A Biomechanical Analysis of the H-Taping Method Used by Rock Climbers as Prophylactic or Stabilizing Fixation of Partial A2 Pulley Tears

PURPOSE

Rock climbing can lead to upper-extremity injuries, such as A2 pulley ruptures, leading to the bowstringing of the flexor tendons. Climbing finger positions are specific and can put undue stress on the pulley systems. This causes severe hand dysfunction and is a difficult problem to treat, and prevention is important. Using a cadaveric, experimental model, we evaluated the effectiveness of the H-taping method, commonly used by rock climbers, to prevent and treat A2 pulley tears.

METHODS

Using fourteen matched pairs of fresh-frozen cadaveric hands with forearms, four experiments were conducted with 56 paired comparisons evaluating the failure force, fingertip force, and mode of failure (112 total tests). Comparisons were as follows: index fingers- intact versus 50% distal A2 pulley tears without H-taping (control); ring fingers- intact versus H-taping as a prophylactic for A2 pulley tears; little fingers- 50% distal A2 pulley tears with H-tape versus without tape; and middle fingers- H-taping as a prophylactic versus H-taping as a stabilizing treatment of torn pulleys.

RESULTS

The mean index finger failure force was significantly higher in intact vs torn A2 pulleys (control). Failure force for intact H-taped fingers was significantly higher than torn H-taped fingers, but no other finger comparisons for failure force were significant. There were no significant findings in comparison of mean fingertip force values in any of the experiments.

CONCLUSIONS

We found that H-taping is not effective as prophylaxis against A2 pulley ruptures or as a stabilizing treatment method for partially ruptured pulleys.

CLINICAL RELEVANCE

While H-taping has not been recommended as prophylaxis for preventing A2 pulley ruptures, the climbing community has embraced this technique as a preventative measure. The present study provides biomechanical evidence against H-taping for this purpose. Furthermore, it does not appear to aid in increasing fingertip force after injury.

Analysis of the Effects of Early Rehabilitation Treatment Conducted by Nurses on the Prevention of Tendon Adhesion after Finger Flexor Tendon Rupture: A Randomized Clinical Trial

OBJECTIVE

This study aims to analyze the application of predictive nursing in the prevention of tendon adhesion, after the anastomosis of finger flexor tendon rupture, so as to provide a basis for clinical nursing.

METHODS

A total of 80 patients with anastomoses of flexor tendon ruptures, investigated in our hospital from December 2017 to December 2018, were enrolled in this study. Their data formed the basis of this research. They were divided into two groups, the routine (control) group (n = 40) and the nursing group (n = 40), by the random number table method. Basic nursing methods only were used in treating the routine group, while the nursing group received basic nursing in combination with early active function exercise. The contrast indices between the two groups were recovery quality of finger flexion and extension, incidence of tendon adhesion, and nursing satisfaction rate.

RESULTS

The probability of tendon rupture and adhesion in the (predictive) nursing group was lower than that found in the control group. The outcomes with predictive nursing were more desirable. The levels of finger flexion and extension in the nursing group were significantly better than those of the control group(P < 0.05).

CONCLUSION

The application of predictive nursing, after the anastomosis of finger flexor tendon rupture, is good for preventing tendon adhesion. Better levels of finger flexion and extension after the operation are guaranteed, and the overall recovery outcomes are better. The satisfaction levels of patients who received predictive nursing were also high, and this method is highly valued and promoted within clinical practice.

Assessment of Functional Conservative Treatment of Acute Complete Achilles Tendon Rupture

BACKGROUND

In recent years, treatment for Achilles tendon rupture (ATR) went through radical changes: from the conservative non-weight bearing approach to a functional protocol. This functional protocol allows complete weight bearing after only 2 weeks by placing the foot in a plastic boot in tapered down equines and using interchangeable wedges under the heel. This change of approach has dramatically lowered the rate of re-rupture.

OBJECTIVES

To describe our preliminary results with this functional protocol and to assess outcome measures in the functional conservative treatment.

METHODS

The study comprised 15 people who were evaluated clinically and by sonograph. We measured calf circumference, ankle joint range of motion (ROM), and single-leg heel-rise test (SLHRT). In addition, standard scoring methods (Achilles Tendon Rupture Score and Physical Activity Scale) were examined.

RESULTS

In our cohort 14 people successfully gained SLHRT. The mean Achilles Tendon Rupture Score functional questionnaire and Physical Activity Scale physical activity questionnaire score was 85.6 of 100, and 4.7 of 6, respectively. There were no significant differences in ankle ROM compared to the uninjured limb. There was statistically significant reduction in the calf circumference and soleus muscle thickness sonographically.

CONCLUSIONS

It seems that the conservative functional treatment of ATR demonstrates good functional outcomes, with the patients returning to close to normal activity, although noted muscle wasting and weakness. This protocol presents a true alternative to surgery and should be considered for most non-insertional Achilles tendon tears.

The Prodrome of Extensor Pollicis Longus Tendonitis and Rupture: Rupture May Be Preventable

Current literature suggests that tendonitis of the extensor pollicis longus (EPL) is a rare condition that has a high rate of progression to rupture. This study documents the prodrome of impending EPL rupture in patients with prior nondisplaced distal radial fracture. A retrospective study identified patients with EPL tendonitis or tendon rupture. Seven patients (6 females and 1 male) had sustained a nondisplaced distal radius fracture within the past year. Among these 7 patients, 4 eventually developed EPL tendon rupture and 3 had tendonitis without rupture. Of the 4 patients with EPL rupture, 2 presented to another provider before rupture with prodromal symptoms documented in the medical record, with pain and difficulty extending the affected thumb at the interphalangeal (IP) joint. The 3 patients with EPL tendonitis but no EPL tendon rupture all presented following a nondisplaced distal radius fracture with tenderness over the EPL tendon and pain with thumb motion. These 3 patients underwent EPL tendon decompression and subsequently did not go on to experience EPL rupture. Extensor pollicis longus tendonitis is a condition that is classically seen in the setting of nondisplaced distal radius fractures and often progresses to tendon rupture. In this study, the following prodrome of impending EPL rupture was identified: tenderness over the EPL tendon and Lister's tubercle and pain with thumb motion. This study suggests that patients with EPL tendonitis and possible impending rupture present with a prodrome of symptoms. If these patients can be identified, they may undergo EPL tendon decompression, which may prevent EPL tendon rupture. [Orthopedics. 2016; 39(5):318-322.].

Achilles or biceps tendon rupture in women and men with type 2 diabetes: A population-based case-control study

AIMS

Previous studies suggest that diabetes causes alterations in tendon collagen structure, but evidence on how such findings translate into clinical practice is scarce. We aimed to analyze the association between type 2 diabetes and the risk of tendon rupture.

MATERIALS AND METHODS

We conducted a matched case-control analysis using the UK-based Clinical Practice Research Datalink. Cases (n=7895) were aged 30-89years and had an incident diagnosis of Achilles- or biceps tendon rupture between 1995 and 2013. In multivariable logistic regression analyses we compared the odds of tendon rupture between patients with or without type 2 diabetes, in men and women separately, and taking into account diabetes severity (HbA1c), duration, and antidiabetic drug treatment.

RESULTS

Within 165 (7.1%) female cases with type 2 diabetes, odds ratios (ORs) were increased with poorer diabetes control (OR 2.03, 95% CI 1.20-3.41, HbA1c ≥9% [≥75mmol/mol]), longer disease duration (OR 1.60, 95% CI 0.93-2.74, ≥10years), and current insulin use (OR 2.25, 95% CI 1.30-3.90, ≥20 prescriptions). Among 372 (6.7%) male cases, there was no effect of type 2 diabetes on the risk of tendon rupture.

CONCLUSIONS

Our results suggest that the risk of tendon ruptures may be increased in women with poorly controlled type 2 diabetes, but not in men.

Enhanced Zone II Flexor Tendon Repair through a New Half Hitch Loop Suture Configuration

This study evaluated the impact of a new half hitch loop suture configuration on flexor tendon repair mechanics. Cadaver canine flexor digitorum profundus tendons were repaired with 4- or 8-strands, 4-0 or 3-0 suture, with and without half hitch loops. An additional group underwent repair with half hitch loops but without the terminal knot. Half hitch loops improved the strength of 8-strand repairs by 21% when 4-0, and 33% when 3-0 suture was used, and caused a shift in failure mode from suture pullout to suture breakage. 8-strand repairs with half hitch loops but without a terminal knot produced equivalent mechanical properties to those without half hitch loops but with a terminal knot. 4-strand repairs were limited by the strength of the suture in all groups and, as a result, the presence of half hitch loops did not alter the mechanical properties. Overall, half hitch loops improved repair mechanics, allowing failure strength to reach the full capability of suture strength. Improving the mechanical properties of flexor tendon repair with half hitch loops has the potential to reduce the postoperative risk of gap formation and catastrophic rupture in the early postoperative period.

Sonographic Detection of Abnormal Plaque Motion of the Carotid Artery: Its Usefulness in Diagnosing High-Risk Lesions Ranging from Plaque Rupture to Ulcer Formation

We investigated the feasibility of using sonography of abnormal plaque motion to diagnose high-risk carotid lesions ranging from plaque rupture to ulcer formation. Fifty consecutive carotid arteries of 49 patients (71 ± 7 y, 37 males) who underwent carotid endarterectomy were investigated by carotid sonography to find a plaque concavity (sonographic ulcer [SU]), fine trembling motion inside the plaque (FTMI) and systolic retractive motion of the plaque surface (SRMS). Plaque rupture or ulcer, necrotic core and intra-plaque hemorrhage were determined at carotid endarterectomy. Twenty-two SUs, 41 cases of FTMI and 20 cases of SRMS were detected by carotid sonography. The sensitivity and specificity of SU in diagnosing plaque rupture or ulcer at carotid endarterectomy were 48% and 90%, and those of FTMI were 93% and 60%. Plaques with SRMS more frequently had both a necrotic core and intra-plaque hemorrhage than those without SRMS (80% vs. 30%, p = 0.0005). Abnormal plaque motion detected by carotid sonography is useful in detecting a ruptured or ulcerated plaque with a necrotic core and/or hemorrhage.

Manual protection of the perineum reduces the risk of obstetric anal sphincter ruptures

INTRODUCTION

During vaginal delivery, the risk of obstetric anal sphincter injuries (OASIS) is well-known. Despite sufficient repair, 30-50% of women will experience anal incontinence. Recent studies from Norway have shown a reduction in the incidence of OASIS when the perineum is supported manually. In Denmark, the frequency of OASIS is the highest in Scandinavia and it is increasing. The aim of this study was to reduce the incidence of OASIS through an interventional programme.

METHODS

We conducted a study inspired by the Norwegian intervention. Our focus was on four points: 1) good communication between the delivering woman and the birth assistant, 2) visualisation of the perineum in the last stages of delivery, 3) support of the perineum during the final minutes of pushing and 4) episiotomy only on indication. A total of 768 primiparous and 1,175 multiparous women were enrolled in this quality improvement cohort study. Data were analysed for association with the occurrence of OASIS.

RESULTS

The proportions of parturients with anal sphincter ruptures decreased significantly during the first year of the study from 4.4% to 1.7% (p < 0.001). The decrease was more pronounced for primiparous women: from 7.2% to 2.9% (p = 0.006). A similar decrease was observed for instrumental deliveries although this was not significant for primiparous women, probably due to the size of the study population. Episiotomies increased significantly from 4.4% to 7.1% for all deliveries.

CONCLUSION

After the first year of intervention, our results demonstrate that manual protection of the perineum reduces the overall risk of OASIS significantly.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

[A case of tracheal tube rupture of an adult patient]

Analysis and summarize the causes and principles of the cases of tracheal tube rupture. Report one case of adult tracheal tube rupture. Review the past literature content and combine with our experience. Comprehend the clinical manifestations and treatment of tracheal tube rupture is very important for prevention.

Pneumothorax in neonates: Trends, predictors and outcomes

OBJECTIVE

To examine rates, trends, predictive risk factors, and outcomes associated with pneumothorax in neonates.

STUDY DESIGN

Retrospective analyses were used to estimate rates and assess trends in pneumothorax among early preterm (GA <32 weeks), moderate-late preterm (GA 32-36), and term (GA ≥37 weeks) neonates admitted to neonatal intensive care units (NICUs) participating in the Canadian Neonatal Network™ from 2005 to 2011. For each GA group, multivariable logistic regression models were derived to predict pneumothorax using risk factors with known clinical relevance. Additional logistic regression analyses assessed associations between pneumothorax and mortality, bronchopulmonary dysplasia, and intraventricular hemorrhage.

RESULTS

The study included 71,237 neonates; of them 16,985 (24%) early preterm, 27,709 (39%) moderate-late preterm, and 26,543 (37%) term neonates. The overall rate of pneumothorax by GA was bimodal with estimates of 4.0%, 2.6%, and 6.7% respectively. No significant temporal trends were detected. Risk factors for pneumothorax included: a) for the overall lpopulation- Score for Neonatal Acute Physiology, version II >20, surfactant use, and respiratory distress syndrome; b) for early preterm infants-chorioamnionitis; c) for moderate-late preterm infants-higher birth weight, male sex, rupture of membranes >24 hours, and outborn status; and d) for term infants- male sex, outborn status, and meconium aspiration in term neonates. In early preterm neonates, pneumothorax was associated with mortality, bronchopulmonary dysplasia, severe intraventricular hemorrhage, and prolonged NICU stay.

CONCLUSIONS

Pneumothorax rates were higher among term and early preterm neonates admitted to the NICU. Predictors of pneumothorax varied between GA groups. Pneumothorax-associated mortality and morbidity were significantly greater in early preterm infants.

[Refixation of tibial bony avulsions of the posterior cruciate ligament with a hook plate]

OBJECTIVE

Posteromedial approach to the knee. Exact reduction and fixation of avulsed tibial attachment of posterior cruciate ligament with small-fragment plate.

INDICATIONS

Avulsed tibial attachment of posterior cruciate ligament.

CONTRAINDICATIONS

Ligamentous rupture of the posterior cruciate ligament. Local soft-tissue problems.

SURGICAL TECHNIQUE

Posteromedial approach with mobilization and retraction of the medial gastrocnemius muscle. Subperiosteal detachment of the popliteal muscle. Identification of fracture site. Longitudinal incision of the posterior capsule of the knee. Debridement of the fracture site, reposition and stabilization with small-fragment plate.

POSTOPERATIVE MANAGEMENT

Partial weight bearing with 15 kg for 6 weeks, limitation of knee flexion to 90° for 6 weeks. A special joint orthesis is not necessary. The use of an EMT unit is recommended to prevent muscular atrophy.

RESULTS

Six patients (four female, two male) with avulsed tibial attachment of posterior cruciate ligament were treated using the posteromedial approach.

The quadriga effect revisited: designing a "safety incision" to prevent tendon repair rupture and gap formation in a canine model in vitro

Loss of experimental animals due to tendon repair failure results in the need for additional animals to complete the study. We designed a relief proximal to the flexor digitorum profundus (FDP) tendon repair site to serve as a "safety incision" to prevent repair site ruptures and maximize safety incision-to-suture strength. The FDP tendons were dissected in 24 canine forepaws. The 2nd and 5th tendons were lacerated at the proximal interphalangeal joint level and sutured using a modified Kessler technique and peripheral running suture. Tendon width was measured where the FDP tendon separates into each individual digit and a safety incision, equal to the 2nd and 5th tendon widths, was performed 3, 4, or 5 mm (Groups 1, 2, and 3) proximal to the separation. The tendons were pulled at a rate of 1 mm/s until either the "safety incision" ruptured or the repair failed. There was no gap formation at the repair site in Groups 1 and 2. However, all Group 3 tendons failed by repair site rupture with the safety incision intact. An adequate safety incision to protect repair gap and rupture and maintain tendon tension for the FDP animal model should be about 4 mm from where the FDP tendon separates.

Mechanics of dynamic needle insertion into a biological material

During needle-based procedures, transitions between tissue layers often lead to rupture events that involve large forces and tissue deformations and produce uncontrollable crack extensions. In this paper, the mechanics of these rupture events is described, and the effect of insertion velocity on needle force, tissue deformation, and needle work is analyzed. Using the J integral method from fracture mechanics, rupture events are modeled as sudden crack extensions that occur when the release rate J of strain energy concentrated at the tip of the crack exceeds the fracture toughness of the material. It is shown that increasing the velocity of needle insertion will reduce the force of the rupture event when it increases the energy release rate. A nonlinear viscoelastic Kelvin model is then used to predict the relationship between the deformation of tissue and the rupture force at different velocities. The model predicts that rupture deformation and work asymptotically approach minimum values as needle velocity increases. Consequently, most of the benefit of using a higher needle velocity can be achieved using a finite velocity that is inversely proportional to the relaxation time of the tissue. Experiments confirm the analytical predictions with multilayered porcine cardiac tissue.

[Drainage of liver abscess by "mini-hepatotomy"]

We have developed a a "mini-hepatotomy" technique to prevent rupture of large superficial liver abscesses.

AIM

The purpose of this report is to describe our results using this technique.

PATIENTS AND METHOD

Data was extracted from the files of 40 patients hospitalized in our department for liver abscess from January 2000 to June 2005. Antimicrobrial therapy including metronidazole was administered to all patients and was the sole treatment in two. Additional treatment included laparotomy for ruptured abscess in 4 cases, pleural drainage for rupture in the right pleural cavity in one, and "mini hepatotomy" in 33. This study includes the 33 patients who underwent mini-laparotomy. There were 30 men and 3 women with a mean age of 38 years. The mean delay for consultation was 51 days.

RESULTS

Liver abscess was classified as amoebic abscess in 28 cases and pyogenic abscess in 5. The mean diameter of the abscess was 11.5 cm. The abscess was located in the right lobe in 21 cases and left lobe in 12. The mean quantity of liquid drained from the abscess was 1060 mL. Outcome was favorable in 28 cases (success rate: 84.8%). In the remaining 5 cases abscess persisted after drain removal including two that required a second drain procedure and three that resolved after medical treatment. The failure rate was 6% (2/33). No patient died.

CONCLUSION

Large size and superficial location are risk factors for rupture of liver abscess. Drainage is warranted in patients at risk for this complication. The results of this study show that our "mini-hepatotomy" drainage technique has a high success rate and can achieve good results.

[Appendiceal tumors found at appendectomy]

There are three main histologic types of appendiceal tumor: adenoma, adenocarcinoma, and neuroendocrine tumor. Neuroendocrine tumors (carcinoids) are by far the most common and account for two-third of all appendiceal tumors. Adenomas and adenocarcinomas are both rare; they share two particularities: (a) a mucinous component is both frequent and predominant, (b) they have a tendency to intraperitoneal dissemination. Rupture of any mucinous tumor-whether spontaneous or occurring during surgery-may result in pseudomyxoma peritonei; treatment of this condition requires complete resection of all lesions followed by hyperthermic intraperitoneal chemotherapy. For unruptured appendiceal tumor, the appendix should be removed by a carcinologic right hemicolectomy if the tumor appears aggressive.

Bioprotection of tendon repair: adjunctive use of botulinum toxin A in Achilles tendon repair in the rat

BACKGROUND

Tendon-repair techniques have evolved to increase the construct strength of the repair site in order to permit early active range of motion without tendon gap or rupture. The present study evaluated the hypothesis that the injection of botulinum neurotoxin type-A (BoNT-A) into the gastrocnemius muscle will reduce the active force production of that muscle below the force required to rupture the associated, repaired Achilles tendon.

METHODS

Seventy-nine rat Achilles tendons were surgically bisected and were repaired with use of a two-strand core suture with a running epitenon repair. After the repair, the animals were treated with unilateral intramuscular (gastrocnemius) injections of either BoNT-A (6 U/kg body weight) (thirty-seven rats) or saline solution (forty-two rats). Operatively treated ankles were fixed in the neutral position with a percutaneous pin for the first two days after surgery. Unrestricted ankle motion and weight-bearing were allowed after the second postoperative day. An assessment of gap formation or rupture at the repair site, electrophysiologic measurements of force applied to the tendon, and an assessment of the strength of the repaired tendon were performed.

RESULTS

Intramuscular BoNT-A injections produced a significant, reversible reduction in active muscle force (p < 0.007). Twitch and tetanus contractions decreased to approximately 25% of the values for the control side within one week, remained at <50% of the values for the control side at one month, and returned to normal levels by six months. The tetanic force capability of the muscles that had been injected with BoNT-A was fivefold to tenfold less than the force required to rupture the associated Achilles tendon for as long as four weeks after tendon repair. The spontaneous Achilles tendon rupture rate of repaired tendons in the BoNT-A group was three times lower than that in the saline solution group at one week, and the tendon rupture force was significantly higher in the BoNT-A group between one and three weeks after repair (p < 0.007). There was no significant difference in tendon rupture force between the two groups after three weeks.

CONCLUSIONS

Intramuscular gastrocnemius BoNT-A injections were associated with a significant reduction in force-generating potential, such that the muscle was incapable of actively producing enough force to rupture the repaired Achilles tendon in this rat model of tendon repair.

Schneiderian membrane perforation rate during sinus elevation using piezosurgery: clinical results of 100 consecutive cases

The lateral window sinus elevation procedure has become a routine and highly successful preprosthetic procedure that is used to increase bone volume in the posterior maxilla for the placement of dental implants. Many surgical techniques have been proposed that provide access to the maxillary sinus through the lateral wall to allow for elevation of the sinus membrane. Among these are the multiple variations of the hinge and complete osteotomy techniques, which make use of rotary cutting instruments for the antrostomy. The most common intraoperative complication with these surgical approaches is perforation of the schneiderian membrane, with perforation rates of 14% to 56% reported in the literature. In most instances, perforation occurs either while using rotary instruments to make the window or when using hand instruments to gain initial access to begin the elevation of the membrane from the sinus walls. This article presents an alternative approach that uses a piezoelectric instrument for the sinus elevation procedure. Although new to the United States, this approach has been used successfully in Europe for many years. The membrane perforation rate in this series of 100 consecutive cases using the piezoelectric technique has been reduced from the average reported rate of 30% with rotary instrumentation to 7%. Furthermore, all perforations with the piezoelectric technique occurred during the hand instrumentation phase and not with the piezoelectric inserts.

Visual acuity prognosis after anterior chamber air replacement to prevent pseudo-anterior chamber formation after deep lamellar keratoplasty

PURPOSE

To investigate the prognosis of patients who received anterior chamber air replacement after deep lamellar keratoplasty (DLKP) during the study period, January 1995 to April 2000.

METHODS

The records were studied of 47 patients (54 eyes) (60.6 +/- 21.3 years of age) who underwent DLKP at Dokkyo University Hospital. Visual acuity and endothelial cell loss were assessed in patients (1) with and without Descemet's membrane perforation; (2) with and without the use of anterior chamber air replacement, and for different durations of air replacement; and (3) in the presence or absence of a pseudo-anterior chamber, and in relation to its duration if present.

RESULTS

No significant differences in relation to the above three items were found in endothelial cell loss in study years 1 to 5. Average best visual acuity was 0.61 in perforated eyes, 0.54 in unperforated eyes, 0.54 in eyes that received air replacement, and 0.57 in eyes that did not. The average best visual acuity was 0.38 in eyes with a pseudo-anterior chamber and 0.68 in eyes without one. There was a significant correlation between the duration of the pseudo-anterior chamber and loss of visual acuity.

CONCLUSIONS

The prolongation of a pseudo-anterior chamber eventually impairs visual acuity, whereas anterior chamber air replacement, used to prevent the development of a pseudo-anterior chamber, causes minimal endothelial cell damage. Anterior chamber air replacement, therefore, is an effective technique by which to prevent the development of a pseudo-anterior chamber.

Effects of menstrual-cycle hormone fluctuations on musculotendinous stiffness and knee joint laxity

The high risk of anterior cruciate ligament (ACL) injuries in female athletes may be related to hormonal fluctuations resulting in an increased laxity of ligaments and muscles. This study examined changes in lower limb musculotendinous stiffness (MTS) and knee laxity over the course of the menstrual cycle and investigated the interaction of warm-up on MTS. Eleven female netball players aged 16-18 years who were not using hormonal contraceptives and demonstrated regular menstrual cycles participated in this study. Test-sessions were conducted at onset of menses, mid-follicular phase, ovulation and mid-luteal phase. ACL laxity was determined at each test-session using a KT2000 knee arthrometer. MTS was assessed prior to, and following a standardised warm-up. Repeated measures ANOVA revealed significant (P < 0.05) main effects of test-session and warm-up on MTS. MTS was found to significantly decrease by 4.2% following the warm-up intervention. MTS was significantly lower at week 3 (ovulatory phase) in contrast to weeks 1 and 2 (8.7 and 4.5%, respectively). For knee laxity measures, repeated measures ANOVA revealed no significant (P < 0.05) differences across the menstrual cycle. A reduction in MTS results in greater reliance on reflexive response from the contractile components of the muscle due to a decreased contribution from passive elastic structures and will also increase electromechanical delay. Given that extreme loads are applied to the knee joint within milliseconds, the contractile components cannot respond quickly enough to counteract these sudden and potentially damaging forces. These effects are augmented following a moderate warm-up. Oestrogen fluctuations had no significant effect on anterior knee laxity, however, the effects on MTS over the 28-day cycle were considerable. Future studies should use matched subjects who are using the monophasic oral contraceptive pill to investigate the effects of oestrogen supplementation on lower limb MTS.

The effect of regular antenatal perineal massage on postnatal pain and anal sphincter injury: a prospective observational study

OBJECTIVE

Antenatal perineal massage has been shown to reduce the incidence of perineal tears in primiparous women. The aim of this study was to determine whether perineal massage impacts on primary prevention of symptomatic disruption of the fecal continence mechanism.

METHODS

An observational study recruited two cohorts of women. The first, massage group (MG) chose to perform daily perineal massage from 34 weeks gestation, and the second, control group (CG) was asked to avoid massage. Perineal injury and postnatal pain were documented and all women were invited to attend at three months postpartum for continence assessment, anal manometry, and endoanal ultrasound.

RESULTS

Of 179 women recruited, 100 were in the MG while 79 women were controls. Mode of delivery was not influenced by perineal massage. Although the impact did not reach statistical significance, women aged over 30 years in the MG were more likely to be delivered with an intact perineum than controls. Postnatal perineal pain was much reduced in the MG compared with the CG (p = 0.029). Of the women recruited, 136 (75.9%) returned for a postnatal continence assessment. Manometry pressures, continence scores, and endoanal ultrasound findings were similar in both groups.

CONCLUSION

Antenatal perineal massage was found to significantly affect postnatal perineal pain scores although it did not impact on the incidence of intact perineum at delivery, postnatal continence scores, anal manometry pressures, or endoanal ultrasound findings.

Dynamic ultrasound as a selection tool for reducing achilles tendon reruptures

BACKGROUND

The optimal method of treatment for acute tendo-Achilles ruptures continues to be debated.

HYPOTHESIS

The reported lower rerupture rate for operatively treated patients is an effect of tendon end apposition during the healing process, and patients in whom apposition can be demonstrated using ultrasound will have a similar rate of rerupture if treated nonoperatively.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHOD

The authors reviewed all patients with an Achilles tendon rupture who were treated to a standard protocol during a 5-year period (2000-2005). Patients with a gap of 5 mm or more in equinus on ultrasound underwent surgery; those with a gap of less than 5 mm received nonoperative treatment. All patients were followed up to a minimum of 12 months.

RESULTS

After exclusions, 125 patients were included: 67 treated operatively and 58 nonoperatively. There were 2 reruptures in the nonoperative group and 1 with surgery. There was no significant difference between the groups for any complication.

CONCLUSION

Reduction of rerupture and surgery risks may be possible using dynamic ultrasound case selection. Further studies are needed to show whether functional results are the same with surgical and nonsurgical treatment when dynamic ultrasound criteria are used for case selection.

Avoiding sural nerve injuries during percutaneous Achilles tendon repair

BACKGROUND

Sural nerve injury is a reported risk during percutaneous repair of the Achilles tendon.

HYPOTHESIS

Exposure of the sural nerve during percutaneous repair can minimize the risk of nerve injury.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

The authors retrospectively examined the results of 84 patients who were treated for acute Achilles tendon rupture at 2 different hospitals. Both hospitals used the same percutaneous repair technique, except that the sural nerve was exposed in the 38 patients (mean age, 38 years; range, 23-68 years) of one hospital; the nerve was not exposed in the 46 patients (mean age, 42 years; range, 24-71 years) of the other hospital (the nonexposure group).

RESULTS

All patients recovered and returned to work after 44 days (range, 5-202 days). All patients returned to their previous sports levels within 1 year. On the 100-point Hannover Achilles Tendon Score, the mean score was 81 points (range, 44-100 points). The overall incidence of sural nerve related complications was 18%. All sural nerve lesions occurred in the nonexposure group. In the total study population, there were 3 cases of deep vein thrombosis, 1 rerupture, and 1 case of infection.

CONCLUSION

Sural nerve injuries can be minimized during surgery by carefully placing the stab incisions to expose the nerve so as to avoid it during repair. If the sural nerve is exposed, percutaneous repair of the ruptured Achilles tendon is a safe and reliable method of treating Achilles tendon ruptures.

Achilles tendon lengthening by triple hemisection in adult

BACKGROUND

The purpose of this study was to investigate the adequate distance between hemisections to prevent complete rupture in a triple hemisection Achilles tendon lengthening.

METHODS

Achilles tendon lengthenings by open triple hemisection were done in 18 patients (25 ankles) with spastic paralysis and were followed for more than 1 year.

RESULTS

There was a significant correlation between the sum of the gaps (partial thickness defects) after sliding and the amount of corrected angles. When the distal gap was regarded as 1, the ratio of the distal gap to the middle gap to the proximal gap was 1:1.3 (range 0.8 to 3.3):1.6 (range 0.8 to 4.0), and the ratio of the distal connecting portion to the proximal portion was 2.1 (range 0.3 to 8.8):1.9 (range 0 to 8.3). There were marked differences of this ratio in individual cases. There were no complete ruptures. There were two recurrences at the last followup.

CONCLUSION

When the angle of correction is more than 30 degrees, there is a risk of complete rupture even though the distance between the hemisections are more than 4 cm.

Posterior polar cataract: minimizing risk of posterior capsule rupture

PURPOSE

To study a preferred technique of phacoemulsification in eyes with posterior polar cataract and report its outcome.

METHODS

Under topical anesthesia, phacoemulsification was carried out after hydrodelination in 23 cases (38 eyes) with ages ranging from 19 to 65 years (mean=33.5 years). Hydrodissection was not performed.

RESULTS

Mean duration of follow-up was 9.5 months. None of the eyes developed posterior capsule rupture, but seven eyes (18.4%) revealed posterior capsule plaque postoperatively, which needed neodymium : YAG laser capsulotomy. Mean visual acuity improved significantly after surgery (P=0.0001, paired t-test); In all, 34 eyes achieved a best-corrected visual acuity of 20/40 or more (89.4%). However, the postoperative visual acuity was less than 20/25 in 11 eyes (28.9%). The causes of the low acuity were amblyopia in eight eyes (21.0%) and macular degeneration due to retinitis pigmentosa in two others (5.2%).

CONCLUSION

Phacoemulsification is an effective and safe method to treat posterior polar cataract with gentle hydrodelination 'hydrodissection free phacoemulsification technique'. This is especially true when great attention is paid to the 'floppy' posterior capsule. Although previous amblyopia might interfere with excellent surgical outcome in patients with a unilateral or highly asymmetric bilateral cataract, visual acuity improved significantly in most cases.

Arthroscopic visualization of the posterior horn of the medial meniscus

We present a method of visualizing the posterior horn of the medial meniscus through the anterolateral portal that has not been previously described in the literature. It allows easy visualization and instrumentation of the posterior horn, an area that commonly has pathology that can be difficult to identify and treat. The technique involves allowing the knee to flex to 60 degrees to 90 degrees over the side of the bed and applying a varus force to the tibia, opening up the posteromedial part of the joint. It does not require any valgus force and therefore minimizes the risk of injury to the medial collateral ligament.

[Rerupture after operation for total Achilles tendon rupture]

BACKGROUND

Over the period 1991-2000 the postoperative treatment of total Achilles tendon ruptures at St. Olav Hospital was changed from plaster cast during 6 weeks to plaster cast during the first 14 days and subsequently orthosis treatment from 2nd to 6th week postoperatively. The purpose of the study was to analyze the treatment of Achilles tendon ruptures at the department with main emphasis on whether there had been an increase in reruptures and, if this was the case, could it be attributed to the change to orthosis treatment postoperatively.

MATERIAL AND METHODS

A questionnaire was mailed to all patients (n = 301) registered in the hospital database during the period 1991-2000 with a diagnosis of rupture of the Achilles tendon.

RESULTS

221 patients returned the questionnaire (73%). In 1991-1995, 16.8% were treated postoperatively with orthosis, compared to 71.9% in 1996-2000. The rerupture frequency had increased from 5.6% to 11.4%, but there was no significant difference in rerupture frequency between those treated with orthosis treated (8.0%) and those treated with plaster only (9.1%). There was no statistically significant difference between the two groups in patient-reported satisfaction with the treatment, nor in the length of sick-leave.

INTERPRETATION

These results do not support the possibility that the tendency towards increased number of reruptures is associated with a change in postoperative treatment with orthosis.

Rupture and perforation of urinary reservoirs made from bowel

A review of the literature involving the rupture or perforation of urinary reservoirs made from the bowel indicates that this complication is perhaps not as rare as commonly perceived. It is a severe complication for which a high index of suspicion needs to be maintained. Physicians attending to patients with such urinary reconstructions should be aware that the diagnosis is often difficult to confirm without resorting to exploratory laparotomy and in particular that a negative cystogram can be misleading. A practical suggestion to help alert these physicians to the possibility of a ruptured urinary reconstruction is that such patients should carry a medical card stating the type of reservoir they have along with their special circumstances. From the reported experiences, it is, however, clear that in carefully selected cases and with vigilant monitoring, some patients may be managed non-operatively.

Endovascular treatment of intracerebral mycotic aneurysm before surgical treatment of infective endocarditis

Mycotic aneurysms are rarely seen in patients who have infective endocarditis, and the management of these patients remains controversial. We present the case of a patient who had infective endocarditis complicated by a mycotic aneurysm of the left middle cerebral artery. There was substantial mitral regurgitation, and Streptococcus viridans was isolated from the blood samples. Dysarthria appeared during the 4th week of the antibiotic therapy, but resolved completely 8 hours after onset. The left middle cerebral artery was embolized with platinum detachable coils. On the 7th day after the radiologic intervention, the native mitral valve was replaced with a 33-mm St. Jude Medical bi-leaflet mechanical mitral prosthesis. Most mycotic aneurysms show notable regression of symptoms with effective antibiotic treatment, and a very few may diminish in size. However it is impossible to predict the response of these aneurysms to therapy. To prevent the perioperative rupture of mycotic aneurysms and intracranial hemorrhage, priority should be given to endovascular interventions to treat cerebrovascular aneurysms in patients such as ours.

Surgical repair of the rotator cuff: a biomechanical evaluation of different tendon grasping and bone suture fixation techniques

OBJECTIVE

This study investigated the initial strength and failure mode of different rotator cuff repair techniques.

BACKGROUND

Full or partial re-rupture of the repair is one of the main post-operative complications for rotator cuff repair. The rate of failure is strongly affected by the extension of the tear, increasing in case of large or massive tears up to 62%.

DESIGN

The study was planned to assess the three individual components of the tendon-to-bone repair (tendon grasping, suture knotting, suture-to-bone fixation) and to identify the best combinations in terms of mechanical strength to failure. The best combinations were tested to compare the mechanical behaviour of the entire repair and suggest potential improvements in the repair technique.

METHODS

Experimental tests were performed using sheep shoulders. Three tendon-grasping techniques, two suture knotting techniques, and the effect of bone augmentation with metallic plate and bone quality on suture-to-bone fixation were investigated.

RESULTS

This study assessed the mechanical behaviour of different repair components. The best combinations of the investigated techniques showed that the weakest link was the tendon-suture interface. More importantly, the compliance of the investigated repairs was large.

CONCLUSIONS

The initial strength of the rotator cuff repair can be improved by changing the repair technique. Nevertheless, even a low physiological load stressing the repaired tendon may cause a gap formation at the tendon-bone interface without necessarily producing failure of the repair.

RELEVANCE

Post-operative protection of the repaired rotator cuff from tension load is necessary to reduce the risk of delaying or preventing of the healing process.

Are the material properties and matrix composition of equine flexor and extensor tendons determined by their functions?

REASONS FOR PERFORMING STUDY

Injury to the superficial digital flexor tendon (SDFT) is common in competition horses. The SDFT contributes to locomotory efficiency by storing energy; such tendons have low safety margins. Tendons which merely position the limb, including the opposing common digital extensor tendon (CDET), are rarely injured. The current failure of strategies to prevent or effectively treat injury to the SDFT indicates the importance of understanding how it differs from tendons which are not injury-prone.

HYPOTHESIS

That the structural and material properties and matrix composition of the SDFT and CDET differ, reflecting their specific functional requirements in vivo.

METHODS

Forelimb tendons were harvested from 26 mature horses and loaded to failure prior to matrix composition analysis of specimens.

RESULTS

The SDFT had a significantly higher cross-sectional area, structural stiffness, failure load and failure strain and a lower elastic modulus than the CDET (P < 0.0001).

CONCLUSIONS

The SDFT has conflicting requirements for strength and elasticity; although as a whole it is a stiffer structure than the CDET, differences in the matrix molecular composition including water and total sulphated glycosaminoglycan contents allow it to remain more elastic as a material.

POTENTIAL RELEVANCE

Further information on how the two tendons attain these different properties may be of use in the development of prevention and treatment strategies for SDFT rupture.

The collagen fibers of the anteroinferior capsulolabrum have multiaxial orientation to resist shoulder dislocation

Instability of the glenohumeral joint can be associated with anteroinferior capsulolabral rupture. To understand its static stabilizing effect better, the collagen fiber orientation of the inferior glenohumeral ligament (IGHL), a component of the anteroinferior capsulolabrum, was studied with a small angle light scattering technique. Three rectangular samples (approximately 11 x 6 mm) were excised from the axillary pouch, one from the anterior band (AB) of the IGHL and one control sample from the long head of the biceps tendon of 7 cadaveric shoulders. The small angle light scattering technique scans the tissue with a helium-neon laser beam and quantifies the fiber alignment based on the resultant scattering pattern. The fiber orientation was quantified by an orientation index, defined as the angle within which 50% of the fibers lie. The axillary pouch had a random orientation, whereas the AB-IGHL was random with some regions of localized alignment. The percentage of tissue with an orientation index range of 25 degrees to 45 degrees was 23.2% +/- 8.5% and 29.0% +/- 13.1% for the axillary pouch and the AB-IGHL, respectively, whereas that for the long head of the biceps tendon was 61.6% +/- 15.2%. This suggests that the collagen fibers in the IGHL are not highly aligned and the anteroinferior capsulolabrum can be modeled as a continuous sheet. Moreover, a biomechanical evaluation of the anteroinferior capsulolabrum that investigates the possibility that the mechanical properties may be directionally independent should be conducted.

Minimizing risk to the capsule during surgery for posterior polar cataract

Posterior polar cataract is associated with a deficiency of the posterior capsule in a high percentage of cases, leading to a high incidence of capsule rupture and potential vitreous loss. We describe an approach that minimizes the risk of vitreous loss. The key is viscodissection, a technique that can be applicable in other situations.

Possible complications of anterior perforation of the vertebral body using cervical pedicle screws

No previous studies have analyzed the possible complications of anterior perforation of the cervical vertebral body with pedicle screws. The objective of this study was to identify the possible implications of an anterior vertebral body perforation. Ten consecutive Euro-American cadavers (C2-C7) were used. The male-to-female ratio was 3:7. The average specimen age was 79.6 years (range: 65-97 years), and average height was 159 cm (range: 155-175 cm). Axial computed tomography scans through the isthmus of pedicles were taken. Five millimeter and 10 mm margins anterior to the vertebral bodies were defined. Within 5 mm anterior to the anterior cortex of the vertebral body, we found mostly muscles (at C2: m. longus colli and pharyngeal constrictors; at C3 and C4: m. scalenus medius, longus colli, pharyngopalatinus and pharyngeal constrictors; at C5 and C6: m. longus colli and longus capitis; and at C7: m. longus colli), except at C3, C4, and C7, where the pharynx and esophagus were within the margin. Between 6 and 10 mm, we found mostly hollow organs (at C2: pharynx and small veins; at C3 and C4: the same muscles as within the 5 mm margin, with addition of the pharynx and some small veins; at C5 and C6: pharynx, pharyngeal constrictors and the thyroid cartilage; and at C7: the esophagus). Except C2, there is no safe zone anterior to the cervical vertebral bodies in the cervical spine, which would allow bicortical purchase of pedicle screws without being close to important surrounding structures.

Prognostic factors in stage I ovarian carcinoma

Most studies on prognostic factors in stage I ovarian carcinoma have been hampered by a relative small number of patients included. In this study we identified the most important independent clinical and pathological prognostic factors in stage I epithelial invasive ovarian carcinoma in a large data base of 1545 patients with stage I epithelial ovarian carcinoma. The patients were treated in 6 different countries but were analysed in the same way. Because of the increasing use of endoscopy to remove possibly malignant cysts and the reports on rapid spread of ovarian carcinoma in the peritoneal cavity after laparoscopic removal of ovarian cancers, special attention was made to the presence and timing of the cysts before or during surgery. The multivariate analyses identified degree of differentiation as the most powerful prognostic indicator of disease-free survival, followed by rupture before surgery, rupture during surgery, International Federation of Gynaecology and Obstetrics (FIGO) 1973 stage and age. When the effects of these factors were accounted for, none of the following were of prognostic value for disease-free survival: histological type, dense adhesions, extracapsular growth, ascites, FIGO stage 1988, and size of tumour. In conclusion, degree of differentiation was the most powerful prognostic indicator in Stage I ovarian cancer and should be used when deciding therapy in clinical practice. We also strongly advocate the inclusion of degree of differentiation in a new FIGO classification of stage I ovarian carcinoma. In addition, rupture before and during surgery, FIGO Stage 1973 (Ib versus Ia) and age were shown to be independent prognostic factors. Hence, every effort should be made to avoid rupture during primary surgery of malignant ovarian tumours confined to the ovaries.

Pleomorphic adenomas of the major salivary glands: a study of the capsular form in relation to surgical management

This was a retrospective study of 126 primary pleomorphic adenomas to correlate capsular characteristics with tumour histopathology in relation to current surgical debate (parotidectomy versus local excision). Capsular thickness was measured by micrometry and tumours classified into subtypes (1-4). Evidence of fine needle aspiration damage (needle tracks, infarction) was sought. Minimal changes were seen in eight tumours. Tumour growth features (bosselations, enveloping) were present in 57% and 33%, respectively, also microinvasion (42%) and tumour 'buds' (12%). Parotid lesions possessed thicker capsules than submandibular tumours. There was little correlation between capsular thickness and cellular structure. The significant exception was large (> 25 mm) hypocellular parotid tumours which had thinner capsules and could be vulnerable to operative rupture. In 110 standard operations (parotidectomy, submandibular gland excision), capsular exposure was evident in 81%. Field irrigation is recommended to lessen the risk of tumour seeding. This study reaffirms many elements of capsular weakness and suggests that parotidectomy is the operation of choice.

Posterior capsule tear with plate-haptic silicone intraocular lens dislocation

We report a case of posterior capsule rupture and posterior dislocation of an intraocular lens (IOL) caused by the tip of a silicone plate-haptic lens. The dislocation occurred during IOL implantation after uneventful phacoemulsification in a patient with a small pupil. Discussed are the possible reasons for the complication and measures to prevent it.

A quick surgical technique for deep, anterior lamellar keratoplasty using visco-dissection

PURPOSE

To describe a new surgical technique for deep, anterior lamellar keratoplasty using a viscoelastic for dissection of Descemet's membrane (DM) from the posterior stroma.

METHODS

Through a paracentesis, aqueous was exchanged by air to visualize the posterior corneal surface-i.e., the air-to-endothelium interface. Using the interface as a reference plane, a 30 gauge needle was inserted into the cornea to just anterior to DM. Viscoelastic was injected to separate DM from the posterior stroma, and a recipient, anterior lamella was excised. A full-thickness donor button was sutured into the recipient bed, after stripping its DM.

RESULTS

In 25 eye bank eyes, the procedure could be completed in 20 eyes; in 5 eyes, DM ruptured during visco-dissection. With light microscopy, dissection depth was located at the level of DM. In two patient eyes the procedure could be completed. In a third patient eye DM ruptured during visco-dissection, and the procedure was converted into a penetrating keratoplasty.

CONCLUSION

Using visco-dissection, a lamellar keratoplasty can be performed quickly, with the donor-to-recipient interface just above the recipient DM, i.e., with a nearly perfect anatomical replacement of all corneal stroma. There is substantial risk of rupture or microperforation of DM during surgery.

Surgical prevention of posterior capsule opacification. Part 2: Enhancement of cortical cleanup by focusing on hydrodissection

PURPOSE

To experimentally analyze the role and efficacy of hydrodissection in achieving maximal cortical cleanup.

SETTING

Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS

Phacoemulsification and irrigation/aspiration were performed in 10 pairs of human eyes (20 eyes) obtained postmortem. Ten eyes had previous hydrodissection and 10 eyes, no hydrodissection. The time (seconds) required for complete lens substance removal in each procedure was measured. In addition, a qualitative evaluation of difficulty of surgery was noted.

RESULTS

Phacoemulsification required 28.6% less time in eyes with previous hydrodissection than in those without. Irrigation/aspiration time was reduced by 50.9% when hydrodissection was performed. The total time of each procedure required for complete evacuation of the capsular bag was reduced by an average of 37.7% in eyes with hydrodissection. Furthermore, qualitatively the procedure was far easier, less stressful, and caused less posterior capsule stress or rupture when copious hydrodissection was performed.

CONCLUSIONS

Hydrodissection enhances the general safety and efficiency of cortical cleanup, especially at 12 o'clock. Hydrodissection is the best available, practical, immediately implementable, and inexpensive means to help remove equatorial E-cells and thus alleviate the incidence of posterior capsule opacification.

Rectus muscle recession and resection without scleral sutures

PURPOSE

To eliminate the risk of scleral perforation during strabismus surgery in susceptible patients, we introduce a technique to allow predictable rectus muscle recession and resection without the placement of scleral sutures.

METHODS

Three patients with thin sclera underwent rectus muscle surgery by use of a double-arm suture technique that avoids placement of sutures directly into the sclera. Two of the patients had esotropia and underwent bilateral lateral rectus muscle resections and a unilateral recess/resect operation, respectively. One of the patients had exotropia and underwent bilateral lateral rectus muscle recessions.

RESULTS

All three patients achieved postoperative alignment to within 15 PD of orthotropia and had no evidence of slipped or lost muscle when examined 2 months postoperatively. The appearance of the ocular surface was excellent in all three cases.

CONCLUSIONS

Predictable and secure rectus muscle recession and resection can be performed without the placement of scleral sutures in patients in whom scleral suturing may be hazardous.

Pregnancy and delivery in Ehlers-Danlos syndrome type V

Ehlers-Danlos syndrome (EDS) is a hereditary dysplasia of connective tissue with an abnormal collagen synthesis. It is characterized by hyperelasticity and fragility of the skin, joint hyperlaxity and fragility of the blood vessels. We describe the problems reported during pregnancy and delivery in women with EDS. Our patient had a type V syndrome. Accurate monitoring during the course of pregnancy is necessary. We believe cesarean section more appropriate than vaginal delivery in order to avoid the risks related to the rupture of the pelvic and perineal vessels which may be difficult to suture.