Showing papers by "Nicola Maffulli published in 2003"
TL;DR: Empirical studies are important when planning prevention programs for tendon injuries because of individual sport cultures and different sport habits in different countries, national epidemiologic studies are of importance in each individual country.
549 citations
TL;DR: Early weightbearing with the ankle plantigrade is not detrimental to the outcome of repair after acute rupture of the Achilles tendon and shortens the time needed for rehabilitation, however, strength deficit and muscle atrophy are not prevented.
Abstract: PurposeTo study the effects of early weightbearing and ankle mobilization after acute repair of ruptured Achilles tendon.Study DesignComparative longitudinal study.MethodsPatients in group 1 were postoperatively immobilized with their ankle in gravity equinus, they were encouraged to bear weight on the operated limb as soon as possible to full weightbearing, and they received a single cast change at 2 weeks, with the ankle accommodated in an anterior splint in a plantigrade position, allowing the ankle to be plantar flexed fully but not dorsiflexed above neutral. Patients in group 2 were immobilized with their ankle in full equinus with a cast change at 2 weeks, when the ankle was immobilized in mid equinus, and at 4 weeks, when the ankle was immobilized in a plantigrade position, and they were advised to bear weight.ResultsPatients in group 1 attended fewer outpatient visits, completely discarded their crutches at an average of 2.5 weeks, and more were satisfied with the results of surgery. At ultrasonog...
265 citations
TL;DR: In patients with tend inopathy of the Achilles tendon with a tender area of intratendinous swelling that moves with the tendon and whose tenderness significantly decreases or disappears when the tendon is put under tension, a clinical diagnosis of tendinopathy can be formulated, with a high positive predictive chance that the tendon will show ultrasonographic and histologic features of Tendinopathy.
Abstract: OBJECTIVE: To evaluate sensitivity, specificity, reproducibility, and predictive value of palpation of the painful arc sign and of the Royal London Hospital test in 10 patients with Achilles tendinopathy and in 14 asymptomatic subjects. DESIGN: Test-retest study. SETTING: University teaching hospital. PARTICIPANTS: Ten male athletes on the waiting list for exploration of one of their Achilles tendons for tendinopathy of the main body of the tendon attended a special clinic. Each was invited to bring at least one athlete of the same sex in the same discipline aged within 2 years of themselves with no history and no symptoms of Achilles tendinopathy. A total of 14 controls were thus recruited. MAIN OUTCOME MEASURES: Pain and tenderness following performance of palpation, the painful arc sign, and the Royal London Hospital test. RESULTS: There were no statistically significant differences at the 5% level among the effects of investigator or between morning and afternoon measurements for any of the three measurement methods. There was no evidence of a difference of the three assessment methods (p > 0.05). When the three methods were combined, the overall sensitivity was 0.586 (confidence interval [CI], 0.469-0.741), and the overall specificity was 0.833 (CI, 0.758-0.889). CONCLUSIONS: In patients with tendinopathy of the Achilles tendon with a tender area of intratendinous swelling that moves with the tendon and whose tenderness significantly decreases or disappears when the tendon is put under tension, a clinical diagnosis of tendinopathy can be formulated, with a high positive predictive chance that the tendon will show ultrasonographic and histologic features of tendinopathy.
199 citations
TL;DR: While there is considerable variation in severe ankle sprain management in UK A&E units, most are treated with the minimal mechanical support of Tubigrip.
Abstract: Objectives: To estimate the incidence of ankle sprains and severe ankle sprains attending accident and emergency (AE to describe current practice for severe ankle sprains in A&E units in the United Kingdom. Methods: Crude age and sex specific incidence rates were calculated for four health districts from cases ascertained from data on seven A&E clinical information systems. Case records of patients with ankle sprains at an A&E unit in another health district were audited and the proportion of severe ankle sprains calculated. UK A&E units were surveyed about their usual treatment of patients with severe ankle sprains. Results: The estimate of the crude incidence rate of ankle sprains was a minimum of 52.7 per 10 000, rising to 60.9 (95% CI 59.4 to 62.4) when figures were adjusted for the proportion of patients without a diagnostic code (13.7%). There were important age-sex differences with unadjusted rates observed from 127.8 per 10 000 (CI 115.5 to 140.0) in girls aged 10–14 years to 8.2 (CI 4.2 to 12.3) in men aged 70–74 years. As 14% of ankle sprains attending A&E were classed as severe, this would equate to 42 000 severe ankle sprains per year in the UK. In the UK wide survey, there was a response rate of 79% (211 of 266). Among the responders, Tubigrip was used routinely in 55%, below knee casts in 3%, and braces in 2%. Boots were not used routinely in any unit. Conclusion: While there is considerable variation in severe ankle sprain management in UK A&E units, most are treated with the minimal mechanical support of Tubigrip.
190 citations
TL;DR: In this article, the authors found that certain joint positions are more likely to place tensile stress on the area of the tendon commonly affected by tendinopathy, and that incorporating different joint positions during stretching exercises may exert more uniform, controlled tensile stresses on these affected areas of tendon and avoid stresshielding.
107 citations
TL;DR: In patients with more advanced degenerative changes, the time from injury to arthroscopy was significantly longer than in patients with lesser articular surface abnormalities, and the presence of a meniscal tear was associated with a greater degree of articular cartilage damage.
Abstract: Purpose: The goal of the study was to report the prevalence of the lesions of the articular cartilage of the femoral condyles and tibial plateau in patients with a symptomatic anterior cruciate ligament (ACL)-deficient knee undergoing day-case arthroscopy. Type of Study: Case series study. Methods: We studied 378 skeletally mature patients (average age, 27.3 years; range, 16–50 years; 282 men and 84 women), part of a sample of 1,978 patients undergoing a primary knee arthroscopy between January 1986 and August 1993. The articular cartilage lesions were classified according to Outerbridge by a single observer. We assessed the relationship between time of injury and articular cartilage lesions and between meniscal lesions and articular cartilage lesions. Results: A complete ACL tear was found in all 378 knees. Of these, 157 showed at least one lesion of the articular cartilage. The medial femoral condyle (MFC) showed the highest frequency of articular cartilage lesions, especially in the weight-bearing portion. Patients with a bucket-handle tear of the medial meniscus had greater degeneration of the MFC than those with other meniscal tears. A meniscal tear was associated with a greater degree of articular damage. The second most common lesion was a combined lesion of the medial and lateral compartments, followed by isolated lateral compartment lesion. A time-dependent pattern of development of articular cartilage lesions was identified. Conclusions: In patients with more advanced degenerative changes, the time from injury to arthroscopy was significantly longer than in patients with lesser articular surface abnormalities, and the presence of a meniscal tear was associated with a greater degree of articular cartilage damage. Patients with a symptomatic ACL-deficient knee and an associated tear of the medial meniscus are at high risk of having a lesion of the articular surface of the weight bearing area of the knee.
107 citations
TL;DR: The role of reamed exchange nailing in the treatment of femoral non-union needs to be re-evaluated after a significant number of patients required additional surgery to achieve union or to deal with complications arising from the exchange nail.
Abstract: We report the results of a single centre prospective study of exchange nailing for aseptic non-union of a femoral fracture. Eighteen patients with 19 aseptic femoral non-unions had exchange nailing performed in our institution. We collected data on mechanism of injury, original fracture type, and indication for exchange nailing, further surgery and major complications. In 11 non-unions (58%), the exchange nail procedure alone resulted in fracture union with a mean time to radiographic union of 9 months (range 3-24 months). The non-union did not heal in five patients, two patients developed an infected non-union, and one patient required dynamisation of the exchange nail. Fracture healing was eventually achieved in 18 non-unions (95%). Complications following exchange nailing occurred in 11 fractures (58%), in which further surgery was required (four repeat exchange nailings, two Ilizarov frame applications and five nail removals). The role of reamed exchange nailing in the treatment of femoral non-union needs to be re-evaluated. Although fracture healing is eventually achieved in most patients, a significant number of them required additional surgery to achieve union or to deal with complications arising from the exchange nailing.
85 citations
Journal Article•
TL;DR: Early weight bearing with the ankle plantigrade is not detrimental to the outcome of repair following rupture of the Achilles tendon.
Abstract: AIM: To study the effects of early weight bearing following acute repair of ruptured Achilles tendon. METHODS: Using a comparative longitudinal study design, following repair of an Achilles tendon rupture, patients in Group 1 were immobilised with their ankle in gravity equinus, were encouraged to weight bear on the operated limb as soon as possible to full weight bearing, and received a single a cast change at 2 weeks, when the ankle was immobilised in a plantigrade position. Patients in Group 2 were immobilised with their ankle in full equinus, and received a cast change at 2 weeks, when the ankle was immobilised in mid equinus, and at 4 weeks, when the ankle was immobilised in a plantigrade position. They were advised to weight bear 4 weeks from the operation. RESULTS: Patients in Group 1 attended less outpatient visits, completely discarded their crutches at an average of 2.5 weeks from the operation (Group 2: average of 5.7 weeks from the operation), (p=0.013), and a greater proportion of them were satisfied with the results of surgery. At ultrasound scan, the average thickness of the repaired tendon was 12.1 mm (SD 2), with no difference in the thickness of the ruptured tendon regardless of the method of postoperative management. There was no significant difference in isometric strength between the two groups of patients. CONCLUSION: Early weight bearing with the ankle plantigrade is not detrimental to the outcome of repair following rupture of the Achilles tendon.
80 citations
78 citations
TL;DR: It is felt that, although surgical management plays an important role in restoring continuity in knee extension and in plantar flexion, functional outcome inevitably relies on patient motivation and a well-established physiotherapy regime.
63 citations
TL;DR: The inflatable expandable nail allows effective management of diaphyseal fractures of the femur and is markedly more expensive than traditional devices, which are not necessary, operative times are reduced, and exposure to ionizing radiation is minimized.
TL;DR: As the risk of injuries sustained by young athletes can be significant, training programmes should take into account their physical and psychological immaturity, so that growing athletes can adjust to their own body’s changes.
Abstract: Sports injuries in children affect both growing bone and soft tissues, and can result in damage of growth mechanisms with subsequent lifelong growth disturbance. During growth, there are significan...
TL;DR: It is maintained that no viable evidence is available to support the contention that sports training adversely effect growth, and those who argue that so called ‘catch-up’ growth observed after reduced or cessation of training provides compelling evidence that growth is affected are wrong.
Abstract: Concern over possible growth inhibition effects of competitive sports has been and continues to be a source of much debate in the scientific literature (3,7,10,21). This is not a new debate. At the beginning of the twentieth century studies in boys, suggested both a stimulatory influence on statural growth and also the potential for negative influences (15). More recently, concerns with regard to potential harmful effects of training on growth have centered on girls, specifically, growth in female gymnasts (21). The concerns now being expressed relate to reports that intensive physical training in gymnasts, whose training is initiated at young ages, may delay subsequent growth and maturation, and perhaps even reduce final adult stature. We maintain that no viable evidence is available to support the contention that sports training adversely effect growth. We disagree with those who argue that so called ‘catch-up’ growth observed after reduced or cessation of training provides compelling evidence that growth is affected (7). However, before discussing the evidence for and against this argument, it should be pointed out that one common element often overlooked is the natural variations in timing and tempo of maturity status observed within a normal healthy population. To understand fully the studies that are about to be discussed one has to first have a clear understanding of the growth process itself.
TL;DR: Several types of randomization including historical controls and pseudorandomization are discussed, as well as methods of treatment allocation, stratification, and minimization techniques.
Abstract: Randomization and blinding are important tools in determining the effectiveness of a new intervention and ensuring the validity of a clinical trial. However, randomness and haphazardness are not equivalent. Randomization cannot overcome poor experimental design or technique. Several types of randomization including historical controls and pseudorandomization are discussed, as well as methods of treatment allocation, stratification, and minimization techniques. The importance of decreasing bias and the advantages and disadvantages of blinding in randomized clinical trials are also covered.
TL;DR: The MacIntosh lateral-substitution over-the-top ACL reconstruction shows results comparable to those of previously reported long-term studies and may be considered in patients needing an intra- and extraarticular reconstruction in whom cosmesis is not an issue.
TL;DR: Preparticipation screening may prevent sudden cardiac deaths in sporting events and using preparticipation screening (PPS) as well as estimating the efficacy of instrumental investigations, adequate prevention can be implemented.
Abstract: Preparticipation screening may prevent sudden cardiac deaths in sporting events
The American Board of Medical Specialties lists sports medicine as a broad area of health care that includes:
1. exercise as an essential component of health care throughout life;
2. medical management and supervision of recreational and competitive athletes and others who exercise on a regular basis;
3. exercise for prevention and treatment of disease and injury.
It combines disciplines from applied physiology to those encompassing clinical, therapeutic, and rehabilitative topics. The preventive aspects of sports medicine are coming of age. Sport is a vehicle for wellbeing and prevention and treatment of diseases, although it can sometimes also represent a risk to health in cases of unacknowledged or asymptomatic pathologies, the most dramatic resulting in sudden cardiac death (SCD) which occasionally strikes apparently healthy athletes.1,2 SCD is a most tragic event, stirring public opinion and commanding a high profile. It is rare, and identifying athletes at risk is a daunting problem. By considering the epidemiology of SCD in athletes and using preparticipation screening (PPS),3–5 as well as estimating the efficacy of instrumental investigations, adequate prevention can be implemented.
Compared with the risk of sudden death in general, the incidence of sports related SCD is low—about 1 event per 100 000 adult athletes per year. The risk increases with age and is more common in men.
There are striking geographical differences. In North America, hypertrophic cardiomyopathy (HCM) is the leading cause of SCD in athletes. In Italy, the most common cause is right ventricular cardiomyopathy. In Germany, there is a high proportion of myocarditis. In China, a major cause is Marfan syndrome. In athletes younger than 35, the most common cause is almost invariably severe coronary artery disease.
A primary goal for prevention should be to identify cardiac pathology …
TL;DR: The objective of this study was to demonstrate the ability to characterize the tremor-like tremor in the knee during the natural course of arthroscopy that is associated with meningitis.
Abstract: Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: pp 203–209
TL;DR: A large number of young athletes train for competitive sport before puberty, yet the understanding of their capabilities to benefit from endurance training is limited, and adequate intensity, type, and duration of training have shown in children the qualitative changes expected from adults.
Abstract: Endurance exercise training enhances exercise tolerance and ultimately improves the performance of young athletes
A large number of young athletes train for competitive sport before puberty, yet the understanding of their capabilities to benefit from endurance training is limited.1,2 Many studies of endurance trainability of children have methodological flaws. Most investigations that have involved adequate intensity, type, and duration of training have shown in children the qualitative changes expected from adults, although children may need a greater exercise intensity than adults to trigger cardiovascular adaptations to training.3
Maximal oxygen uptake (Vo2max) is the key cardiorespiratory determinant of endurance exercise. Not all children and adolescents fulfil the adult criteria of obtaining Vo2max by reaching a plateau in oxygen consumption (Vo2). Peak Vo2, the highest level of Vo2 elicited during an exercise test to exhaustion, is considered a more appropriate index for determining the endurance exercise potential in children.1,2
Another critical variable for endurance performance is anaerobic threshold (AT). In its original concept, AT described the specific level of work below which metabolic acidosis and the associated changes in gas exchange occurred. However, blood lactate levels probably reflect the balance between lactate production and elimination rather than the onset of cellular anaerobiosis. The identification of the threshold point has been circumvented by the use of fixed blood lactate reference levels, although it should be acknowledged that the specific theoretical underpinning of the use of the 4.0 mM level in adults is quite different from that of the classical AT.3 As children can exercise close to exhaustion without exceeding a blood lactate of 4.0 mmol/l, an alternative 2.5 mmol/l level is considered more appropriate.3 The cut off age for when this level is …
01 Jan 2003
TL;DR: It is demonstrated that the clamped-wire system used to suspend bones within an Ilizarov external fixator yields when the perpendicular load exceeds 50 N per wire, in agreement with previous studies.
Abstract: This study demonstrates that the clamped-wire system used to suspend bones within an Ilizarov external fixator yields when the perpendicular load exceeds 50 N per wire. Cyclic loading was applied to tensioned wires clamped within an Ilizarov ring component, with steadily increasing load amplitude. Wires were tested at four initial tension settings. The amount of energy lost within the clamped-wire system per load cycle was calculated for every test. The results showed that there was a consistent trend to increasing non-recoverable energy loss per load cycle when peak loads exceed 50 N for all initial tension settings. A finite element (FE) model replicating the experimental conditions was performed to investigate the levels of stress within the loaded wires. The FE model analyses showed that high stresses were generated in the wires close to the clamping sites, and that the stress levels could reasonably be expected to exceed the material yield stress when loaded to about 55 N, for all initial tension settings. The results show that material yield, accompanied by some wire slippage through the clamps, is responsible for system yield, in agreement with previous studies. Although the initial wire tension has an appreciable effect on the wire stiffness, it did not affect the elastic load range of the clamped-wire system. To prevent yield of the clamped-wire system in practice, the fixator should be assembled with sufficient wires to ensure that the load transmitted to each wire by the patient does not exceed 50 N.
01 Feb 2003
TL;DR: This analysis showed that clamping the wire could be considered to squeeze the wire outwards and so reduce its tension during fixator assembly, highlighting a general engineering problem: how can a tensioned wire be secured to a structure without an appreciable loss of tension.
Abstract: This study demonstrates that clamping a tensioned wire can cause a reduction in wire tension. Tension (about 1275 N) was applied to a wire that was subsequently clamped, using cannulated bo...
Journal Article•
TL;DR: Assessment of the long term clinical and functional results following local flap coverage in 11 patients who developed wound complications after open repair of a ruptured Achilles tendon found local flaps are a reliable means of treating skin defects following open Repair of subcutaneous ruptures of the Achilles tendon.
Abstract: The authors assessed the long term clinical and functional results following local flap coverage (medial plantar flap, peroneal reverse flow island flap, posterior tibial reverse flow flap) in 11 patients who developed wound complications after open repair of a ruptured Achilles tendon. At the latest follow-up, seven patients had achieved a good result, having returned to their pre-injury activities. All patients were able to stand on tiptoes unaided, and were able to walk without aid. In our hands, local flaps are a reliable means of treating skin defects following open repair of subcutaneous ruptures of the Achilles tendon.
01 Feb 2003
TL;DR: Rptured tendons were histologically significantly more degenerated than control tendons and showed different lectin staining properties than nonruptured ones, which may have resulted from posttranslational changes in the extracellular matrix producing alterations in the biochemistry of the tendon.
Abstract: Control and ruptured Achilles tendons underwent lectin staining with Aleuria aurantia, Canavalia ensiformis, Galanthus nivalis, Phaseolus vulgaris, Arachis hypogea, Sambucus nigra, Triticum vulgaris. The mean pathology score of ruptured tendons was significantly greater than that of control Achilles tendons from individuals with no known tendon pathology. Four of the seven lectins used exhibited significantly positive results. Ruptured tendons show different lectin staining properties than non-ruptured ones. This difference may results from post-translational changes in the extracellular matrix producing biochemical alterations which might interfere with the interaction with the lateral sugar residues of the collagen molecules, or cause steric blockade. To ascertain whether lectins could be a useful tool for investigation of the extracellular matrix of degenerated and normal tendons, haematoxylin-eosin stained slides were assessed blindly using a semi-quantitative grading scale for fibre structure; fibre arrangement, rounding of the nuclei; regional variations in cellularity; increased vascularity; decreased collagen stainability; hyalinisation; glycosaminoglycan, with a pathology score giving up to three marks per each of the above variables, with 0 being normal, and 3 being maximally abnormal. For lectin staining with Aleuria aurantia, Canavalia ensiformis, Galanthus nivalis, Phaseolus vulgaris, Arachis hypogea, Sambucus nigra, Triticum vulgaris, assessment of staining on a scale from 0 (no staining) to 5 (strong staining) was performed blindly. The mean pathology sumscore of ruptured tendons (n=14; average age 46.5 years, range 29–61) was significantly greater than the mean pathology score of the control tendons of Achilles tendons from individuals with no known tendon pathology (n=16; average age 62.5 years, range 49–73) (pathology score: 18.5 ± 3.2 vs 6.1 ± 2.3) Four of the seven lectins used exhibited significantly positive results. Ruptured tendons are histologically significantly more degenerated than control tendons. Ruptured tendons show different lectin staining properties than non-ruptured ones. This difference may result from post-translational changes in the extracellular matrix producing alterations in the biochemistry of the tendon which might interfere with the interaction with the lateral sugar residues of the collagen molecules, or cause steric blockade.
TL;DR: Strenuous exercise can reduce 5'-D activity in IBAT in normal environmental conditions and after SCE, and other compensatory mechanisms of heat production are active in exercising rodents.
Journal Article•
TL;DR: A 33-year-old female who sustained metasynchronous (i.e., very close in time) bilateral ruptures of her Achilles tendons with no obvious predisposing factors is presented.
Abstract: Although Achilles tendon ruptures are a common occurrence, bilateral ruptures of the Achilles tendon are not. We present the case of a 33-year-old female who sustained metasynchronous (i.e., very close in time) bilateral ruptures of her Achilles tendons with no obvious predisposing factors. She was treated using a percutaneous technique and six months following surgery has returned to her normal activities.
TL;DR: Measures to modify the present structure of competitive sport should avoid the possible deleterious effects of intensive physical activity on children.
TL;DR: Early fixation of multiple long-bone fractures by intramedullary nailing in polytrauma patients is an acceptable treatment method.
01 Jan 2003
TL;DR: Several types of randomization including historical controls and pseudorandomization are discussed, as well as methods of treatment allocation, stratification, and minimization techniques, and the importance of decreasing bias are covered.
Abstract: Randomization and blinding are important tools in determining the effectiveness of a new intervention and ensuring the validity of a clinical trial. However, randomness and haphazardness are not equivalent. Randomization cannot overcome poor experimental design or technique. Several types of randomization including historical controls and pseudorandomization are discussed, as well as methods of treatment allocation, stratification, and minimization techniques. The importance of decreasing bias and the advantages and disadvantages of blinding in randomized clinical trials are also covered. Key Words: Research methodology—Randomization—Treatment allocation—Bias— Blinding.
Journal Article•
TL;DR: A patient who was referred with a diagnosis of nodular Achilles tendinopathy is presented, and a mass was excised, and histopathology revealed it to be an angioleiomyoma.
Abstract: Angioleiomyoma, a relatively rare tumor of smooth muscle origin, has been reported in many anatomical sites. We present a patient who was referred with a diagnosis of nodular Achilles tendinopathy. At exploration, the mass was excised, and histopathology revealed it to be an angioleiomyoma. Tumoral masses should form part of the differential diagnosis of a subcutaneous lesion on an extremity, particularly the lower limb.
TL;DR: Fundamental statistical concepts and methods frequently used in the analysis of randomized trials, including descriptive statistics, statistical inferences, techniques for the comparison of means or proportions from two samples, correlation, and regression analysis methods are presented.
Abstract: Randomized controlled trials have become the cornerstone of current practice evidence-based medicine. In this article, we present concise descriptions of fundamental statistical concepts and methods frequently used in the analysis of randomized trials. These include descriptive statistics, statistical inferences, techniques for the comparison of means or proportions from two samples, correlation, and regression analysis methods. The uses of these methods are illustrated with a number of practical examples, and the pitfalls of these topics are also briefly discussed. Lastly, some frequently used statistical terms and their meanings are also provided. By the end of the article, the reader should have sufficient knowledge to appreciate the statistical aspects of most clinical trial reports.
TL;DR: The results confirm the important role of 5-HT in thermoregulation, given its peripheral site of action, in modulating heat production controlling intracellular T3 production and may also act peripherally directly on the thyroid and organs containing type II 5'-D, thus controlling energy expenditure through heat production.
Abstract: Serotonin (5-HT) and thyroid hormones are part of a complex system modulating eating behaviour and energy expenditure. 5'-Deiodinase (5'-D) converts the relatively inactive thyroxine (T4) to triiodothyronine (T3), and its activity is an indirect measure of T3 production in peripheral tissues, particularly in the brain, intrascapular brown adipose tissue (IBAT), heart, liver, and kidney. We evaluated the effect of 5-HT on 5'-D activity during basal conditions and after short (30 min) cold exposure (thyroid stimulating hormone stimulation test, TST). 5'-D activity was assessed in the liver, heart, brain, kidney, and IBAT. TST increases 5'-D activity in the brain, heart, and IBAT and decreases it in kidney, leaving it unchanged in the liver. 5-HT alone did not modify 5'-D activity in the organs under study but decreased it in the IBAT, heart, and brain when injected before the TST was administered. Our results confirm the important role of 5-HT in thermoregulation, given its peripheral site of action, in mod...