Previous Level Of Activity Research Articles

Hip Arthroscopy in athletes with Femoroacetabular Impingement: functional outcomes

Introduction:Hip pathology is being recognized with more frequency as source of disability and functional limitation in athletes. It has been stated that the overload made with certain positions during some sports activities can develop condral damage. Moreover, the sum of bone deformity and repetitive movements of the hip requiered in sports may increase the risk of causing injuries. These can be treated with hip arthroscopy. Despite of this, there is a lack of evidence about the time taken to return to sports activity and the level reached afterwards by those patients treated with this procedure.Objective:Describe the clinical evolution, the time taken to return to sports activity and the level reached a year after the treatment of femoroacetabular impingement (FAI) with hip arthroscopy in 23 athletes.Method:23 athletes were included in the study, defined as those patients with a minimum of 6 hours a week of sports practice, who were treated for FAI with hip arthroscopy between 2010 and 2015 by the same surgeon at our institution. The diagnosis was clinical (positive impingement test, hip pain and functional limitation of the hip), radiological (cam and pincer) and with magnetic nuclear resonance (labral tears). Preoperative modified Harris hip score was registered in all cases. Tonnis radiographic score was used. All patients had type 0 or 1 Tonnis hips. After 3 months of ineffective non operative treatment the arthroscopy was performed. Patients were treated in dorsal decubitus with orthopedic table. Labral reconstruction with anchors and femoral and acetabular osteoplasty was made. After surgery, patients were able to walk with support for 4 weeks and began physiotherapy. A year after surgery, all patients were questioned about the time taken to return to sports activity and the level of activity reached at that time compared to the one they had before symptoms appeared. The modified Harris hip score was also registered.Results:Ten patients played soccer as a main sport activity (44%), 3 basketball (13%), 3 martial arts (13%), 3 rugby (13%), 2 running (9%), 1 bicycling (4%) and 1 motocross (4%). The average time taken to return to sports activity was 4.7 months. 12 patients returned at 4 months (52%), 6 patients at 5 months (26%) and 5 patients at 6 months (22%). All patients were able to return to sports activity. Twenty patients reached the same level of activity they had before symptoms appeared (87%). Three patients did not get to previous activity level (13%). The averaged postoperative modified Harris hip score was 92 points (excellent). 20 patients (87%) scored excellent results and 3 patients (13%) regular ones. The average improvement after surgery of this score was 26 points.Conclusion:The treatment of FAI with hip arthroscopy in athletes allowed us to achieve excellent clinical results in 87% of the patients (modified Harris hip score). They took an average of 4.7 months to return to sports activities. 87% of them returned to the same level of practice they had before symptoms appeared.

Treatment of Insertional Achilles Pathology With Dorsal Wedge Calcaneal Osteotomy in Athletes.

Insertional Achilles tendinopathy and retrocalcaneal bursitis is difficult to treat, and several operative techniques have been used after failure of conservative management. Dorsal wedge calcaneal osteotomy has been described for the treatment of insertional Achilles pathology. It was hypothesized that dorsal wedge calcaneal osteotomy would be an effective and safe method for the treatment of athletes with insertional Achilles pathology unrelieved by nonoperative measures. Fifty-two athletes (64 feet) who had painful Achilles tendon syndrome unrelieved by 6 months of nonoperative measures were treated surgically. Dorsally based wedge calcaneal osteotomy was performed through a lateral approach, and 2 staples were used for fixation. Patients were scored pre- and postoperatively with the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot and Victorian Institute of Sports of Australia-Achilles (VISA-A) scores. At a minimum follow-up of 3 years, the patients' AOFAS and VISA-A scores improved from 59.5 ± 15.0 and 65.9 ± 11.1 preoperatively to 95.7 ± 6.2 and 90.2 ± 8.4 postoperatively, respectively. Clinical results were considered excellent in 38 patients, good in 12 patients, and fair in 2 patients. Return to previous sports activity time was 21 (SD, 8.0) weeks. One patient necessitated a revision operation. Operative treatment of insertional Achilles pathology in athletes with dorsal closing wedge calcaneal osteotomy was a safe and effective method that allowed for a quicker return to previous level of sports activities compared with other techniques. Level IV, retrospective case series.

Peripheral neuropathy of a forelimb in horses: 27 cases (2000-2013).

OBJECTIVE To describe the clinical features, diagnostic procedures, management, and outcome of horses with peripheral neuropathy of a forelimb. DESIGN Retrospective case series. ANIMALS 27 horses. PROCEDURES Records from 2000 to 2013 were reviewed to identify horses with peripheral neuropathy of a forelimb. Horses were grouped as having predominant lesions of a suprascapular nerve, axillary nerve, or radial nerve (alone or in association with other brachial plexus nerves) on the basis of physical examination and diagnostic imaging findings. Treatments were primarily conservative. Signalment, history, lameness characteristics, diagnostic imaging features, case management, and outcomes were evaluated. RESULTS Predominant lesions of a suprascapular nerve, axillary nerve, and radial nerve were identified in 11, 2, and 14 horses, respectively. Eight horses with predominant suprascapular nerve injury and 9 with injury to a radial nerve alone or in association with other nerves returned to their previous activity level or intended use after mean recovery periods of 9.3 and 13.3 months, respectively; 2 horses with a predominant axillary nerve injury had this outcome after a mean 3.5-month recovery period. Ultrasonography was useful for evaluation of muscle atrophy and other injuries during the initial examination (in 27 horses) and the rehabilitation period (in 7 horses). CONCLUSIONS AND CLINICAL RELEVANCE Most horses with peripheral neuropathy of a forelimb returned to athletic soundness following an adequate period of rest. Horses with lesions of a radial nerve alone or in association with other nerves typically required longer recovery times than did those with predominant injuries of a suprascapular nerve.

Arthroscopic anterior cruciate ligament repair for proximal anterior cruciate ligament tears in skeletally immature patients: Surgical technique and preliminary results

BackgroundAnterior cruciate ligament (ACL) tears in children are increasingly common and present difficult treatment decisions due to the risk of growth disturbance. Although open primary ACL repair was abandoned in the historical literature, recent studies have suggested that there is a role for arthroscopic primary repair in patients with proximal tears. MethodsThis is a retrospective review of five consecutive patients aged 9.2years (range 8 to 10) who underwent suture anchor ACL reinsertion. Patients were included if they were Tanner stages 1–2 and proximal ACL tears with adequate tissue quality confirmed arthroscopically. The time frame was 81days. Arthroscopic ACL reinsertion was performed with bioabsorbable suture anchor. Clinical evaluation, KT-1000™, and MRI were re-evaluated. Clinical outcomes were measured using International Knee Documentation Committee (IKDC), Lysholm and Tegner activity score. ResultsAt a mean follow-up of 43.4months (range 25 to 56), no re-injury and leg length discrepancies were observed. Four patients had negative Lachman tests. The remainder had a grade 1 Lachman test. The mean side-to-side difference was 3 (2–4mm). In MRI obtained at the last follow-up, no articular lesions or growth arrest were observed and the reinserted ACL was recognized in every exam. All patients returned to previous level of activity and presented normal and nearly normal IKDC score. The mean Lysholm score was 93.6. ConclusionArthroscopic ACL repair can achieve good short-term results with joint stability and recovery of sport activity in skeletally immature patients, with proximal ACL avulsion tear.

Review of Arciero's article (1994) on arthroscopic Bankart repair versus non-operative treatment for acute, initial anterior shoulder dislocations: does the same hold true in 2016?

This classic reexamines the landmark publication ‘Arthroscopic Bankart repair versus non-operative treatment for acute, initial anterior shoulder dislocations’ by Arciero et al, published in 1994 in The American Journal of Sports Medicine. The authors provided pertinent evidence to support the use of arthroscopy to repair associated Bankart lesions found after acute, initial anterior shoulder dislocations in the young, athletic patient population. The recommendations put forth were a departure from the established teachings at the time. The article demonstrated a significantly reduced rate of recurrence after arthroscopic stabilisation compared with non-operative management in US Military Academy cadets. The majority of patients who failed non-operative treatment required subsequent open repair. At the time of arthroscopy, a Bankart lesion was diagnosed in all patients, which the authors postulated are consistently present after acute first-time dislocations. The authors concluded that in young athletes, particularly in this case, military cadets, return to previous levels of activity and training is imperative. These findings remain relevant today and provided the impetus for the evolution in surgical techniques and implants over the past 20 years. Subsequent randomised controlled trials have largely supported the use of arthroscopic stabilisation in the young, high-demand population. Other subsequent studies have further reviewed the risk factors for failure after surgery to continue to refine the treatment algorithm. The treatment of initial anterior dislocations of the shoulder remains a challenging endeavour, with an ever-expanding list of options. This classic work challenged the established treatment approach in a particular patient group, the young athlete. The teachings imparted in the article, and reiterated in subsequent research studies, have taught us treatment decisions should be personalised and formulated on an individual basis.

Return to Sports After Cervical Total Disc Replacement

Total disc replacement (TDR) is typically indicated in young patients with a cervical soft disc herniation. There are few data on the activity level of patients after cervical TDR, in particular from young patients who are expected to have a high activity level with frequent exercising. The expectation is that returning to active sports after cervical TDR is not restricted. Fifty patients were treated with a monosegmental cervical TDR at our department between May 2006 and March 2012. Clinical status and radiographic parameters were evaluated preoperatively and during follow-up. In addition, information was gathered regarding neck disability index, pain, a questionnaire concerning athletic aspects, and a modified Tegner activity score. The study design was a prospective case series. All patients were treated with the Prestige artificial cervical disc for a single-level soft disc herniation with radiculopathy. The average age was 40 years, and the mean follow-up period was 53 months (range, 26-96). The median neck disability index during follow-up was 5, and median visual analog scale for pain was 2. Two professional athletes, 20 semiprofessionals, 24 hobby athletes, and 5 patients with a very low activity level were treated. The median time to resumption of sporting activity was 4 weeks after surgery. All professionals and semiprofessionals recovered to their previous activity level. All of the 20 hobby athletes recovered to resume their sport participation. The modified Tegner preoperative score was 4 and the postoperative score was 3.5 (P= 0.806). We found that cervical TDR did not prohibit sporting activities. All patients recovered and were able to take part in their previous activities at an appropriate intensity level.

Minimally Invasive Double-Button Fixation of Displaced Lateral Clavicular Fractures in Athletes

Background: Early union and a rapid return to prior function are the priorities for young athletes with lateral clavicular fractures. Furthermore, it is essential to avoid nonunion in this subgroup of patients, as this is frequently associated with persistent pain, restriction of movement, and loss of strength and endurance of the shoulder. Purpose: To analyze the time to return to sport, functional outcomes, and complications in a group of athletes with displaced lateral clavicular fractures treated using closed reduction and minimally invasive double-button fixation. Study Design: Case series; Level of evidence, 4. Methods: A total of 21 athletes with displaced lateral clavicular fractures were treated with closed reduction and minimally invasive double-button fixation between March 2008 and October 2013. Patients completed a questionnaire focused on the time to return to sport and treatment course. Functional outcomes were assessed with the Constant score and the short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Pain was evaluated with the visual analog scale (VAS). Radiographs were reviewed to identify radiographic union, malunion, and nonunion. Results: Of the 21 study patients, 20 returned to sport after treatment; 100% returned to the same level. The mean time to return to play was 78 days (range, 41-120 days). Four patients (20%) returned to sport less than 6 weeks after surgery, 14 (70%) returned between 6 and 12 weeks after surgery, and 2 (10%) returned after 12 weeks. The mean Constant score was 89.1 ± 4.2 (range, 79-100), the mean QuickDASH score was 0.4 ± 2.6 (range, 0-7.1), and the mean VAS pain score was 0.4 ± 1.0 (range, 0-3) at final follow-up (mean, 41 months). The only complication was asymptomatic nonunion. Hardware removal was not necessary in any patient. Conclusion: Closed reduction and minimally invasive double-button fixation of displaced lateral clavicular fractures in athletes was successful in terms of returning to the previous level of athletic activity regardless of the type of sport, with excellent clinical results and a low rate of complications.

Roturas completas del manguito de los rotadores. Clasificación del manejo en el paciente joven, el deportista y el anciano. Evidencia de reparación con doble fila o fila sencilla

About 4.5 million people in the US have some type of rotator cuff injury. About 300,000 to 400,000 surgeries are performed each year in the United States. The complete rupture of the rotator cuff tendons is the most common pathology in the shoulder joint. This pathology increases with age even in the asymptomatic population. Work activity, lifestyle, recreation, pain and functional limitation are determining factors for the proper management of this condition. Injuries in adults are mostly kind traumatic and surgical management should be the choice to avoid tendon retraction, muscle atrophy and poor performance in the future. Complete rotator cuff injuries in athletes usually need surgical repair. But nevertheless, the athlete may find it difficult to return to its previous level of sports activities after presenting this type of injury. No study has shown that clinical outcomes are different whether the repair is performed by single or double row techniques. Evidence levelIV.

Arthroscopic suture fixation of comminuted tibial spine fractures-a prospective study

Introduction:Tibial spine fractures are common injuries and various techniques have been described for the fixation. The purpose of the article is to make familiar with thearthroscopic fixation of the anterior cruciate ligament bony avulsion injuries using non absorbable sutures and simple methods and instruments. Adequate reduction, anterior cruciate ligament integrity and regaining the bio-mechanics of the knee are the ultimate goal to be achieved failing which non union and malunion ensues. This technique has resulted in achieving excellent results and thus avoiding complications like joint laxity, flexion deformity&pain.Methods:Twenty one patients underwent arthroscopic suture fixation of the comminutedtibial spine fractures. Mean age of the patient was 24.28 years (range 16 to 38 years). All of the patients belonged to the Meyer type IV. The mean duration of follow up was 15.5 months with a minimum of one year follow-up.Results:All patients showed negative Lachman test except one having grade 1 positive lachman. No patient showed extension loss. 90.4 % (n=19) patients had an IKDC grade A while two patients belonged to grade B. All patients returned to their previous activity level. Conclusion:The above excellent results show that arthroscopic suture fixation of the comminutedtibial spine is promising and reliable technique to achieve the best biomechanics of the knee.

Effectiveness of person-centred care after acute coronary syndrome in relation to educational level: Subgroup analysis of a two-armed randomised controlled trial

AimThe aim of this study was to evaluate the effects of person-centred care (PCC) after acute coronary syndrome (ACS) in relation to educational level of participants. Method199 Patients <75years with ACS were randomised to PCC plus usual care or usual care alone and followed for 6months from hospital to outpatient care and primary care. For the PCC group, patients and health care professionals co-created a PCC health plan reflecting both perspectives, which induced a continued collaboration in person-centred teams at each health care level. A composite score of changes that included general self-efficacy assessment, return to work or previous activity level, re-hospitalisation or death was used as outcome measure. ResultsIn the group of patients without postsecondary education (n=90) the composite score showed a significant improvement in favour of the PCC intervention (n=40) vs. usual care (n=50) at six months (35.0%, n=14 vs. 16.0%, n=8; odds ratio (OR)=2.8, 95% confidence interval (CI): 1.0–7.7, P=0.041). In patients with postsecondary education (n=109), a non-significant difference in favour of the PCC intervention (n=54) vs. usual care (n=55) was observed in the composite score (13.0%, n=7 vs 3.6%, n=2; OR=3.9, 95% CI: 0.8–19.9, P=0.097). ConclusionA PCC approach, which stresses the necessity of a patient–health care professional partnership, is beneficial in patients with low education after an ACS event. Because these patients have been identified as a vulnerable group in cardiac rehabilitation, we suggest that PCC can be integrated into conventional cardiac rehabilitation programmes to improve both equity in uptake and health outcomes.Trial registration: Swedish registry, Researchweb.org, ID NR 65 791

Use of a portable motion analysis system for knee dynamic stability assessment in anterior cruciate ligament deficiency during single-legged hop landing

Background/objectiveAnterior cruciate ligament (ACL) rupture results in knee instability, and patients are often unable to return to their previous level of activity. Current assessments rely on passive laxity tests, which do not correlate with function. Dynamic stability may be a better indicator for return to sport. However, equipment for measuring dynamic stability is ill suited for clinical use. The purpose of this study is to evaluate knee kinematics in ACL-deficient patients with a single-legged hop task using a portable motion analysis system. We hypothesize that the assessment task is able to differentiate ACL-deficient knees from healthy knees. MethodsTen ACL-deficient patients and 10 healthy controls were recruited. Participants were instructed to perform a single-legged hop, while kinematics was measured using a portable motion capture system (Opti-Knee; Shanghai Innomotion Inc., Shanghai, China). Kinematic changes after initial contact were examined. Repeatability of the results was examined by calculating the coefficient of variations of the pooled standard deviation of the tibiofemoral displacements. Side-to-side differences were calculated and compared between the two groups. ResultsOne patient could not perform the task. Intraindividual variability was small after initial contact; the coefficient of variation in this region was 13–26%. ACL-deficient knees demonstrated lower flexion range of motion (p = 0.008) and increased internal/external rotation range of motion after landing (p = 0.038), while no significant differences were detected in the healthy group. Only the side-to-side difference in flexion was significantly different between the two groups (p = 0.002). ConclusionThe altered knee kinematics in ACL-deficient patients can be revealed by a portable motion capture system, which may enable the clinical application of kinematic assessment in the evaluation of ACL deficiency.

Repair of Chronic Tibialis Anterior Tendon Rupture With a Major Defect Using Gracilis Allograft.

Tibialis anterior tendon (TAT) rupture is an uncommon injury, however, it can cause substantial deficit. Diagnosis is often delayed due to lack of initial symptoms; yet loss of function over time typically causes the patient to present for treatment. This delay usually ends up with major defects creating a great technical challenge for the operating surgeon. We present a novel technique and operative algorithm for the management of chronic TAT ruptures with a major gap after a delayed diagnosis not otherwise correctable with currently described techniques in the literature. This technique has been performed in 4 cases without any complications with fairly successful functional outcomes. For the reconstruction of chronic TAT rupture with an average delay of nine weeks after initial injury and gap of greater than 10 cm, a thorough operative algorithm was implemented in 4 patients using a double bundle gracilis allograft. Patients were then kept nonweightbearing for 6 weeks followed by weightbearing as tolerated. They began physical therapy with a focus on ankle exercises and gradual return to normal activity at 8 weeks, with resistance training exercises allowed at 12 weeks. At a mean follow-up time of 24.5 months, all patients reported significant pain relief with normal gait pattern. There were no reported intra- or postoperative complications. The average Foot and Ankle Ability Measure score increased to 90 from 27.5 in the postoperative period. All patients were able to return their previous activity levels. Gracilis allograft reconstruction as used in this study is a viable and reproducible alternative to primary repair with postoperative results being favorable without using complex tendon transfer techniques or autograft use necessitating the functional sacrifice of transferred or excised tendon. To the best of our knowledge, this is the first study demonstrating a successful technique and operative algorithm of gracilis allograft reconstruction of the TAT with a substantial deficit of greater than 10 cm with favorable results. Level IV: Operative algorithm with case series.

Bicompartmental Knee Arthroplasty

Knee arthritis is one of the leading causes of disability and functional limitations in the United States and worldwide. Total knee arthroplasty results in good functional outcomes and high survival rates in patients who have tricompartmental arthritis. Bicompartmental knee arthroplasty is being used more often in patients who have arthritis that is isolated to two compartments: the patellofemoral compartment and either the medial or the lateral compartment. Bicompartmental knee arthroplasty preserves the kinematics, ligaments, and bone stock of the knee and is a good option for younger, active, high-demand patients who wish to return to their previous level of activity.

Rehabilitation exercise program after surgical treatment of pectoralis major rupture. A case report

ObjectiveTo present a rehabilitation exercise program and suggest a schedule of activities for daily living and participation in sports after surgical treatment of a pectoralis major rupture. DesignA single case study. SettingHospital-based study, Thessaloniki, Greece. ParticipantsWe present a 30-year-old male athlete (height, 196 cm; weight, 90 kg; right hand dominant) with a complete rupture of the pectoralis major tendon after a fall. Rehabilitation exercise programThe athlete received a post-operative rehabilitation exercise program for 16 weeks. During the program, there was a gradual increase in the exercise program regime and load across the sessions according to the specific case demands. Main outcome measuresShoulder function was evaluated using Constant score. ResultsMagnetic resonance imaging (MRI) confirmed the diagnosis and the patient had surgical treatment repairing-reattaching the tendon back to its insertion using a bone anchor. At the end of the rehabilitation exercise program, the patient had full range of movement, normal muscle power and a return back to his previous level of athletic activities achieved. ConclusionsPost-operatively, a progressive rehabilitation protocol contributed to the patients' full recovery and allowed an early return to activities of daily living and participation in sports.

Distal biceps reconstruction using an Achilles tendon allograft, transosseous EndoButton, and Pulvertaft weave with tendon wrap technique for retracted, irreparable distal biceps ruptures

Distal biceps ruptures can result in ongoing pain and weakness when treated nonoperatively. If retraction of the tendon renders primary repair impossible, reconstruction using a graft is recommended. The current literature includes a variety of techniques with studies reporting small patient numbers. The aim of this study was to report the results of a larger cohort of patients using a technique modified from those previously described in the literature. Twenty-one consecutive male patients underwent distal biceps reconstruction through 2 small anterior incisions using an Achilles tendon allograft that was fixed distally using a transosseous EndoButton and secured proximally using a Pulvertaft weave and tendon wrap. The mean age was 44 years, and the mean time to surgery was 25 months (range, 2-96 months). Functional outcomes were collected prospectively. The mean preoperative Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score (11 patients) was 1.9 (range, 0-4.5). The mean postoperative Oxford Elbow Score, QuickDASH score, and Mayo Elbow Performance Score were 44.7 (range, 35-48), 4 (range, 0-20.5), and 92.9 (range, 70-100), respectively, at a mean follow up of 15 months (range, 6-35 months). The mean postoperative QuickDASH score was significantly improved compared with preoperatively (P < .001). All patients were satisfied and all returned to their previous level of activity. There were 2 transient lateral antebrachial cutaneous nerve paresthesias, and 2 patients had a 5° extension lag. There were no other complications. Achilles allograft reconstruction of retracted irreparable distal biceps ruptures provides consistently good results with few complications using this technique.

Single‐port laparoscopic incisional hernia repair in a horse

SummaryA 16‐year‐old Italian Saddle Horse gelding was referred for treatment of an incisional hernia that developed 7 months after a ventral midline laparotomy for treatment of acute abdominal pain. Physical examination revealed a hernia approximately 20 cm long and 15 cm wide on the ventral aspect of the abdomen. Ultrasonography revealed the dimensions of the hernia ring to be approximately 15 cm in length and 10 cm in width. A single‐port laparoscopic incisional hernia repair using an operating 0° laparoscope was performed with an appropriately sized (24 × 18 cm) piece of mesh fixed in place with simple interrupted transabdominal sutures. At 4 weeks post operatively, follow‐up physical examination and ultrasonography confirmed healing of the surgical site with no evidence of hernia recurrence. The same evaluation was done 6 months post operatively, and the horse returned to its previous level of activity 8 months post operatively. In horses, laparoscopic application of mesh should be considered among the treatment options for incisional hernia. In the present case, this technique was performed with a single port using an operative laparoscope, in contrast to the multiportal techniques reported previously. The case presented here demonstrates that single‐port laparoscopic herniorrhaphy is feasible, and allows proper placement of an expanded polytetrafluoroethylene intraperitoneal mesh in horses

Adherence to physical activity in an unsupervised setting: Explanatory variables for high attrition rates among fitness center members.

To evaluate the attrition rate of members of a fitness center in the city of Rio de Janeiro and the potential explanatory variables for the phenomenon. An exploratory, observational study using a retrospective longitudinal frame. The records of 5240 individuals, members of the fitness center between January-2005 and June-2014, were monitored for 12 months or until cancellation of membership, whichever occurred first. A Cox proportional hazard regression model was adjusted to identify variables associated to higher risk of 'abandonment' of activities. This study was approved by Southern Cross University's Human Research Ethics Committee (approval number: ECN-15-176). The general survival curve shows that 63% of new members will abandon activities before the third month, and less than 4% will remain for more than 12 months of continuous activity. The regression model showed that age, previous level of physical activity, initial body mass index and motivations related to weight loss, hypertrophy, health, and aesthetics are related to risk of abandonment. Combined, those variables represent an important difference in the probability to abandon the gym between individuals with the best and worse combination of variables. Even individuals presenting the best combination of variables still present a high risk of abandonment before completion of 12 months of fitness center membership. Findings can assist in the identification of high risk individuals and therefore help in the development of strategies to prevent abandonment of physical activity practice.

Prospective Use of a Standardized Nonoperative Early Weightbearing Protocol for Achilles Tendon Rupture

Background: Acute traumatic rupture of the Achilles tendon can be treated operatively or nonoperatively. Throughout the literature, there is no consensus regarding the optimal treatment protocol. Purpose: To report on 17 years of experience with treating this injury with a standardized nonoperative treatment protocol. Study Design: Case Series; Level of evidence, 4. Methods: The treatment protocol was based on a combination of an equinus cast and rehabilitation boot, which promoted immediate full weightbearing and early functional rehabilitation. A total of 171 patients were consecutively treated and prospectively followed from 1996 to 2013. Assessed were subjective parameters such as pain, loss of strength, return to previous activity level, meteosensitivity, and general satisfaction with the treatment outcome. Clinical assessment included testing of plantar flexion strength and endurance, calf circumference, and tendon length. Subjective and clinical parameters were then used to calculate a modified Thermann score. The correlation between tendon lengthening and function was calculated using the Pearson correlation coefficient. Results: A total of 114 patients were followed for a minimum of 12 months (mean, 27 ± 20 months; range, 12-88 months). The mean Thermann score was 82 ± 13 (range, 41-100), and subjective satisfaction was rated “very good” and “good” in 90%. An inverse correlation was found between tendon length and muscle strength (R = −0.3). There were 11 reruptures (8 with and 3 without an adequate trauma). General complications were 5 deep venous thromboses, 1 complex regional pain syndrome, and minor problems such as transient heel pain (n = 3), heel numbness (n = 1), and cast-associated skin abrasions (n = 4). Conclusion: Seventeen years of experience with a nonoperative treatment protocol for acute rupture of the Achilles tendon confirmed good functional outcome and patient satisfaction. Reruptures mostly occurred with new traumatic events in the vulnerable phase from 6 to 12 weeks after the initial injury. Muscle strength correlated to tendon length, making its assessment a crucial follow-up parameter. The protective equinus cast and boot can protect against excessive tendon lengthening during the healing process.

Pearls and pitfalls for the treatment of tibial head fractures

Tibial plateau fractures requiring surgery are severe injuries of the lower extremity. Depending on the fracture pattern, the age of the patient, the range of activity and the bone quality there is a broad variation in adequate treatment. In the last decade we have had a tremendous development, might it be the angular stable anatomical plates as well as new approaches to the proximal tibia. Nevertheless in the recent literature there are still many complications reported. Not only for sports professionals, recreational athletes or heavy load workers tibial plateau fractures affect leisure, all day activity and professional life. This article reports the treatment algorithm showing different cases, outlines the pitfalls and explains treatment strategies with a detailed x-ray follow-up. After a tibial plateau fracture patients are affected in their sporting activity due to an impaired knee function. Despite a long rehabilitation time and programs, physical activity changes to lower impact sports. Among the usual perioperative complications there are the specific complications of postoperative malalignment, implant infections, osteitis of the tibial head, compartment syndrome, secondary loss of reduction, avascular tibial head necrosis, secondary varus or valgus deformity, post-traumatic arthrosis and lesions of the peroneal nerve. In the literature in up to 43% of the cases complications have been noted. Despite surgery the majority of patients cannot return to their previous level of activity. However, overall about 70% of the patients return to sports after a tibial plateau fracture. For a beneficial outcome a detailed fracture analysis with CT scan and precise planning of the surgical strategies and approaches is mandatory.

Anterograde Headless Cannulated Screw Fixation in the Treatment of Medial Malleolar Fractures: Evaluation of a New Technique and Its Outcomes

Objective: To evaluate the functional and radiological outcomes of anterograde headless cannulated screw fixation for medial malleolar fractures. Subjects and Methods: This study included 12 patients (8 males, 4 females; age 27-55 years) with medial malleolar type B fractures according to the Herscovici fracture classification who had undergone anterograde headless cannulated screw fixation surgery between 2012 and 2014. Seven had an isolated medial malleolar fracture and 5 a bimalleolar fracture. All of the bimalleolar fractures were classified as 44-B2 based on the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification. Postoperatively, bone union was evaluated on direct radiographs at the final follow-up examination. The American Orthopaedic Foot and Ankle Society (AOFAS) scoring system was used for clinical evaluation. Results: The mean follow-up period was 17.2 ± 5.3 months (range 12-23). Full union was achieved in all fractures. The mean time to union was 3.4 ± 1.5 months (range 2-5). No instability, loss of reduction, non-union or infection was observed in any patient. The mean AOFAS score was 95.0 ± 5.4 (range 87-99). Based on the AOFAS score, 4 patients showed good results and 8 excellent results. The mean time to return to the previous level of activity was 4.0 ± 2.5 months (range 2-5). Conclusion: In this study, anterograde headless cannulated screw fixation yielded good clinical outcome in the surgical treatment of Herscovici type B fractures.