Surgical Considerations for the Acute and Chronic Charcot Neuroarthropathy of the Foot and Ankle.

Charcot neuroarthropathy (CN) of the foot/ankle is a devastating complication that can occur in neuropathic patients. It is a progressive and destructive process that is characterized by acute fractures, dislocations, and joint destruction that will lead to foot and/or ankle deformities. Early diagnosis is imperative, and early treatment may be advantageous, but the condition is not reversible. There is no cure for CN but only treatment recommendations. Ultimate goals of care should include providing a stable limb for ambulation and no ulcerations.

Noninvasive management of soft tissue disorders of the shoulder: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVES: Objective of this study is to develop an evidence-based guideline for the noninvasive management of soft tissue disorders of the shoulder (shoulder pain), excluding major pathology. METHODS: This guideline is based on high-quality evidence from seven systematic reviews. Multidisciplinary experts considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience is clinicians; target population is adults with shoulder pain. RESULTS: When managing patients with shoulder pain, clinicians should (a) rule out major structural or other pathologies as the cause of shoulder pain and reassure patients about the benign and self-limited nature of most soft tissue shoulder pain; (b) develop a care plan in partnership with the patient; (c) for shoulder pain of any duration, consider low-level laser therapy; multimodal care (heat/cold, joint mobilization, and range of motion exercise); cervicothoracic spine manipulation and mobilization for shoulder pain when associated pain or restricted movement of the cervicothoracic spine; or thoracic spine manipulation; (d) for shoulder pain >3-month duration, consider stretching and/or strengthening exercises; laser acupuncture; or general physician care (information, advice, and pharmacological pain management if necessary); (e) for shoulder pain with calcific tendinitis on imaging, consider shock-wave therapy; (f) for shoulder pain of any duration, do not offer ultrasound; taping; interferential current therapy; diacutaneous fibrolysis; soft tissue massage; or cervicothoracic spine manipulation and mobilization as an adjunct to exercise (i.e., range of motion, strengthening and stretching exercise) for pain between the neck and the elbow at rest or during movement of the arm; (g) for shoulder pain >3-month duration, do not offer shock-wave therapy; and (h) should reassess the patient's status at each visit for worsening of symptoms or new physical, mental, or psychological symptoms, or satisfactory recovery. CONCLUSIONS: Our evidence-based guideline provides recommendations for non-invasive management of shoulder pain. The impact of the guideline in clinical practice requires further evaluation. SIGNIFICANCE: Shoulder pain of any duration can be effectively treated with laser therapy, multimodal care (i.e., heat/cold, joint mobilization, range of motion exercise), or cervicothoracic manipulation and mobilization. Shoulder pain (>3 months) can be effectively treated with exercises, laser acupuncture, or general physician care (information, advice, and pharmacological pain management if necessary).

Understanding and using time series analyses in addiction research.

Time series analyses are statistical methods used to assess trends in repeated measurements taken at regular intervals and their associations with other trends or events, taking account of the temporal structure of such data. Addiction research often involves assessing associations between trends in target variables (e.g. population cigarette smoking prevalence) and predictor variables (e.g. average price of a cigarette), known as a multiple time series design, or interventions or events (e.g. introduction of an indoor smoking ban), known as an interrupted time series design. There are many analytical tools available, each with its own strengths and limitations. This paper provides addiction researchers with an overview of many of the methods available (GLM, GLMM, GLS, GAMM, ARIMA, ARIMAX, VAR, SVAR, VECM) and guidance on when and how they should be used, sample size det ermination, reporting and interpretation. The aim is to provide increased clarity for researchers proposing to undertake these analyses concerning what is likely to be acceptable for publication in journals such as Addiction. Given the large number of choices that need to be made when setting up time series models, the guidance emphasizes the importance of pre-registering hypotheses and analysis plans before the analyses are undertaken.

Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration.

OBJECTIVES: To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic). METHODS: This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain. RESULTS: When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3 months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated. CONCLUSIONS: Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation. SIGNIFICANCE: Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred.

Rapid Aspirin Desensitization is Safe and Feasible in Patients With Stable and Unstable Coronary Artery Disease: A Single-Center Experience.

AIMS: There are limited data on aspirin (ASA) desensitization for patients with coronary disease. We present our experience with a rapid nurse-led oral desensitization regimen in patients with aspirin sensitivity undergoing coronary angiography. METHODS: This single-center retrospective observational study includes patients with a history of ASA sensitivity undergoing coronary angiography with intent to perform percutaneous coronary intervention (PCI). RESULTS: Between January 2012 and January 2017, 24 patients undergoing coronary angiography for stable coronary disease (7 cases) or acute coronary syndromes (non-ST-segment myocardial infarction [NSTEMI; 8 cases], STEMI [9 cases]) underwent aspirin desensitization having reported previous reactions to aspirin. At initial presentation, previous sensitivity reactions were reported as: mucocutaneous reactions in 17 patients (urticaria in 3 [13%], nonurticarial rash in 6 [25%], angio-oedema in 8 [33%]), respiratory sensitivity in 4 (17%), and systemic anaphylactoid reactions in 3 (13%). Seventeen (71%) patients underwent PCI. Desensitization was acutely successful in 22 (92%) patients and unsuccessful in 2 (8%) patients who both had a single short-lived episode of acute bronchospasm treated successfully with nebulized salbutamol. Fifteen successfully desensitized patients completed 12 months of aspirin; no patient had recurrent hypersensitivity reaction. Aspirin was stopped prior to 12 months in 7 patients (replaced by warfarin [1 case], no antiplatelet or single antiplatelet clinically indicated and clopidogrel chosen [4 cases], patient choice without evidence of recurrent hypersensitivity [1 case], and death due to cardiogenic shock following STEMI [1 case]). CONCLUSION: A rapid aspirin desensitization protocol is safe and effective across a broad spectrum of hypersensitivity reactions and clinical presentations.

Tactile-to-Visual Cross-Modal Transfer of Texture Categorisation Following Training: An fMRI Study.

We investigated the neural underpinnings of texture categorisation using exemplars that were previously learned either within modalities (visual training and visual test) or across modalities (tactile training and visual test). Previous models of learning suggest a decrease in activation in brain regions that are typically involved in cognitive control during task acquisition, but a concomitant increase in activation in brain regions associated with the representation of the acquired information. In our study, participants were required to learn to categorise fabrics of different textures as either natural or synthetic. Training occurred over several sessions, with each fabric presented either visually or through touch to a participant. Pre- and post-training tests, in which participants categorised visual images only of the fabrics, were conducted during a functional magnetic resonance imaging (fMRI) scan. Consistent with previous research on cognitive processes involved in task acquisition, we found that categorisation training was associated with a decrease in activation in brain regions associated with cognitive systems involved in learning, including the superior parietal cortex, dorsal anterior cingulate cortex (dACC), and the right dorsolateral prefrontal cortex (DLFC). Moreover, these decreases were independent of training modality. In contrast, we found greater activation to visual textures in a region within the left medial occipital cortex (MOC) following training. There was no overall evidence of an effect of training modality in the main analyses, with texture-specific regional changes associated with both within- (visual) and cross- (touch) modal training. However, further analyses suggested that, unlike categorisation performance following within-modal training, crossmodal training was associated with bilateral activation of the MOC. Our results support previous evidence for a multisensory representation of texture within early visual regions of the cortex and provide insight into how multisensory categories are formed in the brain.

Changes in Regional Brain Grey-Matter Volume Following Successful Completion of a Sensori-Motor Intervention Targeted at Healthy and Fall-Prone Older Adults.

Previous studies have suggested that discrete cross-sensory events could be incorrectly combined in the brain of older adults with a history of falls, possibly undermining motor and balance control. Based on previous findings that multisensory integration is modifiable with practice, even in an ageing population, we designed a serious game, named CityQuest, to train typical, everyday multisensory processes including sensori-motor control, spatial navigation, obstacle avoidance and balance control. Played over several sessions, this game was shown to improve these functions in older adults with and without a history of falls, depending on the specific condition of the game on which they were trained. Here, using voxel-based morphometry analysis of anatomical magnetic resonance imaging (MRI) data, we investigated structural changes in the brain of a smaller group of older adults from those who successfully completed this five-week intervention. A grey-matter (GM) volume increase in the precentral gyrus, and GM volume reduction in the inferior temporal and orbitofrontal gyri, was found for all participants. Changes in GM volume within regions of the cerebellum were differentially associated with fall-prone and healthy older adults. Furthermore, a greater GM volume increase in the precentral gyrus was observed in participants who performed the full CityQuest intervention relative to those required to avoid obstacles only. Our results support previous evidence that multisensory training can affect structural changes in the older brain and have implications for programmes designed for the successful rehabilitation of perceptual and cognitive functions.

Hindfoot Arthrodesis for the Elective and Posttraumatic Foot Deformity.

Triple (talonavicular, subtalar, and calcaneocuboid) joint arthrodesis and most recently double (talonavicular and subtalar) joint arthrodesis have been well proposed in the literature for surgical repair of the elective, posttraumatic, and/or neuropathic hindfoot deformities. The articulation of the hindfoot with the ankle and midfoot is multiaxial, and arthrodesis of these joints can significantly alter the lower extremity biomechanical manifestations by providing anatomic correction and alignment. This article reviews the indications and preoperative planning for some of the most common procedures to address the hindfoot deformity.

Operative Fixation Options for Elective and Diabetic Ankle Arthrodesis.

Ankle arthrodesis remains one of the most definitive treatment options for end-stage arthritis, paralysis, posttraumatic and postinfectious conditions, failed total ankle arthroplasty, and severe deformities. The general aims of ankle arthrodesis are to decrease pain and instability, correct the accompanying deformity, and create a stable plantigrade foot. Several surgical approaches have been reported for ankle arthrodesis with internal fixation options. External fixation has also evolved for ankle arthrodesis in certain clinical scenarios. This article provides a comprehensive analysis of midterm to long-term outcomes for ankle arthrodesis using internal and/or external fixation each for elective and diabetic conditions.

Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

PURPOSE: To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD). METHODS: This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration. RECOMMENDATION 1: Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III. RECOMMENDATION 2: Clinicians should assess prognostic factors for delayed recovery from NAD. RECOMMENDATION 3: Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care. RECOMMENDATION 4: For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat. RECOMMENDATION 5: For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections. RECOMMENDATION 6: For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

Tibialis Anterior Tendon Transfer for Posterior Tibial Tendon Insufficiency.

The Cobb procedure is useful for addressing stage 2 posterior tibial tendon dysfunction and is often accompanied by a medial displacement calcaneal osteotomy and/or lateral column lengthening. The Cobb procedure can also be combined with selected medial column arthrodesis and realignment osteotomies along with equinus correction when indicated.

Health-care interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development.

AIMS: This paper provides a concise review of the efficacy, effectiveness and affordability of health-care interventions to promote and assist tobacco cessation, in order to inform national guideline development and assist countries in planning their provision of tobacco cessation support. METHODS: Cochrane reviews of randomized controlled trials (RCTs) of major health-care tobacco cessation interventions were used to derive efficacy estimates in terms of percentage-point increases relative to comparison conditions in 6-12-month continuous abstinence rates. This was combined with analysis and evidence from 'real world' studies to form a judgement on the probable effectiveness of each intervention in different settings. The affordability of each intervention was assessed for exemplar countries in each World Bank income category (low, lower middle, upper middle, high). Based on World Health Organization (WHO) criteria, an intervention was judged as affordable for a given income category if the estimated extra cost of saving a life-year was less than or equal to the per-capita gross domestic product for that category of country. RESULTS: Brief advice from a health-care worker given opportunistically to smokers attending health-care services can promote smoking cessation, and is affordable for countries in all World Bank income categories (i.e. globally). Proactive telephone support, automated text messaging programmes and printed self-help materials can assist smokers wanting help with a quit attempt and are affordable globally. Multi-session, face-to-face behavioural support can increase quit success for cigarettes and smokeless tobacco and is affordable in middle- and high-income countries. Nicotine replacement therapy, bupropion, nortriptyline, varenicline and cytisine can all aid quitting smoking when given with at least some behavioural support; of these, cytisine and nortriptyline are affordable globally. CONCLUSIONS: Brief advice from a health-care worker, telephone helplines, automated text messaging, printed self-help materials, cytisine and nortriptyline are globally affordable health-care interventions to promote and assist smoking cessation. Evidence on smokeless tobacco cessation suggests that face-to-face behavioural support and varenicline can promote cessation.

The sound-induced flash illusion reveals dissociable age-related effects in multisensory integration.

While aging can lead to significant declines in perceptual and cognitive function, the effects of age on multisensory integration, the process in which the brain combines information across the senses, are less clear. Recent reports suggest that older adults are susceptible to the sound-induced flash illusion (Shams et al., 2000) across a much wider range of temporal asynchronies than younger adults (Setti et al., 2011). To assess whether this cost for multisensory integration is a general phenomenon of combining asynchronous audiovisual input, we compared the time courses of two variants of the sound-induced flash illusion in young and older adults: the fission illusion, where one flash accompanied by two beeps appears as two flashes, and the fusion illusion, where two flashes accompanied by one beep appear as one flash. Twenty-five younger (18-30 years) and older (65+ years) adults were required to report whether they perceived one or two flashes, whilst ignoring irrelevant auditory beeps, in bimodal trials where auditory and visual stimuli were separated by one of six stimulus onset asynchronies (SOAs). There was a marked difference in the pattern of results for the two variants of the illusion. In conditions known to produce the fission illusion, older adults were significantly more susceptible to the illusion at longer SOAs compared to younger participants. In contrast, the performance of the younger and older groups was almost identical in conditions known to produce the fusion illusion. This surprising difference between sound-induced fission and fusion in older adults suggests dissociable age-related effects in multisensory integration, consistent with the idea that these illusions are mediated by distinct neural mechanisms.

Diabetic charcot neuroarthropathy of the foot and ankle with osteomyelitis.

One of the most devastating foot and/or ankle complications in the diabetic population with peripheral neuropathy is the presence of Charcot neuroarthropathy (CN). In recent years, diabetic limb salvage has been attempted more frequently as opposed to major lower extremity amputation for CN of the foot and ankle with ulceration and/or deep infection. Treatment strategies for osteomyelitis in the diabetic population have evolved. This article reviews some of the most common surgical strategies recommended for the diabetic patient with CN of the foot and/or ankle and concomitant osteomyelitis.

Surgical treatment of intra-articular calcaneal fractures.

Most intra-articular calcaneal fractures are a result of high-energy trauma. The operative management of calcaneal fractures has been based on achieving anatomic reduction and minimizing complications of the compromised soft tissue envelope. The traditional extensile lateral approach offers advantages of achieving adequate fracture reduction with the risk of wound-healing complications and infection. Limited open reduction and internal fixation techniques with or without using external fixation focuses on achieving fracture reduction with less risk of wound complications but higher risk of malunion. This article discusses key points of operative management for various intra-articular calcaneal fracture patterns and clinical presentations.

Surgical treatment of tibial plafond fractures.

Intra-articular fractures of the tibial plafond are typically the result of rotational or axial loading forces, and both mechanisms of injuries can result in an associated fibula fracture. Rotational distal tibial plafond fractures are typically of lower energy and are associated with less articular injury and chondral impaction, whereas axial load injuries of the distal tibial plafond are associated with a higher incidence of intra-articular and soft tissue injury. The goal of this article is to review the mechanisms of injury, fracture patterns, and potential complications associated with the most common presentations of tibial plafond fractures.

Supramalleolar osteotomy and ankle arthrodiastasis for juvenile posttraumatic ankle arthritis.

Numerous techniques have been described for posttraumatic ankle arthritis with or without an associated lower extremity deformity in the adult population. These surgical procedures may include, but are not limited to, ankle exostectomy with joint resurfacing, ankle arthrodiastasis, ankle arthroplasty, and ankle arthrodesis. Associated deformities may also be addressed with supramalleolar osteotomies, tibia or fibular lengthening, and calcaneal osteotomies. In juvenile patients, surgical treatment options for posttraumatic ankle arthritis can be challenging, especially when an associated deformity is present. This article describes a combined supramalleolar osteotomy and ankle arthrodiastasis for a juvenile patient with posttraumatic ankle arthritis and valgus deformity.