bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcome of Stainsby Forefoot Arthroplasty for Severe Rheumatoid Feet
Authors: Qasim Sultan N. , Roberts Veronica I. , Allen Patricia E.
Published: October 2016

Category:

Lesser Toes

Introduction/Purpose:

Treatment of the severely deformed rheumatoid forefoot generally involves resection arthroplasty of the lesser toe MTP joints. This can either involve resection of the metatarsal heads or, as described by Stainsby: resection of part of the proximal phalanx and extensor tendon interposition arthroplasty. The Stainsby procedure is a well accepted technique, however despite this there is little information on the outcome of this procedure especially long term results. We present, what we believe is, the largest series with longest follow up in literature apart from original authors’ work.

Methods:

Retrospective review of prospectively collected data was performed of 48 rheumatoid patients with 71 feet treated with the Stainsby procedure, between March 2006 and December 2013, by a single surgeon. American Orthopaedic Foot and Ankle Score (AOFAS) was recorded at both pre- and postoperative assessment alongwith a satisfaction survey at final follow-up. 5 patients had died at final follow up. The follow-up duration was 5.4 years (range 2.2-9.8).

Results:

9/48 patients were on anti TNF therapy and 26/48 were treated with Methotraxate. 57 cases (80%) had 1st Metatarsophalangeal Joint (MTPJ) fusion (Group 1) alongwith Stainsby procedure for lesser toes. There was significant improvement in mean AOFAS from 32.5 to 67.4. The difference in improvement in mean AOFAS for Group 1 (29.4 to 72.0) as compared to Group 2 with Stainsby procedure alone (34.3 to 71.0) was statistically significant. 76% had no (50%) or painfree (26%) callosities at final follow up. Three patients had significant hallux valgus deformity (one for Group 1) at final follow up. There were four cases of superficial wound infection that resolved with oral antibiotics with no further consequences. Two patients had broken retained wires in metatarsal with no consequences and one patient had non-union of 1st MTPJ fusion not requiring revision. 77% were very happy (35%) or pleased (52%) with results of operation. 93% patients would recommend the operation – 78% definitely and 15% with reservation.

Conclusion:

Treatment of the rheumatoid forefoot involving resection of the metatarsal heads is an established procedure, with much published literature to support its use. Stainsby procedure in an effective procedure but unfortunately not as popular probably because of lack of long term results. This study highlights the long term benefits and very good satisfaction results with Stainsby procedure with even better results if combined with 1st MTPJ fusion.
Outcomes and Complications of Total Ankle Replacement in Patients with Post-traumatic, Primary, and Inflammatory Ankle Arthritis
Authors: Rungprai Chamnanni , Phisitkul Phinit , Femino John , Amendola Annunziato
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Total ankle replacement has been evolved and proven to be an effective treatment for varieties of ankle arthritis. Previous literatures reported higher complications in patients who underwent total ankle replacement resulted from post-traumatic and inflammatory arthritis compared to primary arthritis. However, there is a lack of comparative studies to demonstrate outcomes and complications among the three groups of patients who underwent total ankle replacement.

Methods:

Retrospective chart review of 247 consecutive patients with 268 ankles who were diagnosed with end-stage ankle arthritis from primary (73 patients /86 ankle), post-traumatic (149 patients/154 ankle), and inflammatory arthritis (25 patients/ 28 ankle) and underwent total ankle replacement between October 1997 and May 2015. Data was collected prospectively and minimum follow-up was 6 months to allow comparison of early complications and longer term survival in all groups (mean, 41.6 months (range, 6 to 132 months), mean 43.4 months (range, 6 to 180 months), and mean 75.1 months (range, 12-162 months) for primary, post-traumatic, and inflammatory arthritis, respectively). The primary outcome was Visual Analogue Scale (VAS), Foot Function Index (FFI, pain, disability, activity limitations, and total scores), Short Form-36 (SF-36, PCS and MCS), and the secondary outcomes included 5-year and 10-year survival rate, the length of hospital stay, time to return to work, sport activity, and activity daily living, ankle range of motion at final post-operative visit, and complications.

Results:

There were post-traumatic (57.5%), primary (32.1%) and inflammatory arthritis (10.4%). Total ankle replacement of all three groups demonstrated significant improvement in the VAS, FFI, SF-36(p < 0.05). However, FFI, SF-36, VAS, ankle dorsiflexion, and ankle plantarflexion were similar among the three groups (p>0.05). Ankle range of motion was significantly improved in both dorsiflexion and plantarflexion in all groups(p < 0.001). The 5-year and 10-year survival rate were lower in the primary arthritis group but it did not reach statistical significance(p>0.05). Tibial subsidence was significantly higher in the inflammatory group compared to the post-traumatic group (p=0.036), but others complications were similar among the three groups.

Conclusion:

Total ankle replacements demonstrated significant improvement in term of functional outcomes, clinical outcomes, and pain relief as measured with FFI, SF-36, VAS scores, and range of motion of the ankle joint for treatment of end-stage ankle arthritis. The functional outcomes and complications were comparable among the primary, post-traumatic, and inflammatory groups except the talar implant subsidence was significant higher in the inflammatory group. Further prospective clinical study is indicated.
Patient-Centered Outcomes Following Total Ankle Arthroplasty vs Ankle Arthrodesis
Authors: Matheny Lauren M. , Liechti Daniel J. , Johnson Nicholas S. , Clanton Thomas O.
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Ankle arthritis is a debilitating disorder, which has been shown to significantly limit activities of daily living and lead to reduced quality of life. Total ankle arthroplasty (TAA) and ankle arthrodesis are common treatments for ankle arthritis; however, patient indications may differ based on individual patient needs. Few studies compare patient-centered outcomes following these two procedures, which may be useful in determining the appropriate procedure.

Methods:

This study was approved by an IRB. All patients between January 2009 and November 2013 who underwent TAA with a third generation implant or ankle arthrodesis by a single surgeon for treatment of ankle arthritis were included. Patients completed a subjective questionnaire at minimum two years following index surgery. Outcomes measures included Foot and Ankle Disability Index (FADI), Foot and Ankle Ability Measure (FAAM), Lysholm score, WOMAC, SF-12 physical component summary (PCS) and mental component summary (MCS), Tegner activity scale and patient satisfaction with outcome. Detailed operative data and intraoperative findings were documented at time of surgery. All data were collected prospectively.

Results:

There were 77 patients (46 males, 31 females) (mean age = 60.2 years (range 30.2-78.4), (mean BMI=27.7 (range 17.0- 39.1)) included in this study. There was 85% follow-up at an average of 3.5 years (range 2.0-6.6). The arthrodesis cohort was significantly younger than the TAA cohort (54.1 vs. 62.7) (P=.002). Five (7.8%) patients required revision surgery. There was no significant difference in failure rate between cohorts, with 3 patients in the TAA cohort and 2 patients in the arthrodesis cohort (P=.593). There was no significant difference in any outcome measures including FADI and subscales, FAAM and subscales, Lysholm, WOMAC and subscales, SF-12 PCS and MCS or patient satisfaction with outcome, except Tegner (Table 1).

Conclusion:

Patients who underwent TAA or arthrodesis as treatment for end-stage ankle arthritis had low failure rates and similar postoperative function at final follow-up. Activity level was significantly lower in the TAA cohort; however, patients were highly satisfied with their outcome regardless of cohort. Since good outcomes may be achieved with both TAA and arthrodesis, operative procedure should be matched based on patient expectations of activity and function.
Preoperative Templating in Total Ankle Replacement - A Case for 3D Imaging
Authors: Farrier Adam J. , Ramaskandhan Jayasree R. , Siddique Malik S. , Green Justin
Published: October 2016

Category:

Ankle Arthritis

Introduction/Purpose:

Pre-operative templating using plane radiographs is of great importance in planning arthroplasty of the hip and knee. Its role in total ankle arthroplasty (TAR) is less clear. Being able to use the best fitting implant is of paramount importance for transferring forces through the ankle joint. This contributes to the longevity of the TAR prosthesis. It is unclear whether pre-operative templating is more accurately performed using an AP radiograph or 3-Dimensional (3D) imaging using MRI or CT. We sought to compare the accuracy of pre-operative templating with an AP radiograph versus CT/MRI, in relation to the size of the implanted prosthesis.

Methods:

29 patients undergoing TAR with BOX™ TAR between July 2014 and September 2015 were included in the study. Data was collected prospectively using a TAR database. Pre-operative templating of Tibial and Talar width using AP Radiographs was performed and recorded onto the database (Fig1). The implant sizes used was also recorded in the database (small, medium or large). Patients were part of an ongoing clinical trial which has ethics committee approval. 26 patients in this cohort underwent pre-operative CT or MRI assessment and were suitable for inclusion in the study (CT=6, MRI =20). These scans were reviewed retrospectively by two separate authors (AF and JR) to assess for Tibial and Talar width in the Coronal plane at the midpoint of the Tibia in the Sagittal plane (Fig2). A third author (MS), the lead surgeon, resolved any disagreements on measurements. The authors were blinded to the implant size used.

Results:

For templating the Tibial width the AP radiograph predicted the implant size 42.3% of the time while using CT/MRI scan predicted the implant size correctly 80.8% of the time. For templating the Talar width the AP radiograph predicted the implant size 42.3% of the time while using CT/MRI scan predicted the implant size correctly 84.6% of the time. The odds ratio for CT/MRI predicting the implant correctly over the AP radiograph was 5.72 (CI = 1.7 – 19.9) for the tibial component and 7.50 (CI = 2.0- 28.0) for the talar component. These values were statistically significant.

Conclusion:

For pre-operative templating we found 3D templating with an MRI or CT scan to be significantly more accurate than using an AP radiograph. We advise the use of MRI or CT as the most effective way to plan for TAR. MRI and CT are now frequently performed in orthopaedic centres as routine investigations. These modalities have the added benefit of assessing surrounding joints and soft tissues to aid accurate diagnosis. The limitations of this study lie in the small study size and the retrospective methodology.
Radiographic Evaluation of the Normal Ankle Joint in Children and Adolescent
Authors: Lee Seung Yeol , Kwon Soon-Sun , Park Moon Seok , Lee Kyoung Min , Moon Seung Jun , Chung Myung Ki , Jo Byung Chae , Sung Ki Hyuk
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Although comparison to radiographic standards for ankle joint is critical for evaluation of syndemosis injuries, such standards are not well defined for children and adolescents. The purpose of this study was to determine the reliability of numerous radiographic measurements of the skeletally immature ankle joint, timing of ossification of medial malleolus and appearance of tibial incisura and differences in the values of radiographic measurements based on age and sex.

Methods:

This study included 590 subjects (0 to 15 years), who underwent ankle AP, lateral and mortise radiographs. Presence of the medial malleolus and incisura fibularis were recorded (Fig 1). Tibiofibular overlap, tibiofibular clear space, medial clear space, talar tilt, talocrural angle, relative fibular width and fibular position were measured (Fig 2). A inter- and intrareliability test was conducted before the main measurements using intraclass correlation coefficients (ICC). To determine the timing of the ossification center of medial malleolus and appearance of tibial incisura, multinomial logistic regression was used. The generalized linear model was used to estimate the radiographic measurements by age and sex. The 100-quantiles were calculated to determine the normal value of the tibiofibular clear space, tibiofibular overlap and medial clear space.

Results:

All radiographic measurements showed good to excellent intraobserver(ICC, 0.603–0.934) and interobserver reliability(ICC, 0.704–0.972). The timing of ossification of medial malleolus and appearance of tibial incisura between boys and girls were not different. Tibiofibular clear space on mortise view, and medial clear space on AP and mortise view significantly decreased by age. Tibiofibular overlap on AP and mortise views, relative fibular width on AP view significantly increased by age. Talocrural angle, tibiofibular overlap on AP view, tibiofibular clear space on AP and mortise views, medial clear space on AP and mortise views and fibular position were significantly larger in boys than in girls. The difference in tibiofibular overlap, tibiofibular clear space and medial clear space on mortise view of both sides was < 50% in 98.1%, 99.3%, and 100% of patients, respectively.

Conclusion:

Tibiofibular clear space, tibiofibular overlap and medial clear space can be parameter to assess distal tibiofibular syndesmosis or deltoid ligament injury in skeletally immature patients. For these patients, the criteria of absolute radiographic values used in adults cannot be applied, but comparison of both sides could help physicians to predict the need for additional evaluations.
Realignment Osteotomy in Fibular Malunion
Authors: Barg Alexej , Wiewiorski Martin J. , Henninger Heath B. , Valderrabano Victor
Published: October 2016

Category:

Ankle

Introduction/Purpose:

The exact incidence of distal fibula malunions after fibular reconstructions is not known, but incidence up to 33% is described in the literature. The most frequent malunions of the fibula are shortening and malrotation, resulting in the widening of the ankle mortise and talar instability. It has been demonstrated that substantial fibular displacement may substantially increase the contact pressures in the ankle joint. Therefore distal fibular malunion is a risk factor for development of posttraumatic ankle osteoarthritis. The objectives of this study were to (1) describe our treatment algorithm and surgical technique in patients with posttraumatic fibula malunions; (2) determine intra- and postoperative complications rates, and (3) to describe mid-term clinical and radiological outcomes and quality of life.

Methods:

19 consecutive patients (11 male, 8 female, mean age 42 years, range 19 – 68) with symptomatic fibular malunions were included into this prospective study. The initial injury was Weber B and C fracture in 7 and 12 ankles, respectively. The mean time between the injury and reconstructive surgery was 17 months (range 6 – 101). In all patients a z-shaped osteotomy of the fibula was performed to achieve the appropriate length/rotation of the fibula. Fixation was performed using a plate. If necessary, supramalleolar and inframalleolar deformities were corrected by supramalleolar tibial and calcaneal osteotomies, respectively. Prior to the osteotomies an anterior ankle arthroscopy was performed in all patients. All patients were evaluated pre- and postoperatively (mean follow-up 4.9 years, range 3.2 – 6.7). Radiological outcomes were assessed using standardized weight- bearing radiographs. Clinical outcomes were assessed using visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale, and SF-36 questionnaire.

Results:

There were no intraoperative complications. In two patients early wound healing problems were observed, and resolved with i.v. antibiotics. Osseous healing was observed in all ankles within 10 weeks after surgery. The length and rotation of the fibula was improved in all patients, according to Weber criteria. All patients experienced significant pain relief (VAS: 6.5 ± 1.1 to 0.9 ± 0.8, P < 0.001) and functional improvement (AOFAS hindfoot scale: 48.4 ± 14.5 to 85.7 ± 7.4, P < 0.001; ROM:37° ± 6° to 46° ± 5°, P < 0.001). The SF-36 score also significantly increased in all 8 subgroups. In 11 patients hardware was removed due a discomfort after a mean of 11.8 months (range 7.2 – 22.8).

Conclusion:

A z-shaped osteotomy is an efficient and successful method to restore fibula length and rotation in patients with posttraumatic malunion. Our findings in this series confirm that this realignment surgery results in significant pain relief and functional improvement.
Reliability and Validity of Lower Extremity Computed Tomography as a Screening Tool for Osteoporosis
Authors: Lee Seung Yeol , Kwon Soon-Sun , Park Moon Seok , Lee Kyoung Min , Chung Myung Ki , Jo Byung Chae , Moon Seung Jun , Sung Ki Hyuk
Published: October 2016

Category:

Ankle

Introduction/Purpose:

Although previous studies have demonstrated the potential of conventional computed tomography (CT) as a screening tool for osteoporosis, the assessment correlation of BMD in those studies was limited to the spine. This study aimed to evaluate the reliability and validity of CT as a screening tool for osteoporosis and to estimate the correlation between central BMD and peripheral bone attenuation using lower extremity CT.

Methods:

In total, 292 patients who underwent a lower extremity, lumbar spine, or abdomen and pelvic CT scan within a 3- month interval of a dual-energy X-ray absorptiometry (DEXA) examination were included (Fig 1). Following reliability testing, bone attenuation of the L1, L2, L3, L4, femoral head, femoral neck, greater trochanter, distal femur, proximal tibia, distal tibia, and talus was measured by placing a circular region of interest on the central part of each bony region on a coronal CT image (Fig 2 and 3). Partial correlation was used to assess the correlation between CT and DEXA, after adjusting for age and body mass index.

Results:

In terms of reliability, all bone attenuation measurements, except the femoral neck, showed good to excellent interobserver reliability (intraclass correlation coefficients, 0.691–0.941). In terms of validity, bone attenuation of the L1 to L4, femoral neck, and greater trochanter on CT showed significant correlations with BMD of each area on DEXA (correlation coefficients, 0.399–0.613). Bone attenuation of the distal tibia and talus on CT showed significant correlations with BMD of all parts on DEXA (correlation coefficients, 0.493–0.581 for distal tibia, 0.396–0.579 for talus).

Conclusion:

Lower extremity CT is a useful screening tool for osteoporosis, and peripheral bone attenuation on lower extremity CT adequately reflects central BMD on DEXA.
Salvage of Diabetic Foot Osteomyelitis With Antibiotic Impregnated Cement Spacer- Long Term Follow Up
Authors: Melamed Eyal A. , Banker Tali Portal , Peled Eli
Published: October 2016

Category:

Diabetes

Introduction/Purpose:

Diabetic foot infections (DFI) with osteomyelitis often requires minor amputation as a mean to achieve adequate debridement and infection eradication. In the past years we have developed and used a method of utilizing antibiotic impregnated cement spacer (ACS) in DFI surgeries. The ACS release antibiotic locally, fill the cavity created by the extensive debridement of infected bone and stabilize the area to encourage healing. This is a long term report on using ACS in cases of severe DFI.

Methods:

67 cases of severe forefoot DFI with osteomyelitis in 56 consecutive patients (one patient could have several cases in different times and/or sites), mean age 57 ± 11.7 years. Follow-up was 6 to 125 months (mean 39.7± 30 months). Extensive meticulous debridement followed ACS to fill the gap were employed in all cases. ACS contained Gentamycin and Vancomycin routinely and Amikacin in selected cases. Deep cultures were taken routinely. Stabilization was usually achieved Fixation with Kirschner Wires. Success defined as resolution of infection and wound healing without amputation.

Results:

Of the 67 cases 50 (75.7%) healed in 45 patients. Of the 12 patients (17 cases) who did not heal 4 required toe amputation, 2 ray amputation, 1 transmetatarsal amputation and 5 trans tibial amputation.. Of the ACSs: 23 left permanently 12 removed and arthrodesis was performed, and 15 removed without arthrodesis. Two patients recovered but subsequently underwent trans-tibial amputation (after 18 months and 5 years) due to infection in different site.

Conclusion:

ACS is effective and sometimes indispensable adjunct in the surgical treatment of forefoot DFI with osteomyelitis, when extensive debridement is undertaken to eradicate the infection without amputation. ACS stabilizes the infected part; fill the void created by the debridement and release locally broad spectrum antibiotic.
Stability of Ankle Fracture-Dislocations Following Successful Closed Reduction
Authors: Matson Andrew P. , Green Cynthia , Hurwitz Shepard R. , Zura Robert D.
Published: October 2016

Category:

Trauma

Introduction/Purpose:

Acute ankle fracture-dislocations require emergent reduction. Once the dislocation is successfully reduced, the ideal timing of operative fixation is not well understood. At our institution, a protocol enables patients who have a successful closed reduction in the Emergency Department (ED) to go home and return to the clinic to schedule surgery. We sought to describe the rate at which initial reduction is lost between the ED and clinic visits, and to identify factors associated with loss of reduction.

Methods:

We retrospectively reviewed all patients who were treated operatively for an ankle fracture from 2008-2012 at a single, Level 1 trauma center and identified 30 patients who had isolated, closed ankle fracture-dislocations that were successfully reduced and splinted in the ED. Adequate reduction was defined by achievement of congruent joint line with < 5mm medial clear space. If reduction was maintained at the clinic visit, surgery was scheduled electively, defining a success. However, if reduction was lost in the interim between ED and clinic visits the patient was admitted from clinic for urgent surgical stabilization, defining a failure.

Results:

Seventeen patients (57%) successfully maintained closed reduction and 13 (43%) experienced failure of closed reduction in the interim. Compared to the successful group, the failed group had significantly greater posterior malleolus (PM) fracture fragment size (5.1 mm vs. 3.0 mm, p = 0.029). When the ratio of PM fracture fragment size to complete articular surface was > 0.1, rate of failure was 65% compared to 18% when the ratio was ≤0.1 (p = 0.016). There were 2 major wound complications, both of which occurred in the group that failed reduction in the interim.

Conclusion:

Greater PM fracture fragment size is associated with higher rates of interim failure of closed reduction of closed ankle fracture-dislocations. Injuries with a large PM fracture fragment may warrant consideration of earlier operative intervention.
The Dorsal Intermetatarsal Approach for Plantar Plate and Lateral Collateral Ligament Repair of the Lesser Metatarsophalangeal Joints
Authors: Siddappa Vinay Hosuru , Sittapairoj Tinnart , Femino John , Hartog Bryan Den , Gao Yubo , Goetz Jessica E. , Phisitkul Phinit
Published: October 2016

Category:

Lesser Toes

Introduction/Purpose:

Access to the plantar plate has been described using either a plantar approach or an extensile dorsal approach that required complete joint destabilization and often a metatarsal osteotomy. Clinical scenarios related to plantar plate tear vary and the pathologies in early stages are frequently limited to unilateral soft tissue structures, a more focused surgical approach deemed appropriate. A novel approach requiring a release of only the lateral collateral ligament and the lateral half of the plantar plate was described and the adequacy of joint exposure was evaluated in a cadaver model. The ability to place a suture through the lateral collateral ligament and the plantar plate were analyzed and validated with pull-out strength.

Methods:

Nine fresh frozen cadaveric specimens were dissected in a randomized fashion across the 2nd to 4th MTP joints through the intermetatarsal space dorsally. Under distraction, soft tissue was sequentially released including dorsal capsule, lateral collateral ligament, and the lateral half of the plantar plate. Integrity of the extensor tendons, deep transverse intermetatarsal ligament, proximal attachment of the plantar plate, and osseous structures was carefully preserved. The joint exposure was quantified after each step with sizing rods. 2/o non-absorbable sutures were passed into the lateral collateral ligament and the plantar plate using a suture passer; and their pullout strength was measured using a tensiometer.

Results:

Progressive increase in mean of joint exposure was noted after each step of soft tissue release with the final exposure of 6mm after release of the lateral half of the plantar plate. Joint exposures after a capsulotomy and a lateral collateral release were 3mm and 4mm, respectively. Under distraction, the unilateral release of soft tissue created a lateral opening of the joint while the proximal phalangeal base adducted and medially deviated. Successful suture passage was noted in all specimens with mean pullout strength of 76 N for the lateral collateral ligament and 67 N for the plantar plate. There was a statistically significant (p < 0.01) higher suture pullout strength for the lateral collateral ligament in males when compared to female specimens

Conclusion:

The dorsal intermetatarsal approached appeared to be feasible for the access to the lateral collateral ligament and the lateral half of the plantar plate. The average joint exposure of 6 mm allowed a quality suture passage by a suture passer in both structures in all specimens without the need of a metatarsal osteotomy.
The Effect on Radiographic Parameters of Dwyer’s Osteotomy and 1st Metatarsal Osteotomy for Pes Cavo-Varus Correction
Authors: Choi Jun Young , Yeom Ji Woong , Suh Jin Soo
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

Authors retrospectively reviewed and compared the data of patients who underwent 1st metatarsal osteotomy alone, Dwyer’s osteotomy alone and 1st metatarsal osteotomy combined with Dwyer’s osteotomy to figure out the effect on radiographic parameters for the correction of pes cavo-varus.

Methods:

Data on 28 cases in 27 consecutive patients recruited from 2006 to 2014 who underwent 1st metatarsal osteotomy alone (Group F), Dwyer’s osteotomy alone (Group H) or 1st metatarsal osteotomy followed by Dwyer’s osteotomy (Group HF) with a minimum 1-year follow-up were reviewed retrospectively.

Results:

Calcaneal pitch angle on the standing foot lateral radiographs was significantly decreased after operation in group H and HF whereas Meary angle was decreased in group F and HF. Hindfoot alignment angle and ratio on the hindfoot alignment view were improved in group H and HF. Maximal medial cuneiform height reduction was shown in group HF. 1st ray was significantly shortened in group F and HF.

Conclusion:

Combined forefoot and hindfoot operation took the largest correction power for all radiologic parameters.
The Medial Column Fusion Bolt
Authors: Ahluwalia Raju S. , O’dak Saurab , Reichert Ines L. , Vas Prash , Edmonds Michael , Kavarthapu Venu
Published: October 2016

Category:

Diabetes

Introduction/Purpose:

Charcot neuroarthropathy (CN) of the foot can cause severe bone and joint destruction. The aim of reconstruction is to correct the deformity and achieve bone fusion, in order to provide a plantigrade foot to ambulate with using accommodative footwear. Column beaming using the Medial Column Fusion Bolt (MCB) is a new technique described to stabilize - medial and/or lateral columns. We performed a meta-analysis to assess the outcome of the use of column beaming in treatment of CN.

Methods:

We performed a search of the English literature for the following search terms: ‘Charcot’, ‘arthropathy’, ‘column bolt’, ‘superconstruct’, ‘intramedullary’, ‘beaming’, ‘rodding’, ‘midfoot fusion’, ‘midfoot arthrodesis and ‘fusion bolt’. We included all the studies published until 2015. Only 10 studies met the inclusion criteria, and were identified for evaluation.

Results:

There were a total of 197 feet in 191 patients 47; average age 58.1 years (29-81 years). Diabetes mellitus was the most common cause of CN (81.8%). The average follow-up duration post-operatively was approximately 30 months (range 3-137 months). Several classification systems were used to grade deformity, implants were commonly combined with other fixation based on the location and severity of the deformity, presence or absence of ulcers and surgeon’s preference. All studies reported improvement in correction of deformities both clinically & radiologically with an associated-loss of correction over the follow-up period. Overall, we observed 49.8% of patients experienced a complication, including screw breakage or migration (33), infection (42), wound dehiscence (20) and peri-prosthetic fractures (4). Resulting in revision and lower than expected fusion rates and recurrent ulceration.

Conclusion:

The MCB provides excellent correction of deformity, with high-failure-rate. This is especially true if a single-rod is used, as it may not provide enough stability to achieve osseous-fusion, due its inability to provide enough compression, reduce shear stress at bone interfaces when used in isolation. Thus additional-implants in neutralising rotational-instability to achieve a stable ‘‘superconstruct’’ may-avoid implant-failure, recurrent-deformity & high-complication-rates. Further assessment & stratification of CN deformity and implant use must be ascertained prior to definitive conclusions being reached regarding the use of the MCB. Whilst there is significant heterogeneity, current evidence suggests surgeons should use this device with caution.
Treatment of Atraumatic Subtalar Dislocations in Adult Acquired Flatfoot Deformity
Authors: Ramadorai Uma E. , Williams Joan , Sangeorzan Bruce
Published: October 2016

Category:

Hindfoot

Introduction/Purpose:

There is a subset of patients with adult acquired flatfoot deformity (AAFD) in which the deformity has progressed so much that the subtalar joint is dislocated, causing subfibular impingement. These patients can be technically difficult to treat operatively given the loss of soft tissue and articular constraints. Additionally, they tend to have increased rates of reoperation. We sought to describe the common patient characteristics and the reasons for reoperation in this population through our case series of 23 patients.

Methods:

A retrospective chart review was done of all patients who underwent surgical correction of AAFD with subtalar, double, triple, or pantalar arthrodesis based on the treating surgeon’s discretion. This review then used radiographic criteria to identify those patients who qualified as having subtalar dislocation on presentation. The charts of qualifying patients were then evaluated for demographic data, comorbidities, complications, and the need for reoperation.

Results:

We found that the average BMI for patients with this disorder was 34kg/m2 and that of our 23 patients who qualified for the study, 30.4% required reoperation for infection, nonunion, or symptomatic hardware.

Conclusion:

AAFD is a very common problem seen by foot and ankle surgeons and phyisicans should be aware of the challenges presented in treating the subset of patients who have atraumatic dislocation of the subtalar joint. Patients should also be counseled about the high rate of reoperation with surgical treatment of their AAFD if they fall into this category.
Venous Thromboembolism Prophylaxis with Rivaroxaban in Elective Foot and Ankle Surgery
Authors: Wiewiorski Martin J. , Muheim Leander , Huegle Thomas , Valderrabano Victor , Barg Alexej
Published: October 2016

Category:

Other

Introduction/Purpose:

Oral application for prophylaxis of venous thromboembolism (VTE) after total hip and knee arthroplasty has high acceptance among patients due to its non-invasive nature, when compared to traditional subcutaneous application of low- molecular-weight heparin (LMWH). Approximately 10% of the patients in our clinic receive oral thrombosis prophylaxis (rivaroxaban), the remaining patients receive subcutaneous prophylaxis with LMWH (dalteparin). However, no clinical data exists describing the use of oral prophylaxis in elective orthopedic foot and ankle surgery. The aims of this study where: 1. To assess the incidence of VTE after oral prophylaxis after elective foot and ankle procedures. 2. To identify risk factors for VTE after oral prophylaxis after elective foot and ankle procedures.

Methods:

A retrospective chart review of patients undergoing elective foot and ankle surgery between January 2010 and 2013 was performed. The type of medicamentous thrombosis prophylaxis was noted. All patients receiving oral antithrombotic medication (rivaroxaban, Xarelto©, Bayer, Germany) were included in the study. Location, length and type of surgery and tourniquet time were assessed. Co-morbidities (e.g. diabetes, coagulopathy, ASA classification) were noted. Patients previously treated with phenprocoumon or clopidrogel were excluded. A phone interview was performed and patients were asked whether a thromboembolic incident occurred or not. If an incidence was confirmed, the report of the diagnostic findings was obtained from the general practitioner.

Results:

450 patients were included. Two thromboembolic incidents occurred (0.4%; deep venous thrombosis confirmed by ultrasound). Both patients had a history of previous deep venous thrombosis and a positive family history for VTE. Due to the low percentage of patients with VTE, a multivariate analysis could not be performed.

Conclusion:

The incidence of VTE after oral thrombosis prophylaxis with rivaroxaban is low and comparable with the incidence after subcutaneous application of LMWH.
Association of nasopharyngeal microbiota profiles with bronchiolitis severity in infants hospitalised for bronchiolitis
Authors: Hasegawa Kohei , Mansbach Jonathan M. , Ajami Nadim J. , Espinola Janice A. , Henke David M. , Petrosino Joseph F. , Piedra Pedro A. , Shaw Chad A. , Sullivan Ashley F. , Camargo Carlos A.
Published: October 2016

Little is known about the relationship between the specific airway microbiota composition and severity of bronchiolitis. We aimed to identify nasopharyngeal microbiota profiles and link these profiles to acute severity in infants hospitalised for bronchiolitis.

We conducted a multicentre prospective cohort study of 1005 infants (age <1 year) hospitalised for bronchiolitis over three winters, 2011–2014. By applying a 16S rRNA gene sequence and clustering approach to the nasopharyngeal aspirates collected within 24 h of hospitalisation, we determined nasopharyngeal microbiota profiles and their association with bronchiolitis severity. The primary outcome was intensive care use,i.e.admission to an intensive care unit or use of mechanical ventilation.

We identified four nasopharyngeal microbiota profiles: three profiles were dominated by one ofHaemophilus,MoraxellaorStreptococcus,while the fourth profile had the highest bacterial richness. The rate of intensive care use was highest in infants with aHaemophilus-dominant profile and lowest in those with aMoraxella-dominant profile (20.2%versus12.3%; unadjusted OR 1.81, 95% CI 1.07–3.11, p=0.03). After adjusting for 11 patient-level confounders, the rate remained significantly higher in infants withHaemophilus-dominant profiles (OR 1.98, 95% CI 1.08–3.62, p=0.03). These findings were externally validated in a separate cohort of 307 children hospitalised for bronchiolitis.
Exercise, ageing and the lung
Authors: Roman Michael A. , Rossiter Harry B. , Casaburi Richard
Published: October 2016

This review provides a pulmonary-focused description of the age-associated changes in the integrative physiology of exercise, including how declining lung function plays a role in promoting multimorbidity in the elderly through limitation of physical function. We outline the ageing of physiological systems supporting endurance activity: 1) coupling of muscle metabolism to mechanical power output; 2) gas transport between muscle capillary and mitochondria; 3) matching of muscle blood flow to its requirement; 4) oxygen and carbon dioxide carrying capacity of the blood; 5) cardiac output; 6) pulmonary vascular function; 7) pulmonary oxygen transport; 8) control of ventilation; and 9) pulmonary mechanics and respiratory muscle function. Deterioration in function occurs in many of these systems in healthy ageing. Between the ages of 25 and 80 years pulmonary function and aerobic capacity each decline by ∼40%. While the predominant factor limiting exercise in the elderly likely resides within the function of the muscles of ambulation, muscle function is (at least partially) rescued by exercise training. The age-associated decline in pulmonary function, however, is not recovered by training. Thus, loss in pulmonary function may lead to ventilatory limitation in exercise in the active elderly, limiting the ability to accrue the health benefits of physical activity into senescence.
Desipramine improves upper airway collapsibility and reduces OSA severity in patients with minimal muscle compensation
Authors: Taranto-Montemurro Luigi , Sands Scott A. , Edwards Bradley A. , Azarbarzin Ali , Marques Melania , de Melo Camila , Eckert Danny J. , White David P. , Wellman Andrew
Published: October 2016

We recently demonstrated that desipramine reduces the sleep-related loss of upper airway dilator muscle activity and reduces pharyngeal collapsibility in healthy humans without obstructive sleep apnoea (OSA). The aim of the present physiological study was to determine the effects of desipramine on upper airway collapsibility and apnoea–hypopnea index (AHI) in OSA patients.

A placebo-controlled, double-blind, randomised crossover trial in 14 OSA patients was performed. Participants received treatment or placebo in randomised order before sleep. Pharyngeal collapsibility (critical collapsing pressure of the upper airway (Pcrit)) and ventilation under both passive (V′0,passive) and active (V′0,active) upper airway muscle conditions were evaluated with continuous positive airway pressure (CPAP) manipulation. AHI was quantified off CPAP.

Desipramine reduced activePcrit(median (interquartile range) −5.2 (4.3) cmH2O on desipramineversus−1.9 (2.7) cmH2O on placebo; p=0.049) but not passivePcrit(−2.2 (3.4)versus−0.7 (2.1) cmH2O; p=0.135). A greater reduction in AHI occurred in those with minimal muscle compensation (defined asV′0,active−V′0,passive) on placebo (r=0.71, p=0.009). The reduction in AHI was driven by the improvement in muscle compensation (r=0.72, p=0.009).

In OSA patients, noradrenergic stimulation with desipramine improves pharyngeal collapsibility and may be an effective treatment in patients with minimal upper airway muscle compensation.
Mast cells are associated with exacerbations and eosinophilia in children with severe asthma
Authors: Lezmi Guillaume , Galmiche-Rolland Louise , Rioux Sabine , Jaubert Francis , Tillie-Leblond Isabelle , Scheinmann Pierre , Gosset Philippe , de Blic Jacques
Published: October 2016

The role of mast cells in the pathogenesis of childhood asthma is poorly understood. We aimed to estimate the implication of airway mucosal mast cells in severe asthma and their relationship with clinical, functional, inflammatory and remodelling parameters.

Bronchial biopsies were performed in 36 children (5–18 years) with severe asthma: 24 had frequent severe exacerbations and/or daily symptoms in the previous year (symptomatic group), and 12 had few symptoms and a persistent obstructive pattern (paucisymptomatic group). Nine children without asthma were included as control subjects. We assessed mast cells in the submucosa and airway smooth muscle using c-kit antibodies and in the entire biopsy area using Giemsa.

The number of submucosal mast cells was higher in the symptomatic group than in the paucisymptomatic group (p=0.02). The number of submucosal mast cells correlated with the number of severe exacerbations (p=0.02, r=0.37). There were positive correlations between the number of submucosal mast cells (p<0.01, r=0.44), airway smooth muscle mast cells (p=0.02, r= 0.40), mast cells stained by Giemsa (p<0.01, r=0.44) and submucosal eosinophils.

Mast cells are associated with severe exacerbations and submucosal eosinophilic inflammation in children with severe asthma.
Rapid and efficient generation of neural progenitors from adult bone marrow stromal cells by hypoxic preconditioning
Authors: Mung Kwan-Long , Tsui Yat-Ping , Tai Evelyn Wing-Yin , Chan Ying-Shing , Shum Daisy Kwok-Yan , Shea Graham Ka-Hon
Published: October 2016

Background

Bone marrow stromal cells (BMSCs) are attractive as a source of neural progenitors for ex vivo generation of neurons and glia. Limited numbers of this subpopulation, however, hinder translation into autologous cell-based therapy. Here, we demonstrate rapid and efficient conditioning with hypoxia to enrich for these neural progenitor cells prior to further expansion in neurosphere culture.

Method

Adherent cultures of BMSCs (rat/human) were subjected to 1 % oxygen for 24 h and then subcultured as neurospheres with epidermal growth factor (EGF) and basic fibroblast growth factor supplementation. Neurospheres and cell progeny were monitored immunocytochemically for marker expression. To generate Schwann cell-like cells, neurospheres were plated out and exposed to gliogenic medium. The resulting cells were co-cultured with purified dorsal root ganglia (rat) neurons and then tested for commitment to the Schwann cell fate. Fate-committed Schwann cells were subjected to in vitro myelination assay.

Results

Transient hypoxic treatment increased the size and number of neurospheres generated from both rat and human BMSCs. This effect was EGF-dependent and attenuated with the EGF receptor inhibitor erlotinib. Hypoxia did not affect the capacity of neurospheres to generate neuron- or glia-like precursors. Human Schwann cell-like cells generated from hypoxia-treated BMSCs demonstrated expression of S100β /p75 and capacity for myelination in vitro.

Conclusion

Enhancing the yield of neural progenitor cells with hypoxic preconditioning of BMSCs in vitro but without inherent risks of genetic manipulation provides a platform for upscaling production of neural cell derivatives for clinical application in cell-based therapy.
Local versus intravenous injections of skeletal muscle precursor cells in nonhuman primates with acute or chronic intrinsic urinary sphincter deficiency
Authors: Williams J. Koudy , Badlani Gopal , Dean Ashley , Lankford Shannon , Poppante Kimberly , Criswell Tracy , Andersson Karl-Erik
Published: October 2016

Background

Many factors may influence the efficacy of cell therapy for intrinsic urinary sphincter deficiency (ISD), including the route of administration of the cells and the condition of the sphincter. The goal of this study was to compare local versus intravenous administration of autologous skeletal muscle precursor cells (skMPCs) when administered to nonhuman primates (NHPs) with either acute or chronic ISD.

Methods

Thirty-two adult female monkeys were divided into eight groups (n = 4/group): (1) control; (2) surgically induced ISD/no treatment; (3) acute ISD (6-week duration)/local vehicle only; (4) acute ISD/local skMPC injection; (5) acute ISD/systemic skMPC; (6) chronic ISD (6-month duration)/local vehicle; (7) chronic ISD/local skMPC; (8) chronic ISD/systemic skMPC. Maximal urethral pressures (MUP) were measured prior to ISD, prior to treatment and at 3 and 6 months following treatment. Quantitative histology was used to measure muscle/collagen content, somatic innervation, and vascularity of the sphincter complexes.

Results

In NHPs with acute ISD both systemic and local administration of skMPCs increased resting MUP values and sphincter muscle content (p < 0.05 vs. ISD/vehicle). However, the effects of systemic skMPC administration were significantly lower than those of local injection (p > 0.05). In NHPs with chronic ISD local skMPC administration had reduced (compared to NHPs with acute ISD) effects on MUP and sphincter muscle values (p < 0.05 vs. acute ISD/skMPC); systemic administration had no effect. Pudendal nerve-stimulated increases in MUP were significant only in acute ISD NHPs with local skMPC treatment (p < 0.05 vs. resting MUP). The extent of sphincter vascularization and innervation were directly related to MUP and sphincter muscle content.

Conclusions

Both the chronicity of ISD and the route of cell injection influence the efficacy of cell therapy in monkey models of ISD. This may be related to the relative ability of cells to stimulate vascularization and re-innervation in these different treatment conditions.
Mediation analysis of severity of needs, service performance and
outcomes for patients with mental disorders
Authors: Roux Paul , Passerieux Christine , Fleury Marie-Josée
Published: October 2016

Background

Needs and service performance assessment are key components in improving
recovery among individuals with mental disorders.

Aims

To test the role of service performance as a mediating factor between
severity of patients' needs and outcomes.

Method

A total of 339 adults with mental disorders were interviewed. A mediation
analysis between severity of needs, service performance (adequacy of
help, continuity of care and recovery orientation of services) and
outcomes (personal recovery and quality of life) was carried out using
structural equation modelling.

Results

The structural equation model provided a good fit with the data. An
increase in needs was associated with lower service performance and worse
outcomes, whereas higher service performance was associated with better
outcomes. Service performance partially mediated the effect of patient
needs on outcomes.

Conclusions

Poorer service performance has a negative impact on outcomes for patients
with the highest needs. Ensuring more efficient services for patients
with high needs may help improve their recovery and quality of life.