Showing papers by "Nicola Maffulli published in 2001"

The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy

Abstract: Background—There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy. Objective—To develop and test a questionnaire based instrument that would serve as an index of severity of Achilles tendinopathy. Methods—Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire to assess the severity of Achilles tendinopathy. The final version consisted of eight questions that measured the domains of pain, function in daily living, and sporting activity. Results range from 0 to 100, where 100 represents the perfect score. Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy (n = 45), presurgical patients with Achilles tendinopathy (n = 14), and two normal control populations (total n = 87). Results—The VISA-A questionnaire had good test-retest (r = 0.93), intrarater (three tests, r = 0.90), and interrater (r = 0.90) reliability as well as good stability when compared one week apart (r = 0.81). The mean (95% confidence interval) VISA-A score in the non-surgical patients was 64 (59‐69), in presurgical patients 44 (28‐60), and in control subjects it exceeded 96 (94‐99). Thus the VISA-A score was higher in non-surgical than presurgical patients (p = 0.02) and higher in control subjects than in both patient populations (p<0.001). Conclusions—The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects. The continuous numerical result of the VISA-A questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis. (Br J Sports Med 2001;35:335‐341)

Isokinetic Strength and Anaerobic Power of Elite, Subelite and Amateur French Soccer Players

Abstract: Information about the influence of different practice levels on physical characteristics of a large number of soccer players is lacking. Therefore we assessed muscular strength and anaerobic power of elite, subelite and amateur soccer players to clarify what parameters distinguish the top players from the less successful. We tested 95 soccer players from the French first division (elite), second division (subelite), and amateurs and determined the isokinetic strength of the knee extensor and flexor muscles at angular velocities from -120 degrees x s(-1) to 300 degrees x s(-1). Vertical jump, 10 m sprint, 30 m sprint and maximum ball speed during shooting were also measured. The elite players had higher knee flexor torque than the amateurs at all angular velocities (p < 0.05), except at 300 degrees x s(-1). The hamstring/quadriceps ratios proposed with two different methods were significantly lower in the amateur group than in the elite group (p < 0.05), except at 300 degrees x s(-1). Maximum ball speed during shooting and speed over 30 m sprint were not different between elite, subelite, and amateur players while speed over a 10 m sprint was significantly slower in amateur players and faster in the elite group (p < 0.05). Although performance in soccer is not determined only by measurable variables, professional players differ from amateurs in terms of knee flexor muscle strength and short-distance sprinting speed. Based on these findings we conclude that hamstring strength is extremely important in soccer players for joint stabilization during various tasks, notably in eccentric action. Further, short-sprinting performance may mirror actual game situations at high level and could be an important determinant of match-winning actions.

Ruptured Achilles tendons are significantly more degenerated than tendinopathic tendons.

Abstract: TALLON, C., N. MAFFULLI, and S. W. B. EWEN. Ruptured Achilles tendons are significantly more degenerated than tendinopathic tendons. Med. Sci. Sports Exerc., Vol. 33, No. 12, 2001, pp. 1983–1990. ObjectiveTo ascertain whether there is an association between tendinopathic and ruptured Achilles tendon

Outcome of surgery for chronic achilles tendinopathy : A critical review

Abstract: Achilles tendinopathy is often treated surgically after failure of nonoperative management, but results are not uniformly excellent. We critically assessed the methods of 26 studies that reported surgical outcomes of patients with this condition. Using 10 previously published criteria, and blinded to study outcomes, we derived a "methodology score" (0 to 100) for each study. This score was highly reproducible (r = 0.99, P < 0.01). Scores were generally low concerning the type of study, subject selection process, and outcome measures, which indicates methods deficiency in the way the study was designed, performed, and analyzed. We found a negative correlation between reported success rate and overall methods scores (r = -0.53, P < 0.01), and a positive correlation between year of publication and overall methods score (r = 0.70, P < 0.01). Study methods may influence reported surgical outcome, and we suggest guidelines for improving study design in this area of clinical research. We acknowledge that study methods have improved over the course of the past 20 years.

Complex proximal humeral fractures in adults — a systematic review of management

Abstract: We performed a systematic review of the literature to compare the clinical outcomes of the management of three and four part fractures of the proximal humerus by conservative regimes, internal and external fixations and arthroplasty. We identified 147 reports of comparative trials and case series between 1969 and 1999. We selected only studies dealing exclusively with three and four part fractures of the proximal humerus, with at least 15 patients, treated within 48 h of injury by one of the three modalities studied, in which at least one of the outcomes of interest (pain, range of motion, infection and restoration of anatomy) was described. Also, to be included, studies had to have a follow-up period of at least 6 months, in which a minimum of 85% of patients were followed-up. Twenty four reports met our eligibility criteria. Conservatively managed patients had more pain and a poorer range of motion than those managed by either fixation or arthroplasty. Better restoration of anatomy was delivered in the fixation group. There was no significant difference in the functional range of motion between the arthroplasty and fixation groups, but there were very few studies available to compare infection rates in these two management modalities. The results from the present systematic review suggest that the data from the published literature are inadequate for evidence-based decision making with regards to the treatment of complex proximal humeral fractures.

Peroneus brevis tendon transfer in neglected tears of the Achilles tendon.

Abstract: Background: We present the results of a single-center, single-surgeon study in 59 patients with a fresh (4 women and 23 men; mean age, 43.6 ± 8.8 years) or a neglected (1 woman and 21 men; mean age, 41.3 ± 7.4 years) Achilles tendon rupture. Methods: Patients with a fresh rupture were operated on using end-to-end suture, and patients with a neglected rupture received the tendon of the peroneus brevis as an autologous graft. Patients were assessed during the sixth postoperative week, and during the sixth postoperative month. They were discharged within 1 year after the operation, and were reviewed at an average of 53 ± 13 months after surgery. Results: Patients were generally satisfied with the procedure, but those with a neglected rupture tended to have a greater postoperative complication rate, greater loss of isokinetic strength variables at high speeds, and greater loss of calf circumference. Conclusion: The management of acute and neglected subcutaneous tears of the Achilles tendon by peroneus tendon transfer is safe but technically demanding. It affords good recovery, even in patients with a neglected rupture of 6 weeks' to 9 months' duration. Patients with a neglected rupture are at a slightly greater risk of postoperative complications, and their ankle plantar flexion strength can be reduced.

Epidemiological features of supracondylar fractures of the humerus in Chinese children.

Abstract: We studied 450 children with a supracondylar fracture of the humerus in the period 1991 to 1995, and were able to collect full management details in 403 of them (253 boys and 150 girls). The median age at presentation was 6 years (6.6 years in boys, and 5 years in girls), with the nondominant humerus 1.5 times more commonly injured. Fifteen percent of children presented more than 1 day after the injury. Garland type III fractures constituted 45% of cases, type I 30%, and type II 24%, with flexion type fractures present only in 1% of the children. A nerve injury was associated with the fracture in 19 cases. Although the radial pulse was not palpable at presentation in nine patients, only one child had diminished distal circulation requiring exploration. Concomitant fractures were present in 14 patients. Elbow hyperextension was greater than in a comparable group of noninjured children. Open reduction was necessary in 20% of these children, most being managed by manipulation under anaesthesia, at times associated with percutaneous Kirschner wiring. The hospital stay was 2 days or less in two-thirds of the patients, with more than 90% discharged home within 1 week of admission. In conclusion, many Chinese patients attend hospital later than their Western counterparts, and the rate of flexion-type injuries is low.

Epidemiological features of supracondylar fractures of the humerus in Chinese children.

Abstract: We studied 450 children with a supracondylar fracture of the humerus in the period 1991 to 1995, and were able to collect full management details in 403 of them (253 boys and 150 girls). The median age at presentation was 6 years (6.6 years in boys, and 5 years in girls), with the nondominant humerus 1.5 times more commonly injured. Fifteen percent of children presented more than 1 day after the injury. Garland type III fractures constituted 45% of cases, type I 30%, and type II 24%, with flexion type fractures present only in 1% of the children. A nerve injury was associated with the fracture in 19 cases. Although the radial pulse was not palpable at presentation in nine patients, only one child had diminished distal circulation requiring exploration. Concomitant fractures were present in 14 patients. Elbow hyperextension was greater than in a comparable group of noninjured children. Open reduction was necessary in 20% of these children, most being managed by manipulation under anaesthesia, at times associated with percutaneous Kirschner wiring. The hospital stay was 2 days or less in two-thirds of the patients, with more than 90% discharged home within 1 week of admission. In conclusion, many Chinese patients attend hospital later than their Western counterparts, and the rate of flexion-type injuries is low.

Subtrochanteric fractures. A review of treatment options.

Abstract: Subtrochanteric fractures of the femur were originally grouped with comminuted intertrochanteric fractures. However, they pose their own distinct management problems mainly due to biomechanical differences in stability and are now considered separately. There are several classification systems but the most widely accepted is the one proposed by Seinsheimer in 1978. Many different methods have been employed in the management of this group of fractures with varying rates of success. The management has altered as new implants have been developed to try to overcome the shortfalls of the existing implants. This study is a review of the literature and was carried out using Medline and the Cochrane Library to look at the management methods employed in the past and today. Most of the published articles are retrospective uncontrolled reports of the results of management and it is difficult to suggest management principles from them. The other main shortcoming is that, although there are several devices available on the market for the management of these fractures, most of the literature concerns one or two of them. The results reported examine union rates and failure of implants leading to reoperation. This is a crude outcome measure, and there is very little in the literature regarding patient function. In order to provide evidence-based advice on the best management options for these difficult fractures, future studies should be designed as randomized controlled trials and place more emphasis on studying patients' outcomes.

A Review of Treatment Options

Abstract: Subtrochanteric fractures of the femur were originally grouped with comminuted intertrochanteric fractures. However, they pose their own distinct management problems mainly due to biomechanical differences in stability and are now considered separately. There are several classification systems but the most widely accepted is the one proposed by Seinsheimer in 1978. Many different methods have been employed in the management of this group of fractures with varying rates of success. The management has altered as new implants have been developed to try to overcome the shortfalls of the existing implants. This study is a review of the literature and was carried out using Medline and the Cochrane Library to look at the management methods employed in the past and today. Most of the published articles are retrospective uncontrolled reports of the results of management and it is difficult to suggest management principles from them. The other main shortcoming is that, although there are several devices available on the market for the management of these fractures, most of the literature concerns one or two of them. The results reported examine union rates and failure of implants leading to reoperation. This is a crude outcome measure, and there is very little in the literature regarding patient function. In order to provide evidence-based advice on the best management options for these difficult fractures, future studies should be designed as randomized controlled trials and place more emphasis on studying patients’ outcomes.

Magnetic resonance imaging after operative repair of Achilles tendon rupture

Abstract: We performed a magnetic resonance imaging (MRI) study in 16 consecutive patients who had undergone open repair of a unilateral Achilles tendon rupture (ATR) at an average of 32.5 (SD 3.2) (range 29-36) months from the operation. We measured the widest antero-posterior diameter of the tendon, the longest distance between the insertion of the Achilles tendon on the calcaneum and the musculo-tendinous junction of the soleus muscle on the Achilles tendon, the distance between the insertion of the Achilles tendon on the calcaneum and the point of maximal width of the tendon. We also ascertained whether areas of altered signal were present in and around the tendon. The operated tendons were always significantly thicker than the non-operated ones. There was a non-significant trend for the other measurements to be greater in the operated tendons. In five patients, areas of dishomogeneous signal were present in the operated tendon. These areas were less than 25% of the antero-posterior diameter of the tendon, and were clinically silent. These findings probably represent normal features of long-term tendon healing following open repair of an ATR.

Intra-articular hyaluronic acid following knee immobilisation for 6 weeks in rabbits.

Abstract: Thirty-two mature female New Zealand White rabbits were immobilised in an aluminium splint on one knee, using the contralateral non-treated knee as control. After 6 weeks the splints were removed and the rabbits allowed unrestricted movement. On a random basis, 16 rabbits were given an intra-articular injection of 5 mg in 0.5 ml of hyaluronic acid (HA) in the knee of the immobilised hindlimb at weekly intervals for 6 weeks, starting 1 week after the joint had been remobilised, for a total of six injections. In the other 16 rabbits no further intervention was conducted. At the end of the experiment the rabbits were killed, the area of degenerated joint surface of the distal femur, and water and proteoglycan content were measured, and the articular cartilage stained with haematoxylin and eosin and safranin O. Remobilisation without HA administration resulted in a significantly larger degenerated joint surface area. By the end of the experiment both remobilisation and remobilisation and intra-articular HA injections had produced a greater but non-significant water cartilage content compared to the control side. The average cartilage glycosaminoglycan content of the remobilisation and intra-articular HA injection group was significantly greater than in the remobilisation group. In conclusion, in the rabbits with one knee immobilised for 6 weeks, 6 weeks of remobilisation alone are not sufficient to recover from the moderate articular surface changes produced, and the intra-articular administration of HA may produce a morphologically and biochemically more normal cartilage. More extensive animal and human studies should be performed before the routine use of intra-articular administration of HA following musculoskeletal injuries that required immobilisation can be recommended.

Muscle transplant in the rabbit's Achilles tendon.

Abstract: BENAZZO, F., G. STENNARDO, M. MOSCONI, G. ZANON, and N. MAFFULLI. Muscle transplant in the rabbit's Achilles tendon. Med. Sci. Sports Exerc., Vol. 33, No. 5, 2001, pp. 696-701. Achilles tendinopathy (AT) is a degenerative disorder resulting from functional overload, especially during running and jumping, with some inflammatory features at the insertions, bursae, and paratenon. The Achilles tendon is poorly vascularized, especially in the middle third, and the consequent slow metabolic rate allows it to work at very low oxygen tensions but prevents on the other hand a rapid healing. Purpose: To create an animal model to study a novel surgical technique employed in AT: transplanting some fibers of the soleus muscle into the tendon in order to improve its vascularization and healing and to study the histological appearance of the soleus graft incorporated in the tendon. Methods: We operated on 10 white New Zealand rabbits (eight rabbits underwent the procedure, two rabbits the sham operation with incision of the tendon without graft). Two animals were euthanized at 1 wk, 1, 2, and 3 months. Results: Histology showed that after 3 months the muscle fibers were still viable within the tendons, interspersed within connective tissue fibers. Tendon and muscle tissues were intimately fused. Conclusions: The persistence of the soleus muscle pedicle graft within the Achilles tendon tissue is an index of sound blood supply. This surgical model is suitable for application in further studies on tendon healing.

Epiphyseal injuries of the proximal phalanx of the hallux.

Abstract: Fractures of the growth plate are unique in childhood, and constitute approximately 20% of all pediatric fractures. Most of these type of fractures heal without permanent deficits, although some are complicated by growth arrest and deformity. The risk of growth disturbances depends on the type of fracture, its location, the age of the patient, the vascularization to the epiphysis, the state of the surrounding soft tissues, and whether the injury is open or closed. Salter-Harris type III and IV are intraarticular fractures and extend from the joint surface through the epiphysis, the epiphyseal growth plate, and, in type IV, through the metaphysis, and are classically considered to have a poorer prognosis than Salter-Harris type I and II injuries. Often, surgical reduction is required to prevent shortening or angulation. Epiphyseal fractures of the foot are uncommon, and only rarely are the phalanges involved. If the digits are involved, the fractures typically occur at the distal metatarsals or proximal phalanges. We report the long-term results of operative or conservative management of type III epiphyseal fractures at the proximal phalanx of the hallux in young athletes.

Surgical management of radial head fractures.

Abstract: Objective: To compare the outcome of various surgical options exercised in the management of different types of radial head fractures. Method: A retrospective study of 29 patients with radial head fractures managed surgically was undertaken. Case notes were retrieved, and final assessment was performed through a telephone questionnaire. The results were analysed according to the classification of Wesley et al (1983), and compared with the patients' own rating. Results: The best results were obtained in Mason type II fractures, followed by type III and type IV fractures. Comparing different operations, the best outcome was observed with screw fixation, followed by excision of the radial head, Kirschner wire fixation, partial excision, silastic implant, and plating, in that order. Conclusion: The less comminuted a radial head fracture is, the better the outcome. Screw fixation is to be preferred, if technically possible. Our method of outcome assessment closely reflected in patient satisfaction.

Distraction lengthening of the radius for radial longitudinal instability after distal radio-ulnar subluxation and excision of the radial head: a case report.

Abstract: The results of late surgery for symptomatic proximal migration of the radius after resection of the radial head for trauma are usually disappointing. Ulnar variance increases when the interosseous membrane is disrupted. Its integrity should be assessed to predict the results of further surgery. We describe a 29-year-old patient in whom distraction lengthening of the radius through an Ilizarov frame allowed him to regain pain-free function of the wrist and elbow after a complex Essex-Lopresti fracture dislocation and late symptoms of ulnar carpal impingement.

Anterior knee pain : an overview of management options

Abstract: The term ‘anterior knee pain’ includes all pain-related problems of the anterior portion of the knee, and covers terms such as chondromalacia patella, patellofemoral arthralgia, patellar pain, patellar pain syndrome, and patellofemoral pain. Therefore, after excluding anterior knee pain resulting from intra-articular pathologies, patellar tendinopathy, peripatellar bursitis, the plica syndrome, Sinding Larsen’s and Osgood Schlatter’s lesions, and other rarely occurring conditions, the remaining patients with a clinical presentation of anterior knee pain can be diagnosed with patellofemoral pain syndrome (PFPS). All such patients experience pain, but patients also report other symptoms, and it is therefore appropriate to talk of PFPS.

Pathology of chronic achilles-tendon injuries in athletes

Abstract: Overuse tendon conditions have traditionally been considered to result from an inflammatory process and were treated as such. Microscopic examination of abnormal Achilles-tendon tissues, however, reveals a non-inflammatory degenerative process. The histopathology found in surgical specimens in patients with chronic overuse Achilles tendinopathy and those with Achilles-tendon rupture are reviewed. Seminal studies suggest that so-called tendinitis is a rare condition that might occur occasionally in the Achilles tendon in association with a primary tendinosis. These data have clinical implications and require a review of the traditional classification of pathologies seen in tendon conditions, The authors recommend that nomenclature be based on histopathological findings rather than traditional hypothesis.

Subungual glomus tumor of the hallux. A case report

Abstract: The authors report a rare case of subungual glomus tumor in the right hallux, which was excised with complete relief of symptoms. They provide a brief description of histological features and review the literature.

Information About Knee Injuries on the Internet

Abstract: We wished to explore the volume and accessibility of information about anterior cruciate ligament (ACL) and meniscal injuries on the Internet. One hundred patients attending a Sports Trauma NHS outpatient clinic were surveyed to determine Internet use and to identify the terms that the patients used to describe their injuries. These search terms were used to conduct an extensive Internet search on five search engines for information about ACL and meniscal injuries. It emerged that 40% of patients attending outpatient clinic had searched the Internet. Over half of this patient group (58%) stated they would consider using the Internet to retrieve information about their medical condition. A total of 5947 web pages were accessed and categorised according to content. Only 393 (7%) pages contained information relevant to ACL and meniscal injuries. It appears that the number of patients using the Internet to retrieve information on their condition is increasing. As patients usually have no skills in information retrieval and the amount of information retrieved using layman's terms is negligible, their access to reliable and valid web sites containing medical information should be facilitated. Language: en