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The Bone & Joint Journal
Vol. 97-B, Issue 3 | Pages 353 - 357
1 Mar 2015
Maffulli N Oliva F Costa V Del Buono A

We hypothesised that a minimally invasive peroneus brevis tendon transfer would be effective for the management of a chronic rupture of the Achilles tendon. In 17 patients (three women, 14 men) who underwent minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum, at a mean follow-up of 4.6 years (2 to 7) the modified Achilles tendon total rupture score (ATRS) was recorded and the maximum circumference of the calf of the operated and contralateral limbs was measured. The strength of isometric plantar flexion of the gastrocsoleus complex and of eversion of the ankle were measured bilaterally. Functional outcomes were classified according to the four-point Boyden scale.

At the latest review, the mean maximum circumference of the calf of the operated limb was not significantly different from the pre-operative mean value, (41.4 cm, 32 to 50 vs 40.6 cm, 33 to 46; p = 0.45), and not significantly less than that of the contralateral limb (43.1 cm, 35 to 52; p = 0.16). The mean peak torque (244.6 N, 125 to 367) and the strength of eversion of the operated ankle (149.1 N, 65 to 240) were significantly lower (p < 0.01) than those of the contralateral limb (mean peak torque 289, 145 to 419; strength of eversion: 175.2, 71 to 280). The mean ATRS significantly improved from 58 pre-operatively (35 to 68) to 91 (75 to 97; 95% confidence interval 85.3 to 93.2) at the time of final review. Of 13 patients who practised sport at the time of injury, ten still undertook recreational activities.

This procedure may be safely performed, is minimally invasive, and allows most patients to return to pre-injury sport and daily activities.

Cite this article: Bone Joint J 2015;97-B:353–7.

The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 11 | Pages 1546 - 1550
1 Nov 2012
Longo UG Loppini M Romeo G Maffulli N Denaro V

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.

The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 5 | Pages 663 - 667
1 May 2012
Ortiz C Wagner E Mocoçain P Labarca G Keller A Del Buono A Maffulli N

We tested four types of surgical repair for load to failure and distraction in a bovine model of Achilles tendon repair. A total of 20 fresh bovine Achilles tendons were divided transversely 4 cm proximal to the calcaneal insertion and randomly repaired using the Dresden technique, a Krackow suture, a triple-strand Dresden technique or a modified oblique Dresden technique, all using a Fiberwire suture. Each tendon was loaded to failure. The force applied when a 5 mm gap was formed, peak load to failure, and mechanism of failure were recorded. The resistance to distraction was significantly greater for the triple technique (mean 246.1 N (205 to 309) to initial gapping) than for the Dresden (mean 180 N (152 to 208); p = 0.012) and the Krackow repairs (mean 101 N (78 to 112; p < 0.001). Peak load to failure was significantly greater for the triple-strand repair (mean 675 N (453 to 749)) than for the Dresden (mean 327.8 N (238 to 406); p < 0.001), Krackow (mean 223.6 N (210 to 252); p <  0.001) and oblique repairs (mean 437.2 N (372 to 526); p < 0.001). Failure of the tendon was the mechanism of failure for all specimens except for the tendons sutured using the Krackow technique, where the failure occurred at the knot.

The triple-strand technique significantly increased the tensile strength (p = 0.0001) and gap resistance (p = 0.01) of bovine tendon repairs, and might have advantages in human application for accelerated post-operative rehabilitation.

The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 2 | Pages 152 - 157
1 Feb 2012
Longo UG Loppini M Denaro L Maffulli N Denaro V

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing.

In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management.

The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 11 | Pages 1503 - 1507
1 Nov 2011
Maffulli N Del Buono A Testa V Capasso G Oliva F Denaro V

This is a prospective analysis on 30 physically active individuals with a mean age of 48.9 years (35 to 64) with chronic insertional tendinopathy of the tendo Achillis. Using a transverse incision, the tendon was debrided and an osteotomy of the posterosuperior corner of the calcaneus was performed in all patients. At a minimum post-operative follow-up of three years, the Victorian Institute of Sports Assessment scale – Achilles tendon scores were significantly improved compared to the baseline status. In two patients a superficial infection of the wound developed which resolved on antibiotics. There were no other wound complications, no nerve related complications, and no secondary avulsions of the tendo Achillis. In all, 26 patients had returned to their pre-injury level of activity and the remaining four modified their sporting activity. At the last appointment, the mean pain threshold and the mean post-operative tenderness were also significantly improved from the baseline (p < 0.001). In patients with insertional tendo Achillis a transverse incision allows a wide exposure and adequate debridement of the tendo Achillis insertion, less soft-tissue injury from aggressive retraction and a safe osteotomy of the posterosuperior corner of the calcaneum.

The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 6 | Pages 720 - 721
1 Jun 2011
Rangan A Maffulli N

Multicentre clinical trials in trauma care are gaining prominence as a means of generating good-quality evidence to inform and influence clinical practice. We believe multicentre trials have an important role to play in supporting evidence-based practice, and further investment in such trials is justified.

The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 6 | Pages 713 - 719
1 Jun 2009
Denaro V Papalia R Denaro L Di Martino A Maffulli N

Cervical spinal disc replacement is used in the management of degenerative cervical disc disease in an attempt to preserve cervical spinal movement and to prevent adjacent disc overload and subsequent degeneration. A large number of patients have undergone cervical spinal disc replacement, but the effectiveness of these implants is still uncertain. In most instances, degenerative change at adjacent levels represents the physiological progression of the natural history of the arthritic disc, and is unrelated to the surgeon. Complications of cervical disc replacement include loss of movement from periprosthetic ankylosis and ossification, neurological deficit, loosening and failure of the device, and worsening of any cervical kyphosis. Strict selection criteria and adherence to scientific evidence are necessary. Only prospective, randomised clinical trials with long-term follow-up will establish any real advantage of cervical spinal disc replacement over fusion.

The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 8 | Pages 995 - 999
1 Aug 2008
Longo UG King JB Denaro V Maffulli N

There is a trend towards the use of double-bundle techniques for the reconstruction of the anterior cruciate ligament. This has not been substantiated scientifically. The functional outcome of these techniques is equivalent to that of single-bundle methods. The main advantage of a double-bundle rather than a single-bundle reconstruction should be a better rotational stability, but the validity and accuracy of systems for the measurement of rotational stability have not been confirmed.

Despite the enthusiasm of surgeons for the double-bundle technique, reconstruction with a single-bundle should remain the standard method for managing deficiency of the anterior cruciate ligament until strong evidence in favour of the use of the double-bundle method is available.

The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 7 | Pages 991 - 991
1 Jul 2007
Maffulli N

The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 1 | Pages 82 - 87
1 Jan 2005
Gadgil A Hayhurst C Maffulli N Dwyer JSM

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus without vascular deficit, were managed by elevated, straight-arm traction for a mean of 22 days. The final outcome was assessed using clinical (flexion-extension arc, carrying angle and residual rotational deformity) and radiographic (metaphyseal-diaphyseal angle and humerocapitellar angle) criteria. Excellent results were achieved in 71 (63%) patients, 33 (29%) had good results, 5 (4.4%) fair, and 3 (2.6%) poor. All patients with fair or poor outcomes were older than ten years of age.

Elevated, straight-arm traction is safe and effective in children younger than ten years. It can be effectively used in an environment that can provide ordinary paediatric medical care and general orthopaedic expertise. The outcomes compare with supracondylar fractures treated surgically in specialist centres.

The Journal of Bone & Joint Surgery British Volume
Vol. 85-B, Issue 2 | Pages - 307
1 Mar 2003

The Journal of Bone & Joint Surgery British Volume
Vol. 84-B, Issue 2 | Pages 310 - 310
1 Mar 2002
Maffulli N

The Journal of Bone & Joint Surgery British Volume
Vol. 84-B, Issue 1 | Pages 1 - 8
1 Jan 2002
Maffulli N Kader D

The Journal of Bone & Joint Surgery British Volume
Vol. 82-B, Issue 1 | Pages 9 - 10
1 Jan 2000
Sutherland AG Craig N Maffulli N Brooksbank A Moir JS

The Journal of Bone & Joint Surgery British Volume
Vol. 81-B, Issue 2 | Pages 362 - 365
1 Mar 1999
Maffulli N

The Journal of Bone & Joint Surgery British Volume
Vol. 80-B, Issue 1 | Pages 91 - 94
1 Jan 1998
Yung SH Lam CY Choi KY Ng KW Maffulli N Cheng JCY

Displaced fractures of the forearm in children are often treated conservatively, but there is a relatively high incidence of redisplacement, malunion and consequent limitation of function. We have performed percutaneous Kirschner (K) wire fixation in 72 such children under the age of 14 years, of which 57 were reviewed for our study. Both the radius and ulna were fractured in 45 (79%), the radius only in eight and the ulna only in four. The mean initial angulation was 19° in the lateral plane and 9° in the anteroposterior plane for the radius and 15° and 9°, respectively, for the ulna. In 42 patients (74%) we performed closed reduction. In the remaining 15 (26%) closed reduction failed and an open reduction, through a minimal approach, was required before K wiring.

At a mean follow-up of 20 months all patients had good functional results with an excellent range of movement. Only five had angulation of from 10° to 15° and none had nonunion, premature epiphyseal closure or deep infection. Percutaneous intramedullary K wiring for forearm diaphyseal fracture is a convenient, effective and safe operation, with minimal complications.

The Journal of Bone & Joint Surgery British Volume
Vol. 80-B, Issue 1 | Pages 6 - 7
1 Jan 1998
Moir JS Sutherland AG Maffulli N

The Journal of Bone & Joint Surgery British Volume
Vol. 78-B, Issue 2 | Pages 339 - 339
1 Mar 1996

The Journal of Bone & Joint Surgery British Volume
Vol. 75-B, Issue 6 | Pages 945 - 949
1 Nov 1993
Maffulli N Binfield P King J Good C

We made a prospective arthroscopic study of 106 skeletally mature male sportsmen with an average age of 28.35 years (16.8 to 44) who presented with an acute haemarthrosis of the knee due to sporting activities. We excluded those with patellar dislocations, radiographic bone injuries, extra-articular ligamentous lesions or a previous injury to the same joint. The anterior cruciate ligament (ACL) was intact in 35 patients, partially disrupted in 28 and completely ruptured in 43. In the patients with an ACL lesion, associated injuries included meniscal tears (17 patients), cartilaginous loose bodies (6), and minimal osteochondral fractures of the patella (2), the tibial plateau (3) or the femoral condyle (9). We found no age-related trend in the pattern of ACL injuries. Isolated injuries included one small osteochondral fracture of the patella, and one partial and one total disruption of the posterior cruciate ligament. Three patients had cartilaginous loose bodies, and no injury was detected in five. Acute traumatic haemarthrosis indicates a serious ligament injury until proved otherwise, and arthroscopy is needed to complement careful history and clinical examination. All cases with a tense effusion developing within 12 hours of injury should have an aspiration. If haemarthrosis is confirmed, urgent admission and arthroscopy are indicated.

The Journal of Bone & Joint Surgery British Volume
Vol. 75-B, Issue 5 | Pages 825 - 829
1 Sep 1993
Klosok J Pring D Jessop J Maffulli N

We compared the chevron and the Wilson metatarsal osteotomy for hallux valgus in a prospective randomised trial on 87 feet in 51 patients, reviewed at averages of 5.5 and 38 months after operation. The patients in the chevron group returned to work earlier and mobilised faster, but, at the later review, those in the Wilson group had better functional results and were more satisfied with the appearance of the foot. Correction of the hallux valgus angle was better maintained in patients in the Wilson group and they had a better range of motion at the metatarsophalangeal joint; fewer complained of metatarsalgia.