series of patients in whom a TSR for primary osteoarthritis had been performed using either technique at our institution. Subscapularis function was tested using a new graded belly press test, a modification of the traditional belly press test which is described for the first time here. Methods. All patients who underwent surgery at our institution between January 2002 and January 2010 and met the eligibility criteria, were included for analysis. Subscapularis function was assessed post-operatively using a range of functional assessments including; a graded belly press test, lift off test, and an assessment of each patient's range of movement. Results. A total of 36 shoulders in 36 patients were included, ten underwent subscapularis tenotomy and 26 underwent osteotomy of the lesser tuberosity. Patients who had undergone osteotomy of the lesser tuberosity had a more favourable outcome overall. They demonstrated a significantly better grade (grade 1) of the belly press test compared with the tenotomy group (p=0.026) and a trend towards a better range of movement although no statistical significance was shown. All patients (osteotomy and tenotomy) with a grade 1 belly press test had a better clinical outcome with data demonstrating statistical significance. Conclusion. Our results indicate that in this single surgeon sequential series of patients who underwent osteotomy of the lesser tuberosity during TSR for OA had a better functional outcome than those who underwent subscapularis tenotomy. While our modification of the belly press test may require further validation we would suggest it may be a more useful indicator of subscapularis function in future studies

The effect of tenotomy and of immobilisation in lengthened and shortened positions on the intramuscular connective tissue of the calf muscles of the rat was studied morphometrically and with a scanning electron microscope. Both tenotomy and immobilisation produced a marked increase in both the endomysial and the perimysial collagen networks, with a simultaneous decrease in intramuscular capillary density. The increase in connective tissue volume was more pronounced and occurred more rapidly in the soleus, which consists mainly of type I, slow-twitch fibres than in the gastrocnemius, which is mainly of type II, fast-twitch fibres. The relative volume of connective tissue increased in parallel with the duration of immobilisation or after tenotomy. There was slightly more increase after immobilisation in a shortened rather than in a lengthened position

The long head of biceps tendon has been proposed as one of the pain generators in patients with rotator cuff tears. Many surgeons routinely perform tenotomy or tenodesis of the LHB especially in cases of large or massive RC tears. Purpose of this study is to evaluate the condition and position of the tenotomised LHB at a minimum of one year postoperatively. Between 2006 and 2008 96 patients (41 men and 55 women) with RC tears were treated arthroscopically in our clinic, with an average age of 61.2 years (56–80). In 57 cases we proceeded to tenotomy of the LHB. Thirty one of them were available for ultrasound evaluation of the condition and the position of the tenotomised LHB one year post –tenotomy. Intraoperatively the lesions of the LHB varied in degrees from significant hypertrophy- Hourglass deformity (6 cases), subluxation (10 cases), tendinitis (25 cases) to fraying (10 cases). Twelve months postoperatively all the patients reported pain relief and satisfaction from the operation, even in irreparable tears. On ultrasound control the tendon was not found in the bicipital groove or was at its peripheral margin in 10 cases (31%) with only 3 patients having a positive Popeye sign. In the remaining patients the tendon was adhered on the wall of the groove (natural tenodesis). Our results suggest that simple tenotomy of LHB results in pain relief and maintenance of muscle strength. The low percentage of Popeye Sign disputes the necessity for tenodesis, even in younger patients

Purpose: Although hamstring retraction is a frequent complication of spastic hypertoniq, very few series have been reported in adults. The purpose of this study was to evaluate results of therapeutic modalities proposed: distal hamstring tenotomy and use of an external fixator in case of permanent knee flexion. Material and methods: This retrospective series included 37 cerebral palsy patients, 59 with permanent knee flexion. Mean flexion was 69° (20–130°). Mean motion was 61° (10–100°). Deformation of the supra and infra joints was present in 82%. There were 22 patients with bilateral permanent knee flexion. Simple tenotomy of the sartorius, the semitendinous and the gracilis with lengthenings of the semimembranous and biceps. Disinsertion of the gastrocnemius and section of posterior aponeurosis were associated as needed. Postoperative immobilization was achieved with a Zimmer cast in case of moderate flexion and with an external femorotibial fixator in case of major deformation. Postoperative rehabilitation exercises performed several times daily were initiated in all patients. Results: At mean follow-up of 641 days, residual flexion was 6° (0–40°) and mean joint motion was 111°. All knees were stable. Three dehiscent wounds required surgical repair. The function objective, established pre-operatively, was achieved or exceeded. Discussion: When postoperative immobilization is necessary, external fixation limits cutaneous risks and facilitates rehabilitation. It appears to be better than successive cases. Unlike other authors, we did not find section of the posterior cruciate ligament to be necessary. Conclusion: Distal hamstring tenotomy associated with postoperative immobilization with an external fixator is a reliable and effective technique for the treatment of permanent knee flexion in cerebral palsy adults

Purpose: Arthroscopic tenotomy of the long head of the biceps brachial is indicated for pain relief in the treatment of unrepairable tears of the rotator cuff. The purpose of our study was to evaluate clinical and radiological outcome. Material and methods: This retrospective study included 38 patients (21 women and 17 men) mean age 65 years (44–78) who presented rotator cuff tears that could not be repaired by suture. These patients underwent arthroscopic tenotomy associated with acromioplasty in eight cases. Preoperative imaging included arthroscan and standard radiograms to assess retraction of the supraspinatus stump and fatty degeneration. The clinical outcome was assessed with the Constant score and search for loss of biceps force (estimated in comparision of an age- and gender-matched cohort). Modifications of the subarcomial height and the stage of joint degeneration were assessed on AP radiograms (standing and reclining position). Results: Mean follow-up was 31 months. There were no complications related to the operation. The overall constant score improved 19 points from 39 to 58 (pain +7 and motion +6.1 increased most). The activity score improved 6 points. Active joint motion in antepulsion, abduction, and lateral rotation (elbow to body) increased 36.5°, 13.1° and 20.8° respectively. The sub acromial height decreased very little (from 7.4 mm preoperatively to 7.4 mm postoperatively). We observed a 37% decrease in arm force in flexion/supination on the operated side (6.05 kg vs 9.65 kg). Subjectively, 85% of the patients were very satisfied or satisfied, 10% were disappointed and 2.5% were discontent. For 88% of the patients the decision for surgical intervention was wise. Discussion: Tenotomy of the long head of the brachial biceps is effective for pain relief and consequently joint motion. It is a technically simple procedure which does not accelerate degeneration of the excentered joint, at the follow-up considered. It does however reduce flexion force of the arm

Aim: To introduce a mini-invasive surgical treatment for lengthening of knee flexors in cerebral palsied children. Material and methods: Operation is performed in prone position under tourniquet control. The trocar (4mm) is introduced from middle thirds of dorsal surface of the thigh in the direction caudally from small incision. By means of the trocar soft tissues are separated from the superficial fascia and a working tunnel is created. Then optical system is introduced and gas (CO2) is pushed in. Under the guidance of the videoscopic system another two small incision are done, one medially one laterally. By means of the knife blade and arthroscopic scissors the superficial fascia is divided and musculotendinous junction of gracilis and semitendinosus is found and muscular recession is done. The aponeurosis of semi-membranosus is isolated and transversely cut. When necessary, from second mini-incision the aponeurosis of biceps femoris is isolated and cut. Operation method was prepared on a cadaver study, concerning the learning curve, for the operation were selected patients with only moderate flexion contracture, Bleck angle between 50–60°. Results: In 5 operated legs videoscopic tenotomy resulted in full correction of fixed flexion. Small incisions healed uneventfully. No vascular or neurological complications were registered. Discussion: Videoscopic technique firstly was used in our institution for correction of fixed equinus in CP patients. Concerning good results and acquired operation technique, obtained experience was used for correction of fixed flexion contracture. Conclusion: Videoscopic correction of fixed knee flexion in CP seems to be a safe and reliable operation method

This study evaluates the position of the long head of biceps tendon using ultrasound following simple tenotomy, in patients with arthroscopically repaired rotator cuff tears. In total, 52 patients with a mean age of 60.7 years (45 to 75) underwent arthroscopic repair of the rotator cuff and simple tenotomy of the long head of biceps tendon. At two years post-operatively, ultrasound revealed that the tendon was inside the bicipital groove in 43 patients (82.7%) and outside in nine (17.3%); in six of these it was lying just outside the groove and in the remaining three (5.8%) it was in a remote position with a positive Popeye Sign. A dynamic ultrasound scan revealed that the tenotomised tendons had adhered to the surrounding tissues (autotenodesis).The initial condition of the tendon influenced its final position (p < 0.0005). The presence of a Popeye sign was statistically influenced by the pre-operative co-existence of supraspinatus and subscapularis tears (p < 0.0001). It appears that the natural history of the tenotomised long head of biceps tendon is to tenodese itself inside or just outside the bicipital groove, while its pre-operative condition and coexistent subscapularis tears play a significant role in the occurrence of a Popeye sign

Purpose. Controversy exists regarding the optimal technique of subscapularis mobilization during shoulder arthroplasty. The purpose of this multicentre randomized double-blind study was to compare the functional outcomes and healing rates of the lesser tuberosity osteotomy (LTO) to the subscapularis tenotomy (ST). Method. Patients undergoing shoulder arthroplasty were randomized to receive either a LTO or ST. The primary outcome was to compare subscapularis strength, as measured by an electronic hand-held dynamometer at 12 months. Secondary outcomes included range of motion, WOOS, Constant and ASES scores. A sample size calculation determined that 80 patients provided 80% power with a 50% effect size to detect a significant difference between groups. Results. Baseline demographic data did not differ between groups including age (p=0.69), sex (p=0.77), affected side (p=0.59) and arthroplasty type (hemiarthroplasty or total, p=0.77). Strength comparison between groups revealed no statistical differences at any time interval (p=0.744, baseline, p=0.449, 3 month, p=0.203, 6 months, 12 months, p=0.45). Statistically significant improvements occurred in both groups from baseline to 12 month time points in all clinical outcome scores (p<0.0001). Conclusion. No statistically significant differences in primary or secondary outcomes were identified between the LTO and ST. This trial does not demonstrate any clear advantage of one subscapularis mobilization technique over the other

Background: The purpose of this study was to evaluate the results after hallux valgus surgery by transar-ticular adductor tenotomy, distal Chevron metatarsal osteotomy and Akin phalangeal osteotomy using medial one incision. Materials and Methods: From June 2004 to June 2007, eighty feet of 54 patients were included in this study. During the same period, other cases of hallux valgus correction were excluded. Thirty seven patients underwent both feet operation at the same time and 17 patients underwent single foot operation. Among the 37 patients who underwent both feet operation, proximal metatarsal osteotomy was performed for contralateral 11 feet at same time, and these cases with proximal metatarsal osteotomy were excluded from this study. Postoperatively, all patients were allowed immediate full weight bearing walking. Patients were evaluated according to the American Orthopedic Foot and Ankle Society(AOFAS) hallux metatarsophalangeal-interpha-langeal scale, VAS(visual analogue scale), post-operative complications and radiologic parameters such as hallux valgus angle, intermetatarsal angle, T-test was used to evaluate the degree of hallux valgus and intermetatarsal angles. The mean follow up period was 25.9 months. Results: At the last follow up, the mean AOFAS hallux metatarsophalangeal-interphalangeal scale increased from 48.7 to 91.9. The Mean VAS score decreased from 7.1 to 0.8 post-operatively. The mean hallux valgus angle of 31.4° (range, 22° to 46°) improved to 5.3 ° (range, 0° to 20°) after the operation. The mean intermetatarsal angle also showed improvement from 12.3° (range, 7° to 16°) to 5.5 ° (range, 2° to 11°). Comparison between preoperative and postoperative hallux valgus and intermetatarsal angles was done by T test in dependent groups, which showed statistical significance (p< 0.05). There were three cases of mild hallux varus and three cases of recurred valgus deormity. No avascular necrosis or union problem was observed on the radiographs in any of the patients. Conclusion: Hallux valgus deformity correction by transarticular adductor tenotomy, distal Chevron metatarsal osteotomy and Akin phalangeal osteotomy using medial one incision has the advantages of lower morbidity and less scar without avascular necrosis of the metatarsal head

Subscapularis function following Total shoulder joint replacement has been a concern in recent literature. It has been postulated that lesser tuberosity osteotomy approach may have better Subscapularis function than transtendonous approach. To assess whether lesser tuberosity osteotomy vs. subscapularis tenotomy is better for post-operative function of subscapularis in total shoulder replacements done by a single surgeon in a District general hospital. 117 shoulder replacements performed by the senior author (TH) at Waikato district general hospital between years January 2002 to January 2010 were reviewed retrospectively. Revision replacement, inverse shoulder replacement & acute traumatic hemiarthroplasty were excluded. Patients with previous rotator cuff problems, previous surgery to subscapularis, rheumatoid arthritis and post-trauma sequelae were also excluded from the study. Inclusion criteria were normal subscapularis function and intact subscapularis on MRI pre-operatively. 41 shoulders were eligible to participate in study of which 1 pt died (bilateral TSR), 1 pt unfit to participate due to cervical disc problems. Of remaining 38 shoulders 11 shoulders had transtendonous and 27 shoulders had lesser tuberosity osteotomy approach. 37 shoulders were reviewed clinically for range of motion of the shoulder and subscapularis strength. Range of motion and subscapularis strength was significantly higher in the osteotomy group. All osteotomies were united on axillary radiograph. Lesser tuberosity osteotomy approach result in better subscapularis function than transtendonous approach

The December 2022 Shoulder & Elbow Roundup. 360. looks at: Biceps tenotomy versus soft-tissue tenodesis in females aged 60 years and older with rotator cuff tears; Resistance training combined with corticosteroid injections or tendon needling in patients with lateral elbow tendinopathy; Two-year functional outcomes of completely displaced midshaft clavicle fractures in adolescents; Patients who undergo rotator cuff repair can safely return to driving at two weeks postoperatively; Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures; Treatment of acute distal biceps tendon ruptures; Rotator cuff tendinopathy: disability associated with depression rather than pathology severity; Coonrad-Morrey total elbow arthroplasty implications in young patients with post-traumatic sequelae

Aims. Rotator cuff (RC) injuries are characterized by tendon rupture, muscle atrophy, retraction, and fatty infiltration, which increase injury severity and jeopardize adequate tendon repair. Epigenetic drugs, such as histone deacetylase inhibitors (HDACis), possess the capacity to redefine the molecular signature of cells, and they may have the potential to inhibit the transformation of the fibro-adipogenic progenitors (FAPs) within the skeletal muscle into adipocyte-like cells, concurrently enhancing the myogenic potential of the satellite cells. Methods. HDACis were added to FAPs and satellite cell cultures isolated from mice. The HDACi vorinostat was additionally administered into a RC injury animal model. Histological analysis was carried out on the isolated supra- and infraspinatus muscles to assess vorinostat anti-muscle degeneration potential. Results. Vorinostat, a HDACi compound, blocked the adipogenic transformation of muscle-associated FAPs in culture, promoting myogenic progression of the satellite cells. Furthermore, it protected muscle from degeneration after acute RC in mice in the earlier muscle degenerative stage after tenotomy. Conclusion. The HDACi vorinostat may be a candidate to prevent early muscular degeneration after RC injury. Cite this article: Bone Joint Res 2024;13(4):169–183

The February 2023 Shoulder & Elbow Roundup. 360. looks at: Arthroscopic capsular release or manipulation under anaesthesia for frozen shoulder?; Distal biceps repair through a single incision?; Distal biceps tendon ruptures: diagnostic strategy through physical examination; Postoperative multimodal opioid-sparing protocol vs standard opioid prescribing after knee or shoulder arthroscopy: a randomized clinical trial; Graft healing is more important than graft technique in massive rotator cuff tear; Subscapularis tenotomy versus peel after anatomic shoulder arthroplasty; Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty; Conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty

Aims. The Ponseti method is the gold standard treatment for congenital talipes equinovarus (CTEV), with the British Consensus Statement providing a benchmark for standard of care. Meeting these standards and providing expert care while maintaining geographical accessibility can pose a service delivery challenge. A novel ‘Hub and Spoke’ Shared Care model was initiated to deliver Ponseti treatment for CTEV, while addressing standard of care and resource allocation. The aim of this study was to assess feasibility and outcomes of the corrective phase of Ponseti service delivery using this model. Methods. Patients with idiopathic CTEV were seen in their local hospitals (‘Spokes’) for initial diagnosis and casting, followed by referral to the tertiary hospital (‘Hub’) for tenotomy. Non-idiopathic CTEV was managed solely by the Hub. Primary and secondary outcomes were achieving primary correction, and complication rates resulting in early transfer to the Hub, respectively. Consecutive data were prospectively collected and compared between patients allocated to Hub or Spokes. Mann-Whitney U test, Wilcoxon signed-rank test, or chi-squared tests were used for analysis (alpha-priori = 0.05, two-tailed significance). Results. Between 1 March 2020 and 31 March 2023, 92 patients (139 feet) were treated at the service (Hub 50%, n = 46; Spokes 50%, n = 46), of whom nine were non-idiopathic. All patients (n = 92), regardless of allocation, ultimately achieved primary correction, with idiopathic patients at the Hub requiring fewer casts than the Spokes (mean 4.0 (SD 1.4) vs 6.9 (SD 4.4); p < 0.001). Overall, 60.9% of Spokes’ patients (n = 28/46) required transfer to the Hub due to complications (cast slips Hub n = 2; Spokes n = 17; p < 0.001). These patients ultimately achieved full correction at the Hub. Conclusion. The Shared Care model was found to be feasible in terms of providing primary correction to all patients, with results comparable to other published services. Complication rates were higher at the Spokes, although these were correctable. Future research is needed to assess long-term outcomes, parents’ satisfaction, and cost-effectiveness. Cite this article: Bone Jt Open 2023;4(11):865–872

Untreated clubfoot results in serious disability, but mild to moderate residual deformities can still cause functional limitations and pain. Measuring the impact of clubfoot deformities on children's wellbeing is challenging. There is little literature discussing the variability in outcomes and implications of clubfoot based on where geographically the child resides. Although the use of patient reported outcome measures (PROMs) is steadily growing in pediatric orthopaedics, few studies on clubfoot have incorporated them. The most widely used PROM for pediatric foot and ankle pathology is the Oxford Foot and Ankle Questionnaire for Children (OXFAQ-C) that include a physical, school and play, emotional and shoe wear domains. The aim of this study is to evaluate the validity and regional differences in scores of the OXFAQ-C questionnaire to identify functional disability in children with clubfoot in India and Canada. This is a retrospective cohort study of children in Indian and Canadian clubfoot registries aged 5-16 years who completed >1 parent or child OXFAQ-C. The OXFAQ-C was administered once in 01/2020 to all patients in the Indian registry, and prospectively between 06/2019 and 03/2021 at initial visit, 3, 6, 12 months post-intervention, then annually for the Canadian patients. Demographic, clubfoot, and treatment data were compared to OXFAQ-C domain scores. Descriptive statistics and regression analysis were performed. Parent-child concordance was evaluated with Pearson's Coefficient of Correlation (PCC). The cohort had 361 patients (253 from India, 108 from Canada). Non-idiopathic clubfoot occurred in 15% of children in India and 5% in Canada, and bilateral in 53% in India and 50% in Canada. Tenotomy rate was 75% in India and 62% in Canada. Median age at presentation was 3 months in India and 1 month in Canada. Mean Pirani score at presentation and number of Ponseti casts were 4.9 and 6.1 in India and 5.3 and 5.7 in Canada, respectively. Parents reported lower scores in all domains the older the child was at presentation (p Canadians scored significantly lower for all domains (p < 0 .001), with the difference being larger for child-reported scores. The greatest difference was for physical domain. Canadian parents on average scored their child 6.21 points lower than Indian parents, and Canadian children scored a mean of 7.57 lower than Indian children. OXFAQ-C scores differed significantly between Indian and Canadian children despite similar demographic and clubfoot characteristics. Younger age at presentation and tenotomy may improve OXFAQ-C scores in childhood. Parent-child concordance was strong in this population. The OXFAQ-C is an adequate tool to assess functional outcomes of children with clubfeet. Cultural validation of patient reported outcome tools is critical

We have modified the Ponseti casting technique by using a below-knee Softcast instead of an above-knee plaster of Paris cast. Treatment was initiated as soon as possible after birth and the Pirani score was recorded at each visit. Following the manipulation techniques of Ponseti, a below-knee Softcast was applied directly over a stockinette for a snug fit and particular attention was paid to creating a deep groove above the heel to prevent slippage. If necessary, a percutaneous Achilles tenotomy was performed and casting continued until the child was fitted with Denis Browne abduction boots. Between April 2003 and May 2007 we treated 51 consecutive babies with 80 idiopathic club feet with a mean age at presentation of 4.5 weeks (4 days to 62 weeks). The initial mean Pirani score was 5.5 (3 to 6). It took a mean of 8.5 weeks (4 to 53) of weekly manipulation and casting to reach the stage of percutaneous Achilles tenotomy. A total of 20 feet (25%) did not require a tenotomy and for the 60 that did, the mean Pirani score at time of operation was 2.5 (0.5 to 3). Denis Browne boots were applied at a mean of 10 weeks (4 to 56) after presentation. The mean time from tenotomy to boots was 3.3 weeks (2 to 10). We experienced one case of cast-slippage during a period of non-attendance, which prolonged the casting process. One case of prolonged casting required repeated tenotomy, and three feet required repeated tenotomy and casting after relapsing while in Denis Browne boots. We believe the use of a below-knee Softcast in conjunction with Ponseti manipulation techniques shows promising initial results which are comparable to those using above-knee plaster of Paris casts

Introduction. Developmental dysplasia of the hip (DDH) can be managed through a variety of different surgical approaches from closed reduction to simple tenotomies of the adductors and through to osteotomies of the femur and pelvis. The rate of redislocation following open reduction for the treatment of DDH may be affected by the number of intraoperative surgeons. Materials and methods. We performed a retrospective cohort analysis of 109 patients who underwent open reduction with or without bony osteotomies as a primary intervention between 2013 and 2023. We measured the number of redislocations and number of operating surgeons (either 1 or 2 operating surgeons) to assess for any correlation. 109 patients were identified and corresponded to 121 primary hip operations, the mean age at operation was 82.2 months (range 6 to 739 months). During the 10-year period 7 hip redislocations were identified. Results. Of the 7 redislocated hips, the rate of redislocation was found to be higher in patients who had undergone surgery via a single surgeon (5 redislocations) compared to the dual surgeon cohort (2 redislocations), though this did not reach statistical significance. Redislocation was more common in female patients and right laterality 7.2% and 8.7% respectively, though this again did not reach statistical significance. Conclusions. We conclude that a single surgeon approach, female gender and right laterality are potential risk factors for redislocation following open reduction. Further investigation utilising a larger sample size would be required to appropriately explore these potential risk factors further

We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot. Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30). The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients

Aim. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressures. Progressive hindfoot equinus from contraction of gastrocnemius-soleus-tendo-Achilles complex and progressive plantar flexed metatarsal heads secondary to claw toe deformity results callus at the metatarsal heads which break down to ulceration. The aim is to describe 2-stage treatment pathway for managing these ulcers. Methods. Consecutive patients, who presented with forefoot ulcers since February 2019 were treated with a 2-stage treatment pathway. The first stage of this is an out-patient tendo-Achilles lengthening (TAL). The second stage is surgical proximal dorsal closing wedge metatarsal osteotomy for patients with persistent or recurrent ulcers. Patients were followed for a minimum of 12 months. Results. 112 patients (146 feet) underwent TAL by 3 consultants. Of these, 96 patients were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 patients (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with 1. st. metatarsal and 5. th. metatarsal head ulcers respectively. In 12 patients (10%), the ulcer failed to heal or recurred. MRI scan in these patients showed plantar flexed metatarsals from progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy of the metatarsal/s, with no recurrence at a minimum 12months of follow-up. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after the first stage out-patient percutaneous TAL

Aims. Iliopsoas pathology is a relatively uncommon cause of pain following total hip arthroplasty (THA), typically presenting with symptoms of groin pain on active flexion and/or extension of the hip. A variety of conservative and surgical treatment options have been reported. In this retrospective cohort study, we report the incidence of iliopsoas pathology and treatment outcomes. Methods. A retrospective review of 1,000 patients who underwent THA over a five-year period was conducted, to determine the incidence of patients diagnosed with iliopsoas pathology. Outcome following non-surgical and surgical management was assessed. Results. In all, 24 patients were diagnosed as having developed symptomatic iliopsoas pathology giving an incidence of 2.4%. While the mean age for receiving a THA was 65 years, the mean age for developing iliopsoas pathology was 54 years (28 to 67). Younger patients and those receiving THA for conditions other than primary osteoarthritis were at a higher risk of developing this complication. Ultrasound-guided steroid injection/physiotherapy resulted in complete resolution of symptoms in 61% of cases, partial resolution in 13%, and no benefit in 26%. Eight out of 24 patients (who initially responded to injection) subsequently underwent surgical intervention including tenotomy (n = 7) and revision of the acetabular component (n = 1). Conclusion. This is the largest case series to estimate the incidence of iliopsoas pathology to date. There is a higher incidence of this condition in younger patients, possibly due to the differing surgical indications. Arthoplasty for Perthes' disease or developmental dysplasia of the hip (DDH) often results in leg length and horizontal offset being increased. This, in turn, may increase tension on the iliopsoas tendon, possibly resulting in a higher risk of psoas irritation. Image-guided steroid injection is a low-risk, relatively effective treatment. In refractory cases, tendon release may be considered. Patients should be counselled of the risk of persisting groin pain when undergoing THA. Cite this article: Bone Joint J 2021;103-B(2):305–308

Re-rupture rates after rotator cuff repair remain high because of inadequate biological healing at the tendon-bone interface. Single-growth factor therapies to augment healing at the enthesis have so far yielded inconsistent results. An emerging approach is to combine multiple growth factors over a spatiotemporal distribution that mimics normal healing. We propose a novel combination treatment of insulin-like growth factor 1 (IGF-1), transforming growth factor β1 (TGF-β1) and parathyroid hormone (PTH) incorporated into a controlled-release tyraminated poly-vinyl-alcohol hydrogel to improve healing after rotator cuff repair. We aimed to evaluate this growth factor treatment in a rat chronic rotator cuff tear model. A total of 30 male Sprague-Dawley rats underwent unilateral supraspinatus tenotomy. Delayed rotator cuff repairs were then performed after 3 weeks, to allow tendon degeneration that resembles the human clinical scenario. Animals were randomly assigned to: [1] a control group with repair alone; or [2] a treatment group in which the hydrogel was applied at the repair site. All animals were euthanized 12 weeks after rotator cuff surgery and the explanted shoulders were analyzed for biomechanical strength and histological quality of healing at the repair site. In the treatment group had significantly higher stress at failure (73% improvement, P=0.003) and Young's modulus (56% improvement, P=0.028) compared to the control group. Histological assessment revealed improved healing with significantly higher overall histological scores (10.1 of 15 vs 6.55 of 15, P=0.032), and lower inflammation and vascularity. This novel combination growth factor treatment improved the quality of healing and strength of the repaired enthesis in a chronic rotator cuff tear model. Further optimization and tailoring of the growth factors hydrogel is required prior to consideration for clinical use in the treatment of rotator cuff tears. This novel treatment approach holds promise for improving biological healing of this clinically challenging problem

Aim. To describe a 2-stage treatment pathway for managing neuropathic forefoot ulcers and the safety and efficacy of percutaneous tendo-Achilles lengthening (TAL) in out-patient clinics. Methods. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressure. Plantar flexed metatarsal heads secondary to progressive claw toe deformity and hindfoot equinus from changes within the gastrocnemius-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus, secondary to motor neuropathy results in progressive increase in forefoot plantar pressures. Consecutive patients, who presented to our Diabetic Foot clinic since February 2019 with forefoot ulcers or recurrent forefoot callosity were treated with TAL in the first instance, and in patients with recurrent or non-healing ulcers, by proximal dorsal closing wedge osteotomy; a 2-stage treatment pathway. Patients were followed up at 3, 6, and 12 months to assess ulcer healing and recurrence. Results. One hundred and twelve patients (146 feet) underwent TAL by 3 consultants in the out-patient clinics. Of these, 96 feet were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 feet (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. In 12 feet (10%), the ulcer failed to heal or recurred, the MRI scan in these patients showed plantar flexed metatarsals secondary to progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy. In patients with osteomyelitis, the intramedullary canal was curetted and filled with local antibiotic eluting agents such as Cerament G. ®. The osteotomy site was stabilised with a percutaneous 1.6mm k-wire. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after out-patient percutaneous TAL alone. TAL is a safe and effective initial out-patient procedure with improved patient outcomes

The Ponseti method of clubfoot management requires a period of bracing in order to maintain correction. This study compared the effectiveness of ankle foot orthoses and Denis Browne boots and bar in the prevention of recurrence following successful initial management. Between 2001 and 2003, 45 children (69 feet) with idiopathic clubfeet achieved full correction following Ponseti casting with or without a tenotomy, of whom 17 (30 clubfeet) were braced with an ankle foot orthosis while 28 (39 clubfeet) were prescribed with Denis Browne boots and bar. The groups were similar in age, gender, number of casts and tenotomy rates. The mean follow-up was 60 months (50 to 72) in the ankle foot orthosis group and 47 months (36 to 60) in the group with boots and bars. Recurrence requiring additional treatment occurred in 25 of 30 (83%) of the ankle foot orthosis group and 12 of 39 (31%) of the group with boots and bars (p < 0.001). Additional procedures included repeat tenotomy (four in the ankle foot orthosis group and five in the group treated with boot and bars), limited posterior release with or without tendon transfers (seven in the ankle foot orthosis group and two in the group treated with boots and bars), posteromedial releases (nine in the orthosis group) and midfoot osteotomies (five in the orthosis group, p < 0.001). Following initial correction by the Ponseti method, children managed with boots and bars had far fewer recurrences than those managed with ankle foot orthoses. Foot abduction appears to be important to maintain correction of clubfeet treated by the Ponseti method, and this cannot be achieved with an ankle foot orthosis

Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon's visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is a safe alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization. The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week. One hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p < 0 .001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p < 0 .001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups. Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone

Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon's visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is a safe alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization. The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week. One hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p < 0 .001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p < 0 .001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups. Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone

Ponseti method has become the most common and validated initial non-operative and/or minimally invasive treatment modality of idiopathic clubfoot regardless of the severity of the deformity worldwide. Despite hundreds of publications in the literature favoring Ponseti method, the data about secondary procedures performed in the follow-up period of clubfoot and their incidence remains sparse and given as small details in the articles. The objective of this study was to analyse our incidence of secondary procedures performed in the midterm followup period of idiopathic clubfoot patients treated with Ponseti method and review of the relevant literature. For this purpose 86 feet of 60 patients with idiopathic clubfoot who were treated with original Ponseti method were enrolled in this retrospective case control study. Unilateral ankle foot orthosis (AFO) was used rather than standart bar-connected foot abduction orthosis varying from 12 months to 25 months in the follow-up period and 74 of 86 (86%) feet required percutaneous achilles tenotomy. The average age of initial cast treatment was 12.64 days (range 1 to 102 days). The mean follow-up time was 71 months (range 19 to 153 months). Thirty seven feet of 24 patients recieved secondary procedures (43%) consisting of; supramalleolary derotational osteotomy (SMDO) (1 patient/2 feet), complete subtalar release (3 patients/5 feet), medial opening lateral closing osteotomy (double osteotomy) (2 patients/3 feet), double osteotomy with transfer of tibialis anterior tendon (TTAT) (2 patients/3 feet), partial subtalar release (PSTR) (3 patients/5 feet), PSTR with SDO (1 patient/1 foot), posterior release (PR) with repeated achillotomy (1 patient/2 feet), TTAT (6 patients/10 feet), TTAT with PR (2 patients/2 feet), TTAT with Vulpius procedure (1 patient/1 foot) and TTAT with SMDO (2 patients/3 feet) respectively. The amount of percutaneous achilles tenotomy (86%) in our study correlated with the literature which ranged from 80 to 90 %. The transfer of tibialis anterior tendon continued to be the most performed secondary procedure both in our study (51%) and in the literature, but the amount of total secondary procedures in our study (43%) was determined to be higher than the literature data varying from 7 to 27 percent which may be due to unilateral AFO application after Ponseti method for idiopathic clubfoot deformity in our study

We have reviewed a group of patients with iliopsoas impingement after total hip replacement with radiological evidence of a well-fixed malpositioned or oversized acetabular component. A consecutive series of 29 patients (30 hips) was assessed. All had undergone a trial of conservative management with no improvement in their symptoms. Eight patients (eight hips) preferred continued conservative management (group 1), and 22 hips had either an iliopsoas tenotomy (group 2) or revision of the acetabular component and debridement of the tendon (group 3), based on clinical and radiological findings. Patients were followed clinically for at least two years, and 19 of the 22 patients (86.4%) who had surgery were contacted by phone at a mean of 7.8 years (5 to 9) post-operatively. Conservative management failed in all eight hips. At the final follow-up, operative treatment resulted in relief of pain in 18 of 22 hips (81.8%), with one hip in group 2 and three in group 3 with continuing symptoms. The Harris Hip Score was significantly better in the combined groups 2 and 3 than in group 1. There was a significant rate of complications in group 3. This group initially had better functional scores, but at final follow-up these were no different from those in group 2. Tenotomy of the iliopsoas and revision of the acetabular component are both successful surgical options. Iliopsoas tenotomy provided the same functional results as revision of the acetabular component and avoided the risks of the latter procedure

The Ponseti method is the gold standard treatment for clubfoot. It begins in early infancy with weekly serial casting for up to 3 months. Globally, a commonly reported barrier to accessing clubfoot treatment is increased distance patients must travel for intervention. This study aims to evaluate the impact of the distance traveled by families to the hospital on the treatment course and outcomes for idiopathic clubfoot. No prior studies in Canada have examined this potential barrier. This is a retrospective cohort study of patients managed at a single urban tertiary care center for idiopathic clubfoot deformity. All patients were enrolled in the Pediatric Clubfoot Research Registry between 2003 and April 2021. Inclusion criteria consisted of patients presenting at after percutaneous Achilles tenotomy. Postal codes were used to determine distance from patients’ home address to the hospital. Patients were divided into three groups based on distance traveled to hospital: those living within the city, within the Greater Metro Area (GMA) and outside of the GMA (non-GMA). The primary outcome evaluated was occurrence of deformity relapse and secondary outcomes included need for surgery, treatment interruptions/missed appointments, and complications with bracing or casting. A total of 320 patients met inclusion criteria. Of these, 32.8% lived in the city, 41% in the GMA and 26% outside of the GMA. The average travel distance to the treatment centre in each group was 13.3km, 49.5km and 264km, respectively. Over 22% of patients travelled over 100km, with the furthest patient travelling 831km. The average age of presentation was 0.91 months for patients living in the city, 1.15 months for those within the GMA and 1.33 months for patients outside of the GMA. The mean number of total casts applied was similar with 7.1, 7.8 and 7.3 casts in the city, GMA and non-GMA groups, respectively. At least one two or more-week gap was identified between serial casting appointments in 49% of patients outside the GMA, compared to 27% (GMA) and 24% (city). Relapse occurred in at least one foot in 40% of non-GMA patients, versus 27% (GMA) and 24% (city), with a mean age at first relapse of 50.3 months in non-GMA patients, 42.4 months in GMA and 35.7 months in city-dwelling patients. 12% of the non-GMA group, 6.8% of the GMA group and 5.7% of the city group underwent surgery, with a mean age at time of initial surgery of 79 months, 67 months and 76 months, respectively. Complications, such as pressure sores, casts slips and soiled casts, occurred in 35% (non-GMA), 32% (GMA) and 24% (city) of patients. These findings suggest that greater travel distance for clubfoot management is associated with more missed appointments, increased risk of relapse and treatment complications. Distance to a treatment center is a modifiable barrier. Improving access to clubfoot care by establishing clinics in more remote communities may improve clinical outcomes and significantly decrease the burdens of travel on patients and families

The functional importance of the long head of biceps tendon remains controversial, but it is well accepted as an important source of anterior shoulder pain. Both biceps tenotomy and tenodesis have well-documented results in the native shoulder. Management of the long head of biceps tendon during shoulder arthroplasty remains controversial. The existing literature supports surgical treatment of the biceps during shoulder arthroplasty. Walch et al. reported the largest series in multicenter study of over eight hundred shoulder arthroplasty patients with or without biceps tenodesis. The authors found more reproducible pain relief with biceps tenodesis and no difference in range of motion. Similarly, Soliman et al. reported on a prospective review of 37 patients undergoing hemiarthroplasty for fracture randomly assigned to biceps tenodesis vs. no treatment. The authors found a statistically significant improvement in Constant score and shoulder pain with biceps tenodesis. If left untreated during shoulder arthroplasty, the intact biceps tendon may be a source of anterior shoulder pain requiring revision surgery. Tuckman et al. reported excellent pain relief after biceps tenotomy or tenodesis for biceps-related pain after previous shoulder arthroplasty. The decision to perform a biceps tenotomy versus a tenodesis during shoulder arthroplasty also remains controversial. Tenotomy may increase the risk of cosmetic pop-eye deformity and muscle cramping or fatigue over tenodesis. Therefore, routine long head of biceps soft tissue tenodesis is recommended during shoulder arthroplasty as it safe, reproducible, cost-effective, associated with improved outcome scores, and minimises the risk of cosmetic deformity and pain associated with biceps tenotomy

The Pirani scoring system, together with the Ponseti method of club foot management, was assessed for its predictive value. The data on 70 idiopathic club feet successfully treated by the Ponseti method and scored by Pirani’s system between February 2002 and May 2004 were analysed. There was a significant positive correlation between the initial Pirani score and number of casts required to correct the deformity. A foot scoring 4 or more is likely to require at least four casts, and one scoring less than 4 will require three or fewer. A foot with a hindfoot score of 2.5 or 3 has a 72% chance of requiring a tenotomy. The Pirani scoring system is reliable, quick, and easy to use, and provides a good forecast about the likely treatment for an individual foot but a low score does not exclude the possibility that a tenotomy may be required

We studied 24 children (40 feet) to demonstrate that a physiotherapist-delivered Ponseti service is as successful as a medically-led programme in obtaining correction of an idiopathic congenital talipes equinovarus deformity. The median Pirani score at the start of treatment was 5.5 (mean 4.75; 2 to 6). A Pirani score of ≥5 predicted the need for tenotomy (p < 0.01). Of the 40 feet studied, 39 (97.5%) achieved correction of deformity. The remaining foot required surgical correction. A total of 25 (62.5%) of the feet underwent an Achilles tenotomy, which was performed by a surgeon in the physiotherapy clinic. There was full compliance with the foot abduction orthoses in 36 (90%) feet. Continuity of care was assured, as one practitioner was responsible for all patient contact. This was rated highly by the patient satisfaction survey. We believe that the Ponseti technique is suitable for use by non-medical personnel, but a holistic approach and good continuity of care are essential to the success of the programme

Total shoulder arthroplasty is becoming increasingly common. A biceps tenodesis or tenotomy has become a routine part of the operation. There are several advantages to a tenodesis or tenotomy. First, the long head of the biceps tendon is routinely pathologic. One study has shown that there are differences in gene expression and mechanical properties in the long head of the biceps tendon in the setting of glenohumeral joint arthritis. Clinically, we often see inflammation, tearing, adhesions, or other pathology. Second, it is largely accepted that the long head of the biceps tendon has minimal function at the shoulder. The biceps muscle primarily functions at the elbow. Therefore, there is little downside to performing a tenodesis if there is a chance of it generating pain after surgery. Another major reason to perform a tenodesis or a tenotomy is that the technique of total shoulder arthroplasty requires a subscapularis takedown or lesser tuberosity osteotomy. The ligaments and tendon associated with the subscapularis contribute to the stability of the biceps tendon and after subscapularis takedown, it is unlikely that the tendon would remain reduced in the groove. In addition, it is part of a technique to incise and release the rotator interval, additionally creating scarring and/or instability associated with the biceps tendon. Given those reasons, this is a very common and reasonable routine part of the procedure of total shoulder arthroplasty

Shoulder arthroplasty procedures continue to increase in prevalence, and controversy still remains about the optimal method to manage the subscapularis. Scalise et al. performed an analysis of 20 osteotomies and 15 tenotomy procedures, and found the tenotomy group had a higher rate of abnormal subscapularis tendons on ultrasound examination. There was one tendon rupture in the subscapularis tenotomy group and no ruptures in the osteotomy group. Jandhyala et al. retrospectively examined 26 lesser tuberosity osteotomies and 10 subscapularis tenotomies for arthroplasty, and their study demonstrated a significant improvement in the belly press test for the osteotomy group. Lapner et al. performed a randomised controlled trial assigning patient to either a lesser tuberosity osteotomy or a subscapularis peel procedure. They evaluated 36 osteotomies and 37 subscapularis peels. The outcomes evaluated were Dynamometer internal rotation strength, the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) score and American Shoulder and Elbow Surgeons (ASES) score, and in a subsequent paper they evaluated the healing rates and Goutallier grade. Their studies illustrated no difference in the internal rotation strength between groups. Both groups significantly improved WOOS and ASES scores post-operatively, but the difference was not significant between groups. Goutallier grade increased significantly in both groups, but there was no significant difference between the groups. Overall, the different approaches have not demonstrated a meaningful clinical difference. Further studies are needed to help understand issues leading to subscapularis complications after arthroplasty

Aim: The purpose of this study was to evaluate the results after arthroscopic cuff repair using suture anchors with associated lesions of the long head of the biceps. Does biceps tenodesis lead to better results?. Method: 80 patients (age 41 to 74) with one or two tendon lesons of the rotator cuff and associated lesions of the biceps (instability, partial tear) were treated with arthroscopic ruff repair using suture anchors. Preop examination included MRI and ultrasound. The fatty degeneration and infiltration of the tendon was noted according to Goutallier and Thomazeau. Patients were devided into 2 groups. 40 patients were treated with a biceps tenodesis and 40 cases with a tenotomy. Tenodesis was performed using suture anchors. Patients in both groups were comparable in age, sex, tear size and fatty degeneration. Rehanilitation protocol was equal in both groups. Prospective follow up was done at 3, 6, 12, 24 and 36 months using the Constant score. Ultrasound was documented at all follow-ups, MRI at last follow up. Results: 73 Patients could be completely evaluated, 37 in the tenodesis and 36 in the tenotomy group. The constant score gained 42,3 points from 44,3 to 87,6 overall. There were 4 complete re-tears of the cuff in the tenodesis and 5 in the tenotomy group during follow up, requiring 2 revisions in each group. There was one revision due to stiffness in the tenodesis group, no infections were noted. 29 patients in tenotomy group had a visuable deformity compared to 3 cases in tenodesis group, whereas Ultrasound examination revealed 5 not healed tenodesis. 32 patients in the tenodesis group were satisfied with the result and would do surgery again compared to 25 in the tenotomy group, complaining about the visual deformity. There was no statistical difference in score result between the tenodesis or tenotomy group. Discussion: The arthroscopic treatment of rotator cuff lesions leads to good results after 36 months. The way a lesion of the biceps tendon is treated does not seem to have an effect on the postoperative score result. Cosmetic appearance was better in tenodesis group, leading to better patient acceptance

To assess healing pattern of Achilles tendons across the gap created by a percutaneous tenotomy and maintained by cast in club feet. Twenty-one tenotomies in 16 patients (Age range 12 weeks-36 months) were monitored with dynamic and static ultrasonographic studies. Ultrasounds were performed before and immediately after tenotomy and at approximately 3, 6 and 12 weeks post tenotomy. Cast removal was done at three weeks. Two patients above age of two were casted for 6 weeks. The healing pattern went through different phases although they were not distinctively exclusive from each other and did show considerable overlap. First phase showed formation of a bulbous mass with some continuity of scar tissue across tendon gap. The transition zone between new fibre and the original tend quite distinct. However dynamic ultrasound showed the Achilles tendon moved as a single unit. Second phase showed fibres resembling normal tendon crossing the gap and reduction of bulbous mass. The transition zone was still discernible. Final stage demonstrated more homogenous fibres of Achilles tendon with an indistinct transition zone. Two older children showed a distinctly longer process of healing. One child showed an irregular mass of fluid and soft tissue structures in the gap at six weeks. The other child demonstrated a relative reduction in the proportion of tendon fibres across the gap. At 12 weeks there was evidence of continuation of tendon fibres, but transition zone partly visible. Conclusion. Young Child (<1 Year): when cast immobilisation is discontinued, the tendon is in mid phase of healing. There may be a positive effect on continued improvement in dorsiflexion while using boots and bars. Older Child: safe to consider percutaneous tenotomy in children up to 3 years of ages provided the period of immobilisation is extended

Introduction and Aims: The Ponseti technique of clubfoot treatment consists of serial manipulation and casting. Most cases require a percutaneous Achilles tenotomy. Very few cases, if any, require surgical correction. This paper reports the short- to medium-term results of the Ponseti technique at one centre. Method: All idiopathic clubfeet presenting at the clinic over a two-year period from October 2001 to September 2003 were included in the study. The feet were graded weekly using the Pirani score. The first cast attempts to correct the cavus by lifting the first metatarsal. Subsequently, the foot is manipulated and caste weekly, to obtain maximum forefoot abduction, against a fulcrum at the lateral aspect of the talar head. The heel (calcaneum) is free to rotate under the talus at the subtalar joint. No attempt is made to correct the equinus till Achilles tenotomy. Results: Fifty-four idiopathic clubfeet in 38 consecutive babies were treated using the Ponseti technique. All cases scored five or 6/6 on the Pirani score on presentation. Ten babies had been manipulated elsewhere and offered surgery due to ‘failure to respond’ to the manipulation. Four feet presented late at between six and 12 months of age. An average of six casts were applied prior to the Achilles tenotomy. Six feet (four babies) corrected without a tenotomy. Forty-eight feet required the tenotomy, with a score of 1.5/6 prior to the tenotomy. Four of these six feet required a delayed tenotomy. Correction without surgery was obtained in all cases. All feet were maintained in straight lace shoes with abduction bar, with the feet externally rotated to 45 degrees. Abduction bar compliance issues were seen in three babies. At walking age the babies wore straight last high-top lace-up shoes. Residual dynamic forefoot adductus was seen in 11 feet and may require a tibialis anterior tendon transfer at age three years. Inadequate heel descent was seen in four cases. Residual internal tibial torsion was seen in one case. Conclusions: The Ponseti method offers a reliable alternative to ‘traditional’ casting and surgery. Babies presenting early had an excellent chance of achieving full correction without surgery. We included children older than six months in the Ponseti program; the treatment is considered to work best with children under three months at presentation

Aims. The significance of the ‘clicky hip’ in neonatal and infant examination remains controversial with recent conflicting papers reigniting the debate. We aimed to quantify rates of developmental dysplasia of the hip (DDH) in babies referred with ‘clicky hips’ to our dedicated DDH clinic. Patients and Methods. A three-year prospective cohort study was undertaken between 2014 and 2016 assessing the diagnosis and treatment outcomes of all children referred specifically with ‘clicky hips’ as the primary reason for referral to our dedicated DDH clinic. Depending on their age, they were all imaged with either ultrasound scan or radiographs. Results. There were 69 ‘clicky hip’ referrals over the three-year period. This represented 26.9% of the total 257 referrals received in that time. The mean age at presentation was 13.6 weeks (1 to 84). A total of 19 children (28%) referred as ‘clicky hips’ were noted to have hip abnormalities on ultrasound scan, including 15 with Graf Type II hips (7 bilateral), one Graf Type III hip, and three Graf Type IV hips. Of these, ten children were treated with a Pavlik harness, with two requiring subsequent closed reduction in theatre; one child was treated primarily with a closed reduction and adductor tenotomy. In total, 11 (15.9%) of the 69 ‘clicky hip’ referrals required intervention with either harness or surgery. Conclusion. Our study provides further evidence that the ‘clicky hip’ referral can represent an underlying diagnosis of DDH and should, in our opinion, always lead to further clinical and radiological assessment. In the absence of universal ultrasound screening, we would encourage individual units to carefully assess their own outcomes and protocols for ‘clicky hip’ referrals and tailor ongoing service provision to local populations and local referral practices. Cite this article: Bone Joint J 2018;100-B:1249–52

Aim: To assess the healing pattern of Achilles tendons across the gap created by a percutaneous tenotomy and maintained by cast in club feet. Methods and Results: 21 tenotomies in 16 patients (Age range 12 weeks-36 months) were monitored with dynamic and static ultrasonographic studies Ultrasounds were performed before and immediately after tenotomy and at approximately 3, 6 and 12 weeks post tenotomy. Cast removal was done at three weeks. Two patients above age of two were casted for 6 weeks. The healing pattern went through different phases although they were not distinctively exclusive from each other and did show considerable overlap. First phase showed formation of a bulbous mass with some continuity of scar tissue across tendon gap. The transition zone between new fibre and the original tend quite distinct. However dynamic ultrasound showed the Achilles tendon moved as a single unit. Second phase showed fibres resembling normal tendon crossing the gap and reduction of bulbous mass The transition zone was still discernible. Final stage demonstrated more homogenous fibres of Achilles tendon with an indistinct transition zone. Two older children showed a distinctly longer process of healing. One child showed an irregular mass of fluid and soft tissue structures in the gap at six weeks The other child demonstrated a relative reduction in the proportion of tendon fibres across the gap At 12 weeks there was evidence of continuation of tendon fibres, but transition zone partly visible. Conclusion: Ours study demonstrates when cast immobilisation is discontinued, the tendon is in mid phase of healing. This may have positive effect on continued improvement in dorsiflexion while using boots and bars. It is safe to consider percutaneous tenotomy in children up to 3 years of ages provided the period of immobilisation extended

Disturbed muscular architecture, fatty infiltration and muscular atrophy remain irreversible in chronic rotator cuff tears (RCT) even after repair. Poly-[ADP-ribose]-polymerase 1 (PARP-1), a nuclear factor involved in DNA damage repair, has shown to be a key element in the up-regulation of early muscle inflammation, atrophy and fat deposition. We therefore hypothesized that the absence of PARP-1 would lead to a reduction in muscular architectural damage, early inflammation, atrophy and fatty infiltration subsequent to combined tenotomy and neurectomy in a PARP-1 knock-out mouse model. PARP-1 knock-out (KO group) and standard wild type C57BL/6 (WT group) mice were randomly allocated into three different time points (1, 6 and 12 weeks, total n=72). In all mice the supraspinatus (SSP) and infraspinatus (ISP) tendons of the left shoulder were detached and the SSP muscle was denervated according to a recently established model. Macroscopic muscle weight analysis, retraction documentation using macroscopic suture, magnetic resonance imaging, immunohistochemistry gene expression analysis using real time qPCR (RTqPCR) and histology were used to assess the differences in muscle architecture, early inflammation, fatty infiltration and atrophy between knock out and wild type mice in the supraspinatus muscle. The SSP did retract in both groups, however; the KO muscles and tendons retracted less than the WT muscles (2.1±21mm vs 3.4±0.41mm; p=0.02). Further assessment of muscle architecture demonstrated that the pennation angle was significantly higher in the KO groups at 6 and 12 weeks (28±5 vs 36±5 and 29±4 vs 34±3; p<0.0001). Combined Tenotomy and neurectomy resulted in a significant loss of muscle mass in both groups compared to the contralateral unoperated side (KO group 62±11% and WT group 52±11%, p=0.04) at 6 weeks. But at 12 weeks postoperatively, there was a significant increase in muscle mass to near normal levels in KO group compared to the WT group (14±6% and 42±7% lower muscle mass respectively; p<0.0001) and less fatty infiltration (12.5 ± 1.82% and 19.6 ± 1.96%, p=0.027). Immunohistochemistry revealed a significant decrease in the expression of inflammatory, apoptotic, adipogenic and muscular atrophy genes at both the 1 week and 6 weeks time points, but not at 12 weeks in the KO group compared to the WT group. This was confirmed by histology. Our study is the first to show that knocking out PARP-1 leads to decreased loss of muscle architecture, early inflammation, fatty infiltration and atrophy after combined tenotomy and neurectomy of the rotator cuff muscle. Although the macroscopic muscles reaction to injury is similar in the first 6 weeks, its ability to regenerate is much greater in the PARP-1 group leading to a near normalization of the muscle substance and muscle weight, less retraction, and less fatty infiltration after 12 weeks

Aim. To compare outcomes for children treated for idiopathic clubfeet with the Ponseti regimen before (2002–2004) and after (2005–2006) implementation of a dedicated Ponseti service. Method. A retrospective analysis of outcomes for all patients with idiopathic clubfeet treated in the 2 years before and after implementation of a dedicated Ponseti service was undertaken. Results were statistically analysed using Fisher's exact t-test. Results. In the original cohort treated between 2002–2004, with an ad-hoc service where children were treated in general paediatric orthopaedic clinics by a number of different consultants, 100 feet in 66 children were treated. 96 feet (96%) responded to initial casting. 85 feet (85%) required tendo-achilles tenotomy. 31 feet had a recurrence within the first 2 years (16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, the remaining 15 requiring extensive soft tissue release). Between 2005–2006, with a dedicated Ponseti service, 72 feet in 53 children were treated. 72 (100%) responded to initial casting. 60 feet (83.3%) required tendo-achilles tenotomy. Relapse of the initial deformity occurred within 2 years in 11 feet – 4 children required repeat serial casting, 3 feet required tendon of tibialis anterior transfer, 3 required repeat tenotomy of tendo-achilles and one foot required extensive soft tissue release. Conclusion. Our results have shown that a dedicated Ponseti service leads to improved outcomes in the treatment of idiopathic clubfeet. We have shown a statistically significant reduction of recurrence (p=0.02) and extensive soft tissue release (0.002) in those children treated in a specialist service compared to an earlier ad hoc treatment programme

This study is a mid-term follow up of an original series of 51 babies treated with a modified Ponseti technique for idiopathic congenital talipes equinovarus using below-knee Softcast (easier to remove and hygienic). 1. to determine whether this method is as effective as traditional above-knee plastering. Methods. 51 consecutive babies were treated (April 2003-May 2007) and serial Pirani scores were recorded. Dennis Browne Boots (DBB) were applied when correction was achieved and an Achilles tenotomy was performed if necessary to complete the correction. DBB were worn fulltime for 3 months and at night for 3.5 years. Results. Of the original 51, 3 were lost to follow up and 3 were diagnosed with a neuromuscular condition and excluded. 45 patients, 34 boys and 11 girls were followed up for a mean of 55.3 months (range 36–85 months). Mean age at presentation was 16 days with a median Pirani score of 6.0 (5.5, 60). 75.7% required an Achilles tenotomy before DBB. Median Pirani score at tenotomy was 2.5 (2.0, 2.5). Time to boots (weeks) was mean 5.0 (4.2, 6.0) in the non-tenotomy group and 10.7 (9.8, 11.8) in the tenotomy group. 2 patients had residual deformity after plastering requiring surgery and there were 6 recurrences requiring surgery (4 tibialis anterior tendon transfers and 2 open releases). There appears to be a greater risk of operative intervention for girls and non-compliance with DBB. The estimate of 5-year (60 month) survival without surgery was 85% (96% CI; 70,99%). Conclusion. Below knee Softcast allows correction of CTEV with comparable results to traditional above knee techniques. Consistent with current literature, our series found that compliance with DBB is one of the strongest predictors of success. Brewster MB, Gupta M, Pattison GT, Dunn-van der Ploeg ID. Ponseti casting: a new soft option. JBJS(Br) 2008 Nov; 90(11): 1512–1515

Hammer toe involves metatarsophalangeal joint (MTPJ) hyperextension and proximal interphalangeal joint (PIPJ) flexion. Surgery commonly involves excision arthroplasty or fusion of the PIPJ with MTPJ soft tissue release if necessary. Previous series record that MTPJ release was carried out “as required” but not how often release is necessary. Myerson and Shereff's (1989) cadaver study found release of the extensors, MTPJ capsule and collateral ligaments necessary for full hammertoe correction. Hossain (2002) found the clinical results of this procedure were no better than simple PIPJ fusion. We release the MTPJ if hyperextension persists after PIPJ correction and release the components sequentially. We studied how often and how extensive a release was required, and how this corelated with pre-operative assessment. We reviewed the records of 164 patients who had hammer toe correction under one consultant surgeon. Patients with complex corrections were excluded. The severity of the pre-operative deformity was classified as type 1 (PIPJ and MTPJ correctable), 2 (PIPJ fixed, MTPJ correctable) or 3 (neither joint correctable). We recorded the extent of release required for each toe. Results. Of 334 type 2 toes in 146 patients, 178 (53.3%) required no MTPJ release, 11 (3.3%) extensor tenotomy only, 15 (4.5%) extensor tenotomy and MTPJ dorsal capsulotomy and 130 (38.9%) extensor tenotomy, capsulotomy and collateral ligament release. Of 31 type 3 toes in 18 patients, one (3.2%) needed no release, 2 (6.5%) tenotomy, one (3.2%) capsulotomy and 27 (87.1%) complete release. Discussion. Nearly 50% of toes needed MTP soft tissue release, partial in 8%. Pre-operative assessment was not very accurate in predicting the need for release. We have not yet correlated need for release with clinical outcome. Conclusion. MTP release is required in many hammertoe corrections. Assessment of toe position after incision of each structure may avoid the need for complete release

The purpose of this study was to retrospectively review the outcomes of percutaneous flexor tenotomies of diabetic claw toes with ulcers or pending ulcers. A retrospective chart review between January 1999 and June 2005 was performed to identify those patients that had undergone a percutaneous flexor tenotomy for diabetic claw toe deformities. Thirty-four toes in fourteen patients were identified. Twenty-four toes had ulcerations at the terminal aspect and three of these had radiographic evidence of osteomyelitis of the terminal phalange. All patients had palpable pulses and good capillary refill. A percutaneous flexor tenotomy was performed in an outpatient clinic on all toes, patients with a rigid flexor contracture at the proximal interphalangeal (PIP) joint underwent an osteoclaysis to correct a portion of the deformity. The average follow-up was thrirteen months, all patients with ulcers healed and there were no significant complications. Those without osteomyelitis healed within an average of three weeks and those with osteomyelitis healed within an average of eight weeks. A Percutaneous flexor tenotomy with osteoclasis of the PIP joint performed in an outpatient clinic is a safe and effective method to off-load the tip of the toe such that ulcer healing can occur. The presence of osteomyelitis is not a contraindication for this technique; however, an increased healing time can be expected

Aim: Assess healing pattern of Achilles tendons across gap created by percutaneous tenotomy and maintained by cast in club feet. Methods and Results: 21 tenotomies in 16 patients (Age range 12 weeks–36 months) were monitored with dynamic and static ultrasonographic studies. Ultrasounds performed before, immediately after and at approximately 3, 6, 12 weeks post tenotomy. Cast removal was done at 3 weeks. Two patients above age of two were casted for 6 weeks. The healing pattern went through different phases although they were not distinctively exclusive from each other and did show considerable overlap. First phase showed formation of bulbous mass with some continuity of scar tissue across tendon gap. The transition zone between new fibre and the original tend quite distinct. However dynamic ultrasound showed the Achilles tendon moved as a single unit. Second phase showed fibres resembling normal tendon crossing the gap and reduction of bulbous mass. The transition zone was still discernible. Final stage demonstrated more homogenous fibres of Achilles tendon with an indistinct transition zone. Two older children showed a distinctly longer process of healing. At 3 weeks there was no evidence of healing. At 6 weeks an irregular mass of fluid and soft tissue structures was seen. At 12 weeks there was evidence of continuation of tendon fibres, but transition zone partly visible. Conclusion: Young Child (< 1 Year): When cast immobilisation is discontinued, the tendon is in mid phase of healing. There may be a positive effect on continued improvement in dorsiflexion while using boots and bars. Older Child-Safe to consider percutaneous tenotomy in children up to 3 years of ages provided the period of immobilisation is extended

The purpose of this study was to describe the clinical course of patients with Down's syndrome (DS) and congentital talipes equinovarus (CTEV) treated with the Ponseti regimen. The members of the United Kingdom Ponseti Users Group were contacted to provide details of patients with DS and CTEV, whom they had treated using the Ponseti regimen. Nine patients (13 feet: 7 right, 6 left) were identified, and the case notes were reviewed. Six patients were male, 3 female. In all but one case, the DS was diagnosed postnatally. Co-morbidites included atrioventricular septal defect, hearing deficiencies and plagiocephaly. The initial mean Pirani score was 4.5 (range 3.0 to 6.0). Casting was commenced at a mean of 25 days (range 12–84 days). The mean number of casts required was 7 (range 3 to 12), taking a mean of 6.5 weeks (range 3–12) to achieve correction. 6 of the 13 feet (46%) required a tendoachilles tenotomy, and 2 of 13 (15%) required re-casting. No patients have required a tibialis anterior transfer, soft tissue releases or bony procedures, at a mean follow up of 44 months (9–65 months). The results of the Ponseti regimen have not been described in patients with DS. From this small series, we can conclude that all patients responded to the regime. A tendoachilles tenotomy was required in just under half, and further casting was required in only 15% of the treated feet. No patient has required further surgery. The tenotomy rate is lower than in most series, but otherwise, the results are comparable to those for idiopathic CTEV for which the Ponseti regimen has become the gold standard. Parents of children with DS can be reassured that in the short term their feet will respond well to Ponseti treatment

Objectives. A variety of operative techniques have been described as under the term ‘Bristow-Latarjet’ procedure. This review aims to define the original procedure, and compare the variation in techniques described in the literature, assessing any effect on clinical outcomes. Materials and Methods. A systematic review of 24 studies was performed to compare specific steps of the technique (coracoid osteotomy site, subscapularis approach, orientation and position of coracoid graft fixation and fixation method, additional labral and capsular repair) and detect any effect this variability had on outcomes. Results. Overall recurrence rate was 5.36% (2.94% to 43%). Half of the studies performed the procedure for recurrent shoulder instability, with only five studies documenting glenoid bone loss as an indication: 12 studies used the procedure as the primary surgical intervention for recurrent instability. No change in outcome was noted when examining variation in the coracoid osteotomy site, the fixation site on the scapular neck, the fixation method or whether a capsular repair was also performed. Performing a horizontal split in subscapularis may preserve external rotation compared with performing a tenotomy. Conclusions. This is the first review to examine various operative techniques of the Bristow-Latarjet procedure, and their effect on outcome. We found that other than the approach through subscapularis, outcome was independent of the surgical technique, and depended more on patient selection. We would commend future publications on this procedure to provide a detailed description of the surgical technique, and as a minimum present rates of recurrence as an outcome measure. Cite this article: Bone Joint J 2016;98-B:1208–14

Aim: Complete tenotomy was performed on the most important flexor hip muscle; namely the iliopsoas during open reduction in patients with developmental dysplasia of the hip (DDH). The iliopsoas and other flexor-extensor muscles in operated and contralateral hips were evaluated comparatively by magnetic resonance imaging (MRI). Methods: A total of 22 patients with unilateral DDH after the walking age and treated with one-stage combined surgery were analyzed. All patients were operated by the same surgeon with complete tenotomy of iliopsoas muscle hindering open reduction. All patients had functionally excellent results in accordance with the Barrett’s Modified McKay Criteria in their last follow-up visits and according to Severin’s classification all cases were type 1. The imaging was performed by 1,5 T GE Excite MRI device at the supine position, without contrast material and sedation. The sagittal sections for iliopsoas muscle and T2-W FSE axial images for flexor and extensor muscle groups were used. The operated and contralateral sides were compared. Student’s t test, paired t test, and Spearman’s Rank correlation analysis were used for statistical assessment. Results: The mean age was 12,8±2,9 (9–18) years old. The mean postoperative follow-up period was 112,6 ± 32,0 (68–159) months. The reattachment of the iliopsoas to trochanter minor was observed in 7 patients, with no significance in terms of age, postoperative follow-up period, and the duration of postoperative period (p> 0,05). The atrophy in the operated side was significant in the length of iliopsoas muscle section area (p=0,0001); and the section areas of rectus femoris (p=0,002), tensor fascia lata (p=0,0001), and gluteus maximus (p=0,0001). No significance was detected in sartorius muscle section area (p=0,886). However, unlike other muscles; the ratio of operated versus contralateral side mean muscle section areas was above 1 (1,1± 0,3) for the sartorius muscle. Iliopsoas muscle reattachment was not significant for ratios of the other muscles’ operated versus contralateral side muscle section areas (p> 0,05). The atrophy was significant for the second (p=0,03) and the third (p=0,022) section’s diameter ratios in the non-reattachment versus reattachment group for the iliopsoas muscle. Conclusion: The reattachment of the iliopsoas muscle to trochanter minor after complete tenotomy was observed in 32% of patients. Following complete iliopsoas tenotomy, the expected compensatory hypertrophy in other flexor hip muscles was not detected. At the operated side, all evaluated muscles were atrophic except for the sartorius muscle. The atrophy of iliopsoas muscle was significant for the operated hip with non-reattachment to insertion site versus reattachment group

A less invasive surgical treatment of clubfoot is increasingly considered, it aims to limit extensive exposure, to improve the functional and cosmetic outcome and to lower the risk of stiffness and recurrence of the deformity. The Ponseti method consists in an original casting technique followed, only in the most resistant clubfeet, by a percutaneous Achilles tenotomy. Critical decision is the selection of the clubfeet which needs tenotomy. Purpose of this study was to determine if ultrasound assessment of clubfoot may be helpful in making surgical decision. MATERIAL AND Methods: 98 newborns with 122 congenital clubfeet were treated by the Ponseti casting technique from mid-2000 to June 2006. According to Manes classification, there were 20 mild, 47 moderate and 55 severe clubfeet. After 3 to 8 weeks of casting, clubfeet candidate to surgery underwent sonographic assessment according to the original technique previously published by the authors. On the sagittal posterior plane the R.O.M. of the ankle and subtalar joints was stated both in neutral position and under manipulation. No surgery was performed in clubfeet with normal sonographic dorsiflexion, percutaneous tenotomy was done in clubfeet with mild limited sonographic dorsiflexion and more extensive posterior release (tendon Z-lengthening and posterior cut of ankle and subtalar joint) was performed in clubfeet with most evident sonographic persistent equinus and anterior dislodgment of the talus in the ankle mortise. The R.O.M. was checked again by ultrasound at the end of treatment. According to Ponseti method a Denis Browne bar, with clubfoot 60° externally rotated, was worn full time until the walking age. Results: 35/122 clubfeet (28,6%) were treated conservatively (all the 20 mild and 15/47 of moderate deformities), 87/122 (71,4%) surgically (32/47 of moderate deformities and all the 55 severe deformities). On the basis of the dynamic ultrasound evaluation 38 clubfeet underwent simple tenotomy and 49 ones underwent extensive posterior release. At the end of the casting normal dorsiflexion was documented by ultrasound in 72 (82,7%) of the operated feet. Conclusions: The need of surgery in the Ponseti casting technique shows a great variability in Literature. These controversial data are probably due not only to the different confidence in the Ponseti method, but also to the different criteria used in evaluating the correction obtained by casting. Ultrasound assessment of the deformity gives objective qualitative and quantitative information about the restoration of the physiological dorsiflexion and articular biomechanics. On the basis of this simple, non invasive and widely available procedure the surgeon can evaluate the effectiveness of the serial casting and may be able to establish and graduate the need of corrective surgery

Introduction: A cosmetic deformity does not always occur after a biceps tenotomy. The anatomical restraints preventing distal excursion of the long head of biceps tendon following tenotomy have not previously been described. This study aims to evaluate the biceps sheath and its potential role as a restraint to distal excursion of the biceps following tenotomy. Methods: Fifteen fresh cadaveric specimens were dissected free of overlying soft tissues to reveal the rotator cuff, biceps sheath and long head of biceps muscle belly and tendon. Eight specimens were used for gross anatomical analysis. Measurements of the length of the biceps sheath on the humeral (bone) side and tendon side were made using a digital caliper (Mitutoyo, Japan). The long head of biceps tendon was then released from the glenoid labrum and the excursion of the stump relative to the rim of the articular surface measured. The biceps sheaths of two specimens were used for histological analysis. Seven specimens were used for mechanical analysis. A humeral osteotomy was performed distal to the insertion of pectoralis major, leaving intact the biceps sheath and the muscle belly of long head of biceps. The proximal humerus was attached to a custom-designed jig and the muscle belly of biceps grasped in cryogenic grips. Specimens were loaded on an MTS 858 Bionix mechanical testing machine (MTS Systems, MN) in uniaxial tension at a rate of 1 mm/sec until failure was observed. Results: The biceps sheath surrounds the long head of biceps tendon and inserts into the bone of the proximal humerus. It is trapezoidal in cross-section, with a mean length of 75.1 mm on the bone side and 49.3 mm on the tendon side. The average excursion of the stump was to within 2.8 mm of the rim of the articular surface. Histological examination of the biceps sheath revealed membranous tissue consisting of loose soft tissue with fat and blood vessels. Synovial tissue was also identified. The sheath was seen to loosely attach to the biceps tendon, with a more intimate attachment to the periosteum. The mean force to pull the long head of biceps tendon out of the sheath 102.7 N (range 17.4 N–227.6 N). Discussion: The biceps sheath is a consistent structure intimately associated with the biceps tendon. It appears to contain blood vessels which provide nutrition to the tendon, similar to the vincula of flexor digitorum pro-fundus. Mechanical testing reveals that a substantial force is sometimes required to pull the biceps tendon from the sheath. This may explain why biceps tenotomy does not routinely result in a “Popeye” biceps

Purpose of the study: The piriform syndrome is treated medically: functional rehabilitation and injections. If the medical treatment fails, tenotomy of the piriform muscle can be proposed. Published studies report good outcome in 66 to 87% Of patients. The purpose of this study was to examine the extrapelvic innervations of this muscle in order to assess the feasibility of neurotomy of he piriform muscle. Material and method: Twenty gluteal regions were dissected. We studied first the relations between the piriform muscle and the ischiatic nerve. Then the innervations branches of the piriform muscle were localized in three landmarks. Results: We found the of the six types of relation between the ischiatic nerve and the piriform muscle described by Beaton, with frequencies comparable to reports in the literature. Innervation of the piriform muscle does not follow a standard pattern, even though the innervations generally comes from the ischiatic nerve; the nerve branches come from the superior and inferior gluteal pedicles. In addition, these nerve branches penetrate the deep aspect of the muscle in random fashion. In addition, accessibility to the deep aspect of the piriform muscle cannot be achieved easily but requires prior section of its insertion on the greater trochanter. Discussion: In our opinion, these results suggest that isolated neurotomy of the piriform muscle is not clinically feasible; it might be possible to improve function results of isolated tenotomy by performing a neurotomy of the nerve branches visible during the tenotomy procedure. A greater benefit might be expected in forms where the ischiatic nerve crosses the piriform muscle

Purpose: The purpose of this study was to assess long-term functional outcome after arthroscopic acromioplasty for full-thickness rotator cuff tears, to evaluate the efficacy of complementary procedures (biceps tenotomy, extended acromioclavicular resection), and to examine the course of anatomic lesions. Material and methods: From 1988 to 1994, 141 full-thickness rotator cuff tears were treated by arthroscopic acromioplasty. Ninety-eight patients, mean age 60 years, were reviewed clinically, radiographically, and sonographically at more than eight years. The mean preoperative Constant score was 48.5 points. The tear involved the supraspinatus in 18 cases, the supraspinatus and infraspinatus in 40, the supraspinatus and the subscapularis in ten, and all three tendons in 20. Coronal extension showed a distal tear in four, an intermediate tear in 52, and a retracted stump in 32. Systemic acromioplasty was associated in 36 patients with tenotomy of the long head of the brachial biceps and in 44 with acromioclavicular extension. Results: At mean follow-up of 10.7 years (8–13.5), the mean Constant score was 60 points. The clinical outcome was excellent or good in 39.7%, fair in 45.5%, and poor in 14.8. 62.5% of the patients were satisfied or very satisfied. The height of the subacromial space was 5.19 mm at last follow-up compared with 4.3 mm preoperatively. The antalgesic effect of biceps tenotomy was significant when the initial acromiohumeral space was less than 5 mm. This procedure did not produce any significant change in the subacromial height or development of osteoarthritis at last follow-up. Sonography showed stability of the size of the tear in 83.8% of the cases. The results were significantly less satisfactory when the initial tear involved the subscapularis or all three tendons. Conclusion: The clinical results of arthroscopic acropmioplasty for full-thickness tears show long-term stability. Biceps tenotomy improves the antalgesic effect significantly, particularly if the subachromial space measures less than 5 mm preoperatively, without causing significant radiological degradation. Extension to the acromioclavicular level should be systematic in patients with acromioclavicular pain preoperatively and/or radiological anomalies

We report the effect of introducing a dedicated Ponseti service on the five-year treatment outcomes of children with idiopathic clubfoot. Between 2002 and 2004, 100 feet (66 children; 50 boys and 16 girls) were treated in a general paediatric orthopaedic clinic. Of these, 96 feet (96%) responded to initial casting, 85 requiring a tenotomy of the tendo-Achillis. Recurrent deformity occurred in 38 feet and was successfully treated in 22 by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, The remaining 16 required an extensive surgical release. . Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls) were treated in a dedicated multidisciplinary Ponseti clinic. All responded to initial casting: 60 feet (83.3%) required a tenotomy of the tendo-Achillis. Recurrent deformity developed in 14, 11 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The other three required an extensive surgical release. . Statistical analysis showed that children treated in the dedicated Ponseti clinic had a lower rate of recurrence (p = 0.068) and a lower rate of surgical release (p = 0.01) than those treated in the general clinic. This study shows that a dedicated Ponseti clinic, run by a well-trained multidisciplinary team, can improve the outcome of idiopathic clubfoot deformity. Cite this article: Bone Joint J 2014;96-B:1424–6

Outcome studies of the Ponseti method from various centres have reported success rates ranging from 85–95%. The vast majority of patients can expect a supple, functional and pain free foot. The small percentage of feet that are resistant to Ponseti treatment often require open surgical correction, leading to scarring and stiffness. We present a method of correcting resistant equinus by a tenotomy and calcaneal pulldown technique. This method is complimentary to the Ponseti technique. Method. Prospective study of 40 feet in 28 patients who underwent an Achilles tenotomy and calcaneal pulldown technique. The indications for this method were resistant equinus and problems with casting. Feet scored with the Pirani method. Under a general anaesthetic, a standard Achilles tenotomy was performed. The equinus deformity corrected by traction of the calcaneum with a “catspaw” retractor and dorsiflexion of the forefoot. Further treatment was performed according to the Ponseti method. The Ponseti clubfoot brace was used to maintain correction. Results. 28 patients 40 feet. Mean preoperative Pirani score:3.0 (left 3.0, right 3.1 range 1.5–6). Mean preoperative Hindfoot Pirani score:2.5 (left 2.55, right 2.5 Range 1.5–3). Mean post operative Pirani score:2.0(left 2.0, right 2.0 Range 0.5–6). Mean postoperative Hindfoot pirani score:1.45. Three patients had severe arthrogryphosis, of whom 2 did not correct requiring open surgery. All idiopathic CTEV feet corrected with a range of 5–20 degrees of dorsiflexion at last follow up. The mean follow up was 43.64 months (range 7–96 months). Conclusions. The calcaneal pulldown technique is a useful complmentary adjunct to the Ponseti method. It enables the correction of equinus without the need for open surgery. Since the introduction of the technique to our unit it has negated the need for open surgery. The results are encouraging, it is a simple effective technique that can help in difficult CTEV cases

Aim: To evaluate our initial experience using the Ponseti method for the treatment of clubfoot. Materials and Methods: 85 feet in 56 patients treated at Alder Hey Hospital, Liverpool between Nov 2002 – Dec 2004 were included in the study. The standard protocol described by Ponseti was used for treatment. Mean period of follow up was 12 months (6– 30 months). Evaluation was by the Pirani club foot score. Results: Results were evaluated in terms of the number of casts applied, the need for tenotomy and the recurrence of deformity. Average number of casts required were 6. Tenotomy was required in 80% of feet. At the latest follow up approximately 15% of feet recurred following treatment and were managed surgically. Poor compliance was noted to be the main cause of failure in these patients. We have recently modified our splint and hope this will address some of the reasons for poor compliance. There was also a smaller subgroup of patients (approximately 5%) which failed to respond to the treatment regime and could not be brought to the point were tenotomy would be appropriate. Conclusion: In our hands the ponseti technique has proved to be a very effective treatment method for the management of CTEV but like all treatment methods does have some limitations

Aims: We reviewed our experience to determine the results of arthroscopic repair in patients over 50 with rotator cuff tears and Type II SLAP lesion in whom the repair was effected repairing the two lesions, or repairing the rotator cuff tears and performing a tenotomy of the long head of the biceps. Methods: We recruited 121 patients older than 50 years in whom a symptomatic rotator cuff tear had failed non-surgical management and was affecting daily activities. We assigned them retrospectively to one of the two groups: Group 1 underwent arthroscopic repair of the rotator cuff and repair of the type II SLAP lesion. Group 2 underwent arthoscopic repair of the rotator cuff tear and a tenotomy of the long head of the biceps. Results: There was statistically significant difference in total postoperative UCLA scores and ROM when comparing the two groups postoperatively (P< 0.05). Conclusions: We compared the clinical outcome of patients over 50 affected by the association of rotator cuff tears and Type II SLAP lesion, in whom both the defects were repaired, or the rotator cuff tear was repaired and the long head of the biceps tendon was tenotomized. In our hands, the association of rotator cuff repair and biceps tenotomy provides better clinical outcome compared with the association of Type II SLAP lesion repair and rotator cuff repair at three years of follow-up

Introduction: Achilles tendinopathy (AT) is the most common over use syndrome of the lower limb. One of the simple operations performed for this condition is “Multiple longitudinal tenotomies”. This can be performed by either percutaneous or open methods. We compared the outcome of percutaneous versus open method of multiple longitudinal tenotomies for this condition. Methods and materials: It is a retrospective study of patients operated for AT in our hospital from 1997 to 2008. Total of 43 patients. Twenty had percutaneous and 23 had open tenotomies. All of them had a trial of non-operative treatment prior to surgery, in the form of analgesia, physiotherapy, heel inserts, and ultrasound therapy. Data was collected from patient records and by telephonic questionnaire of the patients. Data collected includes pre and postoperative pain scores on a scale of 0–10, duration of symptoms, patient satisfaction scores (0–10) and complications. This questionnaire also included limitation to walk, run, going up/down the stairs, work and sporting activities. Results: In the percutaneous group the mean pre and postoperative pain scores were 8.79 and 2.07 (p value 0.000). In the open group the values were 8.65 and 1.75 (p value 0.000). The mean satisfaction scores in the percutaneous and open groups were 8.25 (range 3–10) and 8.14(range2–10) respectively. The patient satisfaction scores were not significantly different between the two groups (p value 0.942). In the percutaneous group there was one recurrence and in one patient there was no symptomatic relief. In the open group there were 2 superficial infections, which settled with antibiotics and a wound breakdown, which in addition required debridement and eventually healed by secondary intension. Conclusions: Both percutaneous and open methods of longitudinal tenotomies resulted in significant symptomatic relief and good patient satisfaction scores. Although the outcomes of both groups were comparable the percutanous method has an added advantage of less complications and simplicity of the procedure

Aim : To evaluate our initial experience using the Ponseti method for the treatment of clubfoot . Materials and Methods: 85 feet in 56 patients treated at Alder Hey Hospital, Liverpool between Nov 2002 – Dec 2004 were included in the study. The standard protocol described by Ponseti was used for treatment. Mean period of follow up was 12 months (6– 30 months). Evaluation was by the Pirani club foot score. Results : Results were evaluated in terms of the number of casts applied, the need for tenotomy and the recurrence of deformity. Average nuber of casts required were 6. Tenotomy was required in 80% of feet. At the latest follow up approximately 15% of feet recurred following treatment and were managed surgically. Poor compliance was noted to be the main cause of failure in these patients. We have recently modified our splint and hope this will address some of the reasons for poor compliance. There was also a smaller subgroup of patients (approximately 5%) which failed to respond to the treatment regime and could not be brought to the point were tenotomy would be appropriate. Conclusion: In our hands the ponseti technique has proved to be a very effective treatment method for the management of CTEV but like all treatment methods does have some limitations

Purpose: To compare gait kinematics and kinetics in five-year old children treated initially with Ponseti casting versus French physical therapy. A third group, consisting of patients initially treated with these non-operative methods and then undergoing surgery consisting of more than a tendoachilles lengthening, was compared to those children treated entirely non-operatively. Method: Ninety patients (125 clubfeet) were tested at age five years. Thirty-four feet had undergone only Ponseti treatment, 40 the French program, and 51 had initial non-operative treatment with either the Ponseti or French protocols but later had surgery at an average age of 2+3 years. Kinematics and kinetics were compared to age-matched normal subjects. Results: Average stance-phase dorsiflexion did not differ between groups or from normal. Incidence of equinus: French 5%, Ponseti 0%; Increased stance-phase dorsiflexion: French 3%, Ponseti 24%, Surgical 18% (p < 0.05). A similar number of feet that were not operated upon at age five had in-toeing: 30% French, 32% Ponseti. Decreased ankle power generation at push-off: 53% French; 47% Ponseti; 67% Surgical. Average ankle power generation: 2.21 W/kg French, 2.36 W/kg Ponseti, 1.97 W/kg Surgical (2.83 W/kg in normal 5-year-old children). There was a difference in ankle power generation between normal feet and both the French and surgical groups (p< 0.001). Feet in the non-operative groups that had undergone Achilles tenotomy (n=28) had similar ankle power to those feet (n=42) that did not have tenotomies (p =0.223). Hip power generation was increased 33% in children who had undergone Ponseti treatment (1.38 W/kg), and 41% after French nonoperative treatment (1.47 W/kg), compared to normal (1.04 W/kg). This may be to compensate for poor ankle push-off. Conclusion: The gait characteristics of those feet that have not had surgery reveal that the majority had normal ankle kinematics, but reduced efficiency is demonstrated by reduced ankle push-off power, regardless of whether or not an Achilles tenotomy was performed. Decreased ankle power and persistant internal rotation are more frequently seen in feet that have undergone surgery despite initial nonoperative treatment, compared to those treated only by either the Ponseti protocol or the French physical therapy program

Aims

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

Aims

The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV.

Purpose: We report a new pathological entity involving the long head of the biceps tendon (LHBT). In this entity, the hypertrophic LHBT becomes incarcerated in the joint during limb elevation, leading to shoulder pain and blockage. Material and methods: Twenty-one patients were identified. These patients presented hypertrophy of the intra-articular portion of the LHBT with tendon incarceration at limb elevation. The diagnosis was confirmed during open surgery (n=14) or arthroscopy (n=7). All cases were diagnosed in patients with an associated cuff tear. Treatment consisted in resection of the intra-articular portion of the LHBT and appropriate treatment of the cuff. Results: All patients had anterior shoulder pain and deficient anterior flexion because of the incarcerated tendon. An intra-operative dynamic test consisted in raising the arm with the elbow extended, providing objective proof of the tendon trapped in the articulation in all cases. The positive “hour glass” test produce a fold then incarceration of the tendon between the humeral head and the glenoid cavity. Tendon resection after tenodesis (n=19) or biopolar tenotomy (n=2) yielded immediate recovery of passive complete anterior flexion. The Constant score improved from 38 points preoperatively to 76 points at last follow-up. Discussion: The “hour glass” long biceps tendon is caused by hypertrophy of the intra-articular portion of the tendon which becomes unable to glide in the bicipital groove during anterior arm flexion. 10°–20° defective motion, pain at the level of the bicipital groove, and images of a hypertrophic tendon are good diagnostic signs. The “hour glass” LGBT must not be confused with retractile capsulitis. The definitive diagnosis is obtained at surgery with the “hour glass” test which shows a fold and incarceration of the tendon during anterior flexion with an extended elbow. Simple tenotomy is insufficient to resolve the blockage. The intra-articular portion of the tendon must be resected after bipolar tenotomy or tenodesis. Conclusion: Systematic search for “hour glass” LHBT should be undertaken in patients with persistent anterior shoulder pain of unexplained origin associated with deficient anterior arm flexion

Purpose: Arthroscopic arthroplasty for painful shoulder is not always successful. Repeated arthroscopy is sometimes discussed for patients with recurrent pain. The purpose of this work was to determine the technique and identify indications. Material and methods: We conducted a retrospective analysis of 24 patients (13 men, 11 women), mean age 52 years, who underwent repeated arthroscopy after failure within 31 months of arthroscopic acromioplasty with no other intervention. Three groups were formed: group 1 (7 patients): subacromial impingement due to tendinitis with intact supraspinatus; group 2 (11 patients): subacromial impingement secondary to cuff tear; group 3 (6 patients): calcified tendinopathy. In group 1, the acromion was type 1 in three cases, type 2 in three and type 3 in one; repeated arthroscopy included complementary acromioplasty. In group 2, all patients had complementary acromioplasty; six of them with biceps tenotomy. In group 3, the remaining calcification was removed in all patients and complementary acromioplasty in three. Results: Mean follow-up was 21 months. In group 1, outcome was satisfactory in three patients (43%), irrespective of the acromial morphology. In group 2, outcome was satisfactory in six patients (55%), including five with acromioplasty with tenotomy and only one with complementary acromioplasty alone. In group 3, outcome was satisfactory in five patients (83%); one failure was attributed to remaining calcification; acromioplasty did not influence outcome. Discussion, conclusion: The acromion should not be considered as the principal cause of failure after first acromioplasty. In this series, only 33% of the patients who had complementary acromioplasty had a good outcome at last follow-up. Biceps tenotomy in patients with rotator cuff tears and removal of the calcium deposit in patients with calcified tenopathies should be considered first

Several studies showed the efficacy of arthroscopic repair for Type II SLAP lesions without other associated lesions, but the only data reported on the association of arthroscopic repair of Type II SLAP lesion and rotator cuff tears involve young and active patient. To our knowledge, no studies have focused on patients over 50. We evaluated the results of a randomized controlled trial of arthroscopic repair in patients over 50 with rotator cuff tears and Type II SLAP lesion in whom the repair was effected repairing the two lesions, or repairing the rotator cuff tears and performing a tenotomy of the long head of the biceps. We recruited 63 patients. In 31 patients, we repaired the rotator cuff and the Type II SLAP lesion (Group 1). In the other 32 patients, we repaired the rotator cuff and tenotomized the long head of the biceps (Group 2). 7 patients (2 in the group 1 and 5 in the group 2) were lost to final follow up. A modified UCLA shoulder rating scale was used to evaluate pre-operative and post-operative shoulder pain, function, active forward flexion, strength and patient satisfaction. Of 63 patients randomized to one of the two treatments, 5.2 year results were available for 56. 7 patients (2 in the group 1 and 5 in the group 2) did not return at the final follow up. Statistically significant differences were seen with respect to the UCLA score and ROM values at final follow-up In Group 1 (SLAP repair and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.4 (range 6 to 14) to an average of 27.9 (24–35) postoperatively (P< 0.001). In Group 2 (biceps tenotomy and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.1 (range 5 to 14) to an average of 32.1 (range 30 to 35) post-operatively (P< 0.001) There was statistically significant difference in total post-operative UCLA scores and ROM when comparing the two groups post-operatively (P< 0.05). Arthroscopic management has been recommended for some SLAP lesions, but no studies have focused on patients over 50 with rotator cuff tear and Type II SLAP lesion. We compared the clinical outcome of patients over 50 affected with rotator cuff tears and Type II SLAP lesion in whom both the defects were repaired, or the rotator cuff tear was repaired and the long head of the biceps tendon was tenotomized. In our hands, the association of rotator cuff repair and biceps tenotomy provides better clinical outcome compared with repair of Type II SLAP lesion and of the rotator cuff. The repair of the two defects, in fact, can lead to worst clinical results compared with association Rotator cuff repair alone is sufficient to determine a good post-operative outcome, allowing to avoid post-operative stiffness of the shoulder

Aims

This study compared patients who underwent arthroscopic repair of large to massive rotator cuff tears (LMRCTs) with isolated incomplete repair of the tear and patients with incomplete repair with biceps tendon augmentation. We aimed to evaluate the additional benefit on clinical outcomes and the capacity to lower the re-tear rate.

Aims

Iliopsoas impingement occurs in 4% to 30% of patients after undergoing total hip arthroplasty (THA). Despite a relatively high incidence, there are few attempts at modelling impingement between the iliopsoas and acetabular component, and no attempts at modelling this in a representative cohort of subjects. The purpose of this study was to develop a novel computational model for quantifying the impingement between the iliopsoas and acetabular component and validate its utility in a case-controlled investigation.

Aims

We investigated the prevalence of late developmental dysplasia of the hip (DDH), abduction bracing treatment, and surgical procedures performed following the implementation of universal ultrasound screening versus selective ultrasound screening programmes.

Aims

The benefit of a dual-mobility acetabular component (DMC) for primary total hip arthroplasties (THAs) is controversial. This study aimed to compare the dislocation and complication rates when using a DMC compared to single-mobility (SM) acetabular component in primary elective THA using data collected at a single centre, and compare the revision rates and survival outcomes in these two groups.

Background. The gold standard of care of clubfoot is the Ponseti method of serial manipulation and casting, followed by percutaneous tendo-achilles tenotomy. In our setting, registrars work in district hospitals where they run Ponseti clubfoot clinics with little or no specialist supervision. They use the Pirani score to serially assess improvement of the deformity during casting and to determine whether the foot is ready for tenotomy. Purpose of Study. To test the inter-observer reliability of the Pirani score, and whether it can be used by non-specialist doctors running Ponseti clubfoot clinics. Methods. Ethics permission was obtained from our institution. This is a prospective study where patients under the age of one year with idiopathic clubfoot were recruited from clubfoot clinics at our institution, over a period of four months. Following a training session using the original description of the score, each foot was independently assessed using the Pirani score by two paediatric orthopaedic surgeons, two orthopaedic registrars and two medical officers. The inter-observer reliability was assessed using the Fixed-marginal Kappa statistic and Percentage agreement. The first 15 feet were used as a learning curve, and hence excluded from final analysis. Results. 73 feet in 37 patients with idiopathic clubfoot (25 boys, 12 girls) under the age of 1 year were included in the study. The Kappa statistic and percentage agreement for the six variables of the Pirani score were determined. Whilst the overall agreement was determined by the Kappa statistic to be slight to fair, the two consultants were found to have a higher inter-observer reliability than the registrars and medical officers. Conclusion. Our results conflict with previously published studies in that the inter-observer reliability of the Pirani score was poor. In addition, we feel that this score cannot be reliably used by non-specialist doctors running Ponseti clubfoot clinics. NO DISCLOSURES

Minimal or Less Invasive Approaches. Limited medial parapatellar incision – 2–3 inch medial incision; Best for unicompartmental implant; patellar visualization poor; Less invasive but limited visualization therefore overall joint inspection is compromised. MIS TKR approaches - Mini midvastus approach popularised by S.B. Haas - Ideal BMI 30 or less; Incision length 10cm; Vastus incision about 2–3cm; Vastus incision beyond 5–6cm places motor branch to VMO at risk; Coupled with downsized cutting blocks, allows predictable ability to perform TKR; Sliding window concept; Patella eversion not necessary. Mid Subvastus approach – 10cm skin incision; Sub vastus dissection up to septum (watch for bleeders!); VERY difficult in muscular males!. Standard Incisions. Standard medial parapatellar approach - Familiar to most surgeons; Medial arthrotomy facilitates exposure for almost all procedures; Can become more extensile by incising the quad tendon further proximal; Release of posteromedial capsule and semi-membraneosus allows exposure posteriorly. Quad snip - Used occasionally in the fixed varus, flexion contracted knee; More commonly used in revisions; Allows patella eversion without risk of distal avulsion; Motor strength appears to return to baseline level postoperatively. V-Y quadriceps turndown - Technique: initial medial parapatellar arthrotomy, an oblique tenotomy angled toward the tendinous portion of the vastus lateralis and then extended distally; The quadriceps segment is than retracted downward to expose the joint; Tenotomy is closed with robust non-absorbable sutures holding the knee in extension; Postoperative flexion is dictated by integrity of repair while flexing knee at time of closure. Disadvantages include extensor lag, as well as effecting ultimate ROM. Tibial tubercle osteotomy a la Whiteside - Medial arthrotomy; Tubercle segment is 6–8cm long, 2cm wide and 1–1.5cm thick; Segment is beveled distally so as to avoid stress riser; Leave lateral soft tissue intact; Closure with wires preferred although screws or cables have been used as well

Purpose: The purpose of this prospective work was to determine: 1) the frequency of iliopsoas conflicts with prosthetic acetabular material in patients with a painful total hip arthroplasty, and 2) to determine the diagnostic features of this conflict and the results of an adapted therapeutic approach. Material and methods: This prospective study was conducted between 1988 and 2000 in 206 painful total hip arthroplasties. Nine patients (4.%), mean age 50 years (38–65) had a highly suggestive clinical presentation (eight press-fit cups without cement, one metal-backed cemented cup). Mean delay to onset after implantation of the total hip arthroplasty was 7.3 months (1–48). The predominant clinical sign was groin pain triggered by active flexion of the hip with pain from 3° to 70°. For these nine patients, there was no sign of loosening and puncture had ruled out infection. The diagnosis was confirmed by sedation of the pain after extra-articular infiltration in contact with the anterior acetabular rim (rim overhang in six out of nine cases) under computed tomographic guidance. Results: Therapeutic infiltration (xylocaine-slow release corticosteroids) under computed tomographic guidance provided complete sedation in four out of nine cases and partial sedation in one. Four patients experienced recurrence leading to terminal tenotomy of the iliopsoas which provided complete sedation in three and partial sedation in one. In all, seven of the nine patients achieved complete pain relief (four after infiltration including one recurrent case, and three after tenotomy). Physical examination at last follow-up did not disclose any loss of flexion amplitude of the thigh. Discussion and conclusion: The delay to symptom onset was variable, but a symptom-free interval was always observed after implantation of the total hip arthroplasty. An anatomic factor (anterior cup rim) was not indispensable for diagnosis as it was confirmed in one of three cases with a positive infiltration test without rim overhang. The infiltration test was essential to confirm diagnosis and constituted the first therapeutic attempt which allowed complete cure in four of the nine patients. Tenotomy, indicated in case of recurrence, achieved complete cure in three of the four cases. The cup does not have to be changed necessarily to treat iliopsoas conflicts since infiltration or simple tenotomy provided complete cure in seven out of nine cases

Introduction and Aims: Pivotal to most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of Botulinum A toxin (BTX-A) in defunctioning the triceps surae muscle complex as an alternative to tenotomy was investigated. Method: Newborns, infants and children referred for suspected clubfoot deformity to the authors’ institution from September 1, 2000 to September 17, 2003 were reviewed consecutively for inclusion in this prospective study. Patients underwent manipulation and castings (above knee casts) emulating Ponseti’s principles until hindfoot stall was encountered. In order to defunction the triceps surae muscle complex, BTX-A at 10 IU per kilogram was injected into this muscle complex. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: Group I (< 30 days old) and Group II (> 30 days and < 8 month old). Results: Fifty-one patients with 73 feet met the criteria for inclusion in the study with 29 patients in Group I and 22 in Group II. Mean age of Group I was 16 months (2.5–33 months) and average follow-up was nine months post-BTX-A injection (1 week-27 months post-injection). Mean age of Group II was 23.5 months (3.8–44.6 months) and average follow-up was 15 months post BTX-A injection (1 week–27 months post-injection). Ankle dorsiflexion in knee flexion and extension remained above 20/15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. All but one patient (one foot) who reached the point of hindfoot stall during the protocol of manipulations and castings had successful defunctioning of the triceps surae complex using a single BTX-A injection. This one patient out of 51 (1.9% of patients and 1.3% of feet) did not respond to the protocol. Of the 50 patients who responded to the protocol, nine patients lost some degree of dorsiflexion due to non-compliance with boots and bars, with fitting problems accounting for two cases. All these patients have corrected with either a return to manipulations and casting alone (one patient), or a combination of repeated BTX-A injection and further manipulations and castings (eight patients). Conclusion: These results are comparable to those reported in the literature using Ponseti’s method or the physical therapy method and were achieved without the need of tenotomy or more frequent manipulations. The use of BTX-A as an adjunctive therapy in the non-invasive approach of manipulation and casting in idiopathic clubfoot is an effective and safe alternative and one that may be preferable to parents