Long term follow-up and development of foot complaints in a surgically treated mirror foot-A case report and review of literature.

BACKGROUND: Mirror foot is a rare anomaly and limited long term follow-up information is available. METHODS: Seven years after operation a mirror foot patient returned with foot complaints and was evaluated using radiographs and clinical examination. A systematic literature search was conducted to study foot complaints in mirror feet. RESULTS: Different origins of foot pain were considered in our patient; tibia length difference, deformed talus and accessory osseous structures in the tarsal region. Literature search resulted in 118 mirror feet. Based on cases reporting osseous structures, 74.2% showed tibia abnormalities and 94.5% an abnormal tarsal region. Only three cases mentioned a normal talus. Nine cases reported a follow-up period of more than five years. CONCLUSION: Osseous abnormalities are not always visible at birth, but are often present. Therefore, detailed examination of the affected limb in mirror foot patients with foot pain is important, in order to localize the origin.

Predicting complete finger extension in Dupuytren's disease.

Multiple studies have reported the effectiveness of treatment on contracture reduction in Dupuytren's disease. However, very few studies have attempted to quantify to which extent patient and disease characteristics influence the chance of achieving a straight finger after surgery. Therefore, the aim of this study is to explore to which extent pre-operative patient and disease characteristics can reliably predict a straight finger after surgery for Dupuytren's disease. In total, 812 and 281 patients, who underwent a limited fasciectomy or needle fasciotomy, respectively, were included in the final analyses. Analysis was performed using a logistic modeling framework. For both treatments, the combination of the extension deficit at baseline; which finger is most affected, which joint is most affected, and the number of affected fingers provided reliable predictions. Classical patient characteristics, such as age and sex, had no additional predictive value. The models presented in this study provide reliable predictions and could be helpful in informing patients and managing their expectations.

Spatiotemporal distribution of thrombospondin-4 and -5 in cartilage during endochondral bone formation and repair.

During skeletal development most bones are first formed as cartilage templates, which are gradually replaced by bone. If later in life those bones break, temporary cartilage structures emerge to bridge the fractured ends, guiding the regenerative process. This bone formation process, known as endochondral ossification (EO), has been widely studied for its potential to reveal factors that might be used to treat patients with large bone defects. The extracellular matrix of cartilage consists of different types of collagens, proteoglycans and a variety of non-collagenous proteins that organise the collagen fibers in complex networks. Thrombospondin-5, also known as cartilage oligomeric matrix protein (TSP-5/COMP) is abundant in cartilage, where it has been described to enhance collagen fibrillogenesis and to interact with a variety of growth factors, matrix proteins and cellular receptors. However, very little is known about the skeletal distribution of its homologue thrombospondin-4 (TSP-4). In our study, we compared the spatiotemporal expression of TSP-5 and TSP-4 during postnatal bone formation and fracture healing. Our results indicate that in both these settings, TSP-5 distributes across all layers of the transient cartilage, while the localisation of TSP-4 is restricted to the population of hypertrophic chondrocytes. Furthermore, in fractured bones we observed TSP-4 sparsely distributed in the periosteum, while TSP-5 was absent. Last, we analysed the chemoattractant effects of the two proteins on endothelial cells and bone marrow stem cells and hypothesised that, of the two thrombospondins, only TSP-4 might promote blood vessel invasion during ossification. We conclude that TSP-4 is a novel factor involved in bone formation. These findings reveal TSP-4 as an attractive candidate to be evaluated for bone tissue engineering purposes.

Clinical Presentation, Surgical Treatment, and Outcome in Radial Polydactyly.

Radial polydactyly or 'thumb duplication' is the most common congenital upper limb anomaly ('CULA') affecting the thumb. The clinical presentation is highly diverse, ranging from an extra thumb floating on a skin bridge to complicated thumb triplications with triphalangeal, deviating, and hypoplastic components. Radial polydactyly can be classified into one of 7 osseous presentations using the Wassel classification, with type IV (45%), type II (20%), and type VII (15%) occurring most frequently. When faced with a radial polydactyly case, hand surgeons specialised in congenital anomalies must weigh the preoperative functional potential and degree of hypoplasia of both thumbs in order to decide whether to resect one thumb and reconstruct the other ('resection and reconstruction'), excise a central part of both thumbs and unite the lateral tissues into one thumb ('the Bilhaut procedure'), transfer the better-developed distal tissues of one thumb onto the better-developed proximal tissues of the other ('on-top plasty'), or discard both severely hypoplastic thumbs and pollicise the index finger. Mere excision of the hypoplastic thumb is rarely indicated since it often requires subsequent revision surgery. Even after being treated by experienced surgeons, about 15% of patients with polydactyly will need additional procedures to correct residual and/or new problems such as deviation from the longitudinal axis and joint instability. Nevertheless, radial polydactyly patients usually achieve unimpaired everyday hand function postoperatively.

A clinically weighted approach to outcome assessment in radial polydactyly.

UNLABELLED: Currently available outcome assessment systems for radial polydactyly are mainly based on expert opinion. The aim of this study was to develop an outcome assessment system based on clinical data. We performed linear regression analysis on data from a multicentre study of 121 patients with radial polydactyly types II, IV and VII to develop a clinically weighted outcome assessment system. Items were weighted according to their influence on overall functional and aesthetic outcome in the regression analysis. Active flexion, scar appearance and prominence at amputation site were the main items influencing overall functional and aesthetic outcome (ß = 0.393, ß = 0.326 and ß = 0.288, respectively). Palmar abduction, metacarpophalangeal joint deviation and nail appearance influenced overall functional and aesthetic outcome the least (ß = -0.002, ß = -0.104 and ß = 0.070, respectively). Our proposed assessment system for radial polydactyly reflects the way clinicians value individual aspects of outcome as determinants of overall outcome and helps guide future treatment and evaluation of outcome. LEVEL OF EVIDENCE: III.

Ventilator-associated pneumonia: risk factors and patient mortality.

Among critically ill and mechanically ventilated patients, ventilator-associated pneumonia (VAP) is the most common nosocomial infection. Although VAP has a high mortality rate, it is unknown whether patients die from VAP or underlying illness. This article reviews the association between VAP and mortality, and discusses whether prevention of VAP will improve the outcome of mechanically ventilated patients.

Minimally invasive options in Dupuytren's contracture: aponeurotomy, enzymes, stretching, and fat grafting.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Perform needle aponeurotomy, fat grafting, Digit Widget insertion, and collagenase injection for Dupuytren's cords. (2) Describe how cords can be stretched without surgery. (3) Explain to patients the risks and benefits of these new alternatives of treatments. SUMMARY: Surgery for Dupuytren's contracture used to be the only alternative of treatment. The past 5 years have seen the widespread adoption of minimally invasive treatments in the form of needle aponeurotomy and collagenase injection to disrupt the cords and restore range of motion. Even newer and perhaps as effective treatments such as fat grafting and mechanical stretching with the Digit Widget may also end up being important tools of treatment. The reader will be introduced to all of these modalities with text, illustration, and videos.

Relationship between methodological trial quality and the effects of selective digestive decontamination on pneumonia and mortality in critically ill patients.

CONTEXT: Although meta-analyses of randomized trials have shown that selective digestive decontamination (SDD) prevents nosocomial pneumonia in critically ill patients, the influence of trial quality on the effectiveness of SDD has not been rigorously evaluated. OBJECTIVE: To assess the methodological quality of individual studies of SDD and its relation to the reported effects on pneumonia and mortality. DESIGN: Thirty-two studies were identified in a MEDLINE and reference list search and their methodological quality was assessed using a scoring system (range, 0-13 points) based on allocation and concealment, patient selection, patient characteristics, blinding of the intervention, and the definition of pneumonia. MAIN OUTCOME MEASURE: Methodological quality of the primary trials and its effect on the relative risk reductions (RRRs) of SDD on pneumonia and mortality. RESULTS: The mean (SD) methodological quality score was 7.8 (2.9) (range, 1-11). The RRRs ranged from -0.1 to 1.0 for pneumonia and from -0.1 to 0.6 for mortality. The methodological quality score was associated with the RRR for pneumonia so that for each quality-point added, the RRR decreased by 5.8% (95% confidence interval, 2.4%-9.3%). No association between trial quality and the impact of SDD was found on mortality. Of the individual trial quality characteristics, patient selection, allocation of intervention, and blinding most strongly influenced the treatment effect. CONCLUSIONS: The inverse relationship between methodological quality score and the benefit of SDD on the incidence of pneumonia may have resulted in overly optimistic estimates of SDD in prior meta-analyses. This emphasizes the importance of rigorous trial design in evaluating preventive interventions in the intensive care unit.