Operative Repair of Hamstring Injuries From the Jackling Position in Rugby.

Background: The jackling position within rugby has not been previously described as a mechanism for proximal hamstring injuries. Hypothesis: Acute surgical repair of proximal hamstring avulsion injuries sustained from the jackling contact position enables a return to a previous level of sporting activity with low risk of recurrence. Study Design: Case series; Level of evidence, 4. Methods: This study included 54 professional rugby players (mean age, 26 ± 4.8 years) who underwent acute primary surgical repair of complete, proximal hamstring avulsion injuries. The mean follow-up time was 17 months (range, 12-24 months). Mean isometric hamstring strength and function testing was performed at 3 months and 1 year after repair. Results: Of the 54 players, 51 (94.4%) returned to their preinjury level of sporting activity. The mean time from surgical repair to full sporting activity was 7 months (range, 4-12 months). No patients had recurrence of the primary injury. At 1 year postoperatively, patients had significantly restored mean isometric hamstring muscle strength when compared with the uninjured leg at 0° (98.4% ± 2.8%), 15° (95.9% ± 2.9%), and 45° (92.9% ± 4.1%); improved Lower Extremity Functional Score (78.0 ± 2.0); and improved Marx activity rating score (14.3 ± 1.5) (P < .001 for all). Conclusion: Acute surgical repair of proximal hamstring avulsion injuries caused by the contact jackling position produced a high return to preinjury level of sporting activity, increased muscle strength, and improved functional outcome scores, with a low risk of recurrence at short-term follow-up.

Surgical excision of bilateral patella stress fractures in an elite marathon runner.

Vertical stress fractures of the patella are rare, with only a handful of bilateral cases reported. Stress fractures in the athletic community are often due to repetitive strain and submaximal loading, with minimal recovery time. An Olympic marathon runner in her 30s presented with right anterolateral knee pain. MRI revealed an acutely displaced vertical fracture of the lateral patella. After failure of non-operative treatment, she underwent surgical excision of the fracture fragment and lateral patellofemoral retinacular repair. Despite return to light training pain-free 3 weeks after surgery, she presented 2 months later with a contralateral vertical patella stress fracture. On this occasion, early operative treatment was performed with early return to training and resolution of symptoms.This is the first reported case of bilateral vertical patellar stress fractures in an athlete treated with excision of the fracture fragment. This is an excellent option for elite athletes who require a quick postoperative recovery, complete resolution of symptoms and early return to preinjury level of sport.

Surgical Repair of Stener-like Injuries of the Medial Collateral Ligament of the Knee in Professional Athletes.

BACKGROUND: A "Stener-like" lesion of the knee is defined as a distal avulsion of the superficial medial collateral ligament (sMCL) with interposition of the pes anserinus between the ligament and its tibial insertion-a displacement impeding anatomic healing. Because of the scarcity of these injuries, the literature is limited to case reports and small case series. PURPOSE: To assess the effect of surgical repair of acute Stener-like lesions of the sMCL on the following outcomes: return to preinjury level of sporting function; time to return to preinjury level of sporting function; functional performance; injury recurrence; and any other complications. STUDY DESIGN: Case series: Level of evidence, 4. METHODS: This prospective single-surgeon study included 23 elite athletes with a mean age of 27.2 years (range, 19-37 years). Of the participants, 20 were men (87%) and 3 were women (13%). The mean body mass index was 23.1 ± 2.3. A total of 16 athletes were soccer players (70%) and 7 were rugby players (30%), with isolated acute, traumatic Stener-like lesions of the sMCL of the knee confirmed on preoperative magnetic resonance imaging. Surgical repair was undertaken with primary suture anchor repair with ligament repair or reconstruction system (LARS) augmentation. Predefined outcomes were recorded at regular intervals after surgery. The minimum follow-up time was 24 months (range, 24-108 months) from the date of surgery. RESULTS: The mean time from injury to surgical intervention was 9 days (range, 3-28 days). Overall, 15 (65%) athletes had isolated distal sMCL injuries requiring anatomic suture anchor repair at the distal tibial insertion site only, and 8 (35%) athletes had concomitant injuries of the proximal and distal sMCL and required anatomic suture anchor repair at the proximal and distal attachment sites. Ten athletes required LARS augmentation at the time of the index operation. All study patients returned to their preinjury level of sporting activity in professional soccer or rugby. The mean time from surgical intervention to return to full sporting activity was 16.8 ± 2.7 weeks. At 6 and 24 months' follow-up, all patients had Tegner scores of 10. At a 2-year follow-up, all study patients were still participating at their preinjury level of sporting activity. Three patients developed complications around the LARS that required further surgery to remove synthetic material; however, this did not affect function. CONCLUSION: Surgical repair of acute Stener-like lesions of the sMCL is associated with a high return to preinjury level of sporting function, excellent functional performance, and a low risk of recurrence at short-term follow-up in elite athletes.

Centrosomal enrichment and proteasomal degradation of SYS-1/ß-catenin requires the microtubule motor dynein.

The Caenorhabditis elegans Wnt/ß-catenin asymmetry (WßA) pathway utilizes asymmetric regulation of SYS-1/ß-catenin and POP-1/TCF coactivators. WßA differentially regulates gene expression during cell fate decisions, specifically by asymmetric localization of determinants in mother cells to produce daughters biased toward their appropriate cell fate. Despite the induction of asymmetry, ß-catenin localizes symmetrically to mitotic centrosomes in both mammals and C. elegans. Owing to the mitosis-specific localization of SYS-1 to centrosomes and enrichment of SYS-1 at kinetochore microtubules when SYS-1 centrosomal loading is disrupted, we investigated active trafficking in SYS-1 centrosomal localization. Here, we demonstrate that trafficking by microtubule motor dynein is required to maintain SYS-1 centrosomal enrichment, by dynein RNA interference (RNAi)-mediated decreases in SYS-1 centrosomal enrichment and by temperature-sensitive allele of the dynein heavy chain. Conversely, we observe depletion of microtubules by nocodazole treatment or RNAi of dynein-proteasome adapter ECPS-1 exhibits increased centrosomal enrichment of SYS-1. Moreover, disruptions to SYS-1 or negative regulator microtubule trafficking are sufficient to significantly exacerbate SYS-1 dependent cell fate misspecifications. We propose a model whereby retrograde microtubule-mediated trafficking enables SYS-1 enrichment at centrosomes, enhancing its eventual proteasomal degradation. These studies support the link between centrosomal localization and enhancement of proteasomal degradation, particularly for proteins not generally considered "centrosomal."

The future of orthopaedic surgical education: Where do we go now?

INTRODUCTION: COVID-19 will undoubtedly change the future landscape of medical and surgical education. The economic and environmental advantages of virtual learning are clear, while access to a wider range of resources and subject specialists makes the adoption of virtual learning within surgical education an attractive prospect. AIMS: This literature review aims to evaluate evidence on the effectiveness of virtual education in orthopaedics and how we might implement positive changes to educational practice in the future, as a result of lessons learned during the COVID-19 pandemic. METHODOLOGY: We performed a review of the literature reporting on efficacy of learning outcomes achieved as a result of virtual education within orthopaedic surgery. Electronic searches were performed using NICE healthcare databases from the date of inception to March 2021. Relevant studies were identified, data extracted, and qualitative synthesis performed. RESULTS: 14 manuscripts with a total of 1548 participants (orthopaedic trainees or medical students) were included for analysis. Nine studies (n = 1109) selected compared e-learning to conventional learning material (control group). All nine studies reported significantly higher outcome scores for e-learning participants compared to control participants (p < 0.001 to p < 0.05). The remaining studies compared blended e-learning approaches or evaluated pre/post intervention improvements in learning outcomes. All studies demonstrated a significant improvement in learning outcomes (p < 0.0001 to p < 0.01). The majority of studies (64%) used a blended approach. No studies were identified reporting efficacy of webinars or videoconferencing within orthopaedic education. CONCLUSION: A blended approach, combining virtual teaching, face-to-face instruction and distance learning tools, based on the evidence we have provided, would improve the quality of knowledge reception and retention, and learner satisfaction. However, in order to be successful, it is vital that these educational programmes are designed with the needs of the learner in mind, and an awareness of best practice for virtual teaching and learning.

The introduction of day-case total knee arthroplasty in a national healthcare system: A review of the literature and development of a hospital pathway.

INTRODUCTION: As we now drive to reinitiate our full capacity elective services in an attempt to tackle an ever-growing demand for lower limb arthroplasty, this pandemic has presented rare opportunities to revise and re-engage elective arthroplasty pathways aimed at improving patient care and healthcare efficiency. AIMS: We present the development of an evidence-based multidisciplinary perioperative care pathway for day-case total knee arthroplasty (TKA) in a United Kingdom National Health Service (NHS) institution, in conjunction with a review of the literature upon which the protocol is founded. METHODOLOGY: We performed a review of the literature reporting complication or readmission rates at ≥30 day postoperative following day-case TKA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed. RESULTS: 13 manuscripts with a total of 3370 day-case TKAs, defined as discharged on the same-calendar-day of surgery, were included in analysis. Mean 90-day complication rates (8.31% [range, 0-16.3%] vs 9.49% [range, 0-13.1%], respectively) and readmission rates (2.71% [range, 0-10.0%] vs 3.41% [range, 0-9.9%], respectively) were equivocal between day-case and inpatient TKA. The overall rate of successful same-calendar-day discharge was 95.8%. Our evaluation and critique of the evidence-based literature identifies day-case TKA to be safe, effective and economical, benefitting both patients and healthcare systems alike. CONCLUSION: We further validate the introduction of our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) based on the evidence presented. Careful patient selection paralleled with well-defined care pathways are essential for successful introduction of day-case TKA into the NHS.

Efficacy of Surgical Tenodesis for Treatment of Distal Semitendinosus Hamstring Tendon Injuries.

BACKGROUND: Understanding the optimal management of distal semitendinosus hamstring injuries is critical for reducing pain, restoring preinjury function, maintaining knee stability, improving hamstring muscle strength, and minimizing the risk of complications and recurrence. To our knowledge, the outcomes of surgical tenodesis for distal semitendinosus hamstring injuries have not been previously reported. HYPOTHESIS: Surgical tenodesis for injuries of the semitendinosus would enable return to preinjury level of sport with low risk of recurrence. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This prospective single-surgeon study included 13 professional athletes (12 men, 1 woman; mean age, 32 ± 8.2 years; mean body mass index, 26.7 ± 3.9 kg/m2) undergoing treatment for distal semitendinosus hamstring injuries with primary tenodesis to the distal semimembranosus. Indications for surgical tenodesis included distal semitendinosus tendon avulsion injury (n = 8) or residual tendon instability and hamstring weakness after semitendinosus graft harvest for anterior cruciate ligament reconstruction (n = 5). All study patients underwent a standardized postoperative rehabilitation program. The primary outcome was defined as time for return to sporting activity. Secondary outcomes were patient satisfaction, injury recurrence, and complications. The mean follow-up time was 17 months (range, 12-24 months) from date of surgery. RESULTS: All study patients returned to their preinjury level of sporting activity. The mean time from the surgical intervention to return to full sporting activity was 15 ± 4.6 weeks. At 1-year follow-up, all study patients were still participating at their preinjury level of sporting activity, and 12 patients (92%) were very satisfied and 1 patient (8%) was satisfied about the outcomes of their surgery. No study patients had recurrence of the primary injury. No surgical complications, injury recurrence, or reoperations were observed within the follow-up period. CONCLUSION: Early return to sporting activity was seen after surgical tenodesis for distal semitendinosus hamstring injuries after acute trauma or residual symptoms following previous hamstring graft harvest, with high levels of patient satisfaction and low risk of recurrence at short-term follow-up.

Incidence of Symptomatic Venous Thromboembolism in Proximal Hamstring Repair: A Prospective Cohort Study.

BACKGROUND: Surgical repair of proximal hamstring avulsion injuries can enable the return to preinjury levels of sporting function and minimize the risk of recurrence in both professional and recreational athletes. While venous thromboembolism (VTE) is a recognized complication of surgical repair, the incidence thereof is poorly reported in the literature. PURPOSE/HYPOTHESIS: To report the incidence of symptomatic VTE after proximal hamstring avulsion repair and assess the efficacy of our thromboprophylaxis protocol. It was hypothesized that the incidence of VTE after proximal hamstring avulsion repair is low and that aspirin is an adequate choice of chemical prophylaxis. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: We performed a prospective cohort study of 2 groups of patients who underwent proximal hamstring avulsion (partial and complete) repair between 2000 to 2020 with different thromboprophylaxis protocols. No patients were routinely screened for VTEs, and VTE was investigated only if clinically indicated. Prospectively collected data included demographics, the mechanism and sport that caused injury, use of bracing, and clinical diagnosis of deep vein thrombosis (DVT) or pulmonary embolism (PE). The first cohort (n = 380) was given mechanical prophylaxis in the form of compression stockings for 6 weeks postoperatively. The second cohort (n = 600) was given compression stockings and aspirin 150 mg once daily routinely, or prophylactic low-molecular weight heparin in high-risk individuals, until the 6-week follow-up. Patients in both cohorts underwent early mobilization after surgery; a hinged knee brace locked at 60° to 120° was provided if the tendon repair was under significant tension. The surgical technique and rehabilitation protocol remained consistent throughout the study. RESULTS: The overall incidence of symptomatic VTE was 0.51%. A total of 5 patients developed symptomatic VTEs (3 DVTs, 2 PEs) in the first cohort, and no patients developed symptomatic VTEs in the second cohort (1.32% vs 0%; P = .0048). CONCLUSION: The incidence of symptomatic VTE after proximal hamstring avulsion repairs was extremely low. A combination of aspirin, early mobilization despite bracing, compression stockings, and good hydration was an effective thromboprophylaxis strategy.

North central London elective orthopaedic network and health service innovation to improve the quality of NHS patient care.

Health service innovation is required to meet the ever-growing demands of modern medicine. This editorial discusses the transformation of the north central London elective orthopaedic network and the essential principles which future integrated care systems could incorporate.

Fracture of heterotopic mass in the lower limb: surgical case report and review of the literature.

Heterotopic ossification (HO) is a rare sequela of sports injuries with a predominance in young active males located within bulky muscle planes. In most cases it is self-limiting and spontaneous resolution can occur. Fractures of HO are sparsely reported within the literature. We present a rare case of a professional athlete with a recurrent fracture of mature HO within the deep fascial plane between the anterior and posterior thigh compartments. The heterotopic mass and associated fracture had restricted return to sport and thus necessitated surgical management. The athlete successfully returned to sport following surgical excision with postoperative medical therapy to inhibit recurrence.

Analysis of the Exeter V40 femoral stem prosthesis fracture : systematic review and single centre case series.

AIMS: The Exeter V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems. METHODS: A systematic literature search was performed adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. In parallel, we performed a retrospective single centre study of Exeter V40 femoral stem prosthetic fractures between April 2003 and June 2020. RESULTS: There are 25 reported cases of such prosthetic fractures confined to small case series and case reports within the literature. We report an additional 19 cases to the literature (mean age 66.3 years (SD 11.7); 12 (63%) females; BMI 32.9 kg/m2 (SD 5.9)). The mean time from index procedure to fracture was 7.8 years (SD 3.6; 2.5 to 16.3). Exeter V40 stem fracture incidence was 0.15% and 1.21% for primary and revision arthroplasty, respectively. Incidence was significantly higher in revision arthroplasty (p < 0.001) and 125 mm length stems compared to ≥ 150 mm length stems (1.25% vs 0.13%, respectively; p < 0.001). When comparing different stem length cohorts, 125 mm short-stems were associated with stem-body fractures (92% vs 29%; p = 0.0095), earlier time to fracture (6.2 years vs 11.0 years; p = 0.0018), younger patient age at time of fracture (62.7 years vs 72.6 years; p = 0.037), and female sex (75% vs 43%; p = 0.326). CONCLUSION: This complication remains rare, although we report a significantly higher incidence at up to 17 years follow-up than in the literature. Short 125 mm length Exeter V40 stems undoubtedly have a role in restoring anatomy and biomechanics in smaller femoral geometries, although the surgeon has to appreciate the higher risk of stem fracture and the associated predisposing factors which may necessitate particular attention to surgical technique and planning. Cite this article: Bone Jt Open 2021;2(6):443-456.

Chronic tophaceous gout mimicking widespread metastasis.

Gout is a common crystal-induced arthropathy affecting mainly the joints of the appendicular skeleton; however, rarely this condition affects the axial skeleton as well. Spinal gout can cause radiculopathy, cord compression, canal stenosis and discitis. We describe a case of a 71-year-old woman where the initial presentation of destructive arthropathy and spinal masses secondary to axial gout was mistaken for a metastatic malignancy. Despite chronic polyarthropathy and bilateral subcutaneous gouty tophi, spinal gout was not considered a differential diagnosis during initial assessment.The patient was managed conservatively with pharmacological treatment resulting in improvement of her upper limb radiculopathy and systemic joint pain, although little improvement in mobility. Such extensive involvement is rare and the masses can mimic an underlying metastatic disease. Careful history and clinical examination recognising polyarthropathy and subcutaneous tophi can aid the clinician to make the right diagnosis and institute correct treatment. Delay in recognising gout as a differential diagnosis can lead to marked morbidity as illustrated in our case.

Surgical Repair of Distal Biceps Femoris Avulsion Injuries in Professional Athletes.

BACKGROUND: Understanding the optimal management of distal biceps femoris avulsion injuries is critical for restoring preinjury function, restoring hamstring muscle strength, increasing range of motion, and minimizing risk of complications and recurrence. Due to the rarity of these injuries, prognosis and outcomes within the literature are limited to case reports and small case series. PURPOSE: To assess the effect of surgical repair for acute distal avulsion injuries of the biceps femoris tendon on (1) return to preinjury level of sporting function and (2) time to return to preinjury level of sporting function, patient satisfaction, and complications. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This prospective single-surgeon study included 22 elite athletes (18 men [82%], 4 women [18%]; mean age, 26 years; age range, 17-35 years; mean body mass index, 25.3 ± 4.1 kg/m2) undergoing primary suture anchor repair of avulsion injuries of the distal biceps femoris confirmed on preoperative magnetic resonance imaging. Predefined outcomes relating to time for return to sporting activity, patient satisfaction, complications, and injury recurrence were recorded at regular intervals after surgery. Minimum follow-up time was 12 months (range, 12.0-26.0 months) from the date of surgery. RESULTS: The mean time from injury to surgical intervention was 12 days (range, 2-28 days). All study patients returned to their preinjury level of sporting activity, predominately professional soccer or rugby. Mean time from surgical intervention to return to full sporting activity was 16.7 ± 8.7 weeks. At 1- and 2-year follow-up, all study patients were still participating at their preinjury level of sporting activity. There was no incidence of primary injury recurrence, and no patients required further operation to the biceps origin. CONCLUSION: Surgical repair of acute avulsion injuries of the distal biceps femoris facilitated early return to preinjury level of function with low risk of recurrence, low complication rate, and high patient satisfaction in elite athletes. Suture anchor repair of these injuries should be considered a reliable treatment option in athletes with high functional demands to permit an early return to sport with restoration of hamstring strength.

Day-case total hip arthroplasty: a literature review and development of a hospital pathway.

AIMS: We present the development of a day-case total hip arthroplasty (THA) pathway in a UK National Health Service institution in conjunction with an extensive evidence-based summary of the interventions used to achieve successful day-case THA to which the protocol is founded upon. METHODS: We performed a prospective audit of day-case THA in our institution as we reinitiate our full capacity elective services. In parallel, we performed a review of the literature reporting complication or readmission rates at ≥ 30-day postoperative following day-case THA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed. RESULTS: Our evaluation and critique of the evidence-based literature identifies day-case THA to be safe, effective, and economical, benefiting both patients and healthcare systems alike. We further validate this with our institutional elective day surgery arthroplasty pathway (EDSAP) and report a small cohort of successful day-case THA cases as an example in the early stages of this practice in our unit. CONCLUSION: Careful patient selection and education, adequate perioperative considerations, including multimodal analgesia, surgical technique and blood loss management protocols and appropriate postoperative pathways comprising reliable discharge criteria are essential for successful day-case THA. Cite this article: Bone Jt Open 2021;2(2):93-102.