Electron spin resonance (ESR) study of cigarette smoke by use of spin trapping techniques.

The technique of spin trapping has been applied to the gas phase of cigarette smoke to identify and quantify the radicals present. It was found that radicals could be trapped only if the smoke was filtered. Three spin traps were used: N-tert-butyl-alpha-phenyl nitrone (PBN). 5,5-dimethyl-delta1-pyrroline-1-oxide (DMPO) and alpha-[3,5-di-tert-butyl-4-hydroxyphenyl)-N-tert-butyl nitrone (OHPBN). From the electron spin resonance (ESR) splitting constants of the radicals produced by the reaction of smoke radicals with the spin traps and also from the effec of varying the path length between the cigarette and the spin trap solution, it is concluded that three types of signals are observed. Type I signals indicate the presence of oxygenated radicals which appear to be a mixture of alkoxy radicals (RO) and aroyloxy (ArCO2-) radicals. Our data do not allow conclusions about the nature of the R or Ar groups in these two oxy radicals; however, considerations based on lifetimes suggest that the R group probably is tertiary. Type II and III signals are not typical spectra of spin adducts. Instead, we believe they result from reaction of smoke (and probably radicals in smoke) with the PBN spin trap and indicate that smoke has the ability to effect one-electron oxidations. Only type I signals are observed with DMPO and OHPBN. A quantitative study shows that 4 x 10(14) spins/puff are present in the smoke, in contrast with the result of a recent study which used a very different method for determining the radical content of smoke. A discussion of the nature of the radicals in smoke and some tentative conclusions are presented.

A model of Staphylococcus aureus bacteremia, septic arthritis, and osteomyelitis in chickens.

We studied the occurrence, magnitude, and kinetics of bacteremia and the resultant osteomyelitis and septic arthritis in an avian model of Staphylococcus aureus infection. Thirty-day-old male broiler chicks were inoculated i.v. with 10(5), 10(6), or 10(7) cfu of strain Duntravis, a beta-hemolytic, coagulase-producing, capsular type 8 isolate from the synovial fluid of a 2-year-old black boy. Bacteremia occurred in 80%, 90%, and 100% of animals inoculated with 10(5), 10(6), or 10(7) cfu, respectively. The magnitude of bacteremia in surviving, bacteremic animals increased for 96 hours after inoculation and then decreased after a plateau phase. Osteomyelitis and septic arthritis occurred only in chicks that were continuously bacteremic. The occurrence of osteomyelitis was uniform among continuously bacteremic animals and developed 1 to 23 hours after inoculation. Chickens are susceptible to systemic infections with S. aureus. Bacteremia, osteomyelitis, and septic arthritis may be induced in healthy chickens without prior manipulations that depress their resistance.

Endosseous implant placement in conjunction with inferior alveolar nerve transposition: an evaluation of neurosensory disturbance.

This retrospective study evaluated neurosensory dysfunction and the implant success rate associated with 64 implants placed in 15 patients following transposition of the inferior alveolar nerve. A total of 21 inferior alveolar nerve mobilization surgeries were performed. The mean postoperative follow-up time was 41.3 months, with a range of 10 to 67 months. The effects of surgical technique and implant surface geometry on neurosensory dysfunction were evaluated by using light touch, brush stroke direction, and two-point discrimination. The implant success rate was 93.8% (60/64). The surgical technique that involved detaching the mental foramen resulted in a significantly greater incidence of neurosensory disturbance (77.8%, 7/9) than did the technique that left the bony foramen intact (33.3%, 4/12). The overall incidence of neurosensory disturbance was 52.4% (11/21).

Sideburn reconstruction with an arterial V-Y hair-bearing scalp flap after the excision of basal cell carcinoma.

A new flap is presented for sideburn reconstruction. It has good vascularity and hair direction. There is some tension in the closure of the scalp donor site that can be associated with alopecia. The flap should be advanced only to the desired sideburn level, with a cervicofacial flap covering any remaining defect. Follow-up at 2 years 4 months confirmed the satisfactory result. This flap adds another option to those discussed in this article for sideburn reconstruction.

Using restorations borne totally by anterior implants to preserve the edentulous mandible.

BACKGROUND: This study quantifies the changes in bone height of the posterior area of the edentulous mandible when the load of complete dentures is borne entirely by anteriorly placed osseointegrated implants. METHODS: Thirty-three patients, of whom there were radiographs from the beginning of implant loading and from a follow-up visit at least three years later (a mean of 6.6 years later), were included in the study. Working with panoramic radiographs, the authors took height measurements in the premolar area (15 millimeters distal to the most distal implants). A valid correction factor was available because implants of known length were proximal to the area being evaluated. RESULTS: The authors calculated descriptive statistics using means, standard deviations, medians and proportions as appropriate. A P-value of less than .05 was considered significant. Of the 33 subjects, most showed increases in bone height--29 (87.9 percent) on the right side and 28 (84.9 percent) on the left side. The mean change in all subjects was +1.0 mm (range -0.8 to +3.3 mm). A comparison of mandibular height at implant placement vs. follow-up showed a statistically significant increase bilaterally (P < .001). CONCLUSIONS: This study demonstrates that dentures for edentulous mandibles that are borne totally by implants in the anterior area conserve or enhance the bone of the posterior portion of the mandible. An important future study should test the effect of implant-assisted restorations for the edentulous mandible that load the posterior ridge (a bar clasp, for example). CLINICAL IMPLICATIONS: One of the considerations in planning treatment for the edentulous mandible should be the preserving effect of totally implant-borne restorations vs. the continued resorption of the body of the mandible with conventional dentures.

Comparison of results of retrocalcaneal decompression for retrocalcaneal bursitis and insertional achilles tendinosis with calcific spur.

Sixteen feet with retrocalcaneal bursitis (RB) and twenty-two feet with calcific Achilles insertional tendinosis (IAT-CS) underwent retrocalcaneal decompression after failure of nonoperative treatment. Follow-up evaluation at least two years after surgery included AOFAS Ankle-Hindfoot subscale scores, satisfaction, time until maximum symptomatic improvement, and radiographs. Statistically significant differences between the groups include the following: IAT-CS patients were older, required nearly twice the time to reach maximum symptomatic improvement, had lower satisfaction rates, had a lower pain score, and more frequently had shoewear restrictions. Radiographic recurrence did not correlate with outcome or symptomatic recurrence.

Distal soft tissue release using direct and indirect approaches: an anatomic study.

Two surgical approaches for distal soft tissue release in the correction of hallux valgus, one using a dorsal first web space incision and the other a longitudinal medial capsulotomy incision (used also for medial eminence resection), were studied to compare and delineate the structures actually incised. Anatomic dissections were performed on six fresh-frozen amputation specimens using each of the approaches. The adequacy of release of the adductor hallucis, transverse and oblique heads, first metatarsophalangeal lateral capsule, and suspensory ligament was reviewed. Any inadvertent damage to the first metatarsal head cartilage, second metatarsophalangeal capsule, and lateral head of the flexor hallucis brevis tendon was also noted. Distal soft tissue release is thought to be an important part of hallux valgus surgery. Based on our anatomic dissections, the actual extent of the release may be inconsistent and unpredictable, and may have implications for the predictability of results after hallux valgus surgery.

Success of calcaneonavicular coalition resection in the adult population.

Twelve adult patients (13 feet), average age 33 years (range, 19-48 years), with calcaneonavicular coalitions remained symptomatic after a trial of conservative treatment. Surgical resections were performed. Before surgery, there was < 5 degrees of inversion/eversion in 11 patients, radiographic evidence of degenerative arthritis in 10 feet (77%), and talar beaking in 7 feet. At an average postoperative follow-up of 36 months, subjective relief of preoperative symptoms was achieved in all but two patients. Two patients required subsequent hindfoot arthrodesis. Resection of calcaneonavicular coalition in the adult can be successful and provides an option to arthrodesis after nonoperative methods have failed.

Intermediate to long-term follow-up of medial-approach dorsal cheilectomy for hallux rigidus.

Dorsal cheilectomy of the hallux metatarsophalangeal (MTP) joint through a medial approach can effectively provide long-term relief of pain and improve function in symptomatic mild-to-moderate hallux rigidus, despite progression of generalized first MTP joint arthritic degeneration and/or loss of motion. Fifty-seven patients (75 feet) with arthritis of the first MTP joint underwent dorsal cheilectomy through a medial approach for hallux rigidus failing nonoperative management. Excision of the dorsal articular surface of the first metatarsal head and dorsal osteophytes was performed through a medial approach that also allowed for plantar capsular release and removal of lateral osteophytes. Minimum follow-up was 3 years (average, 63 months; range, 37-92 months). Fifty-two patients (68 feet) returned for clinical and radiographic evaluation. American Orthopaedic Foot and Ankle Society Hallux Rating scores improved from a preoperative average of 45 to 85 points at follow-up. Average dorsiflexion improved from 19 degrees to 39 degrees, and the average range of motion improved from 34 degrees to 64 degrees. Preoperative radiographic grade of arthritic degeneration was grade I in 17 feet, grade II in 39 feet, and grade III in 12 feet; at follow-up, the radiographic grade was grade I in 2 feet, grade II in 26 feet, and grade III in 40 feet. Thirty-two feet worsened one grade, 6 feet worsened two grades, and 28 feet demonstrated no change (12 of 28 were grade III, preoperatively). A dorsal spur recurred in 21 feet, 9 of which were symptomatic. Complications included two superficial wound infections and four transient paresthesias of the hallux, all of which resolved uneventfully.

Dorsiflexion metatarsal osteotomy for treatment of recalcitrant diabetic neuropathic ulcers.

Twenty diabetic patients underwent 22 dorsiflexion metatarsal osteotomies for treatment of chronic persistent or recurrent neuropathic forefoot ulcers. Mean duration of nonoperative treatment was 13 months. The procedure consisted of irrigation and debridement of the ulcer followed by basilar closing wedge metatarsal osteotomy performed through a dorsal approach. At follow-up, complete ulcer healing was noted in 21 cases (95%) at an average of 40 days postoperatively. Complications occurred in 15 cases (68%). The main problems encountered postoperatively were acute Charcot disease (32%) and deep wound infections (14%). Transfer lesions under adjacent metatarsal heads developed in two cases (9%). One ulcer (5%) failed to heal secondary to vascular insufficiency and eventually required a below the knee amputation after a failed revascularization attempt. Loss of screw fixation occurred in one patient (5%) but acceptable metatarsal alignment was maintained and the ulcer healed uneventfully. There were no cases of ulcer recurrence. The results of this study suggest that dorsiflexion metatarsal osteotomy is a reliable salvage procedure for the treatment of recalcitrant neuropathic forefoot ulcers that have failed an adequate trial of nonoperative treatment. This procedure is associated with a high complication rate, as would be expected in this patient population.

Clinical evaluation of the Ruiz-Mora procedure: long-term follow-up.

The Ruiz-Mora procedure has been advocated for treatment of congenital overlapping fifth toes, fifth hammertoe, and clavus deformities. This study evaluated the results of the Ruiz-Mora procedure in 12 patients with an average follow-up of more than 4 years. The data indicate the majority of patients are satisfied with the results of the procedure. Unacceptable cosmesis was the primary complaint of all dissatisfied patients. Assessment of preoperative versus postoperative symptoms indicate an improvement in symptoms as well as maintenance of stability and function. The average shortening of the toe was 12.8 mm. This presented no functional problems to the patients. Three patients had transient skin healing problems which resolved with local care. Based on this series, the Ruiz-Mora procedure is effective in dealing with the problem of the cock-up fifth hammertoe and is associated with few complications. Because of patient dissatisfaction with cosmesis, consideration should be given to showing patients postoperative photographs of the procedure before surgery and reserving this procedure for salvage of iatrogenic cock-up deformities, recalcitrant hard corns, and congenital cock-up deformities.

Prospective, randomized comparison of proximal crescentic and proximal chevron osteotomies for correction of hallux valgus deformity.

In this study, intermetatarsal angle (IMA) correction, functional outcome, and healing time for the proximal crescentic and proximal chevron osteotomies in moderate to severe hallux valgus deformity were prospectively compared. Seventy-five patients (97 feet) were prospectively randomized to either a proximal crescentic or proximal chevron osteotomy for the correction of moderate to severe hallux valgus deformity with associated metatarsus primus varus. Criteria for study entry included age (adult patients), IMA greater than or equal to 13 degrees, persistent symptoms despite nonoperative treatment, and minimum follow-up of 12 months. Twenty-nine patients (41 feet) in the crescentic group and 37 patients (43 feet) in the chevron group returned for follow-up at an average of 24 and 20 months, respectively. Good results were achieved with both procedures. No statistically significant differences were found with respect to correction of the IMA or to functional outcome between the two groups. Results held true irrespective of patient age, severity of disease, or bilateral involvement. A statistically significant shorter healing time of the first metatarsal was found after proximal chevron osteotomy. Other potential benefits of the chevron procedure included avoidance of dorsiflexion of the first metatarsal, tendency toward less shortening of the first metatarsal, and more medial distribution of tibial sesamoids following surgery, all of which may reduce the potential for development or persistence of transfer lesions.

Painful os peroneum syndrome: a spectrum of conditions responsible for plantar lateral foot pain.

Plantar lateral foot pain may be caused by various entities and the painful os peroneum syndrome (a term coined by the authors) should be included in the differential diagnosis. Painful os peroneum syndrome results from a spectrum of conditions that includes one or more of the following: (1) an acute os peroneum fracture or a diastasis of a multipartite os peroneum, either of which may result in a discontinuity of the peroneus longus tendon; (2) chronic (healing or healed) os peroneum fracture or diastasis of a multipartite os peroneum with callus formation, either of which results in a stenosing peroneus longus tenosynovitis; (3) attrition or partial rupture of the peroneus longus tendon, proximal or distal to the os peroneum; (4) frank rupture of the peroneus longus tendon with discontinuity proximal or distal to the os peroneum; and/or (5) the presence of a gigantic peroneal tubercle on the lateral aspect of the calcaneus which entraps the peroneus longus tendon and/or the os peroneum during tendon excursion. Familiarity with the various clinical and radiographic findings and the spectrum of conditions represented by the painful os peroneum syndrome can prevent prolonged undiagnosed plantar lateral foot pain. Clinical diagnosis of the painful os peroneum syndrome can be facilitated by the single stance heel rise and varus inversion stress test as well as by resisted plantarflexion of the first ray, which can localize tenderness along the distal course of the peroneus longus tendon at the cuboid tunnel.(ABSTRACT TRUNCATED AT 250 WORDS)

The superior peroneal retinaculum: an anatomic study.

The superior peroneal retinaculum is thought to be the primary restraint to subluxation and/or dislocation of the peroneal tendons as they pass posterior to the distal fibula. The descriptions in anatomy texts vary widely. This anatomical study describes the different patterns of insertions for the superior peroneal retinaculum and its relationship to the peroneal tendons and the ligaments of the lateral ankle.

Clinical evaluation of the modified Brostrom-Evans procedure to restore ankle stability.

The modified Brostrom procedure has become the standard for anatomic repair of symptomatic chronic lateral instability. However, it was our perception that this local tissue repair may fail eventually, particularly in patients that are overweight, hyperflexible, or are involved in strenuous work or athletic activity. This is a retrospective review of 21 lateral ankle reconstructions (20 patients) in which the modified Brostrom technique was augmented with a portion of the peroneus brevis tendon. All patients were interviewed at an average of 29.5 months (range, 14-56 months postsurgery). Fourteen patients also agreed to be evaluated by a physical therapist. No surgical complications were identified. American Orthopaedic Foot and Ankle Society ankle-hindfoot scores averaged 98.2. There was no significant difference in passive or active range of motion of plantarflexion or dorsiflexion when compared to the contralateral ankle. However, a statistically significant loss of inversion (passive, P = 0.011; active, P = 0.018) and eversion (passive, P = 0.004; active, P = 0.007) was noted when compared to the contralateral ankle. Measurement of isometric eversion strength, using a Cybex 340 Isokinetic device, and functional testing, using a lateral lunge test, revealed no significant loss of peroneal strength. The authors conclude that chronic lateral ankle instability in the general population can be successfully managed with a modified Brostrom procedure augmented with a portion of the peroneus brevis. The procedure remains technically simple and provides a greater static restraint for inversion stress without evidence of dramatic overtightening or loss of peroneal strength.

Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures.

A retrospective review was performed on all patients who had an in situ subtalar arthrodesis for painful sequelae of calcaneus fractures between 1989 and 1994. Nineteen feet were available for evaluation, with a mean follow-up of 27 months (range, 12-62 months). Lateral calcaneal wall decompression was performed in seven feet. Although loss of ankle dorsiflexion was associated with anterior ankle tenderness, loss of ankle dorsiflexion was not correlated with either talar declination angles or talar height differences. There was no correlation between American Orthopaedic Foot and Ankle Society hindfoot score and talar declination, talar height, or calcaneal width. Peroneal tendon/subfibular impingement, ankle tenderness, sural nerve injury, and patient smoking were all statistically associated with lower scores. The calcaneocuboid joint was frequently involved in the fracture but was not painful at follow-up. Late pain after a calcaneal fracture is not caused by only subtalar arthrosis. Radiographic criteria alone cannot be relied upon for surgical decision making. Careful physical evaluation should be used to determine sources of pain. Distraction arthrodesis should be considered only if findings of anterior ankle impingement are present. If sural nerve symptoms are present, a sural neurectomy may be added to the procedure. Pain localized to the plantar fat pad should be managed nonoperatively. Radiographic changes in the calcaneocuboid joint rarely require surgical intervention. Based on these results, in situ subtalar arthrodesis with lateral wall decompression is the procedure of choice in most cases of subtalar traumatic arthritis with lateral wall impingement.

Gross, histological, and microvascular anatomy and biomechanical testing of the spring ligament complex.

In recent years there has been an increased interest in the treatment of acquired pes planus. The breakdown of the medial longitudinal arch is most often seen at the talonaviculocalcaneal articulation. This suggests a relationship between the ligamentous complex at this articulation and acquired pes planus. This study was undertaken to gain a better understanding of the gross, histologic, and microvascular anatomy, as well as the biomechanics of the ligamentous structures surrounding the talonaviculocalcaneal articulation. Cadaver dissections of 38 fresh-frozen feet were performed. Detailed descriptions of the gross anatomy of the superomedial calcaneonavicular ligament, inferior calcaneonavicular ligament, and the superficial deltoid ligament were recorded. Their relationships to the posterior tibialis tendon and to the bones of the talonaviculocalcaneal articulation are described. The histology and microvascularity of these structures were also studied. Preliminary biomechanical testing was performed. It was found there are two definitive anatomic structures that are commonly called the spring ligament: the superomedial calcaneonavicular ligament (SMCN) and the inferior calcaneonavicular ligament (ICN). The SMCN ligament was found to have histologic properties that suggest significant load bearing. The histology of the ICN ligament suggests a pure tensile load function. The deltoid ligament and the posterior tibialis tendon had direct attachments to the SMCN ligament in all specimens. An articular facet composed of fibrocartilage was found in each SMCN ligament specimen. The microvascular structures showed an avascular articular facet present in the ligament. The biomechanical testing showed that the SMCN ligament and ICN ligament had strength similar to ankle ligaments. This study suggests this "spring ligament complex" has more of a "sling" function for the talar head. It is hoped that the better understanding of this region will add to our understanding of the etiology of pes planus and possible treatment alternatives.