Sensory dysfunction in the great toe in hallux valgus.

Injury to the dorsomedial cutaneous nerve in the foot may occur after operations for hallux valgus. Pressure neuropathy before operation is also described but remains largely unexplored. We have investigated the incidence of sensory deficit in the great toe before operating for hallux valgus and examined to what extent any deficit was related to the degree of angulation of the joint. Forty-three patients with a total of 61 great toes with hallux valgus presenting for consideration of surgical correction had their sensation tested in pre-designated zones using a five-filament set of Semmes-Weinstein monofilaments. These allowed good inter-observer reliability with an intra-class correlation coefficient of 0.84. Sensory symptoms were noted by only 21% of the patients, a measurable reduction in sensation by one monofilament grade or more was found in an additional 44%. No relationship was found between the degree of sensory loss and the degree of angulation. Patients with symptomatic hallux valgus may have sensory loss in the toe without being aware of it. Normal subjective sensation does not reliably predict normal sensory function. Given the potentially high rates of nerve damage following operations for hallux valgus, we recommend objective sensory testing as part of routine assessment before surgery.

Arthroscopy in sporting and sedentary children and adolescents.

We performed arthroscopic procedures on 97 knees in 91 patients younger than 16 years of age. Sixty arthroscopic procedures in 58 patients were for sports-related injuries or symptoms. The most common diagnosis was maltracking of the patella. In 78 cases, an operative procedure was performed at the time of diagnostic arthroscopy. No complications were experienced. The accuracy of diagnosis for suspected meniscal tears was poor. Further pathologies, especially meniscal tears, were commonly associated with anterior cruciate ligament tears. Arthroscopy of the knee in children is safe, has a high diagnostic accuracy, and, in a significant proportion of patients, it can have not only a diagnostic role but allows the management of a wide variety of intra-articular conditions.

Surgical decompression of chronic central core lesions of the Achilles tendon.

We report the outcome of 14 athletes with chronic recalcitrant achillodynia and central core degeneration of the Achilles tendon. The patients underwent surgery after an average time from onset of symptoms to surgery of 87 months. All patients had undergone conservative management, including physical therapy treatment, orthoses, nonsteroidal antiinflammatory drugs, and steroid injections. At an average follow-up of 35 months (range, 27 to 52), only 5 patients had an excellent or good result, despite reexploration in 6 of the 14 patients. In athletes with long-standing pain and central core degeneration of the Achilles tendon, prognosis is poor, and even reexploration is not successful. If the referral pattern allows, surgery should probably be undertaken earlier.

Surgical management of tendinopathy of the main body of the patellar tendon in athletes.

OBJECTIVE: To report the results of surgery for tendinopathy of the main body of the patellar tendon. DESIGN: Retrospective study. SETTING: A teaching hospital of the University of London. PATIENTS: Twenty-eight patients reviewed at an average follow-up of 42 months from surgery for tendinopathy of the main body of the patellar tendon after failed conservative treatment. INTERVENTION: Exploration of the affected patellar tendon, stripping of the paratenon, excision of pathological areas, and multiple longitudinal tenotomies. MAIN OUTCOME MEASURES: Postoperative complications, ability to return to sport, and subjective satisfaction, as measured by formal clinical assessment or telephone questionnaire. RESULTS: At follow-up, 23 patients were completely free of pain and had resumed full sporting activity at the same preoperative level. Three patients were improved enough to have returned to their preoperative sporting level or just below it. In two patients, the initial operation failed. In the patients who resumed sport, the average time from surgery to resuming full sporting activity was 7 months (range 6 weeks to 12 months). The most common early postoperative complications were wound hematoma and superficial infection. The most common late complications were related to the incision, with anterior knee pain on kneeling and skin dysesthesia. CONCLUSION: Surgical decompression of the patellar tendon with multiple longitudinal tenotomies is an effective treatment for patellar tendinopathy. In the middle term, patients do not seem to relapse once they have recovered, whereas those who do not respond to surgery do not recover at all and may need a new operation.

Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle- and long-distance runners.

From August 1989 to January 1995 we performed multiple percutaneous longitudinal tenotomies under local anesthetic on 52 middle- and long-distance runners with unilateral Achilles tendinitis or peritendinitis that had failed conservative treatment. Forty-eight patients were reviewed at an average of 22.1 months (SD, 6.5) after surgery. Results were rated as excellent in 25 patients, good in 12, fair in 7, and poor in 4. Four patients developed subcutaneous hematomas. One patient developed a superficial infection at one of the incision sites, which was managed by oral antibiotics with full recovery. Three patients complained of over-sensitivity to the incisions; this was resolved by rubbing hand cream over the incisions several times a day. One patient developed hypertrophic painful scars on three of the five incisions, but corticosteroid injections yielded good functional and cosmetic results. Isometric strength and endurance of the gastrocsoleus complex was measured just before the procedure, and at 6 weeks and 6 months later. Both were within 10% of the normal contralateral limb by the 6th postoperative month. Percutaneous longitudinal tenotomy is simple, can be performed on an outpatient basis, requires minimal follow-up care, and, in our experience, has produced no significant complications. We use this procedure as the operative treatment of choice for cases of chronic tendinitis that have failed conservative treatment.

Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases.

We made a prospective arthroscopic study of 106 skeletally mature male sportsmen with an average age of 28.35 years (16.8 to 44) who presented with an acute haemarthrosis of the knee due to sporting activities. We excluded those with patellar dislocations, radiographic bone injuries, extra-articular ligamentous lesions or a previous injury to the same joint. The anterior cruciate ligament (ACL) was intact in 35 patients, partially disrupted in 28 and completely ruptured in 43. In the patients with an ACL lesion, associated injuries included meniscal tears (17 patients), cartilaginous loose bodies (6), and minimal osteochondral fractures of the patella (2), the tibial plateau (3) or the femoral condyle (9). We found no age-related trend in the pattern of ACL injuries. Isolated injuries included one small osteochondral fracture of the patella, and one partial and one total disruption of the posterior cruciate ligament. Three patients had cartilaginous loose bodies, and no injury was detected in five. Acute traumatic haemarthrosis indicates a serious ligament injury until proved otherwise, and arthroscopy is needed to complement careful history and clinical examination. All cases with a tense effusion developing within 12 hours of injury should have an aspiration. If haemarthrosis is confirmed, urgent admission and arthroscopy are indicated.

Patterns of meniscal tears associated with anterior cruciate ligament lesions in athletes.

In this study, 400 clinically anterior cruciate ligament (ACL) deficient knees were arthroscoped and studied prospectively in the period January 1986 to April 1992. An ACL tear was always confirmed, and 41 per cent of these patients did not have an associated meniscal tear. In 30.25 per cent the lateral meniscus was torn; in 21.25 per cent the ACL tear was associated with a medial meniscus tear, and in the remaining 7 per cent both menisci were torn. The most frequently associated meniscal injury was the bucket handle tear of the medial meniscus (9 per cent), followed by the posterior horn tear of the lateral meniscus, which showed the same frequency as the ragged (or degenerated) tear of the lateral meniscus (6 per cent). The horizontal tear of the posterior part of the lateral meniscus showed a prevalence of 4.3 per cent. This picture is probably dependent on a secondary referral nature of the centre surveyed, in which the average time between injury and arthroscopy was 23.3 months.

Isolated ganglions of the anterior cruciate ligament.

We report three athletes with symptomatic isolated ganglion of the anterior cruciate ligament. The symptoms consisted of anteromedial knee pain, worse when changing direction while running, and on squatting. All gave a history of repeated minor knee trauma without a single episode of serious injury. At day-case arthroscopy, a unilobulated cystic mass arising from a clinically and arthroscopically intact anterior cruciate ligament was noted and removed in each case. No further intra- or extra-articular knee lesion was seen. Histology revealed a cystic ganglion in each case. With early physiotherapy, the patients could start gentle training 3 wk after arthroscopy, and, at 6-month review, were fully asymptomatic. A review of the literature shows that an isolated ganglion arising from the anterior cruciate ligament is exceedingly rare, with only three such ganglia having been previously reported.

Extra intestinal influences on exhaled breath hydrogen measurements during the investigation of gastrointestinal disease.

During the clinical investigation of patients with gastrointestinal disease by exhaled breath hydrogen measurement, the occurrence of inexplicable variations in recorded hydrogen values led to a search for extra intestinal factors which were capable of adversely influencing breath hydrogen concentration and impairing the diagnostic accuracy of the test. Serial breath samples were collected from normal subjects under a variety of conditions which might occur during routine clinical study, including, hyperventilation, exercise, cigarette smoking, and carbohydrate ingestion. Breath hydrogen concentrations were consistently reduced by hyperventilation (p less than 0.01) and exercise (p less than 0.05). Cigarette smoking, in contrast, caused a marked rise in measured breath hydrogen (p less than 0.01), as did oral carbohydrate (p less than 0.05). Prior bactericidal mouthwash abolished this carbohydrate associated rise, suggesting that the hydrogen was the result of fermentation by oropharyngeal bacteria. Because, in all instances, the changes in breath hydrogen were of sufficient magnitude to interfere with data interpretation, it is recommended that these factors are eliminated, whenever possible, from conditions of study.