Nikolaos Gougoulias

Long-term Health Outcomes of Youth Sports Injuries

Injuries can counter the beneficial effects of sports participation at a young age if a child or adolescent is unable to continue to participate because of residual effects of injury. This paper reviews current knowledge in the field of long-term health outcomes of youth sports injuries to evaluate the evidence regarding children dropping out of sport due to injury, physeal injuries and growth disturbance, studies of injuries affecting the spine and knee of young and former athletes and surgical outcome of anterior cruciate ligament (ACL) reconstruction in children. Studies of dropping out of sport due to injury are limited primarily to gymnasts and implicate such injuries as ACL rupture and osteochondritis dissecans of the elbow joint in the early retirement of young athletes. Although most physeal injuries resolve with treatment and rest, there is evidence of disturbed physeal growth as a result of injury. Radiological findings implicate the effects of intense physical loading and injury in the development of spinal pathology and back pain during the growth of youth athletes; however, long-term effects are unclear. Follow-up studies of young athletes and adults indicate a high risk of osteoarthritis after meniscus or ACL injury. Prospective cohort studies with a follow-up into adulthood are needed to clarify the long-term health outcomes of youth sports injuries. Important to this research is meticulous documentation of injuries on injury report forms that include age-appropriate designations of the type of injury and accurate determination of exposure-based injury rates.

Sport injuries: a review of outcomes

Injuries can counter the beneficial aspects related to sports activities if an athlete is unable to continue to participate because of residual effects of injury. We provide an updated synthesis of existing clinical evidence of long-term follow-up outcome of sports injuries. A systematic computerized literature search was conducted on following databases were accessed: PubMed, Medline, Cochrane, CINAHL and Embase databases. At a young age, injury to the physis can result in limb deformities and leg-length discrepancy. Weight-bearing joints including the hip, knee and ankle are at risk of developing osteoarthritis (OA) in former athletes, after injury or in the presence of malalignment, especially in association with high impact sport. Knee injury is a risk factor for OA. Ankle ligament injuries in athletes result in incomplete recovery (up to 40% at 6 months), and OA in the long term (latency period more than 25 years). Spine pathologies are associated more commonly with certain sports (e.g. wrestling, heavy-weight lifting, gymnastics, tennis, soccer). Evolution in arthroscopy allows more accurate assessment of hip, ankle, shoulder, elbow and wrist intra-articular post-traumatic pathologies, and possibly more successful management. Few well-conducted studies are available to establish the long-term follow-up of former athletes. To assess whether benefits from sports participation outweigh the risks, future research should involve questionnaires regarding the health-related quality of life in former athletes, to be compared with the general population.

History and evolution in total ankle arthroplasty

INTRODUCTIONnThe current study provides an overview of history and evolution in total ankle arthroplasty.nnnMETHODSnWe conducted a comprehensive literature search without limitations to language. Information from any source, providing evidence of the use ankle of prostheses (e.g. biomechanical testing, cadaveric implantations or clinical use) was evaluated. Data regarding biomechanical concepts, design considerations, published results (patient numbers, surgical method, follow-up, complications and survival rates) were collected.nnnRESULTSnOnly level IV studies were found. Mobile-bearing prostheses are mainly used in Europe, and fixed-bearing implants are mainly used in the USA. The current designs failure rate is 10-12% at approximately 5 years. Survival rates vary among different institutions. Increased surgeons experience is associated with better outcomes.nnnDISCUSSIONnBiomechanical studies and review of previous implant failures has led to the development of a new generation of implants.nnnCONCLUSIONSnResults show that ankle arthroplasty is a viable alternative for the management of ankle arthritis in selected patients.

Prevention of adhesions in surgery of the flexor tendons of the hand: what is the evidence?

INTRODUCTIONnDespite advances in knowledge and refinements of technique, the management of flexor tendon injuries within the digital sheath continues to present a formidable challenge. This in turn has led to a massive expansion in search of modified surgical therapies and various adjuvant therapies, which could prevent adhesion formation without compromising digital function.nnnSOURCES OF DATAnA search of PubMed, Medline, CINAHL and Embase databases was performed using the keywords tendon adhesion prevention, tendon healing, adhesion prevention in tendons and adjuvants for adhesion prevention. Studies detailing the use of surgical, pharmacological and non-pharmacological agents for adhesion prevention in digital flexor tendons were identified, and their bibliographies were thoroughly reviewed to identify further related articles. This search identified 41 studies, which investigated the use of various pharmacological agents in adhesion prevention in digital tendons.nnnAREAS OF AGREEMENTnThere is a need to develop and utilize an optimal method for the prevention of adhesions in the flexor tendons of the hand, due to post-surgical complications.nnnAREAS OF CONTROVERSYnEven though there have been significant advances in the prevention of adhesions in flexor tendons, it remains to be proved which, if any, of the current methods are the most beneficial.nnnGROWING POINTSnThe only thing that appears clinically justified in adhesion prevention is the need for early post-operative mobilization of digits after tendon injury or repair but the best method of mobilization remains controversial.nnnAREAS TIMELY FOR DEVELOPING RESEARCHnSuggested changes in surgical techniques and various proposed pharmacological and non-pharmacological modalities need to withstand the test of adequately powered human trials, before their justification for potential benefit in clinical practice is accepted.

Posterior Thigh Muscle Injuries in Elite Track and Field Athletes

Introduction: Posterior thigh muscle injuries in athletes are common, and prediction of recovery time would be of value. Hypothesis: Knee active range of motion deficit 48 hours after a unilateral posterior thigh muscle injury correlates with time to full recovery. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: One hundred sixty-five track and field athletes with acute, first-time, unilateral posterior thigh muscle injuries were prospectively evaluated regarding knee active range of motion deficit. This was compared with the uninjured side 48 hours after injury. A control group was also examined. Ultrasound was used to image the muscle lesion. All athletes were managed nonoperatively with the same rehabilitation protocol. The “full rehabilitation time” (interval from the injury to full athletic activities) was recorded. Results: Range of motion of the affected leg was decreased in the 165 injured athletes compared with the uninjured side and the control group. Sonography identified abnormalities in 55% (90 of 165) of the injured athletes. The biceps femoris was the most commonly affected muscle (68 of 90 [75%]). The musculotendinous junction (proximal or distal) was involved in 93% (85 of 90) of lesions. Eighty-one percent (133 of 165) of athletes had active range of motion deficit of less than 20°, and had returned to full performance at 2 weeks. In 6 of 165 athletes (3.6%), with active range of motion deficit of more than 30°, recovery time exceeded 6 weeks, with a significant correlation between full rehabilitation time and active range of motion deficit (χ2 = 152.560; P = .0001). Conclusion: Knee active range of motion deficit is an objective and accurate measurement, predicting recovery time in elite athletes.

Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon

BackgroundMany techniques have been developed for the reconstruction of the Achilles tendon in chronic tears. In presence of a large gap (greater than 6 centimetres), tendon augmentation is required.MethodsWe present our method of minimally invasive semitendinosus reconstruction for the Achilles tendon using one para-midline and one midline incision.ResultsThe first incision is a 5 cm longitudinal incision, made 2 cm proximal and just medial to the palpable end of the residual tendon. The second incision is 3 cm long and is also longitudinal but is 2 cm distal and in the midline to the distal end of the tendon rupture. The distal and proximal Achilles tendon stumps are mobilised. After trying to reduce the gap of the ruptured Achilles tendon, if the gap produced is greater than 6 cm despite maximal plantar flexion of the ankle and traction on the Achilles tendon stumps, the ipsilateral semitendinosus tendon is harvested. The semitendinosus tendon is passed through small incisions in the substance of the proximal stump of the Achilles tendon, and it is sutured to the Achilles tendon. It is then passed beneath the intact skin bridge into the distal incision, and passed from medial to lateral through a transverse tenotomy in the distal stump. With the ankle in maximal plantar flexion, the semitendinosus tendon is sutured to the Achilles tendon at each entry and exit pointConclusionThis minimally invasive technique allows reconstruction of the Achilles tendon using the tendon of semitendinosus preserving skin integrity over the site most prone to wound breakdown, and can be especially used to reconstruct the Achilles tendon in the presence of large gap (greater than 6 centimetres).

The effects of LIPUS on soft-tissue healing: a review of literature

INTRODUCTIONnUltrasound is widely used for imaging purposes and as an adjunct to physiotherapy. Low-intensity pulsed ultrasound (LIPUS), having removed the thermal component found at higher intensities, is used to improve bone healing. However, its potential role in soft-tissue healing is still under investigation.nnnMATERIAL AND METHODSnWe searched on Medline using the keywords: low-intensity pulsed ultrasound, LIPUS and LIPUS and soft-tissue healing. Thirty-two suitable articles were identified.nnnRESULTSnResearch, mainly pre-clinical, so far has shown encouraging result, with LIPUS able to promote healing in various soft tissues such as cartilage, inter-vertebral disc, etc. The effect on the bone-tendon junction, however, is primarily on bone. The role of LIPUS in treating tendinopathies is questionable. Adequately powered human studies with standardisation of intensities and dosages of LIPUS for each target tissue are needed.

Minimally invasive total knee arthroplasty: a systematic review.

The concept of minimally invasive total knee arthroplasty surgery evolved to reduce quadriceps muscle strength loss and improve clinical outcome following total knee replacement. We performed a systematic review of the published literature on Minimally Invasive Total Knee Arthroplasty (MITKA) and analyzed the reported surgical outcomes. Twenty-eight studies published from January 2003 to June 2008 that met the inclusion criteria were evaluated using the modified Coleman Methodology Score (CMS). At a mean CMS of 60, most studies reporting on outcome of MITKA are of moderate scientific quality. Patients undergoing MITKA tend to have decreased postoperative pain, rapid recovery of quadriceps function, reduced blood loss, improved range of motion (mostly reported as a short-term gain) and shorter hospital stay compared with patients undergoing standard total knee arthroplasty. These benefits, however, need to be balanced against the incidence of increased tourniquet time and increased incidence of component malalignment in the MITKA group. So far, the evidence based knowledge regarding results of MITKA comes from prospective studies of moderate quality with short follow up periods. Multicenter studies with longer follow-ups are needed to justify the long-term advantages of MITKA over standard total knee arthroplasty.

Morton's neuroma: Clinical testing and imaging in 76 feet, compared to a control group

BACKGROUNDnMortons neuroma is a mechanically induced degenerative neuropathy.nnnMETHODSnWe compared clinical and MRI findings in 76 feet treated operatively for Mortons neuroma and 40 feet with different pathologies (controls).nnnRESULTSnIn the treatment group web space tenderness (WST) was positive in 95%, foot squeeze (SQU) in 88%, plantar percussion (PLP) in 61%, and toe tip sensation deficit (TTSD) in 67%. MRI identified neuromata in 97%. Histological examination confirmed neuroma excision in 99%. Frequency of positive tests was significantly higher in the treatment group compared to controls. MRI revealed (asymptomatic) neuromata in 10/40 (25%) feet in the control group. TTSD was similarly positive in asymptomatic and symptomatic neuromata. TTSD in association with any other test being positive, was significantly more frequent in symptomatic neuromata.nnnCONCLUSIONSnThe diagnosis of Mortons neuroma, based on clinical and imaging findings, was accurate. Positive clinical testing was more frequent in the treatment group compared to the control group.

Supination-External Rotation Ankle Fractures Stability a Key Issue

Stability is a key issue in treating supination-external rotation ankle fractures, but we do not know how it affects functional outcome and subsequent development of radiographic osteoarthritis. With a systematic literature review, we identified 11 clinical studies (Level IV evidence) published in peer-reviewed journals reporting on at least 10 ankles. Followup was at least 1xa0year. Two authors independently scored the quality of the studies using the modified Coleman Methodology Score; the mean score was 58 of 100, with substantial agreement between the two examiners. Four studies used a general health assessment questionnaire. Several literature limitations (debatable fracture stability criteria, few cohort studies with heterogeneous methodology, small patient numbers and limited followup in some studies) do not allow definitive conclusions. Of 213 stable fractures treated nonoperatively, 2.8% of ankles had radiographic osteoarthritis develop (18xa0years’ mean followup) and 84% were free of symptoms. The incidence of radiographic osteoarthritis in 420 unstable fractures treated operatively was 20.9% at 5.5xa0years versus 65.5% at 6.8xa0years in 137 ankles treated nonoperatively. The complication rate in 355 operatively treated fractures was 10.4%. A medial malleolus fracture, female gender, older age, higher American Society of Anesthesiologists grade, smoking, and lower educational level negatively influenced general health outcome, physical function, and pain.Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.