bluuebunny/crossref_metadata_2025 huggingface dataset:
Removal of Vancomycin during Plasmapheresis
Authors: McClellan Syble D , Whitaker Charles H , Friedberg Richard C
Published: January 2017

OBJECTIVE:

To examine the removal of vancomycin during plasmapheresis, determine whether drug administration should be withheld prior to or a supplemental dose given after the procedure, and determine whether a redistribution phenomenon in vancomycin serum concentrations occurs after plasmapheresis.

DESIGN:

Prospective, cohort study.

SETTING:

An 800-bed, tertiary-care, teaching hospital.

PATIENTS:

Twelve patients receiving vancomycin as prescribed who were also undergoing therapeutic plasmapheresis.

METHODS:

Blood samples for determination of vancomycin concentrations were obtained from each patient immediately before, during, immediately after, and 2 hours after plasmapheresis. Vancomycin concentration in plasma removed by plasmapheresis and volume of plasma removed were measured. Patient-specific pharmacokinetic parameters were determined for each patient using serum concentration data and a one-compartment model. Percent of drug removed by plasmapheresis and percent increase in vancomycin total clearance secondary to plasmapheresis were calculated.

RESULTS:

A mean of 6.3% of the total body store of vancomycin was removed by plasmapheresis. Vancomycin clearance during plasmapheresis averaged 1.6 L/h, which was an average increase of 285% in the total clearance of vancomycin from the body. Nine of 10 patients had a higher observed vancomycin concentration 2 hours after plasmapheresis than that predicted by degrading the concentration observed immediately after the procedure, suggesting that redistribution in serum concentrations occurs after the procedure.

CONCLUSIONS:

A single one-volume plasmapheresis does not remove a clinically important amount of vancomycin; therefore, supplemental dosing after the procedure is not necessary. A redistribution phenomenon in vancomycin concentrations appears to exist after plasmapheresis. Further study is needed to determine how long the redistribution phase lasts and when vancomycin concentrations should be measured after plasmapheresis.
Debilitating Reaction following the Initial Dose of Tramadol
Authors: Gleason Patrick P , Frye Reginald F , O'Toole Thomas
Published: January 2017

OBJECTIVE:

To describe a debilitating reaction following a single oral dose of tramadol.

CASE SUMMARY:

A 32-year-old white man with no prior medical problems, allergies, or previous medication reactions experienced ataxia, dilation of the pupils, numbness in his arms and legs, tremulousness, and dysphoria lasting approximately 4 hours following an initial tramadol dose (100 mg). The patient recovered with no sequelae.

DISCUSSION:

Central nervous system (CNS) stimulation during therapy with tramadol was reported in 7% of patients in clinical trials. These reactions are usually mild and transient. This report describes a debilitating CNS-mediated reaction to an initial dose of tramadol in an otherwise healthy adult. The patient was phenotyped for CYP2D6 activity, the major metabolic pathway for tramadol elimination, and was determined to be an extensive metabolizer with very high CYP2D6 activity.

CONCLUSIONS:

The exact mechanism of the adverse response is not known; however, based on phenotyping results, we suspect that it may be related to high concentrations of the active O-desmethyl metabolite of tramadol.
Primary Stroke Prevention in Nonvalvular Atrial Fibrillation: Implementing the Clinical Trial Findings
Authors: Howard Patricia A , Duncan Pamela W
Published: January 2017

OBJECTIVE:

To review the clinical trials evaluating warfarin for primary stroke prophylaxis in nonvalvular atrial fibrillation (NVAF), to discuss the relative benefits and risks of warfarin versus aspirin therapy, and to review the clinical practice guidelines and identify potential barriers to their implementation in clinical practice.

DATA SOURCES:

A MEDLINE literature search was performed to identify clinical trials of antithrombotic therapy for NVAF, clinical practice guidelines, studies evaluating physician practices and attitudes, cost-effectiveness studies, and pertinent review articles. Key search terms included atrial fibrillation, stroke, antithrombotic, warfarin, aspirin, and cost-effectiveness.

DATA EXTRACTION:

Prospective, randomized clinical trials were selected for analysis. Clinical practice guidelines from recognized panels of experts were reviewed. Comprehensive review articles were selected.

DATA SYNTHESIS:

NVAF is a common arrhythmia that is associated with a substantial risk for stroke. Seven prospective, randomized, clinical trials have conclusively demonstrated the efficacy of warfarin for stroke prevention. The greatest benefits are achieved in older patients and those with comorbidities that increase their risk for stroke. The potential benefits of preventing a devastating stroke, however, must be weighed against the potential for bleeding complications. Warfarin has been shown to be cost-effective in high-risk patients, provided the rate of complications is minimized. Nonetheless, many physicians remain hesitant to implement warfarin therapy in older, high-risk patients. The clinical data on aspirin are less consistent than those observed with warfarin. Aspirin appears to be most effective in younger individuals or those considered to be at low risk for stroke.

CONCLUSIONS:

In patients with NVAF, the personal, social, and economic consequences of stroke are often devastating. Clinical trials have provided definitive proof that the risks of stroke can be significantly reduced through the use of appropriate antithrombotic therapy. Despite this evidence and the recommendations of a number of clinical practice guidelines, variations in care exist that continue to place patients at risk. Additional outcomes research is needed to evaluate the impact of the clinical trial findings and practice guidelines on clinical practice and to develop methods for overcoming barriers to implementation.
The AHCPR Clinical Practice Guideline for Heart Failure Revisited
Authors: Adams Kirkwood F , Ellis Melissa L , Williamson Kristin M , Patterson J Herbert
Published: January 2017

OBJECTIVE:

To review the Agency for Health Care Policy and Research (AHCPR) clinical practice guideline for heart failure and comment on the guideline regarding pharmacotherapy from the perspective of the latest clinical trial data and the authors' clinical experience.

DATA SOURCES:

A MEDLINE search (1966 to June 1997) of English-language literature pertaining to the pharmacotherapy of heart failure was performed. Special emphasis was placed on literature published in the last 5 years. Additional literature was obtained from reference lists of key articles identified through the search.

DATA SYNTHESIS:

Pertinent clinical trials were reviewed and considered along with information from the authors' database of over 800 patients with heart failure. Evidence concerning the use of angiotensin-converting enzyme inhibitors at appropriate dosages in all New York Heart Association classes of heart failure and the inclusion of digoxin as part of triple therapy in all symptomatic patients with left ventricular systolic dysfunction are reviewed. Strategies to circumvent clinical problems that may limit the proper application of standard therapeutic agents are considered, and the possible future role of β-blockers as therapeutic agents in patients with heart failure is discussed.

CONCLUSIONS:

The AHCPR guideline provides the clinician with an excellent framework for treating the patient with heart failure. Building on the fundamentals of the guideline, the clinician can carefully apply current therapy at appropriate dosages and in the best combinations to individualize and thereby optimize pharmacologic therapy for this patient population.
Introduction to Coronary Artery Stents and Their Pharmacotherapeutic Management
Authors: Mauro Laurie S , Borovicka Mary C , Kline Sandra S
Published: January 2017

OBJECTIVE:

To provide an introduction to coronary artery stents and their pharmacologic management, including anticoagulant therapy and newer antiplatelet regimens.

DATA SOURCES:

A MEDLINE and current journal search of relevant articles that evaluated coronary stent success rates and anticoagulation or antiplatelet regimens.

STUDY SELECTION:

Data from the use of primarily the Palmaz-Schatz stent were included. Studies using vitamin K antagonists that are not commercially available in the US were excluded unless they compared an antiplatelet regimen with anticoagulation using the international normalized ratio (INR).

DATA SYNTHESIS:

Limitations with percutaneous transluminal coronary angioplasty (PTCA), such as ischemic complications and restenosis, have led to the advent of intracoronary stenting. However, the placement of a stent within the coronary artery lumen is associated with a risk of thrombotic events. Despite current postprocedural anticoagulation and antiplatelet regimens, thrombosis occurs at rates ranging from 0.6% to 21%. When anticoagulation is deemed appropriate, it should be used for 1–2 months and the INR should be maintained between 2 and 3.5. Anticoagulation appears to have no effect on the development of restenosis, but has been shown to cause significant hemorrhagic events in 5–13.5% of patients. Newer data continue to define the subsets of patients who may be managed with antiplatelet agents alone. Combinations of aspirin and ticlopidine or aspirin alone may be used to manage patients who fulfill the following criteria: optimal stent placement, high-pressure inflation, and adequate coronary size.

CONCLUSIONS:

Coronary artery stenting is a novel approach for the management of coronary artery disease, but is associated with the complication of stent thrombosis. Anticoagulation reduces the risk of stent thrombosis, but is associated with bleeding risk. Selected patients may be successfully managed with antiplatelet agents only. More data are needed to better define the optimal antithrombotic regimen.
Current Perspective on the Use of Angiotensin-Converting Enzyme Inhibitors in the Management of Coronary (Atherosclerotic) Artery Disease
Authors: Cheng Judy WM , Ngo Mimi N
Published: January 2017

OBJECTIVE:

To review the pathophysiology of atherosclerosis, the role of the renin—angiotensin system in atherogenesis, and studies supporting the potential beneficial effects of angiotensin-converting enzyme (ACE) inhibitors in reducing cardiovascular events with long-term use.

BACKGROUND:

Through its action in converting angiotensin I to angiotensin II and by degrading bradykinin, local tissue ACE exerts many effects that can contribute to the development of atherosclerosis. Therefore, the use of ACE inhibitors can possibly result in antiatherogenic effects. Possible mechanisms for antiatherogenic effects of ACE inhibitors include: (1) reduction of blood pressure; (2) antiproliferative and antimigratory effects on vascular smooth muscle cells, neutrophils, and monocytes; (3) restoration of endothelial function; (4) stabilization of fatty plaque by preventing vasoconstriction; (5) antiplatelet effects; and (6) enhancement of endogenous fibrinolysis.

DATA SOURCES:

English-language clinical studies, abstracts, and review articles pertaining to the use of ACE inhibitors and atherosclerosis.

STUDY SELECTION AND DATA EXTRACTION:

Relevant human studies examining the role of ACE inhibitors and atherosclerosis.

DATA SYNTHESIS:

Studies evaluating the possible beneficial effects of ACE inhibitors in the development of atherosclerosis are reviewed and critiqued. Design of ongoing studies with clinical and surrogate end points are discussed.

CONCLUSIONS:

Based on current published studies, recommendations are made regarding the use of ACE inhibitors in atherosclerosis. Therapeutic monitoring parameters for efficacy and adverse effects are also reviewed.
Anatomical and Radiological Considerations of the Fifth Metatarsal Bone
Authors: Ebraheim Nabil A. , Haman Steve P. , Lu Jike , Padanilam Thomas G. , Yeasting Richard A.
Published: January 2017

Twenty cadaver fifth metatarsals were harvested from cadaver feet. They were then sectioned coronally in three locations. The cortical thickness (medial, lateral, dorsal, and plantar) and the intra-medullary canal diameter (dorsoplantar and mediolateral) were measured at the three sectional sites. The intra-medullary canal of six specimens was outlined with radiopaque solder wire. The canal was then examined radiographically with the lateral and dorsoplantar views. A lateral bow on the dorsoplantar view was observed in some specimens, which could contribute to surgical complications. On lateral view the intramedullary canal appeared straight in all specimens. The canal projects at least partially into the fifth metatarsal cuboid joint. When considering intra-medullary fixation a surgeon must take into account quality of bone stock and bowing of the canal. A bowed intra-medullary canal lends to vulnerability of the medial cortex at roughly mid-shaft of the fifth metatarsal. The canal has a narrower diameter in the dorsoplantar dimension than the mediolateral dimension. The cortical thickness was found to be less in the dorsal and plantar areas of the fifth metatarsal when compared to medial and lateral cortex. All of these findings lead to causes for complication in intra-medullary fixation of the fifth metatarsal.
Endoscopic release of plantar fasciitis - a benign procedure?
Authors: Jerosch Joerg
Published: January 2017

This is a case report of a patient suffering from subcalcaneal pain syndrome due to plantar fasciitis that was resistant to non surgical treatment. After endoscopic partial release of the plantar fascia the patient was pain free for several weeks, before he became symptomatic again. This new pain was located more proximally. An MRI study showed a stress reaction of the calcaneus.
The Relationship between Chronic Ankle Instability and Variations in Mortise Anatomy and Impingement Spurs
Authors: Scranton Pierce E. , McDermott John E. , Rogers James V.
Published: January 2017

Thirty-five patients undergoing a Bröstrom procedure for ankle instability were studied retrospectively as to the presence or absence of spurs and loose bodies, outcome, and mortise relationships. 100 adult volunteers had their ankles radiographically and clinically examined for spurs, loose bodies, and laxity. 100 patients’ ankles with computed axial tomography were examined to define malleolar relationships.

The AOFAS Hindfoot scores on the Bröstrom patients with or without spurs were not different. Patients undergoing a Bröstrom procedure had a 3.37 times incidence of spurs and/or loose bodies compared to normal adult population. The incidence of asymmetric but asymptomatic ankle laxity in normal adults was 11%. The fibula has a 38° range of position relative to the axis of the talus and the medial malleolus. A posterior fibular position may predispose to injury.
Acute compartment syndrome following revisionai arthroplasty of the forefoot: The dangers of ankle-block.
Authors: Noorpuri B.S.W. , Shahane S.A. , Getty C.J.G.
Published: January 2017

A case of acute compartment syndrome of the forefoot after revisionai arthroplasty of the forefoot is presented. Shortening of the compartments due to bony resection and extensive dissection due to previous scarring may have predisposed to the pathological condition. Prompt decompression based on clinical grounds prevented any long term sequelae. Allowance must be made for the concomitant use of local anaesthetic procedures which may obscure the clinical picture.
Pressure Controlled Esmarch Bandage Used as a Tourniquet
Authors: Abraham Edward , Amirouche Farid M.L.
Published: January 2017

The objective of this paper is to investigate the manual wrapping techniques of Esmarch bandages used as tourniquets by physicians and to study the controllability of their induced pressure. The properties of the Esmarch bandage were first tested using two cylinders to allow uniform stretching of the bandage and to control the elastic exercusion and pressure reading. The pressure was measured using a load cell and a DPSI electronic strain/stress/pressure indicator device. The placement of the load cell sensor was found to yield constant values when measured along the lateral direction normal to the tension directional field of the cylinder. The results also show that the pressure increases at a rate 3 to 4 times the initial pressure when the bandage is stretched after each wrap rather than over the total length initially. The measurements over a plaster foot showed different pressure readings but exhibited a linear relationship in all three wraps performed. The method also shows a linear relationship between the elastic deformation and the number of wraps necessary to achieve a certain degree of mm-Hg.
Influence of Foot, Leg and Shoe Characteristics on Subjective Comfort
Authors: Miller Janice E. , Nigg Benno M. , Liu Wen , Stefanyshyn Darren J. , Nurse Matthew A.
Published: January 2017

The purpose of this study was to determine the relationships between foot and leg characteristics, shoe characteristics, and the short-term subjective comfort of three different pairs of athletic shoes. Static measurements of foot dimension and leg angles were taken from eighteen subjects. Subjects rated the comfort of three different athletic shoes for standing, walking and running. The shoes were quantified by internal dimensions, hardness, flexibility and torsional stiffness. Average comfort ratings decreased from standing to walking to running. One shoe seemed suited for only a small group of subjects. In contrast, another shoe was generally comfortable for a large group. Skeletal alignment, specifically eversion angle, was related to comfort for one shoe. Therefore, fit of the shoe is not sufficient for comfort. Skeletal alignment, shoe torsional stiffness and cushioning seem to be mechanical variables which may be important for comfort.
Skewfoot in Patients with Osteogenesis Imperfecta
Authors: Mirzayan Raffy , Cepkinian Vahan , Cepkinian Joseph , Wellisch Mark D. , Zionts Lewis E.
Published: January 2017

We report skewfoot deformities in two patients who have osteogenesis imperfecta. A discussion will follow proposing etiologies of skewfoot, speculating that the ligamentous laxity often present in children who have osteogenesis imperfecta may predispose the development of skewfoot.
Elastofibroma of the Foot: Uncommon Presentation: A Case Report and Review of the Literature
Authors: McPherson Fiona C. , Norman Lisa S. , Truitt Charlotte A. , Morgan Michael B.
Published: January 2017

We report the clinical, microscopic and ultrastructural features of an elastofibroma arising in the foot. The lesion typically occurs in the elderly, and in 85% of cases arises from the connective tissue of the posterior chest wall. The histopathologic features of this lesion are distinctive, and are characterized by a haphazard array of eosinophilic collagen and elastic fibers, associated with fibroblasts and aggregates of mature fat cells. There are only two reported cases in the literature arising in the foot.
Single-Stage Talectomy and Tibiocalcaneal Arthrodesis as a Salvage of Severe, Rigid Equinovarus Deformity
Authors: Mirzayan Raffy , Early Sean D. , Matthys Gary A. , Thordarson David B.
Published: January 2017

Seven adult males with rigid, severe equinovarus deformities underwent single-stage corrective surgery. The procedure included extensive soft tissue release, talectomy and tibiocalcaneal, calcaneocuboid, and tibionavicular fusion. All seven patients fused successfully at an average of 3.5 months with a plantigrade foot. All feet were stiff and had an average of 3.5 cm limb length discrepancy. All of the patients were satisfied with the surgery and would choose to have the procedure again. This small series represents one method of achieving a plantigrade foot in patients with severe, rigid equinovarus deformities.
The Relationship between Excessive Pronation as Measured by Navicular Drop and Isokinetic Strength of the Ankle Musculature
Authors: Snook Abigail Grover
Published: January 2017

EMG research has shown that excessive pronation affects the timing and magnitude of extrinsic muscle activity. This study was designed to investigate the relationship between excessive pronation and isokinetic strength of the ankle. The following measures were performed on 24 subjects (12 pronators, 12 normals) matched for gender and weight: 1) plantarflexion, dorsiflexion, inversion and eversion strength, both eccentriccally and concentrically, determined by isokinetic peak torque at 30 degrees/sec; and 2) excessive pronation determined by navicular drop. Subjects with excessive pronation were found to have no difference in invertor strength, but decreased concentric plantarflexion strength when compared to normals. This finding agrees with biomechanical theory suggesting that a pronated foot is less rigid and generates less torque. Differences in strength ratios in excessive pronators were also observed and attributed to the decrease in plantarflexion strength.
The Contribution of the Medial Calcaneal Osteotomy to the Correction of Flatfoot Deformities
Authors: Nyska Meir , Parks Brent G. , Chu In-Tak , Myerson Mark S.
Published: January 2017

Hypotheses/Purpose: The success of the medial displacement calcaneal osteotomy in correcting flatfoot deformities is likely to be the result of a shift of the Achilles tendon forces on the hindfoot. The purpose of this study was twofold: 1) to define the contribution of the Achilles tendon to the flatfoot deformity, and 2) to define the effect of a calcaneal medial displacement osteotomy.

Methods: We used six different experimental dynamic stages: 1) intact foot without Achilles loading; 2) intact foot with Achilles loading; 3) flatfoot without medial calcaneal displacement osteotomy and without Achilles loading; 4) flatfoot without medial calcaneal displacement osteotomy but with Achilles loading; 5) flatfoot with medial calcaneal displacement osteotomy but without Achilles loading; and 6) flatfoot with medial calcaneal displacement osteotomy and with Achilles loading. The experimental flatfoot was developed by releasing the posterior tibial tendon, spring ligament, and plantar fascia and applying 7,000 cycles of axial fatigue load (range, 700 to 1,400 N; 1-Hz frequency). To simulate the phase of midstance, the peroneus longus, peroneus brevis, flexor digitorum longus, and flexor hallucis longus tendons were grasped by clamps, connected to pneumatic actuators, and loaded with precalculated forces. Anteroposterior and lateral radiographs were obtained for each stage on which the following measurements were made: talonavicular coverage angle, talar-first metatarsal angle, talocalcaneal angle, and height of the medial cuneiform. These measurements were compared with a one-way ANOVA.

Results: Between stages 1 and 2, all measurements were statistically insignificant. Between stages 3 and 4, for all measurements, Achilles tendon loading aggravated the flatfoot deformity (p < 0.05). After medial calcaneal osteotomy (stages 5 and 6), the Achilles tendon contributed less to the arch-flattening. We found that the medial displacement osteotomy plays an important role in reducing and/or delaying the progress of flatfoot deformity.

Conclusions/Significance: In the flatfoot, loading of the Achilles tendon increases the deformity. Medial calcaneal osteotomy significantly decreases the arch-flattening effect of this tendon and therefore limits the potential increase of the deformity.
Outcome Following Addition of Peroneus Brevis Tendon Transfer to Treatment of Acquired Posterior Tibial Tendon Insufficiency
Authors: Song Suzette J. , Deland Jonathan T.
Published: January 2017

The flexor digitorum longus, the tendon most often used for transfer in posterior tibial tendon insufficiency, is one-half to one-third the size of the posterior tibial tendon. Occasionally it may be particularly small or may have been previously used for transfer. In these cases, the senior author has felt that the addition of a transfer of the Peroneus Brevis (PBr) tendon may be helpful in maintaining sufficient tendon and muscle mass to rebalance the foot. Thirteen patients who underwent this procedure were retrospectively identified and matched by age and length of follow-up to patients who underwent a more standard tendon transfer operation minus the addition of the PBr transfer. Pain and functional status were then assessed by the American Orthopaedic Foot and Ankle Society's ankle/hindfoot rating scale. Each patient was tested by an independent physical therapist to evaluate inversion and eversion strength.

The mean duration of follow-up was 20.6 months (12 to 34 months). The average AOFAS score of the PBr group was 75.8 compared to 71.5 for the standard control group. There was no significant difference between the groups when inversion or eversion strengths were compared. Inversion strength and eversion strength was rated good or excellent (4 or 5) in 12 out of 13 of the PBr transfer group patients. No major complications were encountered in either group. Although it does not increase inversion strength, a PBr transfer can be used to augment a small FDL without causing significant eversion weakness. This can be useful when the FDL is particularly small or in revision surgery.
The Passive Axial Compression (PAC) Test: A New Adjunctive Provocative Maneuver for the Clinical Diagnosis of Hallucal Sesamoiditis
Authors: Casillas Mark M. , Allen Marque A.
Published: January 2017

The authors describe a previously unreported adjunctive passive provocative maneuver that has been found to clinically reproduce the intensity of symptoms in patients diagnosed with disorders of the sesamoids. This test is useful for the initial diagnosis as well as monitoring response to treatment.
Treatment of Type V Osteochondral Lesions of the Talus with Ipsilateral Knee Osteochondral Autografts
Authors: Scranton Pierce E. , McDermott John E.
Published: January 2017

Treatment of symptomatic large cystic lesions of the talus has had mixed results. A technique of treatment using a cored osteochondral graft taken from the ipsilateral knee is presented. Preliminary results in ten consecutive patients show significant improvement in all patients with an average increase of 27 points in the AOFAS Hindfoot score.
Osteochondral Defects of the Talus Treated with Fresh Osteochondral Allograft Transplantation
Authors: Gross Allan Edward , Agnidis Zoe , Hutchison Carol Rose
Published: January 2017

Between 1980 and 1996, 9 patients with osteocartilagenous lesions of the talus were treated surgically using fresh osteochondral allograft transplantation. In 8 cases the reason for surgery was osteochondritis dissecans (4 of these cases had a previous traumatic injury). In 1 case a fresh osteochondral allograft of the talus was required following a traumatic open fracture of the talus sustained in a motor vehicle accident. Of these 9 grafts, 6 grafts remain in situ with a mean survival of 11 years (range 4 to 19). In the three cases requiring fusion the reason for surgery was not related to arthritic deterioration but due to resorption and fragmentation of the graft.
Why Do Ankle Arthrodeses Fail in Patients with Rheumatic Disease?
Authors: Mäenpää Heikki , Lehto Matti U.K. , Belt Eero A.
Published: January 2017

Solid and painless fusion was achieved in 117/130 patients (90%) with rheumatic diseases after primary ankle arthrodesis at the authors’ institution. Operations were performed using internal fixation according to the Adams technique. Critical retrospective analysis of failures in 13 patients (11 nonunions, one postoperative low-grade infection, and one painful arthrodesis) revealed errors in the primary operative technique in 10/13 ankles (77%), resulting typically from the surgeon's attempt to overcompensate a malaligned ankle while ignoring correction of the hindfoot deformity (subtalar complex). The optimum of 0–5° of valgus was found in only 5/13 patients (38%). All four patients with varus alignment presented with malleolar pain. Bone grafting was adequate even in those patients with failure, whereas immobilization time was suboptimal in one patient (eight weeks). Patient satisfaction was lowered in every case of nonunion. Revision arthrodesis of failed primary fusion was successful in 10/13 patients (77%), however three additional stress fractures, two painful ankles without nonunions, and one superficial wound infection were detected. Ankle arthrodesis is a demanding procedure, and the operation should always be performed by an experienced surgeon, taking into account the alignment, ligament, and muscle balance of the rheumatoid ankle and hindfoot. Correction and rebalancing of these factors and the use of bone grafts are of crucial importance when considering the optimal conditions for fusion. Nonunions, infections, and stress fractures occurring after the primary arthrodesis are severe complications, leading eventually to revision operations and problems with osteoporotic bone, fragile soft tissues, and skin.
Arthroscopically Assisted Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talar Dome: An MRI and Clinical Follow-Up Study
Authors: Assenmacher Joseph A. , Kelikian Armen S. , Gottlob Charles , Kodros Steven
Published: January 2017

Osteochondral Lesions of the Talar Dome (OLT) are common problems encountered in orthopedics. Although the etiology remains uncertain, a myriad of treatment options exists. The authors describe arthroscopically assisted autologous osteochondral graft (OCG) transplantation procedures in the treatment of unstable OLTs in nine patients. The patients underwent standard preoperative MRI examination to assess fragment stability (using De Smet criteria for stability). Intraoperative arthroscopy was used to correlate the preoperative MRI assessment (using Cheng/ Ferkel grading). After transplantation procedures, MRI (using De Smet criteria for stability) assessed graft incorporation for stability at an average of 9.3 months after the procedure. Preoperative MRI correlated highly with arthroscopic findings of OLT instability (sensitivity = 1.0). This has been demonstrated in the current orthopedic literature. The post transplantation MRI demonstrated stable graft osteointegration by De Smet criteria in all patients. Postoperative visual analogue pain scales showed significant improvement from preoperative assessment. Postoperative AOFAS Ankle-Hindfoot scores averaged 80.2 (S.D. +/− 18.9). Our favorable early results and those of other authors using similar techniques may validate OCG transplantation as a viable alternative for treating unstable osteochondral defects in the talus that are refractive to more commonly used surgical techniques.
Mosaicplasty for the Treatment of Osteochondritis Dissecans of the Talus: Two to Seven Year Results in 36 Patients
Authors: Hangody László , Kish Gary , Módis László , Szerb Imre , Gáspár Levente , Diószegi Zoltán , Kendik Zsolt
Published: January 2017

An osteochondral defect (OCD) is known as a symptomatic lesion causing pain, recurrent synovitis, and altered joint mechanics most commonly in a weightbearing joint. Loose bodies may develop, which may then cause joint destruction and/or locking. The damage to the articular surface is most likely a precursor of ankle osteoarthritis. With the recent advances in diagnostic imaging, such as MRI, as well as the development of ankle arthroscopy, the identification and classification of these lesions has become much more precise. This allows more accurate staging and improves treatment recommendations. The assessment of a particular treatment is also improved.

A variety of treatment alternatives are now available. These include arthroscopic procedures including debridement, retrograde drilling, and bone grafting. Compared to open treatment, arthroscopic procedures may be particularly advantageous in the treatment of small defects and stable OCD lesions. Until recently, however, favorable results have been less predictable for large or unstable osteochondral defects. We treat these more difficult lesions with a mosaic autogenous osteochondral transplantation. In our hands, this appears to provide an optimal treatment result.

The present report evaluates the clinical outcome of 36 patients followed for two to seven years after a mosaicplasty autogenous osteochondral transplantation from a non or less weight bearing portion of the knee to the ipsilateral talus. Ankle function was measured by the Hannover scoring system and showed good to excellent results in 34 cases (94%) with no long term donor site morbidity. The encouraging clinical results are supplemented with radiographs and histology, which support the premise of lasting relief of symptoms and prevention of ankle arthrosis.
Biomechanical Comparison of Ankle Arthrodesis Techniques: Crossed Screws vs. Blade Plate
Authors: Nasson Scott , Shuff Charles , Palmer David , Owen John , Wayne Jennifer , Carr James , Adelaar Robert , May David
Published: January 2017

Many different techniques for ankle arthrodesis have been described. Experience at our institution with crossed screws internal fixation has not met the 90+% union rate reported in the literature. A compression blade plate is one technique for ankle arthrodesis which has not been evaluated biomechanically. A biomechanical study comparing two groups of sawbone ankle fusion constructs fixed with crossed screws and compression blade plates was performed in order to evaluate the stiffness and rigidity of these two arthrodesis techniques.

The crossed screws construct demonstrated superior stiffness during dorsiflexion (p < 0.001) and valgus (p < 0.001) loading. The two constructs were found to have equal strength in resisting plantarflexion, varus and torsional loads although there was a trend for greater resistance by the crossed screws construct. These findings lend biomechanical support to the use of crossed screws for tibiotalar arthrodesis.
Intramedullary Screw Fixation of Proximal Fifth Metatarsal Fractures: A Biomechanical Study
Authors: Shah Steven N. , Knoblich Guenther O. , Lindsey Derek P. , Kreshak Jennifer , Yerby Scott A. , Chou Loretta B.
Published: January 2017

Intramedullary screw fixation is a popular technique for treatment of proximal fifth metatarsal fractures. The purpose of this study was to compare the fixation rigidity of a 5.5 mm partially threaded cannulated titanium screw, with presumed superior endosteal purchase, to a similar 4.5 mm screw. Acute fifth metatarsal fractures were simulated in cadavers, stabilized with intramedullary screws, and loaded to failure in three-point bending. The initial failure loads for the metatarsals fixed with 4.5 mm and 5.5 mm screws were not significantly different (332.4 N vs. 335.2 N, respectively), nor were the ultimate failure loads (849.8 N vs. 702.2 N, respectively). Based upon our results, maximizing screw diameter does not appear to be critical for fixation rigidity and may increase the risk of intraoperative or postoperative fracture.
Proximal Fourth Metatarsal Injuries in Athletes: Similarity to Proximal Fifth Metatarsal Injury
Authors: Saxena Amol , Krisdakumtorn Tom , Erickson Sonia
Published: January 2017

Proximal fourth metatarsal injuries are rarely reported. We present five case histories in which athletic patients sustained injuries at the shaft-base junction of the fourth metatarsal. Similar to proximal fifth metatarsal injuries, adduction of the forefoot appears to be associated. Our patients returned to their activities in two to eight months.

These patients injuries tended to take longer to heal than other lesser metatarsal fractures and stress fractures (which are typically more distal). Some patients were continually symptomatic, even after three months of rest and immobilization. This coincides with proximal fifth metatarsal injuries and stress fractures.

For treatment of proximal fourth metatarsal injuries to be successful, ideal treatment appears to involve nonweightbearing below-knee cast/boot immobilization for three weeks. This is followed by an additional three or more weeks of weightbearing immobilization. Healing may still be prolonged.
Anterior Dislocation of the Subtalar Joint: A Case Report
Authors: Kanda Toyohiko , Sakai Hiroya , Koseki Kunihiko , Tamai Kazuya , Takeyama Noriyuki , Saotome Koichi
Published: January 2017

We report a very rare case of anterior dislocation of the subtalar joint. Forceful supination of the foot and dorsiflexion of the ankle was considered the cause of the injury in this case. Closed reduction was successful for the talocalcaneal component of subtalar joint, although surgery was subsequently performed because of the residual subluxation of the midtarsal joint including the talonavicular component of subtalar joint and the associated fracture of the lateral process of the talus. Satisfactory results were shown at three-year follow-up.
Isolated Talonavicular Arthrodesis for Talonavicular Arthritis
Authors: Chen Chung-Hwan , Huang Peng-Ju , Chen Tai-Bin , Cheng Yuh-Min , Lin Sen-Yuen , Chiang Hsiu-Chu , Chen Li-Chin
Published: January 2017

We have reviewed a single surgeon's experience with isolated talonavicular fusion in 16 patients with talonavicular arthritis. Fixation was either by staples or screws. Fifteen solid unions were achieved in the 16 patients who were followed (mean: 51 months). The average Ankle-Hindfoot Scale improved from 77.2 preoperatively to 92.9 postoperatively (p < 0.001). Subjectively, 15 patients were satisfied and one patient dissatisfied with the results. Further osteoarthritis in the adjacent joints was noted in five patients. We concluded that isolated talonavicular fusion is an effective method of treatment of talonavicular arthritis regarding pain relief and functional improvement. Though osteoarthritis was found in some adjacent joints postoperatively, the results were still satisfactory.
Basal Cell Carcinoma of the Nail Unit: A Case Report
Authors: Orsini Roman C. , Catanzariti Alan , Saltrick Karl , Mendicino Robert W , Stokar Lawrence
Published: January 2017

Basal cell carcinomas (BCC) of the foot are rare. A review of the English literature found only 23 cases of BCC reported in the foot, none of which involved the nail unit. The nail unit, which is composed of the nail bed and nail-folds, is an exceedingly atypical site for basal cell carcinomas. A case of BCC of the proximal nail fold of the hallux which was treated with Mohs Micrographic Surgery (MMS) is presented. 16 – 21
The Development and Validation of a Multi-Dimensional Measure of Chronic Foot Pain: The Rowan Foot Pain Assessment Questionnaire (ROFPAQ)
Authors: Rowan K.
Published: January 2017

The development and validation of the ROwan Foot Pain Assessment Questionnaire (ROFPAQ) is described. This is the first attempt to develop a multi-dimensional measure of chronic foot pain, and recognizes pain as having sensory, affective and cognitive dimensions. The ROFPAQ was developed from themes that emerged from running focus groups and semi-structured interviews with people with chronic foot pain. Following piloting and selection of appropriate items by both psychometric and semantic means, the scale was found to meet the accepted criteria for validity and reliability. The final scale demonstrates better than standard readability, has a short completion time and a simple scoring method. The scale allows clinicians to determine which dimension(s) of foot pain are the most relevant to the subject, thereby aiding decisions regarding appropriate treatment. Topics for further work on the ROFPAQ are highlighted.
Single Absorbable Polydioxanone Pin Fixation for Distal Chevron Bunion Osteotomies
Authors: DeOrio James K. , Ware Anthony W.
Published: January 2017

The distal chevron osteotomy is a well-established technique for correction of symptomatic mild to moderate metatarsus primus varus with hallux valgus deformity. Fixation of the osteotomy ranges from none to bone pegs, Kirschner wires, screws, or absorbable pins. We evaluated one surgeon's (J.K.D.) results of distal chevron osteotomy fixation with a single, nonpredrilled, 1.3-mm poly-p-dioxanone pin and analyzed any differences in patients with unilateral or bilateral symptomatic metatarsus primus varus with hallux valgus deformities. All osteotomies healed without evidence of infection, osteolysis, nonunion, or necrosis. Equal correction was achieved in unilateral and bilateral procedures. The technique is quick and easy, and adequate fixation is achieved.
Morbidity Associated with ORIF of Intra-Articular Calcaneus Fractures Using a Lateral Approach
Authors: Harvey Edward J. , Grujic Leslie , Early John S. , Benirschke Stephen K. , Sangeorzan Bruce J.
Published: January 2017

This is a review of 183 patients with 218 displaced intra-articular fractures of the calcaneus treated by open reduction and internal fixation. One hundred and ninety four (89%) wounds underwent primary uneventful healing. Twenty-four wounds (11%) required local wound care. One deep infection occurred in a neuropathic foot that required below-knee amputation. No free-tissue transfers, local tissue flaps or skin grafts were needed in patients who presented initially with a closed fracture. Ninety-five fractures (43.5%) required subsequent surgical procedures (hardware removal—88/95 [93% of secondary procedures]). Six patients (2.8%) had postoperative sural nerve findings. Seventeen procedures other than hardware removal were performed. There were five subtalar fusions including two subtalar distraction bone-block arthrodeses. There were seven claw toe correction procedures, four calcaneal valgus osteotomies for varus malunions and one subtalar arthrolysis at the time of hardware removal. These results suggest internal fixation of displaced intra-articular calcaneus fractures using a single lateral approach is a safe, reliable method of treatment.
Traumatic ‘Mallet Toe’ of the Hallux: A Case Report
Authors: Hennessy Michael S. , Saxby Terence S.
Published: January 2017

We describe a case of a traumatic avulsion fracture of the distal phalanx of the hallux. In the upper limb this fracture leads to a “mallet” deformity. Such an injury in the great toe has not been reported previously in the English orthopaedic literature to our knowledge. The injury was treated in a dorsal extension splint for eight weeks. At six months follow-up, a satisfactory clinical outcome was achieved.
Preliminary Results on the Safety and Efficacy of the OssaTron® for Treatment of Plantar Fasciitis
Authors: Alvarez Richard
Published: January 2017

The OssaTron may be another alternative for management of plantar fasciitis (heel pain syndrome) after failure of non-operative management and prior to surgical management. This study evaluated primarily the safety and early preliminary efficacy of the OssaTron in treatment of patients with plantar fasciitis unresponsive to non-operative management. Twenty heels of 20 patients were treated with 1000 extracorporeal shockwaves from the OssaTron to the affected heel after administration of a heel block. The patients were followed for one year. Each patient was evaluated by roentgenogram, KinCom, range of motion and physical examination, including evaluation of point tenderness by means of a palpometer and according to a 10-cm visual analog scale. The control was the contralateral heel. Patients also performed self evaluation by means of patient activities of daily living questionnaire and pain reported by a 10-cm visual analog scale.

There were no complications or adverse effects attributed to the procedure of orthotripsy. Of the 20 patients treated, 18 were improved or pain-free. Eighteen of the 20 subjects treated stated that they would undergo the procedure again instead of surgery.

Based on these results, we concluded that orthotripsy is a safe and effective method of treating heel pain syndrome that has been unresponsive to nonoperative management.
Chronic Subluxation of the Midtarsal Joint of the Foot: A Case Report
Authors: Milgram James W.
Published: January 2017

Traumatic injuries to the midtarsal joint are quite uncommon and usually involve fractures of adjacent bones. Pure dislocations without fracture are very rare. A patient sustained a pure dislocation that was treated with a nonweight-bearing cast for six weeks, but she went on to present with chronic subluxation at the midtarsal joint. Imaging modalities were confusing because the pathology was seen only when the deformation was present throughout the imaging examination, not when it was reduced. Stress varus- valgus radiographs of the foot, not ankle, provided a definitive diagnosis. The patient was treated successful by arthrodesis of calcaneocuboid and talo-navicular joints (the midtarsal joint which was unstable) without subtalar fusion.
Intra-Articular Osteoid Osteoma of the Lower Extremity: Diagnostic Problems
Authors: Francesco Barca , Andrea Leti Acciaro , Vincenzo Spina
Published: January 2017

We report five cases of intra-articular osteoid osteoma. Physical findings of osteoid osteoma vary with the site of the tumor. Juxta- and intra-articular osteoid osteomas present various atypical and nonspecific features. They are recorded both for their rarity and for the unusual clinical and roentgenographic findings that may delay diagnosis or induce misdiagnosis. Specialized imaging techniques may hasten diagnosis, but only an accurate clinical history, with a high index of suspicion, can allow for a proper diagnosis. When the diagnosis is suspected, we suggest that the most sensitive test is a “three-phase” technetium-99m bone-scan followed by computerized tomographic-scanning. Detailed evaluation of the suspected area, using thin sections is required to prevent misinterpretation, especially in a diagnosis involving first sprain of an ankle. The following cases of intra-articular osteoid osteoma illustrate the problems encountered in their diagnosis.
Keller Procedure and Chevron Osteotomy in Hallux Valgus: Five-Year Results of Different Surgical Philosophies in Comparable Collectives
Authors: Schneider Wolfgang , Knahr Karl
Published: January 2017

We evaluated 97 Keller procedures and 64 chevron osteotomies, both combined with the “Cerclage fibreux” distal soft-tissue procedure, with a minimum follow-up period of five years to assess the limits of indications of these two different operations. We then formed two subgroups providing a statistical midrange of the metatarsophalangeal angle, intermetatarsal angle I-II and degree of arthrosis of the first metatarsophalangeal joint to obtain comparable collectives of 40 Keller and 36 chevron procedures.

The postoperative AOFAS score averaged 85.4 for the Keller procedure and 83.0 for chevron patients. The metatarsophalangeal angle was improved to an average of 11.0° and 13.9°, the intermetatarsal angle to values of 8.8° and 9.4°, respectively. The patient's overall satisfaction rated “very satisfied” and “satisfied” in 92.5% and 94.4%, respectively.

The main reason for dissatisfaction was pain. Compared to the literature, the good long-term results in this series following resection arthroplasty are attributed to the routine use of the “Cerclage fibreux” technique. This contemporary type of the Keller procedure is still a valuable surgical procedure for older patients with minor functional expectations. Excellent outcome after chevron osteotomy was not only seen in younger patients with minor deformities, but also in an older population. The chevron osteotomy should not be restricted to younger patients. The combination of the chevron distal metatarsal osteotomy with a distal soft-tissue procedure does not increase the risk of clinically manifest avascular necrosis of the metatarsal head and helps to correct higher metatarsophalangeal and intermetatarsal angles.