Excision of pseudotumour in a patient with haemophilia A and inhibitor managed with recombinant factor VIIa

We describe a patient with haemophilia A and factor VIII inhibitor who underwent surgical excision of a large pseudotumour in the left femoral region. Haemostasis was successfully maintained with bolus doses of recombinant factor VIIa at 2-h intervals and anti-fibrinolytic therapy, and the pseudotumour was removed. Subsequently, the dose interval was gradually prolonged to 8 h for a total of 18 days. Although a spontaneous haemorrhage was observed on postoperative day 8, haemostasis was achieved by reducing the dosage interval. No adverse event occurred during the course of treatment.

The Principle of Margin Convergence in Rotator Cuff Repair as a Means of Strain Reduction at the Tear Margin

The principle of margin convergence applied to rotator cuff repair is achieved by side-to-side suture of the cuff tear in order to converge the free margin of the cuff toward its bone bed. This technique dramatically reduces strain along the "converged" margin, thereby protecting the tendon-bone repair interface during the critical phases of healing.

Post-traumatic ossification of the Achilles tendon: description of a case

The presence of small areas of ossification in the Achilles tendon is a relatively frequent finding. It is instead rare to find large, extensive ossifications for more than half of the tendon. The authors describe a case of a man aged 45 years who, in the wake of an unknown lesion of the Achilles tendon, developed clinically symptomatic ossification 9.5 cm in length and 2.3 cm in width. The patient was treated surgically by removal of the ossified portion and repair of the diastasis with a proximal Achilles flap. After 17 months, the patient is asymptomatic, there are no disorders in walking, and he exclusively shows moderate limitation in range of movement of the ankle joint associated with tricipital hyposthenia. Bone metaplasia of the Achilles tendon is a rare event, that can follow trauma or surgery. The size of the area to be removed implies considerable difficulty in repair of the continuity and in recovery of the length of the tendon.

Flexor hallucis longus tendon transfer: evaluation of postoperative morbidity

Clinical and pedobarograph evaluation was performed on 16 patients following flexor hallucis longus (FHL) tendon transfers to determine the resulting morbidity due to the loss of FHL function. All patients underwent FHL tendon transfer for either chronic tendon Achilles rupture or chronic Achilles tendinosis. Clinical evaluation of hallux function was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale, the SF-36 score, and a clinical questionnaire to assess alteration in the clinical function of the hallux during activities of daily living. Pedobarography was carried out using the Musgrave pedobarograph system to detect changes in forefoot loading in comparison to the contralateral normal foot. Fourteen of the 16 patients scored maximally on the hallux metatarsophalangeal-interphalangeal scale and none of the patients noticed functional weakness of the hallux during activities of daily living at a mean follow-up of 43.6 months (range, 5-120 months). Pedobarograph readings showed a trend toward reduction in peak pressure loading on the distal phalanx, but this was not significant for the numbers of patients studied. There was no significant increase in loading of the first or second metatarsophalangeal joints to suggest that transfer metatarsalgia may complicate FHL tendon transfer. According to the results of the study morbidity from FHL transfer should be clinically insignificant.

Prognostic indicators for outcome following rotator cuff tear repair

PURPOSE

To examine the prognostic indicators associated with outcome following rotator cuff surgery.

METHODS

A retrospective evaluation of records on 1120 shoulders (1067 patients) with rotator cuff tear treated by surgery was performed. Preoperative, intra-operative and postoperative factors were analysed by Kendall's Tau-b correlation analysis and logistic regression analysis.

RESULTS

Positive correlations were seen between the type of tear and the number of tendons involved, retraction, age, degeneration, subacromial bone spur, surgical technique, preoperative and postoperative muscle power, surgical outcome, and preoperative abduction on Kendall's Tau-b analysis. There was a positive correlation seen between degenerative change and age, number of tendons involved, retraction, preoperative pain, tear type, and preoperative musclepower on logistic regression analysis. Additionally, positive correlations were seen between good surgical postoperative outcome and postoperative activities of daily living, preoperative pain, postoperative muscle power, preoperative activities of daily living, tear type, preoperative external rotation, preoperative muscle power, number of tendons involved, preoperative pain, and duration of symptoms.

CONCLUSION

Ageing was found to be the major factor in progressive degeneration of the rotator cuff, and should be considered the single most important contributing factor in the pathogenesis of rotator cuff tears. In addition, degenerative tendonopathy appeared the primary pathology in rotator cuff tear, preceding hypertrophic spur formation. Rotator cuff tears are therefore unlikely to be initiated by impingement; rather, they develop as an intrinsic degenerative tendonopathy.

[Entrapment of the long head of the biceps: the "hourglass biceps". Another cause of pain and locking of the shoulder]

PURPOSE OF THE STUDY

We describe a mechanical condition affecting the long head of the biceps tendon (LHBT) causing potentially unrecognized entrapment within the joint and subsequent pain and locking. This is caused by a hypertrophic intra-articular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm.

MATERIALS AND METHODS

Twenty one patients were identified, during open (14 cases) or arthroscopic (7 cases) surgery, with a so called "hourglass biceps" i.e., hypertrophic intraarticular portion of the LHBT and incarceration of the tendon during elevation. All cases occurred in conjunction with a rotator cuff rupture except one who had a partial deep tear. All patients were treated by excision of the biceps, after tenodesis or bipolar tenotomy, and appropriate treatment of the concomitant lesions.

RESULTS

All patients presented with anterior shoulder pain and loss of passive elevation averaging 10-20 degrees. A dynamic intraoperative test involving forward elevation with the elbow extended demonstrated entrapment of the tendon within the joint in each case. This test creates a characteristic "buckling" of the tendon and "squeezing" of the tendon between the humeral head and the glenoid ("hourglass test"). Excision of the tendon allowed immediate restoration of complete elevation. Mean Constant score increased from 38 points to 76 points postoperatively.

DISCUSSION

The "hourglass biceps" is caused by a hypertrophic intraarticular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm. Loss of 10-20 degrees of passive elevation, bicipital groove tenderness, and radiographic findings of a hypertrophied tendon can aid in diagnosis. The "hourglass biceps" should not be misdiagnosed for a frozen shoulder. Definitive diagnosis is made at surgery with the "hourglass test": incarceration and squeezing of the tendon within the joint during forward elevation of the arm with the elbow extended. Simple tenotomy cannot resolve this mechanical block. Either tenotomy with excision of the intraarticular portion of the LHBT or tenodesis must be performed. The "Hourglass" biceps is an addition to the familiar pathologies of the long head of the biceps tendon (tenosynovitis, prerupture, rupture, instability), and should be considered in any case of chronic anterior shoulder pain associated with a loss of shoulder elevation.

An unusual case of hydatid disease located in the erector spinae muscle

We present a case of hydatid disease localized to the erector spinae muscle. A 60-year-old male was admitted to our hospital with back pain. The diagnosis was made preoperatively by US, CT, and MRI. They showed hydatid disease in erector spinae muscle. Cysts and some part of the erector spinae muscle were resected. Postoperatively pathology confirmed the diagnosis.

Diaphragmatic endometriosis: diagnosis and surgical management--a case report

Endometriosis has been observed in 8 to 15% of the women of reproductive age. Occasionally it can be found outside the pelvis, its usual location. Rather exceptionally it is located on the diaphragm. A case report of preoperatively diagnosed bilateral diaphragmatic endometriosis is presented and its surgical treatment will be discussed.

Relevance of pathology and basic research to the surgeon treating rotator cuff disease

For any physician expecting a successful outcome of a treatment regimen a thorough understanding of the underlying pathogenetic mechanism and the pathology of the disease process is an absolute prerequisite. In addition, the surgeon, obviously wishing to obtain a positive outcome of the procedure, must know the reaction of the body to his or her surgical actions. In particular, he or she must be familiar with the factors guaranteeing an uneventful healing process. For example, with rotator cuff disease it is important to realize that the site of degeneration leading eventually to tearing does not lie in the tendon itself but at its insertion into bone. Moreover, the cells and vessels needed for healing after surgical repair do not originate from the torn tendinous stumps. An important source of cells and vessels is the subacromial bursa overlying the site of tearing. Consequently, the bursa must be preserved at all cost. The subchondral bone trough into which the medial tendon stump is usually anchored during repair represents the other source of healing tissue. Whereas surgeons understandably concentrate their attention on the site of tearing, the fate of the muscle in the torn bone-tendon-muscle unit must not be neglected. In experimental studies we were able to measure muscle atrophy and fat accumulation and could quantify their evolution over time. Finding no reversal of these two parameters after successful repair was disturbing. Shoulder surgeons will benefit from this comprehensive review of updated concepts.

Flexor hallucis longus transfer for repair of chronic achilles tendinopathy

BACKGROUND

The flexor hallucis longus (FHL) tendon has been used to augment the repairs for chronic Achilles tendinopathy. Two common methods of FHL harvesting include a single incision (posterior) technique and a double incision (posterior and medial utility) technique. This cadaver study was designed to measure and compare the lengths of FHL tendon obtainable for reconstruction with each technique.

METHODS

Fourteen fresh-frozen cadaver lower limbs were utilized for FHL harvest. The tendon was first exposed through the single posterior-medial incision approach adjacent to the Achilles. A second medial utility midfoot incision was then made and the FHL was marked at the level of Henry's knot with a suture, to approximate the level of potential harvest via a two-incision technique. The FHL was then harvested and delivered into the posterior wound. Single incision technique graft length was then measured from the tip of the calcaneal tuber to the level of transection. The remaining in situ tendon was then also measured between its level of transection and the more distal suture placed at Henry's knot. These two lengths were then combined to determine the total potential tendon graft length obtainable using a double incision technique.

RESULTS

The average length of the FHL tendon harvested through the single posterior incision technique measured 5.16 cm (range, 3.4-6.9 cm, SD = 1.29). The average total tendon graft length available using the double incision technique measured 8.09 cm (range, 5.1-11.1 cm, SD = 1.63). The difference between the lengths obtained from these two techniques was significant (p < .001).

CONCLUSIONS

These results demonstrate approximate FHL graft lengths obtainable by using either a single or double incision harvest technique and show that a significantly longer graft can be obtained using a double incision technique. Further data need to be obtained, however, to support whether the extra surgery and graft length obtained from a double incision technique are of any benefit in improving the ultimate functional outcome of these repairs.

Results of chronic Achilles tendinopathy surgery on elite and nonelite track athletes

Twenty-seven track athletes/runners with chronic Achilles tendinopathy underwent a retrospective review of 37 surgical Achilles procedures performed between 1990 and 1999. There were 22 males and 5 females. Average age of the group was 36.6 years (range, 16-75 years). The mean "return to activity" (RTA) was 10.6 +/- 6.3 weeks. For elite athletes, RTA was 7.9 = 4.8 weeks. For nonelite athletes, RTA was 15.0 +/- 6.2 weeks, and was statistically higher (p = .003). There was no significant difference between males' and females' RTA. Average follow-up for the group was 4.7 years (range, 1-10 years). Runners on average ran more than 60 miles a week. There were 14 elite and 13 nonelite athletes, including four Olympians, five sub-4-minute milers, and four National Champions. Return to competition and "100%" were 25.0 and 25.4 weeks, respectively, for the elite group. Return to competition for the nonelite group was 27.0 +/- 11.0 weeks. Eighteen patients underwent peritenolysis with a mean RTA of 7.7 weeks. Of this group, four patients with concomitant bony procedures had significantly slower RTA as opposed to the 14 patients who had peritenolysis only (mean, 4.5 weeks). Four patients had Achilles debridement for mucoid degeneration, and a mean RTA of 12.8 weeks. Eleven patients had Haglund-type procedure (retrocalcaneal exostectomy) had a mean RTA of 15.1 weeks. Six Achilles tendocalcinosis repair patients had a mean RTA of 12.0 weeks. There were three reoperations, two of which were performed by the author. Using the Testa Achilles tendon surgery rating scale, this group of patients had 34 "excellent" and 3 "good" results. The patients who underwent a reoperation were able to achieve "good" or better results.

Surgery for chronic Achilles tendinopathy. Review of 91 procedures over 10 years

The authors reviewed 91 surgical procedures in 87 patients with chronic Achilles tendinopathy. There were 62 males and 25 females (mean age, 44.9 years). The average interval between surgery and review for the group was 4.2 years (range, 1 to 10 years). Twenty patients underwent peritenolysis, with a mean return-to-activity time of 7.7 weeks. Four patients with concomitant bony procedures had significantly longer return-to-activity times than 16 patients who underwent peritenolysis only. The mean return-to-activity time was 13.2 weeks in 15 patients who had Achilles debridement for mucoid degeneration, 14.4 weeks in 32 Achilles tendocalcinosis repair patients, 18.6 weeks in 24 patients who had retrocalcaneal exostectomy procedures, and 34.0 weeks in 5 patients who had chronic Achilles rupture repair. Athletic patients (n = 47) had significantly shorter return-to-activity times than active (n = 38) and sedentary (n = 6) patients. Males returned to activity faster than females. Runners returned to activity faster than other patients.

[Intramuscular hydatid cyst: a case report]

The muscular localization of the hydatid cyst is uncommon (0.5 to 5.4%) and it is usually secondary to hepatic or pulmonary disease. A case of gluteus intramuscular hydatid cyst is reported, calling attention to this atypical localization of the disease, which should be taken into account in the practice of surgery. The absence of residual cysts in the most common sites confers a higher interest to the case reported in this work.

Primary hydatid disease of the quadriceps muscle: a rare localization

BACKGROUND

Hydatidosis is a protozoal infestation which generally involves the liver and the lungs. Primary skeletal muscle hydatidosis without involving the thoracic and abdominal organs is extremely rare.

METHODS

A 48-year-old farmer presented with a mass in the quadriceps muscle that had persisted for 10 years. Clinical and radiological investigations revealed a primary hydatid cyst of the vastus medialis of the quadriceps muscle. We did not find any visceral organ involvement. Wide excision was performed without destroying the cyst wall. Then 400 mg albendazole was given daily for 3 months postoperatively.

RESULTS

At the 7th postoperative month, the patient was symptom-free, and the laboratory test results were in the normal ranges.

CONCLUSION

Primary muscular hydatidosis is a rare disease and should be kept in mind in the diagnostic work-up of a cystic mass of a skeletal muscle.

Abdominal wall endometriomas

BACKGROUND

The diagnosis of abdominal wall endometriomas is often confused with other surgical conditions.

METHODS

A retrospective study was made of 12 patients presenting with an abdominal wall mass, which proved to be endometrioma.

RESULTS

Of a total of 297 patients of endometriosis treated in our hospital over a 7-year period, 12 (4%) had isolated abdominal wall endometriomas. Their mean age was 29.4 years. The presenting symptoms were abdominal mass (n = 12), cyclical (n = 5) or noncyclic pain (n = 7), dyspareunia and dysmenorrhea (n = 1). All patients had a history of gynecologic operations and presented, after an average of 1.9 years, with a tender mass (average 4 cm) at the previous incision site. Preoperative diagnosis was correct in 4 patients (33%) who presented with a cyclically painful abdominal mass. The others were diagnosed as incisional hernia (n = 4), "abdominal wall tumor" (n = 2), and inguinal hernia (n = 2). All patients underwent wide excision of their endometrioma; 2 required polytetrafluoroethylene patch grafting for the resulting fascial defect. The diagnosis was confirmed at frozen section or conventional histological examination in all patients. At follow-up, ranging from 4 months to 3 years, there was no recurrence of endometrioma.

CONCLUSIONS

Scar endometrioma commonly presents as an abdominal mass with noncyclical symptoms. Imaging techniques are nonspecific and needle biopsy may confirm the diagnosis. Wide excision is the treatment of choice for abdominal wall endometrioma as well as for recurrent lesions.

Anterior and nasal transposition of the inferior oblique muscles

BACKGROUND

When performing anterior transposition of the inferior oblique (IO) muscle, placement of the posterior suture close to the lateral border of insertion of the inferior rectus (IR) muscle decreases the incidence of antielevation syndrome (AES). We hypothesized that placement of the suture nasal to the IR muscle insertion will convert the IO muscle into an intorter and depressor. Here we present the first series of results obtained with a new procedure for the treatment of elevation in adduction with extorsion and abnormal head postures.

METHODS

Twenty patients with IO muscle overaction, superior oblique (SO) muscle palsy, absent SO muscles, AES, or Duane syndrome were studied. Before surgery, each patient showed at least one, but often more, of the following signs: elevation in adduction, exotropia (XT) in up gaze, abnormal head posture, and extorsion. Each underwent anterior and nasal transposition (ANT) of the IO muscle, with the new insertion typically 2 mm nasal and 2 mm posterior to the nasal border of the IR muscle insertion.

RESULTS

Large improvements in ocular alignment, extorsion, and head posture were found in most patients. However, a poor result was noted in a patient with Y-pattern XT, who developed a mild amount of comitant XT after an extreme degree of ANT (4 mm nasal and 3 mm anterior to the nasal border of the IR muscle insertion). In Duane syndrome, ANT corrects upshoot, but downshoot may get worse. Mersilene permanent sutures, rather than dissolving suture materials, are recommended to avoid postoperative retraction of muscle fibers.

CONCLUSIONS

ANT converts the IO muscle into an intorter and tonic depressor and can significantly improve elevation in adduction. This procedure seems particularly useful in patients with severe or recurrent congenital and acquired SO palsies, particularly as a secondary procedure. Extreme ANT may induce exotropia in the primary position.

Intramuscular juvenile xanthogranuloma: sonographic and MR findings

BACKGROUND

Juvenile xanthogranuloma is a rare benign lesion, most often cutaneous or subcutaneous, and found in infants.

OBJECTIVE

To review the imaging approach to an intramuscular mass in an infant.

METHODS

A case is reported of a 2-month-old boy who presented with a solitary left arm mass which was evaluated with ultrasound and MRI and then biopsied.

RESULTS

Imaging demonstrated a well-defined homogeneous solid mass located in the triceps muscle. The mass was resected and pathology revealed intramuscular juvenile xanthogranuloma.

CONCLUSION

Intramuscular juvenile xanthogranuloma, although extremely rare, has imaging features similar to those of more common malignant tumors of infancy. The imaging findings are nonspecific, but this diagnosis should be considered in the differential of a solid intramuscular mass in an infant.

Flexor hallucis longus transfer for chronic Achilles tendonosis

A technique similar to the one described by Hansen for reconstruction of chronic Achilles tendinosis using the flexor hallucis longus (FHL) tendon was used in 26 patients (29 tendons). Follow-up on all 26 patients (mean age 51.3 years) is provided with an average follow-up 35 months (range, 12 to 58 months). All patients were evaluated postoperatively to assess pain, function, and alignment of the ankle and hindfoot. The AOFAS Foot Ratios for the ankle and hindfoot (total of 100 points) was used. Time to maximum improvement was 8.2 months (range, three to 20 months). Ankle-Hindfoot Scale ratings improved from 41.7 (range, 23 to 63) preoperatively to 90.1 (range, 49 to 100) postoperatively. All but three patients evaluated their result as good or excellent in regards to improved function and pain. No patient had a significant functional deficit or deformity of the hallux after transfer of the FHL tendon.