Trauma and orthopaedics

The release of adhesions improves outcome following minimally invasive repair of Achilles tendon rupture (2022)

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Type of publication:Journal article

Author(s):*Carmont, Michael R; Knutsson, Sara Brandt; Brorsson, Annelie; Karlsson, Jón; Nilsson-Helander, Katarina

Citation:Knee Surgery, Sports Traumatology, Arthroscopy : official journal of the ESSKA; Mar 2022; vol. 30 (no. 3); p. 1109-1117

Abstract:PURPOSE Operative repair of Achilles tendon rupture may lead to complications, which influence outcome adversely. The aim of this study was to determine the incidence, impact and response to treatment of post-operative adhesions. METHODS From February 2009 to 2021, 248 patients operated on with percutaneous or minimally invasive surgical repair have been prospectively evaluated using the Achilles tendon Total Rupture Score (ATRS) and Heel-Rise Height Index (HRHI), following acute Achilles tendon rupture. RESULTS Fourteen (5.6%) patients were identified as having adhesions. Four patients reported superficial adhesions and ten patients reported a deeper tightness of the tendon. At a mean (SD) of 10.5 (2.3) months following repair, the overall ATRS was at a median (IQR) 65 (44.5-78) points and (HRHI) was mean (SD) 81.5 (13.5)%. Of those deemed to have deep adhesions the antero-posterior diameter of the tendon was at mean (SD) 15.6 (4.6) mm. Open release of superficial adhesions resulted in improved ATRS in all patients. Endoscopic debridement anterior to the Achilles tendon led to alleviation of symptoms of tightness and discomfort from deep adhesions and improved outcome in terms of the ATRS score. At a mean (SD) of 15.9 (3.3)-month follow-up from initial rupture and repair, the patients reported at median (IQR) ATRS scores of 85 (64.8-92.8) points, Tegner level 5 (3-9) and mean (SD) HRHI 86.2 (9.5)%. Patients significantly improved both ATRS and HRHI following release at median (IQR) of 16.5 (- 1.8-29.3) points (p = 0.041) and mean (SD) 5.6 (8.3)% (p = 0.043). CONCLUSIONS The incidence of patient-reported adhesions following minimally invasive repair of Achilles tendon rupture was estimated to be 5.6%. The occurrence of superficial adhesions was associated with a lower outcome scores as well as symptoms of anterior tendon tightness and stiffness were associated with a lower score in most patients. Surgical release of adhesions led to a significant improvement in outcome.

Successful diagnosis of gout with use of dual energy CT in a patient presenting with atypical symptoms and negative aspiration (2021)

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Type of publication:Conference abstract

Author(s):*Goel N.; *Amarasena R.

Citation:International Journal of Rheumatic Diseases; Sep 2021; vol. 24 ; p. 177

Abstract:A 42 year old Caucasian gentleman presents with acute left knee swelling, developed over 3 days without preceding trauma. He was referred to Trauma and Orthopaedics who aspirated the knee, finding no organisms or crystals. Following readmission 4 days later with the same complaint, re-aspiration again showed no crystals or organisms. MRI of the left knee showed femoral condyle oedema, initially suggesting Osteomyelitis, but on re-discussion with the radiologist seemed unlikely. The patient was started on Indomethacin and referred to Rheumatology. Despite having some symptomatic relief, he developed progressive swelling in the left calf, ankle and foot. Blood tests confirmed raised D-Dimer and rising CRP: 142 (ref range 0-5). Ultrasound Doppler of the left leg revealed no evidence of DVT, but did show pockets of fluid in the lower thigh, which were noted on previous MRI. X-rays of the knee and ankle did not show any pathological changes. Following Rheumatology review, it was postulated that he could have myofasciitis or infection. RF and CCP were found to be negative with normal complement levels and CK. Further MRI of the left leg showed progressive persistent oedema in the lateral femur. He was commenced on Intravenous flucloxacillin and diclofenac for suspected infection. Following 10 weeks of investigations and management, an MDT discussion opted for Dual Energy CT scan to look for evidence of gout. The Dual Energy CT scan showed extensive gout crystal deposition in the left knee, as well as affecting the popliteus tendon. He was commenced on Prednisolone, counselled on lifestyle factors and later started on Allopurinol that was up-titrated with bridging Colchicine, with excellent response. This case highlights the advances in Dual Energy CT scanning in helping to diagnose gout in those patients with atypical presentation and negative results on needle aspiration.

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Soft tissue extensor mechanism tendon ruptures of the knee (2021)

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Type of publication:Journal article

Author(s):Rhind J.-H.; *Lancaster P.; *Ahmed U.; *Carmont M.

Citation:British Journal of Hospital Medicine; Sep 2021; vol. 82 (no. 9); p. 1-9

Abstract:Ruptures of the extensor mechanism of the knee are serious injuries requiring prompt diagnosis and treatment. They can be divided into soft tissue and bony causes. Soft tissue tendon injuries can be either partial or complete. Rupture of the quadriceps tendon is an uncommon injury and is more frequent in patients over the age of 40 years. Patella tendon ruptures are even rarer and are more frequent in patients under the age of 40 years. Causes can be direct or indirect. Complete ruptures of the quadriceps tendon or patella tendon benefit from early surgical management, while partial ruptures may be managed non-operatively. This article gives an overview of the presentation, assessment and management of soft tissue extensor mechanism tendon ruptures for core surgical, acute care common stem and emergency medicine trainees.

MRI of the Achilles tendon - a comprehensive pictorial review. Part two (2021)

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Type of publication:
Journal article

Author(s):
Szaro P.; Nilsson-Helander K.; *Carmont M.

Citation:
European Journal of Radiology Open; Jan 2021; vol. 8

Abstract:
The most common disorder affecting the Achilles tendon is midportion tendinopathy. A focal fluid signal indicates microtears, which may progress to partial and complete rupture. Assessment of Achilles tendon healing should be based on tendon morphology and tension rather than structural signal. After nonoperative management or surgical repair of the Achilles tendon, areas of fluid signal is pathologic because it indicates re-rupture. A higher signal in the postoperative Achilles tendon is a common finding and is present for a prolonged period following surgical intervention and needs to be interpreted alongside the clinical appearance.

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MRI of the Achilles tendon-A comprehensive pictorial review. Part one (2021)

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Type of publication:
Journal article

Author(s):
Szaro P.; Nilsson-Helander K.; *Carmont M.

Citation:
European Journal of Radiology Open; Jan 2021; vol. 8

Abstract:
The normal Achilles tendon is composed of twisted subtendons separated by thin high signal septae, which are a potential pitfall on MRI because they mimic a tendon tear. Tendinopathy and full thickness tears may be assessed effectively both on MRI and ultrasound. MRI is superior to ultrasound in detection of partial tears and for postoperative assessment. The use of fat suppression sequences allows the ability to detect focal lesions. Sagittal and coronal sections are useful for assessing the distance between stumps of a ruptured tendon. Sequences with contrast are indicated in postoperative investigations and suspicion of infection, arthritis or tumor. MRI may reveal inflammatory changes with minor symptoms long before the clinical manifestations of seronegative spondyloarthropathy. The most common non-traumatic focal lesion of the Achilles tendon is Achilles tendon xanthoma, which is manifested by intermediate or slightly higher signal on T1- and T2-weighted images compared to that in the normal Achilles tendon. Other tumors of the Achilles tendon are very rare, whereas the involvement of the tendon from tumor in adjacent structures is more frequent. The novel MRI sequences may help to detect disorders of the Achilles tendon more specifically before clinical manifestation. Regeneration or remodeling of the Achilles tendon can be non-invasively detected and monitored in diffusion tensor imaging. Assessment of healing is possible using T2-mapping while evaluating the tendon vascularization in intravoxel incoherent motion MRI.

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Is pain properly managed in children presenting with fractures? A retrospective audit of children presenting to the emergency department (2020)

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Type of publication:
Conference abstract

Author(s):
*Rafie A

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 68

Abstract:
Aim: Pain is a common problem in the surgical field, especially when treating children – but how well is it managed, and documented? In this audit we aim to answer a few key questions. Is analgesia administered prehospital? Are pain scores recorded, and re-evaluated? And is analgesia offered and/or administered in the Emergency Department(ED)? Method: A retrospective audit was carried out between two hospitals on 100 patients aged between 5-15 presenting to the ED. A search was carried out using SNOMEDand ICD10 codes, to find patients presenting with fractures – and the ED CAS cards reviewed.
Result(s): The data showed poor compliance between both hospitals – pain scores were seldom recorded, or reevaluated; and in 58% of cases analgesia was not offered and no reason was documented. 28% of patients were given pre-hospital analgesia and only 2% of patients had an analgesia review.
Conclusion(s): Adequate pain management is vital, especially in children – as they often don't self-report pain. The study found that the worst compliance was in documentation of pain scores, and their re-evaluation. However, more concerningly analgesia was only administered in 19% of cases – and in many cases there was no documentation as to why it wasn't offered.

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Boat propeller transection of hemithorax-successful multidisciplinary surgical reconstruction (2020)

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Type of publication:
Conference abstract

Author(s):
*Cheruvu S.; Oo K.T.M.; Erel E.; Satur C.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 37

Abstract:
A 69 year old man fell into canal and was drawn into the propeller of his canal boat that resulted in transection of the right thoracic cavity and the right upper arm. Emergency helicopter transfer was made to our major trauma centre for multidisciplinary surgical care. Injuries included a full thickness antero-posterior transection from the sternum to beyond the tip of the scapula, and an open right midshaft humeral fracture with wound extending obliquely into the axilla. The entire thoracic cavity was contaminated by canal water. There was severe haemodynamic and cardiorespiratory compromise requiring level 3 intensive care. Following emergency resuscitative management, multidisciplinary surgical care was provided by the cardiothoracic, plastic and orthopaedic surgery teams utilising innovative operative techniques. Multistage operative management of chest wall required initial damage control surgery with debridement and negative pressure therapy. After 4 days of intensive care physiological stabilisation, reconstruction of the thoracic defect was undertaken with specialist thoracic titanium implants and the chest wall was reconstructed. This was a major thoracic trauma case treated successfully using revolutionary surgical techniques at the Royal Stoke Hospital. The subsequent impact on practice for thoracic polytrauma has led to improved survival rates by 75%.

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Rothia mucilaginosa: a case of septic arthritis in a native knee and review of the literature (2021)

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Type of publication:
Journal article

Author(s):
*Daoub, Ahmed; *Ansari, Hamza; *Orfanos, George; *Barnett, Andrew

Citation:
BMJ case reports; Jan 2021; vol. 14 (no. 1)

Abstract:
Rothia mucilaginosa is a Gram-positive aerobic coccus usually found in the oral and respiratory tract. Septic arthritis is an uncommon condition, but is an orthopaedic emergency. A rare case of knee septic arthritis due to R. mucilaginosa is presented. Patient management and outcomes are discussed, and learning points from this case are outlined to help manage any further cases that may arise.

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Do the heel-rise test and isometric strength improve after Achilles tendon repair using Dresden technique? (2022)

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Type of publication:
Journal article

Author(s):
De la Fuente, Carlos; Henriquez, Hugo; *Carmont, Michael R; Huincahue, Javiera; Paredes, Tamara; Tapia, María; Araya, Juan Pablo; Díaz, Nicolás; Carpes, Felipe P

Citation:
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons; Jan 2022, 28(1) pages 37-43

Abstract:
BACKGROUND Achilles' tendon ruptures result in impaired plantar flexion strength and endurance. It is interesting to know the plantar flexion strength, the number of heel-rise repetitions, and the maximal calf circumference following Achilles' tendon ruptures repair. METHODS Both the injured and non-injured legs of thirty male patients with Achilles' tendon ruptures treated with the percutaneous Dresden technique were compared with the ankle function of 30 healthy participants. Rehabilitation involved partial weight-bearing for three weeks and then increased to full weight-bearing and ankle exercises. RESULTS The injured legs had weaker plantar flexion strength (1.64 ± 0.17 Nm/kg) compared with the non-injured legs (1.91 ± 0.24 Nm/kg; p = 0.002) and the healthy participants' legs (1.93 ± 0.32 Nm/kg; p < 0.001). The non-injured leg had greater ability in doing heel-rise repetitions (39.4 ± 6.1 rep.) compared with the injured legs (37.2 ± 5.7 rep.; p < 0.023) and the healthy participants' legs (31.0 ± 13.0 rep.; p < 0.001). CONCLUSIONS The injured leg had not recovered full isometric strength but had improved heel-rise repetition.

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No difference in Achilles Tendon Resting Angle, Patient-reported outcome or Heel-rise height Index between Non- and Early-weightbearing the First Year after an Achilles Tendon Rupture (2020)

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Type of publication:
Journal article

Author(s):
*Carmont M; Brorsson, A.; Karlsson, J.; Nilsson-Helander, K.

Citation:
Muscles, Ligaments & Tendons Journal (MLTJ); Oct 2020; vol. 10 (no. 4); p. 651-658

Abstract:
Background. Patient-reported outcome scores and comparable re-rupture rates in randomized controlled trials have not shown a definitive benefit for operative treatment after acute Achilles tendon rupture. This, together with the increasing rupture rates in the older age group has led to non-operative treatment being increasingly used. Objective. This study aimed to determine the variation in Achilles Tendon Resting Angle (ATRA) together with patient reported and functional outcome, with non-operative management of the ruptured Achilles tendon using two different regimes, which have been shown to offer low re-rupture rates. Methods. This is a non-randomised cohort comparison of Achilles tendon rupture patients managed with Non-Weight-Bearing (NWB) for 6 weeks vs. Early Weight-Bearing (EWB). The NWB-group received a cast in plantar flexion for 2 weeks followed by 6 weeks in a controlled ankle motion boot with incremental diminishing plantar flexion. The EWB-group received an initial anterior protective plaster slab in plantar flexion followed by 6 weeks of weight-bearing on the meta-tarsal heads, with an anterior shell restricting dorsiflexion. Results. At 12 months after the injury there were no differences in any of the variables between the two treatment groups. The NWB-group compared to the EWB-group reported at mean (SD) for ATRA -9.8° (4.6°) versus -11.4° (5°), p=0.32, for Achilles tendon Total Rupture Score (ATRS) 87 (10) versus 79 (19), p=0.43 and for Heel-Rise Height Index (HRHI) 71% (19%) versus 59% (13%), p=0.13. Conclusions. The two methods of non-operative treatment studied lead to increased relative ATRA following injury, however, patients report only minor limitation in terms of outcome. Patients had almost a third less heel-rise height compared with the non-injured ankle.

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