Alasdair Sutherland

Naht der rupturierten Achillessehne

ZusammenfassungOperationszielSichere Naht der gerissenen Achillessehne mit einer modifizierten Kessler-Naht.IndikationenFrische und veraltete subkutane Achillessehnenrupturen.KontraindikationenInfizierte Hautläsion.Patienten mit fehlender Bereitschaft zur Zusammenarbeit.OperationstechnikHautschnitt am medialen Rand der Sehne. Darstellung der Sehnenruptur, ohne die Wundränder zu unterminieren. Nur bei veralteten Rupturen Anfrischen der Sehnenrißenden. Sehnennaht nach Kessler, gefolgt von fortlaufender zirkulärer Naht. Intrakutannaht. Unterschenkelgipsverband für sechs Wochen.Ergebnisse47 Patienten wurden nach einem durchschnittlichen Zeitraum von 23,7 Monaten untersucht. 22 von 32 Patienten, welche ein Sporttrauma hatten, konnten ihre sportliche Aktivität wiederaufnehmen. Bis auf zwei Patienten konnten alle den Zehenstand ausführen. Bei zwei Patienten kam es zu Wundheilungsstörungen. Eine Wunddehiszenz wurde bei einem Patienten, der seinen Gipsverband nach drei Wochen postoperativ selbst entfernte, festgestellt. Eine Reruptur wurde nach sechs Monaten beobachtet.

Anterior cruciate ligament integrity in osteoarthritis of the knee in patients undergoing total knee replacement

BackgroundAnterior cruciate ligament (ACL) rupture has been implicated in the development of knee osteoarthritis (OA). This study aimed at determining the incidence of prior ACL deficiency in patients undergoing total knee replacement (TKR), the effect of prior ACL deficiency on function and the macroscopic and microscopic appearance of the ligament.Materials and methodsA total of 95 patients undergoing elective TKR for OA were recruited. Pre-operative knee assessment included questionnaires and KT1000 testing. The ACL was examined macroscopically at TKR in all patients, and 10 ACL specimens were examined histologically.ResultsThe ACL was absent in 12% of the patients. There was no significant correlation between the pre-operative assessment or function and operative findings. The ACL samples all demonstrated degenerative change of varying severities.ConclusionACL deficiency is uncommon in patients undergoing TKR for OA, and does not worsen pre-operative function.

Recovery after musculoskeletal trauma in men and women

BACKGROUND Recent work has suggested that women are more at risk of impaired outcome after traumatic injuries. This would suggest that resources should be targeted at female trauma patients to optimize their outcomes. We wished to explore the physical and psychological outcomes of women treated in our trauma unit. METHODS The Grampian Trauma Outcomes Study recruited patients aged 16 to 70 years with musculoskeletal injuries. Patients with significant head injuries, alcohol intoxication, or low-energy osteoporotic fractures were excluded. Of 227 patients approached, 200 were recruited to the study. Patients were asked to complete physical and psychosocial (Short Form-36 and Musculoskeletal Function Assessment) and psychological (General Health Questionnaire) outcomes measures at initial assessment and at 2- and 6-month follow-up. RESULTS Of the 200 patients, 79% completed 2-month follow-up and 75% completed 6-month follow-up. There were no significant differences in the outcomes scores between male and female patients at either of the follow-up points. CONCLUSION From our study, women do not appear to have impaired recovery after trauma as compared with men. Larger scale studies are required to assess the need to target specific resources toward the treatment of female trauma victims.

Upright MRI in kinematic assessment of the ACL-deficient knee

The ability to quantify in vivo femoro-tibial relations in the knee holds great advantage to further patient care. There is little consensus on the optimal weight-bearing environment and measurement method for MRI assessment of in vivo knee kinematics. This study set out to establish the optimal method of measuring femoro-tibial relations in an upright, weight-bearing environment in normal individuals and those with ACL deficiency. Upright, load bearing, MRI scans of both knees were evaluated by two methods, flexion facet centre (FFC) and femoro-tibial contact point (FTCP), in order to establish femoro-tibial relations in the sagittal plane throughout different angles of knee flexion. A group of healthy volunteers (n=5) and a group with unilateral ACL insufficiency (n=8) were studied. Abnormal femoro-tibial relations were found in all ACL-deficient knees (n=8): the lateral tibial plateau was anteriorly displaced in extension and early flexion and, coupled with smaller changes in the medical compartment, this constitutes internal rotation of the tibia relative to the femur in early flexion. This study found that the FFC measurement technique holds an advantage over the FTCP technique in terms of validity, repeatability and ease of measurements, allowing detection of kinematic changes such as tibial internal rotation in early flexion in ACL-deficient knees in an upright weight-bearing model. We propose that FFC measurement in an upright, weight-bearing position is a reliable and representative tool for the assessment of femoro-tibial movement.

The mind continues to matter: psychologic and physical recovery 5 years after musculoskeletal trauma.

Objectives: Posttraumatic psychopathology may complicate recovery from musculoskeletal injury. This article details the 5-year follow-up of a cohort study examining the relationship between posttraumatic psychopathology and recovery after musculoskeletal trauma. Design: A prospective cohort study of patients with musculoskeletal injuries (Grampian Trauma Outcomes Study) assessed 5 years after their injury. Setting: Orthopaedic trauma unit, Level I equivalent. Patients: One hundred four of the initial group of 200 patients with musculoskeletal injuries. Intervention: Trauma care and prospective evaluation of physical and psychologic recovery. Main Outcome Measures: Development of psychopathology (measured by the General Health Questionnaire [GHQ]) and functional outcome (measured by Short Form-36 [SF-36] and Musculoskeletal Function Assessment [MFA]). Results: Follow-up at 5 years was 104 patients (52%). GHQ caseness was predictive of physical dysfunction (SF-36, MFA), which had not returned to baseline levels by 5 years. Although injury severity was strongly predictive of psychological disturbance (GHQ caseness) at 5 years, linear regression analysis demonstrated that GHQ score was an important predictor of outcome, whereas Injury Severity Score contributed very little. Conclusions: Psychologic disturbance after musculoskeletal trauma is related to adverse functional outcome. This is not influenced by preinjury state, but constitutes a sustained posttraumatic effect that is only weakly related to severity of injury.

Does previous varicose vein surgery alter deep vein thrombosis risk after lower limb arthroplasty

To determine the rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) after total knee arthroplasty (TKA) and total hip arthroplasty (THA) in patients who have had previous varicose vein (VV) surgery.

Is Anterior Cruciate Reconstruction Superior to Conservative Treatment

Not all patients who have a rupture of the anterior cruciate ligament (ACL) elect to have surgical reconstruction. The aim of this study was to assess the short-to-medium-term results of patients who chose conservative management in comparison to patients who had reconstructive surgery within the same time period. Sixty-three patients with an ACL injury were retrospectively studied. Forty patients were managed, according to patient choice, with ACL reconstruction and 23 conservatively. Four validated questionnaires were used to assess general and knee-specific function in a cohort with a median age of 32 years and a median follow-up period of 38 months. Patients were matched on demographic variables except for gender. There were no statistically significant differences in the outcome measures, and the majority of patients would proceed with the same treatment in the event the control leg became injured. Patients who elect to have conservative management of an ACL rupture can achieve similar function and satisfaction to those who elect to have reconstruction. Until a large randomized controlled trial is conducted, patients need to be made aware of the merits of both management strategies and the lack of evidence of superiority of one over the other.

Die perkutane Naht der Achillessehnenruptur in einer modifizierten Technik

ZusammenfassungOperationszielSichere perkutane Naht einer subkutanen Achillessehnenruptur mit einem minimalen Risiko einer Infektion oder ästhetisch unbefriedigenden Narbenbildung.IndikationenGeschlossene komplette Ruptur der Achillessehne bei Patienten mit geringen bis mäßigen sportlichen Ambitionen und bei Patienten, die eine offene Nahttechnik aus ästhetischen Gründen ablehnen.KontraindikationenInfizierte Hautläsionen.Patienten, die wegen mangelnder Kooperation für ein postoperatives Rehabilitationsprogramm ungeeignet sind.Erhöhtes Anästhesierisiko.OperationstechnikPerkutane Adaptation der Achillessehnenstümpfe mit resorbierbarem Nahtmaterial, das über medial und lateral der Achillessehne gelegene Stichinzisionen eingebracht wird.Postoperative Nachbehandlung im Gehgips für sechs Wochen.ErgebnisseZwischen 1989 und 1993 wurden 31 Patienten (26 Männer, fünf Frauen; Durchschnittsalter 46 Jahre) mit einer kompletten, subkutanen Achillessehnenruptur durch eine perkutane Achillessehnennaht versorgt und im Mittel 23 (15 bis 31) Monate nach der Operation nachuntersucht. Fünf Patienten wiesen eine Neurapraxie des Nervus suralis auf. Bei drei Patienten verschwand die Störung über einen Zeitraum von sechs bis neun Monaten komplett. Zwei Patienten erlitten eine erneute Ruptur der Achillessehne innerhalb von elf und 15 Monaten und mußten durch eine offene Achillessehnennaht versorgt werden.SummaryObjectivesRepair of acute rupture of the Achilles tendon through a percutaneous technique under general, regional, or local anesthesia.IndicationsAcute rupture in patients who have moderate or minimal athletic requirements.ContraindicationsInfected skin lesions.Patients unwilling to cooperate postoperatively.Patients objecting to surgery.Surgical TechniqueLocal anesthesia medial and lateral to tendon. Medial and lateral stab incisions proximal and distal to site of rupture. Suture passed back and forth through the proximal stump, then passed subcutaneously to the distal stump. After mounting of the distal stump the suture is tied with the foot in plantar flexion. Below knee cast for 6 weeks.ResultsReview of 31 patients (26 men, 5 women, average age 46 years). Thirteen Patients returned to work within 10 days and the remaining 18 patients at an average of 5 weeks (range 4 to 9). Two reruptures were observed and a paresthesia of the sural nerve in 5 patients. The functional result was satisfactory.

The Benefits of Streamlined Hip Fracture Management in a Regional Hospital

Introduction: Hip fracture is an increasingly common injury in the growing elderly population. The morbidity and mortality associated with this injury can be reduced by minimizing delays to surgical treatment. We describe the impact of a regional hospital service redesign project that utilized the principles of smart simplicity, a management strategy that lays emphasis on collaboration to achieve desired goals. Methods: Prior to the redesign, patients with hip fractures were taking an average of 72 hours for surgical treatment. A hip fracture working group was created to examine closely the process of hip fracture care, and a single key performance indicator (KPI) of “surgery within 48 hours” was adopted. This allowed identification of processes that could be clarified and streamlined, with the agreement of relevant stakeholders, in the creation of a new hip fracture pathway. Results: In the first 3 months of the pathway’s implementation, 16 of 18 patients had surgery within 48 hours of presentation. In a 6-month follow-up audit after 2 years of implementation, 36 of 39 patients were treated within 48 hours. This was significantly different to the time to surgery seen in the 12 months prior to the redesign (P < .001, Student t test). The mean time to surgery was reduced from 72 hours to 36 hours, a saving in an annual acute bed stay cost of A

Ageing, chronic disease and injury: a study in western Victoria (Australia)

152 000. Discussion: Decreased time to the operating room, the cost savings inherent to this, can be achieved with the introduction of the best standard of care. A redesign that mandates collaboration in achieving a single KPI has allowed a significant culture shift in the treatment of hip fractures in our institution in the months following its institution. Conclusion: Collaborative, multidisciplinary collaboration has facilitated a higher standard of care and demonstrated significant cost benefit.