Dural tears

Dural tears are a known complication of cervical, thoracic, and lumbar spine surgery. We present a brief overview of the anatomy of dural tears, diagnostic techniques, and a review of treatment options. Incidence of tearing and treatment varies by location and size, and post-operative management is controversial. The most well evidenced treatment techniques and management protocols have been reviewed and summarized.     

Rotator cuff tears

Rotator cuff tears are a common cause of pain and weakness in the shoulder. We describe the anatomy and function of the normal rotator cuff, before an overview of cuff tears, with reference to their incidence and pathogenesis. Finally, we discuss clinical presentation, examination findings, treatment options and the prognosis of cuff tears. The authors of this article hope to enable the reader to understand rotator cuff disease, assess patients with suspected rotator cuff tears and discuss the basic treatment options with patients.     

Rotator cuff tears

Rotator cuff disease is a common cause of pain and weakness in the shoulder. This article examines the anatomy and function of the rotator cuff; and the incidence, pathogenesis, evaluation, treatment and prognosis of rotator cuff tears.     

Subscapularis tendon tears

Pathology of the subscapularis tendon is both infrequently identified and not commonly considered as a major source of shoulder pain and dysfunction. Subscapularis tendon pathology can present as isolated tears; partial-thickness tears; anterosuperior tears, also involving the supraspinatus tendon; complete rotator cuff avulsion; and rotator interval lesions, in which instability of the long head of the biceps tendon may dominate the clinical presentation. Although an accurate physical examination is paramount, modalities such as arthroscopy, magnetic resonance imaging, and ultrasound have advanced knowledge of the spectrum of abnormalities involving the subscapularis tendon. Nonsurgical management may be effective for most partial tears. Surgically, open repair is more frequent than use of arthroscopic techniques. Tears of the subscapularis tendon portend a different prognosis than do supraspinatus tendon tears, especially when the injury is acute and diagnosis is delayed.     

Instrumental bronchial tears

Two case reports of bronchial tears following airway instrumentation are presented, one of which resulted in death. Both patients developed pneumothoraces and other complications after attempts had been made under general anaesthesia to insert bronchial stents. It appeared that bronchial tears were made during instrumentation with the stent introducer and these cases demonstrate that great care should be taken when rigid materials, such as plastic guides and bougies, are used blindly in the airway.     

Iatrogenic dural tears

A dural tear, or durotomy, is a well-known complication of spine surgery and is among the most common reported complications in spinal surgery with an incidence of 0.5-5%. This text will provide a general review of the relevant anatomy, diagnosis, treatment, and outcomes.     

Intrasubstance meniscal tears

Summary Forty-five athletes with the clinical features of a possible meniscus lesion underwent evaluation by magnetic resonance imaging (MRI). All the patients examined had pain in the medial or lateral compartment on effort, but at least three of the typical symptoms of a meniscus tear (effusion, restricted movement, impactions, blockades, synovial reaction) were at the same time absent. A meniscus lesion was identified on MRI in 43 patients (95.5%). Thirty-five patients (77.7%) had a pure intrasubstance tear, with a predominance of the linear grade-II lesion type (n = 31; 68.8%). Exactly this type of lesion in the posterior horn represents the most frequent cause of false-negative results in other investigational procedures (arthrography, arthrotomy, arthroscopy). In ten cases conservative treatment was performed, 28 patients had a rationale or partial meniscectomy, and in 7 cases refixation of the meniscus was performed. Forty-two patients were free of symptoms at follow-up with this treatment. The advantages of MRI in the diagnosis of a meniscus lesion are: early detection of grade-I and grade-II lesions, visualization of all the extra-articular structures, no radiation loading, noninvasive investigation, definition of a surgical intervention, possibility of monitoring the clinical course, and postoperative follow-up. MRI is indicated when there is a suspected significant meniscus lesion but typical symptoms are absent, in children, and in all cases where conservative treatment seems possible. In only 10% of our patients was any of these indications present. During the period of the study (4 years) we performed 489 arthroscopic operations on menisci with no additional investigations. In summary, MRI can be very helpful for the classification and the surgical intervention, but the patients must be specifically selected and the interpretation needs a lot of experience.     

Radial tears associated with cleavage tears of the medial meniscus in athletes

Purpose: To evaluate the significance of a small radial tear in the root of the posterior horn of the medial meniscus in an otherwise normal-looking meniscus in individuals who play vigorous sports. Type of Study: Retrospective review. Methods: Arthroscopy was performed in 1,270 patients; 11 patients (0.86%) had a small radial tear in the root of the medial meniscus. Trimming of the tear revealed a large horizontal cleavage tear of the posterior horn and body of the meniscus. The average age of the affected patients was 29.6 years (range, 21 to 45 years), and all were active in sports. Magnetic resonance imaging was of dubious diagnostic value. Three patients had undergone previous arthroscopy at which time the small radial root tear had been noted but was not thought to warrant treatment. Results: All 11 patients returned to their former levels of activity after adequate surgery. Conclusions: When a radial root tear in the medial meniscus is found in an athletic patient, the edges of the tear should be trimmed, the root of the medial meniscus examined, and any additional torn cartilage resected.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 3 (March), 2002: pp 254–256     

Lower muscle regenerative potential in full-thickness supraspinatus tears compared to partial-thickness tears

Background and purpose Rotator cuff tears are associated with secondary rotator cuff muscle pathology, which is definitive for the prognosis of rotator cuff repair. There is little information regarding the early histological and immunohistochemical nature of these muscle changes in humans. We analyzed muscle biopsies from patients with supraspinatus tendon tears.

Methods Supraspinatus muscle biopsies were obtained from 24 patients undergoing arthroscopic repair of partial- or full-thickness supraspinatus tendon tears. Tissue was formalin-fixed and processed for histology (for assessment of fatty infiltration and other degenerative changes) or immunohistochemistry (to identify satellite cells (CD56+), proliferating cells (Ki67+), and myofibers containing predominantly type 1 or 2 myosin heavy chain (MHC)). Myofiber diameters and the relative content of MHC1 and MHC2 were determined morphometrically.

Results Degenerative changes were present in both patient groups (partial and full-thickness tears). Patients with full-thickness tears had a reduced density of satellite cells, fewer proliferating cells, atrophy of MHC1+ and MHC2+ myofibers, and reduced MHC1 content.

Interpretation Full-thickness tears show significantly reduced muscle proliferative capacity, myofiber atrophy, and loss of MHC1 content compared to partial-thickness supraspinatus tendon tears.     

Surgical management of meniscal tears

The menisci have an essential function in force transmission across the knee. Injuries to the menisci are common. The indications for repair should be expanded, as the results of partial meniscectomy may deteriorate over time. Tears in younger, higher demand patients should be prepared to optimize the healing environment and be meticulously repaired, particularly in the setting of concurrent anterior cruciate ligament reconstruction. For complex, recurrent, or avascular zone tears, particularly when surgery is limited to meniscal work, consideration can be given to augmenting the repair with a fibrin clot or platelet rich plasma. Partial meniscectomy is a suitable option for lower demand or older patients. Meniscal allograft transplantation is a salvage procedure.     

Acute peroneal tendon tears

Acute peroneal tendon tears lay at one end of a spectrum of peroneal tendon pathology. Because a tear represents a mechanical abnormality, surgical treatment is frequently required. Anatomical variants need to be considered as potential causes of lateral ankle pain. Most acute peroneus brevis tears are longitudinal, occur adjacent to the tip of the fibula, and require surgical treatment. Acute peroneus longus tears more commonly occur at the level of the cuboid tunnel and may initially be managed nonoperatively, but, if associated with stenosing tendonitis, may require debridement and tenodesis. Rarely, complete ruptures of both peronei occur and, if there is a significant defect, reconstructive procedures are required.     

Anaesthesia without tears.

Rectal induction of anaesthesia is a useful method but is not widely used in South Africa. We studied the onset of action and side-effects of 1% methohexitone administered rectally in a dose of 20 mg/kg to 110 preschool children. Ninety-one per cent were adequately sedated for inhalation induction by mask within 10 minutes, and all by 15 minutes, of drug administration. There was no evidence of significant cardiovascular or respiratory depression and only minor complications such as faecal soiling (11.8%) and hiccough (3.6%) were noted. The technique has been favourably received by parents, surgeons and nursing staff and has now become routine practice.     

Peroneus brevis tendon tears

Tears of the peroneus brevis tendon are more frequent than reported in the literature. Because of the vague pain associated with structures of the lateral ankle, peroneal tears are frequently misdiagnosed. Physical signs such as swelling along the course of the peroneal tendon sheath, pain with eversion, and subluxing tendons are diagnostic of peroneal pathologic conditions. The cause of peroneal tears is not completely understood. Possible causes include subluxing peroneal tendons, a sharp posterior ridge of the fibula, overcrowding of the peroneal groove, instability of the superior peroneal retinaculum, lateral ankle instability, contraction of the peroneus longus, hypovascularity of the peroneus brevis tendon, and a shallow peroneal groove of the fibula. Although conservative measures are almost always attempted, surgical repair of peroneus brevis tears remains the standard of care. Débridement and tubularization are recommended for less extensive tears. In more severe cases, resection of the damaged tendon and tenodesis of the proximal and distal segments to the peroneus longus are necessary. Return to maximum activity is prolonged, but with proper patient selection, evaluation, and treatment, good to excellent results can be expected.     

Haemorrhoidectomy without tears.

A study of 50 patients undergoing haemorrhoidectomy under general anaesthesia in Reading was undertaken. Half the patients received, in addition, a caudal anaesthetic given by the surgeon at the beginning of the operation with the patient in the lithotomy position. The rest of the patients had no form of local anaesthetic. The amount of analgesia needed, general comfort after the operation, and the number of days after surgery of the first bowel movement were recorded. The use of caudal anaesthesia resulted in a 79% reduction in the number of doses of papaveretum needed by the patients after the operation and a reduction by half in the period of postoperative constipation. Possible reasons for the latter finding are discussed. The possible risks of caudal anaesthesia are considered, but it is concluded that they are far outweighed by the benefits obtained.