Sport injuries in enduro riders: a review of literature.

INTRODUCTION: enduro is an off road motorcycling event. It is a fast, exciting adventure sport with increasing numbers of participants and competitions. MATERIALS AND METHODS: we performed search of PubMed, Medline, CINAHL, and Embase databases using the following keywords 'Enduro injuries', 'off-road motorcycle injuries' and 'Enduro sport'. We identified four studies which described the physiological characteristic of enduro riders and the injury pattern sustained by these athletes. RESULTS: hands, wrists and forearms are the predominant areas of overuse in enduro riders. The extremities are the most injured parts in enduro. However, 98% of these injuries are mild to moderate with abbreviated injury scale grades 1 and 2. CONCLUSION: there is paucity of published data on enduro injuries. In depth understanding of the physiological aspect of enduro riders with close monitoring of injuries is needed to promote safety measures in enduro and to reduce risk factors of injury which in turn can help to make enduro a safe alternative to the other dangerous motorcycling sports.

Significant impact of the MTHFR polymorphisms and haplotypes on male infertility risk.

BACKGROUND: Methylenetetrahydrofolate reductase (MTHFR) converts 5,10-methylene tetrahydrofolate to 5-methyl tetrahydrofolate and affects the activity of cellular cycles participating in nucleotide synthesis, DNA repair, genome stability, maintenance of methyl pool, and gene regulation. Genetically compromised MTHFR activity has been suggested to affect male fertility. The objective of the present study was to find the impact on infertility risk of c.203G>A, c.1298A>C, and c.1793G>A polymorphisms in the MTHFR gene. METHODS: PCR-RFLP and DNA sequencing were used to genotype the common SNPs in the MTHFR gene in 630 infertile and 250 fertile males. Chi-square test was applied for statistical comparison of genotype data. Linkage disequilibrium between the SNPs and the frequency of common haplotypes were assessed using Haploview software. Biochemical levels of total homocysteine (tHcy) and folic acid were measured. Meta-analysis on c.1298A>C polymorphism was performed using data from ten studies, comprising 2734 cases and 2737 controls. RESULTS: c.203G>A and c.1298A>C were found to be unrelated to infertility risk. c.1793G>A was protective against infertility (P = 0.0008). c.677C>T and c.1793G>A were in significant LD (D' = 0.9). Folic acid and tHcy level did not correlate with male infertility. Pooled estimate on c.1298A>C data from all published studies including our data showed no association of this polymorphism with male infertility (Odds ratio = 1.035, P = 0.56), azoospermia (Odds ratio = 0.97, P = 0.74), or oligoasthenoteratozoospermia (Odds ratio = 0.92, p = 0.29). Eight haplotypes with more than 1% frequency were detected, of which CCGA was protective against infertility (p = 0.02), but the significance of the latter was not seen after applying Bonferroni correction. CONCLUSION: Among MTHFR polymorphisms, c.203G>A and c.1298A>C do not affect infertility risk and c.1793G>A is protective against infertility. Haplotype analysis suggested that risk factors on the MTHFR locus do not extend too long on the DNA string.

Strong association of 677 C>T substitution in the MTHFR gene with male infertility--a study on an indian population and a meta-analysis.

BACKGROUND: Methylenetetrahydrofolate reductase (MTHFR) is an important enzyme of folate and methionine metabolism, making it crucial for DNA synthesis and methylation. The objective of this study was to analyze MTHFR gene 677C>T polymorphism in infertile male individuals from North India, followed by a meta-analysis on our data and published studies. METHODOLOGY/PRINCIPAL FINDINGS: We undertook genotyping on a total of 837 individuals including well characterized infertile (N = 522) and confirmed fertile (N = 315) individuals. The SNP was typed by direct DNA sequencing. Chi square test was done for statistical analysis. Published studies were searched using appropriate keywords. Source of data collection for meta-analysis included 'Pubmed', 'Ovid' and 'Google Scholar'. Those studies analyzing 677C>T polymorphism in male infertility and presenting all relevant data were included in meta-analysis. The genotype data for infertile subjects and fertile controls was extracted from each study. Chi square test was done to obtain odds ratio (OR) and p-value. Meta-analysis was performed using Comprehensive Meta-analysis software (Version 2). The frequency of mutant (T) allele (p = 0.0025) and genotypes (CT+TT) (p = 0.0187) was significantly higher in infertile individuals in comparison to fertile controls in our case-control study. The overall summary estimate (OR) for allele and genotype meta-analysis were 1.304 (p = 0.000), 1.310 (p = 0.000), respectively, establishing significant association of 677C>T polymorphism with male infertility. CONCLUSIONS/SIGNIFICANCE: 677C>T substitution associated strongly with male infertility in Indian population. Allele and genotype meta-analysis also supported its strong correlation with male infertility, thus establishing it as a risk factor.

Does the place of fall influence the time to specialist treatment in patients sustaining hip fractures? A study of 4917 patients falling in four different settings.

Delay to treatment is a multifactorial issue for patients sustaining hip fractures. The place of fall could possibly impact on the time to specialist care. We aimed to investigate the correlation between the place where a hip fracture occurs, and the time to initiation of specialist fracture-specific treatment. We retrospectively analysed data that had been collected on 4917 consecutive hip fracture admissions to our unit. The recorded places of fall were divided into four groups, including those falling 'outside home', 'at home', 'residential or nursing home', and 'hospital inpatients' respectively. A 24-hour scale was used to record times of fall and of initiation of treatment. The latter was the time of admission to Accident & Emergency for groups 1-3, and the time of referral to the Orthopaedic team for group 4.23.5% patients fell outside their own home (group 1), and presented at only 2 hours post-injury. Patients in both group 2 (47.7%) and group 3 (23.6%) presented after 3 hours. Group 4 (4.9%) patients had to wait a median of 8 hours being referred to the Orthopaedic team. We found an interesting correlation between the place of injury and the delay in receiving treatment, in that those patients already receiving maximal healthcare attention, had to wait the longest to be referred to specialist care.

Pressure exerted by finger traps.

It is common practice in wrist arthroscopy to suspend the patient's arm using Chinese finger traps and to distract the wrist joint by applying weight to the arm at the elbow. This may apply significant pressure to the fingers, and potentially damage the digital nerves. We examined the pressure applied by finger traps and considered whether this poses a risk to the digital nerves.

The evidence of low-intensity pulsed ultrasound for in vitro, animal and human fracture healing.

BACKGROUND: Physical stimulation therapies are currently available to enhance fracture healing. SOURCES OF DATA: A search of PubMed, Medline, CINAHL, DH data and Embase databases was performed using the keywords 'ultrasound' and 'fracture healing'. AREAS OF AGREEMENT: The evidence in vitro and animal studies suggests that low-intensity pulsed ultrasound (LIPUS) produces significant osteoinductive effects, accelerating the healing process and improving the bone-bending strength. AREAS OF CONTROVERSY: The evidence in human trials is controversial in fresh, stress fractures and in limb lengthening. LIPUS is effective in delayed unions, in smokers and in diabetic population. GROWING POINTS: LIPUS is an alternative, less invasive form of treatment for complicated fractures, in patients with poor bone healing and may play a role in the management of large-scale bone defects producing substantial cost savings and decreasing associated disability. AREAS TIMELY FOR DEVELOPING RESEARCH: There is heterogeneity among in vitro, animal studies and their application to human studies. Further randomized controlled trials of high methodological quality are needed.

Achilles tendon ruptures in elite athletes.

BACKGROUND: The management of Achilles tendon (AT) ruptures in elite athletes can be challenging. We performed a retrospective review of prospectively collected data study to evaluate the results of percutaneous repair of an acute AT rupture in elite athletes. MATERIALS AND METHODS: Seventeen elite athletes with prodromal tendinous problems sustained an acute tear of the AT and underwent percutaneous surgical repair. We performed preoperative evaluations the day of surgery, and report the results of postoperative evaluation at a final followup at an average of 72 months from the procedure. Each patient was evaluated for limb dominance, trauma history, duration and type of preoperative symptoms, and postoperative AT Total Rupture Score (ATRS). RESULTS: All patients were able to fully weightbear on the operated limb by the end of the 8th postoperative week. The average time to return to full sport participation was 4.8±0.9 months. Two of the 15 elite athletes on whom we have full data suffered from a superficial infection of the surgical wound. CONCLUSION: Our study suggests that percutaneous repair of the AT is a good option for elite athletes, allowing a safe and prompt return to sport activities.

Achilles tendon ruptures in diabetic patients.

AIM: The aim of this study is to evaluate the results of percutaneous repair of an acute AT rupture in diabetic patients. METHOD: The study included 39 subjects who were operated at our institution. We performed pre-operative evaluations the day of surgery, and report the results of post-operative evaluation at the final follow-up. RESULTS: The Achilles tendon total rupture score had a post-operative average rating of 70.4 ± 13 (range 55-92). All patients were able to fully weight bear on the operated limb by the end of the eighth post-operative week. Eight patients suffered from a superficial infection of the surgical wound. CONCLUSION: In conclusion, percutaneous repair of the AT is a viable option for diabetic patients.

Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon ruptures.

A laboratory study was performed to evaluate the histopathological features of the macroscopically intact portion of the Achilles tendon in patients undergoing surgery for an acute rupture of the Achilles tendon. Tendon samples were harvested from 29 individuals (21 men, 8 women; mean age: 46 ± 12) who underwent repair of an Achilles tendon tear tear, and from 11 male patients who died of cardiovascular events (mean age: 61). Three pieces of tendon were harvested: at the rupture site, 4 cm proximal to the site of rupture, 1 cm proximal to the insertion of the Achilles tendon on the calcaneum. Slides were assessed using a semiquantitative grading scale assessing fiber structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinization. Intra-observer reliability of the subscore readings was calculated. The pathological features were significantly more pronounced in the samples taken from the site of rupture than in the samples taken proximally and distal to it (0.008 < P < 0.01). There were no significant differences in the mean pathologic sum-scores in the samples taken proximally and distal to the site of rupture. Unruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations, with the latter demonstrating histopathological evidence of failed healing response even in areas macroscopically normal.

How successful are current ankle replacements?: a systematic review of the literature.

UNLABELLED: Total ankle arthroplasty provides an alternative to arthrodesis for management of ankle arthritis. What is the outcome of total ankle arthroplasty implants currently in use? We conducted a systematic literature search of studies reporting on the outcome of total ankle arthroplasty. We included peer-reviewed studies reporting on at least 20 total ankle arthroplasties with currently used implants, with a minimum followup of 2 years. The Coleman Methodology Score was used to evaluate the quality of the studies. Thirteen Level IV studies of overall good quality reporting on 1105 total ankle arthroplasties (234 Agility, 344 STAR, 153 Buechel-Pappas, 152 HINTEGRA, 98 Salto, 70 TNK, 54 Mobility) were included. Residual pain was common (range, 27%-60%), superficial wound complications occurred in 0% to 14.7%, deep infections occurred in 0% to 4.6% of ankles, and ankle function improved after total ankle arthroplasty. The overall failure rate was approximately 10% at 5 years with a wide range (range, 0%-32%) between different centers. Superiority of an implant design over another cannot be supported by the available data. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Supination-external rotation ankle fractures: stability a key issue.

UNLABELLED: Stability is a key issue in treating supination-external rotation ankle fractures, but we do not know how it affects functional outcome and subsequent development of radiographic osteoarthritis. With a systematic literature review, we identified 11 clinical studies (Level IV evidence) published in peer-reviewed journals reporting on at least 10 ankles. Followup was at least 1 year. Two authors independently scored the quality of the studies using the modified Coleman Methodology Score; the mean score was 58 of 100, with substantial agreement between the two examiners. Four studies used a general health assessment questionnaire. Several literature limitations (debatable fracture stability criteria, few cohort studies with heterogeneous methodology, small patient numbers and limited followup in some studies) do not allow definitive conclusions. Of 213 stable fractures treated nonoperatively, 2.8% of ankles had radiographic osteoarthritis develop (18 years' mean followup) and 84% were free of symptoms. The incidence of radiographic osteoarthritis in 420 unstable fractures treated operatively was 20.9% at 5.5 years versus 65.5% at 6.8 years in 137 ankles treated nonoperatively. The complication rate in 355 operatively treated fractures was 10.4%. A medial malleolus fracture, female gender, older age, higher American Society of Anesthesiologists grade, smoking, and lower educational level negatively influenced general health outcome, physical function, and pain. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Favorable outcome of percutaneous repair of achilles tendon ruptures in the elderly.

UNLABELLED: Percutaneous repair of Achilles tendon (AT) ruptures reportedly reduces the risk of rerupture compared to nonoperative treatment and reduces the risk of wound infection compared to open surgery. We retrospectively reviewed the postoperative Achilles tendon total rupture score (ATRS), and the maximum calf circumference in 35 patients over 65 years of age who sustained an acute tear of the AT and underwent percutaneous repair of the AT. There were 26 men and nine women with a mean age at operation of 73.4 +/- 8.7 years (range, 65-86 years). Of the 35 recruited patients, we report on 27 patients for whom we have a full data set. The minimum followup was 49 months (mean, 88 months; range, 49-110 months). The ATRS had a postoperative average rating of 69.4 +/- 14 (range, 56-93). All patients were able to bear weight fully on the affected limb by the eighth postoperative week. The data suggest that percutaneous repair of the AT is a suitable option for patients older than 65, producing similar outcomes when compared to percutaneous repair in younger patients of previous reports. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Management of calcaneal fractures: systematic review of randomized trials.

INTRODUCTION: The optimal management of calcaneal fractures is controversial, as correlation between anatomical restoration and outcome has not been proven, and complications after surgery are frequent. SOURCES OF DATA: MEDLINE, EMBASE, CINAHL, Google scholar, the Cochrane Controlled Trials Register, and the Cochrane Musculoskeletal Injuries Group Trials Register were searched using the keywords 'calcaneal' and 'fractures', without time limits or restriction to language. Randomized and quasi-randomized trials were included. Two separate comparisons were identified in the trials: operative versus non-operative management (five studies), and impulse compression versus no impulse compression (one study). Two reviewers independently assessed trial quality, with a 12-item scale used by the Cochrane Collaboration. AREAS OF AGREEMENT: Results showed no difference in residual pain, but favoured surgical management on ability to return to the same work and to wear the same shoes as before the fracture. Surgery reduced the need for subsequent subtalar fusion. workers' compensation affected outcome. AREAS OF CONTROVERSY: It is unclear whether general health outcome measures, injury specific scores and radiographic parameters improve after operative management, and whether the benefits of surgery outweigh the risks. GROWING POINTS: The existing trials are of relatively poor quality. AREAS TIMELY FOR DEVELOPING RESEARCH: There is still a need for a carefully designed large-scale trial comparing surgery and non-operative management. Other forms of fixation (external fixation or minimally invasive internal fixation) should be compared with 'conventional' surgery. Trials investigating joint reconstruction versus primary subtalar fusion for highly comminuted fractures, and impulse compression versus placebo could be of value.

Modalities in prevention of flexor tendon adhesion in the hand: what have we achieved so far?

Several modifications in surgical techniques and various pharmacological and non pharmacological modalities have been introduced to prevent adhesions formation in surgery on flexor tendons of the hand. However, most studies have been carried out in animals with very few human trials. Only early postoperative rehabilitation is supported by clinical evidence, while the optimal rehabilitation protocol remains controversial. Innovations in surgical techniques and other modalities need to be tested with adequately powered human trials, before their potential benefit in clinical practice is accepted.

Minimally invasive total knee arthroplasty: a systematic review.

The concept of minimally invasive total knee arthroplasty surgery evolved to reduce quadriceps muscle strength loss and improve clinical outcome following total knee replacement. We performed a systematic review of the published literature on Minimally Invasive Total Knee Arthroplasty (MITKA) and analyzed the reported surgical outcomes. Twenty-eight studies published from January 2003 to June 2008 that met the inclusion criteria were evaluated using the modified Coleman Methodology Score (CMS). At a mean CMS of 60, most studies reporting on outcome of MITKA are of moderate scientific quality. Patients undergoing MITKA tend to have decreased postoperative pain, rapid recovery of quadriceps function, reduced blood loss, improved range of motion (mostly reported as a short-term gain) and shorter hospital stay compared with patients undergoing standard total knee arthroplasty. These benefits, however, need to be balanced against the incidence of increased tourniquet time and increased incidence of component malalignment in the MITKA group. So far, the evidence based knowledge regarding results of MITKA comes from prospective studies of moderate quality with short follow up periods. Multicenter studies with longer follow-ups are needed to justify the long-term advantages of MITKA over standard total knee arthroplasty.

Sports activities after lower limb osteotomy.

INTRODUCTION: Active sports participation can be important in some patients with degenerative joint disease in the lower limb. We investigated whether this is possible after an osteotomy for osteoarthritis of the hip, knee and ankle joints. SOURCES OF DATA: We performed a literature search using Medline, Cochrane, CINAHL and Google Scholar with no restriction to time period or language using the keywords: 'osteotomy and sports'. Eleven studies (all level IV evidence) satisfied our inclusion and exclusion criteria. Nine reported on high tibial osteotomies, one on periacetabular osteotomies and one on distal tibial osteotomies. The Coleman Methodology Score to assess the quality of studies showed much heterogeneity in terms of study design, patient characteristics, management methods and outcome assessment. AREAS OF AGREEMENT: Participation in recreational sports is possible in most patients who were active in sports before lower limb osteotomy. In no study were patients able to participate in competitive sports. AREAS OF CONTROVERSY: Intensive participation in sports after osteotomy may adversely affect outcome and lead to failures requiring re-operation. GROWING POINTS: Patients may be able to remain active in selected sports activities after a lower limb osteotomy for osteoarthritis. More rapid progression of arthritis is however a possibility. AREAS TIMELY FOR DEVELOPING RESEARCH: Prospective comparative studies investigating activities and sports participation in age-matched patients undergoing osteotomy or joint replacement could lead to useful conclusions. Increased activity and active sports participation may lead to progression of arthritis and earlier failure requiring additional surgery.

Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients.

In order to define the optimum timing of surgery for a hip fracture, we performed a systematic review of published evidence. Data was extracted by two independent reviewers and the methodology of each study was assessed. Fifty-two studies involving 291,413 patients were identified. Outcomes measured were mortality, post-operative complications, length of hospital stay and percentage of patients discharged home. We found no randomised trials. For the 25 studies involving 282,470 participants that undertook adjustment for confounding factors, early surgery was associated with a reduced hospital stay. These studies produced conflicting results regarding mortality and morbidity being increased or unaffected by delaying surgery. None of these studies reported any adverse outcomes for early surgery. Those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. In conclusion early surgery (within 48h of admission) after a hip fracture reduces hospital stay and may also reduce complications and mortality.

Open tibial fractures in the paediatric population: a systematic review of the literature.

INTRODUCTION: Open tibial fractures have been studied extensively in adults, and detailed treatment strategies have been developed: wound irrigation and debridement, fracture stabilization and delayed primary wound closure or early flap coverage are basic principles of management. No clear guidelines regarding the management of open tibial fractures in children exist. SOURCES OF DATA: We searched Medline, Embase, Cochrane, CINAHL and Google Scholar databases using the keywords: 'open', 'tibia', 'fracture', 'children', 'paediatric', 'pediatric', 'external fixation', 'nailing'. Fourteen clinical studies were included. Quality of the studies was assessed using the Coleman Methodology Score. AREAS OF AGREEMENT: Age above 10 years and grade III (severe) open fractures are associated with complications and outcomes similar to those in adults. AREAS OF CONTROVERSY: It is unclear whether open fractures of the tibia in children should be managed according to the principles followed in adults. Many authors support primary skin closure and non-operative management for grade I open fractures. There is no clear effect of fracture fixation method on time to union. GROWING POINTS: The quality of the studies was relatively poor. Patients' age affects outcome; adolescents should probably be managed as adults. AREAS TIMELY FOR DEVELOPING RESEARCH: Carefully designed prospective cohort studies including a large number of children would be of value. Adequate follow-up is necessary to assess the long-term effects in the growing skeleton. The efficacy of flexible intramedullary nailing for open fractures needs further evaluation. Outcome studies based on general health measures are needed.

Prevention of adhesions in surgery of the flexor tendons of the hand: what is the evidence?

INTRODUCTION: Despite advances in knowledge and refinements of technique, the management of flexor tendon injuries within the digital sheath continues to present a formidable challenge. This in turn has led to a massive expansion in search of modified surgical therapies and various adjuvant therapies, which could prevent adhesion formation without compromising digital function. SOURCES OF DATA: A search of PubMed, Medline, CINAHL and Embase databases was performed using the keywords 'tendon adhesion prevention', 'tendon healing', 'adhesion prevention in tendons' and 'adjuvants for adhesion prevention'. Studies detailing the use of surgical, pharmacological and non-pharmacological agents for adhesion prevention in digital flexor tendons were identified, and their bibliographies were thoroughly reviewed to identify further related articles. This search identified 41 studies, which investigated the use of various pharmacological agents in adhesion prevention in digital tendons. AREAS OF AGREEMENT: There is a need to develop and utilize an optimal method for the prevention of adhesions in the flexor tendons of the hand, due to post-surgical complications. AREAS OF CONTROVERSY: Even though there have been significant advances in the prevention of adhesions in flexor tendons, it remains to be proved which, if any, of the current methods are the most beneficial. GROWING POINTS: The only thing that appears clinically justified in adhesion prevention is the need for early post-operative mobilization of digits after tendon injury or repair but the best method of mobilization remains controversial. AREAS TIMELY FOR DEVELOPING RESEARCH: Suggested changes in surgical techniques and various proposed pharmacological and non-pharmacological modalities need to withstand the test of adequately powered human trials, before their justification for potential benefit in clinical practice is accepted.