Peripheral nerve surgery of the foot and ankle. A review of current principles

Planning for peripheral nerve surgery requires consideration of a multitude of factors, as well as a surgeon's meticulous skill and experience. With so little room for error, every advantage must be taken to optimize repair. Peripheral nerve surgery of the foot and ankle is an underappreciated area of neurosurgery with comparatively limited published reports and data. The authors reviewed the current trends in the surgical management of peripheral nerve injuries of the foot and ankle in the hope that an understanding of the basic principles involved will allow for future study of the results of such surgery by more surgeons who deal with these problems.     

Causes of recurrence after laparoscopic hernioplasty. A multicenter study

The neurocutaneous disorders frequently involve the central nervous system. This is the second in a pair of articles describing and illustrating the radiological appearances of the central nervous system manifestations of these disorders, this article looking at tuberous sclerosis, von Hippel-Lindau disease and Sturge-Weber syndrome.     

Coralline hydroxyapatite: a bone graft alternative in foot and ankle surgery

The use of coralline hydroxyapatite has become a viable bone grafting alternative. Its efficacy has been well established through multiple human and animal studies. Coralline hydroxyapatite enhances osteogenesis by providing a biocompatible lattice for the passage and assembly of vascular, fibroblastic, and osteoblastic tissues. It also provides support for surrounding osseous structures. The uses of this material are expanding into the realm of foot and ankle surgery. Its consideration as an appropriate bone graft substitute as well as multiple case studies demonstrating its surgical applicability are discussed. The implants utilized at Thorek Hospital and Medical Center over the past eight years, with an average follow-up of three and one-half years, have proven to be a valuable resource for augmentation where an osseous defect has occurred.     

Health-related quality of life after epilepsy surgery: a Swedish multicenter study

PURPOSE: To investigate health-related quality of life (HRQOL) in relation to seizure outcome as part of a multicenter follow-up of epilepsy surgery in Sweden. METHODS: A battery including the SF-36 Health Survey and the Hospital Anxiety and Depression scale (HAD) was distributed to all patients older than 16 years. Mean follow-up time was 4 years (range, 2-13 years) and response rate, 91% (103 of 113 patients). HRQOL data were related to seizure frequency and severity (Chalfont Seizure Severity Scale). RESULTS: Seventy-six percent considered their global health to be better than it was before surgery. Degree of improvement in seizure control correlated with improved satisfaction with health (Spearman's r = 0.44). Higher SF-36 scores (higher HRQOL ratings) correlated with percentage reduction of seizure frequency for all scales and was strongest for perception of general health (Spearman's r = 0.46). When the patients were divided into four categories [A, completely seizure free (n = 29); B, seizure free with aura (n = 18); C, > or =75% reduction in seizure frequency (n = 24); and D, <75% reduction in seizure frequency (n = 32)], a strong positive association was found between higher SF-36 scores (with the exception of physical functioning) and better seizure control. Health-related limitations in role performance differentiated best between the outcome categories. For patients with > or =75% reduction in seizure frequency, low seizure severity correlated with higher HRQOL ratings for scales measuring social function, vitality, and mental health. Depression levels (HAD scale scores) were on average low. Anxiety (HAD) increased significantly from A to D. CONCLUSIONS: HRQOL seems to be scored as a continuum in relation to seizure frequency. Seizure severity measures give complementary information.     

Osteoblastoma of the foot and ankle

A total of 329 patients with osteoblastoma were retrospectively reviewed from the archives of the Armed Forces Institute of Pathology, of which 41 (12.5%) presented with tumors in the foot and ankle. This was the third most common site of disease after the spine and femur. Overall, the mean age was 22.5 years, which was the same for the foot and ankle subset of patients; however, there was a significant male predominance in foot and ankle patients compared with the whole group. The majority of patients were skeletally mature (85.4%). Clinically, most patients presented with pain (97.2%), although one-third of the total related a history of antecedent trauma. The interval between the onset of symptoms and biopsy was 84 days (range, 0-572 days). Radiographically, the majority of lesions were in the hindfoot (N = 18; 44%) of which 16 of 18 tumors (89%) were in the talus. Of these, one-half were subperiosteal and dorsally based and were associated with osseous tumor matrix and a soft tissue mass. Two osteoblastomas, both in the metatarsals, transitioned into sarcomas; the rest were histologically benign. For diagnostic purposes, it was essential to obtain clinical, radiographic, and histologic correlation.     

MRI of the foot and ankle

The foot and ankle are among the hardest of all areas to image because of the complex three-dimensional anatomy. Magnetic resonance imaging (MRI), with its multiplanar capabilities, excellent soft-tissue contrast, ability to image bone marrow, noninvasiveness, and lack of ionizing radiation, has become a valuable tool in evaluating patients with foot and ankle problems. MRI is more specific than bone scintigraphy and provides more information than ultrasound and computed tomography. Arthroscopy of the ankle is limited to the articular surface and joint space. MRI allows a global evaluation of the bones, tendons, ligaments, and other structures with a single examination that exceeds the capabilities of all other available techniques. This monograph was written to provide a useful guide to basic technique, indications, positioning, anatomy, and interpretation of foot and ankle MRI. The first part describes the performance of the MRI examination with reference to the positioning of the foot, types of coils, and advantages and disadvantages of the different sequences and imaging planes. The next section was written by an experienced foot and ankle orthopedic surgeon and outlines the indications for MRI for the common foot and ankle symptom complexes and the information that the surgeon hopes to obtain from the study. This is followed by a review of pertinent anatomy, as it applies to imaging, with emphasis on osseous structures, ligaments, tendons, and muscles. The final section is a comprehensive review of the common pathologic conditions encountered in the foot and ankle. We hope that radiologists and radiologists-in-training find this article a useful reference tool and gain a better understanding of this complex area of musculoskeletal imaging.     

Charcot neuroarthropathy of the foot and ankle

The goal of this study was to characterize Charcot neuroarthropathy of the foot and ankle by specific sites of involvement (ankle, hindfoot, midfoot, and forefoot), modes of presentation, methods of management, and outcome. A summary of treatment and results for 50 ankles, 22 hindfeet, 131 midfeet, and 18 forefeet is presented. Nondisplaced neuropathic ankle fractures typically healed uneventfully with casting and bracing. For displaced ankle fractures, closed reduction and casting generally resulted in loss of reduction and progressive deterioration; better results were obtained with open reduction and internal fixation, using supplemental Kirschner wires and screws. Ankles with Charcot neuroarthropathy and preexisting arthritis typically required arthrodesis. Of the ankles with neuropathic avascular talar necrosis, approximately 1/3 did well with nonoperative intervention and 2/3 required surgery. Chronic, unstable, malaligned Charcot ankles often required arthrodesis. Neuropathic calcaneal fractures were managed successfully nonoperatively. For feet with transverse tarsal joint involvement (Schon Type IV), management was more complex. Nonoperative treatment was successful for less than 1/2. Two thirds of the feet with midtarsus involvement (Schon Types I, II, and III) were managed successfully nonoperatively; 1/3 required surgery for recurrent ulceration, instability, or osteomyelitis. Half of the feet with forefoot neuroarthropathy required surgery for malalignment, ulceration, and/or difficulty with shoewear or braces. This review has established patterns of Charcot involvement of the foot and ankle with corresponding methods of treatment and subsequent responses. From this extensive clinical experience with 221 neuropathic fractures or Charcot joints, recommendations were derived to assist in selecting appropriate management options.     

Treatment approaches following foot and ankle injury

A complete and effective rehabilitation program begins with a thorough subjective and objective evaluation of the problem and injury presented. Biomechanical changes, whether they are anatomically induced or as a result of a form of compensation, must be identified and properly addressed. During the initial phase of rehabilitation, the issues of pain and swelling often must be resolved before full range of motion and return to normal strength can be achieved successfully during the more advanced stages. It is important to incorporate the entire lower quadrant in exercises that are designed to improve proprioception and function, using both in open and closed kinetic chain exercises. Finally, the demands to which the patient is returning to must be recognized to successfully complete the recovery phase.     

Hemophilic arthropathy of the foot and ankle

The major deformities in hemophilic arthropathy of the foot and ankle fall into the three groups of equinus, varus, and cavus. These pathologic positions develop through a repetitive pattern of intra-articular and intramuscular bleeding within the area of the distal calf, foot, and ankle. Appropriate infusion therapy with factor VIII concentrate and factor IX concentrate plus splinting, bracing, and logical rehabilitative maneuvers can delay or prevent the advent of permanent deformity. The actual articular damage seems to be directly related to the release of digestive enzymes from leukocytes, synovial cells, and other blood products. These pathologic mechanisms appear to be similar to those recently described in explaining joint destruction in rheumatoid and degenerative arthritis. The indication for certain reconstructive orthopedic procedures in these situations are given and case examples provided. Total joint replacement in the area of the foot and ankle in hemophilia has been considered for certain patients by the authors but not attempted as yet.     

Amputations in the diabetic foot and ankle

Scientific structured foot salvage clinics will provide surgeons with a large population of peripheral vascular insufficiency patients who may someday become candidates for salvage amputation at the foot or ankle level. This article presents the technology of functional amputation levels.     

Implementation of the Ottawa ankle rules in France. A multicenter randomized controlled trial

OBJECTIVES: To assess the impact of the implementation of the Ottawa ankle rules on radiography requests in French hospitals during a 5-month intervention period and the impact of using posters alone to sustain the effect of the rules during a 5-month postintervention period. DESIGN: Multicenter randomized controlled trial preceded and followed by observational studies of radiological practices. SETTING: The emergency departments of 5 Paris university teaching hospitals of the Assistance Publique-H?pitaux de Paris. PATIENTS: A total of 2218, 1911, and 851 patients-all aged 18 years and older-who were seen for acute ankle or midfoot injuries in emergency departments during preintervention, intervention, and postintervention periods, respectively. INTERVENTION: Implementation of the Ottawa ankle rules by emergency department physicians in the intervention hospitals (using meetings, posters, pocket cards, and data forms). During the postintervention period, posters alone were used to sustain the intervention effect. MAIN OUTCOME MEASURE: Percentage of patients for whom radiography was requested. RESULTS: During the preintervention period, 98% and 98.5% of patients were referred for radiography in the intervention and control groups, respectively. During the intervention period, the mean proportions of patients referred for radiography by physicians was 78.9% in the intervention group and 99% in the control group (P=.03). Between preintervention and intervention periods, a relative reduction of 22.4% (95% confidence interval [CI], 19.8%-24.9%) in radiography requests was observed in the intervention group, while requests increased by 0.5% (95% CI, 0%-1.4%) in the control group. During the postintervention period, the proportion of radiography requests in the intervention hospitals was lower than the proportion observed in the preintervention period (83.1% vs 98%). CONCLUSIONS: Implementation of the Ottawa ankle rules significantly reduced radiography requests in French hospitals. Using a minimal postintervention implementation strategy, the effect of this intervention decreased but persisted after it was discontinued.     

Walking aches and running pains. Injuries of the foot and ankle

Running is enjoyed by approximately 30 million people in the United States, 10 million on a regular basis. It is common to encounter a patient who runs and expects his or her primary physician to have a degree of expertise in injuries caused by running. The primary care clinician also may experience the frustration of motivating a patient to exercise, only to have him or her return with complaints of foot or ankle pain. Running injuries occur from an overload on the muscles, tendons, bones, or joints. The knee, foot, and ankle are the most common sites of injury.     

A multicenter trial of photorefractive keratectomy for residual myopia after previous ocular surgery. Summit Therapeutic Refractive Study Group

PURPOSE: The Summit Therapeutic Refractive Clinical Trial is a nine-center prospective, nonrandomized, self-controlled trial to assess the efficacy, stability, and safety of using a standardized technique of excimer laser photorefractive keratectomy (PRK) to correct residual myopia in eyes with previous refractive surgery or cataract surgery. PATIENTS AND METHODS: Eligible eyes with a mean residual myopia of -3.7 +/- 1.8 diopters (D) (range, -0.63 to -11.00 D) underwent PRK with a 193-nm excimer laser for myopic corrections between -1.50 and -7.50 D. Standardized settings were used for the ablation zone, ablation rate, repetition rate, and fluence. One hundred seven of the first 114 treated eyes were examined 1 year after PRK, with 98% of eyes having had refractive keratotomy and 2% having had cataract surgery. RESULTS: One year postoperatively, the mean manifest spherical equivalent refraction was -0.6 +/- 1.4 D (range, -6.50 to 2.50 D); 63% of eyes were within +/-1.00 D of the attempted correction; and uncorrected visual acuity was 20/40 or better in 74% of eyes. Twenty-nine percent of eyes lost two or more Snellen lines of best-corrected visual acuity, and central corneal haze was moderate or severe in 8% of eyes. CONCLUSIONS: Excimer laser PRK is effective in reducing residual myopia after previous refractive and cataract surgery. However, it is less accurate than PRK in eyes that did not undergo surgery and is more likely to cause a loss of best-corrected visual acuity 1 year after treatment.     

A multicenter, randomized, blind comparison of amrinone with milrinone after elective cardiac surgery

The ability of transglutaminase-synthesized 1,3-diaminopropane, spermidine (Spd), spermine (Spm), and monodansylcadaverine gamma-(glutamyl5)derivatives of substance P (SP) to produce bronchoconstriction was investigated. In urethane-anaesthetized guinea pigs, intravenous injections of SP derivatives contracted differently bronchial smooth muscle and caused hypotension. The most effective bronchoconstrictor among SP analogs was the gamma-(glutamyl5)Spd derivative of SP (Spd-SP; EC50 = 5.3 nmol/kg), which was more potent than the native peptide (EC50 = 26.5 nmol/kg). In contrast, the gamma-(glutamyl5)Spm derivative of SP (Spm-SP) was found completely unable to cause bronchoconstriction and was significantly less effective than SP in determining hypotension. The contractile effect of Spd-SP and Spm-SP was investigated in vitro on rat isolated colon, a well-characterized preparation rich in NK2 receptors. In addition, Spd-SP was tested on the endothelium-denuded rabbit pulmonary artery (RPA) and the hamster isolated trachea (HT), both tissue preparations containing only a single functional receptor subtype (NK2A and NK2B, respectively). The results obtained showed that Spd-SP recognizes NK2 receptors occurring on rat isolated colon more effectively (EC50 = 11 nM) than the native peptide (EC50 = 45 nM). Conversely, Spm-SP evokes a contractile response less effective than that elicited by SP (EC50 = 312 nM). Furthermore, Spd-SP (0.1-10 microg kg(-1)) produced a concentration-dependent contraction of both HT and RPA, exhibiting a potency respectively 12 and 30 times higher than SP in contracting HT and RPA. Our results indicate that the introduction of a Spd moiety at the level of glutamine-5 of SP gives rise to an analog that possesses a different capability to recognize NK2 receptors than the parent peptide. Moreover, since Spd-SP seems to contract more effectively RPA than HT, we conclude that it preferentially recognizes the NK2A receptor subtype.     

Protein-losing enteropathy after the Fontan operation: an international multicenter study. PLE study group

OBJECTIVE: This multicenter study retrospectively analyzes the data on 114 patients with protein-losing enteropathy after Fontan-type surgery. Special attention was given to the different treatment strategies used and their effect on outcome. METHODS AND RESULTS: In 35 participating centers 3029 Fontan operations were performed. The incidence of protein-losing enteropathy in the survivors was 3.7%. The median age at Fontan-type surgery was 8.2 years (range: 0.6 to 32.9 years). Median age at diagnosis of protein-losing enteropathy was 11.7 years with a median time interval between surgery and diagnosis of 2.7 years (range: 0.1 to 16.4 years). Most patients had edema (79%) and effusions (75%). Hemodynamic data revealed a mean right atrial pressure of 17 +/- SD 5.3 mm Hg with a cardiac index of 2.4 +/- 0.8 L/min/m2. Medical treatment only (n = 52) resulted in a complete resolution of symptoms in 25%, no improvement in 29%, and death in 46%. Surgical treatment (n = 52) was associated with relief of protein-losing enteropathy in 19%, no improvement in 19%, and death in 62%. In 13 patients 16 percutaneous interventions were performed. This resulted in symptomatic improvement after 12 interventions and no improvement after 4 interventions. CONCLUSIONS: We conclude that the current treatment of protein-losing enteropathy after Fontan operation is associated with a very high mortality and morbidity rate. Preventive strategies and new therapeutic approaches are necessary.     

Neuropsychological course after surgery for intracranial aneurysms. A prospective study and a critical review

Two techniques for simultaneous detection and typing of plum pox potyvirus (PPV) isolates belonging to the D or M serotypes, heminested PCR (H-PCR) and PCR-ELISA, have been developed. Ten PPV isolates typed using PPV-D and PPV-M specific monoclonal antibodies by ELISA-DASI were used to validate these two methods. The results obtained show a complete coincidence of the nucleic acid-based techniques with the serological data. When serial dilutions of infected plant extracts were assayed, H-PCR and PCR-ELISA were found to be 100 times more sensitive than the more conventional immunocapture-PCR (IC-PCR) assay. Testing of 228 PPV-infected fruit tree samples coming from different hosts and locations indicated that so far only PPV type D appears to be present in Spain and in Chile. Coupled with print-capture sample preparation (Olmos et al., Nucl. Acids Res. 24, 2192-2193, 1996) the increased sensitivity provided by heminested-PCR allowed the detection of PPV targets of D and M types, in wingless individuals of the aphid vector Aphis gossypii.     

Cochlear implant performance after reimplantation: a multicenter study

OBJECTIVE: This study compares auditory performance between original and replacement cochlear implants. STUDY DESIGN AND SETTING: Data from 18 U.S. cochlear implant programs were obtained by retrospective chart review. Patients received and returned subjective questionnaires. PATIENTS: Twenty-eight adults with once-functioning Nucleus 22 cochlear implants that failed received replacement Nucleus 22 cochlear implants in the same ears. MAIN OUTCOME MEASURES: Objective measures included sentence (CID Everyday Sentences or Iowa Sentences) and monosyllabic word (NU-6 Words or CNC Words) speech discrimination scores. Patients also rated and compared performance using subjective scales. RESULTS: Thirty-seven percent of patients had significantly higher sentence or word scores with their replacement cochlear implants than with their original implants, 26% had no significant change, and 37% had significantly poorer scores. Subjectively, 57% of patients reported that the performance of their replacement device was better or the same and 43% reported that it was poorer. There was no correlation between performance with the replacement cochlear implant and cause of the original device failure, duration of original device use before failure, surgical complications with either implantation, changes in electrode insertion depths, or preoperative variables, such as age, etiology, or duration of deafness. CONCLUSIONS: Speech recognition ability with a replacement cochlear implant may significantly increase or decrease from that with the original implant. Experienced cochlear implant patients facing reimplantation must be counseled regarding the possibility of differences in sound quality and speech recognition performance with their replacement device.     

Mask physiotherapy for prevention of pulmonary complications after heart surgery. A controlled study

The objective of this prospective, consecutive, randomized, controlled study was to investigate the effects of mask physiotherapy on postoperative complications after heart surgery. Sixty-six low-risk male patients undergoing coronary artery by-pass graft surgery were evaluated. The patients were treated with routine chest physiotherapy alone or supplied with either positive expiratory pressure (PEP), or inspiratory resistance-positive expiratory pressure (IR-PEP). Postoperative pulmonary complications were assessed by forced vital capacity (FVC), arterial oxygen tension (PaO2), and chest X-ray examination. There was an almost equal decrease and subsequent rise in spirometric and blood gas values in all three groups, but patients treated with the PEP mask had a borderline significantly higher increase in PaO2 from day three to day six compared with patients treated with no mask. There was an almost equal frequency of atelectasis in the three treatment groups. It is concluded that no significant differences in outcome were found between the three groups.