The symptomatic adult flatfoot: Is there a relationship between severity and degree of pre-existing arthritis in the foot and ankle?

BACKGROUND: The acquired adult flatfoot deformity (AFFD) is a potentially debilitating foot condition with a prevalence thought to be between 3 %-10 %. To the authors' best knowledge, no association has been described between severity of AFFD and degree of pre-existing ankle or foot arthritis. The degree and pattern of preexisting ipsilateral arthritis of the foot and ankle was investigated in those with symptomatic AFFD presenting to hospital. METHODS: Retrospective observational study between May 2015 and May 2018, of patients who presented to our tertiary clinic with symptomatic AFFD. Radiographs of one hundred and forty-eight (n=148) patients were reviewed, excluding those with charcot arthropathy, previous trauma or coalition. The primary outcome measure was severity of OA in the ankle, subtalar, talonavicular and calcaneocuboid joints. Secondary outcome was severity of radiographic planovalgus deformity. The independant variables used were age and severity of planovalgus deformity as measured by the Meary angle, calcaneal pitch and medial cuneiform-fifth metatarsal height. A linear regression model was carried out on the outcomes. RESULTS: Median age was 60.0 years (IQR 22). There were 56 males to 92 females, with 75 left sided deformities observed and 73 right sided. With increasing severity of planovalgus measurements, there was no significant association observed in severity of arthritis in the ankle joint (p = 0.766), subtalar joint (p = 0.090), talonavicular joint (p = 0.256) and calcaneocuboid joint (p = 0.091). With increasing age, there was significance observed in degree of ankle arthritis, subtalar, talonavicular and calcaneocuboid joints (p = 0.001). There was no significant correlation observed with age for the angular break of Meary's line (p = 0.73), calcaneal pitch (0.262) and medial cuneiform-fifth metatarsal height (p = 0.937). CONCLUSION: This observational study shows no significant association between severity of radiographic planovalgus deformity and pre-existing arthritis of the ankle, hindfoot and midtarsal joints.

Functional outcome of fifth metatarsal fractures.

INTRODUCTION: Fifth metatarsal fractures are common and the outcome has been reported; however, prospective studies reporting the functional outcome using validated questionnaires are lacking in the literature. The aims of this study were to determine whether fifth metatarsal fractures remain symptomatic in the medium term and whether the fracture type influences outcome. METHODS: Over the course of a year, 117 patients (62 avulsion fractures, 26 Jones fractures, 29 shaft fractures) were followed up (1 month, 4 months, 12 months), with functional outcome assessed using the Foot Function Index (FFI)- and Short Form 36 (SF36)-validated questionnaires. RESULTS: The FFI reduced (function improved) over the course of the year from 22.0 (8.4-38.5) at 1 month to 0.0 (0.0-4.2) at 4 months, to 0.0 (0.0-1.3) at 1 year. There was no significant difference in the FFI scores with regard to gender or fracture type. Pain scores were also observed to decline over the year, with no significant differences between fracture types. However, while the severity of pain was low, the numbers of people reporting pain were relatively high. At 1 month, >80% of patients reported ongoing pain (83% avulsion, 88% Jones and 83% shaft), reducing to 38% at 4 months and 28% at 1 year. At final follow-up, 25% with an avulsion fracture, 28% with a Jones fracture and 33% with a shaft fracture reported pain. CONCLUSIONS: While 25-33% of patients continue to experience pain at 1 year, <10% experience any limitation of their activities. At the final follow-up at 1 year, there were no significant differences in functional outcome by fracture type, gender or patient age. Patients should be advised about the likelihood of ongoing low-level symptoms, even after a year from injury in this previously presumed innocuous injury.

Retrograde nailing for supracondylar fracture around total knee replacement: a compatibility study using the Trigen supracondylar nail.

The incidence of periprosthetic supracondylar femoral fractures around total knee arthroplasties (TKRs) is increasing. An acceptable treatment is to insert a supracondylar nail, but not all TKRs will permit this. An unofficial table of compatibilities is available from Smith and Nephew, but this has not been peer reviewed. We ascertained the ten most common TKR prostheses currently used in the United Kingdom from the National Joint Registry (NJR) Report published in September 2005. We used samples of each prosthesis with a saw bone model and checked their compatibility for accepting a Trigen supracondylar nail. We present the dimensions of the intercondylar notches of the top ten TKR prostheses and our reference chart demonstrates which of these are suitable for use with supracondylar nails. We have found that the notch position, rather than the notch size, was the most important factor in determining nail compatibility. Most of the TKRs commonly used in the UK will allow supracondylar nailing for fixation of periprosthetic fractures. There are, however, notable exceptions and our chart provides a quick and easy reference for knee surgeons involved in these cases.

The use of the long gamma nail in proximal femoral fractures.

The results of 100 'Long Gamma Nails' (LGN) inserted in 97 patients, for the treatment of complex proximal femoral fractures and pathological lesions, are reported. The mean patient age was 74 (16-98). Seven significant complications occurred; four lag screws cut out, one broken nail, one infected non-union and one peri-prosthetic fracture. Five patients underwent revision either to total hip arthroplasty or exchange nailing. Seventy patients had follow-up of greater than 2 months (mean 10.8 months). Success was defined as stability of the fracture until union or death; this was achieved in 85% of cases. The mortality was 10% at 30 days and 25% at 1 year. The complication rate fell with increasing experience. Complex proximal femoral fractures are difficult to treat with all implants demonstrating high complication rates. The long gamma nail allowed early weight bearing and was effective in 85% of cases. Malpositioning of the implant should be avoided, as this was the leading cause of failure. Surgeon experience is an important factor but training of surgeons does not adversely affect outcome.

Arthroscopic treatment of osteochondral lesions of the talus.

We reviewed, retrospectively, 65 patients who had undergone arthroscopic treatment for osteochondral lesions of the talus. The 46 men and 19 women with a mean age at operation of 34.25 years, were followed up for a mean of 3.5 years. The medial aspect was affected in 45 patients and the lateral aspect in 20. All the lateral lesions and 35 (75%) of the medial lesions were traumatic in origin. Medial lesions presented later than lateral lesions (3 v 1.5 years) and had a much greater incidence of cystic change (46% v 8%). At follow-up, 34 patients had achieved a good result, and 17 and 14 fair and poor results, respectively. Of the 14 poor results, 13 involved medial lesions. Cystic lesions had a poor outcome in 53% of patients. Excision and curettage led to better results than excision and drilling of the base. Further arthroscopic surgery for patients with a poor result was disappointing. There was no association between outcome and the patient's age.

Atomic structure of a glycerol channel and implications for substrate permeation in aqua(glycero)porins.

The structure of a glycerol channel from Escherichia coli at 2.2 A resolution serves as a basis for the understanding of selective transmembrane substrate permeation. In the course of permeation, glycerol molecules diffuse through a tripathic channel with their alkyl backbone wedged against a hydrophobic corner, such that OH groups become acceptors and donors of hydrogen bonds at the same time. The structure of the channel explains the preferential permeability for linear carbohydrates and absolute exclusion of ions and charged solutes. Its gene-duplicated sequence has a structural counterpart in a pseudo two-fold symmetry within the monomeric channel protein.

Eponyms - are they relevant?

This study was performed to investigate the value of eponyms of fractures amongst orthopaedic/casualty trainees. Our results show eponyms are not favoured.

Current UK opinion on thromboprophylaxis in orthopaedic surgery: its use in routine total hip and knee arthroplasty.

We surveyed all surgically qualified members of the British Orthopaedic Association as to their views on thromboprophylaxis in routine total hip and knee replacement. The response rate was 92%. In total hip replacement, 13-15% of surgeons used no method of prophylaxis at all, 18-22% did not use a mechanical method of prophylaxis, while 26% did not use a pharamacological agent; 36% believed low-dose anticoagulant thromboprophylaxis to be a medicolegal necessity while 47% disagreed with this. In total knee replacement, 18-33% of surgeons used no method of prophylaxis at all, 20-26% did not use a mechanical method of prophylaxis, while 54-58% did not use a pharmacological agent; 12 believed low-dose anticoagulant thromboprophylaxis to be a medicolegal necessity, while 64% disagreed with this. We conclude that mechanical methods remain a popular method of thromboprophylaxis and pharmacological methods, while commonly used, are not seen as a medicolegal requirement in lower limb arthroplasty and are used less often in total knee replacement.

An orthopaedic theatre timings survey.

The efficient use of operating lists is important to clear waiting lists and because they are expensive to run (at 1988 prices, 151 pounds per hour). Of general surgical theatre session time, 49% is used for performing operations, but no survey of orthopaedic theatre sessions has been published. In light of this we surveyed 151 elective orthopaedic lists at three hospitals. Our aims were to determine the use of operating rooms and the reasons for inefficient use of time. We found 60% of elective list time was used for operating and 21% for turnover. No useful activity occurred during the remaining 19% of theatre time. An average start delay of 26.5 min and average early finish of 14.5 min contributed to this. Only 9/151 (6%) of lists started within 5 min of the scheduled time. Of unnecessary delays contributing to this, 63% involved anaesthetic staff and 24% theatre staff. Surgeons were implicated in 10% of start delays. There were less start delays if senior anaesthetic staff were present. During lists, turnover times were quicker if a consultant surgeon was present (P = 0.0022). We conclude that more efficient use of elective orthopaedic theatre sessions is possible and could be achieved if more detailed preparation was undertaken by the anaesthetic, theatre and surgical staff concerned. If a consultant surgeon is present the list is likely to proceed with fewer delays.

Who should code orthopaedic inpatients? A comparison of junior hospital doctors and coding clerks.

Our principal aim was to determine whether coding for billing purposes is adequately completed by hospital doctors. We also wanted to determine whether events during the inpatient stay prompted coding. We investigated the completeness and accuracy of ICD9 and OPCS4 coding at two departments of orthopaedics. Coding was for billing purposes only; retrieval of clinical data was limited to individual cases. Junior Hospital Doctors (JHDs) undertook coding at one department, coding clerks at the other. At each side 100 sets of notes concerning inpatient admissions were reviewed. Coding clerks returned coding data of higher completeness and quality (completeness x accuracy) than JHDs, but of lower accuracy. Completeness of data from JHDs reflected motivation to code and this was influenced by events during the course of admission. JHDs coded best for patients undergoing elective surgery, and worst for patients managed non-operatively. Coding clerks coded for all groups equally well. In the current study coding data returned by JHDs was of lower completeness and accuracy than has been described for other coding systems. We attribute the lower completeness to the low motivation of JHDs when coding for billing purposes and the lower accuracy to difficulty in using the system. Motivation could be increased by incorporating coding into departmental audit, the generation of discharge summaries and record collection for personal logbooks.

Ultrastructural cytochemistry: effect of Sorbinil on arylsulfatases in cataractous lenses.

We have demonstrated an increase in activity of arylsulfatase A and B during galactose induced cataract development in rats. Our recent investigation shows that acid phosphatase activity, which increases substantially during galactose cataract development in rats, could be contained to near normal level if Sorbinil, an aldose reductase inhibitor, was fed along with galactose to the rat. We have observed that the activity of other lysosomal enzymes, arylsulfatase A and/or B, also increases during galactose cataractogenesis. In the present report, we provide information with regards to the effect of Sorbinil on the activity of these enzymes during cataractogenesis. A modified Hopsu-Havu and Helminen method (1974) with p-nitrocatecholsulfate as substrate was used for localization of both arylsulfatase A and B; and the method of Hara et al. (1979) was utilized to obtain quantitative data on the level of arylsulfatase A and B activity. Ultrastructural cytochemistry shows that arylsulfatase activity in all lenses was primarily localized in epithelial cells in lysosomes with very little or no activity in cortical fibers. The number of arylsulfatase positive lysosomes and the activity level of these enzymes increased with the progression of cataract development. Galactose induced damage to lens morphology and increase in activity of arylsulfatase A and B was inhibited by inclusion of 50mg/Kg (diet) Sorbinil in the galactose containing cataractogenic diet. However, Sorbinil had no significant effect on the enzyme activity following the establishment of mature cataracts.

"Shaker" calf syndrome: a newly recognized inherited neurodegenerative disorder of horned Hereford calves.

The clinical and pathological features of a newly recognized, inherited neurodegenerative disorder in horned Hereford calves are described. The disorder is expressed in newborns by tremulous shaking of the head, body and tail, difficulty in rising, a wobbly spastic gait, and aphonia. Transient improvement is followed by deterioration and progressive spastic paraplegia. Generalized tremors can be induced easily by a variety of stimuli, and spinal reflexes may be exaggerated or depressed. The major pathological finding is an excessive accumulation of neurofilaments within neurons of the central, peripheral, and autonomic nervous systems. The involvement of multiple systems of neurons and the similarity with some forms of human motor neuron disease and spinocerebellar degeneration suggest that this unique bovine disease may serve as a suitable animal model for these human neurodegenerative disorders.

Acid phosphatase II. Cytochemical localization in lenses of normal and galactose-fed rats.

Previous cytochemical and biochemical studies have shown an increase in the activity of acid phosphatase and arylsulfatase during the induction of galactose cataracts in rat lenses. It was postulated that these enzymes may be involved in lens fiber degradation observed during cataractogenesis, however, the role of these enzymes in the repair process was not ruled out. The present investigation has evaluated the level of acid phosphatase activity in lenses in which the induction of opacity is inhibited with the aldose reductase inhibitor sorbinil and during the recovery of galactose induced opacity. Sprague-Dawley rats received 50% galactose diet, or galactose diet with sorbinil, or laboratory chow diet. Following 20 days on this diet all rats received lab chow plus 50 mg kg-1 sorbinil (recovery diet). The lenses were removed at desired intervals following the initiation of the above three diets and following the transfer of animals to the recovery diet. Cytochemical localization and biochemical quantitation of acid phosphatase activity were performed with methods previously reported. Most of the enzyme activity was localized within the epithelial cells and superficial cortical fibers. In the epithelial cell layer, the enzyme activity was primarily localized in lysosomes and at extracellular sites near the epithelial cell membrane which abut each other and cortical fibers. In cortical fibers the enzyme activity was observed at various extracellular sites between the cell membranes of neighboring fibers. The effect of sorbinil, if any, and the possible role of acid hydrolases in the repair process during cataract reversal is discussed.

Clinical signs and pathology of accidental monensin poisoning in sheep.

The clinical signs and postmortem findings in sheep from two flocks accidentally poisoned with monensin are described. Clinical signs began within 24 hours of exposure to monensin. In the acute stages they consisted of lethargy, stiffness, muscular weakness, a stilted gait and recumbency. Feed refusal was seen in one flock but not in the second. Subacute to chronic clinical signs were decreased muscle volume of the rump and thigh. When forced to run, chronically affected sheep had a stilted, stiff legged, rocking horse gait.Gross postmortem changes were not always visible. Where visible, they affected skeletal muscles and consisted of pale streaking, with atrophy in the chronic stages. Lesions were most severe in muscles of the rump and hind limbs. Microscopically myofiber swelling and hyalinization were seen with interstitial mononuclear cell reaction and extensive sarcoplasmic mineralization in some cases. Chronic lesions consisted of fibrosis and myofiber atrophy. In lambs less than one month old, diffuse gastrointestinal hemorrhage was the only finding.

Treatment of feedlot cattle in Alberta for gastrointestinal nematodes.

The effects of a single treatment at entry with three anthelmintics on rates of weight gain and feed conversion efficiency over a 70 day period were studied in 200 feedlot steers. None of the anthelmintic treatments used appeared to confer any improvement in the above parameters under the conditions of this experiment. The results are discussed in relation to routine anthelmintic treatment in western Canada.