Giovanni Capasso

Results of Percutaneous Longitudinal Tenotomy for Achilles Tendinopathy in Middle- and Long-Distance Runners

From August 1989 to January 1995 we performed multiple percutaneous longitudinal tenotomies under local anesthetic on 52 middle- and long-distance run ners with unilateral Achilles tendinitis or peritendinitis that had failed conservative treatment. Forty-eight pa tients were reviewed at an average of 22.1 months (SD, 6.5) after surgery. Results were rated as excellent in 25 patients, good in 12, fair in 7, and poor in 4. Four patients developed subcutaneous hematomas. One patient developed a superficial infection at one of the incision sites, which was managed by oral antibiotics with full recovery. Three patients complained of over- sensitivity to the incisions; this was resolved by rubbing hand cream over the incisions several times a day. One patient developed hypertrophic painful scars on three of the five incisions, but corticosteroid injections yielded good functional and cosmetic results. Isometric strength and endurance of the gastrocsoleus complex was measured just before the procedure, and at 6 weeks and 6 months later. Both were within 10% of the normal contralateral limb by the 6th postoperative month. Percutaneous longitudinal tenotomy is simple, can be performed on an outpatient basis, requires minimal follow-up care, and, in our experience, has produced no significant complications. We use this procedure as the operative treatment of choice for cases of chronic tendinitis that have failed conservative treatment.

Similar histopathological picture in males with Achilles and patellar tendinopathy.

PURPOSE To ascertain whether there are differences in the histopathological appearance of tendinopathic Achilles and patellar tendons. METHODS In males, we studied biopsies from tendinopathic Achilles (N = 28; average age 34.1 yr) and patellar tendons (N = 28; average age 32.1), Achilles tendons (N = 21; average age 61.8 yr) from deceased patients with no known tendon pathology, and patellar tendons (N = 15; average age 28.3) from patients undergoing anterior cruciate ligament reconstruction. Hematoxylineosin stained slides were interpreted using a semiquantitative grading scale (0: normal to 3: maximally abnormal) for fiber structure, fiber arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinization. All slides were assessed blindly twice, the agreement between two readings ranging from 0.170 to 0.750 (kappa statistics). RESULTS The highest mean score of tendinopathic Achilles tendons was not significantly different from that of tendinopathic patellar tendons (11.6 +/- 5 and 10.4 +/- 3, respectively). The ability to differentiate between an Achilles tendon and a patellar tendon was low. CONCLUSIONS Tendinopathic Achilles and patellar tendons show a similar histological picture. It was not possible to identify whether a specimen had been harvested from an Achilles or a patellar tendon on the basis of histological examination. The general pattern of degeneration was common to both tendinopathic Achilles and patellar tendons. A common, as yet unidentified, etiopathological mechanism may have acted on both these tendon populations.

Isolated Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Dislocation

Background Several medial patellofemoral ligament reconstruction procedures have been proposed to manage recurrent patellar dislocation. Hypothesis Reconstruction of the medial patellofemoral ligament using a hamstring graft with a 2 transverse patellar tunnels technique is an effective treatment for recurrent patellar dislocation in patients without any evident predisposing factors. Study Design Case series; Level of evidence, 4. Methods Twenty-eight patients with chronic patellar instability without any anatomic predisposing factors, experiencing recurrent unilateral patellar dislocation, were included in the study. Evaluation included the modified Cincinnati and the Kujala scores, anthropometry, plain radiography, and isokinetic dynamometry. Results The average follow-up was 3.1 years (range, 2.5-4 years). The mean modified Cincinnati score increased from 52 preoperatively to 89 (P = .001). The mean Kujala scores increased from 45 preoperatively to 83 (P = .03). The muscle volume of the thigh of the operated limb increased with time, but remained less well developed than the nonoperated limb (P = .04). The mean Insall-Salvati index was 1.1 (range, 0.9-1.2) preoperatively and remained within normal range (1.1 [range, 0.9 to 1.2]) (P = .07), at latest follow-up. Significant isokinetic strength differences were found between the operated and the contralateral limbs (.05 < P < .006), even at the latest follow-up. Three patients experienced a new patellar dislocation. Conclusion Medial patellofemoral ligament reconstruction using hamstring tendon passed through a double patellar transverse bony tunnel technique is a safe, reliable management option for recurrent patellar dislocation in patients without any predisposing anatomic factors.

Calcific Insertional Achilles Tendinopathy Reattachment With Bone Anchors

Background Recalcitrant calcific insertional Achilles tendinopathy is difficult to treat. Hypothesis Bursectomy, excision of the distal paratenon, disinsertion of the tendon, removal of the calcific deposit, and reinsertion of the Achilles tendon with bone anchors is safe and effective. Study Design Longitudinal study. Methods Twenty-one patients (six women) (21 feet) (average age 46.9 ± 6.4 years) with recalcitrant calcific insertional Achilles tendinopathy were treated surgically with removal of the calcific deposit; the Achilles tendon was reinserted with bone anchors. Results At an average follow-up of 48.4 months, one patient necessitated a further operation. Eleven patients reported an excellent result, and five a good result. The remaining five patients could not return to their normal levels of sporting activity and kept fit by alternative means. The results of the VISA-A questionnaire were markedly improved in all patients, from an average of 62.4% to 88.1%. Conclusions We recommend disinsertion of the Achilles tendon to excise the calcific deposit fully and reinsertion of the Achilles tendon in the calcaneus with suture anchors. No patient experienced a traumatic disinsertion of the reattached tendon. However, five patients were not able to return to their original level of physical activity.

Ultrasound-guided percutaneous longitudinal tenotomy for the management of patellar tendinopathy.

Thirty-eight athletes with unilateral patellar tendinopathy (17 with a tendinopathy of the main body of the tendon, and 21 with an insertional tendinopathy) underwent ultrasound-guided multiple percutaneous longitudinal tenotomy under local anaesthetic infiltration after failure of conservative management. Thirty-four patients were reviewed at least 24 months after the operation. Sixteen patients were rated excellent, nine good, eight fair, and five poor. Nine of the 13 patients with a fair or poor result had an insertional tendinopathy, and eight of them underwent a formal exploration of the patellar tendon. Before the operation, there were some areas of altered echogenicity at and around the site of involvement. These were still visible 6 wk after surgery in 70% of the patients. At the latest follow-up, in the patients with an excellent or good result, the tendon was generally isoechogenic but slightly thicker (P = 0.06) than the normal contralateral. In the patients with a fair or poor result, the tendon was significantly thicker than the contralateral (P = 0.03), and showed some areas of mixed echogenicity. In the patients in whom the procedure was successful, the thicker operated tendon did not interfere with physical training. Bilateral isokinetic peak torque (Nm), average work (Joules), and average power (Watts) were tested at 90 degrees x s(-1). Immediately before the operation, there was no significant difference in peak torque, but total work and average power were significantly lower in the limb to be operated (0.01 < P < 0.05). By the end of the study, although peak torque was, on average, within 7% of the unoperated limb, total work and average power were still significantly lower than in the unoperated limb (0.01 < P < 0.04). Percutaneous longitudinal internal tenotomy is simple, can be performed on an outpatient basis, requires minimal follow-up care, does not hinder further surgery should it be unsuccessful, and, in our experience, has produced no significant complications. In our hands, it has become the first line operative intervention in the treatment of chronic patellar tendinopathy after failure of conservative management. However, patients should be advised that, if they suffer from an tendinopathy at the attachment of the patellar tendon at the lower pole of the patella, a formal surgical exploration with stripping of the paratenon is preferable.

Surgery for chronic achilles tendinopathy yields worse results in nonathletic patients

ObjectiveTo report the outcome of surgery for chronic recalcitrant Achilles tendinopathy in nonathletic and athletic subjects. DesignCase-control study. SettingUniversity teaching hospitals. PatientsWe matched each of the 61 nonathletic patients with a diagnosis of tendinopathy of the Achilles tendon with an athletic patient with tendinopathy of the main body of the Achilles tendon of the same sex and age (±2 years). A match was possible for 56 patients (23 males and 33 females). Forty-eight nonathletic subjects and 45 athletic subjects agreed to participate. InterventionsOpen surgery for Achilles tendinopathy. Main Outcome MeasureOutcome of surgery, return to sport, complication rate. ResultsNonathletic patients were shorter and heavier than athletic patients. They had greater body mass index, calf circumference, side-to-side calf circumference differences, and subcutaneous body fat than athletic patients. Of the 48 nonathletic patients, 9 underwent further surgery during the study period, and only 25 reported an excellent or good result. Of the 45 athletic subjects, 4 underwent further surgery during the study period, and 36 reported an excellent or good result. The remaining patients could not return to their normal levels of activity. In all of them, pain significantly interfered with daily activities. ConclusionsNonathletic subjects experience more prolonged recovery, more complications, and a greater risk of further surgery than athletic subjects with recalcitrant Achilles tendinopathy.

Isolated Anterior Talofibular Ligament Broström Repair for Chronic Lateral Ankle Instability 9-Year Follow-up

Background: Lateral ankle sprains may result in pain and disability in the short term, decreased sport activity and early retirement from sports in the mid term, and secondary injuries and development of early osteoarthritis to the ankle in the long term. Hypothesis: This combined approach to chronic lateral instability and intra-articular lesions of the ankle is safe and in the long term maintains mechanical stability, functional ability, and a good level of sport activity. Study Design: Case series; Level of evidence, 4. Methods: We present the long-term outcomes of 42 athletes who underwent ankle arthroscopy and anterior talofibular Broström repair for management of chronic lateral ankle instability. We assessed in all patients preoperative and postoperative anterior drawer test and side-to-side differences, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Kaikkonen grading scales. Patients were asked about return to sport and level of activity. Patients were also assessed for development of degenerative changes to the ankle, and preoperative versus postoperative findings were compared. Results: Thirty-eight patients were reviewed at an average of 8.7 years (range, 5-13 years) after surgery; 4 patients were lost to follow-up. At the last follow-up, patients were significantly improved for ankle laxity, AOFAS scores, and Kaikkonen scales. The mean AOFAS score improved from 51 (range, 32-71) to 90 (range, 67-100), and the mean Kaikkonen score improved from 45 (range, 30-70) to 90 (range, 65-100). According to outcome criteria set preoperatively, there were 8 failures by the AOFAS score and 9 by the Kaikkonen score. Twenty-two (58%) patients practiced sport at the preinjury level, 6 (16%) had changed to lower levels but were still active in less demanding sports (cycling and tennis), and 10 (26%) had abandoned active sport participation although they still were physically active. Six of these patients did not feel safe with their ankle because of the occurrence of new episodes of ankle instability. Of the 27 patients who had no evidence of degenerative changes preoperatively, 8 patients (30%) had radiographic signs of degenerative changes (5 grade I and 3 grade II) of the ankle; 4 of the 11 patients (11%) with preexisting grade I changes remained unchanged, and 7 patients (18%) had progressed to grade II. No correlation was found between osteoarthritis and status of sport activity (P = .72). Conclusion: Combined Broström repair and ankle arthroscopy are safe and allow most patients to return to preinjury daily and sport activities.

The 3-in-1 Procedure for Recurrent Dislocation of the Patella in Skeletally Immature Children and Adolescents

Background Recurrent patellar dislocations are common injuries in children and adolescents. The subjective and functional results of soft tissue surgical management in a population that was skeletally immature at the time of surgery have not been reported. Hypothesis The 3-in-1 procedure is an effective treatment for recurrent patellar dislocation in skeletally immature patients. Study Design Case series; Level of evidence, 4. Methods Twenty-five skeletally immature patients (age at operation, 13.5 ± 3.8 years) who were practicing sports and suffering from recurrent unilateral patellar dislocation were included in the study and followed until skeletal maturation. Clinical evaluation included the modified Cincinnati rating system and the Kujala score, anthropometry, plain radiography, and isokinetic dynamometry. Results The average follow-up was 3.8 years (range, 2.5-6 years). The mean modified Cincinnati score increased from 51.7 ± 12.6 preoperatively to 94.3 ± 10.8 (P < .02), while the mean Kujala scores increased from 52.4 ± 12.7 preoperatively to 93.8 ± 14.2 (P < .02). The Insall-Salvati index remained essentially unchanged, being 1.04 ± 0.2 preoperatively and 1.02 ± 0.3 at latest follow-up. Significant differences were found between the operated and the contralateral limb in the various isokinetic strength variables at all angular velocities measured at the latest follow-up (.05 < P < .0042). Conclusion The 3-in-1 procedure is a safe, reliable management option for recurrent patellar dislocation in skeletally immature patients. Side-to-side differences in isokinetic strength and in anthropometric indices persist despite subjective success of the procedure.

Italian translation of the VISA-A score for tendinopathy of the main body of the Achilles tendon.

Purpose. To translate and adapt the English VISA-A questionnaire to Italian, to perform reliability and validity evaluations of the Italian VISA-A version in patients with tendinopathy of the main body of the Achilles tendon. Methods. The VISA-A English version was translated into Italian by a bilingual orthopaedic surgeon. The back translation of the Italian version into English was performed by another bilingual orthopaedic surgeon. The original version was compared with the back translation. The VISA-A-I questionnaire was then administered to 50 male athletes (average age 26.4, range 18 – 49 years) with a diagnosis of tendinopathy of the main body of the AT. For test-retest evaluation, the 50 patients were asked to complete the questionnaire at first examination, and 30 minutes following the end of this examination. Results. The kappa statistics for 50 patients was 0.80 (range 0.7 – 0.86). There were no significant differences between the scores immediately after the consultation and 30 minutes later. Conclusions. Italian and the English versions of the VISA-A questionnaire evaluate the same aspects of clinical severity in patients with tendinopathy of the main body of the Achilles tendon.

VISA-P score for patellar tendinopathy in males: Adaptation to Italian

Purpose. To translate and adapt the English VISA-P questionnaire to Italian and to perform reliability and validity evaluations of the Italian VISA-P version in patients with patellar tendinopathy. Methods. The VISA-P English version was translated into Italian by a bilingual orthopaedic surgeon. The back translation of the Italian version into English was performed by another bilingual orthopaedic surgeon. The original version was compared with the back translation. The VISA-P-I questionnaire was then administered to 25 male athletes (average age 27.9, range 18–32 years) with a diagnosis of patellar tendinopathy. For test-retest evaluation, the 25 patients were asked to complete the questionnaire at first examination, and 30 minutes following the end of this examination. Results. The kappa statistics for 25 patients was 0.78. There were no significant differences between the scores immediately after the consultation and 30 minutes later. Conclusions. Italian and the English versions of the VISA-P questionnaire evaluate the same aspects of clinical severity in patients with patellar tendinopathy.