Search

We investigated the effect of oral and intravenous methylprednisolone treatment on subsequent relapse rate in patients with multiple sclerosis. Following a double blind trial designed to compare the effect of oral and intravenous methylprednisolone treatment on promoting recovery from acute relapses of multiple sclerosis, 80 patients were followed for two years with six-monthly assessments during which all subsequent relapses were recorded. The annual relapse rate was slightly higher in the oral compared with the intravenous methylprednisolone-treated patients (1.06 vs. 0.78), but the adjusted difference between the two groups was not statistically significant (0.18; 95% CI -0.19 to 0.55, P=0.3). The time to onset and the severity of the first relapse after treatment, the number of relapse free patients at the end of the follow-up period, and the severity of the relapses during the follow-up period were similar in the two groups. This trial did not show a statistically significant difference in relapse rate during the first two years following oral compared with intravenous methylprednisolone treatment.

Treatment of intra-articular calcaneal fractures has a long and varied history. New techniques and application of computerized tomography technology has greatly improved the prognosis and is summarized here. A case report with the use of a calcaneal reconstruction plate is presented. The authors suggest that in comminuted calcaneal fractures that possess a defect in the cancellous bone of the calcaneal body, this plate will triangulate fixation over the defect and provide for better support of the posterior facet of the subtalar joint.

Fusion of the metatarsocuneiform joint has been documented in the literature for a number of conditions affecting the first ray. The fixation techniques have advanced greatly since Lapidus advocated the procedure, but the indications need to remain rigid and narrow. The review of the literature illustrates numerous complications, and this case presentation specifically depicts the long convalescence of the failed fusion of the first metatarsocuneiform joint. The Lapidus procedure ultimately should be used as a last resort to eliminate painful arthrosis from the metatarsocuneiform joint, reduce severe deformity, or give medial column stability to a paralytic or a spastic foot. If no pathology exists within the metatarsocuneiform joint, then surgeons should use other procedures to correct pathology of the first ray in elective foot surgery.

This article presents an alternative treatment for tibialis posterior tendon rupture in a select group of patients with recent rupture and planovalgus foot structure. Double calcaneal osteotomy is used to realign weightbearing forces in situations where soft-tissue repair alone is not sufficient, and arthrodesis is premature. A single case is presented followed by a discussion, with encouraging results.

To clarify the way in which the clinical response to levodopa changes with the progression of Parkinson's disease, a longitudinal study was performed to quantify motor response characteristics to single doses of levodopa by mouth over three years in 23 patients with fluctuating motor function. A significant increase in motor disability in "on" (time of peak motor improvement) and "off" (before levodopa dose) phases occurred and "on" phase dyskinesia increased by 24%, though the amplitude of motor response was conserved. There was no evidence of progressive loss of response of certain motor deficits affecting axial muscles and gait. The mean duration of motor response decreased by 17%. Both shortening of response duration and increase in "off" phase disability contribute to the development of motor fluctuations. A short response time to the levodopa test dose was not an invariable finding in patients with severe fluctuations, whereas all had large response amplitudes and high "off" phase disability scores. Patients who have developed motor fluctuations may continue to respond to dopaminergic treatment until late in the disease course, despite the unstable nature of their responses.

The authors present a case history that illustrates their surgical procedure to correct congenital hypoplastic metatarsals. The literature is reviewed, and surgical alternatives are discussed. Treatment consisted of transpositional osteotomies performed between the fourth and fifth metatarsals with good results.

Diurnal differences in duration and quality of motor response to levodopa are frequently described by patients. The quality and duration of motor responses were objectively assessed to morning and afternoon oral levodopa doses in five patients with Parkinsonian motor fluctuations who complained of diurnal variation in response to their normal levodopa medication. Results suggest that under controlled conditions which eliminated the effects of diet and overlapping levodopa effects the response to levodopa remained unchanged throughout the day, and that the duration of response could be predicted by plasma levodopa levels.

The magnitude and pattern of motor responses to single doses of subcutaneous apomorphine and oral levodopa were compared in 14 patients with Parkinson's disease. Although apomorphine produced much shorter motor responses than levodopa, the quality of response to the two drugs was virtually indistinguishable. These clinical observations support the notion that integrity of striatal post-synaptic dopamine receptors is a key determinant of responsiveness to dopaminergic treatment in Parkinson's disease.

The great toe sesamoids have been well reported in the literature, in every aspect. Much has been written about the normal anatomic variation of partite metatarsophalangeal sesamoids. It is the purpose of this article to present a theory explaining the common occurrence of a symptomatic partite sesamoid. The authors believe there is a high rate of occurrence of symptomatic partite sesamoids, especially when associated with hallux abducto valgus. Presented is information concerning the internal and external structural components of a bipartite metatarsal sesamoidal joint, which may inherently lead it to symptomatology.

Apomorphine a dopamine receptor agonist was given subcutaneously to 57 levodopa treated parkinsonian patients with refractory off-period disabilities for a median period of 16 months. In 30 given intermittent suprathreshold injections the mean number of hours spent in a disabling off state fell from 6.9 to 2.9. Similar benefit was observed in 21 patients receiving continuous infusions with additional boluses on demand by mini-pump (mean reduction of hours off from 9.9 to 4.5). Twelve patients have been treated for over two years without tachyphylaxis or loss of response. The incidence of neuropsychiatric side-effects has been low (7%). Six patients failed to show a sustained worthwhile response; severe disabilities during "on" periods being the major problem. Subcutaneous apomorphine is proposed as an effective treatment for patients with incapacitating "off" period disabilities refractory to oral medication and should be considered before experimental implantation procedures.

Two L-dopa-treated patients with Parkinson's disease who developed distressing belching during "off" periods are reported. In each case, contrast cine radiography revealed disturbed oesophageal motility which disappeared after injection of the dopamine receptor agonist apomorphine. It is suggested that central dopaminergic abnormalities may be important in the aetiology of "off period belching."

Cases of tophaceous gout amenable to surgical management may be encountered in a podiatric practice. This paper reviews the indications for surgery, the pathology, the principles of surgical technique, the preoperative and postoperative management, and presents a case report.

Pure RBC aplasia (PRCA) and myasthenia gravis (MG) are occasionally associated with thymoma, although the occurrence of all three in a single patient is rare. We describe a patient in whom PRCA and MG occurred in conjunction with the presence of serum autoantibodies, evidence for a serum inhibitor of erythropoiesis, and elevation of circulating thymosin alpha 1. Although a thymoma could not be detected before death, postmortem examination of the mediastinum found scattered cells within a nodule, suggestive of a lymphoepithelial thymic neoplasm.

Fifth metatarsal distal metaphyseal osteotomy represents a very common surgical procedure performed for tailor's bunion deformity. The authors advocate using a cortical bone screw for fixation device offers many advantages over conventional devices (i.e., Kirschner wire). The purpose of this paper is to offer a means to thoroughly evaluate tailor's bunion deformity clinically, biomechanically, and radiographically. This will allow the podiatric surgeon to choose a procedure of choice to correct the deformity. The technique of fifth metatarsal distal metaphyseal osteotomy with cortical bone screw fixation using AO4 principles is fully described.

A new technique for ankle arthrodesis was described in 1983 by Marcus et al. in the Journal of Bone and Joint Surgery. It is a chevron ankle arthrodesis with bone grafting and internal fixation. The operation has many features distinguishing it from previously described methods of ankle arthrodesis. The advantages of the technique over other methods of arthrodesis include: bimalleolar approach to the ankle providing excellent exposure; minimal bone resection of the tibiotalar joint, thereby preserving height of the joint and length of the extremity; inherent mechanical stability at the osteotomy sites afforded by the Chevron cuts; several features designed to enhance rapid fusion, including the congruity and stability of the cuts made, onlay bone grafting and rigid internal compression fixation; a normal-looking ankle contour postoperatively, resulting in a superior cosmetic result. The operation has been utilized at St. Anne's Hospitals and can be augmented for use in pantalar arthrodesis.

Arthrodesis of the interphalangeal joint of the hallux is quite often needed in conjunction with first metatarsophalangeal joint interpositional arthroplasty. With the exception of two cited techniques, the authors believe all previously described methods of achieving interphalangeal joint arthrodesis are inconsistent in their results and in their ability to be performed in conjunction with first metatarsophalangeal joint procedures. The authors, therefore, sought a more practical, efficacious method of achieving hallux interphalangeal joint arthrodesis in the presence of first metatarsophalangeal joint implants, while still using ASIF-AO compressive technique. Presented is their technique of hallux IPJ arthrodesis using a diagonally placed 2-mm. cortical bone screw.

Fibular sesamoidectomy is necessary in certain instances to achieve permanent correction of hallux abducto valgus deformities. The decision to remove the fibular sesamoid is usually based on the position of the tibial sesamoid (which is determined by clinical and radiographic examination). If the fibular sesamoid is in positions 4 to 7, it is difficult, if not impossible, to maintain the correction of the hallux abducto valgus; if the position is 1 through 3, the sesamoids can be moved medially and maintained by the crista which is still intact.

Striated anal sphincter function was studied electrophysiologically and radiologically in six patients with Parkinson's disease and chronic constipation. In five cases, there was paradoxic anal sphincter muscle contraction during simulated defecation straining resembling anismus-type pelvic outlet obstruction. Radiologic studies showed functional improvement of the defecatory mechanism following the administration of the dopamine receptor agonist apomorphine in four patients. Dysfunction of the striated anal sphincter musculature may be a significant cause of constipation in some parkinsonian patients, occurring as part of the generalized extrapyramidal motor disorder.

To assess the relative influence of central pharmacodynamic and peripheral pharmacokinetic factors on the duration of motor response to levodopa, the relationship between motor function and plasma levodopa levels was studied in 31 Parkinsonian patients. Duration of benefit from single levodopa doses while fasting depended on the degree to which the plasma levodopa level had declined over four hours; wearing off occurred when the plasma levodopa level had fallen to approximately 50% of peak concentration, irrespective of the duration of the motor response. Whilst the amplitude of motor response to levodopa is likely to be modified by alternations in dopamine receptor stimulation and sensitivity as the disease progresses, it is proposed that the duration of response is primarily determined by levodopa peripheral pharmacokinetics rather than by central pharmacodynamic factors associated with dopamine storage capacity.

The conventional dose of deprenyl used in Parkinson's disease is 10 mg/day, having been established by in vitro platelet studies and clinical evaluation. Twelve patients with Parkinson's disease on treatment with L-dopa who showed evidence of wearing-off effects or motor oscillation were studied in a double-blind, placebo-controlled, crossover trial to compare conventional doses of deprenyl with higher doses (up to 40 mg/day) and placebo. We did not find higher doses of deprenyl to be superior to conventional doses and in 17% of cases treatment had to be withdrawn because of side effects.

An operation combining the procedures of Cotton and Fowler on the medial cuneiform has been used for the correction of juvenile metatarsus primus varus and is presented in this manuscript. The procedure consists of a biplanar opening wedge osteotomy of the medial cuneiform with insertion of a bone graft and internal fixation. This surgical approach evolves from the procedures of Cotton (a sagittal plane correction of the depressed distal medial column in pes planus), and Fowler (a transverse plane correction of the medial column for metatarsus adductus). The operation has been utilized at St. Anne's Hospitals and provides excellent reduction of the intermetatarsal angle, with realignment of an oblique metatarsal-cuneiform joint. The operation is done with the Hohmann osteotomy/bunionectomy for realignment of the metatarsophalageal joint to correct hallux valgus that exists with juvenile metatarsus primus varus.

Four patients with levodopa induced fluctuations in motor performance were studied during the constant intraduodenal infusion of levodopa. The results confirm that steady plasma levodopa levels with stable motor control can be achieved. However, when patients were given oral protein loads, motor performance declined despite maintenance of plasma levodopa levels. These findings suggest that competition for levodopa carrier mediated transport by amino acids, is more important at the blood-brain barrier than across the gut mucosa; thereby possibly limiting the efficacy of long-term direct intraduodenal administration of levodopa.

Ten patients with Parkinson's disease and urinary symptoms underwent urodynamic assessments before and after subcutaneous administration of the dopamine receptor agonist apomorphine. Voiding efficiency improved after apomorphine injection, with an increase in mean and maximum flow rates in nine patients and reduction in post-micturition residual volume in six. Although the effect on detrusor behaviour was variable, subcutaneous apomorphine may be of use in both the assessment and treatment of voiding dysfunction in patients with Parkinson's disease.