Reconstruction of a Neglected, Extensor Hallucis Longus Tendon Rupture Using Interposed Scar Tissue: A Case Report and Literature Review

Injury of the extensor hallucis longus (EHL) tendon is relatively rare, but surgical repair is necessary to prevent deformity and gait disturbance. Primary suturing is possible if the condition is acute, but not when it is chronic. The scar tissue between the ruptured ends is a proliferative tissue composed of fibroblasts and collagen fibers. Given the histological similarity to normal tendons, several studies have reported tendon reconstruction using scar tissue. Here, we report a reconstruction of a neglected EHL rupture using interposed scar tissue. A 54-year-old female visited our clinic with a weak extension of a big toe. She had dropped a knife on her foot a month prior, but did not go to hospital. The wound had healed, but she noted dysfunctional extension of the toe and increasing pain. Magnetic resonance imaging (MRI) revealed that EHL continuity was lost and that the proximal tendon stump was displaced toward the midfoot. Scar tissue running in the direction of the original ligament was observed between the ruptured ends. In the surgical field, the scar tissue formed a shape similar to the extensor tendon. Therefore, we performed tendon reconstruction using the interposed scar tissue. For the first 2 postoperative weeks, the ankle and foot were immobilized to protect the repair. Six weeks after surgery, the patient commenced full weight-bearing. At the 3-month follow-up, active extension of the hallux was possible, with a full range of motion. The patient did not feel any discomfort during daily life. Postoperative MRI performed at 1 year revealed that the reconstructed EHL exhibited homogeneously low signal intensity, and was continuous. The AOFAS Hallux Metatarsophalangeal-Interphalangeal scale improved from 57 to 90 points and the FAAM scores improved from 74% to 95% (the Activities of Daily Living subscale) and from 64% to 94% (the Sports subscale). Scar tissue reconstruction is as effective as tendon autografting or allografting, eliminates the risk of donor site morbidity and infection, and requires only a small incision and a short operative time.

Electrospun Resorbable Drug-eluting Nanofibers Promote Healing of Allograft Tendons

We developed biodegradable drug-eluting nanofibers employing an electrospinning technique, and evaluated their effectiveness on the healing of allograft tendon. Poly-D-L-lactide-glycolide was used as the polymeric material for nanofiber, while doxycycline was selected as the drug for delivery. The in vitro and in vivo drug release profiles were investigated. The biomechanical properties of allograft Achilles tendons repaired using the nanofibers were tested in euthanized rabbits at 2-, 4-, and 6-week time intervals. Histological examination was performed for the evaluation of tissue reaction and tendon healing. The level of postoperative animal activity was also monitored using an animal behavior cage. The experimental results showed that the degradable nanofibers as a vehicle could provide sustained release of doxycycline for over 40 days after surgery with very low systemic drug concentration. Allograft Achilles tendon reconstruction assisted with the drug-loaded nanofibers was associated with better biomechanical properties at 6 weeks post-surgery. In addition, the animals exhibited a better level of activity after surgery. Use of drug-eluting nanofibrous membranes could enhance healing in Achilles tendon reconstruction surgery with allograft.

REHABILITATION PROTOCOL AFTER ACHILLES TENDON RECONSTRUCTION WITH AN AUTOLOGOUS HAMSTRING GRAFT

Introduction One of the treatment options in chronic damage or unsuccessful suturing of the Achilles tendon is a surgical treatment consisting of its reconstruction using the tendon of semitendinosus and gracilis muscle. The multitude of types of reconstruction causes discrepancies in rehabilitation protocols. All of them aim to return to full functional fitness as the ultimate goal. Aim This study aims to present the proprietary rehabilitation protocol after Achilles tendon reconstruction using the tendon of semitendinosus and gracilis muscle. Material and methods The presented rehabilitation program lasts about 12 months and is divided into six stages. Stage I consists of standing up and anticoagulant exercises, and isometric exercise. Stage II, lasting up to 2 weeks after the procedure, consists of the patient’s independent work in the home environment. Stage III, lasting up to 4 weeks, involves learning to walk and putting weight on the limb in a cam Walker. In the third stage, after the postoperative wounds have healed, exercises in water conditions are started. Stage IV, lasting from 4 weeks after the operation, involves loading the limb with support, increasing the range of dorsiflexion motion, and progressive muscle strengthening. Stage V, which lasts up to 8–12 months after surgery, eliminates functional deficits and prepares the patient for a functional biomechanical assessment. Stage VI is the stage of work on the compensation of deficits resulting from the analysis of the results of the functional biomechanical assessment necessary to return to the full sports activity. Results The rehabilitation time, in accordance with the assumptions of the above protocol, is 8–12 months. After this time, the patient should proceed to a functional biomechanical assessment. Discussion and conclusions The rehabilitation protocol presented by our team describes in detail the stages of post-operative rehabilitation after Achilles tendon reconstruction with a hamstring graft. It provides the conditions necessary for the patient to meet before starting the next phase and returning to sport. Our requirements are consistent with the assumptions available in the scientific base. Keywords: Achilles tendon reconstruction, return to sport, rehabilitation program.

Latissimus Dorsi Tendon Reconstruction at the Myotendinous Junction With Acellular Dermal Allograft

Background: Limited available data have shown latissimus dorsi tendon reconstruction to be an effective treatment for tendon tears in specific subpopulations of elite overhead throwing athletes. Indications: Primary indication for latissimus dorsi tendon reconstruction is a symptomatic, full-thickness humeral avulsion with or without a concomitant teres major tendon tear. Surgical candidates are typically young, high-demand, elite or professional overhead throwing athletes. In this case, the patient is a 29-year-old male former minor league pitcher and current pitching coach with a full-thickness avulsion of the latissimus dorsi tendon. Technique Description: The patient was positioned left lateral decubitus with a dynamic limb positioner maintaining the arm in 90° abduction and maximal internal rotation. This technique used a single posterior axillary incision, which was performed and dissected down to the ruptured latissimus dorsi tendon. We circumferentially applied an acellular dermal allograft to augment the reconstruction at the myotendinous junction. Subsequently, the construct was prepared for transfer with a Krackow suture technique. Suture buttons were used to secure the reconstructed latissimus dorsi tendon to the anatomic footprint on the proximal humerus with a tension slide technique. Results: One case series showed return to the previous level of competition for all baseball pitchers who underwent a latissimus dorsi reconstruction with excellent improvement in visual analog scale pain, American Shoulder and Elbow Surgeons, and Kerlan-Jobe Orthopaedic Clinic scores. Another larger study demonstrated equal return to play rates for professional baseball pitchers with a latissimus dorsi tear treated either nonoperatively or operatively. However, those treated operatively had no decline in performance, whereas the nonoperative cohort saw decline in some statistics. Conclusion: Latissimus dorsi tendon reconstruction using an acellular dermal allograft at the myotendinous junction is a viable treatment option for elite overhead throwing athletes with full-thickness tendon avulsions. It allows for full return to play, particularly if the patient has failed nonoperative management.