Anthony A. Schepsis

Achilles Tendon Disorders in Athletes

Achilles tendon disorders are among the more common maladies seen by sports medicine physicians. Understanding the anatomy and biomechanics of the Achilles tendon and contiguous structures is essential to the diagnosis and treatment of Achilles tendon overuse injuries. Posterior heel pain is multifactorial and includes paratenonitis, tendinosis, tendinosis with partial rupture, insertional tendinitis, retrocalcaneal bursitis, and subcutaneous tendo-Achillis bursitis. Each of these entities is distinct, but they often occur in combination. Although most cases of this disorder are successfully treated nonoperatively, a small subgroup of recalcitrant cases may benefit from surgical intervention. Complete ruptures in active, athletic persons should be treated operatively in most cases and result in predictably good outcomes. There may be some cases that escape early recognition and require a reconstructive procedure to salvage a potentially severe functional deficit.

Surgical management of Achilles tendinitis

Inflammation of the Achilles tendon and its contiguous structures is one of the most common overuse prob lems seen in runners. There are actually several etiol ogies. Involvement of the tendon itself is secondary to areas of mucinoid or fibrotic degeneration, or may be a result of a partial rupture. The sheath (or mesotenon) may also become chronically inflammed. Retrocalca neal bursitis seems to be a separate entity with hyper trophy and fibrosis of the bursa usually occurring in conjunction with a prominent posterior superior angle of the os calcis. The vast majority of patients can be successfully treated nonoperatively; however, there is a group of patients who are refractory to nonoperative management who would like to continue running, par ticularly if they are competitive. A retrospective review of 45 surgical cases in 37 patients was performed. All but two of these patients were competitive long-distance runners. There were 24 cases of Achilles tendinitis and/or tenosynovitis, 14 cases with retrocalcaneal bursitis, and 7 with a combi nation of both. Mean followup was 3 years (range, 1½ to 8 years). Overall there were 87% satisfactory results. Ninety-two percent of the patients with involvement with the tendon and/or sheath had a satisfactory out come as compared with 71 % of patients with retrocal caneal bursitis. Passive dorsiflexion in the 29 unilateral cases improved from a mean of 17° preoperatively to a mean of 25° postoperatively. We feel that surgery offers a solution for highly motivated runners with chronic posterior heel pain who would like to continue running when conservative measures have failed.

Surgical Management of Achilles Tendon Overuse Injuries A Long-term Follow-up Study

We studied 79 cases of surgically treated Achilles ten don overuse injuries in 66 patients. Fifty-three (80%) of these patients were competitive or serious recreational runners operated on between 1978 and 1991. There were 49 men and 17 women with a mean age of 33 years (range, 17 to 59). The cases were divided into surgical subgroups based on their site of primary symp toms and abnormalities: paratenonitis (23), tendinosis (partial rupture or degeneration) (15), retrocalcaneal bursitis (24), insertional tendinitis (7), and combined ab normalities (10). Followup included a comprehensive patient questionnaire and office examination. There were 79% satisfactory (51% excellent, 28% good) and 21 % unsatisfactory (17% fair, 4% poor) results. The per centages of satisfactory results in the paratenonitis group (87%) were best and those in the tendinosis group were the worst (67%). Satisfactory results were obtained in 75% of the patients with retrocalcaneal bur sitis and 86% with insertional tendinitis. Seven of the 45 cases with longer than 5-year followup with initially sat isfactory results deteriorated with time and required re operation (16%). Of these, 4 were in the tendinosis group, 2 had retrocalcaneal bursitis, and 1 had paratenonitis. One of the 34 patients followed less than 5 years required reoperation.

The role of arthroscopy in the assessment and treatment of tibial plateau fractures

This retrospective study compared arthroscopic treatment of certain tibial plateau fractures to traditional open techniques. From January 1989 through August 1992, 40 patients with tibial plateau fractures were evaluated. After reviewing the records and radiologic studies, 23 patients were included in the study based on fracture patterns. Using Hohls revised classification system, patients with either local compression or split compression fractures were included. Twelve of these patients were treated with arthroscopic reduction and percutaneous fixation (ARPF; group A). The remaining 11 underwent open reduction and internal fixation (ORIF; group B). The results of the ARPF group were superior to those of the ORIF group. In the ARPF group, all reductions were anatomic and remained fixed at least 3 months postoperatively, whereas only six (55%) of the ORIF patients had anatomic reductions initially. Furthermore, one of these patients had further loss of reduction on follow-up radiographs. Iliac crest bone graft was used in two patients in group A and 10 in group B. The use of bone graft in the arthroscopically treated group had no effect on the final outcome. The average length of postoperative hospitalization for the ARPF patients with isolated tibial plateau fractures was 5.36 days compared with 10.27 days for patients who were treated with ORIF. Average time to full weight bearing was 8.95 weeks in the ARPF group and 12.30 weeks in the ORIF group. No patients in either group had medial collateral ligament repairs. No ARPF-treated patients experienced valgus laxity after treatment. One patient in the ORIF group had residual instability and another walked with a cane.(ABSTRACT TRUNCATED AT 250 WORDS)

Rupture of the Pectoralis Major Muscle: Outcome After Repair of Acute and Chronic Injuries*

We retrospectively studied 17 cases of distal pectoralis major muscle rupture to compare the results of repair in acute and chronic injuries and to compare operative and nonoperative treatment. Thirteen patients underwent surgery (six acute injuries [less than 2 weeks after injury] and seven chronic injuries) and four had nonoperative management. The mean age of the patients at injury was 29, and 10 of the 17 injuries were the result of weight lifting. Follow-up ranged from 18 months to 6 years (mean, 28 months). All patients subjectively rated strength, pain, motion, function with strenuous sporting activities, cosmesis, and overall satisfaction. Objectively, patients were examined for range of motion, deformity, atrophy, and strength. Isokinetic strength testing was performed in eight patients: six treated operatively (three acute and three chronic) and two treated nonoperatively. Overall subjective ratings were 96% in the acute group, 93% in the chronic group, and only 51% in the nonoperative group. Isokinetic testing showed that patients operated on for acute injuries had the highest adduction strength (102% of the opposite side) compared with patients with chronic injuries (94%) or nonoperative treatment (71%). There were no statistically significant subjective or objective differences in outcome between the patients treated operatively for acute or chronic injuries, but these patients fared significantly better than patients treated nonoperatively.

Surgical management of exertional compartment syndrome of the lower leg Long-term followup

Forty-six limbs in 28 patients were surgically treated for exertional compartment syndrome. One group of 16 patients (26 limbs) underwent a fasciotomy for ex ertional anterior compartment syndrome (Group 1). A second group of 12 patients (20 limbs) underwent a fasciotomy for exertional deep posterior compartment syndrome (Group 2). Patients in Group 2 experienced symptoms for a significantly longer time than those in Group 1:16 versus 6.8 months (P < 0.01). All three of the pressure measurements used in this study (resting pressure, 1 minute after exercise, and 5 minutes after exercise) were significantly higher in both groups than in normal controls (P < 0.01). The 1 minute after exercise values were significantly higher in Group 1 (mean, 36.5) than in Group 2 (mean, 29.1) (P < 0.01). In Group 1, 25 of 26 limbs (96%) had excellent results. In Group 2,13 of 20 limbs (65%) had satisfactory results (5 excellent and 8 good) and 7 (35%) had unsatisfactory results (4 fair and 3 poor). Those patients who had an unsatisfactory outcome did so within 6 months. Pa tients in Group 1 had a significantly higher rate of satisfactory results than those in Group 2 (P < 0.05).

Arthroscopic Versus Mini-open Rotator Cuff Repair A Comprehensive Review and Meta-analysis

Background Controversy remains regarding the results of all arthroscopic rotator cuff repairs compared with the mini-open approach. The purpose of this study was to perform a comprehensive literature search and meta-analysis of clinical trials comparing the results of arthroscopic rotator cuff repairs and mini-open rotator cuff repairs. Hypothesis There is no difference between the clinical results obtained from all arthroscopic rotator cuff repairs compared with mini-open repairs. Study Design Meta-analysis. Methods A computerized search of articles published between 1966 and July 2006 was performed using MEDLINE and PubMed. Additionally, a search of abstracts from 4 major annual meetings each held between 2000 and 2005 was performed to identify Level I to III studies comparing the results of arthroscopic rotator cuff repair and mini-open repair. Studies that included follow-up of an average of over 2 years and a minimum of 1 year and included the use of 1 of 4 validated functional outcome scores used to study shoulder injuries were included in the present meta-analysis. All outcome scores were converted to a 100-point scale to allow for outcome comparison. Results Five studies that met the inclusion criteria were identified. There was no difference in functional outcome scores or complications between the arthroscopic and mini-open repair groups. Conclusion Based on current literature, there was no difference in outcomes between the arthroscopic and mini-open rotator cuff repair techniques.

Salvage of Failed Acromioclavicular Joint Reconstruction Using Autogenous Semitendinosus Tendon from the Knee Surgical Technique and Case Report

The appropriate management of acute type III acromioclavicular dislocations remains controversial. Although the current trend in treatment of these injuries is toward nonoperative therapy, some authors advocate surgical repair of acute injuries in athletes who participate in overhead sports and in heavy laborers. Operative treatment of acute type IV, V, and VI injuries is well accepted. Similarly, surgical reconstruction is required for chronic symptomatic type III acromioclavicular dislocations. Historically, many different surgical techniques have been described to accomplish reconstruction in the acute or chronic condition, with more than 100 different procedures reported in the literature. There has been a trend toward stabilization of the coracoclavicular ligaments for acute injuries. In the symptomatic patient with chronic instability of the acromioclavicular joint, stabilization is mandatory for a successful result. Various procedures are available to achieve this end. Weaver and Dunn transferred the coracoacromial ligament, and Bunnell and Lom used autogenous fascia lata graft. Other authors have used a variety of synthetic materials and implants, such as coracoclavicular screws, cerclage wires, nonabsorbable synthetic sutures, Dacron, and expanded polytetrafluoroethylene (GORE-TEX; W. L. Gore, Flagstaff, Arizona). More recently, absorbable synthetics, such as polydioxanonsulfate bands, have been used. The use of rigid implants, such as coracoclavicular screws, may necessitate a second operation for removal to prevent fatigue failure and possible migration of the hardware. Synthetic materials may produce a foreign body response in the local tissue, as has been described with Dacron. Similarly, particulate polytetrafluoroethylene has been associated with foreign body reaction in regional lymph nodes after its use in the knee. Osteolysis adjacent to a polytetrafluoroethylene implant in the hand has also been described, but this complication has not, to our knowledge, been described in the shoulder. Bony erosion and amputation of the clavicle or coracoid process secondary to clavicular or coracoid cerclage with such material may also result in failure. We present a case of failed acromioclavicular reconstruction in which salvage surgery was performed to reconstruct the coracoclavicular ligaments with a loop of autogenous semitendinosus tendon from the patient’s ipsilateral knee. To our knowledge, no similar reports of coracoclavicular reconstruction using autogenous semitendinosus tendon graft have appeared in the literature.

Arthroscopic distal clavicle resection in athletes : A prospective comparison of the direct and indirect approach

Background The clinical success of arthroscopic distal clavicle resection for athletes has been well documented. There are, however, no published studies that prospectively compare the recovery rates in athletes as well as the outcomes of the indirect versus direct approaches. Hypothesis Both procedures are equally successful; however, the direct approach affords faster return to sports. Study Design Randomized controlled clinical trial; Level of evidence, 2. Methods Thirty-eight consecutive athletes with osteolysis of the distal clavicle or isolated posttraumatic arthrosis of the acromioclavicular joint without instability underwent arthroscopic distal clavicle resection. The patients were randomized into 2 groups: a direct superior approach and an indirect subacromial approach. American Shoulder and Elbow Surgeons and Athletic Shoulder Scoring System scores were measurable outcomes. Results Thirty-four athletes were available for a minimum 2-year follow-up. The 2 groups were similar, including preoperative American Shoulder and Elbow Surgeons and Athletic Shoulder Scoring System scores. Both groups demonstrated significant improvement in both scores at final follow-up when compared with preoperative scores (P < .001). The direct group demonstrated higher American Shoulder and Elbow Surgeons (82 vs 64) and Athletic Shoulder Scoring System (74 vs 56) scores at week 2 (P < .001) and week 6 (American Shoulder and Elbow Surgeons, 88 vs 77; Athletic Shoulder Scoring System, 87 vs 73) (P < .001). At final follow-up, both groups demonstrated excellent clinical outcomes, even though there was a statistical difference in scores, with the direct group scoring better (American Shoulder and Elbow Surgeons, 95.7 vs 91.2; Athletic Shoulder Scoring System -94.9 vs 88.3). The direct group demonstrated faster return to sports (mean, 21 days) than the indirect group (mean, 42 days) (P < .001). Radiographic analysis demonstrated an equivalent resection. One patient in each group had a clinically insignificant increase in coracoclavicular distance. Conclusions Both the direct superior approach and the indirect subacromial approach to the arthroscopic distal clavicle resection result in successful clinical outcome with clinically insignificant difference at final follow-up. Athletes treated with the direct superior approach improved faster clinically and returned to sports earlier.

Long-term results of surgical management of Achilles tendinitis in runners.

Achilles tendinitis is a common occurrence in long-distance runners. Although most respond well to conservative therapy, there are some who require operative intervention. The short-term results of surgical treatment are good, with a success rate more than 85%. The authors present nine successful long-term results in runners. However, in two of the runners who continued to compete and train at long distances, symptoms recurred. Reoperations were performed to permit successful running careers for five and nine years. Runners resumed their careers after the second operation by supervised training and long-distance, competitive activities.