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Background: Lesser toe metatarsophalangeal (MTP) joint pathology presents a challenge for surgical treatment. At our institution, arthroplasty using a polyvinyl alcohol (PVA) hydrogel implant has been utilized in the second and third MTP joints for advanced arthritis, failed management of Freiberg’s infraction, and osteochondral defects. We present a case series describing the clinical outcomes of 13 patients following PVA implantation of the second or third MTP. Methods: We retrospectively identified 13 patients (14 joints) who underwent PVA hydrogel implantation of the second ( n = 12) or third ( n = 2) metatarsal between 2017 and 2019. The average age was 49 (range, 20-67) years, with 100% females. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected preoperatively and at an average of 21.1 (range, 8.3-29.2) months postoperatively. Clinical outcomes were also evaluated. The average time to clinical follow-up was 24.7 (range, 7-35.8) months. Results: On average, patients demonstrated pre- to postoperative improvement in all PROMIS domains, with significant improvements in Pain Intensity ( P = .01) and Pain Interference ( P = .01). Five postoperative complications were observed: 1 case of persistent avascular necrosis, 1 revision with implant removal and bone grafting, 1 periprosthetic fracture, and 2 recurrences of pain requiring ultrasound-guided injection. Conclusion: This study represents the largest case series to date evaluating the use of PVA implant in the surgical correction of lesser toe MTP joint pathology. While the PVA implant presents a viable option in the setting of advanced arthritis, Freiberg’s infraction, and certain osteochondral defects, it is not without complications. The specific indications for use of the PVA implant should be carefully considered. Level of Evidence: Level IV, case series.

Background: There is no current consensus on whether to use an open or minimally invasive (MIS) approach for Achilles tendon repair after acute rupture. We hypothesized that patients in both open and MIS groups would have improved patient-reported outcome scores using the PROMIS system postoperatively, but that there would be minimal differences in these scores and complication rates between operative techniques. Methods: A total of 185 patients who underwent surgery for an acute, unilateral Achilles tendon rupture between January 2016 and June 2019, with minimum 1-year follow-up were included in the cohort studied. The minimally invasive group was defined by use of a commercially available minimally invasive device through a smaller surgical incision (n=118). The open repair group did not use the device, and suture repair was performed through larger surgical incisions (n=67). Postoperative protocols were similar between groups. Preoperative and postoperative PROMIS scores were collected prospectively through our institution’s registry. Demographics and complications were recorded. Results: PROMIS scores overall improved in both study groups after operative repair. No significant differences in postoperative PROMIS scores were observed between the open and MIS repair groups. There were also no significant differences in complication rates between groups. Overall, 19.5% of patients in the MIS group had at least 1 postoperative complication (8.5% deep vein thrombosis [DVT], 3.3% rerupture, 1.7% sural nerve injury, 2.5% infection), compared to 16.4% in the open group (9.0% DVT, 1.5% rerupture, 1.5% sural nerve injury, 0% infection). Conclusion: Patients undergoing either minimally invasive or open Achilles tendon repair after acute rupture have similar PROMIS outcomes and complication types and incidences. Level of Evidence: Level III, retrospective cohort study.

Stress fractures of the proximal fifth metatarsal are common injuries in elite athletes. Fixation using an intramedullary screw represents the most popular surgery performed for treating these injuries, with excellent results in most cases. However, multiple reports in the literature highlight the possibility of painful hardware, usually related to the presence of the screw head, following intramedullary fixation In this case report, we outline 4 cases of professional athletes who developed lateral-based foot symptoms following complete healing of their surgically treated proximal fifth metatarsal fractures and were found to have significant cuboid edema on magnetic resonance images. We also outline recommendations regarding specific surgical technique considerations aiming to minimize this possible complication. Level of Evidence: Level V: Case report.

Background: Hallux valgus (HV) is a triplanar deformity of the first ray including pronation of the first metatarsal with subluxation of the sesamoids. The purpose of this study was to investigate if a first tarsometatarsal fusion (modified Lapidus technique), without preoperative knowledge of pronation measured on weightbearing computed tomographic (CT) scans, changed pronation of the first metatarsal and determine if reduction of the sesamoids was correlated with changes in first metatarsal pronation. Methods: Thirty-one feet in 31 patients with HV who underwent a modified Lapidus procedure had preoperative and at least 5-month postoperative weightbearing CT scans and radiographs. Differences in preoperative and postoperative pronation of the first metatarsal using a 3-dimensional computer-aided design, HV angle, and intermetatarsal angle (IMA) were calculated using Wilcoxon signed-rank tests. After dividing patients into groups based on sesamoid station, Kruskal-Wallis H tests were used to compare first metatarsal pronation between the groups. Results: The mean preoperative and postoperative pronation of the first metatarsal was 29.0 degrees (range 15.8-51.1, SD 8.7) and 20.2 degrees (range 10.4-32.6, SD 5.4), respectively, which was a mean change in pronation of the first ray of −8.8 degrees ( P < .001). There was no difference in pronation of the first ray when stratified by postoperative sesamoid position ( P > .250). The average preoperative and postoperative IMA was 16.7 degrees (SD 3.2) and 8.8 degrees (SD 2.8), which demonstrated a significant change ( P < .001). Conclusions: The modified Lapidus procedure was an effective tool to change pronation of the first ray. Reduction of the sesamoids was not associated with postoperative first metatarsal pronation. Level of Evidence: Level IV, case series.

Background: First metatarsophalangeal (MTP) joint arthrodesis is a common procedure for treatment of arthritis of the first MTP joint. The primary aim of this study was to evaluate the functional outcomes of a series of patients of multiple surgeons undergoing first MTP joint arthrodesis, emphasizing the functional gains with respect to daily activity that can be expected after this procedure. Methods: A retrospective review of 53 patients who underwent successful isolated first MTP joint arthrodesis with either a plate and screw or independent screw construct was performed at our institution over a 6-year period. Successful fusion was defined as no lucency at the first MTP joint and bridging of 2 or more cortices on the anteroposterior, lateral, and oblique radiographic views at final follow-up. Demographic information and radiographs were evaluated for all patients. Preoperative and postoperative Foot and Ankle Outcome Score (FAOS) and Short Form Health Status Survey (SF) 36/12 functional outcome scores, as well as responses from an activity- and footwear-specific questionnaire, were evaluated and compared between the 2 fixation methods. Fifty-three patients (56 feet) had radiographs showing successful fusions after being treated for advanced degenerative arthritis of the first MTP joint with arthrodesis. Average time to union was 5.4 months. Results: There was a significant reduction in difficulty in performing daily activities, with all subscales of the FAOS and the SF-12v2 significantly improving postoperatively ( P < .05). The majority of patients stated that their foot looked and felt better and were satisfied with the procedure. Five patients experienced painful hardware, which required removal. Conclusion: First MTP joint arthrodesis was successful in improving patient-reported outcomes, particularly the ability to perform daily activities. Most patients had little to no functional limitation and were satisfied with their outcome. The greatest functional improvements were seen in patients’ ability to walk distances and perform low-impact sport activity. Level of Evidence: Level III, retrospective comparative study.

Category: Lesser Toes; Other Introduction/Purpose: Lesser toe metatarsal phalangeal (MTP) joint pathology presents a challenge for surgical treatment. Recently, synthetic cartilage implants have been shown to be safe and efficacious in treating hallux ridigus, offering pain relief while preserving motion at the MTP joint. At our institution, metatarsophalangeal joint arthroplasty using a polyvinyl alcohol (PVA) hydrogel implant has been utilized in the 2nd and 3rd MTP joints for advanced arthritis, failed management of Freiberg’s infraction, and osteochondral defects. We present a case series describing the clinical outcomes of 12 patients following PVA implantation of the 2nd or 3rd MTP. Methods: We retrospectively identified 12 consecutive patients (13 joints) who underwent PVA hydrogel implantation of the 2nd (n=12) or 3rd (n=1) metatarsal head between 2017 and 2019. PVA implant was indicated for advanced arthritis in 6 patients (7 joints), Freiberg’s infraction in 4 patients, and osteochondral defect in 2 patients. Average age was 51 years (range, 20-67), with 100% females. Patient-reported outcomes measurement information system (PROMIS) scores were collected preoperatively and at latest follow-up, with an average follow-up of 20.4 months (range, 8.3 to 29.2). Retrospective chart review was performed to evaluate postoperative complications, including need for revision, implant removal, and persistent pain. Results: Overall, patients demonstrated mean improvement in all PROMIS domains, with a significant improvement in Pain Intensity of 11.9 points (p=0.03) postoperatively. A total of 4 postoperative complications occurred in the 12 patients: one case of AVN at 2 years postoperatively, one revision with removal of the implant and bone grafting of the second metatarsal head at 1 year postoperatively, one periprosthetic fracture at 9 months postoperatively, and one recurrence of pain requiring ultrasound- guided injection at 7 months postoperatively. Three additional patients reported persistent pain postoperatively. Conclusion: This study represents the largest case series to date evaluating the use of PVA hydrogel implant in the surgical correction of lesser toe MTP joint pathology. While the PVA implant presents a viable option in the setting of advanced arthritis, Freiberg’s infraction, and certain osteochondral defects, it is not without complications. The specific indications for use of the PVA implant should be carefully considered before implantation.

Preview Sexual abuse of boys by their mothers is being increasingly reported and must be considered in the course of history taking and physical examination. Often there is little objective evidence of such abuse, and only a cluster of signs and risk factors may reveal the victimization. Drs Elliott and Peterson list characteristics that can help physicians identify sexually abusive mothers and sexually abused children; they also discuss how to retrieve a report of abuse from a child and assess its credibility.

Background:The number of opioids prescribed and used has increased precipitously over the past 2 decades for a number of reasons and has led to increases in long-term dependency, opioid-related deaths, and diversion. Most studies examining the role of prescribing habits have investigated nonoperative providers, although there is some literature describing perioperative opioid prescription and use. There are no studies looking at the number of pills consumed after outpatient foot and ankle surgeries, nor are there guidelines for how many pills providers should prescribe. The purpose of this study was to quantify the number of narcotic pills taken by opioid-naïve patients undergoing outpatient foot and ankle surgeries with regional anesthesia.Methods:Eighty-four patients underwent outpatient foot and ankle surgeries under spinal blockade and long-acting popliteal blocks. Patients were given 40 or 60 narcotic pills, a 3-day supply of ibuprofen, deep vein thrombosis prophylaxis, and antiemetics. Patients received surveys at postoperative day (POD) 3, 7, 14, and 56 documenting if they were still taking narcotics, the quantity of pills consumed, whether refills were obtained, their pain level, and their reason for stopping opioids.Results:Patients consumed a mean of 22.5 pills, with a 95% confidence interval from 18 to 27 pills. Numerical Rating Scale pain scores started at 4 on POD 3 and decreased to 1.8 by POD 56. The percentage of patients still taking narcotics decreased from 55% on POD 3 to 2.8% by POD 56. Five new prescriptions were given during the study, with 3 being due to side effects from the original medication.Conclusions:Patients receiving regional anesthesia for outpatient foot and ankle surgeries reported progressively lower pain scores with low narcotic use up to 56 days postoperatively. We suggest that providers consider prescribing 30 pills as the benchmark for this patient population.Level of Evidence:Level II, prospective comparative study.

Background: The calcaneal osteotomy is a common procedure to correct hindfoot malalignment. Reported union rates are high, utilizing fixation methods including staples, plates, and most commonly cannulated screws. We began our practice using 6.5 mm and 7.3 mm cannulated screws, but complaints of postoperative posterior heel pain led to hardware removal in many patients. A switch to smaller 4.5 mm cannulated screws resulted in fewer symptoms, thus we hypothesized that using a smaller screw would decrease screw removal while maintaining an equally high union rate. Methods: The records of patients who underwent a calcaneal osteotomy by 2 surgeons between January 1996 and April 2012 were retrospectively reviewed. The rates of hardware removal and union were compared between osteotomies held with two 7.3 mm, 6.5 mm, and 4.5 mm cannulated screws. Results: There were 272 feet that met the inclusion criteria. The hardware removal rate for 130 osteotomies held with two 7.3 mm screws was 29.2% and the removal rate for 115 osteotomies held with 4.5 mm screws was 13.0%, which was significantly different ( P < .05). The removal rate for 27 osteotomies with 6.5 mm screws was 33.3%. The union rate for all groups was 100%. Conclusion: Fixation of calcaneal osteotomies with two 4.5 mm screws is advantageous over larger screws with respect to future hardware removal. There was no loss of position from the smaller screws and we feel that the 4.5mm cannulated screw provides sufficient compression and achieves a high rate of union equal to that of the larger screws. Level of Evidence: Level IV, retrospective case series.

Background:Weightbearing cone beam computed tomography (WB CBCT) allows detailed 3-dimensional imaging of the foot and ankle in a weightbearing state and provides improved accuracy and reliability of foot alignment measures, especially when compared with conventional radiographic views.Purpose:To describe the foot alignment in National Basketball Association (NBA) players with different symptomatic foot and ankle injuries using WB CBCT and to determine if any predominant morphotype would be identified.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A total of 45 active NBA players (mean age, 24.4 years [range, 20-34 years]; N = 54 feet [29 right, 25 left]) were assessed using WB CBCT. Measurements included the following: (1) foot and ankle offset (FAO), (2) calcaneal offset (CO), (3) hindfoot alignment angle (HAA), (4) angle between the inferior and superior facets of the talus (Inftal-Suptal), (5) angle between the inferior facet of the talus and the horizontal floor line (Inftal-Hor), (6) forefoot arch angle (FAA), (7) navicular-to-floor distance, and (8) medial cuneiform–to-floor distance. Measurements were then compared with values available in the literature for a “normal” foot morphotype.Results:Among the 54 feet, the mean FAO was 0.48% (95% CI, –0.25% to 1.21%), the mean CO was 1.18 mm (95% CI, –0.50 to 2.87 mm), and the mean HAA was 1.42° (95% CI, –0.80° to 3.65°). The mean Inftal-Suptal angle was 5.31° (95% CI, 3.50°-7.12°), while the mean Inftal-Hor angle was 4.04° (95% CI, 2.56°-5.51°). The mean FAA was 15.84° (95% CI, 14.73°-16.92°), the mean navicular-to-floor distance was 38.30 mm (95% CI, 36.19-40.42 mm), and the mean medial cuneiform–to-floor distance was 26.79 mm (95% CI, 25.30-28.28 mm). None of these values were found to be significantly different when comparing forwards, guards, and centers.Conclusion:NBA players presenting with symptomatic foot and ankle injuries had a fairly “normal” foot morphology, with a tendency toward a varus hindfoot and a high-arched morphotype. No significant differences were found between players based on their position on the court. WB CBCT may help to shed light on anatomic risk factors for common injuries in professional players and may aid in the planning of specific prevention programs.

Lateral column lengthening (LCL) is used to address the forefoot abduction associated with the adult acquired flatfoot. This opening wedge osteotomy can be filled with either allograft or autograft bone.The investigators sought to determine union rates and any loss of correction in patients undergoing LCL with autograft versus allograft.Over a 3-year period, 126 LCLs performed by five surgeons in 120 patients were reviewed. Autograft was used in 51 patients, allograft in 75 patients. Times to clinical and radiographic union were established for these patients. Any loss of correction of forefoot abduction as manifested by talonavicular uncoverage was recorded for those grafts that healed. Failure was defined as nonunion or loss of 50% or greater correction. The size of the implanted graft was assessed as a risk factor for failure.There were 20 total failures: seven in patients with autograft and 13 in patients with allograft (p = 0.63). The size of the implanted graft was larger in those patients that did fail (p = 0.04).The rate of nonunion and loss of correction for LCL was not significantly different between allograft and autograft. The overall rate of nonunion may be higher than has previously been reported.

Background: Lateral column lengthening, a commonly used adjuvant for the reconstruction of adult flatfoot deformity, can lead to postoperative complaints of lateral plantar pain or discomfort. We hypothesized that patients with such symptoms would have increased lateral plantar pressures when compared with matched controls without these symptoms. Methods: Ten subjects who had undergone lateral column lengthening and were experiencing pain or discomfort in the plantar-lateral aspect of the foot were selected. Controls who had undergone lateral column lengthening but who were not experiencing such symptoms were matched for age, sex, accessory reconstructive procedures, and time from surgery. At the time of the present study, the patients had been followed for at least two years after the reconstruction and had had removal of hardware. Radiographs of each foot were assessed before and after surgery. The patients completed the Short Form-36 (SF-36) and Foot and Ankle Outcome Score surveys, and standing plantar pressure measurements were obtained. Average mean pressure, peak pressure, and maximum force were assessed at twelve anatomic regions and the two groups were compared. Results: There were no significant preoperative differences between the two groups in terms of radiographic parameters. Patients with pain had significantly lower SF-36 Physical Health Summary scores (p < 0.05), SF-36 Physical Function Subscale scores (p < 0.05), and average Foot and Ankle Outcome Scores (p < 0.05). Patients with pain had significantly higher lateral midfoot average mean pressure (p < 0.05), peak pressure (p < 0.05), and maximum force (p < 0.05). No differences were found in the hindfoot or forefoot regions. Conclusions: Patients who have undergone lateral column lengthening and who experience lateral plantar pain have increased plantar pressure values in the lateral aspect of the midfoot. The increased pressures in this area cannot be accounted for solely by radiographic or demographic factors. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Background: Procedures utilized to address the flatfoot in this study included medializing calcaneal osteotomy, posterior tibial tendon reconstruction with flexor digitorum longus tendon transfer, and in patients with more severe deformity, lateral column lengthening. We evaluated patients age 50 and less at the time of surgery, who underwent surgical reconstruction for Stage 2 posterior tibial tendon dysfunction. Pre- and postoperative activity levels were evaluated to assess the effect of surgical reconstruction in the younger patient. Materials and Method: Thirty-four feet in 30 patients (11 male, 19 female) with an average age of 41.2 (range, 17 to 50) years had surgery between 1997 and 2004. All feet were examined at an average followup of 44.5 (range, 24 to 65) months and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score and SF-36 score. Results: The average preoperative AOFAS-Score was 53.1 ± 14.5 points and 83.2 ± 12.2 points at final postoperative followup. The mean improvement was 29.5. The difference between the preoperative and postoperative AOFAS score was significant ( p < 0.0001) using a two-tailed t-test. The difference in the AOFAS pain and alignment subscales was also significant ( p < 0.0001). The function subscale improvement was also significant ( p = 0.018). The mean physical function component of the postoperative SF-36 score was 79.2. A correlation was found between the SF-36 physical component score and the post operative AOFAS score ( r2 = 0.754). Conclusion: While some lateral discomfort or pain occurred in patients with or without a lateral column lengthening, the posterior tibial tendon reconstruction utilizing medial calcaneal displacement osteotomy with flexor digitorum longus transfer and a lateral column lengthening with more deformity was successful in the higher-functioning, younger patients.

Background: Research regarding outcomes in sports and physical activities after primary partial arthrodesis for Lisfranc injuries has been sparse. The purposes of this study were to assess various sports and physical activities in young patients following primary partial arthrodesis for Lisfranc injuries and to compare these with clinical outcomes. Methods: Patients who underwent primary partial arthrodesis for a Lisfranc injury were identified by a retrospective registry review. Thirty-eight of 46 eligible patients (83%) responded for follow-up at a mean of 5.2 (range, 1.0 to 9.3) years with a mean age at surgery of 31.8 (range, 16.8 to 50.3) years. Physical activity participation was assessed with a new sports-specific, patient-administered questionnaire. Clinical outcomes were assessed with the Foot and Ankle Outcome Score (FAOS). Results: Patients participated in 29 different and 155 total physical activities preoperatively, and 27 different and 145 total physical activities postoperatively. Preoperatively, 47.1% were high impact, and postoperatively, 44.8% were high impact. The most common activities were walking, bicycling, running, and weightlifting. Compared to preoperatively, difficulty was the same in 66% and increased in 34% of physical activities. Participation levels were improved in 11%, the same in 64%, and impaired in 25% of physical activities. Patients spent on average 4.2 (range, 0.0 to 19.8) hours per week exercising postoperatively. In regard to return to physical activity, 97% of respondents were satisfied with their operative outcome. Mean postoperative FAOS subscores were significantly worse for patients who had increased physical activity difficulty. Conclusion: Most patients were able to return to their previous physical activities following primary partial arthrodesis for a Lisfranc injury, many of which were high-impact. However, the decreased participation or increase in difficulty of some activities suggests that some patients experienced postoperative limitations in exercise. Future studies could compare sports outcomes between primary partial arthrodesis and open reduction internal fixation for Lisfranc injuries. Level of Evidence: Level IV, retrospective case series.

Background: The modified Lapidus procedure has successfully relieved pain and corrected deformity in patients with hallux valgus, but its effect on participation in specific sports and physical activities remains unclear. Our goals were to assess sports and physical activities in young patients following the modified Lapidus procedure and to compare these with clinical outcomes. Methods: Fifty-eight eligible patients were identified from a retrospective registry review. Of these, 48 (83%) were reached for follow-up at a mean of 2.8 (range, 1.0 to 6.1) years and had a mean age at surgery of 37.3 (range, 14.1 to 49.3) years. Physical activity participation was evaluated with a new sports-specific, patient-administered questionnaire. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score (FAOS) and compared to sports outcomes. Results: Patients participated in 26 different physical activities, consisting of 212 total physical activities preoperatively and 209 total postoperatively. The most common were walking, running, bicycling, and swimming. Compared to preoperatively, patients rated 29% of activities as less difficult, 52% as the same, and 19% as more difficult and rated participation levels as improved in 40%, the same in 41%, and impaired in 19%. Eighty-one percent of patients were satisfied with their operative outcome in regard to return to physical activity. Changes in the FAOS Pain subscore were significantly associated with improvements in physical activity difficulty ( P < .05), and changes in the Pain, Sports, and QOL subscores were significantly associated with changes in physical activity participation levels ( P < .05). Conclusion: Four in 5 patients were able to participate in previous sports and physical activities, including high-impact activities, at their preoperative participation level or better after the modified Lapidus procedure, and were satisfied with surgery in regard to return to previous activity. However, several patients had increased difficulty and impaired participation in physical activity postoperatively. Altogether, this suggests that the procedure is a viable treatment option for hallux valgus in young, active patients. Level of Evidence: Level IV, retrospective case series.

Repair of the Achilles tendon ruptures is becoming a more accepted means of treatment over casting. However, wound problems are still a problematic complication. Minimally invasive Achilles tendon repair using the Achillon® device is presented and discussed as a treatment method that combine

Metatarsalgia is one of the most common forefoot pain presentations seen in orthopedics. Surgical management has often been suboptimal with more than 20 surgical methods reported, differing in indication, technique, fixation, and postoperative mobilization. The literature has not yet recorded a definitive surgical solution to this problem. Outcome parameters including patient satisfaction, pedobarographic, and radiologic measurements have indicated the relative success of the different surgical techniques and their adverse outcome trends. The current authors present their experience with the Weil, chevron, and oblique sliding diaphyseal techniques in the context of their indications, techniques, and outcomes, and review their success in the literature.

This study prospectively evaluated the effect of treatment of major depression on psychosocial functioning (health-related quality of life (HRQoL)). Previously, we reported on a trial of 75 HIV+ patients who were blindly randomized to receive treatment with drug or placebo (N=25 to each of paroxetine, imipramine, or placebo). Forty-one individuals completed the entire trial (placebo = 14, antidepressant = 27). In this study, we assessed HRQoL using the Quality of Life Enjoyment and Satisfaction Questionnaire (QLESQ) and the Social Adjustment Scale (SAS) at baseline and the end of the trial (12 weeks) using a random effects model to estimate treatment effects. HIV/AIDS patients with a major depressive disorder who completed the clinical trial demonstrated a reduction in depression with response to treatment and a significant improvement in HRQoL with the exception of work and financial functioning. Effective management of depression in HIV/AIDS patients is important, especially with the importance of adherence in current HIV/AIDS antiviral therapy. HRQoL improved in patients regardless of drug or response group and as a function of being in this trial suggesting that medications may not be required to affect HRQoL outcomes and that disease management aspects of care are important.

Progressive neuropsychological dysfunction and complaints of cognitive difficulty frequently accompany HIV-1 infection. Providing appropriate treatment to HIV-1 patients requires determination of the extent to which the presentation of cognitive complaints reflects HIV-1-associated neuropsychological abnormalities or represents expression of depressive symptomatology. We prospectively treated 75 HIV-1 patients who were not demented but met criteria for major mood disorder with antidepressants for 12 weeks and compared pretreatment and posttreatment measures of depression, cognitive complaints, and neuropsychological performance. Complaints of difficulty with memory and attention were found to be independent of neuropsychological impairment, whereas memory complaints were highly correlated with severity of depression. Cognitive complaints declined significantly across the course of treatment for those patients who responded to antidepressant treatment. All patients, regardless of antidepressant treatment response, exhibited parallel improvement on 12-week follow- up neuropsychological examination. These findings suggest that treatment of depression affects cognitive complaints in HIV-1 individuals and that cognitive complaints of patients in asymptomatic or early symptomatic stages of HIV-1 infection may signal the need for evaluation of depression. In patients with more advanced HIV-1 infection, investigation into the basis of cognitive complaints may require a dual assessment of mood disturbance and neuropsychological status.

Background:The incidence of Achilles rupture appears to be less in women, although this notion has not been specifically investigated in the literature.Methods:The medical records of 7 foot-and-ankle orthopaedic surgeons at 1 institution were reviewed by Current Procedural Terminology (code 27650) and International Classification of Diseases–9 (code 727.67) to establish all Achilles tendon ruptures seen and/or treated by these surgeons. Sex, age, side, and mechanism of injury were recorded. Whether the patient had an acute Achilles tendon rupture or nonacute Achilles pathology was also noted.Results:A total of 468 patients were identified, of whom 358 had acute ruptures: 302 male and 56 female (5.39:1). Patients with acute ruptures were significantly younger than those with nonacute pathology (43.8 vs 55.1, P < .001). For acute ruptures, the mean age was not significantly different between men and women (43.9 vs 43.2; P = .780). Athletic activity was causative in 243 of 302 men (80.5%) and in 40 of 56 women (71.4%). This difference was not statistically significant ( P = .130). Six men (2.0%) and 6 women (10.7%) had comorbidities that were thought to increase their risk of rupture ( P = .005).Conclusion:Achilles tendon rupture is more common in men than women. Previous studies using the aforementioned codes to identify patients without chart review may have overestimated the number of women with acute Achilles tendon rupture.Level of Evidence:Level III, retrospective comparative series.

Physicians need to be aware that women and mothers are capable of sexually abusing children and need to watch for signs that a mother may be at risk for perpetrating abuse or that a child may have been abused. Posttraumatic stress disorder, attention-deficit hyperactivity disorder, secondary enuresis and encopresis, nightmares, and inappropriate sexual behavior are often symptoms of sexual abuse. It is important for physicians who are attempting to elicit a report of abuse from a child to keep in mind that (1) children express themselves most easily by nonverbal means, (2) the waiting room, school, and home are settings where information might be retrieved, and (3) the child's statements need to be evaluated using established criteria for analyzing their content. Physicians also need to remember that there is often an absence of physical findings in boys who have been sexually abused, although physical abuse and sexual abuse present simultaneously in some cases.

A structure-activity study of fourteen chemically related flavonoids was conducted to evaluate their abilities to inhibit glutathione reductase (GR). By comparing the I 50 values of flavonoids from different classes possessing an identical hydroxyl configuration, we determined the following order of potency for inhibition of GR: anthocyanidin > dihydroflavonol = chalcone > flavonol > catechin. Enzyme inhibition by delphinidin chloride and myricetin was partially prevented in a N 2 atmosphere which implicates a role for oxygen in the mechanism of inhibition. To determine the role of oxygen species in enzyme inhibition, GR was preincubated with either mannitol, diethylenetriaminepenta-acetic acid (DETAPAC), Superoxide dismutase (SOD), catalase (CAT), or SOD and CAT prior to assays for enzyme inhibition by flavonoids. Enzyme inhibition by delphinidin chloride and myricetin was suppressed by the addition of SOD, suggesting that superoxide (O − 2 ) is involved. However, inhibition by quercetin and morin was not sensitive to antioxidants. To further investigate the role of O τ- 2 in GR inhibition, a superoxide generating system was utilized in the presence and absence of flavonoid. The O τ- 2 generating system failed to inhibit GR in the absence of flavonoid but enhanced the inhibition by myricetin, indicating that the O − 2 did not directly inhibit GR but reacted directly with certain flavonoids to form a reactive intermediate which, in turn, inhibited GR. These findings suggest that the mechanism of inhibition of GR by flavonoids is complex and may have oxygen-dependent and oxygen-independent components.

Level of Evidence: V, Expert Opinion

Larvae of the southern armyworm, Spodoptera eridania, are highly polyphagous feeders which frequently encounter and feed upon plants containing high levels of prooxidant allelochemicals. While ingestion of moderate quantities of prooxidants can be tolerated by these larvae, ingestion of larger quantities can result in toxicity. Studies were conducted to assess the role of the antioxidant enzymes, superoxide dismutase (SOD), catalase (CAT) and glutathione reductase (GR) in the protection of S. eridania against redox active prooxidant plant allelochemicals. Dietary exposure of mid-fifth-instar larvae to either quercetin (a flavonoid) or xanthotoxin (a photoactive furanocoumarin), which generate superoxide radical, and singlet oxygen, respectively, resulted in an increase in SOD levels. CAT levels increased in all groups of S. eridania including control insects. This may have been due to the sudden exposure to food following an extended fast of 18 h (to insure that larvae would not reject the diet because of the prooxidants' bitter taste) with an eventual lowering of CAT values with time. GR activities did not significantly change except for a slight inhibition at the highest prooxidant concentrations used at 12-h post-ingestion. The data from these studies suggest that SOD responds to prooxidant challenges in these insects and together with CAT and GR contributes to the insect's defense against potentially toxic prooxidant compounds.

To evaluate those cases that are suitable for operation by the junior ophthalmic trainee. A prospective survey of 96 consecutive cases from five consultant lists for phacoemulsification over a 1 month period were preoperatively assessed for their suitability for the ophthalmic trainee using set criteria. A checklist was designed for all patients and criteria were marked with reference to suitability by a single examiner. The criteria chosen were arbitrary and had no bearing on a consultant’s final decision to allow the junior to operate. Twenty-two out of 96 cases (22.9%) were deemed to be suitable for operation by a junior ophthalmologist (ie 4.4 cases per consultant list). The three main reasons for exclusion were first eye case, eye for operation with visual acuity 6/12 or better, and mature cataract. Using our results, if 4.4 cases were suitable for a junior ophthalmologist per month, this would allow for adequate exposure during the early stages of training. However, if the number of relatively straightforward cases on training lists were to be reduced owing to unavailability on hospital waiting lists, this could potentially compromise ophthalmic training in the future.

Background: Treatment studies of major depression in patients who are seropositive for the human immunodeficiency virus (HIV) have shown comparable efficacy for both tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). Nefazodone appears to be more tolerable than TCAs and similar to SSRIs. This study examined the efficacy and tolerability of nefazodone in an open 12-week trial of HIV-seropositive outpatients with major depressive disorder. Method: Fifteen HIV-seropositive patients with DSM-IV major depressive disorder and a 21-item Hamilton Rating Scale for Depression (HAM-D) score of > 18 were treated with open-label nefazodone for 12 weeks. Hamilton Rating Scale for Anxiety, HAM-D, Clinical Global Impressions scale, and Systematic Assessment for Treatment Emergent Events general inquiry (for safety and tolerability) scores were obtained at weeks 2, 4, 6, 8, and 12. Results: Of 15 patients receiving nefazodone, 4 discontinued treatment (1 for adverse effects). Of 11 patients who completed the trial, 8 (73%) were classified as full responders with a 50% reduction in HAM-D scores and final CGI score of 1 or 2, and 10 (91%) were classified as partial responders (only 50% reduction in HAM-D scores). Nefazodone-treated subjects experienced few total adverse effects (mean = 1.5), no sexual side effects, and low rates of adverse-effect-related dropout ( 1 subject, 7%). Conclusion: Depressed HIV-seropositive outpatients respond to nefazodone comparably to other outpatient populations and have few adverse effects, suggesting that nefazodone may have a role in the treatment of depression in HIV-seropositive patients. Potential drug interactions with protease inhibitors indicate that it is essential to evaluate for appropriate dosing to avoid adverse effects and increase overall antidepressant efficacy.

The black swallowtail butterfly larvae, Papilio polyxenes, are specialist feeders that have adapted to feeding on plants containing high levels of prooxidant allelochemicals. Third, fourth, and fifth instar larvae were tested for their antioxidant enzyme activities, superoxide dismutase (SOD), catalase (CAT), glutathione reductase (GR), and glutathione peroxidase (GPOX), using 850-g supernatants from whole-body homogenates. The overall antioxidant enzyme profile for P. polyxenes was high compared to other insects, with activities ranging as follows: SOD, 1.1–7.5; CAT, 124–343; GR, 1.0–7.5; and GPOX, 0 units. To determine whether these antioxidant enzymes were inducible, P. poly xenes larvae were given a prooxidant challenge by dipping parsley leaves (their diet in the initial studies) in solutions of quercetin, such that the leaves became coated with this prooxidant flavonoid. Mid-fifth instar larvae fed on quercetin-coated leaves were assayed for antioxidant enzyme activities as was previously done with the larvae fed the standard diet. Food consumption and quercetin intake were monitored. SOD activity was increased almost twofold at the highest quercetin concentration tested. CAT and GR activity, on the other hand, were inhibited by increased quercetin consumption, with GR activity completely inhibited at the highest quercetin concentration after 12 h of feeding. GPOX activity, not present in control insects, was also not inducible by a quercetin challenge. These studies point out the key role that the antioxidant enzymes play in insect defenses against plant prooxidants.

The effects of using epinephrine in the irrigating fluid and intracameral acetylcholine were studied by measuring changes in pupil size in the 48 hours following extracapsular cataract extraction and intraocular lens implantation in 39 eyes. Epinephrine reduced peroperative pupil constriction, but its effect was insignificant thereafter. The pupil constriction following acetylcholine was maximal at 2 hours and was still significant at 4 hours, but pupils redilated by 6 hours. Neither drug had any effect after this time. The edge of most lens implants was visible at 6 hours, after which pupils steadily constricted.

The physicochemical properties of a series of 1,4-naphthoquinones were correlated with their activities against Sarcoma-180 by Hodnett et al. [J. med. Chem. 26, 570 (1983)]. Redox potential was the most important molecular parameter determining antitumor activity in this series of compounds, suggesting that interference with electron transport contributes to their cytotoxicity. We evaluated this same series of quinones for their abilities to inhibit the beef heart mitochondrial succinoxidase and NADH-oxidase enzyme systems. They exhibited a broad range of inhibitory potencies. There was a strong relationship between succinoxidase inhibition, antitumor activity (T/C ratio), and redox potential. The redox potentials of the quinones which inhibited succinoxidase lay within the narrow range of endogenous components of the respiratory chain. In contrast, inhibition of NADH-oxidase was related to redox potential but did not significantly predict antitumor activity. These results suggest that inhibition of mitochondrial succinoxidase may be a useful preliminary screen for antitumor activity.

UMMARY Ten survivors of medulloblastoma were examined for residual opthalmological signs. Gaze-evoked nystagmus occurred in six children, four of whom also had pronounced upbeat nystagmus. This is a rare and specific type of nystagmus associated with lesions of the cerebellar vermis and medulla, and has not been described previously as a long-term sequel of medulloblastoma. The recognition of upbeat nystagmus is important because visual acuity may be reduced in upward gaze and difficulties at school may ensue for these children, who may be already intellectually and behaviourally compromised. RESUME Nystagmus apres medulloblastome Dix survivants de medulloblastome ont ete examines pour des signes ophtalmologiques residuels. Le nystagmus provoque par le regard etait present chez six enfants, parmi lesquels quatre avaient egalement un nystagmus prononce au battement vers le haut. Il s'agit d'un type de nystagmus rare et specifique, associe aux lesions du vermis cerebelleux et de la moelle, et qui n'a pas jusqu'a ce jour ete decrit comme une sequelle a long terme de medulloblastome. La reconnaissance du nystagmus au battement vers le haut est importante parceque l'acuite visuelle peut etre reduite dans le regard vers le haut et des difficultes scolaires peuvent s'en suivre pour ces enfants qui peuvent deja etre diminues sur les plans intellectuels et comportementaux. ZUSAMMENFASSUNG Nystagmus nach Medulloblastom Zehn Patienten, die nach einem Medulloblastom uberlebt hatten, wurden auf ophthalmologische Residualsymptome untersucht. Bei sechs Kindern fand sich ein Einstellungsnystagmus, und vier davon hatten auβerdem einen ausgepragten Nystagmus beim Blick nach oben. Dies ist eine seltene und spezifische Nystagmusart, die bei Lasionen des Vermis cerebelli und der Medulla vorkommt und die bisher noch nicht als Spatfolge des Medulloblastoms beschrieben worden ist. Es ist sehr wichtig, den Nystagmus beim Blick nach oben zu erkennen, da dadurch die Sehscharfe beim Hochblicken herabgesetzt wird und Schulschwierigkeiten fur diese Kinder entstehen konnen, die intellektuell und verhaltensmaβig ohnehin schon Probleme haben konnen. RESUMEN Nistagmus despues de un meduloblastoma Se examinaron diez supervivientes de meduloblastoma buscando signos oftalmologicos residuales. Nistagmus a la mirada lateral ocurria en seis ninos, de los cuales cuatro tenian tambien un pronunciado nistagmus hacia arriba. Este es un raro y especifico tipo de nistagmus asociado con lesiones del vermis cerebeloso y el bulbo y no ha sido descrito anteriormente como una secuela a largo plazo de un meduloblastoma. El reconocimiento de un nistagmus hacia arriba es importante ya que la agudeza visual puede quedar reducida al mirar hacia arriba y producirse dificultades en la escuela en este tipo de ninos, que pueden quedar comprometidos intelectual y conductualmente.

The flavoprotein DT-diaphorase (NAD(P)H: quinone oxidoreductase, EC 1.6.99.2) is an enzyme which has been described as catalyzing the two-electron reduction of quinoid compounds to their representative hydro-quinone forms.1 The enzymatic reduction of quinones to their respective hydroquinones may represent part of the cellular defense mechanism against quinone-induced toxicity, because fully reduced quinones are capable of being conjugated by sulfate, sugars and amino acids and subsequently excreted.2 Both chemically and in biological systems, however, it is easier to reduce quinones by one electron to their semiquinones than by two electrons to their hydroquinone forms. The formation of these semiquinone radicals can lead to alkylation reactions and/or reactions with molecular oxygen to form oxygen radicals, resulting in oxidative stress and quinone toxicity. This mechanism of toxicity has been suggested to be responsible for at least part of the mechanism of antineoplastic activity for some of the quinoid anticancer drugs such as Adriamycin (Adr) and mitomycin C (MMC).3,4 Because DT-diaphorase reduces quinones by two electrons and thereby circumvents the potentially toxic one-electron reduction reactions of these compounds, it is possible that tumor response to treatment by these compounds may be greatly influenced by the endogeneous DT-diaphorase activity in the tumors.