In recent years, the plantaris tendon has been implicated in the development of chronic painful mid-portion Achilles tendinopathy. In some cases, a thickened plantaris tendon is closely associated ...with the Achilles tendon, and surgical excision of the plantaris tendon has been reported to be curative in patients who have not derived benefit following conservative treatment and surgical interventions. The aim of this review is to outline the basic aspects of, and the recent research findings, related to the plantaris tendon, covering anatomical and clinical studies including those dealing with histology, imaging and treatment. Cite this article: Bone Joint J 2016;98-B:1312-19.
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) created national guidelines for resident work hours to promote safe care and high-quality learning. However, some reports ...suggested that the 2003 rules did not reduce resident fatigue or improve patient care. Since July 2011, further restrictions have been in effect. The changes have been the source of much controversy regarding their impact on resident education and patient safety. We reviewed existing literature on the effects of the new and old rules, with a focus on the field of orthopaedics. In addition, we conducted a national survey of orthopaedic residents and residency directors to assess the general opinions of the orthopaedic community. Overall, only 19.7% of all respondents were satisfied with the new 2011 regulations, whereas 58.9% believe the 80-hour work week averaged over 4 weeks is appropriate. The results will inform discussions and decisions related to changing residency education in the future.
Chronic tendinopathies represent a major problem in the clinical practice of sports orthopaedic surgeons, sports doctors and other health professionals involved in the treatment of athletes and ...patients that perform repetitive actions. The lack of consensus relative to the diagnostic tools and treatment modalities represents a management dilemma for these professionals. With this review, the purpose of the ESSKA Basic Science Committee is to establish guidelines for understanding, diagnosing and treating this complex pathology.
ObjectiveTo review existing biomechanical and clinical evidence regarding postoperative weight-bearing and range of motion restrictions for patients following meniscal repair surgery.Methods and data ...sourcesFollowing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, we searched MEDLINE using following search strategy: (((“Weight-Bearing/physiology”Mesh) OR “Range of Motion, Articular”Mesh) OR “Rehabilitation”Mesh)) AND (“Menisci, Tibial”Mesh). Additional articles were derived from previous reviews. Eligible studies were published in English and reported a rehabilitation protocol following meniscal repair on human. We summarised rehabilitation protocols and patients’ outcome among original studies.ResultsSeventeen clinical studies were included in this systematic review. There was wide variation in rehabilitation protocols among clinical studies. Biomechanical evidence from small cadaveric studies suggests that higher degrees of knee flexion and weight-bearing may be safe following meniscal repair and may not compromise the repair. An accelerated protocol with immediate weight-bearing at tolerance and early motion to non-weight-bearing with immobilising up to 6 weeks postoperatively is reported. Accelerated rehabilitation protocols are not associated with higher failure rates following meniscal repair.ConclusionsThere is a lack of consensus regarding the optimal postoperative protocol following meniscal repair. Small clinical studies support rehabilitation protocols that allow early motion. Additional studies are needed to better clarify the interplay between tear type, repair method and optimal rehabilitation protocol.
The treatment of painful chronic tendinopathy is challenging. Multiple non-invasive and tendon-invasive methods are used. When traditional non-invasive treatments fail, the injections of ...platelet-rich plasma autologous blood or cortisone have become increasingly favored. However, there is little scientific evidence from human studies supporting injection treatment. As the last resort, intra- or peritendinous open or endoscopic surgery are employed even though these also show varying results. This ESSKA basic science committee current concepts review follows the first part on the biology, biomechanics and anatomy of tendinopathies, to provide a comprehensive overview of the latest treatment options for tendinopathy as reported in the literature.
Antithrombin deficiency (ATD) is an autosomal dominant thrombophilia presenting with varying phenotypes. In pediatric patients with ATD, thrombosis typically develops during the neonatal period or ...adolescence. However, to date there are no consistent recommendations on the therapeutic management of children with ATD. Inferior vena cava atresia (IVCA) belongs to a range of congenital or acquired vena cava malformations and is described as an independent risk factor for thrombosis. The present case report explores two cases of combined ATD and IVCA in an adolescent and his mother.
A 14-year-old male presented with extensive deep venous thromboses (DVTs) of both lower extremities as well as an IVCA. The patient had previously been diagnosed with an asymptomatic ATD without therapeutic consequences at that time. His mother was suffering from an ATD and had herself just been diagnosed with IVCA, too. The DVTs in the adolescent were treated by systemic anticoagulation and catheter-directed local thrombolysis causing favourable results. Yet, despite adequate oral anticoagulation the DVTs in both lower extremities reoccurred within 1 week after the patient was discharged from hospital. This time, thrombolysis could not be fully achieved. Surprisingly, probing and stenting of the IVCA was achieved, indicating an acquired IVCA which could have occurred after undetected thrombosis in early childhood. Genetic analyses showed the same mutation causing ATD in both son and mother: heterozygote missense mutation c.248 T > C, p.(Leu83Pro), within the heparin binding domain of antithrombin. This mutation was never reported in mutation databases before.
To our knowledge this is the first case report discussing combined ATD and IVCA in two family members. Since ATDs present with clinical heterogeneity, taking a thorough family history is crucial for the anticipation of possible complications in affected children and decisions on targeted diagnostics and therapeutic interventions. Affected families must be educated on risk factors and clinical signs of thrombosis and need an immediate diagnostic workup in case of clinical symptoms. IVCA in patients with ATD could occur due to thrombotic occlusion at a very early age. Therefore, in case of family members with IVCA and ATD ultrasound screening in newborns should be considered.
Abstract Injuries to the acromioclavicular (AC) joint are common, particularly in the young and active population. Approximately 9% of all shoulder girdle injuries involve the AC joint, and AC joint ...dislocations represent approximately 8% of all joint dislocations throughout the body. AC joint injuries are graded as type I through type VI according to the Rockwood classification. Type I and II injuries are typically treated nonoperatively, whereas type IV, V, and VI injuries are most often treated surgically. A variety of surgical techniques have been described, including anatomic and nonanatomic reconstruction. However, up to 80% of patients go on to lose radiographic reduction, and between 20% and 30% have complications leading to reoperation. Therefore, the objective of this Technical Note is to describe our preferred technique for the treatment of AC joint instability in the revision setting. This technique uses a Dog Bone Button (Arthrex, Naples, FL) and 2 allografts.
Background:
Jones fractures result in subsequent dysfunction and remain an issue for athletes.
Purpose:
To (1) describe the epidemiology, treatment, and impact of Jones fractures identified at the ...National Football League (NFL) Scouting Combine on players’ early careers and (2) establish the value of computed tomography (CT) to determine bony healing after a fracture in prospective players.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
All players who attended the combine between 2009 and 2015 were retrospectively reviewed to identify their history of Jones fractures. The playing position, treatment method, and number of missed collegiate games were recorded. The mean overall draft pick number, number of games started and played, snap percentage, and position-specific performance scores (fantasy score) over the first 2 years in the NFL were compared between players with fractures and controls. An imaging classification system was applied based on grading of each quadrant of the fifth metatarsal (plantar, dorsal, medial, lateral), with a score of 0 for not healed or 1 for healed.
Results:
Overall, the number of Jones fractures identified was 72 in 2285 athletes (3.2%), with all treated via intramedullary screw fixation. The mean overall draft pick number for players with fractures was 111.2 ± 67.9 compared with 99.0 ± 65.9 for controls (P = .12). Performance scores for players with fractures were lower than those for controls across all positions, with a significant difference in running backs (2.6 vs 4.0, respectively; P < .001) and defensive linemen (1.4 vs 2.3, respectively; P = .02). The mean CT score was 2.5 ± 1.3. Of the 32 athletes who underwent imaging, 16 Jones fractures (50.0%) were healed or nearly healed, 12 (37.5%) were partially healed, and 4 (12.5%) showed little or no healing. The plantar cortex demonstrated the least healing (18/32; 56.3%), followed by the lateral cortex (15/32; 46.9%). Players with a mean score <1 were found to have fewer games started (2.7 ± 2.5) than those with 1 to 3 cortices healed (17.4 ± 10.4) or all cortices healed (8.7 ± 11.2).
Conclusion:
Based on CT, 50% of all players with a previous Jones fracture demonstrated incomplete healing. Moreover, position-specific performance scores over the first 2 years of a player’s career were lower across all positions for those with fractures compared with controls. Players with CT scores <1 were found to start fewer games and were drafted later than controls.
Background:
The distribution of contact forces across the dysplastic patellofemoral joint has not been adequately quantified because models cannot easily mimic the dysplasia of both the trochlea and ...the patella. Thus, the mechanical consequences of surgical treatments to correct dysplasia cannot be established.
Purpose/Hypothesis:
The objective of this study was to quantify the contact mechanics and kinematics of normal, mild, and severely dysplastic patellofemoral joints using synthetic mimics of the articulating surfaces on cadavers. We tested the hypothesis that severely dysplastic joints would result in significantly increased patellofemoral contact forces and abnormal kinematics.
Study Design:
Controlled laboratory study.
Method:
Patellofemoral dysplasia was simulated in 9 cadaveric knees by replacing the native patellar and trochlear surfaces with synthetic patellar and trochlear implants. For each knee, 3 synthetic surface geometries (normal, showing no signs of dysplasia; mild, exemplifying Dejour type A; and severe, exemplifying Dejour type B) were randomized for implantation and testing. Patellar kinematics and the sum of forces acting on the medial and lateral patellar facets were computed for each knee and for each condition at 10° increments from 0° to 70° of flexion.
Results:
A pronounced lateral shift in the weighted center of contact of the lateral facet occurred for severely dysplastic knees from 20° to 70° of flexion. Compared with normal geometries, lateral patellar facet forces exhibited a significant increase only with mild dysplasia from 50° to 70° of flexion and with severe dysplasia at 70° of flexion. No measurable differences in medial patellar facet mechanics or joint kinematics occurred.
Conclusion:
Our hypothesis was rejected: Severely dysplastic joints did not result in significantly increased patellofemoral contact forces and abnormal kinematics in our cadaveric simulation. Rather, severe dysplasia resulted in a pronounced lateral shift in contact forces across the lateral patellar facet, while changes in kinematics and the magnitude of contact forces were not significant.
Clinical Relevance:
Including dysplasia of both the patella and trochlea is required to fully capture the mechanics of this complex joint. The pronounced lateralization of contact force in severely dysplastic patellofemoral joints should be considered to avoid cartilage overload with surgical manipulation.
Abstract Even though it is generally thought that umami stimuli such as monosodium glutamate (MSG) and sweet stimuli such as sucrose are detected by different taste receptors, these stimuli appear to ...share taste qualities when amiloride (a sodium channel blocker) is present to reduce the sodium taste. Single fiber recording studies of the facial and glossopharyngeal nerves have shown that encoding of l -2-amino-4-phosphonobutyrate ( l -AP4), a potent mGluR4 agonist that elicits a taste quite similar to MSG, may occur in the same fibers that also encode sweet stimuli. This suggests that l -AP4 and sweet substances may activate common receptors or afferent signaling mechanisms. We report results of behavioral experiments that test this hypothesis. In the first study, rats conditioned to avoid sucrose or l -AP4 generalized the aversion to the opposite substance, indicating that both substances elicited similar tastes. However, two taste discrimination experiments showed that rats easily discriminated between sucrose and l -AP4 over a wide range of concentrations, even when the cue function of sodium associated with l -AP4 was reduced by amiloride and neutralized by adding equimolar concentrations of NaCl to sucrose. These data suggest that even though l -AP4 and sucrose elicit similar taste qualities, one or both substances also elicit other taste qualities not shared by the opposite substance. They also suggest that the taste-mGluR4 receptor and the signal pathway activated by l -AP4 are not the same as those activated by sucrose. These data, when combined with fiber recording data, suggest that there is convergence of l -AP4 and sucrose signals at some point early in the gustatory pathway.
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