Successful return to sports in athletes following non-operative management of acute isolated posterior cruciate ligament injuries: medium-term follow-up.

AIMS: The aim of this study was to report the outcome of the non-operative treatment of high-grade posterior cruciate ligament (PCL) injuries, particularly Hughston grade III injuries, which have not previously been described. PATIENTS AND METHODS: This was a prospective study involving 46 consecutive patients who were athletes with MRI-confirmed isolated PCL injuries presenting within four weeks of injury. All had Hughston grade II (25 athletes) or III (21 athletes) injuries. Our non-operative treatment regimen involved initial bracing, followed by an individualised rehabilitation programme determined by the symptoms and physical signs. The patients were reviewed until they had returned to sports-specific training, and were reviewed again at a mean of 5.2 years (3 to 9). RESULTS: The mean time to return to sports-specific training was 10.6 weeks and the mean time to return to full competitive sport was 16.4 weeks (10 to 40). A total of 42 patients (91.3%) were playing at the same or higher level of sport two years after the injury, with a mean Tegner activity score of 9 (5 to 10). At five years, 32 patients (69.5%) were playing at the same or higher level of sport, and 38 patients (82.6%) were playing at a competitive level, with a mean Tegner activity score of 9 (5 to 10). CONCLUSIONS: Medium-term review of a series of athletes suggests that commencing the non-operative management of isolated, Hughston grade II and III PCL injuries within four weeks of injury gives excellent functional outcomes with a high proportion returning to the same or higher level of sport. Cite this article: Bone Joint J 2017;99-B:774-8.

Successful return to high-level sports following early surgical repair of combined adductor complex and rectus abdominis avulsion.

Hip and groin injuries are common in athletes who take part in high level sports. Adductor muscle tendon injuries represent a small but important number of these injuries. Avulsion of the tendons attached to the symphysis pubis has previously been described: these can be managed both operatively and non-operatively. We describe an uncommon variant of this injury, namely complete avulsion of the adductor sleeve complex: this includes adductor longus, pectineus and rectus abdominis. We go on to describe a surgical technique which promotes a full return to the pre-injury level of sporting activity. Over a period of ten years, 15 high-level athletes with an MRI-confirmed acute adductor complex avulsion injury (six to 34 days old) underwent surgical repair. The operative procedure consisted of anatomical re-attachment of the avulsed tissues in each case and mesh reinforcement of the posterior inguinal wall in seven patients. All underwent a standardised rehabilitation programme, which was then individualised to be sport-specific. One patient developed a superficial wound infection, which was successfully treated with antibiotics. Of the 15 patients, four complained of transient local numbness which resolved in all cases. All patients (including seven elite athletes) returned to their previous level of participation in sport.

Metal-on-metal hip arthroplasty: going, going, gone... - opposes.

In this paper, we will consider the current role of metal-on-metal bearings by looking at three subtypes of MoM hip arthroplasty separately: Hip resurfacing, large head (> 36 mm) MoM THA and MoM THA with traditional femoral head sizes.

Hyperplastic polyps of the duodenum: an unusual histological finding.

A 58-year-old man underwent upper gastrointestinal surveillance endoscopy for Barrett's oesophagus. This showed a possible gastric ulcer, although histological examination was normal. Follow-up endoscopy showed white ridges in the distal duodenum and these were subjected to biopsy. Histological examination of the biopsy specimens showed polypoid duodenal mucosa showing features similar to those of a hyperplastic polyp of the colon. In addition, the mucosal surface was focally of gastric surface type. The features were interpreted overall as most likely to represent an unusual form of regenerative change in the setting of previous chronic inflammatory mucosal damage. The case is presented as an unusual histological phenomenon at this site; it would be important not to overdiagnose neoplasia in this situation.

Neonatal accessory digits: a survey of practice amongst paediatricians and hand surgeons in the United Kingdom.

AIM: To describe the management of neonatal accessory digits, comparing views of paediatricians with those of hand surgeons, giving particular emphasis to the form of partial, ulnar duplication of the little finger (ulnar or postaxial polydactyly type B) which has a narrow pedicle. METHODS: Postal questionnaire of management preference using three photographs of ulnar accessory digits of varying complexity. RESULTS: The response rate was 64% in 234 paediatricians and 25% in 260 surgeons. All respondents would intervene in cases of ulnar polydactyly type B with a narrow pedicle: 79% of paediatricians but only 67% of hand surgeons would recommend referral of these cases for specialist assessment, the remainder advocating ligation by the paediatrician in the nursery. Paediatricians and neonatologists working in regional centres or with an on-site specialist service were more likely to refer. There was almost unanimous agreement on the management of the most complex case, but no general consensus on that of the simplest form. CONCLUSION: There is uncertainty and inequality in initial treatment decisions for infants with all but the most complex of accessory digits. Despite published evidence that ligation gives satisfactory results, most respondents in this survey advocate specialist referral, with evidence that the availability of specialist services influences decision making.

Amnesic syndrome and severe ataxia following the recreational use of 3,4-methylene-dioxymethamphetamine (MDMA, 'ecstasy') and other substances.

A 26-year-old woman suffered disseminated intravascular coagulation (DIC) and a brief respiratory arrest following recreational use of 3,4-methylene-dioxymethamphetamine (MDMA; 'ecstasy'), together with amyl nitrate, lysergic acid (LSD), cannabis and alcohol. She was left with residual cognitive and physical deficits, particularly severe anterograde memory disorder, mental slowness, severe ataxia and dysarthria. Follow-up investigations have shown that these have persisted, although there has been some improvement in verbal recognition memory and in social functioning. Magnetic resonance imaging and quantified positron emission tomography investigations have revealed: (i) severe cerebellar atrophy and hypometabolism accounting for the ataxia and dysarthria; (ii) thalamic, retrosplenial and left medial temporal hypometabolism to which the anterograde amnesia can be attributed; and (iii) some degree of fronto-temporal-parietal hypometabolism, possibly accounting for the cognitive slowness. The putative relationship of these abnormalities to the direct and indirect effects of MDMA toxicity, hypoxia and ischaemia is considered.

A cyberclinic in rheumatology.

OBJECTIVE: To evaluate the feasibility of a rheumatology consultation and advisory service using internet and e-mail. METHODS: We placed a detailed rheumatology proforma on our website for general practitioners to complete and e-mail to our outpatients clinic. To study its feasibility, two junior doctors interviewed and completed the proforma for 207 new patients. Based on this information, the consultant provided provisional diagnoses, work up & management plans, which were then compared with those drawn up following face-to-face assessment of the same patients in the outpatients clinic. RESULTS: In most instances the pre- and post-examination diagnoses, work up & management plans were similar. Diagnostic concurrence was noted in 178 (86%) patients; no changes were required in x-rays and other tests requested in 129 (62%) patients; and the suggested treatment (including corticosteroid injections) remained the same in 153 (74%) patients. CONCLUSION: Our results suggest that it is feasible to offer an e-mail or internet based outpatients consultation and advisory service in rheumatology and possibly other disciplines.

Perioperative burn nursing.

Approximately 5,000 people require hospitalization for burn care every year. Of these, the majority will require surgical intervention to survive the injury. The perioperative nurse plays a vital role in the care of the patient during their hospitalization.

Total lymphoid irradiation in multiple sclerosis.

Following a report of the efficacy of total lymphoid irradiation (TLI) in the treatment of chronic progressive multiple sclerosis a further randomised double-blind placebo-controlled study was undertaken with the intention of entering 56 patients. In the event it was possible to recruit only 27 patients in a 2.5 year period. Three patients received active treatment openly and 24 were randomised to either active (14) or sham (10) treatment. Treatment was 1980 cGy to the lymphoid system and spleen or sham treatment after full simulation. The primary outcome measure was a comparison of the mean rates of change between treatment groups on the expanded Kurtzke disability scale (EDSS) over the two year follow up period. Patients were also assessed on other clinical outcome measures, psychometry, and serial MRI of the brain. Active treatment resulted in a profound and prolonged fall in T lymphocytes especially those with the CD4 marker and a reversal in CD4:CD8 ratio. No significant benefit was demonstrated on the rate of clinical disease progression (EDSS). A small but significant benefit was found on a score of bladder function. No significant benefit was demonstrated on other clinical or psychometric indices or on subjective visual analogue scales. There was a small but significant difference in the rate of accumulation of lesions on brain MRI favouring the treatment group. The treated group had a higher incidence of clinically relevant side effects, notably amenorrhoea and infections: three deaths (one in the TLI group, two in the sham treated group) occurred. A post hoc calculation indicates that the study had a possible 35% risk of a false negative result using the principal outcome measure. The study fails to confirm the previously reported clinical benefit of TLI although there may be a minor benefit on disease progression as indicated by MRI lesion counts. It is concluded that TLI cannot be recommended for the routine treatment of chronic progressive multiple sclerosis but the beneficial effect on MRI lesions, though modest, suggests that further research into immune modulation of this condition may be worthwhile.

Endomyocardial fibrosis in a European woman and its successful surgical treatment.

A case of endomyocardial fibrosis of the right ventricle in a European woman is presented. The patient had no history of travel or residency outside of the United Kingdon, Echocardiography was helpful in defining the abnormality. Excision of the fibrotic tissue in the right ventricle and tricuspid valve replacement resulted in symptomatic relief. There was also coincidental absence of the right pulmonary artery.