Hand trauma in English domestic professional county cricket.

Background: Hand trauma is a frequent and disabling injury in cricket. However, there is limited published data on its impact on the sport at the elite level. Objectives: This study investigated the incidence and mechanism of hand injuries in professional cricket over a decade and the impact of these injuries upon player availability. Methods: A retrospective hand injury review at Northampton County Cricket Club (NCCC) over 10 years (2009-2018) was performed. All hand injuries had been contemporaneously documented. They were analysed for cause of injury, treatment, and time away from competitive play. Results: There were 45 hand injuries in total. Eleven percent needed surgical intervention. These hand injuries required a total recovery time of 1561 days, and in-season 1416 days were lost from competitive play. The injuries requiring surgery were unavailable for 229 total days during the season. A player had an annual 18% risk of sustaining a hand injury requiring time away from the sport and resulting in a 4% reduction in playing resources during a season. Conclusion: Hand injuries have major implications for player selection during the cricket season and place a potential burden upon the entire squad and the team's success.

Bilateral arthrodesis of the distal tibiofibular joint for deforming osteochondromatas.

The first case of bilateral distal tibiofibular joint fusions for osteochondromas is reported with excellent long-term outcomes.

Fat mass and obesity associated (FTO) gene influences skeletal muscle phenotypes in non-resistance trained males and elite rugby playing position.

BACKGROUND: FTO gene variants have been associated with obesity phenotypes in sedentary and obese populations, but rarely with skeletal muscle and elite athlete phenotypes. METHODS: In 1089 participants, comprising 530 elite rugby athletes and 559 non-athletes, DNA was collected and genotyped for the FTO rs9939609 variant using real-time PCR. In a subgroup of non-resistance trained individuals (NT; n = 120), we also assessed structural and functional skeletal muscle phenotypes using dual energy x-ray absorptiometry, ultrasound and isokinetic dynamometry. In a subgroup of rugby athletes (n = 77), we assessed muscle power during a countermovement jump. RESULTS: In NT, TT genotype and T allele carriers had greater total body (4.8% and 4.1%) and total appendicular lean mass (LM; 3.0% and 2.1%) compared to AA genotype, with greater arm LM (0.8%) in T allele carriers and leg LM (2.1%) for TT, compared to AA genotype. Furthermore, the T allele was more common (94%) in selected elite rugby union athletes (back three and centre players) who are most reliant on LM rather than total body mass for success, compared to other rugby athletes (82%; P = 0.01, OR = 3.34) and controls (84%; P = 0.03, OR = 2.88). Accordingly, these athletes had greater peak power relative to body mass than other rugby athletes (14%; P = 2 x 10-6). CONCLUSION: Collectively, these results suggest that the T allele is associated with increased LM and elite athletic success. This has implications for athletic populations, as well as conditions characterised by low LM such as sarcopenia and cachexia.

Association of ACTN3 R577X but not ACE I/D gene variants with elite rugby union player status and playing position.

We aimed to quantify the ACE I/D and ACTN3 R577X (rs1815739) genetic variants in elite rugby athletes (rugby union and league) and compare genotype frequencies to controls and between playing positions. The rugby athlete cohort consisted of 507 Caucasian men, including 431 rugby union athletes that for some analyses were divided into backs and forwards and into specific positional groups: front five, back row, half backs, centers, and back three. Controls were 710 Caucasian men and women. Real-time PCR of genomic DNA was used to determine genotypes using TaqMan probes and groups were compared using χ(2) and odds ratio (OR) statistics. Correction of P values for multiple comparisons was according to Benjamini-Hochberg. There was no difference in ACE I/D genotype between groups. ACTN3 XX genotype tended to be underrepresented in rugby union backs (15.7%) compared with forwards (24.8%, P = 0.06). Interestingly, the 69 back three players (wings and full backs) in rugby union included only six XX genotype individuals (8.7%), with the R allele more common in the back three (68.8%) than controls (58.0%; χ(2) = 6.672, P = 0.04; OR = 1.60) and forwards (47.5%; χ(2) = 11.768, P = 0.01; OR = 2.00). Association of ACTN3 R577X with playing position in elite rugby union athletes suggests inherited fatigue resistance is more prevalent in forwards, while inherited sprint ability is more prevalent in backs, especially wings and full backs. These results also demonstrate the advantage of focusing genetic studies on a large cohort within a single sport, especially when intrasport positional differences exist, instead of combining several sports with varied demands and athlete characteristics.

The impact of playing in matches while injured on injury surveillance findings in professional football.

This study aimed to analyze the frequency, nature, and consequences of footballers playing matches while injured, and to examine the impact on injury surveillance findings. High levels of inter-rater reliability and content validity were established for a tool designed to document players who were already injured at the start of a match. The tool was implemented in three English football teams (a Championship, League 1, and League 2 team) for one season, using a "time loss" definition of injury. One hundred forty-three matches were surveyed, revealing 102 match appearances by players who were already injured. Almost half of all games featured at least one injured player, with episodes of playing with injury occurring more frequently and lasting longer in League 2 players compared with higher level players. No association was observed between the number of injured players starting matches and match outcome [χ(2) (4, N = 143) = 3.27, P = 0.514]. Fifteen percent of all injury episodes captured were only through prospective documentation of playing while injured. The findings show that both traumatic and overuse injuries are managed by footballers through competitive matches, and have important implications for aiding understanding of the epidemiology of injury in professional football.

Pathology of the tendo Achillis: do our genes contribute?

The incidence of acute and chronic conditions of the tendo Achillis appear to be increasing. Causation is multifactorial but the role of inherited genetic elements and the influence of environmental factors altering gene expression are increasingly being recognised. Certain individuals' tendons carry specific variations of genetic sequence that may make them more susceptible to injury. Alterations in the structure or relative amounts of the components of tendon and fine control of activity within the extracellular matrix affect the response of the tendon to loading with failure in certain cases. This review summarises present knowledge of the influence of genetic patterns on the pathology of the tendo Achillis, with a focus on the possible biological mechanisms by which genetic factors are involved in the aetiology of tendon pathology. Finally, we assess potential future developments with both the opportunities and risks that they may carry.

The safety profile of a retrospective Accessory Postero-Lateral hind foot portal: the risk of sural nerve damage during visualisation of the Achilles tendon insertion.

INTRODUCTION: The Accessory Postero-Lateral (AccPL) portal has recently been described to improve the visualisation for the endoscopic debridement of Haglund's tubercle. The safety of using this portal has been considered previously for posterior ankle arthroscopy. We performed a study to determine the proximity of the AccPL portal to the sural nerve. METHODS: We compared the distances between AccPL and PL portals to the sural nerve in 17 cadaveric specimens. RESULTS: The AccPL portal was significantly closer (mean 12.0mm, range 6-19 mm, SD=3.64) to the sural nerve than the PL portal (mean 14.1mm, range 11-18 mm, SD=2.34) (t(16)=-2.34, p=0.03). In two cases the sural nerve was in contact with the clip but on close inspection, the nerve had not been damaged in any of the specimens. CONCLUSIONS: We conclude that the AccPL portal is a safe method to allow visualisation during endoscopic debridement of the Achilles tendon insertion. We also recommend that the portal is used for visualisation rather than instrumentation.

Matrix metalloproteinase genes on chromosome 11q22 and the risk of anterior cruciate ligament (ACL) rupture.

As matrix metalloproteinases (MMPs) are critical to ligament homeostasis and integrity, the aim of this study was to investigate whether four functional polymorphisms within four MMP genes, which cluster on chromosome 11q22 associate with risk of ACL ruptures. Three hundred and forty-five [129 with ACL ruptures (ACL group) and 216 asymptomatic controls (CON group)] unrelated Caucasians were recruited for this case-control study. Fifty-four participants reported non-contact mechanisms of ACL rupture (NON subgroup). All participants were genotyped for the MMP10 C/T rs486055, MMP1 1G/2G rs1799750, MMP3 G/A rs679620 and MMP12 A/G rs2276109 variants. After adjusting for sex, age and weight, the AG and GG genotypes of the MMP12 rs2276109 variant were significantly (P=0.030) under-represented among the NON subgroup (14%), when compared with the CON group (26%). No other variants were significantly different between groups. Adjusted for the same confounders, the two four-variant haplotypes T-1G-A-A (CON 14%, ACL 9%, P=0.033) and C-2G-G-G (CON 14%, NON 5%, P=0.021) were significantly different between the CON and the ACL groups, and the CON group and the NON subgroup, respectively. This is the first report that indicates an association between the chromosomal region 11q22 and the risk of ACL rupture.

Cross-sectional study to evaluate radiological parameters in hallux rigidus.

BACKGROUND: Hallux rigidus (HR) is a common condition with X-rays used to evaluate its pathology, grade joint changes and to inform treatment. METHOD: A cross-sectional study was undertaken to evaluate radiological foot parameters in HR. In 110 subjects (180 feet) aged 18-70 years (mean 52 years) standard weight-bearing X-rays were examined using dorsal plantar and lateral views. RESULTS: Seventy (64%) subjects had bilateral HR and 73 (66%) were female. The mean onset of HR (denoted by first metatarsophalangeal (MTP) joint restriction/pain) was 44 (14-68 years) years and median HR duration was 6 years (1-33 years). Flat or chevron-shaped metatarsal heads presented in 131 (73%) feet and a history of first MTP joint trauma in 22% (74% of whom had unilateral HR). In 74% of feet hallux abductus interphalangeus angle (HAI degrees) was greater than normal (< or =10 degrees). Correlations between first MTP joint narrowing and sclerosis (r=0.76, p=0.01) and increased HAI degrees and first MTP joint narrowing (r=0.34, p=0.01) was found. The mean hallux equinus angle of 11 degrees was outside the normal range (16-18 degrees). Abnormal sesamoid morphology presented in 117 (65%) feet (30% irregular or hypertrophic). Proximal sesamoid displacement was greater than that seen in non-HR. Metatarsus primus elevatus was within normal range (< or =8 mm) in 160 (89%) feet. The first metatarsal was longer than the second metatarsal in 66 (37%) feet although the first metatarsal was longer than the third metatarsal in 131 (73%) feet and may be responsible for altered forefoot function in HR. CONCLUSIONS: HR was associated with female gender, bilateral involvement, older age groups, flat or chevron-shaped metatarsal head, longer proximal phalanx, increased HAI degrees and a first metatarsal longer than the third metatarsal. For radiological parameters to be considered valid for inclusion in a classification of HR their content validity needs to be established by formal research.

Hallux rigidus: a cross-sectional study to evaluate clinical parameters.

BACKGROUND: Hallux rigidus (HR) is a common condition with history and physical examination used to help evaluate pathology, grade clinical changes and to inform treatment. METHOD: A cross-sectional study was undertaken to evaluate the demographics of and clinical parameters encountered in HR. In 110 subjects (180 feet) aged 18-70 years (mean 52 years) a standardized history and physical examination was undertaken. Clinical parameters associated with HR were evaluated. The Foot Health Status Questionnaire (FHSQ) was used to measure health-related quality-of-life dimensions. RESULTS: Seventy (64%) subjects had bilateral HR and 73 (66%) were female. Mean HR onset was 44 (14-68 years) years and median HR duration 6 years (1-33 years). A history of 1st MTPJ trauma presented in 22% of subjects; 74% of whom had unilateral HR. Eighty-four (47%) feet had pes planus based on a positive Foot Posture Index. A correlation between pes planus and 1st MTPJ pain was found (r=0.84, p=0.05). In 74% of feet, hallux abductus interphalangeus angle (HAI degrees ) was greater than normal (< or =10 degrees ). A correlation between HAI and reduced 1st MTPJ ROM was found (r=0.92, p=0.05). Second toe length was the same as the hallux in 111 feet (62%). A correlation between valgus hallucal rotation and 1st MTP joint pain in HR was found (r=.78, p=.05). A positive relationship was found between 2nd toe length and 1st MTPJ pain (p=0.001<0.05). A correlation between hallucal interphalangeal joint (IPJ) hyperextension and 1st MTPJ pain was found (r=0.78, p=0.01). A positive relationship was found between lesser MTPJ pain and supination at propulsion (p<0.001). There was no evidence of Achilles tendon contracture. The FHSQ results concur with clinical findings. CONCLUSIONS: HR was associated with female gender, bilateral involvement, older age groups, increased HAI degrees, 2nd toe length similar to hallux, hallucal IPJ hyperextension, lesser MTP joint pain, flat foot and certain gait alterations. HR was not associated with Achilles tendon tightness or footwear. The content validity of clinical parameters of HR needs to be established by formal research prior to their inclusion in a classification of HR.

Variants within the MMP3 gene are associated with Achilles tendinopathy: possible interaction with the COL5A1 gene.

OBJECTIVES: Sequence variation within the COL5A1 and TNC genes are known to associate with Achilles tendinopathy. The primary aim of this case-control genetic association study was to investigate whether variants within the matrix metalloproteinase 3 (MMP3) gene also contributed to both Achilles tendinopathy and Achilles tendon rupture in a Caucasian population. A secondary aim was to establish whether variants within the MMP3 gene interacted with the COL5A1 rs12722 variant to raise risk of these pathologies. METHODS: 114 subjects with symptoms of Achilles tendon pathology and 98 healthy controls were genotyped for MMP3 variants rs679620, rs591058 and rs650108. RESULTS: As single markers, significant associations were found between the GG genotype of rs679620 (OR = 2.5, 95% CI 1.2 to 4.90, p = 0.010), the CC genotype of rs591058 (OR = 2.3, 95% CI 1.1 to 4.50, p = 0.023) and the AA genotype of rs650108 (OR = 4.9, 95% CI 1.0 to 24.1, p = 0.043) and risk of Achilles tendinopathy. The ATG haplotype (rs679620, rs591058, and rs650108) was under-represented in the tendinopathy group when compared to the control group (41% vs 53%, p = 0.038). Finally, the G allele of rs679620 and the T allele of COL5A1 rs12722 significantly interacted to raise risk of AT (p = 0.006). No associations were found between any of the MMP3 markers and Achilles tendon rupture. CONCLUSION: Variants within the MMP3 gene are associated with Achilles tendinopathy. Furthermore, the MMP3 gene variant rs679620 and the COL5A1 marker rs12722 interact to modify the risk of tendinopathy. These data further support a genetic contribution to a common sports related injury.

Coding sports injury surveillance data: has version 10 of the Orchard Sports Injury Classification System improved the classification of sports medicine diagnoses?

OBJECTIVES: To compare versions 8 and 10 of the Orchard Sports Injury Classification System (OSICS) to determine whether the revised version of OSICS has improved its use in a sports medicine setting, and to assess the inter-rater reliability of OSICS-10. METHODS: Injury surveillance data, gathered over a 2 year period in professional football, cricket and rugby union to produce 335 diagnoses, were coded with both OSICS-8 and OSICS-10. Code-diagnosis agreement was assessed for OSICS-8 in terms of whether a diagnosis was codeable or noncodeable, and for OSICS-10 by evaluating the highest available OSICS-10 tier of coding. Eight clinicians coded a list of 20 diagnoses, comprising a range of pathologies to all gross anatomical regions, which were compared to assess inter-rater reliability. RESULTS: All diagnoses could be assigned an appropriate code with OSICS-10, compared with 87% of diagnoses that could be assigned an OSICS-8 code. Contusions comprised almost half of OSICS-8 noncodeable diagnoses. OSICS-10 tier 2 codes accounted for 20% of diagnoses coded with the updated system. Of these 20%, almost half contained a more detailed diagnosis that did not have an available OSICS-10 tier 3 or 4 code. Inter-rater reliability increased with decreasing diagnostic detail, with an overall level shown to be moderate (k = 0.56). CONCLUSIONS: OSICS-10 is a more encompassing system than OSICS-8 to use in classifying sports medicine diagnoses, and has a moderate level of inter-rater reliability. Further minor revision may be required to address lack of detail in some strain, effusion and contusion codes.

Interprofessional relationships between orthopaedic and podiatric surgeons in the UK.

INTRODUCTION: The first comprehensive report on the interprofessional relationships between foot and ankle surgeons in the UK is presented. MATERIALS AND METHODS: A questionnaire was sent to orthopaedic surgeons with membership of the British Foot and Ankle Surgery Society (BOFAS), orthopaedic surgeons not affiliated to the specialist BOFAS and podiatrists specialising in foot surgery. The questionnaire was returned by 77 (49%) of the BOFAS orthopaedic consultant surgeons, 66 (26%) of non-foot and ankle orthopaedic consultant surgeons and 99 (73%) of the podiatric surgeons. RESULTS: While most respondents have experience of surgeons working in the other specialty in close geographical proximity, the majority do not believe that this has adversely affected their referral base. The experience of podiatrists of the outcomes of orthopaedic surgery has been more positive than orthopaedic surgeons of podiatric interventions. Podiatrists are more welcoming of future orthopaedic involvement in future foot and ankle services than in reverse. However, there are a sizeable number of surgeons in both professions who would like to see closer professional liaisons. The study has identified clear divisions between the professions but has highlighted areas where there is a desire from many clinicians to work more harmoniously together, such as in education, training and research. CONCLUSIONS: While major concerns exist over issues such as surgery by non-registered medical practitioners and the suitable spectrum of surgery for each profession, many surgeons, in both professions, are willing to provide training for juniors in both specialties and there is a wish to have closer working relationships and common educational and research opportunities than exists at present.

The impact of implementing the Ottawa ankle rules on ankle radiography requests in A&E.

This audit was set up to quantify the effect of implementing the Ottawa ankle rules in a district general hospital that relies on both medical and nursing radiography requests. Data were collected prospectively on 207 patients who presented with an acute ankle injury between August 2001 and February 2002. The department's activity was recorded before and after a period of teaching on the Ottawa ankle rules. Before teaching, 71% of patients with an acute ankle injury were sent for radiography; teaching reduced this figure to 56% (p < 0.05). Auditing the activity of our department enabled us to observe a significant decrease in the number of patients sent for ankle radiography following acute ankle injury. This correlates well with research in other settings. The difficulties of rationalising radiology investigations are discussed.

Infected joint replacements in HIV-positive patients with haemophilia.

Joint replacement in HIV-positive patients remains uncommon, with most experience gained in patients with haemophilia. We analysed retrospectively the outcome of 102 replacement arthroplasties in 73 HIV-positive patients from eight specialist haemophilia centres. Of these, 91 were primary procedures. The mean age of the patients at surgery was 39 years, and the median follow-up was for five years. The overall rate of deep sepsis was 18.7% for primary procedures and 36.3% for revisions. This is a much higher rate of infection than that seen in normal populations. A total of 44% of infections resolved fully after medical and/or surgical treatment. The benefits of arthroplasty in haemophilic patients are well established but the rates of complications are high. As this large study has demonstrated, high rates of infection occur, but survivorship analysis strongly suggests that most patients already diagnosed with HIV infection at the time of surgery should derive many years of symptomatic relief after a successful joint replacement. Careful counselling and education of both patients and healthcare workers before operation are therefore essential.

Bacterial recolonization during foot surgery: a prospective randomized study of toe preparation techniques.

Fifty patients undergoing foot or ankle surgery were randomized into two groups for the purposes of toe preparation. Twenty-four patients underwent a standard preparation which included placing antiseptic between the toes while 26 were additionally cleaned by sliding a gauze swab soaked in topical antiseptic back and forth several times. Povidone iodine followed by chlorhexidine in alcohol was used in both groups. All toes were covered by a sterile glove during surgery unless the toes themselves were to be operated upon. Bacteria were cultured from the toe clefts in 4% of all patients immediately following preoperative disinfection. Significantly fewer patients whose toes had been additionally scrubbed (group 1) showed bacterial recolonization at the end of surgery compared with those undergoing a standard prep (group 2) (7.7% vs 20.8%). We conclude that additional scrubbing of toe clefts prior to surgery reduces the incidence of recolonization of bacteria during the surgical procedure.

Diagnosis and imaging studies of traumatic hip dislocations in the adult.

Traumatic dislocation of the hip represents a major injury that is associated with significant morbidity. In particular, the risk of osteonecrosis of the femoral head is greatly affected by the time it takes to reduce the hip. Therefore, thorough understanding of the clinical and radiologic features is essential if this injury is to be recognized and treated promptly. Most patients present in severe distress after a high-energy injury such as a motor vehicle accident. Associated injuries, particularly of the knee, are common and the leg usually is held in a specific posture characteristic of the direction of dislocation. Plain anteroposterior radiographs of the pelvis will clearly show the dislocation in most patients but lateral views or a computed tomography scan may be required to confirm the diagnosis and to show the direction if the signs are subtle. Associated acetabular wall fractures and femoral head fractures also may be identified by computed tomography scans. After reduction, plain radiographs alone are not adequate to assess reduction; computed tomography is more sensitive in detecting osteochondral fragments and may reliably detect residual subluxation of 2 mm in any part of the joint. Magnetic resonance imaging is useful in detecting changes of osteonecrosis but rarely is indicated in the early treatment of this condition.

Management of equinus contractures of the ankle in haemophilia.

Equinus deformity has been a significant problem in haemophilia. It causes difficulties in walking and secondary problems in adjacent joints. There are a number of potential causes in haemophilia. A careful history, examination, and plain radiographs will determine the aetiology, which frequently is multifactorial. Hopefully, prophylactic factor replacement will reduce the incidence of such problems in the future. Prompt 'on demand' therapy will reduce the complications of articular and soft-tissue bleeds. Physiotherapy, splints, and orthotics will usually allow a full recovery of function and comfort. Rarely, surgical intervention is required to correct articular and/or musculo-tendinous problems. The choice of surgery depends upon the cause(s) of the deformity and should only be undertaken in experienced haemophilia units following careful counselling of the patient regarding the aims and nature of the operation and the patient's involvement in an effective rehabilitation programme.

Conservative treatment of hemarthrosis for prevention of hemophilic synovitis.

Acute hemarthroses are probably the most frequent type of bleeding in the patient with hemophilia. Delayed and/or inadequate treatment can trigger a series of pathologic changes within the joint leading to a painful and disabling arthropathy. Despite the advent of prophylactic treatment with factor concentrates, the majority of patients in the world have no access to even on demand factor replacement. Care for all patients involves a team approach led by the hematologist but including input from orthopaedic surgeons and physiotherapists. Optimal treatment involves a combination of factor replacement, rest, ice, and supervised rehabilitation. In certain cases, joint aspiration may be considered. In developing countries, where factor concentrates are in short supply, such bleeding episodes usually are treated by physical means alone or with the addition of cryoprecipitate or fresh frozen plasma. After successful resolution of such episodes by whatever means, the events leading to the bleeding episode and its subsequent management should be considered within the setting of the treating unit. Such debriefings should aim to provide counsel regarding any appropriate lifestyle modifications and, where necessary, treatment should be arranged to minimize the risk of additional episodes.