bluuebunny/crossref_metadata_2025 huggingface dataset:
Opiate-Induced Respiratory Depression in Pediatric Patients
Authors: Gill Andrea M , Cousins Alison , Nunn Anthony J , Choonara Imti A
Published: January 2017

OBJECTIVE:

To describe 15 pediatric patients with opiate-induced respiratory depression.

DESIGN:

In-house adverse drug reaction (ADR) report forms were reviewed to identify any patients with suspected opiate-induced respiratory depression. Case review was then performed.

SETTING:

Large pediatric teaching hospital with regional specialties.

PATIENTS:

Fifteen patients aged 2 days to 17 years (median 14 mo).

MAIN OUTCOME MEASURES:

Respiratory depression resulting in apnea, hypoxia, cyanosis, reduced respiratory rate, or the need for naloxone following or during opiate administration was recorded.

RESULTS:

Fifteen patients experienced some degree of respiratory depression over the 3 years of surveillance. Treatment included naloxone (12 patients), admission to the pediatric intensive care unit (8), ventilation (5), and reduction in dosage (1). Predisposing factors for respiratory depression included an age of less than 1 year, excessive dosage, concurrent medical problems, concurrent drugs, and medication errors.

CONCLUSIONS:

Opiate-induced respiratory depression in pediatric patients occurs infrequently, but may have serious consequences. Opiates are potent analgesics that children require and should receive. Safe use of opiates in pediatric patients, however, depends on the dosage, route and method of administration, consideration of any predisposing factors, and adequate monitoring. This article highlights some of the problems with opiate use in children and gives some recommendations on how these problems may be prevented.
Fluvoxamine for Stereotypic Behavior in Patients with Dementia
Authors: Trappler Brian , Vinuela Luis M
Published: January 2017

OBJECTIVE:

To describe the effects of treatment with the selective serotonin reuptake inhibitor fluvoxamine on three patients with advanced dementia who developed a stereotypic movement disorder.

CASE SUMMARY:

Three patients in a skilled nursing facility were referred by their primary physicians for psychiatric consultation to assist with the management of stereotypic behaviors. The patients received a standard medical, neurologic, and psychiatric workup for dementia. Two of the patients were diagnosed with dementia of the Alzheimer type and the other patient was diagnosed with vascular dementia. All three patients were started on fluvoxamine 25 mg/d; behaviors were monitored daily by the nursing staff and their primary care physicians and weekly by their psychiatrist using the Abnormal Involuntary Movement Scales. The dosage was titrated upward weekly to a maximum dosage of 150 mg/d.

RESULTS:

Two patients showed complete resolution of their stereotypic behaviors by week 6. The third patient showed noticeable improvement with some residual movements after 8 weeks of treatment.

CONCLUSIONS:

Fluvoxamine appeared effective in the control of stereotypic behaviors in three patients with advanced dementia.
Effect on Dissolution from Halving Methylphenidate Extended-Release Tablets
Authors: Erramouspe John , Jarvi Eric J
Published: January 2017

OBJECTIVE:

To determine the effect on in vitro dissolution from cutting methylphenidate extended-release tablets in half.

DESIGN:

Ritalin-SR (Ciba Pharmaceutical Co.) and generic methylphenidate extended-release (MD Pharmaceutical Inc.) tablets were dissolved in water according to the method prescribed by the US Pharmacopeia under two conditions: whole and halved. Samples were collected at 15, 30, and 45 minutes and at 1, 2, 3, 3.5, 4, 5, 6, and 7 hours. Methylphenidate content was determined by HPLC.

RESULTS:

Halving the tablets caused a statistically significant increase in cumulative dissolution as early as 15 minutes. The difference in cumulative dissolution reached its maximum for both Ritalin-SR and generic methylphenidate extended-release tablets at 2 hours. At this time point, the percent dissolution of the whole versus halved tablets was 57% versus 74% (Ritalin-SR), respectively, and 49% versus 67% (generic), respectively. The dissolution profiles of halved and whole extended-release methylphenidate tablets were parallel from this point through the 7-hour collection period. At 7 hours, however, there was no difference in the cumulative dissolution of halved versus whole tablets.

CONCLUSIONS:

While statistical differences during in vitro dissolution do exist and pharmacokinetic ramifications have not yet been determined, the absolute differences in dissolution between halved and whole tablets are not great. Halving methylphenidate extended-release tablets may be a clinically acceptable means of achieving a small increment/decrement in dose without converting to a regular-release tablet.
Displaced Intra-articular Calcaneal Fracture Treated Surgically with Limited Posterior Incision
Authors: Park In-Heon , Song Kyung-Won , Shin Sung , Lee Jin-Young , Kim Tae-Gyun , Park Rae-Seong
Published: January 2017

The incidence of calcaneal fracture has been slowly increasing; however, the ideal treatment for displaced intra-articular fracture is not available yet, even though the fracture brings frequent complication and disability. Between April 1991 and March 1998, we treated 103 displaced intra-articular calcaneal fractures of 92 patients surgically with limited posterior incision, modified Gallie approach. There were thirty-seven tongue-type fractures, fifteen tongue-type fractures with moderate comminution, nineteen joint-depression fractures, twenty-nine joint-depression fractures with moderate comminution, and three extensively comminuted fractures. The fracture fragments were fixed mainly with partly threaded small cancellous screws or Steinmann pins without any bone graft. Ankle and subtalar motion was permitted immediately if fixation were stable enough. Otherwise, a short period of cast immobilization was utilized. With a mean follow-up of 28 months (range, 12 to 66 months), eighty six percent of feet had no pain or only occasional pain not requiring medication. Using American Orthopedic Foot and Ankle Society hindfoot score system for assessment, ninety percent of feet rated as good to excellent. We used “Circle draw test” for evaluation of subtalar motion during follow-up visitation and found eight-seven percent of feet showed good to excellent correlation with the functional recovery. We recommend a limited posterior incision for reduction and internal fixation of displaced intra-articular calcaneal fractures. For displaced intra-articular fractures with three or four large fragments without further comminution and without a displaced fracture of the calcaneal cuboid joint, this method is particularly useful. We also recommend a Circle draw test for evaluation of subtalar joint motion as well as an indicator of functional recovery after displaced calcaneal fractures.
Characterization of Patients with Primary Peroneus Longus Tendinopathy: a Review of Twenty-Two Cases
Authors: Brandes Clayton B , Smith Ronald W
Published: January 2017

Between 1985 and 1996 we treated 22 patients with a diagnosis of PLT which was confirmed by MRI and/or surgery. This review identifies the shared clinical traits and associated pathology of our patients. Clinically, 82% of the patients had a cavo-varus hindfoot position. This finding was supported by measurements of the calcaneal pitch angle and the calcaneal-1st metatarsal angle which both showed the patients in this study to be in the 90th percentile for the general population for arch height. The combined MRI and surgical findings revealed injury to the peroneus longus at the cuboid notch in 17 of 22 cases. The subgroup of surgical findings demonstrated that all 6 complete tears occured at the cuboid notch, while 8 of 9 (89%) of the partial tears involved the region of the lateral calcaneal process. In addition, the surgical findings showed 7 of the cases (33%) to have associated peroneus brevis tendon involvement, with an increased incidence when the longus pathology occurred at the cuboid notch. The findings predicated by MRI correlated well with the surgical findings, but there was a tendency for MRI to predict a more severe level of pathology. A grading system developed to compare the MRI and surgical findings is presented. This study facilitates making the diagnosis of PLT by drawing attention to the common characteristic of the cavo-varus foot position and the common locations of tendon injury.
Reliability and Running Speed Effects of In-shoe Loading Measurements During Slow Treadmill Running
Authors: Kemozek T.W. , Zimmer K.A.
Published: January 2017

In-shoe measurement systems allow the clinician and researcher to examine the loading parameters within the shoe. This study sought to investigate the test retest reliability and speed effects of in-shoe loading parameters using the Pedar System (Novel GMBH Munich) during slow treadmill running. The results indicated good to excellent test retest reliability between the two days tested. Intraclass correlation coefficients (ICC's) ranged from 0.84–0.99 depending on the plantar region and variable analyzed. All plantar loading variables increased (peak pressure, peak pressure time impulse, peak force, and force time impulse) with the exception of contact area when treadmill running speed was increased from 2.24 m/s to 3.13 m/s. Results indicate that control of running speed is essential in obtaining reproducible data using this system to measure in-shoe loading data.
Tibialis Posterior Tendon Dysfunction: A Primary of Secondary Problem?
Authors: Yeap Joo seng , Singh Dishan , Birch Rolfe
Published: January 2017

Seventeen patients with a mean follow-up of 64.4 months following a tibialis posterior tendon transfer to regain active foot dorsiflexion were clinically examined specifically for signs of tibialis posterior tendon dysfunction. The results show that 8 patients (47 %) had Grade 4 or better power of eversion but none had a clinical flatfoot on the Harris-Beath footprints. Only 6 % had forefoot abduction; 17 % exhibited hindfoot valgus and 82 % were able to perform the single-heel rise.

Tibialis posterior tendon dysfunction therefore does not appear to be an inevitable sequel of tibialis posterior tendon transfer even in the presence of a functioning peroneal muscle. Other studies have noted that a pre-existent flatfoot was often present in patients with tibialis posterior tendon dysfunction. None of the patients in this study had pre-existent flatfoot. We suggest that a predisposition, in the form of a pre-existent tendency to flatfoot may also be a factor in the pathogenesis of tibialis posterior tendon dysfunction. This may explain the long-term failure of flexor digitorum longus and flexor hallucis longus tendon transfers in the treatment for tibialis posterior tendon dysfunction when the biomechanics of the foot has not been altered.
Salter-Harris III Stress Fracture of the Proximal First Metatarsal: A Case Report
Authors: Kadel Nancy J. , Goldstein Jeffrey , Newberg Arthur H. , Trepman Elly
Published: January 2017

An intraarticular, dorsal, proximal epiphyseal stress fracture (Salter-Harris III) of the first metatarsal was identified in a 14-year-old boy. Successful fracture healing was achieved with a rocker sole shoe modification and activity limitation.
The Influence of Perioperative Soft Tissue Complications on the Clinical Outcome in Surgically Treated Ankle Fractures
Authors: Höiness P. , Engebretsen L. , Strömsöe K.
Published: January 2017

The influence of perioperative soft tissue complications on the functional outcome after open reduction and internal fixation of closed ankle fractures was investigated. Eighty-eight consecutive patients were followed 3.7 years (SD ± 0.6) after the injury. Two major and 21 minor soft tissue complications were registered. Average dorsal extension was 29.9° (range four to 54, SD ± 9.5) of the fractured ankles and 37.2° (range eight to 60, SD ± 9.1) of the non-fractured ankles. The average subjective functional score was 84.6 (range 40 to 100, SD±14.9). A significant difference was found with respect to the subjective functional score (p = 0.048, Kruskal-Wallis test) but not with respect to dorsal extension (0.358, Kruskal-Wallis test) when comparing groups of minor, major and no soft tissue complications. This study suggests that major soft tissue complications have a negative effect on the long-term functional outcome after surgical repair of an ankle fracture. Minor soft tissue complications, primary skin problems, the timing of primary surgery and fracture types according to AO/ASIF have no or minor influence on the long-term functional result. This study confirms previous reports that the presence of osteoarthritis is frequently associated with a reduced functional outcome.
The Scarf Osteotomy for the Treatment of Hallux Valgus Deformity: A Review of 84 Cases
Authors: Crevoisier Xavier , Mouhsine Elyazid , Ortolano Vito , Udin Bachtiar , Dutoil Michel
Published: January 2017

This study reviewed the subjective, clinical and radiological outcome of 71 patients (84 feet) treated by scarf osteotomy for hallux valgus deformity at our institution from 1995 to 1998 with an average follow-up time of 22 months (range, 17 to 48 months). At the time of follow-up, 39% of the patients were very satisfied, 50% were satisfied and 11% were not satisfied. The mean AOFAS score raised significantly from 43 points (14–68) preoperatively to 82 points (39 to 100) at follow-up (p < 0.001). The radiological angles including M1-M2, M1-P1, M1-M5 and DMAA improved significantly (p < 0.001). Among the 16 complications recorded, seven (8%) were minor and nine (11%) required an additional procedure. The scarf osteotomy of the first metatarsal coupled with a lateral soft-tissue release and, in three-quarters of our cases, with a basal closing wedge varisation osteotomy of the first phalanx, resulted in overall high satisfaction rate as well as significant clinical and radiological improvements in our series. Nevertheless, the range of motion of the first MP joint remained low: 30° to 74° in 52 patients (62%) and <30° in four patients (5%). Furthermore, the mobility of the first ray as well as the consequences of the procedure in the sagittal plane need to be assessed more accurately, and this may be achieved by incorporating measurement of the plantar pressures in the forefoot area into the global rating system.
Initial Pull-Out Strength of Tendon Sutures: An In Vitro Study in Sheep Achilles Tendon
Authors: Yıldırım Yakup , Esemenli Tanıl
Published: January 2017

Forty-eight fresh frozen sheep achilles tendons were used to compare the pull-out strengths of Kessler, Bunnell and locking loop techniques which are the standard configurations described for Achilles tendon repair. A simulated Achilles tendon rupture was done with a tenotomy made 2 cm proximal to the calcaneal insertion. One of the configurations was placed at the distal end of the proximal portion of the tendon specimens using No. 5 Ticron. The distal ends of the suture materials were left free and were not used to connect the proximal and distal portions of the tendon. Using a servohydraulic materials testing machine, each tendon was tested to failure in tension at a displacement rate of 20 mm/min. All the specimens failed due to pull-out of the suture material. Since the cause of failure was suture material breakage in the previous studies reporting repair strength, they were unable to represent the effect of configuration on the strength. This study is the first to represent the effect of configuration on the initial strength since there is no failure due to suture material breakage.
Chronic Subtalar Instability Due to Insufficiency of the Calcaneofibular Ligament: A Case Report
Authors: Kamada Kazuo , Watanabe Shohei , Yamamoto Haruyasu
Published: January 2017

Calcaneofibular ligament insufficiency in isolation is an uncommon cause of chronic instability of the subtalar joint. We report one case of chronic subtalar instability due to calcaneofibular ligament insufficiency after an ankle sprain. It was diagnosed with clinical findings and stress radiograph, and successfully treated with proximal advancement of the elongated calcaneofibular ligament.
Peroneus Longus Ligamentoplasty for Chronic Instability of the Distal Tibiofibular Syndesmosis
Authors: Grass Rene , Rammelt Stefan , Biewener Achim , Zwipp Hans
Published: January 2017

The distal tibiofibular syndesmosmotic ligament complex is important for dynamic stability and congruency of the ankle joint. Syndesmotic lesions in the ankle fracture-dislocations are well recognized and classified systematically. Chronic insufficiency of the syndesmosis leads to a lateral shift of the talus and under eversion stress permits a pathological rotation of the talus. There is also retroversion of the distal fibula representing a painful deformity. Little experience exists with surgical reconstruction of the syndesmosis. This article describes a new ligamentoplasty with a split peroneus longus tendon graft that mimics the normal anatomic conditions of the syndesmotic complex in 16 patients with symptomatic chronic syndesmotic insufficiency after pronation-external rotation and pronation abduction injuries to the ankle joint. Postoperatively, no infections or hematomas were seen. One patient had asymptomatic breakage of the syndesmosis screw; one patient had a 10° decrease of dorsiflexion at the ankle because of a partial anterior tibiofibular synostosis. Fifteen of 16 patients had pain relief at a mean follow-up period of 16.4 months (range, 13–29 months); all patients had relief of the chronic swelling of the ankle and the giving way. The mean Karlsson score at follow-up was 88 (range, 70–100) points. It may be concluded that peroneus longus ligamentoplasty in a preliminary series resulted in reliable ankle stability and considerable pain relief in patients with chronic syndesmotic instability.
Can the Use of a Terminal Device Augment Plantar Pressure Reduction with a Total Contact Cast?
Authors: Dhalla Raja , Johnson Jeffrey E. , Engsberg Jack
Published: January 2017

Hypotheses/Purpose:

Total contact casting (TCC) has been shown to promote the healing of plantar neurotrophic ulcers by reducing plantar pressures and has become the established treatment standard by which all others are measured. The purpose of this study was to determine if terminal cast devices (cast shoes and heels) significantly affect the amount of plantar pressure reduction when used with a total contact cast.

Methods/Results:

Plantar pressures were measured in the right feet of 28 healthy adult volunteers using the Novel EMED PEDAR system (Novel GmbH, Munich, Germany) for six conditions: athletic shoe (i.e., control), TCC alone, TCC with a conventional cast shoe (EBI, Parsipanny, NJ), TCC with a custom rigid rocker cast shoe (NPS, St. Louis, MO), TCC with a rubber rocker heel (Cast Walker, DM Systems Inc., Evanston, IL), and TCC with a traditional flat rubber heel (Zimmer, Warsaw, IN). Peak plantar pressures were recorded from the forefoot, midfoot, and hindfoot. Analysis of variance (ANOVA) was used to determine statistical significance. The greatest reductions in forefoot plantar pressures compared to the athletic shoe control were seen in the TCC with the conventional cast shoe and the TCC with the rigid rocker shoe; a mean plantar pressure reduction of 30% was observed for both conditions ( p <.001). Significant midfoot plantar pressure reductions ( p <.001) were achieved with the TCC alone, TCC with the conventional cast shoe, TCC with the rigid rocker heel, TCC with the flat rubber heel, and TCC with the rubber rocker heel. Mean reductions were 42%, 51%, 47%, 40%, and 46%, respectively. While athletic shoe peak hindfoot pressures were only reduced by 15% by TCC alone, the addition of the rubber rocker heel to TCC reduced athletic shoe pressures by 32% and the addition of the flat rubber heel to TCC reduced athletic shoe pressures by 29%. The reductions with TCC and the heels were both significant when using the athletic shoe as the control ( p <.001) and the TCC alone as the control ( p <.05).

Conclusion:

Plantar pressure reduction with TCC can be augmented with the addition of a terminal cast device and the effects shown in this study are significantly different than previously reported. These results suggest that terminal cast devices should be chosen according to location of the neuropathic ulcer. In this study, forefoot pressures were reduced the most with TCC and either the conventional cast shoe or the rigid rocker shoe. The authors therefore recommend these combinations for forefoot ulcers. TCC alone or combined with any of the terminal devices proved equally effective for midfoot plantar pressure reduction. Hindfoot ulcers should be treated with TCC and the rubber rocker heel or the flat rubber heel as these provided the best hindfoot pressure reductions.
Supramalleolar Osteotomy for the Treatment of Distal Tibial Angular Deformities and Arthritis of the Ankle Joint
Authors: Stamatis Emmanouil D. , Cooper Paul S. , Myerson Mark S.
Published: January 2017

In a 5-year period (1996–2001), the authors performed supramalleolar osteotomies for the correction of distal tibial mechanical malalignment of at least 10° with concomitant pain and with or without radiographic evidence of arthritic changes. The method was also applied as an alternative to other common procedures for the treatment of a small group of patients with degenerative changes of the ankle joint without previous traumatic event and with minimal or moderately altered alignment. There were 12 patients (13 feet) with an average follow-up of 33.6 months. All osteotomies healed at an average time of 14 weeks. The average AOFAS score improved from 53.8 to 87 points, the average ankle score in the scale described by Takakura et al. improved from 56.7 to 82, and the average pain score improved from 14.6 to 32.3. In the presence of deformity, the average tibial-ankle surface angles in both the coronal and the sagittal planes were significantly improved. The radiographic degenerative changes in the ankle joint showed no evidence of progression. The choice of technique did not influence the clinical or radiographic outcome or the healing time of the osteotomy.
Variations on the Insertion of the Posterior Tibialis Tendon: A Cadaveric Study
Authors: Bloome David M. , Marymont John V. , Varner Kevin E.
Published: January 2017

This cadaveric study specifically investigates the variations on the insertion of the posterior tibialis tendon (PTT) in the foot, a topic which is not well defined in anatomy discussions. The PTT insertion sites from 11 fresh-frozen cadaver feet (10 subjects) were evaluated. There were three distinct bands of the PTT seen in all specimens with variations on the insertion to the spring ligament (4/11), fifth metatarsal base (7/11), flexor hallucis brevis (9/11), and peroneus longus (4/11). This study also found a distinct slip to the abductor hallucis in five of the specimens.
Disabling Foot Cramping in a Runner Secondary to Paramyotonia Congenita: A Case Report
Authors: Fredericson Michael , Kim Byung-Jo , Date Elaine S.
Published: January 2017

An 18-year-old male runner was referred to the authors' clinic with a 1-year history of cramping left foot pain. His symptoms developed insidiously when he increased his training, with an onset of severe left foot pain and tightness that would develop after about 20 minutes of exercise. The more he continued to run, the more the symptoms were aggravated and evolved to the toes curling with intrinsic muscle spasm. This symptom was easily provoked when he was exposed to cold temperature. A family history of similar symptoms was revealed in his sister and uncle. Physical examination including neurologic examination was normal. Diagnostic workup revealed generalized myotonia. According to the history, physical examination, and diagnostic workup, his diagnosis was considered to be most compatible to paramyotonia congenita. He was given phenytoin, which lessened his symptoms and allowed him to continue running with minimal symptoms, but he stopped running because he was not able to maintain mileage high enough to compete successfully.
Preliminary Experience with Perforator Flaps in Reconstruction of Soft-Tissue Defects of the Foot and Ankle
Authors: Duffy Frederick J. , Brodsky James W. , Royer Christian T.
Published: January 2017

Background: Microsurgical reconstruction has improved limb salvage in patients who because of many etiologies have soft-tissue loss from the lower extremities. Free-tissue transfer to the foot and ankle often interferes with postoperative function and footwear because of the bulk of a muscle flap. The foot and ankle often are best treated using thin flaps that will not contract and fibrose, particularly if secondary procedures are required. We hypothesized that perforator flaps, which are thin free-tissue transfers consisting of skin and subcutaneous tissue, both diminish donor site morbidity and are ideally suited for soft-tissue reconstruction of the foot and ankle. Methods: Ten patients had free- tissue transfers to the foot and ankle using perforator flaps during a 2-year period. Four had acute posttraumatic wounds, three had soft tissue defects with exposed hardware or bone graft after reconstructive surgery, and three had large soft-tissue defects after foot infection secondary to diabetes. Nine had reconstruction with anterolateral thigh perforator flaps and one had reconstruction with a deep inferior epigastric artery (DIEP) perforator flap. Results: All flaps survived. There were no deep infections. Three flaps had minor tissue loss requiring subsequent small skin grafts, all of which healed. There were no donor site complications and no interference of muscle function at the donor sites. Custom shoewear was not required to accommodate the flaps. Conclusion: This series highlights the success and utility of perforator flaps in microsurgical reconstruction of the foot and ankle. The greatest advantage of perforator flaps is the diminished donor site morbidity, which was achieved while maintaining high microsurgical success rates. These skin and fat flaps remained pliable and contracted less than muscle flaps, allowing for smooth tendon gliding and easy flap elevation for secondary orthopaedic procedures.
Combination of Hook Plate and Tibial Pro-Fibular Screw Fixation of Osteoporotic Fractures: A Clinical Evaluation of Operative Strategy
Authors: Panchbhavi Vinod K. , Mody Milan G. , Mason William T.
Published: January 2017

Background: Internal fixation of osteoporotic ankle fractures is technically difficult and may fail because of unreliable purchase. This study was undertaken to determine if a combination of a hook plate and tibial pro-fibular screws can provide secure fixation until fracture union. Methods: Thirty-one patients between the ages of 55 and 90 years had open reduction and internal fixation of ankle fractures between April, 2001, and April, 2003. Sixteen patients with an average age of 71.4 years had ankle fracture fixation with a combination of hook plate and tibial pro-fibular screws for the distal fibular fracture, and 15 patients with an average age of 71.9 years had fixation of their ankle fractures with standard fixation technique using AO/ASIF principles but no tibial pro-fibular screws. All patients were followed with clinical and radiologic assessment at 2 weeks, 6 weeks, and 12 weeks postoperatively. At an average of 15.8 months after injury, patients also completed a mailed questionnaire with the Olerud-Molander ankle score and the AOFAS ankle-hindfoot score for preoperative and postoperative status. Results: All patients who had tibial pro-fibular screw fixation had fracture union without hardware failure or complications. In the standard fixation group two patients had wound breakdown and one had a valgus malunion with screw pull out. The AOFAS and Olerud-Molander scores for the standard open reduction and internal fixation were 57.3 and 82.8 before injury and 37 and 43.8 postoperatively, respectively. The AOFAS and Olerud-Molander scores for the hook plate and tibial pro-fibular fixation group were 55.9 and 81.3 before injury and 42.4 and 50.3 postoperatively, respectively. Conclusions: The combination of hook plate and tibial pro-fibular screws in osteoporotic ankle fractures in a series of patients has not been reported before. This novel technique provides stable fixation for osteoporotic ankle fractures in elderly patients until union is achieved with good clinical scores.
Quantification of Muscle Strength and Imbalance in Neurogenic Pes Cavus, Compared to Health Controls, Using Hand-Held Dynamometry
Authors: Burns Joshua , Redmond Anthony , Ouvrier Robert , Crosbie Jack
Published: January 2017

Background: Pes cavus foot deformity in neuromuscular disease is thought to be related to an imbalance of musculature around the foot and ankle. The most common cause of neurogenic pes cavus is Charcot-Marie-Tooth (CMT) disease. The aim of this investigation was to objectively quantify muscle strength and imbalance using hand-held dynamometry in patients diagnosed with CMT and pes cavus, compared to healthy controls. Methods: Muscles responsible for inversion, eversion, plantarflexion, and dorsiflexion of the foot and ankle were measured in 55 subjects (11 CMT patients with a frank pes cavus, and 44 healthy controls with normal feet) using the Nicholas hand-held dynamometer (HHD). Test-retest reliability of the HHD procedure also was determined for each of the four muscle groups in the healthy controls. Results: Test-retest reliability of the HHD procedure was excellent (ICC3,1 = 0.88 to 0.95) and the measurement error was low (SEM = 0.3 to 0.7 kg). Patients with CMT were significantly weaker than normal for all foot and ankle muscle groups tested ( p <0.001). Strength ratios of inversion-to-eversion and plantarflexion-to-dorsiflexion were significantly higher in the patients with CMT and pes cavus compared to individuals with normal foot types ( p > 0.01). Conclusions: Hand-held dynamometry is an objective and reliable instrument to measure muscle strength and imbalance in patients with CMT and a pes cavus foot deformity.
Preservation of Residual Foot Length in Partial Foot Amputation: A Biomechanical Analysis
Authors: Dillon Michael P. , Barker Timothy M.
Published: January 2017

Background: Partial foot amputation may be preferred to more proximal amputation because of the perceived improvement in function associated with preserving foot length and the ankle joint complex, thus enabling normal gait and push-off. Clinically, partial foot amputees display significant wasting of the triceps surae musculature, strongly indicative of disuse. This investigation aimed to examine the belief that preserving residual foot length should be the primary operative objective necessary to maintain normal foot and ankle function. Method: The gait patterns of eight partial foot amputees and a cohort of matched nonamputee control subjects were analyzed using a peak three-dimensional (3D) motion analysis system incorporating an AMTI force platform (Advanced Mechanical Technology Inc., Waterton, MA). Amputee subjects used their own prostheses for the evaluation. Results: Amputations disarticulating the metatarsophalangeal (MTP) joint had little impact on the normal pattern of ankle power generation. However, amputation proximal to the MTP joint level resulted in virtually negligible power generation across the ankle, regardless of residual foot length. Subjects compensated for the lack of ankle power generation by adopting strategies in which the hip became the primary source of power to advance the body forward. Conclusions: The primary reason for a partial foot amputation is to preserve the normal function of the foot and ankle complex associated with push-off. As such, surgery should strive to preserve the metatarsal heads to allow amputees to use the ankle's contribution to walking. Given that amputation proximal to the metatarsal heads compromised the normal propulsive function of the foot and ankle, surgery should not strive to preserve residual foot length to maintain function but should instead aim to achieve good distal tissue coverage and healing, particularly given that the hip joint(s), not the ankle, become the primary source of power for walking.
Biomechanical Analysis of Tibial Strength After Harvest of Unicortical Tibial Grafts from Two Different Sites
Authors: Hong Yuhwan , Parks Brent G. , Miller Stuart D.
Published: January 2017

Background: Use of tibial strut grafts has several potential advantages over other donor sites and would be ideal as a harvest site for bone grafts if there are minimal or no resulting risks to tibial stability. Methods: Ten matched-pair cadaver tibiae were randomized to have a 1.5 × 4.0 cm cortical graft harvested from the tibial crest or 1 cm posterior to the tibial crest. Both locations were 6 cm distal to the tibial plateau. The grafts were removed using a high-speed oscillating saw, and each end of the tibia was mounted for testing and loaded onto a servohydraulic test frame. The samples were axially loaded with 720 N (162 lbs) of force, and an external rotational torque was applied at 5 degrees per second to failure. Failure torque for each tibia was recorded. A paired Student's t-test was used to determine whether any observed differences in failure torques were significant. Results: The torque to failure range for on-crest grafts was 11.65 to 81.76 Nm (average, 44.53 Nm; SD, 22.82 Nm). The torque to failure range for the tibiae with the graft 1 cm off-crest was 13.30 to 70.45 Nm (average, 41.64 Nm; SD, 17.83 Nm). All fractures were spiral, included the distalmost anterior corner of the donor site, and extended distally. There was no significant difference in torque to failure between the two donor sites ( p = 0.22). The grafts varied consistently in quality. Conclusion: Considering that there was no statistically significant difference in torque to failure between the two groups of tibiae, the site for tibial bone graft can be selected based on the shape of the cortical graft necessary for each specific surgery.
A Mechanical Equinometer to Measure the Range of Motion of the Ankle Joint: Interobserver and Intraobserver Reliability
Authors: Meyer Dominik C. , Werner Clement M.L. , Wyss Tobias , Vienne Patrick
Published: January 2017

Background: Clinical measurement of passive dorsiflexion of the ankle joint is essential for the diagnosis of various pathologic conditions of the foot and ankle but is of unreliable precision with high interobserver variability in nonweightbearing tests. This work was designed to develop and test a precise, standardized, and reliable technique for measurement of passive and active ankle range of motion. Methods: The proposed measurement tool is composed of two mobile parallelograms, one attached to the tibia, the second one to the plantar surface of the foot. The parallelograms are connected with a hinge with an angular scale to measure the angle between the foot and tibia. Results: Interobserver correlation between clinical measure-ments for maximal passive foot dorsiflexion were 0.03 with knee extension and 0.38 with knee flexion, while for measurements with the proposed tool they reached 0.89 and 0.97, respectively, with a mean measurement error of 0.9 degrees. Intraobserver correlations reached values of r = 0.98 and 0.99. Conclusions: The proposed tool allows measurement of the ankle range of motion with very high precision and reproducibility far superior to clinical measurements. Clinical Relevance: Precise measurement of ankle range of motion is clinically challenging. With the use of the proposed tool, measurement precision and reliability are decisively improved.
Treatment of Open Intra-articular Calcaneal Fractures: Evaluation of a Treatment Protocol Based on Wound Location and Size
Authors: Thornton Steven J. , Cheleuitte Domingo , Ptaszek Amy Jo , Early John S.
Published: January 2017

Background: Effective treatment algorithms for open, displaced, intra-articular calcaneal fractures and their potential early complications have not yet been established. This is a retrospective review of the management of open displaced calcaneal fractures at a Level 1 trauma center and their resulting soft-tissue complications in an effort to establish guidelines for management. Method: Between November, 1994, and April, 2002, 31 open intra-articular calcaneal fractures in 29 patients were treated at our institution. All fractures were treated with a standard protocol based on the appearance of the traumatic wound after initial debridement and stabilization. Fracture stabilization was determined by the wound characteristics and was either standard internal fixation or percutaneous fixation. Data on associated injuries, comorbidities, smoking, and subsequent soft-tissue complications were collected and reviewed. Results: Overall there was a 29% soft-tissue complication rate with this protocol. Two of the four laterally based traumatic wounds had complications. Twenty-seven wounds were medial. Nine were considered unstable and were treated with aggressive wound management and percutaneous fixation of the tuberosity reduction; two developed deep infections and required amputation and seven were salvaged with patients returning to full weightbearing. Eighteen fractures with medial wounds were treated with standard internal fixation; soft-tissue complications occurred in five. Initial size greater than 4 cm was associated with an increased complication rate in this group. Conclusion: Management of open calcaneal fractures and the risk of complications depend on the size and position of the traumatic wound. Lateral wounds are rare and in this review, two of the four had complications using this protocol. Medial wounds of less than 4 cm can be treated with open reduction and standard internal fixation if the wound can be closed and remain stable off antibiotics. Larger wounds (more than 4 cm) or unstable wounds should not be treated with open reduction and internal fixation but can be reduced and held in alignment with percutaneous wire fixation.
Evans Calcaneal Lengthening Procedure for Spastic Flexible Flatfoot in 32 Patients (46 Feet) with a Followup of 3 to 9 Years
Authors: Zeifang Felix , Breusch Steffen J. , Döderlein Leonhard
Published: January 2017

Background: The purposes of this study were to evaluate the outcome of calcaneal lengthening in severe pediatric flexible flatfoot deformities of spastic origin and to determine the necessity of additional procedures. Methods: In a prospective study, 32 patients (46 feet) were evaluated clinically and radiologically. The mean age of patients was 11 (range 4 to 22) years. The mean period of followup was 66 (range 36 to 108) months. Results: Additional soft-tissue procedures (Strayer procedure, peroneus lengthening, reefing medial capsule) were performed in 39 of 46 feet; other bony procedures were performed in eight. Among the 46 feet, 11 outcomes were classified as excellent, 19 as good, nine as fair, and seven as poor. Poor outcome was related to overcorrection in three and deformity relapse in four. Calcaneocuboid subluxation was seen in nine feet. Radiographic evaluation demonstrated an improvement of all parameters determined. Conclusion: The Evans procedure is effective for the correction of severe, flexible flatfoot deformity in children with cerebral palsy in the short and mid term. Additional soft-tissue procedures frequently are required. However, correction of this multiplanar deformity predominantly occurs in the forefoot abduction component of the deformity, and the concomitant naviculocuneiform sag remains uncorrected. Despite successful outcomes, overcorrection and undercorrection remains a problem of clinical relevance.
Bending Stiffness and Pull-Out Strength of Tapered, Variable Pitch Screws, and 6.5-mm Cancellous Screws in Acute Jones Fractures
Authors: Sides Steven D. , Fetter Nicole L. , Glisson Richard , Nunley James A.
Published: January 2017

Background: Stabilization of fifth metatarsal Jones fractures with intramedullary screws is popular, particularly in athletes, because nonoperative treatment involves prolonged casting and a distinct risk of nonunion or delayed union. Conventional lag screws of various diameters are routinely used for Jones fracture fixation. More recently, tapered, headless, variable pitch screws have become available as an option. These screws have the advantage of not having a protruding screw head, but information regarding their performance in Jones fracture fixation is limited. To determine whether differences exist in the mechanical integrity of fifth metatarsals fixed with each type of screw, this study was designed to compare Jones fracture fixation with 6.5-mm partially-threaded lag screws and headless, tapered, variable pitch compression screws with a 4-mm leading-thread diameter and 5-mm trailing-thread diameter. Methods: Simulated Jones fractures were created in 20 matched pairs of fresh-frozen fifth metatarsals. One bone from each pair was stabilized with a tapered, variable pitch screw, and the contralateral with a 6.5-mm partially-threaded cancellous lag screw. The stiffness in lateral-to-medial bending of the resulting constructs and the resistance of the screws to pulling out of the distal fragment were quantified. Results: There was no demonstrable difference in bending stiffness between metatarsals fixed with the two types of screws ( p = 0.688). The 6.5-mm screw provided significantly higher resistance to pull-out ( p = 0.001). Conclusions: Headless, tapered, variable pitch compression screws of the size tested are not entirely comparable to 6.5-mm lag screws in this application. They are effective in resisting bending but do not offer equivalent resistance to thread pull-out.
The Neurobiology of Schizophrenia
Authors: Nihart Mary Ann
Published: January 2017

Research into the neurobiology of schizophrenia has led to advances in the drug treatment of this devastating illness. Through imaging studies, drug models of psychoses, and other research techniques, possible anatomic abnormalities and neurotransmitter changes in the brains of individuals with schizophrenia have been identified. By developing drugs that selectively antagonize dopamine, serotonin, and other neurotransmitter receptors, it is possible to effectively control the positive and negative symptoms of schizophrenia and decrease the incidence of drug-related side effects. In addition, by understanding the neuropathology and related cognitive deficits, psychiatric nurses will be able to develop more effective interventions to assist patients and their families.
Early Elective Conversion for Failing Evar
Authors: Aho P.-S. , Roth W. D. , Keto P. , Lepäntalo M.
Published: January 2017

Background:

The aim of the study was to assess the long term results of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms at the Helsinki University Central Hospital 1996–2004 with a special emphasis on elective conversion procedures and their outcome.

Methods:

Treatment results and follow-up data of all 110 elective EVAR procedures performed in our institution were gathered prospectively and evaluated.

Results:

Conversion to open surgery was performed in 23 (21%) of 110 EVAR patients. 30-day mortality after elective stent-graft deployment was 0% as it was also on elective conversions (n = 20). Secondary elective conversions were performed due to infection in two and after failing stent-graft treatment in 12 patients. Six of the conversions were performed primarily. Three urgent conversions (3% overall) were performed: two of these patients died, corresponding to an overall mortality of 9% (2/23) in all conversions. Five-year aneurysm-related mortality after EVAR among patients with elective conversion was 0% and 19% in patients with secondary procedures other than elective conversions.

Conclusions:

As conversions seem to be hazardous only when performed in urgent situations, elective conversion could be an alternative treatment method in complex failing first-generation stent-grafts as it may reduce mortality associated with urgent conversions or repeated attempts to maintain graft integrity with endovascular procedures.
The Place of Screening in the Management of Abdominal Aortic Aneurysm
Authors: Scott R. A. P.
Published: January 2017

The present method of management of Abdominal Aortic Aneurysms (AAA) is ineffective in preventing AAA rupture. 5000 people still die of AAA in the UK each year. Improvements in surgery can only reduce the mortality in the minority who reach hospital following chance detection, and then only by a few percent.

Screening, with detection in the community and planned treatment can reduce the mortality of the disease by 58%. Screening programmes for AAA have recently been approved for men aged 65 years, in both the UK and the USA. The proposed UK National Screening Programme is outlined briefly

Conclusion:

If the aim of treatment is to reduce the mortality of the disease as a whole, resources would be better spent on screening programmes for AAA, rather than developing increasingly sophisticated operative techniques that could only reduce the overall death from AAA by a few percent.
The Impact of Fibrin Glue in the Prevention of Failure after Nissen Fundoplication
Authors: Rantanen T. , Neuvonen P. , Iivonen M. , Tomminen T. , Oksala N.
Published: January 2017

Background and Aims:

Good long term result after Nissen fundoplication is achieved in most of the patients in specialized centres. Still failure occurs in some cases and reoperation after failed conservative treatment is done in 3–6% of the cases. Reoperation is more dangerous and results worse than after primary fundoplication. Therefore we wanted to analyze factors related to failure of Nissen fundoplication with special emphasis on utilization of crural closure, anchoring of the fundic wrap and the use of fibrin glue.

Material and Methods:

Patients records of 258 patients were analyzed by an independent observer. Defective fundic wrap, recurrent oesophagitis and hiatal hernia were defined as failure.

Results:

Failure after Nissen fundoplication was found in 29 patients (14.9%). Crural closure (p = 0.021), anchoring of the wrap (p = 0.020) and fibrin glue (p = 0.029) decreased the incidence of failure. However, only crural closure (p = 0.010) and fibrin glue (p = 0.019) were independent factors in the prevention of failure.

Conclusions:

Fibrin glue as a new method might be worth utilizing to further decrease the incidence of failure after Nissen fundoplication. Because our study was retrospective, prospective randomized study should be performed before universal use of fibrin glue in the prevention of failure after fundoplication.
Elastic Stable Intramedullary Nailing for Pediatric Long Bone Fractures: Experience with 175 Fractures
Authors: Furlan D. , Pogorelić Z. , Biočić M. , Jurić I. , Budimir D. , Todorić J. , Šušnjar T. , Todorić D. , Meštrović J. , Milunović K. P.
Published: January 2017

Purpose:

To demonstrate the effectiveness of intramedullary fixation of displaced long bones shaft fractures in skeletally immature children using the elastic stable intramedullary nails.

Patients and methods:

The case records of 173 children who underwent fixation with titanium intramedulary nails because of long bones fractures were reviewed. The average age of the patients was 11.7 years, and mean follow-up was 41.3 months. There were 55 humeral, 42 forearm, 42 femoral and 36 tibial fractures. Subjective satisfaction was assessed.

Results:

All patients achieved complete healing at a mean of 7.5 weeks. Complications were recorded in 11 (6.3%) patients and included: one neuropraxia, six entry site skin irritations, two protrusions of the wires through the skin and two skin infections at the entry site. In a subjective measure of outcome at follow-up, 89% of patients were very satisfied and 11% satisfied; no patients reported their outcome as not satisfied. The implants were removed at a median time of six months from the index operation.

Conclusion:

Elastic Stable Intra-medullary Nailing is the method of choice for the pediatrics patients, because it is minimaly invasive and shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction.