Chronic Deltoid Insufficiency in Stage IV Adult Acquired Flatfoot Deformity: Do We Have a Good Answer?

Stage IV adult acquired flatfoot deformity (AAFD) with secondary chronic deltoid ligament insufficiency is a challenging deformity to treat, with minimal consensus in the literature concerning its surgical management. Many surgical treatment options have been described, including joint-sparing techniques, fusions, osteotomies, and even arthroplasties. However, questions remain as to what, if any, treatment is optimal. This contribution reviews studies on surgical treatments for stage IV AAFD with deltoid ligament failure and provides a critical analysis regarding the quality of outcomes reported for those different treatment options. PubMed and Google Scholar databases were searched between June 1, 2022, and August 15, 2022, for studies published between 1990 and 2022 that describe the treatment of stage IV AAFD with deltoid ligament insufficiency. Articles included in the study focused on subjects with stage IV AAFD and associated deltoid ligament insufficiency undergoing surgical correction. Exclusion criteria included stage I, II, and III AAFD, as well as deltoid ligament repair following acute injury/rupture. Nine studies covering five different treatment options for patients with stage IV AAFD and chronic deltoid insufficiency were included, with minimal overlap in outcome measures used to assess the efficacy of the procedure. Triple arthrodesis with deltoid ligament reconstruction resulted in a 62.5% (5/8) success rate with a residual tibiotalar (TT) angulation of 2° (success defined as <3°). Tibiotalar arthrodesis of four patients resulted in an average post-operative tibiotalar angulation of 4.8° with all patients showing progressive destabilization of the hindfoot complex at 12-18 year follow-ups. Deltoid arthroscopic laminoplasty (Brostrom) resulted in an increased American Orthopaedic Foot and Ankle Society (AOFAS) score from 49.7 pre-op to 91.9 post-op. There was no long-term follow-up of these patients. Deltoid ligament reconstruction using autografts of the peroneus longus resulted in a post-operative valgus of 2.1° in one study and <5° in another. Deltoid ligament reconstruction using an anterior tibial tendon autograft resulted in a gain of 126.4 + 40.2% in stiffness compared to an intact ligament. Twinfix suture anchors resulted in a post-operative hindfoot angle averaging 5.3°. Combined deltoid and spring ligament reconstruction resulted in a 5.1° valgus angulation. There is currently no standard of care or clinical consensus regarding surgical treatment for stage IV AAFD with deltoid insufficiency. Several studies imply that mild valgus malalignment around the tibiotalar joint can result in satisfactory outcomes. A few studies even deemed <5° of valgus tilt post-operatively successful. However, it has been described that any imbalance in tibiotalar tilt is a significant risk factor for progressive arthritis and future ligamentous failure. No treatment option was able to correct valgus tilt to an anatomical standard (i.e., to normal anatomy). These varied findings, along with the lack of consensus on post-surgical measures to assess efficacy, are worrisome and emphasize the need for better surgical options. Moreover, there is a critical need for additional research on the long-term outcomes following stage IV AAFD and deltoid insufficiency repair, particularly, as over five million people in the United States and 10% of the geriatric population are affected by AAFD with a risk of progressing to stage IV.

Nature is resource, playground, and gift: What artificial intelligence reveals about human-Nature relationships.

This paper demonstrates how artificial-intelligence language analysis can inform understanding of human-nature relationships and other social phenomena. We demonstrate three techniques by investigating relationships within the popular word2vec word embedding, which is trained on a sample from over 50,000 worldwide news sources. Our first technique investigates what theory-generated analogies are most similar to nature:people. The resource:user analogy is most similar, followed by the playground:child and gift:receiver analogies. Our second technique explores whether nature-related words are affiliated with words that denote race, class, or gender. Nature words tend slightly toward associations with femininity and wealth. Our third technique demonstrates how the relationship between nature and wellbeing compares to other concepts' relationships to wellbeing-e.g., spirituality-wellbeing, social relations-wellbeing. Nature is more semantically connected to wellbeing than money, social relations, and multiple other wellbeing correlates. Findings are consistent with previous social science and humanities research on human-nature relationships, but do not duplicate them exactly; our results thus offer insight into dominant trends and prevalence of associations. Our analysis also offers a model for using word embeddings to investigate a wide variety of topics.

Gastrocnemius recession: Discrepancies in the literature.

A gastrocnemius contracture is a common problem that results in decreased ankle dorsiflexion that contributes to an array of foot and ankle ailments. A common surgical treatment for this condition is a gastrocnemius recession (GR). Many adaptations of the original procedure have been described. Misinterpretations of proper GR procedures have potentially caused confusion when selecting a treatment. This paper proposes to identify errors between the use of GR and gastrocnemius-soleus recession (GSR) procedure techniques in the current literature. A systematic literature review was performed in June 2021, using the PubMed database and select orthopedic texts. Only studies that met the established criteria and either correctly or incorrectly described a GR or GSR procedure were included. After applying exclusion criteria, 108 publications were included. These articles and texts were reviewed for surgical technique and terminology errors in accordance with established parameters. The articles were classified as either: "Correct" or "Incorrect." Of the 108 publications and texts included, 18 articles incorrectly described either a GR or a GSR (16.67%). Ninety articles correctly described either a GR or a GSR (83.33%). The literature supports the use of a GR to treat a gastrocnemius contracture. Inaccurate articles create confusion as to what exactly a GR entails. Sources of ambiguity included terminology, inconsistent anatomical zone definition, and technique selection. Due to this confusion, it is suspected that patient outcomes can be impacted. Postoperative outcomes of GSR patients are worse than GR patients. Further investigation is necessary to determine if performing the incorrect procedure negatively affects patient outcomes.

Comparing behavioral risk assessment strategies for quantifying biosecurity compliance to mitigate animal disease spread.

Understanding the impact of human behavior on the spread of disease is critical in mitigating outbreak severity. We designed an experimental game that emulated worker decision-making in a swine facility during an outbreak. In order to combat contamination, the simulation features a line-of-separation biosecurity protocol. Participants are provided disease severity information and can choose whether or not to comply with a shower protocol. Each simulated decision carried the potential for either an economic cost or an opportunity cost, both of which affected their potential real-world earnings. Participants must weigh the risk infection vs. an opportunity cost associated with compliance. Participants then completed a multiple price list (MPL) risk assessment survey. The survey uses a context-free, paired-lottery approach in which one of two options may be selected, with varying probabilities of a high and low risk payouts. We compared game response data to MPL risk assessment. Game risk was calculated using the normalized frequency of biosecurity compliance. Three predominant strategies were identified: risk averse participants who had the highest rate of compliance; risk tolerant participants who had the lowest compliance rate; and opportunists who adapted their strategy depending on disease risk. These findings were compared to the proportion of risk averse choices observed within the MPL and were classified into 3 categories: risk averse, risk tolerant and neutral. We found weak positive correlation between risk measured in our experimental game compared to the MPL. However, risk averse classified participants in the MPL tended to comply with the biosecurity protocol more often than those classified as risk tolerant. We also found that the behavioral risk clusters and categorization via the MPL were significantly, yet weakly associated. Overall, behavioral distributions were skewed toward more risk averse choices in both the MPL and game. However, the MPL risk assessment wasn't a strong predictor for observed game behavior. This may indicate that MPL risk aversion metrics might not be sufficient to capture these simulated, situational risk aversion behaviors. Experimental games have a large potential for expanding upon traditional survey instruments by immersing participants in a complex decision mechanism, and capturing dynamic and evolving behavioral signals.

Epidemiology of Connectional Silence in specialist serious illness conversations.

CONTEXT: Human connection can reduce suffering and facilitate meaningful decision-making amid the often terrifying experience of hospitalization for advanced cancer. Some conversational pauses indicate human connection, but we know little about their prevalence, distribution or association with outcomes. PURPOSE: To describe the epidemiology of Connectional Silence during serious illness conversations in advanced cancer. METHODS: We audio-recorded 226 inpatient palliative care consultations at two academic centers. We identified pauses lasting 2+ seconds and distinguished Connectional Silences from other pauses, sub-categorized as either Invitational (ICS) or Emotional (ECS). We identified treatment decisional status pre-consultation from medical records and post-consultation via clinicians. Patients self-reported quality-of-life before and one day after consultation. RESULTS: Among all 6769 two-second silences, we observed 328 (4.8%) ECS and 240 (3.5%) ICS. ECS prevalence was associated with decisions favoring fewer disease-focused treatments (ORadj: 2.12; 95% CI: 1.12, 4.06). Earlier conversational ECS was associated with improved quality-of-life (p = 0.01). ICS prevalence was associated with clinicians' prognosis expectations. CONCLUSIONS: Connectional Silences during specialist serious illness conversations are associated with decision-making and improved patient quality-of-life. Further work is necessary to evaluate potential causal relationships. PRACTICE IMPLICATIONS: Pauses offer important opportunities to advance the science of human connection in serious illness decision-making.

Conversational stories & self organizing maps: Innovations for the scalable study of uncertainty in healthcare communication.

BACKGROUND: Understanding uncertainty in participatory decision-making requires scientific attention to interaction between what actually happens when patients, families and clinicians engage one another in conversation and the multi-level contexts in which these occur. Achieving this understanding will require conceptually grounded and scalable methods for use in large samples of people representing diversity in cultures, speaking and decision-making norms, and clinical situations. DISCUSSION: Here, we focus on serious illness and describe Conversational Stories as a scalable and conceptually grounded framework for characterizing uncertainty expression in these clinical contexts. Using actual conversations from a large direct-observation cohort study, we demonstrate how natural language processing and unsupervised machine learning methods can reveal underlying types of uncertainty stories in serious illness conversations. CONCLUSIONS: Conversational Storytelling offers a meaningful analytic framework for scalable computational methods to study uncertainty in healthcare conversations.

Wavelet decomposition facilitates training on small datasets for medical image classification by deep learning.

The adoption of low-dose computed tomography (LDCT) as the standard of care for lung cancer screening results in decreased mortality rates in high-risk population while increasing false-positive rate. Convolutional neural networks provide an ideal opportunity to improve malignant nodule detection; however, due to the lack of large adjudicated medical datasets these networks suffer from poor generalizability and overfitting. Using computed tomography images of the thorax from the National Lung Screening Trial (NLST), we compared discrete wavelet transforms (DWTs) against convolutional layers found in a CNN in order to evaluate their ability to classify suspicious lung nodules as either malignant or benign. We explored the use of the DWT as an alternative to the convolutional operations within CNNs in order to decrease the number of parameters to be estimated during training and reduce the risk of overfitting. We found that multi-level DWT performed better than convolutional layers when multiple kernel resolutions were utilized, yielding areas under the receiver-operating curve (AUC) of 94% and 92%, respectively. Furthermore, we found that multi-level DWT reduced the number of network parameters requiring evaluation when compared to a CNN and had a substantially faster convergence rate. We conclude that utilizing multi-level DWT composition in place of early convolutional layers within a DNN may improve for image classification in data-limited domains.

Regional Nerve Block Complication Analysis Following Peripheral Nerve Block During Foot and Ankle Surgical Procedures.

Background Foot and ankle surgeries are frequently accompanied by a peripheral nerve block in order to reduce postoperative pain. Higher than expected complication rates with peripheral nerve blocks have led to increased concern among surgeons and patients. To our knowledge, no study conducted by the treating surgeon has identified risk factors that may predispose a patient to complications. Our goal was to attempt to identify those risk factors. Methods We reviewed patient charts of those who underwent an orthopedic foot and ankle procedure between 2013 and 2018, as performed by the senior author. This yielded 992 procedures performed across four surgical locations. Of these procedures, 137 procedures were removed because no block was used. The remaining cases were analyzed for nerve complications, defined as sensory or motor deficits along the distribution of a nerve. The patients were divided into those with and without complications and were evaluated for differences. Statistical analysis was performed using the SAS® software (SAS Institute Inc., Cary, North Carolina, USA). Results The overall short-term complication rate was 10.1% and the long-term complication rate was 4.3%, with a total of 855 blocks given. Electromyographies (EMGs) were performed on 24.4% of the patients with a complication. Of the EMGs, 95.2% confirmed nerve complications in the distribution of the blocked nerve. The significant factors associated with complications were age, BMI, location, and smoking status. A regression analysis was performed to determine the odds ratio for individual factors. Those with significantly higher odds ratio were between 40 and 65 years of age, had normal or underweight BMI, underwent surgery at an outpatient surgery center, and were current smokers. Conclusions Our study suggests that there are significant epidemiological factors in predicting postoperative complications related to a peripheral nerve block. The study also shows a similar short-term complication rate but a higher long-term complication rate than other studies. This data are important because it allows for an informed decision to be made between a surgeon, anesthesiologist, and the patient regarding the safety and necessity of delivering a preoperative peripheral nerve block based on patient risk factors.

Using experimental gaming simulations to elicit risk mitigation behavioral strategies for agricultural disease management.

Failing to mitigate propagation of disease spread can result in dire economic consequences for agricultural networks. Pathogens like Porcine Epidemic Diarrhea virus, can quickly spread among producers. Biosecurity is designed to prevent infection transmission. When considering biosecurity investments, management must balance the cost of protection versus the consequences of contracting an infection. Thus, an examination of the decision making processes associated with investment in biosecurity is important for enhancing system wide biosecurity. Data gathered from experimental gaming simulations can provide insights into behavioral strategies and inform the development of decision support systems. We created an online digital experiment to simulate outbreak scenarios among swine production supply chains, where participants were tasked with making biosecurity investment decisions. In Experiment One, we quantified the risk associated with each participant's decisions and delineated three dominant categories of risk attitudes: risk averse, risk tolerant, and opportunistic. Each risk class exhibited unique approaches in reaction to risk and disease information. We also tested how information uncertainty affects risk aversion, by varying the amount of visibility of the infection as well as the amount of biosecurity implemented across the system. We found evidence that more visibility in the number of infected sites increases risk averse behaviors, while more visibility in the amount of neighboring biosecurity increased risk taking behaviors. In Experiment Two, we were surprised to find no evidence for differences in behavior of livestock specialists compared to Amazon Mechanical Turk participants. Our findings provide support for using experimental gaming simulations to study how risk communication affects behavior, which can provide insights towards more effective messaging strategies.

Unmet needs and behaviour during the Ebola response in Sierra Leone: a retrospective, mixed-methods analysis of community feedback from the Social Mobilization Action Consortium.

BACKGROUND: The west African Ebola epidemic (2014-15) necessitated behaviour change in settings with prevalent and pre-existing unmet needs as well as extensive mechanisms for local community action. We aimed to assess spatial and temporal trends in community-reported needs and associations with behaviour change, community engagement, and the overall outbreak situation in Sierra Leone. METHODS: We did a retrospective, mixed-methods study. Post-hoc analyses of data from 12 096 mobiliser visits as part of the Social Mobilization Action Consortium were used to describe the evolution of satisfied and unsatisfied needs (basic, security, autonomy, respect, and social support) between Nov 12, 2014, and Dec 18, 2015, and across 14 districts. Via Bayesian hierarchical regression modelling, we investigated associations between needs categories and behaviours (numbers of individuals referred to treatment within 24 h of symptom onset or deaths responded to with safe and dignified burials) and the role of community engagement programme status (initial vs follow-up visit) in the association between satisfied versus unsatisfied needs and behaviours. FINDINGS: In general, significant associations were observed between unsatisfied needs categories and both prompt referrals to treatment and safe burials. Most notably, communities expressing unsatisfied capacity needs reported fewer safe burials (relative risk [RR] 0·86, 95% credible interval [CrI] 0·82-0·91) and fewer prompt referrals to treatment (RR 0·76, 0·70-0·83) than did those without unsatisfied capacity needs. The exception was expression of unsatisfied basic needs, which was associated with significantly fewer prompt referrals only (RR 0·86, 95% CrI 0·79-0·93). Compared with triggering visits by community mobilisers, follow-up visits were associated with higher numbers of prompt referrals (RR 1·40, 95% CrI 1·30-1·50) and safe burials (RR 1·08, 1·02-1·14). INTERPRETATION: Community-based development of locally feasible, locally owned action plans, with the support of community mobilisers, has potential to address unmet needs for more sustained behaviour change in outbreak settings. FUNDING: Bill & Melinda Gates, Bill & Melinda Gates Foundation, and National Institutes of Health.

Clinical Implications of a One-hand Versus Two-hand Technique in the Silfverskiöld Test for Gastrocnemius Equinus.

Introduction Isolated gastrocnemius equinus contracture has been associated with several foot and ankle pathologies within the literature. The Silfverskiöld test is commonly used to identify isolated gastrocnemius contracture, however, the proper technique for performing the test has been scrutinized. The purpose of this study was to determine if there is a clinical significance in the ankle dorsiflexion that is obtained when the examination is performed incorrectly with a single hand versus the correct two-hand technique. Methods Thirty consecutive new patients with conditions associated with gastrocnemius equinus were included in the study. The Silfverskiöld test was performed with a two-hand technique and a single-hand technique. The amount of dorsiflexion obtained with the knee in full extension was measured and recorded using an extendable goniometer for each technique, with the arms aligned with the fifth metatarsal and fibular head. Results The average amount of dorsiflexion that was obtained with the two-hand technique with the knee in full extension was 76.3°±4.2°. When the one-hand technique was utilized the average amount of dorsiflexion obtained with the knee in full extension was 88.4°±4.2°. This was found to be statistically significant (p<0.01). Conclusion This study demonstrates that if the Silfverskiöld test is not performed correctly, the diagnosis of an isolated gastrocnemius contracture could be underappreciated. Accordingly, it may be important to perform the test with two hands in order to neutralize the hindfoot, midfoot, and forefoot, so that the dorsiflexion motion is through the tibiotalar joint alone.

Emulating Agricultural Disease Management: Comparing Risk Preferences Between Industry Professionals and Online Participants Using Experimental Gaming Simulations and Paired Lottery Choice Surveys.

Mitigating the spread of disease is crucial for the well-being of agricultural production systems. Implementing biosecurity disease prevention measures can be expensive, so producers must balance the costs of biosecurity investments with the expected benefits of reducing the risk of infections. To investigate the risk associated with this decision making process, we developed an online experimental game that simulates biosecurity investment allocation of a pork production facility during an outbreak. Participants are presented with several scenarios that vary the visibility of the disease status and biosecurity protection implemented at neighboring facilities. Certain rounds allowed participants to spend resources to reduce uncertainty and reveal neighboring biosecurity and/or disease status. We then test how this uncertainty affects the decisions to spend simulation dollars to increase biosecurity and reduce risk. We recruited 50 attendees from the 2018 World Pork Expo to participate in our simulation. We compared their performance to an opportunity sample of 50 online participants from the survey crowdsourcing tool, Amazon Mechanical Turk (MTurk). With respect to biosecurity investment, we did not find a significant difference between the risk behaviors of industry professionals and those of MTurk participants for each set of experimental scenarios. Notably, we found that our sample of industry professionals opted to pay to reveal disease and biosecurity information more often than MTurk participants. However, the biosecurity investment decisions were not significantly different during rounds in which additional information could be purchased. To further validate these findings, we compared the risk associated with each group's responses using a well-established risk assessment survey implementing paired lottery choices. Interestingly, we did not find a correlation in risk quantified with simulated biosecurity investment in comparison to the paired lottery choice survey. This may be evidence that general economic risk preferences may not always translate into simulated behavioral risk, perhaps due to the contextual immersion provided by experimental gaming simulations. Online recruitment tools can provide cost effective research quality data that can be rapidly assembled in comparison to industry professionals, who may be more challenging to sample at scale. Using a convenience sample of industry professionals for validation can also provide additional insights into the decision making process. These findings lend support to using online experimental simulations for interpreting risk associated with a complex decision mechanism.

Tandem Specialty Management of Complex Lower Extremity Wounds: A Report of Three Cases.

Complex lower extremity wounds present a unique problem to foot and ankle clinicians, with many obstacles to achieving a successful outcome. The decreased vasculature of the lower extremities creates environments where wounds lack the resources to properly heal on their own. Conditions such as diabetes mellitus and smoking can exacerbate these issues by further decreasing vascular flow providing resources to the wound. For physicians trained in orthopedic foot and ankle surgery, they often do not receive training in advanced wound care, whereas podiatric surgeons can obtain fellowship training in wound care management. This dynamic presents a unique opportunity for tandem management of complex lower extremity wounds, which can decrease patient morbidity and the costs associated with care. We present three cases of complex wounds managed in a tandem fashion that achieved optimal outcomes after both orthopedic surgery and podiatric surgery were involved. These cases illustrate the potential benefits associated with tandem wound management in foot and ankle surgery.

Minimal stress shielding with a Mallory-Head titanium femoral stem with proximal porous coating in total hip arthroplasty.

BACKGROUND: As longevity of cementless femoral components enters the third decade, concerns arise with long-term effects of fixation mode on femoral bone morphology. We examined the long-term consequences on femoral remodeling following total hip arthroplasty with a porous plasma-sprayed tapered titanium stem. METHODS: Clinical data and radiographs were reviewed from a single center for 97 randomly selected cases implanted with the Mallory-Head Porous femoral component during primary total hip arthroplasty. Measurements were taken from preoperative and long-term follow-up radiographs averaging 14 years postoperative. Average changes in the proximal, middle and diaphyseal zones were determined. RESULTS: On anteroposterior radiographs, the proximal cortical thickness was unchanged medially and the lateral zone increased 1.3%. Middle cortical thickness increased 4.3% medially and 1.2% laterally. Distal cortical thickness increased 9.6% medially and 1.9% laterally. Using the anteroposterior radiographs, canal fill at 100 mm did not correlate with bony changes at any level (Spearman's rank correlation coefficient of -0.18, 0.05, and 0.00; p value = 0.09, 0.67, 0.97). On lateral radiographs, the proximal cortical thickness increased 1.5% medially and 0.98% laterally. Middle cortical thickness increased 2.4% medially and 1.3% laterally. Distal cortical thickness increased 3.5% medially and 2.1% laterally. From lateral radiographs, canal fill at 100 mm correlated with bony hypertrophy at the proximal, mid-level, and distal femur (Spearman's rank correlation coefficient of 0.85, 0.33, and 0.28, respectively; p value = 0.001, 0.016, and 0.01, respectively). CONCLUSION: Stress shielding is minimized with the Mallory-Head titanium tapered femoral stem with circumferential proximal plasma-sprayed coating in well-fixed and well-functioning total hip arthroplasty. Additionally, the majority of femora demonstrated increased cortical thickness in all zones around the stem prosthesis. LEVEL OF EVIDENCE: Therapeutic Level III.

Is recovery faster for mobile-bearing unicompartmental than total knee arthroplasty?

UNLABELLED: How does unicompartmental compare with total knee arthroplasty in durability, incidence of complications and manipulations, recovery, postoperative function, and return to sport and work? We matched 103 patients (115 knees) treated with a mobile-bearing unicompartmental device through July 2005 to a selected group of 103 patients (115 knees) treated with cruciate retaining total knee arthroplasty for bilaterality, age, gender and body mass index. Patients who underwent a unicompartmental surgery had better range of motion at discharge and shorter hospital stay than those who had a total knee arthroplasty (77 degrees versus 67 degrees and 1.4 versus 2.2 days). At 6 weeks, Knee Society functional scores and range of motion were higher for unicompartmental than total knees (63 versus 55 and 115 degrees versus 110 degrees). Patient-perceived Oxford scores were similar between groups (unicompartmental 5.4 versus total 4.1). Average times to return to work and sport were similar for both groups. Minimally invasive unicompartmental knee arthroplasty demonstrated better early ROM, shorter hospital stays, and improved functional scores. No advantage was seen in terms of return to work, return to sport, or Oxford scores. The data suggest minimally invasive unicompartmental arthroplasty using a rapid recovery protocol allows patients a faster return to a more functional level than total knee arthroplasty. LEVEL OF EVIDENCE: Level III, therapeutic study. See the guidelines online for a complete description of level of evidence.