Assessment and Management of Atraumatic First Metatarsophalangeal Joint Pain.

Nontraumatic pain in the first metatarsophalangeal joint is frequent and can be debilitating. The metatarsophalangeal joint complex comprises four articulating surfaces including the first metatarsal, the proximal phalanx, and tibial and fibular sesamoids, which are all contained within a synovial capsule. The most common causes of pain are hallux valgus and hallux rigidus. However, other diagnoses, such as functional hallux limitus, sesamoiditis, gout, and inflammatory autoimmune arthritis, need to be considered as well. A systematic approach is key to accurately diagnose the source of pain, which can sometimes be the result of more than one condition. The most important clinical information to obtain is a focused history, meticulous clinical examination based on understanding the precise anatomy and biomechanics of the first metatarsophalangeal joint, and analysis of the relevant imaging. Each pathology has a different treatment algorithm, as such, understanding the pathoanatomy and biomechanics is important in forming an effective treatment plan.

Suplementación efectiva de vitamina D en pacientes con fractura tibial / Effective vitamin D supplementation in patients with tibial fracture

OBJETIVOS Determinar la prevalencia de déficit de vitamina D, así como evaluar la seguridad y efectividad de un nuevo método de carga con colecalciferol en pacientes adultos con fractura de tibia. MATERIALES Y MÉTODOS Se reclutaron a 56 pacientes consecutivos con edades entre 18 y 65 años con fractura de tibia ingresados en nuestro hospital durante 1 año. Se determinó el nivel de 25-hidroxivitamina D ([25(OH)-D]) al ingreso y tras suplementación con 100.000 UI semanales de colecalciferol, durante 3 o 5 semanas, en casos de insuficiencia ([25(OH)-D] entre 20 ng/mL y 29,9 ng/mL) o deficiencia ([25(OH)-D] < 20 ng/mL), respectivamente. Se determinó la prevalencia de hipovitaminosis D, el porcentaje de normalización de [25(OH)-D], y los efectos adversos. RESULTADOS Se evaluaron 56 pacientes; 98,2% presentó hipovitaminosis D, y 28 (73,7%) y 10 (26,3%) presentaron déficit e insuficiencia, respectivamente. Tras la suplementación, 92,1% alcanzaron niveles [25(OH)-D] normales. Ningún paciente presentó efectos adversos. DISCUSIÓN La prevalencia de deficiencia de vitamina D en nuestra población fue mayor a la reportada en la literatura. Comprobamos que un esquema de suplementación en altas dosis de vitamina D es seguro, y más efectivo que los previamente recomendados. Este esquema de suplementación puede ser implementado en futuros estudios randomizados. CONCLUSIÓN La prevalencia de hipovitaminosis D en pacientes adultos chilenos con fractura de tibia fue alta (98,2%). El esquema de suplementación con vitamina D propuesto fue efectivo y seguro.

OBJETIVOS Determinar la prevalencia de déficit de vitamina D, así como evaluar la seguridad y efectividad de un nuevo método de carga con colecalciferol en pacientes adultos con fractura de tibia. MATERIALES Y MÉTODOS Se reclutaron a 56 pacientes consecutivos con edades entre 18 y 65 años con fractura de tibia ingresados en nuestro hospital durante 1 año. Se determinó el nivel de 25-hidroxivitamina D ([25(OH)-D]) al ingreso y tras suplementación con 100.000 UI semanales de colecalciferol, durante 3 o 5 semanas, en casos de insuficiencia ([25(OH)-D] entre 20 ng/mL y 29,9 ng/mL) o deficiencia ([25(OH)-D] < 20 ng/mL), respectivamente. Se determinó la prevalencia de hipovitaminosis D, el porcentaje de normalización de [25(OH)-D], y los efectos adversos. RESULTADOS Se evaluaron 56 pacientes; 98,2% presentó hipovitaminosis D, y 28 (73,7%) y 10 (26,3%) presentaron déficit e insuficiencia, respectivamente. Tras la suplementación, 92,1% alcanzaron niveles [25(OH)-D] normales. Ningún paciente presentó efectos adversos. DISCUSIÓN La prevalencia de deficiencia de vitamina D en nuestra población fue mayor a la reportada en la literatura. Comprobamos que un esquema de suplementación en altas dosis de vitamina D es seguro, y más efectivo que los previamente recomendados. Este esquema de suplementación puede ser implementado en futuros estudios randomizados. CONCLUSIÓN La prevalencia de hipovitaminosis D en pacientes adultos chilenos con fractura de tibia fue alta (98,2%). El esquema de suplementación con vitamina D propuesto fue efectivo y seguro.

Voluntary Increase of Minute Ventilation for Prevention of Acute Mountain Sickness.

This study evaluated the feasibility and efficacy of voluntary sustained hyperventilation during rapid ascent to high altitude for the prevention of acute mountain sickness (AMS). Study subjects (n=32) were volunteer participants in a 2-day expedition to Mount Leoneras (4954 m), starting at 2800m (base camp at 4120 m). Subjects were randomized to either: 1) an intervention group using the voluntary hyperventilation (VH) technique targeting an end-tidal CO2 (ETCO2)<20 mmHg; or 2) a group using acetazolamide (AZ). During the expedition, respiratory rate (28±20 vs. 18±5 breaths/min, mean±SD, P<0.01) and SpO2 (95%±4% vs. 89%±5%, mean±SD, P<0.01) were higher, and ETCO2 (17±4 vs. 26±4 mmHg, mean±SD, P<0.01) was lower in the VH group compared to the AZ group - as repeatedly measured at equal fixed intervals during the ascent - showing the feasibility of the VH technique. Regarding efficacy, the incidence of 6 (40%) subjects registering an LLS score≥3 in the VH group was non-inferior to the 3 (18%) subjects in the acetazolamide group (P=0.16, power 28%). Voluntary increase in minute ventilation is a feasible technique, but - despite the underpowered non-inferiority in this small-scale proof-of-concept trial - it is not likely to be as effective as acetazolamide to prevent AMS.

Proximity of the posterior interosseous nerve during cortical button guidewire placement for distal biceps tendon reattachment.

PURPOSE: To assess the distance between the posterior interosseous nerve (PIN) and a distally and ulnarly directed guide pin for placement of a cortical button to reattach a distal biceps tendon. METHODS: We used 10 fresh frozen cadaveric upper limbs without deformities and identified the PIN through a dorsal approach. We performed a single incision anterior surgical approach, detached the biceps tendon, and drilled a 1.6-mm K-wire from the base of the biceps tendon insertion in 3 different trajectories, sequentially, measuring the following drilling angles: 30° distal and 30° ulnar, 30° ulnar, and 30° distal. In each testing scenario, we measured the minimum distance in millimeters between the tip of the K-wire and the PIN using a digital caliper through the dorsal incision. RESULTS: The mean and median distances from the guide wire to the PIN in each testing trajectory were each significantly different from each other, with the 30° ulnar direction leading to the greatest distance from the nerve. CONCLUSIONS: We found that the 30° ulnar drilling direction resulted in a significantly greater distance from the guide wire to the PIN, in comparison with the distal-ulnar and the distal-only trajectories. CLINICAL RELEVANCE: This study helps define the safe trajectory for guide wire placement in bicortical fixation of distal biceps tendon injuries.

Assessment of femoral physeal activity after transitory hemiepiphysiodesis using screws and nonabsorbable filament.

BACKGROUND: Different techniques for gradual correction of angular deformities of lower limbs exist. Long-term behavior of the growth plate after hemiepiphysiodesis is not yet well understood. We assessed the restoration of normal physeal activity in New Zealand rabbits, after transitory hemiepiphysiodesis, using screws and nonabsorbable filament. METHODS: We performed a lateral distal femoral epiphysiodesis using nonabsorbable filament and screws, in the right knees of 14 New Zealand male rabbits, aged 11 weeks. Two groups were created: in group 1, the suture was cut after 1 month, and in group 2 it was left uncut. Simple plain radiographs were taken at the beginning and at 4, 8, and 12 weeks of follow-up to evaluate lower limb deformity rate and femoral length. The left knee of each rabbit served as controls. Angular deformity and femoral length were compared between the groups. RESULTS: Eleven rabbits completed the protocol. The control group had no modification in lower limb mechanical axis. On the fourth week, all operated limbs had a significant valgus tibiofemoral angle variation (mean 24 degrees, P<0.05). When the filament was cut, there was complete restoration of the mechanical axis. When the filament was kept, tibiofemoral angle increased its valgus deformity until the eighth week (mean 32 degrees) without changes thereafter. The final femoral length was shorter in group 2 compared with the other 2 groups (P<0.05), whereas group 1 was slightly longer than the control group (P>0.05). CONCLUSIONS: Lateral distal femoral hemiepiphysiodesis with nonabsorbable filament resulted in a valgus deformity on the femur. Once the filament is cut, the femur can restore its normal alignment, while maintaining longitudinal growth. Keeping the physeal tether increases the valgus achieved during the first 8 weeks, and remained stable throughout the study, shortening the bone. CLINICAL RELEVANCE: This is an effective alternative for the correction of angular limb deformities that maintains physeal function and may be useful for orthopedic surgeons. It could also represent an adequate model for the study of rebound effect.