Extensor digitorum tendon rupture after anterior ankle arthroscopy

Aim: The aim of this paper is to increase awareness of orthopaedic surgeons about an uncommon yet possible complication of ankle arthroscopy – iatrogenic extensor digitorum rupture. Ankle arthroscopy is becoming more widespread and according to the literature, the complication rate varies from 9% up to 17%. Case report: We are presenting a case of 32-year old police officer who recreationally plays soccer. The patient presented with clear signs of anterior ankle impingement confirmed by X-ray and the MRI. During ankle arthroscopy massive tibial and talar bone spurs were found with significant synovial reaction, nearly 10 loose intraarticular bodies and syndesmotic ossification. The patient was placed in a walking boot and early postoperative recovery went as planned. Physical therapy started 14 days after the procedure. Five weeks after the surgery while dorsiflexing his fingers patient felt a "snap" over his ankle followed by swelling. He couldn't dorsiflex his fingers afterwards. MRI showed a rupture of the common extensor digitorum tendon. The patient was treated with open reconstruction of the tendon and lower leg immobilisation for 6 weeks followed by physical therapy and partial weight bearing. The patient made a full recovery. Conclusion: It is of the utmost importance to keep in mind that ankle arthroscopy alongside it's obvious benefits is not void of complications. Iatrogenic tendon lesion is always possible and should be suspected with any loss of movement in foot and ankle after the procedure. Urgent MRI and immediate reconstruction showed good results in our case.

Posterior Tibial Tendon and Spring Ligament Lesions in Rheumatoid Arthritis

In rheumatoid arthritis, a significant number of patients have hindfoot pain while they are considered in low disease activity. Then the rheumatoid hindfoot may evolve in valgus flat foot with disability. The aim of our study was to observe the lesions of the main stabilizers of the hindfoot in rheumatoid arthritis to improve the followup and the treatment of the disease. Thirty-three feet (from 21 patients) with rheumatoid arthritis and pain of the hindfoot were consecutively observed. The patients have had no biologic treatment. Every foot had Magnetic Resonance Imaging (MRI) of the hindfoot with gadolinium injection. The tendon of the tibialis posterior muscle, the spring ligament and the inter-osseous talocalcaneal ligament were considered. All the feet presented tenosynovitis of the posterior tibial tendon. Structural lesions of the posterior tibial tendon (23/33 feet, 69.7%) were more frequent than lesions of the spring ligament (12/33 feet, 36.4%). There was no inferior spring ligament lesion without superior spring ligament lesion. No interosseous talocalcaneal ligament lesion was observed. In rheumatoid arthritis, the hindfoot, and particularly the posterior tibial tendon, should be evaluated during patient follow-up to detect a possible lesion. Posterior tibial tendon lesion arises at the same time as the spring ligament lesion, before interosseous talocalcaneal ligament lesion. Imaging, especially MRI, may complete clinical examination. If rheumatoid involvement of the posterior tibial tendon is observed, treatment intensification is required.

Adverse effects of percutaneous needle electrolysis in carpal tunnel syndrome

Background Percutaneous needle electrolysis is a physical therapy technique which has shown to be useful for the treatment of nerve entrapments. The aim of the present study was to analyze the possible adverse effects and the follow-up pattern after the application of percutaneous needle electrolysis in carpal tunnel syndrome. Material and Methods A descriptive observational study conducted at the Traumatology Service of the Ciudad Real Hospital, in patients with a medical diagnosis of carpal tunnel syndrome confirmed by electromyography (gold standard).Percutaneous needle electrolysis was applied under ultrasound guidance in the superficial and deep interphase of the median nerve in its passage through the carpal tunnel, applied with a frequency of once every seven days over four weeks.The week after each intervention, the follow-up pattern of the adverse effects variables was gathered, grouped in the following categories: type of adverse effect, moment of appearance, prevalence period, impact and causality.At 1.5 weeks and 6 weeks after the last intervention, the following variables were gathered: presence of painful or hypertrophic scar, stiffness at the level of the wrist, hand or fingers, infection of the wound, alteration of reflex sympathetic trophism, symptoms related with a nerve lesion, symptoms related with a tendon lesion, post intervention effusion. The McNemar test was used for comparative measures between the first, second, third and fourth intervention, without significant variations (p < 0.05). Results 30 cases participated in the study, of which one subject had to abandon the treatment after the first application because of apprehension in relation to following through with treatment.Of the 117 intervention applied, one vegetative reaction was recorded, which was transitory and without consequences. Pain appeared during the intervention in 96.5% of the interventions, after the intervention pain was present in 56%, whereas pain experienced days after the intervention occurred in 28.4%. No cases required further medical intervention, and there were no irreversible cases, independent of the cause. For the remaining variables, the records were negative in all interventions.No adverse effects were described for any cases at the follow up at 1.5 and 6 weeks post-intervention. Conclusions No adverse effects were described at the end of the intervention in the short to mid term. Regarding the follow-up pattern, the pain followed a highly homogeneous course, there were no irreversible adverse effects requiring intervention, and no relationship was found with any cause on behalf of the patient.

Laser Photobiomodulation in the acute inflammatory response of the calcaneal tendon injury in rats exposed to cigarette smoke

ABSTRACT Nicotine delays the healing process and increases the levels of myeloperoxidase (MPO), an enzyme that plays a key role in the production of reactive oxygen species during the inflammatory process. Laser Photobiomodulation (PBM) is one of the most used electrophysical agents in the treatment of the calcaneal tendon, however, its effects on MPO activity need to be further elucidated. This study aimed to evaluate the effects of laser PBM on MPO activity after inflicting an injury to the calcaneal tendon of rats exposed to cigarette smoke. Thirty-four male Wistar rats with 90 days of age were used. After 14 days of exposure to cigarette smoke, the animals were divided into three experimental groups: control group (CG, n=12), not submitted to injury or treatment; sham group (ShG, n=10), submitted to partial calcaneal tendon injury and laser PBM simulation; and laser PBM group (PBMG, n=12), submitted to partial calcaneal tendon lesion and treated with laser PBM within the first minute after injury. PBM decreased MPO activity levels in PBMG compared to ShG (CG: 1.38±0.69pg/ml; ShG: 3.78±1.09pg/ml; PBMG: 2.58±0.93pg/ml; p<0.005). In conclusion, applying laser PBM immediately after inflicting damage to the calcaneal tendon attenuates acute inflammatory activity in rats exposed to cigarette smoke.

Eccentric Training for Tendon Healing After Acute Lesion: A Rat Model

Background: The tendon is a dynamic entity that remodels permanently. Platelet-rich plasma (PRP) injection has been shown to have a beneficial effect on tendon healing after lesion in rats. Furthermore, eccentric exercise seems to improve the mechanical quality of the tendon. Hypothesis: A combination of PRP injection and eccentric training might be more effective than either treatment alone. Study Design: Controlled laboratory study. Methods: Adult male rats were anesthetized, an incision was performed in the middle of their left patellar tendon and an injection of physiological fluid (PF) or homologous PRP was randomly made at the lesion level. The rats were then divided into 2 groups: the eccentric group, undergoing eccentric training 3 times a week, and the untrained group, without any training. Thus, 4 groups were compared. After 5 weeks, the tendons were removed and their ultimate tensile strength and energy were measured. Tendons were frozen for proteomic analyses when all biomechanical tests were completed. Statistical analysis was performed with linear mixed effect models. Results: No significant difference was found between the treatments using PF injection or PRP injection alone. However, the value of the ultimate tensile force at rupture was increased by 4.5 N (108% of control, P = .006) when eccentric training was performed. An intragroup analysis revealed that eccentric training significantly improved the ultimate force values for the PRP group. Proteomic analysis revealed that eccentric training led to an increase in abundance of several cytoskeletal proteins in the PF group, while a decrease in abundance of enzymes of the glycolytic pathway occurred in the PRP-treated groups, indicating that this treatment might redirect the exercise-driven metabolic plasticity of the tendon. Conclusion: Eccentric training altered the metabolic plasticity of tendon and led to an improvement of injured tendon resistance regardless of the treatment injected (PF or PRP). Clinical Relevance: This study demonstrates the necessity of eccentric rehabilitation and training in cases of tendon lesion regardless of the treatment carried out.

Serious Delayed Hair Toe Tourniquet Syndrome with Bone Erosion and Flexor Tendon Lesion

Hair toe tourniquet syndrome (HTTS) is an uncommon pediatric condition occurring when the toe is circumferentially strangulated by human hair or fibers. An 8-week-old little girl was admitted to the Emergency Department because of the worsening swelling in the right second and third toes, which had been been previously treated with a local antibiotic thinking of an infection. An unrecognized HTTS was leading the third toe to necrosis. An urgent release of the constricting band on the two toes was performed and bone erosion and partial flexor tendon lesion on the third toe were detected. We would like to raise awareness in the community and in colleagues about HTTS in children, because early recognition and urgent treatment are mandatory to provide an adequate management and prevent severe complications.

Evaluation of Painful Shoulder with High Frequency Sonography and their Comparison with the Clinical Diagnosis made by Physical Examination

Purpose: The purpose of this study is to compare clinical diagnosis made by physical examination with high frequency ultrasonographic findings and also to correlate ultrasonographic findings of painful shoulders of cases with asymptomatic shoulders of control subjects. The most common clinical diagnosis was supraspinatus lesion (38) followed by bicep tendon lesion (14) .Rotator cuff was the most common structure to show abnormality (critical zone of avascularity) with supraspinatus being the most commonly involved tendon in our study. Non-invasiveness, easy availability along with its cost effectiveness justify role of high frequency ultrasound in the assessment of painful shoulder. Nepalese Journal of Radiology; Vol. 2; Issue 2; July-Dec. 2012; 43-50 DOI: http://dx.doi.org/10.3126/njr.v2i2.7684