The saphenous nerve in foot and ankle surgery: its variable anatomy and relevance.

BACKGROUND: Several studies have raised doubt regarding the role of the saphenous nerve (SN) in the foot, and some authors omit the SN from ankle blocks. Our aim was to assess the SN anatomy with reference to foot and ankle surgery. METHODS: In 29 cadaveric feet the SN was traced to its termination. At the ankle, the distances from the SN to the tibialis anterior tendon (TAT) and the long saphenous vein (LSV) were recorded. RESULTS: In 24 specimens, a SN was present at the ankle, and in 19 specimens extended to the foot. The mean distances from the nerve to the TAT and LSV were 15 mm and 4mm respectively. The nerve reached the first metatarsal (MT) in 28% of specimens. CONCLUSION: Although the SN anatomy is less extensive than previously described, it often reaches the first MT and therefore should routinely be included in ankle blocks for forefoot surgery.

Habitat structure mediates biodiversity effects on ecosystem properties.

Much of what we know about the role of biodiversity in mediating ecosystem processes and function stems from manipulative experiments, which have largely been performed in isolated, homogeneous environments that do not incorporate habitat structure or allow natural community dynamics to develop. Here, we use a range of habitat configurations in a model marine benthic system to investigate the effects of species composition, resource heterogeneity and patch connectivity on ecosystem properties at both the patch (bioturbation intensity) and multi-patch (nutrient concentration) scale. We show that allowing fauna to move and preferentially select patches alters local species composition and density distributions, which has negative effects on ecosystem processes (bioturbation intensity) at the patch scale, but overall positive effects on ecosystem functioning (nutrient concentration) at the multi-patch scale. Our findings provide important evidence that community dynamics alter in response to localized resource heterogeneity and that these small-scale variations in habitat structure influence species contributions to ecosystem properties at larger scales. We conclude that habitat complexity forms an important buffer against disturbance and that contemporary estimates of the level of biodiversity required for maintaining future multi-functional systems may need to be revised.

Determination of optimal screw positioning in flexor hallucis longus tendon transfer for chronic tendoachilles rupture.

BACKGROUND: Neglected ruptures of the tendoachilles pose a difficult surgical problem. There are no data to determine the optimal positioning of the FHL tendon to the calcaneus. METHODS: Two computer programmes (MSC.visualNastran Desktop 2002™ and Solid Edge(®) V19) were used to generate a human ankle joint model. Different attachment points of FHL tendon transfer to the calcaneus were investigated. RESULTS: The lowest muscle force to produce plantarflexion (single stance heel rise) was 1355 N. Plantarflexion increased for a more anterior attachment point. The maximum range of plantarflexion was 33.4° for anterior attachment and 24.4° for posterior attachment. There was no significant difference in range of movement when the attachment point was moved to either a medial or lateral position. CONCLUSIONS: A more posterior attachment point is advantageous in terms of power and the arc of motion (24.4°) is physiological. We recommend that FHL is transferred to the calcaneus in a posterior position.

Achilles tendon rupture: what you need to know.

Heel pain and a history of a 'pop' or feeling 'something go' are the buzz phrases classically associated with Achilles tendon rupture. However, the diagnosis is often missed in clinical practice because of the assumption that this is a sporting injury suffered only by the young or middle-aged. In a sedentary older patient, the injury may be dismissed as an ankle sprain. If swelling is present but no injury is recalled then deep vein thrombosis is suspected, but Achilles rupture is not. The diagnosis of Achilles tendon rupture is clinical, based on history and examination. Radiological imaging (ultrasound scan) is useful to plan orthopaedic management and exclude concomitant deep vein thrombosis. In most cases, non-operative management with the ankle held plantar flexed in a boot is the current best practice.

Liparid and macrourid fishes of the hadal zone: in situ observations of activity and feeding behaviour.

Using baited camera landers, the first images of living fishes were recorded in the hadal zone (6000-11000 m) in the Pacific Ocean. The widespread abyssal macrourid Coryphaenoides yaquinae was observed at a new depth record of approximately 7000 m in the Japan Trench. Two endemic species of liparid were observed at similar depths: Pseudoliparis amblystomopsis in the Japan Trench and Notoliparis kermadecensis in the Kermadec Trench. From these observations, we have documented swimming and feeding behaviour of these species and derived the first estimates of hadal fish abundance. The liparids intercepted bait within 100-200 min but were observed to preferentially feed on scavenging amphipods. Notoliparis kermadecensis act as top predators in the hadal food web, exhibiting up to nine suction-feeding events per minute. Both species showed distinctive swimming gaits: P. amblystomopsis (mean length 22.5 cm) displayed a mean tail-beat frequency of 0.47 Hz and mean caudal:pectoral frequency ratio of 0.76, whereas N. kermadecensis (mean length 31.5 cm) displayed respective values of 1.04 and 2.08 Hz. Despite living at extreme depths, these endemic liparids exhibit similar activity levels compared with shallow-water liparids.

Realistic scenarios of environmental disturbance lead to functionally important changes in benthic species-environment interactions.

Changes in community structure concurrent with environmental forcing often form a precursor to changes in species diversity, and can have substantive consequences for ecosystem functioning. Here, we assess the effects of altered levels of evenness that are representative of different levels of eutrophication and changes in salinity associated with altered precipitation patterns, on the mediation of nutrient release by sediment-dwelling invertebrate communities. We find that an adjustment towards a more even distribution of species corresponds with an increase in sediment particle reworking that, in general, translates to increased levels of nutrient release. This response, however, is dependent on the functional role of each species in the community and is influenced by concomitant changes in salinity, especially when salinity extends beyond the range typically experienced by the community. Overall, our findings highlight the dynamic nature of species contributions to functioning and reinforce the importance of understanding when, and how, the mechanistic basis of species-environment interactions are modified as the influence of abiotic and biotic factors flex under periods of directional forcing.

Photographic wound documentation of open fractures: an update for the digital generation.

OBJECTIVE: To examine the availability of working cameras in UK emergency departments and to discuss the merits of digital imaging over Polaroid. DESIGN: This study was conducted by means of a telephone questionnaire to 50 UK emergency departments. RESULTS: It was found that 80% were able to produce either a working Polaroid or digital camera, and that 63% of emergency departments had a digital camera available. CONCLUSIONS: We report a pronounced increase in the ability of emergency departments to photograph open fractures, due in part to the availability of digital cameras. We recommend the appropriate use of these tools in the management of open fractures.

Posterior malleolus fractures: worth fixing.

The posterior malleolus component of a fracture of the ankle is important, yet often overlooked. Pre-operative CT scans to identify and classify the pattern of the fracture are not used enough. Posterior malleolus fractures are not difficult to fix. After reduction and fixation of the posterior malleolus, the articular surface of the tibia is restored; the fibula is out to length; the syndesmosis is more stable and the patient can rehabilitate faster. There is therefore considerable merit in fixing most posterior malleolus fractures. An early post-operative CT scan to ensure that accurate reduction has been achieved should also be considered. Cite this article: Bone Joint J 2017;99-B:1413-19.

Hip fracture surgery in mixed-use emergency theatres: is the infection risk increased? A retrospective matched cohort study.

Introduction The National Institute of Health and Care Excellence recommends that people with hip fracture should have surgery on the day of, or the day after, admission. However, there remains unacceptable variation in performance around the country, with a range of 13-91% of patients meeting this target. Dedicated trauma lists have insufficient capacity in many hospitals. We occasionally employ a mixed-use emergency theatre to facilitate early surgery. Increased risk of infection has been raised as a concern owing to microbial surface contamination from a preceding unclean case and lack of laminar flow in these theatres. The objective of this study was to investigate whether there is an increased risk of surgical site infections in patients who had hip fracture surgery in a mixed-use emergency theatre. Methods Between August 2010 and July 2014, 74 patients had hip fracture surgery in a mixed-use emergency theatre without laminar flow. This group was compared with a control group of patients who had hip fracture surgery in dedicated orthopaedic theatres with laminar flow. Infection was the primary outcome measured. Results There was no statistically significant difference in the rate of infection, length of stay or 30-day mortality, readmission or reoperation rates between the two groups. Conclusions Operating on hip fractures in mixed-use theatre did not lead to an increase in infection or other complications in our series. We feel that the risk of infection can be balanced against advantages of timely operation and it may therefore be justified to use these theatres when faced with lack of time on the trauma list. A much larger series would be required to investigate the effects of confounders.

An approach for the identification of exemplar sites for scaling up targeted field observations of benthic biogeochemistry in heterogeneous environments.

Continental shelf sediments are globally important for biogeochemical activity. Quantification of shelf-scale stocks and fluxes of carbon and nutrients requires the extrapolation of observations made at limited points in space and time. The procedure for selecting exemplar sites to form the basis of this up-scaling is discussed in relation to a UK-funded research programme investigating biogeochemistry in shelf seas. A three-step selection process is proposed in which (1) a target area representative of UK shelf sediment heterogeneity is selected, (2) the target area is assessed for spatial heterogeneity in sediment and habitat type, bed and water column structure and hydrodynamic forcing, and (3) study sites are selected within this target area encompassing the range of spatial heterogeneity required to address key scientific questions regarding shelf scale biogeochemistry, and minimise confounding variables. This led to the selection of four sites within the Celtic Sea that are significantly different in terms of their sediment, bed structure, and macrofaunal, meiofaunal and microbial community structures and diversity, but have minimal variations in water depth, tidal and wave magnitudes and directions, temperature and salinity. They form the basis of a research cruise programme of observation, sampling and experimentation encompassing the spring bloom cycle. Typical variation in key biogeochemical, sediment, biological and hydrodynamic parameters over a pre to post bloom period are presented, with a discussion of anthropogenic influences in the region. This methodology ensures the best likelihood of site-specific work being useful for up-scaling activities, increasing our understanding of benthic biogeochemistry at the UK-shelf scale.

E-mail and oncology: a survey of radiation oncology patients and their attitudes to a new generation of health communication.

Electronic mail (e-mail) is a powerful tool that can greatly enhance communication and has numerous potential applications within the medical profession. Physician-patient e-mail communication volume is increasing, but little research has addressed patient interests and concerns about this now commonplace technology. The goals of this study were to review the available literature regarding physician-patient e-mail practices, evaluate patient interest, assess patient perspectives about how e-mail communication might facilitate medical treatment and advice, and determine areas of patient concern regarding e-mail communication with their physicians. To this end, a population of cancer patients was sent a written survey designed to assess their access to e-mail and attitudes about physician-patient e-mail communication. We found that patients favored e-mail for increased convenience, efficiency, and timeliness about general health problems, while it was not favored for urgent matters.

The role of radiation therapy in the management of intracranial meningiomas.

Thirty-two patients with the diagnosis of intracranial meningioma were treated with radiation therapy over the past 24 years at the Thomas Jefferson University Hospital. Indications for irradiation included incomplete resection, malignant histology, and progressive or recurrent disease after curative surgery. Patients with malignant histology did poorly, with only 2 of 7 alive. This contrasts with 17 of 25 patients with benign histology who are either alive and well or who have enjoyed a long-term disease-free survival. No difference in ultimate outcome could be found between patients with benign histology irradiated in the immediate postoperative period as opposed to those irradiated at time of progression or recurrence.

Multiple primary carcinomas as sequelae of treatment of pulmonary tuberculosis with repeated induced pneumothoraces. Case report and review of the literature.

A case is presented of a patient with four separate primary carcinomas (two breast, one thyroid, one multiple skin cancers) arising in areas of the body subject to repeated low-dose radiation exposure during artificial pneumothorax treatment of pulmonary tuberculosis. Evidence for ionizing radiation as the likely common etiologic agent for all four tumors is presented and substantiated by a review of the literature.

Synovial impingement in the ankle. A new physical sign.

Inversion injuries of the ankle are common and most are managed adequately by functional treatment. A significant number will, however, remain symptomatic. Synovial impingement is one cause of continuing pain. This condition is often difficult to diagnose because the physical signs and investigations are non-specific. If the diagnosis is made, treatment by arthroscopic debridement has been shown to be highly effective. Our aim was to describe a new physical sign to help in the diagnosis of anterolateral synovial impingement in the ankle. A cadaver dissection demonstrated the anatomical basis for the physical sign and a prospective clinical study involving 73 patients showed that the lateral synovial impingement test had a sensitivity of 94.8% and a specificity of 88%. We describe the test and conclude that this physical sign will be of use to practitioners treating patients with chronic pain in the ankle after injury.

The surgical anatomy of the dorsomedial cutaneous nerve of the hallux.

Most techniques described for the correction of hallux valgus require exposure of the distal aspect of the first metatarsal. A dorsomedial incision is often recommended. Texts counsel against damaging the dorsal digital nerve, as a painful neuroma is an unwelcome surgical complication. Our study on cadavers aimed to investigate the anatomy of the dorsomedial cutaneous nerve in the metatarsophalangeal region, with special reference to surgical incisions. A constant, previously unrecognised branch of the nerve was identified. This branch is likely to be damaged if a dorsomedial approach is used. It is recommended that a mid-medial incision be used instead, i.e. at the junction of the plantar and dorsal skin.

Internal fixation after intra-articular fracture of the distal ulna.

We describe a patient who sustained a displaced isolated intra-articular fracture of the distal ulna, causing limitation of rotation of the forearm. The extent of displacement of the fracture which was not evident on plain radiographs was revealed by CT. The fracture was reduced and internally fixed using a standard technique applicable to the fixation of fractures of the radial head. Full movement was restored. An isolated injury to the distal ulna is rare and requires careful clinical and radiological assessment.

Manipulation and injection for hallux rigidus. Is it worthwhile?

Manipulation of the metatarsophalangeal joint and injection with steroid and local anaesthetic are widely practised in the treatment of hallux rigidus, but there is little information on the outcome. We report the results of this procedure carried out on 37 joints, with a minimum follow-up of one year (mean, 41.2 months). Patients with mild (grade-1) changes gained symptomatic relief for a median of six months and only one-third required surgery. Two-thirds of patients with moderate (grade-2) disease proceeded to open surgery. In advanced (grade-III) hallux rigidus, little symptomatic relief was obtained and all patients required operative treatment. We recommend that joints are graded before treatment and that manipulation under anaesthetic and injection be used only in early (grades I and II) hallux rigidus.

Immunoenzymatic detection of staphylococcal enterotoxins: international interlaboratory study.

An international interlaboratory study was performed by 13 laboratories to validate a commercially available, rapid enzyme immunoassay for detection of staphylococcal enterotoxins A, B, C, D, and E in foods. The 5 enterotoxin serotypes were detected at a level of 0.5 ng/g in mushrooms and ravioli, 0.8 ng/g in meat, 1 ng/mL in milk, and 1.5 ng/g in raw milk cheese when these foods were artificially contaminated with enterotoxin A. Enterotoxins A, B, C, D, or E were also detected in culture supernatants with no protein A interference when normal rabbit serum was used. This method was validated by the French Normalization Agency for the identification of staphylococcal enterotoxins in foods and culture fluids.

Management of paediatric clavicle fractures--is follow-up necessary? An audit of 346 cases.

We investigated the incidence of complications following childhood clavicle fractures and the necessity for follow-up in fracture clinic after the first orthopaedic consultation. We found that review in fracture clinic has no impact upon the outcome of clavicle fractures and complications such as non-union, mal-union or neurovascular problems are exceptionally rare. We concluded that there is no need for follow-up of children with isolated, uncomplicated clavicle fractures. These patients should be discharged after their first assessment in fracture clinic.

Ligamentous restraints of the second tarsometatarsal joint: a biomechanical evaluation.

Ligamentous injury of the tarsometatarsal joint complex is an uncommon, but disabling condition that frequently occurs in elite athletes. There are few options for managing these injuries, in part because the relative mechanical contribution of the ligaments of the tarsometatarsal joint is unknown, complicating decisions regarding which ligaments need reconstruction. In the current study, strength and stiffness of the dorsal, plantar, and Lisfranc ligaments of 20 paired cadaver feet were measured and compared. The plantar and Lisfranc ligaments were significantly stiffer and stronger than the dorsal ligament, and the Lisfranc ligament was significantly stronger and stiffer than the plantar ligament.