Biomedical subjects
Publications and source records attributed to N Maffulli.
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.
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.
This review describes structure, function and healing of tendinous tissue and discusses new biologically based treatment options to modulate tendon healing. The repair process after tendon rupture results in a morphologically different and biomechanically inferior structure compared to a normal tendon. The collagen fibril diameters are decreased months after the traumatic lesion and show also different phenotypes. We know that cytokines and growth factors are key components for normal tissue development and regulate wound healing processes. Some growth factors have been detected to influence tenocytes by promoting cell proliferation and matrix synthesis. Application of the adequate growth factors at certain periods during the repair process might improve the healing result after tendon rupture. However, most of these growth factors are proteins which are rapidly metabolized by the organism. Transfer of growth factor genes into tenocytes might eliminate this problem by a continuous local release of growth factors at the healing site.
We studied the seasonal variation of hip fracture admissions at three different latitudes: Scotland (56 degrees North; 54,399 admissions); Shatin, Hong Kong (22 degrees North; 4180 admissions); and Auckland, New Zealand (36 degrees South; 2257 admissions). We calculated the extent of seasonal variation (amplitude) and the time of year of the peak value (acrophase) by fitting a sine curve to monthly data using cosinor analysis. A significant seasonal variation was found in all three countries, at a high level in Scotland (p < 0.01) and Hong Kong (p < 0.001), but just significant in New Zealand (p < 0.05). The extent of the seasonal change was very similar in Scotland and New Zealand, but, as expected, the peak in New Zealand (early September) was approximately six months ahead of Scotland (mid February). In Hong Kong, the amplitude was three times greater than in Scotland and the peak occurred a month earlier. There is neither snow nor ice in Hong Kong, and this provides powerful evidence against a major influence of conditions underfoot causing extra falls in winter. In Scotland there was a significant increase in the proportion of deaths in winter as compared to summer. The Scotland/Hong Kong amplitude difference is striking, but it is unknown whether this has a genetic or environmental explanation. The cause of seasonal death difference to a given injury is also unknown. Possible mechanisms are discussed, but the purpose is to report two new epidemiological features, without wild speculative hypotheses. The findings should be viewed as leads to further epidemiological, clinical and more basic research.
This article presents an overview of sports-related injuries of the lower limb in children, with emphasis on the management. The special injury-related conditions of childhood, epidemiology, and the particular pattern of injuries are discussed. The increased participation of children in sports will continue. Permanent damage is a risk, and, as such, prevention should be the most important management in this age group. For example, stretching exercises should be performed with "warm" muscles. Excessive weight training has an unacceptable risk of injury. In endurance sports, the "10 percent rule," which consists of increasing activity by 10% each week, probably could be applied to prevent overuse injuries. A multifactorial approach may be helpful. The rationale for high performance, competitive sports for children is doubtful. The optimal levels of safe training will remain changeable and not predictable. It should be the responsibility of parents, coaches, and healthcare professionals to try and minimize the potential for injury and disability, and allow children to enjoy the benefits of sports.
Patellar tendinopathy is often treated surgically after failure of conservative treatment but clinical experience suggests that results are not uniformly excellent. The aim of this review was to (i) identify the different surgical techniques that have been reported and compare their success rates, and (ii) critically assess the methodology of studies that have reported surgical outcomes. Twenty-three papers and two abstracts were included in the review. Surgical procedures were categorized and outcomes summarized. Using ten criteria, an overall methodology score was derived for each paper. Criteria for which scores were generally low (indicating methodological deficiency) concerned the type of study, subject selection process and outcome measures. We found a negative correlation between papers' reported success rates and overall methodology scores (r= -0.57, P<0.01). There was a positive correlation between year of publication and overall methodology score (r=0.68, P<0.001). We conclude that study methodology may influence reported surgical outcome. We suggest practical guidelines for improving study design in this area of clinical research, as improved study design would provide clinicians with a more rigorous evidence-base for treating patients who have recalcitrant patellar tendinopathy.
We report the case of a 31-year-old woman who had had the distal end of the ulna resected for a giant cell tumour five years before presenting with a further one in the hamate. The medullary cavity of the hamate was curetted and cancellous bone grafted from the distal radius. Her symptoms resolved, and 26 months postoperatively the cortex of the hamate was fully restored.
BACKGROUND: The purpose of this study was to compare the outcomes of two different techniques of supracondylar osteotomy, French osteotomy and dome osteotomy, for the correction of posttraumatic cubitus varus. METHODS: A comparative randomized study was undertaken of 25 patients (average age 10 years) with an established posttraumatic cubitus varus deformity (mean time from injury to corrective osteotomy, 1.7 years). Patients were followed-up with for 1 year, and carrying angle, Baumann's angle, and internal rotation deformity were measured. Postoperative complications were assessed. RESULTS: A significant (p < 0.01) correction of carrying angle and Baumann's angle was achieved with both techniques, with no statistically significant differences between them. Although internal rotation deformity was corrected by both techniques, the correction was significantly greater with the dome osteotomy (p < 0.01). However, the persistence of internal rotation did not seem to affect the final outcome. There was a higher incidence of postoperative complications in the dome osteotomy group, including infection (1), inadequate correction (1), nerve palsy (1), loss of motion (5), and circulatory compromise (1). CONCLUSION: The dome osteotomy is technically more difficult than the French osteotomy and has a higher incidence of complications. We suggest that the French osteotomy be used for the correction of cubitus varus after supracondylar fractures of the elbow in children.
OBJECTIVE: To test whether the association between blood groups and Achilles tendon rupture (ATR) reported in some Scandinavian countries and in Hungary was present in our region. METHODS: We studied 78 patients treated at Aberdeen Royal Infirmary from 1990 to 1996, and compared their distribution of ABO blood groups with that found in 24.501 blood donors typed at the Blood Transfusion Centre during the same period. RESULTS: Overall, 47 of 78 (60%) of patients with an Achilles tendon rupture belonged to blood group O, compared with 51% of the population as a whole. Only 22 (28%) of the Achilles tendon rupture patients belonged to blood group A, whereas 35% of the general population were members of this group (NS). The A/O ratio was 0.47 for the tendon rupture patients, compared with 0.68 for the general population (NS). CONCLUSIONS: We could not demonstrate any significant association between the proportions of ABO blood groups and ATR in the Grampian Region of Scotland. The findings in other studies could be due to peculiarities in the distribution of the ABO groups in genetically segregated populations.
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External fixation is widely used in the fixation of fractures and limb deformities. The mechanical characteristics of a specific external fixator are major factors in determining the biomechanical environment at a fracture/osteotomy site and, hence, affect the healing process. Although the optimal biomechanical environment for healing of a fracture or an osteotomy is unknown, a specific range of interfragmentary motion exists which promotes healing. It is therefore desirable that the mechanics of an external fixator can be manipulated to enable the surgeon to control the range of interfragmentary motion. The characteristics of an external fixator are defined by a large number of variables. Therefore, to gain control over the degree of interfragmentary motion, an understanding of the effect of each variable and how it interacts with the others to determine the overall characteristics of the device is required. For the past two decades, individual components and whole-frame configurations have been studied in depth. This article provides a summary of previous work concerning the mechanics of external ring fixators and how they affect the biomechanical environment at the fracture/osteotomy site.
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We prospectively audited peri-operative blood loss and blood transfusion practice in 42 elderly patients (mean age, 71.8 years, 68% female) undergoing hip or knee surgery in an orthopaedic unit. Only in 57% of all operations was blood loss recorded. Compliance with the Maximum Surgical Blood Ordering Schedule (MSBOS) was variable, and Cross-matching to Transfusion (C/T) ratios were low. In 86% of operations, blood had been issued pre-operatively (average three units, range = 1-61 units). Of these patients, 75% subsequently received a transfusion. In 26% of all the operations, the transfusion, although confirmed by the blood transfusion laboratory records, had not been recorded in the medical or nursing notes. The average pre-operative Hb in the transfusion group was 123 g/l (range, 80-144 g/l) and 112 g/l postoperatively and after a transfusion (range, 75-133 g/l). This compared to the non-transfusion group's value of 124 g/l (range, 86-186 g/l) and 113 g/l (range, 77-147 g/l) postoperatively. The high blood issuing and transfusion rates raise the concern that transfusions are being given in response to habit or blood availability, and not medical indications. This would imply that some patients are exposed to unnecessary risks. Furthermore, inadequate documentation of the transfusion process opens the medical profession to criticism and medical, legal and ethical complications regarding patient care. Positive improvements suggested by regular medical audit may help address these problems.
We performed arthroscopic procedures on 97 knees in 91 patients younger than 16 years of age. Sixty arthroscopic procedures in 58 patients were for sports-related injuries or symptoms. The most common diagnosis was maltracking of the patella. In 78 cases, an operative procedure was performed at the time of diagnostic arthroscopy. No complications were experienced. The accuracy of diagnosis for suspected meniscal tears was poor. Further pathologies, especially meniscal tears, were commonly associated with anterior cruciate ligament tears. Arthroscopy of the knee in children is safe, has a high diagnostic accuracy, and, in a significant proportion of patients, it can have not only a diagnostic role but allows the management of a wide variety of intra-articular conditions.
We report the outcome of conservative and surgical management in 50 skeletally mature patients (average age 64.6 years, 36 females patients) with 51 supracondylar femoral fractures treated in our unit between June 1991 and December 1993. Thirty-six fractures were caused by low-energy trauma, and 15 were due to high-energy trauma. Open fractures occurred in 5 patients. Of the 34 patients (35 fractures) treated conservatively, 15 (46%) achieved a satisfactory result. Of the 16 patients treated by internal fixation, 10 (62%) reached a satisfactory outcome. Osteoporosis, severe comminution of the fracture, involvement of the knee joint, and soft tissue injury in open fractures were associated with unsatisfactory results. Conservative management of these fractures is associated with a lesser chance of achieving a good functional result. With the advent of new fixation devices and our experience that conservative management can actually lead to many complications, the proportion of patients operated upon is likely to increase.
UNLABELLED: We performed a 3-year longitudinal study of a group of 179 healthy Chinese adolescents (92 boys and 87 girls) aged from 12 to 16 years to determine the effects of puberty, physical activity, physical fitness, and calcium intake on the acquisition of bone mass. At yearly intervals for 3 consecutive years we recorded nutrition, calcium intake and anthropometric measurements, and assessed pubertal status according to Tanner. Bone mass of the lumbar spine was determined by dual-energy X-ray absorptiometry and radial bone mass by single-photon absorptiometry. Physical fitness and level of physical activity were assessed and muscle strength and power determined by isokinetic testing. Peripheral bone mass correlated with axial skeleton bone mass. Age, pubertal staging, physical fitness and muscle strength were significantly associated with bone mass increments on cross-sectional univariate and regression analysis. Longitudinal regression analysis showed that the most important factor affecting bone mass accretion in adolescents in both sexes was their pubertal stage. In boys, bone mass increment throughout the study was greater in children who were already in the advanced pubertal stages on entering the study than in those who started puberty in year 2 or 3 of the study. The percentage change in bone mineral content of the forearm and in bone mineral density of the lumbar spine was greater than 25% in the advanced pubertal group as compared to around 20% in the less mature group. For girls, the reverse was true. The increment of bone mass during the study period was significantly greater in those who presented in the earlier pubertal stages than in those who were at the more advanced stage of puberty on entry into the study. There was no significant effect of calcium intake and physical activities on the bone mass accretion. CONCLUSION: In Chinese adolescents, bone mineral accretion at adolescence is not influenced by exercise, level of physical fitness and calcium intake. In both sexes, and especially in girls, to optimally increase bone mass, regular physical exercise programmes should be instituted well before the onset of puberty rather than at or after it. Once puberty starts, these interventions may have no or only limited effect.
Anterior cruciate ligament (ACL) injury is the most common ligament injury in the knee, and a significant number of patients may develop progressive instability and disability despite aggressive rehabilitation. Various materials have been used for its reconstruction. These include autografts, allografts, prosthetic ligaments, and synthetic augmentation of the biological tissue. The concept of ligament augmentation device (LAD) arose from the observation that biological grafts undergo a phase of degeneration and loss of strength before being incorporated. The LAD is meant to protect the biological graft during this vulnerable phase. However, it provokes an inflammatory reaction in the knee, and has been found to delay maturation of autogenous graft in humans. In experimental situations, the LAD has been found to share loads in a composite graft. It has also been found to be substantially stronger than the biological graft. However, in clinical situations no significant advantages have been observed with the use of LAD to augment patellar tendon or hamstring reconstruction of the chronic ACL-deficient knee or in the acute setting to augment repair of the torn ACL. There are very few reports of the use of LAD in reconstruction of the posterior cruciate ligament, and again these do not suggest any advantage in its use. Insertion of the LAD implies the introduction of a foreign material into the knee, has been associated with complications such as reactive synovitis and effusions, and may also be associated with an increased risk of infection. At present, there is no evidence that its routine use should be advocated in uncomplicated reconstructions of the ACL using biological grafts.