bluuebunny/crossref_metadata_2025 huggingface dataset:
Laboratory measurements of infiltration capacity by a double ringed infiltrometer and the Cornell Sprinkle Infiltrometer
Authors: Barrett Kirk R. , Rodgers Danielle
Published: December 2015

The infiltration capacities (IC) of three different sands were measured repeatedly in a laboratory using a double-ring infiltrometer (DRI) and the Cornell Sprinkle Infiltrometer (CSI). The study assessed (1) the level of agreement between the infiltrometers, and (2) the reproducibility of values produced by each infiltrometer. The results were inconclusive regarding the agreement of IC measurements: the percentage difference in the mean IC was small for one sand (4%), but larger for the other two (32 and 48%), with the CSI yielding higher values than the DRI in both of these cases. For these latter two sands, the measurements were different at a statistical significance level of 0.01 and 0.05, respectively. Likewise, the results were inconclusive regarding the reproducibility of each instrument. The CSI showed much better reproducibility than the DRI for one sand (relative standard deviations of 7% and 26%, respectively), but slightly worse for the other two (23% and 18%, and 22% and 19%), respectively.
Water user survey on expectations of service in Guelph, ON, Canada
Authors: Dziedzic R. M. , Karney B. W.
Published: December 2015

A survey was developed and conducted with residential water users in the City of Guelph, ON, Canada, with the objective of assessing their awareness, preferences, concerns, motivations, and priorities. The overall goal of this data is to improve the water system on different fronts: infrastructure, conservation programs, communication with users, and long-term strategies. Results highlight the local concerns with water scarcity, currently addressed by conservation programs, as well as water quality, aging infrastructure, and costs. Correlations between user type and answers were seldom found, showing that different residential customer segments share concerns and motivations. Even so, feedback must be sought from all customer segments, residential as well as industrial, commercial, and institutional, through different channels. The findings will allow the utility to identify preferred solutions to current issues and openness to change, as well as gaps in user and utility knowledge.
Field-data on parameters relevant for design, operation and monitoring of communal decentralized wastewater treatment systems (DEWATS)
Authors: Reynaud N. , Buckley C.
Published: December 2015

Decentralized Wastewater Treatment Systems (DEWATS) are increasingly being recognized by decision makers and city developers across the world as an option for service delivery in densely populated low-income areas. However, little knowledge and field-data are available on some key design-, operation- and monitoring-parameters. This paper addresses these gaps by presenting data on per capita wastewater production of communities connected to DEWATS, hydraulic peak flow factors, per capita BOD5 load estimates, biogas-production of DEWATS biogas digesters, DEWATS effluent characteristics and their fluctuation over time and settled reactor sludge characteristics concerning TS and VS concentrations, specific methanogenic activity (SMA), effect of sludge storage on SMA and accumulation rates. The investigations have been conducted over five years at 24 communal systems in Indonesia, India and South Africa.
Pumps: energy efficiency & performance indicators
Authors: Papa Fabian , Cavaleiro de Ferreira Rita , Radulj Djordje
Published: December 2015

Pumping is a central component to many water supply and distribution systems, and one which consumes significant amounts of energy. Increased attention to energy conservation is a common theme globally and, in the context of water supply systems, the need to understand the energy efficiency with which pumps operate in situ, and the opportunity to improve upon any inefficiencies, is becoming increasingly recognized. This paper discusses two separate and independently conceived and delivered initiatives that, while taking very different approaches to raising awareness and improving the industry's state of practice in this regard, are rather synergistic when viewed in a holistic sense. Recent work in Mexico is engaging the numerous utilities across the country to begin the measurement of pump energy efficiency, having wide-reaching impact, while work in Canada is exploring the details of individual pump performance through accurate field testing. Both these initiatives use a common approach to measuring performance of pump efficiency, based on the normalization of energy consumption relative to the output of the pump, namely the flow and total dynamic head delivered. The exact performance indicators used are somewhat different, but very closely related, and this paper explores the nuances of these differences in detail. As well, results from both the Mexican and Canadian experiences are presented, and guidance on the use of the performance indicators is provided.
Removal of phosphate from coating wastewater using magnetic Fe-Cu bimetal oxide modified fly ash
Authors: Xu Ke , Tao He , Deng Tong
Published: December 2015

In this work, magnetic Fe-Cu bimetal oxide modified fly ash was used to remove phosphate from coating wastewater. The influences of pH, dosage amount and adsorption time on the removal of phosphate were investigated. The experimental results showed that pH had a significant effect on the adsorption of phosphate. The removal percentage of phosphate reached a maximum at pH 10. The removal efficiency of phosphate increased with the increase in adsorbent dosage. A kinetic study showed that the phosphate adsorption was well described by a pseudo second order model. The adsorption isotherm of phosphate could be described by the Langmuir model and Freundlich model. The Langmuir maximum capacity Q0 was 12.69 mg/g and the value of n of the Freundlich model was 3.82. The experimental results indicated that magnetic Fe-Cu bimetal oxide modified fly ash was a potential adsorbent for the removal of phosphate from the wastewater.
In situ microscopy as a tool for the monitoring of filamentous bacteria: a case study in an industrial activated sludge system dominated by M. parvicella
Authors: Dunkel Thiemo , Dias Philipe Ambrozio , de León Gallegos Erika Lizette , Tacke Viola , Schielke Andreas , Hesse Tobias , Fajado Diego Andrés Sierra , Suhr Hajo , Wiedemann Philipp , Denecke Martin
Published: December 2015

The present study demonstrates the application of in situ microscopy for monitoring the growth of filamentous bacteria which can induce disturbances in an industrial activated sludge process. An in situ microscope (ISM) is immersed directly into samples of activated sludge with Microthrix parvicella as dominating species. Without needing further preparatory steps, the automatic evaluation of the ISM-images generates two signals: the number of individual filaments per image (ISM–filament counting) and the total extended filament length (TEFL) per image (ISM–online TEFL). In this first version of the image-processing algorithm, closely spaced crossing filament-segments or filaments within bulk material are not detected. The signals show highly linear correlation both with the standard filament index and the TEFL. Correlations were further substantiated by comparison with real-time polymerase chain reaction (real-time PCR) measurements of M. parvicella and of the diluted sludge volume index. In this case study, in situ microscopy proved to be a suitable tool for straightforward online-monitoring of filamentous bacteria in activated sludge systems. With future adaptation of the system to different filament morphologies, including cross-linking filaments, bundles, and attached growth, the system will be applicable to other wastewater treatment plants.
Comparing high-dimensional confounder control methods for rapid cohort studies from electronic health records
Authors: Low Yen Sia , Gallego Blanca , Shah Nigam Haresh
Published: December 2015

Aims:Electronic health records (EHR), containing rich clinical histories of large patient populations, can provide evidence for clinical decisions when evidence from trials and literature is absent. To enable such observational studies from EHR in real time, particularly in emergencies, rapid confounder control methods that can handle numerous variables and adjust for biases are imperative. This study compares the performance of 18 automatic confounder control methods.Methods:Methods include propensity scores, direct adjustment by machine learning, similarity matching and resampling in two simulated and one real-world EHR datasets.Results & conclusions:Direct adjustment by lasso regression and ensemble models involving multiple resamples have performance comparable to expert-based propensity scores and thus, may help provide real-time EHR-based evidence for timely clinical decisions.
Cross-Cultural Comparison of USA and South Korea in Estimated Rate of Organ Donation
Authors: Park Hee Sun , Yun Doshik , Oh Ju Yeon , Song Chang-Ik
Published: December 2015

In this study, we examined cultural differences in estimation of both the percentage of people who would donate organs to others when they died and the percentage of people who would discuss their decision to donate organs with their parents. Participants were 79 undergraduates at a
Midwestern university in the USA and 116 undergraduates at a university in Seoul, Republic of Korea. Results showed that the South Korean participants exhibited a greater false consensus effect in regard to discussion with parents about organ donation than did the group from North America.
Among those not willing to donate organs, the underestimation of the South Koreans was greater than that the North Americans regarding the willingness of others to discuss donation with their parents. These findings imply that campaigns promoting organ donation may need to be targeted at correcting
people's misperceptions about relative prevalence of organ-donation-related behaviors, thereby motivating people to sign up for organ donation, and encouraging discussion by donors with their parents.
Australian Attitudes Toward Asylum Seekers: Roles of Dehumanization and Social Dominance Theory
Authors: Trounson Justin S. , Critchley Christine , Pfeifer Jeffrey E.
Published: December 2015

We employed a theoretical model of dehumanization to identify the factors influencing attitudes toward asylum seekers within an Australian context. Specifically, we hypothesized that Australians high in social dominance orientation (SDO) would be more likely than those low in SDO to
dehumanize asylum seekers. Participants (N = 311) completed an online survey designed to assess SDO, their attitudes and emotions toward asylum seekers, and their tendency to engage in dehumanization. Results indicated that the model can be successfully applied to an Australian context
and that dehumanization played a significant role in influencing our participants' attitudes toward asylum seekers. Findings are discussed in terms of future research as well as policy implications for Australian immigration issues.
Fans' Attention to, Involvement in, and Satisfaction with Professional Soccer in China
Authors: Gong Bo , Pifer Nathan David , Wang Jerry Junqi , Kim Minhong , Kim Minkil , Qian Tyreal Yizhou , Zhang James J.
Published: December 2015

We investigated the level of Chinese soccer fans' satisfaction with the development of professional soccer in China on the basis of their attention to, and involvement with, the Chinese Football Association Super League (CSL) and its teams. Research participants (N = 926) were
spectators at CSL games who responded to a questionnaire. Results revealed that the attention consumers paid to, and their involvement with, the CSL were negatively related to their satisfaction with the league's operation and marketing. These findings contradict existing theories and beliefs
that positive consumer cognition leads to positive consumer affect, indicating the presence of serious issues associated with the CSL administration. The failings of the CSL are discussed.
Factors Influencing Knowledge-Sharing Behaviors and Learning Effect: A Multilevel Investigation
Authors: Lin Quan , Lin Lan , Ye Di
Published: December 2015

In this longitudinal study, we investigated the effects of the Big Five personality traits, team characteristics, and the cross-level interactions on individual knowledge-sharing behaviors (KSBs). Using the survey data of 481 Chinese university students who had been assigned to 67 teams,
we found that conscientiousness, extraversion, and agreeableness explained within-team variance of KSBs, and that team identification and innovation climate accounted for between-team variance of KSBs. Individual KSBs aggregated to the team level explained the between-team variance of the
individual learning effect.
Effects of Congruence of Product, Visual Image, and Consumer Self-Image on Art Infusion Advertising
Authors: Lee Jieun , Kim Junghyun , Yu Jinhyun
Published: December 2015

Although previous researchers have reported that use of visual art in advertising induces more positive responses in consumers than does no art, which variables are important in inducing these responses has been largely unexamined. We investigated the moderating effects on advertising
of the congruence between product and visual image, and also the congruence between visual image and self-image. The sample consisted of 228 university students in Korea and the results showed that the students experienced stronger purchase intention when exposed to art infusion advertising
with high levels of advertisement–product congruence and advertisement–self-image congruence than they did when the levels of congruence were low. Further, we found that positive emotion mediated the effects of art infusion advertising on attitude toward advertising only for a
hedonic product, and that consumer response to art infusion advertising differed according to product type.
Simulating the impact of laser eye protection on color vision
Authors: Williamson Craig A. , Boontanrart Michael Y.
Published: December 2015

Laser eye protection (LEP) imparts coloration to the visual scene observed by the wearer, which can make interpreting color information problematic. A model has been developed to allow rapid visualization of the impact of LEP on the appearance of reflective color patches and emissive displays. This model uses the transmission spectra of LEP and spectral information of color stimuli, in conjunction with an implementation of the CIECAM02 model to account for complex aspects of human vision including chromatic adaptation. Applications include training LEP users of anticipated color shifts and iterative testing of LEP and display designs to optimize color presentation. (DSTL/JA87054)
Influence of Air Temperature Variations on Incidence of Epistaxis
Authors: Comelli Ivan , Vincenti Vincenzo , Benatti Mario , Macri Gian Franco , Comelli Denis , Lippi Giuseppe , Cervellin Gianfranco
Published: December 2015

Objective

Epistaxis is the most common ear, nose, and throat emergency observed in the emergency department (ED). An increased frequency of this condition has been observed during cooler months, but the results of available studies are controversial. The aim of this study was to investigate the seasonality and association of epistaxis presentations to a large urban ED with variations of air temperature and humidity.

Methods

This study was a retrospective case series. Information on all the patients who presented for epistaxis in the ED of the Academic Hospital of Parma during the years 2003-2012 and ages ≥14 years were retrieved from the hospital data base, excluding those attributable to trauma. The chronologic data of all visits were associated with climate data (air temperature and humidity) by univariate linear regression analysis.

Results

Among the 819,596 ED patients seen throughout the observational period, 5404 were admitted for epistaxis. Of these, 5220 were discharged from the ED, whereas 184(3.4%) needed hospital admission. A strong seasonality of epistaxis was observed, with a peak during winter. A strong negative correlation was also found between the daily number of epistaxes and the mean daily temperature in the whole population as well as in patient subgroups (those undergoing anticoagulant or antiplatelet therapy, or those with hypertension, inherited bleeding disorders, liver cirrhosis, or advanced malignancy). A weaker correlation was also found between air humidity and epistaxis but only in certain subgroups.

Conclusions

The results of this study provided a contribution to improve our understanding of the epidemiology of epistaxis and for specific health policies that should also be planned by considering the seasonality of nosebleed.
Amphotericin B Nasal Irrigation as an Adjuvant Therapy after Functional Endoscopic Sinus Surgery
Authors: Jiang Rong-San , Hsu Shuo-Hsiu , Liang Kai-Li
Published: December 2015

Background

Fungus-driven inflammation is proposed to play an important role in the pathogenesis of chronic rhinosinusitis (CRS). Previous studies evaluated the efficacy of intranasal amphotericin B (AMB) in the treatment of patients with CRS, but the results were controversial. The purpose of this study was to evaluate the efficacy of 100 pg/mL of AMB nasal irrigation as postoperative care after functional endoscopic sinus surgery (FESS).

Methods

Patients with CRS who received FESS for treatment were recruited and randomly assigned to two groups at 1 month after surgery. Patients in the AMB group received 100 pg/mL of AMB nasal irrigation daily for 2 months, and those in the normal saline (NS) group received NS solution nasal irrigation daily for 2 months. Pre-FESS, pre-irrigation, and postirrigation sinonasal symptoms were assessed by questionnaires, and the patients received endoscopic examination, acoustic rhinometry, smell test, and saccharine transit test.

Results

Seventy-seven patients were enrolled between June 2012 and December 2014. Among the patients who completed the study, 38 received AMB irrigation, and 39 received NS solution irrigation. Although all the patients reported improvement after irrigation, there was no difference in outcome between patients who received AMB and those who received NS solution.

Conclusion

Our study showed that nasal irrigation with 100 pg/mL of AMB did not confer a greater benefit than that of NS solution nasal irrigation in post-FESS care.
Prognostic Models in Adults Undergoing Physical Therapy for Rotator Cuff Disorders: Systematic Review
Authors: Braun Cordula , Hanchard Nigel C. , Batterham Alan M. , Handoll Helen H. , Betthäuser Andreas
Published: December 2015

Background

Rotator cuff–related disorders represent the largest subgroup of shoulder complaints. Despite the availability of various conservative and surgical treatment options, the precise indications for these options remain unclear.

Purpose

The purpose of this systematic review was to synthesize the available research on prognostic models for predicting outcomes in adults undergoing physical therapy for painful rotator cuff disorders.

Data Sources

The MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, and PEDro databases and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) up to October 2015 were searched.

Study Selection

The review included primary studies exploring prognostic models in adults undergoing physical therapy, with or without other conservative measures, for painful rotator cuff disorders. Primary outcomes were pain, disability, and adverse events. Inclusion was limited to prospective investigations of prognostic factors elicited at the baseline assessment. Study selection was independently performed by 2 reviewers.

Data Extraction

A pilot-tested form was used to extract data on key aspects of study design, characteristics, analyses, and results. Risk of bias and applicability were independently assessed by 2 reviewers using the Prediction Study Risk of Bias Assessment tool (PROBAST).

Data Synthesis

Five studies were included in the review. These studies were extremely heterogeneous in many aspects of design, conduct, and analysis. The findings were analyzed narratively.

Limitations

All included studies were rated as at high risk of bias, and none of the resulting prognostic models was found to be usable in clinical practice.

Conclusions

There are no prognostic models ready to inform clinical practice in the context of the review question, highlighting the need for further research on prognostic models for predicting outcomes in adults who undergo physical therapy for painful rotator cuff disorders. The design and conduct of future studies should be receptive to developing methods.
Metabolic alterations and hearing acuity
Authors: Pirodda Antonio , Brandolini Cristina , Raimondi Maria Chiara , Pelligra Irene , Strocchi Enrico , Cicero Arrigo F.G. , Rosticci Martina , Borghi Claudio
Published: December 2015

Objective:

To contribute to assessing the extent of the clinical significance of metabolic alterations in terms of hearing deterioration.

Study design:

The design enabled comparison of the serum level of cholesterol, apolipoproteins, glucose and uric acid in a homogeneous, controlled population of subjects with normal hearing and with symmetrical sensorineural hearing loss, respectively. All subjects were enrolled within the Brisighella Heart Study (BHS), a prospective, population based longitudinal epidemiological investigation involving almost 3000 randomly selected Caucasian subjects living in Brisighella, a small town in northern Italy.

Results:

No statistical difference was identified in the metabolic assessment of the two groups (normal hearing vs. impaired hearing). In particular, alteration of the serum lipids, glucose and uric acid parameters is not significantly associated with hearing loss (p > 0.01).

Conclusions:

The findings, apparently in disagreement with common opinion, seem to imply that the role of metabolic disorders is not pre-eminent in the genesis of non-acute hearing loss. It is possible to hypothesize that all mechanisms regulating the microcirculation of the inner ear can constitute a ‘buffer’ against the related cellular damage. It is likely that if a convenient and sufficiently stable degree of oxygenation is maintained, this might be enough to preserve hearing function even under unfavourable metabolic conditions.
J. Leonard Goldner Award 2008: Effect of Extracorporeal Shock Wave Therapy on Cultured Tenocytes
Authors: Han Seung Hwan , Lee Jin Woo , Guyton Gregory P. , Parks Brent G. , Courneya Jean-Paul , Schon Lew C.
Published: December 2015

Background: Little has been reported about the biologic effect of shock waves on human normal or pathologic tendon tissue. We hypothesized that inflammatory cytokine and MMP production would be down-regulated by shock wave stimulation. Materials and Methods: Diseased Achilles tendon tissue and healthy flexor hallucis longus tissue were used. Shock wave treatment was applied to cultured cells at 0.17 mJ/mm2energy 250, 500, 1000, and 2000 times. Results: A dose-dependent decrease in cell viability was noted in cells receiving 1000 and 2000 shocks (86.0 ± 5.6%, p = 0.01 and 72.4 ± 8.9%, p = 0.001) as compared with the normal control. Cell count in the 500-shock group increased by 23.4% as compared with the control ( p = 0.05). The concentration of MMP 1, 2, and 13 was higher in diseased tenocytes as compared with normal cells ( p = 0.04, all comparisons). IL-6 levels were higher in the diseased tenocytes as compared with normal tenocytes (44.10 ± 16.72 versus 0.21 ± 0.55 ng/ml, ( p < 0.05). IL-1 levels in normal cells increased (2.24 ± 5.02 ng/ml to 9.31 ± 6.85 ng/ml) after shock wave treatment ( p = 0.04). In diseased tenocytes, levels of MMP-1 (1.12 ± 0.23 to 0.75 ± 0.24 ng/ml; p = 0.04) and MMP-13 (1.43 ± 0.11 to 0.80 ± 0.15 ng/ml; p = 0.04) were significantly decreased after shock wave treatment. The IL-6 level in diseased tenocytes was decreased (44.10 ± 16.72 to 14.66 ± 9.49 ng/ml) after shock wave treatment ( p = 0.04). Conclusion: Higher levels of MMPs and ILs were found in human tendinopathy-affected tenocytes as compared with normal cells. ESWT decreased the expression of several MMPs and ILs. Clinical Relevance: This mechanism may play an important role in shock wave treatment of tendinopathy clinically.
Outcome of Fusion of a Painful Accessory Navicular to the Primary Navicular
Authors: Chung Jin-Wa , Chu In-Tak
Published: December 2015

Background: An accessory navicular bone may cause pain due to continuous irritation at its interface with the navicular. The authors performed the fusion of the accessory navicular and navicular with screw(s) to relieve the symptoms while preserving the continuity of the posterior tibial tendon. Materials and Methods: We analyzed the clinical and radiological outcomes of 31 consecutive patients (34 feet) with a painful type II accessory navicular. Results: Bone union was confirmed on plain radiography in 28 (82%) of 34 feet. Twenty-two patients (24 feet) were assessed as excellent, two (three feet) as good, and one (one foot) as fair. Nonunion developed in six patients (six feet) and was defined as poor. Conclusion: When conservative treatment fails to relieve pain in a type II accessory navicular, fusion of the accessory navicular to the navicular may successfully relieve pain without disrupting the tibialis posterior tendon insertion.
Use of a Patient-Controlled Stretching Device to Improve the Ankle Range of Motion
Authors: Trevino Saul G. , Buford William L. , Vallurupalli Santaram , Rowell Margaret , Panchbhavi Vinod K.
Published: December 2015

Background: Ankle and subtalar stiffness are widely associated with many foot and ankle conditions and functional deficits. Loss of range of motion, particularly dorsiflexion, results in significant gait dysfunction. A variety of methods have been evaluated to address this problem, including yoga, manipulation, dance training, jogging and static stretching exercises. No tools have been described that effectively and efficiently stretch the ankle and subtalar joint without requiring supervision or assistance of a trained physical therapist. Materials and Methods: Twenty-two subjects with varying foot and ankle diagnoses who had little or no improvement in range of motion after traditional assisted physical therapy were recruited from a foot and ankle orthopaedic clinic. The subjects'ankle and subtalar range of motion (ROM) in plantarflexion (PF), dorsiflexion (DF), inversion (INV), and eversion (EVR) were measured using a standard goniometer by a single physiotherapist prior to using the stretching device. The subjects were trained on the proper use of the stretching device and then instructed to use it daily for a 6-week period. Then the same examiner repeated the above measurements. Statistical analysis was performed using a two sample t-test assuming unequal variances. Results: There were statistically significant increases in ROM in all planes tested: DF to PF ( p = 0.0052), and INV to EVR ( p = 0.018). Conclusion: Stretching with the device significantly increased ankle and subtalar ROM. Clinical Significance: The stretching device can be used at home on a regular basis with minimal training and can effectively treat stiffness of the ankle and subtalar joints. It can be cost-effective when compared to use of physiotherapy services.
Treatment of Hallux Rigidus with Cheilectomy Using a Dorsolateral Approach
Authors: Lin Johnny , Murphy G. Andrew
Published: December 2015

Background: Degenerative arthritis of the hallux metatarsophalangeal (MTP) joint can be treated in a variety of ways depending on the severity of the disease. If nonoperative treatment fails, then surgical treatment of Stage I and II has traditionally been cheilectomy. The purpose of this paper was to determine the potential advantages of cheilectomy using a less conventional dorsolateral approach. Materials and Methods: Twenty feet in 20 patients were included in the study with an average age of 53.8 (range, 29 to 69) years. The average followup was 2.8 years. Patient charts and radiographs were reviewed to determine preoperative patient characteristics and clinical-radiographic stage. All patients who qualified for the study were asked to return for evaluation using clinical examination, radiographs, and the AOFAS outcome score. Comparisons were made between preoperative and postoperative values using appropriate statistical analysis. Results: The mean AOFAS score improved from 53.5 to 84.0 ( p < 0.001). The mean range of motion arc improved from 45 to 58 degrees ( p < 0.001). Clinical-radiographic stage progressed in 50%. The most common complication was numbness in the first web space (40%). This loss was imperceptible in all patients until asked during the exam. No patients progressed to fusion during the followup period. Conclusion: Using a dorsolateral approach to perform a cheilectomy is a viable alternative to the more traditional dorsal technique. No obvious advantage over the traditional technique was identified.
Use of Platelet-Rich Concentrate and Bone Marrow Aspirate in High-Risk Patients with Charcot Arthropathy of the Foot
Authors: Pinzur Michael S.
Published: December 2015

Background: Diabetic patients with Charcot arthropathy of the foot are at high risk for nonunion when undergoing arthrodesis. There is increasing evidence that cytokines identified in platelet rich concentrate and bone marrow aspirate may show equivalence to autologous bone graft in supporting arthrodesis. Materials and Methods: Prospectively, 44 high-risk diabetic patients with Charcot foot arthropathy underwent surgical correction of 46 feet through a limited surgical approach. The average age of the patients was 54.9 ± 10.4 years. Their mean BMI was 38.0 ± 9.7. Twenty-four were male and 20 were female. Twenty-eight had open wounds with chronic draining osteomyelitis. Surgical correction was maintained postoperatively with static circular ring fixation. At the time of wound closure, all of the patients had injection of autologous platelet rich concentrate and bone marrow aspirate. Results: Forty-two of the 46 feet had radiographic evidence of bony union at 26.2 ± 12.2 months following surgery. One patient died of unrelated causes. Two underwent amputation for persistent infection. Six had recurrent ulcers which resolved with local treatment. One patient required a fifth ray resection for gangrene following surgery. There were three tibial stress fractures, with two requiring intramedullary nailing to achieve union. Conclusions: Platelet-rich concentrate, when combined with a small amount of autologous bone marrow aspirate, may well be as effective as autologous bone grafting when performing arthrodesis of high risk diabetic patients with Charcot foot arthropathy.
Sclerotherapy for Intractable Ganglion Cyst of the Hallux
Authors: Tanaka Yasuhito , Takakura Yoshinori , Kumai Tsukasa , Sugimoto Kazuya , Taniguchi Akira , Hattori Koji
Published: December 2015

Background: We devised a method of sclerotherapy using OK432. The present study comprised a retrospective followup of sclerotherapy outcomes. Materials and Methods: Eighteen feet in 18 consecutive patients (seven men, 11 women; mean age, 55 years) were treated with sclerotherapy. Previous surgery had been performed one to four times for seven feet. After aspirating the contents of the ganglion cysts, 0.2 to 0.3 ml of suspension of OK432 (lyophilized strep pyogenes) was injected. The volume of fluid aspirated was from 0.2 to 2.5 ml, with an average of 0.9 ml. Mean duration of followup was 3 years 6 months. Clinical evaluation was performed using the AOFAS hallux scale. Results: All ganglion cysts disappeared after sclerotherapy. However, recurrences were observed in eight feet. Mean duration until recurrence was 13 months. Sclerotherapy was again performed for all patients with recurrence. Re-recurrence occurred in three feet. A third sclerotherapy was performed for all three patients. All ganglion cysts had disappeared by final followup. Mean AOFAS score improved from 75 points before therapy to 95 points at followup. Six patients had complications with local redness and pain for 1 to 6 days after injection. Conclusion: Sclerotherapy using OK432 is a minimally invasive treatment of symptomatic ganglion cysts of the hallux. Recurrence is common but complications are infrequent and self-limited.
Screw Versus Plate Fixation of Proximal First Metatarsal Crescentic Osteotomy
Authors: Varner Kevin E. , Matt Victoria , Alexander Jerry W. , Johnston James D. , Younas Shiraz , Marymont John V. , Noble Philip C.
Published: December 2015

Background: Hallux valgus associated with metatarus primus varus is a deformity that disrupts normal foot function. Standard treatment has often included distal or proximal metatarsal osteotomy with or without a distal soft tissue procedure. The intrinsically unstable proximal crescentic osteotomy relies on operative fixation for stability. This study examined the strength of fixation of a single screw versus a plate for stabilization of proximal first metatarsal crescentic osteotomies for correction of hallux valgus. Materials and Methods: A crescentic osteotomy was performed on nine pairs of fresh/frozen cadaveric feet. The distal fragment was rotated laterally and the osteotomy was temporarily stabilized with a Kirschner wire. The osteotomized metatarsal fragments were fixed with a cancellous screw on one side and single plate on the contralateral side. Each specimen was loaded in a mechanical testing machine, and its response was measured by monitoring the opening of the osteotomy and change in alignment of the fragments. Position and alignment of the proximal and distal fragments were calculated. Results: All of the measures of fixation strength were statistically greater in specimens treated with a plate rather than with screw fixation. Plate fixation provided approximately twice the resistance to disruption of the osteotomy under cyclic loading conditions. Conclusion: The dorsal plate is biomechanically more stable than a single cancellous screw when applied to proximal crescentic osteotomies. Clinical Relevance: The greater stability of the plate construct may be helpful in selecting the fixation device for these osteotomies.
Biomechanical Comparison of Screw Versus Plate/Screw Construct for Talonavicular Fusion
Authors: Jarrell Shelby E. , Owen John R. , Wayne Jennifer S. , Adelaar Robert S.
Published: December 2015

Background: Talonavicular fusion is performed for a variety of indications. This study examined the effects of fixation techniques on plantar pressures, construct stiffness, and strength. Materials and Methods: Eight matched pairs of cadaveric lower extremities were axially loaded intact and after talonavicular fixation with a 3.5 reconstruction plate, reconstruction plate plus cancellous screw (plate/screw), or three screws (screws). Recorded plantar pressures were divided into three forefoot, two midfoot, and two hindfoot regions. Cantilevered bending of excised constructs provided stiffness data for plantar and lateral directions, and failure characteristics in plantar bending. Results: Relative to the intact state, all fixations decreased peak pressure in the medial forefoot, while generally increasing it in the lateral forefoot and midfoot. Average pressure shifted laterally for all fixation methods in the forefoot, generally in the hindfoot and the lateral midfoot. Generally, contact areas decreased in the medial forefoot, midfoot, and hindfoot while increasing laterally in the midfoot and hindfoot. The only difference among fixation methods was a decreased medial midfoot contact area for screws. No differences were found between screws and plate/screw in bending stiffness or failure ( p < 0.5 and p < 0.2 respectively). Plantar and lateral bending stiffness for the plate/screw method averaged approximately 363 N/mm while stiffness of the screw only construct averaged approximately 380 N/mm. The load to failure averaged 946 N for the plate/screw construct and 1099 N for the screw construct. Conclusion: This study showed lateralization of plantar pressures following talonavicular fixation. Minimal differences were found between plate/screw and screws. Fixation across the joint may be key to achieving stability sufficient to resist shear and rotational stresses. Clinical Relevance: Plate/screw or screws would likely be similarly effective in fusing the talonavicular joint. However, the fusion induced lateralization of plantar pressures may unintentionally result in adjacent joint arthritis and foot pain.
Prediction of Three-Dimensional Contact Stress and Ligament Tension in the Ankle During Stance Determined from Computational Modeling
Authors: Haraguchi Naoki , Armiger Robert S. , Myerson Mark S. , Campbell John T. , Chao Edmund Y.S.
Published: December 2015

Background: Our goal was to quantify and visualize the three-dimensional loading relationship between the ligaments and articular surfaces of the ankle to identify and determine the stabilizing roles of these anatomical structures during the stance phase of gait. Materials and Methods: We applied discrete element analysis to computationally model the three-dimensional contact characteristics and ligament loading of the ankle joint. Physiologic loads approximating those at five positions in the stance phase of a normal walk cycle were applied. We analyzed joint contact pressures and periankle ligament tension concurrently. Results: Most ankle joint loading during the stance phase occurred across the articular surfaces of the joint, and the amount of ligament tension was small. The tibiotalar articulation showed full congruency throughout most of the stance phase, with peak pressure developing anteriorly toward the toe-off frame. Of the periankle ligaments, the deep deltoid ligament transferred the most force during the stance phase (57.2%); the superficial deltoid ligament transferred the second-most force (26.1%). The anterior talofibular ligament transferred force between the talus and fibula continuously, whereas the calcaneofibular ligament did not carry force during gait. The distal tibiofibular ligaments and the interosseous membrane were loaded throughout the stance phase. Conclusion: Force transmission through the ankle joint during the stance phase is predominantly through the articular surfaces, and the periankle ligaments do not play a major stabilizing role in constraining ankle motion. The medial ligaments have a more important role than do the lateral ligaments in stabilizing the ankle joint. Clinical Relevance: In addition to ligament insufficiency, other factors, such as varus tilt of the tibial plafond, may be important in the development of recurrent instability. Continuous loading of syndesmosis ligaments provides a theoretical basis for evidence of syndesmosis screw breakage or loosening. The analysis method has potential applications for clarifying ankle joint function and providing a basis for comparison between normal and abnormal joint conditions.
Direct Visualization for Syndesmotic Stabilization of Ankle Fractures
Authors: Miller Anna N. , Carroll Eben A. , Parker Robert J. , Boraiah Sreevathsa , Helfet David L. , Lorich Dean G.
Published: December 2015

Background: Ankle fractures with syndesmotic injury treated via standard trans-syndesmotic fixation have a high percentage of syndesmotic malreduction. 10 We established a protocol involving both direct syndesmosis visualization and meticulous tibial incisura reconstruction via the posterior malleolus fracture fragment, when present, via the attached, intact PITFL, then compared this with historic controls to assess improvement after this type of syndesmosis reconstruction. Materials and Methods: One hundred forty-nine consecutive direct visualization patients were treated prospectively with either open posterior malleolus reduction and fixation, regardless of fragment size (“PM”: 38 patients), or, with no posterior malleolar fracture, open fixation with locked syndesmotic screws (“S”: 97 patients); fracture-dislocations combined both fixation types (“C”: 16 patients). The syndesmosis was opened and debrided in all. All patients had preoperative MRI and postoperative CT. Distances between the fibula and anterior and posterior incisura facets were measured on axial CT. An incongruent joint was defined as an A-P difference greater than 2 mm. Our historic controls were 25 patients previously fixed via indirect, fluoroscopic reduction and syndesmotic screws. Results: In the direct visualization group, 24 ankles (16%) had incongruity, compared with 13 controls (52%). The average difference between anterior and posterior colliculi measurements between PM and C was significant ( p = 0.017). Conclusion: Malreductions were significantly decreased in the direct visualization group. However, our reduction sometimes remains imprecise, even with direct visualization and attention to detail. Also, posterior malleolar reconstruction was more accurate than syndesmotic screw fixation in our study.
Three-Dimensional In Vivo Kinematics of the Subtalar Joint During Dorsi-Plantarflexion and Inversion–Eversion
Authors: Goto Akira , Moritomo Hisao , Itohara Tomonobu , Watanabe Tetsu , Sugamoto Kazuomi
Published: December 2015

Background: It is difficult to determine the kinematics of the subtalar joint because of its anatomical and functional complexity. The purpose of the study was to clarify the 3D kinematics of the subtalar joint in vivo. Materials and Methods: Subjects were four healthy female volunteers. Magnetic resonance imaging (MRI) sequences were acquired in seven positions during dorsi-plantarflexion (DPF) and in 10 positions during inversion-eversion (IE) at intervals of 10 degrees. MRI data of the talus and calcaneus in the neutral position were superimposed on images of the other positions using voxel-based registration, and relative motions and axes of rotation were visualized and quantitatively calculated. Results: The calcaneus always rotated from dorsolateral to medioplantar during DPF and IE, and the motion plane was very similar to that of the entire foot in IE. The axes of rotation of the calcaneus relative to the talus during DPF and IE had a very close spatial relationship, running obliquely from antero-dorsomedial to postero-planto-lateral and penetrating the talar neck. The rotation angle around each of these calcaneal axes tended to be greater in IE (20 degrees ± 2 degrees) than in DPF (16 degrees ± 3 degrees). In DPF, motion of the calcaneus relative to the talus occurred predominantly around maximum dorsiflexion and plantarflexion, with little movement observed at intermediate positions. During IE, the calcaneus exhibited uninterrupted motion related to foot movement. Conclusion: The subtalar joint is essentially a uniaxial joint with a motion plane almost identical to that of IE of the entire foot. Clinical Relevance: Knowledge of normal subtalar kinematics may be helpful when evaluating pathologic conditions.
Zone 2 Flexor Hallucis Longus Tendoscopy: A Cadaveric Study
Authors: Lui Tun Hing , Chan Kwok Bill , Chan Lap Ki
Published: December 2015

Background: The purpose of this study was to verify the safety and efficacy of zone 2 flexor hallucis longus tendoscopy with the patient in the prone position. Materials and Methods: The technique was performed in 12 cadaver feet (6 pairs). The endoscopic findings were compared to an anatomic dissection. The locations of the posteromedial and plantar portals were studied. The relationship between the medial plantar nerve and the tract of FHL tendoscopy was also studied. Result: The average distance of the posteromedial portal above the medial malleolar tip was 10.3 mm. The average distance between the posteromedial portal and the posterior tibial nerve was 9.9 mm. The average distance between the plantar portal and the intermalleolar line was 41.5 mm. The average distance between the rod simulating the tenoscope and the nerve was 4.8 mm. The nerve was medial to the rod in 4 specimens and lateral to the rod in 8 specimens. Conclusion: Zone 2 flexor hallucis longus tendoscopy was a feasible approach to the deep portion of the flexor hallucis longus tendon in this cadaveric study. There is potential risk of damage to the medial plantar nerve. Clinical Relevance: These findings can help guide a surgeon who is considering trying this clinically.
Axial Load Weightbearing Radiography in Determining Lateral Malleolus Fracture Stability: A Cadaveric Study
Authors: Stewart Christopher , Saleem Omar , Mukherjee Debi P. , Suk Michael , Marymont John , Anissian Lucas
Published: December 2015

Background: Ankle fractures are the most common fracture treated by orthopaedic surgeons in the United States. Isolated lateral malleolus fractures are treated nonoperatively, while associated deltoid disruption injuries are unstable and usually treated by fixation of the fracture. Various stress radiographs and MRI have been used to determine deltoid competency and the subsequent need for operative stabilization of lateral malleolus fractures. To date, no standardization of stress radiography has been performed. The aim of this study was to evaluate the ability of weightbearing ankle X-rays to determine stability and their reliability. Methods: This study sought to utilize simulated weightbearing radiography as a potential method to determine the need for lateral malleolus fixation. Twelve cadaveric ankle specimens were tested by obtaining ankle mortise radiographs for interpretation of medial clear space. Each ankle was tested with 0, 25, 36, and 50 kg of axially applied weight. The groups of measurements obtained were: intact ankles (Group A), ankles with an isolated oblique fibular osteotomy (Group B), and osteotomized ankles after complete deltoid ligament transaction (Group C). Three authors measured the medial clear space for every ankle using PACSR software. Instability of the ankle mortise was defined as medial clear space widening of greater than 2 mm from the intact ankle. Results: An isolated lateral malleolus fracture (Group B) and a lateral malleolus fracture with an incompetent deltoid ligament (Group C) showed no statistical medial clear space widening with simulated axial weightbearing radiography when compared to intact ankles (Group A). ANOVA's between Group A and B had p < 0.001, and between Group A and C of p < 0.001. Conclusion: Our model did not find instability with an osteotomized fibula and a disrupted deltoid. Clinical Relevance: This study suggests a weightbearing radiograph of an isolated lateral malleolus fracture cannot determine deltoid ligament integrity and thus need for fibular operative fixation.
Early Results After Tibialis Anterior Tendon Transfer for Severe Varus in Total Ankle Replacement
Authors: Hamel Johannes
Published: December 2015

Background: Treatment of severe ankle arthritis with varus malalignment remains controversial. Methods: In 14 consecutive total ankle replacements (TAR) with tibiotalar varus malalignment of above 15 (range, 16 to 41) degrees, a complete transfer of the tibialis anterior tendon together with other soft-tissue and bony realignment measures was added to the primary procedure. Results: After mean followup time of 33.4 (range, 21 to 49) months, only one case showed minor tibiotalar tilt in the frontal plane. The overall clinical results were good to excellent in all but two cases with an average AOFAS-score of 86.4 (range, 70 to 98) points. However, three cases of tibial nerve neuropathy due to entrapment or overtensioning were observed; one of these cases developed clinical problems with incomplete recovery. Conclusion: Tibialis anterior tendon transfer can be recommended in conjunction with TAR in cases of varus malalignment with severe muscular or ligamentous imbalance with neuropathy of the tibial nerve being the main complication.

Level of Evidence: IV, Retrospective Case Series