A mechanical comparison of first metatarsal diaphyseal osteotomies for the correction of hallux abducto valgus.

The purpose of this study was to perform a mechanical comparison of four commonly performed diaphyseal first metatarsal osteotomies. Fifty first metatarsal-first cuneiform sawbone models were divided equally into five groups: control, offset V, inverted Z, Mau, and Ludloff osteotomy groups. All osteotomies were fixated with two 2.7-mm Synthes cortical screws. Each specimen was then stressed through a computer-controlled hydraulic tensile testing machine while recording the maximum load, energy, stiffness, and fracture pattern. The offset V was superior in terms of maximum load (137.8 N) and energy (0.86 J), as compared to the inverted Z (maximum load 74.7 N and energy 0.24 J), the Mau (maximum load 74.3 N and energy 0.15 J), and the Ludloff (maximum load 67.0 N and energy 0.32 J). The offset V (16.6 N/mm) demonstrated no significant difference in stiffness with the Mau (19.7 N/mm), and was stiffer to the inverted Z (14.4 N/mm) and the Ludloff (9.4 N/mm). We conclude that one could expect a safer and immediate return to weightbearing postoperatively with the offset V osteotomy as compared to the inverted Z, Mau, and Ludloff osteotomies.

Resection of talocalcaneal middle facet coalition. Interposition with a tensor fascia lata allograft: a case report.

Tensor fascia lata is utilized in the management of complex soft-tissue injuries and defects, but has not been described in the literature in the use of tissue interposition with resection of talocalcaneal middle facet coalitions. This article is a case presentation of a resection of a middle facet coalition with interposition of an allograft of tensor fascia lata. At 14 months postoperative follow-up, range of motion of the subtalar joint was noted to be 20 degrees, and without pain or crepitus. There was no radiographic evidence of degenerative changes in Chopart's joint. The patient returned to all routine and sports activities without pain. He was satisfied with the outcome of the procedure.

Rupture of the tibialis anterior tendon.

Closed rupture of the tendon of tibialis anterior is an infrequently reported entity. A thorough review of the literature was performed with 49 reported cases of this condition identified. Those patients who were treated conservatively experienced late sequelae, including continued slapping of the foot, mild to moderate flatfoot deformity, and ankle arthrosis. Low morbidity associated with surgical reconstruction should preclude only the most sedentary of patients from operative treatment.

Prospective analysis of postoperative wound infections using an early exposure method of wound care.

The management of operative wounds in most surgical procedures is important in preventing many complications, most notably, infection. Among most surgical subspecialties, postsurgical dressings vary in type of materials utilized as well as duration left in place. The authors propose that the contemporary method of postoperative wound management (i.e., dressings left in place until sutures are removed) is overly conservative when dealing with the uncomplicated patient population. This study involves 100 patients who underwent forefoot, rearfoot, or ankle procedures in which skin incisions were made on nonweightbearing surfaces and percutaneous pins, external fixators, or casts were not utilized. All wounds were considered clean and patients displayed an uncomplicated medical history. Postoperatively, the patients were treated by an early exposure method (i.e., the wounds were left undressed on the 4th postoperative day and patients were allowed to bathe in their usual manner). Patients returned on postoperative day 10-14 at which time sutures were removed. Wounds were inspected up to 12 weeks following surgery. An infected wound was defined by the presence of cellulitis or lymphangitis or by the secretion of purulence from the incision line. The incidence of wound infection was 1.0%. This study also includes analysis via questionnaire of the postoperative care utilized by 495 randomly selected diplomates of the American Board of Podiatric Surgery as well as the surgery department chairs at the seven podiatric medical colleges.

Bilateral congenital peroneal tendon subluxation.

Congenital subluxation of the peroneal tendons is an uncommon, but not rare condition. In almost all cases, it will spontaneously resolve without requiring any treatment. Presented is a case report of the condition affecting the patient bilaterally. The subluxation did not resolve and the patient was subsequently treated with a modification of the Kelly procedure.

A comparison of the efficacy of injectable dexamethasone sodium phosphate versus placebo in postoperative podiatric analgesia.

Forty-two patients undergoing identical bilateral foot surgery were evaluated in a double-blind study designed to evaluate the efficacy of injectable dexamethasone sodium phosphate versus placebo as an analgesic. Patients who had elective foot surgery on an outpatient basis received an injection of dexamethasone sodium phosphate in one foot and an equivalent injection of normal sterile saline in the contralateral foot. Both the patients and the surgeons were unaware of which foot was injected with each agent. The results suggest that there was not a difference in the patient perception of which foot was most painful. Forty-eight to 72 hours after surgery, 18 (44%) patients identified the foot that received steroid as less painful, 18 (44%) patients identified the foot that received placebo as less painful, and 5 (12%) patients did not perceive a difference. In addition, there was not a difference in outcome based on soft-tissue or osseous procedures.

Sonographic evaluation of interdigital neuromas.

The purpose of this study is to evaluate the effectiveness of sonography to accurately identify interdigital neuromas. Twenty patients, all complaining of interdigital neuroma type pain, underwent sonographic evaluation of the symptomatic intermetatarsal space and adjacent interspaces. Each patient subsequently had surgical exploration of the symptomatic site. Fourteen patients had sonographic evidence of neuromas which were confirmed surgically; one patient had sonographic evidence of a neuroma that was not confirmed surgically. The remaining five patients did not have sonographic or surgical evidence of neuroma in spite of clinical signs and symptoms. No adjacent neuromas were appreciated. The correlation of sonography and clinical measurements was determined using Pearson's product moment correlation coefficient (r = 0.804, p < 0.001). Measurements performed with ultrasound were highly correlated with surgical findings. The mean size (standard deviation) of neuromas identified with ultrasound and during surgical inspection was 5.35 mm. (1.36) and 5.43 mm. (1.04). Ultrasound demonstrated a sensitivity of 100% and a specificity of 83.3%. Ultrasound was able to accurately predict the presence, size, and location of Morton's neuromas.

Bilateral os peroneum fractures: comparison of conservative and surgical treatment and outcomes.

Acute fracture of the os peroneum without concurrent rupture of the peroneus longus is a rarely cited injury. Sudden violent contraction of the peroneus longus muscle and direct trauma are documented mechanisms of injury. This injury can easily be overlooked due to its infrequency, and it may lead to chronic pain and impairment of function. Presented is a case of acute fracture of the os peroneum bilaterally. The fractures occurred approximately 21 months apart. Treatment varied with the right foot responding to 4 months of conservative therapy, and the left foot undergoing surgical excision of the fractured ossicle following 5 weeks of failed conservative therapy. This case is unique as it presents bilateral os peroneum fractures. This unique situation allows for a comparison of the two distinct treatment options. A fractured os peroneum without peroneus longus tendon rupture may be treated conservatively, however, surgical excision of the ossicle following 4 weeks of conservative therapy may expedite the recovery period and avoid chronic pain.

Protein-tyrosine phosphatases PTP1B and syp are modulators of insulin-stimulated translocation of GLUT4 in transfected rat adipose cells.

The protein-tyrosine phosphatases PTP1B and Syp have both been implicated as modulators of the mitogenic actions of insulin. However, the roles of these protein-tyrosine phosphatases in the metabolic actions of insulin are not well characterized. In this study, we directly assessed the ability of PTP1B and Syp to modulate insulin-stimulated translocation of the insulin-responsive glucose transporter GLUT4 in a physiologically relevant insulin target cell. Primary cultures of rat adipose cells were transiently transfected with either wild-type PTP1B (PTP1B-WT), wild-type Syp (Syp-WT), or the catalytically inactive mutants PTP1B-C/S or Syp-C/S. The effects of overexpression of these constructs on insulin-stimulated translocation of a co-transfected epitope-tagged GLUT4 were studied. Cells overexpressing either PTP1B-C/S or Syp-WT had insulin dose-response curves similar to those obtained with control cells expressing only epitope-tagged GLUT4. In contrast, for cells overexpressing PTP1B-WT the level of GLUT4 on the cell surface at each insulin dose (ranging from 0 to 60 nM) was significantly lower than that observed in the control cells. Interestingly, cells overexpressing the dominant inhibitory mutant Syp-C/S also had a small but statistically significant impairment in insulin responsiveness. At a maximally stimulating concentration of insulin (60 nM), cell surface epitope-tagged GLUT4 was approximately 20% less than that of the control cells. It is possible that effects from high level overexpression of Syp and PTP1B constructs may not reflect what occurs under physiological conditions. Nevertheless, our data raise the possibility that PTP1B may be a negative regulator of insulin-stimulated glucose transport, while Syp may have a small role as a positive mediator of the metabolic actions of insulin.

Intravascular fasciitis in the foot.

Intravascular fasciitis is a rare benign condition characterized by reactive fibroblastic proliferation arising from the superficial or deep fascia and involving arteries and/or veins. Intravascular fasciitis is a distinct variant of a more common condition called nodular or pseudosarcomatous fasciitis, which possesses clinical and histologic features similar but lacks vascular invasion. The fibroblastic violation of the vascular network suggests a malignant component and often leads to an inappropriate diagnosis for this benign condition. A thorough review of the literature revealed less than 25 reported cases of intravascular fasciitis, with this publication being the only case involving the foot or ankle. A case of intravascular fasciitis affecting the plantar aspect of the foot in a pediatric patient is presented and its clinical and histologic features are discussed.

Major arthrodeses in patients with neuropathic arthropathy.

Neuropathic arthropathy is a complex deformity found in a multitude of disease processes. Various forms of conservative and surgical treatment options have been reported throughout the literature; however, a limited number of such treatments address the underlying deformity. This article reviews the indications and surgical criteria necessary to perform successful arthrodesis procedures in patients afflicted with this problem. A case report is presented, using arthrodesis as a salvage procedure for a painful Charcot deformity of the midfoot in a patient with diabetic neuroarthropathy.

Antibiotic prophylaxis and tourniquet application in podiatric surgery.

The use of prophylactic antibiosis in podiatric surgery is common, especially in patients undergoing endoprosthetic procedures, major arthrodeses, lengthy procedures, or in immunocompromised patients. The goal of prophylaxis is to prevent infection. For this to occur, there must be an adequate concentration of the antimicrobial agent in the tissue at the time of the incision. Historically, prophylaxis has consisted of intravenous administration of 1 gm. of cefazolin, 30 to 60 minutes prior to surgery. Cefazolin concentrations in the medial eminence of the first metatarsal were measured in patients undergoing bunionectomy procedures where pneumatic ankle tourniquets were used for hemostasis. The goal of this study was to determine if the current standards of prophylactic antibiotic administration provide adequate bone levels of cefazolin to effectively inhibit potential infection-causing pathogens.

Retrospective analysis of operative ankle fractures.

Closed-ankle fractures presenting to the podiatric service between 1978 and 1991 are reviewed. Patients able to return for follow-up were tested through Cybex isokinetic testing, proprioception, and radiographic studies. All patients reviewed had equal or greater strength and endurance on the involved side when compared to the uninvolved side. Proprioceptive deficits were noted in all patients with lateral malleolar involvement regardless of time of follow-up.

Reconstruction of an Achilles tendon defect utilizing an Achilles tendon allograft.

Acute ruptures of the Achilles tendon are common. Treatment for such ruptures is well documented. Treatment for chronic ruptures with a significant defect poses a surgical dilemma. The authors present the use of a tendon allograft to replace an Achilles tendon defect with a 2.5-year clinical follow-up inclusive of isokinetic testing.

Aeromonas hydrophila--its implications in freshwater injuries.

Lacerations or puncture wounds sustained in freshwater environments are susceptible to contamination by Aeromonas hydrophila. Numerous cases have been reported of cellulitis secondary to water-related injuries requiring hospitalization where A. hydrophila was the isolated organism. The typical presentation of an infection of A. hydrophila mimics a streptococcal soft tissue infection, which may result in delay in administration of appropriate antibiotics. A case is presented of a nonimmunocompromised patient who developed an A. hydrophila infection following freshwater-related injuries.

The large diverse gene family var encodes proteins involved in cytoadherence and antigenic variation of Plasmodium falciparum-infected erythrocytes.

The human malaria parasite Plasmodium falciparum evades host immunity by varying the antigenic and adhesive character of infected erythrocytes. We describe a large and extremely diverse family of P. falciparum genes (var) that encode 200-350 kDa proteins having the expected properties of antigenically variant adhesion molecules. Predicted amino acid sequences of var genes show a variable extracellular segment with domains having receptor-binding features, a transmembrane sequence, and a terminal segment that is a probable submembrane anchor. There are 50-150 var genes on multiple parasite chromosomes, and some are in clustered arrangements. var probes detect two classes of transcripts in steady-state RNA: 7-9 kb var transcripts, and an unusual family of 1.8-2.4 kb transcripts that may be involved in expression or rearrangements of var genes.

Surgical considerations for hematogenous osteomyelitis.

Surgical treatment of hematogenous osteomyelitis is uncommon in the literature. Indications for surgical decompression, along with a review of the literature, is presented. A case history of a 7-year-old male with hematogenous osteomyelitis of the first metatarsal treated by surgical decompression and 12-month follow-up is discussed.

Tibiofibular arthrodesis for malunion of the talocrural joint.

Reconstruction of malunited or an incongruous talocrural articulation is relatively unrecognized within the literature and few procedures have been described. This article reviews a case of a 36-year-old male who presented with chronic ankle pain, secondary to a malunion of the ankle joint. The case presentation, including surgical treatment and follow-up care, is presented. A review of the literature is also provided.