What Kind Of Doctor Repairs A Muscle Tear

Curr Rev Musculoskelet Med. 2022 Jun; viii(2): 188–192.

Surgical treatment for muscle injuries

Leonardo Addêo Ramos

Department of Orthopaedic Surgery, Federal University of Sao Paulo, São Paulo, SP Brazil

Department of Orthopaedic Surgery, Hospital Nipo-Brasileiro, São Paulo, SP Brazil

Rogério Teixeira de Carvalho

Department of Orthopaedic Surgery, Federal University of Sao Paulo, São Paulo, SP Brazil

Section of Orthopaedic Surgery, Hospital exercise Servidor Público Estadual, São Paulo, SP Brazil

Rene Jorge Abdalla

Department of Orthopaedic Surgery, Federal University of Sao Paulo, São Paulo, SP Brazil

Knee Constitute, Hospital do Coração, São Paulo, SP Brazil

Sheila Jean McNeill Ingham

Department of Orthopaedic Surgery, Federal University of Sao Paulo, São Paulo, SP Brazil

Knee joint Institute, Hospital practice Coração, São Paulo, SP Brazil

Abstruse

Muscle injury causes functional harm. The healing procedure takes time and fibrotic tissue can outcome. Recurrence and delayed recovery remain every bit unsolved issues. Surgical intervention tin be a feasible alternative to avoid early and late complications associated with complete musculus tear in try to improve functional results. This article hopes to provide an update about surgical treatments for muscle tears in different scenarios.

Keywords: Musculus injury, Surgical treatment, Repair, Scaffold, Myositis ossificans, Compartmental syndrome

Introduction

Muscle injuries (MI) are common in sports, and their prevalence is high in many modalities like soccer [ane], rugby [ii], basketball [3] and track and field [four]. The machinery of injury can exist direct, indirect or combined trauma [2, 3] and tin result in disability that will take time to heal. The correct diagnosis is based on clinical history, physical examination and imaging findings (ultrasonography, CT or MRI) [1], while a safety render to sports and activities requires a specialized team for an enhanced recovery [four].

A judicious interpretation of all these elements is key to obtain a suitable approach. However, there is a myriad of classification systems with different terminologies that makes the authentic decision for a better MI treatment a hard task [five]. Complications related with MI tin can occur: severe muscle haematoma, myositis ossificans and compartmental syndrome [1, 4, 5].

The bulk of MIs can exist adequately managed with conservative treatments [half dozen]. There is no consensus when a surgical approach for MI should be implemented. Nonetheless, few studies have mentioned the demand for surgical intervention. The main surgical indications include a big intramuscular heamatoma(southward), a complete (III degree) strain or tear of a musculus with few or no agonist muscle or a partial (Two degree) strain if more than than one-half of the muscle belly is torn [seven, 8]. Another situation can exist taken into account, if there is a persistent hurting for more than 4 months with functional impairment [nine].

Musculus haematoma

The mechanism that causes a MI tin can occur later a direct trauma like an impact or contusion or indirectly following a stretch or a tear with muscle damage. In some situations after a MI, mainly in sports, a localized bleeding can form a haematoma [ten]. There are two types of haematoma: intramuscular and intermuscular. The principal differences are described in Tabular arrayi.

Table 1

Types of muscle haematoma

	Intramuscular	Intermuscular
Fascia/musculus sheath	Remains intact	Torn
Haemorrhage	Within the muscle	Spread between musculus and fascia
Swelling	Persistent and increases beyond 48 h	Pronounced within few hours
Symptoms	Localized at the site of injury	Diffuse and distal the injured area
Discoloration	Appears few days afterward injury	Marked within few hours

The prognosis for intermuscular haematomas is meliorate than that of the intramuscular type. Poor prognosis indicators include increment and fluctuating swelling after 24 h, persistent swelling after 48–72 h, increased hurting intensity, extension of tenderness from the site of injury, prolonged restricted limb range of motion acquired by hurting or muscle weakness and, potentially, macerated distal pulses or numbness and paraesthesia beneath the injury [10].

An overlooked muscle haematoma blazon, spontaneous, tin occur in some scenarios. Risk factors that could contribute to haematoma formation need to be investigated: anticoagulation therapy (especially in the elderly); intense non-contact exercise, haemophilia, hypertension and following total hip arthroplasty [11–13]. The iliopsoas muscle is the near affected followed by the rectus sheath. Differential diagnosis with intestinal and gynaecological diseases should be remembered to avoid misdiagnosis [14].

Surgical haematoma drainage should exist indicated when nerve and/or vascular compression is detected based on clinical signs and symptoms corroborated with subsidiary examination findings and when haematoma infection is clinically relevant. There is no gold standard rule to make a decision to signal surgery.

Musculus repair

Muscle repair can be advocated for fractional or complete tears in the musculus belly when more than one-half of its volume is compromised associated with functional disability [seven, 8]. Notwithstanding, the brittle muscle damaged tissue makes the repair technically challenging. This biological component does not allow u.s.a. to reach a mechanically strong stop-to-end repair with an appropriate tension that would provide a beneficial environs to reach an constructive healing with a sutured contractile musculus tissue [9]. In attempt to minimize bug with surgeries for muscle repair and improve healing with a viable contractile muscle formation, the employment of scaffolds has been proposed as a biological augmentation for muscle repair. There are a plenty of suture techniques, generally described for tenorrhaphy procedures: Kessler grasping suture, modified Kessler grasping, Mason-Allen suture, Chinese finger trap, horizontal, in "8", Bunnell suture, Nicoladoni technique and a combination of sutures [fifteen–20] There is no consensus about which suture technique is the best. Aarimaa et al. (2004) showed, in an experimental written report, that volumetric musculus loss greater than 20 % cannot be biologically repaired and, consequently, event in a loss of office [21]. Thereby, a consummate muscle tear with loss of office, like a laceration, remains a challenge for a conservative treatment because information technology can bring about functional disability and musculus weakness [22]. Oliva et al. reported a case of a patient that underwent a muscle repair with common separated stitches in the quadriceps muscle, including the epimysium, with satisfactory functional recovery after functional tests and complementary imaging exams at a half-dozen-year follow-upwards [16]. It has been noticed that the best musculus repair should enclose endomysium, epimysium and besides perimysium. This way, combined sutures with Kessler stitches and Bricklayer-Allen techniques provide a better repair with loftier-resistance tension forces in comparison with common separated stitches. He at al demonstrated, in an experiment with rabbits, that there is no difference between Mason-Allen and Kessler sutures related to maximal axial load. All the same, in the Mason-Allen technique, the failure point was near the sutures, whereas in the Kessler suture, the fibres breached longitudinally. Because of this, the all-time option to promote a firm musculus suture should be with combined different sutures [18, 23].

Scaffolds

The scaffolds keep the tridimensional design and composition of the original tissue and help to heighten musculus regeneration. These scaffolds can exist acquired from dissimilar biological tissues like swine or bovine dermal tissue, mucous or pericardium. There are, in the American health marketplace, 9 scaffolds brands in commercialization, being that 06 derived from swine tissue, hereof 03 derived from non-cross-linked small intestinal submucosa, 01 cross-linked hydrated small intestinal submucosa and 02 cross-linked hydrated dermal. There are three other products derived from bovine tissue, existence that 02 are non-cantankerous-linked dermal tissue and 01 is a cross-linked pericardial tissue [24, 25••]. The biological scaffolds are efficient every bit they change the tissue repair machinery, produce less fibrotic tissue and more muscle tissue tin exist synthetized [24]. This is possible due to the scaffold's ability in altering the macrophages phenotypic delivery causing an increased release of tissue growth factors and promoting chemotaxis, from degraded tissue, alluring feasible contractile tissue that enables tissue healing. Tissue differentiation into viable myoblasts, in the presence of a biological scaffold, is possible due to the presence of macrophages with a M1 pro-inflammatory phenotypic differentiation (macrophages derived from monocytes that enter the injured tissue). M1 macrophages enhance tissue proliferation, stalk jail cell and satellite jail cell migration. The M1 maturation process is simply possible due to the presence of M2 macrophages. Studies have investigated macrophages function during the tissue repair process, and the question about anti-inflammatory drugs prescription in the early treatment after muscle injuries and its outcome on the macrophages remains unsolved [21, 25••, 26, 24, 27].

Information technology is desirable to accept an adequate micro-surroundings for cell evolution too as the presence of growth factors to optimize muscle tissue strength during the healing process. Growth factors help to attune the myogenesis guiding tissue proliferation and differentiation. Some cells have the capability to produce growth factors that are activated past the presence of the biological scaffolds. These scaffolds activate latent growth factors, mainly the fibroblast growth gene (bFGF) and the vascular endothelial growth factor (VEGF) that are essential to angiogenesis and tissue repair [20]. Turner et al., in 2010, evaluated dogs that underwent a gastrocnemius musculus resection that was posteriorly imbedded with scaffolds. Subsequently 6 months, the resultant muscle presented with 48 % of muscle forcefulness in comparison to the contralateral gastrocnemius, innervation and vascularization were similar to the original tissue. Scaffold use, for musculus tears, represents a promising treatment alternative for cases with volumetric loss. These scaffolds are able to increase migration and proliferation of progenitor cells in the damaged area [28].

Other studies have tried to elucidate which factors are related with tissue integration and mechanisms evolved to heighten the formation of the best viable and functional tissue. Scaffolds cultivated with stem cells can regenerate the damaged muscle and can be a good choice to better performance after a muscle injury [29]. However, fifty-fifty if the scaffolds are used with no cells, it is possible to restore muscle office. Valentin et al. (2010) demonstrated that acellular scaffolds were able to grow a tissue with 80 % functionally in comparison with the original tissue, after 6 months. Sometimes, these repaired healed tissues from scaffolds, even without stem cells implantation, can attain a similar tissue with good vascularization and innervation [25••, 27].

The biological solution for muscle injury treatment will exist one possible selection to develop better role. It is necessary to ameliorate scaffolds that optimize tissue repair and growth factor delivery associated with improvement in suture techniques that upgrade the final viable tissue, with less fibrosis and with mechanical forcefulness almost the normal muscle.

Myositis ossificans

Myositis ossificans (MO) is a serious and relatively common complication after MI (Fig.1). Information technology is related to trauma from a single blow or repeated episodes of micro-traumas [30]. It tin be diagnosed and monitored by serial X-rays, existence radiologically evident 3–vi weeks later injury [31]. Mutual symptoms are tenderness, swelling, loss of motion and hardening of the tissue perceived by musculus palpation [32]. The erythrocyte sedimentation charge per unit and white claret jail cell count may be elevated. The alkaline metal phosphatase tin can be helpful to plant the degree of different stages of maturation in MO. The nearly common reported sites of MO are in the thigh and arm muscles: quadriceps femoris, brachialis and the adductor muscles of the thigh [31, 32]. Other factors associated with MO are severe recurrent contusion or trauma resulting in haemorrhage or tissue necrosis, subsequently hamstring graft harvest for knee surgery, after stress fracture in the foot [33–35]. In the bulk of cases, it is asymptomatic and tin can be managed with non-operative treatments with spontaneous resolution monitored by imaging exams. Biphosphonate therapy with oral medication, which has strong anti-osteoclastic furnishings, tin be prescribed in the astute phase with favourable outcomes [36]. If MO progress to permanently limit range of motion and function with pain or when the lesion is vulnerable to a repeated trauma causing disability, surgical intervention to remove persistent calcium deposits can exist pointed out. Surgery should not be attempted until iv–half-dozen months afterward trauma to allow for complete maturation of the process. When early on open intervention is performed prior to maturation, recurrences are more likely to occur [32, 33].

An external file that holds a picture, illustration, etc. Object name is 12178_2015_9272_Fig1_HTML.jpg

3D CT showing myositis ossificans in the quadriceps

Compartment syndrome

Compartment syndrome (CS) results from meridian of pressure inside a compartment and impaired tissue perfusion. Acute CS tin be caused later a straight accident, crush injury, burns, penetrating trauma and haematoma afterwards a muscle tear [37]. Male gender and age less than 35 years take also been shown to exist take chances factors [38]. Other factors should be investigated and can be associated with CS like prolonged exercises, some medicaments (anabolic steroids, simvastatin, gabapentin), diabetes mellitus, impaired mental status and neuropathies [39–41]. The most mutual areas affected are leg, thigh and forearm.

The most common symptom is a hurting disproportionate to the injury, ofttimes associated with neurological aberration [42]. Elevated intracompartmental pressure, obtained from a dynamic pressure measurement, is widely recognized as the most objective diagnostic parameter for CS. Whitesides et al. identified the pressure perfusion gradient at which ischemia is imminent and prophylactic fasciotomy should be done equally <20 mmHg below the diastolic blood pressure [42]. Later, a pressure of 30 mmHg was suggested as an absolute threshold for the diagnosis of compartment syndrome [43]. Other methods to evaluate muscle oxygenation and CS can be used like about infra-red spectroscopy; intramuscular glucose concentration and partial pressure of oxygen chop-chop aid to identify muscle ischemia [44, 45•]. Early diagnosis is determinant for a good prognosis. Surgical intervention with open up fasciotomy is mandatory when CS is confirmed [42]. It is crucial to identify all compartments involved to avoid incomplete or delayed fasciotomies that are associated with muscle necrosis and death [46–48]. If rhabdomyolysis occurs, haemodialysis should be considered when life-threatening hyperkalaemia and metabolic acidosis be [49].

Conclusions

Surgical treatment for muscle injuries depends on several factors. Improvements in surgical suture techniques have evolved for musculus repair. Cell-based therapy with scaffolds has been shown as a viable option for a improve functional recovery. Surgical intervention for myositis ossificans should be delayed if functional disability remains unresolved. Haematoma drainage and fasciotomy can be required, when symptomatic nerve and/or vascular compression inside the compartment is detected.

Compliance with Ethics Guidelines

Conflict of Interest

Leonardo Addêo Ramos, Rogério Teixeira de Carvalho, Rene Jorge Abdalla, and Sheila Jean McNeill Ingham declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This commodity does not contain any studies with human or brute subjects performed past whatsoever of the authors.

Footnotes

This article is office of the Topical Drove on Muscle Injuries

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