Endotoxin-induced inhibition of growth hormone receptor signaling in rat liver in vivo.

The bacterial lipopolysaccharide endotoxin induces a catabolic response characterized by resistance to multiple anabolic hormones. The objective of this study was to determine the effects of endotoxin on the GH signaling pathway in rat liver in vivo. After the iv injection of Escherichia coli endotoxin (1 mg/kg), there was a progressive decrease in liver STAT5 (signal transducer and activator of transcription-5) tyrosine phosphorylation in response to GH (40% decrease 6 h after endotoxin), which occurred in the absence of a change in abundance of the STAT5 protein. Endotoxin resulted in a rapid 40-fold increase in liver Janus family kinase-2 (JAK2) messenger RNA, followed by a 2-fold increase in JAK2 protein abundance. This was associated with a 50% decrease in phosphorylated/total JAK2 after GH stimulation. GH receptor abundance was unchanged, suggesting a postreceptor site of endotoxin-induced GH resistance. Rat complementary DNAs for three members of the suppressor of cytokine signaling gene family were cloned [cytokine-inducible sequence (CIS), suppressor of cytokine signaling-2 (SOCS-2), and SOCS-3] and, using these probes, messenger RNAs for SOCS-3 and CIS were shown to be increased 10- and 4-fold above control values, respectively, 2 h after endotoxin infusion. The finding of endotoxin inhibition of in vivo STAT5 tyrosine phosphorylation in response to a supramaximal dose of GH in the absence of a change in GH receptor abundance or total GH-stimulated JAK2 tyrosine phosphorylation provides the first demonstration of acquired postreceptor GH resistance. We hypothesize that this may occur through a specificity-spillover mechanism involving the induction of SOCS genes by cytokines released in response to endotoxin and subsequent SOCS inhibition of GH signaling.

Arthroscopic ankle debridement and fusion: indications, techniques, and results.

The use of the arthroscope in arthritis of the ankle has been well described and there is no question that it is a significant part of the armamentarium for the orthopaedic surgeon dealing with these patients. Unfortunately, those patients with advanced arthritis and loss of joint space do not respond well to traditional arthroscopic debridement, removal of loose bodies, debridement and drilling of osteochondral lesions, and removal of anterior osteophytes. These procedures should only be used on those patients with minimal to no degenerative arthritis. Arthroscopic ankle arthrodesis is becoming more of the accepted primary procedure for most cases of arthritis of the ankle, in my opinion. Some varus or valgus tilting of the tibial talar joint can be accepted if clinical alignment is relatively normal. Significant malalignments cannot be corrected with arthroscopic fusion.

Treatment of diabetic (neuropathic) foot ulcers with two-stage debridement and closure.

We reviewed 33 patients with 37 wounds treated between November of 1991 and December of 1995 in the Wound Care Center. A two-stage debridement and closure technique for neuropathic foot ulcers was performed. Patients selected included those with obvious osteomyelitis and those who had failed nonsurgical treatment. The approach included initial surgical excision of the ulcer with biopsy, bone resection with biopsy, and deep culture. The second-stage procedure 4 to 8 days later included debridement of the wound and delayed closure. Intravenous antibiotic treatment using a central line was given postoperatively in patients with documented osteomyelitis for at least 6 weeks and in patients with infected soft tissues only for about 4 weeks. All patients remained nonweightbearing for 4 weeks; this was felt necessary to prevent separation of the wound edges. Four wounds in four patients failed to heal, and two of these went on to amputation. Satisfactory healing occurred in 29 of 33 patients and in 33 of 37 wounds. The authors conclude that two-stage surgical debridement and closure is an acceptable treatment in selected nonhealing diabetic (neuropathic) foot ulcers.

Glomangioma of the ankle simulating injury to the flexor hallucis longus: a case report.

The glomangioma is one of a group of benign tumors of glomus body origin. Commonly found in the distal extremities, they may present with pain, tenderness to palpation, and sensitivity to temperature. Histologically, varying proportions of glomus cells, as well as vascular and smooth muscle elements, are found. Complete surgical excision is usually curative. We report on a glomangioma of the ankle in a 12-year-old male patient that simulated injury to the flexor hallucis longus tendon.

Complications following arthroscopic ankle arthrodesis.

Forty-two patients underwent an arthroscopic ankle arthrodesis utilizing a bi-framed distraction technique and demineralized bone matrix-bone marrow slurry as a graft substitute. The average follow-up was 27 months (range, 12-64 months). The overall complication rate was 55%, including three nonunions (7%), two fractures (4.8%), four pin site infections (9.5%), one deep infection, four hardware problems (9.5%), and four symptomatic painful subtalar joints (9.5%). Overall, 85% of patients were satisfied with their final result. The complication rate was high but most complications were minor and manageable. The demineralized bone matrix and bone marrow did not seem to increase the fusion rate over what has been documented previously for arthroscopic ankle fusions without the use of this graft substitute.

Open reduction and internal fixation of type II intra-articular calcaneus fractures.

Open reduction and internal fixation of 23 type II calcaneus fractures in 21 patients was performed using a standard extended lateral approach. Average follow-up was 26 months (range, 12-47 months). The Creighton-Nebraska Health Foundation Assessment Score for Fractures of the Calcaneus was used to evaluate fractures. The average score was 91.4 (range, 80-100), which represented an excellent result. A series of 10 type II fractures treated with closed methods was also evaluated using the same evaluation methods. The average score was 70 (range, 60-84), which represented a fair result. There was a clear statistically significant superiority with type II calcaneus fractures treated with open reduction and internal fixation (P < 0.0001). We recommend type I calcaneus fractures (nondisplaced) be treated with closed methods, and type II calcaneus fractures (displaced) be treated with open reduction and internal fixation.

Valgus tilting of the ankle joint after subtalar (hindfoot) fusion: complication or natural progression of valgus hindfoot deformity?

Six patients treated over a 2-year period were noted to have valgus tilting of the talus at the ankle joint on standing anteroposterior ankle films taken after subtalar (hindfoot) fusions. All patients had significant preoperative hindfoot valgus, but no changes on ankle films. All patients underwent "moldable insitu fusions." Severity and duration of preoperative deformity, as well as obesity, appear to be predisposing factors. Most patients were satisfied with their pain relief despite their persistent valgus deformity. Treatment alternatives may include medial displacement calcaneal osteotomy, lateral column lengthening, combination bone and soft tissue procedures, or even tibial talar calcaneal fusion.

Chopart's fracture dislocation: a case report and review of the literature.

The prompt identification of peri-talar dislocation with immediate reduction and early range of motion will generally result in a good outcome. Higher energy injury with greater soft tissue compromise and associated fractures worsen the prognosis. Salvage procedure for post-traumatic degenerative changes require arthrodesis for relief of pain. The deformity is usually apparent on physical examination, but occasionally is masked by marked early swelling. A high index of suspicion should be maintained with high or low energy injury to the foot and ankle with normal ankle radiographs. This particular case is unusual in that the patient was able to function as a farmer even with the fracture dislocation. This again is probably explained by his mild peripheral neuropathy. This case, however, does demonstrate the difficulty in making the diagnosis.

Melorheostosis of the foot: a case report and review of the literature.

As seen in the case presented, melorheostosis is a bony dysplasia showing irregular wavy lines of hyperostotic bone. Clinically, patients present variably, ranging from incidental radiographic discovery of the syndrome to severe deformities and pain. Subsequently, diagnosis is often delayed or missed. Treatment is usually symptomatic, although surgical correction of deformities is often pursued. Unfortunately, these surgeries may be complicated with frequent vascular problems and deformities usually recur. Thus, treatment of melorheostosis should be individualized based on the patient's lifestyle, progression of disease and age.

Intraarticular fracture of the calcaneus.

The treatment of displaced intraarticular fractures of the calcaneus continues to challenge the orthopaedic community. The recent development of prognostic classification systems based on computerized tomography has clarified the roles of non-operative and operative treatment. It has also opened the door for further prospective study of the appropriate treatment of this injury and comparison of operative methods. Based on current literature and our experience, we recommend CT evaluation of all intraarticular fractures of the os calcis in patients who are operative candidates with treatment guided by fracture classification.

Talar neck fracture.

Despite advancement in the knowledge and understanding of talar neck fracture biomechanics and refined techniques of treatment, a significant number of patients with these fractures have long term complications. Anatomic reduction is the goal in all situations where possible. Careful follow-up of patients is mandatory to prevent unrecognized displacement of the fracture fragment as the swelling of the extremity subsides in the cast. Weight bearing should be delayed until radiographic union of the fracture is apparent, if possible. There is a tendency today towards increased use of open reduction and internal fixation of talar neck fractures. This more aggressive approach appears to give patients the best chance for healing without complications. The results of open reduction and internal fixation studies seem to show better maintenance of the fracture reduction, reduction of time until fracture union, and overall better long-term results. Careful assessment of tibiotalar, subtalar, and talonavicular joints is essential prior to any salvage procedure. The use of CT scans, MRI's, and plain tomograms seems to be of most help in assessment of these patients prior to arthrodesis or other salvage procedures. The incidence of poor results following talar neck fracture still continues to remain high, unfortunately, despite the advancement in the understanding and knowledge of these fractures.

Intraarticular calcaneal fractures. Results of closed treatment.

Thirty intraarticular calcaneal fractures were studied by computed tomography and then treated with a variety of closed methods. A classification of the fractures was devised according to the amount of displacement of the posterior facet. Follow-up evaluation showed that Type I fractures recovered function and healed extremely well. Closed treatment should be the treatment of choice for Type I fracture patterns. Type II and III fractures had unacceptable results with closed treatment. Alternate forms of treatment should be considered in dealing with more severely displaced fractures.

Calcaneal fracture after cortical bone removal.

Four patients developed calcaneal fractures while walking, soon after bone removal from the undersurface of the calcaneus. Heel spur or osteomyelitic bone removal can lead to this complication.

Computerized tomography scanning of acute intra-articular fractures of the calcaneus. A new classification system.

Computerized tomography was used to evaluate thirty intra-articular fractures of the calcaneus in twenty-seven patients. A classification of the fractures was devised on the basis of fracture patterns involving the posterior facet joint of the calcaneus. In Type I, the fracture fragments were small or not displaced; in Type II, they were displaced; and in Type III, they were comminuted. There were thirteen Type-I, ten Type-II, and seven Type-III fractures, all of which were treated with a variety of closed methods. The length of follow-up ranged from eighteen to fifty-two months (mean, thirty-six months). The results were graded by a predetermined point system that included the evaluation of motion of the subtalar joint. Of the thirteen Type-I fractures, eight had an excellent result; four, a good result; and one, a fair result. Of the ten Type-II fractures, two had a good result; four, a fair result; and four, a poor result. All of the seven Type-III fractures had a poor result. On the basis of our study of the fracture patterns as seen on the computerized tomography scans, we believe that it is possible to predict which fractures will do well with closed treatment and which will not. Type-I fractures did well with closed treatment. Type-II fractures can be treated closed but with a lower success rate than Type-I fractures. All of the Type-III fractures had a poor result after closed treatment.