Application Value of Musculoskeletal Ultrasound in DAA-THA with Conjoined Tendon Repair

Objective: To observe the ultrasonographic characteristics of conjoined tendon repair in direct anterior approach for total hip arthroplasty (DAA-THA), and to evaluate the efficacy of musculoskeletal ultrasound in determining the healing after joint tendon repair. Methods: A total of 60 patients who required primary total hip arthroplasty in Yulin Orthopedic Hospital of Chinese and Western Medicine from July 2020 to July 2021 were selected; the patients were divided into two groups, an observation group, group A (n = 30), and a control group, group B (n = 30), according to different intraoperative methods. There was no significant difference in gender, age, and diagnosis between the two groups. Direct anterior approach was used for both the groups. For group A, the joint capsule and conjoined tendon (superior gemellus, obturator internus, and inferior gemellus) were repaired in situ, whereas for group B, only the joint capsule was repaired in situ, while the conjoined tendon was not repaired. The healing of the tendon was observed. Results: (1) in terms of diagnosis, after conjoined tendon repair, 26 cases in group A showed good tendon continuity, good tension, and a small amount of effusion echo around, three cases showed partial interruption of tendon echo, low echo, or no echo inside with insufficient structural clarity, and a case showed complete interruption; in group B, all 30 cases had continuous interruption, poor tension, tendon retraction, and thickening; the healing rate of group A’s conjoined tendon repair was 96.67%; (2) in terms of prognostic assessment, one month after the surgery, the Harris score of group A was significantly higher than that of group B (P < 0.05); however, there was no significant difference in the terms of the Harris score between the two groups 3-6 months after surgery (P > 0.05); the effective tension of conjoined tendon and the effective muscle strength of group A were significantly higher than those of group B (P < 0.05). Conclusion: Musculoskeletal ultrasound has high diagnostic value in the healing of conjoined tendon and provides dynamic clinical observation after conjoined tendon repair in DAA-THA; it is proven that DAA-THA with conjoined tendon repair on the premise of reconstructing the joint capsule can well restore its tension, enhance its muscle strength, significantly improve early joint stability and joint function, as well as facilitate the rapid recovery of patients.

Conjoined tendon preserving posterior approach in hemiarthroplasty for femoral neck fractures: A prospective multicenter clinical study of 322 patients

Purpose The posterior approach is widely used in femoral hemiarthroplasty. The major problem with this approach is the high risk of postoperative dislocation. A modified posterior approach, the conjoined tendon preserving posterior approach (CPP), was developed to reduce postoperative dislocations. The objective of this multicenter study was to evaluate the efficacy and safety of hemiarthroplasty performed using the CPP approach for femoral neck fractures. Methods A total of 322 patients with femoral neck fracture, from 10 facilities, were prospectively studied. Bipolar hemiarthroplasty using the CPP approach was performed, using the same type of implants. Hip joint movement was not restricted following surgery, regardless of a patient’s cognitive status. Final follow-up was performed 9.1 ± 1.5 months after surgery. Results Hemiarthroplasty was undertaken in 320 patients using the CPP approach. The mean age, operative time, and intraoperative blood loss were 83.3 ± 7.4 years, 70.0 ± 22.7 min, and 134.8 ± 107.9 mL, respectively. No postoperative dislocations were observed during the study period. Intraoperative adverse events related to the hip joint included femoral fractures in five patients (1.6%) and trochanteric fractures in four patients (1.3%). Postoperative hip joint adverse events included a periprosthetic fracture in one patient (0.3%), deep infection in two patients (0.6%), and stem subsidence in one patient (0.3%). Postoperative deaths occurred in 23 patients (7.2%). One patient (0.3%) had a severe non-hip adverse event unrelated to surgery that prevented independent living, while five patients (1.6%) had a moderate non-hip adverse event that required treatment. Conclusion The CPP approach prevented postoperative dislocation following femoral hemiarthroplasty in elderly patients, with no CPP-associated specific adverse events.

Factors Affecting Stability of the Reverse Total Shoulder Arthroplasty: A Cadaveric Biomechanical Study

Background: The overall objective of this study was to investigate whether a reverse shoulder arthroplasty could provide adequate stability to a shoulder even with extreme soft tissue loss. The specific objectives of this study were: to determine if just the deltoid, conjoined tendon, and triceps are sufficient soft tissues to allow a Reverse Shoulder Arthroplasty (RSA) to provide shoulder stability and to determine the influence of load direction, rotation, shoulder position, and polyethylene thickness on RSA stability in this soft-tissue deficient model. Methods: This study utilized six cadaveric shoulders that had all soft tissue removed, with the exception of the deltoid, conjoint tendon, and long head of triceps. A reverse shoulder arthroplasty was then performed (Delta III, DePuy Inc., Warsaw, IN) and an increasing dislocation force was applied perpendicular to the humeral socket centerline until dislocation occurred, or a maximum load of 100 N was reached. This was repeated to measure the effect of four factors: load direction, arm position, polyethylene thickness, and arm rotation on force to dislocation. Results: For load direction, there was an increase in force to dislocate an inferior load direction (p=0.01). There was a lower not dislocated percentage and lower survival for a posterior load direction (p=0.02). For arm position, there was a decrease in force for dislocation and lower survival for both abduction and extension arm positions. There was a higher not dislocated percentage for a flexion arm position (p=0.01). For arm rotation, there was a lower not dislocated percentage and lower survival for an external rotation arm position (p=0.03). There was no statistically significant influence of polyethylene thickness (p=0.26). Conclusion: The deltoid, conjoined tendon, and triceps are sufficient to stabilize an RSA. Load direction, arm position, and arm rotation were all shown to significantly affect stability. Finally, polyethylene thickness may not affect overall RSA stability in this soft-tissue deficient model. Level of Evidence: Basic science study, Biomechanical study.

Bipolar hip arthroplasty in geriatric patients using a conjoined tendon-preserving posterior approach

Background In bipolar hemiarthroplasty (BHA), it is important to preserve soft tissue to reduce the risk of postoperative dislocation. While a variety of surgical approaches have been reported recently, extra care is needed with muscle- and tendon-preserving approaches in geriatric patients due to the fragility of their soft tissue. We investigated the usefulness of BHA using a conjoined tendon-preserving posterior (CPP) approach, which only dissects the external obturator muscle, in geriatric patients. Methods This retrospective study included 40 femoral neck fracture patients (10 men, 30 women) aged ≥ 80 years who underwent BHA using the CPP approach. The average age of the subjects was 85.8 years (80–94 years). We examined operation time, bleeding, preservation of short external rotator muscles, complications, and stem alignment and subsidence from postoperative radiographs. Results Although, gemellus inferior muscle injury was detected in 4 patients (10%), hip joint stability was very excellent in all cases. There was no intraoperative fracture and postoperative dislocation. On postoperative radiographs, all femoral stems were in a neutral position. There was no stem subsidence in all the patients. Conclusions BHA using the CPP approach was not associated with postoperative dislocation and appeared to be useful even in geriatric patients with soft tissue fragility.

Bipolar hip arthroplasty in geriatric patients using a conjoined tendon-preserving posterior approach

Background In bipolar hemiarthroplasty (BHA), it is important to preserve soft tissue to reduce the risk of postoperative dislocation. While a variety of surgical approaches have been reported recently with this in mind, extra care is needed with muscle- and tendon-preserving approaches in geriatric patients due to the fragility of their soft tissue. We investigated the usefulness of BHA using a conjoined tendon-preserving posterior (CPP) approach, which only dissects the external obturator muscle, in geriatric patients. Methods This retrospective study included 40 femoral neck fracture patients (10 men, 30 women) aged ≥80 years who underwent BHA using the CPP approach. The average age of the subjects was 85.8 years (80 - 94 years). We examined operation time, bleeding, preservation of short external rotator muscles, complications, and stem alignment and subsidence from postoperative radiographs. Results Although, gemellus inferior muscle injury was detected in 4 patients (10%), hip joint stability was very excellent in all cases. There was no intraoperative fracture and postoperative dislocation. On postoperative radiographs, all femoral stems were in a neutral position. There was no stem subsidence in all the patients. Conclusions BHA using the CPP approach was not associated with postoperative dislocation and appeared to be useful even in geriatric patients with soft tissue fragility.

Preservation technique of the piriformis tendon is superior to reattachment technique in terms of contiguity and muscle atrophy: using magnetic resonance imaging

Purpose: The preservation technique of the piriformis tendon during the posterolateral approach in total hip arthroplasty (THA) is reportedly superior to the reattachment technique in terms of dislocation. However, the long-term effects of preservation of the piriformis tendon during THA remain unknown. In this study, we evaluated the contiguity of the piriformis/conjoined tendon and atrophy of the piriformis/internal obturator muscle during a long-term postoperative follow-up using magnetic resonance imaging (MRI). Methods: We retrospectively evaluated 48 patients with available MRI. The 48 patients were classified into a P group ( n = 29), in which the piriformis tendon was preserved, and an R group ( n = 19), in which the piriformis was reattached after sectioning. The mean follow-up duration was 45.9 months. The contiguity of the piriformis/conjoined tendon and atrophy of the piriformis/internal obturator muscle were evaluated in all patients. Results: The piriformis tendon remained attached to the greater trochanter in all P-group patients and 68.4% of R-group patients. The mean piriformis muscle atrophy ratios were 15.9% ± 21.1% in the P group and 41.6% ± 19.1% in the R group ( p < 0.001). The conjoined tendon repair remained intact in 72.4% of P-group patients and 36.8% of R-group patients ( p < 0.05). The mean internal obturator muscle atrophy ratio was 31.4% ± 26.2% in the P group and 50.4% ± 19.1% in the R group ( p < 0.05). No postoperative pulmonary embolism, wound infection, deep infection, or hip dislocation occurred. Conclusions: In our study, we suggest that the preservation technique of the piriformis tendon is superior to the reattachment technique in terms of contiguity and muscle atrophy.