bluuebunny/crossref_metadata_2025_split huggingface dataset:
Hazards of Doubling Phenytoin Dose in the Face of an Unrecognized Interaction with Ciprofloxacin
Authors: Pollak P Timothy , Slayter Kathryn L 
Published: January 2017

OBJECTIVE: To underscore the need for caution when making dramatic changes in phenytoin dosing, and to report a possible ciprofloxacin interaction in which failure of seizure control led to inappropriately high phenytoin dosing and subsequent intoxication. CASE SUMMARY: A 61-year-old African-American man receiving long-term therapy with phenytoin 100 mg po tid for seizures secondary to a stroke was admitted for community-acquired pneumonia. His serum phenytoin concentration at admission was therapeutic at 12.6 μg/mL. Eight days after admission, ciprofloxacin 750 mg po bid was started for possible aspiration. Two days later he experienced a seizure; the serum phenytoin concentration was 2.5 μg/mL. In response to the 80% decline in phenytoin concentration, the dosage was gradually titrated upward to produce a serum concentration of 12.6 μg/mL. This eventually required a doubling of the original phenytoin dosage and he was discharged on 200 mg po tid. The patient subsequently developed severe ataxia and sustained a head injury for which he was seen again in the emergency department. Serum phenytoin concentration at that time was 42.8 μg/mL. Concentrations declined at a normal rate when phenytoin was withheld. CONCLUSIONS: It appears that a rapid decline in phenytoin concentration during the first admission was related to coadministration of ciprofloxacin, either through inhibition of absorption or induction of metabolism. In a conscientious effort to titrate phenytoin concentrations back to therapeutic values, the issue as to why this required such a dramatic change in dosage was ignored. Thus, in trying to prevent further seizures, the patient was unknowingly placed in jeopardy a second time when his usual dosage of phenytoin was doubled. As a result, phenytoin intoxication ensued after discharge when the ciprofloxacin was discontinued. This case illustrates a potentially dangerous interaction between ciprofloxacin and phenytoin, and it underscores the need to maintain a high index of clinical suspicion for drug interactions in any patient requiring a substantial change in drug dosage.
Haglund's Syndrome: Disappointing Results Following Surgery-A Clinical And Radiographic Analysis
Authors: Schneider Wolfgang , Niehus Wolfgang , Knahr Karl 
Published: January 2017

Clinical and radiographic data were analyzed for 49 surgical interventions of painful heel syndrome with a mean follow-up of 4 years and 7 months. In all patients the surgical procedure consisted of a triangular shaped resection of the posterosuperior portion of the calcaneus. The clinical evaluation showed disappointing results with complete relief of complaints in only 34 procedures (69.4%), and 7 patients (14.3%) with even a worsening of their symptoms. The time course of rehabilitation was long with an average of 6 months of functionally significant pain after surgery, reducing the willingness to undergo this operation again. Formerly published angular thresholds of radiographic calcaneal angles could not be confirmed to be predictors for the preoperative symptoms or the postoperative outcome. There was no accumulation of pathologic clinical foot shapes, only a slight increased calcaneal pitch in patients with isolated pain on the posterosuperior lateral part of the calcaneus. According to Haglund's description of painful heel syndrome, the clinical picture of our patients included affections of bone, tendon, peritendon, bursae, soft tissue and skin in different combinations. Based on this evaluation, we advise to be cautious to indicate the operation. All possibilities of conservative treatment should be performed prior to surgery.
Prognostic Value of 99m Tc Leukocyte Scintigraphy in Diabetic Pedal Osteomyelitis
Authors: Van der Wall Hans , Lunz David , Stanton David , Bruce Warwick 
Published: January 2017

While leukocyte scintigraphy is accurate in detection of pedal osteomyelitis, there has been little data relating the technique to outcomes. We designed a trial to examine the prognostic value of sequential 99m Tc labeled leukocyte scans to establish the diagnosis of osteomyelitis and after three to four weeks of culture-guided antibiotic therapy. Twenty-three diabetic patients with proven pedal osteomyelitis (21/23) or persistent uptake (2/23) on the sequence of scans were studied. Five additional episodes of osteomyelitis developed in the group over the period of the study. Eleven patients demonstrated persistent uptake in the sequential scans. Nine progressed to amputation. The remaining two patients were biopsy-negative for infection, did not have cutaneous ulceration and were thought to have rapidly progressive arthropathy. Sequential leukocyte scintigraphy accurately predicts the need for amputation and can circumvent ineffective prolonged antibiotic therapy.
Hallux Valgus in Men Part II: First Ray Mobility after Bunionectomy and Factors Associated with Hallux Valgus Deformity
Authors: Coughlin Michael J. , Shurnas Paul S. 
Published: January 2017

Methods: A retrospective study of 30 men (35 feet) was performed. First ray mobility, ankle dorsiflexion, pes planus, and metatarsus adductus were evaluated at the final follow-up. All internal fixation was routinely removed at six to eight weeks postoperatively. Standard radiographs were evaluated and angular measurements were calculated on all feet. Conclusion: Hallux valgus in this group of male patients was not associated with limited ankle dorsiflexion or pes planus. Men with toe pronation and a positive family history had a greater hallux valgus deformity than those without after a distal soft tissue repair with proximal first metatarsal osteotomy. There was no evidence of first ray hypermobility after a DSTP-PMO.
Fourth Brachymetatarsia Treated with Distraction Osteogenesis
Authors: Song Hae-Ryong , Oh Chang-Wug , Kyung Hee-Soo , Kim Sung-Jung , Guille James T. , Lee Sung-Man , Kim Poong-Taek 
Published: January 2017

Background: This study investigated metatarsal lengthening by distraction osteogenesis for fourth brachymetatarsia in 22 metatarsals (16 patients). Methods: From May 1997 to May 2000, lengthening was performed with a monoexternal fixator, and distraction was started at a rate of 0.5 mm per day after a latency period of approximately 7–10 days. Results: The average gain in length was 16.5 mm (range, 13–21 mm), equivalent to an increase of 39% (range, 28–51%), and the average healing index was 72.9 days/cm (range, 51.7–95.7 days/cm). The American Orthopaedic Foot and Ankle Society (AOFAS) average score for lesser toe was 86.3 (range, 47–100). The most common residual complication was subluxation of metatarsophalangeal (MTP) joint in five cases, with partial or total stiffness of the MTP joint. These complications happened in the group of metatarsals excessively lengthened more than 40% and made the AOFAS score poorer. The other complications were three cases of angular deformity in the lengthened bone, and two cases of pin-tract infection. Conclusion: Although distraction osteogenesis is an effective method to address fourth brachymetatarsia, stiffness or subluxation of the MTP joint was not uncommon. To avoid complications that can happen as a result of excessive lengthening, careful preoperative radiographic measurement to calculate the optimal amount of lengthening may help us to avoid over-lengthening and the complications that accompany it.
Evaluation of the Esmark Bandage as a Tourniquet for Forefoot Surgery
Authors: Grebing Brett R. , Coughlin Michael J. 
Published: January 2017

Purpose: Although used routinely as a tourniquet in forefoot surgery, the pressure under an Esmark bandage has had little evaluation, and its use has been discouraged by some. The purpose of this study was to quantitate the pressure generated by an elastic bandage in a clinical setting and compare several different types of commercially available Esmark bandages. Methods: Five foot and ankle fellowship program directors and five foot and ankle fellowship trained surgeons comprised the volunteer group which performed clinical simulations with a 6-inch Esmark bandage at the ankle level. Variables were then added, including different padding, a change in the position of the surgeon, and a 4-inch Esmark bandage. A questionnaire on their use of an elastic bandage in practice was also administered. Differences in pressure between different types of available 6-inch Esmark bandages were also compared. Pressure measurements were recorded by a pressure monitor device. Results: The average pressure of the 10 surgeons' trials for three wraps with a tuck was 222 mm Hg (range, 146–319 mm Hg); four wraps with a tuck averaged 288 mm Hg (range, 202–405 mm Hg). No significant difference was seen between the standard technique and when the surgeon stood (three wraps and a tuck, p = .26; four wraps and a tuck, p = .33), when cast padding was used (three wraps and a tuck, p = .62; four wraps and a tuck, p = .74), or a 4-inch Esmark bandage (three wraps and a tuck, p >.99; four wraps and a tuck, p = .34). There was a significant decrease in the pressure when a blue towel was used as padding (three wraps and a tuck, p = .05; four wraps and a tuck, p = .04). Pressures obtained by the 10 different volunteers were uniform with little variation (three wraps and a tuck = 222 ± 61 mm Hg; four wraps and a tuck = 288 ± 68 mm Hg). No significant difference was seen between the different types of 6-inch Esmark bandages ( p > .05). The combined complication rate for the 10 surgeons is estimated to be less than 0.1%. Conclusion: The practice of using a 6-inch Esmark bandage as a tourniquet at the ankle level for forefoot procedures is a safe and reliable method. Although pressures between surgeons vary, the average pressure is in an effective yet safe range. Recommendations for the application of the Esmark bandage as a tourniquet are given.
Immunohistochemistry of the Enthesis Organ of the Human Achilles Tendon
Authors: de Palma Luigi , Marinelli Mario , Memè Luca , Pavan Matteo 
Published: January 2017

Background: The insertional region of the Achilles tendon includes: the fibrocartilage of the enthesis at the tendon-bone junction, the sesamoid fibrocartilage in the deep surface of the tendon, and the periosteal fibrocartilage covering the superior tuberosity of the calcaneus. The mechanism by which compressive stress and low oxygen concentration modulate the phenotypical expression of cartilaginous cells in mesenchymal tissue is still unknown. Tenascin-C isoform, with its anti-adhesive properties, has been hypothesized to have a role in cellular adaptation to compression. The purpose of this study was to define the immunohistochemical localization of tenascin-C in the enthesis organ of the Achilles insertion in man. Methods: Five specimens of Achilles tendon and its insertion were obtained from adult patients during below-knee amputation surgery. To determine the histochemistry, for light microscopy, specimens were stained with hematoxylin-eosin, safranin-O, Verhoeff, alcian blue methods. For immunohistochemistry, the following antibodies were used: anti-S-100 protein; anti-chondroitin sulfate; anti-types I and II collagen, anti-type IV collagen, anti-type X collagen, and anti-tenascin-C. Results: The enthesis, sesamoid, and periosteal fibrocartilages have been defined by a separate region of immunohistochemical labeling for S-100 antibody and type II collagen and chondroitin-sulfate. The sesamoid and periosteal fibrocartilages stained for tenascin-C, which in cartilaginous areas was closely associated with rounded cells in the extracellular matrix. Conclusion: By showing a relationship between chondrocyte-like cells and immunolabeling for tenascin-C in periosteal and sesamoid fibrocartilage, the present data suggest a role in the dynamic equilibrium in the formation of fibrocartilaginous foci in tendon areas exposed to compressive stress. Clinical relevance: The data support the surgical practice of the resection of the diseased tendinous portion in case of chronic Achilles tendinitis. The decompression removed the enthesis organ that in an inflammatory environment could be altered and would not contribute to the distribution of the tensive load. After the decompression, it was hypothesized that in tendon areas exposed to compressive stress there was restoration of the fibrocartilaginous foci that constitute the enthesis organ.
First Metatarsophalangeal Joint Arthrodesis as a Treatment for Failed Hallux Valgus Surgery
Authors: Grimes Jerry Speight , Coughlin Michael J. 
Published: January 2017

Background: The results of first metatarsophalangeal (MTP) joint arthrodesis as a specific treatment for failed hallux valgus correction has not been previously reported. We evaluated the results of first metatarsophalangeal (MTP) joint arthrodesis as a treatment for failed hallux valgus surgery. Methods: The records of the senior author (MJC) were reviewed to identify patients treated for symptomatic failed hallux valgus procedures with arthrodesis of the first metatarsophalangeal joint over a 20-year period. Twenty-nine patients (33 feet) were available for followup examination. The patients completed a visual analog pain score, the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale, and a patient satisfaction scale at the final followup. Radiographs were obtained of both feet. Results: The average followup was 8 (1 to 22) years. The average pain score improved from 7 to 3 points. The mean AOFAS score was 73 points at followup. Patient satisfaction was excellent for 13 feet (39%), good in 11 (33%), fair in eight (24%), and poor in one (3%). The mean hallux valgus angle was 16 degrees, with an intermetatarsal angle of 8 degrees. There were three asymptomatic and one symptomatic nonunions. Twenty-two feet (67%) had corrective procedures performed on the lesser toes at the time of the first MTP joint arthrodesis. Conclusions: First MTP joint arthrodesis is a reliable option for revision after failure of surgical treatment of hallux valgus. This procedure can be used to treat a number of failure modes following initial hallux valgus surgery including recurrence, hallux varus, cock-up deformity, degenerative arthritis of the MTP joint, and associated transfer lesions beneath the lesser metatarsals. First MTP joint arthrodesis can be used after failed proximal and distal osteotomies, arthrodesis of the metatarsocuneiform joint, McBride procedure, exostectomy, and resection arthroplasty. Revision procedures have poorer clinical outcomes than successful primary hallux valgus procedures.
Bone Graft Harvest from the Proximal Tibia in Foot and Ankle Arthrodesis Surgery
Authors: Whitehouse Michael R. , Lankester Ben J.A. , Winson Ian G. , Hepple Stephen 
Published: January 2017

Background: Fresh autogenous cancellous bone graft is the material of choice in reconstruction and fusion procedures in foot and ankle surgery. There are many potential donor sites for graft harvest, all with recognized minor and major complications. The proximal tibia is one such potential site and is particularly suited to foot and ankle surgery, because it is within the operative field and under tourniquet control. Methods: A retrospective review was performed of 148 procedures using bone graft from the proximal tibia performed over a period of 5 years. Minimum followup was 3 months. Data were obtained from operative notes and patient interviews to establish pain, morbidity, and overall satisfaction. Results: Most patients had no pain (78%) or very mild pain (20%) at the site of graft harvest immediately after surgery. At followup, 96% had no pain and 4% had very mild pain with certain activities such as kneeling. There were no major complications. Four patients (2.7%) had persisting areas of paresthesia at followup, but none were troubled by it. One patient had a superficial wound infection that resolved. The period of nonweightbearing, usually 2 to 3 weeks, was dictated by the primary procedure. There were no complications related to early weightbearing Conclusions: The proximal tibia is a suitable and safe site for bone graft harvest for foot and ankle surgery. There is no need for additional restrictions in weightbearing after this procedure.
Responsiveness of the Foot Function Index, AOFAS Clinical Rating Systems, and SF-36 after Foot and Ankle Surgery
Authors: SooHoo Nelson F. , Vyas Raj , Samini David 
Published: January 2017

Background: There is uncertainty regarding which outcomes tools should be used to report the results of treatment for patients with foot and ankle disorders. This study compared the responsiveness of the Foot Function Index (FFI), American Orthopaedic Foot and Ankle Society (AOFAS) Clinical Rating Systems, and Medical Outcomes Study Short Form-36 (SF-36) in patients with foot and ankle surgery. Methods: Twenty-five patients were recruited at a tertiary referral foot and ankle practice. The mean age of the patient sample was 40 years (range 21 to 69) and 19 were women (76%). Thirteen patients (52%) had conditions affecting the ankle, hindfoot, or midfoot, while 12 patients (48%) had conditions affecting the forefoot. Patients completed packets preoperatively and 6-months postoperatively which included informed consent forms, the FFI, the AOFAS, and the SF-36 questionnaires. Standardized response means (SRM) and effect sizes (ES) were used as the measures of responsiveness and were calculated for the AOFAS scores, the three domains of the FFI, the eight SF-36 sub-scales, and the two SF-36 summary scales. Results: The standardized response mean (SRM) for the AOFAS scores was 1.10 and the effect size (ES) was 1.12. The SRM for the three FFI domains ranged from −0.39 to −0.83, while the ES ranged from −0.55 to −0.86. The SRM for the SF−36 ranged from 0.09 to 0.72 (ES ranged from 0.09 to 0.77) with the highest values occurring with the Bodily Pain sub-scale (SRM 0.72, ES 0.77) and Physical Component Summary scale (SRM 0.76, ES 0.68). Conclusions: This study demonstrated increased responsiveness of foot and ankle specific outcomes tools compared to the SF-36. However, the Bodily Pain sub-scale and Physical Component Summary scale of the SF-36 had levels of responsiveness approaching those of the FFI and AOFAS Systems after foot and ankle surgery. This suggests that the SF-36 may be used alone to monitor the outcomes in these patients without sacrificing adequate sensitivity to clinical change.
Ankle Ligament Tensile Forces at the End Points of Passive Circumferential Rotating Motion of the Ankle and Subtalar Joint Complex
Authors: Ozeki Satoru , Kitaoka Harold , Uchiyama Eiichi , Luo Zong-Ping , Kaufman Kenton , An Kai-Nan 
Published: January 2017

Background: Ankle ligament injuries and instability are commonly observed. Knowledge of the relationship between the foot position and tensile forces of the ankle ligaments could be useful for treatment of ankle ligament disorders. The aim of this study was to measure the tensile forces of the ankle ligaments at the end points of passive circumferential rotating motion of the ankle and subtalar joint complex in various foot positions. Methods: Ligament tensile forces of the anterior talofibular (ATF), calcaneofibular (CF), posterior talofibular (PTF), and tibiocalcaneal (TC) ligaments were measured simultaneously in eight cadaver specimens, with a force probe in each ligament in a custom-made ankle ligament testing device. Weights of 0.5 kg and 1 kg were applied to the foot through a loading arm to provide axial compression and a bending moment to the foot and ankle. The position of the loading arm was changed circumferentially in 10-degree increments. Results: Maximal tensile force in the ATF ligament was observed in supination with plantarflexion (108 ± 62.8 N at 0.5 kg and 130 ± 39.1 N at 1 kg). The maximal tensile force in the CF ligament was observed in pronation with plantarflexion (68 ± 48.6 N at 0.5 kg and 135 ± 92.9 N at 1 kg). The maximal tensile force in the PTF ligament was observed in dorsiflexion (131 ± 80.1 N at 0.5 kg and 109 ± 36.3 N at 1 kg). The maximal tensile force of the TC ligament was observed in pronation with plantarflexion (49.0 ± 80.1 N at 0.5 kg and 67.4 ± 69.6 N at 1 kg). Relatively high magnitudes of tensile force were observed in the ankle ligaments, and the peak forces were related to the anatomic position of individual ligaments. Conclusions: The ATF ligament has an important role in the supination position in plantarflexion, CF and TC ligaments also are important for pronation in plantarflexion, and the PTF is an important stabilizer in dorsiflexion. This study provides baseline information for further research related to ligament instability and reconstruction operations.
Kinematic Analysis of the Agility Total Ankle during Gait
Authors: Conti Stephen , Lalonde Karl-Andre , Martin RobRoy 
Published: January 2017

Background: With the increasing use of total ankle prostheses, kinematic analysis of these implants is important to our understanding of their specific biomechanics. Fluoroscopic analysis as used in this study has distinct advantages over previous experimental approaches and allows kinematic determination in vivo of dynamic weightbearing motions. Methods: Ten patients with unilateral Agility (Depuy, A Johnson & Johnson Company, Warsaw, IN) total ankle replacements were tested using video fluoroscopy in weightbearing dynamic gait conditions. Their prosthetic ankle and normal ankle kinematics were then analyzed by computer with two-dimensional and three-dimensional model-fitting techniques. Results: All of the total ankle prostheses in this study demonstrated less than 3.5 mm of posterior-to-anterior translation from heel strike to toe-off. In comparison, more variability was seen in posterior-to-anterior motion of the normal contralateral ankles, with three ankles translating more than 6 mm. When inversion and eversion and internal and external rotation of the ankle were measured, wide variations were seen among patients. Conclusions: While the relative incongruence theoretically decreases the shear stresses transmitted to the bone-prosthesis interface, it does allow more inversion-eversion and rotational freedom that can lead to edge loading and higher contact stresses. Despite good medium-term results having been published for this prosthesis, polyethylene wear and osteolysis have been observed. Further studies looking at the effect of the inversion and eversion and rotational freedom on polyethylene wear and prosthesis survival will assist in our understanding of the factors leading to successful outcome of total ankle prostheses.