bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of the Esmark Bandage as a Tourniquet for Forefoot Surgery
Authors: Grebing Brett R. , Coughlin Michael J.
Published: January 2017

Purpose:

Although used routinely as a tourniquet in forefoot surgery, the pressure under an Esmark bandage has had little evaluation, and its use has been discouraged by some. The purpose of this study was to quantitate the pressure generated by an elastic bandage in a clinical setting and compare several different types of commercially available Esmark bandages.

Methods:

Five foot and ankle fellowship program directors and five foot and ankle fellowship trained surgeons comprised the volunteer group which performed clinical simulations with a 6-inch Esmark bandage at the ankle level. Variables were then added, including different padding, a change in the position of the surgeon, and a 4-inch Esmark bandage. A questionnaire on their use of an elastic bandage in practice was also administered. Differences in pressure between different types of available 6-inch Esmark bandages were also compared. Pressure measurements were recorded by a pressure monitor device.

Results:

The average pressure of the 10 surgeons' trials for three wraps with a tuck was 222 mm Hg (range, 146–319 mm Hg); four wraps with a tuck averaged 288 mm Hg (range, 202–405 mm Hg). No significant difference was seen between the standard technique and when the surgeon stood (three wraps and a tuck, p = .26; four wraps and a tuck, p = .33), when cast padding was used (three wraps and a tuck, p = .62; four wraps and a tuck, p = .74), or a 4-inch Esmark bandage (three wraps and a tuck, p >.99; four wraps and a tuck, p = .34). There was a significant decrease in the pressure when a blue towel was used as padding (three wraps and a tuck, p = .05; four wraps and a tuck, p = .04). Pressures obtained by the 10 different volunteers were uniform with little variation (three wraps and a tuck = 222 ± 61 mm Hg; four wraps and a tuck = 288 ± 68 mm Hg). No significant difference was seen between the different types of 6-inch Esmark bandages ( p > .05). The combined complication rate for the 10 surgeons is estimated to be less than 0.1%.

Conclusion:

The practice of using a 6-inch Esmark bandage as a tourniquet at the ankle level for forefoot procedures is a safe and reliable method. Although pressures between surgeons vary, the average pressure is in an effective yet safe range. Recommendations for the application of the Esmark bandage as a tourniquet are given.
Immunohistochemistry of the Enthesis Organ of the Human Achilles Tendon
Authors: de Palma Luigi , Marinelli Mario , Memè Luca , Pavan Matteo
Published: January 2017

Background:

The insertional region of the Achilles tendon includes: the fibrocartilage of the enthesis at the tendon-bone junction, the sesamoid fibrocartilage in the deep surface of the tendon, and the periosteal fibrocartilage covering the superior tuberosity of the calcaneus. The mechanism by which compressive stress and low oxygen concentration modulate the phenotypical expression of cartilaginous cells in mesenchymal tissue is still unknown. Tenascin-C isoform, with its anti-adhesive properties, has been hypothesized to have a role in cellular adaptation to compression. The purpose of this study was to define the immunohistochemical localization of tenascin-C in the enthesis organ of the Achilles insertion in man.

Methods:

Five specimens of Achilles tendon and its insertion were obtained from adult patients during below-knee amputation surgery. To determine the histochemistry, for light microscopy, specimens were stained with hematoxylin-eosin, safranin-O, Verhoeff, alcian blue methods. For immunohistochemistry, the following antibodies were used: anti-S-100 protein; anti-chondroitin sulfate; anti-types I and II collagen, anti-type IV collagen, anti-type X collagen, and anti-tenascin-C.

Results:

The enthesis, sesamoid, and periosteal fibrocartilages have been defined by a separate region of immunohistochemical labeling for S-100 antibody and type II collagen and chondroitin-sulfate. The sesamoid and periosteal fibrocartilages stained for tenascin-C, which in cartilaginous areas was closely associated with rounded cells in the extracellular matrix.

Conclusion:

By showing a relationship between chondrocyte-like cells and immunolabeling for tenascin-C in periosteal and sesamoid fibrocartilage, the present data suggest a role in the dynamic equilibrium in the formation of fibrocartilaginous foci in tendon areas exposed to compressive stress.

Clinical relevance:

The data support the surgical practice of the resection of the diseased tendinous portion in case of chronic Achilles tendinitis. The decompression removed the enthesis organ that in an inflammatory environment could be altered and would not contribute to the distribution of the tensive load. After the decompression, it was hypothesized that in tendon areas exposed to compressive stress there was restoration of the fibrocartilaginous foci that constitute the enthesis organ.
Glomus Tumor of the Hallux: Case Presentation and Review of the Literature
Authors: Pater Timothy J. , Marks Richard M.
Published: January 2017

Glomus tumor is an unusual benign neoplasm of the extremity. Although it is most commonly found as a painful subungual lesion in the digits of the hand, the diagnosis has been reported at various sites throughout the lower extremity. Presented is a glomus tumor of the hallux with correlative imaging and surgical findings, including a review of the literature.
Plantar Pressure and Load in Cadaver Feet After a Weil or Chevron Osteotomy
Authors: Snyder John , Owen John , Wayne Jennifer , Adelaar Robert
Published: January 2017

Background: Since metatarsal osteotomy was first used to treat metatarsalgia in the early twentieth century, many techniques have been described to accomplish the basic aim of reduction of load transmission through the operated metatarsal and reduction of localized high pressure on the plantar surface of the metatarsal. Our study examined two popular distal metatarsal neck osteotomies used for the relief of central metatarsalgia and the biomechanical changes that result from their use in a cadaver forefoot model. Methods: After applying 445N (100 lbs) of axially directed force, we measured plantar pressure using the TekScan HR Mat™ (TekScan, Inc., South Boston, MA) in twelve paired, thawed, fresh-frozen intact cadaver legs, then after either a Weil or chevron osteotomy of the second metatarsal and finally after the addition of the same osteotomy of the third metatarsal. Results: Load in the forefoot was not significantly affected by the Weil osteotomy. A significant increase in load was produced in the first metatarsal region, and significant decreases in load were produced beneath the operated metatarsal heads after the chevron osteotomy. Average pressure in the contact area of the forefoot showed similar trends; however, load and pressure changes occurred independently, owing to the changes in contact area produced by the osteotomies. No significant changes were observed in the nonoperated metatarsal regions. Conclusions: In this model, the chevron osteotomy more effectively reduced load and plantar pressure in the operated metatarsal regions; however, increases in load and pressure were observed in the first metatarsal region. The increase in pressure without a change in load in region 3 (third metatarsal) after a Weil osteotomy of the third metatarsal was attributed to the creation of a plantar prominence. This study did not show a reduction in load transmission as a result of the Weil osteotomy, which contradicts the proposed mechanism of clinical benefit. An intact first ray likely prevents transfer of load or pressure to adjacent lesser metatarsals with chevron osteotomy.
Prospective CT Scan Evaluation of Hindfoot Nonunions Treated with Revision Surgery and Low-Intensity Ultrasound Stimulation
Authors: Jones Caroll P. , Coughlin Michael J. , Shurnas Paul S.
Published: January 2017

Background: The reported fusion rates of revision arthrodesis for hindfoot nonunions are relatively low compared to primary procedures. Exogenous ultrasound has been shown to accelerate the healing process of acute fractures and fracture nonunions but has not been previously evaluated for the treatment of hindfoot pseudarthroses. The purpose of this study was to evaluate the clinical and radiographic outcomes of revision hindfoot arthrodeses treated with postoperative low-intensity ultrasound. Methods: Thirteen patients (13 feet) with established hindfoot nonunions were treated with revision arthrodesis and adjunctive postoperative low-intensity ultrasound. The patients were prospectively evaluated with hindfoot American Orthopaedic Foot Ankle Society (AOFAS) and pain visual analog scores, subjective satisfaction surveys, and serial radiographs. All patients underwent postoperative CT to evaluate the fusion mass, which was quantitated using a novel system. The mean follow-up from revision surgery was 16.3 (range 12 to 25) months. The 10 subtalar and three triple revision arthrodeses comprised a total of 19 joints. Results: Based on the CT scans and the grading system devised, there was one nonunion (isolated subtalar revision), five partial unions, and 13 complete unions. The 10 isolated subtalar revision arthrodeses demonstrated a mean fusion ratio of 65.1% (range 14% to 100%). Excluding the one nonunion, the average fusion ratio for the subtalar revisions was 77.3%. The mean hindfoot AOFAS score improved significantly ( p < 0.005) from 45.3 (range 18 to 65) preoperatively to 72.3 (range 47 to 92) postoperatively out of 94 possible points. There was a significant ( p < 0.005) decrease in the pain visual analog scale (VAS) from a preoperative value of 7.7 (range 4 to 10) to a postoperative value of 2.5 (range 0 to 6). There was a weak inverse correlation between the fusion percentages and the pain VAS scores ( r = −0.26) and a weak correlation ( r = 0.29) between the fusion percentages and the final AOFAS scores. Conclusions: When used to evaluate hindfoot arthrodeses, plain radiographs may be misleading. CT provides a more accurate assessment of the healing, and we have devised a new system to quantitate the fusion mass. Postoperative low-intensity ultrasound is easy to apply and administer, with no identifiable risks or contraindications. Although this modality may facilitate the fusion process, we cannot definitely conclude the specific relative value of low-intensity ultrasound because this was not a controlled series.
Quality of Life of Adults with Unhealed and Healed Diabetic Foot Ulcers
Authors: Goodridge Donna , Trepman Elly , Sloan Jeff , Guse Lorna , Strain Laurel A. , McIntyre John , Embil John M.
Published: January 2017

Background: Diabetic foot ulcers cause major treatment morbidity and cost of care. This study evaluated quality of life in patients with unhealed and healed diabetic foot ulcers. Methods: This was a cross-sectional study of adult diabetic patients (age 45 years or older) treated in a tertiary care foot clinic who had foot ulcers within the preceding 2 years. Patients with other diabetic complications or conditions that would potentially affect quality of life were excluded. Two patient groups of comparable age, gender distribution, and duration of diabetes were studied: 57 patients with unhealed ulcers (minimum duration, 6 months) and 47 patients with healed ulcers. Telephone interviews were done using the Short Form 12 (SF-12) (both groups) and a Cardiff Wound Impact Scale (CWIS) (unhealed ulcer group). Results: The mean SF-12 Physical Component Summary score was significantly lower for the group with unhealed ulcers (unhealed, 35 ± 8 points; healed, 39 ± 10 points; p = 0.04); these scores for both groups were significantly lower than published Short Form 36 (SF-36) scores for general, diabetic, and hypertensive populations. The mean SF-12 Mental Component Summary scores of the groups did not differ significantly from each other or from published population scores. CWIS responses showed that patients with unhealed ulcers were frustrated with healing and had anxiety about the wounds, resulting in marked negative impact on the average Well-being Component Score (35 ± 6 points). Conclusions: Individuals with diabetic foot ulcers experience profound compromise of physical quality of life, which is worse in those with unhealed ulcers.
First Metatarsophalangeal Joint Arthrodesis as a Treatment for Failed Hallux Valgus Surgery
Authors: Grimes Jerry Speight , Coughlin Michael J.
Published: January 2017

Background:

The results of first metatarsophalangeal (MTP) joint arthrodesis as a specific treatment for failed hallux valgus correction has not been previously reported. We evaluated the results of first metatarsophalangeal (MTP) joint arthrodesis as a treatment for failed hallux valgus surgery.

Methods:

The records of the senior author (MJC) were reviewed to identify patients treated for symptomatic failed hallux valgus procedures with arthrodesis of the first metatarsophalangeal joint over a 20-year period. Twenty-nine patients (33 feet) were available for followup examination. The patients completed a visual analog pain score, the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale, and a patient satisfaction scale at the final followup. Radiographs were obtained of both feet.

Results:

The average followup was 8 (1 to 22) years. The average pain score improved from 7 to 3 points. The mean AOFAS score was 73 points at followup. Patient satisfaction was excellent for 13 feet (39%), good in 11 (33%), fair in eight (24%), and poor in one (3%). The mean hallux valgus angle was 16 degrees, with an intermetatarsal angle of 8 degrees. There were three asymptomatic and one symptomatic nonunions. Twenty-two feet (67%) had corrective procedures performed on the lesser toes at the time of the first MTP joint arthrodesis.

Conclusions:

First MTP joint arthrodesis is a reliable option for revision after failure of surgical treatment of hallux valgus. This procedure can be used to treat a number of failure modes following initial hallux valgus surgery including recurrence, hallux varus, cock-up deformity, degenerative arthritis of the MTP joint, and associated transfer lesions beneath the lesser metatarsals. First MTP joint arthrodesis can be used after failed proximal and distal osteotomies, arthrodesis of the metatarsocuneiform joint, McBride procedure, exostectomy, and resection arthroplasty. Revision procedures have poorer clinical outcomes than successful primary hallux valgus procedures.
Bone Graft Harvest from the Proximal Tibia in Foot and Ankle Arthrodesis Surgery
Authors: Whitehouse Michael R. , Lankester Ben J.A. , Winson Ian G. , Hepple Stephen
Published: January 2017

Background:

Fresh autogenous cancellous bone graft is the material of choice in reconstruction and fusion procedures in foot and ankle surgery. There are many potential donor sites for graft harvest, all with recognized minor and major complications. The proximal tibia is one such potential site and is particularly suited to foot and ankle surgery, because it is within the operative field and under tourniquet control.

Methods:

A retrospective review was performed of 148 procedures using bone graft from the proximal tibia performed over a period of 5 years. Minimum followup was 3 months. Data were obtained from operative notes and patient interviews to establish pain, morbidity, and overall satisfaction.

Results:

Most patients had no pain (78%) or very mild pain (20%) at the site of graft harvest immediately after surgery. At followup, 96% had no pain and 4% had very mild pain with certain activities such as kneeling. There were no major complications. Four patients (2.7%) had persisting areas of paresthesia at followup, but none were troubled by it. One patient had a superficial wound infection that resolved. The period of nonweightbearing, usually 2 to 3 weeks, was dictated by the primary procedure. There were no complications related to early weightbearing

Conclusions:

The proximal tibia is a suitable and safe site for bone graft harvest for foot and ankle surgery. There is no need for additional restrictions in weightbearing after this procedure.
Responsiveness of the Foot Function Index, AOFAS Clinical Rating Systems, and SF-36 after Foot and Ankle Surgery
Authors: SooHoo Nelson F. , Vyas Raj , Samini David
Published: January 2017

Background:

There is uncertainty regarding which outcomes tools should be used to report the results of treatment for patients with foot and ankle disorders. This study compared the responsiveness of the Foot Function Index (FFI), American Orthopaedic Foot and Ankle Society (AOFAS) Clinical Rating Systems, and Medical Outcomes Study Short Form-36 (SF-36) in patients with foot and ankle surgery.

Methods:

Twenty-five patients were recruited at a tertiary referral foot and ankle practice. The mean age of the patient sample was 40 years (range 21 to 69) and 19 were women (76%). Thirteen patients (52%) had conditions affecting the ankle, hindfoot, or midfoot, while 12 patients (48%) had conditions affecting the forefoot. Patients completed packets preoperatively and 6-months postoperatively which included informed consent forms, the FFI, the AOFAS, and the SF-36 questionnaires. Standardized response means (SRM) and effect sizes (ES) were used as the measures of responsiveness and were calculated for the AOFAS scores, the three domains of the FFI, the eight SF-36 sub-scales, and the two SF-36 summary scales.

Results:

The standardized response mean (SRM) for the AOFAS scores was 1.10 and the effect size (ES) was 1.12. The SRM for the three FFI domains ranged from −0.39 to −0.83, while the ES ranged from −0.55 to −0.86. The SRM for the SF−36 ranged from 0.09 to 0.72 (ES ranged from 0.09 to 0.77) with the highest values occurring with the Bodily Pain sub-scale (SRM 0.72, ES 0.77) and Physical Component Summary scale (SRM 0.76, ES 0.68).

Conclusions:

This study demonstrated increased responsiveness of foot and ankle specific outcomes tools compared to the SF-36. However, the Bodily Pain sub-scale and Physical Component Summary scale of the SF-36 had levels of responsiveness approaching those of the FFI and AOFAS Systems after foot and ankle surgery. This suggests that the SF-36 may be used alone to monitor the outcomes in these patients without sacrificing adequate sensitivity to clinical change.
Ankle Ligament Tensile Forces at the End Points of Passive Circumferential Rotating Motion of the Ankle and Subtalar Joint Complex
Authors: Ozeki Satoru , Kitaoka Harold , Uchiyama Eiichi , Luo Zong-Ping , Kaufman Kenton , An Kai-Nan
Published: January 2017

Background:

Ankle ligament injuries and instability are commonly observed. Knowledge of the relationship between the foot position and tensile forces of the ankle ligaments could be useful for treatment of ankle ligament disorders. The aim of this study was to measure the tensile forces of the ankle ligaments at the end points of passive circumferential rotating motion of the ankle and subtalar joint complex in various foot positions.

Methods:

Ligament tensile forces of the anterior talofibular (ATF), calcaneofibular (CF), posterior talofibular (PTF), and tibiocalcaneal (TC) ligaments were measured simultaneously in eight cadaver specimens, with a force probe in each ligament in a custom-made ankle ligament testing device. Weights of 0.5 kg and 1 kg were applied to the foot through a loading arm to provide axial compression and a bending moment to the foot and ankle. The position of the loading arm was changed circumferentially in 10-degree increments.

Results:

Maximal tensile force in the ATF ligament was observed in supination with plantarflexion (108 ± 62.8 N at 0.5 kg and 130 ± 39.1 N at 1 kg). The maximal tensile force in the CF ligament was observed in pronation with plantarflexion (68 ± 48.6 N at 0.5 kg and 135 ± 92.9 N at 1 kg). The maximal tensile force in the PTF ligament was observed in dorsiflexion (131 ± 80.1 N at 0.5 kg and 109 ± 36.3 N at 1 kg). The maximal tensile force of the TC ligament was observed in pronation with plantarflexion (49.0 ± 80.1 N at 0.5 kg and 67.4 ± 69.6 N at 1 kg). Relatively high magnitudes of tensile force were observed in the ankle ligaments, and the peak forces were related to the anatomic position of individual ligaments.

Conclusions:

The ATF ligament has an important role in the supination position in plantarflexion, CF and TC ligaments also are important for pronation in plantarflexion, and the PTF is an important stabilizer in dorsiflexion. This study provides baseline information for further research related to ligament instability and reconstruction operations.
Kinematic Analysis of the Agility Total Ankle during Gait
Authors: Conti Stephen , Lalonde Karl-Andre , Martin RobRoy
Published: January 2017

Background:

With the increasing use of total ankle prostheses, kinematic analysis of these implants is important to our understanding of their specific biomechanics. Fluoroscopic analysis as used in this study has distinct advantages over previous experimental approaches and allows kinematic determination in vivo of dynamic weightbearing motions.

Methods:

Ten patients with unilateral Agility (Depuy, A Johnson & Johnson Company, Warsaw, IN) total ankle replacements were tested using video fluoroscopy in weightbearing dynamic gait conditions. Their prosthetic ankle and normal ankle kinematics were then analyzed by computer with two-dimensional and three-dimensional model-fitting techniques.

Results:

All of the total ankle prostheses in this study demonstrated less than 3.5 mm of posterior-to-anterior translation from heel strike to toe-off. In comparison, more variability was seen in posterior-to-anterior motion of the normal contralateral ankles, with three ankles translating more than 6 mm. When inversion and eversion and internal and external rotation of the ankle were measured, wide variations were seen among patients.

Conclusions:

While the relative incongruence theoretically decreases the shear stresses transmitted to the bone-prosthesis interface, it does allow more inversion-eversion and rotational freedom that can lead to edge loading and higher contact stresses. Despite good medium-term results having been published for this prosthesis, polyethylene wear and osteolysis have been observed. Further studies looking at the effect of the inversion and eversion and rotational freedom on polyethylene wear and prosthesis survival will assist in our understanding of the factors leading to successful outcome of total ankle prostheses.
Geometric Analysis of the Weil Osteotomy
Authors: Grimes Jerry , Coughlin Michael
Published: January 2017

Background:

The Weil osteotomy has been reported to be a clinically effective treatment of metatarsalgia and intractable plantar keratosis. The plantar inclination of the metatarsal influences the effect of the osteotomy but has never been studied in detail.

Methods:

This study examined five fresh or fresh-frozen cadaver specimens. The data obtained from the specimens was used to model the geometry of the Weil osteotomy. The effect of thick saw blades on the Weil osteotomy was determined.

Results:

The inclination of the second metatarsal averaged 24.6 (range 19 to 31) degrees. The displacement of the capital fragment in the plantar direction was dependent on the angle of the osteotomy and the inclination of the metatarsal. A 5-mm proximal displacement along a 25-degree osteotomy displaced the capital fragment in a plantar direction if the inclination of the metatarsal was 19 degrees and displaced it dorsally if the inclination was 25 degrees or more.

Conclusions:

The results of this study showed that a thick saw blade could offset a portion of the plantar displacement of the capital segment that can occur with the Weil osteotomy. A 1-mm thick saw blade is recommended for most osteotomies, and a 2-mm thick saw blade is recommended for shortening of more than 5 mm or with plantar inclination of the lesser metatarsal of less than 19 degrees. A thicker saw blade should be considered for the treatment of plantar keratosis.
Relationship Between Tightness of the Posterior Muscles of the Lower Limb and Plantar Fasciitis
Authors: Bolívar Yolanda Aranda , Munuera Pedro V. , Padillo Juan Polo
Published: January 2017

Background:

The aim of this study was to determine whether tightness of the posterior muscles of the lower extremity was associated with plantar fasciitis.

Methods:

A total of 100 lower limbs of 100 subjects, 50 with plantar fasciitis and 50 matching controls were recruited. Hamstring and calf muscles were evaluated through the straight leg elevation test, popliteal angle test, and ankle dorsiflexion (knee extended and with the knee flexed). All variables were compared between the 2 groups. In addition, ROC curves, sensitivity, and specificity of the muscle contraction tests were also calculated to determine their potential predictive powers.

Results:

Differences between the 2 groups for the tests used to assess muscular shortening were significant ( P < .001) in all cases. The straight leg elevation test and ankle dorsiflexion with the knee extended presented respective sensitivities of 94% and 100% and specificities of 82% and 96% as diagnostic tests for the participants in this study.

Conclusion:

Tightness of the posterior muscles of the lower limb was present in the plantar fasciitis patients, but not in the unaffected participants.

Clinical Relevance:

The results of this study suggest that therapists who are going to employ a stretching protocol for treatment of plantar fasciitis should look for both hamstring as well as triceps surae tightness. Stretching exercise programs could be recommended for treatment of plantar fasciitis, focusing on stretching the triceps surae and hamstrings, apart from an adequate tissue-specific plantar fascia-stretching protocol.

Level of Evidence:

Level III, case control study.
Total and Distributed Plantar Loading in Subjects With Stage II Tibialis Posterior Tendon Dysfunction During Terminal Stance
Authors: Neville Christopher , Flemister A. Samuel , Houck Jeff
Published: January 2017

Background:

In subjects with stage II tibialis posterior tendon dysfunction (TPTD), the function of the tibialis posterior muscle is altered and may be associated with a change in total and distributed loading.

Methods:

Thirty subjects with a diagnosis of stage II TPTD and 15 matched control subjects volunteered to participate in a study to examine the total and distributed plantar loading under the foot during the terminal stance phase of gait. Plantar loading, measured as the subject walked barefoot, was assessed using instrumented flexible insoles. A secondary analysis was done to explore the contribution of flatfoot kinematics to plantar loading patterns.

Results:

Overall, there was reduced total plantar loading in subjects with stage II TPTD compared with controls. Accounting for differences in total loading, the presence of clinically measured weakness in subjects with TPTD was associated with reduced lateral forefoot loading. Medial longitudinal arch height was significantly correlated with loading patterns but explained only 21% of the variance in observed loading patterns.

Conclusion:

Subjects with TPTD who are strong exhibited loading patterns similar to controls. Changes in total and distributed loading during terminal stance suggest there are altered ankle mechanics at push-off during the functional task of gait.

Clinical Relevance:

Strength, in the presence of TPTD, may be important to stabilize the midfoot during gait and might be important in rehabilitation protocols.
Total Ankle Arthroplasty With Combined Calcaneal and Metatarsal Osteotomies for Treatment of Ankle Osteoarthritis With Accompanying Cavovarus Deformities
Authors: Jung Hong-Geun , Jeon Seung-Hyub , Kim Tae-Hoon , Park Jong-Tae
Published: January 2017

Background:

Our study evaluated the short-term clinical and radiographic results of total ankle arthroplasty (TAA) with combined bony reconstructions for treatment of end-stage ankle osteoarthritis with accompanying cavovarus/hindfoot varus deformities.

Methods:

This study included 8 patients (10 ankles) with ankle osteoarthritis (OA) who were treated by TAA with combined calcaneal and metatarsal osteotomies between September 2004 and June 2010 and were followed an average of 17.9 months (12-43 months). Visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographic measurements, and patient satisfaction were evaluated.

Results:

The average patient age was 66.2 years (range, 55-76 years). Eighteen bony reconstruction procedures such as lateral sliding calcaneal osteotomy (n = 9) and first metatarsal dorsiflexion osteotomy (n = 4) were performed in addition to TAA. VAS pain score improved from an average of 8.8 (range, 6-10) preoperatively to an average of 2.4 (range, 0-7) ( P < .05), and the AOFAS score improved from 36.9 (range, 14-71) preoperatively to 89.3 (range, 68-100) ( P < .05). Ninety percent of the patients were satisfied with the results. Radiographically, the tibiocalcaneal angle (TCA) improved from a preoperative average of 19.0 degrees (range, 13-23 degrees) to 0.2 degrees (range, –5.4 to 2.8 degrees), the tibial axis–talar dome angle (TA-TDA) improved from a preoperative average of 15.6 degrees (range, 11.1-18.0 degrees) to 3.3 degrees (range, 1.7-5.6 degrees), and the talar dome–ground surface angle (TD-GSA) improved from a preoperative average of 21.2 degrees (range, 15.4-27.5 degrees) to 5.1 degrees (range, 1.8-10.2 degrees) ( P < .05).

Conclusion:

We found that it was occasionally necessary to perform combined calcaneal and metatarsal osteotomies with TAA in order to successfully treat ankle OA with an accompanying cavovarus/varus deformity. The TD-GSA and TCA were also found to be important radiographic parameters in assessing varus ankles.

Level of Evidence:

IV, retrospective case series.
A Comparison of Botulinum Toxin A and Intralesional Steroids for the Treatment of Plantar Fasciitis
Authors: Elizondo-Rodriguez Jorge , Araujo-Lopez Yariel , Moreno-Gonzalez J. Alberto , Cardenas-Estrada Eloy , Mendoza-Lemus Oscar , Acosta-Olivo Carlos
Published: January 2017

Background:

The objective of this study was to compare intramuscularly applied botulinum toxin A (BTX-A) in the gastroc-soleus complex with intralesional steroids for the treatment of plantar fasciitis.

Methods:

The patients were randomly divided into 2 groups according to the treatment received. The patients were evaluated over 6 months. The evaluation scores included the Visual Analog Scale (VAS), Maryland Foot and Ankle, Foot and Ankle Disability Index (FADI), and American Orthopaedic Foot and Ankle Society (AOFAS) score. Moreover, patients were instructed to perform plantar fascia stretching exercises over the course of the study. The final number of patients was 36, of whom 19 received BTX-A (10 men and 9 women) and 17 (6 men and 11 women) received steroids.

Results:

When compared to patients who received steroids, the patients who received BTX-A exhibited more rapid and sustained improvement over the duration of the study.

Conclusion:

A combination of BTX-A and plantar fascia stretching exercises yielded better results for the treatment of plantar fasciitis than intralesional steroids.

Level of Evidence:

Level I, therapeutic studies.
Solution-oriented Questions: An Analysis of a Key Intervention in Solution-focused Therapy
Authors: Hillyer Dana
Published: January 2017

Psychiatric nurses must look for new approaches to behavior change as managed care environments influence the nature of theirpractice. Solution-focused therapy is one model of brief therapy that can offer interventions congruent with nursing's core values. The focus of this article is the analysis of one key solution-focused therapy intervention, solution-oriented questions. Three of the most frequently used questions, the miracle, exception, and coping questions, are described in detail Concepts underlying the use of these questions are explored, and a case example is presented.
The Role of Public Health Nurses in Service Delivery to Youth with Mental Disabilities
Authors: Kennedy Carol W. , Polivka Barbara J. , Chaudry Rosemary V.
Published: January 2017

BACKGROUND: The mental health needs of children and adolescents are not being adequately addressed.

OBJECTIVES: To describe the roles of public health nurses in the care of children and adolescents with mental disabilities and to explore incentives and barriers to expansion of the role in the care of this population.

METHODS: Directors of nursing of public health agencies and executive directors of mental health agencies in Ohio responded to a mailed survey.

RESULTS: The majority of respondents reported that public health nurses currently work with youth with mental disabilities, primarily in the roles of referral and providing physical health care. Both groups of directors saw potential for increasing roles-provided public health nurses received education and consultation. Both groups reported that barriers to expanding public health nurses' roles were the organization and funding of mental and public health systems.

CONCLUSION: Although better utilization of public health nurses could improve children's health care and make more efficient use of scarce specialty mental health resources, financial and organizational barriers present significant challenges to collaboration.
Managing Transitions and Placement of Caring for a Relative With Alzheimer’s Disease
Authors: Liken Michelle A.
Published: January 2017

Alzheimer’s disease (AD) is hallmarked by progressive cognitive impairment. As memory loss worsens and functional abilities decline, family caregivers may need additional communitybased support. In later stages of the disease, families must often consider institutional placement. Home care nurses are frequently put in the difficult position of approaching family caregivers about the need for supportive services and placement in a care facility. A better understanding of phase-based interventions will help home care nurses more effectively assist family caregivers of a relative with AD manage transitions and possible facility placement.
Bridging Time and Distance: Continuing Education Needs for Rural Health Care Providers
Authors: Molinari Deana
Published: January 2017

A gulf exists between urban educators and rural home health providers resulting in a lack of available training and education in rural America. This article details the purpose behind the federal government’s AHEC legislation responsible for the development of Area Health Education Centers in rural pockets of America. Home health agencies in rural America will find this article useful as it will undoubtedly open up existent opportunities for health care education.
Cutaneous Angiosarcoma of the Scalp Masquerading as a Squamous Cell Carcinoma: Case Report and Literature Review
Authors: Dhanasekar Padmanabhan , Karthikeyan Vilvapathy Senguttuvan , Rajkumar Nagarajan , Sistla Sarath Chandra , Ali S. Manwar , Basu Debdatta , Malathi Munisamy
Published: January 2017

Background:

Cutaneous angiosarcoma is a rare tumor of the elderly male, most commonly affecting the head and neck region. It is difficult to differentiate this tumor from hemangiomas, hemangioblastomas, Kaposi sarcoma, squamous cell carcinoma and anaplastic melanomas.

Methods:

Case report and review of pertinent English medical literature.

Case summary:

We report a case of a 60-year-old male presenting with multiple nodules over the scalp where a preoperative histopathologic diagnosis of squamous cell carcinoma was made by wedge biopsy from the tumor. Postoperative histopathology and immuno histochemistry of the wide local excision specimen proved the tumor to be cutaneous angiosarcoma and the patient completed adjuvant radiotherapy. He is now on regular follow-up for 1 year without recurrence.

Conclusions:

Cutaneous angiosarcoma must be kept in mind in view of its rarity especially in extensive involvement of the scalp by malignancy. The primary treatment is wide local excision with adequate skin cover and adjuvant chemotherapy and radiotherapy in positive margins and lymph node metastasis.
Actinic Superficial Folliculitis in a 29-Year-Old Man
Authors: Laberge Lauren , Glassman Steven , Kanigsberg Nordau
Published: January 2017

Background:

Since actinic superficial follicultis was first described in 1985, only three further cases have been published. The characteristics of this disease are monomorphous, superficial, follicular pustules that appear on the back, upper chest, and shoulders annually after the first sun exposure of the year. The lesions resolve on their own within 10 days. Recurrence occurs under similar conditions after a latency period of at least 4 weeks.

Methods:

A 29-year-old man presented to our clinic with a 5-year history of an intermittent follicular rash. These eruptions occurred on his back and chest only when he was exposed to the sun, with his shirt off. They developed 24 to 36 hours after the first sun exposure of the year and resolved spontaneously after 5 to 7 days. Photographs of the affected area were impressive, with follicular pustules grouped along his left flank.

Conclusion:

According to our literature search, this is the sixth reported case of actinic superficial folliculitis. This is the first case in which provocative phototesting was done. We review the clinical and pathologic attributes of actinic superficial folliculitis.
Efficacy of Topical Calcineurin Inhibitors in Lichen Planus
Authors: Samycia Michael , Lin Andrew N.
Published: January 2017

Background:

Topical calcineurin inhibitors have been studied in many skin disorders, including lichen planus.

Objective:

To evaluate published reports of the use of topical calcineurin inhibitors in lichen planus.

Methods:

We searched PubMed, Ovid/Cochrane, and Embase using the keywords “tacrolimus,” “pimecrolimus,” “topical calcineurin inhibitors,” and “lichen planus.”

Results:

We examined 5 double-blind studies, 1 investigator-blinded study, 10 open prospective studies, 6 retrospective studies, and 28 case reports evaluating tacrolimus or pimecrolimus for oral, vulvovaginal, and cutaneous lichen planus.

Conclusions:

Strong evidence (double-blind and open studies) supports the use of topical tacrolimus ointment in oral lichen planus, with efficacy at least equal to topical clobetasol propionate 0.05% ointment. Treatment of oral lichen planus with topical tacrolimus ointment can result in demonstrable blood tacrolimus levels, but without clinically significant adverse events. Strong evidence (double-blind and open studies) supports the use of topical pimecrolimus 1% cream in oral lichen planus, with efficacy equal to that of topical triamcinolone acetonide 0.1% paste. For vulvovaginal lichen planus, pimecrolimus was superior to placebo in one double-blind study, and tacrolimus was effective in open studies. Only case reports support the efficacy of topical calcineurin inhibitors in cutaneous lichen planus.
Vitiligo and Associated Autoimmune Disease: Retrospective Review of 300 Patients
Authors: Sawicki Jakub , Siddha Sanjay , Rosen Cheryl
Published: January 2017

Background:

Vitiligo, the most common cutaneous depigmentation disorder, has reported associations with other autoimmune diseases. However, literature on the strengths of the associations is conflicting, and no data on the subject exist from a Canadian population.

Objective:

To determine autoimmune disease associations with vitiligo and which, if any, screening bloodwork is appropriate in vitiligo patients.

Methods:

A retrospective review of vitiligo patients admitted to the Toronto Western Hospital phototherapy unit was conducted from January 1, 2000, to August 30, 2009. Data regarding patient characteristics, vitiligo clinical features (family history, age at onset, type, extent), associated diseases in the patient and family, and admission bloodwork (hemoglobin, vitamin B12, thyroid-stimulating hormone [TSH], antinuclear antibody) were recorded and compared, using the Fisher exact test where applicable.

Results:

A total of 300 patient charts were reviewed (average age 41.5 ± 15.5 years; 47% male, 53% female). Hypothyroidism was present in 12.0% and pernicious anemia in 1.3% of patients—significant increases over the population prevalence. No other differences in prevalence were seen compared to the general population. TSH was increased in 3.7% of patients without a history of hypothyroidism. Hemoglobin and vitamin B12 were decreased in 0.3% of vitiligo patients without a history of pernicious anemia.

Conclusion:

We found a significantly higher prevalence of hypothyroidism and pernicious anemia in vitiligo patients.
The British Quasi-Market in Health Care: A Balance Sheet of the Evidence
Authors: Mays Nicholas , Mulligan Jo-Ann , Goodwin Nick
Published: January 2017

Objectives:

To summarise the findings from a comprehensive review of research on the effects of the three main elements of the quasi-market reforms of the UK National Health Service (NHS) introduced in 1991/92: General practices becoming fundholders by volunteering to purchase elective care for their patients; Health authorities becoming purchasers of emergency, unplanned and elective services, together with a range of alternatives to fundholding operating under their auspices; The conversion of providers of hospital and community health services to NHS trusts separate from their local health authorities.

Methods:

Published and unpublished studies which included any data on the impact of the three main planks of the quasi-market changes, produced between 1991 and late 1998, were identified using a combination of electronic databases, library catalogues at the King's Fund, London, bibliographies, reference lists of individual studies, a survey of NHS directors of public health and consultations with subject area experts. Each main element of the quasi-market was assessed in relation to its impact on: efficiency (primarily productivity); equity; quality; choice and responsiveness; and accountability.

Results:

There was relatively little measurable change that could be related unequivocally to the core mechanisms of the quasi-market.

Conclusions:

The incentives were generally too weak and the constraints too strong to generate the consequences predicted by either proponents or critics of the quasi-market. On the other hand, the way in which the NHS operates was changed irrevocably by the reforms.
Were Practice Nurses Distributed Equitably across England and Wales, 1988–1995?
Authors: Hirst Michael , Lunt Neil , Atkin Karl
Published: January 2017

Objective:

To examine whether variations in the number of whole-time equivalent (wte) practice nurses across family health services authorities (FHSAs) can be explained by population characteristics and the organisation of general practice.

Methods:

Analysis of nine health and 16 social indicators for 98 FHSAs identified three factors underlying health care needs. These factors and seven practice characteristics were analysed by stepwise regression. A formula for allocating health care resources and a logistic growth model were used to estimate the ‘expected’ number of nurses.

Results:

Past trends indicate an eventual (wte) practice nurse workforce of 12 500 (95% CI ± 3500). Although geographical disparities have declined, there was a two-fold variation in nurse numbers across FHSAs. Around 2000 (wte) posts would be required to bring under-provided areas, mostly in northern England and metropolitan districts, up to the highest level of provision. There were more nurses in areas with higher proportions of elderly people but fewer where deprivation, morbidity and mortality levels were above average. The number of general practitioners was the most significant predictor of practice nurse provision ( t = 5.0); population needs and practice characteristics explained 24% of the variation.

Conclusions:

The distribution of practice nurses scarcely corresponded with health care needs at the FHSA level. Despite a lack of evidence that nurses are a cost-effective addition to the primary health care team, their role and numbers will be driven by the extent to which they take on responsibilities performed by doctors. Achieving equity in practice nurse provision probably requires explicit consideration in a formula for allocating primary care funds, backed by audit of the services they provide.
Hope and Hyperbole: The Rhetoric and Reality of Managerial Reform in Health Care
Authors: Marmor Theodore R.
Published: January 2017

The scope of this essay is broad — the dangers that much conventional management commentary represents for health care institutions and those who work in them. It emphasizes two themes in the hype and hyperbole of management talk about health care. The first is the character of the language used to describe health care arrangements — the ‘rhetoric of medical managerialism’ – a rhetoric that powerfully and misleadingly combines the jargon of modem management schools with the marketing hype of advertising. Second, it includes some observations about what this cautionary tale might mean for the daily work of those in health care.
Informed Consent: Ideal or Reality?
Authors: Alderson Priscilla
Published: January 2017

Is it ever possible to give informed consent to treatment or research? Are the standards of consent set by ethicists and lawyers too high for ordinary people to reach? Should these standards be abandoned or modified? These questions are discussed in this paper mainly in relation to the extensive literature on consent in medicine, with exa mples about consent to children's treatment and research which raise extra dilemmas. Paradoxical meanings are considered: consent as an informed correct choice or a courageous best guess, and autonomy as isolated, uncompromised freedom or reasonably uncoerced self-realisation. Beyond being informed, consent involves evaluating, making and signifying a decision. It is better understood as a process than an event, in which reasoned understandings can be complemented by emotional insights. Ethical and legal standards of voluntary consent, although partly an unrealistic ideal, provide important guidelines for people who request and give consent to research.
Decision Analysis in the Selection, Design and Application of Clinical and Health Services Research
Authors: Lilford Richard , Royston Geoff
Published: January 2017

Research evidence will never be sufficient to tell us how treatments compare in every group or class of patients. It will always be necessary to particularize from the general to the specific. The ad hoc way this is normally done contrasts with the rigour of the research process. However, extrapolating from the general to the particular can be made equally rigorous by Decision Analytic modelling. Furthermore, research evidence is not enough when decisions turn on multiple objectives, which must be traded off against each other. Research evidence and patients' preferences can be reconciled, again rigorously, by using Decision Analysis to show how probabilities and values interact. In addition, research should be designed around likely clinical impact, and this in turn can be made explicit by Decision Analytic modelling. In particular, sample size calculations should be based on such explicit modelling, rather than current procedures, which seldom seek to defend the size of clinical effects sought.