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Background: The primary aim of this longitudinal study was to describe patient satisfaction and clinical outcome at least 2 years following cavovarus foot surgery, utilizing a peroneus longus to brevis transfer, lateral ligament reconstruction, and corrective osteotomies of the first metatarsal, occasionally with the added calcaneal osteotomy. Methods: Sixteen patients (17 feet) were examined in 2010-2012, 3.5 (range, 2-6.5) years after cavovarus foot surgery performed in 2004-2010 utilizing a peroneus longus to brevis transfer, lateral ligament reconstruction, and osteotomy of the first metatarsal with or without additional calcaneal osteotomy. The mean age at surgery was 45 years. Evaluation at baseline before surgery and at follow-up assessed patient satisfaction, using the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. At follow-up, visual analog scale (VAS) score for pain at walking was recorded, and a clinical and radiographic evaluation was included. Results: The mean AOFAS score improved from 57 (SD 11) to 83 (SD 12.5) points, with an average score improvement of 25 score points (95% confidence interval 16-35, P < .0001). Postoperative VAS score for pain at walking was mean 2 (range, 0-6). All feet had a residual cavovarus both clinically and on the radiographs. Conclusion: Patient satisfaction and clinical outcome was shown to improve pre- to postsurgery at intermediate follow-up after peroneus longus to brevis transfer and metatarsal osteotomies with or without additional calcaneal osteotomies as part of a cavovarus foot correction. Level of Evidence: Level IV, case series.

Obtaining informed consent from patients considering bunion surgery can be challenging. This study assessed the efficacy of a multimedia technology as an adjunct to the informed consent process. Methods: A prospective, cohort study was conducted involving 55 patients (7 males, 48 females) who underwent a standardized verbal discussion regarding bunion correction surgery followed by completion of a knowledge questionnaire. A multimedia educational program was then administered and the knowledge questionnaire repeated. Additional supplementary questions were then given regarding satisfaction with the multimedia program. Results: Patients answered 74% questions correctly before the multimedia module compared with 94% after it (P < 0.0001). Patients rated the ease of understanding and the amount of information provided by the module highly. Eighty-four percent of patients considered that the multimedia tool performed as well as the treating surgeon. Conclusion: Multimedia technology is useful in enhancing patient knowledge regarding bunion surgery for the purposes of obtaining informed consent.

Background. Obtaining “informed consent” is an integral aspect of surgery that can be fraught with difficulty. This study assessed the efficacy of a multimedia education tool in improving patients’ understanding when used as an adjunct to the traditional verbal consent process regarding ankle lateral ligament reconstruction surgery. Methods. A total of 56 patients (28 males and 28 females) were recruited with a mean age of 36 years. A standardized verbal discussion regarding surgical treatment was provided to each patient. Understanding was then assessed using a knowledge questionnaire. Subsequently, each patient observed a multimedia educational program following which the knowledge questionnaire was repeated. Additional supplementary questions were then given regarding the ease of understanding and satisfaction with the 2 methods of education delivery. Results. The patients answered 75% of the questions correctly before the multimedia module compared with 88% after it (P < .001). Patients rated the ease of understanding and the amount of information provided by the module highly (9.5 cm and 9.0 cm on a 10-cm Visual Analogue Scale scale, respectively), and 61% of patients considered that the multimedia tool performed as well as the treating surgeon. Conclusion. Multimedia tools used in sequence after a verbal consent resulted in improved patient understanding of pertinent information regarding ankle lateral ligament reconstruction surgery. Levels of Evidence: Therapeutic Level II.

Background: Transient bone marrow edema in the foot and ankle is an uncommon condition that should be distinguished from early avascular necrosis, stress fracture, or bone bruise. The diagnosis is based on the clinical presentation of pain with weightbearing without a history of trauma, combined with typical findings on magnetic resonance imaging. The etiology is not known, but recent case reports have suggested a possible link to systemic osteoporosis. This study examined the relationship between transient bone marrow edema of the foot and ankle and low systemic bone mineral density. Material and Methods: Over a period of 2 years, ten patients (eight women and two men) who were referred to our foot and ankle clinic were diagnosed as having transient bone marrow edema. Their mean age was 59 years. All underwent dual energy X-ray absorptiometry (DEXA) scan and were tested for serum vitamin D levels. The patients were treated with either a controlled ankle motion (CAM) walker or a stiff-soled postoperative shoe and all recovered in 5 to 10 months. Results: Four patients were found to have osteoporosis and five had osteopenia. Only one patient had normal bone density. Serum vitamin D levels were low in nine patients, and normal in one. Conclusion: Our study found a strong association with transient bone marrow edema in the foot and ankle and low systemic bone mineral density, which appears to be due to a vitamin D deficiency. We recommend that, when TBME is diagnosed, patients should be referred for assessment and treatment of their bone mineral density. Level of Evidence: IV, Retrospective Case Series

Background: In contemporary clinical practice, the ability for orthopaedic surgeons to obtain true ‘informed consent’ is becoming increasingly difficult. This problem has been driven by factors including increased expectations of surgical outcome by patients and increasing complexity of surgical procedures. Surgical pamphlets and computer presentations have been advocated as ways of improving patient education, but evidence of their efficacy is limited. The aim of this study was to compare the efficacy of a computer-based multimedia (MM) presentation against standardized verbal consent and information pamphlets for patients considering knee arthroscopy surgery. Methods: A randomized, controlled prospective trial was conducted, comparing the efficacy of three methods of providing preoperative informed consent information to patients. Sixty-one patients were randomly allocated into MM, verbal consent or pamphlet groups 3–6 weeks prior to knee arthroscopy surgery. Information recall after the initial consent process was assessed by questionnaire. Retention of this information was again assessed by questionnaire at the time of surgery and 6 weeks after surgery. Results: The MM group demonstrated a significantly greater proportion of correct responses, 98%, in the questionnaire at the time of consent, in comparison with 88% for verbal and 76% for pamphlet groups, with no difference in anxiety levels. Information was also better retained by the MM group up to 6 weeks after surgery. Patient satisfaction with information delivery was higher in the MM group. Conclusion: MM is an effective tool for aiding in the provision and retention of information during the informed consent process.

Background: Preoperative education and discussion is a crucial part of the surgeon-patient relationship. The purpose of this study was to assess the efficacy of a multimedia education tool to improve patients' understanding when used as an adjunct to the usual verbal consent process regarding first metatarsophalangeal joint (MTPJ) arthrodesis surgery. Materials and Methods: Thirty-one patients were prospectively recruited. There were 24 female and seven male patients with an average age of 56 years. Well-rehearsed, standardized and thorough information regarding the surgery, its risks, benefits, and usual post-operative course were supplied verbally to each patient. Patient understanding was then assessed with a condition specific questionnaire. Following this, each completed a multimedia educational program and repeated the questionnaire, including supplementary questions regarding ease of understanding and satisfaction with the two methods. Results: The patients answered 62% questions correctly before the multimedia presentation compared to 87% after it ( p < 0.001). Patients rated the ease of understanding of the multimedia module as a median 9.3 cm along a 10-cm visual analogue scale and 9.1 cm when asked whether it contained the appropriate amount of information to make a decision about surgery. Ninety percent of patients considered that the multimedia tool answered their questions about surgery as well or better than the treating surgeon. Conclusion: This study demonstrated that incorporation of a computer-based, multimedia education tool into to the surgical consent process improved patient understanding of the risks, benefits and usual postoperative course following first MTPJ arthrodesis surgery Level of Evidence: II, Prospective Cohort Study

Cerebrotendinous xanthomatosis is a rare autosomal recessive lipid-storage disease caused by a mutation in the sterol 27-hydroxylase (CYP27) gene1,2. It is important that orthopaedic surgeons be aware of this condition because the initial presentation may be symmetric, painful enlargement and deformity of the Achilles tendons. Early diagnosis is the key to treatment because medical therapy is effective in halting progression of, although not reversing, the devastating neurological lesions of this condition. The subject of this case report was aware that data concerning the case would be submitted for publication. A thirty-one-year-old man presented to the clinic of the senior author (J.W.B.) with a six-year history of bilateral, slowly progressive, painful swelling of the Achilles tendon. He stated that it interfered with his ability to walk, which was already affected by a neurological condition. The pain was exacerbated by walking, was relieved somewhat by rest, and at the time of presentation restricted the patient's walking distance to a maximum of two city blocks. A neurologist had previously diagnosed multiple sclerosis on the basis of the clinical findings of tremor, sensory neuropathy in the extremities, an ataxic gait, and plaque-like changes in the cerebral cortex on magnetic resonance imaging. The patient had a family history of type-2 diabetes mellitus but no other inherited disorders. Fig. 1 Clinical photograph demonstrating bilateral symmetrical fusiform swelling of the Achilles tendon. Figs. 2-A and 2-B Sagittal T1-weighted magnetic resonance imaging scan demonstrating fusiform swelling of the right Achilles tendon just proximal to its insertion. All other tendons around the foot and ankle appear normal. Axial T1-weighted image of the right Achilles tendon 2.5 cm proximal to the tibial plafond. A heterogeneous signal can be observed in the tendon. Remaining fibers of normal tendon (black) are interspersed between areas of intermediate signal (gray), representing inflammatory tissue, and high signal …

We prospectively evaluated the results of plantar pressure measurement in 32 patients (43 feet) who had a proximal crescentic osteotomy of the first metatarsal with a modified McBride procedure. The procedure's effectiveness in increasing weightbearing under the first ray, decreasing pressure under the second metatarsal head, and the relationship of radiographic measurements of first metatarsal length and position to postoperative pressure measurements were evaluated. Mean followup was 29 months. Average peak pressure increased postoperatively under the second metatarsal head. Almost identical numbers of feet had first metatarsal elevation (12) or depression (11) greater than 2 mm. Radiographic evidence of first metatarsal elevation, but not shortening, was associated with diminishing peak pressure and pressure-time integral under the first metatarsal head and hallux. Five feet that had first metatarsal elevation greater than 2 mm had new second metatarsal transfer lesions develop. Eleven feet preoperatively and nine feet postoperatively had symptomatic second metatarsal pressure lesions. One lesion persisted, 10 resolved, and eight new lesions developed. Control of the crescentic osteotomy in the sagittal plane was unpredictable despite modification of the surgical technique to plantarly displace the distal segment of the first meta-tarsal. Although average second metatarsal pressure increased postoperatively, there was variability in the correlation of radiographic change and pedobarographic measurements.

The Ludloff first metatarsal osteotomy is used to correct the increased 1-2 intermetatarsal angle associated with hallux valgus deformity. We studied the spatial geometry of this osteotomy to determine the ideal parameters of the osteotomy saw cut and its rotation to give an optimal correction.Three-dimensional computer modeling software was used to perform a virtual Ludloff osteotomy of the first metatarsal. Different geometric parameters of the osteotomy were studied. The osteotomy was rotated in virtual space and the geometric changes occurring in the virtual bone were then measured by the software.The optimal Ludloff osteotomy started at the dorsum of the first metatarsal base at the first tarsometatarsal joint and extended distally and plantarly to a point just proximal to the sesamoid articulation. A tilt of 10 degrees in the coronal plane of the osteotomy was necessary to limit first metatarsal head elevation. The best axis of rotation was within 5 mm of the proximal end of the osteotomy.The optimal geometric parameters of a modified Ludloff osteotomy limited first metatarsal shortening, elevation, and sagittal plane rotational malalignment that may occur with the use of this osteotomy.

Most clinical presentations of the hallux concern the metatarsophalangeal joint; however, interphalangeal joint (IPJ) pathology also may be clinically significant. This article reviews conditions that commonly affect the hallucal IPJ and the appropriate treatment.

This study investigated the results of first metatarsophalangeal (MTP) arthrodesis in terms of clinical outcome measures, plantar pressure distribution, and gait patterns. Ten feet in nine patients with severe hallux rigidus (HR) who underwent first MTP arthrodesis were studied. The preoperative evaluation included a subjective questionnaire, physical exam, AOFAS hallux score, radiographs and dynamic pedobarography (EMED). At follow-up (average 34 months) these were repeated, and gait analysis studies were obtained. Patients showed significant clinical improvement based on the subjective criteria. The mean AOFAS score improved from 38 preoperatively to 90 postoperatively. Postoperative EMED analysis showed restoration of the weightbearing function of the first ray, with greater maximum force carried by the distal hallux at toe-off. Kinematic and kinetic gait analysis from each patient's operative limb were compared to the unaffected contralateral limb and to age- and sex-matched healthy subjects. The kinematic data indicated a significantly shorter step length with some loss in ankle plantar flexion at toe-off on the fused side. The kinetic data indicated a reduction in both ankle torque and ankle power at push-off. Clinical results indicated effective pain relief and a high level of patient satisfaction, consistent with previous reports in patients with symptomatic Hallux Rigidus.

Fusion of the PIP joint of the lesser toes provides sound correction of deformity of that joint. Fusion is achieved reliably in most cases and fibrous ankylosis is well tolerated in those that fail. Patients at the extremes of the age scale are perhaps less tolerant of the procedure; complaints include poor cosmesis and subjective lack of control of the toes [18]. Although fusion of the DIPJ is a sound primary procedure, it would seem prudent to reserve PIP fusion as a revision procedure [7] or for the treatment of severe, fixed hammer toe deformities. For flexible or mild, fixed hammer toe deformities, consideration should be given to the use of tendon lengthening or transfer surgery in association with joint release as the primary approach to correct the deformity. Complete failure of surgery occurs when muscular imbalance or pre-existing deformity at another level is not properly addressed. This may result in patient complaints of persistent metatarsalgia or toe deformity despite a successful PIP fusion. The use of either sound fixation or a stable bony construct is recommended, as it is likely to reduce the incidence of mal-union and non-union.

Background: The purpose of this study was to assess if a computer-based multimedia education module (MEM) improved patients’ comprehension when used as an adjunct to the standard verbal consent process for Morton’s neuroma resection surgery. Methods: Nineteen patients (15 females and 4 males) considered candidates for Morton’s neuroma resection surgery were prospectively recruited. A standardized verbal discussion was had with each patient regarding risks and benefits of surgery, alternative treatments, and the usual postoperative course. Patient understanding was then assessed with a questionnaire. Each patient subsequently viewed the MEM and the questionnaire was repeated. Patients also rated ease of understanding and satisfaction with both methods of patient education. Results: Patients answered a significantly greater proportion of correct answers after viewing the MEM module (85%), compared to verbal discussion alone (61%) ( P = .002). Patients rated both the ease of understanding of the module and amount of information provided by the module as a mean of 9.3 cm on a 10 cm Visual Analog Scale (VAS). The majority of patients (76%) rated the multimedia tool as having answered their questions about surgery as well or better than the treating surgeon. Conclusion: An interactive multimedia educational tool was a useful adjunct to the informed consent process for patients considering Morton’s neuroma resection surgery. Levels of Evidence: Level II, prospective cohort study.

Carcinoma of the pancreas is the fifth leading cause of cancer death, with the majority of patients presenting with unresectable disease. Research into new adjuvant therapies is hampered by the lack of suitable in vivo and in vitro models. We have examined the potential of seven pancreatic carcinoma cell lines to grow as multicellular tumor spheroids (MTS). Three of seven (43%) cell lines were scored positive for MTS formation, and the growth characteristics for spheroid models of the cell lines PANC1 and MIAPaCa2 are presented. Implantation of PANC1 MTS into the pancreas of athymic nude mice produces tumors with reproducible growth characteristics and histology. .

In contemporary clinical practice, the ability for orthopaedic surgeons to obtain true 'informed consent' is becoming increasingly difficult. This problem has been driven by factors including increased expectations of surgical outcome by patients and increasing complexity of surgical procedures. Surgical pamphlets and computer presentations have been advocated as ways of improving patient education, but evidence of their efficacy is limited. The aim of this study was to compare the efficacy of a computer-based multimedia (MM) presentation against standardized verbal consent and information pamphlets for patients considering knee arthroscopy surgery.A randomized, controlled prospective trial was conducted, comparing the efficacy of three methods of providing preoperative informed consent information to patients. Sixty-one patients were randomly allocated into MM, verbal consent or pamphlet groups 3-6 weeks prior to knee arthroscopy surgery. Information recall after the initial consent process was assessed by questionnaire. Retention of this information was again assessed by questionnaire at the time of surgery and 6 weeks after surgery.The MM group demonstrated a significantly greater proportion of correct responses, 98%, in the questionnaire at the time of consent, in comparison with 88% for verbal and 76% for pamphlet groups, with no difference in anxiety levels. Information was also better retained by the MM group up to 6 weeks after surgery. Patient satisfaction with information delivery was higher in the MM group.MM is an effective tool for aiding in the provision and retention of information during the informed consent process.

A fluorescent pH indicator in conjunction with confocal microscopy, was used to map intracellular pH in a variety of cells and tissues with high spatial resolution. The new pH-sensitive fluorescent probe SNARF-1 was excited with the 488 nm band of the argon ion laser of a Bio-Rad MRC-500 confocal microscope. Ratio images were created with pixel-by-pixel division, with the intensity of these images representing a function of pH, that is independent of dye concentration, photobleaching or path length. Cell cultures of rat aortic smooth muscle were loaded with 20 μм SNARF-1/AM for 20 min at 37°C. Intracellular pH levels were calibrated in situ by treatment of each cell with nigericin (20 μм) in solutions of known pH. The cytosolic pH of the majority of cells was uniform, however, pH gradients were evident between the cytosol and nuclear regions, indicating the ability of this technique to map intracellular and intraorganelle pH. Rat C6 glioblastoma spheroids were cultured then loaded with SNARF-1/AM at 10°C for 90 min. The pH values were calibrated in vitro , using SNARF-1 acid in buffered solutions of known pH. Ratio images of the bisected spheroids showed a marked gradient in pH from the outer cells compared with central necrotic cells. The degree of involvement of acidification in muscle fatigue was investigated by simultaneously determining force generation and intracellular pH in individual fibres of an intact rat muscle. The investigation was performed during a stimulation protocol which induced significant fatigue in the force response of the muscle. The fatigue protocol induced little change in cytosolic pH in the fibres. We show that the use of SNARF-1, in conjunction with confocal microscopy is a powerful technique for accurately mapping pH within single cells, multicellular tissues and intact organs, as well as for accurately recording dynamic changes in pH.

Background: The results of operative management for distal tibialis anterior tendinopathy (DTAT) without rupture have not previously been described in the literature. We present the results of 12 operative procedures. Materials and Methods: Of 40 patients diagnosed clinically and radiographically with DTAT, we reviewed 11 patients who underwent surgery for failure of nonoperative management. Assessment included pre and postoperative AOFAS midfoot scores, clinical examination and postoperative VAS pain scoring, at a mean followup of 29 months. Results: Ten women (ten feet) and one man (2 feet) underwent surgery. The mean age at surgery was 59 years. The mean duration of symptoms prior to surgery was 1 year. The mean preoperative AOFAS score was 52. Preoperative MRI showed tendinosis in two tendons and tendinosis with longitudinal split tears in ten tendons. Six of the twelve cases showed some associated degenerative changes of the midfoot. Six tendons were simply debrided and the insertion reinforced with a suture anchor. Six tendons were augmented with an extensor hallucis longus (EHL) transfer into the medial cuneiform. All patients improved postoperatively, with a mean improvement in AOFAS score of 33 and the mean postoperative pain VAS of 0.9 out of 10. Two patients underwent concomitant procedures on the same foot. Three of the six treated with EHL transfer have some symptomatic hallux interphalangeal joint extensor lag. In six cases the patient was completely satisfied. Three were satisfied with minor reservations. Of the three that were dissatisfied, two underwent subsequent surgery improving their symptoms. The third, though pain-free, was troubled by her toe-catching when walking barefoot. No patient regretted having had the surgery. Conclusion: Debridement and repair of DTAT, with EHL augmentation for greater than 50% tendon involvement, provided a high level of patient satisfaction after nonoperative management failed in this series. Level of Evidence: IV, Retrospective Case Series

Background: Disorders of the tibialis anterior (TA) tendon have infrequently been reported but spontaneous rupture of this tendon is well recognized. The clinical presentation of tendinosis without rupture of the distal TA has not previously been reported and is the basis of this paper. Materials and Methods: A study of 29 patients diagnosed with distal TA tendinosis was undertaken. Data collected included, patient demographics, weight, height, pain profile and examination findings. All patients underwent MRI of the symptomatic foot. Operative findings of those patients undergoing surgery for this condition were collected. Results: Twenty-nine patients (32 feet) were included in the study group. Their mean age was 62 years and 27 patients were female. Twenty-one patients were overweight. The usual presenting symptom was burning medial midfoot pain that was often reported to be worst at night. Swelling over the TA tendon was frequently observed. On MRI the TA was thickened in all patients. Longitudinal split tears were observed in 19 feet. Chondral thinning and/or osteophyte formation at the first tarsometatarsal or medial naviculocuneiform joints was observed in 11 feet. Eleven feet underwent surgery. Universally the TA tendon was macroscopically thickened and had lost its normal fibrillary appearance. Longitudinal split tears were observed in eight tendons. Pathology was typical of a degenerative tendinosis. Conclusion: Distal TA tendinosis is a condition that seems to predominantly affect overweight elderly women. It often presents with nocturnal burning medial midfoot pain.Level of Evidence: IV, Retrospective Case Series

At present there is no ideal minimally invasive method for ablating inflamed synovium in joints that has been unresponsive to optimal medical management in patients with rheumatoid arthritis. The aim of this study was to determine whether photo-dynamic therapy could be used for this purpose.In a rabbit knee model of rheumatoid arthritis the pharmacokinetics of the photosensitizer Haematoporphyrin Derivative (HpD) into periarticular tissues and blood was measured following intravenous injection of HpD. The second phase of the study was to determine the histological effect of HpD activation by 63 nm light delivered via an intra-articular optic fibre using a dye pumped KTP-YAG laser. The light dose was varied from 0-200 joule/cm2.Pharmacokinetic studies determined that inflamed synovium rapidly accumulated HpD, with peak levels being reached 12 h following intravenous injection. The ratio of HpD uptake into inflamed synovium versus peri-articular quadriceps muscle was found to be 22.8. Histological examination of the treated knees indicated that selective destruction of inflamed synovium was achieved at light doses 100 joules/cm2 and above. No significant effect was observed on normal intra-articular tissues.We have demonstrated that the first generation photosensitizer HpD selectively accumulates within inflamed -synovium. Activation of HpD by intra-articular light administration resulted in selective ablation of the inflamed synovium. These findings indicate that PDT offers potential as a new selective, minimally invasive synovectomy technique.