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Various techniques of surgical detachment for treatment of insertional Achilles tendinopathy have been described, including lateral release, medial release, central tendon splitting (CTS), and complete detachment. A systematic review of electronic databases was performed, encompassing 17 studies involving 703 patients and 746 feet, to compare outcomes associated with surgical takedown techniques. Observed results include wound complication rates (CTS 2.8%; Lateral 0%; Medial 0.4%; Complete 1.3%), postoperative rupture rates (CTS 0.7%; Lateral 0.8%; Medial 0.7%; Complete 2.6%), rate of revision (CTS 0.4%; Lateral 0.9%; Medial 4.2%; Complete 2.6%), rate of infection (CTS 1.1%; Lateral 1.7%; Medial 3.7%; Complete 6.5%). Lateral takedown group was found to have a statistically significant lower rate of complications compared to the complete takedown group (p = .0029). In light of these results, it is recommended that patient characteristics such as case specific tendon pathology and calcaneal morphology take precedent in determining the surgical approach to Achilles takedown.

Objective: Omohyoid muscle syndrome (OMS) is a condition that causes a X-shaped lateral neck lump on swallowing, caused by the failure of the central tendon of the omohyoid muscle to restrict movement of the muscle during swallowing. We aim to review the etiology, pathophysiology, diagnostic tests, and management options for this condition. Data Sources: Pubmed, MEDLINE, EMBASE, and Cochrane databases were searched for all articles and abstracts related to OMS up to 29th July 2020. Review Methods: A systematic review was performed, data extracted from relevant full text articles. Both quantitative data and qualitative data were analyzed. Results: Twenty cases of OMS were reported. Patients presented at a mean age of 36.0. All cases were Asian. There is a 7:3 ratio of males to females. The most common symptom was a transient neck mass. Most cases were managed conservatively with good prognosis. Open or endoscopic transection of the muscle and ultrasound-guided botulinum toxin injection were 3 treatment options, with no recurrence at 4 years, 6 months, and 6 months respectively. Conclusion: OMS could be genetic as all cases were Asian in ethnicity. The deep cervical fascia which usually envelopes the omohyoid muscle may be weakened by stress as 20% of cases had a preceding traumatic event. Real-time ultrasonography establishes the diagnosis, demonstrating the anterolateral displacement of the sternocleidomastoid muscle by a thickened omohyoid muscle during swallowing. Surgical transection can achieve cure, but due to limited studies available, they should be reserved for patients who are extremely bothered. Intramuscular injection of botulinum toxin is an effective alternative, but recurrence is expected.

Background: Current research shows that the anterior cable plays an essential role in rotator cuff tissue. To determine whether the distance between the supraspinatus central tendon and the long head of the biceps tendon, on a sagittal shoulder MRI scan, can predict anterior cable injury in rotator cuff tear patients before surgery. Method: A retrospective MRI scan was performed and a review of 103 patients with a rotator cuff tear – 50 patients with anterior cable injury and 53 patients without anterior cable injury. The distance between the supraspinatus central tendon and the biceps tendon’s long head was measured based on a sagittal MRI scan, and the tear size, degree of tear, and fatty degeneration of supraspinatus was also reviewed. SPSS software was used for statistical analysis of the relevant data. Two Independent Samples t-Test, binary logistics regression and receiver operating curve were also performed to evaluate select parameters.Results: The distance between the supraspinatus central tendon and the long head of the biceps tendon (DTD) was bigger in the anterior cable disrupted group (10.05±2.73 mm) when compared to the intact anterior cable group (7.96±2.30 mm) with a significant difference (P

Background: Severe rectus femoris central tendon rupture is an uncommon sports-related injury. Most rectus femoris central tendon injuries can be treated by nonoperative means, but some tend to reinjure, resulting in chronic symptoms. Physicians treating athletes with rectus femoris injuries should be aware of this clinical condition and know that surgical treatment could be beneficial to the athlete if the rectus femoris central tendon rupture becomes chronic. Purpose: To describe the clinical picture, magnetic resonance imaging (MRI) findings, and surgical treatment results of rectus femoris central tendon injuries. Study Design: Case series; Level of evidence, 4. Methods: This study included 12 patients who underwent successful repair of recurrent rectus femoris central tendon rupture. Presurgical MRI scans were obtained and compared with the surgical findings. The time of return to play was recorded, and the outcome of surgical treatment was evaluated with validated Subjective Patient Outcome for Return to Sports (SPORTS) criteria: good = full return to preinjury level of sports without any symptoms; moderate = return to preinjury level of sports with some residual symptoms (mild discomfort during sports); and poor = did not return to preinjury level of sports. Results: Overall, 10 patients had a good outcome (83%), and 2 had a moderate outcome (17%). All athletes included in the study were able to return to sport at their preinjury levels 2.5 to 4 months postoperatively. Presurgical MRI scans correlated well with the surgical findings. Conclusion: The surgical treatment of rectus femoris central tendon rupture seems to be a good option in chronic and recurrent cases. After surgery and successful rehabilitation, the athlete is expected to continue sports at the preinjury level.

Background: the aim of this study was to compare the echotexture of patients with soleus muscle injury and age matched controls. Methods: a sample of 62 athletes was recruited at the private clinic and was divided in two group: a healthy group (n=31) and a soleus pathology group whose athletes had soleus muscle injury, located in the central tendon (n=31). The muscle thickness (MTh), echointensity (EI) and echovariation (EV) were analyzed. An intra-rater reliability test (Intraclass Correlation Coefficient-ICC) was performed in order to analyze the reliability of the values of the measurements. Results: Sociodemographic variables did not show statistically significant differences (p &gt, 05). Ultrasound imaging measurements who reported statistically significant differences were EI (p = .001) and standard deviation (SD) (p = 0.001). MTh and EV variables did not show statistically significant differences (p = .381 and p = .364, respectively). Moreover, reliability values for the MTh (ICC = .911), EI (ICC = .982), SD (ICC = .955) and EV (ICC = .963). Based on these results the intra-rater reliability was considered excellent. Conclusion: Athletes with a central tendon injury of soleus muscle showed a lower EI when they were compared to healthy athletes. The echogenicity showed by the quantitative ultrasound imaging measurement may be a more objective parameter for the diagnosis and follow-up the soleus muscle injuries.

Background Soleus muscle injuries are common in different sports disciplines. The time required for recovery is often difficult to predict, and reinjury is common. The length of recovery time might be influenced by different variables, such as the involved part of the muscle. Hypothesis Injuries in the central aponeurosis have a worse prognosis than injuries of the lateral or medial aponeurosis as well as myofascial injuries. Study Design Case series; Level of evidence, 4. Methods A total of 61 high-level or professional athletes from several sports disciplines (soccer, tennis, track and field, basketball, triathlon, and field hockey) were reviewed prospectively to determine the recovery time for soleus muscle injuries. Clinical and magnetic resonance imaging evaluation was performed on 44 soleus muscle injuries. The association between the different characteristics of the 5 typical muscle sites, including the anterior and posterior myofascial and the lateral, central, and medial aponeurosis disruption, as well as the injury recovery time, were determined. Recovery time was correlated with age, sport, extent of edema, volume, cross-sectional area, and retraction extension or gap. Results Of the 44 patients with muscle injuries who were analyzed, there were 32 (72.7%) strains affecting the myotendinous junction (MT) and 12 (23.7%) strains of the myofascial junction. There were 13 injuries involving the myotendinous medial (MTM), 7 affecting the MT central (MTC), 12 the MT lateral (MTL), 8 the myofascial anterior (MFA), and 4 the myofascial posterior (MFP). The median recovery time (±SD) for all injuries was 29.1 ± 18.8 days. There were no statistically significant differences between the myotendinous and myofascial injuries regarding recovery time. The site with the worst prognosis was the MTC aponeurosis, with a mean recovery time of 44.3 ± 23.0 days. The site with the best prognosis was the MTL, with a mean recovery time of 19.2 ± 13.5 days ( P < .05). There was a statistically significant correlation between recovery time and age ( P < .001) and between recovery time and the extent of retraction ( P < .05). Conclusion Wide variation exists among the different types of soleus injuries and the corresponding recovery time for return to the same level of competitive sports. Injuries in the central aponeurosis have a significantly longer recovery time than do injuries in the lateral and medial aponeurosis and myofascial sites.

Two cases of traumatic sagittal band rupture causing extensor tendon subluxation are reported. A case of subacute rupture is repaired and a new surgical technique for reconstruction of a chronic rupture is described. Extensor tendon subluxation at the metacarpophalangeal joint is a rare occurrence in patients not affected by rheumatoid arthritis. The majority of cases involve the disruption of the radial sagittal band with consequent ulnar subluxation of the extensor tendon. The technique of sagittal band reconstruction described involves harvesting a distally based ulnar-sided strip of the extensor digitorum communis tendon, passing it transversely through the radial component of the tendon, and then looping it deep to the deep transverse metacarpal ligament. From here the tendon is then sutured back onto the central tendon, creating a delta-shaped graft. This technique reconstructs the normal anatomy of the sagittal band and has been found to eliminate the subluxation of the tendon and its associated pain.

Introduction The soleus muscle (SM) is located in the superficial posterior compartment of the leg, together with the gastrocnemius muscle (GM) and plantaris muscle. There is little information on the morphological variability (pennation) of the SM. The aim of the study is to characterize the variations in the morphology of the pennation of the SM and to create the first accurate classification. Material and methods Eighty lower limbs (40 left, and 40 right) fixed in 10% formalin solution were examined. The morphology of the central tendon, medial and lateral aponeuroses was evaluated, together with the pennation angle. Results In all cases, the soleus muscle was present. Four types could be distinguished based on muscle fibre morphology. In order of frequency: Type 1 – bipennate (43.75%); Type 4 – non-pennate (36.25%); Type 2 – unipennate (15%); Type 3 – multipennate (5%). No significant difference in type distribution was observed with regard to body side (p = 0.9018) or gender (p = 0.0844). Conclusion The soleus muscle is characterized by high morphological variability. Based on the pennation angle, four types (1–4) of soleus muscle are distinguishable.

Transdiaphragmatic hernia via the central tendon in the pericardium is a rare entity. Most often, these hernias are acquired and related to the iatrogenic creation of a transdiaphragmatic-pericardial defect. We would like to present a case of a 62-year-old male who presented with acute chest pain and was diagnosed to have a transdiaphragmatic-pericardial hernia on computed tomography. He has a history of cardiac intervention via an abdominal approach 12 years earlier. A segment of jejunum was found strangulated in the defect. We used DaVinci Xi® (Intuitive Surgical, Sunnyvale, CA) robot and were able to successfully reduce the hernia, repair the defect, and resect a short segment of jejunum which was non-viable. The utilization of a minimally invasive approach may be feasible, and the use of a robotic surgical system may enhance the surgeon's ability to repair the defect.

We aimed to uncover which rectus femoris strain injury types affect regional activation within the rectus femoris. The rectus femoris has a region-specific functional role, the proximal region of the rectus femoris contributes more than the middle and distal regions during hip flexion. Although a history of strain injury modifies the region-specific functional role within the rectus femoris, it was not obvious which rectus femoris strain injury types affect regional activation within it. We studied 12 soccer players with a history of rectus femoris strain injury. Injury data were obtained from a questionnaire survey and magnetic resonance imaging. To confirm the region-specific functional role of the rectus femoris, surface multichannel electromyographic signals were recorded. Accordingly, eight legs had a history of central tendon injury, four had a history of myofascial junction injury, and four had a healed strain injury. When the injury was limited to the central tendon, the region-specific functional role disappeared. The region-specific functional role was confirmed when the injury was outside the central part. The neuromuscular function was also inhibited when the longitudinal range of the injured region was long. Our findings suggest that a central tendon injury with a long injury length impairs regional neuromuscular activation of the rectus femoris muscle.

We describe a combined sternotomy/laparotomy approach as a novel technique in central tendon diaphragmatic hernia repair. During a routine second trimester prenatal ultrasound, a 19-year-old woman was found to have a fetus with a diaphragmatic hernia. Subsequent fetal MRI at 28 weeks demonstrated a large central tendon defect through which the majority of the liver was herniated. The fetus was closely followed until her delivery at 38 weeks. The patient was intubated shortly after delivery and treated for pulmonary hypertension. A thoraco-abdominal CT scan revealed a large, mushroom-shaped herniation of the liver. By day of life 7, the patient demonstrated physiological stability. Following a multidisciplinary meeting, the decision was made to proceed to surgery. A sternotomy with an upper midline laparotomy revealed the liver herniating through a central tendon defect without any hernia sac. The liver was reduced into the abdomen without kinks in the hepatic veins. The defect was then closed using a polytetrafluoroethylene patch. She did not develop any compartment syndrome despite pre-operative concerns. Post-operatively, she was weaned to conventional mechanical ventilation after brief requirement of high-frequency oscillatory ventilation, and subsequently extubated. A combined sternotomy/laparotomy provided an excellent operative exposure and may be effective in a large congenital central tendon diaphragmatic hernia repair.

Background. When Achilles tendon ruptures become chronic, a defect often forms at the rupture site. There is scant literature regarding the treatment of chronic Achilles ruptures with defects of 6 cm or larger. We examined outcomes from combining a turndown of the proximal, central Achilles with a flexor hallucis longus (FHL) tendon transfer to treat this condition. Materials. Between September 2002 and December 2013, 32 patients presented with a chronic Achilles rupture and a defect of 6 cm or more. Twenty patients were male and 12 were female. Patient age was between 20 and 74 years, with a mean of 53.3 years. Eighteen and 14 patients had their right and left Achilles tendon affected, respectively. The number of days between injury and surgery ranged from 30 to 315 days, with a mean of 102 days. Reconstruction of the Achilles involved a turndown of the proximal, central tendon and FHL augmentation. Final patient follow-up ranged from 18 to 150 months, with a mean of 62.3 months. Results: At surgery, the gap between the ruptured ends of the Achilles ranged from 6 to 12 cm, with a mean gap of 7.5 cm. Full healing was achieved in all 32 patients (100%) by 5 months postoperatively. Mean Foot and Ankle Ability Measures scores increased from 36.3% to 90.2% between initial and latest follow-up (P < .05). Mean visual analogue scales of pain decreased from 6.6 to 1.8 of 10 between first and last encounter (P < .05). Postoperative complications occurred in 5 patients (15.6%), including 3 (9.4%) superficial wound problems, 1 (3.1%) deep wound infection, and 1 (3.1%) deep vein thrombosis. Discussion. Outcomes from treating chronic Achilles ruptures with large defects are scant within the orthopaedic literature. Our method of Achilles reconstruction results in a high rate of improved function and pain relief.Levels of Evidence: Therapeutic, Level IV: Case series

Intrapericardial diaphragmatic hernia (IDH) can occur from traumatic, congenital or iatrogenic diaphragmatic defect of central tendon. In patients with thoracoabdominal trauma, it is relatively rare and has been reported in less than 1% of cases. 63-year-old female with Idiopathic thrombocytopenic

Post traumatic loss of segment of the central tendon of extensor expansion is common in crush injury of the hand. Central tendon forms the inherent part in the dynamics of extensor expansion mechanism. When a segmental loss of central tendon occurs, usually the reconstruction of the tendon is done with autogenous Palmaris longus tendon as it is more expendable. In this particular clinical scenario, the absence of Palmaris longus tendon was dealt with partial removal of Flexor Carpi radialis tendon which proved to be effective. The outcome following surgery was reasonable. Post operatively Hyperbaric oxygen therapy was given to improve the survival of crushed tissue. [Hand Microsurg 2020; 9(3.000): 167-170]

Background: As compared with injuries involving muscle only, those involving the central hamstring tendon have a worse prognosis. Limited information is available regarding the surgical treatment of central tendon injuries of the hamstrings. Purpose: To describe the operative treatment and outcomes of central tendon injuries of the hamstrings among athletes. Study Design: Case series; Level of evidence, 4. Methods: Eight athletes (6 top level, 2 recreational) with central hamstring tendon injuries underwent magnetic resonance imaging and surgical treatment. The indication for surgery was recurrent (n = 6) or acute (n = 2) central hamstring tendon injury. All patients followed the same postoperative rehabilitation protocol, and return to play was monitored. Results: Magnetic resonance imaging found a central tendon injury in all 3 hamstring muscles (long head of the biceps femoris, semimembranosus, and semitendinosus) with disrupted tendon ends. In acute and recurrent central tendon injuries, full return to play was achieved at 2.5 to 4 months. There were no adverse events during follow-up. Conclusion: Central tendon injuries of the hamstrings can be successfully repaired surgically after acute and recurrent ruptures.

Achilles tendinopathy affects athletes at all levels. While tendinopathy is usually found in either the midsubstance or the Achilles insertion, it is rarely seen in both areas of the tendon concomitantly. We report on a rare case of bilateral chronic insertional Achilles tendinosis and chronic midsubstance Achilles tendinosis with Haglund deformity treated with central tendon debridement, flexor hallucis longus (FHL) transfer, Haglund resection, and reattachment of the Achilles insertion using the Arthrex Speedbridge® system. To our knowledge, this case report is the first for the treatment of combined midsubstance and insertional Achilles tendinosis. Our method allows us to reapproximate the Achilles to its normal anatomy while eliminating the need for bulky suture knots and simultaneously giving an excellent clinical result.

Background Detachment of the central tendon of the supraspinatus from its insertion is considered to be crucial to functional deficit. The aim of the present study was to assess the function of the supraspinatus in terms of abduction moments by introducing different tear configurations to assess the functional effect of the central tendon insertion. Methods Ten fresh frozen shoulders from five cadavers were prepared for testing. A testing protocol was established to measure the abduction moment of the supraspinatus under physiological loading tailored to the anthropometrics of each specimen. Four conditions were tested: intact supraspinatus; complete detachment of portion of the supraspinatus tendon anterior to the main central tendon; detachment of the main central tendon; and detachment of the region of the supraspinatus posterior to the main central tendon. Results There was a significant and large reduction in abduction moment when the central tendon was sectioned ( p Conclusions The central tendon is vital in the role of functional arm abduction through force transmission through the intact rotator cuff. Reinsertion of the central tendon in the correct anatomical location is desirable to optimize functional outcome of surgery.

Introduction Central congenital diaphragmatic hernia that involves a central tendon defect is a very rare form of diaphragmatic hernias. Experience in the thoracoscopic repair of congenital diaphragmatic hernia has expanded in recent years, but this expansion was mainly for the most common type; the posterolateral. We report a case of central congenital diaphragmatic hernia, which is supposed to be the case number seventeen of those reported in literature. And we report the first use of thoracoscopic repair in such rare entity. Case presentation We present a case report of a Bengali neonate who had a prenatal diagnosis of left congenital diaphragmatic hernia, which was supposed to be the usual posterolateral type. As we usually approach such cases by thoracoscopy, the patient had an intraoperative diagnosis of central congenital diaphragmatic hernia. The defect was amenable to a successful thoracoscopic repair. Conclusion The rare neonatal central congenital diaphragmatic hernia could present as a left sided herniation that clinically resembles the usual posterolateral congenital diaphragmatic hernia. Thoracoscopic approach offers a tremendous tool for diagnosis as well as the management of this kind of presentation of a central congenital diaphragmatic hernia.

Muscle injury is generally treated conservatively. Operative treatment is seldom considered. Highly specific indications might be beneficial for severe injuries, shown in Table 36.1. Proximal hamstring and rectus femoris muscles are the most often injured and surgically treated in football players. The distinction between injury to the hamstring muscle and injury to the central tendon is underappreciated as being a distinct entity. Postoperative surgery rehabilitation is guided by the diagnosis, the surgical procedure, and the patient’s progress. Return to play full sport activity within 3–4 months.

A 4.3 kg, nine-year-old, spayed female Shih Tzu was presented for a two-month history of seizures, ataxia, and hyper-salivation. A diagnosis of a splenophrenic shunt was made by use of computed tomography angi - ography with volume-rendered imaging. A cellophane band was placed around the shunt after its isolation from the central tendon of the diaphragm. Clinical signs continued to wax and wane. Preprandial and postprandial bile acids levels were still elevated 10 months after surgery. An ameroid ring constrictor was placed around the shunt vessel before the vessel entered the diaphragm from its caudal aspect. At three months after the second surgery, the dog was near the normal ranges of preprandial and postprandial bile acids. Although a study of the anatomy of different types of extrahepatic portosystemic shunts has been reported in dogs, to the authors' knowledge, there is a lack of information on clinical presentation, treatment, and postoperative results in a specific type of extra - hepatic portosystemic shunt, such as a splenophrenic shunt. Cellophane banding should be avoided for occlusion of a splenophrenic shunt passing along the central tendon of the diaphragm.

Traumatic cardiac tamponade due to blunt chest injury is a life threatening and time-critical emergency that requires early recognition and prompt management often alongside other resuscitative considerations. We present here a case of 25 year old male with history of blunt chest trauma with hypotension and raised central pressures. The patient was taken up for exploratory laparotomy which proved negative and the central tendon bulge of diaphragm was seen. Hence, the decision was made to examine the pericardial space via thoracotomy to find cardiac tamponade of 400 cc. Immediate intra- operative stabilization of vitals was seen on relieving the intra pericardial pressures. Any patient with severe blunt chest trauma, disproportionate hypotension that is not responding to fluid resuscitation along with elevated central venous pressures should be thoroughly evaluated for cardiac tamponade.

From a recent systemic review, vascularized toe proximal interphalangeal joint (PIPJ) transfer achieved an average arc of motion (AOM) of merely 37 degrees for finger PIPJ reconstruction. Despite the technical refinement over the past 3 decades, the resulting active motion of the reconstructed joint remains unpredictable and often fraught with extension lag. The technique for vascularized toe PIPJ transfer at our institute has evolved over the years to its current state, with simultaneous extensor mechanism reconstruction being a major component. During the transfer, the quality of extensor tendons on the recipient finger and donor toe are carefully evaluated. If the central slip of finger extensor is destroyed but the quality of lateral bands is adequate, centralization of lateral bands overlying the transferred PIPJ is performed. If there is acceptable central slip remnant at the proximal phalanx level, modified Stack procedure is performed for central slip reconstruction while leaving the lateral bands in continuity. If both lateral bands are poor, modified Stack procedure is performed unless the central tendon of the toe is strong enough to extend the PIPJ. From November 2008 to October 2010, 7 joints were transferred with this modified technique. The average follow-up was 18.2 months. The average active AOM of the transferred PIPJ was 56.4 degrees. The average extension lag of the toe PIPJ was 10.7 and 16.4 degrees before and after the transfer, respectively. Simultaneous reconstruction of extensor mechanism decreases the extension lag without sacrificing AOM of the transferred PIPJ.

Congenital diaphragmatic hernia (CDH) is a birth anomaly where there is a defect in the diaphragm. Bochdalek hernia, which involves a posterolateral defect with herniation of the abdominal organs into the thoracic cavity, and a varying degree of lung hypoplasia, accounts for more than 95% of CDH. Non posterolateral hernias are classified into three groups: (a) retrosternal or parasternal (Morgagni-Larrey); (b) other anterior hernias that extend into the anterior portion of the central tendon and are associated with other anomalies; and (c) central hernias, where the defect primarily involves the non-muscular central tendinous part of the diaphragm (1). HISTORY (2-4)

Soleus muscle exhibits bipennate arrangement on its centro-anterior aspect and the longitudinal parallel muscle fibers on its posterior and lateral margins. Till date soleus muscle was studied as a whole muscle with less attention given on its bipennate arrangement. As per according to standard texts, increase in cross sectional area due to bipennate arrangement in soleus muscle augments the power and force of contraction. The current study was done on 50 cadaveric lower limbs. Out of them 25 were of right side and 25 were of left side. The soleus muscle was divided into four equidistant hypothetical segments i.e- I, II, III, IV by imaginary lines drawn from the highest point of origin of muscle fibers to the lowest point of merging of muscle fibers to the tendocalcaneus. In 6% of cases the pennation was not clearly visible as it was covered anteriorly with nonseparable fascial sheath due to its adherence to subfascial muscle fibers. In 94% of cases pennation was present, out of which 6% cases showed pennation from segment I to IV, 4% cases showed pennation from segment I to III, 42% cases showed pennation from segment II to IV and 38% cases showed pennation from segments II to III, while 4% cases showed pennation only in segment III. The width, length and angle of muscle fasciculus of pennation are maximum in segment II.

Omohyoid muscle syndrome (OMS) featuring marked omohyoid muscle bulging during swallowing, not present at rest, was first reported by R.B. Zachary in 1969. We report a case of this condition. A 41-year-old woman reporting right neck discomfort during swallowing was found to have bulging corresponding to the omohyoid muscle course, diagnosed as OMS. We excised the muscle, found to be of normal size, at the central tendon under general anesthesia. No recurrence has been seen in the 12 months post operative. Pathological findings included omohyoid muscle degeneration, hypertrophy, and atrophy. Cases reported in Japan numbered 22 since 1983, 10 of which were treated surgically and remedied satisfactorily. No common features were seen, although normal and abnormal findings were present in macroscopic and pathological intra- or postoperative examination. OMS is benign, and warrants surgery only in cases of severe subjective symptoms or at the subject's request.

During exercise, the horse can achieve oxygen uptakes and ventilations in excess of 200 ml/kg/min and 1800 l/min, respectively. Whether the diaphragm has the capacity to contribute substantially to inspiratory effort in the exercising horse is not known. To investigate the potential for the horse diaphragm to generate tension, lung displacement and sustain ventilatory function, we measured diaphragm thickness, muscle length and oxidative enzyme activity (citrate synthase) within the ventral, medial and dorsal costal and crural diaphragm. In the diaphragms of 6 mature horses (5 Thoroughbreds, one Quarter Horse; body mass (mean +/- s.e.) 475 +/- 14 kg, age 4 +/- 1 years), the mass of the freshly-excised diaphragm was 4.54 +/- 0.19 kg of which 79% was the costal diaphragm, 17% the crural diaphragm and 4% the central tendon. The medial costal region (2.1 +/- 0.1 cm) was significantly thicker (P0.05) than either the ventral (1.4 +/- 0.1 cm) or dorsal (1.2 +/- 0.2 cm) costal regions and the crural diaphragm was significantly thicker (3.2 +/- 0.3 cm, P0.05) than any costal diaphragm region. With respect to the costal diaphragm, excised muscle length was greatest (P0.05) in the medial costal (17.2 +/- 1.0 cm) than either the ventral costal (12.6 +/- 1.5 cm) or dorsal costal (13.9 +/- 1.8 cm) regions and therefore the medial region would be expected to exhibit the greatest absolute length change on inspiration. Citrate synthase activity was high throughout the diaphragm (40.8 +/- 113 to 55.3 +/- 9.7 micromol/g/min), but was not significantly different among regions. These structural characteristics and the oxidative potential of the horse diaphragm are consistent with the diaphragm providing a significant and substantial contribution to the inspiratory effort during exercise in the horse. Consequently, clinical and physiological investigations of exercise performance should not ignore the potentially crucial importance of the diaphragm.

Hypothesis Triceps tendon anatomy is important for surgical approaches to the elbow and tendon repair. The purpose of this study is to describe both the qualitative and quantitative anatomy of the triceps brachii tendon insertion. Materials and methods Thirty-six elbows were dissected from twenty-three cadavers. Dimensions of the triceps tendon proper, lateral triceps expansion, and tendon insertion were measured. The central triceps tendon morphology was described. Results All specimens showed a distinct lateral tendon expansion continuous with the anconeus fascia (mean width, 16.8 mm). The mean width of the proper triceps tendon was 23.7 mm. The mean maximum olecranon width was 26.9 mm. The ratio of the triceps tendon width to the olecranon width averaged 0.88. The mean thickness of the central tendon insertion was 6.8 mm. The medial triceps tendon showed a distinct, rolled medial edge and an insertion consistently confluent with the central tendon. The triceps footprint insertion was dome shaped. The mean insertional width and length of the tendon proper were 20.9 mm and 13.4 mm, respectively. The mean distance from the olecranon tip to the tendon was 14.8 mm. The tendon width, thickness, and insertional dimensions correlated with the olecranon width. Conclusions The lateral triceps expansion is a consistent anatomic finding with a width that is approximately 70% of the width of the central tendon. The triceps insertion has a broad width and narrow thickness that expands distally and correlates with the size of the olecranon. Knowledge of this anatomy will help the surgeon optimize surgical approaches and triceps repair techniques.

The laparoscopic sacrocolpopexy is the preferred procedure for the young woman. The procedure is that used for pelvic laparoscopy. The steps are identical as during open sacrocolpopexy, with the advantages of pneumodissection and better vision. The success rate is more than 90% and redux is mostly cystocele. Mesh erosion is reported in 2,7 to 9%. The indication for a posterior mesh is recommended if there is a rectocele or if a colposuspension at the same time. The fixation of the mesh must be posteriorly on the central tendon of perineum and the levator ani with a non resorbable stitches. The best mesh is type I in Amid classification. The comparative studies with open sacrocolpopexy and sacrospinifixation show an advantage for pain and hospital stay, but greater operative time for identical results. In preliminary results, the robotic abdominal sacrocolpopexy give the same results with a greater cost.

Objective: This study is a statistical analysis to establish whether a correlation exists between the level and degree of rectus femoris (RF) central tendon injury and the amount of time that an athlete is unable to participate subsequently, referred to as ‘‘sports participation absence’’ (SPA). Design: Causal‐comparative study. Patients: 35 players from two high-level Spanish soccer teams with an injury to the central tendon of the RF based on clinical and ultrasound criteria. Main Outcome Measure: Ultrasound examination was performed with an 8‐2 MHz linear multifrequency transducer. All studies included both longitudinal and transverse RF sections. Results: At the proximal level the SPA time is 45.1 days when the injury length is 4.0 cm. This value increases by 5.3 days with each 1 cm increase in the length of injury. In the case of distal level injury, SPA time is 32.9 days when the injury length is 3.9 cm. This value increases by 3.4 days with each 1 cm increase. In the total representative sample, SPA time when the injury length is 4.2 cm corresponds to 39.1 days. This value increases by 4.2 days per length unit. Conclusions: RF central tendon injury at the proximal level is associated with a greater SPA time than at the distal level. Patients with a grade II injury have an SPA time longer than those with a grade I injury whether the injury is located proximal or distal.

The patellar extensor apparatus is composed of the quadriceps muscles that converge to a central tendon that inserts on and invests the patella. It continues by the patellar tendon to act on the tibial tuberosity and thereby extends the leg at the knee. The structure can be thought of as a chain with pathology able to occur at each level. Pathological processes are generally caused by the great force experienced at each level both chronically and acutely. The forces are, however, greatly modified by the particular geometries present at each level. The various pathological processes and factors that modify them are reviewed at each level, beginning with the quadriceps musculature and ending at the terminal point of action, the tibial tuberosity.

Omohyoid muscle syndrome was first reported in 1969. Only two cases of this disease were reported in Japan. The patient was a 27-year-old woman, who had been complaining of so-called globus sensation during swallowing for several years. She also had slight foreign body sensation in the right neck. Right lateral mass during swallowing was detected in correspondence with the omohyoid muscle by ultrasonography. Surgery was carried out under general anesthesia. The muscle was excised at the central tendon. The patient immediately became free from globus sensation during swallowing. Pathological examination did not demonstrate any specific change in the muscle specimen except for hypertrophy.

Background Discrimination between acute traumatic and chronic degenerative rotator cuff lesions (RCLs) is an important aid to decision making in therapeutic management. To date, no clinical signs or radiologic findings that enable confident differentiation between these distinct etiologic entities have been identified. The purpose of this investigation was to perform a systematic analysis of known radiographic and magnetic resonance imaging (MRI) features of RCLs and of further, not yet accurately described parameters. The hypothesis was that there are specific radiologic features that allow reliable discrimination between traumatic and nontraumatic RCLs. Methods Fifty consecutive patients with RCLs confirmed by MRI were enrolled in this study. Group A was made up of 25 patients with a history of trauma within the previous 6 weeks and no pre-existing shoulder pain, whereas group B comprised 25 patients with shoulder pain for not more than 12 months and no history of relevant trauma. Radiographs and magnetic resonance images were analyzed in a standardized protocol. Results No radiographic features were found to differ significantly between the 2 groups. On MRI, edema in the injured muscle was more common in group A (37.5% vs 4%, P = .04). A characteristic feature in traumatic RCLs was a wavelike appearance (kinking) of the central tendon (64% vs 32%, P = .03). In group B, more muscular atrophy was found (29.2% vs 60%, P = .02). Thinning and retraction did not differ between the groups. Conclusion MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic RCLs. Although no absolute distinguishing feature was found, edema, kinking, and muscular atrophy are positive criteria for differentiation.

Background: Insertional calcific Achilles tendinosis is a painful, frequently disabling condition. Numerous operative approaches for this problem have been described. This study evaluated the outcome of a central tendon splitting approach. Methods: Twenty-two patients were evaluated after a central tendon splitting approach for persistent insertional calcific Achilles tendinosis. Followup averaged 34 (11 to 64) months. Suture anchors were routinely used to augment the tendon insertion after debridement. An American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, shoewear comfort, and return to work were evaluated. A paired t-test was used to evaluate the results. Results: Pain significantly improved from 7 points preoperatively to 33 points postoperatively ( p < 0.001). Function improved significantly from 36 points to 46 points ( p < 0.001). The ankle-hindfoot score improved from 53 points to 89 points ( p < 0.001). Age older or younger than 50 years did not affect outcome. Conclusion: A central tendon splitting approach yielded good relief of pain with improved function, shoewear, and ability to work without painful postoperative scars.

Background There has been no research examining the magnetic resonance imaging findings, and in turn the prognosis, for a series of acute quadriceps muscle strains. Hypothesis The magnetic resonance imaging findings of acute quadriceps muscle strain injuries are helpful in predicting their prognosis. Study Design Causal-comparative study. Method Forty professional players of Australian Rules football were followed over 3 years. Magnetic resonance imaging examinations were performed within 24 to 72 hours of muscle-strain injury. Imaging features of muscle strain injury included the anatomical location, size (cross-sectional area and length), and site (proximal, middle, or distal). The time from injury to return to full training was termed the rehabilitation interval. Results 25 clinical quadriceps muscle strain injuries occurred, with 15 cases involving the rectus femoris. The rectus femoris injuries could be further categorized into cases with straining about the central tendon (n = 7, mean rehabilitation interval = 26.9 days) or cases with straining in the periphery (n = 8, mean rehabilitation interval = 9.2 days). Six cases involved one of the vastus muscles (mean rehabilitation interval = 4.4 days). Three players had normal magnetic resonance imaging examinations (mean rehabilitation interval = 5.7 days). Conclusions The rectus femoris–central tendon injury is the red flag diagnosis associated with a significantly longer rehabilitation interval. Clinical Relevance Magnetic resonance imaging is helpful in predicting the prognosis for acute quadriceps strains.

Twenty-two heels in 21 patients treated surgically for a primary diagnosis of insertional Achilles tendinosis were reviewed on the basis of preoperative and postoperative examinations, office records, and a comprehensive questionnaire administered to each subject. Each patient underwent surgical treatment using a midline-posterior skin incision combined with a central tendon splitting approach for debridement, retrocalcaneal bursectomy, and removal of the calcaneal bursal projection as necessary.The findings at surgery revealed involvement of the middle third of the insertion in 21 of 22 cases with only one patient manifesting isolated lateral involvement. Thirteen of 22 had an associated prominent calcaneal bursal projection and four of 22 a superficially inflamed bursa. Three patients required reinsertion of the tendo Achilles via drill holes and one underwent augmentation with a plantaris tendon.Operative findings and complications were reported. Eight male and 13 female patients underwent 22 procedures (one case bilaterally) with an average follow-up of 33 months. Preoperative symptoms include presence of symptoms over a range of three months to two years and pain associated with activities of daily living (17 of 22), limitation of regular activities (six of 22), and pain present at rest in six of 22.Postoperatively, 20 of 22 patients were able to return to work or routine activities by three months; only 13 of 22 were completely pain free. Only 13 of 22 also claimed that they were able to return to unlimited activities. Overall, there was an 82% (18 of 22) satisfaction rate with surgery and 77% (17 of 22) stated they would have the surgery again.

BACKGROUND Bilaterality of congenital diaphragmatic pathologies is well documented in the English literature. Nevertheless, ipsilateral simultaneous congenital diaphragmatic pathologies, though rare, are worth revisiting to shed more light into their embryology and management. METHODS A review of the literature for reported cases of multiple ipsilateral congenital diaphragmatic pathologies was performed. Their findings, management and outcomes were classified and reviewed, in addition to reporting and comparison with a new case from our medical center. RESULTS Two patients were adult females with multiple defects in the right central tendon of the diaphragm. The remaining four were all pediatric cases. Two had double congenital hernial defects on the same side and two had the defect associated with ipsilateral diaphragmatic eventration. Our case is the third one with diaphragmatic eventration, but the first being associated with a posterolateral defect on the same side. Its presentation with acute rectal bleeding proved difficult to diagnose. CONCLUSION There are various postulated theories concerning the pathogenesis of ipsilateral pathologies during embryologic development of the diaphragm. Management of asymptomatic congenital eventrations remains debatable. However, when symptoms become apparent, ipsilateral defects though rare, should be considered and prompt surgical management through a thoracotomy or laparotomy approach is recommended.