The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle.

We carried out an experiment to measure the relationship between tensile force in the tendoachilles and plantar fascia strain, and how this relationship is affected by the metatarsophalangeal joint dorsiflexion angle. Eight cadaver lower extremity specimens underwent biomechanical testing. Using a servo-hydraulic testing machine, a tensile force up to 500 N was applied to the tendoachilles while the strain on the plantar fascia was measured using an extensometer. The experiment was repeated at four different metatarsophalangeal joint dorsiflexion angles (0 degrees, 5 degrees, 30 degrees, and 45 degrees). Measurements and calculations showed that dorsiflexion of the toes tightens the plantar fascia (the windlass effect) and increases the effect that a tensile force in the tendoachilles has on the tensile strain and tensile force in the plantar fascia.

Wrist arthrodesis using a wrist fusion plate.

All wrist arthrodeses done between 1990 and 1996 using a Synthes wrist fusion plate were reviewed. Independent assessment done by a certified hand therapist included a patient survey, standardized Jebsen-Taylor hand function test and activities of daily living test, and a Buck-Gramcko and Lohmann evaluation. We evaluated 13 wrists in 11 patients. Overall satisfaction was 100% of patients (mean follow-up, 31.5 months; range, 13 to 61 months). Mean preoperative and postoperative pain scores improved from 7.2 to 0.8, respectively, and functional scores improved from 5.0 to a postoperative mean value of 7.4. Jebsen-Taylor scores were virtually identical for fused and uninvolved wrists. There were no pseudarthroses, no plate failures, no tendon ruptures, and no significant postoperative infections; there was a single plate removal because of tenuous skin coverage. Short-term results using a comprehensive assessment of a custom plate designed for wrist arthrodesis show promising clinical outcomes.

Treatment of acquired adult planovalgus deformities with subtalar fusion.

A retrospective review was conducted of isolated subtalar arthrodeses performed on 32 adults (34 fusions) between August 1990 and September 1993. Each fusion was performed using a single large cannulated lag screw through the talar neck. The American Orthopaedic Foot and Ankle Society standard clinical rating system for the ankle and hindfoot was used to assess outcome. Patients answered subjective questions based on the scale. Followup examination was done to evaluate clinically and radiographically each patient's foot and ankle according to the scale. Average patient age was 53 years (range, 27-80 years). Average followup was 30.8 months (range, 16-55 months). Twenty-four patients answered the subjective questions, and the average subjective score was 47 of a maximum 60 points (range, 9-60 points). Clinical data from 17 patients showed an average objective score of 30 of a maximum 34 points (range, 25-34 points). The average total score was 77 of a maximum 94 possible points (range, 34-94 points). Forty-two percent of the patients indicated a 100% improvement, 42% a 75% improvement, and 16% a 50% improvement. Eighty-three percent stated they definitely would have the procedure again. Results indicate that subtalar arthrodesis is an effective treatment for adult patients with pain and disability secondary to acquired planovalgus, posttraumatic, and inflammatory conditions of the hindfoot. In addition, the American Orthopaedic Foot and Ankle Society standard rating system of the ankle and hindfoot corresponds to clinical outcome.

Venomous snake bite: current concepts of treatment.

The optimal treatment of venomous snake-bites remains controversial. Because of the variables involved in treatment, an ideal, prospective clinical trial likely will never be done. The purpose of this article is to review the available treatment methods and outline the treatment methods preferred in our institution for crotalidae envenomation.

Myoelectric prostheses. A long-term follow-up and a study of the use of alternate prostheses.

Forty-four patients who had had a total of forty-seven amputations of an upper extremity and who had had a myoelectric prosthesis for more than two years were evaluated retrospectively for the amount of use of the prosthesis, the use of any other prosthesis, and the demographic factors that might be related to use of the prosthesis. The average duration of follow-up was five years (range, twenty-five months to seventeen years). Forty of the forty-four patients also had a conventional prosthesis. Twenty-two patients (50 per cent) rejected the myoelectric prosthesis completely; thirteen (32 per cent) of the forty patients who also had a conventional prosthesis rejected the conventional prosthesis completely. The patients who used the myoelectric device the least were employed in occupations that required high-demand use of the prosthesis (lifting of more than 4.5 kilograms [ten pounds] or repetitive manual labor) or were receiving or seeking Workers' Compensation, or both.

The blood supply to the great toe sesamoids.

The purpose of this study was to define the intraosseous and extraosseous blood supply of the hallucal sesamoids by studying a total of 10 fresh-frozen, below-knee specimens with no evidence of vascular disease. Most specimens were injected with high grade India ink, cleared using a standard Spalteholz technique, and processed to delineate the extraosseous and intraosseous blood supply to include soft tissue dissection and coronal sectioning. Two additional specimens were injected with blue Mercox acrylic solution to further define the extraosseous vasculature. The major extraosseous blood supply to the sesamoids is via the posterior tibial artery. This vessel then branches into the medial plantar artery which further divides upon entering the medial and lateral sesamoids in their proximal poles. Vessels in the peripheral soft tissues, although abundant, do not seem to penetrate the cortex of the sesamoids. The intraosseous blood supply to the sesamoids seems to be threefold. Mainly, sesamoid arteries enter the lateral and medial sesamoids from the proximal aspect via a single vessel. This proximal vessel proceeds distally with a network of branching. Plantar, nonarticular vessels enter the sesamoids, constituting a second source of vascularity. Finally, small vessels also enter the sesamoids through medial and lateral capsular attachments. Based on this study, a possible explanation for avascular necrosis and nonunion of sesamoids is proposed, and an optimal surgical approach is discussed.(ABSTRACT TRUNCATED AT 250 WORDS)

Abnormal pedal thermoregulation in interstitial cystitis.

Isolated cold stress tests were used to evaluate the thermoregulatory capacity in the feet of 19 patients with interstitial cystitis (IC) and of 11 healthy volunteer control subjects. Mean pedal skin temperature fell more rapidly in the IC group as compared with controls; significant differences were found at 10-min (P = 0.002) and 20-min (P = 0.0008) cooling. Mean skin temperature remained lower in the IC group throughout the study. Sixteen feet (42%) in the IC group and five (22%) of the control feet failed to return to within 2 degrees C of baseline temperature during the 20-min recovery period. These findings may reflect abnormal vasomotor control in the IC group and, if so, may be indicative of increased spinal sympathetic activity in interstitial cystitis.

Silicone rubber distal ulnar replacement arthroplasty.

We retrospectively reviewed 42 patients who underwent resection of the distal ulna with implantation of a silicone rubber ulnar head prosthesis (45 wrists). Two prostheses were used: the original Swanson prosthesis, and a prosthesis of our own design. Follow-up X-rays showed migration or breakage of 63% of the prostheses. No statistically significant correlation existed between the quality of functional outcome and the integrity of the prostheses. There was no significant difference between pre-operative and post-operative range of motion for the entire group or between patients with broken or intact prostheses. Histological confirmation of silicone synovitis was documented in one patient who required implant removal. We suggest that destabilization and breakage of prostheses result from fatigue failure secondary to the torque generated at the distal radio-ulnar joint during repeated pronation and supination. Use of a silicone rubber ulnar head prosthesis following distal ulna resection is not recommended.

Intravenous regional bretylium and lidocaine for treatment of reflex sympathetic dystrophy: a randomized, double-blind study.

Patients with reflex sympathetic dystrophy, who received transient pain relief from stellate ganglion blocks or lumbar sympathetic blocks and had abnormal isolated cold stress tests, were enrolled in a study to determine the efficacy of intravenous regional bretylium. Each patient received two control treatments (0.5% lidocaine) and two treatments with 0.5% lidocaine and bretylium 1.5 mg/kg in a randomized, double-blind fashion. A standard intravenous regional technique was used with a 300-mm Hg tourniquet pressure for 20 min. Patients kept a daily record of pain relief (0 = no relief, 100% = complete relief). A decrease in pain of more than 30% was considered clinically significant. Therefore, once the patient's pain relief was less than 30%, the next intravenous regional treatment was performed. Bretylium and lidocaine provided more than 30% pain relief for a mean of 20.0 (+/- 17.5) days, whereas lidocaine alone provided relief for only 2.7 (+/- 3.7) days (Mann-Whitney U-test, P less than 0.001). A mean temperature increase in the treated limb of +2.64 +/- 3.41 degrees C above the baseline temperature was noted after bretylium administration, whereas after control treatments the change was -0.086 +/- 1.30 degrees C (Mann-Whitney U-test, P less than 0.02). We conclude that the combination of bretylium and lidocaine is significantly more effective than lidocaine alone when an intravenous block is used to treat reflex sympathetic dystrophy.

Total hip arthroplasty in patients who have sickle-cell hemoglobinopathy.

Eleven patients who had a form of sickle-cell hemoglobinopathy had a total hip arthroplasty for avascular necrosis of the hip. Four patients had a revision and three had a resection arthroplasty. Four had a serious infection postoperatively. Both acute and late complications were numerous. We concluded that patients who have a sickle-cell hemoglobinopathy are at markedly increased risk for complications after total hip replacement arthroplasty, yet that over-all the results are favorable.

Digestion and absorption of fiber carbohydrate in the colon.

Most dietary carbohydrates are digested and absorbed in the small bowel. However, fiber carbohydrate and other carbohydrates can be metabolized by the normal flora of the colon. The substrate for bacterial fermentation includes compounds for which small bowel digestive and absorptive mechanisms may, or may not, exist and soluble and some insoluble fiber. Products of fermentation include gases and volatile fatty acids which may be absorbed or nourish the colon mucosa. Total body nutrition and metabolism may also be affected by the products digested and absorbed in the colon.

Staged versus simultaneous bilateral total knee replacement.

Bilateral total knee replacements were reviewed to determine whether any difference exists in the perioperative course between procedures done under one anesthetic (simultaneous) and those done under two anesthetics (staged). There were 29 staged and 18 simultaneous cases, therefore 76 separate procedures and 94 knees done. The total operative time, blood loss, and complications were similar between the two groups. However, the staged replacements had more than twice the hospital days (34.6 +/- 7.7 vs. 16.8 +/- 5.6, P less than .001) and 18% greater hospital bills. In fact, for a given patient, the hospital bill may be greater than 50% higher if a staged rather than simultaneous replacement is done. Therefore, simultaneous replacement is recommended for appropriate patients.

Computerized tomography in the evaluation and classification of fractures of the acetabulum.

Sixty-seven consecutive patients with acetabular injuries were assessed first by conventional roentgenograms and Judet oblique views and then by computerized tomography. The fractures were evaluated with Letournel's classification and reclassified by computerized tomographic views alone. The degree of comminution and displacement was further evaluated by Pennal's classification. Computerized tomograms (CT) presented only one classification change in the Letournel system. CT observations significantly changed Pennal's classification by revealing the degree of comminution of the superior articular surface in 14 of the 67 fractures. CT also delineates the superior articular surface of the acetabulum, the degree of comminution in Letournel's complex fractures, the extent and comminution of posterior wall fractures, and the location of intra-articular fragments in postreduction films of hip dislocations.

Immediate, early, and late postsurgical management of upper-limb amputation.

This series is composed of 47 patients who underwent immediate, early, or late postoperative prosthetic fitting after upper-limb amputation. The purpose of this review was to analyze the impact of rapid postoperative fitting on upper-limb amputation, and to assess general prosthetic prescription and guidelines for upper-limb amputees. It would appear that in adult amputations there is a "Golden Period" of fitting for upper-limb prosthetic devices and this period appears to be within the first month after amputation. There appears to be no difference in ultimate prosthetic acceptance rate or use patterns as a function of the type of prosthesis initially provided. Based upon this combined review between the Tucson and Atlanta VA Medical Centers, the authors would suggest that all upper-limb amputees be fitted as rapidly as possible (within 30 days) with conventional prosthetic devices, and when they have shown motivation and skill in the use of conventional devices, then to re-evaluate them for appropriate externally powered prosthetic components.

The Cybex II evaluation of lateral ankle ligamentous reconstructions.

Chronic lateral ankle instability is a costly disability to the athlete. The Chrisman-Snook and Evans lateral ligamentous reconstructions are two procedures frequently performed to correct ligamentous instability. The entire peroneus brevis tendon is transected in the Evans procedure, thus sacrificing its eversion strength and power. The importance of preserving the eversion function of the peroneus brevis muscle is speculative, but may be of significance for good long-term results. The ankle eversion strength and power of 10 patients with Chrisman-Snook and 10 patients with Evans lateral ligamentous reconstructions were objectively evaluated with the Cybex II Isokinetic Dynamometer. The mean postoperative time to testing was 4.2 years. The uninvolved ankle was also tested and used as the normal strength of the patient. Twenty normal controls matched for age, sex, and physical activity were tested to assure maximum test reproducibility. The eversion strength was tested at several speeds, but torque values at speeds of 30 and 120 deg/sec were selected for analysis. At slow speeds, 30 deg/sec, and ankles that had Evans and Chrisman-Snook reconstruction were 4% and 7% weaker, respectively, than the contralateral normal ankles. At 120 deg/second the ankles were 8% and 9% weaker with the Evans and Chrisman-Snook reconstructions, respectively. A three factor analysis of variance with repeated measures on two of the factors was used to analyze the data.(ABSTRACT TRUNCATED AT 250 WORDS)

The stable internal fixation of peritrochanteric hip fractures.

Most series found in the literature on peritrochanteric fractures report failure rates of 9% to 35% for nonsliding fixation and 5% to 12% for devices that allow collapse about the axis of the barrel of the device, indicating that the concept of load sharing is a valid principle in the management of these injuries. Reviewing our experience with the fully collapsible devices reveals a remarkably low incidence of complications related to both metal failure and postoperative penetration of the femoral head. Most of the failures in our series occurred before the routine use of fluoroscopic operative placement control and can be related to inadvertent intraoperative penetration of the femoral head. With modern techniques, therefore, these complications are largely preventable. Despite those failures, which cannot be explained by technical error, we are extremely pleased with our overall results because the fully collapsible devices appear to allow early weight bearing without fear of fixation complications, even in unstable fractures. This concept allows for easier postoperative rehabilitation and attendant diminished mortality rates as compared with other devices currently used. Although no study can conclusively demonstrate the clear superiority of the slotted Richards screw and Ken-Pugh nail over other forms of sliding fixation, we believe that if the concept of load sharing is valid, this modification is a simple, sensible, and effective addition to most nail plate devices used today.

Soft-tissue reconstruction of the leg associated with the use of the Hoffmann external fixator.

Soft-tissue injuries and defects associated with severe fractures of the tibia treated with the Hoffmann external fixator were reviewed. Of 84 cases of open tibia fractures (classified as Gustilo's Type II and III), 54 patients with 55 injured limbs required soft-tissue reconstruction other than skin grafts or small rotational flaps. These 55 cases were constructed with 37 local musculocutaneous flaps (20 gastrocnemius, 17 soleus and other smaller muscle flaps), 15 free musculocutaneous flaps (14 latissimus dorsi, and one tensor fascia lata), and three medial gastrocnemius cross leg flaps. In all cases the soft-tissue reconstruction was done with the external fixator in place. All but three of the musculocutaneous flaps healed with no problems (94%). Bony healing was found in 30 cases (69.09%) at 18-month followup. There was one amputation after two failed local flaps and three late amputations due to patient's request (infected nonunion). There was a nonunion rate of 25.45% (14 cases) at 18 months postinjury. The Hoffmann external fixator has allowed bony stabilization and has not precluded the subsequent soft-tissue reconstruction or bone grafting. Muscle and musculocutaneous flaps, both local and free, have been employed in the reconstruction of the leg with minimal interference from the Hoffmann device.

Open fractures of the tibia treated by the Hoffmann external fixator.

In a prospective study 40 consecutive patients with open tibial fractures were treated by the Hoffmann external fixator; the follow-up period was 18 months. All fractures were irrigated, debrided, and fixed rigidly with the Vidal-Adrey modification of the Hoffmann device as soon as the patients' condition allowed. The wounds were left open, to be closed secondarily with skin grafts, muscle flaps, and other plastic surgical procedures. The 40 wounds were all classified as Gustilo's Type II or III in relation to soft tissue damage; 36 injuries were due to motor vehicle accidents and four to gunshot wounds. At the 18-month follow-up examination there had been five amputations and five nonunions had healed after bone grafting; in addition, five patients had persistent pin drainage. Pin site drainage (80%) was the most common problem, but most cleared after removal of the fixator and five after curettage of ring sequestra. There was a high number of associated surgical procedures (2.4% per patient) related to the open fracture. At the 18-month follow-up examination bony healing was noted in all patients.

Computerized tomography in the evaluation of peroneal tendon dislocation. A report of two cases.

Dislocation or subluxation of a peroneal tendon is a relatively uncommon entity, and the diagnosis is rarely made at the time of initial injury. If untreated, chronic lateral instability and pain may develop which can be a diagnostic dilemma. These patients usually will have a history of frequent episodes of ankle instability and may be aware of a pop or snap just prior to the episode of instability. There is usually no significant anterior drawer or inversion laxity present on stress testing. Unfortunately, it is often difficult to passively or actively dislocate the involved peroneal tendon. Surgical treatment may have to be recommended on strong suspicion alone. Two patients with chronic lateral ankle pain underwent computerized tomography preoperatively and postoperatively. In addition, eight normal ankles were scanned for comparison. In the two cases of peroneal tendon dislocations presented, computerized tomography was found to be a very beneficial aid in making the diagnosis, and may be of significant value in those with suspected peroneal tendon subluxation/dislocations.