Metatarsus Primus Elevatus Resolution After First Metatarsophalangeal Joint Arthroplasty.

BACKGROUND: Hallux limitus (HL) is the second-most common pathology associated with the first metatarsophalangeal joint. A common etiology believed to be associated with HL is metatarsus primus elevatus (MPE), although causation has been unsubstantiated by evidence. Historically, correction of MPE is surgically addressed with an osteotomy. However, some believe MPE is a secondary manifestation of HL due to retrograde pressure and lack of dorsiflexion at the first metatarsophalangeal joint. This study sought to determine whether MPE resolves spontaneously after first metatarsophalangeal joint arthroplasty and reinstitution of normal joint dorsiflexion. METHODS: Twenty-seven weightbearing lateral radiographs from patients with HL were reviewed before and after nonimplant first metatarsophalangeal joint arthroplasty. Radiographs were taken preoperatively and at postoperative visits 1 (mean, 2 weeks) and 2 (mean, 10 weeks). Measurements included first to second metatarsal elevation, Seiberg Index, first to fifth metatarsal distance, sagittal plane first to second metatarsal angle, Meary's angle, metatarsal declination angle, and hallux equinus angle. RESULTS: Statistically significant improvement was seen at both postoperative visits in all of the previously mentioned measurements except first to fifth metatarsal distance, which was reduced but was not statistically significant. CONCLUSIONS: Metatarsus primus elevatus was reduced significantly after first metatarsophalangeal joint arthroplasty. Resolution occurred rapidly and was maintained at the final postoperative visit. This could be due to MPE being a manifestation of HL and not a cause. Based on the results of this study, osteotomies may be unnecessary to surgically address MPE because it can spontaneously correct after reinstitution of first metatarsophalangeal joint motion.

Use of Dehydrated Human Amnion/Chorion Membrane Allografts in More Than 100 Patients with Six Major Types of Refractory Nonhealing Wounds.

BACKGROUND: Biochemical properties of the amniotic membrane help modulate inflammation and enhance soft-tissue healing. In controlled trials, the efficacy of dehydrated human amnion/chorion membrane (dHACM) allografts has been established. Our purpose is to describe our experience with using dHACM to treat nonhealing wounds of various etiologies. METHODS: We conducted a retrospective review of deidentified data from 117 consecutive patients treated in an outpatient clinic with dHACM allografts with wounds of various etiologies over 2 years. The decision to use advanced wound-care treatments is based on rate of healing observed after initiation of standard wound care and patient risk factors. Eligibility for treatments such as amniotic membrane allografts includes wounds without 50% reduction after 4 weeks, or earlier in patients deemed to be at high risk for nonhealing or with a history of chronic wounds. In micronized or sheet formulation, dHACM is applied to the wound weekly after sharp/mechanical debridement as necessary, and wound-care practices appropriate for wound type and location are continued. RESULTS: Thirty-four percent of allograft recipients had diabetic foot ulcers, 25% had venous leg ulcers, 20% had surgical wounds, 14% had pressure ulcers, 6% had ischemic wounds, and 2% had traumatic wounds. Complete healing occurred in 91.1% of treated patients, with a mean ± SD number of weekly applications per healed wound of 5.1 ± 4.2. CONCLUSIONS: In addition to wounds of diabetic origin, dHACM can significantly expedite healing in refractory wounds of varying etiologies.

Nonimplant Arthroplasty for the Treatment of End-Stage Hallux Rigidus.

Surgical management of end-stage hallux rigidus involves joint-sparing techniques, including cheilectomy and decompression osteotomies, and joint-destructive procedures, including arthroplasty (resection, interpositional, implant, Valenti) and arthrodesis. Joint-destructive procedures have traditionally been reserved for the end stages of hallux rigidus involving grade 3 and 4. We present a modification of the previously reported Valenti arthroplasty with short-term patient outcomes. We performed a retrospective review of the medical records of 96 patients who had undergone the nonimplant arthroplasty procedure for treatment of end-stage hallux rigidus with a minimum follow-up period of 6 months. The preoperative and postoperative dorsiflexion of the first metatarsophalangeal joints and visual analog scale (VAS) scores were compared. Of the 96 medical records, 27 (28%) met the inclusion criteria. The mean patient age was 60.2 (range 48 to 73) years, and the mean follow-up period was 12 (range 6 to 23) months. The mean preoperative range of motion for first metatarsophalangeal joint dorsiflexion was 4.69° (range -3° to 10°), and the mean postoperative dorsiflexion was 48.23° (range 30° to 65°), with a mean difference of 43.54° (range 25° to 60°). The preoperative VAS score averaged 6.46° (range 4° to 10°), and the postoperative VAS score averaged 0.69° (range 0° to 3°). Nonimplant arthroplasty was found to increase first metatarsophalangeal joint dorsiflexion and significantly decrease patient pain. Thus, it is a viable option for the treatment of end-stage hallux rigidus.

Priming of neutrophils and differentiated PLB-985 cells by pathophysiological concentrations of TNF-α is partially oxygen dependent.

Activation of polymorphonuclear leukocytes (PMN) can be modulated to intermediate 'primed' states characterized by enhanced responsiveness to subsequent stimuli. We studied priming in response to TNF-α in human PMN and PLB-985 cells, a myeloid cell line differentiated to a neutrophilic phenotype (PLB-D). PMN generated reactive oxygen species (ROS) in response to TNF-α alone, and NADPH oxidase activity increased in response to stimulation with formyl-Met-Leu-Phe after priming. PLB-D cells also demonstrated priming of NADPH oxidase activity. Similar to priming by endotoxin, priming of the respiratory burst by TNF-α was predominantly oxygen dependent, with marked attenuation of ROS generation if primed anaerobically. Both PMN and PLB-D cells displayed significant increases in cell surface CD11b and gp91(phox) expression after TNF-α priming and PMN displayed activation of MAPK. In response to TNF-α priming, neither mobilization of intracellular proteins nor activation of MAPK pathways was NADPH oxidase dependent. Priming of PMN and PLB-D cells by low TNF-α concentrations enhanced chemotaxis. These data demonstrate that pathophysiological concentrations of TNF-α elicit NADPH oxidase-derived ROS and prime cells for enhanced surface protein expression, activation of p38 and ERK1/2 MAPK pathways, and increased chemotaxis. Furthermore, PLB-D cells undergo TNF-α priming and provide a genetically modifiable model to study priming mechanisms.