Distal soft tissue correction for hallux valgus with proximal screw fixation of the first metatarsal.

These early results with short-term to medium-term followup demonstrate the effectiveness of this distal soft tissue procedure with proximal realignment in a subset of patients with moderate to severe hallux valgus and mobility of the first ray. With up to 2-year followup, the correction seems to hold with no significant recurrence and only mild increases in the hallux valgus and intermetatarsal angles with time. Obviously, longer-term followup with a larger group of patients is needed, but these early results are encouraging. In this group of patients, this procedure provides reliable correction of hallux valgus while possibly avoiding some of the morbidity of the different procedures for proximal osteotomy.

Pigmented villonodular synovitis of the ankle: a case report and review of the literature.

Pigmented villonodular synovitis is an unusual benign tumor of the joint lining. It is most common in the knee, but occasionally occurs in the ankle. It can present with pain and swelling of the joint. The appearance is characteristic on a magnetic resonance imaging scan. Complete excision and synovectomy is the usual treatment.

Surgical treatment for primary interdigital neuroma.

We studied 366 feet in 313 patients who underwent surgical treatment for a primary interdigital neuroma through a dorsal web-splitting incision. Three hundred five feet in 259 patients were available for follow up, which averaged 5.9 years (range: 2.8 to 13); 45.2% of these patients were completely satisfied, 33.8% were satisfied with minor reservations, 9.2% were satisfied with major reservations, and 11.8% were dissatisfied after the surgical procedure. Patient satisfaction was directly related to the size of the neuroma found at the time of operation. Bilateral procedures were associated with a higher rate of dissatisfaction. The third web space accounted for 91% of the neuromas.

Rotational osteotomy for proximal femoral focal deficiency.

Thirteen patients who had a proximal femoral focal deficiency and were treated with a rotational osteotomy of the tibia (Van Nes procedure) were evaluated at an average of five years after operation. Five patients needed a repeat osteotomy of the tibia: four because the limb had spontaneously derotated toward the original position and one because the limb had had insufficient rotation at the time of operation. One patient had a disarticulation at the ankle after the first stage of a planned two-stage procedure because the mother was not happy with the child's appearance. In ten limbs, the distal femoral growth plate and epiphysis were removed and in two, the femoral epiphysis and growth plate and the tibial growth plate were removed so that the joint of the prosthetic knee would be positioned at the proper height at the completion of the child's growth. Neither growth plate was removed from one limb, the shorter one in the child who had bilateral involvement. A ten-point grading scale based on use and fit of the prosthesis, gait, range of motion of the ankle, use of external support, and final height of the ankle compared with that of the contralateral knee was used to evaluate the result, which was excellent in six patients, good in four, fair in one, and poor in one. One patient, who had a disarticulation at the ankle, was excluded from the final evaluation. Rotational osteotomy provided good function and acceptable cosmetic appearance in the patients who had unilateral involvement.

Warfarin prophylaxis to prevent mortality from pulmonary embolism after total hip replacement.

Between 1970 and 1987, 3000 total hip replacements were performed at the University of California at Los Angeles, and all patients were given warfarin prophylactically, in conjunction with early postoperative elevation of the lower limb in balanced suspension and the application of elastic hose. Since 1973, the first dose of warfarin has been given on the night of the operation, and the prothrombin time has been maintained between sixteen and eighteen seconds. A pulmonary embolism occurred after fourteen (0.5 per cent) of the 3000 operations. It was never fatal. Bleeding occurred after forty-four operations (1.5 per cent). The effectiveness of the protocol of the University of California at Los Angeles was demonstrated in a large number of patients over a seventeen-year period. Since 1974, the protocol has included closer monitoring of the prothrombin time. After 2595 hip replacements that were done between 1974 and 1987, the rate of pulmonary embolism was 0.2 per cent and the rate of bleeding complications was 1.0 per cent. However, recently a higher incidence of bleeding complications (2.3 per cent) has been noted after non-cemented total hip (stem-type) replacement.

Deleterious influence of hypothyroidism on evolving myocardial infarction in conscious dogs.

To study the influence of hypometabolism on evolving myocardial infarction in a model with intact autoregulation, we investigated 53 awake dogs after coronary artery occlusion. Severe hypothyroidism was induced by the intravenous administration of 131I. Animals were instrumented to obtain hemodynamic measurements, and regional myocardial blood flow was measured with radioactive microspheres. Infarct size was determined by the creatine kinase depletion method, and dysrhythmia analysis was performed from 24-h Holter monitor tapes in animals matched for infarct size. The microarchitecture of hypothyroid myocardium was determined by the electron microscope. Before coronary occlusion, mean systemic pressure in hypothyroid dogs was reduced by 14% and cardiac output reduced by 32%, with no change in left ventricular end-diastolic pressure, first derivative of left ventricular pressure rise, (dP/dt), or heart rate. After coronary occlusion, there was deterioration in hemodynamic measurements in both groups, with lower absolute levels of mean systemic blood pressure and cardiac output obtained in hypothyroid dogs. Hypothyroidism was detrimental to evolving infarction with a 36% increase in infarct size present in hypothyroid dogs (30 +/- 2%) compared to euthyroid controls (22 +/- 3%), P less than 0.05. Dysrhythmias were more severe in hypothyroid dogs. There were no changes in the relationship between regional myocardial blood flow and the extent of infarction after coronary occlusion. Abnormalities in microarchitecture were present in hypothyroid dog myocardium. Severe hypometabolism in this model was associated with alterations in hemodynamics, more severe dysrhythmias and changes in microarchitecture. The combined effect of these alterations resulted in an overall detrimental influence of hypothyroidism on evolving myocardial necrosis in this model.