bluuebunny/crossref_metadata_2025 huggingface dataset:
Dynamic Ultrasonography During Nonoperative Treatment following Achilles Tendon Rupture
Authors: Lee Kang
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Many recent studies suggest similar outcome and rerupture rates between operative and nonoperative treatment with accelerated rehabilitation for acute Achilles tendon rupture. Nevertheless, it is very difficult for surgeons who have traditionally been performing surgery for Achilles tendon rupture to adopt nonoperative treatment. Unlike fracture healing, surgeons cannot confirm the amount of tendon healing with plain radiography to begin accelerated rehabilitation. The aim of the present study was to determine visually the amount of Achilles tendon healing with dynamic ultrasonography and therefore aid in surgeons decision-making process during nonoperative treatment following Achilles tendon rupture.

Methods:

Thirty-one patients with acute Achilles rupture were included in the study. The mean age at the time of rupture was 42 years. There were 32 male and 10 females. Ultrasonographic evaluation was performed at the time of initial diagnosis, and at 2, 3, 5, 7, 10, 13 weeks after injury. Initially the amount of gap with ankle in neutral position was measured, then the amount of tendon healing(continuity) was measured during the follow-up.

Results:

Initially, the mean gap was 13 mm with ankle neutral, then the mean gap was reduced to 3 mm with maximum ankle plantarflexion. At 3 weeks, proximal stump motion was confirmed with mean gap of less than 2 mm during passive ankle motion from maximum plantarflexion to neutral in all patients, indicating that tendon healing began between the distal and proximal stumps. Yet, there were no definitely visible continuity between the two stumps. At 5 weeks, 30% of entire tendon width showed continuity, 50% at 7 weeks, 70% at 10 weeks, and the entire tendon healed at 13 weeks. Clinically, all patients returned to previous activities of daily living without any complications at the final follow-up.

Conclusion:

Surgeons beginning to adopt nonoperative treatment for acute Achilles tendon rupture may safely remove the cast or orthosis at three weeks after injury for gradual increase in ankle range of motion and to reduce patient disability.
Anatomical Features of Dislocation of the Peroneal Tendon
Authors: Taki Masanori , Hasegawa Atsushi , Monden Satoshi , Hio Naohiro
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Dislocation of the peroneal tendons is one of the major injuries of the ankle. However, the pathology underlying this condition is still unclear. The purpose of this study was to evaluate the anatomical features of dislocation of the peroneal tendon using MRI.

Methods:

We compared twenty cases of dislocation of the peroneal tendon and twenty three controls. Both groups were matched for age, gender and BMI. The following patients were excluded: those with an acute injury within the past three weeks and/or findings of peroneal tendon tears or a dislocated peroneal tendon on MRI. MRI axial images of the ankle were retrospectively observed and the shape (concave, convex or flat) of the posterior fibular malleolar groove and the soft tissue dimensions within the peroneal tendon sheath at the level of the ankle joint (joint level) and the middle level between the ankle joint and the fibular malleolar tip (lower level) were investigated. The measurement was performed using a Konica i-pacs SX measurement system (Konica Minolta Health Care, Tokyo, Japan).

Results:

No significant differences were observed in the shape of the posterior fibular malleolar groove at both levels (Joint level, peroneal dislocation: concave, convex, flat = 2, 10, 8 cases vs. control: 4, 12, 7 cases. P=0.70. Lower level, peroneal dislocation: concave, convex, flat = 3, 6, 11 cases vs. control: 6, 6, 11 cases. P=0.36, Chi-square test for independence). However, a significant difference was confirmed in the soft tissue dimensions within the peroneal tendon sheath (Joint level, peroneal dislocation: 144.6±41.4mm2 vs. control: 97.5±29.1mm2. P < 0.0001. Lower level, peroneal dislocation: 120.2±36.1mm2 vs. control: 84.3±26.8mm2. P < 0.0001, Student's t-test).

Conclusion:

These results suggest that a larger amount of soft tissue inside of the peroneal tendon sheath at the level of the distal fibula is a significant anatomical feature associated with peroneal tendon dislocation, and could be a potential risk factor for unstable peroneal tendons. It remains unclear whether the soft tissue was bulky prior to injury. However, the presence of enlarged soft tissue within the peroneal tendon sheath is considered to be involved in the pathology of recurrent dislocation of the peroneal tendon.
Evaluation of Normal Ankle Cartilage by Magnetic Resonance Imaging (MRI) T1ρ Mapping
Authors: Katsui Ryuhei , Taniguchi Akira , Ogawa Munehiro , Tanaka Yasuhito , Kurokawa Hiroaki , Tomiwa Kiyonori
Published: October 2016

Category:

Ankle

Introduction/Purpose:

With the recent remarkable progresses in image diagnosis using magnetic resonance imaging (MRI), it could be possible to evaluate articular cartilage in detail. T1ρ mapping by MRI has recently drawn attention as a noninvasive cartilage evaluation method. While its validity has been proven, there are no reports describing T1ρ mapping for the ankle; therefore, in this present study, T1ρ values of the articular cartilage surfaces of the talar dome were measured in healthy individuals.

Methods:

The study sample comprised 10 ankles from 10 healthy volunteers (4 male and 6 female), with a mean age of 32.2 years. Images taken using a 3.0 T MRI device, manufactured by Philips, were processed using the PRIDE software (Philips, Inc.) and analyzed using Image J, a specialized analysis software. Evaluations were performed using slices in the coronal plane from the trochlear ridge of the talus and slices 10 mm anterior and posterior of the ridge. Each slice was divided into three equal parts including the medial, central, and lateral areas of cartilage on the articular surface of the trochlea tali, to totally yield 9 regions of interests where T1ρ values (ms) were measured. Furthermore, values were measured thrice for each region in each volunteer, and the mean was calculated.

Results:

T1ρ values for the medial, central, and lateral regions were 31.0 ± 6.4 ms, 31.2 ±7 .2 ms, and 32.2 ± 6.9 ms, respectively for the anterior talus; 24.2 ± 4.2 ms, 21.7 ± 5.6 ms, and 25.1 ± 5.5 ms, respectively for the trochlear ridge of the talus; and 33.8 ± 4.8 ms, 31.9 ± 4.5 ms, and 35.1 ± 4.8 ms, respectively for the posterior talus. T1ρ values were significantly lower in the anterior and posterior areas of the talar dome than in the trochlear ridge of the talus (p < 0.05).

Conclusion:

Proteoglycan content of articular cartilage in the talar dome was determined to be low in the anterior and posterior areas, that reveals load application might be concentrate on these areas.
Interest of Tantalum for Arthrodesis-Reconstruction of TAR Revision
Authors: Besse Jean-Luc , Aubret Syvain , Lomberget-Daubie Marie-Caroline , Fessy Michel-Henry
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Ten-year Total Ankle Replacement (TAR) survivorship improved from 80 to 90%. But periprosthetic osteolysis associated with implant subsidence remains the main problem, with difficult revision surgery by arthrodesis; bone defect requiring massive graft. We proposed an original approach using porous tantalum as spacer to fill the defect and reinforce arthrodesis-reconstruction

Methods:

From October 2013 to September 2015, eleven patients underwent TAR revision (7 AES TM, 2 Hintegra TM, 1 Salto TM, 1 Albatros TM) by ten TTC arthrodesis and one ankle arthrodesis using tantalum (with Zimmer Trabecular Metal Ankle Interpositional SpacerTM introduced in July 2013). All patients were followed up prospectively clinically and radiologically (X-rays and CT scan at 4-6 months, and 1 year); and a bone scan with SPECT- CT if residual pain at one year. Mean age was 53.2 yrs [37-82yrs] at TAR, 66.6 yrs [41–90 yrs] at revision-arthrodesis, with a mean interval of 7.2 yrs [2-12yrs].

Results:

We used a tantalum cone (25-40 mm height) and osteosynthesis by a retrograde nail in 10 TTC arthrodesis cases (Tornier–AFN611TM, 10 or 12 mm diameter, 6° or 11° lateral angulation) associated or not to a complementary anterior sub- talar screw (Unima-BiotechTM 4.5 mm), and a double anterior plate in one ankle arthrodesis case . Tantalum implants were surrounded by antologous bone graft (1 posterior iliac crest, 10 iliac wing harvested with hip reamers) mixed with Lyophylized fragmented Human Bone. Postoperatively, patients were 6 weeks without weight-bearing, followed by 2 months of boot with weight-bearing. At a mean 1 year follow-up (4 -18 mo), ankle fusion was confirmed on CT in all cases but with doubt for 2 cases. But there remained three case of unexplained residual severe pain associated with hyperactivity on bone scan: incomplete fusion (difficult to assess on CT due to tantalum)? impingement between locking-screws and Tantalum?

Conclusion:

Porous tantalum had biological and biomechanical properties close to those of natural bone. The use of Trabecular MetalTM in hip, knee, spine surgery recently demonstrated efficacy; but there are few recent publications in TAR revision. Our preliminary results are encouraging; tantalum allows primary stability of reconstruction. Is it better than Titanium cages? We need longer follow-up to analyze integration and fusion; and to check the residual pain in some cases.
Interobsever Variability of Measurements for Flatfoot Deformity Using High Resolution Weightbearing Cone-Beam CT Examination According to Reader Experience
Authors: Netto Cesar Cesar , Demehri Shadpour , Dein Eric J. , Zhang Hanci , Thawait Gaurav K. , Zahoor Talal A. , Fonseca Lucas F. , Lee Moses , Asomugha Eva U. , Ficke James R. , Schon Lew C.
Published: October 2016

Category:

Other

Introduction/Purpose:

To evaluate interobserver reliability among readers of different clinical experience by applying measurements for adult acquired flatfoot deformity (AAFD) using high-resolution three-dimensional (3D) weightbearing (WB) cone-beam CT (CBCT) examination.

Methods:

In this IRB approved study, 20 patients with flexible AAFD [12 male, 8 female; mean age 54.2 (20-88) years] were scanned with standing (weightbearing) CTs. Two blinded observers, a medical student and a foot/ankle surgeon, applied validated AAFD measurements in sagittal, coronal, and axial planes using predefined anatomical landmarks. Interobserver reliability was calculated using Pearson correlation.

Results:

There was significant interobserver agreement with high correlation for the following measurements(p < 0.0001): distances between medial cuneiform to-floor (r=0.981) and to-skin (r=0.986), navicular to-floor (0.992) and to-skin (r=0.900); cuboid to-floor (r=0.975) and to-skin (r=0.978), and calcaneus-to-fibula (r=0.808); calcaneal inclination angle (r=0.795); forefoot arch angle (r=0.983); and subtalar horizontal angles at 25%, 50%, and 75% of the anteroposterior joint length (r=0.784, 0.891, 0.809). Significant agreement with moderate correlation was additionally demonstrated for talar-first metatarsal angle (r=0.553, p < 0.014), medial cuneiform-first metatarsal angle (r=0.668, p < 0.001), and navicular-cuneiform angle (r=0.746, p < 0.0002). Level of training did not influence the reliability of any measurements except medial cuneiform-first metatarsal angle (specialist: 8.83°; student: 1.61°; p < 0.01). Statistically insignificant difference between readers (p>0.05) was noted in mean talar-first metatarsal and subtalar horizontal angles.

Conclusion:

While literature describes large variability for AAFD measurements from plain radiographs among readers of varying medical experience, 3D WB CBCT can yield similar measurements using predefined planes with high reliability, independent of reader experience.
Results of Augmented Half-Thickness Tibialis Anterior Tendon Segment Transposition, a Novel Technique for Tibialis Anterior Tendon Reconstruction
Authors: Stenson James F. , Reb Christopher W. , Pedowitz David I. , Daniel Joseph N.
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Tibialis anterior tendon (TAT) rupture causes substantial morbidity. Nearly 200 surgical cases have been reported in the literature since 1905 wherein primary repair was not achieved approximately 40% of the time due to post- debridement tendon defect size. The present study describes the clinical outcomes of augmented, half-thickness TAT segment transposition, a novel reconstruction technique for managing post-debridement TAT defect. The purpose was to assess this technique as an alternative to tendon transfer and allograft tendon interposition.

Methods:

IRB-approved, retrospective electronic medical record review of patients with attritional distal TAT rupture. In all cases, the post-debridement tendon defect prohibited primary repair or reinsertion and was managed by distal transposition of a half-thickness TAT segment to span the defect. This graft was secured with a six core suture end-to-end anastomosis. Then, this repair was augmented with human acellular dermal matrix allograft (Graftjacket®, Wright Medical Technology, Memphis, TN). A total of five patients were treated with this technique. One patient died of unrelated causes remote from surgery and one was lost to follow up. Three patients with a minimum one year follow up were included. Outcomes were assessed via observed range of motion, clinical motor power assessment, ability to heel walk 15 feet, visual analog scale pain score, Foot and Ankle Ability Measure score, postoperative complications, and patient satisfaction at one year. Outcomes data were analyzed using descriptive statistics.

Results:

The mean age was 68 years (range, 59 to 73 years). Two patients were female. Mean interval between injury and surgery was 59.3 days (range, 15 to 146 days). All patients regained symmetrical range of motion, medical research council grade 5 motor power and the ability to heel walk. Mean pain scores improved from 4.6 (range, 2.5 to 8.5) preoperatively to 0.7 (range, 0 to 2) postoperatively. Mean FAAM scores increased from 30.6 (range, 23.8 to 43.8) preoperatively to 78.7 (range, 72.6 to 97.6) postoperatively. No postoperative complications occurred. At one year, one patient was satisfied and two were very satisfied with their outcome.

Conclusion:

Although constrained by a small sample size, the present findings appear to indicate that this technique produces short term clinical results comparable to those described for other techniques for TAT reconstruction. Future work should assess if these results are reproducible and long lasting. Additionally, the relative value of saving donor site morbidity or the cost of allograft tendon in comparison to the added cost of the Graftjacket should be determined
Single-Stage Bipedicle Local Tissue Transfer and Skin Graft for Achilles Tendon and Posterior Heel Wound Complications
Authors: Dekker Travis J. , Matson Andrew P. , Mithani Suhail K. , Adams Samuel B.
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Achilles tendon and posterior heel wound complications are difficult to treat. These typically require soft tissue coverage via microvascular free tissue transfer at a tertiary referral center. Here we describe coverage of a series of posterior heel and achilles wounds via simple, local tissue transfer, a bipedicle fasciocutaneous flap. This surgical technique can be performed by an orthopaedic foot and ankle surgeon without resources of tertiary/specialized care or microvascular support.

Methods:

Three patients with separate pathologies were treated with a single-stage bipedicle fasciocutaneous local tissue transfer. Case 1 was a patient with wound breakdown following midsubstance Achilles tendon repair. Case 2 was a patient with insertional wound breakdown after Achilles debridement and repair to the calcaneus. Case 3 was a heel venous stasis ulcer with calcaneal exposure in a diabetic vasculopath. All three cases were treated with the following technique: an incision was immediately posterior to the lateral malleolus. The length of the incision was approximately 25% greater than the proximal to distal measurement of the wound. The dissection was carried to the flexor retinaculum and carried posteriorly to create a fasciocutaneous flap attached proximally and distally. This flap was then mobilized posteriorly to close the desired defect, leaving an ellipsoid shaped skin defect laterally. A split thickness skin graft was used to cover the defect created by the flap transposition.

Results:

All three patients demonstrated initial complete healing of the posterior defect, lateral ankle skin graft recipient site, and the skin graft donor site following surgery. Case 3 had a subsequent recurrent ulceration after initial healing. This was superficial and healed with local wound care. All patients regained full preoperative range of motion and were able to ambulate independently without modified footwear.

Conclusion:

The bipedicled fasciocutaneous flap described offers a simple, predictable single stage procedure that can be accomplished by an orthopaedic foot and ankle surgeon without resources of a tertiary care center for posterior foot and ankle defects. This flap allows for relatively short operative times and can be customized to facilitate defect coverage. Ultimately, the flap is sufficiently durable to withstand the local tissue stresses required for ambulation at an early stage. This provides a reasonable alternative to complicated and time consuming microvascular reconstruction, but does require careful follow-up to manage the patient’s underlying comorbid conditions that may complicate wound healing.
The Biomechanical Evaluation of Revision First Metatarsophalangeal Arthrodesis
Authors: Aiyer Amiethab , Myerson Mark S. , Dall Graham , Price Jamey , Widmer Jason
Published: October 2016

Category:

Midfoot/Forefoot

Introduction/Purpose:

First metatarsophalangeal (MP) arthrodesis in the setting of bone loss is a difficult problem. Bone loss may compromise stability of implant fixation. Union rates may be adversely affected by these circumstances. The primary goals of this cadaveric, biomechanical study were as follows: 1) To investigate stiffness of a dual mini-plate construct versus a standard MP arthrodesis plate in the setting of severe bone loss, 2) To evaluate arthrodesis interface motion when an interpositional graft is used.

Methods:

Twelve matched pairs of fresh, frozen cadaveric foot/ankle specimens were utilized in this study. Pairs were randomized to fixation constructs via computerized randomization (Excel, Microsoft, WA). Within a matched pair one construct used the dual mini plate fixation technique while the other was secured with a standard MP arthrodesis plate. (Fig 1) A revision MP fusion construct with structural bone graft was simulated on six of the specimen pairs, while the remaining constructs did not utilize any interpositional graft.

Results:

Based on load to failure data, there were no differences between the various constructs in terms of stiffness. There was a high degree of calculated plantar gapping with the placement of a bone block, irrespective of the fixation type. In the presence of an interpositional graft, regardless of plating construct, the calculated proximal interface strain was an average of 26%. Subsequently, failure was most commonly seen at the proximal interface of the interpositional graft group (83%, 10 out of 12). Distal interface strain in the interpositional graft group was calculated to be 11%. The proximal interface strain was significantly larger than the distal interface strain (26% vs 11%) (p < 0.05).

Conclusion:

Although no construct differences were observed in terms of stiffness, the dual mini-plate is an alternative option for fixation when asymmetric bone loss is either seen on the phalangeal or metatarsal head side. The high degree of plantar gapping of the proximal interface with the placement of the bone block may have implications for healing potential across the arthrodesis site.
The Circular Arc Internal Fixation for Tibio-Talo-Calcaneal Arthrodesis
Authors: Klaue Kaj , Mittlmeier Thomas , Zwipp Hans
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Stabilizing a tibio-talo-calcaneal arthrodesis in anatomical alignment allowing for weight bearing is a technical challenge. Normal anatomy demonstrates alignment of the heel, the subtalar facet, the talus, the ankle joint and the distal tibia on a regular curve. This curve lies on a vertical plane which is slightly angulated inwards in relation to the sagittal plane. Today’s hindfoot nails are either straight or bent. The hole which accommodates the implant is always straight and thus does not respect the normal alignment of the hindfoot. This technique may cause a plantar neurapraxia, the nail holds poorly the calcaneus and tends to create a hindfoot varus. Purpose of the study is to optimize the technique to stabilize the hindfoot in anatomical alignment.

Methods:

A preliminary trial using 15 cadaveric feet was performed to find the optimal shape of a central hindfoot nail. An instrumentation was designed to create a circular arc bore hole crossing the heel, the posterior subtalar facet, the tibio-talar joint and the distal tibia metaphysis. At the operation, the desired definitive position of the hindfoot is fixed temporarily with Kirschner wires. A guiding frame is fixed to three critical spots of the hindfoot to drill the central hole. Using an image amplifier the hole is bored using a motor driven end cutting flexible reamer which is seated within a rigid curved hull. The nail has the same shape than the hull and is impacted up to the distal tibia. A distal locking screw crossing the subtalar joint and a proximal locking screw within the tibia concludes the central fixation. 9 patients have been treated so far using this technique.

Results:

In vitro trials demonstrated an excellent spontaneous stability of the hindfoot after introduction of the nail. The pathology of the operated patients include post-traumatic, congenital and metabolic (diabetes) conditions. The mean follow-up is 12 months. We did observe 3 ruptures of the tibial locking screw which allowed for more spontaneous impaction. All cases went to consolidation without malunion or other complications. One diabetic patient developed a stable pseudarthrosis at the midfoot joints. All patients were treated for 2 weeks post-op with a closed circular cast without weight bearing. After 2 weeks our patients did practise partial weight bearing using a cam walker for other 6 weeks.

Conclusion:

The tibio-talo-calcaneal arthrodesis can be successfully treated using a central circular arc shaped nail respecting form fit function. The anatomical bony alignment of the hindfoot is preserved. Due to the safe approaches, the technique may prevent shortcomings such as neurological complications and non-unions. We expect a shorter period between surgical fixation and full weight bearing.
The Epidemiology of Lisfranc Injuries at the NFL Combine
Authors: Vopat Bryan G. , McHale Kevin J. , Beaulieu-Jones Brendin R. , Sanchez George , Logan Catherine , Whalen Jim , Guss Daniel , DiGiovanni Christopher W. , Provencher Matthew T.
Published: October 2016

Category:

Sports

Introduction/Purpose:

Lisfranc injuries can have detrimental consequences to an athlete’s career. If left inadequately treated, these injuries can result in persistent pain and lead to advanced osteoarthritis. Understanding the prevalence of these injuries in collegiate athletes and their effect on NFL draft position can help team physicians counsel future players and determine optimal treatment. The purpose of this study was to determine the epidemiology of Lisfranc injuries in players participating in the NFL combine and to determine the positions that are at higher risk for sustaining these injuries.

Methods:

Data was collected from the NFL combine website on all players who participated in the combine and had sustained a Lisfranc injury before entering the NFL from 2009 to 2015. Medical records, imaging, and treatments were reviewed on players who were identified with these injuries. The epidemiology of Lisfranc injuries was determined by evaluating the number of injuries, surgeries, games missed, position played and draft position of each player. Odds ratios were calculated using logistic regression to assess the risk of sustaining each injury by position. Two-sample, two-tailed T-tests were computed to assess games missed and draft position in players with operative versus non-operative management. Players with a Lisfranc injury as well a second primary midfoot injury (n=3) were excluded from analysis.

Results:

Thirty-nine(1.7%) players at the NFL combine had an isolated Lisfranc injury during their collegiate football career. Of these players, 27(69.2%) required surgical intervention. The average number of collegiate football games missed for this injury was 3.0±5.0. The average number of games missed for players requiring operative fixation was statistically greater(4.2±5.7) than those in the non-operative group (0.3 ±0.9, p=0.02). The average NFL draft position was 141.7±69.4, and 13(33.3%) went undrafted. There was no statistical difference in the average draft position(p=0.84) and number of undrafted players(p=0.15) between the operative and non-operative groups. No position was found to be at increased risk for Lisfranc injury; however, as a whole, offensive players had a significantly increased risk(Odds ratio=2.7, p = 0.01) of having a Lisfranc injury when compared to all other players. Overall, 24(61.5%) of the players with a Lisfranc injury played on offense.

Conclusion:

The majority of players who reported a Lisfranc injury required operative intervention, and offensive players were at a higher risk for this injury. Lisfranc requiring operative management did not significantly change a player’s draft position or chance of being drafted.
The Predicting Factor for Avascular Necrosis After Talus Fracture — the Study Based on CT Findings
Authors: Ikezawa Hiroko , Usami Norio , Hiraishi Eiichi , Inokuchi Suguru
Published: October 2016

Category:

Trauma

Introduction/Purpose:

Treatment of talus fracture is difficult. Because talus fracture often cause the avascular necrosis, and necessitate a prolonged non-weight-bearing period or arthrodesis in these cases. Identification of the fracture type that results in necrosis before a surgery may help in the determination of the planning of treatment and the prognosis. However, necrosis cannot be identified directly by a conventional fracture classification. We investigated the sites in which fracture lines of the talus are visible by using CT to determine the association between fracture of the talus and the occurrence of necrosis.

Methods:

Twenty-five patients (25 feet; 18 men and 7 women; mean age at the first visit, 48.4 years [range, 15–80 years]) treated through 2003 to 2013 were included in this study. Fracture lines were assessed using radiography and CT. According to the conventional classification, 12 neck fractures and 13 body fractures were found. The Inokuchi–Ogawa classification was used to assess the fracture line on the subtalar joint surfaces. A fracture line was defined as the line connecting 1 with the other point as follows: (a) the sulcus tali ; (b) the sinus tarsi; (c) between the lateral process and the lateral tubercle; and (d) the medial tubercle. MRI was used for the assessment of necrosis. The subjects were divided into the non-necrosis group (group A) and the necrosis group (group B), and relationship between fracture lines and appearance of necrosis was examined.

Results:

With the exclusion of 2 unclassifiable cases, group A consisted of 15 feet, whereas group B consisted of 8 feet. At the Inokuchi–Ogawa classification, 1fracture line was found in 8 feet,2:5, and and 3:1 in group A. In group B, all cases showed multiple fracture lines. Among the lines connecting a-b, a-c, and b-d, fracture was observed in more than 2 lines in the all cases .

Conclusion:

The most important factor for determining the prognosis of talus fracture is the presence or absence of necrosis. The results of this study indicate that fracture lines connecting a-b, a-c, and b-d interrupt major blood routes, and talus fracture more than 2 fracture lines were highly likely to develop avascular necrosis. Thus, fracture lines may predict the occurrence of necrosis and possible sites of its occurrence.
Haploidentical hematopoietic transplantation for the cure of leukemia: from its biology to clinical translation
Authors: Mancusi Antonella , Ruggeri Loredana , Velardi Andrea
Published: October 2016

The present review describes the biology of human leukocyte antigen haplotype mismatched (“haploidentical”) transplantation, its translation to clinical practice to cure leukemia, and the results of current transplantation protocols. The 1990s saw what had been major drawbacks of haploidentical transplantation, ie, very strong host-versus-graft and graft-versus-host alloresponses, which led respectively to rejection and graft-versus-host disease (GVHD), being overcome through transplantation of a “mega-dose” of T cell–depleted peripheral blood hematopoietic progenitor cells and no posttransplant pharmacologic immunosuppression. The absence of posttransplant immunosuppression was an opportunity to discover natural killer cell alloreactions that eradicated acute myeloid leukemia and improved survival. Furthermore, it also unveiled the benefits of transplantation from mother donors, a likely consequence of the mother-to-child interaction during pregnancy. More recent transplantation protocols use unmanipulated (without ex vivo T-cell depletion) haploidentical grafts combined with enhanced posttransplant immunosuppression to help prevent GVHD. Unmanipulated grafts substantially extended the use of haploidentical transplantation with results than even rival those of matched hematopoietic transplantation. In T cell–depleted haploidentical transplantation, recent advances were made by the adoptive transfer of regulatory and conventional T cells.
Reshaping the Non-Aligned Movement: challenges and vision
Authors: Keethaponcalan S. I.
Published: October 2016

With the end of the Cold War, the Non-Aligned Movement (NAM) has lost its relevance and significance. Many believed that the international system was moving towards a permanent unipolar new world order. The last decade, however, witnessed the emergence of new power-centers with the ability to restructure the world into several blocs. Now, some believe in a Second Cold War. Despite these changes, several common challenges faced by societies of the Global South remain and new challenges have emerged. The Global South does not have to reinvent the wheel to effectively deal with the new global realities and challenges. The institutional framework, the NAM is still functioning. It, however, needs to be reshaped and reenergized. This paper is written with secondary data. First, the paper surveys the theoretical and practical problems faced by NAM. Second, it explores the possibility of reshaping and transforming NAM into a robust, unifying institution.
Treatments and Outcomes of Patients With Extranodal Natural Killer/T-Cell Lymphoma Diagnosed Between 2000 and 2013: A Cooperative Study in Japan
Authors: Yamaguchi Motoko , Suzuki Ritsuro , Oguchi Masahiko , Asano Naoko , Amaki Jun , Akiba Takeshi , Maeda Takeshi , Itasaka Satoshi , Kubota Nobuko , Saito Yoshihiro , Kobayashi Yukio , Itami Jun , Ueda Kyoko , Miyazaki Kana , Ii Noriko , Tomita Naoto , Sekiguchi Nodoka , Takizawa Jun , Saito Bungo , Murayama Tohru , Ando Toshihiko , Wada Hideho , Hyo Rie , Ejima Yasuo , Hasegawa Masatoshi , Katayama Naoyuki
Published: October 2016

Purpose

To elucidate the management and outcomes of patients with extranodal natural killer/T-cell lymphoma, nasal type (ENKL), who were diagnosed between 2000 and 2013 in Japan.

Patients and Methods

Data from 358 patients with ENKL diagnosed between 2000 and 2013 from 31 institutes were retrospectively analyzed.

Results

Patients’ median age was 58 years, and 257 (72%) had localized disease. The most common first-line treatment was radiotherapy with dexamethasone, etoposide, ifosfamide, and carboplatin (RT-DeVIC) (66%) for localized ENKL and L-asparaginase–containing chemotherapy (30%) for advanced ENKL. With a median follow-up of 5.8 years, overall survival (OS) rates at 5 years for localized and advanced ENKL were 68% and 24%, respectively. The prognostic index of natural killer lymphoma was validated in our study, although only 4% of patients with localized ENKL were classified as high risk. With a median follow-up of 5.6 years, OS and progression-free survival at 5 years in the 150 patients who received RT-DeVIC in clinical practice were 72% (95% CI, 63% to 78%) and 61% (95% CI, 52% to 69%), respectively. Toxicities of RT-DeVIC were comparable to those in a previous trial. Multivariate analysis in patients with localized ENKL who received RT-DeVIC identified elevated soluble interleukin-2 receptor as an independent predictive factor for worse OS and progression-free survival (adjusted hazard ratios, 2.28 and 2.46; 95% CI, 1.24 to 4.23 and 1.42 to 4.28; P = .008 and .0014, respectively).

Conclusion

Favorable OS in response to new treatments was demonstrated in a large number of patients. Improved treatment approaches are needed for localized ENKL exhibiting elevated pretreatment soluble interleukin-2 receptor.
Human Papillomavirus Drives Tumor Development Throughout the Head and Neck: Improved Prognosis Is Associated With an Immune Response Largely Restricted to the Oropharynx
Authors: Chakravarthy Ankur , Henderson Stephen , Thirdborough Stephen M. , Ottensmeier Christian H. , Su Xiaoping , Lechner Matt , Feber Andrew , Thomas Gareth J. , Fenton Tim R.
Published: October 2016

Purpose

In squamous cell carcinomas of the head and neck (HNSCC), the increasing incidence of oropharyngeal squamous cell carcinomas (OPSCCs) is attributable to human papillomavirus (HPV) infection. Despite commonly presenting at late stage, HPV-driven OPSCCs are associated with improved prognosis compared with HPV-negative disease. HPV DNA is also detectable in nonoropharyngeal (non-OPSCC), but its pathogenic role and clinical significance are unclear. The objectives of this study were to determine whether HPV plays a causal role in non-OPSCC and to investigate whether HPV confers a survival benefit in these tumors.

Methods

Meta-analysis was used to build a cross-tissue gene-expression signature for HPV-driven cancer. Classifiers trained by machine-learning approaches were used to predict the HPV status of 520 HNSCCs profiled by The Cancer Genome Atlas project. DNA methylation data were similarly used to classify 464 HNSCCs and these analyses were integrated with genomic, histopathology, and survival data to permit a comprehensive comparison of HPV transcript-positive OPSCC and non-OPSCC.

Results

HPV-driven tumors accounted for 4.1% of non-OPSCCs. Regardless of anatomic site, HPV+ HNSCCs shared highly similar gene expression and DNA methylation profiles; nonkeratinizing, basaloid histopathological features; and lack of TP53 or CDKN2A alterations. Improved overall survival, however, was largely restricted to HPV-driven OPSCCs, which were associated with increased levels of tumor-infiltrating lymphocytes compared with HPV-driven non-OPSCCs.

Conclusion

Our analysis identified a causal role for HPV in transcript-positive non-OPSCCs throughout the head and neck. Notably, however, HPV-driven non-OPSCCs display a distinct immune microenvironment and clinical behavior compared with HPV-driven OPSCCs.
Impact of Health Insurance Expansion on the Treatment of Colorectal Cancer
Authors: Loehrer Andrew P. , Song Zirui , Haynes Alex B. , Chang David C. , Hutter Matthew M. , Mullen John T.
Published: October 2016

Purpose

Colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in the United States. Lack of insurance coverage has been associated with more advanced disease at presentation, more emergent admissions at time of colectomy, and lower survival relative to privately insured patients. The 2006 Massachusetts health care reform serves as a unique natural experiment to assess the impact of insurance expansion on colorectal cancer care.

Methods

We used the Hospital Cost and Utilization Project State Inpatient Databases to identify patients with colorectal cancer with government-subsidized or self-pay (GSSP) or private insurance admitted to a hospital between 2001 and 2011 in Massachusetts (n = 17,499) and three control states (n = 144,253). Difference-in-differences models assessed the impact of the 2006 Massachusetts coverage expansion on resection of colorectal cancer, controlling for confounding factors and secular trends.

Results

Before the 2006 Massachusetts reform, government-subsidized or self-pay patients had significantly lower rates of resection for colorectal cancer compared with privately insured patients in both Massachusetts and the control states. The Massachusetts insurance expansion was associated with a 44% increased rate of resection (rate ratio = 1.44; 95% CI, 1.23 to 1.68; P < .001), a 6.21 percentage point decreased probability of emergent admission (95% CI, −11.88 to −0.54; P = .032), and an 8.13 percentage point increased probability of an elective admission (95% CI, 1.34 to 14.91; P = .019) compared with the control states.

Conclusion

The 2006 Massachusetts health care reform, a model for the Affordable Care Act, was associated with increased rates of resection and decreased probability of emergent resection for colorectal cancer. Our findings suggest that insurance expansion may help improve access to care for patients with colorectal cancer.
Pomalidomide for Symptomatic Kaposi's Sarcoma in People With and Without HIV Infection: A Phase I/II Study
Authors: Polizzotto Mark N. , Uldrick Thomas S. , Wyvill Kathleen M. , Aleman Karen , Peer Cody J. , Bevans Margaret , Sereti Irini , Maldarelli Frank , Whitby Denise , Marshall Vickie , Goncalves Priscila H. , Khetani Vikram , Figg William D. , Steinberg Seth M. , Zeldis Jerome B. , Yarchoan Robert
Published: October 2016

Purpose

Kaposi's sarcoma (KS) is a multicentric tumor caused by Kaposi's sarcoma–associated herpesvirus. Unmet needs include therapies that are oral, anthracycline sparing, and deliverable in resource-limited settings. We evaluated pomalidomide, an oral immune modulatory agent, in patients with symptomatic KS.

Methods

The primary objectives were to assess tolerability, pharmacokinetics, and activity. Initial dosage level was 5 mg once per day for 21 days per 28-day cycle, with a de-escalated level of 3 mg if not tolerable, and aspirin 81 mg once per day thromboprophylaxis. HIV-infected patients required controlled viremia with either persistent KS despite 3 months of antiretroviral therapy (ART) or progressive KS despite 2 months of ART. Evaluations included tumor response and health-related quality of life (HRQL).

Results

Twenty-two patients were treated; 15 (68%) were HIV infected, 17 (77%) had advanced (T1) disease, and 17 (77%) previous KS therapy excluding ART. All were treated with 5 mg because no dose-limiting toxicities occurred. Over 156 cycles, the grade 3/4 adverse events possibly attributable to therapy were neutropenia (23 cycles, 10 patients), infection (1 cycle), and edema (1 cycle). Sixteen patients responded (73%; 95% CI, 50% to 89%): nine of 15 HIV-infected patients (60%; 95% CI, 32% to 84%) and all seven HIV-uninfected patients (100%; 95% CI, 59% to 100%). Median time to response was 4 weeks (range, 4 to 36 weeks). HRQL showed no impairment during therapy and improved satisfaction with appearance at end therapy ( P = .03). Significant increases in CD4+ and CD8+ cells were seen in patients with and without HIV, together with a transient increase in Kaposi's sarcoma–associated herpesvirus viral load at week 4 ( P = .05).

Conclusion

Pomalidomide is well tolerated and active in KS regardless of HIV status. Responses were rapid, with improved self-reported outcomes, and occurred in advanced and heavily pretreated disease. Correlative studies support, at least in part, an immunologic mechanism of activity.
Perioperative Surgical Home in Pediatric Settings: Preliminary Results
Authors: Thomson Karen , Pestieau Sophie R. , Patel Janish J. , Gordish-Dressman Heather , Mirzada Ariana , Kain Zeev N. , Oetgen Matthew E.
Published: October 2016

BACKGROUND:

The Perioperative Surgical Home (PSH) is a patient-centered, team-based approach that aims to improve the value of perioperative care. We implemented a PSH for patients with adolescent idiopathic scoliosis who were undergoing posterior spinal fusion at Children’s National Health System. We hypothesized that this PSH would improve patient surgical outcomes and reduce hospital length of stay (LOS).

METHODS:

A multidisciplinary group created evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care of this patient population. After a 5-month design and training period, PSH for spinal fusion was implemented in March 2015, with reduction in LOS as the primary outcome measure. Anesthesia comanagement of patients additionally allowed a new pathway for patients to recover in the postanesthesia care unit and reduce intensive care unit utilization. Patients before and after the implementation of the PSH were compared on clinical and efficiency metrics.

RESULTS:

The spinal fusion PSH achieved the primary outcome measure by a significant reduction in LOS. Care improvement was illustrated by achievement of the secondary outcome measure of reduced perioperative transfusion.

CONCLUSIONS:

The PSH model presented a ready structure that proved successful at our institution for patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion.
First visual record of rare purple dogwhelks (Nucella lapillus) on the Atlantic coast of Nova Scotia, Canada
Authors: Ehlers Sonja M. , Ellrich Julius A.
Published: October 2016

The dogwhelk Nucella lapillus is a rocky intertidal gastropod of the North Atlantic coast. Individual shell color varies. Common colors range between white and brown, with darker dogwhelks being more affected by heat stress than lighter-colored conspecifics. Other reported shell colors are black, mauve, pink, yellow, and orange from European coasts, red and grey from the Bay of Fundy coast of New Brunswick and Nova Scotia (Canada), and purple, black, gray, yellow, and orange from the coasts of Maine and Massachusetts (USA), with purple being considered as a rare color. On the Atlantic coast of Nova Scotia, dogwhelks are active from April until November, but information on dogwhelk shell color is missing for this coast. On 16 June 2016, we found two purple dogwhelks in the mid-to-high intertidal zone of a moderately wave-exposed rocky shore near Duncans Cove, on the Atlantic coast of Nova Scotia while collecting dogwhelks (n= 1000) for manipulative field experiments. All other dogwhelks collected on that day were of common white and brown colors. During earlier dogwhelk collections in Atlantic Nova Scotia (between 2011-2013) and field surveys in Duncans Cove (between 2014-2016), we did not find any purple dogwhelks, indicating the rareness of this color in that region. Interestingly, the purple dogwhelks were detected on a relatively cool day (12.3 ± 0.4 °C, mean ± se, n= 96 temperature measurements) compared to the intertidal temperatures of all other survey days (≥ 18.2 ± 0.5 °C), suggesting that purple dogwhelks may find it less thermally stressful to venture out of crevices and macroalgal cover under relatively cool temperatures. Our observations provide the first visual record of rare purple dogwhelks on the Atlantic coast of Nova Scotia, Canada.
Homicide offending and its main determinants in patients with schizophrenia or bipolar mood disorders
Authors: Assareh Marzieh , Ebrahimi Mohammad Reza , Rakhshani Tayebeh , rai amir reza
Published: October 2016

Aim of the study

This study aimed to assess the prevalence of homicide in those patients suffered from schizophrenia or bipolar mood disorders and also determine main underlying determinants of this violent behavior in the patients.

Subject or material and methods

In a retrospective study, the characteristics of 600 consecutive patients hospitalized at Farabi hospital in kermanshah with one of the main diagnosis of schizophrenia or bipolar mood disorders were reviewed. In this regard, diagnosis of schizophrenia (n = 300) and bipolar mood disorders (n = 300) was made by the psychiatric report and based on the DSM-IV criteria. Study information was collected by reviewing hospital recorded files.

Results

Among schizophrenic patients, 13.3% were committing homicide and homicide offending was prevalent in 20.0% of those with the diagnosis of bipolar mood disorders. In both groups, more than two-third of offending homicide were male and more than half of them were younger than 30 years. In schizophrenics, the main trigger of homicide was delusional beliefs (50.0%) followed by auditory hallucinations (50.0%). Also, in those who suffered bipolar mood disorders, the main triggers of homicide included paranoid delusional beliefs in 73.3%, excitement, irritability and impulsive behavior in 20.0%, and auditory hallucinations in 6.6%.

Discussion

The observed high prevalence of homicide in these patients highlights the importance of psychopathy assessment among violence-prone individuals with schizophrenia and bipolar mood disorders

Conclusions

A notable number of our psychological affected patients with schizophrenia or bipolar mood disorders experience homicide that is considerably more prevalent in men, in younger ages, and in those with delusional beliefs
Memory and Commemoration
Authors: Bomba Jacek
Published: October 2016

Relations between explicit and implicit memory of traumatic events are discussed in context of common memory manipulations for present political reasons. Destructive consequences of stirring up group cohesion with negative emotions are emphasized. Reaction for traumatic event is discussed in context of mourning process. Memory of Shoah as unique traumatic experience is analyzed in perspective of commemoration and part of group common memory. Frizzing of individual memory process is suggested to be a consequence. Ways of commemoration of the Shoah and victims of the Holocaust in form of monuments are used as examples. As well as selected pieces of art. being a form of individual mourning.
The Autonomy of Psychiatric Wards’ Patients
Authors: Jantos Małgorzata
Published: October 2016

For many years now, a conscious consent of the patient to their medical treatment is fundamental for medical ethics. The patients’ acceptance is a confirmation of his autonomy here. Since the time when the issue of autonomy became a fundamental issue in the doctor – patient relationship, the concept of „autonomy” has been given numerous definitions. This text includes a number of suggestions of how to understand this concept. However, an elementary questions becomes vital: whether the autonomy applies to all types of patients to the same degree. Whether psychiatric wards’ patients, patients addicted to alcohol, drug addicts, patients serving a jail sentence are entitled to the same extent of autonomy as others. Whether they are capable of undertaking, together with their doctors, their course of medical treatment, whether they are capable of taking conscious decisions relating to their state of health and needs. Where are the limits of their autonomy, is their autonomy possible at all and to which extent?. It was only in 2009 that the legal regulations relating to the patient’ right for their personal life to be respected came into force in Poland. The summary of the text is a statement, that paternalistic approach of doctors to their patients is dangerous and that there is a need to reflect on the scope of autonomy of psychiatric wards’ patients.