We reviewed 11 patients who had been treated between January 1986 and June 1994 for severe foot injuries by tendon transfer with microvascular free flaps. Their mean age was 5.6 years (3 to 8). Five had simultaneous tendon transfer and a microvascular free flap and six had separate operations. The mean interval between the tendon transfer and the microvascular free flap was 5.8 months (2 to 15) and the mean time between the initial injury and the tendon transfer was 9.6 months (2 to 21). The anterior tibial tendon was split in five of six cases. The posterior tibial tendon was used three times and the extensor digitorum longus tendon twice. The mean follow-up was 39.7 months (24 to 126). There were nine excellent and two good results. Postoperative complications included loosening of the transferred tendon (2), plantar flexion contracture (1) mild flat foot deformity (1) and hypertrophic scars (2). We recommend tendon transfer with a microvascular free flap in children with foot injuries combined with nerve injury and extensive loss of skin, soft tissue and tendon

INTRODUCTION. In order to address high failure rates following rotator cuff repairs, a greater understanding is required of the underlying structural changes so that treatments can be appropriately targeted and biomarkers of failure can be identified. As collagen is the primary constituent of tendon and determines force transmission, collagen structural changes may affect responses to loading. For example changes in collagen 1 and 5 are associated with the hyperelastic Ehlers-Danlos syndrome, which is diagnosed by looking for pathopneumonic altered collagen fibres or ‘collagen flowers’ in skin using transmission electron microscopy (TEM). To date no study has been performed on the microstructure of torn human rotator cuff tendons using TEM. It was hypothesized that normal, small and massive human rotator cuff tendons tears will have altered microscopic structures. The unique study aimed to use TEM to compare the ultrastructure of small and massive rotator cuff tears, to normal rotator cuff tendons. METHODS. Samples from 7 human rotator cuff tendons repairs were obtained, including 4 massive (>5 cm) and 3 small (< 1 cm) tears, and 3 matched normal controls with no history of connective tissue disorders. Specimens were fixed in 4% glutaraldehyde in 0.1M phosphate buffer, processed and examined blind using routine TEM examination. To assess whether changes in the relative expression of collagen 1 and 5 (COL1A1, COL5A1 and COL5A2) occurred in all tears, qPCR was performed on another 6 phenotypically matched patients. RESULTS. The basic structure of the normal tendon consisted of tightly packed clumps of dense packed parallel running collagen fibers with few fibroblasts and small amounts of fine filamentous material between clumps. In contrast, torn samples were more variable with areas of less dense packing of collagen fibers and larger areas of filamentous material plus variable numbers of lipid droplets both within the fibroblast and between the collagen bundles. There was also evidence of twisting and random orientation of individual collagen fibers. All torn tendons showed evidence of a proportion of the fibers within the collagen bundles being enlarged with a serrated outline, similar in appearance to ‘collagen flowers’. Clear differences between the small and massive tears were not identified. qRT-PCR of torn rotator cuff tendon specimens demonstrated no altered collagen expression compared to normal tendons. DISCUSSION. This novel study has identified the previously unreported presence of atypical collagen fibers with focal swelling resulting in the appearance of ‘collagen flowers’ in torn rotator cuff tendons only. This appearance is considered pathognomonic of Ehlers-Danlos syndrome, classical type 1 and 2. Torn tendons also showed an increase in filamentous material, and infiltration with fat droplets. These novel findings may offer insight into the mechanisms of structural damage that contribute to rotator cuff failure. Further examination is required, to evaluate the significance of these observations

INTRODUCTION. There is increasing evidence for a multi-stage model of rotator cuff (RC) tendon tears, wherein healing is affected by tear size. The underlying pathophysiology however is not fully understood. Changes in the production and remodeling of the RC extracellular matrix (ECM) are likely to be important determinants of RC tendinopathy as they affect healing and the ability to bear loads. This study aimed to gain greater insight into size related tear pathogenesis by analyzing gene expression profiles from normal, small and massive RC tears. METHODS. The genetic profiles of 28 human RC tendons were analyzed using microarrays representing the entire genome. 11 massive and 5 small torn RC tendon specimens were obtained from tear edges intraoperatively, and compared to 12 age matched normal controls. Semiquantitative real-time polymerase chain reaction (RT-PCR) and immunohistochemistry were performed for validation. RESULTS. Numerous insightful gene changes were detected. Key changes included upregulation of aggrecan in massive tendon tears compared to normal controls, but not in small tears (p < 0.05 and > 2-fold change). Matrix metallopeptidases (MMP)-3,-10,-12,-13,-15,-21,-25 and a disintegrin and metallopeptidase (ADAMs)-12,-15,-22 were significantly upregulated in tears. Aggrecan was upregulated in massive tendon tears but not in small tears. Amyloid was downregulated in the small and massive tear groups when compared to normals. BMP-5 was upregulated in small tears only when compared to normals. As part of the chemotaxis pathway, IL-3,-10,-13,-15,-18 were upregulated in tears, whereas downregulation of IL-1,-8,-11,-27, was seen. RT-PCR and immunohistochemistry confirmed altered gene expression. CONCLUSION. The gene profiles of normal, small and massive RC tear groups suggested they are biologically distinct groups. In addition to confirming altered gene expression in pathways reported in previous studies, this study has identified a number of novel pathways which are affected between the different tendon tear and normal groups. This study identified that RC tear pathogenesis is contributed to by ECM remodeling genes, chemotaxis genes, aggrecan and amyloid. Further investigation is required to determine whether some of these genes may potentially have a role as biomarkers of failure. Modulating these ECM pathways may be a useful treatment strategy for improving clinical outcomes

INTRODUCTION. Patellar tendon (PT) autograft is an excellent choice repairing anterior cruciate ligament (ACL) ruptures. Published studies testing the biomechanical characteristics after plasty usually refer to grafts with 10mm wide. The thickness of PT and geometry of the patella have been overlooked. The purpose of this study was to understand the geometry of PT and patella in our population, regarding their use in Bone - Patellar Tendon - Bone (BTB) technique, in order to evaluate their biomechanical efficiency and study their relationship with anthropometric parameters. MATERIAL. 100 individuals (50/50) who underwent knee MRI (3-Tesla). Ages between 18–65years. METHODS. Retrospective study. Standardized protocol for measuring the PT and patella based in MRI images. Interview to obtain personal data. Statistical analysis using SPSS®. RESULTS. Sample (mean ±SD): age 41 ±14years, weight 73 ±12kg, height 167 ±10cm, BMI 26,04 ±4,13; length PT/patella −41,3 ±6,1mm/29,6 ±4,2 mm, width PT/patella −25,3 ±3,2mm/43,4 ±4,14mm; thickness PT −3,79 ±1,01mm/22,8 ±2,2mm; Men have thicker and wider patella and PT than women (p<0.001). The patella is also longer in males (p<0.001). There is statistical significant relationship between weight and height to width, thickness and length of PT and patella (p<0.01). Body Mass Index (BMI) doesn't have statistical correlation with geometry of the PT and patella. DISCUSSION. The PT remains as an excellent option in ACL repair. The anatomy and quality of the graft are essential to achieving good functional results. The choice of middle third tendon to the BTB plasty does not always correspond to the 10mm width, as used in most biomechanical tests. Also patellar integrity can be at risk (when collecting the bone block) if patella geometry is not considered. To our knowledge, there is only one similar study in literature, preformed in Asian individuals. CONCLUSION. Preoperatively accessing the geometry of Patella and PT can be crucial in obtaining efficient grafts and decreasing morbidity over the extensor mechanism

The imaging techniques available to aid the diagnosis of ruptures of tendo Achillis, the rotator cuff and the tendon of tibialis posterior in rheumatoid patients are well described. However, ruptures of tendon or muscle at other sites are uncommon and may be overlooked. Diagnosis is often made by localised tenderness, swelling and a lack of active movement associated with a palpable defect. Clinical examination may be inconclusive and can be aided by imaging studies. We report two cases in which ruptures of a tendon were suspected, and ultrasound imaging demonstrated the palpable defect to be a cleavage plane in the subcutaneous fat – a ‘fat fracture’

Introduction. Following tear of its tendon, the muscle undergoes retraction, atrophy and fatty infiltration. These changes are inevitable and considered irreversible and limit the potential of successful repair of musculotendinous units. It was the purpose of this study to test the hypothesis that administration of anabolic steroids can prevent these muscular changes following experimental supraspinatus tendon release in the rabbit. Methods. The supraspinatus tendon was experimentally released in 20 New Zealand rabbits. Musculotendinous retraction was monitored over a period of 6 weeks. The seven animals in group I had no additional intervention, six animals in group II had local and seven animals in group III had systemic administration of nandrolone deconate during six weeks of retraction. At the time of sacrifice, in-vivo muscle performance as well as radiologic and histologic muscle changes were investigated. Results. Supraspinatus retraction was significantly higher in group I (1.8 ± 0.2cm) than in group II (1.5 ± 0.3cm, p = 0.044) or III (1.2 ± 0.3cm, p = 0.001). The reduction in radiological cross sectional area, as a measure for atrophy, was significant in groups I (p = 0.013) and II (p = 0.030) and insignificant in group III (p = 0.149). Histologically, there was no fatty infiltration in the treated groups II (p = 1.000) and III (p = 0.812), but in the untreated group I (p = 0.0312). The work of the respective muscle during one standardized contraction with supramaximal stimulation decreased markedly in groups I (p = 0.056) and II (p = 0.0528), and also but less in group III (p = 0.23). Conclusion. This is the first documentation of prevention of important muscle alterations after chronic retraction of the musculotendinous unit caused by rotator cuff tear. Nandrolone deconate administration in the post tendon release phase prevented fatty infiltration of the supraspinatus muscle and reduced functional muscle impairment caused by myo-tendinous retraction

It appears that double bundle anterior cruciate ligament reconstruction can reproduce the original anatomy of the ligament, restoring normal kinematics and rotational control of the tibia. But an anatomical single bundle reconstruction may present very similar results, with minor technical difficulties and lower costs. We compared two groups of 25 patients each, that underwent ACL reconstruction by the same surgeon, with a follow-up of 12–36 months. One group had double bundle reconstruction with hamstring and the other had single bundle anatomical reconstruction with patellar tendon. Patients underwent a subjective evaluation and clinical testing with instrumented laxity with Rolimeter, and the data entered in the IKDC 2000 scale Double tunnel hamstring Vs bone-tendon-bone: Functional outcome of 85.6% Global Class A and B vs. 82.1% Class A and B. The subjective outcome (IKDC 2000) was 90.93 vs. 91.47. Pivot-shift test with 87% patients in class A and class B at 9.7% Vs 75% patients in class A, 21.4% for class B. The Rolimeter gave an average Lachman value of 2,56 and anterior drawer test of 2,88 Vs average Lachman value of 3.59 and anterior drawer test of 2.92. One leg hop test showed 85.7% knees class A, 9.5% knees class B vs. 90.4% knees class A and, 2.8% knees class B. The subjective score was slightly higher in the single bundle anatomical reconstruction with patellar tendon, despite the overall functional outcome being higher in the double tunnel technique with hamstrings. The average Lachmann in the patellar tendon group was 1 mm higher. The rotational stability in the double tunnel was higher. The same surgeon had better results in the double tunnel hamstrings technique, despite less experienced with this technique, which is more demanding, probably reflecting objective advantages over the single bundle reconstruction with patellar tendon

The equinovarus hind foot deformity is one of the most common deformities in children with spastic paralysis and is usually secondary to cerebral palsy. Split posterior tibialis tendon transfer is performed to balance the flexible spastic varus foot and is preferable to posterior tibialis lengthening, as the muscle does not loose its power and therefore the possibility of a valgus or calcaneovalgus deformity is diminished. The cohort of the study consisted of 50 children with cerebral palsy who underwent split posterior tibial lengthening to manage spastic equinovarus hind foot deformity. Our inclusion criteria were: ambulatory patients with cerebral palsy, age less than 6 years at the time of the operation, varus deformity of the hind foot during gait, flexible varus hind foot deformity, and the follow-up at least 4 years. We retrospectively evaluated 33 ambulant patients with flexible spastic varus hind foot deformity. Twenty-eight patients presented unilateral and 5 bilateral involvement. The mean age at the time of the operation was 10,8 years (6–17) and the mean follow-up was 10 years (4–14). Eighteen feet presented also equinus hind foot deformity, requiring concomitant Achilles cord lengthening. Clinical evaluation was based on the inspection of the patients while standing and walking, the range of motion of the foot and ankle, callus formation and the foot appearance using the clinical criteria of Kling et al. Anteroposterior and lateral weight-bearing radiographs of the talo-first metatarsal angle were measured. The position of the hind foot was evaluated according to the criteria of Chang et al for the surgical outcome. 20 feet were graded excellent, 14 were graded good and 4 were graded poor. Feet with recurrent equinovarus deformity or overcorrection into valgus or calcaneovalgus deformity were considered as poor results. There were 23 feet presenting concomitant cavus foot component that underwent supplementary operations performed at the same time with the index operation. None of the feet presented mild or severe valgus postoperatively, while 4 feet presented severe varus deformity and underwent calcaneocuboid fusion sixteen and eighteen months after the index operation. On the anteroposterior and lateral weight-bearing radiographs the feet with severe varus had a negative talo-first metatarsal angle (mean −26,8 ± 18,4), those with mild varus had a mean of −14,5 ± 12,2. In feet with the hind foot in neutral position the mean value was 5.0 ± 7.4. The results of the feet in patients with hemiplegic pattern were better and significantly different than the diplegic and quadriplegic ones (p = 0.005). The results in our cases were in general satisfactory as 34 out of 38 feet were graded excellent and good. The feet with poor results presented a residual varus deformity due to intraoperative technical errors

Introduction. Patellofemoral instability is one of the most common presentations to a children's orthopaedic clinic. Recurrent patellar dislocations and instability episodes are painful, disabling and increase the risk of irreversible chondral damage. The medial patellofemoral ligament is the primary static stabiliser to prevent lateral dislocation of the patella and is almost always torn or attenuated in these cases. Reconstruction of this ligament is commonly performed using autologous hamstring tendon however there has been some interest recently in use of quadriceps tendon as a graft. Children with patellar instability also present unique challenges due to the small size of the patella and the presence of open growth plates which may require adaptations to the common techniques. Methods. Patients undergoing medial patellofemoral ligament reconstruction using quadriceps tendon autograft were identified using electronic theatre records. Prospectively collected clinical records and imaging findings were reviewed and underlying pathology, additional procedures at time of MPFL reconstruction, current function and need for further revision surgery determined. Results. Between January 2019 and August 2023, 50 MPFL reconstructions were performed in 37 children using partial thickness quadriceps autograft. Patient age at time of surgery ranged from 5 to 17 years (median age 13 years). The technique was utilised for a variety of indications including recurrent traumatic and habitual patellofemoral instability, fixed dislocations, and revision MPFL reconstruction. Conclusion. Partial thickness quadriceps tendon autograft can be used safely to primarily reconstruct the medial patellofemoral ligament in paediatric population, including those children with open growth plates. It also has utility in revision cases following previous failed hamstring MPFL reconstruction. We have noted that the younger the child, the more distal to the physis lies the femoral point of isometricity, rendering this a safe and reproducible treatment in this age group. Use of this technique has increased in our unit as we have observed that patients seem to be satisfied with their clinical and functional outcomes with a low incidence of short- and medium-term complications

This prospective study explores the outcomes of the Forth Valley Protocol (FVP) for the management of acute Achilles tendon ruptures. The protocol uses ultrasound as the primary mechanism to guide treatment. All patients presenting with acute tendoachilles rupture over a three-year period were included. Patients under 18 years of age, chronic ruptures, or prior surgery to the Achilles tendon were excluded. Patients with a gap ≤2cm had conservative management following an Early Rehabilitation Protocol (ERP) and >2cm underwent surgery (if an appropriate surgical candidate). Achilles Tendon Rupture Scores (ATRS) were obtained retrospectively. Fischer's exact test was used to determine statistical significance. 158 patients were included with a mean age of 53 (range 20–89). Ultrasound scans were obtained for 121 patients (76.5%), demonstrating a mean tendon gap of 1.61cm. 143 patients managed conservatively and 15 surgically. The overall re-rupture rate was 3.8% (n=6). All the re-ruptures occurred in patients treated conservatively, but this was not found to be statistically significant (n=6, P=1.0). The overall complication rate (excluding re-ruptures) was 1.9%. ATRS was comparable between both treatment modalities (P=0.382, 0.422), with a mean score of 86.6 in the conservative group and 81.4 in the surgical group. The FVP demonstrates low re-rupture and complication rates in line with other published studies. Patients with gaps ≤2.0cm on the ultrasound can be successfully treated conservatively with an ERP. This has potential benefits in terms improved patient outcomes, satisfaction, and preservation of resources

Aims

To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture.

Deficiency in the gluteus medius and minimus abductor muscles is a well-recognised cause of hip pain and considerable disability. These patients present a management challenge, with no established consensus for surgical intervention. Whiteside in 2012 described a surgical technique for gluteus maximus tendon transfer, with successful outcomes reported. This study is the largest known case series to date of patients undergoing gluteus maximus tendon transfer with clinical and patient reported outcomes measured. 13 consecutive patients were included in the study. All patients had clinical evidence of abductor dysfunction together with MRI evidence of gluteal atrophy and fat infiltration. All patients underwent gluteus maximus transfer with surgery performed according to the procedure described by Whiteside. Patients were followed up with both clinical assessment and patient questionnaires conducted. Mean age was 69 (range 54–82) with 9 patients (69%) having previous Hardinge approach to the affected hip. 6 patients (46%) reported they were satisfied overall with the procedure and 5 patients (38%) were unsatisfied. 7 patients (54%) had improvements in visual analogue scale of pain and 5 patients (54%) reported overall improvements in function. Mean Oxford Hip Score on follow up was 20/48 (range 5–48) and trendelenberg test was positive in 11 patients (85%). No differentiating variable could be identified between patients with positive and negative outcomes (Assessed Variables: Age, sex, BMI, aetiology and gluteus maximus muscle thickness). Clinical outcomes were varied following gluteus maximus tendon transfer for chronic hip abductor dysfunction. Results are considerably less promising than pre-existing studies would suggest

Aims

Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery.

PURPOSE. We performed an anatomical study to clarify humeral insertions of coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHL) and their relationship with subscapularis tendon. The purpose of our study was to explain the « Comma Sign » observed in retracted subscapularis tears treated by arthroscopy. MATERIAL AND METHODS. 20 fresh cadaveric shoulders were dissected by wide delto-pectoral approach. After removal the deltoid and posterior rotator cuff, we removed humeral head on anatomical neck. So we obtained an articular view comparable to arthroscopical posterior portal view. We looked for a structure inserted on subscapularis tendon behind SGHL. By intra-articular view we removed SGHL and CHL from the medial edge of the bicipital groove, then subscapularis tendon from lesser tuberosity. We splitted the rotators interval above the superior edge of subscapularis tendon and observed the connections between subscapularis tendon, CHL and SGHL. RESULTS. 6 shoulders had massive cuff tears and were excluded. No ligamentous structure was visible between rotators interval and subscapularis tendon by simple intra and extra-articular examination. After removal of LGHS humeral insertion, no structure showed vertical attach on tendon yet. But after removal of subscapularis tendon from lesser tuberosity and medial traction we saw constantly a fibers bundle directly inserted onto supero-lateral edge of subscapularis tendon. DISCUSSION/CONCLUSION. Most authors agree about existence of CHL and SGHL and their bone insertions, whereas relations between themselves and subscapularis tendon aren't so well defined. We constantly found an effective link between subscapularis tendon and a fibers bundle mainly coming from LCH. It layed into supero-lateral edge of subscapularis tendon and could be seen only by medial traction of it. This ligamentous structure yields the « Comma Sign » in subscapularis tendon tears. This study confirms our clinical datas

Introduction. Differing levels of tendon retraction are found in full-thickness rotator cuff tears. The pathophysiology of tendon degeneration and retraction is unclear. Neoangiogenesis in tendon parenchyma indicates degeneration. Hypoxia inducible factor 1(HIF) and vascular endothelial growth factor (VEGF) are important inducers of neoangiogenesis. Rotator cuff tendons rupture leads to fatty muscle infiltration (FI) and muscle atrophy (MA). The aim of this study is to clarify the relationship between HIF and VEGF expression, neoangiogenesis, FI, and MA in tendon retraction found in full-thickness rotator cuff tears. Methods. Rotator cuff tendon samples of 33 patients with full-thickness medium-sized rotator cuff tears were harvested during reconstructive surgery. The samples were dehydrated and paraffin embedded. For immunohistological determination of VEGF and HIF expression, sample slices were strained with VEGF and HIF antibody dilution. Vessel density and vessel size were determined after Masson-Goldner staining of sample slices. The extent of tendon retraction was determined intraoperatively according to Patte's classification. Patients were assigned to 4 categories based upon Patte tendon retraction grade, including one control group. FI and MA were measured on standardized preoperative shoulder MRI. Results. HIF and VEGF expression, FI, and MA were significantly higher in torn cuff samples compared with healthy tissue (p<0.05). HIF and VEGF expression, and vessel density significantly increased with extent of tendon retraction (p<0.04). A correlation between HIF/VEGF expression and FI and MA could be found (p<0.04). There was no significant correlation between HIF/VEGF expression and neovascularity (p>0.05). Conclusion. Tendon retraction in full-thickness medium-sized rotator cuff tears is characterized by neovascularity, increased VEGF/HIF expression, FI, and MA. VEGF expression and neovascularity may be effective monitoring tools to assess tendon degeneration

Introduction. In order to prepare hamstring autograft, suture fixation to the tendon is required to secure and handle the tendon during harvest and preparation. We use a simple, grasping suture which doesn't require suture of the tendon, thus saving time and avoiding violation of the graft itself. We present this technique, with results of mechanical testing compared to a standard whip suture, traditionally used to handle hamstring autograft. Methods and materials. Twelve uniform ovine flexor tendons were prepared. A number two braided polyester suture was used in all cases. Six tendons were prepared with a standard, non-locking whip-suture, maintaining uniformity of suture bite and working length between samples. Six tendons were prepared with the utility suture, also taking care to maintain uniformity. The suture was applied by tying the thread around the tendon with a single-throw granny knot then symmetrically wrapping the suture ends from proximal to distal and securing with another single throw, allowing compression of the tendon with longitudinal tension on the suture. All the samples were tested to failure in uniaxial tension in a materials testing machine. Peak load values and load/displacement curves were acquired and results analysed with a two-sample T-test assuming significance at P<0.05. Results. Modes of failure between the groups, as characterised by the load/displacement curves were quite distinct. Peak load to failure was lower in the utility suture group but all failures occurred when the suture snapped. Thus the peak load to failure of the suture/tendon construct exceeded the breaking strain of the suture material. Conclusion. The grasping utility suture described here is sufficiently strong to harvest and handle hamstring autograft without passing a needle through the graft, saving time and avoiding violation of the graft itself. The lower loads at failure, despite failure occurring due to suture snapping, may reflect differing knot orientation between groups

Background. The long-term impact of dividing Piriformis when performing a standard posterior approach to the hip has not been assessed. A less invasive approach in which the tendon is preserved has been described (the Piriformis-sparing minimally invasive [PSMI] approach). With advances in MRI technology it is now possible to image structures in close proximity to metal without artifact. The aim of the study was to compare the MRI features (muscle grade and bulk) of the divided and repaired Piriformis tendon group (by the standard posterior approach) with the preserved tendon group (by the PSMI approach). Methods. As part of an on-going randomized controlled trial comparing the PSMI approach with the standard posterior approach for total hip replacement, a subgroup of 20 consecutive patients who fulfilled the inclusion criteria were recruited. Patients received preoperative and 3 months and 2 year postoperative MRI scans. Patients and evaluators were blinded to allocation. Outcomes assessed included grade, volume and integrity of Piriformis. Results. There was significantly less deterioration in muscle grade (p = 0.002) and bulk (p = 0.013) in the preserved Piriformis tendon group in comparison to the divided and repaired Piriformis group. There was equal deterioration in muscle grade and bulk of all divided tendons (Obturator Internus and Piriformis by the standard approach and Obturator Internus by the PSMI approach). The majority (10/11) of the Piriformis tendons by the PSMI approach were intact post-operatively. Conclusions. The PSMI approach, in which the Piriformis tendon is preserved, is successful in maintaining the integrity of the tendon as well as preventing deterioration in grade and bulk of the muscle belly

Introduction. ACL reconstruction using hamstring tendons has gained general acceptance. However, it has been recommended to seek a tight fit of the tendon in the bone canal in order to provide circumferential contact and healing of the graft, and to prevent secondary tunnel widening. Recent findings show, that the graft dynamically adapts to pressure in the canal resulting in a potentially loose graft-bone contact. It was the goal of this study to understand the viscoelastic behaviour of hamstring grafts under pressure and to develop a new method for tendon pre-conditioning to reduce the graft volume before implantation, in order to reduce the necessary bone canal diameter to accommodate the same graft. Material and Methods. Flexor digitorum tendons of calf and extensor digitorum tendons of adult sheep were identified to be suitable as ACL grafts substitutes for human hamstring tendons in vitro. The effect of different compression forces on dimensions and weight of the grafts were determined. Further, different strain rates (1mm/min vs 10mm/min), compression methods (steady compression vs. creep) and different compression durations(1, 5, 10min) were tested to identify the most effective combination to reduce graft size by preserving its macroscopic structure. Results. The effect of compression on volume reduction (25% of initial volume) reached a plateau at 6000N. Both, steady compression and creeping were able to reduce dimensions of the graft, however, creeping was more effective. There was no difference in effect with different durations for compression (p>0.05) in both methods. With a strain rate of 1mm/min no macroscopic destruction was documented, however with 10mm/min some parts were ruptured. During all pressure tests, considerable amounts of liquid were pressed out from the tendons, and if the graft was submersed in saline solution overnight, the volume reduction was mostly reversible. Conclusion. Compression reduces the dimensions of the ACL graft reversibly, to the greatest part by squeezing out of interstitial water. It is reasonable to assume that this effect also occurs if tendons are under constant pressure in the body, such as at the bend where entering a bone tunnel or under the pressure of interference screws. This in vitro experiment suggests that preconditioning of a 8mm hamstring graft is achieved best by creeping compression with 6kN at a strain rate of 1mm/min. By using this technique, indeed a canal of approximately 10–15% less diameter (i.e. 7 instead of 8mm) may be drilled for the same tendon, resulting in a tight fit of the graft in the bone

Introduction. It has been postulated that a mild clubfoot does better than a severe clubfoot no matter what treatment course is taken. There have been previous efforts to classify clubfoot. For units worldwide that use the Ponseti Method of clubfoot management, the Pirani scoring system is widely used. This scoring system has previously been shown to predict the number of plasters required to gain correction. Our study aimed to investigate whether the Pirani score gave an indication of longer-term outcome using tibialis anterior tendon transfer as an endpoint. Methods. A prospectively collated database was used to identify all patients treated in the Ponseti clinic at the Royal Manchester Children's Hospital between 2002 and 2005 with idiopathic clubfoot who had not received any treatment prior to their referral. Rate of tibialis tendon transfer as well as the patient's presenting Pirani score were noted. Feet were grouped for analytical purposes into a mild clubfoot (Pirani score <4) and a severe clubfoot (Pirani score 4) category depending on initial examination. Clinic records were reviewed retrospectively to identify patients who were poorly compliant at wearing boots and bars and were categorised into having “good” or “bad” compliance with orthosis use. Results. 132 feet in 94 children were included in the study. 30 (23%) tibialis tendon transfers were performed at a mean of 4.2 years (range 2.3–5.5 years). Children with severe clubfoot had a significantly higher rate of tendon transfer compared with those with mild clubfoot (28% vs. 6%; p=0.0001). 81% of patients were classified as being “good” boot wearers. Tibialis tendon transfer rates in those who were poorly compliant with boot usage were significantly higher compared with those with good compliance (52% vs. 16%; p=0.0003). There was a significantly higher tendon transfer rate in those with severe disease and poor compliance compared with good compliance (69% vs. 20%; p=0.0002). There was no association between boot compliance and tendon transfer rates in those with mild disease. Conclusion. This study shows that late recurrences, requiring tibialis anterior tendon transfer, are associated with severity of disease at presentation and compliance with use of orthoses. Tendon transfer rates are higher for those with severe disease. We have confirmed previous reports that compliance with orthotic use is associated with recurrence. However, the novel findings regarding recurrence rates in mild clubfeet may have implications regarding usage of orthoses in the management of mild idiopathic clubfeet after initial manipulation using the Ponseti method

Introduction. Anterior Cruciate ligament reconstruction is a common operation in orthopaedics surgery. A common complication of whilst havesting the hamstring tendon is injury to the infra-patellar branch of the saphenous nerve (IPBSN), resulting in altered sensation to the anterior and lateral aspects of the knee and leg. Aim. The aim of this study was to further understand the course of this nerve in relation to surgical approach to anterior cruciate ligament reconstruction. Material and method. The nerve was traced and dissected in 25 knees from 14 different cadavers. Four paths of IPBSN in relation to the Sartorius muscle were identified: (1) a posterior path which ran round the inferior posterior border of the muscle, (2) a transmuscular path that penetrated through the muscle, (3) an anterior path that ran from the anterior border of the muscle and (4) posterior patellar path that ran round the posterior of the muscle at the same level as the patellar. Dissections were carried out with further 14 knees in a standard manner using both type of incision techniques, vertical incision or horizontal, in ten pair of knees. Using a tendon stripper, the hamstrings tendon were harvested in a standard fashion in different angles of the knee ie full extension and flexion at 90 degrees. Results. Of these paths the posterior was the most common featuring in 57% of specimens and the nerve was at higher risk of being injured due to the proximity of that pathway and the gracilis and semintendinosus muscle tendons. Horizontal incision has a higher chance of damage to the saphenous nerve and the infra-patellar branch. The saphenous nerve was injured on every occasion by this incision. Vertical incision, 1.5cm from the midline, avoided the infra-patellar branch and the saphenous nerve. Harvesting of the tendon in full extension was difficult, and it made the incision sites both horizontal and vertical at greater risk injuring the tendons. When the knee was flexed at 90 degrees these problems were overcome. Conclusions. A vertical incision with a flexed knee gave the best method to harvest the tendon with minimal risk to damaging the infra-patellar branch and the saphenous nerve when using the tendon stripper