Two men, aged 21 and 50 years, were seen with ossification of the patellar tendon after injury to the knee in adolescence. They complained of pain and had patella alta. Large bony masses were excised from below the affected patellae. The patellar tendon was then reconstructed using a Leeds-Keio ligament. The results at six and ten years, respectively, were good, with neither patient having pain or an extension lag

The formation of restrictive adhesions around the musculotendinous unit after injury is one of the most vexing processes faced by the surgeon. In flexor tendons it has been shown that the synovial tissue is the source of aggressive fibroblasts which contribute to this process. Using a rabbit model, we have examined the effects of treating the synovial sheath with the antimetabolite 5-fluorouracil (5-FU) for five minutes. Inflammatory, proliferative and molecular markers were compared in the response of the treated and control tendons to injury. Compared with a control group we found that the proliferative and inflammatory responses were significantly reduced (p < 0.001) in the treated tendons. Not only was there a reduction in the cellular and cytokine response, but there also was a significant (p < 0.001) reduction in the level of activity of the known pro-scarring agent, transforming growth factor beta 1 (TGF-β1). These pilot studies indicate that the formation of restrictive adhesions may be modulated using a simple single-touch technique in the hope of producing a better return of function

Ten cases of post-traumatic recurrent dislocation of the peroneal tendons were operated on between 1974 and 1982. In all cases the disturbed superior peroneal retinaculum was reconstructed by transposition of the calcaneofibular ligament to the lateral side of the peroneal tendons. The calcaneal insertion of the calcaneofibular ligament was mobilised with a small bone block and reinserted in its bed after the transposition. After an average follow-up of four years all the results were satisfactory

Simple decompression of the extensor tendons at the wrist was carried out on fifty-four wrists in a total of forty-one patients with rheumatoid disease. This procedure was combined with excision of the ulnar head in forty-five wrists. Complete resolution of the synovitis occurred in 81.5 per cent of the wrists. In two patients the tendons ruptured soon after operation and in both cases this was due to prolapse of the ulnar stump after an associated Darrach procedure. The clinical results of decompression compare favourably with those of the widely accepted operation of dorsal tenosynovectomy

The effects of splintage, suture and excision of the tendon sheath on the healing of incompletely transected flexor tendons in the rabbit have been evaluated separately and in various combinations. When all procedures were done together, repair was accompanied by dense adhesion formation with little evidence of any healing activity by the tendon cells. The experiments indicated that the adhesions were the result not of any one single factor studied but of all three contributing in varying degrees. Suturing produced the most adhesions but synovial sheath excision and immobilisation also contributed. It is suggested that these factors are also responsible for the adhesions which occur after flexor tendon repair in clinical practice

We studied changes in patellar tendon length after reconstruction of the anterior cruciate ligament using either the medial third of the patellar tendon as a graft (n = 40) or a Leeds-Keio artificial ligament (n = 40). Both types of ligament replacement had been supplemented with a MacIntosh extra-articular lateral substitution. The mean change in length in the tendon graft group was 6% (SD 5.39); in the Leeds-Keio group it was 2.4% (SD 4.93). The change in length was significant in both groups, but shortening was more frequent and more severe in the tendon graft group. There was shortening of 10% or more in 25% of knees after patellar tendon graft and 7.5% after use of a Leeds-Keio prosthesis

Subcutaneous rupture of the tendon of tibialis anterior immediately proximal to its insertion affects patients over the age of 45 years and is most common in the seventh decade. The symptoms at the time of rupture are milder than is the case with rupture of the calcaneal tendon and the early disability is slight. Thus, affected patients commonly present several weeks or months after rupture and at a stage when reattachment of the tendon to its normal site of insertion (the most satisfactory surgical management) is impossible. Although the disability is slight if repair is not performed, there should be no disability after surgical repair and this should be offered to those patients who lead an active life and who present in the first three months after rupture. The relevant literature is reviewed and experience with four further patients is recounted

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’

We performed MRI on 16 patients who had had reconstruction of the anterior cruciate ligament (ACL) with a mid-third bone-patellar-tendon-bone autograft. Our aim was to assess the tendon and the site of its insertion at an average of seven years after the original operation. In four of these patients biopsies were taken from the donor site when they had revision of their original operation. MRI showed reconstitution of the tendon into the patellar defect with no evidence of bone formation. Six patients had a persistent defect in the patellar tendon itself. Histological examination of the biopsies of the donor site showed an indirect pattern of insertion with absence of the normal fibrocartilage zone. These morphological changes may adversely affect the biomechanical properties of the healed donor site and we suggest that another graft taken from this site may not be suitable for use in a further operation for reconstruction of the ACL

Patella infera can cause knee pain and lead to patellofemoral osteoarthritis. Treatment is usually unsatisfactory. We describe a case of severe patella infera after operative treatment for fracture of the patella. We used Ilizarov external fixation and gradual lengthening of the patellar tendon. The patellar height was restored and the patient’s symptoms were much improved

Experiments have been performed on rabbits and sheep which demonstrate that pure carbon, in a flexible and filamentous form of great strength, can be used successfully to induce the formation of new tendons. A concept fundamentally different from that underlying the use of other artificial tendon replacements is involved, in which rapidly developing tendon-like tissue is induced to form around the implant. This gradually takes over the function of the implant. The early results in rabbits and the late results in sheep suggest that filamentous carbon may have a place in the replacement of the calcaneal tendon and the collateral ligaments of the knee

We have investigated the effects of the intra-operative application of a combination of hyaluronic acid and amniotic membrane on adhesions in the flexor tendons of a chicken model. We used 144 tendons which were partially divided and then repaired by a modified Kessler technique. There were four test groups: group 1, simple tendon repair, group 2, repair site wrapped with amniotic membrane, group 3, hyaluronic acid injected around the repair site, and group 4, repair site wrapped with amniotic membrane and hyaluronic acid injected within it. At three and six weeks, the extent of the adhesions and the healing of the tendon were evaluated macroscopically and histologically. The range of movement of the toe and tensile strength of the repaired tendons were measured at 20 weeks. The least adhesions were observed in group 4 but no significant difference was found in the healing of the tendons. Overall, the intra-operative application of a combination of hyaluronic acid and amniotic membrane appears to be effective in preventing adhesions of the flexor tendon

Congenital dislocation of the peroneal tendons is a rare and infrequently reported deformity of the foot in the neonate. Four cases of this deformity associated with a congenital calcaneovalgus deformity of the foot have been treated and followed to the resolution of both of the deformities. The calcaneovalgus foot proved more resistant to correction and required more prolonged and aggressive treatment than was usual when it was found as an isolated deformity. All four patients demonstrated other stigmata of intra-uterine malposition and oligohydramnios or both. Our anatomical studies suggested that the superior peroneal retinacular ligament was the critical stabilising structure for the peroneal tendons. A concept of the pathogenesis of this deformity is discussed and a proven regimen for its treatment presented

This is a retrospective study of primary repairs of flexor pollicis longus in 16 children under 15 years of age. Patients with injuries to the median or ulnar nerve at the wrist, crush injuries, skin loss or fracture were excluded. Repairs were carried out within 24 hours using a modified Kessler technique. The mean follow-up was for two years. The final results were evaluated using the criteria of Buck-Gramko and Tubiana. They were good or excellent in all except one patient who had a secondary tendon rupture. When compared with the non-injured thumb, however, there was a significant decrease in active interphalangeal flexion (> 30°) in one-third of cases. A new method of assessment is proposed for the recovery of function of the flexor pollicis tendon which is more suitable for children. Postoperative immobilisation using a short splint had a negative effect on outcome. The zone of injury, an early mobilisation programme or concurrent injury to the digital nerve had no significant effect on the final result

Giant-cell tumour of the tendon sheath (GCT-TS) is a benign solitary tumour which usually arises in the limbs. It occurs most often in the hand where local recurrence after excision has been reported in up to 45% of cases. It is less common in the foot where the biological behaviour and risk of local recurrence have not been defined. We have studied 17 cases of GCT-TS of the foot and ankle in which treatment was by excision. Fifteen presented as a solitary, painless, slow-growing soft-tissue swelling. One lesion was associated with sensory deficit of a digital nerve and one with pain on walking. Thirteen cases originated from the periarticular tendon-sheath complex of the small joints of the toes and four from the capsule or long tendons of the ankle. A correct preoperative diagnosis was made in only three cases. MRI proved to be the most useful preoperative investigation as GCT-TS has a characteristic appearance which allows planned local excision to be carried out. None of the patients with histologically confirmed GCT-TS required further surgery. There was no local recurrence in 15 patients who were available for follow-up at a mean of 85 months

We aimed to determine the distribution of the ABO and Rh blood groups in 832 patients with a tendon rupture. Among these, the frequency of blood group O (52.8%) was significantly higher than in the general population of Hungary (31.1%) and the frequency of group A was significantly lower. Of the 83 cases of multiple ruptures or re-rupture, 57 patients (68.7%) had group O blood. The dominance of group O was found for all sites of tendon rupture, but there was no significant association with the Rh groups. Individuals with blood group O appear to have an increased risk of tendon rupture

We describe a new method of stabilising a painful unstable sternoclavicular joint using the sternocleidomastoid tendon and passing it through the medial clavicle and onto the manubrium sternum. This method is simple, reproducible and avoids the potential risks of reefing the joint to the first rib. The technique was used in seven cases of sternoclavicular joint instability in six patients who were reviewed at a mean of 39.7 months (15 to 63). Instability was markedly reduced or eliminated in all cases, but in one there was occasional persistant subluxation. There were minor scar complications after two procedures and one patient had transient ulnar neuritis. This procedure provides satisfactory results in the medium term

Traumatic rupture of the tendon of the subscapularis muscle was documented as an isolated lesion in the shoulders of 16 men. The injury was caused either by forceful hyperextension or external rotation of the adducted arm. The patients complained of anterior shoulder pain and weakness of the arm when it was used above and below the shoulder level. They did not experience shoulder instability. The injured shoulders exhibited increased external rotation and decreased strength of internal rotation. A simple clinical manoeuvre called the 'lift-off test', reliably diagnosed or excluded clinically relevant rupture of the subscapularis tendon. Confirmation of the clinical diagnosis was best achieved by ultrasonography or MRI, but arthrography or CT arthrography were also useful. Surgical exploration confirmed the diagnosis in every case. Repair of the ruptured tendon was technically demanding and required good exposure to identify and protect the axillary nerve

Giant cell tumours (GCT) of the synovium and tendon sheath can be classified into two forms: localised (giant cell tumour of the tendon sheath, or nodular tenosynovitis) and diffuse (diffuse-type giant cell tumour or pigmented villonodular synovitis). The former principally affects the small joints. It presents as a solitary slow-growing tumour with a characteristic appearance on MRI and is treated by surgical excision. There is a significant risk of multiple recurrences with aggressive diffuse disease. A multidisciplinary approach with dedicated MRI, histological assessment and planned surgery with either adjuvant radiotherapy or systemic targeted therapy is required to improve outcomes in recurrent and refractory diffuse-type GCT. Although arthroscopic synovectomy through several portals has been advocated as an alternative to arthrotomy, there is a significant risk of inadequate excision and recurrence, particularly in the posterior compartment of the knee. For local disease partial arthroscopic synovectomy may be sufficient, at the risk of recurrence. For both local and diffuse intra-articular disease open surgery is advised for recurrent disease. Marginal excision with focal disease will suffice, not dissimilar to the treatment of GCT of tendon sheath. For recurrent and extra-articular soft-tissue disease adjuvant therapy, including intra-articular radioactive colloid or moderate-dose external beam radiotherapy, should be considered

Surgical repair of posterosuperior rotator cuff tears has a poorer outcome and a higher rate of failure compared with repairs of supraspinatus tears. In this prospective cohort study 28 consecutive patients with an irreparable posterosuperior rotator cuff tear after failed conservative or surgical treatment underwent teres major tendon transfer. Their mean age was 60 years (48 to 71) and the mean follow-up was 25 months (12 to 80). The mean active abduction improved from 79° (0° to 150°) pre-operatively to 105° (20° to 180°) post-operatively (p = 0.011). The mean active external rotation in 90° abduction improved from 25° (0° to 70°) pre-operatively to 55° (0° to 90°) post-operatively (p < 0.001). The mean Constant score improved from 43 (18 to 78) pre-operatively to 65 (30 to 86) post-operatively (p < 0.001). The median post-operative VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to 5 (0 to 56) post-operatively (p < 0.001). In conclusion, teres major transfer effectively restores function and relieves pain in patients with irreparable posterosuperior rotator cuff tears and leads to an overall clinical improvement in a relatively young and active patient group with limited treatment options. Cite this article: Bone Joint J 2013;95-B:523–9