Case report: reconstruction of the distal tibia with porous tantalum spacer after resection for giant cell tumor.

Treatment options for giant cell tumors of the distal tibia include curettage and cement packing, curettage and bone grafting, or resection and reconstruction for aggressive tumors. Curettage of aggressive tumors often leads to severe bone loss requiring reconstruction. Allograft and autograft may be effective options for reconstruction, but each is associated with drawbacks including the possibility of infection and collapse. We present a case of giant cell tumor of the distal tibia treated with curettage and arthrodesis using a porous tantalum spacer. Complete removal of the tumor and successful arthrodesis of the ankle were accomplished using the spacer. The patient returned to pain-free walking along with eradication of the giant cell tumor. We believe porous tantalum spacers are a reasonable option for reconstructing the distal tibia after curettage of a giant cell tumor with extensive bone loss.

Crescentic proximal metatarsal osteotomy for moderate to severe hallux valgus: a mean 12.2 year follow-up study.

The senior author's (R.C.) first 25 patients (37 feet) treated with a combination proximal crescentic osteotomy and distal soft-tissue reconstruction made up the patient cohort. All 25 patients were reviewed at a minimum of one year post-op (short-term follow-up) and 20/25 (31/37 feet) were reviewed again at a mean 12.2 years (range 11.4 to 13.0 yrs) post-op (long-term follow-up). This allowed for a comparison of short- and long-term results and led to a long-term follow-up rate of 84% (31/37 feet, mean 12.2 yrs). Clinical, radiographic and patient outcome measures were obtained and compared pre-op and at short- and long-term follow-up. The mean preoperative hallux valgus (HVA) and intermetatarsal angles (IMA) were 37degrees and 16 degrees respectively. The mean HVA correction was 24 degrees and IMA correction 10 degrees at long-term follow-up with no tendency toward recurrence. Sesamoid position and first MTP subluxation was markedly improved postoperatively and the correction was maintained at long-term follow-up. Patients were asked about their satisfaction in terms of pain, appearance and motion. At long-term follow-up, more than 90% of patients were completely satisfied with pain and motion and greater than 80% with their appearance. Ninety-four percent of patients said they would have the operation again. The AOFAS clinical rating scale for the hallux was calculated retrospectively for pre-op and short-term follow-up and prospectively for long-term follow-up. The mean pre-op score was 37/100 (16 to 60) which significantly improved to 92/100 (67 to 100) at both follow-up periods, suggesting no evidence of decrease in outcome over time. Complications included two patients (5%) that were over-corrected into varus (one symptomatic, one asymptomatic), and four patients (11%) that were undercorrected, developing asymptomatic recurrences (>10 degrees increase HVA) at long-term follow-up. In addition, two patients (5%) developed new transfer lesions postoperatively, likely related to technical error (one varus overcorrection, one dorsiflexion malunion). In conclusion, the long-term results, with a mean follow-up of 12.2 years, of the resection realignment procedure for moderate to severe hallux valgus are generally excellent and the complication rate is low and acceptable. Attention to detail, avoiding both undercorrection, which can lead to recurrence, and overcorrection, which can cause symptomatic varus, is essential.

Talocalcaneal coalition. Diagnosis with the C-sign on lateral radiographs of the ankle.

We analysed 42 weight-bearing lateral radiographs of the ankle, 20 of which were from patients with a clinical and plain radiological diagnosis of talocalcaneal coalition (TCC) who subsequently had CT. The remainder were from 22 healthy volunteers with no clinical findings suggestive of hindfoot pathology. Four observers, blinded to the CT findings, independently evaluated the radiographs on two separate occasions. With the 95% confidence interval and using the CT findings as the comparison we calculated the sensitivity, specificity, accuracy, and positive and negative predictive values for the C-sign, and for other signs known to be associated with TCC. Similarly, we also calculated the interobserver and intraobserver reliability for these signs using the kappa statistic. Our results suggest that the C-sign is highly sensitive and specific for TCC. It is an accurate indicator and significantly more reliable than other previously recognised radiological signs of TCC. Features of the C-sign, however, cannot be relied upon to indicate whether the TCC is fibrous or bony.

Large-magnitude high-spin nuclear parameters in a Ti3+ center from X-band EPR measurements at 10 K.

Precise 10 K X-band EPR measurements and subsequent spin-Hamiltonian analysis by direct matrix diagonalization methods are reported for a Ti3+ (S = 1/2) center in tetragonal zircon (zirconium silicate, ZrSiO4). A special, and previously unobserved, feature of the supposedly uniaxial spectrum is the marked angular dependence of the titanium hyperfine lines in the perpendicular, ab crystal plane. As discussed, this can only arise from the presence of high-spin nuclear terms of dimension BIk, SIk (k = 3, 5) in the spin Hamiltonian. Parameters arising from these terms were determined to have magnitudes very much larger than observed previously in first-row transition ions. The consequences of precise determination of these high-spin parameters are significant and several: a precise determination of the nuclear quadrupole tensor leading to a ratio 47P/49P in excellent agreement with the ratio derived from the corresponding nuclear quadrupole moments; an apparent anisotropy in the nuclear Zeeman interaction which can be identified with anisotropy in the chemical shielding "tensor"; a marked hyperfine anomaly. The origin and significance of these observations are discussed.

The role of diagnostic block in the management of Morton's neuroma.

OBJECTIVE: To determine the outcome of surgical excision of Morton's neuroma after a local anesthetic diagnostic block into the neuroma has relieved symptoms. DESIGN: A cohort study. SETTING: A university affiliated hospital. PATIENTS: A sequential series of 37 patients who underwent 41 excisions with at least 2 years' follow-up. Seven patients had undergone repeat excision of a neuroma, and 34 primary excisions were performed. Surgery was performed by a specialist in orthopedic surgery of the foot and ankle. INTERVENTION: Excision of the Morton's neuroma after a positive diagnostic block. MAIN OUTCOME MEASURES: Grade of symptoms at follow-up done by independent review on a 4-point scale. RESULTS: Of 41 procedures, 11 had an unfavourable outcome: 4 procedures were graded 3, and 7 procedures were graded 4. Eight (24%) of the 34 primary procedures were reported as failures, and 3 (43%) of the 7 revision procedures were reported as failures. Most patients reported poor results owing to persistent pain. CONCLUSIONS: Diagnostic blocks do not improve the results of surgery for excision of Morton's neuroma and are not recommended. Because failure rates are greater than 20%, surgery for Morton's neuroma should only be offered after a full course of nonoperative management.

Lateral popliteal sciatic nerve block compared with ankle block for analgesia following foot surgery.

The purpose of this study was to compare postoperative analgesia after foot surgery in patients anaesthetised either with popliteal sciatic nerve block or ankle block. In a prospective study, 40 patients scheduled for foot surgery involving osteotomies were allocated randomly into one of two groups. Following induction of general anaesthesia, Group PS (n = 21) received a lateral popliteal sciatic nerve block and Group AB (n = 19) received an ankle block. Both groups received 20 ml bupivacaine 0.5% plain. In group PS 43% required morphine analgesia in the Post Anaesthetic Recovery Room (PAR) compared with 16% in group AB. Postoperative analgesia was assessed using VAS and a pain scale in the PAR and a questionnaire by telephone follow-up on the day after surgery. The ankle block appeared to be more reliable, providing more consistent analgesia in the PAR. Postoperative analgesia in Group PS lasted a median of 18.0 hr and in Group AB lasted 11.5 hr (P < 0.05). Both techniques provided effective analgesia after discharge home and high levels of patient satisfaction.

Chevron osteotomy for bunionette.

Numerous procedures have been described for the surgical treatment of symptomatic bunionettes. We describe the technique, results, and follow-up of patients treated with a chevron osteotomy of the distal fifth metatarsal. This surgical approach to the treatment of bunionette is presented as a viable alternative to other surgical procedures. Sixteen distal fifth metatarsal chevron osteotomies were performed on 12 patients. Follow-up was from 15 months to 6 years, with an average follow-up of 3.2 years. A 100-point scoring system was devised and the average score improved from 44 points before surgery (range 20-65) to 91 points after surgery (range 65-100). There was one complication of a transfer metatarsalgia. The overall results were good to excellent, except for the transfer metatarsalgia, which was rated as fair. We have used the procedure in a laterally deviated, plantar metatarsal. There is concern that alternatives be used in a laterally deviated, plantarflexed fifth metatarsal. We have continued to use the chevron osteotomy with this condition.

Lateral popliteal sciatic nerve block compared with subcutaneous infiltration for analgesia following foot surgery.

A new lateral approach to blocking the sciatic nerve in the popliteal fossa is described. In a prospective study, 40 patients scheduled for foot surgery involving osteotomies were allocated randomly into one of two groups following induction of general anaesthesia: group PS (n = 21) received a lateral popliteal sciatic nerve block and group SC (n = 19) received subcutaneous infiltration of the wound. Both groups received 20 ml bupivacaine 0.5% plain. The lateral approach to the popliteal sciatic nerve was found to be an effective, quick, and easy to perform, block. Postoperative analgesia in groups PS lasted a median of 18.0 hr and in group SC lasted 6.3 hr (P < 0.05). The lateral popliteal sciatic nerve block provided effective analgesia following foot surgery and had a high level of patient satisfaction.

Reconstructive surgery of the lower extremity.

Non-operative treatments for degenerative arthritis, such as physiotherapy, anti-inflammatory medication, and occupational therapy, can help reduce the impact of the disease on the joint and hence on the mobility of the patient. Once the joint has become so diseased that non-operative modalities are inadequate, it is the task of the orthopedic surgeon to evaluate these individuals and determine which ones would benefit from a reconstructive procedure. The author explores the indications for arthrotomies, resection arthroplasties, arthrodeses, osteotomies, and total joint replacements. Total joint arthroplasty has revolutionized the treatment of degenerative arthritis of the lower extremity, although it is not a panacea for arthritis in the lower extremity.

Practical management of perinatal death.

After the loss of a newborn baby the parents are usually too shocked and unfamiliar with the complicated administration procedures to cope with the registration of death and burial (or cremation). The medical and nursing staff also tend to be unfamiliar with the procedures. Some of these can be streamlined, thus reducing the stress caused to parents. By giving positive instruction the staff will in their turn be able to improve their care of the bereaved parents.

The reaction of menadione with haemoglobin. Mechanism and effect of superoxide dismutase.

1. Menadione was found to react with both the haem groups and the beta-93 thiol groups of haemoglobin. 2. It oxidized the haem groups of oxyhaemoglobin, giving mainly methaemoglobin and a smaller amount of haemichrome. The reaction rate was decrease in the presence of catalase and markedly accelerated in the presence of superoxide dismutase. It is proposed that the overall reaction involves the initial reversible formation of methaemoglobin and the semiquinone, and that the effect of superoxide dismutase is to prevent the reverse reaction, by removing superoxide and hene O2-. E.s.r. evidence for the information of the semi-quinone and its reactions is presented. 3. The reaction of menadione with the beta-93 thiol groups of haemoglobin appeared to be similar to that with other thiols, forming the 3-thioether derivative of menadione, but it was also accompanied by reduction of methaemoglobin. This reduction was prevented by superoxide dismutase, but appeared to be caused by the semiquinone radical, which was produced as an intermediate. 4. Reduced glutathione functioned only to a limited extent as a scavenger of the menadione semiquinone. Its main reaction was directly with menadione to form the thioether. Ascorbate was a more efficient scavenger, and accelerated the oxidation of oxyhaemoglobin by menadione. 5. The significance of these findings in relation to menadione-induced erythrocyte haemolysis is discussed.

Solo mothers after delivery at Christchurch.

A questionnaire was sent to 130 single mothers who kept their infants after delivery. The questionnaire was designed to find out the needs if any, of solo mothers. The Social Welfares Services were not fully utilised.