bluuebunny/crossref_metadata_2025 huggingface dataset:
Depression in Primary Care: Review of AHCPR Guidelines
Authors: Cohen Lawrence J , Guthrie Sally K
Published: January 2017

OBJECTIVE:

To present an overview and evaluation of the Agency for Health Care Policy and Research (AHCPR) clinical practice guidelines for the treatment of depression.

INTRODUCTION:

One responsibility of the AHCPR is the development and periodic review and update of clinical practice guidelines. This process is undertaken by an independent panel composed of groups of clinicians and other experts from the private sector. Their findings are published in a four-volume, softcover set of booklets.

DATA SOURCE AND EVALUATION:

Volume 2 in the four-volume set includes a comprehensive compilation, synthesis, and critical evaluation of the studies of different treatments for depression. Studies included for evaluation were randomized, prospective clinical trials that were pertinent to all topics concerning the treatment of depression. In some areas, the opinions of the panel were included due to a paucity of data from well-controlled clinical trials. Each AHCPR guideline was followed by a code that indicated whether the strength of evidence supporting that guideline was based on good or fair research-based evidence, or whether it was based primarily on panel members' opinions.

CONCLUSIONS:

With regard to drug treatment, the guidelines are good. However, since these guidelines were published in 1993 they might be considered somewhat dated because more antidepressants have become available in the interim. Overall, the AHCPR guidelines reflect an extensive review of the literature provided by the panel, as well as input from a highly respected group of reviewers. The panel included physicians, a nurse, a social worker, a psychologist, and a consumer representative. Unfortunately, a pharmacist was not included on the panel. Input from pharmacy practitioners would have been valuable.
Pharmacokinetics of Methotrexate in Plasma and Cerebrospinal Fluid
Authors: Morikawa Norifumi , Mori Teruaki , Abe Tatsuya , Ghoda Makoto , Takeyama Masaharu , Hori Shigeaki
Published: January 2017

OBJECTIVE:

To investigate the pharmacokinetics of methotrexate (MTX) in plasma and cerebrospinal fluid (CSF) during osmotic disruption of the blood-brain barrier and the intraarterial administration of combination chemotherapy postoperatively in a patient with glioblastoma.

CASE SUMMARY:

A 60-year-old Japanese woman with a glioblastoma received two courses of combination intraarterial chemotherapy. In the first course of treatment, 20 mL of mannitol 20%, peplomycin 10 mg, vindesine 2 mg, and MTX 500 mg were administered via the right internal carotid artery, and then via the right vertebral artery. In the second course of treatment, 20 mL of mannitol 20%, peplomycin 15 mg, vindesine 2.5 mg, and MTX 1000 mg were similarly administered. Blood samples and CSF samples from the ventricle and the space left by tumor removal were obtained; the MTX concentrations were measured from these sites by fluorescence polarization immunoassay. The pharmacokinetic parameters of MTX in plasma and CSF were estimated.

DISCUSSION:

The plasma concentration of MTX decreased in a biexponential decay pattern during each course of treatment. CSF concentrations of MTX in the ventricle and in the space left by tumor removal peaked at 2 and 6 hours, respectively, after drug administration and decreased monoexponentially. When the dose of MTX was doubled, the AUC for the plasma MTX concentration increased 2.4-fold and the AUCs for MTX in the ventricle and the space left by tumor removal increased 3.4- and 9.1-fold, respectively. The half-life of MTX in the CSF in the space left by tumor removal exceeded the half-lives of MTX in the plasma and in the ventricular CSF.

CONCLUSIONS:

The CSF AUCs of MTX in the ventricle and the space left by tumor removal increased markedly and in parallel with the MTX dosage increase during osmotic disruption of the blood-brain barrier and intraarterial combination chemotherapy. Such treatment improves the delivery of chemotherapy agents to the brain.
Pharmacy and Tobacco
Authors: Rumore Martha M
Published: January 2017

With the recognition that smoking begins in youth and that tobacco products are readily available to those under 18 years of age, new Food and Drug Administration (FDA) regulations restrict the sale, distribution, promotion, and advertising of cigarettes to minors. The objective is to decrease the use of tobacco by young people and consequently reduce the future morbidity and mortality from tobacco. Pharmacists currently have three choices with regard to the sale of tobacco in pharmacies: display and sell tobacco products, refuse to sell tobacco products, or make tobacco products available but counsel on smoking cessation. Each choice, as well as the impact of the new FDA regulations on pharmacy, is discussed.
Paclitaxel-Induced Acute Bilateral Pneumonitis
Authors: Khan Amir , McNally Daniel , Tutschka Peter J , Bilgrami Syed
Published: January 2017

OBJECTIVE:

To report three cases of paclitaxel-induced acute bilateral pneumonitis, as well as to ascertain its incidence and outcome.

CASE SUMMARIES:

A total of 239 patients with a variety of underlying malignancies received 528 courses of paclitaxel-containing chemotherapy. Paclitaxel 200 mg/m2 was infused over 3 hours with standard premedication. Three patients developed bilateral interstitial infiltrates either during or within 6 hours of the administration of paclitaxel. Symptoms included a nonproductive cough, dyspnea, and sudden arterial oxygen desaturation. Response to parenteral corticosteroids was dramatic and reversed the process in all 3 patients.

DISCUSSION:

Paclitaxel-induced acute bilateral pneumonitis appears to be a rare adverse reaction. It may either be a direct toxic effect of the chemotherapeutic agent or an adverse effect of its Cremophor EL diluent. Although the exact pathophysiology is unclear, a variety of immune and nonimmune mechanisms have been postulated, including hypersensitivity reactions, release of cytokines from macrophages, and the possible role of prior thoracic irradiation.

CONCLUSIONS:

Acute bilateral pneumonitis occurs in less than 1% of individuals receiving 3-hour infusions of paclitaxel, and responds dramatically to parenteral corticosteroid therapy.
Ofloxacin-Lnduced Seizure
Authors: Walton Gary D , Hon Jeremy K , Mulpur Tejanand G
Published: January 2017

OBJECTIVE:

To describe a possible case of ofloxacin-induced generalized tonic—clonic seizure. Although the etiology is unknown, ofloxacin most likely precipitated this patient's seizure threshold because of sepsis or secondary to drug accumulation due to the patient's compromised renal function.

CASE SUMMARY:

A 69-year-old white woman with non-small-cell lung cancer and a history of central nervous system metastatic disease treated with radiation therapy presented to the emergency department with symptoms of urosepsis. Because of multiple drug allergies she was started on ofloxacin (hospital formulary quinolone). After 4 days of therapy she developed a generalized tonic—clonic seizure. A computed tomography scan of the head with and without contrast was negative. The ofloxacin was discontinued and aztreonam therapy was started. Phenytoin therapy was instituted and, despite serum concentrations below the conventional therapeutic range, there was no recurrence of seizure. Subsequent discontinuation of phenytoin did not result in a seizure for this patient.

DISCUSSION:

Seizures induced by the fluoroquinolones are uncommon. The histopathologic features of this phenomenon are currently unknown. In this patient, imaging studies were negative for structural defects, ruling out metastasis as the cause of the seizure. Therefore, an investigation of drug-related causes ensued. The most likely offending agent was ofloxacin. Ofloxacin has been reported in the literature as a cause of seizures in patients with compromised renal function.

CONCLUSIONS:

This case and other reports indicate that fluoroquinolones, including ofloxacin, may contribute to seizure development in patients with or without a history of epilepsy. Fluoroquinolone therapy should be used with caution in patients with risk factors for the development of drug-induced seizures.
Extrapyramidal Reactions and the Selective Serotonin-Reuptake Inhibitors
Authors: Caley Charles F
Published: January 2017

OBJECTIVE:

To review the known published reports of extrapyramidal reactions (EPRs) associated with the use of selective serotonin-reuptake inhibitors (SSRIs).

DATA SOURCES:

Information was selected from a MEDLINE search (January 1990 to January 1996) of English-language medical literature. Manual searches of pertinent journal article bibliographies were also performed.

DATA EXTRACTION:

Appropriate information from all reports obtained was included, with specific attention directed toward patient age, gender, primary psychiatric diagnosis, total daily SSRI dosage, dosage escalation strategy, and concurrent psychotropic medications.

DATA SYNTHESIS:

Reports of EPRs associated with SSRI use have been accumulating in the medical literature for several years. More commonly associated with high-potency antipsychotics, EPRs can have an adverse impact on medication compliance and hospital readmissions. The proposed hypothesis for EPRs occurring with SSRI use involves serotonin's inhibitory actions on extrapyramidal dopamine activity. Other possible contributing factors include pharmacokinetic interactions or drug—disease interactions. EPRs may include dystonias, dyskinesias, akathisia, parkinsonism, exacerbations of Parkinson's disease, and possibly the neuroleptic malignant syndrome. The majority of SSRI-related reactions appear to occur within the first month of treatment. Information from available case reports does not strongly support any consistent risk factor, although some worth considering may include total SSRI daily dose, rapid dose escalation strategies, increased age, female gender, concurrent psychotropics known to also precipitate EPRs, and concurrent disease states such as Parkinson's disease. Since SSRI-related EPRs have occurred in different situations with different possible contributing factors, clinical pharmacy practitioners and other healthcare providers should remain aware of these reactions and carefully consider educating and monitoring their patients accordingly.

CONCLUSIONS:

The use of SSRIs may be associated with the development of EPRs; therefore, appropriate monitoring should be considered for patients so that optimal pharmaceutical care may be provided.
Tetanus: Pathophysiology and Management
Authors: Ernst Michael E , Klepser Michael E , Fouts Michelle , Marangos Markos N
Published: January 2017

OBJECTIVE:

To review the epidemiology, pathophysiology, clinical manifestations, diagnosis, and management of tetanus and its complications.

DATA SOURCES:

MEDLINE and Iowa Drug Information Services databases were searched for literature pertaining to tetanus. Additional literature was obtained from the references of selected articles identified in the search. Information from all articles was considered for inclusion in the manuscript.

STUDY SELECTION AND DATA EXTRACTION:

Articles selected were those considered by the authors to assist in providing the reader an understanding of the epidemiology, pathophysiology, clinical manifestations, diagnosis, and management of tetanus.

DATA SYNTHESIS:

While the number of tetanus cases has decreased markedly since data reporting for the disease began in 1947, mortality among those who acquire the disease remains high. Elderly patients are particularly susceptible to tetanus and its complications. Prevention of tetanus focuses on primary immunization and scheduled boosters. Management of tetanus involves initial stabilization of the patient and protection of the airway, prevention of tetanospasmin absorption by administration of human tetanus immune globulin 3000–6000 IU, and eradication of Clostridium tetani with antimicrobial therapy (metronidazole 500 mg q8h). Supportive measures include the administration of neuromuscular blocking agents such as pancuronium in patients requiring artificial ventilation, as well as benzodiazepines (midazolam 5–15 mg/h) for sedation and muscle relaxation. Autonomic dysfunction should be managed with β-adrenergic blockers such as propranolol or labetalol.

CONCLUSIONS:

Despite the relative inffequency of tetanus cases, mortality among untreated patients remains significantly high. Clinicians should become knowledgeable in the pathophysiology, clinical manifestations, and management of this potentially fatal disease.
The Results of a Primary and Staged Pantalar Arthrodesis and Tibiotalocalcaneal Arthrodesis in Adult Patients
Authors: Acosta Roman , Ushiba James , Cracchiolo Andrea
Published: January 2017

Twenty-three patients (twenty-seven feet) with either a primary or staged pantalar arthrodesis or a tibiotalocalcaneal arthrodesis were evaluated to determine their clinical status. The main indication for the operation was the presence of severe pain unresponsive to non-operative treatment. Fourteen feet (twelve patients) had a pantalar arthrodesis; a fusion of the ankle, subtalar, talonavicular and calcaneocuboid joints. Half the feet in this group had either a triple arthrodesis or an ankle fusion performed at an earlier time. The remaining seven feet had all joints fused during the same operation. Thirteen feet (eleven patients) had a tibiotalocalcaneal arthrodesis. Two of these feet had an ankle arthrodesis performed four and six years previously. The other eleven had the ankle and subtalar joints fused during the same operation. All patients were followed for a mean of fifty-five months (14 to 159 months) from the time of their final arthrodesis procedure. Overall, twenty-three of the twenty-seven feet achieved a solid arthrodesis of all joints operated upon. Four feet had a failure of fusion of only a single joint and all were in the pantalar group. The mean time to radiographic fusion was twenty-three weeks and resulted in a plantigrade foot with an average tibia-floor angle of 87°. Complications occurred in ten feet (37%); of which there were three deep infections; two ankles and one subtalar joint. These arthrodeses procedures resulted in marked relief of the patients' preoperative pain, the main indication for performing the surgery. Postoperatively there was no pain in eleven feet, mild occasional pain in thirteen feet, and moderate pain in only three feet. However, when all parameters of our clinical rating scale were evaluated, only five patients had an excellent clinical result, nine were rated good, three were rated fair and six patients had a poor result. These operations must be considered to be salvage procedures. They are technically difficult to perform and major complications may occur. Pain relief appears to be the main indication for performing these operations, and may account for whatever improvement occurs in the patient's function.
An Insole Pressure Measurement System: Repeatability of Postural Data
Authors: Bauer Jeffrey A. , Cauraugh James H. , Tillman Mark D.
Published: January 2017

This study analyzed the ability of an in-shoe plantar pressure measurement system to provide repeatable measurements of postural sway data for both healthy and clinical patients. Each participant's in-shoe pressure data were recorded for three trials during each test session during quiet stance. Healthy individuals (n=9) participated on three consecutive days while clinical participants (n=5) were tested on one day. Nine response variables were measured to assess their postural stability. Intra-subject measures were evaluated using the Kerlinger reliability procedure. Values provided directly by the Parotec System® for a single day of testing yielded the following average coefficients: r = 0.95 (left), r = 0.97 (right) with mean coefficient values from the three day tests of: r = 0.98 (left), r = 0.98 (right). Variables calculated from raw data on a single day produced mean coefficients of: r = 0.77 (left), r = 0.76 (right) and over three days of: r = 0.65 (left), r =0.66 (right). The ability to record highly reproducible data of postural sway parameters should assist clinicians to treat patients more confidently for balance deficiencies.
Anatomy of the sural nerve and its relation to the Achilles Tendon
Authors: Webb Jonathan , Moorjani Narain , Radford Mike
Published: January 2017

Sural nerve injury is a complication of Achilles Tendon (TA) rupture. We dissected 30 cadaveric lower limbs to describe the course of the sural nerve in relation to the TA. At the level of insertion of the TA into the calcaneum, the sural nerve was a mean 18.8 mm from the lateral border of the TA. The proximal course of the nerve was towards the midline such that it crossed the lateral border of the TA at a mean distance of 9.8 cm from the calcaneum. The significant individual variation in the position of the sural nerve in relation to the achilles tendon should be borne in mind when placing sutures in the proximal part of the achilles tendon. Percutaneous sutures should not be placed in the lateral half of the TA.
Peripheral Nerve Vein Wrapping For Intractable Lower Extremity Pain
Authors: Easley Mark E. , Schon Lew C.
Published: January 2017

Hypothesis/Purpose: The purpose of this study was to determine the effectiveness of lower extremity peripheral nerve vein wrapping procedures in the management of patients with intractable lower extremity pain. The hypothesis was that nerve insulation through vein wrapping is effective in treating symptoms related to adhesive neuralgia, but not those secondary to intraneural damage. Methods: We retrospectively reviewed 25 consecutive patients whose intractable chronic lower extremity peripheral neuralgia had been treated with revision neurolysis and vein wrapping. The 14 women and 11 men had an average age of 39 years (range, 21 to 53 years). Vein wrapping was performed using a saphenous vein autograft in 19 patients and a fetal umbilical vein in six patients. The average length of follow-up after vein wrapping was 24 months (range, 12 to 63 months). Assessment of pain and dysfunction was on a scale of 0 (no pain/dysfunction) to 10 (severe enough to prompt request for amputation and required use of a wheelchair). Results: Pain scores improved from a preoperative average of 8.7 points (range, 6 to 10 points) to a postoperative average of 4.6 points (range, 0 to 10 points); dysfunction improved from a preoperative average of 7.3 points (range, 3 to 10 points) to a postoperative average of 4.4 points (range, 0 to 9 points). Although 17/25 patients were satisfied with the procedure, only 14/25 stated they would undergo the surgery again. All eight patients who exhibited no improvement had preoperative and intraoperative evidence of an idiopathic etiology and/or intraneural damage. Preoperatively, 18/25 patients could not work; postoperatively, that number improved to 8/25. Conclusions: Vein wrapping of lower extremity peripheral nerves is most effective in relieving symptoms related to adhesive neuralgia and less beneficial in the presence of intraneural damage. Although symptoms are rarely relieved completely, vein wrapping typically results in a substantial improvement in symptoms related to scar entrapment of peripheral nerves.
Congruity of the Subtalar Joint in Tongue Fracture of the Calcaneus: An Anatomical Study
Authors: Ebraheim Nabil A. , Sabry Fady F. , Haman Steve , Elgafy Hossein
Published: January 2017

Study Design: An anatomic study.

Objectives: To evaluate the effect of displacement of the fractured posterior facet in tongue fracture of the calcaneus on the congruity of the subtalar joint.

Methods: Eleven feet were used in this study. Seven females and four males with age range from 59 to 78. The specimens were dissected from both the lateral and the medial aspects of the calcaneus to expose these surfaces. A primary fracture line was created first, then a secondary line was engineered to simulate tongue fracture. Displacement of the superio-lateral fragment was done with 5-mm increment. Radiography was performed and the graphs were scanned and studied on specific computer software to explore the effects of displacement on joint congruity.

Results: The anterior end of the fragment of the tongue fracture, when displaced, not only is depressed but also rotated in the sagittal plane in a downward or planterward direction. The articular surface of the posterior facet of the calcaneus and the inferior facet of the talus are maintained in congruence with each other despite the varying degree of displacement and rotation.

Conclusion: Congruity of the subtalar joint in tongue fractures is maintained despite different degrees of displacement. This study explains why the non-surgical treatment outcome is comparable to that of the operative treatment in tongue fractures of calcaneus. It also explains why tongue fractures have a good outcome with closed reduction.
Tarsal Coalition in Adults
Authors: Varner Kevin E. , Michelson James D.
Published: January 2017

32 feet in 27 adults, seen at The Johns Hopkins Hospital Foot and Ankle Clinic from 1993-1998, with the diagnosis of tarsal coalition were retrospectively reviewed. There were 18 subtalar coalitions, 14 calcaneonavicular coalitions and 1 naviculocuneiform coalition. The average age was 40 years. Clinically, 22 feet had a neutral heel, 7 had a valgus heel with flattening of the longitudinal arch, 1 had a varus heel and 2 heels had an unknown position. Subtalar motion was decreased in 23 feet. Peroneal spasm was only seen in 2 patients. 11 feet were asymptomatic.

Nonoperative treatment consisting of activity modification, nonsteroidal anti-inflammatory medications and casting was successful in the majority of patients. Subtalar fusion was performed in 4 feet and coalition resection in 1.

The treatment of a symptomatic tarsal coalition in the adult is as in children but the clinical presentation may differ.
Fracture of an Interphalangeal Coalition: a Report of Two Cases
Authors: Sammarco G. James , Hockenbury R. Todd
Published: January 2017

Congenital coalition of the middle and distal phalanges in the fifth toe are common. They have been reported to occur in up to 50% of American and European populations and in up to 73% of people of Japanese descent. Congenital interphalangeal coalition of the other toes is less common. We report two cases of fracture through an interphalangeal coalition following blunt trauma. Diagnosis was delayed in these fractures. One fracture healed only after prolonged immobilization and the other developed a delayed union. Patients with this fracture should be advised of the prolonged convalescence since this may delay their return to preinjury activities.
Spontaneous Rupture of the Tibialis Anterior Tendon: A Case Report and Literature Review
Authors: Patten Andrew , Pun Wai-Ki
Published: January 2017

Spontaneous rupture of the tibialis anterior tendon is uncommon. This article presents a case report in which spontaneous rupture of the tibialis anterior tendon occurred secondary to a gouty tophaceous deposit within the tendon. This report adds to the list of pathological conditions that should be considered in closed spontaneous rupture of the tibialis anterior tendon.
Primary Subtalar Arthrodesis of Calcaneal Fractures
Authors: Huefner T. , Thermann H. , Geerling J. , Pape H.C. , Pohlemann T.
Published: January 2017

We evaluated retrospectively the long-term results of isolated calcaneal fractures treated with open reduction and internal fixation and a primary subtalar arthrodesis. From 1990 to 1997 258 patients were treated with a calcaneal fracture, for the current study six patients were included. Six different surgeons operated on the patients. The indication for the fusion was based on the comminution of the posterior facet according to the preoperative CT as well as the intraoperative evaluation of destruction of the cartilage. The restoration of length, axes and angles of the calcaneus was almost anatomical in all cases. Follow-up was done at a mean of 4.9 (2.5–7.5 years). Using the AOFAS score, the results were good or excellent in five patients. In one patient with a painful arthritis in the talonavicular joint and hyperesthesia of the sural nerve, the results were fair. All returned to their profession within 9 months and had no or only minor daily restrictions. The results are comparable with single surgeon series.

We found open reconstruction of the calcaneus with primary fusion of the subtalar joint may be indicated in selected patients and, in these 6 patients led to good results.
The Adductor Hallucis Revisited
Authors: Owens Stephen , Thordarson David B.
Published: January 2017

To evaluate anatomic variability in the insertion of the adductor hallucis into the lateral sesamoid and proximal phalanx of the great toe and to evaluate the extent of release of the adductor hallucis tendon performed through an incision in the dorsal first-web space, we recorded the angle of hallux valgus in 42 fresh-frozen specimens from human cadavers. An incision was made for a realignment of the soft tissues, dissecting down to the level of the intermetatarsal ligament. A loop of suture was placed around the identifiable adductor hallucis tendon through this incision along the lateral aspect of the lateral sesamoid. Then a plantar dissection removed all soft tissue to the level of the intermetatarsal ligament, adductor hallucis (transverse and oblique heads), lateral sesamoid, and lateral flexor hallucis brevis. The insertion of these muscles into the proximal phalanx was evaluated. Specifically, we looked for separate slips of the adductor tendon inserting into the base of the proximal phalanx or separate insertions of the adductor tendon and the tendon of the flexor hallucis brevis muscle.

In 33 of the 42 specimens, the entire adductor hallucis tendon had been isolated by the loop of suture through the incision in the dorsal first web. In eight of the remaining nine specimens, a small slip of the tendon (comprising less than 25% of its substance) had not been included. No specimen was found to have a separate slip of the adductor tendon inserting into the base of the proximal phalanx. Instead, all specimens were found to have only a conjoined insertion of fibers of the adductor hallucis and of the flexor hallucis brevis from the lateral sesamoid into the base of the proximal phalanx. We did not identify a separate tendon-insertion into the proximal phalanx in any specimen. Therefore, great caution should be exercised in releasing an isolated insertion of the adductor tendon from the base of the proximal phalanx of the great toe since it may actually represent the conjoined insertion of the lateral flexor hallucis brevis tendon and the adductor tendon. We found that by simply releasing the adductor tendon from its insertion along the lateral aspect of the sesamoid, accomplished through an incision in the dorsal first web, that an adequate release was achieved in most specimens.
Age-Based Outcomes of Cheilectomy for the Treatment of Hallux Rigidus
Authors: Feltham Glen T. , Hanks Steven E. , Marcus Randall E.
Published: January 2017

The results of cheilectomy, performed on 67 consecutive patients with hallux rigidus resulting in primary extra-articular symptoms are presented. Four patients who underwent subsequent fusion were rated as failures. Follow-up evaluation, averaging 65 months (28–117) on 53 additional patients available for follow-up, revealed an average AOFAS score of 80. with 91% of the patients stating that they were currently better than before surgery. There was a statistically significant higher mean score (89) in patients over 60 years of age at the time of surgery. There were no differences between other age groups, preoperative grade, duration of symptoms, or length of follow-up. Cheilectomy should be the treatment of choice for hallux rigidus with predominantly extra-articular symptoms, especially in patients over 60 years of age.
Surgical Treatment for Hallux Valgus with Painful Plantar Callosities
Authors: Okuda Ryuzo , Kinoshita Mitsuo , Morikawa Junichi , Jotoku Tsuyosi , Abe Muneaki
Published: January 2017

We retrospectively reviewed the results of a distal soft-tissue procedure and proximal crescentic osteotomy of the first metatarsal combined with a proximal shortening osteotomy of the second and/or third metatarsal. This was in patients who had hallux valgus with painful plantar callosities. The review covered seven years of procedures (1989–1996) in 12 patients (14 feet) averaging 53 years of age. Average follow-up was 52 months. All patients had pain at the first metatarsophalangeal joint and had metatarsalgia preoperatively.

At follow-up, 11 feet had no pain at the first metatarsophalangeal joint, and three had some improvement of pain. Ten feet had no metatarsalgia, two had improvement of metatarsalgia, and two feet had transfer lesions postoperatively and required reoperation. The angle of hallux valgus averaged 40 degrees preoperatively and 13 degrees postoperatively. The intermetatarsal angle averaged 18 degrees preoperatively and 6 degrees postoperatively. Mean decreases in length of the second and third metatarsal after surgery were 5.4 mm and 4.8 mm, respectively. Our results suggested that this combined procedure for hallux valgus with painful plantar callosities may be successful, in carefully selected patients.
Biomechanical Evaluation of the Ability of Casts and Braces to Immobilize the Ankle and Hindfoot
Authors: Raikin Steven M. , Parks Brent G. , Noll Kenneth H. , Schon Lew C.
Published: January 2017

We evaluated the ability of seven devices to immobilize a prosthetic ankle-foot complex against plantarflexion, dorsiflexion, inversion, and eversion forces: two casts (plaster of Paris and Fiberglas®) and five removable braces (molded ankle/foot orthosis, composite boot brace, pneumatic boot walker, nonarticulating fracture boot, and ankle stirrup). Each device was applied to a prosthetic ankle-foot complex and evaluated on a test frame for resistance to sagittal motion and coronal torque. Results showed that casts offered significantly (P ≤ 0.05) more resistance to motion in all directions tested than did the braces. The resistance offered by the devices tested depends on the conformity of the device to the shape of the foot in that plane and the material properties of the device. Braces offer the advantage of being easily removed and reapplied. Different braces offer specific advantages and disadvantages in different planes tested, and immobilization selection should be individualized based on this information.
The Effect of Posterior Tibial Tendon Dysfunction on Hindfoot Kinematics
Authors: Niki Hisateru , Ching Randal P. , Kiser Patti , Sangeorzan Bruce J.
Published: January 2017

This biomechanical study investigated the functional role of the posterior tibial tendon (PTT) in acquired flatfoot mechanics. Acquired flatfoot deformity has been attributed to PTT dysfunction; however, the progression from acute dysfunction to end-stage deformity has not been fully demonstrated. Eight human cadaver lower leg and foot specimens were used in two phases of experimental testing. In Phase 1, intact (normal) specimens were loaded to simulate (a) heel strike, (b) stance, and (c) heel rise both with and without PTT function. Then, each specimen was subjected to a procedure designed to create a simulated flatfoot deformity. The resulting flattened feet were used in Phase 2 to examine the effect of restoring PTT function to a flatfoot model. During both phases of testing, the 3-D kinematic orientation of the hindfoot complex was recorded.

Small but statistically significant changes in the angular orientation of the hindfoot complex were observed, during both Phase 1 and 2 testing, when comparing the effects of a functional and dysfunctional PTT. The greatest angular changes were recorded during heel rise. For the normal foot, the small changes observed in the orientation of the hindfoot complex following release of the PTT load suggest that the intact osteo-ligamentous structure of the hindfoot is initially able to maintain normal alignment following acute PTT dysfunction. Once the soft tissues have been weakened, as in our flatfoot model, the PTT had little effect in overcoming the soft tissue laxity to correct the position of the foot.
Treatment of Stage II Posterior Tibial Tendon Dysfunction with Flexor Hallucis Longus Transfer and Medial Displacement Calcaneal Osteotomy
Authors: Sammarco G. James , Hockenbury R. Todd
Published: January 2017

Nineteen consecutive patients underwent flexor hallucis longus (FHL) tendon transfer and medial displacement calcaneal osteotomy for the treatment of Stage 2 posterior tibial tendon dysfunction. The FHL tendon was utilized for transfer because it approximates the strength of the posterior tibialis muscle and is stronger than the peroneus brevis muscle. Seventeen patients returned for follow-up examination, follow-up time 18 months (ave.). The AOFAS hindfoot score improved from 62.4/100 to 83.6/100. The subjective portion of the AOFAS hindfoot score improved from 31.0/60.0 to 48.9/60. Weightbearing preoperative and postoperative radiographs revealed no statistically significant improvement for the medial longitudinal arch in measurements of lateral talo-first metatarsal angle, calcaneal pitch, vertical distance from the floor to the medial cuneiform, or talonavicular coverage angle. Three feet had a normal medial longitudinal arch and six feet had a longitudinal arch similar to the opposite side following the procedure. Patient satisfaction was high: 10 patients satisfied without reservations, 6 patients satisfied with minor reservations, and 1 dissatisfied. No patient complained of donor deficit from the harvested FHL tendon. Despite the inability of the procedure to improve the height of the medial longitudinal arch, FHL transfer combined with medial displacement calcaneal osteotomy yielded good to excellent clinical results and a high patient satisfaction rate.
Morphology of Tibiotalar Osteophytes in Anterior Ankle Impingement
Authors: Berberian Wayne S. , Hecht Paul J. , Wapner Keith L. , DiVerniero Richard
Published: January 2017

The purpose of this study was to document radiographic trends in the size and location of osteophytes occurring in patients who have undergone surgical treatment of bony anterior ankle impingement. All patients over a period of 31 months who had undergone surgical excision of anterior ankle osteophytes were identified. 9 patients (10 ankles) in whom preoperative CT scans were available were selected as the study group. This group was retrospectively reviewed in terms of basic preoperative characteristics (age, sex, symptomatology, sports history, systemic disease, passive dorsiflexion). Osteophyte size was measured on plain lateral radiographs, and axial CT images were used to determine both tibial and talar osteophyte location by referencing them to the midline of the talar dome. 95% confidence intervals demonstrated that the talar spur peak lies medial to the midline, the tibial spur peak lies lateral to the midline, and the spurs typically do not overlap each other. Further, the tibial spur is wider than the talar spur, and the talar spur usually protrudes medially off the medial edge of the talar neck. Thus, there is evidence that anterior tibiotalar osteophytes may have a relatively consistent pattern of formation, with the talar spur occurring on the medial aspect of the talar neck, and the tibial spur peaking lateral to the midline. This information, if substantiated with additional patients, may provide insight into the pathophysiology of anterior ankle impingement, as well as facilitate the open and arthroscopic approaches toward resection of these lesions.
Hyperbaric Oxygen Therapy in the Treatment of Soft Tissue Necrosis Resulting from a Stingray Puncture
Authors: Rocca Andrew F. , Moran Elizabeth A. , Lippert Frederick G.
Published: January 2017

Necrotizing soft tissue processes of the foot secondary to an acute stingray envenomation can be a challenge to manage. Very little is reported in the orthopaedic literature to aid the practicing surgeon faced with this problem. In this case report, we describe the wound management and team approach employed in this patient's care, including the indications for hyperbaric oxygen therapy, which, in this case, was ultimately successful.
Missed and Associated Injuries after Subtalar Dislocation: The Role of CT
Authors: Bibbo Christopher , Lin Sheldon S. , Abidi Nicholas , Berberian Wayne , Grossman Mark , Gebauer Greg , Behrens Fred F.
Published: January 2017

Subtalar joint dislocation (STJD) is an uncommon injury, but carries with it a potential for significant functional disability. We hypothesized that a significant number of injuries associated with subtalar joint dislocation may be unrecognized by plain radiographic examination. Therefore, we reviewed the records of all STJDs over a three-year period, identifying nine cases. The majority of injuries occurred in men (78%) with a mean age of 29 years. Overall, the mean age at injury was 32 years. The right lower extremity was most frequently injured (87.5%). Plain films initially diagnosed a STJ dislocation in all patients. A CT scan was performed in ail cases. In 100% of patients, CT identified additional injuries missed on initial plain radiographs. In 44% of patient, new information gathered by CT dictated a change in treatment. Based on our findings, we conclude that CT is an invaluable tool to assess for associated injuries in STJ dislocation, and should be performed in all cases of STJ dislocation.
Bioabsorbable Versus Stainless Steel Screw Fixation of the Syndesmosis in Pronation-Lateral Rotation Ankle Fractures: A Prospective Randomized Trial
Authors: Thordarson David B. , Samuelson Michael , Shepherd Lane E. , Merkle Paul F. , Lee Jackson
Published: January 2017

Thirty-two patients who had pronation-lateral rotation (PLR) fractures occurring four centimeters or more proximal to the ankle joint or lower if the talus was displaced greater than one centimeter laterally were enrolled in this study. Seventeen patients were randomized to fibular plate fixation with a 4.5 ml polylactic acid (PLA) bioabsorbable syndesmotic screw, and fifteen patients randomized to fibular plate fixation with a 4.5 mm stainless steel syndesmotic screw.

All thirty-two patients had uncomplicated healing of their fibular fracture without loss of reduction. There was neither evidence of osteolysis nor sterile effusion in the patients who were treated with the PLA screw. There were no wound complications in either group. No difference in range of motion or subjective complaints was noted in either group. Use of the PLA syndesmotic screw at short-term follow-up was well tolerated and avoided the need for subsequent screw removal.
A Pacinian Hyperplasia of the Foot
Authors: Satge Daniel , Nabhan Jihad , Nandiegou Yendoubane , Hermann Birgit , Goburdhun Jocelyne , Labrousse François
Published: January 2017

A case of Pacinian hyperplasia of the right great toe is reported. Pacinian hyperplasia is a rare benign and recently recognized painful lesion composed of an excess of well formed or hyperplastic Pacinian corpuscules, normaly involved in sensory innervation. This lesion that is usually observed in the hand, must be distinguished from nerve tumors harboring onion-bulb structure which are not true well formed Pacinian corpuscules and from Morton neuroma. Pacinian hyperplasia is considered a reactive lesion and not a true neoplasm. To our knowledge, this case is the first described in the foot.
Anatomic Study of the Medial Neurovascular Structures in Relation to Calcaneal Osteotomy
Authors: Greene David L. , Thompson Michael C. , Gesink Dirk S. , Graves Stanley C.
Published: January 2017

Medial displacement osteotomy of the calcaneous is commonly performed for stage II posterior tibial tendon insufficiency in an effort to improve the valgus deformity of the hindfoot. We performed an anatomic study examining the medial neurovascular anatomy and its relation to the osteotomy in an attempt to determine which structures may be at risk during the procedure.

Calcaneal osteotomies were performed through a lateral approach on 22 fresh-frozen cadaver below-knee specimens. Dissection was then performed medially to identify the Medial Plantar Nerve (MPN), the Lateral Plantar Nerve (LPN), the Posterior Tibial Artery (PTA), and their respective branches. Measurements determined either 1) where the structure crossed the osteotomy or 2) if the structure did not cross, the closest perpendicular distance from the osteotomy and at which point along its length this occurred. Perpendicular distances were recorded in millimeters and position along the osteotomy as a percentage of the total length from the posterosuperior aspect.

An average of four neurovascular structures crossed each osteotomy site (range 2 to 6), most of which were branches of the LPN or the PTA. The MPN did not cross in any of the specimens studied, the LPN crossed in one specimen, and the PTA crossed in two specimens. The MPN distributed no crossing branches. The calcaneal sensory branch of the LPN was identified and crossed in 86% of the cadavers at 19% (+/− 15%) along the osteotomy length. A more distal second branch of the LPN (Baxter's nerve) was identified and crossed in 95% of the specimens at 61% (+/ 20%) along the osteotomy length. A third crossing branch existed in one specimen. Each PTA distributed from zero to three branches which variably crossed the osteotomy at a point from 2% to 100% along its length. The PTA bifurcated in 77% of the specimens at 49% (+/− 9%) along the osteotomy length. A consistent finding in every specimen was the presence of two veins accompanying the PTA with one on either side.

A number of medial neurovascular structures may be at risk when perfoming a calcaneal osteotomy through a lateral approach. A minimum of two structures crossed the osteotomy site at variable positions in this study, although most of these structures represented branches off of the LPN or the PTA, with the LPN and the PTA themselves crossing only infrequently. The authors recommend that the completion of the osteotomy through the medial calcaneal cortex be performed in a carefully controlled manner to reduce the risk of post-operative complications including pain, numbness, and hematoma formation.
Effect of Distal Fibular Resection on Ankle Laxity
Authors: Jones Richard B. , Ishikawa Susan N. , Richardson E. Greer , Murphy G. Andrew
Published: January 2017

Ten cadaver specimens were used to study the effect of distal fibular resection and ligamentous repair on ankle laxity. The distal fibula was resected sequentially at three levels. Talar tilt and anterior drawer were measured on stress radiographs after resection and then after ligament repair. Sequential resection of the distal fibula caused a progressive increase in talar tilt and anterior drawer at each cut level (p < 0.5), regardless of whether the ligaments were repaired or not. Ligament repair significantly decreased talar tilt at cuts above the ATFL insertion and decreased anterior drawer at cuts at the tibiotalar level, but these values did not approach control values.
Foot and Ankle Injuries in Motor Vehicle Accidents
Authors: Wilson Lynnford S. , Mizel Mark S. , Michelson James D.
Published: January 2017

Background: We studied foot and ankle (F/A) injuries that occurred in motor vehicle accidents treated in a Level 1 trauma center.

Methods: The records of F/A injuries of 2248 consecutive orthopedic patients were reviewed to find foot and ankle injuries.

Results: Pilon fractures were common. Motor Vehicle Accident (MVA) occupants with F/A injuries had a higher injury Severity Score than those without (17.9 vs. 11.6, p <. 001). MVA F/A injury risk was higher without restraint [relative risk ratio (rrr) 1.68, p <. 0032] than with restraint except for air bagged drivers who were similar to unrestrained drivers (rrr 1.18, p > .05, NS).

Conclusion: Patients with F/A injuries may have serious associated injuries. Air bags may not protect feet.
Ground Reaction Forces at Discrete Sites of the Foot Derived from Pressure Plate Measurements
Authors: Wearing S.C. , Urry S.R. , Smeathers J.E.
Published: January 2017

While the literature is replete with studies investigating the pressure beneath the human foot during walking, ground reaction forces experienced at discrete sites may provide a more valuable insight into its mechanical behavior during gait. Despite the fact that changes in the distribution of force have been reported to occur with both foot deformity and fatigue, site-specific force data for nonpathological gait is not well documented. The current study provides an indirect estimate of force and accompanying temporal parameters, for discrete sites of the foot in young, healthy adults walking at their preferred speed.
Angioleiomyoma: Clinical Presentation and Surgical Management
Authors: Yates Ben John
Published: January 2017

Angioleiomyomas are relatively rare, benign, vascular soft tissue tumors with a predilection for the lower extremity. They may occur in either the cutaneous or subcutaneous tissue and are usually well encapsulated. Erosion of adjacent bone due to secondary compression phenomenon has rarely been reported in the literature. This study describes three cases.
An Evaluation of the Use of Retrospectively Acquired Preoperative AOFAS Clinical Rating Scores to Assess Surgical Outcome after Elective Foot and Ankle Surgery
Authors: Toolan Brian C. , Quinones Vonda J. Wright , Cunningham Benjamin J. , Brage Michael E.
Published: January 2017

The use of retrospectively acquired preoperative AOFAS rating scores in clinical research to assess the outcomes of elective foot and ankle surgery has not been validated. The data obtained utilizing this methodology may misrepresent the results and lead to spurious conclusions. This investigation compared preoperative AOFAS Ankle-Hindfoot scores obtained before and after surgery from patients who had undergone elective surgery to determine if retrospectively acquired scores match those collected prospectively.

Only two out of 47 patients (4%) recalled identical AOFAS scores. The mean difference between the preoperative scores (preoperative score obtained after surgery minus preoperative score obtained before surgery) was −5.3 points. Fifteen patients (32%) had preoperative scores that differed by 20 points or more. Kappa statistics found little agreement among the five elements that comprised the two preoperative scores when responses obtained before and after surgery were compared to one another. The results suggest that preoperative clinical rating scores obtained after elective surgery are a poor predictor of the patient's preoperative condition and that studies which employ retrospectively acquired preoperative AOFAS clinical rating scores may overestimate the benefit of surgery.
Validation of the Foot and Ankle Outcome Score for Ankle Ligament Reconstruction
Authors: Roos Ewa M. , Brandsson Sveinbjörn , Karlsson Jon
Published: January 2017

We studied the validity and reliability of the Foot and Ankle Outcome Score (FAOS) when used to evaluate the outcome of 213 patients (mean age 40 years, 85 females) who underwent anatomical reconstruction of the lateral ankle ligaments with an average postoperative follow-up of 12 years (range, three to 24 years). The FAOS is a 42-item questionnaire assessing patient-relevant outcomes in five separate subscales (Pain, Other Symptoms, Activities of Daily Living, Sport and Recreation Function, Foot- and Ankle-Related Quality of Life). The FAOS met set criteria of validity and reliability. The FAOS appears to be useful for the evaluation of patient-relevant outcomes related to ankle reconstruction.
Wide Excision and Free Flap Reconstruction of Two Cases with Adult Form of Juvenile Hyalin Fibromatosis Localized on the Foot
Authors: Turgut G. , Kuran I. , Kabukçuoglu F. , Ugurlu K. , Hüthüit I.
Published: January 2017

Juvenile Hyalin Fibromatosis (JHF) or systemic hyalinosis is a rare, sporadic or hereditary disorder characterized by skin lesions, gingival hypertrophy, muscle weakness, and flexion contractures of large joints. There is still dispute in its pathogenesis and treatment. We described two cases with adult form of Juvenile Hyalin Fibromatosis localized in the foot and discussed the local control we achieved by surgery.