Severe and recalcitrant Greater Trochanteric Pain Syndrome (GTPS), previously known as Trochanteric bursitis, has been associated with torn gluteal tendons. The aim of this study was to assess the physical, functional and quality of life outcomes of combined bursectomy and gluteal tendon reconstructive surgery. 24 patients underwent combined bursectomy and gluteal tendon reconstruction under one surgeon. They were contacted by mail, email, and telephone. 16 were available for examination, two had revision surgery, one had interview only, one moved interstate, one declined and three were lost to follow up. An independent standardised assessment was undertaken. Hip muscle strength was measured by hand-held dynamometry. Trendelenburg sign was measured according to Hard-castle’s protocol and by observing gait. Functional and quality of life measures were assessed via the Harris Hip Score and the Oswestry Disability scale. Pain and satisfaction was measured via a 10cm visual analogue scale. All patients were female. The mean time from surgery was 18.9 months +/− 8.50. 10 had right sided surgery. The two patients who had revision surgery are not included in this data. Strength of hip abduction was weaker on the ipsilateral side (p< =.05). External rotation appeared to be weaker, however this was not statistically significant. Hardcastle’s single leg standing Trendelenburg sign was shorter on the ipsilateral side (16.3secs +/− 12.3 vs 22.1secs +/− 10.1, p< =.05). Five patients had an ipsilateral Trendelenburg gait, two had a contralateral Trendelen-burg gait. The mean recalled preoperative pain score was 67.73 +/− 31.51 out of 100. The mean post operative score was 14.44 +/− 16.1 (p< =.0005). Patient satisfaction with the results of surgery was rated at 80.7 +/−17.69, out of 100. With regard to function, the mean post operative Harris hip score was 70.9 +/− 25.73 out of 91, and the Oswestry disability score was 15.5 +/− 11.39, out of 100 where a low score indicates better outcome. Combined bursectomy and gluteal tendon reconstruction appears to be an effective procedure for the relief of pain in patients with recalcitrant GTPS in most patients. High patient satisfaction levels suggest that function and quality of life are improved following surgery. A prospective longitudinal study has commenced to verify these results

Neglected rupture of quadriceps tendon is an infrequently occurring lesion resulting from sport, but it is very interesting as regards the physiological and functional repercussions. The lesion is common in football players. The pathogenesis is a flexion trauma of knee. Many authors point out the importance of a pre-existent degeneration due to exogenous and endogenous factors. Pain, inextensible knee, ecchymosis, axe hit are a common presentation in acute events, difficult knee extension and pain in chronic. X-ray study shows calcification at the tendon-bone junction.

The treatment of neglected rupture of quadriceps tendon is surgical. If a defect of 5 cm or more is present between the ends of tendon the fascia lata can be used to correct the gap. When the ends can be apposed an end-to-end repair is possible. We treated a neglected rupture of quadriceps femoris muscle tendon in a bodybuilder with a particular technique: we stripped and harvested the semitendinosus and gracilis tendon and sutured them together. Then we made a transverse hole in the mid-portion of the patella; the tendons were passed through the transverse hole in the patella and sutured with the lateral, medial and intermendial vastus, and with the rectum femoral. At 6-month follow-up the patient has no pain and stability is improved, a practical range of knee motion regained. Full forceful extension is not completely restored.

We examined the mechanical properties of Vicryl (polyglactin 910) mesh in vitro and assessed its use in vivo as a novel biomaterial to attach tendon to a hydroxyapatite-coated metal implant, the interface of which was augmented with autogenous bone and marrow graft. This was compared with tendon re-attachment using a compressive clamp device in an identical animal model. Two- and four-ply sleeves of Vicryl mesh tested to failure under tension reached 5.13% and 28.35% of the normal ovine patellar tendon, respectively. Four-ply sleeves supported gait in an ovine model with 67.05% weight-bearing through the operated limb at 12 weeks, without evidence of mechanical failure.

Mesh fibres were visible at six weeks but had been completely resorbed by 12 weeks, with no evidence of chronic inflammation. The tendon-implant neoenthesis was predominantly an indirect type, with tendon attached to the bone-hydroxyapatite surface by perforating collagen fibres.

We describe a new method for reconstructing the patellar tendon following combined injury to the patellar tendon and anterior cruciate ligament (ACL).

Combined injuries to the patellar tendon and the ACL represent a rare and potentially serious injury pattern. The injury to the patellar tendon can often go undiagnosed at primary presentation. Reconstructive options for the patellar tendon are described but can be technically difficult, particularly if ipsilateral hamstring has been used for anterior cruciate ligament reconstruction. Evidence suggests combined injuries generally lead to poor long term outcome.

We describe a case of a 26 year old male who presented with a reconstructed ACL and a patellar tendon deficient knee. Diagnosis was confirmed on Magnetic Resonance Imaging (MRI). Ipsilateral hamstrings had been used as donor for ACL reconstruction. An Achilles tendon allograft with distal bone block was used in combination with contralateral semitendinosus and gracilis autograft to reconstruct the three bundles of the patellar tendon. The patient experienced no postoperative complications and was followed up radiologically and clinically. Computer Topography imaging performed at 6 months post-operatively showed union of the bony Achilles tendon block. MRI performed 1 year post-operatively showed good incorporation of the tendinous grafts and no evidence of degeneration or tearing. Oxford knee score at 6 months post-operatively was 31/48. One year post-operatively full pre-injury activity level had been achieved.

We believe this method to provide adequate strength and integrity, enabling early rehabilitation following this rare injury. It has also been shown to give a good functional outcome.

A total of seven patients (six men and one woman) with a defect in the Achilles tendon and overlying soft tissue underwent reconstruction using either a composite radial forearm flap (n = 3) or an anterolateral thigh flap (n = 4). The Achilles tendons were reconstructed using chimeric palmaris longus (n = 2) or tensor fascia lata (n = 2) flaps or transfer of the flexor hallucis longus tendon (n = 3). Surgical parameters such as the rate of complications and the time between the initial repair and flap surgery were analysed. Function was measured objectively by recording the circumference of the calf, the isometric strength of the plantar flexors and the range of movement of the ankle. The Achilles tendon Total Rupture Score (ATRS) questionnaire was used as a patient-reported outcome measure. Most patients had undergone several previous operations to the Achilles tendon prior to flap surgery. The mean time to flap surgery was 14.3 months (2.1 to 40.7).

At a mean follow-up of 32.3 months (12.1 to 59.6) the circumference of the calf on the operated lower limb was reduced by a mean of 1.9 cm (sd 0.74) compared with the contralateral limb (p = 0.042). The mean strength of the plantar flexors on the operated lower limb was reduced to 88.9% of that of the contralateral limb (p = 0.043). There was no significant difference in the range of movement between the two sides (p = 0.317). The mean ATRS score was 72 points (sd 20.0). One patient who had an initial successful reconstruction developed a skin defect of the composite flap 12 months after free flap surgery and this resulted in recurrent infections, culminating in transtibial amputation 44 months after reconstruction.

These otherwise indicate that reconstruction of the Achilles tendon combined with flap cover results in a successful and functional reconstruction.

Cite this article: Bone Joint J 2015;97-B:215–20.

Aim. Arthroscopic interventions have revolutionized the treatment of joint pathologies. The appropriate diagnostics and treatment are required for infections after ligament reconstructions using non-resorbable material such as tendon grafts, anchors, and sutures, prone to biofilm formation. The infection rate is around 1% for knee and shoulder, while up to 4% for Achilles tendon reconstructions. Despite high number of these procedures worldwide, there is limited evidence about the best treatment protocol. Our study aimed to provide a general protocol for the treatment of small implants for soft tissue reconstruction. Method. Between 2019 and 2023, we treated 48 infections of ligament, meniscus, and tendon reconstructions out of 7291 related procedures performed in the same time period. Early infection (<30 days) were treated with an arthroscopic debridement and implant retention (DAIR), except Achilles tendons had open DAIR, while those with delayed or chronic infection (>30 days) were treated with extensive debridement and lavage combined with one-stage exchange (OSE) or implant removal. During surgery, at least 5 microbiological s and samples for histopathology were obtained. The removed material was sonicated. After surgery, all patients were one week on iv. antibiotics, followed by oral antibiofilm antibiotics for 6 weeks including rifampicin and/or a quinolone. All patients were followed for at least 1 year. Failure was defined as the need for additional revision surgery after finished iv. antibiotic treatment. Results. Among 48 patients, 38 were early and 10 were late acute or chronic infections. The incidence of infection for our cohort was 0.7%. We observed 27 infections after ligament reconstruction of the knee, 15 of the shoulder, 5 of the ankle, and 1 infection of the elbow joint. 40 patients were treated with DAIR, 5 with OSE, and 3 with implant removal. We had 11 C. acnes, 10 S. aureus, 6 S. epidermidis, 2 P. aeruginosa, 2 S. lugdunensis, 10 mixed flora, and 3 culture-negative infections. 12 patients received antibiotics before surgery, and all culture-negative infections were related to this subgroup. We observed 2 failures, both in a combination of proximal tibial osteotomy and ligament reconstruction of the knee joint. The success rate of our protocol was 96%. Conclusions. Prompt surgical treatment followed by 6 weeks of antibiotic treatment cured 96% of infections of small implants after reconstruction procedures of knee, shoulder, and ankle joints. Our study is the first to provide a treatment protocol for infections of small implants after ligament reconstruction procedures

Introduction. Chronic ruptures of the quadriceps tendon after total knee arthroplasty (TKA) are rare but are a devastating complication. The objective of this study was to validate the use of fresh frozen total fresh quadriceps tendon allografts for quadriceps tendon reconstruction. The hypothesis of this work was that the graft was functional in more than 67% of cases, a higher percentage than the results of conventional treatments. Material – methods. We designed a continuous monocentric retrospective study of all patients operated on between 2009 and 2017 for a chronic rupture of the quadriceps tendon after TKA by quadriceps allograft reconstruction. The usual demographic and perioperative data and the rehabilitation protocols followed were collected. Initial and final radiographs were analyzed to measure patellar height variation. The main criterion was the possibility of achieving an active extension of the knee with a quadriceps contraction force greater than or equal to 3/5 or the possibility of lifting the heel off the ground in a sitting position. Results. 29 patients with 33 allografts were included; 3 iterative allografts were performed on ruptures of the initial transplant and 1 patient was grafted on both sides in one step. There were 21 women and 8 men with a mean age of 73 years, and a mean body mass index of 33 kg/m. 2. Ruptures occurred in 22 cases after chronic periprosthetic infection. Walking was allowed immediately in 29 cases, but free mobilization was delayed in 29 cases. Complications affected 22 cases, but the majority of complications were not related to allograft use (including infectious failures and periprosthetic fractures). After a mean follow-up of 52 months, 28 allografts were still in place, and 22 allografts were considered functional. The active quadriceps extension force was rated on average at 3.5/5. The average pre/post-operative patellar height differential was +2 mm. Discussion. This continuous series of 33 allografts is in line with recent publications on the subject. It confirms their negative impact on the functional outcome of the TKA. The complication rate is high but the specific complication rate is not prohibitive. Two thirds of transplants are functional in the long term. Early rehabilitation procedures can be used in these difficult patients with encouraging results. The management of chronic ruptures of the quadriceps tendon after TKA by quadriceps allograft must be part of the current therapeutic options

Aims

Arthroplasty surgery of the knee and hip is performed in two to three million patients annually. Periprosthetic joint infections occur in 4% of these patients. Debridement, antibiotics, and implant retention (DAIR) surgery aimed at cleaning the infected prosthesis often fails, subsequently requiring invasive revision of the complete prosthetic reconstruction. Infection-specific imaging may help to guide DAIR. In this study, we evaluated a bacteria-specific hybrid tracer (^99mTc-UBI_29-41-Cy5) and its ability to visualize the bacterial load on femoral implants using clinical-grade image guidance methods.

Aims

The proximal tibia (PT) is the anatomical site most frequently affected by primary bone tumours after the distal femur. Reconstruction of the PT remains challenging because of the poor soft-tissue cover and the need to reconstruct the extensor mechanism. Reconstructive techniques include implantation of massive endoprosthesis (megaprosthesis), osteoarticular allografts (OAs), or allograft-prosthesis composites (APCs).

The effect of screw geometry on the pullout strength of Anterior Cruciate Ligament [ACL] reconstruction is well documented. Most research has looked at the effect of screw length and diameter, however other factors such as the degree of taper may also be important. Tapered screws should in theory be associated with increased pullout strength. This has not been demonstrated either clinically or in vitro before. The aim of this study was to compare the pullout strength of ACL reconstruction with a parallel against a tapered screw. A parallel and tapered screw were manufactured which were identical in all other respects. Sixty superficial digital flexors from the hind legs of sheep were harvested. The tendons were paired and combined to form a quadruple tendon reconstruction of approximately 7mm diameter as measured with graft sizer. An ACL reconstruction was performed on the proximal tibia of 30 bovine knees, which had been harvested in right and left knee pairs, using the quadruple tendon. Fifteen reconstructions were fixed using tapered screws and fifteen with non-tapered screws. The insertion torque of both tapered and non tapered screws were recorded using an instrumented torque screwdriver. The reconstructions were mounted in an Instron materials testing machine with an x-ray bearing system to eliminate horizontal forces, to ensure that the forces were all directed along the line of the tibial tunnel. The maximum pullout strengths were recorded in each case. Five knee pairs were subjected to bone densitometry scanning to ensure that any difference in pull out strength was not due to changes in bone density between right and left knee pairs. Results indicated that there was no difference between right and left knee pairs [p = 0.58] and that tapered screws were associated with significantly higher pull-out strengths [p=0.007] and insertion torques [p = 0.001]

The purpose of this study was to report the outcome of ‘isolated’ anterior cruciate ligament (ACL) ruptures treated with anatomical endoscopic reconstruction using hamstring tendon autograft at a mean of 15 years (14.25 to 16.9). A total of 100 consecutive men and 100 consecutive women with ‘isolated’ ACL rupture underwent four-strand hamstring tendon reconstruction with anteromedial portal femoral tunnel drilling and interference screw fixation by a single surgeon. Details were recorded pre-operatively and at one, two, seven and 15 years post-operatively. Outcomes included clinical examination, subjective and objective scoring systems, and radiological assessment. At 15 years only eight of 118 patients (7%) had moderate or severe osteo-arthritic changes (International Knee Documentation Committee Grades C and D), and 79 of 152 patients (52%) still performed very strenuous activities. Overall graft survival at 15 years was 83% (1.1% failure per year). Patients aged < 18 years at the time of surgery and patients with > 2 mm of laxity at one year had a threefold increase in the risk of suffering a rupture of the graft (p = 0.002 and p = 0.001, respectively). There was no increase in laxity of the graft over time. ACL reconstructive surgery in patients with an ‘isolated’ rupture using this technique shows good results 15 years post-operatively with respect to ligamentous stability, objective and subjective outcomes, and does not appear to cause osteoarthritis

This study was undertaken to assess for equivalence or superiority in tendon reconstruction techniques. This is an in vitro analysis of several, different, reconstruction techniques for chronic Achilles tendon ruptures. The surgical techniques have been borne out of surgical preference rather than biomechanical principles with little published research into their comparability. Surgical preferences are a result of the supposed benefits of reduced operative time, single operative incision and decreased morbidity. An animal model, after human cadaveric tissue dissection to guide the specimen construction, was used to compare the different techniques using bovine bone and tendon and tested using a material testing machine. Ultimate load to failure was recorded for all specimens and statistical analysis of the results was undertaken. A statistically significant difference was shown between all the techniques by analysis of variance. This will guide clinical application of these techniques. The use of bone tunnels, through which the flexor hallucis longus tendon can be passed, were found to be biomechanically superior, with regard to ultimate load to failure, to either bone anchors or end-to-end tendon suture techniques. Interference screws were found to have a large range in their ultimate load suggesting a lack of consistency in the results. The mean of the bone tunnel group (482.8N, SD 83.6N) is significantly (p < 0.01) higher than the mean of the bone anchor group (180.2N, SD 19.3N), which is, in turn, significantly (p < 0.01) higher than the mean of the Bunnell group (73.7N, SD 20.9N). This study is larger than any previous study found in the literature with regard to number of study groups and allows the techniques to be compared side by side

The calcaneal tendons of rabbits were excised and either replaced with a carbon or polyester fibre implant, or left as controls. The strength of the neotendons and their mode of failure under tension were examined at intervals up to six months after operation. Return to near normal strength took six months to develop, suggesting that patients having ligament or tendon reconstructions should not resume normal activity for several months. Carbon fibre-based neotendons showed progressive elongation which, unless avoided by a sufficient period of immobilisation, would affect the functional result

Introduction. A deficient abductor mechanism leads to significant morbidity and few studies have been published describing methods for reconstruction or repair. This study reports the reconstruction of hip abductor deficiency using human allograft. Methods. All patients were identified as having deficient abductor mechanisms following total hip arthroplasty through radiographic assessment, MRI, clinical examination and intra-operative exploration. All patients underwent hip abductor reconstruction using a variety of human allografts including proximal humeral, tensor fascia lata, quadriceps and patellar tendon. The type of allograft reconstruction used was customized to each patient, all being attached to proximal femur, allograft bone adjacent to host bone, with cerclage wires. If a mid-substance muscle rupture was identified an allograft tendon to host tendon reconstruction was performed. Results. Allograft reconstruction was performed in 15 patients over 18 months. One patient had an abductor deficiency after a primary total hip. All patients had an abductor lurch gait and positive Trendelenburg test preoperatively. Manual muscle strength testing showed significant weakness with a mean MRC grade of 3+/5. Peri-trochanteric pain was cited as a significant complaint in > 80 % of patients. Proximal humeral allografts, with rotator cuff, were used in 8 patients, 5 had tensor fascia lata and the remainder had patella with attached tendon allograft. The majority of patients had a reduction in pain and 8/15 (53%) increased their abductor strength by almost a full grade. A reduced lurch was observed in 10 (66%) patients and one patient re-dislocated after a failed revision for instability. Conclusion. To our knowledge, this is the largest reported series of allograft reconstruction for a deficient abductor mechanism following hip arthroplasty. A viable solution is demonstrated, with promising early results for a difficult problem, utilizing a straightforward technique with low morbidity

Large and retracted rotator cuff tendon tears fail to repair, or re-tear following surgical intervention. This study attempted to develop novel tissue engineering approaches using tenocytes-seeded bioscaffolds for tendon reconstruction of massive rotator cuff tendon defect in rabbits. Porcine small intestine submucosa (Restore™) and type I/III collagen bioscaffold (ACI-MaixTM) were chosen as bioscaffold carriers for autologous tenocytes. Biological characterization of autologous tenocytes was conducted prior to the implantation. The tenocyte-seeded bioscaffolds were implanted as interposition grafts to reconstruct massive rotator cuff tendon defects in rabbits. In situ re-implantation of the autologous rotator cuff tendon, excised during defect creation served as a positive control. Histological outcomes were analysed and semi-quantitatively graded at four and eight weeks after surgery. The results demonstrate that at four weeks both tenocyte-seeded bioscaffolds display inflammatory reaction similar to bioscaffold-only cuff reconstruction and the histological grading were inferior to control repair. However, at eight weeks inflammatory reaction of both tenocyte-seeded bioscaffolds were dramatically reduced as compared to bioscaffold alone. In addition, bioscaf-folds seeded with tenocytes generated similar histological appearance to that of the positive control. The implantation of autologous tenocytes on collagen-based bioscaffold offers improved rotator cuff tendon healing and remodelling compared to the implantation of bioscaffold alone

Pupose: The purpose of this study was to analyze the outcome of proximal tibia osteoarticular allografts after tumor resections. Material amd Methods: We performed a retrospective study over 58 patients in which a proximal tibia allograft reconstruction was undertaken. All patients were followed for a minimum of 5 years and allografts survival from the date of implantation to the date of revision or the time of the latest follow-up was determined with the use of the Kaplan-Meier method. In all patients, the patellar tendon from the host was reattached by suturing to overlapped donor flaps. Patients were clinically evaluated with the MSTS score system. Results: The global rate of allograft survival was 65% +/− 12% (+/− 2 SE) at five and ten years, with no significant difference between patients who received chemotherapy and those who did not. Allografts needed to be removed in twenty patients due to 12 infection, 4 local recurrences and 4 fractures. Active knee extension was restored in all patients with an average functional score of 26.3 points. Discussion: Survival analysis showed that 65% of proximal tibia osteoarticular allograft reconstructions remain stable at five and ten years. Patellar tendon reconstruction with allogeneic tissue in proximal tibia allograft restores active knee extension with an excellent functional result. Despite the incidence of complications, proximal tibia osteoarticular allografts continue to be a very valuable reconstructive procedure for large defects after resection of bone tumors

Material & Methods: Twenty three patients (15 male; 8 female) with an average 30 years old (16–63) presented with a posttraumatic multidirectional instability of the distal RU joint. In two occasions instability was associated to a malunited distal radial fracture which was corrected with a osteotomy. Through a dorsoulnar approach, the RU joint in all cases was inspected and found with no cartilage defects that could preclude this intervention. Also in all occasions there was an unrepairable peripheral TFCC detachment. In 11 cases the palmaris longus tendon was utilized, while in one the flexor superficialis of the ring finger was used. The graft was passed through an anteroposterior tunnel in the distal-medial edge of the radius and attached into another tunnel in the basistyloid fovea. The forearm was then immobilized in neutral pronosupination for 4–6 weeks, followed by appropriate physiotherapy. Results: At an average 18 months follow-up (6–36) 21 patients regained radioulnar stability (symmetrical passive displacement of the joint relative to the contralateral side). In two there was a limitation of more than 25° pronosupination. All 15 patients with a follow-up longer than one year had returned to their previous activities with a less than 20% loss of grip strength. Conclussion: Tendon reconstruction as suggested by Adams& Berger is anatomically sound, and it has shown promising short term results, certainly superior to the results obtained with other soft-tissue reconstructions

The recent advance of drug therapy for RA tends to replace preventive surgery, for example synovectomy. A rupture of a dorsal extensor tendon of the hand is an absolute indication for surgery, however. Such tendon ruptures are usually treated by tendon reconstruction and synovectomy of wrist joint. At our department, reconstructive surgery was administered with synovectomy for extensor tendon ruptures of the hand in 97 hands for 86 patients until June 2005. Recently, however, we occasionally encounter ruptures of extensor tendons not associated with severe synovitis. To treat such tendon ruptures, we usually administer tendon transfers in combination with tenosynovectomy through a small skin incision. Because this surgical procedure has achieved excellent results, we report our experience. This study included 15 patients who received tenosynovectomy in combination with tendon transfers in 14 hands since February 2001. This surgical procedure is indicated for tendon ruptures associated with mild synovitis (swelling) without instability on the ulnar distal end. As a rule, a 2–3 cm transverse skin incision was made on the dorsum of the hand under maxillary nerve block. After exposure of the distal ruptured end of the tendon, tenosynovectomy was administered through the incision. Then, the distal end was transferred to the adjacent normal tendon and fixed to it with sutures. Postoperatively, the repair was immobilized with bandage. The patient was allowed actively to extend and bend the hand on the next day. As a rule, this operation is administered on an outpatient basis. The postoperative course was uneventful, without rupture of the repair. The preoperative ranges of motion of the MP and PIP joints were retained postoperatively without difficulty in ADL

Aim: Although primary ßexor tendon repair in children yields satisfactory results, some children end up with poor function because of delay in diagnosis, technical difþculties and the inability to follow a structured rehabilitation program. The aim of this study is to evaluate the functional outcome after two stage reconstruction with the modiþed Paneva technique (which includes creating a loop between the proximal stumps of Flexor Digitorum Profundus and Superþcialis in the þrst stage and reßecting the latter as a Ç pedicled È graft through the pseudosheath created around the silicone rod, in the second stage) in children. Methods: Nine patients (9 digits) with a mean age of 8,2 years (range 3 Ð15) were treated for zone II lesions. Their pre-operative status in the Boyes and Hunter scale was grade two in 3, grade three in 3, grade four in 1 and grade þve in 2 patients. Results: After a mean of 42 months of follow-up (minimum 12 months), according to the Buck-Gramco scale there were 4 excellent, 4 good and 1 poor result and according to the revised Strickland scale 3 excellent, 5 good and 1 poor. Children over the age of 10 had slightly improved Total Active Motion (mean +350) compared to younger ones. No signiþcant length discrepancies were noted. Two postoperative infections were treated and one graft-related re-operation was necessary. Conclusions: Staged ßexor tendon reconstruction in children is technically feasible and efþcient. Delaying such a reconstruction in younger children does not seem justi-þed