Midified Bunnell Suture in Achilles Tendon Injuries

Midified Bunnell Suture in Achilles Tendon Injuries I. Samota, R. Necula, Florin Sabou, Radu Vaidahazan, I. Szava, Alina Pascu. SUMMARY The treatment of Achilles tendon lesions is still controversial. Even the usual Bunnell technique of suture is appreciated to be a good ones, it is steel associated with a low rate of reruptures. In order to improve the suture strength, we modified the original Bunnell suture by using two sutures in Bunnell manner, one starting from the superior and the other from the inferior tendon stumps. The manner of fixing the knots is in double points and realizes a superior tight fitting than the usual Bunnell suture. We used this suture in four cases of accidental section and in 11 cases of acute rupture, with no reruptures. Based on our own experience, we consider this modification of Bunnell sutures increases the strength of the sutured tendon and generates a low rate of reruptures. BACKGROUND The Achilles tendon is the largest and the most frequently injured tendon of the human body (1, 2, 3). In cases with accidental section, the only surgical treatment is accepted. Treatment protocols for patients with acute Achilles tendon rupture include surgical and nonsurgical management, but they are constantly being modified (4, 5). The rerupture following acute lesion is the most frequent major complication and it is higher in nonsurgical treatment than in surgical one (6). In surgery the rates is lower, but it is still up to 3% (7, 5). Various surgical methods have been described including open, minimally invasive and percutaneous repair (8, 9). In chronic ruptures of Achilles tendon, most authors consider the surgical treatment to be the only satisfactory one (12, 13, 14). In chronic ruptures, we never used any type of suture but the angmentation only. Each surgeon chooses one surgical techniques because considers it to be associated with a low rate of complication. Base on our experience, we consider, in the acute Achilles tendon ruptures, the surgical treatment has some advantages. We present our experience with Bunnell modified suture surgical of Achilles tendon lesions and discus the used techniques in accidental sections and acute ruptures. We believe our modified Bunnell suture to be associated with a lower level of rerupteres than the original one. MATERIALS AND METHODS This study is a retrospective evaluation of patients with accidental section or acute Achilles tendon ruptures treated by a modified Bunnell suture. Every patient who underwent a modified Bunnell suture of an Achilles between January 2010 and December 2014, was identified and information was abstracted from the medical records. All the patients with Achille lesions operated in this period by a modified Bunnell suture were included. It was a number of four patients with section and 11 with acute rupture. In cases with accidental sections the diagnoses was established by clinical examination, and in all cases an immediate surgical repair were performed. It was three male and one female, between 37 and 42 years old. In all of them an end-to-end modified Bunnell suture was done. In acute ruptures cases the diagnoses was based on history and physical examination. In some cases, an ultrasound or MRI examination was added. All the patients accepted for surgery had to present a palpable depression on the tendon, a positive Thompson test and disability to stand on their tiptoes on the injured side. The duration of ruptures from injury to surgery was from a couple of days to five weeks. The patients group comprised 11 men and two women ranging in age from 24 to 59 years. The majority of the ruptures were at about 4 to 6 cm proximal to the calcaneal insertion. All the patients were treated by the same technique, a modified Bunnell suture. SURGICAL TECHNIQUES With the patient under anesthesia, tourniquet control and in prone position, the surgery started by a posteromedial incision from 4 cm. up to 4 cm. down to the rupture site. The incision is without dissection, sharply through the skin, subcutaneous tissue and fibrous tendon sheath. Then, the synovial sheath is carefully dissected and then longitudinally incised on both side of tendon section or rupture, and protected in order to be easy sutured at the end of tendon repair. The ragged ends of the ruptured tendon are limited excised and with the ankle plantarflexed up to 35Â ° a direct modified Bunnell suture is done. Fig. 1. Original Bunnell suture (from Coughlin MJ, Schon LC. Disorders of Tendons. In: Surgery of the Foot and Ankle. Eighth edition, Mosby, Inc. 2007.) Fig. 2 Modified centrally running Bunnell suture with two distal knots fixation. This initial variant was not used in cases included in this study. Fig. 3 Modified Bunnell with two laterally sutures. This is our technique which was used in all cases of the study. Fig. 4. Our technique – detail. In our technique, instead of one centrally running suture as in original Bunnell (Fig. 1), two laterally sutures on both sides of each stamp, were used (Fig. 3 and Fig. 4). One of the sutures starts from the superior and the other from the inferior tendon stumps. Each of the two sutures is passed through the level of section or rupture and then is fixed in the opposite tendon stump. This fixation is by four knots, two in the end of the proximal stump and two in the end of the distal stump in the manner described in fig. 2. In some cases, especially in cases of tendon sections, the tendon repairing was supplemented with interrupted circumferential sutures. After tendon repairing, we pay special attention to the synovial sheath suture. It is carefully sutured to cover as long as possible the repaired tendon. Postoperatively, a series of three casts a used. First is a long cast with the knee in 20 degree of flexion and the ankle in 30 degree of plantar flexion is applied. After three weeks another below-knee with the ankle in 15-20 degree of plantar flexion is applied. The patient is encouraged to move his knee. Five weeks after surgery the third below-knee walking cast with the ankle in neutral position or slight flexion is applied. The last cast is for another two weeks and the progressive weight-bearing is commenced. After cast removal the patient is advised to wear shoe with high heel for another three month and increased activity and physical therapy are begun. RESULTS In the cases of section the average follow-up was 6 months and ll of them have had the evolutions with no major or minor complications. In the cases of acute ruptures the average follow-up was 12 months. In all cases, no surgery related major complications, such as tendon rerupture or necroses, sural nerve injury, skin necrosis, wound infection, or deep infection. As minor complications, there were two tendon contracture and one superficial wound infection which were conservatively treated. In all patients with minor complications, no supplementary surgical treatment was done. None of them had tendon adhesion to the skin and the skin over the tendon was movable. Two patients had cosmetic complaints concerning the scar but without affecting the ankle function. All patients were able to stand on their tiptoes and single affected side leg hopping was possible one year postoperatively. Active range of motion was found to be reduced with limited dorsiflexion in two cases with acute rupture, and the difference was less than 10Â °. At the last follow-up, there had been no cases of rerupture and the subjective satisfaction was excellent or good in all the patients. DISCUSSION In accidental section of Achilles tendon, an end-to-end tendon suture is usually done but simple interrupted suture are not sufficient. In these cases, we consider Bunnell suture to be the method of choice. Initially, we modified centrally running Bunnell suture in the manner depicted in fig. 2. This initial variant was not used in cases included in this study. Then, in order to improve the suture strength we used two running suture of the original Bunnell, in the manner depicted in fig. 2. This surgical variant was used in all patients of this study. In acute ruptures of the Achilles tendon the treatment options include nonsurgical and surgical variants. The nonsurgical one avoids the surgical risks but it is associated with a high risk of rerupture (15). Despite the surgical risks, a number of authors consider surgery as a common treatment of Achilles acute ruptures (16, 17, 7). Although, in acute cases, percutaneous procedure increases in popularity, surgery is commonly performed as an open technique (16). The most usual techniques for primary open repair are Bunnel, Kessler and Krackow sutures (6, 19). Although there were reported reruptures after a Bunnell suture, we consider this method and used a modified Bunnell one in the majority of our patients with direct primary sutures. This modified Bunnell is a preference of the main author (IS). Our manner of fixing the knots realizes a superior tight fitting than the usual Bunnell suture. In this variant, instead of two knots both of them placed in the level of section or rupture, there are four knots, two in the end of the proximal stump and two in the end of the distal stump. These four knots are not in the level of section, but two up and two down, proximal to the level of section. Our results suggest this modified Bunnell suture improve the suture strength and is associated with a low rate of reruptures. We consider to be important the protection and dissection of the synovial sheath. At the end of the tendon repairing, a carefully synovial sheath suture has the advantage to create good biological conditions for tendon healing. Based on this special attention to the synovial sheath, in our series none of them had tendon adhesion to the skin. Conclusions The results of this study suggest the modified Bunnell suture in our manner has some advantages. In Achilles tendon section or acute ruptures, it is associated with good functional results and a low rate of complications. We consider this type of suture increases the strength of the sutured tendon and generate a low rate of reruptures.

Hypogravitational Osteoporosis :: essays research papers

Osteoporosis: a condition characterized by an absolute decrease in the amount of bone present to a level below which it is capable of maintaining the structural integrity of the skeleton. To state the obvious, Human beings have evolved under Earth's gravity "1G". Our musculoskeleton system have developed to help us navigate in this gravitational field, endowed with ability to adapt as needed under various stress, strains and available energy requirement. The system consists of Bone a highly specialized and dynamic supporting tissue which provides the vertebrates its rigid infrastructure. It consists of specialized connective tissue cells called osteocytes and a matrix consisting of organic fibers held together by an organic cement which gives bone its tenacity, elasticity and its resilience. It also has an inorganic component located in the cement between the fibers consisting of calcium phosphate [85%]; Calcium carbonate [10%] ; others [5%] which give it the hardness and rigidity. Other than providing the rigid infrastructure, it protects vital organs like the brain], serves as a complex lever system, acts as a storage area for calcium which is vital for human metabolism, houses the bone marrow within its mid cavity and to top it all it is capable of changing its architecture and mass in response to outside and inner stress. It is this dynamic remodeling of bone which is of primary interest in microgravity. To feel the impact of this dynamicity it should be noted that a bone remodeling unit [a coupled phenomena of bone reabsorption and bone formation] is initiated and another finished about every ten seconds in a healthy adult. This dynamic system responds to mechanical stress or lack of it by increasing the bone mass/density or decreasing it as per the demand on the system. -eg; a person dealing with increased mechanical stress will respond with increased mass / density of the bone and a person who leads a sedentary life will have decreased mass/density of bone but the right amount to support his structure against the mechanical stresses she/she exists in. Hormones also play a major role as seen in postmenopausal females osteoporosis (lack of estrogens) in which the rate of bone reformation is usually normal with the rate of bone re-absorption increased. In Skeletal system whose mass represent a dynamic homeostasis in 1g weight- bearing,when placed in microgravity for any extended period of time requiring practically no weight bearing, the regulatory system of bone/calcium reacts by decreasing its mass. After all, why carry all that extra mass and use all that energy to maintain what is not needed? Logically the greatest loss -demineralization- occurs in the weight bearing bones of the leg [Os Calcis] and spine. Bone loss has been estimated by calcium-balance studies and excretion studies. An increased urinary

The Power of Poetic Discourse

Poetry serves as a potent tool in providing insight, as it expresses universal themes and universal sentiments that enlightens readers. The poem of Countee Cullen entitled, â€Å"Yet Do I Marvel,† is one such piece of literature. In the first reading, the first eight lines of the poem, the octave, seems to illustrate examples of injustices. Cullen begins the poem by establishing that he does not doubt the goodness, the kindness, of God; but he questions the acts of God.Acts which seem to be incredulous, like creating the mole to be blind and yet making the creature toil and work without sight; making humans appear like him, but making them mortal; and handing down cruel punishments, as in the cases of Tantalus and Sisyphus, Greek mythological figures who suffer cruel punishments. Upon examination of the verses, however, the reader understands that these examples are not illustrations of injustice; they are instead illustrations that God is wise enough to render entities and ev ents in their current state.It is only right for the mole to be blind, because his natural task is to burrow hole underground, where sight is not necessary. It is only right for human beings to be mortal, because the soul is more important than the flesh, and without death, spiritual fulfillment could not be realized. It is only right for Tantalus to suffer hunger and thirst because his immoral act of stealing the food of the Gods, and presenting his son as a food offering was a terrible crime. It is only right for Sisyphus to work on a never-ending task because he was overly ambitious and vain to aim for eternal life.Following this insight, the reader is led to the thought that the last six lines, the sestet, offer the resolution that it is only right for a poet to be black and for God to, â€Å"bid him sing† (line 14, Cullen) because it is only appropriate for a black poet to express and articulate his hopes, his dreams and his sentiments about his people and about his race . Cullen clearly emphasizes the power of poetic discourse in this poem, a power he wielded during his time as an important Harlem Renaissance figure. Poetic Discourse Page 03 References (Please cite your source)

Peterborough and District Youth League Essay Example

Peterborough and District Youth League Essay Example Peterborough and District Youth League Essay Peterborough and District Youth League Essay I cannot be critical of these leagues because they provide good, structured competitive football for everyone and varied abilities. Every age group has 3 divisions because of this I would say you can play competitive football no matter what skill level you play at. Although there is one way I could criticise these league because the league finishes late in February which is a huge gap until the new start in September, if this was my league I would increase the length of the season to allow the players to compete more often without the massive gap. High quality football locally is limited. This is only the third year the Peterborough centre of excellence has been running after it was shut down 6 years ago due to lack of funding at the club. This gap caused many good standard players to look elsewhere for further development in football.  In Peterborough are only small amounts of disability football. There is one disabled football club for senior and junior age groups in Peterborough the clubs is called Netherton United. The closest disabled league is ran in Cambridge. The junior league in the area is the Cambridge Ability Counts League, This league enables competitive opportunities for disability teams. The league allows all disabled players to take part in structured games against other teams across the county. The league consists of festivals throughout the season with scores being made into a league table. Histon Hornets, Wisbech St Marys, Castle, Cambs Deaf Utd, St Ives Rangers and Netherton Utd all take part in the fixtures. There is also a disabled league for senior players, which is the Eastern Region Ability Counts League.  There is a lot of provision for womens football in Peterborough. There are quite a few teams all ranging in ability levels, with the top team being Peterborough ladies and the lower ends being teams such as Netherton United. There is quite a few leagues that the teams in the area play in, both for juniors and seniors. The problem is though that these leagues also incorporate teams from further afield meaning more travel is required, however this can also be advantageous as the quality of opponent will be greater. There are 4 junior leagues in the area in which city teams play in.An example of funding locally would be Hampton FC. Hampton Football Club has a variety of sponsors. The club ranges from under 8s to under 18s, each age group at the club have different sponsors. Overall the club is sponsored by Serpentine Green, who have sponsored the club and brought the club kit since 2OO7. Facilities for the lower level of performance are relatively strong in Peterborough. There is lots of local Sunday league football clubs that have good facilities in the area, a brilliant example of this would be Netherton Uniteds facilities at the grange. There are also facilities that are council owned in the area, for example bushfield astro turf and Powerleague, which has numerous 5 a side leagues. Peterborough doesnt have any great facilities. There is not a lot of high level coaching in the local area; however there is alot of coaching at community level. So for a player that has just had just taken up the sport there are many coaches but the problems come when a player is looking to improve as a performer. High quality coaching in Peterborough is very limited with Peterborough and Cambridge united having the only development centres in the city.  Peterboroughs local FA are committed to promoting and developing referees and refereeing the County, Cambridgeshire FA and Huntingdon FA offer courses for new referees throughout the year.

Tips for Breaking into Travel Writing

Tips for Breaking into Travel Writing Being a travel writer has its perks. Travel publications pay well and on time, and once those initial articles are published, free trips start rolling in courtesy of public relations firms. But how do you acquire those first few published articles? Pick Locations Wisely Know your fellow countrymen. United States residents prefer the Caribbean, Hawaii and Mexico, so U.S. travel magazines prefer stories on these regions. While Taipei may intrigue you, these other stories improve your odds of a sale. Party Crashing   Tourism boards, like Atout France or the Puerto Rico Tourism Company, will host events in big cities like Los Angeles or New York to give updates about the latest news in tourism, like new airports or hotel openings. You can use the information given at these events to write an article, even if youve never been to the country hosting the event. Typically, attendees are invited via their publications, but emailing different tourism boards can land you an invite. Follow them on Twitter to find out when theyll be hosting events and shoot them an email request a few weeks in advance. Will Blog for Trips PR firms constantly seek high traffic blogs and may offer bloggers free trips in exchange for a post or two, even if their blog themes are about topics besides travel. You don’t have to pitch editors or have experience to blog, so it’s a good way to break into travel writing Look into Less Popular Publications Everyone knows Travel + Leisure, Conde Nast Traveler and AFAR, but what about magazines catering to travel agents? Magazines like Recommend, Travelweek and Travel Agent. Writing for trade publications is different from writing for consumer publications, but its easy enough to get the hang of the style. Just remember that whoever is reading the article is not going on the trip themselves. Local newspapers also have travel sections. Check with them and see which locations are popular. Make Friends The travel industry thrives on networking. Everyone you meet can offer you an in with an editor, a press trip, an invite to an event. Make friends on every trip you go on, with travel agents, and every publication you write for. When on assignment, always reach out to the tourism board of whatever country youre going to as well as local tour operators. They are more than happy to help you, and once you post an article about a location, you will be on their radar for future trips and opportunities. Pick Up and Move (or Stay Where You Are) Travel magazines love when someone actually lives in the location theyre writing for. If you live in Mexico, Myanmar, or Montevideo, search for publications that have newsletters related to these areas. They love having someone local to attend hotel openings or inaugural flights. Twitter Chats Twitter chats are when groups coordinate a time and hashtag to talk about travel-related topics. Many big publications like Conde Nast Traveler have their own (#TravelerChats). They are the perfect way to network, net followers, and place you on the radar of editors. To find out when theyre happening, follow tour operators, travel agents and travel magazines on Twitter. Two you can start with are Conde Nast Traveler and Travel Weekly.

Foucault notions of power and its implications of studying power in Essay

Foucault notions of power and its implications of studying power in international relations - Essay Example are few of the pertinent examples of power play within the society. But Foucault’s concept of power within the international relation becomes vital elements of global politics that has wide ranging implications for world at large (Patton, 1998). In the contemporary times, power within and across nations has emerged as major contentious issue that tends to suppress the wider objectives of democratic principles and sovereignty of nations which are less power powerful in terms of socio-economic, technology and military superiority. He describes it as a relation that is only visible when it is applied or used strategically in a situation to achieve one’s own vested interests (Foucault, 1982; Mills, 2003). Thus, it use or misuse becomes vital ingredients of maintaining one’s status in global political arena. The hegemony of America in global politics is prime example of economic, technological and military power that it applies over other nations. America has used its power either directly like invading Iraq on false pretence or indirectly through leading financial institutions like World Bank, IMF and international agencies like United Nations etc. and forcing developing and under-developed nations to open their markets for foreign business. Thus, Foucault’s concept of power can easily be applied on international

International Marketing Strategy Essay Example | Topics and Well Written Essays - 2000 words - 1

International Marketing Strategy - Essay Example The company whose headquarters are in Switzerland has embraced an international marketing program partly because its local market is too small to address its projections (Nestle.com, 2014). Nevertheless, the program has had associations with different matters. There was a boycott that was started in the 80s against the marketing of the infant formula that is manufactured by the company in the developing countries and has progressed from time to time (Multinationalmonitor.org, 1987). In the present times, the company has had to deal with issues associated with its growth through acquisitions. This paper will evaluate Nestles international marketing strategy with specific emphasis on the strategies it uses in Europe. The present set up of Nestle was established in the early 1900 when a company that has American owners and was based in Switzerland merged its operations with a company of Swiss origins (http://www.nestle.com.eg, 2014). Initially, the American company had been employing canning technology to process milk while the Swiss company had employed technology that had fruitfully marketed infant formula (Wilkins, 2004, p. 27). The company adopted the Swiss name and started a run of acquisitions as well as a global expansion program. The initial expansions, including in to the United States, took place as the First World War progressed (Encyclopedia.com, 1999). Even though the company was largely unaffected by the war particularly because of the neutrality of Switzerland, its main markets as well as sources of milk were heavily affected (Referenceforbusiness.com, 2014). This made the owners of the company to look for diversification so that they could make sure the company could survive this and other shakeups that may be faced in the market. After the war ended, the company continued its global expansion, creating new categories of products through acquisition as