Aims. The aim of this study was to analyse human muscle tissue before and after rotator cuff repair to look for evidence of regeneration, and to characterise the changes seen in the type of muscle fibre. Patients and Methods. Patients were assessed pre-operatively and one year post-operatively using the Oxford Shoulder Score (OSS) and MRI. The cross-sectional area and distribution of the type of muscle fibre were assessed on biopsies, which were taken at surgery and one year post-operatively. Paired samples from eight patients were analysed. There were three men and five women with a mean age of 63 years (50 to 73). Results. All but one patient showed improvement in OSS (p = 0.004). The mean increase in the cross-sectional area of the muscle was 1220 μm. 2. (-801 to 3712; p = 0.03). There was a reduction of type 2a fibres (p = 0.02). A clear relationship could not be seen between the MRI findings and the histological appearances. Conclusion. This is the first study to provide evidence that atrophy of the supraspinatus muscle is reversible. Changes in the types of fibre are discussed. MRI assessment of muscle atrophy may not be fully representative of myofibre atrophy. Cite this article: Bone Joint J 2016;98-B:1389–94

1. Direct injury to skeletal muscle results in fragmentation and necrosis of muscle fibres, though this is patchy in distribution. 2. The sarcolemmal basement membranes form the interface along which fibre regeneration takes place. 3. Phagocytosis of disorganised sarcoplasm is an essential prelude to the reconstitution of severely damaged fibres. 4. Regeneration of injured muscle begins with proliferation of basophilic cells probably originating from muscle satellite cells. After a few days typical myoblast nuclear chains are present. By a week following injury the chains of myoblasts have formed myotubes, which possess myofibrils and sarcomeres. 5. By twelve days in the monkey and by eighteen days in man the muscle fibre regenerative process shows many new fibres which have not reached a mature diameter. 6. Much collagen may be formed in the tissue space at the site of injury. It appears that as the muscle fibres increase in diameter the collagen decreases in extent. 7. In the monkey by three weeks the muscle at the fracture site appears normal. This is also true in the specimens examined at four, six and twelve weeks. 8. In the monkeys the injured limb was immediately used to run and jump. A parallel intense and early activity of muscle and joints was a cardinal point in the management of this series of fracture patients. The clinical results were satisfactory. 9. It is concluded that in both the monkey and in man, given active limb movements, permanent and functionally useful muscle regeneration occurs following soft-tissue injury associated with a bone fracture

1. Biopsies of muscle were taken during the course of operation from sixteen patients with vascular injuries to the limbs. Three types of histological change were found. 2. In the first, there was massive necrosis of muscle fibres—a group of cases in which there had always been serious damage to the main artery of the limb or to the vessel supplying the affected muscles. 3. In the second type there was dense interstitial fibrosis, the muscle fibres sometimes being normal and sometimes showing necrosis or denervation—a group of cases in which the vascular injury varied from severance of the vessels by gunshot wounds to trivial damage, causing slow haemorrhage within fascial-bound spaces. 4. The third type showed scattered foci of necrosis together with patchy interstitial fibrosis—due to the pressure of tight plasters, crushing of the limb, fractures with arterial contusion, or slow haemorrhage or extravascular transfusion within fascial planes. The rise of tension within the muscles was probably sufficient to occlude the smaller arterioles with resultant patchy necrosis. 5. The vulnerability of certain muscles to vascular damage is partly related to the intramuscular vascular pattern, of which five types have been described. 6. In ischaemic muscles the intramuscular nerve trunks may be normal or they may show evidence of degeneration or necrosis; but in favourable circumstances there may be regeneration of axons. 7. In some cases there was evidence of regeneration of muscle fibres in man, the regeneration being dependent to some extent upon the efficiency of intramuscular anastomoses. 8. The prognosis, in cases of ischaemia of human voluntary muscle, depends upon the extent and the reversibility of damage to both muscle and nerve fibres and upon the extent of regeneration of muscle fibres

Aims. Improvements in the evaluation of outcomes following peripheral nerve injury are needed. Recent studies have identified muscle fatigue as an inevitable consequence of muscle reinnervation. This study aimed to quantify and characterize muscle fatigue within a standardized surgical model of muscle reinnervation. Patients and Methods. This retrospective cohort study included 12 patients who underwent Oberlin nerve transfer in an attempt to restore flexion of the elbow following brachial plexus injury. There were ten men and two women with a mean age of 45.5 years (27 to 69). The mean follow-up was 58 months (28 to 100). Repeated and sustained isometric contractions of the elbow flexors were used to assess fatigability of reinnervated muscle. The strength of elbow flexion was measured using a static dynamometer (KgF) and surface electromyography (sEMG). Recordings were used to quantify and characterize fatigability of the reinnervated elbow flexor muscles compared with the uninjured contralateral side. Results. The mean peak force of elbow flexion was 7.88 KgF (. sd. 3.80) compared with 20.65 KgF (. sd . 6.88) on the contralateral side (p < 0.001). Reinnervated elbow flexor muscles (biceps brachialis) showed sEMG evidence of fatigue earlier than normal controls with sustained (60-second) isometric contraction. Reinnervated elbow flexor muscles also showed a trend towards a faster twitch muscle fibre type. Conclusion. The assessment of motor outcomes must involve more than peak force alone. Reinnervated muscle shows a shift towards fast twitch fibres following reinnervation with an earlier onset of fatigue. Our findings suggest that fatigue is a clinically relevant characteristic of reinnervated muscle. Adoption of these metrics into clinical practice and the assessment of outcome could allow a more meaningful comparison to be made between differing forms of treatment and encourage advances in the management of motor recovery following nerve transfer. Cite this article: Bone Joint J 2019;101-B:867–871

The lower limbs of five cadavers were dissected and the lengths of the muscle fibres and the weights of all the muscles below the knee were measured. From this information the relative strength and excursion of each muscle was determined. We found that the plantarflexors of the ankle were six times as strong as the dorsiflexors. We have therefore discarded the concept of "muscle balance" in tendon transfer surgery and propose that task appropriateness should be the guide. The constant relationship between muscle fibre length and muscle excursion means that contractures are accompanied by decreased excursion. Tendon lengthening improves deformity but does not improve the decreased active range of movement

We retrospectively studied the possibility that direct trauma to the biceps muscle might be the cause of poor elbow flexion and supination in 18 consecutive children with birth lesions of the brachial plexus who had delayed or impaired biceps recovery despite neurophysiological evidence of reinnervation. All had good shoulder and hand function at three months of age. Eight recovered a strong biceps after six months, but nine required a pectoralis minor to biceps transfer to augment elbow flexion and supination. One had a delayed but good recovery of the biceps after microsurgical reconstruction of the plexus. All had a clinical ‘pseudotumour’ in the biceps muscle, which was biopsied during pectoralis minor transfer in two patients and showed rupture and degeneration of muscle fibres with a fibro-fatty infiltrate, suggesting previous muscle trauma. Direct muscle trauma is an uncommon but important cause of delayed or impaired biceps recovery after brachial plexus birth injuries. Surgery to reinnervate the biceps muscle will not work if substantial muscle damage is present when a suitable muscle transfer should be considered

A histochemical analysis was made of 103 muscle biopsies taken from 62 patients with idiopathic club feet. Any reduction in the diameter of the muscle fibres associated with wasting of the calf muscle was recorded. Histochemical abnormalities existing in these biopsies were revealed by comparison with normal biopsies obtained from the normal legs of 13 children with unilateral deformities. No significant difference was found between the diameter of the muscle fibres taken from normal and affected legs aged under six months. This indicates that wasting of the calf muscle is due to a reduction in the number of fibres rather than their size. The muscle structure was normal excluding denervation and reinnervation. The soleus muscle in patients aged under six months contained 61 per cent Type 1 fibres in the affected legs, compared to 44.3 per cent in normal legs. Similar values were found in the normal and abnormal tibialis posterior muscles, long flexors of the toe and peroneal muscles. The change in composition of the soleus muscle and the reduction in the number of fibres may be caused by a defective neural influence on the development of the limb in club foot

We used an experimental rabbit model of leg lengthening to study the morphology and function of muscle after different distraction rates. Lengthening was in twice-daily increments from 0.4 to 4 mm per day. New contractile tissue formed during lengthening, but some damage to the muscle fibres was seen even at rates of less than 1 mm per day; abnormalities increased with larger rates of lengthening. There was proliferation of fibrous tissue between the muscle fibres at distraction rates of over 1 mm per day. Active muscle function showed adaptation when the rate was 1.0 mm per day or less, but muscle compliance was normal only after rates of 0.4 mm per day. Muscle responded more favourably at rates of distraction slower than those shown to lead to the most prolific bone formation. At present the rate of distraction in clinical practice is determined mainly by factors which enhance osteogenesis. Our study suggests that it may be advisable to use a slower rate of elongation in patients with poor muscle compliance associated with the underlying pathology; this will allow better accommodation by the contractile and connective tissues of the muscles

1 . The extensor digitorum longus of the rabbit was partly denervated by section of one of its two nerve branches and examined histologically for evidence of sprouting of new fibres. 2. Sections from material fixed two and three days after operation showed terminal bundles in which varying numbers of axons and motor end-plates have degenerated. This supports the concept that the motor unit is not confined to single groups of neighbouring muscle fibres, but innervates fibres scattered throughout the muscle. 3. New fine fibres branching from intact intramuscular axons to reinnervate denervated muscle fibres were observed as early as four days after operation. 4. Such new fibres were most numerous in the early weeks after operation and their numbers then declined. Two months after operation no small fibres or simple end-plates were seen. 5. No new fibres were seen in areas of the muscle containing only denervated nerve fibres. The new fibres were formed only under the stimulus of proximity to the degenerating ones. 6. The relationship of these findings to the mechanism of recovery of human muscle affected by poliomyelitis is discussed

1. The effects of heavy training on a skeletal muscle have been studied in the rat. After denervation of the triceps surae muscle the tendon of the plantaris muscle was implanted into the tuberosity of the calcaneum. It was then possible to demand an unusual performance of the plantaris, the weight of which is only 18 per cent of the weight of the triceps surae. 2. Formation of new muscle fibres was observed after prolonged heavy training. This is incontrast to the opinion of most investigators, who have seen no new fibres formed after training. Degenerative changes followed by regeneration were also seen. 3. The trained muscle could almost double its weight, and treble its force. Paradoxically, the supposedly non-contractile sarcoplasm was seen to have increased after training. 4. Training induced a strong protein synthesis in muscle. In normal muscle protein synthesis can hardly be demonstrated. 5. Connective tissue grew between single muscle fibres in the heavily trained muscle. Its distribution was unequal. 6. Heavy exercise caused marked swelling of an untrained muscle. 7. Functional recovery was satisfactory after the operation. This showed that a muscle can be replaced by one only one-fifth its weight, provided the latter is trained adequately. 8. Not even the most arduous training could inflict permanent damage on the muscle

At the apex of an idiopathic scoliotic curve there is a greater proportion of "slow twitch" muscle fibres in multifidus on the convex as compared to the concave side. To determine whether this represents a primary muscular imbalance relevant to the aetiology of idiopathic scoliosis or merely a secondary change, the lengths of multifidus on opposite sides of the curve were measured. Multifidus is shorter on the convex side. This is consistent with the theory of primary muscular imbalance, in which the more tonically acting muscle with its higher proportion of "slow twitch" fibres contracts and shortens as the deformity is produced. The paradox of multifidus being shorter on the convex rather than on the concave side is explained by consideration of its action

1 . Funnel chest deformity is a common cause of progressive postural defects in children. 2. The underlying pathology of the funnel chest is a congenital deficiency of the muscle fibres of the anterior part of the diaphragm which allows the stronger posterior element to pull backwards the xiphoid and sternum. The postural changes are secondary to the chest deformity. 3. Operative correction of the chest deformity is described. 4. Post-operative physiotherapy is essential to correct the postural deformities. Patients must remain under orthopaedic supervision to maintain the correction obtained. 5. A series of twelve children treated by operation is reported, with excellent results in all

An orientated substratum has been implicated in the development and regeneration of axons and synapses. We prepared a basement membrane matrix from autogenous striated muscle, used it to repair the sciatic nerve in rats, then investigated the results by histology and electrophysiology. When treated grafts were coaxially aligned with the nerve fascicles functional recovery appeared within 30 days, with good growth of axons into the distal nerve. Grafts with myotubes at right angles to the nerve fascicles supported nerve regeneration but at a slower rate. Grafts of coaxially aligned but untreated muscle allowed axon penetration only through naturally degenerated muscle fibres, with minimal axon penetration of the distal nerve. It is concluded that in the rat a treated graft with correctly orientated empty myotubes can facilitate and guide the regeneration of peripheral nerve after injury and so lead to recolonisation of the distal stump with functional recovery

The elbow flexor muscles of four men were trained using maximal voluntary isometric contractions. Thirty contractions a day were performed for five weeks. The four men and four control subjects were tested once a week: measurements of the supramaximally stimulated isometric twitch force, the time taken for the twitch force to peak and the tetanic force were carried out; simultaneously, measurements of the force of maximal voluntary isometric contraction and resistance to fatigue were made. The testing sessions produced no training effect on control subjects. Training produced a 20 per cent increase in the force of maximal voluntary isometric contraction after five weeks, but the forces of electrically evoked twitch and tetanus showed no increase. It was concluded that the increase in the force of maximal voluntary isometric contraction must be related to factors other than the force-generating capacity of the muscle fibres themselves

In talipes equino-varus the diminished bulk of the calf muscle suggests a neuromuscular defect. Accordingly, biopsies were taken from the postero-medial and peroneal muscle groups, and occasionally from abductor hallucis, in sixty patients mostly under the age of five years; 111 were studied histochemically and histologically, and a further fifty-three by electron-microscopy. Histochemical anomalies were revealed in ninety-two specimens; the muscle fibres in the other nineteen varied in size but were abnormal at the ultramicroscopic level, as were all specimens examined with the electron microscope. Evidence of neurogenic disease was seen in most instances and was more obvious in the older patients. The pattern of abnormality was similar in both muscle groups. It is thought that shortening of the postero-medial muscles may result from a small increase of fibrosis due to minor innervation changes occurring in intra-uterine life. There is evidence that immobilisation, stretching or relaxation of muscles does not account for the anomalies observed. This study of the extrinsic muscles in talipes equino-varus indicates a dominant neurogenic factor in its causation

Biopsies of lumbar multifidus muscles were obtained at operation on seventeen patients aged from fifteen to fifty-eight with lumbar spinal derangement, and further material was taken from the cadavers of three subjects aged from nineteen to fifty-one. Sections were prepared to show the presence of ATPase activity, so distinguishing Fast from Slow types of muscle fibre. The normal mosaic pattern arising from the intermingling of fibres from Fast and Slow motor units was seen in sections from cadaveric material and from many of the biopsies. With age and limited lumbar flexibility, the Fast fibres became relatively smaller but with increasing variation in size, suggesting a reduced capacity for phasic activity. The presence of positive root signs was associated with a greater proportion of Slow fibres, and in some patients with the occurrence of atrophied Fast fibres, giving rise to differences in the populations of the two fibres in neighbouring fascicles. The results suggest that multifidus adopts an increasingly postural role with advancing age and with disabling lesions of the lumbar spine

1. A clinico-pathological study of a patient who suffered traumatic rupture of his right popliteal artery is outlined. 2. Collateral circulation from the genicular anastomosis developed within twenty hours. 3. Ischaemic necrosis of the belly of the tibialis anterior occurred, but voluntary power began to return about twenty-one weeks after injury. 4. Biopsy of the muscle nineteen, fifty-seven and seventy-six weeks after injury showed that the muscle belly was being reconstituted by new fibres and that the ischaemic tissue remained entombed in the deepest part of the muscle. The regenerating fibres arose from small numbers of subfascial fibres which either survived the ischaemic episode or had arisen by myoblastic differentiation of connective tissue cells. Sarcoplasmic outgrowths produced new contractile substance, and new fibres were formed by amitotic fission. Many of the fibres matured and the regenerative process was still active seventy-six weeks after injury. 5. Growth of new nerve bundles containing myelinated axons accompanied the development of new muscle fibres

1. The results of electrodiagnostic tests reveal the level and progress of nerve lesions. 2. The findings in a myopathic lesion are: a) a normal SD curve; b) no fibrillation on the E.M.G.; c) on volition a full interference pattern-because motor units have not been lost, but only muscle fibres within the units; d) the action potentials are short in duration, polyphasic and of low amplitude; e) conduction times are normal. 3. In peripheral nerve affections these findings are evidence of denervation: a) a sluggish response to a long duration current; b) a kinked SD curve; c) fibrillation at rest on the E.M.G.; d) a reduced interference pattern of motor unit action potentials on volition; e) a preponderance of polyphasic action potentials of long and short duration; f) slowing of conduction times. 4. Evidence of reinnervation is given by: a) a kink in the SD curve; b) the appearance of a response in the muscle to nerve stimulation; c) a progressive increase in conduction velocity; d) the appearance of polyphasic action potentials on volition; e) fibrillation becoming more difficult to detect. 5. The following findings suggest a lesion of the anterior horn cell: a) difficulty in detecting fibrillation, and a relatively normal SD curve in the presence of marked wasting. (Intact axons have "mopped up" denervated fibres.) b) Marked reduction in interference pattern with ‘giant units’. c) Normal conduction velocity

Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes.

Cite this article: Bone Joint J 2023;105-B(12):1244–1251.

Aims

The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system.