bluuebunny/crossref_metadata_2025 huggingface dataset:
“I Do It With Love”
Authors: Todorova Irina , Turner Hope , Castaneda-Sceppa Carmen , Young David , Bonner Alice
Published: October 2016

For caregivers, the impacts of caring for their loved ones with dementia at home are complex. The purpose of this study was to gain understanding of the meaning and experience of engagement for caregivers of individuals with dementia living in the community. Participants are from a culturally diverse population of low-income caregivers and care recipients in the northeastern United States. We conducted in-depth semi-structured interviews with caregivers ( n = 17) who were caring for parents, friends, or other relatives with dementia. We used interpretative phenomenological analysis and identified the superordinate themes of connectedness, meaningfulness, acceptance, and vigilance. We conclude that caregiver engagement is a multidimensional phenomenon, with some dimensions being contextual and specific to caregiving. It is a relational concept, referring to a committed, vigilant, and meaningful relationship of caregivers and care recipients as active collaborators. The different aspects of engagement can complement each other, or they can be in contradiction.
Birth Care Providers’ Experiences and Practices in a Brazilian Alongside Midwifery Unit
Authors: Nunes Michelly Christiny M. , Reberte Gouveia Luciana M. , Reis-Queiroz Jessica , Hoga Luiza A. K.
Published: October 2016

The implementation of a new birthing facility in a country such as Brazil requires an extensive in-depth analysis of the challenges faced. The aim of this study was to explore beliefs, values, experiences, and practices related to the provision of birthing and neonatal care with the implementation of a new birth care facility structure called alongside midwifery units in Brazil. The study utilizes an ethnographic method to evaluate members of a Brazilian public hospital’s midwifery unit. The ethnographic study focuses on the cultural theme of “between the proposed and the possible”: the following birthing care guidelines require overcoming numerous obstacles, and four other cultural subthemes toward revealing the analyzed birth care team’s perspectives. The study found that prior training and preparation of all members of the care team, as well as the provision of adequate institutional infrastructure are essential for the implementation of a new and innovative birthing care center.
Stigma
Authors: Santos Jussara C. , Barros Sônia , Santos Irma M. M.
Published: October 2016

In this study, we have surveyed how professionals from multidisciplinary teams at psychosocial care centers (CAPS), in the city of São Paulo, understand the concept of mental illness stigma. The aim of the survey was to characterize the actions developed by the team to overcome stigma and, thus, contribute to develop strategies that incorporate overcoming stigma in the territory. Our objective is to get acquainted to the concepts about stigma shared by the participants. This survey was based on the theory of stigma by Erving Goffman; data were collected through semi-structured interviews with mental health professionals belonging to the CAPS teams. Results indicate that social exclusion is understood as a synonym to stigma, and that proximity of CAPS to society in the territory facilitates social inclusion and the overcoming of the mental illness stigma.
Teaching Economic Evaluation of Health Promotion Programs
Authors: Brown Stephen L.
Published: October 2016

One of the essential functions of public health is evaluating the effectiveness and quality of population-based health services. To do this, health professionals and lawmakers must understand the true cost of programs and, in many cases, the future monetary savings that these programs generate. To address calls for consistent economic evaluation of health promotion programs, the Council on Linkages Between Academia and Public Health Practice directs that public health professionals should know how to “describe/use financial analysis methods used in making decisions about policies, programs, and services (e.g., cost-effectiveness, cost–benefit, cost–utility analysis, return on investment).” Anecdotal experience suggests that many undergraduate students are initially intimidated by the prospect of doing economic analysis, worried that it will involve understanding and applying complicated statistics—when, in reality, the math required is very basic. This article outlines, with handouts and instructor notes, a 50-minute lesson on simplified economic evaluation of health programs using lecture, examples, and an in-class, group-based case study.
Impact of the “Linked Evidence Approach” Method on Policies to Publicly Fund Diagnostic, Staging, and Screening Medical Tests
Authors: Merlin Tracy L. , Hiller Janet E. , Ryan Philip
Published: October 2016

Background: The linked evidence approach (LEA) is used in health technology assessment (HTA) to evaluate the clinical utility of new medical tests in the absence of direct trial evidence. Objective: To determine whether use of LEA affects decisions to publicly fund medical tests. Methods: Australian HTAs that evaluated medical tests before and after LEA was mandated (in 2005) were screened for eligibility. Data were extracted and the impact of LEA and other possible clinical predictors (selected a priori) on funding decisions was modelled. Regression diagnostics were performed to estimate model fit, model specification, and to inform model selection. The unit of analysis was per clinical indication for each new test, so analyses were adjusted for clustering. Results: 83 HTAs (for 173 clinical indications) were eligible from the 259 screened. When health policy was compared before and after 2005, there was an 11% reduction in overall positive funding decisions, including a 25% decrease in “interim” (coverage with evidence development) funding decisions. The odds of obtaining interim funding reduced by 98% (odds ratio = 0.02, 95% confidence interval = 0.0005, 0.17), but there was no change in the direction of funding decisions (odds ratio = 1.36, 95% confidence interval = 0.62, 3.01). Across both time periods, when LEA was used there was a very strong likelihood that the medical test would not receive interim funding (χ2 = 12.63, df = 1, P = 0.001). For positive funding decisions, the strongest predictors were whether or not the new test would replace an existing test and whether the available evidence was limited. Conclusions: The use of LEA did not predict the direction of funding decisions. Application of the method did predict that a “coverage with evidence development” decision was unlikely. This suggests that LEA may reduce decision-maker uncertainty.
A Novel Method for Measurement of Ankle Joint Reaction Force and Response to Syndesmotic Injury
Authors: Kelly Meghan , Maqsoodi Noorullah , Vasconcellos Daniel , Osman Walid , Oh Irvin C. , Fowler Xavier , Elfar John C. , Olles Mark , Ketz John
Published: October 2016

Category:

Ankle.

Introduction/Purpose:

Increasing evidence has suggested that alterations in joint mechanics results in articular pathology. Previous studies demonstrated noninvasive measurements of joint reactive forces (JRF) can be performed reliably without destruction of the peri-articular soft tissue in medium and small size joints of the upper extremity. This study presents a novel, noninvasive measurement of the JRF to investigate the normal and the effects of a syndesmotic injury. The JRF of the tibiotalar joint was also evaluated following anatomic reduction with fixation and malreduction of the syndesmosis.

Methods:

Eight fresh-frozen human cadaveric lower extremity limbs were obtained disarticulated above the knee. A distraction force was applied across the tibio-talar joint to determine the baseline (normal) ankle force displacement curve. Next, a syndesmotic injury was created by releasing the interosseous syndesmotic ligaments, the transverse tibiofibular ligament and the anterior and posterior tibiofibular ligaments. Prior to sectioning, two drill holes were placed across the joint and tapped to ensure anatomic reduction. JRF were measured using a quadricortical technique with a single or double screw configuration. The syndesmosis was malreduced by anteriorly displacing the fibula 5 mm. After each step, the resultant JRFs were determined using a distraction force across the tibiotalar joint.

Results:

Force displacement curves obtained from multiple measurements from each specimen with a mean ankle JRF of 31.4 + 2.6 N. Syndesmotic injury resulted in a 35% decrease in tibiotalar JRF (20.3 + 3.0 N, p=0.002). Fixation of the injury using one syndesmotic screw resulted in significant increase in JRF compared to injury JRF (28.7 + 1.4 N, p=0.02). Syndesmotic fixation with 2 screws also demonstrated a trend towards restoration of tibiotalar JRF (28.3 + 2.2 N, p=0.06). There was no statistical difference between fixation of one versus two syndesmotic screws. The JRF for the malreduced syndesmosis was 31.5 + 1.8 N (p=0.03,) resulting in increased forces approaching the baseline JRF.

Conclusion:

This study demonstrates a non-destructive model by which to measure joint reactive forces (JRF) across the tibiotalar joint and that these forces are diminished as a result of a syndesmotic injury, suggesting joint instability. Surgical stabilization with either 1 or 2 screws creates JRF that are similar to the normal JRF. Even with a malreduced syndesmosis, there appeared to be a JRF similar to baseline tibiotalar joint forces. However malreduction of the syndesmosis may alter the joint dynamics of the ankle in ways that were not measured in this study.
Clinical Trial of Osteochondral Lesion of Talus Treated with Human Mesenchymal Stem Cell
Authors: Sung Ki Sun , Yim Hyun Seok , Hong Sung-Ha
Published: October 2016

Category:

Ankle.

Introduction/Purpose:

The aim of surgery for osteochondral lesion of talus is to restore the damaged articular surface with a nearly normal cartilage and supporting subchondral bone. The operative treatment paradigms are still controversial. Though arthroscopic bone-marrow stimulation, autologous osteochondral transplantion and chondrocyte implantation have been performed, but the limitations of these techniques necessitate innovative methods such as cell-based treatment. We investigated the safety and efficacy of human umbilical cord-blood derived mesenchymal stem cell product (CartistemTM) in the treatment of symptomatic osteochondral lesion of the talus.

Methods:

Between Feb 2014 and March 2015, 25 symptomatic OLT patiens were enrolled and randomized into 2 groups with informed consents. They have all suffered from ankle pain more than 6 months despite of conservative treatment. The control group(12 patients) underwent the standard arthroscopic curettage and microfracture, and the study group(13 patients) had additional application of Cartistem on the defect after the same procedure. We measured and analyzed AOFAS ankle-hindfoot scale and MRI features of T2mapping, dGEMRIC, and MOCART scale as well as arthroscopic gross finding with ICRS(international cartilage repair society) scale at 48th week after the index surgery. Also any adverse reactions or complications were recorded. We acquired IRB approval and registered this study at clinicalTrial.gov as NCT02338375.

Results:

There was no adverse effect or complication related to procedures and test drug. Clinically AOFAS ankle-hindfoot score was improved significantly after surgery in both groups, but there was no difference between them. Radiologically both groups showed significant improvement of MRI features without any differences. However on second look arthroscopic exam there was a tendency of better regenerative pattern(ICRS gross finding) in study group.

Conclusion:

There was no adverse reaction and additional benefit of human mesenchymal stem cell product in treatment of symptomatic OLT. However in terms of arthroscopic findings, it might help better histologic regeneration. Further investigation with longer term follow-up can guarantee its usefulness in treatment of OLT.
Prospective Evaluation of Structural Allograft Transplantation for Osteochondral Lesions of the Talar Shoulder
Authors: Adams Samuel B. , Schiff Adam P. , Gross Christopher E. , Nunley James A. , Easley Mark E.
Published: October 2016

Category:

Ankle.

Introduction/Purpose:

The management of large osteochondral lesions of the talar shoulder remains a clinical challenge. Their size, three-dimensional geometry, and subchondral cystic degeneration often preclude treatment with traditional measures such as microfracture and osteochondral autograft transplantation. Structural or bulk osteochondral allograft transplantation has demonstrated efficacy in several retrospective reviews. The purpose of this study was to prospectively evaluate patients who received fresh structural allograft transplantation to the talus.

Methods:

A prospective evaluation of consecutive patients who underwent fresh structural allograft transplantation for an OLT form 2010 to 2013 was performed under Institutional Review Board approval. All patients failed a minimum of 6 months of conservative management. Preoperative MRI and/or CT, as well as plain radiographs were obtained on all patients. The following patient reported outcomes questionnaires were administered preoperatively and yearly after surgery: 100 mm VAS pain scale, AOFAS Ankle-Hindfoot Scale, SF-36, and the Short Musculoskeletal Functional Assessment (SMFA). Pre- and postoperative radiographs were assessed for allograft incorporation and the development of arthritis.

Results:

Fourteen patients underwent fresh osteochondral allograft transplantation. The mean follow-up was 47 months (range 24-73). The average size of the OLT was 2,269 mm3 (range 813-8,366) based on CT imaging and 5,797 mm3 (range 1,136-12,489) based on MRI imaging. There was significant improvement in the VAS pain score, AOFAS Ankle-Hindfoot Scale score, the SF-36 total score, and the SMFA functional and bother indices. Five (36%) of the patients required subsequent arthroscopy and removal of the screw(s) used to secure the graft. Three of these second-look patients had stable grafts without chondral damage. Two grafts demonstrated cartilage delamination. One of these patients had continued pain and progression of arthritis without additional surgery and one was converted to an ankle replacement. Therefore, the failure rate was 14%.

Conclusion:

Significant improvement in pain and function can be achieved with structural allograft transplantation for large OLTs. However, it is important to council patients that painful hardware and stiffness can occur in approximately one-third of patients. An unstable graft and cartilage delamination are indicators of subsequent failure. The use of a structural allograft does not preclude subsequent ankle arthrodesis or arthroplasty.
How do 5 Year Patient Reported Outcomes (PROMs) of Total Ankle Arthroplasty Compare to Total Hip and Knee Arthroplasty?
Authors: Ramaskandhan Jayasree R. , Rashid Anjum , Siddique Malik S.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthritis is a leading cause of pain and disability. The effect of this condition on physical and mental health is similar to end stage hip arthritis. There is paucity of literature on PROMS outcomes following total ankle replacements (TAR) in comparison to total hip replacement (THR) or knee replacement (TKR). We aimed to study the 5 year outcomes of TAR in comparison with TKR and THR

Methods:

PROMS data from patients who underwent a primary THR, TKR or TAR from March 2003 to 2013 were collected from our hospital patient registry. They were divided into 3 groups based on the type of primary joint replacement. Patient demographics and patient reported outcomes (WOMAC, SF-36 scores and patient satisfaction scores at follow up) were compared at pre-op and 5 year follow up.

Results:

There was data available on 1920 THR, 2582 TKR and 248 TAR patients. Pre-operatively, TAR patients reported higher function scores when compared to THR and TKR (40.2 vs. 34.2 and 35.8; p < 0.05). For SF-36 scores, there was no difference between groups for general health, role emotional components (P>0.05); TAR patients reported similar scores to TKRs for physical domains; to THRs for the mental domains (P>0.05). At 5 years post-op, TARs reported lower scores than THRs and TKRs for function and stiffness. For SF-36 scores, TARs reported similar outcomes to THR and TKR for mental health components (p>0.05), similar scores to TKR for 3/4 physical domains (p < 0.05), but lower satisfaction rates for ADL and recreation when compared to THR (P < 0.05).

Conclusion:

TAR patients had similar outcomes to THR or TKR patients for disease specific and mental health domains, and lower patient satisfaction rates in terms of pain relief, ADL and recreation. Further research is warranted including clinical outcomes along with PROMS with a long term follow up.
Secondary Fusions Following Total Ankle Arthroplasty
Authors: Gross Christopher E. , Adams Samuel B. , Huh Jeannie , Easley Mark E. , DeOrio James K. , Nunley James A. , Shi Glenn G.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

While it is thought that stresses through the subtalar and talonavicular joints will be decreased in total ankle replacement (TAR) relative to ankle fusion, progressive arthritis or deformity of these joints may require a fusion after a successful TAR. However, after ankle replacement, it is unknown how hindfoot biomechanics and blood supply may have been affected. Consequently, subsequent hindfoot joint fusion may be adversely affected. We hypothesize that fusion rates are not significantly affected following a TAR.

Methods:

We retrospectively identified a consecutive series of 1001 primary TARs performed between January 1998 and December 2014. We identified patients who underwent a secondary triple, subtalar or talonavicular arthrodesis to treat progressive arthritis or pes planus deformity. Clinical outcomes including pain and functional outcome scores, revision procedures, delayed union, nonunion, complications, and failure rates were recorded. We then compared these patients to patients who had a subtalar fusion after an ankle arthrodesis (13).

Results:

26 patients required a subtalar (18), talonavicular (3), talonavicular and subtalar (3), or triple arthrodesis (2) with a mean 70.9 months follow-up. The mean time between TAR and secondary fusion was 37.5 months. 92.7% of the patients went successfully fused. Two patients (7.7%) had a delayed union. Two patients had a nonunion who had one revision talonavicular and one revision subtalar fusion. The mean time to radiographic and clinical fusion was 26.5 weeks. Pain and functional outcome scores improved significantly. There were no differences in the rates of subsequent fusions among implant choices. Compared to thirteen patients with prior ipsilateral ankle arthrodeses and subtalar fusions, patients who had TAR had a higher fusion rate (p=0.03), but did not have a longer time to fusion.

Conclusion:

Hindfoot arthrodesis following a TAR is safe and effective in improving function and pain. Additionally, arthrodesis following a TAR is more successful than a subtalar fusion following an ankle arthrodesis. While the time to healing is relatively long, various hindfoot fusions can be used to treat progressive arthritis and deformity with high fusion rates.
Predictors of Time to Clinical Union in Ankle Fractures
Authors: Matson Andrew P. , Hamid Kamran S. , Adams Samuel B.
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Ankle fractures are an increasingly common musculoskeletal injury and represent a substantial source of societal economic loss due to missed days of work and utilization of healthcare resources. While common protocols exist for postoperative management of these fractures, predictors of time to union have not been analyzed. We aim to evaluate patient characteristics, injury features and perioperative factors that predict time to union and may allow for optimized postoperative protocols and improved patient counseling.

Methods:

A cohort of consecutive patients with isolated, closed operative ankle fractures treated by multiple surgeons at a tertiary care academic medical center from 2008-2012 was retrospectively reviewed for time to clinical union. Clinical union was defined as plain film radiographic evidence of bony healing and minimal to no pain clinically. Patients with pilon fractures, open injuries, additional fractures and incomplete outcomes data were excluded from analysis. Means and standard deviations were calculated and multivariate linear regression modeling was utilized to identify predictors of time to clinical union.

Results:

A total of 108 isolated, closed operative ankle fractures met inclusion criteria. Of these, 99.1% achieved clinical union in less than 6 months and the remaining one patient completed union in a delayed fashion with the use of non-operative adjuncts. Mean time to union was 14.1 weeks (SD 5.3 weeks). Statistically significant negative predictors of time to union were BMI, dislocation of the tibiotalar joint, external fixation for initial stabilization and delay of definitive management (all p < 0.05). Sex, age, diabetes mellitus, tobacco usage and high-energy mechanism were not significant after adjustment (Table 1). Fracture pattern and definitive operative fixation technique did not contribute to a parsimonious regression model and were excluded from final analysis.

Conclusion:

Time to clinical union after ankle fracture is significantly correlated with BMI, tibiotalar dislocation, external fixation for initial stabilization and delay of definitive management. In these instances, it is important to counsel patients about the potential for nonunion and consideration should be given to healing adjuncts such as prolonged non-weightbearing immobilization, bone stimulation and vitamin D.
Validity of a Revision Surgery Classification System for Ankle Arthritis Surgery
Authors: Younger Alastair S. , Wong Hubert , Wing Kevin , Penner Murray J. , Daniels Timothy R. , Veljkovic Andrea , Glazebrook Mark A. , Lalonde Karl , Dryden Peter
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Reoperations may be a better way of tracking adverse outcomes than complications. Repeat surgery causes cost to the system, and often indicate failure of the primary procedure resulting in the patient not achieving the expected improvement in pain and function. Understanding the cause of repeat surgery at the primary site may result in design improvements to implants or improvements to fusion techniques resulting in better outcomes in the future. Repeat operations around the primary site may also be relevant to the primary surgery. The COFAS group have designed a reoperation classification system. The purpose of this study was to outline the inter and intra observer reliability of this classification scheme.

Methods:

To verify the inter- and intra-observer reliability of this new coding system, six fellow ship trained practicing foot and ankle Orthopaedic surgeons were asked to classify 61 repeat surgeries. The six surgeons read the operation reports in random order, and reread the reports 2 weeks later in a different order. Reliability was determined using regression analysis and intraclass correlation coefficients (ICC) were calculated and proportions of agreement. The agreement between pairs of readings (915 for inter observer for the first and second read; 61 readings with 15 comparisons) was determined by seeing how often each observer agreed. This was repeated for the 366 ratings for intra observer readings (61 times 6).

Results:

The inter-observer reliability test on the first read had a mean intra-class correlation coefficient (ICC) of 0.89, range 0.80 to 0.96. For 61 cases, 45 (74%) observations that were given the same code across all six observers for the first read. The inter-observer reliability test on the second read had a mean ICC of 0.94, range .90 to to 1.0. There were 43 (72%) observations that were the same across all six observers. Of all pairs (915 in total) there was agreement in 804 pairs for the first reading (88%). For the second reading there was agreement in 801 pairs (86%). The observers agreed with themselves in the intra-observer observation 324 times out of 366 paired readings (89% agreement of pairs).

Conclusion:

The COFAS classification of reoperations for end stage ankle arthritis was reliable. This scheme potentially could be applied to other areas of Orthopaedic surgery and should replace the Claiden Dindo modifications that do not accurately reflect Orthopaedic outcomes. As complications are hard to define and lack consistent terminology (Mercer) reoperations and resource utilization (extra clinic visits, extra days in hospital and extra hours of surgery may be more reliable measures of the negative effects of surgery.
Development of a Novel Small Animal Ankle Arthrodesis Model
Authors: Kadakia Rishin J. , Bariteau Jason T. , Kephart Donald T. , Willet Nick
Published: October 2016

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Ankle arthrodesis is performed for a variety of ankle joint pathology with the most common being post traumatic arthritis. It is estimated that there are nearly twenty-five thousand ankle fusions performed annually in the United States. Reported complication rates vary between studies and patient population characteristics and comorbidities. Our understanding of the biology of ankle arthrodesis is based largely upon spine fusion and long bone animal models. However, bony healing and infection is greatly influenced by local soft tissue and vascular anatomy, therefore the application of data from these models may not be entirely accurate. There is currently no small animal ankle fusion model. Accordingly, the purpose of this study is to develop a reliable small animal ankle arthrodesis model.

Methods:

A total of twenty Lewis rats were included in this study. Ankle arthrodesis was performed on one extremity of fourteen rats with the other ankle serving as an internal control. An anterior approach was used to expose the tibiotalar joint. Careful technique was utilized to protect neurovascular structures. After adequate joint exposure, a power burr and sharp curette was used to remove joint cartilage. A .042 kirschner wire was then passed through the calcaneus and through the subtalar and tibiotalar joint. Six rats served as controls and their procedures did not involve any joint cartilage removal. Radiographs were taken immediately postoperatively and at 8 weeks. Bony healing was assessed in a blinded fashion by a board certified foot and ankle orthopaedic surgeon using a grading system based upon assessment of cortical bridging and joint space.

Results:

Sixteen rats – eleven fusions and five controls - underwent the procedure without any perioperative complications and were included in analysis. Four rats were excluded due to a perioperative complication and/or death. The most common postoperative complication encountered was a wound complication (n=3). Of the eleven rats in the fusion group, six (55%) were determined to be fused radiographically. Two of the five controls were radiographically fused (40%).

Conclusion:

This study demonstrates preliminary data from a novel small animal ankle arthrodesis model. Fifty-five percent of the rats in the fusion group fused based on radiographic evaluation at eight weeks postoperatively. Further work involves improving upon the surgical technique for fusion in this small animal model to help increase fusion rates, and using CT scans and biomechanical testing to further assess fusion. The development of a small animal ankle fusion model will enhance our understanding of the biology of ankle arthrodesis and allow for development of novel therapies aimed at increasing fusion rates and decreasing complications.
Conservative Sharp Wound Debridement by Nurses in the Outpatient Management of Diabetic Foot Ulcers
Authors: Schumer Ross A. , Guetschow Brian , Ripoli Marissa V. , Tennant Joshua N. , Gardner Sue , Phisitkul Phinit , Femino John
Published: October 2016

Category:

Diabetes

Introduction/Purpose:

With approximately 29.1 million diabetics in the United States and estimated total annual cost of $245 billion, diabetes and its associated complications continue to be an increasing burden on society. The management of diabetic foot ulcers accounts for a significant portion of those expenses. We propose a safe, efficacious and economically prudent model for the outpatient treatment of uncomplicated diabetic foot ulcers.

Methods:

Enrolled patients had initial sharp wound debridement by one of two foot and ankle fellowship trained orthopaedic surgeons. Patients were treated with total contact casting and subsequently evaluated every two weeks by nurses who utilized a clinical management algorithm and performed conservative sharp wound debridement (CSWD). Results of healing and complications were recorded. Digital photographs of the ulcers from each clinical encounter were retrospectively reviewed in a blinded fashion by two orthopaedic foot and ankle surgeons and compared to the nursing decisions at the time of treatment. Financial calculations estimated the potential cost savings by having nurses perform CSWD. State boards of nursing were systematically surveyed to assess current policies related to CSWD.

Results:

Average time to clinical healing was 6.03 weeks. There were no identified complications of CSWD performed by nurses. The sensitivity for the timely identification of wound deterioration was 100%, specificity = 86.49%, PPV = 68.75% and NPV = 100% with an overall accuracy of 89.58%. Thirty-six of 51 (70.59%) state boards of nursing responded to the survey with 33 of 36 (91.67%) defining CSWD as within the nursing scope of practice. The estimated cost savings by having nurses perform CSWD over a 6 week treatment period, with all other factors being equal, was $774.60 per patient. When extrapolated to the estimated number of diabetic foot ulcers annually within the United States, this could approach $1.8 to $2.1 billion in potential annual healthcare savings.

Conclusion:

CSWD of diabetic foot ulcers and calluses by trained nurses is a safe, effective and fiscally responsible clinical practice supported by greater than 90% of state boards of nursing. Utilizing a clinical decision algorithm, nursing evaluation and appropriate referral of ulcers at risk demonstrated 100% sensitivity and 89.58% accuracy. There were no complications associated with nurses performing conservative sharp debridement. When considering the most recent CDC estimates of 29.1 million diabetics with an 8% annual incidence of DFU, implementation of this clinical model on a national scale could result in approximately $2 billion in annual healthcare savings.
Ankle Joint Pressure Changes in High Tibial and Distal Femoral Osteotomies
Authors: Krause Fabian , Barandun Ariane , Klammer Georg , Zderic Ivan , Gueorguiev Boyko , Schmid Timo
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

There is evidence from clinical studies and case reports that realignment of knee deformities for accompanying arthritis by high tibial- (HTO) and distal femoral osteotomies (DFO) inevitably changes the hindfoot alignment and ankle pressure characteristics.

Methods:

Varus and valgus malalignment of the knee was simulated in 12 fresh-frozen human cadaver full-length legs by removal of 5° bony wedges below and above the knee, respectively. Three hundred Newton, representing half body weight were applied onto the femoral head for static axial compression. Intra-articular high-resolution ankle sensors captured pressure. Testing included four measurements: baseline malalignment (1), 5° (2) and 10° realigning osteotomy (3), and control baseline malalignment (4). For the more common HTO, testing was rerun with the subtalar joint fixed in varus and valgus position.

Results:

Compared to the baseline measurement the opening HTO of 5° led to a mean center of force (COF) medialization of 0.1 mm and a HTO of 10° to a mean lateralization of 0.5 mm. The closing DFO of 5° and 10° both led to a COF mean medialization of 0.3 mm. No COF migration or change of Pmax was significant. With the subtalar joint fixed in varus position significant lateralizations of the COF was seen for the 5° HTO (2.5 mm) and the 10° HTO (2.9 mm). With the subtalar joint fixed in valgus position the 5° HTO led to a COF lateralization of 1.1 mm (significant) and the 10° to a COF lateralization of 0.9 mm (not significant). Pmax changes were not significant.

Conclusion:

In this biomechanical study, realignment of coronal plane deformities around the knee by HTO and DFO altered ankle pressure characteristics. The COF migration after HTO was significant, when the subtalar joint was fixed. Clinical relevance When indicating a HTO for medial rather than DFO for lateral knee arthritis or deformities, the impact on ankle pressure characteristics should be considered, particularly when compensatory capacity of the subtalar joint is restricted.
Complications After Resection of Os Trigonum or Posterior Talar Process
Authors: Frigg Arno , Studer Claudia , Maquieira Gerardo Juan J.
Published: October 2016

Category:

Sports

Introduction/Purpose:

The resection of os trigonum or posterior talar process for posterior ankle impingement is a technically easy and frequent operation. So far, the scientific literature has focused only on the surgical approach and perioperative problems. However, the author has encountered unfavorable followup results (professional athletes had to stop their career), which also other surgeons tell to have encountered. This study aims to describe for the first time this complication rate and possible reasons therefore.

Methods:

From 3/11 to 7/15 29 patients (17male, 12 female, 32+/-14 years) with 30 feet were operated (22 endoscopic, 8 open resections). Average followup was 27+/-13 months. All charts and pre- and postoperative radiographs were retrospectively evaluated. Patients were grouped into “no complications”, “minor temporary (< 3 months)”, “major follow up (end of athletic career)” complications. The following radiographic parameters were measured referenced on the intersection of the talar radius with the calcaneus (Fig. 1): (1) length of posterior talar process/ os trigonum, (2) length of the calcaneus below the posterior process/os trigonum, (3) length of the uncovered subtalar joint after resection.

Results:

The major complication rate was 13.3% (4 of 30 feet, 2 os trigonum, 2 posterior talar process): all 4 had symptomatic talar edema and 3 of 4 had symptomatic subtalar osteoarthritis. 1 minor complication (persistent pain for 3 months) was found. The length of the posterior talar process was preoperatively 9.37 +/- 2.89 mm (os trigonum 8.62+/- 2.62 mm) postoperatively 0.64+/-1.8 mm. The length of the posterior calcaneus preoperatively was 8.35 +/- 4.63 mm, postoperatively 1.97 +/-3.0 mm. The uncovered subtalar joint surface postoperatively was 1.77+/- 2.92 mm. All patients with major complications showed retrospectively what we call the “deadly configuration”: the radius of the talus ends within the subtalar joint. Consequently the free subtalar joint surface was significantly larger (6.4 mm +/- 3.33) in feet with major complications than in feet without (1.06 mm +/- 2.15, P < 0.001). Feet without complications but with this deadly configuration (7/26) had a lower free subtalar surface (3.27 mm +/- 1.81, P=0.09) than feet with major complications.

Conclusion:

The resection of os trigonum or posterior talar process has a high complication rate of 13.3% with symptomatic talar edema and subtalar osteoarthritis at follow up which can be career-ending in professional athletes. The only risk factor found was what we call the “deadly configuration” characterized by the ending of the talar radius into the subtalar joint. In such cases, the resection has to be made sparingly preferably not anterior into the subtalar joint and patients have to be informed about this possible unfavorable course.
Sustained Release of Bone Morphogenetic Protein 2 via Coacervate
Authors: Hogan MaCalus V. , Hicks Justin H. , Engineering Biomedical , Rocha Jorge L. , Li Hongshuai , Wang Yadong , Huard Johnny
Published: October 2016

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Currently, there is no cure for osteoarthritis (OA) with treatment aimed at symptom relief and improved function. Muscle-derived stem cells (MDSCs) have been shown to exhibit long-term proliferation, high self-renewal, and can undergo chondrogenic differentiation when cultivated in chondrogenic medium in vitro and can differentiate into chondrocytes and repair injured articular cartilage (AC) in vivo. MDSCs retrovirally transduce to express chondrogenic proteins (BMPs) to differentiate into chondrocytes and enhance cartilage repair in vivo. Gene therapy is a promising approach to promote the chondrogenic potentials of MDSCs for AC repair. We have developed a unique sustained growth factor delivery platform comprised of native heparin and a synthetic polycation incorporated with BMP2 (BMP2 coacervate) which can sustain delivery of BMPs to stimulate the chondrogenesis of MDSCs for AC repair.

Methods:

MDSC were stimulated in vitro with single dose of free BMP2, multi-dose BMP2, BMP2 coacervate, coacervate alone (vehicle only), or in the absence of BMP2 and coacervate (control). BMP2 effects on MDSCs were evaluated by RT-PCR. 20μl of a MIA solution was injected into the knee joint of C57B6 mice to induce osteoarthritic lesions. Two weeks after MIA injection, 20μl of PBS (PBS control), 1×106 MDSCs with 1μg of free BMP2 (MDSC-free BMP), or MDSCs with 1μg BMP2-coacervate (MDSC- BMP coacervate) were injected into the knee joints of the OA injured mice. After 4 weeks, macroscopic and histologic evaluations of cartilage regeneration were conducted.

Results:

mRNA expression of Aggrecan and Col2A were significantly higher in each BMP2 group compared to control or vehicle only (P < 0.05). Multi-dosage free BMP2 demonstrated significantly higher Aggrecan expression compared to single dose free BMP2 (p < 0.05). Col2A and aggrecan expression in the BMP coacervate group was superior to both single and mult-dose free BMP2 delivery (p < 0.05) (Fig 1A). Histologic examination demonstrated superior cartilage repair and integration in the BMP2 coacervate group (Fig. 1B).

Conclusion:

This study demonstrates that sustained growth factor delivery (BMP2) is a potential therapeutic option for muscle- derived stem cell based cartilage regeneration for the treatment of osteoarthritis. Prolonged delivery of BMP2 via coacervate led to enhanced MDSC chondrogenesis in vivo and improved cartilage regeneration in vivo. Our results demonstrate an effective method for prolonged exposure to BMP2 and is more clinically translatable.
Early Weight Bearing Following First TMT Arthrodesis
Authors: Bohay Donald R. , Hooper Jessica M. , Anderson John G. , Maskill John D. , Padley Michelle A. , Behrend Lindsey , Rust C. Luke , Beuchel Matthew W.
Published: October 2016

Category:

Midfoot/Forefoot

Introduction/Purpose:

The modified Lapidus arthrodesis is an accepted method of correcting varying degrees of hallux valgus with or without associated first ray insufficiency. Improved operative techniques have led to more reliable outcomes and lower incidence of nonunion. As a result, the modified Lapidus procedure has increased in popularity. Historically, surgeons have followed cautious postoperative protocols, initially restricting weight bearing until bone consolidation is confirmed radiographically. More recently, an alternative approach to postoperative management has been proposed, allowing patients to bear weight as tolerated two weeks after surgery with the goal of improving patient compliance while minimizing postoperative disability. The purpose of this study is to compare outcomes of patients randomized to either early weight bearing or standard non-weight bearing postoperative course following modified Lapidus arthrodesis.

Methods:

We determined that at least 130 patients would need to be enrolled in this study to achieve statistical significance (p < 0.05). Beginning in 2012, patients with hallux valgus indicated for modified Lapidus arthrodesis were assigned to either the investigational Group A (early weight bearing) or to the control Group B (standard of care) by a random number generator. All patients underwent modified Lapidus arthrodesis by one of the three senior authors (JGA, DRB, JDM). Specific demographic, clinical, patient-centered, and radiographic data were collected during the preoperative visit, the operative procedure, and at defined intervals during the postoperative period. The primary outcome variable was defined as first tarsometatarsal joint fusion at six months.

Results:

To date, 100 subjects have been enrolled, 57 of whom (40 patients in Group A, 17 patients in Group B) have completed one year of follow up. At six months, 38/40 patients in Group A had achieved radiographic union, compared to 17/17 patients in Group B (p = 0.495). Smoking status, BMI, and age at surgery were not found to be significantly associated with rate of union in either group. Patients in Group A required less time to reach full weight bearing status (p < 0.001). At six weeks after surgery, Group A reported significantly higher levels of physical function and overall composite scores on the SF-36 questionnaire. The rate of adverse events was not significantly different between the two groups at any postoperative timepoint.

Conclusion:

Though data collection is ongoing, our results indicate that clinical, patient-centered, and radiographic outcomes were comparable following modified Lapidus arthrodesis in both the early weight bearing and standard of care patient groups. Early weight bearing does not appear to increase the rate of adverse events or significantly slow rate of fusion, and also reduces postoperative disability.
Two-Year-Followup in 20 Patients After Matrix-Associated Stem Cell Transplantation (MAST) in Chondral Defects of the 1st Metatarsophalangeal Joint
Authors: Richter Martinus , Zech Stefan , Meissner Stefan A.
Published: October 2016

Category:

Other

Introduction/Purpose:

For treatment of chondral defects, matrix-associated stem cell transplantation (MAST) is a modification of autologous matrix-induced chondrogenesis (AMIC) with a potential higher concentration of stem cells due to harvesting fluid at the bone marrow and in-vitro processing. The aim of the study was to assess the 2-year-followup of MAST in chondral defects of the 1st MTP.

Methods:

In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral defect that were treated with MAST from April 1st 2009 to March, 30th, 2013 were analyzed. Patients with bilateral treatment or with MAST at more than one joint surface were excluded from the study. The size and location of the chondral defects, method-associated problems and the Visual-Analogue-Scale Foot and Ankle (VAS FA) and range of motion were registered and analyzed. MAST was performed as a single open procedure including debridement and microfracturing of the chondral defects. Stem cell- rich blood was harvested during the procedure from the ipsilateral pelvic bone marrow and was centrifuged (10 minutes, 1,500 RPM). The supernatant was used to impregnate a collagen I/III matrix (Chondro-Guide®, Geistlich, Baden-Baden, Germany) that was cut to the size of the defect before. The matrix with stem cells was fixed into the chondral defect with fibrin glue (Tissucoll, Deerfield, USA).

Results:

Twenty-five chondral defects in 20 patients were included in the study. The age of the patients was 42 years on average (range, 35-62 years), 14 (70%) were male. The VAS FA before surgery was 50.5 on average (range, 18.3-78.4). The defects were located as follows, medial metatarsal head, n=7; lateral metatarsal head, n=18 (medial and lateral metatarsal head, n=5). The defect size was 0.7 cm2 on average (range, .4 - 1.5 cm2). ROM was 10.2/0/18.8° on average. All patients completed 2-year- followup. No method related complications were registered. The VAS FA improved to an average of 91.5 (range, 74.2-100; t-test (comparison with preoperative scores), p=.01). ROM improve to 32.5/0/25.5 one average (p=.05).

Conclusion:

MAST led to good clinical scores and improved range of motion. No complications were registered. Even though a control group is missing, we conclude that MAST is a safe and effective method for the treatment of chondral defects of the 1st MTP joint. The main advantage of MAST in comparison with ACI and MACI is the single procedure methodology. The advantage in comparison with AMIC is the potential higher concentration of stem cells. It remains unclear if this method is superior to AMIC, and what kind of tissue is created.
A Novel Stocking to Improve Venous Return Compared to the Class 1 Compression Stocking
Authors: Paramasivan Arjun C. , Sampathkumar Kandasamy
Published: October 2016

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Venous thromboembolism (VTE) is a serious risk of major orthopaedic surgery, associated with significant morbidity and mortality. VTE events are annually costing the US healthcare system over $13.5 billion and causing approximately 200,000 deaths each year. In current clinical practice, the risk of VTE events are reduced with various pharmacological and mechanical thromboprophylactic measures. Class 1 compression stockings are frequently used as mechanical prophylaxis due to few associated complications. The purpose of this study was to determine if the addition of a novel device to the conventional compression stockings improved venous return.

Methods:

This prospective study measured ejected venous volume (EVV) of the superficial femoral vein in both legs of healthy volunteers (n=10). The novel device wraps around the heel and holds the meta-tarsophalangeal joint of the great toe flexed, encouraging active toe dorsiflexion and partial ankle dorsiflexion. EVV was obtained using duplex scanning, and measured 1) when participants were supine at rest 2) with the addition of the compression stocking and 3) with the novel device in addition to the compression stocking.

Results:

The use of compression stockings compared to the baseline did not demonstrate a difference in EVV (6.13±0.43 ml vs 6.02±0.32 ml, p=1.000). However, the addition of the novel device significantly increased EVV compared to the baseline (6.13±0.43 ml vs 12.16±1.20 ml, p < 0.001) and more importantly compared to the compression stockings alone (6.02±0.32 ml vs 12.16±1.20 ml, p < 0.001). The novel device therefore augmented the EVV, two times greater than the compression stocking used as monotherapy.

Conclusion:

We have demonstrated that the addition of the novel device significantly improves venous return, compared to the compression stocking used as a monotherapy. DVT outcome studies assessing efficacy of this novel device in the clinical setting are now required. Nevertheless, these preliminary results demonstrate excellent potential in the next generation of VTE prophylaxis.