Safety of fluoroquinolones

Fluoroquinolones (FQs) are one of the most commonly prescribed classes of antibiotics. Although they were initially well tolerated in randomized clinical trials, subsequent epidemiological studies have reported an increased risk of threatening, severe, long-lasting, disabling and irreversible adverse effects (AEs), related to neurotoxicity and collagen degradation, such as tendonitis, Achilles tendon rupture, aortic aneurysm, and retinal detachment. This article reviews the main potentially threatening AEs, the alarms issued by regulatory agencies and therapeutic alternatives.

Reverse Fragility Index Comparing Rates of Rerupture After Open Achilles Tendon Repair Versus Early Functional Rehabilitation: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Despite similar published rates of rerupture among patients treated with early functional rehabilitation and open repair for acute Achilles tendon rupture, uncertainty still exists regarding the optimal treatment modality. The reverse fragility index (RFI) is a statistical tool that provides an objective measure of the study's neutrality by determining the number of events that need to change for a nonsignificant result to be significant.

PURPOSE

The purpose was to utilize the RFI to appraise the strength of neutrality of randomized controlled trials (RCTs) comparing the rerupture rates of acute Achilles tendon ruptures treated with open repair versus early functional rehabilitation.

STUDY DESIGN

Systematic review; Level of evidence, 1.

METHODS

A systematic review was performed including all RCTs comparing the rerupture rates after operative repair and early functional rehabilitation for acute Achilles tendon ruptures. Studies were included that explicitly used early functional rehabilitation, defined as weightbearing and exercise-based interventions initiated within 2 weeks, as compared with open repair and reported a nonsignificant difference in rerupture rates. The RFI, with rerupture as the primary outcome, was calculated for each study (significance threshold, P < .05). The RFI quantifies a study's strength of neutrality and is defined as the minimum number of event reversals necessary to change a nonsignificant result to statistically significant.

RESULTS

Nine RCTs were included, with 713 patients and 46 reruptures. The median (interquartile range) rerupture rate was 7.69% (6.38%-9.64%) overall, 4.00% (2.33%-7.14%) in the operative group, and 10.00% (5.26%-12.20%) in the nonoperative group. The median RFI was 3, indicating that an outcome reversal of 3 patients was necessary to change the results from nonsignificant to statistically significant. The median number of patients lost to follow-up was 6 (3-7). Of 9 studies, 7 (77.8%) had a loss to follow-up greater than or equal to its RFI.

CONCLUSION

The statistical nonsignificance of studies reporting equivalent rerupture rates in the management of acute Achilles tendon ruptures with open repair versus nonoperative management with early functional rehabilitation can be reversed by changing the outcome status of only a few patients.

Anabolic steroids and the evaluation of patients with acute PM tendon rupture using microscopy and MRI

This study presented a pioneering investigation of the changes in the magnetic resonance imaging images of pectoralis major muscle (PMM) tendon rupture. In all, 26 men were evaluated with acute total PMM rupture (<3 months since injury) with a mean age of 37.3 years (SD = 9.7 years) and 10 control patients with a mean age of 32.6 years (SD = 4.2 years). The evaluation of the tendon PMM injuries was based on the magnetic resonance imaging exam and the histological analysis. The magnetic resonance imaging of the surgically showed two (7.1%) contralateral sides were normal, 16 (57.1%) showed superior tendinopathy, and 10 (35.7%) had total tendinopathy. Inferior tendinopathy was not observed. The tendon histology revealed degenerative changes in 16 (66.7%) fragments, with 12 (50.0%) considered as mild (<25%), and four considered as (16.7%) high (>50.0%) tendinopathy. Total acute rupture of the PMM tendon among weightlifters might be associated with tendinous degeneration prior to injury.

Patellar and quadriceps tendon rupture are associated with hip fracture in hemodialysis patients with severe hyperparathyroidism

Spontaneous rupture of the patellar (PTR) and quadriceps (QTR) tendon is infrequent. Systemic diseases such as diabetes mellitus, CKD, and secondary hyperparathyroidism (SHPT) are risk factors. The present cohort study aimed to evaluate risk factors associated with tendon rupture in hemodialysis (HD) patients with SHPT, as well as outcomes including surgical complications, re-ruptures, and fracture. Baseline clinical, laboratorial data, and radiographs were analyzed. Patients were followed up from March 2012 to March 2020. One-hundred thirty-one patients (≥18 yr of age, on HD ≥ 6 mo, with SHPT) were included. Incidence rates of PTR and QTR were 2.3 and 1.7/10000 HD patients/yr, respectively. The mean age of patients with tendon rupture was 44.0 ± 11.2 yr. These patients exhibited higher serum levels of phosphorus (6.3 ± 1.5 mg/dL vs 5.6 ± 1.1 mg/dL; P = .005), PTH (2025.7 ± 667.6 pg/mL vs 1728.4 ± 684.8 pg/mL; P = .035), and C-reactive-protein (35.4 ± 32.9 mg/dL vs 17 ± 24.5 mg/dL; P = .002) compared to the group without tendon rupture. The mean follow-up was 56.7 ± 27.1 mo. No patient required a new surgical approach or experienced re-rupture. Of all patients, 31% experienced hip fracture: 50% in the group with rupture (29.5 ± 17.4 mo after the tendon rupture) vs 26% without tendon rupture (P = .015). After adjustment, the hazard ratio for hip fracture was 2.87 (95% CI, 1.27-6.49; P = .012). Patients with SHPT and high levels of phosphorus, PTH, and inflammatory markers were at greater risk for tendon rupture. Surgical complication rates were low. However, results suggest that tendon rupture of knee extensor mechanism in HD patient with SHPT should be regarded as a "red flag" for future hip fracture.

Complications of operatively treated distal radial fractures

Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications.Level of evidence: V.

Minimally Invasive Peroneal Tenodesis Assisted by Peroneal Tendoscopy: Technique and Preliminary Results

Introduction: Peroneal disorders are a common cause of ankle pain and lateral instability and have been described in as much as 77% of patients with lateral ankle instability. Clicking, swelling, pain, and tenderness in the peroneal tendons track are frequent symptoms, but they can be confused with other causes of lateral ankle pain. The management of peroneal disorders can be conservative or surgical. When the conservative treatment fails, surgery is indicated, and open or tendoscopic synovectomy, tubularization, tenodesis or tendon transfers can be performed. The authors present a surgical technique of tendoscopy associated to minimally invasive tenodesis for the treatment of peroneal tendon tears, as well as the preliminary results of patients submitted to this procedure. Methods: Four patients with chronic lateral ankle pain who were diagnosed with peroneal brevis pathology were treated between 2020 and 2022 with tendoscopic-assisted minimally invasive synovectomy and tenodesis. Using a 2.7 mm 30° arthroscope and a 3.0 mm shaver blade, the entire length of the peroneus brevis tendon and most parts of the peroneus longus tendon can be assessed within Sammarco's zones 1 and 2. After the inspection and synovectomy, a minimally invasive tenodesis is performed. Results: All patients were evaluated at least six months after surgery. All of them reported improvement in daily activities and in the Foot Function Index (FFI) questionnaire (pre-surgery mean FFI = 23.86%; post-surgery mean FFI = 6.15%), with no soft tissue complications or sural nerve complaints. Conclusion: The tendoscopy of the peroneal tendons allows the surgeon to assess their integrity, confirm the extent of the lesion, perform synovectomy, prepare the tendon for tenodesis, and perform it in a safe and minimally invasive way, reducing the risks inherent to the open procedure.

Radiographic study of the distal ulna in rheumatoid arthritis with extensor digitorum communis ruptures

OBJECTIVES

Extensor digitorum communis (EDC) rupture of the wrist often occurs in patients with rheumatoid arthritis (RA). Early operation is desirable for patients with a high risk of rupture; therefore, rheumatologists should diagnose it during daily examinations. This study aimed to clarify radiographic changes in the distal ulna and related factors associated with EDC rupture in patients with RA.

METHODS

We analysed plain radiographs of 40 patients with RA associated with EDC rupture and 62 healthy controls. We investigated the deformation of the distal ulna, Larsen grades, and radiological parameters such as ulnar variance (UV), ulnar bowing angle, dorsal protrusion (DP), and dorsal bowing angle.

RESULTS

The ratios of the ulna head deformation, Larsen grades, UV, DP, and dorsal bowing angle were significantly larger in the ruptured group than in the control group. Multiple logistic regression analysis revealed that DP and Larsen grades were significantly associated with EDC rupture.

CONCLUSIONS

Deformity of the distal ulna is evident in patients with an EDC rupture. Ulnar head deformation, high Larsen grades, and large DP are the potential risk factors for EDC rupture.

Bilateral Spontaneous Supraspinatus Tendon Rupture Under Prolonged BRAF/MEK Targeting Treatment in a Melanoma Patient

The B-Raf proto-oncogene, serine/threonine kinase (BRAF)/ mitogen-activated protein kinase kinase (MEK) targeting agents have become the treatment of choice for BRAF-mutated melanoma during the last decade. However, it is possible that some long-term adverse events of these drugs have not yet been reported. A case of bilateral spontaneous, non-traumatic, supraspinatus tendon rupture in a 65-year-old Caucasian male suffering metastatic melanoma under prolonged and successful combination treatment with dabrafenib plus trametinib is presented. These damages could not be attributed to some other probable cause. The ruptured tendons were promptly restored arthroscopically. Oncologists should remain vigilant for the early detection of potential side effects of BRAF/MEK targeting agents that have not been systematically recorded yet but may appear and affect patients in the long run.

Rupture of the bilateral and simultaneous tendon of the pectoralis major muscle. Description of three cases

Pectoralis major muscle tendon ruptures associated with physical activity or effort are no longer uncommon in the medical literature. Treatment has also evolved significantly in the last 20 years. However, simultaneous bilateral rupture has only been described in a few cases. This article reports three cases with simultaneous bilateral rupture and describes the examinations and treatment performed. Bilateral lesions, although infrequent, also require early diagnosis and treatment in the acute phase. The chronic phase requires tendon grafting for full correction and a slow rehabilitation process.

Complement factor D regulates collagen type I expression and fibroblast migration to enhance human tendon repair and healing outcomes

Introduction

Dense connective tissues (DCTs) such as tendon, ligament, and cartilage are important stabilizers and force transmitters in the musculoskeletal system. The healing processes after DCT injuries are highly variable, often leading to degenerative changes and poor clinical outcome. Biomarkers in relation to repair quality for human DCTs, especially tendon are lacking. This study expands our previous findings and aimed to characterize the mechanisms by which a potential biomarker of good outcomes, complement factor D (CFD), regulates tendon healing.

Methods

Quantitative mass spectrometry (QMS) profiling of tissue biopsies from the inflammatory phase of healing (n = 40 patients) and microdialysates from the proliferative phase of healing (n = 28 patients) were used to identify specific biomarkers for tendon healing. Further bioinformatic and experimental investigations based on primary fibroblasts and fibroblast cell line were used to confirm the identified biomarkers.

Results

The QMS profiling of tissue biopsies from the inflammatory phase of healing identified 769 unique proteins, and microdialysates from the proliferative phase of healing identified 1423 unique proteins in Achilles tendon rupture patients. QMS-profiling showed that CFD expression was higher during the inflammatory- and lower during the proliferative healing phase in the good outcome patients. Further bioinformatic and experimental explorations based on both inflammatory and proliferative fibroblast models demonstrated that CFD potentially improved repair by regulating cell migration and modulating collagen type I (Col1a1) expression. Moreover, it was shown that the enhanced Col1a1 expression, through increased fibroblast migration, was correlated with the validated clinical outcome.

Discussion

The results of the current studies characterized underlying inflammatory- and proliferative healing mechanisms by which CFD potentially improved tendon repair. These findings may lead to improved individualized treatment options, as well the development of effective therapies to promote good long-term clinical outcomes after tendon and other DCT injuries.

Trial registration

http://clinicaltrials.gov, identifiers NCT02318472, NCT01317160.

Quantitative Analysis of Supraspinatus Tendon Pathologies via T2/T2* Mapping Techniques with 1.5 T MRI

The aim of this study was to quantitatively assess supraspinatus tendon pathologies with T2/T2* mapping techniques, which are sensitive to biochemical changes. Conventional magnetic resonance imaging (MRI) and T2/T2* mapping techniques were applied to 41 patients with shoulder pathology, and there were also 20 asymptomatic cases included. The patients were divided into two groups: tendinosis and rupture. The supraspinatus tendon was divided into medial, middle, and lateral sub-regions, and the T2/T2* values were measured in both the coronal and sagittal planes for intergroup comparison. Intra-class and inter-class correlation coefficients (ICCs) were calculated to assess test reproducibility. Receiver operating characteristic (ROC) analysis was used to determine the cut-off value in each group. A total of 61 patients (27 males and 34 females)-including 20 asymptomatic individuals, 20 with tendinosis, and 21 with rupture-were evaluated using T2/T2* mapping techniques. In the rupture group, there were significant differences in the values of the lateral region (p < 0.001), as well as in the middle and medial regions (p < 0.05) of the supraspinatus tendon compared to the tendinosis and asymptomatic groups. These were determined using both T2* and T2 mapping in both the coronal and sagittal plane measurements. In the tendinosis group, there were significant differences in the values of the lateral region with T2* mapping (p < 0.001) in both the coronal and sagittal planes, and also with the T2 mapping in the coronal plane (p < 0.05) compared to the asymptomatic groups. The cut-off values for identifying supraspinatus pathology ranged from 85% to 90% for T2 measurements and above 90% for T2* measurements in both planes of the lateral section. The ICC values showed excellent reliability (ICC > 0.75) for all groups. In conclusion, T2 and T2* mapping techniques with 1.5 T MRI can be used to assess tendon rupture and tendinosis pathologies in the supraspinatus tendon. For an accurate evaluation, measurements from the lateral region in both the coronal and sagittal planes are more decisive.

Concomitant Extensor Pollicis Longus and Extensor Digitorum Longus Tendon Rupture may Complicate Surgical Reconstruction following Volar Plate Fixation of the Distal Radius: A Case Report

Introduction

Hardware prominence is one of the major established complications following volar plating of distal radius fractures. In particular, dorsal prominence of screws is the leading risk factor associated with post-surgical extensor pollicis longus (EPL) tendon rupture. Although there are many descriptions of attritional EPL ruptures in the literature, concomitant presentation of attritional EPL and extensor digitorum communis (EDC) ruptures following volar plating of distal radius fractures are minimal.

Case Report

We present a case of concomitant rupture of the EPL and occult rupture of the EDC to the index finger following volar plating of the distal radius. This was discovered intraoperatively and complicated the proposed tendon transfer reconstruction.

Conclusion

Locked volar plate fixation has become the preferred technique for surgical management of distal radius fractures. The complication of multiple extensor tendon ruptures is rare but nevertheless may be encountered. We discuss strategies for diagnosis, treatment, and prevention. Surgeons should be aware of and prepared to proceed with alternative reconstructive procedures if this complication is discovered.

Systematic Review of Safety of Selective Androgen Receptor Modulators in Healthy Adults: Implications for Recreational Users

Selective Androgen Receptor Modulators (SARMs) are not FDA approved, and obtaining SARMs for personal use is illegal. Nevertheless, SARM use is increasingly popular amongst recreational athletes. Recent case reports of drug-induced liver injury (DILI) and tendon rupture raise serious concerns for the safety of recreational SARM users. On 10 November 2022 PubMed, Scopus, Web of Science, and ClinicalTrials.gov were searched for studies that reported safety data of SARMs. A multi-tiered screening approach was utilized, and any study or case report of generally healthy individuals exposed to any SARM was included. Thirty-three studies were included in the review with 15 case reports or case series and 18 clinical trials (total patients N = 2136 patients, exposed to SARM N = 1447). There were case reports of drug-induced liver injury (DILI) (N = 15), Achilles tendon rupture (N = 1), rhabdomyolysis (N = 1), and mild reversible liver enzyme elevation (N = 1). Elevated alanine aminotransferase (ALT) was commonly reported in clinical trials in patients exposed to SARM (mean 7.1% across trials). Two individuals exposed to GSK2881078 in a clinical trial were reported to have rhabdomyolysis. Recreational SARM use should be strongly discouraged, and the risks of DILI, rhabdomyolysis, and tendon rupture should be emphasized. However, despite warnings, if a patient refuses to discontinue SARM use, ALT monitoring or dose reduction may improve early detection and prevention of DILI.

Tibialis Anterior Tendon Rupture Surgical Treatments and Outcomes: A Systematic Review and Meta-Analysis

Tibialis anterior tendon ruptures are a rare condition with an often-delayed diagnosis due to transient pain and compensation of remaining anterior compartment tendons. Previous systematic reviews have limited their recommendations to surgical treatment over nonoperative cares given the relatively small sample size in the literature. This current systematic review and meta-analysis was performed to compare the outcomes amongst the various surgical techniques and define factors that may affect long term patients results. Twenty-six references (217 cases) were identified. Use of extensor tendon autograft (odds ratio [OR] 5.55; I²=46%), autograft repair through semitendinosus/gracilis/ plantaris/ Achilles tendon/ peroneus longus ([OR] 4.14; I²=71%), or direct repair ([OR] 3.59; I²=57%), provided the best postoperative outcomes, whereas allograft repair ([OR] .52; I²=77%),and ipsilateral split/ turn-down tibialis anterior tendon ([OR] .69; I²=71%), were associated with poorer outcomes. Ruptures fixed in the acute phase ([OR] 8.3; I²=26%), were associated with statistically significant better outcomes when compared to these ruptures fixed in the chronic phase ([OR] .52; I²=77%). Results of this systematic review and meta-analysis suggests that ruptures should be surgically repaired in the acute phase whenever possible and comparable outcomes can be achieved through extensor tendon autograft repair, autograft repair, and direct repair.

Quadriceps Tendon Ruptures in Middle-Aged to Older Patients: A Retrospective Study on the Preoperative MRI Injury Patterns and Mid-Term Patient-Reported Outcome Measures

(1) Quadriceps tendon rupture (QTR) is a rare pathology, usually occurring in elderly patients with comorbidities, requiring surgical therapy. The aim of this study was to analyze rupture patterns and concomitant injuries using preoperative magnetic resonance imaging (MRI) and to evaluate patient-reported outcome measures. (2) In this retrospective cross-sectional study, 113 patients with QTR were screened and rupture patterns/concomitant injuries (n = 33) were analyzed via MRI. Clinical outcome was assessed in 45 patients using the International Knee Documentation (IKDC) and Lysholm score with a mean follow-up of 7.2 (±5.0) years. (3) The evaluation of preoperative MRIs showed multiple ruptures of subtendons in 67% with concomitant knee injuries in 45%. The most common associated pathology detected using MRI was pre-existing tendinosis (31.2%). Surgical refixation demonstrated good results with a mean post-operative IKDC score of 73.1 (±14.1) and mean Lysholm score of 84.2 (±16.1). Patient characteristics and individual radiologic rupture patterns did not significantly affect the clinical outcome of patients. (4) Acute QTRs are complex injuries with common involvement of multiple subtendons. MRI imaging can be useful for achieving an accurate diagnosis as pre-existing tendinosis as well as concomitant injuries are common, and might be useful for providing an individual surgical strategy and improving outcomes.

Quinolone Ear Drops and Achilles Tendon Rupture

BACKGROUND

Delayed eardrum healing has been observed in the ear opposite to the ear treated with otic quinolones (OQ) in rats. Case reports describe tendinopathies after OQ treatment, suggesting adverse systemic effects.

METHODS

We studied patients aged 19 to 64 years with diagnosis of otitis externa or media in private insurance between 2005 and 2015. We compared OQ treatment against otic neomycin, oral amoxicillin, or azithromycin. Outcomes included Achilles tendon rupture (ATR), Achilles tendinitis (AT), and all-type tendon rupture (ATTR). We applied an active comparator, new-user design with 1-year look-back and ceased follow-up at initiation of systemic steroids or oral quinolones, external injury, hospitalization, and after 35 days. We used trimmed stabilized inverse probability of treatment weights to balance comparison groups in a survival framework. Negative outcomes (clavicle fractures or sports injuries) were examined to rule out differences from varied physical activity (unmeasured confounding).

RESULTS

We examined 1 501 009 treated otitis episodes. Hazard ratios (HR) for OQ exposure associated with ATR were 4.49 (95% confidence interval [CI], 1.83-11.02), AT 1.04 (95% CI, 0.73-1.50), and ATTR 1.71 (95% CI, 1.21-2.41). Weighted risk differences (RD) per 100 000 episodes for OQ exposure were ATR 7.80 (95% CI, 0.72-14.89), AT 1.01 (95% CI, -12.80 to 14.81), and ATTR 18.57 (95% CI, 3.60-33.53). Corresponding HRs for clavicle fractures and sports injuries were HR,1.71 (95% CI, 0.55-5.27) and HR,1.45 (95% CI, 0.64-3.30), suggesting limited residual confounding.

CONCLUSIONS

OQ exposure may lead to systemic consequences. Clinicians should consider this potential risk and counsel patients accordingly. Risk factors and mechanisms for this rare, adverse effect deserve further evaluation. Mechanistic and other clinical studies are warranted to corroborate this finding.

Optimizing repair of tendon ruptures and chronic tendinopathies: Integrating the use of biomarkers with biological interventions to improve patient outcomes and clinical trial design

Tendons are dense connective tissues of the musculoskeletal system that link bones with muscles to foster mobility. They have complex structures and exist in varying biomechanical, metabolic and biological environments. In addition, tendon composition and mechanical properties can change over the lifespan as an individual ages. Many tendons function in high stress conditions with a low vascular and neuronal supply, conditions often leading to development of chronic tendinopathies, and in some cases, overt rupture of the tissues. Given their essential nature for human mobility and navigation through the environment, the effective repair and regeneration of different tendons after injury or damage is critical for quality of life, and for elite athletes, the return to sport participation at a high level. However, for mainly unknown reasons, the outcomes following injury are not always successful and lead to functional compromise and risk for re-injury. Thus, there is a need to identify those patients who are at risk for developing tendon problems, as well those at risk for poor outcomes after injury and to design interventions to improve outcomes after injury or rupture to specific tendons. This review will discuss recent advances in the identification of biomarkers prognostic for successful and less successful outcomes after tendon injury, and the mechanistic implications of such biomarkers, as well as the potential for specific biologic interventions to enhance outcomes to improve both quality of life and a return to participation in sports. In addition, the implication of these biomarkers for clinical trial design is discussed, as is the issue of whether such biomarkers for successful healing of one tendon can be extended to all tendons or are valid only for tendons in specific biomechanical and biological environments. As maintaining an active lifestyle is critical for health, the successful implementation of these advances will benefit the large number of individuals at risk.

Spontaneous Tear of the Tibialis Anterior Tendon Presenting as a Pseudotumor

Teaching Point: Spontaneous rupture of the anterior tibial tendon at the ankle joint may mimic a tumor.

Spontaneous rupture of the extensor pollicis longus tendon in a lacrosse player

Spontaneous rupture of the extensor pollicis longus (EPL) tendon at the wrist has been reported with predisposing factors to include distal radius fractures, rheumatoid arthritis, systemic or local steroids, and repetitive abnormal motion of the wrist joint.We present a case of an 18-year-old college lacrosse player without history of known predisposing factors who presented with an acute inability to extend the interphalangeal (IP) joint of his right thumb. Preoperative musculoskeletal ultrasound demonstrated rupture of the EPL tendon proximal to the carpometacarpal (CMC) joint of the thumb. A tendon transfer was therefore performed, where the extensor indicis proprius (EIP) was surgically rerouted to reconstruct the ruptured EPL. The athlete eventually returned to competition without sequela.We suggest that the tendon rupture was secondary to repetitive stick checking during play, causing microtrauma to his exposed dorsal wrist. Lacrosse team physicians, athletic trainers, and equipment managers should be aware of this injury mechanism and ensure that their players, and attackmen in particular, are equipped with gloves which adequately pad the dorsal wrist to decrease the risk of microtrauma to the EPL tendon.

The Interobserver Reliability of Grading of Distal Radius Volar Plate Prominence

PURPOSE

The 3-category rating of volar plate prominence in relation to the most volar edge of the distal radius (the watershed line) on lateral radiographs was reliable among a small group of surgeons and associated with the probability of flexor tendon irritation and potential rupture. Classifications are often less reliable when tested among a large group of practicing surgeons in different environments.

METHODS

In this survey-based experiment, an international group of 115 fracture and upper extremity surgeons viewed 1 of 4 sets of 24 lateral radiographs (96 unique lateral radiographs) of patients with distal radius fractures who underwent volar plating in the practice of a single surgeon using 2 types of plates. Surgeons were asked to rate the following metrics: (1) the grade of plate prominence according to Soong, (2) whether the plate was more prominent than the watershed line, (3) whether the plate was separate from the bone distally, and (4) whether there is more than 5° of dorsal angulation of the distal radius articular surface.

RESULTS

The interobserver agreement of the classification was "fair" (κ = 0.32; 95% confidence interval [CI] = 0.27-0.36), and grading was more reliable among surgeons who do not supervise trainees. Volar prominence was less reliable (κ = 0.034; 95% CI = 0.013-0.055) than plate separation from bone (κ = 0.50; 95% CI = 0.42-0.59) and more than 5° of dorsal angulation (κ = 0.42; 95% CI = 0.35-0.48).

CONCLUSIONS

Among a large number of international practicing surgeons, the classification of volar plate prominence in 3 categories was fair.

CLINICAL RELEVANCE

The diagnosis of plate prominence might develop toward criteria with moderate reliability, such as separation of the plate from the bone and residual angulation of the distal radius.

Risk factors for reoperation after flexor tendon repair: a registry study

The aim of this study was to identify risk factors for reoperations after Zones 1 and 2 flexor tendon repairs. A multiple logistic regression model was used to identify risk factors from data collected via the Swedish national health care registry for hand surgery (HAKIR). The studied potential risk factors were age and gender, socio-economics and surgical techniques. Included were 1372 patients with injuries to 1585 fingers and follow-up of at least 12 months (median 37 IQR 27-56). Tendon ruptures occurred in 80 fingers and tenolysis was required in 76 fingers. Variables that affected the risk of rupture were age >25 years (p < 0.001), flexor pollicis longus tendon injuries (p < 0.001) and being male (p = 0.004). Injury to both finger flexors had an effect on both rupture (p = 0.005) and tenolysis (p < 0.001). Understanding the risk factors may provide important guidance both to surgeons and therapists when treating patients with flexor tendon injuries.Level of evidence: III.

Investigation of Factors Associated with Leg Trimmings at Processing: A 12-Year Review

Gastrocnemius tendon injury or rupture is a common consequence from various etiologies and conditions in poultry production. The occurrence of tendon injury can cause significant morbidity and lameness in chickens, as well as quality downgrades and increased trimming on carcasses at processing. In this study, 12 yr of data from a poultry processing plant on leg trim only were compiled and analyzed. The association between grower, season, shift, and time were investigated in relation to the prevalence of ruptured tendons and carcass condemnations. A total of 8585 separate data entries from 195 growers were analyzed. Problem flocks were defined as those that had a carcass trimming rate of the percentage change equal to or above the 95th percentile of all data points (0.603%). We identified 430 instances of high trimmings in this study period, involving 90 growers. Of those, eight growers had 10 or more problem flocks in the study period. Overall, there were no differences in trimming rates due to shift; however, problem flocks had a higher trimming rate (percentage) during the night shift. A significantly higher rate of carcass trimmings was noted in the winter months. In problem flocks, a second and lower peak of a higher trimming was also observed in August. There was an upward trending carcass trimming that peaked in 2014, and it trended downward each year through 2020 overall. However, when the problem flocks were excluded, the trimming rate percentage change of trimming decreased slightly from 2008 to 2012 and remained steady through 2020. In conclusion, this study was able to demonstrate noninfectious causes that may be associated with increased leg trimmings and consequently made it possible to narrow down management practices to help decrease the instances of leg trimmings in the processing plant.

Treatment of acute distal biceps tendon ruptures - A survey of the British Elbow and Shoulder Society surgical membership

Background

Acute distal biceps tendon ruptures result in weakness and deformity. While in other jurisdictions the rate of surgical repair has outpaced rises in incidence, UK practice for distal biceps tendon ruptures is unknown. The aim of this survey was to characterise current UK clinical practice.

Methods

An online survey was sent to the surgeon members of the British Elbow and Shoulder Society. Questions covered respondent demographics, clinical decision making, surgical experience and willingness to be involved in future research.

Results

A total of 242 surgeons responded; 99% undertook acute distal biceps tendon repairs with 83% repairing at least half of all distal biceps tendon ruptures, and 84% of surgeons would have their own, hypothetical, acute distal biceps tendon rupture repaired in their dominant arm and 67% for their non-dominant arm. Patient age, occupation and restoration of strength were the commonest factors underpinning a recommendation of surgical fixation. Most surgeons (87%) supported a national trial to study operative and non-operative treatments.

Conclusions

UK upper limb surgeons currently advise surgical repair of acute distal biceps tendon ruptures for the majority of their patients. This is despite a paucity of evidence to support improved outcomes following surgical, rather than non-operative, management. There is a clear need for robust clinical evaluation in this area.

Chronic Rupture of Achilles Tendon Caused by Haglund's Deformity: A Case Report

A chronic Achilles tendon rupture is a tendon rupture occurring more than 4-6 weeks after a traumatic injury. Haglund's deformity, caused by bony abnormalities in the ankle (mostly due to osteophyte or bone spur), can cause chronic inflammation and degeneration of the Achilles tendon, eventually leading to rupture. This presents a challenge for clinicians who provide tendon repair procedures. We present a 69-year-old woman who had difficulty moving her left leg and had a deformity on the left leg compared to her right leg after falling nine months before but with pain starting three months before the accident. There was a seven-centimeter gap in the calcaneus with a positive Thompson test. The Haglund's deformity on the left calcaneus was visible on the ankle X-ray. The patient had a chronic total rupture of the left Achilles tendon, which was treated with a flexor hallucis longus (FHL) tendon transfer and resection of the deformity. One week after surgery, the patient's ability to walk and the shape of the left leg improved. This case report describes a chronic left Achilles tendon condition that was successfully repaired through tendon repair surgery using FHL tendon transfer and removal of Haglund's deformity.

Spontaneous Rupture of the Extensor Pollicis Longus Tendon in Console Video Game Players: A Case Series

Introduction

Extensor pollicis longus (EPL) tendon spontaneous rupture has been related to numerous risk factors including wrist fractures, rheumatoid arthritis, and steroids administered locally or systemically, as well as repetitive and excessive wrist motion.

Case Report

Four cases of spontaneous rupture of the EPL tendon, diagnosed clinically, in console video game players, were reported by the authors. None of the patients had a predisposing factor. Intraoperatively, the rupture of the EPL tendon was observed at the level of the extensor retinaculum. The ruptured tendon was repaired using a conventional extensor indicis proprius to EPL tendon transplant. At the last follow-up, 2 years following surgery, the patients had satisfactory full extension of the thumb.

Conclusion

This series reported the spontaneous rupture of the EPL tendon without underlying chronic inflammation or bony abnormalities. It is hypothesized that chronic repetitive movements weaken the tendon leading to rupture. The possibility that playing video games can decrease pain sensation evokes concerns regarding overuse.

Distal Biceps Repairs in Females: A Large Single-Center Case Series

BACKGROUND

Distal biceps repair is a commonly reported procedure in male patients, with reliable outcomes and minimal long-term complications. Information on female patients, however, is limited, and variation in presentation and clinical outcomes is unknown.

QUESTIONS/PURPOSE

We sought to report on the presentation, treatment algorithm, and outcomes of a case series of female patients with distal biceps pathology.

METHODS

A retrospective evaluation was performed from a large, single specialty orthopedic group from 2005 to 2017. Inclusion criteria were surgical treatment of the distal biceps in female patients, with minimum 3 months of follow-up. The primary outcome variable was the Mayo Elbow Performance Score (MEPS).

RESULTS

Of 26 patients who met inclusion criteria, 18 (70%) were available for follow-up with patient-reported outcomes. Median age at time of injury was 56.1 years; 46.2% of patients presented with a complete tear of the distal biceps, and the remaining 53.8% presented with a partial tear that failed nonoperative treatment. Six patients had lateral antebrachial cutaneous neuritis in early follow-up, which ultimately resolved. Median MEPS score was 100 (interquartile range: 20).

CONCLUSION

This study represents the largest case series to date describing the presentation, treatment, and outcomes of female patients with distal biceps repair. Women tend to be older than men, have more insidious onset of pain, present with partial tearing, and may benefit from nonoperative treatment. Ultimately, based on this case series we believe distal biceps repair in female patients is a successful operation with minimal complications and high patient satisfaction.

Mechanical and strain behaviour of human Achilles tendon during in vitro testing to failure

The Achilles tendon is the strongest tendon in the human body but its mechanical behaviour during failure has been little studied and the basis of its high tensile strength has not been elucidated in detail. In the present study, healthy, human, Achilles tendons were loaded to failure in an anatomically authentic fashion while the local deformation and strains were studied in real time, with very high precision, using digital image correlation (DIC). The values determined for the strength of the Achilles tendon were at the high end of those reported in the literature, consistent with the absence of a pre-existing tendinopathy in the samples, as determined by careful gross inspection and histology. Early in the loading cycle, the proximal region of the tendon accumulated high lateral strains while longitudinal strains remained low. However, immediately before rupture, the mid-substance of the Achilles tendon, its weakest part, started to show high longitudinal strains. These new insights advance the understanding of the mechanical behaviour of tendons as they are stretched to failure.

Positive Association Between Fluoroquinolone Exposure and Tendon Disorders: A Nationwide Population-Based Cohort Study in Taiwan

Introduction: Fluoroquinolone exposure is reportedly associated with a higher risk of tendon disorders, tendonitis, or tendon rupture. However, studies in East Asian populations have not confirmed these risks in patients with comorbidities or concomitant medication use. This cohort study was designed to investigate the associations among fluoroquinolone exposure, comorbidities, medication use, and tendon disorders in Taiwan.

Materials and Methods: This population-based, nationwide, observational, cohort study used data from the National Health Insurance Research database in Taiwan, a nationwide claims database that covers more than 99% of the Taiwanese population. The study period was from January 2000 to December 2015, and the median follow-up time was 11.05 ± 10.91 years. Patients who were exposed to fluoroquinolones for more than three consecutive days were enrolled, and patients without fluoroquinolone exposure who were matched by age, sex, and index year were enrolled as controls. The associations of comorbidities and concomitant medication use with tendon disorder occurrence were analyzed using Cox regression models.

Results: The incidence of tendon disorders were 6.61 and 3.34 per 10⁵ person-years in patients with and without fluoroquinolone exposure, respectively (adjusted hazard ratio, 1.423; 95% confidence interval [1.02,1.87]; p = 0.021). Sensitivity analyses yielded similar results. Patients under 18 and over 60 years with fluoroquinolone exposure; those with chronic kidney disease, diabetes, rheumatologic disease, cardiac disease, lipid disorder, or obesity; and those who concomitantly used statins, aromatase inhibitors, or glucocorticoids, had a significantly higher risk of tendon disorders.

Conclusion: The long-term risk of tendon disorders was higher in patients with fluoroquinolone exposure than in those without fluoroquinolone exposure. Clinicians should assess the benefits and risks of fluoroquinolone use in patients at high risk of tendon disorders who require fluoroquinolone administration.

Altered Gastrocnemius Contractile Behavior in Former Achilles Tendon Rupture Patients During Walking

Achilles tendon rupture (ATR) remains associated with functional limitations years after injury. Architectural remodeling of the gastrocnemius medialis (GM) muscle is typically observed in the affected leg and may compensate force deficits caused by a longer tendon. Yet patients seem to retain functional limitations during-low-force-walking gait. To explore the potential limits imposed by the remodeled GM muscle-tendon unit (MTU) on walking gait, we examined the contractile behavior of muscle fascicles during the stance phase. In a cross-sectional design, we studied nine former patients (males; age: 45 ± 9 years; height: 180 ± 7 cm; weight: 83 ± 6 kg) with a history of complete unilateral ATR, approximately 4 years post-surgery. Using ultrasonography, GM tendon morphology, muscle architecture at rest, and fascicular behavior were assessed during walking at 1.5 m⋅s-1 on a treadmill. Walking patterns were recorded with a motion capture system. The unaffected leg served as control. Lower limbs kinematics were largely similar between legs during walking. Typical features of ATR-related MTU remodeling were observed during the stance sub-phases corresponding to series elastic element (SEE) lengthening (energy storage) and SEE shortening (energy release), with shorter GM fascicles (36 and 36%, respectively) and greater pennation angles (8° and 12°, respectively). However, relative to the optimal fascicle length for force production, fascicles operated at comparable length in both legs. Similarly, when expressed relative to optimal fascicle length, fascicle contraction velocity was not different between sides, except at the time-point of peak series elastic element (SEE) length, where it was 39 ± 49% lower in the affected leg. Concomitantly, fascicles rotation during contraction was greater in the affected leg during the whole stance-phase, and architectural gear ratios (AGR) was larger during SEE lengthening. Under the present testing conditions, former ATR patients had recovered a relatively symmetrical walking gait pattern. Differences in seen AGR seem to accommodate the profound changes in MTU architecture, limiting the required fascicle shortening velocity. Overall, the contractile behavior of the GM fascicles does not restrict length- or velocity-dependent force potentials during this locomotor task.

Delayed diagnosis and treatment of a distal patellar tendon avulsion in an adolescent

Distal patellar tendon avulsions are uncommon. While much is known about proximal patella tendon ruptures, there are very few reports to guide treatment of a patellar tendon disruption near the tibial tuberosity. Moreover, delayed diagnosis and treatment presents additional challenges. We present a distal patellar tendon avulsion in an adolescent whereby diagnosis and treatment were delayed due to a distracting nearby contaminated wound. The tendon was separated from post-traumatic scar then repaired back to its native footprint using suture anchors. This report aims to increase awareness of this rare diagnosis as well as provide details about our chosen treatment and rehabilitation protocol.

Minimally Invasive Repair of Subacute Achilles Tendon Ruptures: A Report of 2 Cases

Level IV: Case report.

An Atypical Presentation of Primary Hyperparathyroidism With Multiple Spontaneous Tendon Ruptures: A Case Report and Literature Review on the Management of Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine condition, increasingly presenting asymptomatically and detected on routine laboratory examination in developed countries. Multiple spontaneous tendon ruptures as the initial presentation of PHPT is extremely rare. We present the case of a 28-year-old male diagnosed with severe hypercalcemia secondary to PHPT after presenting with complications of multiple spontaneous tendon ruptures,and discuss the management issues in PHPT for this patient.

Outcomes of Tibialis Anterior Tendon Reconstruction with Autograft or Allograft

BACKGROUND

In cases of tibialis anterior tendon (TAT) ruptures associated with significant tendon defect, an interposition graft is often needed for reconstruction. Both auto- and allograft reconstructions have been described in the literature. Our hypothesis was that both graft types would have a good integrity and provide comparable outcomes.

METHODS

Patients who underwent TAT reconstruction using either an auto- or allograft were identified. Patient-reported outcomes (PROs) were collected using the 12-Item Short Form Health Survey (SF-12) questionnaire, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the Foot Function Index (FFI), and the Karlsson-Peterson score. Functional outcome was assessed by isokinetic strength measurement. Outcomes were further assessed with magnetic resonance imaging (MRI) evaluation of graft integrity. All measurements were also performed for the contralateral foot.

RESULTS

Twenty-one patients with an average follow-up of 82 months (20-262 months), comprising 12 allograft and 9 autograft TAT reconstructions, were recruited. There were no significant differences in patient-reported outcomes between allograft reconstructions and autografts: SF-12 (30.7 vs 31.1, P = .77); AOFAS (83 vs 91.2, P = .19); FFI (20.7% vs 9.5%, P = .22); and Karlsson-Peterson (78.9 vs 87.1, P = .23). All grafts (100%) were intact on MRI with a well-preserved integrity and no signs of new rupture. There were no major differences in range of motion and functional outcomes as measured by strength testing between the operative and nonoperative side.

CONCLUSION

Reconstructions of TAT achieved good PROs, as well as functional and imaging results with a preserved graft integrity in all cases. There were no substantial differences between allograft and autograft reconstructions.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Bilateral multipartite patellae avulsions associated with a unilateral quadriceps tendon rupture

Multipartite (or bipartite) patella is a developmental anomaly that occurs in 2%-6% of individuals. In 50%, the variant is bilateral. Multipartite patella is usually an asymptomatic condition. Quadriceps tendon rupture is also a rare entity occurring mostly in men aged >40 years and usually results from an acute eccentric quadriceps contracture. The authors present a case of a patient with bilateral multipartite patellae that sustained bilateral multipartite avulsions as well as an associated unilateral quadriceps tendon rupture. This constellation of injuries has never been reported in the literature. The patient was treated with excision of the multipartite patella fragments and quadriceps tendon repair on the side with the extensor mechanism disruption. He was treated non-operatively for the contralateral lower extremity multipartite patella avulsion. This report, along with a thorough review of the literature, serves to demonstrate the clinical and radiographic characteristics of this unusual injury.

Diagnosing Achilles Tendon Rupture with Ultrasound in Patients Treated Surgically: A Systematic Review and Meta-Analysis

BACKGROUND

Achilles tendon rupture is a common injury with increasing incidence due to the rising popularity of high-velocity sports, continued physical activity of the aging American population, and use of fluoroquinolones and steroid injections. The diagnosis can often be missed or delayed, with up to 20% misdiagnosed, most commonly as an ankle sprain.

OBJECTIVE

The aim of our study was to systematically evaluate the reported sensitivity, specificity, and likelihood ratios of ultrasound for detecting Achilles tendon rupture in patients who were treated surgically.

METHODS

In January 2020, we performed a literature search of MEDLINE and EMBASE databases to identify eligible articles according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were original studies with at least five patients, which reported data on the sonographic diagnosis of Achilles tendon rupture (complete or partial) compared to surgery as the reference standard.

RESULTS

A total of 15 studies with 808 patients were included in the primary analysis. The sensitivity of ultrasound for detecting complete Achilles tendon ruptures was 94.8% (95% confidence interval [CI] 91.3-97.2%), specificity was 98.7% (95% CI 97.0-99.6%), positive likelihood ratio was 74.0 (95% CI 31.0-176.8), and negative likelihood ratio was 0.05 (95% CI 0.03-0.09), in patients who underwent surgical treatment.

CONCLUSIONS

The results from our study suggested that a negative ultrasound result may have the potential to rule out a complete, as well as a partial, Achilles tendon rupture.

Intratendinous hamstring injuries: sequential MRIs as a tool to reduce the risk of reinjury in elite sport

Hamstring injuries are the most common muscle injuries in elite football. Injuries involving the intramuscular tendon are considered more significant, with longer return to play (RTP) times and an increased risk of reinjury. MRI is the gold standard investigation for muscle injuries, but initial findings cannot accurately determine RTP times. The role of MRI in monitoring muscle and tendon healing is not well described. We present three cases of hamstring injuries with intramuscular tendon involvement, illustrating the changes seen on MRI during progressive tendon healing and describing how we utilised this information to inform safe rehabilitation progression. We conclude that intramuscular hamstring tendon healing can be accurately seen on sequential MRI scans and that this information, when combined with traditional rehabilitation markers in and elite sport environment, can be utilised by clinicians to determine the earliest but safe RTP.

Collagenase Use and a Trap for the Unwary in Patients With Upper Limb Spasticity

Collagenase has revolutionized the treatment of Dupuytren's disease. It acts by lysing collagen in Dupuytren's cords. It can also act on collagen in tendons, leading to tendon rupture. In this letter, we highlight caution where bowstringed flexor tendons were masquerading as Dupuytren's cords in a patient with upper limb spasticity. The initial plan was to inject the cords with collagenase; however, we proceeded with an open approach. If we had proceeded with our initial plan to inject the palpable cords with collagenase, tendon rupture would have been the likely outcome. We advise that administrators of collagenase proceed with caution in patients with upper limb neurological disorders, bearing in mind that bow-stringed flexor tendons can mimic Dupuytren's cords.

Increase in Achilles Tendon Rupture Surgery in Japan: Results From a Nationwide Health Care Database

Background:

Nationwide epidemiologic studies in Scandinavian countries have shown that the incidence of Achilles tendon ruptures (ATRs) has increased, and the rate of surgical treatment has declined markedly in the past decade. However, there is a lack of national-level data on the trend of ATRs and surgical procedures in other regions.

Purpose:

To clarify the trend in the incidence of ATRs and the proportion of surgery using the nationwide health care database in Japan.

Study Design:

Descriptive epidemiology study.

Methods:

Age- and sex-stratified data on the annual number of ATRs and surgical procedures between 2010 and 2017 were obtained from the Japanese national health care database, which includes almost all inpatient and outpatient medical claims nationwide. The Japanese population data were also obtained from the population census. The change in the annual incidence of ATRs per 100,000 people was assessed using a Poisson regression analysis. The trend in the annual proportion of surgeries relative to the occurrence of tendon ruptures was determined using a linear regression analysis.

Results:

A total of 112,601 ATRs, with men accounting for 67%, were identified over 8 years. Patients aged ≥60 years accounted for 27,106 (24%), while those aged 20 to 39 years and 40 to 59 years accounted for 36,164 (32%) and 49,331 (44%), respectively. The annual incidence of ATR ranged from 12.8/100,000 to 13.9/100,000 (women, 8.2-8.9/100,000; men, 17.2-19.5/100,000), which did not change over the study period (P = .82). Moreover, the annual incidences did not change across sexes and age categories. The annual proportion of surgery increased significantly, from 67% in 2010 to 72% in 2017 (P = .003). The annual proportions increased across sexes and age categories except for women aged 40 to 59 years.

Conclusion:

The incidence of ATR did not change between 2010 and 2017, according to the Japanese nationwide health care database. Furthermore, the proportion of surgical treatment increased during the study period. Overall, 70% of patients underwent surgical treatment. This study suggested that the trend in ATR and surgery differed across regions.

Tendoachilles reconstruction and overlying skin cover with a peroneus brevis flap

We report a post-traumatic case of tendoachilles injury with an overlying skin defect. Following debridement, tendon reconstruction was done by using vascularised peroneus brevis musculotendinous unit and proximal part of the same muscle provided the skin cover. Postoperative recovery was uneventful. At 2 years follow-up, he had a near-normal gait. The main advantage of this flap is not being only a local flap but also providing a vascularised tendon.

Anatomical Variations of the Tibialis Anterior Tendon Insertion: An Updated and Comprehensive Review

The tibialis anterior muscle originates on the lateral condyle of the tibia, on the upper two-thirds of the lateral surface of this bone, on the anterior surface of the interosseous membrane and on the deep surface of the fascia cruris. The distal attachment is typically at the medial cuneiform and first metatarsal. However, the tibialis anterior tendon can vary morphologically in both adults and fetuses. Different authors have created new classification systems for it. The main aim of this review is to present condensed information about the tibialis anterior tendon based on the available literature. Another aim is to compare classification systems and the results of previous studies.

Rehabilitation after a Complete Avulsion of the Proximal Rectus Femoris Muscle: Considerations from a Case Report

BACKGROUND

A complete avulsion of the proximal rectus femoris muscle is a rare but severity injury. There is a lack of substantial information for its operative treatment and rehabilitation; in particular there is a lack of biomechanical data to evaluate long-term outcomes.

CASE PRESENTATION

The case report presents the injury mechanism and surgical treatment of a complete avulsion of the proximal rectus femoris muscle in a 41-year-old recreational endurance athlete. Moreover, within a one-year follow-up period, different biomechanical tests were performed to get more functional insights into changes in neuromuscular control, structural muscle characteristics, and endurance performance. Within the first month post-surgery, an almost total neuromuscular inhibition of the rectus femoris muscle was present. A stepwise reduction in inter-limb compensations was observable (e.g., in crank torque during cycling) during the rehabilitation. Muscular intra-limb compensations were shown at six months post-surgery and even one year after surgery, which were also represented in the long-term adaption of the muscle characteristics and leg volumes. A changed motor control strategy was shown by asymmetric muscle activation patterns during ergometer cycling, while the power output was almost symmetric. During rehabilitation, there might be a benefit to normalizing neuromuscular muscle activation in ergometer cycling using higher loads.

CONCLUSIONS

While the endurance performance recovered after six months, asymmetries in neuromuscular control and structural muscle characteristics indicate the long-term presence of inter- and intra-limb compensation strategies.

Analysis of risk factors associated with flexor pollicis longus injury after volar plating of distal radius fractures

Objective

This study was performed to analyze the risk factors associated with flexor pollicis longus (FPL) attrition or rupture after volar plating of distal radius fractures.

Methods

Three hundred thirty-eight patients with distal radius fractures were included in this retrospective study. Univariate analysis and multivariate logistic regression analysis were performed to predict risk factors.

Results

Univariate analysis showed that sex, volar tilt, the Soong grade, the plate-to-critical line distance (PCLD), the plate-to-volar rim distance (PVRD), and the time of plate removal were significantly associated with FPL attrition or rupture. Multivariate logistic regression analysis demonstrated that decreased volar tilt, Soong grade 2, PCLD of >2 mm, PVRD of <3 mm, and plate removal at ≥1 year were the risk factors significantly associated with FPL attrition or rupture.

Conclusions

Reduced volar tilt, Soong grade 2, PCLD of >2 mm, and PVRD of <3 mm appear to be risk factors that are significantly associated with FPL attrition or rupture. The findings of this study also suggest that the risk of tendon rupture is lower if a Soong grade 2 plate is removed, the PCLD is >2 mm, the PVRD is <3 mm, or reduced volar tilt is achieved earlier (at <1 year).

Single incision latissimus dorsi surgical technique: a three button repair

Due to the infrequent occurrence of latissimus dorsi insertional avulsions or tendon ruptures, there is no clear evidence on the optimal surgical fixation strategy. A three suture unicortical button repair technique through a single incision offers an anatomic reconstruction of the broad insertional footprint with adequate exposure. This fixation strategy is the preferred technique by the senior author.

Supernumerary extensor pollicis longus tendon masking an extensor pollicis longus rupture following non-surgical treatment of a distal radius fracture

Extensor pollicis longus tendon pathology is a recognised complication following non-surgical treatment of non-displaced distal radius fractures. Tendon entrapment typically presents with pain, but preservation of thumb retropulsion during complete rupture results in loss of active thumb retropulsion and tenodesis effect. We present the case of a 52-year-old woman who developed extensor pollicis longus tendon entrapment with full active thumb extension following a non-displaced distal radius fracture. During her elective third dorsal compartment release, the extensor pollicis longus tendon was found to be completely ruptured and a rare supernumerary extensor pollicis longus tendon was found emerging from the fourth dorsal compartment. Gentle traction of this tendon resulted in thumb interphalangeal joint extension and simultaneous index finger metacarpophalangeal joint extension. An extensor indicis proprius to extensor pollicis longus tendon transfer was performed. At her final 6-month follow-up, she had painless full active thumb motion comparable to her contralateral side.

Articular cartilage and soft tissue damage from radiofrequency thermal ablation wands at wrist arthroscopy

We report six cases of complications from use of a thermal wand at wrist arthroscopy. Complications included skin necrosis, extensor tendon lesions and thermal articular cartilage damage, one with a catastrophic outcome. Thermal wands have the potential for substantial soft tissue damage causing severe harm to patients. The damage could be related to the design of the wands. User error poses an additional risk. These risks need to be appreciated and should be minimized. The complications indicate the need for careful use of the thermal wands to minimise risk including using only short bursts of thermal energy, the use of high flow irrigation with an outflow and trying to ensure that the collar of the device and not just the tip is within the joint. In addition, the design of thermal wands for use in the wrist may need to be reviewed.Level of evidence: IV.

Chronic hyperglycemia, hypercholesterolemia, and metabolic syndrome are associated with risk of tendon injury

Tendon injury is a considerable problem affecting both physically active and sedentary people. The aim of this study was to examine the relationship between markers for metabolic disorders (hyperglycemia, hypercholesterolemia, and metabolic syndrome) and the risk of developing tendon injuries requiring referral to a hospital. The Copenhagen City Heart Study is a prospective study of diabetic and non-diabetic individuals from the Danish general population with different physical activity levels. The cohort was followed for 3 years via national registers with respect to tendon injuries. Data from 5856 individuals (median age 62 years) were included. The overall incidence of tendon injury in both upper and lower extremities that required an out-patient or in-house visit to a hospital was ~5.7/1000 person years. Individuals with elevated HbA1c (glycated hemoglobin) even in the prediabetic range (HbA1c>5.7%) had a ~3 times higher risk of tendon injury in the lower extremities only, as compared to individuals with normal HbA1C levels. Hypercholesterolemia (total cholesterol>5 mmol/L) increased risk of tendon injury in the upper extremities by ~1.5 times, and individuals with metabolic syndrome had ~2.5 times higher risk of tendon injury in both upper and lower extremities. In conclusion, these data demonstrate for the first time in a large cohort with different physical activity levels that the indicators for metabolic syndrome are a powerful systemic determinant of tendon injury, and two of its components, hyperglycemia and hypercholesterolemia, each independently make tendons susceptible for damage and injury.

Range of Motion after the Sauvé-Kapandji and Darrach Procedures without Extensor Tendon Rupture

Background  Previous study demonstrated that distal radioulnar joint (DRUJ) plays a biomechanical role in extension and flexion of the wrist and suggested that fixation of the DRUJ could lead to loss of motion of the wrist. Little is known about the pre- and postoperative range of motion (ROM) after the Sauvé-Kapandji (S-K) and Darrach procedures without tendon rupture. To understand the accurate ROM of the wrist after the S-K and Darrach procedures, enrollment of patients without subcutaneous extensor tendon rupture is needed. Purpose  This study aimed to investigate the pre- and postoperative ROM after the S-K and Darrach procedures without subcutaneous extensor tendon rupture in patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Methods  This retrospective study included 36 patients who underwent the S-K procedure and 10 patients who underwent the Darrach procedure for distal radioulnar joint disorders without extensor tendon rupture. Pre- and postoperative ROMs after the S-K and Darrach procedures were assessed 1 year after the surgery. Results  In the S-K procedure, the mean postoperative ROM of the wrist flexion (40 degrees) was significantly lower than the mean preoperative ROM (49 degrees). In wrist extension, there were no significant differences between the mean preoperative ROM (51 degrees) and postoperative ROM (51 degrees). In the Darrach procedure, the mean postoperative ROM of the wrist flexion and extension increased compared with the mean preoperative ROM; however, there were no significant differences. Conclusion  In the S-K procedure, preoperative ROM of the wrist flexion decreased postoperatively. This study provides information about the accurate ROM after the S-K and Darrach procedures. Level of Evidence  This is a Level IV, therapeutic study.

A rare case of Levofloxacin-related Iliopsoas and Achilles tendon rupture

Achilles tendon rupture is a well-documented adverse effect of Fluoroquinolones; however, herein we present a case of complete iliopsoas and Achilles, and partial semimembranosus tendon rupture secondary to Levofloxacin.

Orthobiologics in Hand Surgery

Orthobiologic agents are used as innovative adjuvant therapy to treat common upper-extremity pathology, including carpal tunnel syndrome, de Quervain tenosynovitis, and distal radius fractures. In this article, we perform a narrative review and evaluate current literature on orthobiologics in the upper extremity. Orthobiologics evaluated include bone morphogenetic proteins, platelet-rich plasma, bone marrow aspirate concentrate, mesenchymal stem cells, and amniotic membrane. Studies selected include randomized control trials, case studies, and animal studies. Although there is some clinical evidence regarding the use of orthobiologic agents in the treatment of shoulder, elbow, and sports injuries, there is a paucity of literature regarding their use to treat pathology of the hand and wrist. Further investigation is necessary to determine their effectiveness and therapeutic value in treatment of upper extremity injuries.

Peroneal Tendons Rupture in a Closed Talar Body Fracture: A Rare Injury

The combination of tendon and ligament ruptures with fracture of the talus is very rare. We demonstrate our experience in the acceptable management of a 34-year-old male referred with a closed comminuted fracture of the talar body after falling 7 meters. During the surgery, complete rupture of the peroneus brevis tendon, partial rupture of the peroneus longus tendon, and an avulsed superficial deltoid ligament from medial malleolus were found. Twelve months after open reduction and internal fixation of the talar body fracture and repair of the peroneal tendons and superficial deltoid ligament, the patient was satisfied, without any talar dome collapse, sclerosis, or arthritic changes. It is recommended to take care of possible tendon or ligament ruptures during fixation of talar fractures in cases of high-energy trauma.