Surgical Reconstruction of Chronic Achilles Tendon Ruptures Using Various Methods

Surgical Reconstruction of Chronic Achilles Tendon Ruptures Using Various Methods

Early indicators may predict recovery time from concussion in athletes, study finds

Early indicators may predict recovery time from concussion in athletes, study finds

Therapeutic Interventions for Acute Hamstring Injuries: Abstract and Introduction

Therapeutic Interventions for Acute Hamstring Injuries: Abstract and Introduction

Abstract and Introduction

Abstract

Background Despite the high rate of hamstring injuries, there is no consensus on their management, with a large number of different interventions being used. Recently several new injection therapies have been introduced.
Objective To systematically review the literature on the effectiveness of therapeutic interventions for acute hamstring injuries.
Data sources The databases of PubMed, EMBASE, Web of Science, Cochrane Library, CINAHL and SPORTDiscus were searched in May 2011.
Study eligibility criteria Prospective studies comparing the effect of an intervention with another intervention or a control group without intervention in subjects with acute hamstring injuries were included.
Data analysis Two authors independently screened the search results and assessed risk of bias. Quality assessment of the included studies was performed using the Physiotherapy Evidence Database score. A best evidence synthesis was used to identify the level of evidence.
Main results Six studies were included in this systematic review. There is limited evidence for a positive effect of stretching, agility and trunk stability exercises, intramuscular actovegin injections or slump stretching in the management of acute hamstring injuries. Limited evidence was found that there is no effect of non-steroidal anti-inflammatory drugs or manipulation of the sacroiliac joint.
Conclusions There is a lack of high quality studies on the treatment of acute hamstring injuries. Only limited evidence was found to support the use of stretching, agility and trunk stability exercises, intramuscular actovegin injections or slump stretching. Further research is needed using an appropriate control group, randomisation and blinding.

Introduction

Acute hamstring injury is common in the athletic population. In different types of sport, such as football, Australian rules football and rugby, 12–16% of all injuries are hamstring injuries.^[1–5] These injuries have significant consequences for the performance of players and their clubs: a professional athlete with a hamstring injury cannot perform in match play for an average of 14–27 days.^{[3 6 7]} Despite the high injury rate, there is no consensus on the best management because of a lack of scientific evidence on effectiveness.^[8] This is underlined by the diversity of interventions used in the management of hamstring injuries: rest, ice, compression, elevation,^[9] use of non-steroidal anti-inflammatory drugs (NSAIDs),^[10] exercise therapy,^[11] mobilisation and manipulation therapy,^[12] injection therapies including corticosteroids,^[13] autologous blood products^{[14 15]} and traumeel/actovegin injections.^{[8 15]} Traumeel is a homoeopathic formulation containing botanical and mineral components to which anti-inflammatory effects are ascribed. Actovegin is a deproteinised haemodialysate obtained from filtered calf blood. It is suggested that it contains active components with muscle regenerating promoting effects.^{[8 15]} The most recent systematic review of management of hamstring injuries was published by Harris et al in 2011.^[16] Its subject was operative treatment compared with non-operative treatment in acute proximal hamstring ruptures. The most recent systematic review of conservative therapeutic interventions for acute hamstring injuries was published by Mason et al in 2007.^[17] It looked at rehabilitation interventions for hamstring injuries based on only three studies. Since the latter publication, additional studies on therapeutic interventions in hamstring injuries have been published, and new injection therapies have been introduced.^{[14 15]}

The purpose of this study is to systematically review the literature on the effectiveness of therapeutic interventions for acute hamstring injuries.

Surgical vs Conservative Treatment for Acute Ankle Sprains: Background

Surgical vs Conservative Treatment for Acute Ankle Sprains: Background

Main Outcome Measures

The primary outcome measures of the review were return to preinjury activity (sport or work), recurrence, persistent pain and subjective instability (giving way). The secondary outcome measures were objective instability (talar tilt, anterior drawer measures), swelling, stiffness, ankle mobility, muscle atrophy, complications and satisfaction.

Results

Twenty studies (n=2562 participants) were included in the review, although it is noted that only 12 studies (57% of participants) reported data that could be pooled. The publication dates span the period from 1965 to 2006. The participants in the included studies were mostly young adult (median about 25 years), active men (55–100%).

Several of the primary outcomes show pooled effects in favour of surgical interventions (point estimate of RR between 0.57 and 0.80). However, in all analyses the effect size is heavily influenced by one low-quality study from 1978 that shows striking effects in favour of surgery. When appropriate analyses are conducted to account for the statistical heterogeneity caused by this study (random effects model) or it is excluded from the analysis, there is no longer any difference between the surgical and conservative conditions for any of the outcomes. The results for long-term pain shown in figure 1 are typical of those for all the primary outcomes.

With respect to the secondary outcomes the pattern is very similar, although the results suggest a possible positive effect of surgery on objectively measured instability (radiographical assessment of talar tilt or anterior drawer test). Different types of conservative treatment were not shown to influence the differential effect. In the studies that measured complications, these were generally higher in the surgical group, although it should be noted that some complications are clearly not applicable to both groups, for example scar tenderness and wound infection.

Clinical Implications

Current best evidence does not endorse the choice of surgical over conservative treatment (or vice versa) following acute ankle sprain. It should be noted though that surgical interventions are usually followed by a period of rehabilitation, similar to that tested in the 'conservative' arms of the included studies. As such this review could be said to investigate the question of whether adding surgery to conservative management confers any benefit. It appears at this stage that both treatment regimens result in similar effects on important outcomes for this population; that is, no evidence of the superiority of one intervention over the other. Importantly, the results of this review are not generalisable to people with chronic ankle problems who have failed to respond to previous treatment.

Impingement syndrome: Diagnostic approaches have increased accuracy and treatment options

Impingement syndrome: Diagnostic approaches have increased accuracy and treatment options

Jackson: What are your current indications for the commonly performed acromioplasty? What can the patient expect in terms of outcomes when it is performed?

Warme: We do not change the morphology of the CA arch or acromion in any way when performing cuff repairs. At this point, we only modify the undersurface of the acromion if it is misshapen from trauma, such as in cases of a malunion, or it there is an abnormal growth on it such as an osteochondroma. These cases are exceedingly rare.

Need for sports medicine stressed: National Conference on Sports Medicine and Rehabilitation held at the Gulf Medical University Ajman

Need for sports medicine stressed:

Dr William Murrell, Consultant Orthopaedic Sports, Dubai Bone and Joint Centre focused on the advances in arthroscopy that have changed the face of sport. The lecture talked about advances in Anatomic ACL reconstruction and Shoulder Instability and how these problems have effected the health and welfare of athletes in the UAE as a whole. Outlined some of the research programs currently underway at Dubai Bone and Joint Center, in Dubai Healthcare City-Dubai.

PRP an unproven option, agree forum experts

PRP an unproven option, agree forum experts

By Mary Ann Porucznik

An international group of orthopaedic surgeons, clinician scientists, and researchers agreed that, for many orthopaedic conditions, administration of platelet-rich plasma (PRP) may be an option, but its efficacy is unproven. The participants of the 2011 PRP Forum also endorsed the development of standards in the manufacture of PRP, noted that PRP may be contraindicated in some conditions, and called for the establishment of a study group to follow up on the other recommendations resulting from the session.

Attendees discussed the applicability of PRP in the following areas:

• treatment of acute soft-tissue injuries, such as Achilles tendon rupture and rotator cuff repair
• chronic tendinopathies such as plantar fasciitis or medial/lateral epicondylitis
• augmentation of soft tissue or bone such as in spinal fusion
• treatment of cartilage defects such as those resulting from osteochondral lesions or osteoarthritis.

The 2011 PRP Forum was staged by AAOS Now, and cochaired by AAOS Now Editor-in-Chief S. Terry Canale, MD, and AAOS Now editorial board member Frank B. Kelly, MD. It brought together approximately 50 of the most knowledgeable and experienced clinicians and researchers in the field of PRP therapy, including Steven P. Arnoczky, DVM; Freddie H. Fu, MD; Wellington Hsu, MD; Elizaveta Kon, MD; Allan K. Mishra, MD; Nicola Maffulli, MD, PhD; Pietro Randelli, MD; and Scott A. Rodeo, MD. It combined a series of presentations, followed by break-out group discussions, resulting in a series of recommendations for future study of PRP.

All PRPs are not the same
In opening the forum, Dr. Arnoc-zky noted that “All PRPs are not the same, and we have to be aware of what we are putting in the patient.” Although PRP is a concentrated, autologous preparation developed from the patient’s own blood, some concentrations may contain double the number of platelets while others may contain five or ten times the number of platelets. The proportion of white blood cells, growth factors, and other compounds such as thrombin can also affect the compound.

The problem, however, is that “we don’t know how PRP works,” admitted Dr. Arnoczky. Most of the published literature on the efficacy of PRP in treating orthopaedic conditions that range from acute rotator cuff tears to chronic Achilles tendinitis have not specified the formulation used. The variation in composition does not enable scientists to compare results… “we’re talking apples and oranges and bananas,” said Ramon B. Cugat, MD.

Dr. Mishra presented a potential classification system for PRP, based on the presence or absence of white blood cells, the concentration of platelets, and the activation status. He noted that much current use of PRP in orthopaedics is patient-driven and based on reports of its use in elite athletes such as Tiger Woods and Cliff Lee.

Most major league sports governing bodies (National Football League, Major League Baseball, and National Basketball Association) have approved the use of PRP on athletes, and the World Anti-Doping Association recently removed platelet-derived preparations from its list of prohibited substances and methods, based on the lack of current evidence concerning the use of PRP for performance enhancement.

At the end of the day, an informal survey of participants found most in agreement that PRP would be an option, particularly if conservative treatments have failed and the next step would be surgery.

“PRP is a simple concept,” concluded Dr. Mishra, “but it is surrounded by a complex set of questions that are still unanswered.”