Clinical outcomes of subtalar arthroereisis for the treatment of stage 1 flexible progressive collapsing foot deformity.

BACKGROUND: The use of subtalar arthroereisis as an adjunct to the surgical treatment of stage 1 flexible progressive collapsing foot deformity (PCFD) is controversial. The aim was to investigate the clinical outcomes and report the implant removal rate of subtalar arthroereisis as an adjunct for stage 1 PCFD. METHODS: A retrospective study of 212 consecutive feet undergoing operative management of stage 1 PCFD with adjunctive subtalar arthroereisis between October 2010 and April 2018. The primary outcome was the Foot and Ankle Outcome Score (FAOS). Secondary outcomes included Foot and Ankle Disability Index (FADI), Euroqol-5D-5L Index and implant removal rate. RESULTS: Post-operative clinical FAOS outcomes were collected for 153 feet (72.2%). At mean 2.5-year follow-up, the mean ± standard deviation FAOS for each domain was as follows; Pain: 81.5 ± 18.5, Symptoms: 79.5 ± 12.9, Activities of Daily Living: 82.5 ± 15.4 and Quality of Life: 64.2 ± 23.7. EQ-5D-5L Index was 0.884 ± 0.152. Pre-operative scores were available for 20 of these feet demonstrating a statistically significant improvement in all FAOS, FADI and EQ-5D-5L domains (p < 0.05). The implant removal rate for persistent sinus tarsi pain was 48.1% (n = 102). CONCLUSION: Use of a subtalar arthroereisis implant as an adjunct to conventional procedures in stage 1 flexible PCFD can result in significant improvement in pain and function. Patients should be counselled as to the relatively frequent rate of subsequent implant removal. LEVEL OF EVIDENCE: IV.

Results of Arthroscopic Talar Osteochondral Lesions Treatment with BST-CarGel.

Osteochondral lesions (OCLs) are a diverse group of articular cartilage lesions with or without a subchondral component. They often result from ankle injuries in the young population. Lateral talar dome lesions are encountered more frequently in trauma. Bone marrow stimulation with microfracture is an established form of treatment for symptomatic OCL in the literature; however, reparative fibrocartilaginous tissue has inferior wear characteristics to hyaline cartilage, and clinical symptoms have been found to recur in 2 years. Recalcitrant OCL already treated with microfracture presents a considerable challenge to clinicians. Results of microfracture combined with chitosan-based biomaterial have been reported favorably in hip and knee. Chitosan glycerol phosphate has cationic properties that enhance clot adhesiveness within the space of an OCL and prevent blood clot retraction. Greater volume and better quality of reparative tissue using chitosan have been demonstrated in randomized controlled trials and in vivo studies. We prospectively report chitosan blood implant with microfracture results in patients with recalcitrant talar OCLs who were previously treated with microfracture alone in a single-surgeon study. We found a statistically significant improvement in Foot and Ankle outcome score (FAOS) and EQ-5D, with an average follow-up of >2 years.

Randomized Controlled Trial of Topical Skin Adhesive vs Nylon Sutures for Incision Closure in Forefoot Surgery.

BACKGROUND: There are many options for incision closure in forefoot surgery. The aim of this study was to compare topical skin adhesive (2-octyl-cyanoacrylate) to simple interrupted nylon sutures. METHODS: A prospective randomized controlled trial comparing topical skin adhesive (TSA) and nylon sutures (NSs) for elective open forefoot surgery. Primary outcome was Hollander Wound Evaluation Scale (HWES) assessed 2 weeks following surgery. Secondary objectives included time taken for wound closure, wound assessment, patient satisfaction with wound cosmesis, incision pain, and infection rate. RESULTS: Between January and December 2018, 84 feet (70 patients) underwent hallux valgus scarf/Akin osteotomy or first metatarsophalangeal arthrodesis and were randomized to receive either intervention (topical skin adhesive) or control (3/0 nylon sutures). We found worse HWES scores when using TSA compared to NSs (1.07 vs 0.60). Incision closure time was slower for TSA (mean, 272 vs 229 seconds). At 2 weeks postoperatively, wound care was faster for TSA (mean 71 secs) vs NSs (mean 120), and patient-reported pain was less with TSA (visual analog scale: TSA 1.2 vs NSs 2.1). A high degree of overall patient satisfaction was reported in both groups, without significant difference. CONCLUSION: Closure of elective forefoot surgery incisions with topical skin adhesive or interrupted nylon sutures offers high satisfaction rates, low pain scores, and low complications. However, topical skin adhesive was associated with more inflammation and areas of wound separation compared to nylon sutures. We recommend the use of sutures for wound closure in forefoot surgery. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

CSF bone cyst in a cervical vertebra.

A 43 year male patient presented with neck pain, upper limb paraesthesia and right foot weakness. A MRI scan revealed a bone cyst involving C4 spinous process, lamina, pedicles and the posterior part of the vertebral body causing focal spinal stenosis. A C4 laminectomy and C3-C5 lateral mass screw fixation was done. Intra-operatively the cyst was found to contain CSF with an associated dural defect. A CSF cervical vertebral cyst has not been previously reported in the literature. The clinical presentation, radiological features and management of this CSF vertebral cyst is discussed.

A marine viral halogenase that iodinates diverse substrates.

Oceanic cyanobacteria are the most abundant oxygen-generating phototrophs on our planet and are therefore important to life. These organisms are infected by viruses called cyanophages, which have recently shown to encode metabolic genes that modulate host photosynthesis, phosphorus cycling and nucleotide metabolism. Herein we report the characterization of a wild-type flavin-dependent viral halogenase (VirX1) from a cyanophage. Notably, halogenases have been previously associated with secondary metabolism, tailoring natural products. Exploration of this viral halogenase reveals it capable of regioselective halogenation of a diverse range of substrates with a preference for forming aryl iodide species; this has potential implications for the metabolism of the infected host. Until recently, a flavin-dependent halogenase that is capable of iodination in vitro had not been reported. VirX1 is interesting from a biocatalytic perspective as it shows strikingly broad substrate flexibility and a clear preference for iodination, as illustrated by kinetic analysis. These factors together render it an attractive tool for synthesis.

Bilateral transient osteoporosis of the hip in a 20-year-old man.

Transient osteoporosis is a rare musculoskeletal condition that has been reported in pregnant women and middle-aged men. We present a bilateral case in a young man. A 20-year-old man presented with spontaneous onset left hip pain. Investigations excluded other differential diagnoses such as infection or fracture. The pain resolved completely; 6 months later the patient presented with a similar episode of pain in the contralateral hip. This also resolved spontaneously. Doctors need to be aware of the possibility of spontaneous onset musculoskeletal pain due to transient osteoporosis occurring in young men. The typical presentation is of spontaneous onset progressive pain, often affecting the hip. Other pathology must be excluded. The investigation of choice is MRI, and the treatment is simple analgesia.

Spontaneous psoas abscess: presenting with phlegmasia cerulea dolens.

Phlegmasia cerulea dolens (PCD) is a limb-threatening venous disorder involving massive proximal venous thrombosis. The clinical manifestations are of oedema, cyanosis and pain of lower extremity. Patients presenting with PCD have an underlying pathological condition that predisposes to the thrombotic process. We report a diabetic patient who presented with PCD and septicaemia due to a spontaneous psoas abscess. Anticoagulation with heparin and treatment of the underlying psoas abscess led to complete resolution of symptoms. An understanding of the underlying pathological process responsible is vital to early recognition and successful outcome in this rare limb- and life-threatening venous disorder.