Ankle fusion following failed initial treatment of complex ankle fractures in neuropathic diabetics.

BACKGROUND: Unstable ankle fractures in diabetics with peripheral neuropathy have an increased risk of postoperative complications, often leading to amputation. Primary ankle arthrodesis has been suggested as an alternative when acceptable reduction and mechanical stabilization cannot be obtained. METHODS: Over a fourteen year period, thirteen diabetic patients with peripheral neuropathy underwent an attempt at primary ankle arthrodesis following the early post-fracture development of acute neuropathic (Charcot) deformity of the ankle after sustaining a low energy unstable ankle fracture. Eight patients with open wounds and osteomyelitis underwent single stage debridement of the osteomyelitis and primary ankle fusion with an ankle fusion construct circular external fixator. Five patients without evidence of infection underwent primary arthrodesis with a retrograde locked intramedullary nail used for fixation. A successful clinical outcome was achieved with either successful radiographic arthrodesis or stable pseudarthrosis, when community ambulation was achieved with commercially-available therapeutic footwear and a short ankle orthosis. RESULTS: Eight of the thirteen patients achieved a successful clinical outcome at a mean follow-up of 48 (range 12-136) months following the initial surgery. Three achieved clinical stability following a second surgery and one following a third. One patient with radiographic nonunion expired due to unrelated causes. One patient underwent transtibial amputation due to persistent infection. Of the five patients with failure of radiographic union, three successfully ambulated in the community with a short ankle orthosis. Postoperative complications included wound and pin-site infection, infected nonunion, chronic wounds, and tibial stress fracture. CONCLUSION: In spite of the high risk for complications and initial failure, primary ankle fusion is a reasonable option for diabetic neuropathic patients who develop acute neuropathic arthropathy following ankle fracture. LEVEL OF EVIDENCE: Level IV retrospective case series.

The Economic Burden of Residency Interviews on Applicants.

Background: The residency match is increasingly competitive. The interview is an essential component, yet little has been documented about the costs applicants incur during the interview process and it is unclear how they manage these expenses. Objective: The purpose of this study was to define the economic burden of residency interviews for United States (U.S.) allopathic students participating in the 2016 Main Residency Match. We hypothesized that the financial burden of residency interviews varies based on specialty and plays a role in the applicant's ability to participate in all desired interviews. Methods: A 26 question electronic survey was developed following pilot study of applicants to a single residency program. Following validation, the survey was distributed to administrative officials at all U.S. allopathic medical schools for circulation to senior students. Results were pooled for statistical analysis. Results: We received responses from 759 U.S. allopathic seniors. A single interview most commonly costs $250 - $499. Most applicants incurred substantial interview related costs. Sixtyfour percent of respondents spent at least $2,500, while 13% spent $7,500 or more. Specialty competitiveness was predictive of higher interview costs. Seventy-one percent of respondents borrowed money to fund interview costs, and 41% declined interviews for financial reasons. Conclusions: Senior medical students incur substantial costs to participate in residency interviews, often adding to already burdensome educational debt. We encourage residency programs, especially those in competitive specialty fields, to pursue cost reduction strategies. Additionally, medical schools should provide financial counseling to allow students to anticipate interview costs.

Targeted three-dimensional liquid chromatography: a versatile tool for quantitative trace analysis in complex matrices.

Targeted multidimensional liquid chromatography (MDLC), commonly referred to as 'coupled-column' or 'heartcutting', has been used extensively since the 1970s for analysis of low concentration constituents in complex biological and environmental samples. A primary benefit of adding additional dimensions of separation to conventional HPLC separations is that the additional resolving power provided by the added dimensions can greatly simplify method development for complex samples. Despite the long history of targeted MDLC, nearly all published reports involve two-dimensional methods, and very few have explored the benefits of adding a third dimension of separation. In this work we capitalize on recent advances in reversed-phase HPLC to construct a three-dimensional HPLC system for targeted analysis built on three very different reversed-phase columns. Using statistical peak overlap theory and one of the most recent models of reversed-phase selectivity we use simulations to show the potential benefit of adding a third dimension to a MDLC system. We then demonstrate this advantage experimentally by developing targeted methods for the analysis of a variety of broadly relevant molecules in different sample matrices including urban wastewater treatment effluent, human urine, and river water. We find in each case that excellent separations of the target compounds from the sample matrix are obtained using one set of very similar separation conditions for all of the target compound/sample matrix combinations, thereby significantly reducing the normally tedious method development process. A rigorous quantitative comparison of this approach to conventional 1DLC-MS/MS also shows that targeted 3DLC with UV detection is quantitatively accurate for the target compounds studied, with method detection limits in the low parts-per-trillion range of concentrations. We believe this work represents a first step toward the development of a targeted 3D analysis system that will be more effective than previous 2D separations as a tool for the rapid development of robust methods for quantitation of low concentration constituents in complex mixtures.