Conventional vs Accelerated Rehabilitation Protocol Following Reattachment of Achilles Tendon for Insertional Achilles Tendinopathy.

BACKGROUND: No studies have compared early vs conventional postoperative weightbearing following suture bridge Achilles tendon reattachment. We, therefore, evaluated postoperative functional outcomes in these patients. METHODS: We collected data on 49 patients who underwent surgical treatment of insertional Achilles tendinopathy using a central Achilles tendon-splitting approach and reattachment with suture bridge technique by a single surgeon. Functional outcomes were measured by a visual analog scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM), and Short Form Health Survey (SF-36) at 3, 6, and 12 months postoperatively. The differences in outcomes were analyzed using multiple linear regression. RESULTS: Eighteen and 31 patients underwent the conventional and accelerated protocols, respectively; their corresponding mean ages were similar, 53 and 57 years, as were all other baseline characteristics. The mean scores (conventional vs accelerated group) for VAS for pain, FAAM, and SF-36 in the conventional group at 3 months postoperatively were 4 ± 1 vs 3 ± 1 points, 53 ± 8 vs 68 ± 3 points, and 57 ± 15 vs 67 ± 10 points (P < .05 for each comparison). There were no statistically significant differences between the groups at 6 and 12 months postoperatively. All patients could perform the single heel raise test at 6 months, and none experienced complications. CONCLUSION: In this small study, short-term functional outcomes were better in the accelerated group. More data are needed before the accelerated program can be recommended. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Radiographic parameters in gravity stress view of the ankle: Normative data.

BACKGROUND: In rotational ankle injury with isolated fibular fracture, deltoid integrity is important for determining stability of ankle. Medial clear space and superior clear space in gravity stress view are parameters widely used to predict deltoid ligament tear. The purpose of this study is to report radiographic parameters in gravity stress view in normal population. METHODS: 120 persons were enrolled. Non weight-bearing ankle mortise and gravity stress view were obtained. Radiographic measurements were made by 2 investigators, including medial clear space (MCS), superior clear space (SCS), tibiofibular overlaps, tibiofibular clear space and talocrural angle. Statistical analysis included mean, mean difference, SD, 95%CI, paired T-test were calculated and subgroup analysis by foot length. Intraclass correlation coefficients were used to determine intra/interobserver reliability of measurement. RESULTS: Mean MCS in gravity stress view was 3.19mm (95%CI 3.1-3.31). This compared to mean MCS of 3.01mm (95%CI 2.9-3.12) in mortise view which was statistically significant (P=0.02). Mean difference was 0.18mm (95%CI 0.07-0.3). SCS in gravity stress view was 3.29mm (95%CI 3.19-3.39) and when compared to MCS in gravity stress view, no statistical significance was found (P=0.158). Mean difference was 0.1mm (95%CI 0.03-0.21). In subgroup analysis by foot length, no significant difference was found in any parameters. CONCLUSIONS: This study provides normative radiographic data for a gravity stress radiograph and supports that if measurable MCS >4mm on gravity stress view, it should be aware of an unstable ankle in supination-external rotation injury.

Hydrogen Peroxide Induces Muscle Nociception via Transient Receptor Potential Ankyrin 1 Receptors.

BACKGROUND: H2O2 has a variety of actions in skin wounds but has been rarely studied in deep muscle tissue. Based on response to the transient receptor potential ankyrin 1 antagonists after plantar incision, we hypothesized that H2O2 exerts nociceptive effects via the transient receptor potential ankyrin 1 in muscle. METHODS: Nociceptive behaviors in rats (n = 269) and mice (n = 16) were evaluated after various concentrations and volumes of H2O2 were injected into the gastrocnemius muscle or subcutaneous tissue. The effects of H2O2 on in vivo spinal dorsal horn neuronal activity and lumbar dorsal root ganglia neurons in vitro were evaluated from 26 rats and 6 mice. RESULTS: Intramuscular (mean ± SD: 1,436 ± 513 s) but not subcutaneous (40 ± 58 s) injection of H2O2 (100 mM, 0.6 ml) increased nociceptive time. Conditioned place aversion was evident after intramuscular (-143 ± 81 s) but not subcutaneous (-2 ± 111 s) injection of H2O2. These H2O2-induced behaviors were blocked by transient receptor potential ankyrin 1 antagonists. Intramuscular injection of H2O2 caused sustained in vivo activity of dorsal horn neurons, and H2O2 activated a subset of dorsal root ganglia neurons in vitro. Capsaicin nerve block decreased guarding after plantar incision and reduced nociceptive time after intramuscular H2O2. Nociceptive time after intramuscular H2O2 in transient receptor potential ankyrin 1 knockout mice was shorter (173 ± 156 s) compared with wild-type mice (931 ± 629 s). CONCLUSIONS: The greater response of muscle tissue to H2O2 may help explain why incision that includes deep muscle but not skin incision alone produces spontaneous activity in nociceptive pathways.

Validity and Reliability of Thai Version of the Foot and Ankle Ability Measure (FAAM) Subjective Form.

BACKGROUND: Self-administered questionnaires have become an important aspect for clinical outcome assessment of foot and ankle-related problems. The Foot and Ankle Ability Measure (FAAM) subjective form is a region-specific questionnaire that is widely used and has sufficient validity and reliability from previous studies. OBJECTIVE: Translate the original English version of FAAM into a Thai version and evaluate the validity and reliability of Thai FAAM in patients with foot and ankle-related problems. MATERIAL AND METHOD: The FAAM subjective form was translated into Thai using forward-backward translation protocol. Afterward, reliability and validity were tested. Following responses from 60 consecutive patients on two questionnaires, the Thai FAAM subjective form and the short form (SF)-36, were used. The validity was tested by correlating the scores from both questionnaires. The reliability was adopted by measuring the test-retest reliability and internal consistency. RESULTS: Thai FAAM score including activity of daily life (ADL) and Sport subscale demonstrated the sufficient correlations with physical functioning (PF) and physical composite score (PCS) domains of the SF-36 (statistically significant with p < 0.001 level and ≥ 0.5 values). The result of reliability revealed highly intra-class correlation coefficient as 0.8 and 0.77, respectively from test-retest study. The internal consistency was strong (Cronbach alpha = 0.94 and 0.88, respectively). CONCLUSION: The Thai version of FAAM subjective form retained the characteristics of the original version and has proved a reliable evaluation instrument for patients with foot and ankle-related problems.

General anesthesia with thoracic paravertebral block for modified radical mastectomy.

OBJECTIVE: To evaluate the effect of single-injection paravertebral block (PVB) combined with general anesthesia on 24-hour postoperative morphine requirement in patients undergoing modified radical mastectomy (MRM). MATERIAL AND METHOD: 20 patients were randomly assigned into 2 groups. Patients in the control group were given only general anesthesia. Patients in the PVB group received 0.3 ml/kg of 0.5% plain bupivacaine at T4 paravertebral space followed by general anesthesia. Both groups received intravenous morphine patient-controlled analgesia (PCA) device postoperatively. All patients were evaluated at 1 and 24 hours for pain, nausea and vomiting. Twenty-four hour morphine consumption, antiemetics requirement, and overall satisfaction were recorded. RESULTS: Patients with PVB had lower incidence and severity of postoperative pain, nausea and vomiting and other serious complications. No patients were unsatisfied with anesthetic techniques. CONCLUSION: PVB can reduce postoperative opioid requirement, pain, and severity of nausea and vomiting in MRM.

Level of undercarboxylated osteocalcin in hip fracture Thai female patients.

The undercarboxylated osteocalcin (ucOC) level is increased in the elderly and postmenopausal women compared with the young, healthy, and reproductive women. The high level of serum UcOC reflects the vitamin K2 deficiency which not only results in high skeletal turnover, low bone quality, and low bone density, but also increases a risk of fracture. The objective of the study is to measure the ucOC level, the 25-hydroxy vitamin D (25(OH)D) levels, and the prevalence of vitamin K2 and vitamin D deficiency in Thai female patients with hip fracture. The serum UcOC and 25(OH)D levels of the 40 female patients with hip fracture (the mean age 77.2 +/- 9.7 years) were measured and compared to the control group of the 47 randomly selected female volunteers (the mean age 75.2 +/- 8.1 years) without osteoporosis-related problems. The serum level of UcOC (median) in the female patients with hip fracture was significantly higher than the control group (p = 0.0001). Fifty-three percent had the serum UcOC level above the cut-off point at 2.314 ng/ml and 83% had lower serum 25(OH)D than the cut-off point at 30 ng/ml. The serum UcOC levels; however, were not correlated with 25(OH)D levels (r = 0.191, p = 0.237). The high prevalence of vitamin K2 and vitamin D deficiency was found in the Thai female patients with hip fracture. The additional treatment with vitamin K2 supplement besides calcium and vitamin D is a beneficial effect for osteoporosis.