The use of surgeon-performed ultrasound assessment in a foot and ankle clinic.

BACKGROUND: We describe the first reported use of ultrasound examination performed by an orthopaedic surgeon in the setting of a foot and ankle clinic. METHODS: The senior author attended a course in musculoskeletal ultrasound and performed 100 examinations each checked against the results from a consultant radiologist. Records were kept of all examinations performed in the clinic over a 6-month period with results. RESULTS: Of the 622 patients seen, 91 had an ultrasound scan and 36 had guided injections. All patients had one hospital attendance spared, for most two. Time saved on the treatment pathway per patient was on average 6 weeks. CONCLUSION: Ultrasound assessment performed by a clinician during an outpatient clinic appointment reduces delay in treatment and cuts costs by reducing patient episodes.

Reversible disaggregation of myofilaments in vertebrate smooth muscle.

Strips of taenia coli from guinea pigs were incubated under isometric conditions in Krebs-Ringer bicarbonate saline (MKR) containing various concentrations of Ca(+2) and/or Mg(+2). Spontaneous or chemically induced contractile activity was abolished within 15 min of exposure to MKR containing Ca(+2) at concentrations below 10(-6) M; contractile activity was restored by reincubation in normal MKR after 1-2 h. Exposure of taenia coli to MKR containing Ca(+2) at concentrations below 10(-6) M for 1 h or more led to loss of thick and thin myofilaments from the sarcoplasm as observed with the electron microscope. Except for the loss of these two filament types, the cells contained all other structural features observed in preparations incubated in MKR containing Ca(+2) at its normal level (1.3 x 10(-3) M). The loss of thick and thin myofilaments in strips exposed to a Ca(+2) concentration below 10(-6) M was reversed by reincubation for 30 min in MKR containing normal Ca(+2) levels. The observed loss of thick and thin myofilaments in response to low Ca(+2) is interpreted as resulting from the disaggregation of some or all of the molecular components of these two filament types.

Correlation between fiber length, ultrastructure, and the length-tension relationship of mammalian smooth muscle.

The length-tension relationship was determined for strips of guinea pig taenia coli and correlated with the length and ultrastructural organization of the component fibers. The mean fiber length in "stretched" strips (passive >/= active tension) was 30% greater than that for fibers in "unstretched" strips (active >> passive tension). In stretched fibers the dense bodies and 100 A diameter myofilaments were consolidated into a mass near the center of fibers in cross-sectional profile. The thick myofilaments were segregated into the periphery of the fiber profiles. In unstretched fibers the dense bodies-100 A diameter filaments and the thick myofilaments were uniformly distributed throughout cross-sectional profiles. A tentative model is proposed to account for the change in fiber length and ultrastructural organization that accompanies stretch. The basic features of the model require the dense bodies to be linked together into a network by the 100 A diameter filaments. The functional consequences of stretching the fibers are discussed in relation to the model proposed for this network.

Periodic organization of the contractile apparatus in smooth muscle revealed by the motion of dense bodies in single cells.

To study the organization of the contractile apparatus in smooth muscle and its behavior during shortening, the movement of dense bodies in contracting saponin skinned, isolated cells was analyzed from digital images collected at fixed time intervals. These cells were optically lucent so that punctate structures, identified immunocytochemically as dense bodies, were visible in them with the phase contrast microscope. Methods were adapted and developed to track the bodies and to study their relative motion. Analysis of their tracks or trajectories indicated that the bodies did not move passively as cells shortened and that nearby bodies often had similar patterns of motion. Analysis of the relative motion of the bodies indicated that some bodies were structurally linked to one another or constrained so that the distance between them remained relatively constant during contraction. Such bodies tended to fall into laterally oriented, semirigid groups found at approximately 6-microns intervals along the cell axis. Other dense bodies moved rapidly toward one another axially during contraction. Such bodies were often members of separate semirigid groups. This suggests that the semirigid groups of dense bodies in smooth muscle cells may provide a framework for the attachment of the contractile structures to the cytoskeleton and the cell surface and indicates that smooth muscle may be more well-ordered than previously thought. The methods described here for the analysis of the motion of intracellular structures should be directly applicable to the study of motion in other cell types.

The advantages gained by the use of modern materials in the post operative casting procedure for foot and ankle surgery.

BACKGROUND: In June 2006, the post operative plaster immobilisation protocol for patients undergoing hindfoot and ankle surgery, at our institution, changed from multiple plaster changes to the immediate application of a definitive removable and reusable split synthetic cast. This study aims to assess the savings to the hospital and patient, following this change in practice. METHODS: A retrospective analysis of plaster room records from June 2005 to June 2007 was performed. The difference in cost to the hospital of the two different post operative journeys was then calculated. RESULTS: Two-hundred and twenty-two patients from 2005 to 2006 were managed at a total cost of 97,125 euro. From 2006 to 2007, 203 patients were managed with the new technique at a total cost of 37,860 euro. The net saving to the hospital of this change in practice was 251 euro per patient and 50,953 euro in total, while 203 patient visits and costs associated therewith were also saved. CONCLUSIONS: This study demonstrates how small changes in local practice can result in significant financial and temporal savings for hospitals and patients.

Acquired adult flat foot due to isolated plantar calcaneonavicular (spring) ligament insufficiency with a normal tibialis posterior tendon.

BACKGROUND: We present nine cases of acquired flat foot deformity (AFFD) in adults caused by isolated spring ligament insufficiency. METHODS: We present the clinical sign that allows differentiation of this diagnosis from posterior tibialis tendon (PTT) dysfunction namely the ability to single leg tiptoe, but with persistent forefoot abduction and heel valgus. In addition we illustrate the unique radiological features which allow confirmation of the diagnosis. Only a solitary previous case report has documented this alternative aetiology of AFFD; in that case, diagnosis was made intra-operatively. RESULTS: Six patients have been managed with orthoses. Three patients underwent surgery; one patient who presented early had isolated repair of the spring ligament complex. The remaining two required a calcaneal osteotomy and flexor digitorum longus transfer as for a PTT reconstruction. CONCLUSION: We propose that early diagnosis (with ultrasound confirmation) and management of this condition would offer a better prognosis and allow less interventional surgery.

Arthrodesis of the hindfoot for valgus deformity. An entirely medial approach.

Correction of valgus deformity of the hindfoot using a medial approach for a triple fusion has only recently been described for patients with tight lateral soft tissues which would be compromised using the traditional lateral approach. We present a series of eight patients with fixed valgus deformity of the hindfoot who had correction by hindfoot fusion using this approach. In addition, we further extended the indications to allow concomitant ankle fusion. The medial approach allowed us to excise medial ulcers caused by the prominent medial bony structures, giving simultaneous correction of the deformity and successful internal fixation. We had no problems with primary wound healing and experienced no subsequent infection or wound breakdown. From a mean fixed valgus deformity of 58.8 degrees (45 degrees to 66 degrees) pre-operatively, we achieved a mean post-operative valgus angulation of 13.6 degrees (7 degrees to 23 degrees). All the feet were subsequently accommodated in shoes. The mean time to arthrodesis was 5.25 months (3 to 9). We therefore recommend the medial approach for the correction of severe fixed valgus hindfoot deformities.

The management of failed ankle replacement.

Advances in the design of the components for total ankle replacement have led to a resurgence of interest in this procedure. Between January 1999 and December 2004, 16 patients with a failed total ankle replacement were referred to our unit. In the presence of infection, a two-stage salvage procedure was planned. The first involved the removal of the components and the insertion of a cement spacer. Definitive treatment options included hindfoot fusion with a circular frame or amputation. When there was no infection, a one-stage salvage procedure was planned. Options included hindfoot fusion with an intramedullary nail or revision total ankle replacement. When there was suspicion of infection, a percutaneous biopsy was performed. The patients were followed up for a minimum of 12 months. Of the 16 patients, 14 had aseptic loosening, five of whom underwent a revision total ankle replacement and nine a hindfoot fusion. Of the two with infection, one underwent fusion and the other a below-knee amputation. There were no cases of wound breakdown, nonunion or malunion. Management of the failed total ankle replacement should be performed by experienced surgeons and ideally in units where multidisciplinary support is available. Currently, a hindfoot fusion appears to be preferable to a revision total ankle replacement.

Properties of whey protein isolates extruded under acidic and alkaline conditions.

Whey proteins have wide acceptance and use in many products due to their beneficial nutritional properties. To further increase the amount of whey protein isolates (WPI) that may be added to products such as extruded snacks and meats, texturization of WPI is necessary. Texturization changes the folding of globular proteins to improve interaction with other ingredients and create new functional ingredients. In this study, WPI pastes (60% solids) were extruded in a twin-screw extruder at 100 degrees C with 4 pH-adjusted water streams: acidic (pH 2.0 +/- 0.2) and alkaline (pH 12.4 +/- 0.4) streams from 2 N HCl and 2 N NaOH, respectively, and acidic (pH 2.5 +/- 0.2) and alkaline (pH 11.5 +/- 0.4) electrolyzed water streams; these were compared with WPI extruded with deionized water. The effects of water acidity on WPI solubility at pH 7, color, microstructure, Rapid Visco Analyzer pasting properties, and physical structure were determined. Alkaline conditions increased insolubility caused yellowing and increased pasting properties significantly. Acidic conditions increased solubility and decreased WPI pasting properties. Subtle structural changes occurred under acidic conditions, but were more pronounced under alkaline conditions. Overall, alkaline conditions increased denaturation in the extruded WPI resulting in stringy texturized WPI products, which could be used in meat applications.

The myosin molecule--charge response to nucleotide binding.

A decrease in the net fixed electric charge in the A-bands of cross-striated muscle was observed by Bartels and Elliott [2,10] when the muscle went from the rigor to the relaxed condition. The current work localises the source of the charge decrease by following the net charge on myosin (in the form of concentrated gels) and also myosin rod and light meromyosin gels when the gels are exposed to different concentrations of ATP. The work includes a study of muscle A-bands when the muscle is exposed to the same variations in ATP concentrations as the protein gels. The work shows that (i) Only 100-200 microns ATP is needed to initiate the charge decrease between the rigor and relaxed conditions; (ii) the effect of ATP is seen in the muscle A-band and the myosin and myosin rod gels, but not in LMM gels; (iii) pyrophosphate (PPi) shows a similar charge effect to ATP. ADP does not affect the charge on myosin gels, on the other hand. The results suggest that the charge decrease caused by ATP or PPi is due to ligand interaction with one or more sites on the myosin molecule. This interaction causes a disseminated effect in the protein, and a consequent loss in net negative charge either by a decrease in the absorption, of anions to Saroff sites on the protein, or, less probably, by an increase in the absorption of cations at those sites.

Enzymatic hydrolysis, grease permeation, and water barrier properties of zein isolate coated paper.

An inexpensive zein-lipid mixture was isolated from yellow dent, dry-milled corn. Grease permeation through zein isolate applied to brown Kraft paper was found to be independent of loading levels at zein isolate levels above 30 mg/16 in.(2). The data shows that water vapor transmission rates depended on the amount of coating applied. Triacylglycerols were the most abundant lipid in milled corn but were absent in the zein isolate (perhaps due to hydrolysis by lipases). Zein from the paper was hydrolyzed enzymatically and the hydrolysis monitored by SDS-capillary electrophoresis. At an E:S ratio of 1:100 no further increase in the hydrolysate peak occurred after 10 and 30 min for alpha-chymotrypsin and pancreatin 8 x; however, zein and lipid were still present 1 h after hydrolysis by pancreatin 1 x.

The effect of exercise and anabolic steroids on the mechanical properties and crimp morphology of the rat tendon.

The administration of anabolic steroids is believed to be widespread among athletes, but convincing evidence relating to the beneficial effect of such compounds on collagenous structures of the locomotor system is not available. Since it has not been possible to analyze relevant human tissue, an animal model was used to investigate the change in particular mechanical and morphological properties of rat tendon after a period of controlled exercise, with or without anabolic steroid supplementation. A significant difference (P less than 0.001) was found between the crimp angles and lengths of collagen fibrils and theoretical toe limit strains of the four groups under study. No other significant differences (P greater than 0.05) were observed. Controlled exercise and anabolic steroid administration produced the greatest change in crimp parameters and the largest theoretical toe limit strain. This implies that muscle contraction will be greater for a given stress and thus alter the normal biomechanics of limb movement. Further studies are required to determine more definitively the effects of anabolic steroids on a connective tissue such as tendon.

Fractures of the femur in relation to cemented hip prostheses.

We have reviewed the results of treating 75 fractures of the proximal femoral shaft in the presence of a cemented femoral prosthesis. A simple radiographic classification into four types is proposed, and suggestions are made on the appropriate management of each. Comminuted fractures around the implant need early revision, whilst spiral fractures in this region may be treated conservatively or by operation. Transverse fractures at the level of the tip of the prosthesis are difficult to manage, and may require open reduction and internal fixation.

Dislocation of the hip in cerebral palsy. Natural history and predictability.

To determine the natural history of dislocation of the hip in cerebral palsy, and to evolve methods to predict dislocation, the notes and radiographs of 462 patients with cerebral palsy were reviewed. Dislocation occurred in 10% of patients by progressive migration and subluxation of the proximal femur in the presence of acetabular dysplasia. Statistical analysis identified the radiographic features that helped to predict dislocation. Measurement of acetabular index, by a method that allows for rotation of the acetabulum, was the most powerful single predictor. Measurement of this index at two and four years of age could identify patients who would dislocate unless effective treatment was undertaken, those at risk of dislocation only if scoliosis developed, and those who would not dislocate. On the basis of this method of screening for dislocation, a logical system of surgical prophylaxis is proposed.

Giant-cell tumour of the tendon sheath in the foot and ankle.

Giant-cell tumour of the tendon sheath (GCT-TS) is a benign solitary tumour which usually arises in the limbs. It occurs most often in the hand where local recurrence after excision has been reported in up to 45% of cases. It is less common in the foot where the biological behaviour and risk of local recurrence have not been defined. We have studied 17 cases of GCT-TS of the foot and ankle in which treatment was by excision. Fifteen presented as a solitary, painless, slow-growing soft-tissue swelling. One lesion was associated with sensory deficit of a digital nerve and one with pain on walking. Thirteen cases originated from the periarticular tendon-sheath complex of the small joints of the toes and four from the capsule or long tendons of the ankle. A correct preoperative diagnosis was made in only three cases. MRI proved to be the most useful preoperative investigation as GCT-TS has a characteristic appearance which allows planned local excision to be carried out. None of the patients with histologically confirmed GCT-TS required further surgery. There was no local recurrence in 15 patients who were available for follow-up at a mean of 85 months.

Divot sign: a new observation in anterior impingement of the ankle.

Anterior impingement of the ankle results from osteophyte formation on the anterior edge of the distal tibia. Classically, subsequent degeneration results in an osteophyte forming on the anterior neck of the talus. This results in limited dorsiflexion and impingement seen in the ankles of athletes. Recent clinical observation in high performance soccer players has revealed a previously unrecognized pattern of a localized divot forming in the talar neck in place of the osteophyte. This accepts the tibial osteophyte during dorsiflexion, which is therefore not limited in these patients.

Localization, growth, and inactivation of Salmonella Saintpaul on jalapeño peppers.

Consumption of Salmonella-contaminated jalapeño peppers has been implicated in one of the largest foodborne illness outbreaks in the summer of 2008. The objective of this study was to investigate representative groups of native microflora and the distribution, growth, and inactivation of experimentally-inoculated Salmonella Saintpaul on jalapeño peppers. Two genetically modified strains of Salm. Saintpaul producing either green- or red-fluorescent protein were constructed and used in the study. Microbiological analyses showed that jalapeño peppers contained an average of 5.6 log units of total aerobic count and 3.5, 1.8, and 1.9 log units, respectively, of enterobacteriaceae, lactic acid bacteria, and yeast/mold per gram of tissue. Strains typical of Pseudomonas accounted for 8.3% of total aerobic count, and 0.2% of which exhibited pectolytic activity. On inoculated peppers, a vast majority (>90%) of Salm. Saintpaul was recovered from stem/calyx and only a small proportion recovered from fleshy pods. Growth of Salm. Saintpaul on peppers was indicated by an increase in the population of 3 log units after incubation of samples at 20 degrees C for 48 h. Fluorescent Salm. Saintpaul aggregates could be readily detected on stem/calyx using stereofluorescence imaging microscopy and scanning electron microscopy. Data presented showed that Salm. Saintpaul could survive for at least 8 wk on peppers stored at 4 degrees C. Immersion of inoculated peppers in 200 ppm of sodium hypochlorite, acidified sodium chlorite, or peroxy acetic acid for 10 min could reduce the number of Salm. Saintpaul on stem/calyx by 1.5 to 1.7 and that on flesh by 2.1 to 2.4 log units. Practical Application: Consumption of Salmonella-contaminated jalapeño peppers has been implicated in foodborne illness outbreaks. The vast majority of Salmonella Saintpaul recovered from inoculated jalapeño peppers (>90%) was from stem/calyx. Salmonella increased by 3 log units during storage at 68 degrees F (20 degrees C) for 48 h. Salmonella could survive for at least 8 wk on peppers stored at 4 degrees C. Immersion of inoculated peppers in 200 ppm of sodium hypochlorite, acidified sodium chlorite, or peroxyacetic acid for 10 min reduced Salmonella on stem/calyx by 1.5 to 1.7 log units, compared with reductions of 2.1 to 2.4 log units on flesh. These results highlight the need to consider the stem/calyx as the most likely area for contamination of jalapeño peppers, and to process this commodity accordingly to minimize exposure and cross-contaminations.