Biochemistry and biomechanics of healing tendon: Part II. Effects of combined laser therapy and electrical stimulation

Twenty-two closed Achilles tendon ruptures caused by sports injuries in 22 patients (average age, 37.6 years) were repaired with Kirschmayer core suture and cross-stitch epitenon suture, and early active ankle motion with weightbearing was implemented after surgery. This study was undertaken to evaluate the effectiveness of the repair technique and rehabilitation protocol by assessing clinical results and magnetic resonance imaging findings. The follow-up period averaged 24.6 months. Twenty of the tendons (91%) healed without rerupture, and two tendons (9%) suffered a partial rerupture at 23 and 56 days, respectively. Active ankle extension reached from the minus range to 0 degree in an average of 9.7 days, and ankle motion recovered to normal in an average of 6.0 weeks. Full weightbearing without heel raising became possible in an average of 16.4 days, and heel raising with both legs became possible in an average of 7.3 weeks. The patients returned to full sports activity in 13.1 weeks. The interval until the area of high-intensity signal at the tendon repair site on T2-weighted magnetic resonance imaging scans became intermediate-intensity signal averaged 6.9 weeks, and the tendon repair site became low-intensity signal in an average of 12.6 weeks, demonstrating excellent tendon healing. Treatment employing Kirschmayer core suture and cross-stitch epitenon suture may help athletes return to sports activity in a shorter period than that allowed by previous methods of repair for Achilles tendon ruptures.     

The hindfoot alignment view

A modification of Cobey's method for radiographically imaging the coronal plane alignment of the hindfoot is described. Using this view, we estimated the moment arm between the weightbearing axis of the leg and the contact point of the heel. Normative data on 57 asymptomatic adult subjects are presented. The weightbearing line of the tibia falls within 8 mm of the lowest calcaneal point in 80% of subjects and within 15 mm of the lowest calcaneal point in 95% of subjects. The technique for measuring coronal plane hindfoot alignment is reliable, with an interobserver correlation coefficient of 0.97. This radiographic technique should help in the evaluation of complex hindfoot malalignments.     

Diagnosis of 4 cases of intestinal microsporidiosis in AIDS patients

Because of its excellent soft tissue contrast and ability to demonstrate soft tissue structures, magnetic resonance imaging is ideally suited to the evaluation of the soft tissues surrounding the ankle, including the lateral collateral ligaments. This study was undertaken to compare the clinical evaluation of 15 patients who suffered inversion injuries of the ankle with the results found on magnetic resonance imaging within 48 hours of the injury. Physical examination was found to be 100% accurate in the diagnosis of grade III ligament injuries but only 25% accurate in the diagnosis of grade II injuries. Clinicians most often underestimate the damage with a grade II ligament tear. Furthermore, other associated injuries, such as significant capsule ruptures and tendon damage, were often overlooked at physical examination.     

The management of acute traumatic haemarthrosis of the knee

The knee is the largest synovial joint in the body, with a number of diverse soft tissue structures contributing to its stability. It is subject to enormous stresses and is the most commonly injured joint. These injuries usually occur in young, active patients. This article describes the approach to managing these important injuries.     

Tibio-talo-calcaneal fusion with a free vascularized fibular graft in comminuted open fractures of the talus and the calcaneus

An operation is described in which a free vascularized fibular graft with a peroneal cutaneous flap is used for tibio-talo-calcaneal fusion and simultaneous skin coverage in treatment of comminuted open fractures of the talus and the calcaneus involving large skin loss. Nine months postoperatively, the tibio-talo-calcaneal arthrodesis was successful, with good coverage of the skin defect on the medial aspect of the sole. One year 7 months postoperatively, the patient is free of pain and able to walk with full weightbearing on the foot.     

Magnetic resonance imaging of the wrist

MR imaging of the wrist has the unique capability of simultaneously demonstrating bone and soft tissue structures. Its exquisite sensitivity for detecting bone marrow edema makes it and ideal screening tool for diagnosing radiographically occult osseous injuries and areas of AVN. This, together with its ability to provide a comprehensive, non-invasive assessment of the ligaments, tendons, nerves, and components of the TFC make MRI a very powerful tool for evaluating patients with wrist pain of uncertain etiology. Its exact role in the work-up of these patients has not been entirely established, but with further advances in technology and the radiologist's understanding of wrist anatomy and pathology, MRI is assuming a more central role in this clinical setting.     

Arthroscopic stabilization of the ankle

Arthroscopic lateral ankle stabilization is a method for repair of the anterior talofibular ligament which involves decreased morbidity and minimal soft tissue disruption while restoring function and stability to the joint. This technique utilizes soft tissue anchoring systems that reinforce or repair the anterior talofibular ligament. Several techniques are described for the various types of ligamentous injuries. These methods are compared and contrasted with standard open reconstructive and reparative techniques. Advantages of the newer anchoring systems are discussed.     

Effect of chronic hypoxemia on the regulation of nitric-oxide synthase in the fetal sheep brain

We undertook a prospective study to determine the type and distribution of foot and ankle snowboarding injuries. Reports of 3213 snowboarding injuries were collected from 12 Colorado ski resorts between 1988 and 1995. Of these, 491 (15.3%) were ankle injuries and 58 (1.8%) were foot injuries. Ankle injuries included 216 (44%) fractures and 255 (52%) sprains. Thirty-three (57%) of the foot injuries were fractures and 16 (28%) were sprains. The remaining injuries were soft tissue injuries, contusions, or abrasions. There was no significant correlation between boot type (soft, hybrid, or hard) and overall foot or ankle injury rate. There were significantly fewer ankle sprains in patients wearing hybrid boots and fewer fractures of the lateral process of the talus in patients wearing soft boots. An unexpectedly high number of fractures of the lateral process of the talus were noted. These 74 fractures represented 2.3% of all snowboarding injuries, 15% of all ankle injuries, and 34% of the ankle fractures. Many of these fractures are not visible on plain radiographs and require computed tomography imaging to be diagnosed. Diagnosis of this fracture pattern is paramount; the physician should be very suspicious of anterolateral ankle pain in the snowboarder, where subtle fractures that may require surgical intervention can be confused with anterior talofibular ligament sprains.     

Therapy of soft tissue injuries--biological strategies

The traumatic soft tissue injury plays a central role in fracture healing. The knowledge of pathophysiological mechanisms has completely changed the management and therapy of injuries accompanied by soft tissue lesions. Treatment is aiming for prevention of the circle of hypoxia, microvascular perfusion disturbance, increased membrane permeability and potential infections. General therapeutic principles are decontamination, debridement, revascularisation and decompression. Modern methods of soft tissue treatment take these principles into consideration.     

Traumatic dental disease and soft tissue injuries of the oral cavity

Trauma to the oral cavity can result in an array of injuries affecting teeth, bone, and soft tissue. A thorough examination of the oral cavity is often facilitated by employing a full-mouth speculum after the horse has been tranquilized. Identification of broken, loose, or split teeth; fractures of the premaxilla or mandible; and avulsion or laceration of soft tissue structures such as the lips or tongue is usually straightforward. Treatment options vary depending on the structure involved; however, appropriate treatment generally results in a functional and cosmetically acceptable end result.     

Surgical hazards posed by marine and freshwater animals in Florida

Marine and freshwater animals can cause injury to humans by biting, stinging, being poisonous to eat, and causing infections. Biting aquatic animals in Florida include sharks, barracudas, alligators, and moray eels. Devitalized tissue should be débrided, and vascular, neurologic, and tendinous injuries should be repaired. Radiographs should be obtained to examine the injury sit for fractures and retained foreign bodies (teeth). The spines of stingrays and marine catfish can cause soft tissue injury and infection. The spine has a recurved, serrated shape that may cause further injury and break if it is pulled out. The venom may cause local tissue necrosis requiring débridement. Soft tissue infections with marine Vibrio bacteria can occur after eating raw oysters or receiving even minor injuries from marine animals. Thirty-one individuals developed soft tissue infections, 49 developed sepsis, and 23 developed both sepsis and soft tissue infection with marine Vibrio species during a 12-year period. Sixteen patients developed necrotizing soft tissue infections. Treatment is with antibiotics and débridement when necrosis occurs.     

Early, full weightbearing with flexible fixation delays fracture healing

Secondary fracture healing is known to be accelerated by the process of periosteal callus formation that can be induced by flexible fracture fixation in connection with loading of the injured extremity. The purpose of this study was to compare the healing of experimental fractures of long bones in sheep under early weightbearing with that of fractures under delayed, steadily increasing weightbearing. Differences in the quality of fracture healing were described by biomechanical (rigidity of fracture, indentation stiffness of callus) and histologic methods. Prevention from early, full weightbearing resulted in a higher flexural rigidity of the fracture, an increased mechanical stiffness of the callus tissue, and an enhanced bone formation at the healing front. Although early loading of a fresh fracture initiated an enormous amount of periosteal callus, the healing of the osteotomy was significantly delayed, and the quality of the newly formed tissue was reduced as compared with fractures with a reduced loading situation. A reduction of load transfer by delaying full weightbearing is advantageous for the healing of fractures stabilized with flexible fixation systems.     

Alteration in the brain content of substance P (1-7) during withdrawal in morphine-dependent rats

OBJECTIVE: To evaluate hoof size, shape, and balance as risk factors for catastrophic musculoskeletal injuries (CMI), including suspensory apparatus failure (SAF) and cannon bone condylar fracture (CDY) in Thoroughbred racehorses. ANIMALS: 95 Thoroughbred racehorses that died between 1994 and 1996. PROCEDURE: 38 quantitative measures of hoof size, shape, and balance were obtained from orthogonal digital images of the hoof and were compared between case horses with forelimb CMI (70), SAF (43), and CDY (10) injuries and control horses whose death was unrelated to the musculoskeletal system (non-CMI, 25). Comparison of group means between cases and controls was done using ANOVA, and multivariable logistic regression was used to estimate odds ratios. RESULTS: Odds of CMI were 0.62 times lower for a 5mm increase in ground surface width difference and 0.49 times lower for a 100-mm2 increase in sole area difference. Odds of SAF were 6.75 times greater with a 10 degrees increase in toe-heel angle difference and 0.58 times lower with a 100-mm2 increase in sole area difference. Odds of CDY were 0.26 times lower with a 3 degrees increase in toe angle, 0.15 times lower with a 5-mm increase in lateral ground surface width, and 0.35 times lower with a 100-mm2 increase in sole area difference. CLINICAL RELEVANCE: Decreasing the difference between toe and heel angles should decrease risk of SAF for Thoroughbred racehorses and should be considered in addition to increasing toe angle alone to help prevent catastrophic injury. Trimming the hoof to perfect mediolateral symmetry may not be a sound approach to avoiding injury.     

Soft tissue coverage for the upper extremity

Soft tissue coverage of the upper extremity continues to be a challenging and evolving field. The expeditious and reliable methods of soft tissue coverage currently in use are discussed with reference to their shortcomings and advantages. For soft tissue coverage of fingertip injuries, open treatment or local flaps from the hand remain the mainstay of treatment. For dorsal and volar hand defects, distal axial flaps, such as the groin flap or microvascular tissue transfer, are utilized most commonly. For large defects proximal to the wrist, trunk axial pattern flaps, microvascular transfer, or the radial forearm flap have the greatest utility. Finally, technical points necessary for the success of some of the flaps are discussed.     

Minor oral injuries in children

Traumatic injuries involving the oral cavity in children often result from falls or collisions with stationary objects. Repair of lacerations involving the soft tissue structures within the oral cavity is described. These injuries often can be managed by emergency department personnel, with referral to an oral and maxillofacial surgeon for follow-up care. Initial management of more extensive injuries such as dentoalveolar fractures, penetrating injuries and burns is also described. Immediate consultation with the appropriate specialist is suggested, because significant deformity and/or morbidity may result from minor oral injuries.     

Elbow, forearm and wrist injuries in the athlete

Competitive and recreational athletes sustain a wide variety of soft tissue, bone, ligament, tendon and nerve damage to their upper extremities. Most such injuries are related to direct trauma or repetitive stress, and account for a significant amount of 'down time' for athletes participating in a wide range of sports, particularly those in which the arm is utilised for throwing, catching or swinging. Overuse injuries to the elbow include musculotendinous injuries, ulnar nerve injuries and ligamentous injuries. Osteochondrol lesions of the capitellum and posterior impingement injuries in the joint are frequently seen in athletes as well. Acute traumatic injuries to the elbow include tendon ruptures, elbow dislocations and intra-articular fractures. Forearm overuse injuries in athletes include fracture of the carpal scaphold, fracture of the hook of the hamate, Kienbock's syndrome and pisoquetral syndromes. ligamentous injuries include scapholunate, lunotriquetral and midcarpal instability injuries. Injuries to the distal radio-ulnar joint and triangular fibrocartilage are also quite common in athletes, and require careful evaluation and treatment.     

Tumors of the elbow and forearm

The trend in the treatment of bone and soft tissue sarcomas of the extremities has been away from radical surgery and toward conservative, limb-sparing surgery, a trend that is present throughout other subdisciplines of surgical oncology. Organ-sparing and limb-sparing surgery has been combined with the use of adjuvants to give equivalent local control and in some cases improved survival. This article summarizes the current staging and treatment of bone and soft tissue tumors of the extremities and discusses some of the features that are unique to the elbow and forearm.     

Digital infarction in a patient with Raynaud''s phenomenon associated with treatment with a specific serotonin reuptake inhibitor. A case report

Palatopharyngeal injuries due to impaction of rigid objects held in the mouth are common. Most are essentially innocuous injuries requiring no specific treatment. However, there is the potential for perforation of the pharyngeal wall with the subsequent development of serious infection such as retropharyngeal abscess or mediastinitis. This possibility is more likely to be suspected in the presence of a visible laceration or puncture wound at the site of impact in the mouth or pharynx. We report three cases in which occult pharyngeal perforation occurred without any clinical signs of breech of the pharyngeal wall. In all cases a lateral soft tissue neck X-ray was diagnostic of perforation, showing the presence of retropharyngeal air. We, therefore, advocate the routine performance of soft tissue neck X-rays in all patients who present with a history of falling on a rigid object held in the mouth.     

AO external mini-fixateur for the hand bones. Surgical technique and initial experiences

Fractures of the hand and fingers showing comminution or associated soft-tissue lesions are best treated with external fixation. In contrast to other systems, the new AO mini-external fixator enables less bulky unilateral fixation facilitating early mobilisation and the special design of the double clamps allows preliminary intraoperative stabilisation with only one wire in each fragment. Modular fixation makes free placement of the wires possible with accommodation of bone and soft tissue lesions. Twenty patients with hand injuries showed uneventful soft tissue healing and there were no cases of non-union in 19 metacarpal and phalangeal fractures.     

Spine injuries in combat troops--Panama, 1989

Operation Just Cause was until recently the largest American combat operation since Vietnam, and remains the largest nighttime parachute operation since World War II. All 252 casualties were airlifted to San Antonio, Texas, for medical treatment. Greater than 80% sustained orthopedic injuries. Sixteen patients were admitted for injuries to the back or neck. Three of the four patients with significant fractures or fracture-dislocations were paraplegic. Two of the three patients with gunshot wounds to the back required extensive reconstruction for wound management. In addition to the 252 casualties, there were 23 fatalities, among whom 7 suffered major injuries to the spine. Spine injuries represented the most significant source of long-term morbidity among those soldiers wounded in combat in Panama, and were common among the fatalities. Noteworthy in these cases was the high percentage of severe neurologic injuries in patients with significant fractures (75%), particularly fractures associated with gunshot wounds. Also of interest were the cases of major soft tissue injury associated with high-velocity gunshot wounds (66%) and the extensive soft tissue surgery needed to treat these injuries.