Breaking point: Case series of tendon ruptures in Hemodialysis patients

Breaking point: Case series of tendon ruptures in... | F1000Research "use strict";function _typeof(t){return(_typeof="function"==typeof Symbol&&"symbol"==typeof Symbol.iterator?function(t){return typeof t}:function(t){return t&&"function"==typeof Symbol&&t.constructor===Symbol&&t!==Symbol.prototype?"symbol":typeof t})(t)}!function(){var t=function(){var t,e,o=[],n=window,r=n;for(;r;){try{if(r.frames.__tcfapiLocator){t=r;break}}catch(t){}if(r===n.top)break;r=r.parent}t||(!function t(){var e=n.document,o=!!n.frames.__tcfapiLocator;if(!o)if(e.body){var r=e.createElement("iframe");r.style.cssText="display:none",r.name="__tcfapiLocator",e.body.appendChild(r)}else setTimeout(t,5);return!o}(),n.__tcfapi=function(){for(var t=arguments.length,n=new Array(t),r=0;r 3&&2===parseInt(n[1],10)&&"boolean"==typeof n[3]&&(e=n[3],"function"==typeof n[2]&&n[2]("set",!0)):"ping"===n[0]?"function"==typeof n[2]&&n[2]({gdprApplies:e,cmpLoaded:!1,cmpStatus:"stub"}):o.push(n)},n.addEventListener("message",(function(t){var e="string"==typeof t.data,o={};if(e)try{o=JSON.parse(t.data)}catch(t){}else o=t.data;var n="object"===_typeof(o)&&null!==o?o.__tcfapiCall:null;n&&window.__tcfapi(n.command,n.version,(function(o,r){var a={__tcfapiReturn:{returnValue:o,success:r,callId:n.callId}};t&&t.source&&t.source.postMessage&&t.source.postMessage(e?JSON.stringify(a):a,"*")}),n.parameter)}),!1))};"undefined"!=typeof module?module.exports=t:t()}(); dataLayer = dataLayer || []; // Standard GTM initialization - Google Consent Mode handles consent automatically (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= 'https://www.googletagmanager.com/gtm.js?id='+i+dl+ '>m_auth=hzk0Vc3qFsQYhCrIoHz68A>m_preview=env-1>m_cookies_win=x';f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-MWFK8L5J'); ;window.NREUM||(NREUM={});NREUM.init={distributed_tracing:{enabled:true},privacy:{cookies_enabled:true},ajax:{deny_list:["bam.nr-data.net"]}}; ;NREUM.loader_config={accountID:"438030",trustKey:"438030",agentID:"772317073",licenseKey:"97f8f67f26",applicationID:"772317073"} ;NREUM.info={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net",licenseKey:"97f8f67f26",applicationID:"772317073",sa:1} ;/*! For license information please see nr-loader-spa-1.236.0.min.js.LICENSE.txt */ (()=>{"use strict";var e,t,r={5763:(e,t,r)=>{r.d(t,{P_:()=>l,Mt:()=>g,C5:()=>s,DL:()=>v,OP:()=>T,lF:()=>D,Yu:()=>y,Dg:()=>h,CX:()=>c,GE:()=>b,sU:()=>_});var n=r(8632),i=r(9567);const o={beacon:n.ce.beacon,errorBeacon:n.ce.errorBeacon,licenseKey:void 0,applicationID:void 0,sa:void 0,queueTime:void 0,applicationTime:void 0,ttGuid:void 0,user:void 0,account:void 0,product:void 0,extra:void 0,jsAttributes:{},userAttributes:void 0,atts:void 0,transactionName:void 0,tNamePlain:void 0},a={};function s(e){if(!e)throw new Error("All info objects require an agent identifier!");if(!a[e])throw new Error("Info for ".concat(e," was never set"));return a[e]}function c(e,t){if(!e)throw new Error("All info objects require an agent identifier!");a[e]=(0,i.D)(t,o),(0,n.Qy)(e,a[e],"info")}var u=r(7056);const d=()=>{const e={blockSelector:"[data-nr-block]",maskInputOptions:{password:!0}};return{allow_bfcache:!0,privacy:{cookies_enabled:!0},ajax:{deny_list:void 0,enabled:!0,harvestTimeSeconds:10},distributed_tracing:{enabled:void 0,exclude_newrelic_header:void 0,cors_use_newrelic_header:void 0,cors_use_tracecontext_headers:void 0,allowed_origins:void 0},session:{domain:void 0,expiresMs:u.oD,inactiveMs:u.Hb},ssl:void 0,obfuscate:void 0,jserrors:{enabled:!0,harvestTimeSeconds:10},metrics:{enabled:!0},page_action:{enabled:!0,harvestTimeSeconds:30},page_view_event:{enabled:!0},page_view_timing:{enabled:!0,harvestTimeSeconds:30,long_task:!1},session_trace:{enabled:!0,harvestTimeSeconds:10},harvest:{tooManyRequestsDelay:60},session_replay:{enabled:!1,harvestTimeSeconds:60,sampleRate:.1,errorSampleRate:.1,maskTextSelector:"*",maskAllInputs:!0,get blockClass(){return"nr-block"},get ignoreClass(){return"nr-ignore"},get maskTextClass(){return"nr-mask"},get blockSelector(){return e.blockSelector},set blockSelector(t){e.blockSelector+=",".concat(t)},get maskInputOptions(){return e.maskInputOptions},set maskInputOptions(t){e.maskInputOptions={...t,password:!0}}},spa:{enabled:!0,harvestTimeSeconds:10}}},f={};function l(e){if(!e)throw new Error("All configuration objects require an agent identifier!");if(!f[e])throw new Error("Configuration for ".concat(e," was never set"));return f[e]}function h(e,t){if(!e)throw new Error("All configuration objects require an agent identifier!");f[e]=(0,i.D)(t,d()),(0,n.Qy)(e,f[e],"config")}function g(e,t){if(!e)throw new Error("All configuration objects require an agent identifier!");var r=l(e);if(r){for(var n=t.split("."),i=0;i {r.d(t,{D:()=>i});var n=r(50);function i(e,t){try{if(!e||"object"!=typeof e)return(0,n.Z)("Setting a Configurable requires an object as input");if(!t||"object"!=typeof t)return(0,n.Z)("Setting a Configurable requires a model to set its initial properties");const r=Object.create(Object.getPrototypeOf(t),Object.getOwnPropertyDescriptors(t)),o=0===Object.keys(r).length?e:r;for(let a in o)if(void 0!==e[a])try{"object"==typeof e[a]&&"object"==typeof t[a]?r[a]=i(e[a],t[a]):r[a]=e[a]}catch(e){(0,n.Z)("An error occurred while setting a property of a Configurable",e)}return r}catch(e){(0,n.Z)("An error occured while setting a Configurable",e)}}},6818:(e,t,r)=>{r.d(t,{Re:()=>i,gF:()=>o,q4:()=>n});const n="1.236.0",i="PROD",o="CDN"},385:(e,t,r)=>{r.d(t,{FN:()=>a,IF:()=>u,Nk:()=>f,Tt:()=>s,_A:()=>o,il:()=>n,pL:()=>c,v6:()=>i,w1:()=>d});const n="undefined"!=typeof window&&!!window.document,i="undefined"!=typeof WorkerGlobalScope&&("undefined"!=typeof self&&self instanceof WorkerGlobalScope&&self.navigator instanceof WorkerNavigator||"undefined"!=typeof globalThis&&globalThis instanceof WorkerGlobalScope&&globalThis.navigator instanceof WorkerNavigator),o=n?window:"undefined"!=typeof WorkerGlobalScope&&("undefined"!=typeof self&&self instanceof WorkerGlobalScope&&self||"undefined"!=typeof globalThis&&globalThis instanceof WorkerGlobalScope&&globalThis),a=""+o?.location,s=/iPad|iPhone|iPod/.test(navigator.userAgent),c=s&&"undefined"==typeof SharedWorker,u=(()=>{const e=navigator.userAgent.match(/Firefox[/\s](\d+\.\d+)/);return Array.isArray(e)&&e.length>=2?+e[1]:0})(),d=Boolean(n&&window.document.documentMode),f=!!navigator.sendBeacon},1117:(e,t,r)=>{r.d(t,{w:()=>o});var n=r(50);const i={agentIdentifier:"",ee:void 0};class o{constructor(e){try{if("object"!=typeof e)return(0,n.Z)("shared context requires an object as input");this.sharedContext={},Object.assign(this.sharedContext,i),Object.entries(e).forEach((e=>{let[t,r]=e;Object.keys(i).includes(t)&&(this.sharedContext[t]=r)}))}catch(e){(0,n.Z)("An error occured while setting SharedContext",e)}}}},8e3:(e,t,r)=>{r.d(t,{L:()=>d,R:()=>c});var n=r(2177),i=r(1284),o=r(4322),a=r(3325);const s={};function c(e,t){const r={staged:!1,priority:a.p[t]||0};u(e),s[e].get(t)||s[e].set(t,r)}function u(e){e&&(s[e]||(s[e]=new Map))}function d(){let e=arguments.length>0&&void 0!==arguments[0]?arguments[0]:"",t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:"feature";if(u(e),!e||!s[e].get(t))return a(t);s[e].get(t).staged=!0;const r=[...s[e]];function a(t){const r=e?n.ee.get(e):n.ee,a=o.X.handlers;if(r.backlog&&a){var s=r.backlog[t],c=a[t];if(c){for(var u=0;s&&u {let[t,r]=e;return r.staged}))&&(r.sort(((e,t)=>e[1].priority-t[1].priority)),r.forEach((e=>{let[t]=e;a(t)})))}function f(e,t){var r=e[1];(0,i.D)(t[r],(function(t,r){var n=e[0];if(r[0]===n){var i=r[1],o=e[3],a=e[2];i.apply(o,a)}}))}},2177:(e,t,r)=>{r.d(t,{c:()=>f,ee:()=>u});var n=r(8632),i=r(2210),o=r(1284),a=r(5763),s="nr@context";let c=(0,n.fP)();var u;function d(){}function f(e){return(0,i.X)(e,s,l)}function l(){return new d}function h(){u.aborted=!0,u.backlog={}}c.ee?u=c.ee:(u=function e(t,r){var n={},c={},f={},g=!1;try{g=16===r.length&&(0,a.OP)(r).isolatedBacklog}catch(e){}var p={on:b,addEventListener:b,removeEventListener:y,emit:v,get:x,listeners:w,context:m,buffer:A,abort:h,aborted:!1,isBuffering:E,debugId:r,backlog:g?{}:t&&"object"==typeof t.backlog?t.backlog:{}};return p;function m(e){return e&&e instanceof d?e:e?(0,i.X)(e,s,l):l()}function v(e,r,n,i,o){if(!1!==o&&(o=!0),!u.aborted||i){t&&o&&t.emit(e,r,n);for(var a=m(n),s=w(e),d=s.length,f=0;fn,p:()=>i});var n=r(2177).ee.get("handle");function i(e,t,r,i,o){o?(o.buffer([e],i),o.emit(e,t,r)):(n.buffer([e],i),n.emit(e,t,r))}},4322:(e,t,r)=>{r.d(t,{X:()=>o});var n=r(5546);o.on=a;var i=o.handlers={};function o(e,t,r,o){a(o||n.E,i,e,t,r)}function a(e,t,r,i,o){o||(o="feature"),e||(e=n.E);var a=t[o]=t[o]||{};(a[r]=a[r]||[]).push([e,i])}},3239:(e,t,r)=>{r.d(t,{bP:()=>s,iz:()=>c,m$:()=>a});var n=r(385);let i=!1,o=!1;try{const e={get passive(){return i=!0,!1},get signal(){return o=!0,!1}};n._A.addEventListener("test",null,e),n._A.removeEventListener("test",null,e)}catch(e){}function a(e,t){return i||o?{capture:!!e,passive:i,signal:t}:!!e}function s(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2],n=arguments.length>3?arguments[3]:void 0;window.addEventListener(e,t,a(r,n))}function c(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2],n=arguments.length>3?arguments[3]:void 0;document.addEventListener(e,t,a(r,n))}},4402:(e,t,r)=>{r.d(t,{Ht:()=>u,M:()=>c,Rl:()=>a,ky:()=>s});var n=r(385);const i="xxxxxxxx-xxxx-4xxx-yxxx-xxxxxxxxxxxx";function o(e,t){return e?15&e[t]:16*Math.random()|0}function a(){const e=n._A?.crypto||n._A?.msCrypto;let t,r=0;return e&&e.getRandomValues&&(t=e.getRandomValues(new Uint8Array(31))),i.split("").map((e=>"x"===e?o(t,++r).toString(16):"y"===e?(3&o()|8).toString(16):e)).join("")}function s(e){const t=n._A?.crypto||n._A?.msCrypto;let r,i=0;t&&t.getRandomValues&&(r=t.getRandomValues(new Uint8Array(31)));const a=[];for(var s=0;s {r.d(t,{Bq:()=>n,Hb:()=>o,oD:()=>i});const n="NRBA",i=144e5,o=18e5},7894:(e,t,r)=>{function n(){return Math.round(performance.now())}r.d(t,{z:()=>n})},7243:(e,t,r)=>{r.d(t,{e:()=>o});var n=r(385),i={};function o(e){if(e in i)return i[e];if(0===(e||"").indexOf("data:"))return{protocol:"data"};let t;var r=n._A?.location,o={};if(n.il)t=document.createElement("a"),t.href=e;else try{t=new URL(e,r.href)}catch(e){return o}o.port=t.port;var a=t.href.split("://");!o.port&&a[1]&&(o.port=a[1].split("/")[0].split("@").pop().split(":")[1]),o.port&&"0"!==o.port||(o.port="https"===a[0]?"443":"80"),o.hostname=t.hostname||r.hostname,o.pathname=t.pathname,o.protocol=a[0],"/"!==o.pathname.charAt(0)&&(o.pathname="/"+o.pathname);var s=!t.protocol||":"===t.protocol||t.protocol===r.protocol,c=t.hostname===r.hostname&&t.port===r.port;return o.sameOrigin=s&&(!t.hostname||c),"/"===o.pathname&&(i[e]=o),o}},50:(e,t,r)=>{function n(e,t){"function"==typeof console.warn&&(console.warn("New Relic: ".concat(e)),t&&console.warn(t))}r.d(t,{Z:()=>n})},2587:(e,t,r)=>{r.d(t,{N:()=>c,T:()=>u});var n=r(2177),i=r(5546),o=r(8e3),a=r(3325);const s={stn:[a.D.sessionTrace],err:[a.D.jserrors,a.D.metrics],ins:[a.D.pageAction],spa:[a.D.spa],sr:[a.D.sessionReplay,a.D.sessionTrace]};function c(e,t){const r=n.ee.get(t);e&&"object"==typeof e&&(Object.entries(e).forEach((e=>{let[t,n]=e;void 0===u[t]&&(s[t]?s[t].forEach((e=>{n?(0,i.p)("feat-"+t,[],void 0,e,r):(0,i.p)("block-"+t,[],void 0,e,r),(0,i.p)("rumresp-"+t,[Boolean(n)],void 0,e,r)})):n&&(0,i.p)("feat-"+t,[],void 0,void 0,r),u[t]=Boolean(n))})),Object.keys(s).forEach((e=>{void 0===u[e]&&(s[e]?.forEach((t=>(0,i.p)("rumresp-"+e,[!1],void 0,t,r))),u[e]=!1)})),(0,o.L)(t,a.D.pageViewEvent))}const u={}},2210:(e,t,r)=>{r.d(t,{X:()=>i});var n=Object.prototype.hasOwnProperty;function i(e,t,r){if(n.call(e,t))return e[t];var i=r();if(Object.defineProperty&&Object.keys)try{return Object.defineProperty(e,t,{value:i,writable:!0,enumerable:!1}),i}catch(e){}return e[t]=i,i}},1284:(e,t,r)=>{r.d(t,{D:()=>n});const n=(e,t)=>Object.entries(e||{}).map((e=>{let[r,n]=e;return t(r,n)}))},4351:(e,t,r)=>{r.d(t,{P:()=>o});var n=r(2177);const i=()=>{const e=new WeakSet;return(t,r)=>{if("object"==typeof r&&null!==r){if(e.has(r))return;e.add(r)}return r}};function o(e){try{return JSON.stringify(e,i())}catch(e){try{n.ee.emit("internal-error",[e])}catch(e){}}}},3960:(e,t,r)=>{r.d(t,{K:()=>a,b:()=>o});var n=r(3239);function i(){return"undefined"==typeof document||"complete"===document.readyState}function o(e,t){if(i())return e();(0,n.bP)("load",e,t)}function a(e){if(i())return e();(0,n.iz)("DOMContentLoaded",e)}},8632:(e,t,r)=>{r.d(t,{EZ:()=>u,Qy:()=>c,ce:()=>o,fP:()=>a,gG:()=>d,mF:()=>s});var n=r(7894),i=r(385);const o={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net"};function a(){return i._A.NREUM||(i._A.NREUM={}),void 0===i._A.newrelic&&(i._A.newrelic=i._A.NREUM),i._A.NREUM}function s(){let e=a();return e.o||(e.o={ST:i._A.setTimeout,SI:i._A.setImmediate,CT:i._A.clearTimeout,XHR:i._A.XMLHttpRequest,REQ:i._A.Request,EV:i._A.Event,PR:i._A.Promise,MO:i._A.MutationObserver,FETCH:i._A.fetch}),e}function c(e,t,r){let i=a();const o=i.initializedAgents||{},s=o[e]||{};return Object.keys(s).length||(s.initializedAt={ms:(0,n.z)(),date:new Date}),i.initializedAgents={...o,[e]:{...s,[r]:t}},i}function u(e,t){a()[e]=t}function d(){return function(){let e=a();const t=e.info||{};e.info={beacon:o.beacon,errorBeacon:o.errorBeacon,...t}}(),function(){let e=a();const t=e.init||{};e.init={...t}}(),s(),function(){let e=a();const t=e.loader_config||{};e.loader_config={...t}}(),a()}},7956:(e,t,r)=>{r.d(t,{N:()=>i});var n=r(3239);function i(e){let t=arguments.length>1&&void 0!==arguments[1]&&arguments[1],r=arguments.length>2?arguments[2]:void 0,i=arguments.length>3?arguments[3]:void 0;return void(0,n.iz)("visibilitychange",(function(){if(t)return void("hidden"==document.visibilityState&&e());e(document.visibilityState)}),r,i)}},1214:(e,t,r)=>{r.d(t,{em:()=>v,u5:()=>N,QU:()=>S,_L:()=>I,Gm:()=>L,Lg:()=>M,gy:()=>U,BV:()=>Q,Kf:()=>ee});var n=r(2177);const i="nr@original";var o=Object.prototype.hasOwnProperty,a=!1;function s(e,t){return e||(e=n.ee),r.inPlace=function(e,t,n,i,o){n||(n="");var a,s,c,u="-"===n.charAt(0);for(c=0;c 2?n-2:0),o=2;o {r(A[T],e,w),r(E[T],e,w)})),r(l._A,"fetch",y),t.on(y+"end",(function(e,r){var n=this;if(r){var i=r.headers.get("content-length");null!==i&&(n.rxSize=i),t.emit(y+"done",[null,r],n)}else t.emit(y+"done",[e],n)})),t}const O={},j=["pushState","replaceState"];function S(e){const t=function(e){return(e||n.ee).get("history")}(e);return!l.il||O[t.debugId]++||(O[t.debugId]=1,s(t).inPlace(window.history,j,"-")),t}var P=r(3239);const C={},R=["appendChild","insertBefore","replaceChild"];function I(e){const t=function(e){return(e||n.ee).get("jsonp")}(e);if(!l.il||C[t.debugId])return t;C[t.debugId]=!0;var r=s(t),i=/[?&](?:callback|cb)=([^&#]+)/,o=/(.*)\.([^.]+)/,a=/^(\w+)(\.|$)(.*)$/;function c(e,t){var r=e.match(a),n=r[1],i=r[3];return i?c(i,t[n]):t[n]}return r.inPlace(Node.prototype,R,"dom-"),t.on("dom-start",(function(e){!function(e){if(!e||"string"!=typeof e.nodeName||"script"!==e.nodeName.toLowerCase())return;if("function"!=typeof e.addEventListener)return;var n=(a=e.src,s=a.match(i),s?s[1]:null);var a,s;if(!n)return;var u=function(e){var t=e.match(o);if(t&&t.length>=3)return{key:t[2],parent:c(t[1],window)};return{key:e,parent:window}}(n);if("function"!=typeof u.parent[u.key])return;var d={};function f(){t.emit("jsonp-end",[],d),e.removeEventListener("load",f,(0,P.m$)(!1)),e.removeEventListener("error",l,(0,P.m$)(!1))}function l(){t.emit("jsonp-error",[],d),t.emit("jsonp-end",[],d),e.removeEventListener("load",f,(0,P.m$)(!1)),e.removeEventListener("error",l,(0,P.m$)(!1))}r.inPlace(u.parent,[u.key],"cb-",d),e.addEventListener("load",f,(0,P.m$)(!1)),e.addEventListener("error",l,(0,P.m$)(!1)),t.emit("new-jsonp",[e.src],d)}(e[0])})),t}var k=r(5763);const H={};function L(e){const t=function(e){return(e||n.ee).get("mutation")}(e);if(!l.il||H[t.debugId])return t;H[t.debugId]=!0;var r=s(t),i=k.Yu.MO;return i&&(window.MutationObserver=function(e){return this instanceof i?new i(r(e,"fn-")):i.apply(this,arguments)},MutationObserver.prototype=i.prototype),t}const z={};function M(e){const t=function(e){return(e||n.ee).get("promise")}(e);if(z[t.debugId])return t;z[t.debugId]=!0;var r=n.c,o=s(t),a=k.Yu.PR;return a&&function(){function e(r){var n=t.context(),i=o(r,"executor-",n,null,!1);const s=Reflect.construct(a,[i],e);return t.context(s).getCtx=function(){return n},s}l._A.Promise=e,Object.defineProperty(e,"name",{value:"Promise"}),e.toString=function(){return a.toString()},Object.setPrototypeOf(e,a),["all","race"].forEach((function(r){const n=a[r];e[r]=function(e){let i=!1;[...e||[]].forEach((e=>{this.resolve(e).then(a("all"===r),a(!1))}));const o=n.apply(this,arguments);return o;function a(e){return function(){t.emit("propagate",[null,!i],o,!1,!1),i=i||!e}}}})),["resolve","reject"].forEach((function(r){const n=a[r];e[r]=function(e){const r=n.apply(this,arguments);return e!==r&&t.emit("propagate",[e,!0],r,!1,!1),r}})),e.prototype=a.prototype;const n=a.prototype.then;a.prototype.then=function(){var e=this,i=r(e);i.promise=e;for(var a=arguments.length,s=new Array(a),c=0;c e())),t};function m(e,t){i.inPlace(t,["onreadystatechange"],"fn-",E)}function b(){var e=this,t=r.context(e);e.readyState>3&&!t.resolved&&(t.resolved=!0,r.emit("xhr-resolved",[],e)),i.inPlace(e,f,"fn-",E)}if(function(e,t){for(var r in e)t[r]=e[r]}(o,p),p.prototype=o.prototype,i.inPlace(p.prototype,J,"-xhr-",E),r.on("send-xhr-start",(function(e,t){m(e,t),function(e){h.push(e),a&&(y?y.then(A):u?u(A):(w=-w,x.data=w))}(t)})),r.on("open-xhr-start",m),a){var y=c&&c.resolve();if(!u&&!c){var w=1,x=document.createTextNode(w);new a(A).observe(x,{characterData:!0})}}else t.on("fn-end",(function(e){e[0]&&e[0].type===d||A()}));function A(){for(var e=0;e {r.d(t,{t:()=>n});const n=r(3325).D.ajax},6660:(e,t,r)=>{r.d(t,{A:()=>i,t:()=>n});const n=r(3325).D.jserrors,i="nr@seenError"},3081:(e,t,r)=>{r.d(t,{gF:()=>o,mY:()=>i,t9:()=>n,vz:()=>s,xS:()=>a});const n=r(3325).D.metrics,i="sm",o="cm",a="storeSupportabilityMetrics",s="storeEventMetrics"},4649:(e,t,r)=>{r.d(t,{t:()=>n});const n=r(3325).D.pageAction},7633:(e,t,r)=>{r.d(t,{Dz:()=>i,OJ:()=>a,qw:()=>o,t9:()=>n});const n=r(3325).D.pageViewEvent,i="firstbyte",o="domcontent",a="windowload"},9251:(e,t,r)=>{r.d(t,{t:()=>n});const n=r(3325).D.pageViewTiming},3614:(e,t,r)=>{r.d(t,{BST_RESOURCE:()=>i,END:()=>s,FEATURE_NAME:()=>n,FN_END:()=>u,FN_START:()=>c,PUSH_STATE:()=>d,RESOURCE:()=>o,START:()=>a});const n=r(3325).D.sessionTrace,i="bstResource",o="resource",a="-start",s="-end",c="fn"+a,u="fn"+s,d="pushState"},7836:(e,t,r)=>{r.d(t,{BODY:()=>A,CB_END:()=>E,CB_START:()=>u,END:()=>x,FEATURE_NAME:()=>i,FETCH:()=>_,FETCH_BODY:()=>v,FETCH_DONE:()=>m,FETCH_START:()=>p,FN_END:()=>c,FN_START:()=>s,INTERACTION:()=>l,INTERACTION_API:()=>d,INTERACTION_EVENTS:()=>o,JSONP_END:()=>b,JSONP_NODE:()=>g,JS_TIME:()=>T,MAX_TIMER_BUDGET:()=>a,REMAINING:()=>f,SPA_NODE:()=>h,START:()=>w,originalSetTimeout:()=>y});var n=r(5763);const i=r(3325).D.spa,o=["click","submit","keypress","keydown","keyup","change"],a=999,s="fn-start",c="fn-end",u="cb-start",d="api-ixn-",f="remaining",l="interaction",h="spaNode",g="jsonpNode",p="fetch-start",m="fetch-done",v="fetch-body-",b="jsonp-end",y=n.Yu.ST,w="-start",x="-end",A="-body",E="cb"+x,T="jsTime",_="fetch"},5938:(e,t,r)=>{r.d(t,{W:()=>o});var n=r(5763),i=r(2177);class o{constructor(e,t,r){this.agentIdentifier=e,this.aggregator=t,this.ee=i.ee.get(e,(0,n.OP)(this.agentIdentifier).isolatedBacklog),this.featureName=r,this.blocked=!1}}},9144:(e,t,r)=>{r.d(t,{j:()=>m});var n=r(3325),i=r(5763),o=r(5546),a=r(2177),s=r(7894),c=r(8e3),u=r(3960),d=r(385),f=r(50),l=r(3081),h=r(8632);function g(){const e=(0,h.gG)();["setErrorHandler","finished","addToTrace","inlineHit","addRelease","addPageAction","setCurrentRouteName","setPageViewName","setCustomAttribute","interaction","noticeError","setUserId"].forEach((t=>{e[t]=function(){for(var r=arguments.length,n=new Array(r),i=0;i 1?r-1:0),i=1;i {e.exposed&&e.api[t]&&o.push(e.api[t](...n))})),o.length>1?o:o[0]}(t,...n)}}))}var p=r(2587);function m(e){let t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:{},m=arguments.length>2?arguments[2]:void 0,v=arguments.length>3?arguments[3]:void 0,{init:b,info:y,loader_config:w,runtime:x={loaderType:m},exposed:A=!0}=t;const E=(0,h.gG)();y||(b=E.init,y=E.info,w=E.loader_config),(0,i.Dg)(e,b||{}),(0,i.GE)(e,w||{}),(0,i.sU)(e,x),y.jsAttributes??={},d.v6&&(y.jsAttributes.isWorker=!0),(0,i.CX)(e,y),g();const T=function(e,t){t||(0,c.R)(e,"api");const h={};var g=a.ee.get(e),p=g.get("tracer"),m="api-",v=m+"ixn-";function b(t,r,n,o){const a=(0,i.C5)(e);return null===r?delete a.jsAttributes[t]:(0,i.CX)(e,{...a,jsAttributes:{...a.jsAttributes,[t]:r}}),x(m,n,!0,o||null===r?"session":void 0)(t,r)}function y(){}["setErrorHandler","finished","addToTrace","inlineHit","addRelease"].forEach((e=>h[e]=x(m,e,!0,"api"))),h.addPageAction=x(m,"addPageAction",!0,n.D.pageAction),h.setCurrentRouteName=x(m,"routeName",!0,n.D.spa),h.setPageViewName=function(t,r){if("string"==typeof t)return"/"!==t.charAt(0)&&(t="/"+t),(0,i.OP)(e).customTransaction=(r||"http://custom.transaction")+t,x(m,"setPageViewName",!0)()},h.setCustomAttribute=function(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2];if("string"==typeof e){if(["string","number"].includes(typeof t)||null===t)return b(e,t,"setCustomAttribute",r);(0,f.Z)("Failed to execute setCustomAttribute.\nNon-null value must be a string or number type, but a type of was provided."))}else(0,f.Z)("Failed to execute setCustomAttribute.\nName must be a string type, but a type of was provided."))},h.setUserId=function(e){if("string"==typeof e||null===e)return b("enduser.id",e,"setUserId",!0);(0,f.Z)("Failed to execute setUserId.\nNon-null value must be a string type, but a type of was provided."))},h.interaction=function(){return(new y).get()};var w=y.prototype={createTracer:function(e,t){var r={},i=this,a="function"==typeof t;return(0,o.p)(v+"tracer",[(0,s.z)(),e,r],i,n.D.spa,g),function(){if(p.emit((a?"":"no-")+"fn-start",[(0,s.z)(),i,a],r),a)try{return t.apply(this,arguments)}catch(e){throw p.emit("fn-err",[arguments,this,"string"==typeof e?new Error(e):e],r),e}finally{p.emit("fn-end",[(0,s.z)()],r)}}}};function x(e,t,r,i){return function(){return(0,o.p)(l.xS,["API/"+t+"/called"],void 0,n.D.metrics,g),i&&(0,o.p)(e+t,[(0,s.z)(),...arguments],r?null:this,i,g),r?void 0:this}}function A(){r.e(439).then(r.bind(r,7438)).then((t=>{let{setAPI:r}=t;r(e),(0,c.L)(e,"api")})).catch((()=>(0,f.Z)("Downloading runtime APIs failed...")))}return["actionText","setName","setAttribute","save","ignore","onEnd","getContext","end","get"].forEach((e=>{w[e]=x(v,e,void 0,n.D.spa)})),h.noticeError=function(e,t){"string"==typeof e&&(e=new Error(e)),(0,o.p)(l.xS,["API/noticeError/called"],void 0,n.D.metrics,g),(0,o.p)("err",[e,(0,s.z)(),!1,t],void 0,n.D.jserrors,g)},d.il?(0,u.b)((()=>A()),!0):A(),h}(e,v);return(0,h.Qy)(e,T,"api"),(0,h.Qy)(e,A,"exposed"),(0,h.EZ)("activatedFeatures",p.T),T}},3325:(e,t,r)=>{r.d(t,{D:()=>n,p:()=>i});const n={ajax:"ajax",jserrors:"jserrors",metrics:"metrics",pageAction:"page_action",pageViewEvent:"page_view_event",pageViewTiming:"page_view_timing",sessionReplay:"session_replay",sessionTrace:"session_trace",spa:"spa"},i={[n.pageViewEvent]:1,[n.pageViewTiming]:2,[n.metrics]:3,[n.jserrors]:4,[n.ajax]:5,[n.sessionTrace]:6,[n.pageAction]:7,[n.spa]:8,[n.sessionReplay]:9}}},n={};function i(e){var t=n[e];if(void 0!==t)return t.exports;var o=n[e]={exports:{}};return r[e](o,o.exports,i),o.exports}i.m=r,i.d=(e,t)=>{for(var r in t)i.o(t,r)&&!i.o(e,r)&&Object.defineProperty(e,r,{enumerable:!0,get:t[r]})},i.f={},i.e=e=>Promise.all(Object.keys(i.f).reduce(((t,r)=>(i.f[r](e,t),t)),[])),i.u=e=>(({78:"page_action-aggregate",147:"metrics-aggregate",242:"session-manager",317:"jserrors-aggregate",348:"page_view_timing-aggregate",412:"lazy-feature-loader",439:"async-api",538:"recorder",590:"session_replay-aggregate",675:"compressor",733:"session_trace-aggregate",786:"page_view_event-aggregate",873:"spa-aggregate",898:"ajax-aggregate"}[e]||e)+"."+{78:"ac76d497",147:"3dc53903",148:"1a20d5fe",242:"2a64278a",317:"49e41428",348:"bd6de33a",412:"2f55ce66",439:"30bd804e",538:"1b18459f",590:"cf0efb30",675:"ae9f91a8",733:"83105561",786:"06482edd",860:"03a8b7a5",873:"e6b09d52",898:"998ef92b"}[e]+"-1.236.0.min.js"),i.o=(e,t)=>Object.prototype.hasOwnProperty.call(e,t),e={},t="NRBA:",i.l=(r,n,o,a)=>{if(e[r])e[r].push(n);else{var s,c;if(void 0!==o)for(var u=document.getElementsByTagName("script"),d=0;d {s.onerror=s.onload=null,clearTimeout(h);var i=e[r];if(delete e[r],s.parentNode&&s.parentNode.removeChild(s),i&&i.forEach((e=>e(n))),t)return t(n)},h=setTimeout(l.bind(null,void 0,{type:"timeout",target:s}),12e4);s.onerror=l.bind(null,s.onerror),s.onload=l.bind(null,s.onload),c&&document.head.appendChild(s)}},i.r=e=>{"undefined"!=typeof Symbol&&Symbol.toStringTag&&Object.defineProperty(e,Symbol.toStringTag,{value:"Module"}),Object.defineProperty(e,"__esModule",{value:!0})},i.j=364,i.p="https://js-agent.newrelic.com/",(()=>{var e={364:0,953:0};i.f.j=(t,r)=>{var n=i.o(e,t)?e[t]:void 0;if(0!==n)if(n)r.push(n[2]);else{var o=new Promise(((r,i)=>n=e[t]=[r,i]));r.push(n[2]=o);var a=i.p+i.u(t),s=new Error;i.l(a,(r=>{if(i.o(e,t)&&(0!==(n=e[t])&&(e[t]=void 0),n)){var o=r&&("load"===r.type?"missing":r.type),a=r&&r.target&&r.target.src;s.message="Loading chunk "+t+" failed.\n("+o+": "+a+")",s.name="ChunkLoadError",s.type=o,s.request=a,n[1](s)}}),"chunk-"+t,t)}};var t=(t,r)=>{var n,o,[a,s,c]=r,u=0;if(a.some((t=>0!==e[t]))){for(n in s)i.o(s,n)&&(i.m[n]=s[n]);if(c)c(i)}for(t&&t(r);u {i.r(o);var e=i(3325),t=i(5763);const r=Object.values(e.D);function n(e){const n={};return r.forEach((r=>{n[r]=function(e,r){return!1!==(0,t.Mt)(r,"".concat(e,".enabled"))}(r,e)})),n}var a=i(9144);var s=i(5546),c=i(385),u=i(8e3),d=i(5938),f=i(3960),l=i(50);class h extends d.W{constructor(e,t,r){let n=!(arguments.length>3&&void 0!==arguments[3])||arguments[3];super(e,t,r),this.auto=n,this.abortHandler,this.featAggregate,this.onAggregateImported,n&&(0,u.R)(e,r)}importAggregator(){let e=arguments.length>0&&void 0!==arguments[0]?arguments[0]:{};if(this.featAggregate||!this.auto)return;const r=c.il&&!0===(0,t.Mt)(this.agentIdentifier,"privacy.cookies_enabled");let n;this.onAggregateImported=new Promise((e=>{n=e}));const o=async()=>{let t;try{if(r){const{setupAgentSession:e}=await Promise.all([i.e(860),i.e(242)]).then(i.bind(i,3228));t=e(this.agentIdentifier)}}catch(e){(0,l.Z)("A problem occurred when starting up session manager. This page will not start or extend any session.",e)}try{if(!this.shouldImportAgg(this.featureName,t))return void(0,u.L)(this.agentIdentifier,this.featureName);const{lazyFeatureLoader:r}=await i.e(412).then(i.bind(i,8582)),{Aggregate:o}=await r(this.featureName,"aggregate");this.featAggregate=new o(this.agentIdentifier,this.aggregator,e),n(!0)}catch(e){(0,l.Z)("Downloading and initializing ".concat(this.featureName," failed..."),e),this.abortHandler?.(),n(!1)}};c.il?(0,f.b)((()=>o()),!0):o()}shouldImportAgg(r,n){return r!==e.D.sessionReplay||!1!==(0,t.Mt)(this.agentIdentifier,"session_trace.enabled")&&(!!n?.isNew||!!n?.state.sessionReplay)}}var g=i(7633),p=i(7894);class m extends h{static featureName=g.t9;constructor(r,n){let i=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];if(super(r,n,g.t9,i),("undefined"==typeof PerformanceNavigationTiming||c.Tt)&&"undefined"!=typeof PerformanceTiming){const n=(0,t.OP)(r);n[g.Dz]=Math.max(Date.now()-n.offset,0),(0,f.K)((()=>n[g.qw]=Math.max((0,p.z)()-n[g.Dz],0))),(0,f.b)((()=>{const t=(0,p.z)();n[g.OJ]=Math.max(t-n[g.Dz],0),(0,s.p)("timing",["load",t],void 0,e.D.pageViewTiming,this.ee)}))}this.importAggregator()}}var v=i(1117),b=i(1284);class y extends v.w{constructor(e){super(e),this.aggregatedData={}}store(e,t,r,n,i){var o=this.getBucket(e,t,r,i);return o.metrics=function(e,t){t||(t={count:0});return t.count+=1,(0,b.D)(e,(function(e,r){t[e]=w(r,t[e])})),t}(n,o.metrics),o}merge(e,t,r,n,i){var o=this.getBucket(e,t,n,i);if(o.metrics){var a=o.metrics;a.count+=r.count,(0,b.D)(r,(function(e,t){if("count"!==e){var n=a[e],i=r[e];i&&!i.c?a[e]=w(i.t,n):a[e]=function(e,t){if(!t)return e;t.c||(t=x(t.t));return t.min=Math.min(e.min,t.min),t.max=Math.max(e.max,t.max),t.t+=e.t,t.sos+=e.sos,t.c+=e.c,t}(i,a[e])}}))}else o.metrics=r}storeMetric(e,t,r,n){var i=this.getBucket(e,t,r);return i.stats=w(n,i.stats),i}getBucket(e,t,r,n){this.aggregatedData[e]||(this.aggregatedData[e]={});var i=this.aggregatedData[e][t];return i||(i=this.aggregatedData[e][t]={params:r||{}},n&&(i.custom=n)),i}get(e,t){return t?this.aggregatedData[e]&&this.aggregatedData[e][t]:this.aggregatedData[e]}take(e){for(var t={},r="",n=!1,i=0;i t.max&&(t.max=e),e 2&&void 0!==arguments[2])||arguments[2];super(e,r,j.t,n),c.il&&((0,t.OP)(e).initHidden=Boolean("hidden"===document.visibilityState),(0,N.N)((()=>(0,s.p)("docHidden",[(0,p.z)()],void 0,j.t,this.ee)),!0),(0,O.bP)("pagehide",(()=>(0,s.p)("winPagehide",[(0,p.z)()],void 0,j.t,this.ee))),this.importAggregator())}}var P=i(3081);class C extends h{static featureName=P.t9;constructor(e,t){let r=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];super(e,t,P.t9,r),this.importAggregator()}}var R,I=i(2210),k=i(1214),H=i(2177),L={};try{R=localStorage.getItem("__nr_flags").split(","),console&&"function"==typeof console.log&&(L.console=!0,-1!==R.indexOf("dev")&&(L.dev=!0),-1!==R.indexOf("nr_dev")&&(L.nrDev=!0))}catch(e){}function z(e){try{L.console&&z(e)}catch(e){}}L.nrDev&&H.ee.on("internal-error",(function(e){z(e.stack)})),L.dev&&H.ee.on("fn-err",(function(e,t,r){z(r.stack)})),L.dev&&(z("NR AGENT IN DEVELOPMENT MODE"),z("flags: "+(0,b.D)(L,(function(e,t){return e})).join(", ")));var M=i(6660);class B extends h{static featureName=M.t;constructor(r,n){let i=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];super(r,n,M.t,i),this.skipNext=0;try{this.removeOnAbort=new AbortController}catch(e){}const o=this;o.ee.on("fn-start",(function(e,t,r){o.abortHandler&&(o.skipNext+=1)})),o.ee.on("fn-err",(function(t,r,n){o.abortHandler&&!n[M.A]&&((0,I.X)(n,M.A,(function(){return!0})),this.thrown=!0,(0,s.p)("err",[n,(0,p.z)()],void 0,e.D.jserrors,o.ee))})),o.ee.on("fn-end",(function(){o.abortHandler&&!this.thrown&&o.skipNext>0&&(o.skipNext-=1)})),o.ee.on("internal-error",(function(t){(0,s.p)("ierr",[t,(0,p.z)(),!0],void 0,e.D.jserrors,o.ee)})),this.origOnerror=c._A.onerror,c._A.onerror=this.onerrorHandler.bind(this),c._A.addEventListener("unhandledrejection",(t=>{const r=function(e){let t="Unhandled Promise Rejection: ";if(e instanceof Error)try{return e.message=t+e.message,e}catch(t){return e}if(void 0===e)return new Error(t);try{return new Error(t+(0,D.P)(e))}catch(e){return new Error(t)}}(t.reason);(0,s.p)("err",[r,(0,p.z)(),!1,{unhandledPromiseRejection:1}],void 0,e.D.jserrors,this.ee)}),(0,O.m$)(!1,this.removeOnAbort?.signal)),(0,k.gy)(this.ee),(0,k.BV)(this.ee),(0,k.em)(this.ee),(0,t.OP)(r).xhrWrappable&&(0,k.Kf)(this.ee),this.abortHandler=this.#e,this.importAggregator()}#e(){this.removeOnAbort?.abort(),this.abortHandler=void 0}onerrorHandler(t,r,n,i,o){"function"==typeof this.origOnerror&&this.origOnerror(...arguments);try{this.skipNext?this.skipNext-=1:(0,s.p)("err",[o||new F(t,r,n),(0,p.z)()],void 0,e.D.jserrors,this.ee)}catch(t){try{(0,s.p)("ierr",[t,(0,p.z)(),!0],void 0,e.D.jserrors,this.ee)}catch(e){}}return!1}}function F(e,t,r){this.message=e||"Uncaught error with no additional information",this.sourceURL=t,this.line=r}let U=1;const q="nr@id";function G(e){const t=typeof e;return!e||"object"!==t&&"function"!==t?-1:e===c._A?0:(0,I.X)(e,q,(function(){return U++}))}function V(e){if("string"==typeof e&&e.length)return e.length;if("object"==typeof e){if("undefined"!=typeof ArrayBuffer&&e instanceof ArrayBuffer&&e.byteLength)return e.byteLength;if("undefined"!=typeof Blob&&e instanceof Blob&&e.size)return e.size;if(!("undefined"!=typeof FormData&&e instanceof FormData))try{return(0,D.P)(e).length}catch(e){return}}}var X=i(7243);class W{constructor(e){this.agentIdentifier=e,this.generateTracePayload=this.generateTracePayload.bind(this),this.shouldGenerateTrace=this.shouldGenerateTrace.bind(this)}generateTracePayload(e){if(!this.shouldGenerateTrace(e))return null;var r=(0,t.DL)(this.agentIdentifier);if(!r)return null;var n=(r.accountID||"").toString()||null,i=(r.agentID||"").toString()||null,o=(r.trustKey||"").toString()||null;if(!n||!i)return null;var a=(0,_.M)(),s=(0,_.Ht)(),c=Date.now(),u={spanId:a,traceId:s,timestamp:c};return(e.sameOrigin||this.isAllowedOrigin(e)&&this.useTraceContextHeadersForCors())&&(u.traceContextParentHeader=this.generateTraceContextParentHeader(a,s),u.traceContextStateHeader=this.generateTraceContextStateHeader(a,c,n,i,o)),(e.sameOrigin&&!this.excludeNewrelicHeader()||!e.sameOrigin&&this.isAllowedOrigin(e)&&this.useNewrelicHeaderForCors())&&(u.newrelicHeader=this.generateTraceHeader(a,s,c,n,i,o)),u}generateTraceContextParentHeader(e,t){return"00-"+t+"-"+e+"-01"}generateTraceContextStateHeader(e,t,r,n,i){return i+"@nr=0-1-"+r+"-"+n+"-"+e+"----"+t}generateTraceHeader(e,t,r,n,i,o){if(!("function"==typeof c._A?.btoa))return null;var a={v:[0,1],d:{ty:"Browser",ac:n,ap:i,id:e,tr:t,ti:r}};return o&&n!==o&&(a.d.tk=o),btoa((0,D.P)(a))}shouldGenerateTrace(e){return this.isDtEnabled()&&this.isAllowedOrigin(e)}isAllowedOrigin(e){var r=!1,n={};if((0,t.Mt)(this.agentIdentifier,"distributed_tracing")&&(n=(0,t.P_)(this.agentIdentifier).distributed_tracing),e.sameOrigin)r=!0;else if(n.allowed_origins instanceof Array)for(var i=0;i 2&&void 0!==arguments[2])||arguments[2];super(r,n,Z.t,i),(0,t.OP)(r).xhrWrappable&&(this.dt=new W(r),this.handler=(e,t,r,n)=>(0,s.p)(e,t,r,n,this.ee),(0,k.u5)(this.ee),(0,k.Kf)(this.ee),function(r,n,i,o){function a(e){var t=this;t.totalCbs=0,t.called=0,t.cbTime=0,t.end=E,t.ended=!1,t.xhrGuids={},t.lastSize=null,t.loadCaptureCalled=!1,t.params=this.params||{},t.metrics=this.metrics||{},e.addEventListener("load",(function(r){_(t,e)}),(0,O.m$)(!1)),c.IF||e.addEventListener("progress",(function(e){t.lastSize=e.loaded}),(0,O.m$)(!1))}function s(e){this.params={method:e[0]},T(this,e[1]),this.metrics={}}function u(e,n){var i=(0,t.DL)(r);i.xpid&&this.sameOrigin&&n.setRequestHeader("X-NewRelic-ID",i.xpid);var a=o.generateTracePayload(this.parsedOrigin);if(a){var s=!1;a.newrelicHeader&&(n.setRequestHeader("newrelic",a.newrelicHeader),s=!0),a.traceContextParentHeader&&(n.setRequestHeader("traceparent",a.traceContextParentHeader),a.traceContextStateHeader&&n.setRequestHeader("tracestate",a.traceContextStateHeader),s=!0),s&&(this.dt=a)}}function d(e,t){var r=this.metrics,i=e[0],o=this;if(r&&i){var a=V(i);a&&(r.txSize=a)}this.startTime=(0,p.z)(),this.listener=function(e){try{"abort"!==e.type||o.loadCaptureCalled||(o.params.aborted=!0),("load"!==e.type||o.called===o.totalCbs&&(o.onloadCalled||"function"!=typeof t.onload)&&"function"==typeof o.end)&&o.end(t)}catch(e){try{n.emit("internal-error",[e])}catch(e){}}};for(var s=0;s 1?e[1]=i:e.push(i)}else e[0]&&e[0].headers&&s(e[0].headers,n)&&(this.dt=n);function s(e,t){var r=!1;return t.newrelicHeader&&(e.set("newrelic",t.newrelicHeader),r=!0),t.traceContextParentHeader&&(e.set("traceparent",t.traceContextParentHeader),t.traceContextStateHeader&&e.set("tracestate",t.traceContextStateHeader),r=!0),r}}function x(e,t){this.params={},this.metrics={},this.startTime=(0,p.z)(),this.dt=t,e.length>=1&&(this.target=e[0]),e.length>=2&&(this.opts=e[1]);var r,n=this.opts||{},i=this.target;"string"==typeof i?r=i:"object"==typeof i&&i instanceof Y?r=i.url:c._A?.URL&&"object"==typeof i&&i instanceof URL&&(r=i.href),T(this,r);var o=(""+(i&&i instanceof Y&&i.method||n.method||"GET")).toUpperCase();this.params.method=o,this.txSize=V(n.body)||0}function A(t,r){var n;this.endTime=(0,p.z)(),this.params||(this.params={}),this.params.status=r?r.status:0,"string"==typeof this.rxSize&&this.rxSize.length>0&&(n=+this.rxSize);var o={txSize:this.txSize,rxSize:n,duration:(0,p.z)()-this.startTime};i("xhr",[this.params,o,this.startTime,this.endTime,"fetch"],this,e.D.ajax)}function E(t){var r=this.params,n=this.metrics;if(!this.ended){this.ended=!0;for(var o=0;o 2&&void 0!==arguments[2])||arguments[2];super(e,t,we.t,r),this.importAggregator()}}new class{constructor(e){let t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:(0,_.ky)(16);c._A?(this.agentIdentifier=t,this.sharedAggregator=new y({agentIdentifier:this.agentIdentifier}),this.features={},this.desiredFeatures=new Set(e.features||[]),this.desiredFeatures.add(m),Object.assign(this,(0,a.j)(this.agentIdentifier,e,e.loaderType||"agent")),this.start()):(0,l.Z)("Failed to initial the agent. Could not determine the runtime environment.")}get config(){return{info:(0,t.C5)(this.agentIdentifier),init:(0,t.P_)(this.agentIdentifier),loader_config:(0,t.DL)(this.agentIdentifier),runtime:(0,t.OP)(this.agentIdentifier)}}start(){const t="features";try{const r=n(this.agentIdentifier),i=[...this.desiredFeatures];i.sort(((t,r)=>e.p[t.featureName]-e.p[r.featureName])),i.forEach((t=>{if(r[t.featureName]||t.featureName===e.D.pageViewEvent){const n=function(t){switch(t){case e.D.ajax:return[e.D.jserrors];case e.D.sessionTrace:return[e.D.ajax,e.D.pageViewEvent];case e.D.sessionReplay:return[e.D.sessionTrace];case e.D.pageViewTiming:return[e.D.pageViewEvent];default:return[]}}(t.featureName);n.every((e=>r[e]))||(0,l.Z)("".concat(t.featureName," is enabled but one or more dependent features has been disabled (").concat((0,D.P)(n),"). This may cause unintended consequences or missing data...")),this.features[t.featureName]=new t(this.agentIdentifier,this.sharedAggregator)}})),(0,T.Qy)(this.agentIdentifier,this.features,t)}catch(e){(0,l.Z)("Failed to initialize all enabled instrument classes (agent aborted) -",e);for(const e in this.features)this.features[e].abortHandler?.();const r=(0,T.fP)();return delete r.initializedAgents[this.agentIdentifier]?.api,delete r.initializedAgents[this.agentIdentifier]?.[t],delete this.sharedAggregator,r.ee?.abort(),delete r.ee?.get(this.agentIdentifier),!1}}}({features:[J,m,S,class extends h{static featureName=oe;constructor(t,r){if(super(t,r,oe,!(arguments.length>2&&void 0!==arguments[2])||arguments[2]),!c.il)return;const n=this.ee;let i;(0,k.QU)(n),this.eventsEE=(0,k.em)(n),this.eventsEE.on(se,(function(e,t){this.bstStart=(0,p.z)()})),this.eventsEE.on(ae,(function(t,r){(0,s.p)("bst",[t[0],r,this.bstStart,(0,p.z)()],void 0,e.D.sessionTrace,n)})),n.on(ce+ne,(function(e){this.time=(0,p.z)(),this.startPath=location.pathname+location.hash})),n.on(ce+ie,(function(t){(0,s.p)("bstHist",[location.pathname+location.hash,this.startPath,this.time],void 0,e.D.sessionTrace,n)}));try{i=new PerformanceObserver((t=>{const r=t.getEntries();(0,s.p)(te,[r],void 0,e.D.sessionTrace,n)})),i.observe({type:re,buffered:!0})}catch(e){}this.importAggregator({resourceObserver:i})}},C,xe,B,class extends h{static featureName=de;constructor(e,r){if(super(e,r,de,!(arguments.length>2&&void 0!==arguments[2])||arguments[2]),!c.il)return;if(!(0,t.OP)(e).xhrWrappable)return;try{this.removeOnAbort=new AbortController}catch(e){}let n,i=0;const o=this.ee.get("tracer"),a=(0,k._L)(this.ee),s=(0,k.Lg)(this.ee),u=(0,k.BV)(this.ee),d=(0,k.Kf)(this.ee),f=this.ee.get("events"),l=(0,k.u5)(this.ee),h=(0,k.QU)(this.ee),g=(0,k.Gm)(this.ee);function m(e,t){h.emit("newURL",[""+window.location,t])}function v(){i++,n=window.location.hash,this[ve]=(0,p.z)()}function b(){i--,window.location.hash!==n&&m(0,!0);var e=(0,p.z)();this[pe]=~~this[pe]+e-this[ve],this[ye]=e}function y(e,t){e.on(t,(function(){this[t]=(0,p.z)()}))}this.ee.on(ve,v),s.on(be,v),a.on(be,v),this.ee.on(ye,b),s.on(ge,b),a.on(ge,b),this.ee.buffer([ve,ye,"xhr-resolved"],this.featureName),f.buffer([ve],this.featureName),u.buffer(["setTimeout"+le,"clearTimeout"+fe,ve],this.featureName),d.buffer([ve,"new-xhr","send-xhr"+fe],this.featureName),l.buffer([me+fe,me+"-done",me+he+fe,me+he+le],this.featureName),h.buffer(["newURL"],this.featureName),g.buffer([ve],this.featureName),s.buffer(["propagate",be,ge,"executor-err","resolve"+fe],this.featureName),o.buffer([ve,"no-"+ve],this.featureName),a.buffer(["new-jsonp","cb-start","jsonp-error","jsonp-end"],this.featureName),y(l,me+fe),y(l,me+"-done"),y(a,"new-jsonp"),y(a,"jsonp-end"),y(a,"cb-start"),h.on("pushState-end",m),h.on("replaceState-end",m),window.addEventListener("hashchange",m,(0,O.m$)(!0,this.removeOnAbort?.signal)),window.addEventListener("load",m,(0,O.m$)(!0,this.removeOnAbort?.signal)),window.addEventListener("popstate",(function(){m(0,i>1)}),(0,O.m$)(!0,this.removeOnAbort?.signal)),this.abortHandler=this.#e,this.importAggregator()}#e(){this.removeOnAbort?.abort(),this.abortHandler=void 0}}],loaderType:"spa"})})(),window.NRBA=o})(); window.jQuery || document.write(' ') CKEDITOR_BASEPATH='https://f1000research.com/js/vendor/ckeditor/' window.reactTheme = 'research'; window.MathJax = { CommonHTML: { linebreaks: { automatic: true } }, 'HTML-CSS': { linebreaks: { automatic: true } }, SVG: { linebreaks: { automatic: true } }, AuthorInit: function() { MathJax.Hub.Register.MessageHook('End Process', function () { let timeout = false; // holder for timeout id const delay = 250; // delay after event is "complete" to run callback const reflowMath = function() { const dispFormulas = document.querySelectorAll('.disp-formula.panel'); if (!dispFormulas) { return; } for (const dispFormula of dispFormulas) { const child = dispFormula.querySelector('.MathJax_Preview').nextSibling.firstChild; const isMultiline = MathJax.Hub.getAllJax(dispFormula)[0].root.isMultiline; if (dispFormula.offsetWidth < child.offsetWidth || isMultiline) { MathJax.Hub.Queue(['Rerender', MathJax.Hub, dispFormula]); } } }; window.addEventListener('resize', function() { clearTimeout(timeout); // clear the timeout timeout = setTimeout(reflowMath, delay); // start timing for event "completion" }); }); }, }; if (window.location.hash == '#_=_'){ window.location = window.location.href.split('#')[0] } !function(f,b,e,v,n,t,s){if(f.fbq)return;n=f.fbq=function() {n.callMethod? n.callMethod.apply(n,arguments):n.queue.push(arguments)} ;if(!f._fbq)f._fbq=n; n.push=n;n.loaded=!0;n.version='2.0';n.queue=[];t=b.createElement(e);t.async=!0; t.src=v;s=b.getElementsByTagName(e)[0];s.parentNode.insertBefore(t,s)}(window, document,'script','https://connect.facebook.net/en_US/fbevents.js'); fbq('init', '1641728616063202'); fbq('track', "PixelInitialized", {}); (function(h,o,t,j,a,r){ h.hj=h.hj||function(){(h.hj.q=h.hj.q||[]).push(arguments)}; h._hjSettings={hjid:2318163,hjsv:6}; a=o.getElementsByTagName('head')[0]; r=o.createElement('script');r.async=1; r.src=t+h._hjSettings.hjid+j+h._hjSettings.hjsv; a.appendChild(r); })(window,document,'https://static.hotjar.com/c/hotjar-','.js?sv='); search file_upload Submit your research search menu close search Browse Gateways & Collections How to Publish Submit your Research My Submissions Article Guidelines Article Guidelines (New Versions) Open Data, Software and Code Guidelines Open Data and Accessible Source Materials Guidelines (HSS) Open Data, Software and Code Guidelines (PSE) Prepublication Checks Production Process Posters and Slides Guidelines Document Guidelines Article Processing Charges Peer Review Finding Article Reviewers About How it Works For Reviewers Our Advisors Policies Glossary FAQs For Developers Newsroom Contact My Research Submissions Content and Tracking Alerts My Details Sign In file_upload Submit your research { "@context": "https://schema.org", "@type": "ScholarlyArticle", "mainEntityOfPage": { "@type": "WebPage", "@id": "https://f1000research.com/articles/13-1121" }, "headline": "Breaking point: Case series of tendon ruptures in Hemodialysis patients", "datePublished": "2024-10-03T16:36:35", "dateModified": "2024-12-12T14:59:07", "author": [ { "@type": "Person", "name": "Muhammed Ehsan Nazeer" }, { "@type": "Person", "name": "Dr Askhar Haphiz" }, { "@type": "Person", "name": "Dr Muhammed Nazeer" }, { "@type": "Person", "name": "Dr Pradeep Moni" }, { "@type": "Person", "name": "Dr Praveen Muraleedharan" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": " Introduction Spontaneous tendon ruptures in end stage kidney disease patients have the potential to cause long- term morbidity, and timely intervention is required to prevent complications that can severely affect the functional status of the patient. Case presentation A series of six tendons (two triceps tendons and two bilateral patellar tendons) in three patients with ESKD undergoing hemodialysis is discussed in this case series. Patients were aged 61, 44 and 26 years, and on hemodialysis for 5, 10 and 5 years, respectively. Conclusion End -stage kidney disease is associated with a multitude of physiological changes, and the musculoskeletal system is no exception to this. Spontaneous tendon rupture is a multifactorial complication of ESKD, with serious implications for mobility and quality of life. As a result, these patients require a multifaceted approach to ensure optimum results and an early return to activity. We report a series of 6 spontaneous tendon ruptures in 3 patients with ESKD at our institution. We would like to outline the methods of repair for each case and further attempt to assess biochemical parameters that may have contributed to the disease process. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/13-1121", "name": "Breaking point: Case series of tendon ruptures in Hemodialysis patients" } } ] } Home Browse Breaking point: Case series of tendon ruptures in Hemodialysis patients ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Nazeer ME, Haphiz DA, Nazeer DM et al. Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.12688/f1000research.155799.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Clinical Practice Article Revised Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] Muhammed Ehsan Nazeer https://orcid.org/0000-0003-4355-6861 1 , Dr Askhar Haphiz 2 , Dr Muhammed Nazeer 3 , Dr Pradeep Moni 4 , Dr Praveen Muraleedharan 5 Muhammed Ehsan Nazeer https://orcid.org/0000-0003-4355-6861 1 , Dr Askhar Haphiz 2 , [...] Dr Muhammed Nazeer 3 , Dr Pradeep Moni 4 , Dr Praveen Muraleedharan 5 PUBLISHED 12 Dec 2024 Author details Author details 1 Trauma and Orthopaedics, North Cumbria integrated care trust,, Cumberland Infirmary, Carlisle, England, UK 2 Trauma and arthroscopy, MS Orthopedicsorthopaedics, P.B.No.1, Anayara P.O, Trivandrum, KIMSHEALTH, Thiruvananthapuram, Kerala, 695029, India 3 Consultant, Trauma and Group coordinator orthopaedics, MS Orthopedics, P.B.No.1, Anayara P.O, FRCS (Glasgow) KIMSHEALTH, Trivandrum, Kerala, 695029,, India 4 Resident, Trauma and orthopaedics, MBBS, P.B.No.1, Anayara P.O,, KIMSHEALTH, Thiruvananthapuram, Kerala, 695029, India 5 Nephrology, Senior consultant, DM Nephrology P.B.No.1, Anayara P.O, – Kerala, India, KIMSHEALTH, Trivandrum, Kerala, 695029, India Muhammed Ehsan Nazeer Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Dr Askhar Haphiz Roles: Conceptualization, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Dr Muhammed Nazeer Roles: Conceptualization, Investigation, Methodology, Project Administration, Supervision Dr Pradeep Moni Roles: Writing – Original Draft Preparation, Writing – Review & Editing Dr Praveen Muraleedharan Roles: Supervision OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Introduction Spontaneous tendon ruptures in end stage kidney disease patients have the potential to cause long- term morbidity, and timely intervention is required to prevent complications that can severely affect the functional status of the patient. Case presentation A series of six tendons (two triceps tendons and two bilateral patellar tendons) in three patients with ESKD undergoing hemodialysis is discussed in this case series. Patients were aged 61, 44 and 26 years, and on hemodialysis for 5, 10 and 5 years, respectively. Conclusion End -stage kidney disease is associated with a multitude of physiological changes, and the musculoskeletal system is no exception to this. Spontaneous tendon rupture is a multifactorial complication of ESKD, with serious implications for mobility and quality of life. As a result, these patients require a multifaceted approach to ensure optimum results and an early return to activity. We report a series of 6 spontaneous tendon ruptures in 3 patients with ESKD at our institution. We would like to outline the methods of repair for each case and further attempt to assess biochemical parameters that may have contributed to the disease process. READ ALL READ LESS Keywords ESRD, Quadriceps, Hyperparathyroidism, Tendon rupture, Hemodialysis, Case series Corresponding Author(s) Muhammed Ehsan Nazeer ( [email protected] ) Close Corresponding author: Muhammed Ehsan Nazeer Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Nazeer ME et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Nazeer ME, Haphiz DA, Nazeer DM et al. Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.12688/f1000research.155799.2 ) First published: 03 Oct 2024, 13 :1121 ( https://doi.org/10.12688/f1000research.155799.1 ) Latest published: 12 Dec 2024, 13 :1121 ( https://doi.org/10.12688/f1000research.155799.2 ) Revised Amendments from Version 1 This updated version of the article addresses the following revisions, based on reviewer feedback and further clarification of clinical findings: Abstract : The case presentation was revised to correctly describe the patellar tendon as the involved structure instead of the quadriceps tendon, as the injury was infrapatellar rather than suprapatellar. Case 2 : The description of the triceps tear was updated from "grade 0" to a more precise explanation of the clinical presentation, highlighting an inability to activate the elbow extensor mechanism. While the triceps muscle could contract upon attempted activation, the tear prevented complete movement. Additionally, the section on page 3 clarifies that no radiological or histopathological investigations were performed. Clinical diagnosis was considered sufficient in this instance. As authors, we acknowledge the value of histopathological analysis and will consider it in future similar cases. Figures and Legends : On page 5, the legend for Figure 5 has been corrected to identify the patellar tendon instead of the quadriceps tendon, aligning with the described injury. On page 6, Figure 6 now includes annotations for the cranial and caudal ends of the specimen for improved clarity. This updated version of the article addresses the following revisions, based on reviewer feedback and further clarification of clinical findings: Abstract : The case presentation was revised to correctly describe the patellar tendon as the involved structure instead of the quadriceps tendon, as the injury was infrapatellar rather than suprapatellar. Case 2 : The description of the triceps tear was updated from "grade 0" to a more precise explanation of the clinical presentation, highlighting an inability to activate the elbow extensor mechanism. While the triceps muscle could contract upon attempted activation, the tear prevented complete movement. Additionally, the section on page 3 clarifies that no radiological or histopathological investigations were performed. Clinical diagnosis was considered sufficient in this instance. As authors, we acknowledge the value of histopathological analysis and will consider it in future similar cases. Figures and Legends : On page 5, the legend for Figure 5 has been corrected to identify the patellar tendon instead of the quadriceps tendon, aligning with the described injury. On page 6, Figure 6 now includes annotations for the cranial and caudal ends of the specimen for improved clarity. To read any peer review reports and author responses for this article, follow the "read" links in the Open Peer Review table. READ REVIEWER RESPONSES Introduction Spontaneous tendon rupture is rare in the general population. Most cases of tendon rupture occur secondary to trauma or degenerative changes resulting from obesity or old age. Other etiologies of tendon rupture include pathological alterations in the substance of the tendon itself, such as gout, 1 autoimmune arthritis, 1 and end stage renal disease. 2 Long-term use of drugs such as statins, quinolones and steroids 3 constitute yet another often implicated cause of spontaneous tendon ruptures. Literature on spontaneous tendon ruptures in patients with ESKD undergoing hemodialysis is uncommon and studies on the exact underlying mechanism and management guidelines for such patients are sparse. The objective of this case series was to report a series of patients on hemodialysis for ESKD who experienced spontaneous tendon ruptures with emphasis on the methods and results of surgical management. An assessment of laboratory parameters was also performed to identify risk factors for the same. Case reports Case 1 A 61 year old male suffering with ESKD due to nephrosclerosis on hemodialysis for the last 5 years presented to the emergency department with complaints of acute onset pain and swelling in both knees while attempting to stand up from a sitting position. Examination revealed effusion in both knees with a palpable defect in the bilateral patellar tendons and bilateral extension lag. Lateral radiographs showed bilateral patella alta with calcified patellar tendons ( Figure 1 ). Figure 1. Patella alta noted with calcified patellar tendon. Surgical repair was performed in a staged fashion with an interval of 2.5 weeks in view of his physiological status. Surgical exploration revealed friable tendon edges with partial avulsion and mid substance tear patterns. The degenerated tissue was excised, and the ends of the tendon were reattached to the patella using suture anchors and non-absorbable sutures, followed by closure of the defects in the medial and lateral paratenon using bioabsorbable sutures ( Figure 2 ). Figure 2. Post operative radiographs after fixation of tendons with suture anchors. Post operatively the knees were immobilized in full extension for 6 weeks. DVT prophylaxis was administered using low molecular weight heparin (40 mg, sub-cutaneous injections, once daily) during the hospital stay and Rivaroxaban on Discharge. He was started on active Knee ROM and quadriceps strengthening exercises at six weeks. He complained of left elbow extension weakness in his review for suture removal on the second knee, and further evaluation revealed a spontaneous rupture of the triceps tendon. This was likely caused by sustained forces while using a walker to assist ambulation. He has been advised to undergo surgical repair, for which he is yet to be reported. Follow-up examinations at 8 and 8.5-months post-op respectively, examination revealed a knee ROM of 0-120 degrees with bilateral full extension and no residual weakness in the quadriceps mechanism. End stage renal disease was managed by our nephrology department with thrice weekly hemodialysis sessions and regular monitoring of renal parameters. The patient has been receiving hemodialysis for the past five years. Case 2 A 44-yr old male with ESRD secondary to immunoglobinA nephropathy with a history of allograft rejection during three weekly hemodialysis sessions for 10 years presented with complaints of right elbow extension weakness following trivial trauma. Physical examination revealed swelling of the right elbow with inability to activate the elbow extensor mechanism. Radiographs showed an avulsed triceps tendon ( Figure 3 ). Figure 3. Anteroposterior and lateral radiographs of Case 2 with avulsed triceps tendon. He underwent open repair of the triceps tendon with a suture anchor inserted in the olecranon after excision of the devitalized tongue of the tissue ( Figure 4 ). The elbow was immobilized in an above elbow slab at approximately 110° for 6 weeks, after which active mobilization was started. The last follow-up at 7 months revealed grade 5/5 power with full elbow ROM. Figure 4. Post-operative radiographs after fixation of tensons using suture anchors. Case 3 A 26-year-old male, suffering from lupus nephritis presented to ER with acute loss of extension in both knees and inability to ambulate following a fall while descending stairs at his house. The treatment history was significant for the intake of methylprednisolone for the last 3 months and twice weekly hemodialysis for ESKD for a duration of 5 years. Examination revealed bilateral patella alta and boggy swelling in both knees with grade 0 power in bilateral knee extension. Imaging revealed isolated patella alta without any avulsed bony edges ( Figure 5 ). Figure 5. Patella Alta noted in case 3 due to patellar rupture. He was diagnosed with bilateral patellar tendon rupture and underwent open repair during which severe fraying of the tendons was noted ( Figure 6 ). Robust repair was performed using non-absorbable sutures in a mattress pattern ( Figure 7 ). He was given bilateral long knee immobilizers for 6 weeks to protect the repair, following which he was started on assisted ambulation with walker support over the next 4 weeks. At the final review at 6 months, he had grade 5/5 power in both his knee extensors with no appreciable lag on either side. Figure 6. Frayed ends of patellar tendon noted in case 3. Figure 7. Post operative radiographs of 3 after patellar tendon repair. Discussion Normal tendons are strong, with Ultimate Tensile Strengths ranging from 45 to 125 MPa which exceed three times the strain caused by muscle contraction. 4 The tendency for spontaneous tendon ruptures in patients with ESKD has often been attributed to five main factors: 1) elastosis secondary to chronic acidosis, 5 2) chronically elevated blood urea levels, 1 3) amyloidosis with beta 2 microglobulin deposition, 6 4) increased cortical bone resorption because of secondary hyperparathyroidism, 2 5) high circulating calcium levels resulting in dystrophic calcification of the tendon. 7 This contrasts with other cases of spontaneous tendon rupture, which is a condition of middle-aged overweight patients, with bilaterality being an exception rather than the norm. 8 A quick diagnosis is paramount because early surgical intervention is a key factor in ensuring optimal results. 9 This rare diagnosis should always be considered when dealing with sudden unexplained motor deficits in the lower limbs. Hemarthrosis can further complicate the matter by making it difficult to identify infrapatellar defects. Such cases warrant the use of incongruous techniques, such as ultrasound and MRI to confirm the diagnosis. A prolonged duration of hemodialysis appears to be a reliable risk factor for the development of spontaneous tendon ruptures. 10 The markedly elevated PTH and ALP levels in our patients were also concurrent with the existing literature and explain the avulsed tendon ends noted both intraoperatively and radiographically in 2 cases in our series ( Table 1 ). Table 1. Lab results of cases showing elevated PTH and ALP levels. Parameter Case 1 Case 2 Case 3 Normal range Hemoglobin 7.6 11.2 8.4 13-16 g/dL Calcium 8.2 8.3 8.1 8.6-10.2 mg/dL PTH 1101 1826 1220 15-65 pg/mL Phosphorous 5.5 4.5 4.9 2.7-4.5 mg/dL Albumin 3.2 4.4 3.3 3.5-5.2 g/dL ALP 200 1399 866 40-129 U/L The repairs were performed as soon as fitness could be obtained, in view of the compromised physiological status of the patients. No additional procedures were required to compensate for retraction or shortening of tendons. Repair was performed using suture anchors and heavy non absorbable sutures. The patients attained full active extension in all cases at an average of 2 months from the date of surgery with no re-ruptures or residual weakness at a minimum 6 months follow up. Although the exact mechanism of injury remains unknown, most existing studies implicate sub-tendon bone resorption due to secondary hyperparathyroidism, 2 in addition to chronic inflammation, as evidenced by reduced serum hemoglobin and albumin levels, which was noted in 50% of cases. Conclusion Spontaneous tendon rupture in patients with ESKD remains a significant complication with considerable potential to cause disability. Robust repair with adequate immobilization and protection during the healing phase is instrumental in ensuring reliable results. Moreover, these patients require cautious physio rehabilitation, including careful walker- assisted mobilization to prevent further tendon ruptures during the postoperative period. Optimization of renal parameters, such as hyperparathyroidism and hypoalbuminemia, may help improve outcomes and prevent recurrence. Overall, a high index of suspicion for spontaneous tendon rupture is advised in patients with ESKD presenting with acute-onset limb weakness to prevent long-term morbidity. Consent The patients have given their informed consent for the case series to be published. Written consent was obtained for the same. Data availability All data underlying the results are available as part of the article and no additional source data are required. References 1. Shah MK: Simultaneous bilateral rupture of quadriceps tendons: analysis of risk factors and associations. South. Med. J. 2002 Aug; 95 (8): 860–866. PubMed Abstract | Publisher Full Text 2. Basic-Jukic N, Juric I, Racki S, et al. : Spontaneous tendon ruptures in patients with end-stage renal disease. Kidney Blood Press. Res. 2009a; 32 (1): 32–36. PubMed Abstract | Publisher Full Text 3. Seng C, Lim YJ, Pang HN: Spontaneous disruption of the bilateral knee extensor mechanism: a report of two cases. J. Orthop. Surg. (Hong Kong). 2015 Aug; 23 (2): 262–266. PubMed Abstract | Publisher Full Text 4. Hench LL: The skeletal system.Hench LL, Jones JR, editors. Biomaterials, artificial organs and tissue engineering. Woodhead Publishing; 2005; pp. 79–89. (Woodhead Publishing Series in Biomaterials). 9781855737372. Publisher Full Text 5. Ruiz J, Ríos A, Rodríguez JM, et al. : Roturas tendinosas espontáneas en la insuficiencia renal crónica. Nefrologia. 2017; 37 : 341–343. PubMed Abstract | Publisher Full Text 6. Grecomoro G, Camarda L, Martorana U: Simultaneous chronic rupture of quadriceps tendon and contra-lateral patellar tendon in a patient affected by tertiary hyperparathyroidism. J. Orthop. Traumatol. 2008 Sep; 9 (3): 159–162. PubMed Abstract | Publisher Full Text | Free Full Text 7. Hartono F, Besinga KE, Tjie H, et al. : Considerations in spontaneous quadriceps tendon rupture repair in end-stage renal disease patients: A case report. Int. J. Surg. Case Rep. 2021 Sep; 86 : 106298. Epub 2021 Aug 10. PubMed Abstract | Publisher Full Text | Free Full Text 8. Dhar S: Bilateral, simultaneous, spontaneous rupture of the quadriceps tendon: A report of 3 cases and a review of the literature. Injury. 1988; 19 (1): 7–8. Publisher Full Text 9. Wani NA, Malla HA, Kosar T, et al. : Bilateral quadriceps tendon rupture as the presenting manifestation of chronic kidney disease. Indian J. Nephrol. 2011 Jan; 21 (1): 48–51. PubMed Abstract | Publisher Full Text | Free Full Text 10. Pei YC, Hsieh PC, Huang LZ, et al. : Simultaneous bilateral quadriceps tendon rupture in a uremic patient. Formos. J. Musculoskelet. Disord. 2011; 2 (1): 35–39. Publisher Full Text Comments on this article Comments (1) Version 2 VERSION 2 PUBLISHED 12 Dec 2024 Revised Comment ADD YOUR COMMENT Version 1 VERSION 1 PUBLISHED 03 Oct 2024 Discussion is closed on this version, please comment on the latest version above. Reviewer Response 12 Nov 2024 Nijil Vasukutty , United Lincolnshire Hospitals NHS Trust, Lincoln, UK 12 Nov 2024 Reviewer Response Informative and useful paper highlighting a lesser known issue and how the biochemical changes of renal disease affect musculoskeletal system. Good variety of upper and lower limb cases and adequate ... Continue reading Informative and useful paper highlighting a lesser known issue and how the biochemical changes of renal disease affect musculoskeletal system. Good variety of upper and lower limb cases and adequate explanation on management. Areas for improvement: Explanation of the biochemical basis of tendon rupture in kidney disease would add to the value of the paper. This is a poorly recognised problem and I must congratulate the authors in collecting these unusual cases and writing this up. Informative and useful paper highlighting a lesser known issue and how the biochemical changes of renal disease affect musculoskeletal system. Good variety of upper and lower limb cases and adequate explanation on management. Areas for improvement: Explanation of the biochemical basis of tendon rupture in kidney disease would add to the value of the paper. This is a poorly recognised problem and I must congratulate the authors in collecting these unusual cases and writing this up. Competing Interests: No conflict of interest Close Report a concern Discussion is closed on this version, please comment on the latest version above. Author details Author details 1 Trauma and Orthopaedics, North Cumbria integrated care trust,, Cumberland Infirmary, Carlisle, England, UK 2 Trauma and arthroscopy, MS Orthopedicsorthopaedics, P.B.No.1, Anayara P.O, Trivandrum, KIMSHEALTH, Thiruvananthapuram, Kerala, 695029, India 3 Consultant, Trauma and Group coordinator orthopaedics, MS Orthopedics, P.B.No.1, Anayara P.O, FRCS (Glasgow) KIMSHEALTH, Trivandrum, Kerala, 695029,, India 4 Resident, Trauma and orthopaedics, MBBS, P.B.No.1, Anayara P.O,, KIMSHEALTH, Thiruvananthapuram, Kerala, 695029, India 5 Nephrology, Senior consultant, DM Nephrology P.B.No.1, Anayara P.O, – Kerala, India, KIMSHEALTH, Trivandrum, Kerala, 695029, India Muhammed Ehsan Nazeer Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Dr Askhar Haphiz Roles: Conceptualization, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Dr Muhammed Nazeer Roles: Conceptualization, Investigation, Methodology, Project Administration, Supervision Dr Pradeep Moni Roles: Writing – Original Draft Preparation, Writing – Review & Editing Dr Praveen Muraleedharan Roles: Supervision Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 12 Dec 2024, 13:1121 https://doi.org/10.12688/f1000research.155799.2 version 1 Published: 03 Oct 2024, 13:1121 https://doi.org/10.12688/f1000research.155799.1 Copyright © 2024 Nazeer ME et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Nazeer ME, Haphiz DA, Nazeer DM et al. Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.12688/f1000research.155799.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 12 Dec 2024 Revised Views 0 Cite How to cite this report: Vasukutty N. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.174955.r353382 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v2#referee-response-353382 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 28 Dec 2024 Nijil Vasukutty , United Lincolnshire Hospitals NHS Trust, Lincoln, England, UK Approved VIEWS 0 https://doi.org/10.5256/f1000research.174955.r353382 In this paper, the authors report on a series of six cases with spontaneous tendon ruptures due to chronic renal disease The have reported on a variety of cases with the involvement of quadriceps and triceps. This is ... Continue reading READ ALL In this paper, the authors report on a series of six cases with spontaneous tendon ruptures due to chronic renal disease The have reported on a variety of cases with the involvement of quadriceps and triceps. This is not an easily recognised condition and a high index of suspicion will be required to diagnose this in a timely fashion. Any delay in diagnosis will make the surgical procedure technically challenging and the outcomes suboptimal. The authors do give a brief description of their diagnostic methods, surgical procedures and post-operative rehabilitation with intermediate term outcomes. There is a section on the biochemical mechanism behind tendon rupture in end stage renal disease This paper will form a valuable addition to the literature on this subject as they look at a different ethology to this difficult problem. This is a short series but that would be expected as this is not a common problem. The first line of introduction may be revised as most degenerate ruptures do occur spontaneously like in the Achilles and these are not rare . Avoid using abbreviations the first time this term is referred to as in ESKD Case reports Could the authors clarify whether they used any three dimensional imaging like MRI or ultrasound before undertaking surgery or did they just depend on plain x-rays? In case three the authors are report that the end of the patella tendon were frayed . In such a situation were the frayed ends excised and if so, how did they make up the lost length as the patella tendon may not be amenable to stretching. In the discussion session it may be helpful to add a short paragraph on other causes of spontaneous tendon rupture like use of Ciprofloxacin and degenerate tendon rupture. Is the background of the cases’ history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the conclusion balanced and justified on the basis of the findings? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Trauma and Orthopaedics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Vasukutty N. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.174955.r353382 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v2#referee-response-353382 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Vijayan S. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.174955.r348090 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v2#referee-response-348090 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 16 Dec 2024 Sandeep Vijayan , Additional Professor, Department of Orthopaedics, Kasturba Medical College Manipal,, Manipal Academy of Higher Education, Manipal, India Approved VIEWS 0 https://doi.org/10.5256/f1000research.174955.r348090 No further comments to make. Add (ESKD) after it is ... Continue reading READ ALL No further comments to make. Add (ESKD) after it is mentioned first time in the introduction. Correct spelling of tendon in figure 4 legend Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Vijayan S. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.174955.r348090 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v2#referee-response-348090 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Abramowitz M. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.174955.r348092 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v2#referee-response-348092 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 13 Dec 2024 Matthew Abramowitz , Albert Einstein College of Medicine, Bronx, New York, USA Approved VIEWS 0 https://doi.org/10.5256/f1000research.174955.r348092 Lack of description of the ... Continue reading READ ALL Lack of description of the dialysis prescriptions remains a limitation. Competing Interests: No competing interests were disclosed. Reviewer Expertise: physical function, muscle physiology in CKD I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Abramowitz M. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.174955.r348092 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v2#referee-response-348092 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 03 Oct 2024 Views 0 Cite How to cite this report: Abramowitz M. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.171011.r335309 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v1#referee-response-335309 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 12 Nov 2024 Matthew Abramowitz , Albert Einstein College of Medicine, Bronx, New York, USA Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.171011.r335309 This case series brings attention to the risk of tendon rupture in patients with ESKD. There are several areas in which it could be strengthened: 1. To improve the generalizability of this report to other patients with ESKD, it ... Continue reading READ ALL This case series brings attention to the risk of tendon rupture in patients with ESKD. There are several areas in which it could be strengthened: 1. To improve the generalizability of this report to other patients with ESKD, it would be helpful to present details of the patients’ dialysis prescriptions, such as use of high flux dialyzers (which would reduce the likelihood of beta-2 microglobulin as an etiologic factor), pre-dialysis bicarbonate levels, Kt/V, dialysate settings (especially bicarbonate), and treatment of hyperparathyroidism. If beta-2 microglobulin levels were measured, those data should be presented. 2. Regarding case 3, the duration of dialysis should be presented. If the patient was not recently started on dialysis and did not have significant residual kidney function, it would be helpful to know why he was only receiving dialysis twice per week. 3. The abstract describes quadriceps tendon ruptures but the case descriptions report patella tendon ruptures. This should be clarified. 4. Abstract, Case presentation: the years on hemodialysis should be presented in the same order as the patients’ ages. 5. It would be helpful to further discuss potential mechanisms by which risk factors in ESKD may impact tendon physiology and structure. Is the background of the cases’ history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the conclusion balanced and justified on the basis of the findings? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: physical function, muscle physiology in CKD I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Abramowitz M. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.171011.r335309 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v1#referee-response-335309 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Malta LM. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.171011.r335311 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v1#referee-response-335311 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 07 Nov 2024 Luis Marcelo Malta , Universidade Federal Fluminense, Rio de Janeiro, Brazil Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.171011.r335311 The authors show their experience with a series of tendon ruptures on regular-based hemodialysis patients, addressing aspects of surgical treatment and functional results. Despite the fact that it is a case series, giving it a less favorable view in ... Continue reading READ ALL The authors show their experience with a series of tendon ruptures on regular-based hemodialysis patients, addressing aspects of surgical treatment and functional results. Despite the fact that it is a case series, giving it a less favorable view in terms of scientific strength or evidence, the study brings important information about the understanding and management of this unusual occurrence. There are also some details I would like to point: 1- Abstract says that the authors report on two bilateral QUADRICEPS ruptures, but both case 1 and 3 are PATELLAR tendon ruptures. Maybe it was just a typing mistake but should be corrected to prevent confusion. 2- All cases include physical evaluation, both pre and postoperative, without clarifying which scale or functional score was used to do such measurements. I consider this is a minor but important point to address. 3- Discussion is well done but could include more recent articles at surgical repair aspects and risk factors associated with ruptures available in the literature. I consider this a major point to be revised, because there are much work documented on the field and it would make this section more complete. Is the background of the cases’ history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the conclusion balanced and justified on the basis of the findings? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Orthopaedics / orthopedic surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Malta LM. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.171011.r335311 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v1#referee-response-335311 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Vijayan S. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.171011.r332004 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v1#referee-response-332004 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 06 Nov 2024 Sandeep Vijayan , Additional Professor, Department of Orthopaedics, Kasturba Medical College Manipal,, Manipal Academy of Higher Education, Manipal, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.171011.r332004 Abstract – case presentation: better to mention as 'patellar tendon' as the involved part is infrapatellar and not suprapatellar. Page 3- case 2: I am not sure if it is correct to say grade 0 power. Here ... Continue reading READ ALL Abstract – case presentation: better to mention as 'patellar tendon' as the involved part is infrapatellar and not suprapatellar. Page 3- case 2: I am not sure if it is correct to say grade 0 power. Here we are dealing with mechanical disruption of the muscle without loss in power of the muscle. Attempt to move the elbow will definitely contract the triceps muscle without the force transmitting across the tear. So, is it truly grade 0 power in the muscle ? Page 3, case 2: was there any USG or MRI images available confirming the diagnosis and assess the quality of the tissue. Was histopathological examination of the excised tissue performed to understand the type of degenerative changes commonly happening in tendons and ligaments in ESRD. Page 5, figure 5 legend - better to mention as 'patellar tendon rupture'. Page 6, figure 6- Please add cranial end and caudal end in the picture for easy understanding for the readers, The picture on the left side appear skewed (stretched horizontally). Please re-size it correctly. Page 7- discussion - It is interesting to note that in most of the reported literatures. it the quadriceps / patellar tendon which is getting ruptured. In your review of literature, did you come across any specific reasoning from the affection of quadriceps tendon in particular. Few more minor corrections are suggested. Same has been commented on in the main manuscript and may be accessed by opening the manuscript with Adobe reader. Is the background of the cases’ history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the conclusion balanced and justified on the basis of the findings? Yes Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Vijayan S. Reviewer Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.171011.r332004 ) The direct URL for this report is: https://f1000research.com/articles/13-1121/v1#referee-response-332004 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (1) Version 2 VERSION 2 PUBLISHED 12 Dec 2024 Revised Comment ADD YOUR COMMENT Version 1 VERSION 1 PUBLISHED 03 Oct 2024 Discussion is closed on this version, please comment on the latest version above. Reviewer Response 12 Nov 2024 Nijil Vasukutty , United Lincolnshire Hospitals NHS Trust, Lincoln, UK 12 Nov 2024 Reviewer Response Informative and useful paper highlighting a lesser known issue and how the biochemical changes of renal disease affect musculoskeletal system. Good variety of upper and lower limb cases and adequate ... Continue reading Informative and useful paper highlighting a lesser known issue and how the biochemical changes of renal disease affect musculoskeletal system. Good variety of upper and lower limb cases and adequate explanation on management. Areas for improvement: Explanation of the biochemical basis of tendon rupture in kidney disease would add to the value of the paper. This is a poorly recognised problem and I must congratulate the authors in collecting these unusual cases and writing this up. Informative and useful paper highlighting a lesser known issue and how the biochemical changes of renal disease affect musculoskeletal system. Good variety of upper and lower limb cases and adequate explanation on management. Areas for improvement: Explanation of the biochemical basis of tendon rupture in kidney disease would add to the value of the paper. This is a poorly recognised problem and I must congratulate the authors in collecting these unusual cases and writing this up. Competing Interests: No conflict of interest Close Report a concern Discussion is closed on this version, please comment on the latest version above. keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 4 Version 2 (revision) 12 Dec 24 read read read Version 1 03 Oct 24 read read read Sandeep Vijayan , Manipal Academy of Higher Education, Manipal, India Luis Marcelo Malta , Universidade Federal Fluminense, Rio de Janeiro, Brazil Matthew Abramowitz , Albert Einstein College of Medicine, Bronx, New York, USA Nijil Vasukutty , United Lincolnshire Hospitals NHS Trust, Lincoln, UK Comments on this article All Comments (1) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Vasukutty N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Dec 2024 | for Version 2 Nijil Vasukutty , United Lincolnshire Hospitals NHS Trust, Lincoln, England, UK 0 Views copyright © 2024 Vasukutty N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions In this paper, the authors report on a series of six cases with spontaneous tendon ruptures due to chronic renal disease The have reported on a variety of cases with the involvement of quadriceps and triceps. This is not an easily recognised condition and a high index of suspicion will be required to diagnose this in a timely fashion. Any delay in diagnosis will make the surgical procedure technically challenging and the outcomes suboptimal. The authors do give a brief description of their diagnostic methods, surgical procedures and post-operative rehabilitation with intermediate term outcomes. There is a section on the biochemical mechanism behind tendon rupture in end stage renal disease This paper will form a valuable addition to the literature on this subject as they look at a different ethology to this difficult problem. This is a short series but that would be expected as this is not a common problem. The first line of introduction may be revised as most degenerate ruptures do occur spontaneously like in the Achilles and these are not rare . Avoid using abbreviations the first time this term is referred to as in ESKD Case reports Could the authors clarify whether they used any three dimensional imaging like MRI or ultrasound before undertaking surgery or did they just depend on plain x-rays? In case three the authors are report that the end of the patella tendon were frayed . In such a situation were the frayed ends excised and if so, how did they make up the lost length as the patella tendon may not be amenable to stretching. In the discussion session it may be helpful to add a short paragraph on other causes of spontaneous tendon rupture like use of Ciprofloxacin and degenerate tendon rupture. Is the background of the cases’ history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the conclusion balanced and justified on the basis of the findings? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Trauma and Orthopaedics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Vasukutty N. Peer Review Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.174955.r353382) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1121/v2#referee-response-353382 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Vijayan S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 16 Dec 2024 | for Version 2 Sandeep Vijayan , Additional Professor, Department of Orthopaedics, Kasturba Medical College Manipal,, Manipal Academy of Higher Education, Manipal, India 0 Views copyright © 2024 Vijayan S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions No further comments to make. Add (ESKD) after it is mentioned first time in the introduction. Correct spelling of tendon in figure 4 legend Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Vijayan S. Peer Review Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.174955.r348090) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1121/v2#referee-response-348090 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Abramowitz M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 13 Dec 2024 | for Version 2 Matthew Abramowitz , Albert Einstein College of Medicine, Bronx, New York, USA 0 Views copyright © 2024 Abramowitz M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Lack of description of the dialysis prescriptions remains a limitation. Competing Interests No competing interests were disclosed. Reviewer Expertise physical function, muscle physiology in CKD I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Abramowitz M. Peer Review Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.174955.r348092) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1121/v2#referee-response-348092 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Abramowitz M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 12 Nov 2024 | for Version 1 Matthew Abramowitz , Albert Einstein College of Medicine, Bronx, New York, USA 0 Views copyright © 2024 Abramowitz M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This case series brings attention to the risk of tendon rupture in patients with ESKD. There are several areas in which it could be strengthened: 1. To improve the generalizability of this report to other patients with ESKD, it would be helpful to present details of the patients’ dialysis prescriptions, such as use of high flux dialyzers (which would reduce the likelihood of beta-2 microglobulin as an etiologic factor), pre-dialysis bicarbonate levels, Kt/V, dialysate settings (especially bicarbonate), and treatment of hyperparathyroidism. If beta-2 microglobulin levels were measured, those data should be presented. 2. Regarding case 3, the duration of dialysis should be presented. If the patient was not recently started on dialysis and did not have significant residual kidney function, it would be helpful to know why he was only receiving dialysis twice per week. 3. The abstract describes quadriceps tendon ruptures but the case descriptions report patella tendon ruptures. This should be clarified. 4. Abstract, Case presentation: the years on hemodialysis should be presented in the same order as the patients’ ages. 5. It would be helpful to further discuss potential mechanisms by which risk factors in ESKD may impact tendon physiology and structure. Is the background of the cases’ history and progression described in sufficient detail? No Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the conclusion balanced and justified on the basis of the findings? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise physical function, muscle physiology in CKD I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Abramowitz M. Peer Review Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.171011.r335309) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1121/v1#referee-response-335309 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Malta L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 07 Nov 2024 | for Version 1 Luis Marcelo Malta , Universidade Federal Fluminense, Rio de Janeiro, Brazil 0 Views copyright © 2024 Malta L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors show their experience with a series of tendon ruptures on regular-based hemodialysis patients, addressing aspects of surgical treatment and functional results. Despite the fact that it is a case series, giving it a less favorable view in terms of scientific strength or evidence, the study brings important information about the understanding and management of this unusual occurrence. There are also some details I would like to point: 1- Abstract says that the authors report on two bilateral QUADRICEPS ruptures, but both case 1 and 3 are PATELLAR tendon ruptures. Maybe it was just a typing mistake but should be corrected to prevent confusion. 2- All cases include physical evaluation, both pre and postoperative, without clarifying which scale or functional score was used to do such measurements. I consider this is a minor but important point to address. 3- Discussion is well done but could include more recent articles at surgical repair aspects and risk factors associated with ruptures available in the literature. I consider this a major point to be revised, because there are much work documented on the field and it would make this section more complete. Is the background of the cases’ history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the conclusion balanced and justified on the basis of the findings? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Orthopaedics / orthopedic surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Malta LM. Peer Review Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.171011.r335311) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1121/v1#referee-response-335311 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Vijayan S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 06 Nov 2024 | for Version 1 Sandeep Vijayan , Additional Professor, Department of Orthopaedics, Kasturba Medical College Manipal,, Manipal Academy of Higher Education, Manipal, India 0 Views copyright © 2024 Vijayan S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Abstract – case presentation: better to mention as 'patellar tendon' as the involved part is infrapatellar and not suprapatellar. Page 3- case 2: I am not sure if it is correct to say grade 0 power. Here we are dealing with mechanical disruption of the muscle without loss in power of the muscle. Attempt to move the elbow will definitely contract the triceps muscle without the force transmitting across the tear. So, is it truly grade 0 power in the muscle ? Page 3, case 2: was there any USG or MRI images available confirming the diagnosis and assess the quality of the tissue. Was histopathological examination of the excised tissue performed to understand the type of degenerative changes commonly happening in tendons and ligaments in ESRD. Page 5, figure 5 legend - better to mention as 'patellar tendon rupture'. Page 6, figure 6- Please add cranial end and caudal end in the picture for easy understanding for the readers, The picture on the left side appear skewed (stretched horizontally). Please re-size it correctly. Page 7- discussion - It is interesting to note that in most of the reported literatures. it the quadriceps / patellar tendon which is getting ruptured. In your review of literature, did you come across any specific reasoning from the affection of quadriceps tendon in particular. Few more minor corrections are suggested. Same has been commented on in the main manuscript and may be accessed by opening the manuscript with Adobe reader. Is the background of the cases’ history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the conclusion balanced and justified on the basis of the findings? Yes Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Vijayan S. Peer Review Report For: Breaking point: Case series of tendon ruptures in Hemodialysis patients [version 2; peer review: 3 approved, 1 approved with reservations] . F1000Research 2024, 13 :1121 ( https://doi.org/10.5256/f1000research.171011.r332004) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1121/v1#referee-response-332004 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). You work at the same institute as any of the authors. You hope/expect to benefit (e.g. favour or employment) as a result of your submission. You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Stay Updated Sign up for content alerts and receive a weekly or monthly email with all newly published articles Register with F1000Research Already registered? Sign in Not now, thanks close PLEASE NOTE If you are an AUTHOR of this article, please check that you signed in with the account associated with this article otherwise we cannot automatically identify your role as an author and your comment will be labelled as a “User Comment”. If you are a REVIEWER of this article, please check that you have signed in with the account associated with this article and then go to your account to submit your report, please do not post your review here. If you do not have access to your original account, please contact us . All commenters must hold a formal affiliation as per our Policies . The information that you give us will be displayed next to your comment. User comments must be in English, comprehensible and relevant to the article under discussion. We reserve the right to remove any comments that we consider to be inappropriate, offensive or otherwise in breach of the User Comment Terms and Conditions . Commenters must not use a comment for personal attacks. When criticisms of the article are based on unpublished data, the data should be made available. I accept the User Comment Terms and Conditions Please confirm that you accept the User Comment Terms and Conditions. Affiliation ✕ refresh Please enter your institution. Note: To add your institution or organisation, start typing the name and then select the correct name from the list. Where applicable, the name will appear in both the original language and in English. Do not paste in the name. If the name does not appear in the drop-down list, we will display the information you have entered. ✕ refresh Country/Region * USA UK Canada China France Germany Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo (Serbia and Montenegro) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Minor Outlying Islands of the United States Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Is South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Gambia The Netherlands Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu UK USA Uganda Ukraine United Arab Emirates United States Virgin Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna West Bank and Gaza Strip Western Sahara Yemen Zambia Zimbabwe Please select your country/region. You must enter a comment. Competing Interests Please disclose any competing interests that might be construed to influence your judgment of the article's or peer review report's validity or importance. Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). You work at the same institute as any of the authors. You hope/expect to benefit (e.g. favour or employment) as a result of your submission. You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Please state your competing interests The comment has been saved. An error has occurred. Please try again. Cancel Post var lTitle = "Breaking point: Case series of tendon ruptures...".replace("'", ''); var linkedInUrl = "http://www.linkedin.com/shareArticle?url=https://f1000research.com/articles/13-1121/v2" + "&title=" + encodeURIComponent(lTitle) + "&summary=" + encodeURIComponent('Read the article by '); var deliciousUrl = "https://del.icio.us/post?url=https://f1000research.com/articles/13-1121/v2&title=" + encodeURIComponent(lTitle); var redditUrl = "http://reddit.com/submit?url=https://f1000research.com/articles/13-1121/v2" + "&title=" + encodeURIComponent(lTitle); linkedInUrl += encodeURIComponent('Nazeer ME et al.'); var offsetTop = /chrome/i.test( navigator.userAgent ) ? 4 : -10; var addthis_config = { ui_offset_top: offsetTop, services_compact : "facebook,twitter,www.linkedin.com,www.mendeley.com,reddit.com", services_expanded : "facebook,twitter,www.linkedin.com,www.mendeley.com,reddit.com", services_custom : [ { name: "LinkedIn", url: linkedInUrl, icon:"/img/icon/at_linkedin.svg" }, { name: "Mendeley", url: "http://www.mendeley.com/import/?url=https://f1000research.com/articles/13-1121/v2/mendeley", icon:"/img/icon/at_mendeley.svg" }, { name: "Reddit", url: redditUrl, icon:"/img/icon/at_reddit.svg" }, ] }; var addthis_share = { url: "https://f1000research.com/articles/13-1121", templates : { twitter : "Breaking point: Case series of tendon ruptures in Hemodialysis.... Nazeer ME et al., published by " + "@F1000Research" + ", https://f1000research.com/articles/13-1121/v2" } }; if (typeof(addthis) != "undefined"){ addthis.addEventListener('addthis.ready', checkCount); addthis.addEventListener('addthis.menu.share', checkCount); } $(".f1r-shares-twitter").attr("href", "https://twitter.com/intent/tweet?text=" + addthis_share.templates.twitter); $(".f1r-shares-facebook").attr("href", "https://www.facebook.com/sharer/sharer.php?u=" + addthis_share.url); $(".f1r-shares-linkedin").attr("href", addthis_config.services_custom[0].url); $(".f1r-shares-reddit").attr("href", addthis_config.services_custom[2].url); $(".f1r-shares-mendelay").attr("href", addthis_config.services_custom[1].url); function checkCount(){ setTimeout(function(){ $(".addthis_button_expanded").each(function(){ var count = $(this).text(); if (count !== "" && count != "0") $(this).removeClass("is-hidden"); else $(this).addClass("is-hidden"); }); }, 1000); } close How to cite this report {{reportCitation}} Cancel Copy Citation Details $(function(){R.ui.buttonDropdowns('.dropdown-for-downloads');}); $(function(){R.ui.toolbarDropdowns('.toolbar-dropdown-for-downloads');}); $.get("/articles/acj/155799/174955") new F1000.Clipboard(); new F1000.ThesaurusTermsDisplay("articles", "article", "174955"); $(document).ready(function() { $( "#frame1" ).on('load', function() { var mydiv = $(this).contents().find("div"); var h = mydiv.height(); console.log(h) }); var tooltipLivingFigure = jQuery(".interactive-living-figure-label .icon-more-info"), titleLivingFigure = tooltipLivingFigure.attr("title"); tooltipLivingFigure.simpletip({ fixed: true, position: ["-115", "30"], baseClass: 'small-tooltip', content:titleLivingFigure + " " }); tooltipLivingFigure.removeAttr("title"); $("body").on("click", ".cite-living-figure", function(e) { e.preventDefault(); var ref = $(this).attr("data-ref"); $(this).closest(".living-figure-list-container").find("#" + ref).fadeIn(200); }); $("body").on("click", ".close-cite-living-figure", function(e) { e.preventDefault(); $(this).closest(".popup-window-wrapper").fadeOut(200); }); $(document).on("mouseup", function(e) { var metricsContainer = $(".article-metrics-popover-wrapper"); if (!metricsContainer.is(e.target) && metricsContainer.has(e.target).length === 0) { $(".article-metrics-close-button").click(); } }); var articleId = $('#articleId').val(); if($("#main-article-count-box").attachArticleMetrics) { $("#main-article-count-box").attachArticleMetrics(articleId, { articleMetricsView: true }); } }); var figshareWidget = $(".new_figshare_widget"); if (figshareWidget.length > 0) { window.figshare.load("f1000", function(Widget) { // Select a tag/tags defined in your page. In this tag we will place the widget. _.map(figshareWidget, function(el){ var widget = new Widget({ articleId: $(el).attr("figshare_articleId") //height:300 // this is the height of the viewer part. [Default: 550] }); widget.initialize(); // initialize the widget widget.mount(el); // mount it in a tag that's on your page // this will save the widget on the global scope for later use from // your JS scripts. This line is optional. //window.widget = widget; }); }); } close Error Close Add Reset F1000.MICROSERVICES.AFFILIATION = ''; $(document).ready(function () { $('.js-affiliations-form').each((index, form) => { new AffiliationForm({ formId: form.id, institutionErrorSelector: '.comment-enter-institution', departmentErrorSelector: '.comment-enter-department', placeSelector: '.js-add-comment-place', stateSelector: '.js-add-comment-state', zipCodeSelector: '.js-add-comment-zipcode', countrySelector: '.js-add-comment-country', countryErrorSelector: '.comment-enter-country', }); }); }); $(document).ready(function () { var reportIds = { "332005": 0, "332004": 11, "335303": 0, "332007": 0, "353382": 1, "332006": 0, "332003": 0, "332002": 0, "335309": 9, "335308": 0, "335311": 9, "335310": 0, "335305": 0, "332009": 0, "335304": 0, "332008": 0, "335307": 0, "332011": 0, "335306": 0, "332010": 0, "335312": 0, "348092": 5, "348091": 0, "348090": 3, }; $(".referee-response-container,.js-referee-report").each(function(index, el) { var reportId = $(el).attr("data-reportid"), reportCount = reportIds[reportId] || 0; $(el).find(".comments-count-container,.js-referee-report-views").html(reportCount); }); var uuidInput = $("#article_uuid"), oldUUId = uuidInput.val(), newUUId = "d7428454-5dcc-4f0a-984a-24a4e37b885f"; uuidInput.val(newUUId); $("a[href*='article_uuid=']").each(function(index, el) { var newHref = $(el).attr("href").replace(oldUUId, newUUId); $(el).attr("href", newHref); }); }); An innovative open access publishing platform offering rapid publication and open peer review, whilst supporting data deposition and sharing. Browse Gateways Collections How it Works Contact For Developers Cookie Notice Privacy Notice RSS Submit Your Research Follow us © 2012-2026 F1000 Research Ltd. ISSN 2046-1402 | Legal | Partner of Research4Life • CrossRef • ORCID • FAIRSharing R.templateTests.simpleTemplate = R.template(' $text $text $text $text $text '); R.templateTests.runTests(); var F1000platform = new F1000.Platform({ name: "f1000research", displayName: "F1000Research", hostName: "f1000research.com", id: "1", editorialEmail: "[email protected]", infoEmail: "[email protected]", usePmcStats: true }); $(function(){R.ui.dropdowns('.dropdown-for-authors, .dropdown-for-about, .dropdown-for-myresearch');}); // $(function(){R.ui.dropdowns('.dropdown-for-referees');}); $(document).ready(function () { if ($(".cookie-warning").is(":visible")) { $(".sticky").css("margin-bottom", "35px"); $(".devices").addClass("devices-and-cookie-warning"); } $(".cookie-warning .close-button").click(function (e) { $(".devices").removeClass("devices-and-cookie-warning"); $(".sticky").css("margin-bottom", "0"); }); $("#tweeter-feed .tweet-message").each(function (i, message) { var self = $(message); self.html(linkify(self.html())); }); $(".partner").on("mouseenter mouseleave", function() { $(this).find(".gray-scale, .colour").toggleClass("is-hidden"); }); }); Sign In Remember me Forgotten your password? Sign In Cancel Email or password not correct. Please try again Please wait... $(function(){ // Note: All the setup needs to run against a name attribute and *not* the id due the clonish // nature of facebox... $("a[id=googleSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("GOOGLE"); $("form[id=oAuthForm]").submit(); }); $("a[id=facebookSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("FACEBOOK"); $("form[id=oAuthForm]").submit(); }); $("a[id=orcidSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("ORCID"); $("form[id=oAuthForm]").submit(); }); }); If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password. The email address should be the one you originally registered with F1000. Email address not valid, please try again You registered with F1000 via Google, so we cannot reset your password. To sign in, please click here . If you still need help with your Google account password, please click here . You registered with F1000 via Facebook, so we cannot reset your password. To sign in, please click here . If you still need help with your Facebook account password, please click here . Code not correct, please try again Reset password Cancel Email us for further assistance. Server error, please try again. If your email address is registered with us, we will email you instructions to reset your password. If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance. Please wait... Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); });