Return to competition following clavicle fractures in professional road cyclists.

Objectives: Clavicle fractures are common injuries sustained by cyclists, but there is little evidence about return to competition times (RTCT) in elite cyclists. Our aim was to investigate this, and risk factors for delayed return. Method: We identified elite cyclists who sustained clavicle fractures between 2015 and 2020. Freely available records were reviewed to validate data for RTCT. Secondary outcomes included return to outdoor cycling, management, time to surgery, cause of injury, other injuries, and ability to complete the event returned to. Results: Records were reviewed of 1449 cyclists, identifying 188 clavicle fractures. 44 were recurrent fractures and were excluded. Those with isolated clavicle fractures (111; 92 male, 19 female) had a mean RTCT of 56.7 days, compared with 74.9 for those with multiple injuries (33) (p = 0.048). Those with multiple injuries were excluded from secondary outcome measures. All those with isolated injuries returned to elite competition. 83% were managed surgically with an RTCT of 53.8d, with no significant difference to those managed non-operatively, 59.3d (p = 0.61). RTCT was significantly lower for injuries sustained January-July (46.5d) than August-December (95.8d, p = 0.00). The incidence during Grand Tours was 0.06/1000 h for males (95% C.I 0.03-0.09), and 0.11/1000h (95% C.I 0.00-0.26) for females. Conclusion: This is the largest study evaluating return to sport in elite cyclists with clavicle fractures. Athletes with isolated clavicle fractures, able to return the same season, took an average 46.5 days to return to competition. Elite cyclists are at high risk of clavicle fractures and the majority are managed surgically. RTCT is longer than often expected by the media, and this data can help plan rehabilitation, and manage expectations in both professional and amateur cyclists. Level of Evidence: Level V.

The natural orientation of the Anterior Cruciate Ligament compared to the tibial plateau on magnetic resonance imaging scans.

PURPOSE: Remnant preserving Anterior Cruciate Ligament (ACL) reconstruction requires the graft to be passed through the remnant ACL stump. This requires knowledge of the native alignment of the ACL. We investigated the alignment and orientation compared directly to the tibial plateau on Magnetic Resonance Imaging. We assessed if current equipment is adequate for anatomical reconstruction. METHODS: 50 MRI scans with intact ACL and PCL were reviewed. Measurements were taken of; a) angle of ACL and tibial plateau in the sagittal plane, b) angle of ACL and tibial plateau in the coronal plane, c) position of ACL insertion into tibia as percentage of anterior-posterior width, d) position of ACL insertion into tibia as percentage of medio-lateral width. Statistical analysis included intra and interobserver agreement. Commonly used tibial guides were assessed for range of angles possible in use. RESULTS: The mean results for each measurement (+/- standard deviation) were; a) 45°(4.4°), b) 69°(5.5°), c) 37.2%(5.5%) d) 47.4%(1.5%). Intra-observer and inter-observer reliability were measured with satisfactory values. Not all tibial guides were able to produce an angle <45°. CONCLUSION: Our study is the first comparing the angle of inclination of the ACL directly with the tibial plateau. We demonstrate the angle in the sagittal plane is lower than reported previously. This data can be used in planning the tibial tunnel using remnant preserving techniques, to orientate in the natural alignment of the ACL. Not all reconstruction systems include options to align at the lower than previously thought natural angle of the ACL. EVIDENCE LEVEL: III.

Leiomyosarcoma of the ischiorectal fossa: report of a novel sphincter and sciatic nerve sparing simultaneous trans-abdominal and trans-gluteal resection and review of the literature.

Leiomyosarcomas are rare tumours of smooth muscle origin, and there have been no reported cases of such tumours arising within the ischiorectal fossa. Surgical resection with clear margins remains the gold standard treatment; however, there is limited literature on surgical approaches to the ischiorectal fossa for such tumours. We report a case of a high-grade leiomyosarcoma in a 59-year-old lady, occurring within the ischiorectal fossa that was managed using a novel simultaneous sphincter and sciatic nerve preserving trans-abdominal and trans-gluteal technique. This novel approach could be utilized not only for sarcomas but also for other tumours of the ischiorectal fossa extending into the gluteal region.