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Showing papers by "Nicola Maffulli published in 2006"


Journal Article
TL;DR: The structure of tendons is described, the process of tendon healing is an indivisible process that can be categorized into three overlapping phases for descriptive purposes, and the pathophysiology of tendon injury and healing is reviewed.
Abstract: Tendon disorders are frequent, and are responsible for much morbidity both in sport and the workplace. Although the presence of degenerative changes does not always lead to symptoms, pre-existing degeneration has been implicated as a risk factor for acute tendon rupture. The term tendinopathy is a generic descriptor of the clinical conditions in and around tendons arising from overuse. The terms "tendinosis" and "tendinitis/tendonitis" should only be used after histopathological examination. Disordered healing is seen in tendinopathy, and inflammation is not typically seen. In acute injuries, the process of tendon healing is an indivisible process that can be categorized into three overlapping phases for descriptive purposes. Tendon healing can occur intrinsically, via proliferation of epitenon and endotenon tenocytes, or extrinsically, by invasion of cells from the surrounding sheath and synovium. Despite remodeling, the biochemical and mechanical properties of healed tendon tissue never match those of intact tendon. Tendon injuries account for considerable morbidity, and often prove disabling for several months, despite what is considered appropriate management. Chronic problems caused by overuse of tendons probably account for 30% of all running-related injuries, and the prevalence of elbow tendinopathy in tennis players can be as high as 40%. The basic cell biology of tendons is still not fully understood, and the management of tendon injury poses a considerable challenge for clinicians. This article describes the structure of tendons, and reviews the pathophysiology of tendon injury and healing.

732 citations


Journal ArticleDOI
TL;DR: A systematic review of the literature on the frequency and characteristics of sports related growth plate injuries affecting children and youth in organised sport found most physeal injuries appeared to resolve with treatment and rest.
Abstract: A systematic review of the literature on the frequency and characteristics of sports related growth plate injuries affecting children and youth in organised sport was carried out. Both acute and chronic physeal injuries related to participation in sports have been reported to occur, although injury incidence data are somewhat limited. Of particular concern is the growing number of stress related physeal injuries, including those affecting the lower extremities. Although most physeal injuries appeared to resolve with treatment and rest, there is also evidence of growth disturbance and deformity. Possible injury risk factors and countermeasures are discussed, and suggestions for directing future research provided.

311 citations


Journal ArticleDOI
TL;DR: In the UK, an estimated 302,000 ankle sprains are seen each year in Accident and Emergency Departments as discussed by the authors, accounting for 85% of all all ankle sprain injuries.
Abstract: Lateral ankle sprains account for 85% of all ankle sprains. This common injury is most frequently sustained during sporting activity. The ATFL is the weakest of the lateral ankle ligament complex, and is most frequently injured. Ankle sprains are often undertreated, resulting in chronic pain, muscular weakness, and instability. The consequence of this common injury for professional sports clubs is days lost in training and matches missed due to injury as well as the cost of rehabilitation. In the UK, an estimated 302,000 ankle sprains are seen each year in Accident and Emergency Departments.

310 citations


Journal ArticleDOI
TL;DR: This review will assist in targeting the relevant groups and in designing future research on the epidemiology of pediatric sports injuries and well-designed descriptive and analytical studies are needed to identify the public health impact of pediatric sport injury.
Abstract: OBJECTIVE:: To provide a critical review of the available literature on the descriptive epidemiology of pediatric sport-related injuries. DATA SOURCES:: MEDLINE (1966 to 2006) and SPORTDiscus (1975 to 2006) were searched to identify potentially relevant articles. A combination of medical subject headings and text words was used (epidemiology, children, adolescents, athletic injuries, sports, injury, and injuries). Additional references from the bibliographies of retrieved articles were also reviewed. STUDY SELECTION:: Published research reports on the incidence and distribution of injury in children's and youth sports. Specific emphasis was placed on reviewing original studies, which report incidence rates (rate of injuries per unit athlete time). Forty-nine studies were selected for this review. DATA EXTRACTION:: Data summarized include incidence of injury relative to who is affected by injury (sport, participation level, gender, and player position), where injury occurs (anatomical and environmental location), when injury occurs (injury onset and chronometry), and injury outcome (injury type, time loss, clinical outcome, and economic cost). DATA SYNTHESIS:: There is little epidemiological data on injuries for some pediatric sports. Many of the studies retrieved were characterized by methodological short-comings and study differences that limit interpretation and comparison of findings across studies. Notwithstanding, the studies reviewed are encouraging and injury patterns that should be studied further with more rigorous study designs to confirm original findings and to probe causes of injury and the effectiveness of preventive measures. CONCLUSIONS:: Incidence and severity of injury are high in some child and youth sports. This review will assist in targeting the relevant groups and in designing future research on the epidemiology of pediatric sports injuries. Well-designed descriptive and analytical studies are needed to identify the public health impact of pediatric sport injury. Language: en

223 citations


Journal ArticleDOI
TL;DR: In this article, the authors characterize the phenotype of human Achilles tenocytes and assess how this is affected by passaging, showing that the phenotype rapidly drifts with progressive passage, and that cells became more rounded, were more widely spaced at confluence, and confluent cell density declined from 18,700/cm2 to 16,100/ cm2.
Abstract: Tendon ruptures are increasingly common, repair can be difficult, and healing is poorly understood. Tissue engineering approaches often require expansion of cell numbers to populate a construct, and maintenance of cell phenotype is essential for tissue regeneration. Here, we characterize the phenotype of human Achilles tenocytes and assess how this is affected by passaging. Tenocytes, isolated from tendon samples from 6 patients receiving surgery for rupture of the Achilles tendon, were passaged 8 times. Proliferation rates and cell morphology were recorded at passages 1, 4, and 8. Total collagen, the ratio of collagen types I and III, and decorin were used as indicators of matrix formation, and expression of the integrin beta1 subunit as a marker of cell-matrix interactions. With increasing passage number, cells became more rounded, were more widely spaced at confluence, and confluent cell density declined from 18,700/cm2 to 16,100/cm2 ( p = 0.009). No change to total cell layer collagen was observed but the ratio of type III to type I collagen increased from 0.60 at passage 1 to 0.89 at passage 8 ( p < 0.001). Decorin expression significantly decreased with passage number, from 22.9 +/- 3.1 ng/ng of DNA at passage 1, to 9.1 +/- 1.8 ng/ng of DNA at passage 8 ( p < 0.001). Integrin expression did not change. We conclude that the phenotype of tenocytes in culture rapidly drifts with progressive passage.

221 citations


Journal ArticleDOI
TL;DR: Monitoring of creatine kinase and lactate dehydrogenase can reveal the state of the muscle and its biochemical adaptation to physical load.
Abstract: Monitoring of creatine kinase and lactate dehydrogenase can reveal the state of the muscle and its biochemical adaptation to physical load

109 citations


Journal ArticleDOI
TL;DR: If an anatomical approach is used, reattachment of the superior retinaculum is a most appropriate technique that returns patients to a high level of physical activity and gives a high rate of satisfactory results both objectively and subjectively.
Abstract: Background: Recurrent peroneal tendon subluxation is uncommon.Hypothesis: The authors tested the null hypothesis that there are no differences between preoperative and postoperative status after anatomical repair of the superior peroneal retinaculum.Study Design: Case series; Level of evidence, 4.Methods: In the period 1996 to 2001, the authors operated on 14 patients (all men; mean age, 25.3 ± 6.3 years; range, 18-37 years) with traumatic recurrent unilateral peroneal tendon subluxation, with a follow-up of 38 ± 3 months (range, 22-47 months).Results: No patient experienced a further episode of peroneal tendon subluxation, and all had returned to their normal activities. Maximum calf circumference, functional ability, peak torque, total work, and mean power of plantar flexion were always lower in the operated leg, but the differences did not reach statistical significance. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score increased significantly from 54.3 ± 11.4 to 94.5 ± 6.4 (P ...

98 citations


Journal ArticleDOI
TL;DR: The augmented reconstruction technique of ATFL and CFL with a semitendinosus tendon allograft through a peroneal bone tunnel fixed with biodegradable anchors is described and advocated as a safe, effective method to manage lateral ankle instability.
Abstract: The management of chronic lateral instability of the ankle remains controversial. In general, the anterior talofibular ligament (ATFL) must be reconstructed in all patients. Some will also need reconstruction of the calcaneofibular ligament (CFL) (or its function) to regain stability of both the ankle and the subtalar joints, and to avoid recurrence of instability. After reconstruction, most authors report good to excellent results in 80% to 85% of patients. We describe the augmented reconstruction technique of ATFL and CFL with a semitendinosus tendon allograft through a peroneal bone tunnel fixed with biodegradable anchors, and advocate this procedure as a safe, effective method to manage lateral ankle instability.

86 citations


Journal ArticleDOI
TL;DR: Tenocytes from tendons from patients with calcific insertional Achilles tendinopathy exhibit chondral metaplasia, and produce abnormally high quantities of collagen type II and III.
Abstract: Objective To ascertain whether tendon samples harvested from patients with calcific insertional Achilles tendinopathy showed features of failed healing response, and whether abnormal quantities of type II collagen had been produced in that area by these tenocytes. Design Comparative laboratory study. Design University teaching hospitals. Patients Tendon samples were harvested from eight otherwise healthy male individuals (average age 47.5±8.4 years, range 38 to 60) who were operated for calcific insertional Achilles tendinopathy and from nine male patients who died of cardiovascular events (mean age 63.1±10.9 years) while in hospital. Interventions Open surgery for calcific insertional Achilles tendinopathy. Main Outcome Measure Semi-quantitative histochemical, immunohistochemical, and immunocytochemical methods to ascertain whether tendinopathic tendons were morphologically different from control tendons, and whether abnormal types of collagen were produced. Results Tenocytes from tendons from patients with calcific insertional Achilles tendinopathy exhibit chondral metaplasia, and produce abnormally high quantities of collagen type II and III. Conclusions The altered production of collagen may be one reason for the histopathological alterations described in the present study. Areas of calcific insertional Achilles tendinopathy have been subjected to abnormal loads. These tendons may be less resistant to tensile forces. Further studies should investigate why some tendons undergo these changes.

81 citations


Journal ArticleDOI
TL;DR: Chronic tendinopathy may well be the final manifestation of a long-standing metabolic process in which inflammation, although an initiator, does not participate in the final histopathologic and biochemical features of chronic tendinopathies.
Abstract: Tendinopathy, a broad term used to describe disorders in and around tendons, 1,2 is associated with repetitive tensile forces exerted on tendons. Rapid increases in the duration and intensity of these forces may cause tendon injuries, possibly the starting point in the pathogenesis of chronic tendinopathy. The exact incidence of chronic tendinopathy is unknown given the vast population of professional and recreational athletes suffering from this condition at different anatomic sites. Studies on incidence of tendinopathies are usually site or sport specific, and only provide an approximation of the magnitude of the problem faced by musculoskeletal and sports medicine clinicians in treating this disorder. In addition, a large number of sedentary subjects develop tendinopathy with no apparent history of increased physical activity. Disorganized, haphazard healing, with frayed, separated, and otherwise disrupted collagen fibrils, are features of tendinopathy. These lesions are characterized by the absence of inflammatory cells and a poor healing response. Age-related tendon changes, and not just mechanical overload, may thus play a role in the pathogenesis of tendinopathy, although the exact etiologic, pathophysiologic, and healing mechanisms are still unknown. Gene expression studies have shown an absence of any inflammatory process in chronic Achilles tendinopathy. Microdialysis experiments have shown no evidence of intratendinous chemical inflammation, with prostaglandin E2 (PGE2) levels being normal in chronic tendinopathies. Microdialysis has also shown higher levels of glutamate, an excitatory neurotransmitter and a potent modulator of pain in the central nervous system, in tendinopathic tendons compared with normal tendons. The same technique reveals that the local concentration of lactate in the tendinopathic Achilles tendon is almost twice that of the normal Achilles tendon. It is possible that there is an ischemic component in the pathogenesis of tendinopathy. Ischemia may precede the start of tendinopathy, but examination of tendinopathic lesions reveals neovascularization and increased blood flow in the affected area of the tendon. Neovascularization may be a response to a primary injury or may be the result of a metabolic disorder. It is possible that anaerobic conditions exist in areas of tendinopathy that have a poor blood supply, and are the primary cause of neovascularization. Neovessels and their accompanying nerves, may be responsible for the pain in the tendinopathic tendon, which would account for the success of local injection of sclerosants such as Polidocanol in the management tendinopathy. Chronic tendinopathy may well be the final manifestation of a long-standing metabolic process in which inflammation, although an initiator, does not participate in the final histopathologic and biochemical features of chronic tendinopathy. It is important in understanding this hypothesis to recall the mechanism of tendon healing. A tendon heals by undergoing inflammatory (1–7 days of injury), proliferative (7–21 days), and remodeling (3 weeks–1 year) phases. Despite collagen maturation and remodeling, tendons are biochemically and metabolically less active than bone and muscle. Type III collagen synthesized by fibroblasts in the proliferative phase is gradually replaced by type I collagen from days 12 to 14, with a progressive increase in tensile strength.

78 citations


Journal ArticleDOI
TL;DR: Nonathletic subjects experience more prolonged recovery, more complications, and a greater risk of further surgery than athletic subjects with recalcitrant Achilles tendinopathy.
Abstract: Objective To report the outcome of surgery for chronic recalcitrant Achilles tendinopathy in nonathletic and athletic subjects. Design Case-control study. Setting University teaching hospitals. Patients We matched each of the 61 nonathletic patients with a diagnosis of tendinopathy of the Achilles tendon with an athletic patient with tendinopathy of the main body of the Achilles tendon of the same sex and age (±2 years). A match was possible for 56 patients (23 males and 33 females). Forty-eight nonathletic subjects and 45 athletic subjects agreed to participate. Interventions Open surgery for Achilles tendinopathy. Main Outcome Measure Outcome of surgery, return to sport, complication rate. Results Nonathletic patients were shorter and heavier than athletic patients. They had greater body mass index, calf circumference, side-to-side calf circumference differences, and subcutaneous body fat than athletic patients. Of the 48 nonathletic patients, 9 underwent further surgery during the study period, and only 25 reported an excellent or good result. Of the 45 athletic subjects, 4 underwent further surgery during the study period, and 36 reported an excellent or good result. The remaining patients could not return to their normal levels of activity. In all of them, pain significantly interfered with daily activities. Conclusions Nonathletic subjects experience more prolonged recovery, more complications, and a greater risk of further surgery than athletic subjects with recalcitrant Achilles tendinopathy.

Journal ArticleDOI
TL;DR: The retrofibular groove is formed not by the concavity of the fibula itself, but by a relatively pronounced ridge of collagenous soft tissue blended with the periosteum that extends along the posterolateral lip of the distal fibula.
Abstract: Recurrent peroneal tendon subluxation is an uncommon sports-related injury. The retrofibular groove is formed not by the concavity of the fibula itself, but by a relatively pronounced ridge of collagenous soft tissue blended with the periosteum that extends along the posterolateral lip of the distal fibula. The shape of the groove is primarily determined by this thick fibrocartilagenous periosteal cushion, and not by the bone itself. The superior peroneal retinaculum is extremely variable in width, thickness and insertional patterns. Peroneal tendon subluxation is commonly associated with longitudinal splits in the peroneus brevis tendon and lateral ankle instability. Disruption of the lateral collateral ankle ligaments places considerable strain on the superior peroneal retinaculum. This explains why the two conditions commonly coexist. In recurrent subluxation, patients usually give a history of previous ankle injury, which may have been misdiagnosed as a sprain. An unstable ankle that gives way or is associated with a popping or snapping sensation is another common complaint. The peroneal tendons may actually be seen subluxing anteriorly on the distal fibula during ambulation. The role of imaging has been debated, and the diagnosis and management plan are based on clinical evidence. Conservative management may be attempted in acute dislocations, and can be successful in up to 50% of patients, although there is a trend for operative management in athletes. Recurrent dislocations should be managed surgically. Five basic categories of repair have been described: (i) anatomical reattachment of the retinaculum; (ii) bone-block procedures; (iii) reinforcement of the superior peroneal retinaculum with local tissue transfers; (iv) rerouting the tendons behind the calcaneofibular ligament; and (v) groove deepening procedures. However, it is impossible to determine from the relatively small series which procedure is superior. If an anatomical approach to treating the pathology is utilised, reattachment of the superior retinaculum seems a most appropriate technique. Randomised controlled trials may be the way forward in determining the best surgical management method. However, the relative rarity of the condition and the large number of techniques described make such study difficult.

Journal ArticleDOI
TL;DR: Hyperthermia at 434 MHz appears safe and effective in the short term for the management of supraspinatus tendinopathy.
Abstract: BackgroundHyperthermia has been introduced as a physical therapy modality for soft tissue injuriesHypothesisThe authors tested the null hypothesis that there are no short-term differences after the use of hyperthermia, ultra-sound, and exercises for tendinopathy of the supraspinatus tendonStudy DesignRandomized controlled trial; Level of evidence, 1MethodsThe authors studied 37 athletes (29 men, 8 women; mean age, 267 ± 58 years; range, 19-43 years) with supraspinatus tendinopathy who had had symptoms between 3 and 6 months Subjects were randomly assigned to 3 groups Group A (n = 14) received hyperthermia at 434 MHz Group B (n = 12) received continuous ultrasound at 1 MHz at an intensity of 20 w/cm23 times a week Group C (n = 11) undertook exercises, consisting of pendular swinging and stretching exercises 5 minutes twice a day every day All interventions were undertaken for 4 weeks Subjects were evaluated at baseline, immediately on completion of treatment, and at 6 weeks after the end of the

Journal ArticleDOI
TL;DR: There is agreement among orthopedic surgeons on the role of ICPs for diagnosis and the choice of fasciotomy as a first-line surgical procedure, but there is a divergence of opinions regarding the ICP diagnostic thresholds, the roles of conservative management and the surgical techniques for fAsciotomy and failure of decompression.
Abstract: ObjectiveTo investigate current practice in the diagnosis and management of chronic exertional compartment syndrome (CECS) of the lower leg among orthopedic surgeons in the United Kingdom.DesignQuestionnaire survey.SettingSecondary care (NHS and private).ParticipantsTwo hundred six orthopedic surgeo

Journal ArticleDOI
TL;DR: The range of motion-edema-stress radiographs classification that is proposed evaluates the severity of lateral ankle injuries, is an easy and practical method, and predicts full return in athletic activities without residual complaints, if the proper rehabilitation program is executed.
Abstract: We present a longitudinal observational study on classification of acute lateral ankle ligament injuries in track and field athletes, based on objective criteria. These very common and sometimes troublesome sports injuries are treated functionally, but there is a lack in international literature on predicting the time needed for full recovery. Taking into consideration (1) active range of motion, (2) edema, (3) stress radiographs findings, and (4) full rehabilitation time, we divided grade III sprains in IIIA and IIIB, proposing that these injuries can be classified in four categories (I, II, IIA, IIIB). The range of motion-edema-stress radiographs classification that we propose evaluates the severity of lateral ankle injuries, is an easy and practical method, and predicts full return in athletic activities without residual complaints, if the proper rehabilitation program is executed.

Journal ArticleDOI
TL;DR: Conservative management of chronic ankle instability can be a viable option in selected patients and failure of conservative management can be an indication for surgery if morbidity warrants it.
Abstract: The mechanism of injury of lateral ankle sprains is usually a forced inversion injury with the tibiotalar joint in plantar flexion. Up to 20% of lateral ankle sprains progress to functional instability [1]. Inversion injuries of the ankle account for up to 25% of all musculoskeletal injuries [2]. Despite the high incidence, there is still some contention about the optimal method of management. Proposed management modalities include surgical repair/reconstruction, rigid/semirigid casting, bracing, elastic bandaging, strapping, ultrasound, temperature contrast baths, electric current therapy, hyperbaric oxygen, oral anti-inflammatories, oral proteolytic enzymes, and injectable steroids [3]. These options are usually combined with rest, compression, ice, and elevation. Conservative management involves one or more of the above modalities within a program of either strict immobilization or early controlled movement and rehabilitation [3]. This article discusses some of the conservative management modalities described in the literature. Types of instability Two types of ankle instability are described, namely functional and mechanical. Mechanical instability is abnormal laxity of the ligamentous restraints, and is a sign. Functional instability refers to abnormal function, with recurrent episodes of the ankle giving way, and is a symptom. The two types of instability can exist independently of one another, but often occur together. Indeed, a patient can have minimal mechanical instability

Journal ArticleDOI
TL;DR: The abuse of children in the name of their sports is relatively widespread, even in so-called civilised societies as mentioned in this paper, and it includes the imposition of training regimes suited for adult athletes, punishment, encouraging the development of eating disorders and doping, psychological, sexual and emotional abuse from parents and coaches, and other competitors.
Abstract: Edited by P David. London: Published by Routledge, 2005, £70.00 (soft cover), pp 338. ISBN 0415305594 It may not be apparent unless one works in the field, but abuse of athletic children in the name of their sports is relatively widespread, even in so-called civilised societies. It includes the imposition of training regimes suited for adult athletes, punishment, encouraging the development of eating disorders and doping, psychological, sexual and emotional abuse from parents and coaches (who should be the protectors of the child athlete), and other competitors (who might be …

Journal ArticleDOI
TL;DR: Direct anatomic surgical repair with the Brostrom procedure with or without its modifications is advocated for patients who suffer recurrent ankle instability with activities of daily living, work on uneven terrain, or sports.
Abstract: Symptomatic ankle instability will develop in upto 20% of patients after inversion injury. Although most patients can be successfully managed with rehabilitation and bracing, some will continue to suffer recurrent ankle instability with activities of daily living, work on uneven terrain, or sports. For this group of patients, we advocate direct anatomic surgical repair with the Brostrom procedure with or without its modifications.

Journal ArticleDOI
TL;DR: This study does not support an in utero enterovirus infection as an etiology of idiopathic talipes equinovarus in industrialized populations.
Abstract: Background: One proposed etiology of idiopathic talipes equinovarus is an in utero enterovirus infection. Enterovirus infections demonstrate seasonal variation in temperate climates. Methods: We collected data on 1202 children with idiopathic talipes equinovarus born in the Northeastern United States, Midwestern United States, and the United Kingdom to investigate a seasonal variation in this congenital deformity. Birth date, gestational age at the time of delivery, gender, race, and laterality were tabulated and subjected to univariate and bivariate analyses. Results: There were 774 boys and 428 girls with idiopathic talipes equinovarus. The birth location was the United Kingdom (458 children), the Midwestern United States (426 children), and the Northeastern United States (318 children). No significant differences were detected among the geographic groups with respect to gender, race, or laterality, and no variation in month of birth or month of conception was noted. Conclusions: This study does not support an in utero enterovirus infection as an etiology of idiopathic talipes equinovarus in industrialized populations.

Journal ArticleDOI
TL;DR: Dynamic radiography is a useful tool to differentiate posttraumatic from idiopathic coccygodynia and MRI may be useful for further evaluation of the patients after inconclusive dynamic radiography.

Journal ArticleDOI
TL;DR: An integrated clinical-pathologic diagnosis helps to clarify the nature of extraskeletal cartilaginous tumors that can arise at unusual anatomic site.
Abstract: Extraskeletal cartilaginous tumors are uncommon. Osteochondromas usually arise from the metaphyseal region of the growing skeleton. A 53 year old man presented with a three years history of anterior knee pain and inability to flex his knee more than 90°. Clinical examination and imaging studies revealed a nodular calcific mass in the anterior portion of the knee, displacing the medial portion of the patellar tendon. Following excision, histopathology confirmed the diagnosis of extra-osseous osteochondroma-like soft tissue mass, with no recurrence 24 months after surgery. An integrated clinical-pathologic diagnosis helps to clarify the nature of extraskeletal cartilaginous tumors that can arise at unusual anatomic site. Complete local surgical excision is the management of choice.

Journal ArticleDOI
TL;DR: A body builder taking a cocktail of anabolic drugs for several years in whom reconstruction of a chronic quadriceps tendon tear was performed using ipsilateral hamstring tendons with good results despite the 7 month delay between injury and surgery.
Abstract: Chronic quadriceps tendon tears are uncommon. We report about a body builder taking a cocktail of anabolic drugs for several years in whom reconstruction of a chronic quadriceps tendon tear was performed using ipsilateral hamstring tendons with good results despite the 7 month delay between injury and surgery. The use of hamstring tendons is a good option for the management of these lesions.

Journal ArticleDOI
TL;DR: The aetiology and management of Achilles tendinopathy is reviewed, which shows an increase in incidence among athletes participating in racquet sports, track and field, volleyball and soccer in recent years.
Abstract: Achilles tendinopathy is common among athletes participating in racquet sports, track and field, volleyball and soccer. Greater participation in recreational and competitive sporting activities has lead to an increased incidence of Achilles tendinopathy in recent years. However, Achilles tendinopathy does not exclusively affect athletes. This article reviews the aetiology and management of Achilles tendinopathy

Journal ArticleDOI
TL;DR: This is the first known report of a specific genetic polymorphism associated with clubfoot, and the direction of the association is intriguing and suggests that DNA synthesis may be relevant in clubfoot development.
Abstract: Worldwide, 1-4 per 1,000 births are affected by clubfoot. Clubfoot etiology is unclear, but both genetic and environmental factors are thought to be involved. Low folate status in pregnant women has been implicated in several congenital malformations, and folate metabolism may be affected by polymorphisms in the methylenetetrahydrofolate reductase gene (MTHFR). Using a case-parent-triad design, the authors investigated whether the MTHFR C677T polymorphism, and maternal periconceptional folic acid supplement use, influenced risk of isolated clubfoot. Three hundred seventy-five United Kingdom case-parent triads were recruited in 1998-1999. Among the children, there was a significant trend of decreasing clubfoot risk with increasing number of T alleles: relative risk for CT vs. CC = 0.75, 95% confidence interval: 0.57, 0.97; relative risk for TT vs. CC = 0.57, 95% confidence interval: 0.35, 0.91; p trend = 0.006. This association was not modified by maternal folic acid use. Maternal MTHFR genotype did not influence clubfoot risk for the offspring overall, although a possible interaction with folic acid use was found. This is the first known report of a specific genetic polymorphism associated with clubfoot. The direction of the association is intriguing and suggests that DNA synthesis may be relevant in clubfoot development. However, clubfoot mechanisms are poorly understood, and the folate metabolism pathway is complex. Further research is needed to elucidate these relations.

Journal ArticleDOI
TL;DR: Nails with additional locking options, by altering strain and motion at the fracture site, may have the clinical potential to affect fracture healing.
Abstract: Background:We studied the effect of additional locking screws on fracture strain and stability in tibial intramedullary nailing.Methods:We drilled an additional diaphyseal locking hole into 8-mm solid tibial nails 185 mm from the proximal end of the nail, and locked it proximally and distally. An os

Journal ArticleDOI
TL;DR: Ten years of trauma audit data from one hospital are modelled as an Artificial Neural Network in order to compare the results with a more traditional logistic regression analysis, which shows the usefulness of using both traditional and non-traditional analysis techniques together and of including as many factors in the analysis as possible.
Abstract: Trauma audit is intended to develop effective care for injured patients through process and outcome analysis, and dissemination of results. The system records injury details such as the patient’s sex and age, the mechanism of the injury, various measures of the severity of the injury, initial management and subsequent management interventions, and the outcome of the treatment including whether the patient lived or died. Ten years’ worth of trauma audit data from one hospital are modelled as an Artificial Neural Network (ANN) in order to compare the results with a more traditional logistic regression analysis. The output was set to be the probability that a patient will die. The ANN models and the logistic regression model achieve roughly the same predictive accuracy, although the ANNs are more difficult to interpret than the logistic regression model, and neither logistic regression nor the ANNs are particularly good at predicting death. For these reasons, ANNs are not seen as an appropriate tool to analyse trauma audit data. Results do suggest, however, the usefulness of using both traditional and non-traditional analysis techniques together and of including as many factors in the analysis as possible.

Journal ArticleDOI
TL;DR: Recurrent peroneal subluxation occurs when an acute injury is misdiagnosed or not adequately managed, and reattachment of the SPR, as it has been described, seems a most appropriate technique.
Abstract: Recurrent peroneal subluxation occurs when an acute injury is misdiagnosed or not adequately managed. The primary pathology is failure of the SPR, the principal restraint to the peroneal tendons. Several surgical techniques have been described. Determining the most effective technique from the small case series and reports in the literature is impossible. If an anatomic approach to treating the pathology is used, reattachment of the SPR, as we have described, seems a most appropriate technique. Rarely, the retinaculum in recurrent cases may not be robust enough to withstand repair, and a different approach to the problem may be required. In the future, there may be an emerging role for minimally invasive SPR repair with the use of endoscopic techniques.


Journal Article
TL;DR: A technique for the reconstruction of the superior peroneal retinaculum using anchors using anchors is described, safe and effective in managing instability.
Abstract: Recurrent subluxation of the peroneal tendons is rare but can produce marked functional impairment in athletes. We describe a technique for the reconstruction of the superior peroneal retinaculum using anchors. This procedure is safe and effective in managing instability.

Journal ArticleDOI
Nicola Maffulli1
TL;DR: Patients with operatively managed rupture of the tendo Achillis have faster return to normal walking and stair climbing with weight- bearing mobilisation, and non-operatively managed patients attained similar functional outcomes regardless of weight-bearing status.
Abstract: Question For patients with either operatively or non-operatively managed rupture of the tendo Achillis, does immediate weight-bearing mobilisation in an off-the-shelf orthosis improve functional outcomes over non-weight-bearing mobilisation? Design Two randomised, controlled trials with concealed allocation, blinded assessors, and intention-to-treat analysis. Setting Participants were recruited from the orthopaedic centres of three UK hospitals. Patients Patients who had ruptured their tendo Achilles within the previous seven days. Forty-eight operatively-treated patients were randomised to weight-bearing (n = 23) or non-weight-bearing (n = 25) groups on the first post-operative day. In a second trial, forty-eight non-operatively-treated patients were randomised to weight-bearing (n = 22) or non-weightbearing (n = 26) groups upon presentation during working hours. Interventions In both trials, the weight-bearing group mobilised in an off-the-shelf, carbon-fibre orthosis with three 1.5 cm heel raises, while the non-weight-bearing group had a traditional plaster cast applied. Operatively-treated patients were reviewed fortnightly for eight weeks, with progressive reductions in the amount of plantarflexion of the orthosis/cast until plantigrade was reached. The orthosis/cast was removed at eight weeks. Non-operatively-treated patients only commenced reducing the amount of plantarflexion of the orthosis/cast after 6 weeks, continuing at fortnightly intervals until 12 weeks. Outcomes All patients were reviewed at 3, 6 and 12 months. The primary outcome was the time taken to return to normal performance of the following activities: sport, walking, stair climbing, and work. Secondary outcomes included health-related quality of life, calf diameter, joint range of movement, and dynamometry. Adverse events were also recorded. Results In the operatively-treated patients, return to normal walking was significantly earlier in the weight-bearing group, difference in medians 5.5 weeks (95% CI 0 to 11). Return to normal stair climbing was also significantly earlier in the weight-bearing group, difference in medians 9 weeks (95% CI 5.3 to 12.7). Weight-bearing did not affect time to return to sport or work, nor any of the secondary outcomes. In the non-operatively-treated patients, the weight-bearing and non-weight-bearing groups did not differ significantly on any outcomes. In both trials, adverse events including re-rupture were few and were not significantly different between weight-bearing and non-weight-bearing groups. Conclusion Patients with operatively managed rupture of the tendo Achillis have faster return to normal walking and stair climbing with weight-bearing mobilisation. Non-operatively managed patients attained similar functional outcomes regardless of weight-bearing status. The practical advantages of immediate weight-bearing nevertheless make it a preferable management strategy.