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