The prevalence of proximal hamstring pathology on MRI in the asymptomatic population.

PURPOSE: Injury to the proximal hamstring complex (PHC) is becoming more frequently diagnosed. Patients attending our tertiary referral centre demonstrated 'pathological changes' in the unaffected normal contralateral PHC on MRI. The prevalence of PHC pathology, however, has not been previously documented in the literature in asymptomatic subjects. It is the hypothesis of this study that the natural history of asymptomatic pathological change on MRI in the PHC is not clear. The aim is to quantify the natural history of PHC degeneration. METHOD: Two hundred and fifty-three consecutive patients with an asymptomatic PHC were reviewed retrospectively between 2009 and 2010. The PHC was assessed in multiple MRI planes by a specialist musculoskeletal consultant radiologist. RESULTS: Five hundred and six proximal hamstrings complexes were reviewed. Eighty-nine patients (35 %) were radiological normal both sides, median age 51 years (range 13-88). Thirty-four patients (13 %) had unilateral pathology, median age 55 years (range 25-89). Of these, 3 patients (1 %) had presence of a complete tear, median age 81 years (range 72-87). Sixteen patients (7 %) had tendinosis, median age 60 years (range 37-78). Fifteen patients (6 %) had a unilateral partial tear, median age 57 years (range 35-78). One hundred and thirty patients (52 %) had bilateral pathology, median age 65 years (range 25-89). Fifty-three patients (21 %) had the presence of bilateral tendinopathy alone, median age 56 years (range 25-89). Twenty-seven patients (11 %) had a partial tear on one side and tendinosis on the other, median age 68 years (range 38-89). Thirty-nine patients (15 %) had evidence of bilateral partial tears, median age 63 years (range 36-89), with 52 % demonstrating a torn conjoined and semi-membranosus tendon. The remaining 48 % had either an isolated tear of the conjoined or the semi-membranosus (the more commonly injured tendon 74 % of the time). Four patients (2 %) had bilateral complete ruptures with a median age of 68 years (range 59-78). Six patients (2 %) had a complete tear on one side and a partial tear on the other, median age 68 years (range 34-83). One patient had a complete tear on one side and tendinosis on the other, age 81 years. CONCLUSION: There is a higher prevalence of pathology in the asymptomatic population, 15 % have bilateral partial tears, and 2 % have bilateral complete tears. The semi-membranosus being the most affected, this may help clinically stratify the need for surgical intervention. LEVEL OF EVIDENCE: I.

Reattachment of the proximal hamstring origin: outcome in patients with partial and complete tears.

PURPOSE: To assess the subjective and functional outcome in complete and partial injuries, both acute and chronic. METHODS: One hundred and thirty-two consecutive proximal hamstring reattachments were performed by a single surgeon between 1999 and 2009. The mean age at the time of operation was 42.5 years (SD 12.2), the mean duration of follow-up was 53.8 months (SD 19.5), and all patients with a minimum 2-year follow-up were included in the study. Patients were reviewed independently. Functional outcome was evaluated using quantitative assessments of pre-operative and postoperative hamstring strength and endurance, while subjective outcome was undertaken at the latest follow-up using a three-tier questionnaire. RESULTS: The most common cause of injury was waterskiing (29 patients). There were 96 complete injuries and 36 partial injuries. Overall, 112 of 132 patients rated their result as good/excellent, 91 had returned to their pre-injury level of sporting activity, and 114 said that they would undergo surgery again. Mean postoperative hamstring strength was 83 %, and mean hamstring endurance was 108 % compared to the contralateral limb. Patients with complete injuries and those operated and those operated on acutely (<6 weeks) were more likely to have a good/excellent result. There was no significant correlation between time to repair, type of injury (partial vs. complete) and functional outcome. CONCLUSION: Good to excellent results can be expected in the majority of patients, following surgical reattachment. Surgery is well tolerated with the vast majority of patients, reporting that they would undergo surgery again. LEVEL OF EVIDENCE: IV.

Incomplete avulsion of the proximal insertion of the hamstring: outcome two years following surgical repair.

Incomplete avulsion of the proximal hamstrings can be a severely debilitating injury that causes weakness, pain while sitting and inability to run. The results of the surgical treatment of 23 consecutive patients with such injuries at least two years after surgery are described. The surgery consisted of the repair of the hamstrings directly onto the ischial tuberosity. At review, using a visual analogue scale (VAS, 0 to 100), pain while sitting improved from a mean of 40 (0 to 100) to 64 (0 to 100) (p = 0.024), weakness from a mean of 39 (0 to 90) to 76 (7 to 100) (p = 0.0001) and the ability to run from a mean of 24 (0 to 88) to 64 (0 to 95) (p = 0.0001). According to a VAS, satisfaction was rated at a mean of 81 (0 to 100) and 20 patients (87%) would have the same procedure again. Hamstring strength measured pre- and post-operatively had improved significantly from a mean of 64% (0% to 95%) to 88% (50% to 114%) compared with the normal side. Most of these patients with symptomatic incomplete hamstring avulsions unresponsive to conservative treatment had an improved outcome after surgical repair.

Understanding heat facilitated drug transport across human epidermis.

The application of moderate heat is a safe and effective means to increase drug transport across human skin. However, the cascade of events that follows the exposure of a topical skin formulation to a heating source is not well understood. The aim of this study was to elucidate how three potential rate limiting stages in the drug transport process; formulation release, drug partitioning and epidermal diffusion, responded to changes in local temperature using the model drug lidocaine. Release from the formulation measured using regenerated cellulose membrane was shown to be driven by drug diffusion in the vehicle; it responded linearly when the local temperature was changed (21.6 µg/cm(2)/h for every 1 °C rise) and displayed no measurable partitioning of lidocaine into RCM. Once the drug was within the human epidermis, the structural changes of the barrier controlled its transport. The apparent lidocaine diffusion coefficient through silicone membrane increased from 6.52 to 8.43 × 10(-4) over the 32-45 °C temperature range, but it increased from 7.74 × 10(-5)cm(2)h(-1) to 4.8 × 10(-4)cm(2)h(-1) in the human epidermis. In the absence of large increases in drug partitioning, fluidisation of the lipids in the upper layers of the epidermis at 37-45 °C was shown to facilitate lidocaine diffusion which for human skin transport was the rate limiting process.

Medial meniscus posterior root attachment injury and degeneration: MRI findings.

The posterior root attachment of the medial meniscus is readily identifiable on MRI. Unless specifically reviewed, injuries involving this structure may be overlooked. Significant meniscal root pathology may cause functional incompetence of the meniscus, with consequent early onset cartilage degeneration and osteoarthritis. This review article emphasizes the importance of positive identification of an intact meniscal root and illustrates the known association of meniscal root injury or tear with medial extrusion of the medial meniscus by greater than 3 mm beyond the joint margin.

Ultrasound-guided internal jugular venous cannulation: an introduction for non-radiologists to a technique that is here to stay.

The availability of relatively low-cost, portable ultrasound units has increased interest among non-radiologists in performing image-guided central venous cannulation, especially in high-risk patients. The essential elements of this relatively simple method of increasing the success and safety of internal jugular cannulation are presented.

The treatment of hyposmia with intranasal steroids.

Hyposmia is a neglected symptom in patients with rhinitis. We studied 25 patients presenting with perennial rhinitis. Fifteen patients expressed hyposmia as a significant symptom. University of Pennsylvania smell identification test (UPSIT) and visual analogue scales (VAS) were used to score the symptoms of hyposmia, nasal obstruction and nasal discharge before and after six weeks treatment with betamethasone sodium phosphate drops. Those patients with initial symptoms of hyposmia significantly improved their UPSIT scores (p = 0.00009) and their VAS scores for hyposmia (p = 0.00133). Despite a significant decrease in the sensation of nasal obstruction, the non-hyposmics showed no increase in UPSIT scores after betamethasone therapy. There was no clear correlation between UPSIT results and other symptom scores. The judicious use of betamethasone drops in the treatment of rhinogenic hyposmia can be recommended.

Temporal bone dissection for display.

Increasing concern with medicolegal issues has heightened the need for surgical simulation in training. Familiarity with the surgical anatomy of the temporal bone is essential for effective and safe otological surgery. Refinement of surgical technique and intimate knowledge of temporal bone anatomy can be gained by accurate dissection. The products of such endeavours are both illustrative and instructive. The issues, methods and techniques necessary for display of anatomical dissections are discussed.

Fatal cardiac perforation caused by the dilator of a central venous catheterization kit.

We report a case of cardiac perforation and tamponade caused by the dilator of a central venous catheterization kit. Standards for dilator manufacture and guidelines for safe use of these instruments are suggested.

Treatment of post-traumatic external nasal neuralgia.

Pain about the bridge of the nose is often a diagnostic dilemma. There is a small but important recognizable subgroup who may, as a consequence of involvement of the external nasal nerve in nasal injury, exhibit neuralgic pain after a latent interval. Temporary relief by local anaesthesia is diagnostic and cure is possible by division of the anterior ethmoidal nerve. We present a series of six cases to illustrate this rare cause of facial pain.

Tegmental dehiscence and brain herniation into the middle ear cleft.

The tegmen tympani may occasionally be breached by herniation of the temporal lobe with or without dural cover. The clinical presentation may be obvious with CSF otorrhoea but less so with apparent middle ear effusion, CSF rhinnorrhoea, conductive hearing loss, recurrent meningitis or intracranial sepsis. Diagnosis requires suspicion of the condition, which may be aided by radiological imaging. Surgical repair is to be recommended: various techniques are available but bone enveloped by fascia placed by subtemporal approach is preferred. The features of this problem are highlighted by four cases.

Post-traumatic external nasal neuralgia--an often missed cause of facial pain?

Pain about the bridge of the nose is often a diagnostic dilemma. There is an important recognizable subgroup who may, as a consequence of involvement of the external nasal nerve in nasal injury, exhibit neuralgic pain after a latent interval. Temporary relief by anaesthesia can be achieved and cure is possible by division of the anterior ethmoidal nerve. This rare cause of facial pain is presented using two illustrative cases.

'Two-stage turbinectomy': sequestration of the inferior turbinate following submucosal diathermy.

Submucous diathermy of the inferior turbinates is a widely practised procedure. Three cases are presented in which surgery was complicated by avascular necrosis of the turbinate bone. Each patient required a debridement procedure before healing and recovery of normal mucociliary function could take place.

Uses and complications of uvulopalatopharyngoplasty.

Uvulopalatopharygoplasty has become widely performed for chronic snoring and for cases of obstructive sleep apnoea. Unfortunately this operation is not without morbidity and complications. We report our results of a prospective series of 50 patients undergoing uvulopalatopharyngoplasty with a minimum follow-up of one year. Snoring was abolished in 18 (36 per cent) and substantially reduced in the remainder. Obstructive sleep apnoea syndrome, identified in 11 patients pre-operatively, was reduced in severity in all but three. Troublesome complications were seen in 18 (36 per cent) patients, namely intermittent velopharyngeal incompetence in five (10 per cent), pharyngeal dryness in 11 (22 per cent) and loss of taste in five (10 per cent). One patient had nasopharyngeal stenosis requiring correction. A cautious approach to this operation is required with rigorous case selection. The importance of full assessment and careful follow-up should not be underestimated.

Assessment of chronic snorers.

Snorers represent a heterogenous group that require adequate assessment before recommending surgical treatment. There are unfortunately no specific features either in the history or physical examination that might predict those chronic snorers with obstructive sleep apnoea. We have used trained observation together with pulse oximetry ('sleep screening') and fibreoptic nasendoscopy with Muller manoeuvre in our unit to assess snorers. This combination is a reliable means of distinguishing apnoeic patients from simple snorers and determining the level of the obstructing segment. We report our experience in using these methods in the management of 71 chronic snorers. We stress the value of conservative management, and emphasize that obesity, habitual alcohol ingestion and nasal obstruction should be corrected before embarking on pharyngeal surgery.

Vertical transmission of human immunodeficiency virus is correlated with the absence of high-affinity/avidity maternal antibodies to the gp120 principal neutralizing domain.

Many, but not all, infants born to mothers infected with the human immunodeficiency virus (HIV) are infected in utero. We have now shown that mothers who have high-affinity/avidity antibodies directed toward the principal neutralizing domain (PND) of gp120 are less likely to transmit HIV to their children. An ELISA that preferentially measures the level of the biologically functioning, high-affinity/avidity antibodies against PND is described. In a retrospective study of 15 maternal/neonatal serum samples, the assay correctly identified the 4 uninfected and the 11 HIV-infected infants. Other clinical and laboratory parameters such as p24 antigen, phytohemagglutinin mitogenic index, and absolute surface antigen T4+ cell counts did not accurately predict HIV fetal transmission. In addition to introducing a promising diagnostic tool, this study provides the in vivo evidence that protective antibodies may prevent infection by HIV.

Patellofemoral malalignment: a report of 68 cases treated by proximal and distal patellofemoral reconstruction.

A series of 68 knees were reviewed retrospectively at an average of 56 months following surgical treatment for patellar dislocation and subluxation. Fifty-three knees in 48 patients were assessed both subjectively by questionnaire and objectively by examination, and 15 knees were evaluated by questionnaire only. All cases were treated by a proximal and distal reconstruction as described by Trillat (1964). The surgery was performed by one surgeon (MC) and reviewed independently (DW). The results were excellent in 48 knees (71 per cent), good in 12 (17 per cent) and poor in 8 (12 per cent). In no patient had there been any further episodes of dislocation. We consider this a straightforward procedure producing consistent correction of patellofemoral instability with a low morbidity.

Selective alteration of constitutive hepatic cytochrome P-450 enzymes in the rat during parenteral hyperalimentation.

Decreased drug metabolism and hepatic cytochrome P-450 levels have been shown previously to occur in rats receiving total parenteral nutrition (TPN) compared to animals receiving the same hyperalimentation solution enterally (TEN). In the present studies, animals received a 7-day infusion of a 25% glucose-2.75% crystalline amino acid solution via a catheter in the jugular vein or stomach; hepatic microsomal levels of four major constitutive cytochromes P-450 were determined subsequently by immunoquantitation and correlated with metabolism of selected substrates biotransformed by these enzymes. TPN resulted in a marked decrease in apoprotein of two constitutive cytochromes P-450, P-450UT-A and P-450PCN-E, compared to TEN experiments (for P-450UT-A, 11.0 +/- 1.8 vs 44.7 +/- 6.5% of total cytochrome P-450 measured by CO-difference spectra, P greater than 0.001; for P-450PCN-E, 15.4 +/- 4.4 vs 30.2 +/- 7.6%, P less than 0.01), but apoprotein levels of two other constitutive cytochromes P-450, P-450PB-C and P-450UT-F, showed relatively little change. Concordant reductions in metabolism of benzphetamine, ethylmorphine and erythromycin were seen in TPN animals. While the mechanisms responsible for these selective changes in the synthesis and function of individual cytochromes P-450 remain to be elucidated, altered gene transcription due to differences in portal blood composition elicited by intravenous versus enteral feeding is a possible hypothesis. These studies also provide information which should be valuable in designing studies to probe further the clinical question of whether TPN induces significant alterations in human drug metabolism.

The lingual tonsil. A neglected symptomatic structure?

Surgical treatment of the lingual tonsil is seldom performed because problems attributable to chronic lingual tonsillar hypertrophy are infrequently diagnosed. We have reviewed a series of 25 patients with symptoms from enlarged lingual tonsils. The variety of presentation of lingual tonsillar lesions and the methods of surgical treatment are discussed.