Patient Satisfaction and Pain Relief After Deep Peroneal Nerve Neurectomy for Midfoot Arthritis: A Preliminary Short Report.

BACKGROUND: The deep peroneal nerve (DPN) plays a role in afferent nociceptive dorsal midfoot joint pain perception. DPN neurectomy for treatment of symptomatic dorsal midfoot osteoarthritis allows early mobilization and weightbearing. The purpose of our study was to evaluate the patient satisfaction and pain relief after DPN neurectomy for treatment of chronic dorsal midfoot pain due to osteoarthritis. METHODS: In this retrospective, IRB-approved, questionnaire-based study, we evaluated 48 patients (55 feet) with an average follow-up of 35.1 (range, 16-51) months who underwent DPN neurectomy at our institution between September 2017 and February 2021. There were 38 women and 10 men, 41 unilateral (22 right, 19 left) and 7 bilateral procedures, with an average age of 67.8 (range, 35-88) years at the time of surgery. A questionnaire that included questions regarding postsurgical dorsal midfoot pain relief, surgical result satisfaction, and current functional limitations was administered via telephone. Demographic information, patient responses, and complications were recorded. RESULTS: Of the 48 patients, 80.8% were satisfied with the result of the surgery in relieving their dorsal midfoot pain, 84.6% would repeat the surgery under the same circumstances, 83.8% would recommend the surgery to a friend, 10.4% reported they wish they had undergone arthrodesis, 91.7% reported pain relief in the first 6 months, and 55.6% reported current activity limitations. Six feet (10.9%) underwent a second procedure with an average postoperative time of 20.5 (range, 1-36) months. Complications included 1 hematoma and deep wound infection, 1 DPN neuroma and superficial peroneal nerve entrapment, and 4 patients with inadequate pain relief. CONCLUSION: In this cohort, DPN neurectomy appeared to be a reasonable surgical alternative to arthrodesis for the management of chronic dorsal midfoot pain due to midfoot osteoarthritis after failed nonoperative management. LEVEL OF EVIDENCE: Level IV, retrospective case series.

A Retrospective Study Characterizing the Radiographic Progression of Hallux Valgus.

BACKGROUND: Hallux valgus deformity is the lateral deviation of the metatarsophalangeal (MTP) joint and is the most common pathology of the great toe, affecting 2%-4% of the population. It is commonly believed that the condition progresses over time both in the magnitude of deformity and development of arthritic changes. To our knowledge, there are rare studies describing the rate of deformity progression and the development of arthritic changes. Our aim is to quantify the progression of hallux valgus and associated arthritic changes in an adult population using radiographs. METHODS: Patients who are 18 years of age and older (mean age: 61.7 years and range: 18.6-94.2) who presented to our institutions between January 1, 2004, and December 1, 2019, were included. Patients were included in the study if they had hallux valgus on weight-bearing radiographs and two such radiographs at least six months apart. Hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsophalangeal (MTP) arthritis, tarsometatarsal (TMT) osteoarthritis, Hardy-Clapham sesamoid position, and round sign were collected per patient in the initial and final radiographs. Included cases were first studied together in a whole group. Then, cases were separated into three groups based on the time between initial and final radiographs. RESULTS: A total of 52 radiographic records for 43 patients were included. HVA and IMA progress with time; however, progression does not follow a direct relationship with the time elapsed between initial and final radiographs (p = 0.92 and p = 0.35, respectively). The progression of TMT osteoarthritis, sesamoid position, and round sign do not show a dependence on the time elapsed (p = 0.20, p = 0.11, and p = 0.42, respectively). An increase of one sesamoid unit position over baseline is associated with a 0.85-degree increase in IMA. A one-unit progression of sesamoid position at baseline raises the odds of MTP osteoarthritis progression at the follow-up visit by 2.14 (OR = 2.14, p = 0.0007, CI = [1.35, 3.83]). A HVA increase of one degree increases the odds of TMT osteoarthritis progression at follow-up by a factor of 1.17 (OR = 1.17, p = 0.0005, CI = [1.07, 1.34]). Patients with MTP arthritis at the initial visit have 3.77 times higher odds of round sign progression on their follow-up visit (OR = 3.77, p = 0.027, CI = [1.16, 13.13]). DISCUSSION: Hallux valgus progression can be quantified. Upon their first visit, a patient's hallux valgus parameters can be utilized to demonstrate expected progression. Progression of the deformity and arthritic changes is slow. Nonetheless, the results should be considered by surgeons and patients when developing a treatment plan with patients.

Understanding Patient Preference of Providers to Treat Foot and Ankle Disorders.

Objective: The purpose of this study is to evaluate patients' knowledge of the professional training between doctors of podiatric medicine (DPM) and orthopedic surgery doctors (MD or DO), patients' confidence in understanding these differences, and factors that are important to patients when selecting a provider.Design: A 28-question survey was administered to new patients who were referred to the foot and ankle service in an orthopedic department. Survey questions included data on patient demographics, patient opinion, and knowledge of differences between podiatrists and orthopedic surgeons.Setting: Patient surveys were administered at Froedtert Memorial Lutheran Hospital in Wauwatosa, Wisconsin USA and Mayo Clinic in Jacksonville, Florida USA.Participants: 186 patients completed the survey.Methods: Study population characteristics and survey results were analyzed with variance (ANOVA), Fisher's Exact test, binomial tests, and chi-square tests.Results: Of the 186 patients who completed the entire survey, 108 chose "orthopedic surgeon" as their provider of preference for any foot or ankle injury. Patients preferred an orthopedic surgeon over a DPM for ankle (65.7% vs. 9.6%, P<0.01) and knee injuries (86.0% vs. 5.0%, P<0.01), while they preferred a DPM for toe pain (29.4% vs. 42.2%, P<0.03). 80.8% of patients thought orthopaedic surgeons and podiatrists undergo the same professional training.Conclusions: Patients have poor understanding of the different provider training between a DPM and orthopedic surgeon. Patients showed a preference based on anatomic location with podiatrist favored for conditions affecting the toes. Those patients that demonstrate a higher level of knowledge of the specialties were more likely to prefer an orthopaedic surgeon. Other factors, such as physician interpersonal skills and provider availability, may be more important for patients than training backgrounds.

Multi-segment foot kinematics during gait following ankle arthroplasty.

Ankle arthritis is a debilitating disease marked by pain and limited function. Total ankle arthroplasty improves pain while preserving motion and offers an alternative to the traditional treatment of ankle fusion. Gait analysis and functional outcomes tools can provide an objective balanced analysis of ankle replacement for the treatment of ankle arthritis. Twenty-nine patients with end-stage ankle arthritis were evaluated before and after ankle arthroplasty. Multi-segment foot and ankle kinematics were assessed annually following surgery (average 3.5 years, range 1-6 years) using the Milwaukee Foot Model and a Vicon video motion analysis system. Functional outcomes (American Orthopedic Foot and Ankle Society [AOFAS] ankle/hindfoot scale, short form 36 [SF-36] questionnaire) and temporal-spatial parameters were also assessed. Kinematic results were compared to findings from a previously collected group of healthy ambulators. AOFAS and SF-36 mean scores improved postoperatively. Walking speed and stride length increased after surgery. There were significant improvements in tibial sagittal range of motion in terminal stance and hindfoot sagittal range of motion in preswing. Decreased external rotation of the tibia and increased external rotation of the hindfoot were noted throughout the gait cycle. Pain and function improved after ankle replacement as supported by better outcomes scores, increased temporal-spatial parameters, and significant improvement in tibial sagittal range of motion during terminal stance and hindfoot sagittal range of motion during preswing. While multi-segment foot kinematics were improved, they were not restored to control values. Statement of clinical significance: Total ankle arthroplasty does not fully normalize mutli-segment gait kinematics despite improved patient-reported outcomes and gait mechanics.

Safety and Efficacy of Using Fracture Tables for Prosthetic Hip Dislocations.

The incidence of prosthetic hip dislocation continues to increase because of the overall increase in volume of total hip replacement surgery. Closed reduction is often the preferred treatment, particularly in the first few months after surgery. No matter the closed reduction technique, linear traction is a requirement, thus posing a physically demanding stress opening both surgeon and patient to potential injury. We describe a fracture table closed reduction technique along with outcomes and safety data for a sample of patients. In all 10 reduction procedures, reduction was achieved quickly and without fracture or anesthetic complication. The use of a fracture table for reduction of prosthetic hip dislocation is a viable option, particularly when the surgeon may not have the physical requirements and/or qualified assistance necessary for reduction in the emergency department.

[Type 1 diabetes mellitus and Graves Basedow's disease, a case of Autoimmune Polyglandular Syndrome]. / Diabetes mellitus tipo 1 y enfermedad de Graves Basedow, un caso de Síndrome Poliglandular Autoinmune.

INTRODUCTION: Type 1 diabetes mellitus (T1DM) is one of the most frequent autoimmune diseases in childhood. Its diagnosis requires the search for other autoimmune diseases. OBJECTIVE: to present the case of a pediatric patient with two rare concomitant autoimmune endocrine diseases. CLINICAL CASE: A 12-year-old male with no significant morbid history, is hospitalized due to a 3-month clinical pic ture of fatigue, eye pain, intermittent eyelid edema, goiter, polyphagia, polydipsia, polyuria, and weight loss (12 kilograms), compatible with T1DM and Graves-Basedow disease. It was confir med by laboratory tests which showed elevated glycemia (207 mg/dL, HbA1C 10.9%), suppressed TSH (< 0.01 uIU/mL), elevated FT4 (6.99 ng/dL), and the presence of anti-autoantibodies thyroid peroxidase, antithyroglobulin, and anti-TSH receptor, along with suggestive ultrasound findings. Therefore, we established the diagnosis of autoimmune polyglandular syndrome (APS) 3A and initiated treatment with insulin, propranolol, and thiamazole. The patient evolved satisfactorily and was discharged with outpatient follow-up. CONCLUSION: We present the case of an adolescent who presented APS due to T1DM and hyperthyroidism. This APS may be more common than is reported in clinical practice. The alteration of two or more endocrine glands or other autoimmune diseases should make us suspect its diagnosis, with important clinical implications, such as co morbidity and quality of life prognosis.

First Tarsometatarsal Joint Loading After Sequential Correction of Hallux Valgus Using a Proximal Opening Wedge Metatarsal Osteotomy and Distal Soft Tissue Procedure.

BACKGROUND: The proximal opening wedge osteotomy (POWO) of the first metatarsal (TMT-1) is commonly performed in the operative treatment of hallux valgus. Limited work has been dedicated to study POWO's effect on the TMT-1 joint, however. The purpose of this study is to evaluate the changes in TMT-1 joint contact stress following POWO of the first metatarsal. METHODS: Five fresh-frozen cadaveric below-knee specimens (mean age: 73 years) with hallux valgus deformities (mean hallux valgus angle [HVA]: 37.4 ± 8.5 degrees) were studied. The specimens were loaded to 400 N on an MTS servohydraulic load frame. Joint contact characteristics at TMT-1 joint were measured with a Tekscan pressure sensor (Model 6900, 1100 psi; Tekscan Inc, Boston, MA) with various opening wedge sizes of 3, 5, and 7 mm both without and with a distal soft tissue release (DSTR). The contact force, area, and peak contact stress were compared among groups using analysis of variance and post hoc multiple comparisons over the untreated (Dunnett test, P < .05). RESULTS: The mean contact force was 47.7 ± 33.5 N for untreated specimens. This increased sequentially with opening wedge size and reached statistical significance for 7-mm opening wedge (129.7 ± 62.3 N, P = .01) and 7-mm wedge + DSTR (134.8 ± 60.5 N, P = .008). The mean peak contact stress was 2.8 ± 1.3 MPa for the untreated specimens and increased incrementally with wedge size to 5.7 ± 3.0 MPa for 7-mm wedge only (P = .03) and 5.6 ± 2.5 MPa for 7-mm wedge + DSTR (P = .05). The contact area increased with corrections, but none reached significance. CONCLUSION: With increasing opening wedge size, loading of the TMT-1 joint increases. Joint stresses higher than 4.7 MPa have been shown to be chondrotoxic, potentially predisposing patients to arthritic joint changes following POWO. LEVEL OF EVIDENCE: XXXXXX.

Factors used in Applicant Ranking of Orthopedic Foot and Ankle Fellowships and the Availability of Online Information.

BACKGROUND: The Internet is often the first resource used by applicants to evaluate fellowship programs. However, information on these websites can be often incomplete, inaccessible, and/or inaccurate. The primary objective of this study was to examine key factors that orthopedic foot and ankle fellowship applicants use to rank programs. The secondary objective was to assess both the accessibility and availability of the information on orthopedic foot and ankle fellowship program websites. METHODS: A Qualtrics survey was distributed via e-mail to those who matched into an orthopedic foot and ankle fellowship position from years 2008-2020. A comprehensive list of orthopedic foot and ankle fellowship programs was created. Program websites were evaluated for accessibility as well as the quality of recruitment and educational content. RESULTS: There were a total of 114 survey responses out of 644 invites (17.7%). The most important factors for establishing a rank list were operative experience, current faculty, and program reputation. Eighty-five percent (41/48) of orthopedic foot and ankle fellowship websites were directly accessible using Google. On average, accessible orthopedic foot and ankle fellowship websites contained only 57% (11.5/20) of the content deemed desirable. CONCLUSION: Orthopedic foot and ankle websites are widely accessible and have higher recruitment and educational quality content scores compared with previously published data. The most important factors for establishing a rank list are consistent with previous literature. Those who ranked operative experience as one of the most important factors when establishing a rank list did not complete more operative cases than those who did not. LEVEL OF EVIDENCE: Level IV.

Ultrasound-guided diagnostic deep peroneal nerve blocks prior to potential neurectomy: a retrospective review.

OBJECTIVE: To describe our technical and preliminary clinical experience with ultrasound-guided diagnostic deep peroneal nerve (DPN) blocks for patients considering deep peroneal neurectomy. MATERIALS AND METHODS: Retrospective analysis of ultrasound-guided diagnostic DPN blocks performed in the anterior lower leg in patients pursuing deep peroneal neurectomy for foot pain not directly attributable to the DPN. Patient age, sex, foot laterality, diagnosis, nerve block complications, location of the DPN with respect to vascular landmarks in the lower leg, pain relief from nerve block, and pain relief from neurectomy (if performed) were recorded. RESULTS: Twenty-six DPN blocks were performed for 25 feet, of which a majority had pain attributable to midfoot osteoarthritis (22/25). Variable DPN locations with respect to vascular landmarks in the lower leg were observed, including lateral to the anterior tibial artery (12/25), anterior to the artery (5/25), medial to the artery (3/25), lateral to the lateral paired vein (4/25), and 1-cm lateral to the artery (1/25). After DPN blocks, patients reported pain relief in 22/25 feet. Of the eleven patients who proceeded to have a deep peroneal neurectomy, ten reported improved foot pain. CONCLUSION: Diagnostic deep peroneal nerve blocks for patients considering deep peroneal neurectomy for denervation therapy should be performed in the anterior lower leg where the anterior tibial vessels serve as anatomic landmarks. Those who perform DPN blocks with ultrasound guidance should be aware of variable DPN position with respect to the vascular landmarks.

An Anatomic and Clinical Study of the Innervation of the Dorsal Midfoot Capsule.

BACKGROUND: Dorsal pain from osteoarthritic midfoot joints is thought to be relayed by branches of the medial and lateral plantar, sural, saphenous, and deep peroneal nerves (DPN). However, there is no consensus on the actual number or pathways of the nervous branches for midfoot joint capsular innervation. This study examined the DPN's terminal branches at the midfoot joint capsules through anatomic dissection and confirmation of their significance in a clinical case series of patients with midfoot pain relief after DPN block. METHODS: Eleven cadaveric lower leg specimens, 6 left and 5 right, were dissected using operative loupe magnification. We preserved the terminal branches and recorded their paths and branching patterns. Joint capsular innervations were individually noted. To confirm our hypothesis of significant dorsal midfoot joint capsular innervation by the DPN, we also performed an institutional review board-approved retrospective chart review of 37 patients with painful dorsal midfoot osteoarthritis who underwent diagnostic local anesthetic injection block of the DPN. The percentage of temporary pain relief after the injection was recorded. RESULTS: Terminal innervation of the DPN branches showed distribution of the second and third tarsometatarsal joints in all specimens. Inconsistent innervation of the naviculocuneiform (9/11), fourth (7/11), first (6/11), and fifth (4/11) tarsometatarsal and calcaneocuboid joints (1/11) were observed. The retrospective review of pain relief in patients with dorsal midfoot pain due to arthritis after diagnostic injection demonstrated a mean of 92.1% improvement. CONCLUSION: Innervation of the dorsal midfoot joint capsule appears to follow a consistent distribution across 3 joints: second and third tarsometatarsal joints and the naviculocuneiform joint. Acute relief of dorsal midfoot arthritic pain after diagnostic injection suggests that dorsal midfoot nociceptive pain is at least partly transmitted by the DPN. LEVEL OF EVIDENCE: Level IV, case series.

Is There a Difference between Ultrasonographic (US) Uterine Changes of Oral Versus Transdermal (TD) 17ß Estradiol (17ß E2) in Girls with Turner Syndrome (TS)? Own Experience and Literature Review.

BACKGROUND: Among patients with Turner Syndrome (TS), premature ovarian failure is a main feature. Recently published consensus guidelines recommend that transdermal (TD) estradiol is the preferred route for estrogen replacement. Studies related to ultrasound (US) measurements during estrogen replacement in TS patients using estradiol (17ß E2) and correlating uterine growth with estrogen metabolites are limited. OBJECTIVES: To compare uterine morphology and hormonal changes depending on route of administration of 17ß E2 (oral vs. TD) in a small population of girls with TS. SUBJECTS: 11 hypogonadal girls with TS (mean (SE) age 14.5 ± 1.4 years; BMI -0.98 ± -1.0 SDS) who participated in a larger study on the effects of oral versus TD 17ß E2 agreed to do a sub-study on the effect of the form of 17ß E2 treatment on uterine size. METHODS: 17ß E2 was given orally or TD for 12 months, titrated to doses up to 2 mg orally or 100 µg TD to achieve normal estradiol levels. Subjects received monthly progesterone for 1 week for withdrawal bleeding. At baseline, 6 and 12 months, a pelvic ultrasound was performed while on estradiol only. RESULTS: Uterine morphology and endometrial thickness increased comparably in both groups. E2 concentrations were comparable at 12 months between both groups but E1 and E1S were lower in TD group at 12 months. CONCLUSIONS: According to our experience, in a group of TS patients randomized to oral vs TD 17ß E2 and monitored with trans-abdominal US, both groups achieved similar increases in uterine size comparable to normal women. To confirm our observation a larger sample and a longer evaluation period is needed.

Intraosseous and extraosseous blood supply to the medial cuneiform: implications for dorsal opening wedge plantarflexion osteotomy.

BACKGROUND: Osteotomies of the medial cuneiform are commonly used to correct forefoot deformity. Bone healing occurs despite periosteal stripping of the dorsal and medial surfaces of this widely articulated bone followed by osteotomy in the midsection of the bone. The objective of this study was to characterize the blood supply of the medial cuneiform. METHODS: Thirty matched pairs of adult cadaver legs, 60 legs total, were amputated below the knee, and arterial casts were created with India ink and latex. Soft tissues were debrided, allowing visualization of the extraosseous blood vessels. In 53 specimens the vascular supply to the medial cuneiform was photographed and recorded. Forty-nine specimens were then cleared using a modified Spälteholz technique. The intraosseous vascularity of the medial cuneiform was successfully characterized and reviewed in 48 of these specimens. RESULTS: The extraosseous blood supply was similar to previous reports with a middle pedicle branch originating from the dorsalis pedis artery. The medial plantar and superficial medial plantar artery supplied the plantar aspect of the bone. Intraosseous analysis showed a dense capillary network throughout the cuneiform, with typically one central medial major and several minor nutrient arteries noted. Areas of hypovascularity were infrequent and when noted occurred at inconsistent locations. CONCLUSION: These findings support the clinical suspicion that the medial cuneiform is well vascularized from multiple sources. The plantar blood supply is likely sufficient to allow bone healing after dorsal periosteal exposure and possible injury to the middle pedicle branch of the distal medial tarsal artery. CLINICAL RELEVANCE: A medial cuneiform opening wedge osteotomy can be used to correct forefoot deformity. This study investigates the blood supply to that bone to better characterize the healing potential of the medial cuneiform.

Geometry of the lateral sliding, closing wedge calcaneal osteotomy: review of the two methods and technical tip to minimize shortening.

BACKGROUND: A lateral closing wedge osteotomy is used for correction of varus hindfoot deformities. Since its original description, different techniques and geometries of the calcaneal bone wedge resection have been described. Even though the techniques seem similar, very different final bone architectures result from each technique, the effects of which are not known. This paper explores several of these techniques and the implications in deformity correction as well as the secondary effects of calcaneal shortening. METHODS: Mathematical and geometric analysis is performed in 2-dimensions for several hypothetical calcaneal osteotomies as described by the original authors. The resulting changes are calculated and compared. RESULTS: The shape of the bone resection for the lateral closing wedge osteotomy does not result in significantly different final calcaneal architectures. Both techniques studied result in the same amount of calcaneal shortening and deformity correction. However, when lateral calcaneal wedge resection is combined with lateral translation of the tuberosity for additional deformity correction, more calcaneal shortening is seen with posteriorly directed osteotomies than those that are transverse. CONCLUSION: The lateral closing wedge osteotomy of the calcaneus results in correction of varus hindfoot deformity at the expense of some calcaneal shortening. Lateral translation of the tuberosity may result in additional calcaneal. The clinical effects of calcaneal shortening or medial soft tissue or nerve tethering from these different techniques are unknown and deserve further investigation. LEVEL OF EVIDENCE: Level V, expert opinion.

High sensitivity C-reactive protein and endothelial function in Chilean patients with history of Kawasaki disease.

Kawasaki disease (KD) produces endothelial inflammation, which may lead to dilatation and aneurysms of coronary and peripheral arteries. Previous studies have suggested that these patients can present endothelial dysfunction that can predispose to coronary vascular events late after KD. The purpose of this study was to determine the cardiovascular risk profile and endothelial function of Chilean children with history of KD. In a prospective case-control study, 11 patients with history of KD (age 10.6 +/- 2.0 years, interval from initial episode 8.1 +/- 3.6 years) and 11 healthy, age-, gender-, and BMI z score-matched controls were evaluated with blood pressure (BP), a fasting lipid profile, high sensitivity C-reactive protein (hsCRP), and flow-mediated dilatation of the brachial artery (FMD). One KD patient (9.1%) had persistent coronary aneurysms. There was a significant difference of mean and log-transformed concentrations of hsCRP between case and control groups (2.3 +/- 3.0 vs 0.5 +/- 0.3 mg/l, P = 0.045). None of the patients with elevated hsCRP had persistent coronary arterial lesions. No difference was found in systolic BP z score between the case and control groups. Diastolic BP z score was significantly higher in cases than controls (P = 0.039). There were no significant differences of FMD between cases and controls. Mean fasting total cholesterol, high-density and low-density lipoprotein, and triglycerides in cases were normal, with no significant difference vs controls. This study shows that Chilean children with history of KD have increased levels of hsCRP, possibly reflecting persistent low-grade inflammation. The prognostic value of hsCRP in KD patients deserves further investigation.

JUMONJI, a critical factor for cardiac development, functions as a transcriptional repressor.

JUMONJI (JMJ) is a nuclear factor that is critical for normal cardiovascular development, evidenced by the analysis of jmj homozygous mutant mice. However, the molecular function of JMJ remains to be elucidated. In the present study, we investigated whether JMJ is a transcriptional modulator. Reporter gene assays using the GAL4-DNA binding domain fused to JMJ and a reporter gene consisting of the GAL4 binding sites upstream of a luciferase reporter gene indicated that JMJ functions as a powerful transcriptional repressor. The DNA binding motif of JMJ was determined using CASTing experiments by incubating a random oligonucleotide library with the GST-JMJ fusion protein coupled to agarose beads. Among the selected binding oligonucleotides, the high affinity DNA binding sequences were identified by gel retardation assays. JMJ repressed expression of the reporter genes containing the high affinity JMJ binding sequences, indicating that JMJ is a DNA-binding transcriptional repressor. The domains for transcriptional repression, DNA binding, and nuclear localization signal were mapped by mutational analyses using reporter gene assays, gel retardation assays, and immunostaining experiments, respectively. The present data demonstrate for the first time that JMJ functions as a DNA-binding transcriptional repressor. Therefore, JMJ may play a critical role in transcription factor cascade to regulate expression of heart-specific genes and normal cardiac development.