Niv Marom, MD Department of Orthopaedic surgery Meir medical center

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1 Niv Marom, MD Department of Orthopaedic surgery Meir medical center

2 Tendons basic science. Tendon avulsion injuries general concepts. Specific tendon avulsion injuries: Distal Biceps. Proximal Hamstrings. Distal Quadriceps.

3 Transfer forces from muscle to bone to produce joint motion. Composition: Water. Type I collagen - 85% of dry weight of tendons. Type III collagen - 0-5% of dry weight of tendons. Proteoglycans - 0-5% of dry weight of tendons (Decorin, Aggrecan). Structure: Highly ordered hierarchical structure.

4 Main cell type: Fibroblasts - spindle shaped and arranged in parallel rows in direction of muscle loading.

5 Paratenon covered tendons (Patellar, Achilles): Rich vascular supply. Most often fail: The musculotendinous junction. Tendon-bone junction. Sheathed tendons (hand flexor tendons): Less vascularization. Avascular areas that receive nutrition by diffusion.

6 Insertion into bone via 4 transitional tissues : Tendon Fibrocartilage Mineralized fibrocartilage (Sharpey's fibers) Bone These gradients minimize stress concentrations and mediate load transfer between the soft and hard tissues.

7 I Hemostasis - (minutes) Platelets initiate coagulation cascade. Fibrin clot and fibronectin interaction. Chemotaxis. Stabilize torn tendon edges. II Inflammation (1-7 days) Fibroblasts produce type III collagen. Macrophages help initiate healing and remodeling. III Organogenesis (7-21 days) Tissue modeling - large amounts of disorganized collagen and angiogenesis. IV Remodeling (<18 months) Tissue remodeling replacing type III collagen to type I collagen.

8 Occur in both the skeletally immature and adult patient populations. Most common in the adolescent age group and usually present as an avulsion of the unfused apophysis at the level of tendon attachment. In the adult, tendon avulsion injuries may result from a single episode of trauma but are often associated with repetitive stresses involving a tendon with underlying chronic insertional tendinosis.

9 Rupture of the distal biceps tendon accounts for 10% of all biceps brachii ruptures. Patient s characteristics: Dominant elbow (86%). Men (93%) in their 40s. Most (70%) are not athletically active or have physically demanding occupations. Risk in smokers x7.5. Sutton et al. J Am Acad Orthop Surg 2010

10 Excessive eccentric tension as the arm was forced from a flexed to an extended position.

11 Insertion: bicipital tuberosity. 2 distinct insertions.

12 History: Painful pop at the time of injury. Physical examination: Varying degrees of proximal retraction of the muscle belly. Change in contour. Ecchymosis. Weakness and pain, primarily in supination. Hook test sensitivity and specificity of 100%. REMEMBER: The underlying brachialis tendon may be mistaken for the biceps.

13 Flexion & Supination

14 Imaging X rays - small fleck or avulsion of bone from the radial tuberosity, R/O associated elbow injuries. US MRI specific location, retraction evaluation, partial tears.

15 Nonsurgical management: Low-demand or medically infirm patient. Weakness and early fatigue in supination (inability to use a screwdriver). Surgical repair: Hetsroni et al. (2007) Superior to nonsurgical treatment in terms of restoring: Elbow flexion strength (30% improved). Supination strength (40% improved). Better upper extremity endurance. Acute repair is Ideal.

16 Reinsertion procedure. Single vs. dual incision: Complications: Nerve injuries (lateral antebrachial cutaneous nerve, PIN), HO. Fixation: Suture anchor. Bone tunnel. Screw fixation. Suspensory cortical button.

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19 Immobilized in a posterior splint for the first 1 to 2 weeks Gravity-assisted flexion and extension may be started. Light strengthening is resumed at approximately 8 weeks. Expected return to heavy activities at 3 to 5 months. Vs. Immediate, unbraced active motion.

20 Hamstrings injuries are common among athletes. Complete rupture (or avulsion) of the proximal hamstrings tendon are less common than the typical muscle-tendon junction strain injuries which are usually treated conservatively. Cohen et al. J Am Acad Orthop Surg 2007

21 Proximal hamstring rupture from the ischial tuberosity (with or w/o bony avulsion) occurs acutely in both well trained athletes and middle-aged individuals who sustain sudden hip flexion/knee extension causing hamstring eccentric contraction.

22 GT Greater trochanter IT Ischial tuberosity LB Long head of the biceps femoris SM Semimembranosus ST Semitendinosus STL Sacrotuberous ligament

23 History Sensation of being shot in the posterior thigh. Subsequent difficulty ambulating. Physical examination: Stiff-legged gait pattern. Posterior thigh pain. Ecchymosis as a result of the hematoma from the tendon rupture. Difficulty sitting secondary to pain at the avulsion site. Retraction may be seen in complete ruptures/avulsions.

24 Imaging X ray US MRI

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26 Soft tissue including sciatic nerve. Complete vs. partial. Number of tendons involved. Retraction/displacement measurements. Bony fragments.

27 Disruption of the proximal hamstrings complex has a much more debilitating natural history, In Comparison to other hamstrings injuries: Significant functional impairment in active individuals. Persistent weakness. Residual pain. Late sciatic nerve symptoms. Formation of heterotopic ossifications.

28 No consensus on optimal treatment: Conservative treatment Acute surgical repair Delayed surgical repair

29 Indication (no consensus): Single tendon avulsion. Retraction < 2 cm. Treatment: NSADIS. RICE. Gentle stretching, therapeutic exercise. Gradual return to athletic activity over approximately 4 to 6 weeks.

30 Complications: Knee flexion weakness. Mild hip extension weakness. Difficulty sitting. Deformity. Hamstring syndrome (bony mass or involvement of sciatic nerve) : Local posterior buttock pain. Discomfort over the ischial tuberosity. Painful sitting. Pain may worsen with stretching and during exercise.

31 There is more and more evidence in recent years that early surgical treatment in cases of complete ruptures/displaced avulsion has better results, in comparison to conservative and delayed surgical treatment. Acute surgical treatment of proximal hamstring avulsions allows anatomic repair and lessens symptoms similar to those of hamstring syndrome. Acute anatomic repair also allows most patients to achieve functional return to activities, including high-level athletics. Chakravarthy, Br J Sports Med, 2005 Wood, J Bone Joint Surg, 2008 Sarimo, Am J of Sports Med, 2008 Sallay, Orthopedics, 2008 Shyamalan, Injury, 2010 Orava, Am J of Sports Med, 2015

32 Indications (no consensus): Failure of conservative treatment persistent hamstring syndrome. Complete avulsion/rupture of more than 1 tendon Displacement/retraction > 2 cm. Acute vs. Delayed. Reinsertion of tendons to iscial tuberosity ± Debridment, neurolysis and excision of bony fragments.

33 Patient prone. Mild knee flexion.

34 10 cm posterior longitudinal incision starting gluteal crease and extanding distally

35 Exposure of avulsed damaged tendons

36 Exposure of sciatic nerve and its branches, careful neurolysis under microscope and mobilization

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38 Exposure, seperation and exicion of bony calcified masses

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40 Reinsertion of tendons origin to the ischial tuberusy with suture anchors.

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44 Sutures by anatomic layers

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46 Week Brace 4-6 weeks vs. No brace. Activity Lying with flexed knee Assisted weightbearing with toetouch Gradual bearing weight with heel touch, ROM Full weightbearing and gradual strengthening of muscles Functional training Continuous sports Gradual return to specific sport

47 Demographics: +40 years of age. M>F. Underlying medical condition (renal failure, diabetes, rheumatoid arthritis, hyperparathyroidism, connective tissue disorders, steroid use, intraarticular injections). Non dominant leg. Mechanism: Direct (usually young patients) vs. Indirect (eccentric load foot is planted and knee is slightly bent). Ilan et al. Quadriceps Tendon Rupture J Am Acad Orthop Surg 2003

48 Quadriceps tendon is a coalescence of the tendinous portions of : Rectus femoris *. Vastus intermedius. Vastus lateralis. Vastus medialis. The muscle fibers from the quadriceps blend with its tendinous portion approximately 3 cm proximal to the superior border of the patella. The four muscles that form thequadriceps unite into one common tendon that incorporates the patella and composed of 3 layers: Superficail (Anterior) Middle Deep.

49 Deep to these layers is the synovium, which, when torn, accounts for the large hemarthrosis associated with quadriceps tendon rupture. The quadriceps is innervated by the femoral nerve (L2-4). The extensor mechanism is composed of the quadriceps tendon, patella, and patellar tendon. The anterior location of the patella enables it to act as a fulcrum, which increases the lever arm of the quadriceps.

50 History: Pain (an immediate, intense tearing sensation) Inability to actively extend the knee. Immobilization of the extremity in extension results in pain relief. Physical examination: Inability to actively extend the knee and maintain extension against gravity. A suprapatellar gap is pathognomonic. Diagnostic failure rates of 10% to 50% have been reported (hemarthrosis, intact patellar retinaculum).

51 X-ray Quadriceps tendon shadow. Bony avulsion fragment. Inferior patella. US MRI

52 Insall-Salvati measurement Blackburn-Peel measurement

53 Indications: Incomplete tears. C/I for surgery. Treatment: RICE, NSAIDS, Aspiration. Immobilization with the knee in full extension for 6 weeks. Protected range of motion and strengthening exercises. Quadriceps muscle control. Gradual unprotected mobilization.

54 Complications: Poor results with complete tears. Long term disability. Weakness (Lag).

55 Surgical repair of a complete rupture to achieve optimal functional results is well accepted. Early intervention is recommended. Common technique: Heavy, nonabsorbable sutures through parallel transosseous tunnels in the patella.

56 Locked, hinged brace. Full weight bearing. Range-of-motion exercises and physical therapy. Brace removed after 6-12 weeks or when the patient has good quadriceps muscle control and can straight-leg raise.

57 Loss of knee motion - full knee flexion. Extensor weakness (Atrophy). Wound infection. Skin Dehiscence. Patellofemoral degeneration (Alignment and height of patella).

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