Reliability of Achilles tendon resting angle and calf circumference measurement techniques.

BACKGROUND: The resting angle of the ankle joint may be altered following apparently successful management of Achilles tendon rupture. The reliability of the Achilles Tendon Resting Angle and Calf Circumference measurements was determined. METHODS: Three test-retest measurements for reliability assessment were performed on 16 healthy subjects: 10 males and 6 females. RESULTS: The mean left Achilles Tendon Resting Angle was mean 50.1° (range [26-61]), ICC 0.92 (CI [0.83-0.97]), SEM 2.4°. The mean right Achilles tendon resting angle was mean 49.9° (range [26-60]), ICC 0.91 (CI [0.80-0.96]), SEM 2.6°. The mean left calf circumference was mean 38.5cm (range [33.3-44.2]), ICC 0.97 (CI [0.94-0.98]), SEM 0.6cm, and the mean right calf circumference was mean 38.4cm (range [33.3-43.6]), ICC 0.97 (CI [0.94-0.99]), SEM 0.5cm. CONCLUSIONS: The Achilles Tendon Resting Angle and Calf Circumference at 15cm from the antero-medial joint line had excellent test-retest reliability. These are simple, quick and inexpensive measurements, which have the potential to correlate with tendon elongation and functional outcome. The Achilles tendon resting angle may be used as a guide to tendon length during intra-operative repair and rehabilitation.

Surgical repair of the ruptured Achilles tendon: the cost-effectiveness of open versus percutaneous repair.

PURPOSE: Recent meta-analyses have shown reduced re-rupture rates for the surgical management of Achilles ruptures. However, percutaneous repair has been demonstrated to lead to improved function and patient satisfaction but greater complications than open repair. In the current economic climate, it is reasonable to consider the financial cost of rupture management for both the patient and the provider. The cost-effectiveness of operative treatment of ruptures of the Achilles tendon was determined based upon theatre occupancy, clinic attendance and cast changes, operative complications and functional assessment score. METHODS: The cost-effectiveness of the surgical management of Achilles tendon ruptures between 2005 and 2011 in our unit was audited by comparing 49 patients receiving percutaneous repair to 35 patients whom had open repairs. RESULTS: There was no significant difference in complications between the two surgical techniques: (Open vs. Percutaneous) overall rates 14.3 versus 10.4 %: infection; 2.7 versus 2.0 %, transient sural nerve damage: 5.6 versus 8.1 %, wound breakdown: 2.8 versus 0.0 %, re-rupture: 2.8 versus 2.0 %. Achilles Total Rupture Scores (ATRS) were comparable [Open 89 (65-100) at 49 months vs. Percutaneous 88.8 (33-100) at 12 months (n.s.)]. Theatre occupancy (P < 0.00) and hospital stay (P < 0.00) were significantly longer with open repair [43 min (26-70) and 2.9 days (0-4)] compared to percutaneous repair [15 min (12-43) and 1.2 days (0-2)]. Excluding the costs of running the operating theatre, we have estimated the costs of surgery for open repair to be £ 935 and percutaneous repair to be £ 574. CONCLUSIONS: This study suggests that percutaneous repair of the Achilles tendon resulted in reduced costs and yet had comparable outcome and complications rates to open repair in surgical management of the Achilles tendon. Percutaneous repair should be considered as the primary method of cost-effective surgical management of Achilles tendon rupture.

Meniscal scaffolds: early experience and review of the literature.

INTRODUCTION: Meniscal scaffold implants support the in-growth of new "meniscus like" tissue with the aim of alleviating post-meniscectomy knee pain and preventing further articular cartilage degeneration. PATIENTS AND METHODS: Twenty-three patients underwent meniscal scaffold implantation (14 medial, 9 lateral) with either the Menaflex (ReGen Biologics) (n=12) or Actifit (Orteq) (n=11) scaffolds. Minimum follow-up was 1 year with a mean of 24.1 months (18-27) for the Menaflex and 14.7 months (12-18) for the Actifit groups. Mean age at surgery was 35 years (17-47) with a mean Outerbridge grade of 1.9 in the affected compartment. Eight (36%) underwent concurrent osteotomy, ligament reconstruction or microfracture of the tibial plateau. KOOS, Lysholm, Tegner activity and IKDC scores were collected pre-operatively and at six-month interval post-surgery. Assessment of the reconstruction was obtained with MRI scanning and arthroscopy. One scaffold tore and was revised at 19 months post-operatively. RESULTS: Twenty-one out of 23 (91.3%) had a significant improvement in knee scores when compared to pre-surgery levels at latest follow-up. Second-look arthroscopy in 14 at 1-year post-implantation showed variable amounts of regenerative tissue. There was no progression in chondral wear noted on repeat MRI scanning. CONCLUSION: Treatment with meniscal scaffold implants can provide good pain relief for the post-meniscectomy knee following partial meniscectomy. Longer follow-up is required to ascertain whether they also prevent the progressive chondral wear associated with a post-meniscectomy knee.

The safety profile of a retrospective Accessory Postero-Lateral hind foot portal: the risk of sural nerve damage during visualisation of the Achilles tendon insertion.

INTRODUCTION: The Accessory Postero-Lateral (AccPL) portal has recently been described to improve the visualisation for the endoscopic debridement of Haglund's tubercle. The safety of using this portal has been considered previously for posterior ankle arthroscopy. We performed a study to determine the proximity of the AccPL portal to the sural nerve. METHODS: We compared the distances between AccPL and PL portals to the sural nerve in 17 cadaveric specimens. RESULTS: The AccPL portal was significantly closer (mean 12.0mm, range 6-19 mm, SD=3.64) to the sural nerve than the PL portal (mean 14.1mm, range 11-18 mm, SD=2.34) (t(16)=-2.34, p=0.03). In two cases the sural nerve was in contact with the clip but on close inspection, the nerve had not been damaged in any of the specimens. CONCLUSIONS: We conclude that the AccPL portal is a safe method to allow visualisation during endoscopic debridement of the Achilles tendon insertion. We also recommend that the portal is used for visualisation rather than instrumentation.

An anatomical and radiological study of the fascia cruris and paratenon of the Achilles tendon.

BACKGROUND: The Achillon jig permits the placement of sutures deep to the fascia cruris and the paratenon through the substance of the ruptured tendon, permitting a safe minimally invasive repair. Our experience has suggested that these two layers may not be as clearly delineated as first thought or may merge at an, as yet, undefined level. METHODS: We performed an anatomical and radiological (US and MRI) study of the layers of tissue superficial to the Achilles tendon in cadaveric specimens. RESULTS: The mean distance for the confluence of the fascia cruris and paratenon from the postero-superior calcaneal tubercle (PSCT) was found to be 37.3mm (range 17-58mm). Ultrasound examination was found to be less distinct than MRI scanning. CONCLUSIONS: We recommend careful identification of the fascia cruris and paratenon and insertion of the central branches of the jig adjacent to the tendon substance when using this method for repair.

Medial patellofemoral ligament reconstruction for subluxating patellofemoral arthroplasty.

Patellofemoral joint (PFJ) arthroplasty has become a successful operation for patellofemoral osteoarthritis. The post-operative complication of patella subluxation is uncommon. We report the stabilisation of a subluxating patella following PFJ arthroplasty using autogenous hamstring tendons. Medial patellofemoral ligament reconstruction may be considered a method of stabilising a subluxating patellofemoral replacement in patients for whom revision arthroplasty is not recommended.

The impact of an extreme sports event on a district general hospital.

BACKGROUND: Extreme sports events are increasing in popularity, particularly in mountainous areas throughout Great Britain. Emergency medical care for these events is usually provided by voluntary organisations, providing event side first aid and referring patients to nearby District General Hospitals. The Fort William Mountain Bike Race is part of the UCI World Cup Series: 173 competitors racing in cross country, downhill and 4X events. The Belford Hospital provides year round medical care for the Lochaber community, which frequently swells during the tourist season. The hospital has 8300 new attendances per annum, 35 patient reviews per 24 hrs. METHODS AND RESULTS: We have reviewed the impact of the event on the local hospital. In total 52 riders reported 61 injuries. The hospital treated 24q (14%) riders. Retrospective analysis of attendances has revealed 19 riders attended on race days, increasing attendees by up to 28%. 46% of injured riders were seen at the A &E department, 1 rider requiring admission for observation and 1 rider required inter-hospital transfer Injury patterns (knee 20%, hand/wrist 18% and shoulder 18%) were similar to other reported series. CONCLUSIONS: We believe that extreme sports events can have considerable impact on small district general hospitals. Additional triage and staffing resources should be utilised and event organisers should anticipate the additional problems they present to the local community. District General Hospitals continue to provide a substantial contribution to the provision of health care for extreme sports within the UK.

The Advanced Trauma Life Support course: a history of its development and review of related literature.

The origins, development, and success of the ATLS course are described with reference to the literature.

Acquisition of a chronic subdural haematoma during training for competitive race walking?

A 65 year old man, anticoagulated for cardiac problems, developed hemiparesis while training for race walking. A computed tomography scan showed a chronic subdural haematoma. This is the first report of a chronic subdural haematoma possibly caused by the jarring action of race walking.