Association Between Bone Mineral Density and Elderly Ankle Fractures: A Systematic Review and Meta-Analysis.

Ankle fractures are becoming increasingly more common in the elderly population and present a significant burden to the United States health care system. Many factors have been associated with fragility ankle fractures including age, gender, body mass index, diabetes, tobacco use, and osteoporosis. However, the literature is inconsistent regarding the relationship between ankle fractures and osteoporosis. The primary aim of this meta-analysis was to quantify the relationship between bone mineral density (BMD) in elderly patients with ankle fractures compared with BMD in elderly patients without ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Data were combined using standard meta-analysis methods. Seven studies were used in the final analysis. A small-pooled effect size was found indicating the control group had increased BMD regardless of measurement used (95% confidence interval 0.09-0.58; I2 = 98.39%). Lower femoral neck BMD showed a small-pooled effect size (femoral neck 0.36; 95% confidence interval 0.00-0.73; I2 = 94.91%) with the ankle fracture cohort. This is the first meta-analysis to quantify the relationship between BMD and ankle fractures in the elderly population. Elderly ankle fractures showed a significant association with femoral neck BMD. The current data can be used in orthopedic clinics and Fracture Liaison Service programs to assign the appropriate subgroup of ankle fracture patients to investigative and treatment groups, assess fracture risk, and serve as an indication for secondary fracture prevention by stimulating an osteoporosis prevention workup. There may be a role for a team approach to fracture care including metabolic optimization.

Vergence facility with stereoscopic and nonstereoscopic targets.

PURPOSE: To compare vergence facility with nonstereo and stereo targets in binocular symptomatic and asymptomatic subjects. METHODS: Sixty-six students were divided into symptomatic and asymptomatic groups according to the Convergence Insufficiency Symptom Survey Questionnaire score. Vergence facility was tested at 40 cm by flipper prism 3Δ BI/12Δ BO (BI, base-in; BO, base-out). The targets used were a nonstereo target (a vertical column of small letter "E" of ~20/30 size), a stereo-local target (fifth set of circles of the Titmus test with stereoacuity of 100 arcsec), and a stereo-global target (page 6 of the TNO test with stereoacuity of 120 arcsec). RESULTS: Repeated-measures analysis of variance showed differences in the mean vergence facility with different targets in all subjects and separately in two symptom groups (p < 0.001). In all subjects and separately in the symptomatic subjects, this difference was statistically significant among the three different targets (p < 0.05). In the asymptomatic subjects, this difference was not significant between the measured values with nonstereo and stereo-local targets (p > 0.05) but significant for the comparison of stereo-global targets with the other two targets. The receiver operating characteristic curve analysis showed the cutoff points 10.5, 10.5, and 9.75 cycles per minute with nonstereo, stereo-local, and stereo-global targets, respectively. The sensitivity of the three targets used was the same (97%). Specificity was 0.93 or higher with all three targets, with the highest specificity obtained with the stereo-global target (100%). CONCLUSIONS: The highest vergence facility was obtained with a nonstereo target and the lowest was obtained with a stereo-global target. High sensitivity with all three targets means that there are few false-negative results with them, and the high specificity is indicative of low false-positive results. Hence, the vergence facility predictive value would be high in diagnosing binocular symptomatic patients using a 3Δ BI/12Δ BO prism flipper at near and a response cutoff of about 10 cycles per minute or less.

Accommodative response/stimulus by dynamic retinoscopy: near add guidelines.

PURPOSE: Monocular estimation method (MEM) dynamic retinoscopy and low neutral (LN) dynamic retinoscopy are common procedures for evaluating the need for near-point plus adds for improved near-point performance in non-presbyopes. A combination of MEM and LN has been suggested to be a method of plotting accommodative response/accommodative stimulus functions and evaluating guidelines for prescribing from MEM. METHODS: Using a combined MEM-LN procedure, MEM was performed on 80 young adults at 40 cm, with distance correction and with plus adds in 0.25 D steps up to and including +2.00 D. Modified Thorington dissociated phorias were also performed with each of the plus adds. Subjects picked a preferred add, which subjectively made print easiest and most comfortable to read. RESULTS: The mean preferred add was +0.58 D over the distance prescription. The add derived from subtracting 0.25 D from the lag of accommodation with distance correction averaged 0.10 D more plus than the preferred add. The add at which dynamic retinoscopy showed a "with" motion of 0.25 D averaged 0.54 more plus than the preferred add. The add at which dynamic retinoscopy showed a "with" motion of 0.50 D averaged 0.16 more plus than the preferred add. CONCLUSIONS: Adds derived from subtracting 0.25 D from the lag with distance correction and from finding the add that yields 0.50 D of "with" motion compared favorably with the preferred adds on average, but the standard deviations of the differences were high. Those guidelines could be reasonable starting points for the prescription of near-point plus adds for non-presbyopes, but follow-up testing to confirm or adjust add power would be advisable in the clinical setting.

Direct Plantar Approach to Plantar Plate Repair and Associated Wound Complications.

BACKGROUND: Lesser toe metatarsophalangeal joint (MTPJ) instability, secondary to plantar plate tear, has been the focus of numerous recent publications, the majority reporting on repair through a dorsal approach. A plantar approach has been described with the advantage of direct ligamentous repair or repair to bone, which follows conventional techniques employed throughout the body. Previous clinical studies have shown success in deformity correction and the longevity of both approaches. The proponents of the dorsal approach advocate that indirect repair of the plantar plate avoids perceived risks of complications with a plantar incision without evidence of superior outcomes. The purpose of this study was to investigate the safety and efficacy of the direct plantar approach to plantar plate repairs (PPRs) by reporting the rate of specific complications in a large clinical series. METHODS: This was the institutional review board (IRB) approved retrospective study of 204 PPRs in 185 patients (194 lesser MTP, 10 hallux MTP) with an average age of 56 and a mean body mass index (BMI) of 28. Surgical technique involved repair with absorbable braided suture (88%) versus suture anchor (12%) with or without MTPJ pinning (80%). Mean follow up was 53 weeks (range 5-170). Patients were screened for associated risk factors, including diabetes mellitus (8%), tobacco use (5%), neuropathy (1%), and additional concurrent procedures (96%). Complications were defined as superficial or deep infection, painful scars, and reoperation. Analysis was conducted using the Wilcoxon-Mann-Whitney test or Fisher's exact tests for continuous and categorical variables, respectively. Risk factors were analyzed using univariate logistic analysis to produce odds ratios (OR) with a 95% confidence interval (CI) and an inclusion criterion of a P-value, P > .2 for multivariate analysis as determined by Wald tests (significance at P < .05 for final modeling). RESULTS: Overall, there were 31 total complications (15%) demonstrated by 14 superficial infections (6.8%) and 17 painful scars (8.3%) along with three reoperations (1.4%). All reoperations were performed for deformity or instability, not scar revision. There were no deep infections. No increased odds of complications were found with suture anchor repair, MTPJ pinning, neuropathy, or diabetes. Patients that used tobacco had 7.5 (CI 1.66, 34.06) the odds of developing any wound complication compared with nonsmokers. Tobacco use was also found to significantly increase the odds of superficial infection by 9.8 (CI 2.08, 46.15). There was no increase in painful scars or reoperation in tobacco users. This study did not find an increased complication rate with additional ipsilateral procedures performed at the time of surgery. CONCLUSION: To our knowledge, this is the largest study evaluating the direct plantar approach to PPR as well as the evaluation of associated complications with the plantar incision. With low complication and minimal reoperation rates, the results of this study have demonstrated the clinical viability of plantar-based incisions. Previous studies have demonstrated the success of PPR and correction of deformity with a direct approach. This case series further demonstrates the safety and efficacy of plantar-based incisions, particularly for direct PPRs. LEVEL OF EVIDENCE: IV Retrospective Case Series. CATEGORY: Lesser Toes.

Neurophysiologic effects of spinal manipulation in patients with chronic low back pain.

BACKGROUND: While there is growing evidence for the efficacy of SM to treat LBP, little is known on the mechanisms and physiologic effects of these treatments. Accordingly, the purpose of this study was to determine whether SM alters the amplitude of the motor evoked potential (MEP) or the short-latency stretch reflex of the erector spinae muscles, and whether these physiologic responses depend on whether SM causes an audible joint sound. METHODS: We used transcranial magnetic stimulation to elicit MEPs and electromechanical tapping to elicit short-latency stretch reflexes in 10 patients with chronic LBP and 10 asymptomatic controls. Neurophysiologic outcomes were measured before and after SM. Changes in MEP and stretch reflex amplitude were examined based on patient grouping (LBP vs. controls), and whether SM caused an audible joint sound. RESULTS: SM did not alter the erector spinae MEP amplitude in patients with LBP (0.80±0.33 vs. 0.80±0.30 µV) or in asymptomatic controls (0.56±0.09 vs. 0.57±0.06 µV). Similarly, SM did not alter the erector spinae stretch reflex amplitude in patients with LBP (0.66±0.12 vs. 0.66±0.15 µV) or in asymptomatic controls (0.60±0.09 vs. 0.55±0.08 µV). Interestingly, study participants exhibiting an audible response exhibited a 20% decrease in the stretch reflex (p<0.05). CONCLUSIONS: These findings suggest that a single SM treatment does not systematically alter corticospinal or stretch reflex excitability of the erector spinae muscles (when assessed~10-minutes following SM); however, they do indicate that the stretch reflex is attenuated when SM causes an audible response. This finding provides insight into the mechanisms of SM, and suggests that SM that produces an audible response may mechanistically act to decrease the sensitivity of the muscle spindles and/or the various segmental sites of the Ia reflex pathway.

Robert M. Lockwood and George A. Rogers, early twentieth century optometry authors.

A significant factor in the continuing development and maturation of professional optometry in the early twentieth century was book and journal literature. Some of the prominent optometric writers of that era do not seem to be remembered today. Two examples are Robert Minturn Lockwood (1857-1920) and George A. Rogers (1852-1935). This article provides biographical sketches of each of them and brief descriptions of the contents of the books they published.

Ankle Arthrodesis With Structural Grafts Can Work for the Salvage of Failed Total Ankle Arthroplasty.

Background. Treatment options after failed total ankle arthroplasty (TAA) are limited. This study reports midterm outcomes and radiographic results in a single-surgeon group of patients who have undergone ankle arthrodesis with intramedullary nail fixation and structural allograft augmentation following failed TAA. Methods. A retrospective review on patients who underwent failed TAA revision with structural femoral head allograft and intramedullary tibiotalocalcaneal (TTC) nail fixation was completed. Foot Function Index (FFI), American Orthopaedic Foot & Ankle Society (AOFAS) outcome scores, and radiographs were obtained at each visit with 5-year follow-up. Results. Five patients were followed to an average of 5.2 years (range 4.7-5.6). Enrollment FFI was 34.82 (range 8.82-75.88); at midterm follow-up it was 20.42 (range 0-35.38). Enrollment AOFAS scores averaged 66.6 (range 61-77); at midterm follow-up it was 70.33 (range 54-88). Radiographs showed union in 4 of 5 patients at enrollment and 2 of 3 patients at midterm. Conclusions. Utilization of TTC fusion with femoral head allograft is a salvage technique that can produce a functional limb salvage. Our results show continued improvement in patient-reported outcomes, with preservation of limb length and reasonable union rate. Levels of Evidence: Therapeutic, Level II: Prospective, comparative trial.

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.

Maintenance of Correction of the Modified Lapidus Procedure With a First Metatarsal to Intermediate Cuneiform Cross-Screw Technique.

BACKGROUND: Recurrence of deformity remains a concern when fusing the first tarsometatarsal joint for correction of hallux valgus (HV). A recently described construct adds an additional point of fixation from the plantar medial first metatarsal to the intermediate cuneiform. The purpose of this study was to determine the maintenance of correction of the first and second intermetatarsal angle, hallux valgus angle, and tibial sesamoid position after undergoing a first tarsometatarsal joint arthrodesis using the proposed construct. METHODS: A radiographic review was performed of patients with HV treated with a first tarsometatarsal joint arthrodesis with the addition of a cross-screw intermediate cuneiform construct. Three observers reviewed radiographic data, including preoperative weightbearing, first weightbearing, and final weightbearing plain-film radiographs. Initial improvement and maintenance of intermetatarsal angle, hallux valgus angle (HVA), and tibial sesamoid position were evaluated radiographically. A total of 62 patients met inclusion criteria and were included in the study. Mean follow-up time was 9.3 months (SD 6.7). RESULTS: Bony union was achieved in 60 of 62 patients (96.7%). Two of 62 patients required revision surgery as a result of recurrence (3.3%). Final mean improvement of the intermetatarsal angle (IMA) was 6.8 degrees (±2.9 degrees), HVA was 14.8 degrees (±7.5 degrees), and tibial sesamoid position was 2.4 (±1.4) positions. Mean loss of IMA correction was 1.5 degrees (±1.6), HVA was 2.9 degrees (±4.8 degrees), and tibial sesamoid position was 0.8 (±0.8). CONCLUSION: This study showed that the cross-screw intermediate cuneiform construct for first tarsometatarsal joint arthrodesis had a good union rate, a low complication rate, and maintained radiographic correction. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Minimally Invasive Retrograde Method of Harvesting the Flexor Hallucis Longus Tendon: A Cadaveric Study.

BACKGROUND: Use of the flexor hallucis longus (FHL) tendon is well described for several tendon augmentation procedures. Harvesting the FHL through an open medial approach is commonly done, but is associated with anatomic risks. Recently, several authors have described a minimally invasive (MI) technique to harvest the FHL tendon utilizing a hamstring tendon stripper commonly used in ACL reconstruction. The purpose of this study was to evaluate the safety and effectiveness of harvesting the FHL tendon using this novel minimally invasive retrograde approach. METHODS: The FHL tendon was harvested through a transverse plantar incision over the interphalangeal joint of the great toe in 10 fresh-frozen cadaver lower extremities. A lateral-based incision for peroneal tendon repair was made and the FHL was retrieved. Tendon length, complications, and interconnections between the FHL and flexor digitorum longus (FDL) were recorded and classified. The specimens were then dissected by a single surgeon in a standardized fashion, and damage to any surrounding structures was recorded. RESULTS: The average length of the FHL tendon from the distal stump to the first intertendinous connection was 13.3 cm (range 8.8-16 cm, SD 2.3 cm). Eight cadavers demonstrated Plaass type 1 interconnections whereas 2 demonstrated type 3. There was no injury to the medial and lateral plantar arteries and nerves, plantar plate, or FDL tendons. One FHL tendon was amputated at the level of the sustentaculum during graft harvest. No injury of the medial neurovascular structures occurred with retrieval of the FHL tendon through the lateral incision. CONCLUSIONS: We found that care must be taken when approaching the sustentaculum with the tendon harvester in order to avoid amputation of the graft against a hard bony endpoint. Additionally, flexion and extension of the lesser toes could aid in successful tendon harvest when tendon interconnections were encountered. CLINICAL RELEVANCE: Using this MI technique appears to be a safe and effective way to obtain a long FHL tendon graft for tissue augmentation.

Spontaneous Compartment Syndrome in a Patient with McArdle Disease: A Case Report and Review of the Literature.

CASE: McArdle disease, a glycogen storage disorder, often manifests as exercise intolerance secondary to muscle ischemia. Few authors have reported on rhabdomyolysis or compartment syndrome following inciting events among patients with McArdle disease. We present the case of a 40-year-old woman who developed spontaneous compartment syndrome of the right forearm and subsequently underwent emergency fasciotomy. CONCLUSION: On the basis of the present case and our review of the current literature, we advocate a high level of suspicion for compartment syndrome in patients with a history of McArdle disease.

Anatomic Structures at Risk When Utilizing an Intramedullary Nail for Distal Fibular Fractures: A Cadaveric Study.

BACKGROUND: Retrograde intramedullary fibular nail fixation is being utilized with increasing frequency, particularly in patients at higher risk of wound complications. The purpose of this anatomic study was to assess the relative risk to nearby anatomic structures when implanting a contemporary retrograde locked intramedullary fibular nail. METHODS: Ten human cadaveric lower extremities were instrumented with a fibular nail. The cadavers were dissected. The shortest distance, in millimeters (mm), between the site of procedural steps and nearby named structures of interest (ie, sural nerve, superficial peroneal nerve, and the peroneal tendons) was measured and recorded. Levels of risk were assigned based on observed distances as high (0 to 5 mm), moderate (5.1-10 mm), and low (greater than 10 mm). RESULTS: The peroneus brevis (PB) tendon was found to be less than 5.0 mm from the distal skin incision in all specimens. When reaming and inserting the nail through the distal fibula aperture, the PB was less than 5.0 mm in 6 specimens. The peroneus longus tendon was at moderate to high risk when inserting both the proximal and distal syndesmotic screws in 9 specimens. The superficial peroneal nerve was at high risk when inserting an anterior to posterior distal locking screw in 7 specimens. The sural nerve was at low risk for all procedural steps. No structures were violated or damaged during any portion of the fibular nail instrumentation. CONCLUSION: The peroneal tendons and superficial peroneal nerve were at the highest risk; however, no structures were injured during instrumentation. CLINICAL RELEVANCE: The current findings indicate that strict adherence to sound percutaneous technique is needed in order to minimize iatrogenic damage to neighboring structures when performing retrograde locked intramedullary fibular nail insertion. This includes making skin-only incisions, blunt dissection down to bone, and maintaining close approximation between tissue protection sleeves and bone at all times.

Arthroscopically Assisted Reduction and Internal Fixation of a Displaced Posterior Glenoid Fracture: A Case Report.

CASE: We report the successful use of arthroscopy for reduction and internal fixation of a posterior glenoid fracture in a 62-year-old man 5 days following a skiing accident. Additionally, we review the technique utilized for successful fixation of this rare fracture, and we report the postoperative return of function. CONCLUSION: Arthroscopically facilitated fixation of glenoid fractures has been reported in the literature with excellent clinical outcomes. However, arthroscopic reduction and screw fixation of a posterior intra-articular glenoid fracture (Ideberg type Ib), to our knowledge, has not been previously published. The unique benefits of arthroscopic screw fixation are discussed.

Normative data for modified Thorington phorias and prism bar vergences from the Benton-IU study.

BACKGROUND: The use of a phoropter for measuring phorias and vergences in children is common in the optometric profession. For young children, the use of the phoropter can be confusing, making it difficult to obtain accurate measurements. Free space testing allows for direct observation of the eyes in a natural environment and is easier for children to understand the directions. The normal values for phorias and vergences used with children are derived from testing with a phoropter or free space measurements with mostly adult patients. METHODS: The Benton-IU Project was a large multidisciplinary study of factors affecting school performance conducted by the Indiana University School of Optometry and the Indiana University Department of Speech and Hearing with the cooperation of the Benton Community School Corporation (Benton County, Indiana). This project allowed the authors to obtain data on modified Thorington phorias and prism bar vergences from a nonselected group of first and fourth graders as part of an eye/vision examination. RESULTS: In this report, central tendency and variability statistics for modified Thorington and prism bar vergences are reported based on the data from the Benton-IU Study. CONCLUSION: The data presented in this report can be used by optometrists when deciding if the patient's phorias and vergences are within normal limits for children in the first through fourth grades.

A history of the Distinguished Service Foundation of Optometry.

The Distinguished Service Foundation of Optometry was an organization which sought to encourage research and education to facilitate the conservation of vision through publications and the awarding of medals. It existed from 1927 to 1979, but was most active in the 1930s and 1940s. Its leaders and activities are discussed.

Sensory, cognitive, and linguistic factors in the early academic performance of elementary school children: The Benton-IU project.

Standardized sensory, perceptual, linguistic, intellectual, and cognitive tests were administered to 470 children, approximately 96% of the students entering the first grade in the four elementary schools of Benton County, Indiana, over a 3-year period (1995--1997). The results of 36 tests and subtests administered to entering first graders were well described by a 4-factor solution. These factors and the tests that loaded most heavily on them were reading-related skills (phonological awareness, letter and word identification); visual cognition (visual perceptual abilities, spatial perception, visual memory); verbal cognition (language development, vocabulary, verbal concepts); and speech processing (the ability to understand speech under difficult listening conditions). A cluster analysis identified 9 groups of children, each with a different profile of scores on the 4 factors. Within these groups, the proportion of students with unsatisfactory reading achievement in the first 2 years of elementary school (as reflected in teacher-assigned grades) varied from 3% to 40%. The profiles of factor scores demonstrated the primary influence of the reading-related skills factor on reading achievement and also on other areas of academic performance. The second strongest predictor of reading and mathematics grades was the visual cognition factor, followed by the verbal cognition factor. The speech processing factor was the weakest predictor of academic achievement, accounting for less than 1% of the variance in reading achievement. This project was a collaborative effort of the Benton Community School Corporation and a multidisciplinary group of investigators from Indiana University.

Comparisons of dynamic retinoscopy measurements with a print card, a video display terminal, and a PRIO System Tester as test targets.

BACKGROUND: Dynamic retinoscopy is a common clinical test for assessment of visual function in patients with symptoms related to computer use. It has been suggested that performing dynamic retinoscopy with a fixation target resembling a computer screen may be valuable in the examination of computer users. However, such targets differ in luminance and other characteristics from the printed paper test cards typically used for dynamic retinoscopy. METHOD: To address the effect of varying test targets on dynamic retinoscopy results, this study compared lag of accommodation results from dynamic retinoscopy with three different fixation targets: (a) a printed paper target, (b) a video display terminal, and (c) the PRIO vision testing device, which is designed to simulate a computer screen. MEM (monocular estimate method) dynamic retinoscopy was performed with the print target and with the PRIO device. RESULTS: The difference between results with the different test conditions were generally small, with a statistically significant 0.32 D lower lag found on MEM retinoscopy with the PRIO target IMEM-PRIO) than on MEM retinoscopy with a print target (MEM-PRINT). Mean lag measurements on MEM with a print target and on Nott retinoscopy with the video display terminal (NOTT-VDT) were only 0.04 D different. The 95% limits of agreement for the difference between MEM-PRINT and MEM-PRIO (+/- 0.6 D) was similar to the 95% limits of agreement for the interexaminer reliability of the two procedures (+/- 0.6 D for MEM-PRINT and +/- 0.7 D for MEM-PRIO). CONCLUSION: There was a small but statistically significant difference in lag of accommodation measured with MEM dynamic retinoscopy on the PRIO testing device when compared to a print card.

Historical note on distance test charts and projectors.

The first documented letter distance test charts appeared in the 19th century. The first electronic projectors for eye and vision examination arrived in the early 20th century. This paper comments on some of those and other developments in distance testing charts and projectors. Brief biographical information is given on some of the inventors of projector systems.

Biographical note on Harold Solan (1921-2012), optometrist and learning disabilities researcher.

This paper gives a brief biographical sketch of the career of Harold A. Solan and discusses his five books.