Prevalence and consequences of delayed diagnosis of anterior cruciate ligament ruptures.

PURPOSE: Rupture of the anterior cruciate ligament (ACL) is a common injury, often presenting with a typical injury pattern. Historically, the literature indicates that the accuracy of diagnosis of ACL ruptures is poor at the initial medical consultation. The aims of this study were to determine: the mechanism of injury; changes in accuracy of diagnosis of ACL ruptures at initial presentation over the last decade; and the effect of subsequent delay in diagnosis and definitive treatment. METHODS: A prospective cohort of one hundred and thirty-two consecutive patients who underwent ACL reconstruction between 2005 and 2009 were analysed. The median age of the patients was 18 years (12-57). Sixteen patients were excluded due to chronic ACL injury. RESULTS: One hundred and sixteen patients (117 ACL ruptures) were included in the analysis. A typical injury pattern was documented in 87 (74.4 %) of cases. The most common sporting activities associated with an ACL injury were football (35.3 %), skiing (21.6 %) and rugby (10.3 %). The majority of patients (67.5 %) sought medical attention within 1 week from time of injury. The correct diagnosis of an ACL rupture was made in 33 cases (28.2 %) at the initial medical consultation. The diagnosis was made following medical consultation in 13 (11.1 %) of cases with the use of magnetic resonance imaging and 6 (5.1 %) cases at arthroscopy. The median time to diagnosis was 6 weeks (0-192), and the median time to ACL reconstruction was 24 weeks (1-240). A delay in diagnosis of >6 months was associated with a medial meniscal tear rate of 72.2 % compared to 23.1 % if the diagnosis was made within 4 months of the injury (p < 0.05). CONCLUSIONS: Despite a 'typical' mechanism of injury leading to ACL rupture, the rate of initial diagnosis in the UK still remains poor. This often leads to an unnecessary delay in the diagnosis and subsequent treatment and increases the risk of secondary injury to the knee. A delay in diagnosis of >6 months was associated with an increased medial meniscal tear rate. Patients who present with a 'typical' injury pattern should therefore be referred for further assessment by a knee specialist within 6 weeks. LEVEL OF EVIDENCE: IV.

Coronal plane partial articular fractures of the distal femoral condyle: current concepts in management.

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Tarsometatarsal joint complex and midtarsal injuries.

In this article the following areas will be reviewed; the anatomy of the midfoot; mechanisms of injury and current classification systems; diagnosis; treatment options and the evidence for current practice; areas of treatment uncertainty and recommended guidelines for management.

Current concepts review: ankle fractures.

Ankle fractures are common injuries that require meticulous technique in order to optimise outcome. The Lauge-Hansen and Danis-Weber classifications in addition to careful evaluation of the injury mechanism can help guide treatment but surgeons must be aware that there are injury patterns that will not always fit the afore mentioned patterns. The principles of atraumatic soft tissue handling, rigid internal fixation and early range of motion exercises are critical for successfully treating these injuries. There are still areas of treatment uncertainty and future directed research is needed in order to address some of these questions.

Determination of optimal screw positioning in flexor hallucis longus tendon transfer for chronic tendoachilles rupture.

BACKGROUND: Neglected ruptures of the tendoachilles pose a difficult surgical problem. There are no data to determine the optimal positioning of the FHL tendon to the calcaneus. METHODS: Two computer programmes (MSC.visualNastran Desktop 2002™ and Solid Edge(®) V19) were used to generate a human ankle joint model. Different attachment points of FHL tendon transfer to the calcaneus were investigated. RESULTS: The lowest muscle force to produce plantarflexion (single stance heel rise) was 1355 N. Plantarflexion increased for a more anterior attachment point. The maximum range of plantarflexion was 33.4° for anterior attachment and 24.4° for posterior attachment. There was no significant difference in range of movement when the attachment point was moved to either a medial or lateral position. CONCLUSIONS: A more posterior attachment point is advantageous in terms of power and the arc of motion (24.4°) is physiological. We recommend that FHL is transferred to the calcaneus in a posterior position.