bluuebunny/crossref_metadata_2025 huggingface dataset:
Hospital Nuclear Pharmacy—A Comparison of Physician and Pharmacist Practice
Authors: Dansereau Raymond N. , Dansereau Richard J.
Published: January 2017

OBJECTIVE:

Nuclear pharmacy is practiced in every hospital with a nuclear medicine clinic. Pharmacists control this practice in fewer than four percent of these institutions. The authors wish to bring to the attention of hospital pharmacists an area of practice in which they can make a significant contribution to the state of pharmacy practice.

METHOD:

The current state of the physician practice of nuclear pharmacy is described and compared with the accepted standards of pharmacy practice.

CONCLUSIONS:

Hospital pharmacists can improve pharmaceutical care administered in nuclear medicine by their participation in nuclear pharmacy practice and by the application of hospital pharmacy practice standards. It is also suggested that nuclear pharmacy should be integrated into the pharmacy curriculum at schools of pharmacy.
Prediction of Glomerular Filtration Rate Using Aminoglycoside Clearance in Critically Ill Medical Patients
Authors: Zarowitz Barbara J. , Robert Sylvie , Peterson Edward L.
Published: January 2017

OBJECTIVE:

The aim of this preliminary investigation was to evaluate the use of aminoglycoside serum concentrations as a surrogate measure of the glomerular filtration rate (GFR) in comparison with other measured and empiric methods against inulin, the criterion standard measure of GFR.

DESIGN:

A consecutive sample of all eligible patients.

SETTING:

An eight-bed medical intensive care unit in a university-affiliated tertiary-care teaching hospital.

PATIENTS:

Ten critically ill medical patients receiving gentamicin or tobramycin for presumed or documented gram-negative bacillary infection were enrolled in the study. The patients were mechanically ventilated and had underlying organ system dysfunction. All ten patients completed the study.

INTERVENTION:

Patients underwent renal functional assessment by measured inulin (Clin) and 24-hour urinary creatinine clearance (Clcr). Aminoglycoside serum concentrations were used to estimate GFR and were compared with the two measured methods and a creatinine clearance calculated with the Cockcroft-Gault method (ClCG). All evaluations were performed the same day.

RESULTS:

Clin averaged 51.6 ± 35.0 mL/min and serum creatinine ranged from 0.3 to 5.4 mg/dL (26.5 to 477.3 μmol/L). Steady-state peak and trough aminoglycoside concentrations were 6.1 ± 1.4 and 1.3 ± 0.9 μg/mL, respectively. There were no statistically significant differences between the various methods, although the aminoglycoside-calculated GFR (Clamg) 95 percent confidence intervals were smaller man Clcr and ClCG compared with Clin. Mean absolute errors were smaller with Clamg than with Clcr and ClCG. Regression results indicated that only Clang and ClCG demonstrated agreement with Clin (lines not different from y=x). However, the Clamg showed closer agreement, with a mean square error almost half that of ClCG (9.6 vs. 18.1).

CONCLUSIONS:

Clamg can be used routinely as an estimate of GFR in critically ill patients, with less error man empiric methods.
Pamidronate
Authors: Kellihan Michael J. , Mangino Paul D.
Published: January 2017

OBJECTIVE:

The primary objective of this article is to introduce readers to the use of a new agent, pamidronate. The article discusses its use in hypercalcemia of malignancy (HCM), osteolytic lesions, and Paget's disease. Pharmacokinetic data and clinical trials are reviewed, as well as adverse effects and dosage guidelines.

DATA SOURCES:

A MEDLINE search was used to identify English-language studies involving pamidronate for the period from 1970 to 1992.

STUDY SELECTION:

As comparative trials were few in number, trials using pamidronate as a single agent were also reviewed.

DATA EXTRACTION:

Sparse pharmacokinetic data were obtained from clinical trials. All clinical trials available at the time of publication that met the following criteria were reviewed: (1) allowed for adequate rehydration prior to drug therapy; (2) reported standardized and corrected serum calcium concentrations; (3) separated data obtained from patients who received pamidronate alone from those who received pamidronate and concurrent chemotherapy.

RESULTS:

Pamidronate has a pharmacologic profile similar to that of etidronate, but pamidronate is more potent and has a longer duration of effect. It has been investigated primarily in the treatment of HCM as well as in the treatment of osteolytic bone metastases and Paget's disease. In hypercalcemia of malignancy it appears to be as effective as established agents with the advantage that a single dose of pamidronate 90 mg iv provides a durable response. In Paget's disease chronic oral administration has also been shown to be effective in relieving bone pain. Adverse reactions with intravenous administration are transient and self-limiting and usually occur with the first dose. The most common adverse effect is a transient and self-limiting fever. Chronic oral administration of doses >600 mg/d is associated with gastrointestinal toxicities.

CONCLUSIONS:

Although more well-designed clinical trials comparing pamidronate with standard therapies and other available agents are necessary, initial results indicate that pamidronate is an effective and promising alternative for use in the treatment of HCM.
Renal Insufficiency Associated with Intramuscular Administration of Ketorolac Tromethamine
Authors: Corelli Robin L. , Gericke Kristin R.
Published: January 2017

OBJECTIVE:

To evaluate reports of renal toxicity associated with intramuscular ketorolac tromethamine. Medical charts were reviewed for all cases of renal toxicity associated with ketorolac therapy.

METHODS:

Patients with possible ketorolac-associated nephrotoxicity were identified through our institution's adverse drug reaction reporting program. Patients were included in this report if: (1) renal insufficiency was temporally related to ketorolac administration; (2) resolution of renal insufficiency occurred after discontinuation of ketorolac; and (3) no other causes of renal insufficiency, including other medications, could be identified.

RESULTS:

Six patients had renal insufficiency secondary to ketorolac administration. The mean age of the patients was 58 years and cardiovascular disease was present in five. Serum creatinine values increased from a mean of 106 ± 26 μmol/L (1.2 ± 0.3 mg/dL) to a mean peak value of 256 ± 195 μmol/L (2.9 ± 2.2 mg/dL). Recovery of renal function was observed after a mean of 2.3 ± 0.5 days.

CONCLUSIONS:

Short-term administration of ketorolac can be associated with reversible oliguric renal insufficiency. Indiscriminate use of ketorolac for pain management in place of narcotic analgesics should be avoided, especially in patients at high risk for toxicity induced by nonsteroidal antiinflammatory drugs.
Felbamate
Authors: Graves Nina M.
Published: January 2017

OBJECTIVE:

To provide an up-to-date review of the current literature on felbamate (FBM) and its use as an antiepileptic medication (AEM).

DATA SOURCES:

All published literature (manuscripts and abstracts) on FBM was reviewed. The initial bibliography (up to September 1992) was provided by the manufacturer (Carter-Wallace Laboratories); subsequent literature was obtained from American Epilepsy Society presentations in December 1992 and manuscripts published up to January 1993.

STUDY SELECTION/DATA EXTRACTION:

All pertinent literature was reviewed. Information from the publications was abstracted and organized by the author.

DATA SYNTHESIS:

FBM is effective in complex partial seizures either as monotherapy or as an adjunct in patients receiving other AEMs. In addition, it has shown efficacy in some seizures associated with the Lennox-Gastaut syndrome. Adverse effects appear to be mild. When FBM is given as monotherapy, the primary adverse effects are insomnia and weight loss. Patients receiving multiple AEMs may have increased adverse effects.

CONCLUSIONS:

FBM appears to be an effective new AEM. Additional studies as to its role in newly diagnosed and pregnant patients are needed. Pharmacokinetic studies in children, patients with renal failure, and patients on nonepilepsy drugs also are needed.
New Macrolide Antibiotics: Usefulness in Infections Caused by Mycobacteria other Than Mycobacterium Tuberculosis
Authors: Rapp Robert P. , McCraney Scott A. , Goodman Norman L. , Shaddick David J.
Published: January 2017

OBJECTIVE:

To compare the pharmacology, in vitro activity, and clinical use of the new macrolide antibiotics, azithromycin and clarithromycin, in the treatment of infections caused by mycobacteria other than Mycobacterium tuberculosis.

DATA IDENTIFICATION:

An English-language literature search using MEDLINE (1987–1994), Index Medicus (1987–1994), Program and abstracts of the 31st (1991) and 32nd (1992) Interscience Conference on Antimicrobial Agents and Chemotherapy, and bibliographic reviews of related textbooks, review articles, and professional society publications.

STUDY SELECTION:

105 articles were selected. In vitro and in vivo reports on the pharmacokinetics, microbiology, pharmacology, and effectiveness of clarithromycin and azithromycin were assessed to compare their effectiveness and safety. Emphasis was placed on the use of these new drugs in treating infections caused by Mycobacterium avium complex, Mycobacterium chelonae, and Mycobacterium fortuitum infections.

RESULTS:

A review of the in vitro activity of the new macrolides revealed moderate to very good activity against many strains of mycobacteria other than M. tuberculosis. Early clinical trials show promising results in pulmonary infections, lymphadenitis, cutaneous infections, and disseminated infections.

CONCLUSIONS:

The new macrolides, azithromycin and clarithromycin, show great promise for treating infections caused by these acid-fast bacteria. Clarithromycin is recommended as a component of combination therapy for the treatment of M. avium complex infections in patients with AIDS. The development of resistance in patients, particularly when these agents are used alone, has been reported.
Autism and Associated Behavioral Disorders: Pharmacotherapeutic Intervention
Authors: Gilman Jamie T. , Tuchman Roberto F.
Published: January 2017

Objective:

To review the literature on autism and pervasive developmental disorders (PDDs) as well as their respective pharmacotherapies.

Data sources:

An Index Medicus, MEDLINE, and bibliographic search of the literature pertaining to autism, PDDs, and respective treatments.

Study selection:

Because of the paucity of literature on the treatment of autism and PDDs, the selection of reported data for this review included both controlled and uncontrolled studies, as well as case reports and any other information reported in the literature on the treatment of these disorders.

Data synthesis:

Autism and PDDs are severe developmental disabilities defined by behavioral criteria. These disorders are lifelong in nature and present in varying severity of clinical manifestations. Behavioral manifestations of patients with autism include core deficits in social interaction, communication, and imaginative activities, with a restricted repertoire of activities and interests. The present understanding of the neurochemical basis of the disorder is limited. The role of pharmacotherapy in the management of autism and PDDs is to ameliorate behavioral symptoms that interfere with the patient's ability to participate in educational, social, work, and family systems. Agents that have shown positive clinical effects in the treatment of children with autism and PDDs are reviewed in this article.

Conclusions:

Autism is a complex developmental disorder representing a heterogeneous group of individuals with similar symptomatologies and multiple biologic etiologies. Present pharmacotherapeutic intervention seeks to resolve behavioral symptoms. Treatment of autism and PDDs requires appropriate delineation of the behaviors and neurobiologic disorders associated with each patient. No single therapeutic agent, or combination thereof, is appropriate for the treatment of all children and adults with autism or PDDs.
Tobramycin-Induced Hypersensitivity Reaction
Authors: Schretlen-Doherty Janet S , Troutman William G
Published: January 2017

Objective:

To report a case of a hypersensitivity reaction associated with the use of intravenous tobramycin in a patient with cystic fibrosis.

Case Summary:

An 18-year-old man was hospitalized for exacerbation of his cystic fibrosis. Tobramycin 125 mg iv q6h and ceftazidime 2 g iv q8h were administered through the patient's implantable access system in the left chest. Within seconds of receiving the third dose of tobramycin, the patient experienced shaking, his left arm turned white, and urticaria and pruritus were noted on the left side of the patient's chest. The patient had experienced a similar incident, accompanied by breathing difficulty, with intravenous tobramycin 4 years príor to this incident. The patient had been skin-tested for tobramycin allergy and had been desensitized and was receiving tobramycin since that time without incident. The patient's desensitization was maintained with tobramycin 160 mg/d hs by nebulization, but the drug had been discontinued by the patient 6 months prior to the latest event.

Discussion:

Hypersensitivity reactions to aminoglycosides are unusual. Hypersensitivity to 1 aminoglycoside antibiotic frequently is associated with hypersensitivity to at least 1 other aminoglycoside. In patients who develop hypersensitivity to an aminoglycoside antibiotic, desensitization may be an effective alternative to changing therapy.

Conclusions:

Tobramycin is very important in the drug regimen for Pseudomonas aeruginosa infections in patients with cystic fibrosis. Effective desensitization can be maintained by daily administration of nebulized tobramycin.
Dissolution of Phenytoin Precipitate with Sodium Bicarbonate in an Occluded Central Venous Access Device
Authors: Akinwande Kayode I , Keehn Diane M
Published: January 2017

Objective:

To report a case of restored patency of a central venous access device occluded by precipitate of phenytoin sodium injection.

Case Summary:

A patient experienced total occlusion of an implanted subcutaneous port caused by precipitation of phenytoin. Phenytoin sodium injection was mixed inadvertently with dextrose 5% in NaCl 0.45% injection during intravenous administration. Dextrose 5% in NaCl 0.45% injection, which is acidic (pH 4.0), caused the phenytoin sodium injection, a basic solution (pH 12.0), to precipitate. Local instillation of sodium bicarbonate 8.4% injection to decrease the pH of the medium restored patency of the occluded port.

Discussion:

There are reports of local instillation of solvent restoring central ports occluded by lipid-containing parenteral nutrient admixture, calcium phosphate salt precipitate, and coagulated blood. No report of local instillation into an occluded port to dissolve precipitate of phenytoin could be found. Several factors are involved in the precipitation and dissolution of phenytoin. The key factor in this case was the hydrogen ion concentration (pH) of the solution. Decreased pH caused the precipitation, but increased pH caused the dissolution of the precipitate of phenytoin.

Conclusions:

Sodium bicarbonate injection was a suitable agent for clearing precipitate of phenytoin in this case of an occluded implanted central venous access device.
Peripheral Diabetic Neuropathy: Current Concepts in Treatment
Authors: Calissi Piera T , Jaber Linda A
Published: January 2017

Objective:

To review pathophysiology and current concepts in the treatment of diabetic peripheral neuropathy (PN).

Data Sources:

References were identified through a MEDLINE search of the English-language literature from 1976 through 1994. Additional references were obtained from reference lists of articles identified through the search.

Study Selection and Data Extraction:

All articles were considered for possible inclusion in the review. Clinical trials that involved an adequate number of patients and review articles were selected. Information from articles that was judged by the authors to be significant was selected for discussion.

Data Synthesis:

PN affects 5-50% of people with diabetes in the US and most commonly is characterized by tingling or burning sensations, particularly in the calves, ankles, and feet, with a loss of vibratory sense. Treatment of PN, for the most part, has been unsatisfactory. Therapy has been directed toward either improving nerve function or alleviating symptoms of PN, including pain and paresthesia. Glycemic control may slow the progression of PN. Hyperglycemia also is associated with decreased pain threshold in patients with diabetes mellitus. The aldose reductase inhibitors, particularly tolrestat, have been shown to improve objective and subjective neurologic function. Pain or paresthesia has been treated effectively with antidepressants, lidocaine, mexiletine, and capsaicin. The anticonvulsants phenytoin and carbamazepine may be effective, but are associated with a greater degree of adverse effects. Experimental treatments, such as gamma-linolenic acid, gangliosides, uridine, and the corticotropin4-9 analog ORG 2766, have been effective in improving neurologic function.

Conclusions:

Treatment of PN remains unsatisfactory. Therapy should be directed toward prevention with glycemic control and symptomatic treatment of existing PN.
Extrapyramidal Symptoms following Accidental Ingestion of Risperidone in a Child
Authors: Cheslik Tamara A , Erramouspe John
Published: January 2017

OBJECTIVE:

To describe the development of extrapyramidal symptoms (EPS) precipitated by an accidental overdose of risperidone in a 3.5-year-old boy.

CASE SUMMARY:

The boy presented to the emergency department with bilateral upward eye gaze, jerky movements of his extremities, and motor restlessness following an accidental ingestion of a single 4-mg risperidone tablet. Decontamination with NaCl 0.9% lavage and activated charcoal with sorbitol was performed. His symptoms responded immediately to intravenous diphenhydramine (on 3 different occasions) during his first 9.5 hours of hospitalization. He experienced no additional EPS, and was discharged home approximately 33 hours following initial presentation. At home, he received three oral doses of diphenhydramine in the 24 hours following hospital discharge because of hand tremor, total body shivering, and eye wandering. These signs resolved without further complications.

DISCUSSION:

Although the incidence of EPS associated with therapeutic risperidone use is low, its occurrence following overdose is less clearly defined. This represents the first published case, to our knowledge, of risperidone overdose in a child and highlights the potential for dystonic reactions at low doses in this population. Seven intentional overdoses of risperidone in adults (aged 21–68 y) have been reported in the literature and are reviewed. Amounts ingested ranged from 5 to 270 mg. All adult patients appeared to have a relatively benign course. Reported symptoms included drowsiness, slurred speech, altered levels of consciousness, hypertension, tachycardia, electrocardiogram abnormalities, atypical motor behavior, tremors, and other EPS (not specified).

CONCLUSIONS:

Accidental ingestion of low doses of risperidone can cause EPS in children that may respond well to an anticholinergic agent. Overdose management includes gastrointestinal lavage, activated charcoal with cathartic, cardiovascular monitoring, and supportive therapy.
Possible Pharmacokinetic Interaction with Quinidine: Ciprofloxacin or Metronidazole?
Authors: Cooke Catherine E , Sklar Grant E , Nappi Jean M
Published: January 2017

OBJECTIVE:

To discuss a potential pharmacokinetic interaction between quinidine, ciprofloxacin, and metronidazole.

CASE SUMMARY:

A 51-year-old black woman was admitted for shortness of breath, abdominal pain, and atrial fibrillation. Procainamide and diltiazem were begun for the atrial fibrillation and ciprofloxacin and metronidazole for suspected diverticulitis. The therapy was switched to quinidine on day 5 because of adverse events associated with procainamide. A trough serum quinidine concentration (SQC) on day 7 was 6.3 μg/mL (normal 2–5) with normal QT and QTc intervals. On day 8, the patient was discharged in normal sinus rhythm. She took her last doses of antibiotics on day 15 and a follow-up SQC on day 18 was 2.3 μg/mL.

DISCUSSION:

The possible explanations for the changes in SQCs include: (1) laboratory error, (2) compliance with medication regimen, and (3) altered hepatic metabolism. The first two are not likely in this case. The laboratory verified the elevated SQC and the patient had her prescriptions refilled within appropriate time limits. The third explanation seems more plausible. Quinidine is metabolized by the hepatic mixed-function oxidase system, specifically cytochrome P450 (CYP) 3A4. We found that metronidazole has been shown to inhibit CYP3A activity and ciprofloxacin has been shown to inhibit certain isozymes in the cytochrome P450 system as well.

CONCLUSIONS:

When metronidazole and ciprofloxacin are administered concomitantly with quinidine, clinicians should be aware of this potential interaction. Quinidine concentrations should be monitored and patients should be assessed for signs and symptoms of quinidine toxicity.
Combining Event Rates from Clinical Trials: Comparison of Bayesian and Classical Methods
Authors: Su Xiang Y , Po Alain Li Wan
Published: January 2017

OBJECTIVE:

TO compare an empirical Bayesian, a fully Bayesian, and a classical fixed-effect (Peto) method for pooling event rates from separate epidemiologic studies or clinical trials.

DESIGN:

Four data sets used in meta-analyses by previous authors were evaluated. The first data set concerned death rates observed in clinical trials of beta-blockers, the second to lung cancer and smoking in 14 case-control studies, the third to drowsiness induced by the antihistamine compound chlorpheniramine, and the fourth to the use of intravenous magnesium in patients with suspected myocardial infarction. Randomly chosen data points were made more extreme to test the methods further.

MAIN OUTCOME MEASURES:

Pooled estimates of effect expressed as odds ratios and their associated 95% confidence intervals.

RESULTS:

All three methods gave comparable results with respect to the 95% confidence interval, although the Bayesian methods gave generally wider interval estimates. However, the point estimates for the individual studies were substantially different, particularly for small studies.

CONCLUSIONS:

For the data sets considered, Bayesian methods, which are computer intensive but intuitively appealing, provided results that were consistent with the classic fixed-effect Peto method. Introduction of the more extreme data points did not alter this conclusion.
Apoptosis: Its Role in the Development of Malignancies and its Potential as a Novel Therapeutic Target
Authors: Dixon Shannon C , Soriano Barbara J , Lush Richard M , Borner Markus M , Figg William D
Published: January 2017

OBJECTIVE:

To review the current literature regarding the role of apoptosis in the development of malignant cells and how the induction of this pathway could be used in cancer therapy.

DATA SOURCE:

A MEDLINE search of basic science articles pertinent to the understanding of the normal physiologic process of apoptosis was conducted.

STUDY SELECTION:

Because of the rapidly growing literature regarding apoptosis, only articles describing key processes in the biology of the cell and the genetic control of apoptosis were included.

DATA SYNTHESIS:

Apoptosis is imperative for host survival since it discards unwanted, damaged, and atypical cells. The process is therefore implicated in the continuous regulation of development, differentiation, and homeostasis. Furthermore, apoptosis is a response to physiologic and pathologic stresses that disrupt the balanced rates of cell generation and elimination. In a disease such as cancer, there is a lack of equilibrium between the rates of cell division and cell death; agents that promote or suppress apoptosis can manipulate these rates, influencing the anomalous accumulation of neoplastic cells. Pharmacologic manipulation of apoptosis represents a novel approach in targeting malignant cells and has far-reaching implications for new directions in cancer therapy.

CONCLUSIONS:

Apoptosis is a highly organized physiologic mechanism of destroying injured and abnormal cells as well as maintaining homeostasis in multicellular organisms. Both the activation and inhibition of apoptosis are tightly controlled. Pharmacologic manipulation of this pathway is a novel therapeutic target in cancer therapy.
Respiratory Syncytial Virus Immune Globulin Intravenous
Authors: Wandstrat Todd L
Published: January 2017

OBJECTIVE:

To review the clinical data detailing the use of respiratory syncytial virus immune globulin intravenous (RSV—IGIV) in infants and children.

DATA SOURCES:

A MEDLINE search (1990–1996) was used to identify all publications that dealt with RSV—IGIV clinical trials, pharmacology, and pharmacokinetics in infants and children. Bibliographies of articles were also used.

STUDY SELECTION:

All abstracts and clinical trials were reviewed.

DATA EXTRACTION:

Study design, population, efficacy, and safety data were retained.

DATA SYNTHESIS:

RSV—IGIV is an immunoglobulin product with serum neutralizing titers against RSV. It has been shown to reduce hospital stay, admissions, intensive care unit admissions, and mechanical ventilation days in infants and children with RSV pneumonia or bronchiolitis who are younger than 24 months of age and were born prematurely, or have bronchopulmonary dysplasia. RSV—IGIV is well tolerated by infants and children.

CONCLUSIONS:

RSV—IGIV is an effective prophylactic agent against serious RSV disease in select groups of infants and children.
Lipoprotein Disorders in Women: Which Women are the Best Candidates for Hormone Replacement Therapy?
Authors: Plushner Susyn L
Published: January 2017

OBJECTIVE:

To review the data examining hormone replacement therapy (HRT) in the treatment of lipoprotein disorders in women.

DATA SOURCE:

A MEDLINE search (1975–1995) of the English-language literature was performed to identify pertinent primary literature and review articles. Articles were also identified through bibliographies of selected articles.

DATA EXTRACTION:

Controlled and uncontrolled studies evaluating the effects of lipoprotein concentrations on coronary risk and the effects of estrogen and HRT on coronary heart disease and lipoprotein concentrations in women were evaluated. Trials pertaining to adverse effects of therapy were also examined. Emphasis was placed on recent clinical trials.

DATA SYNTHESIS:

The National Cholesterol Education Program's (NCEP's) 1993 report recommends estrogen replacement therapy as a treatment option in postmenopausal women with hyperlipidemia. Recent trials suggesting that triglycerides and high-density lipoproteins are more closely related to coronary risks in women necessitate an improved understanding of estrogen and progestin's effects on lipoprotein concentrations. A recent trial has clarified the lipoprotein effects of HRT in women with normal lipid concentrations and suggests that beneficial effects on low-density lipoproteins are maintained, although progestins attenuate beneficial changes in high-density lipoproteins and triglyceride elevations persist. The few trials evaluating estrogen use in women with hyperlipidemia suggest a beneficial effect as well.

CONCLUSIONS:

In the absence of contraindications, postmenopausal women with hyperlipidemia should be offered estrogen replacement therapy as conjugated equine estrogen 0.625 mg/d. Pending further information, NCEP's recommendations should be followed regarding goals of therapy.
Distal Tarsal Tunnel Release with Partial Plantar Fasciotomy for Chronic Heel Pain: An Outcome Analysis
Authors: Watson Troy S. , Anderson Robert B. , Davis W. Hodges , Kiebzak Gary M.
Published: January 2017

This study evaluated the effectiveness of distal tarsal tunnel release with a partial plantar fasciotomy for chronic subcalcaneal pain syndrome in patients who failed nonoperative management through a retrospective review of all patients undergoing this procedure between 1994 and 1999. Distal tarsal tunnel release and a partial plantar fasciotomy were offered only to those patients with disabling heel pain and were performed under general anesthesia or ankle block. Seventy-five patients (80 heels), averaging 20 months of nonoperative treatment, were identified (group I). Postoperative outcome questionnaires (SF-36 and Foot Function Index [FFI]) were sent to these patients and 44 (46 heels) responded (group II). In group I, 88% of patients had a good to excellent result. Many continued with mild to moderate residual symptoms, which typically did not limit their activity. In group II, 91% of patients were somewhat to very satisfied with their outcome. Visual analogue scale scores for pain were reduced by a mean of 55. SF-36 scores, matched against a control group of patients receiving just nonoperative treatment, showed a statistically significant improvement in all pain and functioning subcategories. We conclude that a distal tarsal tunnel release with a partial plantar fasciotomy may successfully increase function and decrease pain in patients who fail nonoperative treatment.
Anatomical Study of the Medial Ankle Ligament Complex
Authors: Boss Andreas Peter , Hintermann Beat
Published: January 2017

The purpose of this in vitro study was to determine insertion area, length and thickness of the various bundles and their anatomical relationship with inter-individual differences. Twelve ankles from human cadavers (ages 56 to 95 years, from nine men and three women) were dissected to the capsuloligamentous structures. Marked inter-individual differences were found for the five main ligaments (tibiospring, tibiocalcaneal, posterior and anterior deep tibiotalar and superficial posterior tibiotalar). The tibionavicular ligament is a thickened fibrous layer of the ankle capsule. The tibiocalcaneal and tibiospring ligaments are the longest, and the tibiocalcaneal and posterior deep tibiotalar ligaments are the thickest of these ligaments. Fibrils run in the direction of the tibia or dorsally. Knowledge of the deltoid ligament complex is necessary for anatomically and biomechanically correct reconstruction that provides stability without hazard to biomechanics of function.
Perioperative Complications of Total Ankle Arthroplasty
Authors: Mroczek Kenneth
Published: January 2017

A retrospective radiographic and chart review was performed for the initial 50 patients who underwent Agility (DePuy, Warsaw IN) total ankle arthroplasty by the senior author (M.S.M.). The review focused on the perioperative complications of nerve or tendon lacerations, intraoperative fractures, acute deep infections, wound complications and component positioning. Major wound complications were defined as those requiring a soft-tissue coverage procedure. Minor wound complications did not require soft tissue coverage and included wound breakdowns, wound edge necrosis, and superficial infections. The immediate mortise and lateral postoperative radiographs were reviewed to measure component positioning. The patients were divided into two groups to compare the initial 25 patients (Group A) with the subsequent 25 patients (Group B). There were no major wound complications in either group. Minor wound complications decreased from six in Group A to two in Group B. There were four lacerations (flexor hallucis longus, posterior tibial tendon, deep peroneal nerve, and superficial peroneal nerve), all occurring in Group A. Five patients sustained intraoperative fractures in Group A, as compared with two fractures in Group B. The number of components varying greater than 4° from neutral as measured by the lateral talar, lateral tibial and mortise tibial component angles decreased by 9% from Group A to Group B. The only tibial component to be placed in more than 4° of valgus occurred in Group A. It seems that a notable learning curve exists in the performance of total ankle arthroplasty as demonstrated by a comparison of the initial 25 patients with the subsequent 25 patients performed by one orthopaedic surgeon. This improvement most likely resulted from the use of enhanced techniques and further training with the prosthesis. This information can be used as a teaching tool to decrease the incidence of complications for surgeons performing their initial arthroplasties with this potentially technically demanding procedure.
Scarf Osteotomy for Hallux Valgus Repair: The Dark Side
Authors: Coetzee J. Chris
Published: January 2017

Hypothesis/Purpose:

The Scarf osteotomy has gained popularity as treatment of choice in parts of Europe and is based on sound structural principles. The excellent results reported by others could not, however, be reproduced by the author and the results are presented.

Methods:

From January 1997 to June 1997 the Scarf osteotomy was selected in 20 consecutive patients (12 female and eight male patients, ages 18 to 60, mean: 41 years) with moderate metatarsus primus varus (IMA 13 to 20°) and hallux valgus deformities (less than 40°). The AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale, visual analog scale and patient satisfaction were monitored prior to surgery, six and 12 months post-op. The patients were treated in a short leg cast, non-WB for two weeks followed by four weeks partial WB in a cast shoe. Routine post-bunion rehabilitation followed once the radiological and clinical diagnosis of healing was made.

Results:

Multiple complications were encountered. The most common was “troughing” of the metatarsal with loss of height. This occurred in seven patients (35%). Other complications include delayed union (5%), rotational malunion (30%), proximal fracture (10%), infection (5%) and early recurrence of deformity in 25%. All 20 patients were available for follow-up at six months, and 19 of 20 at 12 months. The AOFAS score pre-op was a mean of 53. At six months a mean of 54 (19 to 69) and at 12 months 62 (24–100). Forty-five percent (9/20) were unsatisfied at one year and would not recommend the surgery to a friend.

Conclusions/Significance:

The Scarf osteotomy has multiple potential pitfalls and should probably be reserved for moderate bunions in young people with good bone quality. There are multiple potential problems and the salvage of a failed Scarf osteotomy is difficult.
Anchor Enhanced Capsulorraphy in Bunionectomies Using an L-Shaped Capsulotomy
Authors: Gould John S. , Ali Sheriff , Fowler Rachel , Fleisig Glenn S.
Published: January 2017

The objective of this study was to investigate potential benefit of a suture anchor-enhanced capsulorraphy in the early maintenance of correction in bunionectomies. We compared, retrospectively, in successive series, the loss of correction of the Hallux Valgus (HV) and intermetatarsal (IM) angle, in those repaired with an L-shaped capsulorraphy enhanced with anchors to those without. Intraoperative and second week postoperative simulated weightbearing anterior posterior (AP) X-rays were used to evaluate results. By using only intraoperative and early postoperative X-rays, we should have effectively eliminated extraneous factors that might have influenced our results. A Total of 106 cases were investigated, 65 of which were repaired using anchors, the remaining 41 without. In the anchor group, 38 underwent a proximal metatarsal concentric shelf osteotomy (CSO)/modified McBride procedure, while the remaining 27 had a distal Chevron correction. In the without-anchor group, 21 had a CSO/modified McBride procedure while 20 underwent the Chevron procedure. In the without-anchor group, the average HV and IM loss of correction was 4.60° (range, −2 to 21°) and 0.6° (range, −1 to 9°) respectively. In the anchor group, the corresponding loss was 2.8° (range, −3 to 17°) and 0.6° (range, −2 to 14°) respectively. These results, when statistically analyzed, demonstrated that while the IM angle change was not statistically significant, the HV angle change was statistically significant, implying that the anchor plays a significant role in maintaining the surgical correction in both the distal Chevron and CSO/modified McBride bunionectomies.
Tendon Transfer Fixation in the Foot and Ankle: A Biomechanical Study Evaluating Two Sizes of Pilot Holes for Bioabsorbable Screws
Authors: Louden Keith W. , Ambrose Catherine G. , Beaty Stacy G. , McGarvey William C. , Clanton Thomas O.
Published: January 2017

The purpose of this study was to compare the initial fixation strengths of bioabsorbable screws for tendon transfers in the foot and ankle when the pilot hole size varied. A 7times20 mm screw was used with 5.5 mm and 6.5 mm drill holes, and a 5times20 mm screw was used with 3.9 mm and 4.5 mm drill holes. Biomechanical testing was performed on each tendon transfer in cadaver specimens. A paired t-test showed no significant difference in pullout strength when pilot hole size varied between 79 to 93% of the screw size for the 7 mm screw and 78 to 90% of the screw size for the 5 mm screw. Previous studies have found a critical value of tendon tension equaling 50 N with passive dorsiflexion of the foot. With an average value of approximately 170 N, the 7 mm screw provided three times the requisite strength. The 5 mm screw provided 1.5 times the requisite strength, but the transfer was technically more difficult.
Technique Tip: A Revised Method of the Cotton Test for Intra-Operative Evaluation of Syndesmotic Injuries
Authors: Mizel Mark S.
Published: January 2017

The Cotton test assists the orthopaedic surgeon in the intra-operative evaluation of potential incompetence of the ankle syndesmosis. A variation of this test is proposed that simplifies this test, while providing a direct distraction force to the syndesmotic ligamentous complex.
A Biomechanical Evaluation of Clinical Stress Tests for Syndesmotic Ankle Instability
Authors: Beumer Annechien , van Hemert Wouter L.W. , Swierstra Bart A. , Jasper Louis E. , Belkoff Stephen M.
Published: January 2017

Displacement transducers were placed across the anterior and posterior tibiofibular ligaments of 17 fresh cadaver (78.4±6.7 years old at death) lower extremities. Displacements induced by various clinical tests (squeeze, fibula translation, Cotton, external rotation, and anterior drawer) were measured with the ankle ligaments intact and after sequential sectioning of the anterior tibiofibular ligament, anterior deltoid ligament, and posterior tibiofibular ligament.

None of the syndesmotic stress tests could distinguish which ligaments were sectioned. Furthermore, the small displacements measured during the stress tests (with the exception of the external rotation test) suggest it is unlikely that the displacement induced in injured syndesmoses can be clinically differentiated from normal syndesmoses. Therefore, pain, rather than increased displacement, should be considered the outcome measure of these tests.
Topography of the Distal Tibial Nerve and Its Branches
Authors: Lumsden David B. , Schon Lew C. , Easley Mark E. , Duouguih Wiemi A. , Anderson Claude D. , Miller Stuart D. , Ottey Deron K.
Published: January 2017

The tibial nerve trunk and its branches were dissected in 20 embalmed cadaver legs and the relative topographic anatomy was defined at 3-cm intervals up to 15 cm proximal to the medial malleolar-calcaneal (MMC) axis. Each nerve branch was found in various locations. The calcaneal nerve was found to descend from medial to posteromedial. It was never found anterolaterally and only rarely laterally. The lateral plantar nerve was found to rotate externally from lateral and posterolateral to lateral and posteromedial as it descends. This nerve was not found medially or anteromedially. The first branch of the lateral plantar nerve was indistinguishable from the trunk of the tibial nerve descending medially to between the lateral plantar and calcaneal nerves. The overall pattern of the medial plantar nerve was an internal rotation from anteromedial (proximal) to anterior (distally). It was not found posteriorly. The flexor hallucis longus motor branch was located an average of 17.9 cm (range, 10–24 cm) proximal to the MMC axis. Preliminary application of these data has facilitated surgical dissection and afforded an understanding of how tibial nerve trunk pathology correlates with clinical manifestations.
Biomechanical Differences Among Pes Cavus, Neutrally Aligned, and Pes Planus Feet in Subjects with Diabetes
Authors: Ledoux William R. , Shofer Jane B. , Ahroni Jessie H. , Smith Douglas G. , Sangeorzan Bruce J. , Boyko Edward J.
Published: January 2017

The purpose of this study was to quantify differences in joint range of motion, foot deformity, and foot morphology among pes cavus, neutrally aligned, pes planus rigid, and pes planus flexible feet. A cohort of 1047 veterans with diabetes (contributing 2047 feet) was enrolled in a prospective study of diabetic ulcer risk factors (the Seattle Diabetic Foot Study). Significant differences between foot types were found. Pes cavus feet had an increased percentage of prominent metatarsal heads, bony prominences, and hammer/claw toes ( p <.0001), as well as significantly increased amounts of hallux dorsiflexion and decreased amounts of hallux plantarflexion ( p <.0001) with a total range of motion equal to the other foot types ( p =.3). Neutrally aligned feet had a lower percentage of intrinsic muscle atrophy, bony prominences, and hammer/claw toes ( p <.0001). Pes planus feet had an increased lateral talometatarsal angle ( p <.0001) and an increased second metatarsal length. These data demonstrate structural differences between foot types in a population with diabetes.
Operative Treatment of Osteochondral Lesions of the Talar Dome: Current Concepts Review
Authors: Giannini Sandro , Vannini Francesca
Published: January 2017

Osteochondral lesions of the talar dome are common problems encountered in orthopaedics. Procedures for the treatment of osteochondral lesions of the talus, including debridement of the joint, shaving of fibrillated cartilage, and resection or perforation of subchondral bone in the last decade, have been performed arthroscopically with very low morbidity. These seem to be inadequate in lesions larger than 1.5 cm2 and have not been histologically effective in restoring the hyaline cartilage sheath. Osteochondral allografts or autogenous grafts and autologous chondrocyte transplantation have proven to be capable of restoring the articular hyaline cartilage surface, including defects larger than 2 cm2, although with higher costs and morbidity. In this review, the aforementioned methods of operative treatment are examined and issues that are related to these methods are discussed.
Clinical Outcome of Tibiotalar Arthrodesis Utilizing the Chevron Technique
Authors: Kopp Franz J. , Banks Michael A. , Marcus Randall E.
Published: January 2017

Tibiotalar arthrodesis remains the gold standard reconstructive procedure for the treatment of disabling ankle arthritis. The purpose of this study was to review the clinical results of tibiotalar arthrodesis utilizing the chevron fusion technique. The results of 46 consecutive patients who underwent ankle arthrodesis utilizing the chevron technique were reviewed. The etiology of the tibiotalar arthritis was posttraumatic in 29 of 46 patients. Of the remaining 17 patients, seven had osteoarthritis, five had talar osteonecrosis, two had rheumatoid arthritis, one had hemophilic arthropathy, one had gouty arthropathy, and one had unrecognized chronic osteomyelitis. Three patients had prior hind-foot arthrodeses, and two patients had bilateral ankle fusions at last follow-up. All patients were followed for a minimum of 2 years. Of the 46 patients, 41 were available for review, with an average follow-up of 7.3 years (range, 2–20 years). Twelve patients had greater than 10-year follow-up. The Mazur ankle score was calculated for all 41 patients. The average Mazur ankle score for the 41 patients available for review was 72.8, out of a maximum possible score of 90. Eighteen patients had excellent results, 11 patients had good results, five patients had fair results, and seven patients had poor results. The most common reasons for fair or poor results were symptomatic subtalar arthritis and multiple medical comorbidities. All patients with postoperative symptomatic subtalar arthritis had preoperative radiographic evidence of subtalar arthrosis. Of the 12 patients with greater than 10-year follow-up, nine had excellent or good results, and an average Mazur ankle score of 76.6. All patients with either prior hindfoot arthrodeses or bilateral ankle fusions had excellent or good results. Of the 41 arthrodeses included in the study, 38 (38/41, 93%) went on to clinical and radiographic union. The chevron technique provides a predictable method to obtain fusion of the tibiotalar joint. Most patients can expect excellent or good results. In the current study, 90% (37/41) of patients were satisfied with the outcome of their surgery and would undergo the same operation again under similar circumstances.
Peroneus Brevis is a More Effective Evertor than Peroneus Longus
Authors: Otis James C. , Deland Jonathan T. , Lee Samuel , Gordon Jonathan
Published: January 2017

A primary function of the peroneus longus and peroneus brevis is to provide the eversion moment necessary to balance the opposing inversion moments. Surgeons often deal with the loss of or need to sacrifice one of these tendons. This study compares the evertor mechanisms of the peroneus brevis and peroneus longus muscle. This is accomplished in a cadaver model in which the performance of each of the muscle tendons during early heel rise of gait is assessed utilizing the same tendon loads in each so that force is not a variable. Six fresh-frozen cadaver foot-ankle specimens were studied during a simulated early heel rise phase of the gait cycle. The study compared the effect of the peroneus brevis and peroneus longus by separately applying the same load to the each of the tendons. At the talonavicular joint, the peroneus brevis loaded condition externally rotated the navicular 2.1° more than when the peroneus longus was loaded. At the subtalar joint, the peroneus brevis loaded condition resulted in 0.9° more calcaneus valgus relative to the talus than was present during the peroneus longus loaded condition. The experimental data support the hypothesis that the peroneus brevis tendon mechanism is more effective than is the peroneus longus mechanism in rotating the navicular externally and the calcaneus into valgus. This has clinical implications for assisting surgeons in trying to preserve evertor function.