Reconstruction of a quadriceps tendon tear using Polyvinylidene fluoride sutures and patellar screw fixation: A biomechanical study.

BACKGROUND: Acute quadriceps tendon tears are infrequent injuries requiring surgical treatment. Improved stability after surgical repair may allow for earlier weight-bearing and range of motion. Therefore, a new implant was tested and compared with the "gold standard", using transosseous sutures. METHODS: Quadriceps tendon tears were constructed using a cadaveric model of 12 fresh matched-pair specimens (aged 61-97; mean age: 82 years). The biomechanical testing compared non-absorbable suture anchors (Polyvinylidene fluoride) versus transosseous absorbable sutures (Polydioxanon). Following anatomic reconstruction, the repaired specimens were loaded until they failed (testing machine: Hounsfield H10KM, Redhill, United Kingdom; maximum force: 1000 N; load speed: 25 mm/min; maximum test length: 150 mm; pre-load: 5 N). Values for load until tear displacement, maximum load until complete failure of the construct (pullout or breakage of the sutures or anchors) and stiffness of the reconstruction were recorded. RESULTS: The stiffness found in the Polyvinylidene fluoride reconstruction (mean 9.83 N/mm) (standard deviation (SD) 7.75) showed a significant increase compared to the Polydioxanon reconstruction (mean 6.66 N/mm (SD 3.32); P=0.045). Transosseous fixation showed comparable results to the suture anchor system. There was no significant difference found in the maximum load to tear displacement (PVDF: 290.88 N (SD 106.01) vs. PDS: 266.75 N (SD 82.61); P=0.358). CONCLUSIONS: Using the Polyvinylidene fluoride thread showed comparable results to the established method in reconstruction of ruptured quadriceps tendon. Stiffness of the Polyvinylidene fluoride thread reconstruction was even greater than Polydioxanon thread. CLINICAL RELEVANCE: Improved stiffness may facilitate healing and is suggested as clinical relevance in reconstruction.

A metabolic basis for fibromyalgia and its related disorders: the possible role of resistance to thyroid hormone.

It has long been recognized that the symptom complex of fibromyalgia can be seen with hypothyroidism. Hypothyroidism may been categorized, like diabetes, into type I (hormone deficient) and type II (hormone resistant). Most cases of fibromyalgia fall into the latter category. The syndrome is reversible with treatment, and is usually of late onset. It is likely more often acquired than due to mutated receptors. Now that there is evidence to support the hypothesis that fibromyalgia may be due to thyroid hormone resistance, four major questions appear addressable. First, can a simple biomarker be found to help diagnose it? Second, what other syndromes similar to Fibromyalgia may share a thyroid-resistant nature? Third, in non-genetic cases, how is resistance acquired? Fourth, what other methods of treatment become available through this new understanding? Preliminary evidence suggests that serum hyaluronic acid is a simple, inexpensive, sensitive, and specific test that identifies fibromyalgia. Overlapping symptom complexes suggest that chronic fatigue syndrome, Gulf war syndrome, premenstrual syndrome, post traumatic stress disorder, breast implant silicone sensitivity syndrome, bipolar affective disorder, systemic candidiasis, myofascial pain syndrome, and idiopathic environmental intolerance are similar enough to fibromyalgia to merit investigation for possible thyroid resistance. Acquired resistance may be due most often to a recently recognized chronic consumptive coagulopathy, which itself may be most often associated with chronic infections with mycoplasmids and related microbes or parasites. Other precipitants of thyroid resistance may use this or other paths as well. In addition to experimentally proven treatment with supraphysiologic doses of thyroid hormone, the thyroid-resistant disorders might be treatable with anti-hypercoagulant, anti-infective, insulin-sensitizing, and hyaluronolytic strategies.

Preliminary results comparing two methods of lateral column lengthening.

Forty-five patients (49 feet) underwent lateral column lengthening as treatment for painful pes planus. Twenty-five patients (27 feet) were available for both radiographic and clinical evaluation at least one year postoperatively. Of these 25 patients, 10 feet underwent Evans opening wedge osteotomy with tricortical iliac crest bone graft; 17 feet underwent calcaneocuboid distraction arthrodesis utilizing iliac crest bone graft. In addition, both groups underwent debridement of the posterior tibial tendon combined with transfer of the flexor digitorum longus into the navicular for reinforcement. Radiographic results documented marked improvement in all parameters. There was more improvement in the calcaneocuboid fusion group than the osteotomy group, but the difference was not statistically significant. Postoperative AOFAS rating scores averaged 87.9 for the osteotomy group and 80.9 for the distraction arthrodesis group. The difference was not statistically significant. Twenty of 25 patients (83.5%) in both groups were very satisfied. Twenty-four of 25 patients (96%) stated that knowing the final result they would have the same surgery again. Complications were reported for 32 patients (34 feet). Both the Evans opening wedge calcaneal osteotomy and calcaneocuboid distraction arthrodesis offer significant improvement in the radiographic parameters and AOFAS clinical scores for patients with painful, flexible flatfoot deformity. However, the complication rate remains high with both methods, and the rate of nonunion and delayed union with the calcaneocuboid distraction arthrodesis method remains a significant problem with this technique.

The five generations of American medical revolutions.

Current medical authors frequently use the term "revolution," yet American medicine is resisting change rather than embracing it. The last completed American medical revolutionary movement was the specialist-technologist movement of the late 19th and early 20th centuries. This paper describes a five-generational model of revolution. First-generation persons foment revolution; second-generation persons shape it into workable form and precipitate conflict; third-generation persons join the fight only when it appears to be all but won; fourth-generation persons enjoy the fruits of revolution; and fifth-generation persons, having risen to domination in the mature system, resist all attempts at reform by the next round of revolutionaries. In political revolutions, severe reactionary activity by the ruling party is often an indicator of an imminent overthrow by revolution. In scientific revolutions, the opposition of an established (specialist-technologist) paradigm to an emerging alternative (generalist) paradigm increases in intensity as the old order declines in strength; the opposition becomes most fierce just before the collapse of the old order. American specialist-technologist medicine, declining into its senescent fifth generation, will resist all but incremental change whenever possible, and accept major change only by force.

Multiple facial trauma complicated by occlusion of the internal carotid artery.

The occurrence of thrombosis of the internal carotid artery is a rare entity. Such a case, in association with multiple facial fractures, has been presented. The management of the patient was complicated by neurological disturbances that affected definitive treatment. This case illustrates the importance of close monitoring of all patients with facial trauma before, during, and after surgery.