bluuebunny/crossref_metadata_2025 huggingface dataset:
Minor Environmental Trauma and Lower Extremity Amputation in High-Risk Patients with Diabetes: Incidence, Pivotal Events, Etiology, and Amputation Level in a Prospectively Followed Cohort
Authors: Smith Douglas G. , Assal Mathieu , Reiber Gayle E. , Vath Christy , LeMaster Joseph , Wallace Carolyn
Published: January 2017

This study determined the incidence, pivotal events, etiology, and levels of amputation in a prospectively followed cohort of 400 people with diabetes and a prior healed foot ulcer who participated in a randomized footwear trial. Participants were seen every 17 weeks for 2 years. Subjects with foot lesions were referred to their healthcare provider for treatment. In this cohort, 11 participants required lower limb amputation (rate 13.8 per 1000 person-years). Pivotal event analysis revealed that only one amputation was related to footwear, six amputations were due to non-footwear-related minor environmental trauma, two were due to progression of vascular disease (dry gangrene from critical ischemia), one was due to a self-care injury while cutting the toenails, and one was due to a decubitus ulcer. Previously proposed strategies to reduce the amputation rates in individuals with diabetes have focused heavily on footwear and education. However, even with this emphasis, amputation rates in the United States are still high. This study suggests that the prevention of minor environmental trauma, including household accidents, merits additional attention. We believe that further efforts to reduce amputation rates for individuals with diabetes will need to emphasize the prevention of minor trauma, especially in those already compromised with neuropathy and vascular disease.
Kinematic Changes After Fusion and Total Replacement of the Ankle Part 1: Range of Motion
Authors: Valderrabano Victor , Hintermann Beat , Nigg Benno M. , Stefanyshyn Darren , Stergiou Pro
Published: January 2017

Background: The purpose of this study was to determine how closely the present designs of ankle prostheses mimic the unique requirements of the foot and ankle. The three-dimensional range of motion (ROM) of the ankle joint complex, before and after ankle arthrodesis and after implantation of three currently used total ankle prostheses, was investigated. Methods: The three-dimensional ROM was determined in six fresh-frozen cadaver leg specimens using a 6-df device with an axial load of 200 N and a four-camera high-speed video system. A moment of 100 Nm was applied to the footplate to determine the ROM in the sagittal (dorsiflexion and plantarflexion) and frontal (inversion and eversion) planes. The same moment was applied to the tibia to determine the ROM for the internal and external tibial rotation. The measurements were performed for the normal ankle, the fused ankle, and the AGILITY, HINTEGRA, and S.T.A.R. prostheses. Results: Compared to the normal condition, the ROM for dorsiflexion and plantarflexion was changed for all surgical interventions. The changes were highest for the ankle arthrodesis. The changes due to the prostheses were significantly less than the changes due to ankle arthrodesis. Compared to the normal condition, the total ROM for inversion/eversion was slightly decreased by the fused ankle and not changed by the three-component prostheses (HINTEGRA, S.T.A.R.). However, the ROM for inversion/eversion was significantly higher for the two-component prosthesis, AGILITY. The ROM for internal and external tibial rotation was not altered by the AGILITY and HINTEGRA ankle, but it was significantly reduced by the ankle arthrodesis. S.T.A.R. showed a significant shift of the total ROM toward internal tibial rotation. Conclusions: The three tested ankle joint prostheses changed the ROM of the ankle joint complex less than ankle fusion did. Total ankle prostheses were shown to replicate normal joint ROM closely. However, ankle arthrodesis was found to reduce the ROM substantially in all three planes: the sagittal, frontal, and horizontal planes. Clinical Implications: With respect to the ROM, total ankle replacement changes the natural ankle joint condition less than ankle arthrodesis, which reduces the ROM in all three planes and might increase stress in adjacent structures. The prosthesis that replicated the normal ankle joint ROM best was the one with the most anatomical design.
Reliability of Isokinetic Dynamometry in Assessing Plantarflexion Torque Following Achilles Tendon Rupture
Authors: Chester Rachel , Costa Matthew L. , Shepstone Lee , Donell Simon T.
Published: January 2017

Background: Research investigating the most effective management of Achilles tendon injury has been limited by a lack of reliable outcome measurements. Calf strength may be a valid outcome measure, not only in terms of identifying possible risk factors for reoccurrence of rupture, but also as an indicator of recovery. Isokinetic dynamometry has been suggested as an effective tool for measuring the torque of the calf muscles. Such measurements have demonstrated high reliability for the assessment of calf muscle torque in healthy subjects. However, there are no published data to demonstrate the reliability of isokinetic dynamometry in subjects with pathology in the Achilles tendon. The purpose of this study was to assess the inter- and intraobserver reliability of isokinetic dynamometry for assessing plantarflexion torque following Achilles tendon rupture. Methods: Two independent observers used the Kin-com Dynamometer to measure the torque of the plantarflexors in 22 subjects 6 months after unilateral rupture of the Achilles tendon. Twelve subjects had been managed operatively and 10 nonoperatively. Subjects were placed in the prone position with the knee extended. Measurements of peak torque, average torque, and total work were made for both concentric and eccentric plantarflexion movements at 60° per second. Results: Intraclass correlation coefficients were used to calculate reliability of measurements both within and between observers. Reliability was slightly greater on the healthy side (0.74–0.92 ICC) in comparison with the injured side (0.74–0.89 ICC). Conclusion: The results of this study suggest that isokinetic dynamometry provides a reliable method of measuring the torque of the plantarflexors following rupture of the Achilles tendon, with levels of reliability comparable with those from healthy subjects. The study concludes that this would be a valuable and reliable outcome measure for use in clinical trials.
Lesser Metatarsophalangeal Joints: Intra-articular Distension, Volumetric Measurements, and Changes of Position
Authors: Mizel Mark S. , Gutmann Joseph M. , Ahn Uri , Temple H. Thomas
Published: January 2017

Plantarflexion of the second metatarsophalangeal (MTP) joint with intra-articular injection has previously been observed and commented upon, and the purpose of this study was to determine motion of the lesser toes with direct fluid infusion into the lesser MTP joints. Fluid distension was found to cause variable postural changes in all lesser toes; the most consistent change was plantarflexion of the second metatarsophalangeal joint. Dorsiflexion of the third, fourth, and fifth MTP joints was observed, but less reliable than plantarflexion of the second MTP joint. The average volume in each of the lesser MTP joints was less than 1 cc. Plantarflexion of the second MTP joint was usually, but not always, indicative of intra-articular distention. Aspiration of these joints (given their small volume capacity) may not be a reliable or therapeutically useful technique.
Arthroscopic Treatment for Anterior Impingement Exostosis of the Ankle: Application of Three-Dimensional Computed Tomography
Authors: Takao Masato , Uchio Yuji , Naito Kohei , Kono Taisuke , Oae Kazunori , Ochi Mitsuo
Published: January 2017

The purpose of this study was to evaluate the operative results of excision of anterior impingement exostoses of the ankle. Preoperative three-dimensional computed tomography (3DCT) was used to make the diagnoses. The authors evaluated 16 ankles of 16 patients who underwent arthroscopic resection of the osteophytes of their anterior distal tibia or dorsal talus. They were followed up for 24–51 months. All 16 patients had 3DCT preoperatively, which allowed the authors to determine the exact location, shape, size, and number of the osteophytes. All of the osteophytes were resected using arthroscopic techniques. At the time of the most recent follow-up, the mean AOFAS score was 80.5 ± 4.9 points at preoperation, and 97.0 ± 3.7 points at the most recent follow-up. There were significant differences between the pre- and postoperative AOFAS scores and those of the most recent follow-up period for each group ( p < .0001). It is necessary to clarify the location, size, shape, and number of all of the osteophytes preoperatively using 3DCT, and to then resect them all.
The Nomenclature for Intra-articular Vertical Impact Fractures of the Tibial Plafond: Pilon Versus Pylon
Authors: Michelson James , Moskovitz Peter , Labropoulos Panos
Published: January 2017

Although most of the controversy surrounding the treatment of intra-articular, vertical impact fractures of the lower tibia is due to the difficult clinical problems they pose, there is a minor, ongoing dispute regarding nomenclature. In the last several decades, these fractures have been called either pilon or pylon fractures. This study traces the etymology of both terms and relates them to their usage in the orthopaedic literature. Based on the origins of each word, and how they were introduced into the orthopaedic literature, it is concluded that the correct term for an intra-articular, vertical impact fracture of the lower tibia is pilon fracture.
Percutaneous versus Open Tendo Achillis Repair
Authors: Haji Amyn , Sahai Arun , Symes Andrew , Vyas J.K.
Published: January 2017

A retrospective analysis was conducted comparing open and percutaneous repair of ruptured Achilles tendon, over a 14-year period. One hundred and eight patients were identified; 70 underwent traditional open repair and 38 had a modified Ma & Griffith repair. The mean operating time with percutaneous repair was 28.5 minutes compared to 45.9 in the open group ( p = < .0001). Comparable results were obtained in a subjective analysis of range of movement, stiffness, and power in both groups at time of discharge from clinic. In the open group there were four cases of rerupture (5.7%), four deep infections (4.7%), two palpable suture knots (2.9%), and one sural nerve lesion (1.4%). Complications with percutaneous repair included one rerupture (2.6%), five palpable suture knots (13.2%), four transient sural nerve lesions (10.5%), and no wound infections. There was no statistical significance between the two groups. The authors advocate percutaneous repair, in experienced hands, as a suitable alternative to traditional open techniques.
Comprehensive Reconstruction of the Lateral Ankle for Chronic Instability Using a Free Gracilis Graft
Authors: Coughlin Michael J. , Schenck Robert C. , Grebing Brett R. , Treme Gehron
Published: January 2017

Purpose:

The purpose of this retrospective study was to assess the results of a novel surgical technique for the treatment of chronic lateral ankle instability using both a direct repair of the anterior talofibular ligament and a free gracilis tendon transfer to reconstruct anatomically the anterior talofibular and calcaneofibular ligaments.

Methods:

Between December 1998 and February 2002, 28 patients (29 ankles) underwent an anatomic reconstruction of the lateral ankle ligaments for chronic ankle instability. Patients returned for a clinical and radiologic follow-up evaluation at an average of 23 months following surgery (range, 12–52 months). Outcomes were assessed by comparison of preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores and visual analog pain scores as well as a postoperative Karlsson score. A subjective self-assessment rating was also obtained. All patients underwent preoperative and postoperative radiographic assessment including talar tilt and anterior drawer stress radiographs.

Results:

Twenty-eight patients (29 ankles) (100%) returned for final evaluation. Good or excellent outcome was noted on patient subjective self-assessment, pain scores, AOFAS, and Karlsson scores at final follow-up in all patients. Ankle range of motion was not affected by lateral ankle reconstruction. The talar tilt was reduced from a mean of 13° to 3° ( p < .0001) and the anterior drawer was reduced from a mean of 10 mm to 5 mm ( p < .0001) by the lateral ankle ligamentous reconstruction.

Conclusion:

In the present study, lateral ankle reconstruction with a direct anterior talofibular ligament repair and free gracilis tendon graft augmentation resulted in a high percentage of successful results, excellent ankle stability with a minimal loss of ankle or hindfoot motion, and marked reduction of pain at an average follow-up of almost 2 years.
Factors affecting Recurrence Rate of Ingrown Toenail Treated with Marginal Toenail Ablation
Authors: Kuru Ilhami , Sualp Turan , Ferit Dereboy , Gunduz Tezeren
Published: January 2017

This retrospective study analyzed marginal toenail ablation for ingrowing toenails and the factors affecting recurrences. Recurrence was defined as a return of the previous symptoms, regrowth of the nail edge, or patient dissatisfaction with the clinical outcome. Based on these criteria, nine patients (10.7%) were considered to have had a failed operation. There were significant differences for recurrence rate ( p < .05) in the patients operated on under local anesthesia and in previously treated patients. Full exposure and excision of the germinal matrix were essential to avoid recurrence.
Morbidity Associated With Anterior Iliac Crest Bone Grafting in Foot and Ankle Surgery
Authors: DeOrio James K. , Farber Daniel C.
Published: January 2017

Background: Substitutes for bone graft have been advocated to avoid the potential morbidity associated with harvest of autogenous iliac crest graft. However, no current commercially available graft equals autogenous bone's osteoinductive and osteoconductive qualities. We reviewed our patients' morbidity after harvest of anterior iliac crest bone grafts for procedures involving the foot and ankle. Methods: A computerized analysis of patient records was undertaken to identify all patients who had a harvest of unicortical iliac crest bone graft during a 12-year period. Patients were contacted either by telephone or by mailed questionnaire, inquiring about the postoperative morbidity of the procedure. Medical records were reviewed for any related complications. Results: Of the 169 patients identified, 134 could be contacted. Follow-up ranged from 1 to 13 years. Not all patients answered every question. At latest follow up, 120 (90%)-patients reported no pain at the bone graft site. Eleven patients complained of persistent residual numbness lateral to the harvest site on the pelvis. Of these 120 patients, 32 (27%) reported that pain at the graft site was greater than the pain at the operative site during the initial postoperative period. No patients had extra hospital days as a result of the bone graft harvest. No deep infections occurred, although 12 (6.7%) of 180 patients had a postoperative hematoma or seroma. Overall, 116 (90%) of 129 patients were satisfied or very satisfied with their bone graft harvest. Conclusions: Harvesting of autogenous iliac crest bone graft provides the optimal bone graft material, yields minimal morbidity, and is an acceptable choice in supplementing surgical procedures on the foot and ankle.
Proximal Crescentic Metatarsal Osteotomy: The Effect of Saw Blade Orientation on First Ray Elevation
Authors: Jones Carroll , Coughlin Michael , Villadot Ramon , Golanó Pau
Published: January 2017

Background: Moderate and severe hallux valgus deformities generally require a proximal metatarsal osteotomy to correct a widened intermetatarsal angle. Although excellent results have been reported using the proximal crescentic osteotomy, concerns have been raised about the incidence of postoperative dorsal malunion, which may lead to transfer lesions. The objectives of this paper were to evaluate the influence of saw blade angulation on the final position of the first metatarsal and to test a new technique used to ensure proper orientation of the osteotomy. Methods: For part I of the study, 26 Sawbones® specimens with hallux valgus deformities were corrected using a proximal crescentic osteotomy with the saw blade position incrementally rotated in the coronal plane. The sagittal change in the final position of the metatarsal was quantified radiographically and correlated to the saw blade orientation. For part II of the study, a Kirschner wire was placed in a vertical position into the medial cuneiform to serve as a guide for the crescentic saw blade in 13 cadaver feet with hallux valgus. Metatarsus primus elevatus was measured after surgical correction. Results: Part I of the study demonstrated a highly linear relationship ( R2 = 0.95) between first metatarsal elevation and the orientation of the saw blade. Every 10-degree of saw blade angulation resulted in a 2-mm change in the sagittal position of the first metatarsal. In part II of the study, the average change in metatarsus primus elevation for the 13 specimens after surgical correction of the hallux valgus deformity was only 1.1 mm (range −3.9 to +4.9 mm). Eleven of the 13 specimens had less than 2.5 mm of elevatus. Conclusion: Dorsal malunion of the first metatarsal after proximal crescentic osteotomy is a recognized complication. The final position of the hallux metatarsal is influenced by the coronal plane orientation of the saw. A new technique is described to aid the surgeon in proper alignment of the saw and help prevent excessive first ray elevation.
Tenosynovitis of the Flexor Hallucis Longus: A Clinical Study of the Spectrum of Presentation and Treatment
Authors: Michelson James , Dunn Laura
Published: January 2017

Background: Symptoms associated with flexor hallucis longus (FHL) pathology can manifest themselves anywhere along its length from the posterior leg to the plantar foot and the hallux. This study describes the spectrum of clinical presentations seen with FHL pathology, illustrates the relevant physical examination findings, and outlines a treatment approach. Materials: Computerized medical data was prospectively collected on 81 patients treated between January, 1997 and March, 2002. The 55 females and 26 males had an average age of 38.3 years, with a mean follow-up of 21.3 months. Forty-five of 81 had previous therapy that failed, usually for “plantar fasciitis.” Twenty-seven were active athletically and 24 related the onset of symptoms to a specific traumatic episode. Pain was located at the posteromedial ankle in 40, plantar heel in 23, plantar midfoot in 22, and multiple locations in 16. All patients had tenderness of the FHL. Restriction of FHL excursion was demonstrated in 30 patients by limited hallux metatarsophalangeal joint dorsiflexion when the ankle was dorsiflexed (“FHL stretch test”). Thirty-four patients had magnetic resonance imaging of the FHL, 28 (82%) of which were positive for synovitis of the FHL. Treatment included an FHL stretching program, short-term immobilization, and operative decompression and synovectomy in patients for whom nonoperative treatment failed. Results: Of the 58 patients treated nonoperatively, 37 (64%) had successful results. Twenty-three patients had surgery, 20 at the posterior ankle fibro-osseous tunnel, and three in the sesamoid region. All patients treated operatively had successful outcomes. A subset of 10 patients had hallux rigidus symptoms without significant osteophyte formation. All 10 obtained successful results with treatment directed at restoring normal FHL excursion (nine nonoperatively, one by FHL release). This suggests that limited FHL excursion may be an etiology for the development of hallux rigidus. Conclusions: Clinical syndromes related to the FHL are more frequent than previously reported. The close relationship of the FHL to commonly injured structures (such as the plantar fascia) contributes to significant delays in effective treatment.
Clinical and Radiographic Features of Operatively Treated Stiff Clubfeet after Skeletal Maturity: Etiology of the Deformities and How to Prevent Them
Authors: Docquier Pierre-Louis , Leemrijse Thibaut , Rombouts Jean-Jacques
Published: January 2017

Backgrounds: Residual deformities of operatively treated severe clubfeet evaluated radiographically have been rarely studied in detail in adults. Methods: Twenty-five operatively treated stiff clubfeet were analyzed at a mean age of 21 years and 6 months. The clinical evaluation used the Laaveg and Ponseti scale for clubfeet. Radiographic assessment was done with weight-bearing and dynamic views. Results: Clinical evaluation was globally good except for motion (poor). Radiographic assessment showed residual abnormalities in all feet. The distal tibial epiphysis showed slanting of its posterior part in seven feet (28%) and notching of its anterior lip in 13 (52%). Talar length, calcaneal length, and talar trochlear height were significantly smaller in clubfeet compared to normal feet. Undercorrection of hindfoot varus, was found in 19 feet (76%) but was well tolerated. Navicular wedging was present in seven (28%), and cavus deformity was found in seven (28%). Dorsal bunion, hallux varus, and skewfoot were found in four (16%), two (8%), and three (12%), respectively. The dynamic views demonstrated a significant decrease in the foot and ankle mobility with compensation mechanisms such as anterior talar incongruence or midfoot hypermobility. Conclusion: Severe clubfeet never become normal at adult age either clinically or radiographically. Multiple radiographic deformities exist. Their etiology and possible prevention are discussed. Despite the numerous abnormalities, clinical results were good at skeletal maturity.
An Analysis of Talar Surface Area Occupied by Screw Fixation in Ankle Fusions
Authors: Brodsky Adam R. , Bohne Walther H.O. , Huffard Benjamin , Kennedy John G.
Published: January 2017

Background: Ankle arthrodesis remains the benchmark of treatment for end-stage arthrosis of the ankle joint. Despite that, the incidence of nonunion can be as high as 15%. Various strategies have been used to reduce the incidence of nonunion, including multiple compression screws and larger diameter screws to improve mechanical stability and compression. The space occupied by an increasing amount of hardware across a finite surface area available for fusion has prompted concern that this strategy may be counterproductive and may reduce the biological potential of the construct. The purpose of this study was to look at 40 anatomic sawbone specimens of the ankle to determine the amount of talar surface contact area used by the screw fixation during arthrodesis. Methods: Four groups were created to examine different techniques for arthrodesis. Simulated ankle arthrodeses were done using two- or three-screw fixation with 6.5-mm and 7.3-mm screws. Hardware was subsequently removed and the surface area used by the passing screws was measured. Total surface areas were calculated for each of the 40 specimens. Results: The maximal surface area of the talus occupied by screws occurred when using three 7.3mm screws. This configuration used 16% of the possible talar surface area available for arthrodesis. Conclusion: The use of additional screw fixation when performing an ankle arthrodesis does not sacrifice a major amount of the tibiotalar contact area and will most likely not affect the biologic environment needed to obtain fusion.
Surgical Management of Insertional Calcific Achilles Tendinosis With a Central Tendon Splitting Approach
Authors: Johnson Keith W. , Zalavras Charalampos , Thordarson David B.
Published: January 2017

Background: Insertional calcific Achilles tendinosis is a painful, frequently disabling condition. Numerous operative approaches for this problem have been described. This study evaluated the outcome of a central tendon splitting approach. Methods: Twenty-two patients were evaluated after a central tendon splitting approach for persistent insertional calcific Achilles tendinosis. Followup averaged 34 (11 to 64) months. Suture anchors were routinely used to augment the tendon insertion after debridement. An American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, shoewear comfort, and return to work were evaluated. A paired t-test was used to evaluate the results. Results: Pain significantly improved from 7 points preoperatively to 33 points postoperatively ( p < 0.001). Function improved significantly from 36 points to 46 points ( p < 0.001). The ankle-hindfoot score improved from 53 points to 89 points ( p < 0.001). Age older or younger than 50 years did not affect outcome. Conclusion: A central tendon splitting approach yielded good relief of pain with improved function, shoewear, and ability to work without painful postoperative scars.
Scarf Osteotomy for Hallux Valgus Deformity: An Intermediate Followup of Clinical and Radiographic Outcomes
Authors: Aminian Arash , Kelikian Armem , Moen Todd
Published: January 2017

Background:

The scarf osteotomy is a versatile and reproducible procedure for the correction of moderate to severe hallux valgus deformity (intermetatarsal angle 12 to 20 degrees hallux valgus angle 20 to 46 degrees).

Methods:

We evaluated the results of 27 consecutive scarf osteotomies at an average followup of 16.1 months. Radiographic parameters, foot pressure analysis, and AOFAS scores were analyzed before and after surgery.

Results:

Hallux valgus angles improved from 34.5 to 16.9 degrees, intermetatarsal angles improved from 15.4 to 10.1 degrees, AOFAS scores improved from 54.5 to 86.5. There was no change between the preoperative and postoperative relative lengths of the first and second metatarsals, defined as the difference between the first and second metatarsal lengths. The measurement was based on the anteroposterior standing radiographs and measured by a line intersecting the midway point at the diaphyseal-metaphyseal junction of the metatarsal and extending from the most proximal to distal aspects of the bone. The angle of Meary (talo-first metatarsal angle) did not change, except in one patient. Foot pressure analysis showed no evidence of transfer metatarsal lesions. The complication rate was 1.1% including superficial infection and recurrence.

Conclusions:

The scarf osteotomy provides a predictable and effective correction of moderate to severe hallux valgus deformities.
Metatarsophalangeal Joint Arthrodesis after Failed Keller-Brandes Procedure
Authors: Vienne Patrick , Sukthankar Atul , Favre Philippe , Werner Clement M.L. , Baumer Andrea , Zingg Patrick O.
Published: January 2017

Background:

Keller-Brandes resection arthroplasty for correction of symptomatic hallux valgus deformity can obtain early good results, but late complications, such as recurrence of the deformity and instability of the first ray, have been described. Arthrodesis of the first metatarsophalangeal, (MTP) joint can be done as a salvage procedure. The aim of this prospective study was to evaluate the clinical outcome of the arthrodesis and its effect on the biomechanics of the first ray.

Methods:

Between October, 1999, and December, 2002, arthrodesis of the MTP joint was done after a failed Keller-Brandes procedure in 28 feet of 26 consecutive patients. Twenty patients (22 feet) with a minimum of 24 months followup were available for clinical and radiographic assessment. Pedobarographic measurements were obtained at latest followup in 16 patients (17 feet).

Results:

Sixteen feet (72%) were pain-free and six feet (28%) had mild, occasional pain. The American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score increased from a preoperative 44 (range 29 to 67) points to 85 (range 73 to 90) points at longest clinical followup (average 34 months, range 23 to 48, p < 0.001). The average hallux valgus angle was corrected from 24.0 (range 7 to 47) degrees preoperatively to 16.0 (range 0 to 40) degrees postoperatively ( p < 0.001). Two feet had pseudoarthroses. Biomechanically, the MTP joint arthrodesis could not fully restore the function of the hallux but produced a significant improvement, allowing a more physiologic loading pattern under the hallux and the metatarsal heads.

Conclusions:

First MTP joint arthrodesis after a failed Keller-Brandes procedure is a technically safe and reliable technique. It resulted in a marked reduction of pain and gain of function that produced high patient satisfaction.
Achilles Tendon Torsion Has No Effect on Percutaneous Triple-Cut Tenotomy Results
Authors: Hoffman Brian , Nunley James
Published: January 2017

Background:

Achilles tendon lengthening is an important part of the operative management of numerous foot and ankle disorders. The most commonly used percutaneous technique involves three hemitenotomies: medial, lateral, and medial. The discovery that Achilles tendon fibers may undergo external torsion created concern that improper consideration of this feature could result in fiber division insufficient to allow adequate percutaneous lengthening. Varying degrees of torsion have been reported since it was originally described. We hypothesized that torsion of the Achilles tendon does not decrease the effectiveness of a percutaneous lengthening procedure. This hypothesis was tested by comparing the medial-lateral- medial tenotomy pattern to a lateral-medial-lateral pattern. If tendon torsion affects fiber division, then asymmetrical tenotomy patterns should yield different results.

Methods:

Mechanical testing was performed using 22 human fresh tissue lower extremities. Specimens were divided into two groups (11 in each group): “MLM” which underwent testing using a medial-lateral-medial pattern and “LML” which underwent a lateral-medial-lateral pattern. Dorsiflexion load was applied evenly across the forefoot and measured with a force transducer. Dorsiflexion measurements were made from reproducible reference marks. After testing, specimens were dissected to examine tenotomy gap widths and other tissue effects.

Results:

All specimens lengthened successfully. None of the following parameters were statistically different: pre-tenotomy or post-tenotomy dorsiflexion, force to lengthen, total tissue lengthening, and individual gap widths. In no specimen was there complete disruption of the Achilles tendon, and in 18 of 22 specimens (81.8%) the paratenon sleeve was intact except for the tenotomy puncture. In one LML specimen, the sural nerve was partially cut at the distal tenotomy site.

Conclusions:

Regardless of pattern, percutaneous triple-cut Achilles tendon lengthening was effective in achieving additional dorsiflexion at roughly one-third degree per millimeter of tissue lengthening. The pattern of the Achilles tendon lengthening used and, by inference, Achilles tendon torsion had no effect on achievable dorsiflexion. One explanation is that both patterns cut all tendon fibers at least once. We concluded that a properly designed triple-cut tenotomy would be successful regardless of Achilles torsion. Percutaneous Achilles tendon lengthening also appears to be a safe procedure if care is taken to avoid the sural nerve.
Aircast Walking Boot and Below-Knee Walking Cast for Avulsion Fractures of the Base of the Fifth Metatarsal
Authors: Shahid Mohammad Kamran , Punwar Shahid , Boulind Caroline , Bannister Gordon
Published: January 2017

Background:

Acute avulsion fractures of the base of the fifth metatarsal are common and are treated in a variety of ways. The aims of this study were to compare pain, functional outcome, and time taken off work after treatment with a walking boot or a short-leg cast.

Methods:

Of 39 patients with acute avulsion fractures of the base of the fifth metatarsal, 23 were treated with a short-leg cast and 16 with a walking boot, according to the preference of the consultant present at outpatient clinic. Functional outcome was assessed by the Visual Analogue Scale Foot and Ankle Questionnaire (VAS FA), pain, and other complaints on presentation and at 3, 6, 9, and 12 weeks after injury. The VAS FA scores were compared between the 2 groups by a paired Student t test.

Results:

The mean time to return to the level of pain and function before injury was approximately 9 weeks after treatment in the walking boot group and 12 weeks with a short-leg cast. Patients with walking boots reported less pain between 3 and 12 weeks than did those with short-leg casts after 6 ( P = .06), 9 ( P = .020), and 12 weeks ( P = .33). Function was significantly better with Aircast walking boots after 3 ( P = .006), 6 ( P = .002), and 9 weeks ( P = .002) but not after 12 weeks ( P = .09). Patients returned to their preinjury level of driving after 6 weeks with walking boots and 12 weeks with short-leg casts ( P = .006). Employed patients took a mean of 35.8 days off work (range, 28-42 days), fewer with boots (31.5 days) than with short-leg casts (39.2 days).

Conclusion:

The walking boot was better treatment than a short-leg cast for avulsion fractures of the base of the fifth metatarsal. Patients had an improved combined level of pain and function 3 weeks earlier, at 9 weeks post injury, when managed in a walking boot.

Level of Evidence:

Level II, prospective comparative series.
Cavovarus Foot Realignment to Treat Anteromedial Ankle Arthrosis
Authors: Krause Fabian G. , Henning Julia , Pfander Gilles , Weber Martin
Published: January 2017

Background:

Adult patients with cavovarus feet were seen with symptomatic anteromedial ankle arthrosis and, frequently, lateral hindfoot instability. Static and dynamic realignment was performed to redistribute joint contact pressures and restore stability.

Methods:

Thirteen patients with fixed cavovarus feet (6 neurogenic, 7 idiopathic; 6 with hindfoot instability, 7 without) and mild to moderate anteromedial ankle arthrosis were treated by osteotomies and tendon transfers but no lateral ligament reconstruction. Anteromedial cheilectomy of the ankle was added to increase dorsiflexion and alleviate anteromedial impingement.

Results:

Failure occurred in 2 patients, who required additional procedures. The remaining 11 patients improved from preoperative 45 to 71 points (American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score) at the latest follow-up (average 84 months). Ankle dorsiflexion improved 7 degrees on average. There was no recurrent hindfoot instability and no progression of anteromedial ankle arthrosis over time.

Conclusion:

Cavovarus foot realignment with anteromedial ankle cheilectomy reliably improved patients’ symptoms related to ankle arthrosis, restored lateral hindfoot stability, and stabilized the extent of anteromedial ankle arthrosis when talar varus tilt was reduced.

Level of Evidence:

Level IV, retrospective case series.
Treatment of Displaced Intra-Articular Calcaneal Fractures With Combined Transarticular External Fixation and Minimal Internal Fixation
Authors: Fu Te-Hu , Liu Hao-Chen , Su Yu-Sheng , Wang Ching-Jen
Published: January 2017

Background:

The aim of this study was to evaluate clinical outcomes after surgery for displaced intra-articular fractures using an external fixator and minimal internal fixation.

Methods:

In this retrospective observational study, a total of 39 patients (32 [82%] men and 7 [18%] women) with 48 displaced intra-articular calcaneal fractures were included. An extended lateral approach was used to stabilize fractures using multiple sagittal plane screws, axial percutaneous threaded Kirschner wires for the frontal fracture plane, and an external fixator for reduction assistance and maintenance. The following variables were assessed: preoperative and postoperative Böhler’s angle; calcaneal length, height, and width; postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores; and complications. Mean duration of follow-up was 74 ± 26 months.

Results:

The mean time from surgery to external fixator removal was 12 ± 1 weeks. The mean preoperative Böhler’s angle (–3 ± 21 degrees), calcaneal length (7.9 ± 0.6 cm), and calcaneal height (3.6 ± 0.5 cm) were significantly increased ( P < .05) at final follow-up (28.3 ± 6.5, 8.3 ± 0.6, and 4.5 ± 0.5, respectively), whereas the mean preoperative calcaneal width (4.2 ± 0.5) was significantly decreased from the final follow-up mean (3.8 ± 0.5). There were no significant differences between any of the normal and postoperative measures. The mean AOFAS score was 82 ± 12. Complications included superficial pin tract infection (n = 7, 15%), superficial wound edge necrosis (n = 4, 8%), and deep infection (n = 2, 4%).

Conclusion:

Our findings suggest that use of an external fixator with minimal internal fixation is an effective option for treating displaced intra-articular calcaneal fractures.

Level of Evidence:

Level IV, retrospective case series.
The Effectiveness of Extracorporeal Shock Wave Therapy on Chronic Achilles Tendinopathy
Authors: Al-Abbad Hani , Simon Joel Varghese
Published: January 2017

Background:

Achilles tendinopathy is a pathological state resulting from repetitive loading or stress on the tendon. Extracorporeal shock wave therapy (ESWT) is hypothesized to be an effective alternative intervention to surgery when other conservative therapies fail. This systematic review investigated the effectiveness of ESWT in the treatment of insertional and noninsertional Achilles tendinopathies.

Methods:

Articles were electronically searched from the Cochrane Controlled Trials Register, MEDLINE, CINAHL, EMBASE, and SPORTDiscus using a comprehensive search strategy. Studies were included if they were prospective clinical trials examining the effectiveness of ESWT for insertional or noninsertional Achilles tendinopathies. Methodological quality of included studies was assessed using PEDro scale and Modified McMaster tool. The strength of the evidence was reported using the National Health and Medical Research Council body of evidence framework. A narrative summary of the findings was presented.

Results:

Four of the included studies were randomized controlled trials, and 2 were pre-post study designs. Common methodological deficiencies included not blinding the clinician and participants. There was consistent evidence from 4 reviewed studies on the effectiveness of ESWT in the management of patients with chronic Achilles tendinopathies at a minimum 3 months’ follow-up.

Conclusion:

Overall, our review showed satisfactory evidence for the effectiveness of low-energy ESWT in the treatment of chronic insertional and noninsertional Achilles tendinopathies at a minimum 3 months’ follow-up before considering surgery if other conservative management fails. However, combining ESWT with eccentric loading appears to show superior results.

Level of Evidence:

Level 1, systematic meta-analysis
Outpatient Group Therapy for Dissociative Trauma Survivors
Authors: Applegate Maureen
Published: January 2017

Outpatient group therapy is an effective treatment modality for survivors of trauma with varying presentations of dissociative phenomena. Outpatient symptoms of dissociation can be measured through use of the Dissociative Experiences Scale. Advanced practice psychiatric nurses leading groups for dissociated clients can use the Dissociative Experiences Scale to assess symptoms, combine group participants by severity of dissociative symptoms, and plan interventions appropriate to the needs of the groups. This article reviews a clinical experience of three long-standing survivor groups. Interventions and implications for nurse psychotherapists are discussed.
Successful Treatment of Pyoderma Gangrenosum with Intravenous Immunoglobulins during Pregnancy
Authors: Erfurt-Berge Cornelia , Herbst Christine , Schuler Gerold , Bauerschmitz Juergen
Published: January 2017

Background:

Pyoderma gangrenosum is a rare ulcerative skin disease usually starting with a pustular lesion that rapidly progresses to painful ulcers with undermined violaceous borders. Numerous associated disorders have been described, including inflammatory bowel disease, rheumatologic or hematologic disorders, chronic active hepatitis, and malignancies. The occurrence of pyoderma gangrenosum during pregnancy is uncommon.

Objective:

We report a case of a patient with an aggravation of preknown pyoderma gangrenosum during pregnancy who was successfully treated with intravenous immunoglobulins.

Conclusion:

Administration of immunoglobulins represents a safe and effective treatment option for this subset of patients, as demonstrated in the present case.
Comparison of Dermatologists' and Nondermatologists' Diagnostic Accuracy for Malignant Melanoma
Authors: Corbo Michael D. , Vender Ronald , Wismer Judy
Published: January 2017

Background:

The incidence of malignant melanoma is increasing annually in Canada and patients present to nondermatologist groups (NDGs) first to have suspicious lesions examined.

Objective:

To determine the ability of Canadian NDGs in the recognition and management of melanoma.

Methods:

A survey of 25 malignant and benign skin lesion photographs was distributed to dermatologists and NDGs across Canada. Participants were asked to list whether the lesions were malignant or benign, and could answer ‘uncertain’ if needed. Dermatologists were subsequently asked if they would biopsy the lesion, whereas NDGs were asked if they would biopsy/refer.

Results:

Dermatologists achieved mean sensitivities, specificities, and diagnostic accuracies of 0.79, 0.77, and 0.71, respectively. They consistently decided to biopsy malignant lesions. NDGs attained mean scores of 0.61, 0.62, and 0.53, respectively, and selected to refer/biopsy the majority of lesions, malignant and benign.

Conclusions:

NDGs should receive more dermatologic training in the recognition of malignant melanoma.
Effect of Age on Health State Valuations
Authors: Dolan Paul
Published: January 2017

Objectives:

Valuations for health states defined by the EQ-5D measure of health-related quality of life, which were elicited using the time trade-off method, from a large sample of the UK general population have previously been shown to be related to the age of the respondent. This paper presents population valuation tariffs for all EQ-5D health states for those aged 18–59 and those aged 60 and over.

Methods:

Health state valuations were elicited from a representative sample of over 3000 members of the UK general population using one-to-one interviews. The same regression technique which had previously been used to estimate the EQ-5D tariff for the whole population is used in the current analysis. Additional variables were created which were the product of the original variables and the dummy attached to the age group of the respondent. An earlier qualitative study had suggested that some of the observed differences in valuations might have resulted from more older respondents doubting the plausibility of the ‘worse than dead’ scenario. Therefore, the model was estimated both when the scores of those aged 60 and over were unmodified and when they were modified to account for this possibility.

Results:

The tariff based on values from those aged 60 and over, was considerably lower than that based on values from those aged 18–59. When changes between health states were calculated, the difference could be as much as 0.15 on a scale between −1 and 1. However, when the scores of older respondents were adjusted, on the assumption that their lower values for states rated as worse than dead were due to an experimental artefact, the differences between the valuation tariffs of the two age groups greatly diminished.

Conclusion:

These results suggest that whose values are used may have an important effect on health state valuations, and in turn, therefore, on resource allocation decisions, but more research is needed to understand the source of the differences between the values given by different population subgroups.
Opening Pandora's Box? Freedom of Information and Health Services Research
Authors: Hughes David , Griffiths Lesley , Lambert Sue
Published: January 2017

The introduction, or extension, of freedom of information legislation in Britain and other Western countries seems certain to influence the climate for health services research. However, researchers should be clear that, although such legislation may improve access to certain types of data, it will also create new problems and dilemmas. Statutory freedom of information regimes are likely to raise difficult issues of adaptation and compliance for health service bodies. Researchers may find that this translates into reluctance to agree access and accentuates difficulties in managing field relationships. They may, inter alia, face difficult dilemmas in deciding whether, or how, to report non-compliance, judging whether to extend research into areas where consent has not been obtained and weighing the benefits of using the official rules to insist on disclosure against the dis-benefits of jeopardising relationships. Health services researchers should regard freedom of information legislation, not simply as a resource, but a topic deserving study in its own right.
Why is it so Difficult to Organise an Outpatient Clinic?
Authors: McKee Martin , Waghorn Alison
Published: January 2017

Objectives:

The shift from inpatient to outpatient care in the UK is drawing attention to the role of the outpatient clinic. Yet, outpatient clinics have received less attention than other elements of hospital work. This study sought to identify key problems perceived by staff in the functioning of outpatient clinics and to understand their responses to these problems.

Methods:

Interviews were conducted with 57 hospital staff in two hospitals (one teaching, one district general) in South-East England. Staff were selected through snowball sampling to provide a cross-section of those working in, and interacting with, the outpatient department. Constant comparison was used to generate hypotheses from the data collected in the first hospital, which were then tested in the second hospital.

Results:

Four main themes emerged. These were the role of the individual consultant, pressure on time, weaknesses in communication and problems with training. The personality of the consultant — in particular, his or her attitude to risk — was often central to the functioning of the clinic. The actions arising from differing personalities were remarkably resilient to managerial action. Most clinics operated in the face of pervasive pressures on time, which created a service that was seen as meeting no-one's needs adequately. Communication was almost universally poor in all directions and through all media. Training of medical staff was haphazard.

Conclusions:

Despite its growing importance, the hospital outpatient clinic is often ill-equipped to respond to the new challenges it faces. Overall, there is a need for the system to be managed, rather than simply to respond to whatever comes its way, and to ensure that the growing literature on individual and organisational change is understood and applied.