ALT in combination with triple-rolled TFL for reconstruction of a complex tendoachilles defect: technical details and rehabilitation regime.

A fit man in his 60s presented with an infected Achilles tendon (AT) following two failed repairs for a traumatic rupture. Initial debridement of necrotic tissue resulted in a large soft tissue defect requiring robust coverage. Following aggressive wound management, an anterolateral thigh flap was elevated with tensor fasciae latae (TFL) which was triple-rolled to provide soft tissue coverage and tendon reconstruction.The flap remained healthy and was monitored with a flow coupler device. Initially, the foot was placed in plantarflexion before gradually increasing the angle to neutral and a thermoplastic splint was used to offload pressure on the flap. Following 1 month of non-weight-bearing, gentle mobilisation began. Three months postoperatively, the patient could walk, had resumed indoor cycling and demonstrated a comparable heel raise with the contralateral side. MRI showed a taut TFL attached to the distal AT and ultrasound showed a smoothly gliding TFL.

The accuracy of plain radiographs in diagnosing degenerate rotator cuff disease.

BACKGROUND: A number of radiographic signs have been previously demonstrated to be associated with degenerative rotator cuff tears. An ability to predict the presence of a tear by radiography would permit the early commencement of appropriate treatment and the avoidance of unnecessary invasive investigations. The aim of the present study was to determine the accuracy of using radiographic signs to predict the presence of a cuff tear on arthroscopy. METHODS: Fifty consecutive patients who had undergone shoulder arthroscopy and had pre-operative plain radiographs were included. Pre-operative radiographs were reviewed by a consultant shoulder surgeon, a consultant radiologist and a senior clinical fellow for the following signs: acromial spur; subjective reduction of subacromial space; sourcil sign; acromial acetabularization; os acromiale; greater tuberosity cortical irregularity; greater tuberosity sclerosis; humeral head rounding; cyst; and reduction in acromiohumeral head distance. RESULTS: The presence of tuberosity sclerosis (p < 0.0001), tuberosity irregularities (p < 0.0001), tuberosity cyst (p = 0.004) and sourcil sign (p = 0.019) was associated with the presence of a rotator cuff tear. The combined sensitivity of prediction of tear by the observers following radiographic review was 91.7%, with a combined negative predictive value of 80%. CONCLUSIONS: The assessment of radiographs by senior clinicians is a useful tool for confirming the absence of a rotator cuff tear.

Correlation of multidetector CT findings with splenic arteriography and surgery: prospective study in 392 patients.

BACKGROUND: To determine the accuracy of contrast-enhanced multidetector CT (MDCT) in demonstrating splenic vascular injury based on results of splenic angiography and operation. STUDY DESIGN: This institutional review board-approved study included 392 hemodynamically stable blunt trauma patients whose admission MDCTs demonstrated splenic injury. Images were assessed for parenchymal injury grade, hemoperitoneum volume, and evidence of bleeding and nonbleeding splenic vascular injury. Splenic arteriography was performed for high splenic injury grade and splenic vascular injury. Medical records were reviewed to determine arteriographic interpretation, surgery indications and findings, outcomes, and demographics. Sensitivity, specificity, predictive values, and accuracy of MDCT in detecting vascular injury were calculated based on results of arteriography and operation. RESULTS: Splenic vascular injury was seen in 22% of patients (86 of 392) on MDCT. Presence of a vascular injury correlated with the CT-based parenchymal splenic injury grade (p < 0.0001). Active splenic bleeding was associated with subsequent clinical deterioration (p < 0.0001). Overall, MDCT had a sensitivity of 76% (76 of 100); specificity of 90% (95 of 106); negative and positive predictive values of 80% (95 of 119) and 87% (76 of 87), respectively; and accuracy of 83% (171 of 206) in detecting vascular injury compared with reference standards. The success rate of nonoperative management was 96%. CONCLUSIONS: MDCT provides valuable information to direct initial clinical management of patients with blunt splenic trauma by demonstrating both active bleeding and nonbleeding vascular injuries. Not all vascular injuries are detected on MDCT, and splenic angiography is still indicated for high-grade parenchymal injury.

Experience with splenic main coil embolization and significance of new or persistent pseudoaneurym: reembolize, operate, or observe.

BACKGROUND: To determine the need for further therapy in patients with persistent or new pseudoaneurysms (PSAs) after splenic main coil embolization. METHODS: The institutional review board approved the study. The study group consisted of 400 hemodynamically stable patients (261 men, 139 women; mean age, 38.5 years) with blunt splenic injury. Abdominal computed tomography (ACT) images were assessed for grade of splenic injury, volume of hemoperitoneum, and evidence of splenic vascular injury including splenic vascular lesions and active bleeding. Splenic arteriography was performed for high-grade splenic injury and for ACT evidence of vascular injury. Follow-up ACT was reviewed for evidence of new or persistent PSAs after main coil embolization of the splenic artery. Medical records were reviewed to determine final outcome and any additional therapies used. RESULTS: Thirty-two patients had persistent (27) or new PSAs (5) after main coil embolization. Of these patients, two required splenectomy and one splenorrhaphy. The nonoperative salvage rate was 91% and the splenic salvage rate was 94%; this was comparable to the overall salvage rate of 95%. CONCLUSION: Splenic embolization remains a valuable adjunct in splenic salvage. Patients with persistent or new splenic PSAs after main coil embolization have similar splenic salvage rates to the overall cohort without additional therapies.

Optimization of selection for nonoperative management of blunt splenic injury: comparison of MDCT grading systems.

OBJECTIVE: The purpose of this study was to compare the usefulness of two CT grading systems of blunt splenic trauma in predicting which patients need surgery or angioembolization. MATERIALS AND METHODS: Four hundred patients in hemodynamically stable condition admitted with blunt splenic injury were included in the study. All patients underwent contrast-enhanced MDCT. Grade of splenic injury was prospectively assigned according to the American Association for the Surgery of Trauma (AAST) splenic injury scale. Patients were treated with surgical intervention, splenic arteriography with or without embolization, or observation alone. All MDCT images were retrospectively reviewed and regraded according to a novel grading system that specifically incorporates the findings of active bleeding or splenic vascular injury, including pseudoaneurysm and arteriovenous fistula. Receiver operating characteristics curves were generated with both grading systems for all splenic interventions, and statistical analyses were performed. RESULTS: The area under the ROC curves for the new splenic grading system for splenic arteriography, surgery, and both interventions exceeded 80%. The area under the curve for the new splenic grading system was greater than that for the AAST injury scale for all interventions. Differences were found to be statistically significant for splenic arteriography (p = 0.0036) and the combination of arteriography and surgery (p = 0.0006). CONCLUSION: The proposed CT grading system is better than the AAST system for predicting which patients with blunt splenic trauma need arteriography or splenic intervention.

Multidetector-row computed tomography imaging of splenic trauma.

The spleen is the intra-abdominal organ most often injured as a result of blunt trauma. Multidetector-row computed tomography (MDCT) plays an important role in the detection and characterization of splenic injury. It has been shown to be highly accurate and can detect splenic vascular lesions, the presence of which has been shown to be a predictor of failure of nonoperative management. The increased use of angiography and splenic artery embolization in the management of such injuries has led to improved success rates with nonoperative management. This article reviews the various appearances of the injured spleen and discusses the use of MDCT in the initial evaluation of injury. The indications for angiography and embolization are reviewed, with examples of appearances of the postembolization spleen.