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Background: Surgeons frequently add an Achilles tendon lengthening or gastrocnemius recession to increase dorsiflexion following total ankle replacement. Previous studies have looked at the effects of these procedures on total tibiopedal motion. However, tibiopedal motion includes motion of the midfoot and hindfoot as well as the ankle replacement. The current study examined the effects of Achilles tendon lengthening and gastrocnemius recession on radiographic tibiotalar motion at the level of the prosthesis only. Methods: Fifty-four patients with an average of 25 months follow-up after total ankle replacement were divided into 3 groups: (1) patients who underwent Achilles tendon lengthening, (2) patients who had a gastrocnemius recession, (3) patients with no lengthening procedure. Tibiotalar range of motion was measured on lateral dorsiflexion-plantarflexion radiographs using reference lines on the surface of the implants. Results: Both Achilles tendon lengthening and gastrocnemius recession significantly increased tibiotalar dorsiflexion when compared to the group without lengthening. However, the total tibiotalar range of motion among the 3 groups was the same. Interestingly, the Achilles tendon lengthening group lost 11.7 degrees of plantarflexion compared to the group without lengthening, which was significant. Conclusion: Both Achilles tendon lengthening and gastrocnemius recession increased radiographic tibiotalar dorsiflexion following arthroplasty. Achilles tendon lengthening had the unexpected effect of significantly decreasing plantarflexion. Gastrocnemius recession may be a better choice when faced with a tight ankle replacement because it increases dorsiflexion without a compensatory loss of plantarflexion. Level of Evidence: Level III, retrospective comparative study.

Displaced talar neck fractures no longer constitute a surgical emergency; timing of definitive surgery has no bearing on the risk of osteonecrosis. Amount of initial fracture displacement is best predictor of osteonecrosis. Grossly displaced fractures or fracture-dislocations should be provisionally reduced, with or without temporary external fixation. Periosteal stripping should be limited to only that necessary to obtain anatomic reduction. Dissection within the sinus tarsi or tarsal canal should be avoided. Rigid internal fixation with solid cortical screws countersunk within the talar head and placed below the "equator" of the talar head is imperative for optimum stability.

Category: Bunion; Basic Sciences/Biologics Introduction/Purpose: Minimally-invasive surgery (MIS) for hallux valgus correction has become increasingly common. This technique involves an osteotomy of the first metatarsal, followed by fixation with two cannulated screws. Since screws are typically not bicortical, they rely upon bone quality within the metatarsal head for fixation strength. However, bone mineral density (BMD) within different regions of the metatarsal head is unknown. Measuring the BMD in the target region may predict the strength of the bone-screw fixation. Similar to previous work which determined the optimal position for lag screw placement in the femoral head during hip fracture fixation, this study aimed to determine average BMD within four quadrants of the metatarsal head using CT and thus predict the optimal trajectories for cannulated screws during the MIS bunion procedure. Methods: All patients between 18-75 years of age scheduled to undergo MIS hallux valgus correction by one of two surgeons experienced in the MIS technique were eligible to participate. Patients were excluded if they had a prior first metatarsal surgery, pre-existing hardware, previous first metatarsal fracture, or a history of osteoporosis treatment. Patients were enrolled prospectively, and a weight-bearing CT scan of the affected foot was obtained pre-operatively. Demographic factors including age, sex, laterality, body mass index (BMI), comorbidities, and smoking status as well as standard three-view weight-bearing radiographs were collected for all patients.Using the coronal CT slice at maximal metatarsal head diameter, each head was divided into equal quadrants. Hounsfield units (HU) within each quadrant were measured independently by three study investigators using our hospital’s radiology viewing software (Merge PACS; IBM Corporation, Armonk, NY), and these density measurements were averaged. Statistical analysis was conducted using ANOVA and Student’s t-test. Results: Fifteen patients were included for preliminary analysis. All patients were female. The average age was 45.7 years. 9 of the 15 included feet were right feet. Average BMI was 28.0. One patient reported active smoking prior to surgery. Comorbidities included obesity in three patients; none were diabetic. One had a history of diplegic cerebral palsy. The average HVA on a weight- bearing AP foot x-ray was 28.2°, and the average IMA was 12.6°. The BMD within the metatarsal head varied by quadrant, with the two combined dorsal quadrants having higher average BMD than the two combined plantar quadrants (122 vs 85 HU; pConclusion: The density of the metatarsal head did vary by region within the head. The highest BMD was found in the dorsal lateral quadrant, and the lowest in the plantar lateral and plantar medial quadrants, which did not differ significantly from each other. Because strength of screw fixation is predicated upon screw design as well as bone density, these results suggest that surgeons may wish to direct screws toward the dorsolateral region of the metatarsal head in order to achieve optimal fixation. Further work is needed to determine whether this varies with patient age, gender, or hallux valgus angle. [Table: see text]

Category: Bunion; Other Introduction/Purpose: Minimally Invasive Chevron and Akin (MICA) surgery is growing in popularity. There are now multiple studies comparing minimally invasive bunion correction to traditional open techniques. Many of these studies include percutaneous lateral soft tissue release using a specific blade, while others use an open technique. To our knowledge, there is no prior study confirming the accuracy of soft tissue release via percutaneous technique. Our objective was to evaluate the precision of the percutaneous release, both the structures released and percent release. Additionally, we identified adjacent nerves potentially at risk with a lateral soft tissue release, measuring their proximity to the incision and if they were damaged. Methods: Sixteen fresh frozen cadaveric foot specimens (8 paired limbs) underwent percutaneous lateral release utilizing a beaver blade under fluoroscopic guidance by two Foot and Ankle Fellowship Faculty who regularly perform the procedure. As described in early MICA technique papers by Redfern and Vernois, the blade was inserted into the plantar plate between the lateral sesamoid and the proximal phalanx. Then the blade was rotated laterally while the hallux was directed into varus. The goal was to release the lateral head of the Flexor Hallucis Brevis (FHB) without violating the Lateral Collateral Ligament (LCL). During our experiment the sesamoids were able to be successfully reduced after each release. The specimens were then dissected to reveal the extent of release of the FHB and LCL. Distance was measured between the blade path and the dorsal digital branch of the deep peroneal nerve, as well as the plantar digital nerve. Results: The FHB was at least partially released in 15/16 specimens. It was completely released in two specimens. 5/16 specimens had greater than 50% but less than 100% release and 8/16 specimens had Conclusion: This study sought to verify the effectiveness of percutaneous lateral release. We found the FHB to be at least partially released in all but one case, resulting in adequate clinical correction of sesamoid position. Full FHB release may not be necessary to achieve the clinical objective of sesamoid reduction. There was no correlation between percent of FHB release and concomitant release of the LCL, which demonstrates the challenge of an isolated FHB release. The dorsal cutaneous nerve was consistently near the blade path but was never injured, suggesting patients should be counseled regarding the risk. [Table: see text]

Although knee dislocations are relatively rare, serious complications make treatment difficult. Common peroneal nerve (CPN) palsy is a debilitating complication with an incidence reported as high as 50%. Even after successful ligament reconstruction or repair, unresolved CPN palsy is a major factor contributing to poor outcomes. CPN palsy is more common with open dislocations, rotatory dislocations, and in patients with posterolateral corner injuries. CPN palsy can be readily diagnosed clinically, although a high index of suspicion is needed. Conservative management can be appropriate in the early phase of treatment; however, for persistent nerve damage, surgery is the treatment of choice because it results in better functional outcomes. The benefits of surgical exploration in the acute setting are controversial. Neurolysis, primary nerve repair, nerve grafting, and posterior tibialis tendon transfer have all been used as surgical options. As late surgical treatment of CPN typically results in poor prognosis, prompt diagnosis and close follow-up are of paramount importance.

Early recognition of sepsis and septic shock in children relies on obtaining an attentive clinical history, accurate vital signs, and a physical examination focused on mental status, work of breathing, and circulatory status. Laboratory tests may support the diagnosis but are not reliable in isolation. The goal of septic shock management is reversal of tissue hypoperfusion. The therapeutic end point is shock reversal. Mortality is significantly better among children when managed appropriately. Every physician who cares for children must strive to have a high level of suspicion and keen clinical acumen for recognizing the rare but potentially seriously ill child.

Purpose To determine function and complications after reverse total shoulder arthroplasty (RTSA) in obese patients compared with a control group of nonobese patients. Methods Between 2005 and 2011, we performed 76 RTSAs in 17 obese, 36 overweight, and 23 normal weight patients, based on World Health Organization body mass index classification. We reviewed the charts for age, sex, body mass index, date of surgery, type of implant, type of incision, length of stay, comorbidities, surgical time, blood loss, American Society of Anesthesiologists score, shoulder motion, scapular notching, and postoperative complications. Complications and outcomes were analyzed and compared between groups. Results Reverse total shoulder arthroplasty in obese patients was associated with significant improvement in range of motion. Complication rate was significantly greater in the obese group (35%), compared with 4% in the normal weight group. We found no significant differences between scapular notching, surgical time, length of hospitalization, humeral component loosening, postoperative abduction, forward flexion, internal and external rotation, pain relief, or instability between groups. Conclusions Our results show that obese patients have significant improvement in motion after RTSA but are at an increased risk for complication. Obesity is not a contraindication to RTSA, but obese patients need to understand fully the increased risk of complication with RTSA. Type of study/level of evidence Therapeutic III.

Purpose To test the hypothesis that the result of steroid injection in the carpal tunnel in a patient with recurrent carpal tunnel symptoms would serve as a good predictor of the outcome of later carpal tunnel release (CTR). Methods We conducted a retrospective review of all patients who underwent revision CTR for recurrent or persistent carpal tunnel syndrome over a 2-year period at our institution. A total of 28 wrists in 23 patients met inclusion criteria. We evaluated patients to determine whether preoperative factors or the result of injection predicted the outcome of revision CTR. We used a multivariate logistic regression analysis to predict surgical success when multiple preoperative findings were considered. Results Of the 23 wrists that had relief from injection, 20 had symptom improvement with surgery. Although they did not reach statistical significance, the sensitivity and positive predictive value for injection alone predicted outcome of revision CTR in 87%. No patient characteristic or physical examination finding predicted successful revision CTR. Multivariate logistic regression analysis combining preoperative injection results with physical examination findings (numbness and/or motor weakness in median nerve distribution, positive Durkin test, and positive Phalen test) provided a sensitivity of 100% and a specificity of 80%. Conclusions In a small group of patients with recurrent carpal tunnel syndrome, cortisone injection into the carpal tunnel was not, by itself, a statistically significant predictor of successful revision surgery. However, relief from injection as a diagnostic test for predicting successful revision CTR was found to have both a high sensitivity and a positive predictive value. Coupled with the components of the physical examination, injection provides a good screening test to establish surgical success with revision CTR. Type of study/level of evidence Therapeutic III.

Pelvic dislocations are rare during labor, and the treatment is controversial. We report two cases of young women who sustained postpartum disruption of the pelvic ring: one case is an 8.8 cm wide separation of the pubic symphysis with sacroiliac joint disruption underwent surgical stabilization and the second case with 4.0 cm disruption being treated non-operatively. These cases illustrated of importance of accurate diagnosis, careful physical exam, fully informed consent and specific treatment for this condition.

A series of 1H-imidazol-1-yl- and 3-pyridyl-substituted 3,4-dihydroquinolin-2(1H)-ones was designed and synthesized as combined inhibitors of thromboxane (TXA2) synthase and cAMP phosphodiesterase (PDE) in human blood platelets. A number of structures, e.g. 4b, 7a, 7e, 13a, and 21-25, were superior to dazoxiben 26 as inhibitors of TXA2 synthase in in vitro ADP-induced aggregation experiments with human blood platelets. The TXA2 synthase inhibitory activity was confirmed by measurement of the prostanoid metabolites derived from 14C-labeled arachidonic acid. Three compounds (7a, 7e, and 25) demonstrated in vitro inhibition of human platelet cAMP PDE at micromolar concentrations in conjunction with their TXA2 synthase inhibitory activity. Synergistic enhancement of antiaggregatory and antithrombotic actions was expected when simultaneous stimulation of adenylate cyclase (through increased PGI2 production) and inhibition of platelet cAMP PDE were possible from the same compound. Ex vivo and in vivo experiments were conducted in rats and mice, respectively, to evaluate the effects of compounds 7e and 23 on platelet aggregation and thrombotic events within these animals. Compound 7e, which has a comparable level of TXA2 synthase (IC50 1.2 microM) and human platelet cAMP PDE (IC50 6.4 microM) inhibitory activities, was found to be orally bioavailable with a long duration of action and offered effective protection against mortality in a collagen-epinephrine-induced pulmonary thromboembolism model in mice. Significant blood pressure and heart rate effects were observed for several compounds, e.g. 7e, 9e, 13a, 13d, 18, 20, 21, and 23, when dosed orally in conscious spontaneously hypertensive rats.

A series of novel ω-(N,N,N-trialkylammonium)alkyl ester and thioester derivatives [RCOM(CH2) n NR3+X−, M = O or S, n = 2–6, X = I or Cl] of 11 nonsteroidal antiinflammatory carboxylic acid agents (naproxen, ketorolac, indomethacin, ibuprofen, sulindac, ketoprofen, flufenamic acid, mefenamic acid, zomepirac, etodolac, and tifurac) was prepared and evaluated for their antiinflammatory, analgesic, and gastrointestinal erosive properties. In general, each prodrug retained the antiinflammatory activity characteristic of the corresponding parent drug but exhibited moderately to greatly reduced gastrointestinal erosive properties and significantly reduced analgetic potencies. This profile is likely due to a combination of factors including the rate of hydrolysis of the esters in the stomach, gut, and plasma, changes in the locus of absorption of the prodrug or nonsteroidal antiinflammatory drug (NSAID), and altered metabolic disposition patterns resulting from these changes. The results obtained from the compounds of this series indicate that esters of this general class may offer a means to modulate both the aqueous/lipid solubility and the hydrolytic/enzymatic cleavage indices of NSAID prodrugs which potentially possess a more favorable therapeutic ratio of antiinflammatory to gastrointestinal erosive activities.

Although the platelets of the mouse are refractory to the direct effects of platelet-activating-factor (PAF), tail vein injection of 10-150 micrograms/kg PAF produces lethal anaphylactic shock. Sensitivity varies with strain and source: Swiss Webster mice show a range of sensitivity and DBA/2 (complement C5-deficient) mice are very resistant. At lethal doses of PAF, animals show labored respiration and general depression; death occurs within 15-45 min. Dexamethasone administered at least 1.5 hr prior consistently protects, whereas the cyclooxygenase inhibitors do not. Antihistamines, adrenergic antagonists, and methysergide have no effect, but cyproheptadine is partially protective at near lethal doses. Calcium entry blockers and calcium chelators, tetracycline and chlortetracycline are partially protective at very high doses consistent with non-specific effects on calcium dependent processes. The arachidonic acid lipoxygenase inhibitors BW755c, phenidone, nordihydroguaiaretic acid and diphenyldisulfide provide nearly complete protection after oral administration of 50-200 mg/kg. Phosphodiesterase inhibitors and dapsone are also effective orally. The leukotriene antagonist FPL55712 administered intraperitoneally (10 mg/kg) 5 min. prior to PAF challenge provides almost complete protection. PAF-induced mortality in the mouse represents a small animal model of systemic anaphylaxis particularly useful for the systemic testing of arachidonic acid lipoxygenase inhibitors and leukotriene antagonists.

Renal homotransplantation has been successful in a patient with rapidly progressive glomerulonephritis. This patient had normal serum complement levels at the time of operation. Since the serum complement concentration has been shown to parallel the activity of acute glomerulonephritis, normal complement levels would appear to indicate the disease was essentially inactive at the time of surgery. The results in this case support the conclusion that the activity of the preexisting glomerulonephritis plays an important role in the survival and function of the transplanted kidney.