bluuebunny/crossref_metadata_2025 huggingface dataset:
Lesser Metatarsophalangeal Instability: Presentation, Management, and Outcomes
Authors: Peck Christopher N. , Macleod Alan , Barrie Jim
Published: December 2015

Background: Lesser metatarsophalangeal (MTP) instability is a common cause of forefoot pain. In this prospective study, we looked at its presentation, management and outcome. Methods: We studied characteristics of patients presenting to a specialist foot and ankle clinic with lesser MTP instability. We used the drawer test to diagnose and stage instability. Patients were followed up in clinic or by telephone interview. Results: We identified 154 patients with lesser MTP instability; 127 (82%) were female, median age was 56 years. One foot was affected in 107 patients (69%). The second toe only was affected in 99 patients (64%) and multiple toes in 52 (34%) but always involving the second toe if multiple toes involved. 150 toes (52%) had Grade 1 instability, 108 (37%) Grade 2 and 21 (7%) Grade 3 instability. Twelve toes (4%) presented dislocated. Ninety nine patients (64%) were treated nonoperatively, using functional taping, shoe modifications, and injections. Fifty five patients (36%) were treated operatively, including lesser toe straightening, flexor-extensor transfer, Weil and Stainsby procedures. At followup, the mean AOFAS score and standard deviation was 69 ± 16.3 for the nonoperative group compared to 67 ± 17.8 in the operative group. The mean pain score and standard deviation was 31 mm ± 23.7 mm for the nonoperative group and 23 mm ± 24.1 mm in the operative group. Thirty-nine patients (52%) were either satisfied or very satisfied with treatment in the nonoperative group compared to 31 patients (66%) in the operative group. None of these differences were statistically significant. Conclusion: Painful MTP instability is a common cause of forefoot pain. Most patients can be treated nonoperatively. Operatively treated patients had no significant improvement in outcomes with regards to pain or function.

Level of Evidence: III, Comparative Case Series
Nonoperative Management of Retrocalcaneal Pain with AFO and Stretching Regimen
Authors: Johnson Michael D. , Alvarez Richard G.
Published: December 2015

Background: Retrocalcaneal heel pain is caused by a spectrum of etiologies all resulting in the same symptom of pain at the tendon-Achilles insertion. Several studies have reported the outcomes of operative treatment, but none have reported the outcomes or success rates of nonoperative treatment. We describe a detailed treatment algorithm and report the clinical outcomes. Methods: One hundred thirty-five patients were prescribed a treatment regimen consisting of an AFO and stretching program and were enrolled in our prospective study. One hundred three patients completed pre- and post-treatment Foot Function Indices and were included in the analysis. The effect on FFI from clinical and radiographic factors was examined. Results: Of the study population, 76% had a BMI greater than 25, 80% were older than 50 years, and 75% had an exostosis on radiographs. The mean pre-treatment FFI was 48.4 and the mean post-treatment FFI was 18.6 indicating a statistically significant improvement in function of 29.8. Neither BMI nor age had a significant effect on the magnitude of improvement; though, smokers had significantly less improvement. FFI improvement in patients with an exostosis were less than those without an exostosis. Patients with an exostosis less than 1 cm had less improvement than those with an exostosis of 1 cm or more. Patients with Types I and III exostoses had significantly less improvement in FFI compared to Types II and IV. Twelve of the 103 (11.6%) were not pleased with the results of nonoperative treatment and elected to have a procedure performed. Conclusion: Our study is the first to report the outcome of non operatively treated retrocalcaneal heel pain and to classify retrocalcaneal exostoses. Using our treatment algorithm, we had an 88% success rate in alleviating symptoms and avoiding surgery. Our data suggests that the use of an AFO and stretching regimen may benefit patients suffering from retrocalcaneal heel pain.

Level of Evidence: IV, Case Series
Fifth Toe Plantar Plate Repair in a Professional Soccer Player: Case Report
Authors: Sonnery-Cottet Bertrand , Archbold Pooler , Thaunat Mathieu , de Oliveira Alves Tostes Marcelo Duarte , Besse Jean-Luc
Published: December 2015

Level of Evidence: V, Expert Opinion
Functional Results of Posterior Tibial Tendon Reconstruction, Calcaneal Ostetomy, and Gastrocnemius Recession
Authors: Kou Joseph X. , Balasubramaniam Mamtha , Kippe Matthew , Fortin Paul T.
Published: December 2015

Background: This study aimed to assess and provide prospective outcome data following reconstruction of Stage II posterior tibial tendon insufficiency, as well as evaluate the effect of reconstruction with gastrocnemius recession on plantarflexion strength. Methods: A prospective evaluation of 24 patients undergoing reconstruction for Stage II posterior tibial tendon insufficiency was granted IRB approval. The reconstructive procedures consisted of a flexor digitorum longus transfer, medial displacement calcaneal osteotomy, lateral column lengthening, and gastrocnemius recession. Patients were asked to complete multiple outcome measures preoperatively, 6 months, 1 year, and 2 years postoperatively. A dynamometer was utilized to evaluate peak torque plantarflexion preoperatively, 6 months, and 1 year postoperatively. Results: In the study, 14 patients completed preoperative surveys, and 23 patients had 2-year followup. Patients were highly satisfied with the results of their surgery. All outcome measures showed statistically significant improvement. Improvement was seen at 6 months, but results continued to improve at the 1-year mark. By the second year, improvement largely reached a plateau. Biodex testing showed no loss of plantarflexion strength after reconstruction and gastrocnemius recession. Conclusion: Reconstruction of the flexible adult acquired flatfoot with FDL transfer, double calcaneal osteotomy, and gastrocnemius recession yielded excellent functional results for the treatment of Stage II posterior tibial tendon insufficiency. Plantarflexion weakness was not found to be a concern. A good functional outcome can be anticipated after the early postoperative period. However, it should be expected to take at least 1 year for maximal benefit.

Level of Evidence: III, Prospective Case Series
Anatomic Location and Morphology of Symptomatic, Operatively Treated Osteochondral Lesions of the Talus
Authors: Orr Justin D. , Dutton Jason R. , Fowler Justin T.
Published: December 2015

Background:

Historically, osteochondral lesions of the talus (OCLTs) were thought to occur most commonly in the anterolateral and posteromedial talar dome; however, new classification systems are able to describe OCLT location more precisely. A recent magnetic resonance imaging (MRI) study introduced a novel nine-zone anatomic grid of the talar dome, demonstrating that most OCLTs occur in the central portion of the medial and lateral talar dome, with medial lesions being more common as well as larger in depth and surface area. The current study sought to determine if similar location and morphology patterns were consistent in symptomatic, operatively treated OCLTs.

Materials and Methods:

The preoperative MRI images of 65 consecutive patients who underwent operative management for symptomatic OCLTs at a single institution were reviewed using a previously described nine-zone anatomic grid of the talar dome to determine location frequency, morphology, and Hepple et al. MRI staging classification characteristics. All patients were active-duty service members in the United States Armed Forces. The cohort consisted of 60 (92%) males and 5 (8%) females with an overall mean patient age of 34 (range, 19 to 58) years. Statistical analyses were performed, and significant differences are reported.

Results:

The most common location for symptomatic, operatively treated OCLTs was the central third of the lateral talar dome, followed by the central third of the medial talar dome. Anterolateral and posteromedial lesions accounted for relatively few OCLTs. Compared with lateral OCLTs, medial OCLTs were significantly larger in transverse and anteroposterior diameters and surface area, but no significant differences existed with regard to lesion depth. Overall, the majority of lesions were MRI stage II; however, stage II lesions were more likely located laterally, whereas stage III lesions were more likely located medially.

Conclusions:

With regard to symptomatic, operatively treated OCLTs, the results of the current study parallel current evidence that posteromedial and anterolateral OCLTs are not the most common locations of OCLTs. As well, medial OCLTs were larger in surface area than lateral OCLTs, but no differences existed with regard to lesion depth. It is interesting that operatively treated OCLTs were twice as commonly located in the centrolateral third rather than the centromedial third of the talar dome. Level of Evidence: IV (Retrospective Chart Study)
Comparison of Arthroscopic and Magnetic Resonance Imaging Findings in Osteochondral Lesions of the Talus
Authors: Bae SooHo , Lee Hyeon Kyeong , Lee Kyunghee , Lim Sanghyeok , Rim Nae-Jung , Kim Jin-Su , Cho Jaeho
Published: December 2015

Background:

Magnetic resonance imaging (MRI) is widely used for diagnosing osteochondral lesions in the talus. The purpose of this study was to directly compare the MRI with the arthroscopic findings.

Materials and Methods:

MR images of 42 ankles were retrospectively reviewed during a period of 67 months. The osteochondral lesions were evaluated by both MRI (0, normal; 1, subchondral trabecular compression and marrow edema; 2A, subchondral cyst; 2B incomplete separation fragment; 3, unattached, nondisplaced fragment with synovial fluid surrounding it; 4, displaced fragment) and arthroscopy (A, smooth and intact, but soft and ballottable cartilage; B, rough surfaces; C, fibrillations or fissures; D, flap present or bone exposed; E, loose, undisplaced fragment; F, displaced fragment). Arthroscopic grade A was considered to be equivalent to MR grade 1, B and C to MR grade 2A, D to 2B, E to 3, and F to 4.

Results:

Of the 44 lesions in 42 ankles, 29 lesions marked the same grade on both MRI and arthroscopy (65.9%). Nine lesions were upgraded on arthroscopy (20.5%), and six were downgraded (13.6%). MR grade 3 lesions showed the best correlation (83.3%) and MR grade 1 and 2B lesions showed the worst (50.0 and 55.6 %). Arthroscopic grade A and F showed good correlation (80 and 100%). Grade C and E showed poor (25.0%) and intermediate correlation (66.7%), respectively.

Conclusion:

The MRI grading of osteochondral lesions in the talus was useful and showed a fairly good correlation with arthroscopic classification. Level of Evidence: IV, Retrospective Case Series
Treatment of Osteomyelitis in Charcot Foot with Single-Stage Resection of Infection, Correction of Deformity, and Maintenance with Ring Fixation
Authors: Pinzur Michael S. , Gil Joseph , Belmares Jaime
Published: December 2015

Background:

There is both increased interest and awareness in diabetes-associated Charcot foot arthropathy. The number of affected patients will likely increase as the incidence of both diabetes and morbid obesity increases. Many experts now favor surgical correction of the deformity rather than longitudinal management with accommodative bracing. In patients with open wounds and exposed bone and/or chronic osteomyelitis, it is controversial whether resolution of the bony infection should be achieved before attempting surgical correction of the acquired deformity.

Methods:

During a 78-month period, 178 patients underwent surgical correction of deformity with diabetes-associated Charcot foot or ankle arthropathy by a single surgeon. Seventy-three had evidence of osteomyelitis at the time of surgery. There were 41 males and 32 females. Their average age was 57.9 (range, 31 to 76) years, and body mass index was 36.9 (range, 21.8 to 60.9). The clinical diagnosis of osteomyelitis was made by ( a) an open wound overlying the deformity with exposed bone and chronic drainage; ( b) a history of biopsy-diagnosed osteomyelitis that was not currently draining, but had clinical and pathologic evidence of abnormal bone in the region of the previous infection; or ( c) a history of previous wound overlying bony deformity with abnormal bone observed at the time of surgery. Surgery involved radical resection of the clinically infected bone, combined with acute correction of the deformity to a plantigrade foot. Parenteral culture-specific antibiotic therapy was administered and monitored by an infectious disease comanagement service. A three-level preconstructed static circular external fixator was applied to maintain the surgically obtained correction.

Results:

Sixty-eight of 71 patients (95.7%) achieved limb salvage and were able to ambulate with commercially available therapeutic footwear. One patient died shortly after removal of the external fixator from unrelated causes. Three patients required amputation. Resolution of infection and wound closure was achieved in five patients following a second surgical debridement. Two noninfected wounds were resolved with local soft tissue flaps. Two patients have persistent noninfected wounds that have been resistant to wound care therapy.

Discussion:

A plantigrade noninfected foot can be achieved in patients with infected diabetic Charcot foot deformity with single-stage radical resection of osteomyelitis, correction of the deformity, maintenance of the correction with static external fixation, and culture-specific antibiotic therapy. Level of Evidence: IV, Retrospective Case Series
Gastrocsoleus Fascial Release for Correction of Equinus Deformity in Residual or Relapsed Clubfoot
Authors: Park Soo-Sung , Lee Ho Seong , Han Sang-Ho , Park Jin-Woong , de Peralta Maria Josephine B.
Published: December 2015

Background:

Regardless of the mode of treatment, clubfoot has a strong tendency to relapse, especially hindfoot equinus. Because contraction or shortening of the Achilles tendon causes an equinus deformity of the ankle, release of this tendon is required to correct equinus deformity in patients with residual or relapsed clubfoot. This study assessed the effectiveness of the Vulpius technique in correcting equinus deformity in patients with residual or relapsed clubfoot.

Methods:

Of the 80 idiopathic clubfeet treated conservatively using the Ponseti protocol, between March 2000 and July 2008, 32 were found to have residual or relapsed equinus deformity, with 22 feet in 17 patients undergoing Vulpius-type Achilles tendon lengthening. Mean age at the time of surgery was 29 (range, 6 to 52) months, and mean follow-up was 48 (range, 24 to 78) months. Clinical evaluation included the dorsiflexion angle of the ankle and radiographic evaluation included the talocalcaneal and tibiocalcaneal angles on dorsiflexion lateral views.

Results:

All 22 feet showed satisfactory results at last follow-up, with significant improvements in mean ankle dorsiflexion angle, mean tibiocalcaneal angle, and mean lateral talocalcaneal angle ( p <.05 each).

Conclusion:

The Vulpius procedure is an effective surgical procedure for correcting equinus deformity in residual and relapsed clubfeet. Level of Evidence: IV, Case Series
Long-Term Follow-up of Lateral Reconstruction with Extensor Retinaculum Flap for Chronic Ankle Instability
Authors: Tourné Yves , Mabit Christian , Moroney Paul J. , Chaussard Christophe , Saragaglia Dominique
Published: December 2015

Background:

Chronic instability is a common complication of lateral ankle sprains. Furthermore, patients often have unrecognized associated lesions affecting the ankle and subtalar joints. Many stabilizing surgical techniques have been described, each with variable results. This article reports the long-term results of ligamentous retensioning combined with reinforcement using an extensor retinaculum flap.

Patients and Methods:

This is a retrospective, multicenter study. One hundred fifty cases were reviewed at a mean follow-up of 11 years. Functional results were assessed using the Karlsson score. Pre- and postoperative radiological assessment employed stress x-rays to measure varus tilt and anterior drawer and the Van Dijk classification to grade osteoarthrosis. The Stata 10 program was used for statistical analysis.

Results:

A thorough preoperative workup identified ligamentous lesions of the subtalar joint in 30% of cases. At review, 93% of patients were satisfied. Residual instability was present in only 4.8%. Radiographic analysis of both ankles revealed a differential in varus tilt of only 0.12° and in anterior drawer of 0.17 mm. There was no deterioration of the articular surfaces after 11 years of follow-up.

Conclusion:

To the authors' knowledge, this is the largest series reported with such a follow-up. This technique addressed both lateral ankle and subtalar instability without sacrificing the peroneal tendons. It protected against progression of posttraumatic arthrosis and provided superior results to other reported techniques in terms of patient satisfaction and residual instability. Level of Evidence: IV, Retrospective Case Series
Modified Mitchell Osteotomy with Screw Fixation for Correction of Hallux Valgus
Authors: Huang Shih-Hao , Cheng Yuh-Min , Chen Chung-Hwan , Huang Peng-Ju
Published: December 2015

Background:

The authors have performed more than 1500 cases of a Mitchell osteotomy and traditionally used two crossed pins for fixation. The previous series showed some complications related to pin tract infection, pin migration, and transfer metatarsalgia. Since 2009, the authors have used a compression screw for fixation and made some technical modifications and the results are reported in this article.

Methods:

A total of 95 patients underwent a Mitchell ostotomy to correct hallux valgus deformity with fixation with multi-use compression (MUC) screws. Hallux valgus angle (HVA), intermetatarsal angle (IMA), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale were measured preoperatively and postoperatively.

Results:

There were statistically differences between the preoperatively and postoperatively HVA, first IMA, and AOFAS hallux metatarsophalangeal-interphalangeal scores. Five patients (8/137 feet, 5.8%) underwent removal of the screw because of screw tip irritation. Eight patients (9/137 feet, 6.5%) had transfer metatarsalgia of the second metatarsal, with two of them caused by dorsal tilt of the metatarsal head. One patient (1/137 feet, 0.7%) had undercorrection. There was no superficial infection, deep infection, nonunion, or osteonecrosis of the first metatarsal head.

Conclusion:

On the basis of the results observed in this study, it appears that the use of a multi-use compression screw provides satisfactory stabilization of the modified Mitchell osteotomy and was not associated with any serious complications. The modified technique also helped reduce transfer metatarsalgia. Level of Evidence: IV, Retrospective Case Series
Arthroscopic Treatment of Tenosynovitis of the Flexor Hallucis Longus Tendon
Authors: Corte-Real Nuno Manuel , Moreira Rodrigo Manuel , Guerra-Pinto Francisco
Published: December 2015

Background:

Tenosynovitis of the flexor hallucis longus (FHL) tendon is a condition typically found in ballet dancers and sometimes in soccer players and is related to chronic overuse. A traumatic cause for this situation, such as an ankle sprain, is considered rare. In case of failure of conservative treatment, the tendon can be surgically released, which is usually done through an open procedure. This article presents the results of an arthroscopic release of the FHL.

Methods:

Twenty-seven patients underwent surgery for FHL tenosynovitis over a period of 18 months. The mean age of the patients was 34 years. All patients related the onset of the condition with an ankle sprain. Eighteen patients were on worker's compensation and five had sport-related accidents. None of the patients was a professional athlete or a ballet dancer. The mean follow-up was 32 months. The outcome was measured with a satisfaction questionnaire and with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scoring system.

Results:

The mean postoperative AOFAS score was 89 with 70% excellent or good results. Mean satisfaction rate was 4 (range, 0 to 5); 89% of the patients would undergo the procedure again. Twenty-two patients (81%) returned to the same level of activity in work and sports. A complication rate of 18% (five patients) and reoperation rate of 4% (one patient) were found.

Conclusion:

Arthroscopic release of the FHL tendon was a valid procedure. It was a minimally invasive surgery that allowed good visualization of the involved structures and yielded good results. This condition can be related to trauma and is not an exclusive disease of ballet dancers or overuse. Level of Evidence: IV, Retrospective Case Series
External Fixation with Supercutaneous Calcaneal Locking Plate for Displaced Intra-Articular Calcaneal Fractures
Authors: Zhang Guozhu , Jiang Xieyuan , Wang Manyi
Published: December 2015

Objective:

The purpose of this study was to retrospectively evaluate patients who had open reduction and external fixation of displaced intra-articular calcaneal fractures with supercutaneous calcaneal locking plates used as external fixators.

Methods:

Between October 2007 and June 2009, 25 cases were performed. According to the Sanders classification system, 17 cases were type IIA and there were two cases each of type IIB, type IIC, type IIIAC, and type IV. Three months after surgery, when imaging studies confirmed bone union, the plates and screws were removed in the outpatient clinic. The average time of follow-up was 36 (range, 33 to 48) months.

Results:

Two cases (8%) had superficial wound necrosis and no pin tract infections were noted. The reduction of the articular surface and bone union were good. Two cases of type IIA developed lateral wall exostosis, which resulted in peroneal tendinitis. The preoperative x-rays of the 25 patients had an average Böhler's angle of 12° ± 9° and Gissane's angle of 87° ± 8°. Their postoperative x-ray films demonstrated that the Böhler angle improved to 30° ± 7° and the Gissane angle to 116° ± 7° ( p < .01). According to the Ankle-Hindfoot Clinical Rating System of the American Orthopaedic Foot and Ankle Society (AOFAS), their average score was 91 (range, 68 to 100) points.

Conclusion:

Using a supercutaneous calcaneal locking plate to treat calcaneal fractures caused limited tissue irritation, a low rate of local skin infection, satisfactory reduction of the articular surface, stable fixation, and an overall reduced cost. Level of Evidence: IV, Retrospective Case Series
Harvest of Autogenous Bone Graft Using Reamer-Irrigator-Aspirator in Tibiotalocalcaneal Arthrodesis: Surgical Technique and Case Series
Authors: Lehman Andrew Arthur Robert , Irgit Kaan Suleyman , Cush Gerard John
Published: December 2015

Level of Evidence: V, Technique Tip
User-Friendly Instrument for Modified Strayer Procedure: Technical Tip
Authors: Roche Andrew J. , Calder James D. F.
Published: December 2015

Level of Evidence: V, Technique Tip
Growth hormone–secreting macroadenoma of the pituitary gland successfully treated with the radiolabeled somatostatin analog 90Y-DOTATATE: case report
Authors: Waligórska-Stachura Joanna , Gut Paweł , Sawicka-Gutaj Nadia , Liebert Włodzimierz , Gryczyńska Maria , Baszko-Błaszyk Daria , Blanco-Gangoo Al Ricardo , Ruchała Marek
Published: December 2015

Pituitary tumors causing acromegaly are usually macroadenomas at the time of diagnosis, and they can grow aggressively, infiltrating surrounding tissues. Difficulty in achieving complete tumor removal at surgery can lead toward a strong tendency for recurrence, making it necessary to consider a means of treatment other than those currently used such as somatostatin analogs (SSAs), growth hormone (GH) receptor antagonist, surgical removal, and radiotherapy. The purpose of this paper is to describe a patient diagnosed with an aggressive, giant GH-secreting tumor refractory to medical therapy but ultimately treated with the radiolabeled somatostatin analog 90Y-DOTATATE.

A 26-year-old male with an invasive macroadenoma of the pituitary gland (5.6 × 2.5 × 3.6 cm) and biochemically confirmed acromegaly underwent 2 partial tumor resections: the first used the transsphenoidal approach and the second used the transcranial method. The patient received SSAs pre- and postoperatively. Because of the progression in pituitary tumor size, he underwent classic irradiation of the tumor (50 Gy). One and a half years later, the patient presented with clinically and biochemically active disease, and the tumor size was still 52 mm in diameter (height). Two neurosurgeons disqualified him from further surgical procedures. After confirming the presence of somatostatin receptors in the pituitary tumor by using 68Ga-DOTATATE PET/CT, we treated the patient 4 times with an SSA bound with 90Y-DOTATATE. After this treatment, the patient attained partial biochemical remission and a reduction in the tumor mass for the first time.

Treatment with an SSA bound with 90Y-DOTATATE may be a promising option for some aggressive GH-secreting pituitary adenomas when other methods have failed.
Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study
Authors: Riva-Cambrin Jay , Kestle John R. W. , Holubkov Richard , Butler Jerry , Kulkarni Abhaya V. , Drake James , Whitehead William E. , Wellons John C. , Shannon Chevis N. , Tamber Mandeep S. , Limbrick David D. , Rozzelle Curtis , Browd Samuel R. , Simon Tamara D. , _ _
Published: December 2015

OBJECT

The rate of CSF shunt failure remains unacceptably high. The Hydrocephalus Clinical Research Network (HCRN) conducted a comprehensive prospective observational study of hydrocephalus management, the aim of which was to isolate specific risk factors for shunt failure.

METHODS

The study followed all first-time shunt insertions in children younger than 19 years at 6 HCRN centers. The HCRN Investigator Committee selected, a priori, 21 variables to be examined, including clinical, radiographic, and shunt design variables. Shunt failure was defined as shunt revision, subsequent endoscopic third ventriculostomy, or shunt infection. Important a priori–defined risk factors as well as those significant in univariate analyses were then tested for independence using multivariate Cox proportional hazard modeling.

RESULTS

A total of 1036 children underwent initial CSF shunt placement between April 2008 and December 2011. Of these, 344 patients experienced shunt failure, including 265 malfunctions and 79 infections. The mean and median length of follow-up for the entire cohort was 400 days and 264 days, respectively. The Cox model found that age younger than 6 months at first shunt placement (HR 1.6 [95% CI 1.1–2.1]), a cardiac comorbidity (HR 1.4 [95% CI 1.0–2.1]), and endoscopic placement (HR 1.9 [95% CI 1.2–2.9]) were independently associated with reduced shunt survival. The following had no independent associations with shunt survival: etiology, payer, center, valve design, valve programmability, the use of ultrasound or stereotactic guidance, and surgeon experience and volume.

CONCLUSIONS

This is the largest prospective study reported on children with CSF shunts for hydrocephalus. It confirms that a young age and the use of the endoscope are risk factors for first shunt failure and that valve type has no impact. A new risk factor—an existing cardiac comorbidity—was also associated with shunt failure.
Growth patterns of craniopharyngiomas: clinical analysis of 226 patients
Authors: Pan Jun , Qi Songtao , Liu Yi , Lu Yuntao , Peng Junxiang , Zhang XiAn , Xu YiKai , Huang Guang-long , Fan Jun
Published: December 2015

OBJECT

Craniopharyngiomas (CPs) are rare epithelial tumors that are often associated with an enigmatic and unpredictable growth pattern. Understanding the growth patterns of these tumors has a direct impact on surgical planning and may enhance the safety of radical tumor removal. The aim of this study was to analyze the growth patterns and surgical treatment of CPs with a focus on the involvement of the hypothalamopituitary axis and the relationship of the tumor to the arachnoid membrane and surrounding structures.

METHODS

Clinical data from 226 consecutive patients with primary CP were retrospectively reviewed. Tumor location and the relationship of the tumor to the third ventricle floor and the pituitary stalk were evaluated using preoperative MRI and intraoperative findings. A topographic classification scheme was proposed based on the site of tumor origin and tumor development. The clinical relevance of this classification on patient presentation and outcomes was also analyzed.

RESULTS

The growth of CPs can be broadly divided into 3 groups based on the site of tumor origin and on tumor-meningeal relationships: Group I, infrasellar/infradiaphragmatic CPs (Id-CPs), which mainly occurred in children; Group II, suprasellar subarachnoid extraventricular CPs (Sa-CPs), which were mainly observed in adults and rarely occurred in children; and Group III, suprasellar subpial ventricular CPs (Sp-CPs), which commonly occurred in both adults and children. Tumors in each group may develop complex growth patterns during vertical expansion along the pituitary stalk. Tumor growth patterns were closely related to both clinical presentation and outcomes. Patients with Sp-CPs had more prevalent weight gain than patients with Id-CPs or Sa-CPs; the rates of significant weight gain were 41.7% for children and 16.7% for adults with Sp-CPs, 2.2% and 7.1% for those with Id-CPs, and 12.5% and 2.6% for those with Sa-CPs (p < 0.001). Moreover, patients with Sp-CPs had increased hypothalamic dysfunction after radical removal; 39% of patients with Sp-CPs, 14.5% with Id-CPs, and 17.4% with Sa-CPs had high-grade hypothalamic dysfunction in the first 2 postoperative years (p < 0.001).

CONCLUSIONS

The classification of CPs based on growth pattern may elucidate the best course of treatment for this formidable tumor. More tailored, individualized surgical strategies based on tumor growth patterns are mandatory to provide long-term tumor control and to minimize damage to hypothalamic structures. Differences in the distribution of growth patterns between children and adults imply that hierarchical comparison is necessary when investigating outcomes and survival across treatment paradigms in patients with CP.
The unusual presentation of a vascular injury after lumbar microdiscectomy: case report
Authors: Huttman Daniel , Cyriac Mathew , Yu Warren , O'Brien Joseph R.
Published: December 2015

Vascular injury during lumbar spine surgery is a relatively rare complication but can have devastating outcomes. The injury may not be apparent during surgery and can present acutely or late in various manners, and some injuries can be asymptomatic. This report discusses the unusual case of a 35-year-old woman who underwent a right L4–5 microdiscectomy for disc herniation and 4 days postoperatively presented with a pulmonary embolus. A subsequent CT scan revealed a pseudoaneurysm and arteriovenous fistula of the right common iliac vein and artery, which gave rise to the embolus. The patient received a right iliac artery stent, and at 4 months after surgery she continues to be symptom free. This report describes the atypical presentation of vascular injury after lumbar microdiscectomy and stresses the importance of cautiously using the pituitary rongeur when removing deeper disc fragments.
Effects of fusion and conservative treatment on disc degeneration and rates of subsequent surgery after thoracolumbar fracture
Authors: D'Oro Anthony , Spoonamore Mark J. , Cohen Jeremiah R. , Acosta Frank L. , Hsieh Patrick C. , Liu John C. , Chen Thomas C. , Buser Zorica , Wang Jeffrey C.
Published: December 2015

OBJECT

The objective of this study was to compare the incidence of degeneration and need for subsequent fusion surgery between patients who were treated nonsurgically and patients treated with fusion after a diagnosis of thoracic-or lumbar-level fracture without degenerative disease.

METHODS

The authors performed a retrospective study of Orthopedic United Healthcare patients diagnosed with thoracic or lumbar fracture. Patients were filtered into thoracic and lumbar fracture groups using diagnostic codes and then assigned to one of 2 treatment subgroups (fusion surgery or no surgery) on the basis of procedural codes. Disc degeneration and follow-up surgery were recorded. Chi-square statistical analysis was used.

RESULTS

Of 3699 patients diagnosed with a thoracic fracture, 117 (3.2%) underwent thoracic fusion and 3215 (86.9%) were treated nonsurgically. Within 3 years, 147 (4.6%) patients from the nonsurgical subgroup and fewer than 11 (0.9%–8.5%) from the fusion subgroup were diagnosed with thoracic disc degeneration. From the nonsurgical subgroup, 11 (0.3%) patients underwent a thoracic surgery related to disc degeneration compared with zero from the fusion group (p > 0.05). Of 5016 patients diagnosed with lumbar fracture, 150 (3.0%) underwent fusion and 4371 (87.1%) had no surgery. Within 3 years, 503 patients (11.5%) from the nonsurgical subgroup and 35 (23.3%) from the fusion subgroup were diagnosed with lumbar disc degeneration (p < 0.05). From the nonsurgical subgroup, 42 (1.0%) went on to have surgery related to disc degeneration, compared with fewer than 11 (0.7%–6.7%) from the fusion subgroup (values not precise due to privacy limitations).

CONCLUSIONS

Fusion surgery for thoracic fracture does not appear to increase the likelihood of undergoing future surgery. In the lumbar region, initial fusion surgery appears to increase the incidence of disc degeneration and could potentially necessitate future surgeries.
Role of Noncoding RNAs as Biomarker and Therapeutic Targets for Liver Fibrosis
Authors: Teng Kun-Yu , Ghoshal Kalpana
Published: December 2015

Noncoding RNAs (ncRNAs) including microRNAs (miRNAs) regulate gene expression at the posttranscriptional level, whereas long coding RNAs (lncRNAs) modulate gene expression both at transcriptional and posttranscriptional levels in mammals. Accumulated evidence demonstrates the widespread aberrations in ncRNA expression associated with almost all types of liver disease. However, the role of ncRNAs in liver fibrosis is poorly understood. Liver fibrosis is the process of excessive accumulation of extracellular matrix (ECM) proteins in the liver that lead to organ dysfunction and tumorigenesis. In this review, we summarize the current knowledge on the role of ncRNAs in promoting or repressing liver fibrosis caused by nonviral agents, potential use of circulating miRNAs as biomarkers of liver fibrosis, and therapeutic approaches to treat liver fibrosis by targeting the dysregulated miRNAs.
Association of Genetic Variants of SIRT1 With Type 2 Diabetes Mellitus
Authors: Han Junfeng , Wei Meilin , Wang Qianqian , Li Xu , Zhu Chaoyu , Mao Yueqin , Wei Li , Sun Yongning , Jia Weiping
Published: December 2015

SIRT1 has been demonstrated in nutrient-sensing and insulin-signaling pathways in in vivo and in vitro experiments, but there is minimal information concerning the association between gene polymorphisms of SIRT1 and type 2 diabetes mellitus (T2DM) in a Chinese Han population.
Using case-control design, we recruited 310 unrelated T2DM patients from inpatients at Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, while 301 healthy controls were volunteers from the community for regular medical checkup. All participants were genotyped within the
SIRT1 region. The following five SNPs rs10509291, rs12778366, rs10997870, rs10823112, and rs4746720 cover 100% of common genetic variations (minor allele frequency ≥ 0.05) within the SIRT1 gene (r2 ≥ 0.8). The genotypes of SIRT1
gene polymorphisms were analyzed by the Snapshot assay and DNA sequencing. The resulting data show that there was significant genetic differentiation in rs10823112 [p = 0.003; OR (95% CI) = 1.515 (1.152‐1.994) for genotype], rs4746720 [p = 0.024;
OR (95% CI) = 1.37 (1.037‐1.674) for genotype], and rs10509291 [p = 0.002; OR (95% CI) = 1.551 (1.179‐2.04) for genotype] between T2DM and control subjects. However, the result of rs4746720 was no longer significant after correction
for multiple testing (p after Bonferroni correction = 0.12); the results of rs10509291and rs10823112 were still significantly different between the two groups (p after Bonferroni correction = 0.01 and 0.015, respectively). Linear regression analyses
adjusting for age, gender, and body mass index (BMI) showed that HbA1c and HOMA-IR in subjects with rs10509291 AA genotype were higher than those with TT genotype in T2DM group (p = 0.045, p = 0.035, respectively). Together, our data show that genetic
variation of the SIRT1 gene is related to insulin resistance and increase risk of T2DM in Chinese Han population. The risk allele A at SIRT1 rs10509291 was closely associated with T2DM, and subjects who were homozygous of the A allele were more likely to develop T2DM.
ELK3 Expression Correlates With Cell Migration, Invasion, and Membrane Type 1-Matrix Metalloproteinase Expression in MDA-MB-231 Breast Cancer Cells
Authors: Heo Sun-Hee , Lee Je-Yong , Yang Kyung-Min , Park Kyung-Soon
Published: December 2015

ELK3 is a member of the Ets family of transcription factors. Its expression is associated with angiogenesis, vasculogenesis, and chondrogenesis. ELK3 inhibits endothelial migration and tube formation through the regulation of MT1-MMP transcription. This study assessed the function of
ELK3 in breast cancer (BC) cells by comparing its expression between basal and luminal cells in silico and in vitro. In silico analysis showed that ELK3 expression was higher in the more aggressive basal BC cells than in luminal BC cells. Similarly, in vitro analysis showed that ELK3 mRNA
and protein expression was higher in basal BC cells than in normal cells and luminal BC cells. To investigate whether ELK3 regulates basal cell migration or invasion, knockdown was achieved by siRNA in the basal BC cell line MDA-MB-231. Inhibition of ELK3 expression decreased cell migration
and invasion and downregulated MT1-MMP, the expression of which is positively correlated with tumor cell invasion. In silico analysis revealed that ELK3 expression was associated with that of MT1-MMP in several BC cell lines (0.98 Pearson correlation coefficient). Though MT1-MMP expression
was upregulated upon ELK3 nuclear translocation, ELK3 did not directly bind to the 1.3-kb promoter region of the MT1-MMP gene. These results suggest that ELK3 plays a positive role in the metastasis of BC cells by indirectly regulating MT1-MMP expression.
Selling Spirituality: Issues in Tourism
Authors: Bone Kate
Published: December 2015

This article seeks to address the somewhat contentious issue regarding the marketing and selling of spirituality as a highly sought-after commodity in the West at present. Findings of ethnographic case study research conducted at two spiritual retreat tourism sites in New Zealand are
presented. Spirituality will be framed though the conceptualizations and definitions provided by tourist and tourist host participants. The perceptions of people engaged in spiritual retreat tourism will be discussed alongside issues surrounding the commoditization and commodification of spirituality.
The critical analysis provided in this article has led the researcher to conclude that it may be a condition of modern capitalist society that people feel comfortable and are willing to pay for spiritual experiences. The case studies presented may be considered best practice examples of when
spirituality is commodified in an ethical way according to the consumers involved.
Gender Differences in Vacation Behavior
Authors: Vespestad May Kristin , Mehmetoglu Mehmet
Published: December 2015

This study directs attention to the gender aspects of the vacation. In tourism, gender differences are evident in that male and female consumption differ in various phases of a vacation. This study intends to shed light on gender intricacies as it relates to nature-based vacations.
Based on a quantitative survey, the vacation experience is measured in the dimensions of tourism motivation, evaluation of attributes, and activity involvement. A survey questionnaire was handed out among tourists in northern Norway, resulting in a sample size of 867 respondents. The study
findings show a clear disparity between genders in the dimensions measured. Women placed higher importance on vacation motivations relating to mental relaxation, escape, physical activity. and learning about places and cultures. Women also value the tourism company attributes of price, products,
and hygiene higher than men do. In terms of destination attributes, women value restaurant options, price level at destination, and climate higher than men do. The results also reveal that women are more prone to participate in activities that are culturally oriented, as well as hiking, and
men take more interest in fishing and boating. The study thus raises awareness of how gender dissimilarities in tourism consumption might contribute to the knowledge of how women and men differ in their preferences when being on vacation.
The Discriminant Effect of Perceived Value on Travel Intention: Visitors Versus Nonvisitors of Florida Keys
Authors: Chen Chun-Chu , Petrick James F.
Published: December 2015

This research attempts to examine the relationships between perceived value and travel intention while comparing the differences between previous visitors and nonvisitors of the Florida Keys. Results from a sample of 565 respondents revealed that perceived value had a positive association
with travel intention, while high perceived value did not always lead to high travel intention. As shown in this research, many previous visitors did not want to visit the Florida Keys in the foreseeable future because they wanted to visit other destinations. This article concludes with recommendations
for the tourism industry to maintain the perceived novelty of their products.
Patient Survival and Technique Failure in Continuous Ambulatory Peritoneal Dialysis Patients with Prior Stroke
Authors: Wu Xianfeng , Yang Xiao , Liu Xinhui , Yi Chunyan , Guo Qunying , Feng Xiaoran , Mao Haiping , Huang Fengxian , Yu Xueqing
Published: December 2015

Background

To investigate patient survival and technical failure of patients with prior stroke receiving continuous ambulatory peritoneal dialysis (CAPD) in Southern China.

Methods

This was a retrospective study. All subjects were recruited from the peritoneal dialysis center in The First Affiliated Hospital of Sun Yat-sen University from 1 January 2006 to 31 December 2010. All eligible patients were assigned to stroke group and non-stroke group according to a history of stroke before receiving CAPD. The primary outcomes were all-cause mortality and death-censored technical failure. Cox regression was used to estimate risk factors of all-cause mortality and death-censored technique failure.

Results

Of the 1,068 recruited patients, 75 (7.0%) patients had a previous history of stroke. The all-cause mortality and death-censored technique failure were significantly higher in the stroke group compared with the non-stroke group, respectively (odds ratio [OR] 2.67, 95% confidence interval [CI] 1.59 – 4.46 and OR 2.52, 95% CI 1.19 – 5.34). Older age (changed by 10 years, hazard ratio [HR] 1.90, 95% CI 1.07 – 3.38), lower body mass index (BMI 18.5 – 23.9 vs < 18.5 kg/m2 reference, HR 0.17, 95% CI 0.05 – 0.55) and time to the first episode of peritonitis (HR 0.93, 95% CI 0.89 – 0.96) were independently associated with increased risk of all-cause mortality in patients with prior stroke. In addition, time to the first episode of peritonitis was associated with decreased risk of death-censored technique failure (HR 0.91, 95% CI 0.84 – 0.99) in those with prior stroke.

Conclusions

Continuous ambulatory peritoneal dialysis patients with prior stroke had high rates of all-cause mortality and technique failure compared with those without prior stroke. Older age, lower BMI, and time to the first episode of peritonitis were independent risk factors of all-cause mortality in patients with prior stroke.
Equivalent Fall Risk in Elderly Patients on Hemodialysis and Peritoneal Dialysis
Authors: Farragher Janine , Rajan Tasleem , Chiu Ernest , Ulutas Ozkan , Tomlinson George , Cook Wendy L. , Jassal Sarbjit V.
Published: December 2015

♦ Background

Accidental falls are common in the hemodialysis (HD) population. The high fall rate has been attributed to a combination of aging, kidney disease-related morbidity, and HD treatment-related hazards. We hypothesized that patients maintained on peritoneal dialysis (PD) would have fewer falls than those on chronic HD. The objective of this study was to compare the falls risk between cohorts of elderly patients maintained on HD and PD, using prospective data from a large academic dialysis facility.

♦ Methods

Patients aged 65 years or over on chronic in-hospital HD and PD at the University Health Network were recruited. Patients were followed biweekly, and falls occurring within the first year recorded. Fall risk between the 2 groups was compared using both crude and adjusted Poisson lognormal random effects modeling.

♦Results

Out of 258 potential patients, 236 were recruited, assessed at baseline, and followed biweekly for falls. Of 74 PD patients, 40 (54%) experienced 86 falls while 76 out of 162 (47%) HD patients experienced a total of 305 falls (crude fall rate 1.25 vs 1.60 respectively, odds ratio [OR] falls in PD patients 0.78, 95% confidence interval [CI] 0.61 – 0.92, p = 0.04). After adjustment for differences in comorbidity, number of medications, and other demographic differences, PD patients were no less likely to experience accidental falls than HD patients (OR 1.63, 95% CI 0.88 – 3.04, p = 0.1).

♦ Conclusions

We conclude that accidental falls are equally common in the PD population and the HD population. These data argue against post-HD hypotension as the sole contributor to the high fall risk in the dialysis population.
Long-Term Exit-Site Gentamicin Prophylaxis and Gentamicin Resistance in a Peritoneal Dialysis Program
Authors: Chen Shan Shan , Sheth Heena , Piraino Beth , Bender Filitsa
Published: December 2015

Background

Daily gentamicin cream exit-site prophylaxis reduces peritoneal dialysis (PD)-related gram-negative infections. However, there is a concern about the potential for increasing gentamicin resistance with the long-term use of prophylactic gentamicin. This study evaluated the incidence of gentamicin-resistant PD-related infections over more than 2 decades.

Methods

Study data on prevalent PD patients were retrieved from a prospectively maintained institutional review board (IRB)-approved PD registry at a single center from January 1, 1991, to December 31, 2000, and January 1, 2004, to December 31, 2013. The rates of gram-negative infections, fungal infections and those infections with organisms resistant to gentamicin were examined for the 2 periods. Period 1 from 1991 to 2000 when S. aureus prophylaxis consisted initially of oral rifampin to treat nasal carriage with S. aureus, and was then daily exit-site mupirocin ointment for all PD patients, was compared to the period from 2004 to 2013 when daily exit-site gentamicin cream was prescribed as prophylaxis (Period 2).

Results

The study included a total of 444 PD patients (265 and 179 in Period 1 and Period 2, respectively). No significant difference was noted in demographics between the 2 periods except race. The gram-negative exit-site infection rates for Period 1 and Period 2 were 0.109 versus 0.027 ( p < 0.0001). Gram-negative peritonitis rates were similar. There were 3 episodes of gentamicin-resistant infections in each period. Fungal infections remained consistently low.

Conclusion

Despite a decade of exit-site gentamicin prophylaxis, gentamicin-resistant PD-related infections and fungal infections remained very low and similar to the prior period.