Stress fractures of the foot - current evidence on management.

Stress fractures are a consequence of repeated submaximal loads with inadequate time for recovery and biologic repair or remodelling. The foot and ankle complex (FAC) represents a common site for development of stress fractures. Whilst the overall incidence of stress fractures is low, they are prevalent in athletes and military personnel causing significant time away from sports or work. Within these populations, certain stress fractures directly correlate to specific activities. Factors that commonly influence these fractures include an acute increase in new repetitive physical activity combined with muscle fatigue, training errors or improper athletic techniques, which challenge the regenerative and remodelling capacity of bone. Depending on the site that is subject to repetitive loading, various biomechanical factors can result in abnormal concentration of forces to specific areas of the FAC resulting in stress fracture. Decreased bone marrow density (BMD) is a major biologic cause for developing stress fractures. The female athlete triad comprising eating disorder, amenorrhea and osteoporosis in competitive athletes also predisposes to stress fractures. Vitamin D deficiency is also postulated to be the cause of these fractures and may contribute to poor healing. Clinical presentation is usually with vague pain of insidious onset which worsens with activity and improves with rest. Diffuse tenderness over the affected bone is common with only a minority having any visible swelling. Plain radiographs are the first line of investigation but rarely reveal an obvious fracture. MRI scans aid in diagnosis and CT scans help in treatment and characterisation of the fracture and monitor healing. Management relates to the site of injury, which stratifies them into high or low-risk. Stress fractures of the calcaneus, cuboid and cuneiforms are classed as low-risk fractures as they usually heal with simple activity modification or short duration of non-weight bearing. Stress fractures of the navicular, talus and hallucal sesamoids are classed as high-risk fractures due to higher rates of non-union and prolonged recovery time. Metatarsal fractures can be considered high or low-risk depending on location. These warrant aggressive management, often requiring surgical intervention. Adjuncts such as vitamin D supplements, external shockwave therapy, low-intensity pulsed ultrasound therapy have been used with varying success but there remains little supportive evidence of superiority in the available literature.

Localized delivery of Erlotinib using liposomal gel formulations for the treatment of oral squamous cell carcinoma.

Oral cancer accounts for more than 350,000 cases worldwide with 90% of them being oral squamous cell carcinomas (OSCC). The current treatment modalities of chemoradiation have poor outcomes along with harmful effects to neighbouring healthy tissues. The present study aimed to deliver Erlotinib (ERB), locally at the site of tumor arising in the oral cavity. ERB was encapsulated in liposomal formulations (ERB Lipo) and optimized using full factorial, 32 experimental design. The optimized batch was then coated with chitosan to obtain CS-ERB Lipo and were characterized further. Both liposomal ERB formulations had size <200 nm and PDI < 0.4. Zeta potential was upto -50 mV for ERB Lipo and upto +25 mV for CS-ERB Lipo indicating stable formulation. Liposomal formulations were freeze dried and loaded into gel to study in-vitro release and chemotherapeutic evaluation. CS-ERB Lipo showed sustained release upto 36 h from gel as compared to control formulation. In-vitro cell viability studies showed potent anti-cancer activity on KB-cells. In-vivo studies showed better pharmacological efficacy in terms of tumor volume reduction for ERB Lipo gel (49.19%) and CS-ERB Lipo gel (55.27%) as compared to plain ERB Gel (38.88%) applied locally. Histology also revealed that formulation could alleviate dysplasia condition to hyperplasia. The locoregional therapy of ERB Lipo gel and CS-ERB Lipo gel thus show promising outcome in improving pre-malignant and early-stage oral cavity cancers.

Surface modifications of gold nanoparticles: stabilization and recent applications in cancer therapy.

Gold nanoparticles (GNPs) are noble metal nanocarriers that have been recently researched upon for pharmaceutical applications, imaging, and diagnosis. These metallic nanocarriers are easy to synthesize using chemical reduction techniques as their surface can be easily modified. Also, the properties of GNP are significantly affected by its size and shape which mandates its stabilization using suitable techniques of surface modification. Over the past decade, research has focused on surface modification of GNP and its stabilization using polymers, polysaccharides, proteins, dendrimers, and phase-stabilizers like gel phase or ionic liquid phase. The use of GNP for pharmaceutical applications requires its surface modification using biocompatible and inert surface modifiers. The stabilizers used, interact with the surface of GNP to provide either electrostatic stabilization or steric stabilization. This review extensively discusses the surface modification techniques for GNP and the related molecular level interactions involved in the same. The influence of various factors like the concentration of stabilizers used, their characteristics like chain length and thickness, pH of the surrounding media, etc., on the surface of GNP resulting in stability have been discussed in detail. Further, this review highlights the recent applications of surface-modified GNP in the management of tumor microenvironment and cancer therapy.

The ability to wear heeled footwear following first metatarsophalangeal joint fusion.

INTRODUCTION: Fusion remains the gold standard treatment for symptomatic first metatarsophalangeal joint (MTPJ) arthritis. Surgeons have traditionally advised female patients during the consenting process that they would have limitations or be unable to wear heeled footwear following first MTPJ fusion due to the loss of dorsiflexion at the first MTPJ. Anecdotally, surgeons have found that some patients were still able to continue wearing heeled footwear post fusion surgery. Heeled footwear has long been a trendy fashion accessory dating back from ancient Egyptian times and are regularly worn by a significant proportion of women today. Given the lack of literature in this matter, this study was conducted to investigate the effect of first MTPJ fusion surgery on the ability to wear heeled footwear, to aid in the consenting process. METHODS: A retrospective review of 50 female patients who have had an isolated first MTPJ fusion between 2004 and 2015 at the authors' institution was undertaken with a follow-up telephone survey which included questions on ability to wear heeled footwear pre and post-operatively, duration, and the height of heels they could wear. RESULTS: This study included 50 patients (62 feet) with a mean age of 63 years (range 43-78 years) at the time of surgery, with a mean follow-up of eight years (range 5-16years) from surgery. Of the 42 patients who wore heeled footwear pre-surgery, 26 (62%) continued wearing them. The majority of them (n = 23, 88%) were able to wear the same height heels. Patients could use heeled footwear from 30 min to eight hours continuously (mean=3 h) and, 88% were able to wear heel heights of 1.5 in. or higher. None of the patients wearing heeled footwear returned to the clinic with midfoot/hindfoot symptoms, one returned for worsening of pre-existing first IPJ (interphalangeal joint) symptoms. CONCLUSION: This study has important implications for information given to patients during the consent process for this operation. The results have shown that many patients continue to wear heeled footwear following first MTPJ fusion with minimal or no symptoms in neighbouring joints.

Tacrolimus encapsulated mesoporous silica nanoparticles embedded hydrogel for the treatment of atopic dermatitis.

Atopic dermatitis (AD) is a repetitive inflammatory skin disorder with limited treatment options. Innovative targeted therapies are gaining significant interest and momentum towards disease control including better ways to deliver drugs topically. Tacrolimus is one such compound which is used to manage moderate to severe AD without causing atrophy which is one of the common side effects of steroids. However, Tacrolimus suffers from poor solubility and retention in the skin when used alone in hydrogel. Therefore, we have prepared Tacrolimus loaded mesoporous silica nanoparticles (TMSNs) to overcome the issues related to its solubility and effective topical delivery. Mesoporous silica nanoparticles (MSNs) were synthesized using sol gel technique and surface functionalized using amino (-NH2+) and phosphonate (-PO3-) groups. Tacrolimus was loaded into MSNs and the particles were characterized for particle size (TEM and DLS), zeta potential (DLS), solubility studies, FTIR, TGA, XRD, BET and cytotoxicity studies. Water solubility of Tacrolimus was increased by 7 folds with phosphonate functionalized MSNs compared to free Tacrolimus. Further the TMSNs were incorporated in to carbopol gel, and the gel formulation was evaluated for various gel characterization tests (pH, spreadability, viscosity), in vitro tests (drug release, permeability studies) and in vivo tests (skin irritation study and efficacy studies) using 1-Fluoro-2,4-dinitrobenzene (DNFB) induced dermatitis in Balb/c mice. Results of in vitro and in vivo study showed that TMSNs loaded gel showed significantly higher amount of Tacrolimus retained (ex vivo - rat skin) and much higher reduction in ear thickness and improved histology (in vivo - in mice). Our data collectively suggest that MSNs incorporated hydrogel as a promising new formulation strategy for topical delivery of poorly soluble drugs.

Stimuli responsive and receptor targeted iron oxide based nanoplatforms for multimodal therapy and imaging of cancer: Conjugation chemistry and alternative therapeutic strategies.

Cancer being one of the most precarious and second most fatal diseases evokes opportunities for multimodal delivery platforms which will act synergistically for efficient cancer treatment. Multifunctional iron oxide magnetic nanoparticles (IONPs) are being studied for few decades and still attracting increasing attention for several biomedical applications owing to their multifunctional design and intrinsic magnetic properties that provide a multimodal theranostic platform for cancer therapy, monitoring and diagnosis. The review article aims to provide brief information on various surface chemistries involved in modulating IONPs properties to exhibit potential therapy in cancer treatment. The review addresses structural, magnetic, thermal and optical properties of IONPs which aids in the fabrication of efficient multimodal nanoplatform in cancer therapy. The review discussed the pharmacokinetics of IONPs and attributes influencing them. This review inculcates recent advancements in therapies, focused on tumor-microenvironment-responsive and targeted therapy along with their eminent role in cancer diagnosis. The concept of stimuli-responsive including endogenous, exogenous and dual/multi stimuli-based delivery platform demonstrated significantly enhanced anticancer therapy. Several therapeutic approaches viz. chemotherapy, radiotherapy, immunotherapy, hyperthermia, gene therapy, sonodynamic therapy, photothermal, photodynamic-based therapy along with biosensing and several toxicity aspects of IONPs have been addressed in this review for effective cancer treatment.

Clinical Outcomes Following Minimally Invasive Dorsal Cheilectomy for Hallux Rigidus.

BACKGROUND:: Following failure of conservative treatment, a dorsal cheilectomy can be performed for patients in early stages of hallux rigidus by a traditional open approach or by a minimally invasive technique. We report our clinical outcomes following minimally invasive dorsal cheilectomy (MIDC). METHODS:: Eighty-nine patients (98 feet) with symptomatic hallux rigidus treated between 2011 and 2016 were included in this study. The average age was 54 years. Manchester-Oxford Foot Questionnaire (MOxFQ) scores and visual analog scale (VAS) pain scores were collected. The mean follow-up was 50 months. RESULTS:: The average VAS score improved from 8.0 preoperatively to 3 postoperatively. The mean MOxFQ summary index score decreased from 58.6 preoperatively to 30.5 postoperatively. All 3 MOxFQ domains also improved. Swelling took an average of 5.3 weeks to settle. There were 2 wound infections and 2 delayed wound healings. Two patients had transient nerve paraesthesia, while 2 patients had permanent numbness in the dorsomedial cutaneous nerve distribution. Twelve patients (12%) underwent reoperation, of which 7 had a first metatarsophalangeal joint arthrodesis for ongoing pain, 4 had repeat cheilectomy for residual impingement, and 1 had an open removal of loose bone. CONCLUSION:: Our results suggest that MIDC resulted in improvement in patient-reported outcome measures and was a safe technique with minimal complications. The complications were similar to open cheilectomy. There was an associated learning curve as 5 of our reoperations were due to incomplete cheilectomy. Coughlin grade 1 did well with MIDC as with open cheilectomy as none went onto an arthrodesis. However, 10% (7/65) of our grade 2 and 3 cases went on to an arthrodesis. LEVEL OF EVIDENCE:: Level IV, retrospective case series.

Minimally Invasive Dorsal Cheilectomy of the First Metatarsal: A Cadaveric Study.

BACKGROUND:: Minimally invasive dorsal cheilectomy (MIDC) for hallus rigidus is gaining in popularity. The optimal position for the stab incision for MIDC is dorsomedial to allow an ergonomic sweeping movement of the burr, potentially putting the dorsomedial cutaneous nerve (DMCN) to the hallux at risk. We aimed to quantify the risk of using this minimally invasive technique with a cadaveric study. METHODS:: A total of 13 fresh-frozen cadaveric specimens amputated below the knee were obtained for this study. After the procedure, the specimens were dissected, and structures were inspected for damage. RESULTS:: The DMCN to the hallux was cut completely in 2 specimens (15%). All the extensor hallucis longus tendons were intact, although in 1 specimen, the tendon showed some fraying on the underside of the tendon. The average distance of the stab incision from the first metatarsophalangeal (MTP) joint was 17.7 (range, 10-23) mm. The relationship of the DMCN to the stab incision was variable. The average distance of the DMCN to the incision was 3.8 (range, 0-7) mm. The danger zone for damaging the DMCN was at one-third the length of the first metatarsal proximal to the first MTP joint. CONCLUSION:: The DMCN has been well studied by several authors and has a variable course. This nerve was damaged in 15% of our specimens following MIDC. CLINICAL RELEVANCE:: We believe patients should be made aware of this risk when considering surgery. A carefully made working capsular pocket for the burr and marking this nerve before making the incision if palpable could mitigate this risk.

The use of low-intensity pulsed ultrasound in treating delayed union of fifth metatarsal fractures.

BACKGROUND: There are no studies looking at the success rate of low-intensity pulsed ultrasound (LIPUS) in fifth metatarsal fracture delayed unions to our knowledge. The aim of this study is to investigate the use of LIPUS treatment for delayed union of fifth metatarsal fractures. METHODS: A retrospective review of patients who were treated with LIPUS following a delayed union of fifth metatarsal fracture was conducted over a three-year period. RESULTS: There were thirty patients (9 males, 21 females) in this cohort. The average age was 39.3 years. Type 2 fractures made up 43% of our cohort. Twenty-seven (90%) patients went on to progress to union clinically and radiologically following LIPUS treatment. Smoking (p=0.014) was predictive of non-union. Assuming that there were 10 delayed unions a year and 6 went on to non-union as previously suggested by a systematic review, the cost savings of using LIPUS (90% success rate; 10 LIPUS machine and surgery for 1 non-union) vs operative intervention (surgery for 6 non-union) equates to a cost saving of £7765 a year. CONCLUSION: There is a role for the use of LIPUS in delayed union of fifth metatarsal fractures and can serve as an adjunct prior to consideration of surgery. The findings of this study also suggest the use of LIPUS to be a cost effective treatment modality compared to surgical management. LEVEL OF EVIDENCE: Level 4.

Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) of the Fifth Metatarsal for Bunionette Correction.

BACKGROUND: Different osteotomies have been proposed for the treatment of bunionette deformity. Minimally invasive surgery is now increasingly popular for a variety of forefoot conditions. The aim of this study was to evaluate the outcome following fifth minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) for bunionette deformity. METHODS: Nineteen patients (21 feet) who had symptomatic bunionette deformity and failed conservative treatment between 2014 and 2016 were included in this retrospective study. Clinical data were recorded, and pre- and postoperative Manchester-Oxford Foot Questionnaire (MOXFQ) scores and visual analog scale (VAS) pain score were collected. The mean follow-up was 28 months (range, 12-47). RESULTS: The mean MOXFQ summary index score decreased from 71 (range, 59-81) preoperatively to 10 (range, 0-30) postoperatively. All 3 MOXFQ domains also improved. The average improvement in VAS score was 7. Forefoot swelling and some painful symptoms took an average of 3 months to settle. There were no wound or nerve complications. One patient required a dorsal cheilectomy for a symptomatic prominent dorsolateral callus formation. CONCLUSION: The minimally invasive fifth DMMO for bunionette deformity was a safe and effective technique. It had relatively few complications and led to good clinical results. We believe it is important to warn patients that the forefoot swelling will take months to settle compared to an osteotomy with fixation, and there is a 10% chance of a prominent callus over the osteotomy site. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Hallux varus following scarf osteotomy.

Hallux varus is an uncommon condition and majority of the cases are iatrogenic. It can occur as a result of any type of hallux valgus correction surgery and in our cases scarf osteotomy is not an exception. Treatment of this complication can be challenging and it is important to understand the factors that cause this deformity before embarking on surgical correction. Four cases of hallux varus following Scarf osteotomy (1% of our total Scarf osteotomy cases) and discuss the salient features of these patients. The authors ascertained the factors that caused iatrogenic hallux varus and formulated a classification of the nature of the deformity. The management of iatrogenic hallux varus based on our experience and proposed classification system has also been outlined and discussed.

Minimally Invasive Calcaneal Osteotomy: Does the Shannon Burr Endanger the Neurovascular Structures? A Cadaveric Study.

Calcaneal osteotomies are used to correct hindfoot alignment. Traditional open procedures have been plagued with complications. Various minimally invasive techniques have been described but are laborious and time-consuming. A percutaneous technique using a side cutting "Shannon" burr offers a simple and reliable alternative; however, little evidence is available to address the safety concerns. The aim of the present study was to quantify the risk posed to the medial and lateral neurovascular structures using this technique. The study was performed at the anatomy department, University of Sussex, using 13 fresh-frozen, below-the-knee cadaveric specimens during a training session held by WG Healthcare UK, Ltd. (Letchworth, Herts). The participants were 11 consultant orthopedic surgeons, who were inexperienced in minimally invasive surgery, and 2 demonstrators. Each performed a chevron calcaneal osteotomy using a Shannon burr by way of a lateral percutaneous approach under fluoroscopic guidance. The authors subsequently dissected the specimens to identify the neurovascular structures, describe their anatomic relations and proximity to the burr, and note any damage incurred. No evidence was found of significant neurovascular injury. Two very small proximal branches of the sural nerve were transected, the nerve itself passing safely 9 to 21 mm anterosuperior to the entry point. The medial neurovascular bundle crossed the path of the osteotomy in 4 specimens but was protected by the medial head of the quadratus plantae muscle. In conclusion, the Shannon burr for calcaneal osteotomy has the potential to minimize the surgical morbidity and maximize surgical efficiency without compromising safety in all patients with normal anatomy of the quadratus plantae muscle.

Forefoot Deformity in Rheumatoid Arthritis: A Comparison of Shod and Unshod Populations.

UNLABELLED: All reported rheumatoid arthritis (RA) forefoot deformities in the literature thus far have arisen from shoe wearing populations. Our aim in this study was to compare hallucal deformities seen in a shod population with an unshod population. A population comparison was undertaken in 2 specialized foot and ankle units, one in India and one in the United Kingdom. In the shod population, there was 1 hallux varus deformity, 10 without hallucal deformity, and 90 hallux valgus deformities. In contrast, in the unshod population, there were 19 hallux varus deformities and 6 hallux valgus deformities. There was great variability in the lesser toe deformity seen. In the shod population, it was most common to see dorsal subluxation or dislocation, with the fifth toe in a varus position. In the unshod population, the most common lesser toe deformity seen was varus deviation or dislocation. Instability of the metatarsophalangeal joint in the rheumatoid foot predisposes it to significant deformity. In the non-shoe wearing population, intrinsic muscle forces and weight bearing forces are the most likely determinants of the deformity, with hallux varus being a more common presenting problem. In the shod population, the external forces of shoe wear dictate the direction of deformity. LEVELS OF EVIDENCE: Prognostic, Level III: Case control study.

The rheumatoid forefoot.

Rheumatoid arthritis (RA) manifests itself in a variety of ways, with its effect being seen in around 90 % of sufferers' feet. The foot has been found to be the most common reason for incapacity in patients with RA, with the forefoot the most common area. The foot is second, behind only the hand, as the most common place for manifestation of RA. Pain in the foot is commonly the most debilitating condition, which causes the patient to seek specialist help. As well as pain, foot deformities such as hallux valgus and claw toes are common complaints. These symptoms often arise as a result of continued walking on an unstable foot, leading to painful callosities and dislocation of the metatarsophalangeal joints. Other conditions, such as pannus formation and Morton's neuroma, can be related to RA. This review sets out what we believe to be a successful approach to the rheumatoid forefoot, which aims at the relief of pain and the preservation of ambulation. Key to a successful outcome is appropriate medical control with a multidisciplinary approach that enables close liaison between orthopaedic surgeons, orthotists, and rheumatologists. Combined clinics provide this multidisciplinary care. Those treating RA need to be aware of the high incidence of foot involvement and how early intervention may benefit the patient. The aim of this article is to present current evidence to enable people to develop a treatment algorithm for this condition.

Rheumatoid forefoot reconstruction: 1st metatarsophalangeal fusion and excision arthroplasty of lesser metatarsal heads.

This is a retrospective review of 66 feet (mean follow-up of 3 years) in 43 patients with painful severe rheumatoid forefoot deformities. All were treated by arthrodesis of the first metatarsophalangeal (MTP) joint through a dorsomedial incision and excision of the lesser metatarsal heads through a separate plantar approach. The mean post-operative AOFAS scores were 65.94 (range: 32 to 82). The mean post-operative Foot Function Index (FFI) was 0.47 (range: 0.23 to 0.63). Eighty five percent (57/67 feet) reported excellent or good pain relief, improved cosmetic appearance, and improved footwear comfort. The mean hallux valgus angles improved from 39 degrees to 16 degrees and the intermetatarsal angle from 16 degrees to 8 degrees. Five feet had nonunion of the 1st MTP joint arthrodesis. There were five re-operations for non-union of the 1st MTP joint arthrodesis. The success of the operation as evidenced by this study depends upon attention to metatarsal length harmonisation, stabilisation of the 1st MTP joint and thereby even distribution of loading of the forefoot. The poor results in this study were as a result of a failure to secure the stability of the 1st MTP joint.

Revisiting the concept of talar shift in ankle fractures.

BACKGROUND: In 1976, Ramsey and Hamilton published a classic experiment investigating the biomechanical effects of talar shift in a simple ankle fracture model. Their finding was that 1 mm of talar shift resulted in a 42% decrease in tibiotalar contact surface area. Based on this conclusion, 1 mm of talar shift became the recognized indication for operative fixation. METHODS: Twelve cadaver ankles were dissected and the distal tibia coated with carbon powder. A 70-kg load was applied to the distal tibia that resulted in transference of the carbon onto the talus. The contact surface area was determined at 0, 1, 2, 4 and 6 mm of talar shift using spacers fixed in the medial gutter. Tracing paper was used to mark the outline of the contact area and measured using graph paper. RESULTS: Our results were similar to Ramsey and Hamilton's original experiment. One millimeter of lateral talar shift resulted in 40% loss of contact surface area compared with 42% in the original experiment. A large variance was seen in talar contact surface area depending on the morphology of the ankle joint. CONCLUSION: Ramsey and Hamilton's original experiment was valid.

Multiple osseous tarsal coalitions: a case report and review of the literature.

A patient with multiple tarsal coalitions presenting with symptoms at the age of 47 years is reported. The report highlights the presentation of symptomatic coalitions following trauma in adulthood. Coalitions can pose difficulties in diagnosis, particularly without previous history of pain or disability in childhood. A decrease or loss of subtalar movement, painful movement, and valgus deformity of the hindfoot are usually present in the adult patient but are not often pathognomonic and present a diagnostic conundrum, particularly with x-rays being misinterpreted. This report highlights the problem of diagnosing such a condition with the attendant difficulties in formulating treatment.

Outpatient clinics. Down the line.

A hospital with a 157-week wait for orthopaedic outpatient appointments has introduced a telephone booking system which has reduced waiting by 53 weeks. The system, introduced with a 23,000 Pounds grant from the local health group, has cut non-attendance from 17 to 5 per cent and is estimated to have saved the orthopaedics department 216,000 Pounds. Two part-time clerical workers staff the initiative. Telephone booking is now being rolled out to include outpatient clinics of other specialties and orthopaedic day case lists.