E. Ippolito

A classification of Achilles tendon disease.

Athletic Injuries (American Medical Association) is based on symptomatology and clinical findings. This classification is as follows: ( 1 ) tenosynovitis, (2) tendinitis, (3) ruptures. The term tenosynovitis is used indiscriminately to refer to tendons that are invested by true synovial sheaths as well as tendons, like the tendo Achilles, that are in actuality surrounded by peritendon.1 Our opinion is that a precise difference exists between the structures of these two types of coverings. We reserve the use of the term tenosynovitis exclusively to refer to acute and chronic inflamatory processes involving true synovial sheaths.

Long-term comparative results in patients with congenital clubfoot treated with two different protocols

Background: Long-term follow-up studies of adults who had been treated for congenital clubfoot as infants are rare. The purpose of this study was to review and compare the long-term results in two groups of patients with congenital clubfoot treated with two different techniques. In both groups, treatment was started within the first three weeks of life by manipulation and application of toe-to-groin plaster casts, with a different technique in each group. At the end of the manipulative treatment, a posteromedial release was performed when the patient was between eight and twelve months of age in the first group and a limited posterior release was performed when the patient was between two and four months of age in the second group. Methods: At the follow-up evaluations, all patients were interviewed and examined, and standing anteroposterior and lateral radiographs and computed tomography scans of the foot were made. The results of treatment were graded according to the system of Laaveg and Ponseti. Numerous angular measurements were made on the radiographs, and the measurements in the two groups were compared. Results: The first group, which included thirty-two patients (forty-seven clubfeet), was followed until an average age of twenty-five years. The second group, with thirty-two patients (forty-nine clubfeet), was followed until an average age of nineteen years. In the first group, there were two excellent, eighteen good, eleven fair, and sixteen poor results. In the second group, there were eighteen excellent, twenty good, six fair, and five poor results. According to the system of Laaveg and Ponseti, the mean rating in the first group was 74.7 points and that in the second group was 85.4 points. Conclusions: In the second group, use of Ponsetis manipulation technique and cast immobilization followed by an open heel-cord lengthening and a limited posterior ankle release gave much better long-term results than those obtained in the first group, treated with our manipulation technique and cast immobilization followed by an extensive posteromedial release of the foot. In our hands, this operation did not prevent relapse, and neither cavovarus nor forefoot adduction was completely corrected. Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Morphological, immunochemical, and biochemical study of rabbit achilles tendon at various ages.

UNLABELLED With aging, rabbit tendon tissue undergoes a series of morphological and biochemical changes which involve both the cells and the extrace-lular matrix. The extracellular matrix increases in volume, causing a relative decrease of the number of cells per unit of tissue surface. The tenoblasts become longer and more slender, while their cytoplasmic processes increase in number and become thinner and more elongated, forming a dense network. In addition, tendon cells show a marked decrease in the intracytoplasmic organelles responsible for protein synthesis, while their intracellular content of contractile proteins does not change. With aging collagen fibers increase in diameter and vary more in thickness. These morphological changes correspond to biochemical changes that include an increase in collagen, a decrease in mucopolysaccharides, and a decrease in water content. During aging parallel changes occur in the elastic fibers, which decrease in number and show structural alterations. CLINICAL RELEVANCE Ultrastructural and biochemical studies of tendon diseases need a normal comparison. Out ultrastructural and biochemical findings in aging tendon may be useful in that regard. The presence of actin and myosin in tendon cells could be related to some aspects of tendon physiology and pathology.

Long-term Results of Treatment of Fractures of the Medial Humeral Epicondyle in Children

Background: The treatment of isolated, displaced fractures of the medial humeral epicondyle in children is controversial. Both plaster cast immobilization without reduction and open reduction and internal fixation have been advocated. The purpose of this long‐term retrospective study was to analyze the functional and radiographic results of both nonsurgical and surgical management of these injuries. Methods: Forty‐two patients who had had an isolated fracture of the medial humeral epicondyle with displacement of >5 mm at an average age of twelve years (range, eight to fifteen years) were evaluated at an average age of forty-five years (range, thirty to sixty-one years). The patients were divided into three groups that were comparable with regard to the amount of fracture displacement, age at the time of the fracture, age at the time of follow‐up, sports activities and occupation, and duration of follow‐up. In Group I (nineteen patients), the fracture had been treated with a long-arm plaster cast without reduction of the displaced medial epicondyle. In Group II (seventeen patients), open reduction and internal fixation with either Kirschner wires or a T‐nail had been performed. In Group III (six patients), the epicondylar fragment had been excised with suture reattachment of the tendons and the medial collateral ligament. Results: According to a functional grading scale, there were sixteen good and three fair results in Group I. All but two patients were seen to have nonunion of the fragment on follow‐up radiographs, but all had a normal result on valgus stress-testing of the elbow. The range of motion of the elbow was either normal or minimally decreased, and the grip strength of the ipsilateral hand was normal. There were fifteen good and two fair results in Group II. All patients had union of the medial epicondyle, with various radiographic deformities of the medial epicondyle, but the functional results were similar to those of the Group-I patients. The Group-III patients had four poor and two fair results. Four had constant pain at the elbow and paresthesias in the distribution of the ulnar nerve. One patient had a restricted range of motion of the elbow, four patients had an unstable elbow, and three patients had decreased grip strength of the ipsilateral hand. Conclusions: In our study, nonsurgical treatment of isolated fractures of the medial humeral epicondyle with between 5 and 15 mm of displacement yielded good long‐term results similar to those obtained with open reduction and internal fixation. The nonunion of the epicondylar fragment that was present in most patients who had been treated only with a cast did not adversely affect the functional results. Surgical excision of the medial epicondylar fragment should be avoided because the long‐term results are poor.

Arthrodesis of the toe joints with an intramedullary cannulated screw for correction of hammertoe deformity

Twenty-four patients (37 feet, 51 toes) affected by hammertoe deformity of the lesser toes and treated surgically by arthrodesis of the proximal interphalangeal joint, stabilized with an intramedullary titanium cannulated screw, were reviewed 1–4 years after the operation. At follow-up, the arthrodesis was fused in 48 toes; three toes showed an asymptomatic radiographic nonunion, and in one of them the screw was broken. In seven toes, the cannulated screw was removed because of persistent pain at the tip of the toe where the head of the screw was located. In one case only, there was a late infection, with toe malalignment. All the patients were able to use street shoes 2 weeks after surgery. The average AOFAS score at follow-up was 86.54 points. Compared to the conventional temporary stabilization with an intramedullary Kirschner wire, the stabilization with a cannulated screw decreases the risk of infection, of radiographic nonunion, and of mallet toe deformity.

Vertebra plana. Long-term follow-up in five patients.

Five patients with vertebra plana were followed for twelve to thirty years after the diagnosis had been made. Histiocytosis X had been the presumptive diagnosis in all five patients. Their ages at diagnosis ranged from four to twelve years and at follow-up, from nineteen to forty years. When they were last seen, none of the patients complained of symptoms related to the original disease, and the radiographs showed reconstitution of the vertebral height equivalent to 48 to 95 per cent of normal, with no sign of osteoarthritis. The best radiographic results occurred in the two youngest patients, who had involvement of the first lumbar vertebra, whereas the patient who was oldest at follow-up, with vertebra plana in the ninth thoracic vertebra, had the worst result. The four patients with just vertebra plana were treated with a plaster jacket and a brace, whereas the one with multicentric skeletal involvement had chemotherapy as well as orthopaedic treatment.

Supracondylar fractures of the humerus in children. Analysis at maturity of fifty-three patients treated conservatively.

From a pool of 131 supracondylar fractures of the humerus in 131 patients who were treated conservatively, all of which healed in an average time of 4.5 weeks without complications related to the treatment itself, the cases of fifty-three patients were reviewed at maturity. The average age at follow-up was twenty-six years. Nine patients had unimportant limitation of elbow motion, and slight atrophy of the musculature of the arm or forearm, or of both, was present in six patients. Arm-length discrepancy was never observed. The carrying angle remained at about the same value that had been present at the time of fracture-healing in eighteen patients, decreased in twenty-two patients, and increased in thirteen. Malrotation of the distal fragment of the fracture only rarely caused medial tilting of the fragment with consequent cubitus varus. Varus deformity was present in four patients and valgus deformity, in three. None of the patients with valgus deformity had ulnar-nerve palsy. According to our results, varus and valgus deformities of the elbow after supracondylar fractures of the humerus seem to be caused either by growth imbalance of the growth plate of the distal end of the humerus (four patients) or by malreduction of the fracture (three patients). Twelve patients in the entire pool had neurological complications at the time of the fracture. Ten of those patients fully recovered from the deficit, whereas two--one with a radial-nerve deficit and the other with ulnar-nerve involvement--still had neurological impairment at follow-up.

Long-term results of open sternocleidomastoid tenotomy for idiopathic muscular torticollis.

At the end of their skeletal growth, we evaluated the cases of sixty-seven patients who had had an open tenotomy of the sternal and clavicular origins of the sternocleidomastoid muscle for idiopathic muscular torticollis. The average length of follow-up was 15.4 years, and the average age at the last follow-up was 23.9 years. The patients were divided into three groups according to their age at the time of operation. Group I consisted of patients who were operated on between the ages of five months and six years; Group II, of patients who were operated on between the ages of seven and eleven years; and Group III, of patients who were operated on when they were twelve years old or older. According to our method of evaluation, 37 per cent of the patients had a good, 45 per cent had a fair, and 18 per cent had a poor result. The patients in Group I had the best results and those in Group III, the worst. In general, the patients age at operation, the duration of the disease, and the severity of the deformity before the operation had the major effects on both cosmetic and functional results.

Histology and ultrastructure of arteries, veins, and peripheral nerves during limb lengthening

The effects of lengthening of the metacarpal bone on peripheral nerves and blood vessels were studied in 8 calves. Specimens for light and electron microscopy were obtained from the palmar neurovascular bundle at 1 cm (8% of the initial length), 2.5 cm (20% of the initial length), and 4 cm (33% of the initial length) of metacarpal lengthening. In 2 calves, specimens were studied 2 months after the end of the lengthening procedure. At 8% of lengthening, myelinated fibers of the palmar nerve showed moderate degenerative changes in the myelin sheath. This became severe at 20% and 33% of lengthening, and affected the axoplasm as well. At 20% of lengthening, the palmar vein started to show fibrous metaplasia of the smooth muscle tissue of the tunica media. This became much thinner than normal. The palmar artery showed moderate alterations of the inner part of the tunica media and the intima. The palmar nerve and blood vessels recovered their normal structure almost completely 2 months after the end of the lengthening procedure. The morphologic alterations of peripheral nerves and vessels may constitute the pathophysiologic basis of the nervous and circulatory disturbance observed in clinical practice.

Anterior tibial tendon transfer in relapsing congenital clubfoot: long-term follow-up study of two series treated with a different protocol.

Two series of patients with relapsing congenital clubfoot were treated by transfer of the anterior tibial tendon to the third cuneiform under the extensor retinaculum. The two series were reviewed at the end of skeletal growth to evaluate the effectiveness of the surgical procedure. The first series included 19 clubfeet and the second 16. The two series of clubfeet were initially treated by two different manipulative techniques and two different complementary soft tissue release operations. In relapsing clubfeet, the foot dorsiflexion/eversion activity of the tibialis anterior was suppressed and the muscle functioned as an invertor. At follow-up the functional results of the second series of patients, in whom the relapsing deformity was passively correctable at the time of surgery, were better than those of the first series of patients, in whom the relapsing deformity was sometimes less passively correctable. None of the operated patients had a further relapse. In both series, the angles formed by the longitudinal axis of the navicular and the first cuneiform, the calcaneus and the fifth metatarsal, and the calcaneus and the cuboid, evaluated both by plain radiographs and by CT scan, were smaller than in normal feet and in the clubfeet that did not relapse. Transfer of the anterior tibial tendon to the third cuneiform underneath the extensor retinaculum corrects and stabilizes relapsing clubfeet by restoring their normal function of foot dorsiflexion/eversion. As a consequence, the cuneiforms and the cuboid were shifted more laterally than normal, as shown by both x-rays and CT scan.