Hallux valgus and metatarsus adductus measurements: inter-reader reliability and correlations on radiographs and MRI.

AIM: To assess inter-reader reliability of metatarsus adductus (MA) using the traditional method and Engel's angle (EA) on radiography and magnetic resonance imaging (MRI) and assess correlations with hallux valgus (HV). METHODS AND MATERIALS: Ninety consecutive patients with radiographs and MRI of the foot were included. Two readers measured HV angle (HVA), traditional metatarsus adductus angle (MAA), and EA on radiographs and HVA and EA on MRI. Three- and two-way mixed model analyses were used for reader agreements. Ninety-five percent bootstrap confidence intervals were calculated. The linear mixed model was used for association between HVA and EA/MAA. RESULTS: Mean age and male to female ratio was 54.2±15.4 and 0.4:1, respectively. Mean HVA and EA were 20.6±9.4 and 21.2±8, 21.2±8.3 and 22.4±7.5 on radiographs and MRI, respectively. Mean MAA was 18.5±5.7 on radiographs. Inter-reader agreement was good for EA (ICC=0.73, 0.6) and moderate for MAA (ICC=0.41). Positive correlations between HVA, MAA, and EA on radiographs and MRI were found, but none were statistically significant (p=0.44 and 0.87). CONCLUSION: Engel's angle is more reproducible. Although positive correlations exist between the degrees of HV and MA, they are not statistically significant.

Self-reported outcomes of trans-tibial amputations for non-reconstructable Charcot neuroarthropathy in patients with diabetes: a preliminary report.

AIMS: Lower-extremity amputation in patients with diabetes is associated with premature mortality and impaired ambulatory status. Despite advances in limb salvage techniques, certain patients will require major amputation. The hypothesis of this study is that self-reported outcomes of patients with non-reconstructable Charcot neuroarthropathy and chronic osteomyelitis improve after trans-tibial amputation. METHODS: Self-reported outcome was assessed using the Medical Outcome Study Short Form 36-item health survey (SF-36) and the Foot and Ankle Ability Measure. The study group included 13 patients with diabetes who underwent a trans-tibial amputation and completed both the Medical Outcome Study SF-36 and the Foot and Ankle Measure pre- and post-operatively. RESULTS: Significant improvement after trans-tibial amputation occurred in the SF-36 Physical Component Summary score and both the Foot and Ankle Measure Activity of Daily Living and Sports scores at a mean follow-up of 79 weeks (range 53-122 weeks). Although the SF-36 Mental Component Summary score improved, the improvement did not achieve statistical significance (P = 0.30). Twelve of the 13 patients were satisfied with the amputation and had no reservations. CONCLUSIONS: In a select group of Charcot neuroarthropathy patients with chronic osteomyelitis, trans-tibial amputation resulted in improvement in self-reported outcomes. Although major lower-extremity amputation is a devastating complication in patients with diabetes, the results of this study provides some evidence for optimism in these high-risk patients.

The consequences of complacency: managing the effects of unrecognized Charcot feet.

AIMS: Several authors have discussed an early prodromal state of neuroarthropathy (stage 0 Charcot) prior to the development of frank radiographic changes. However, very few reports are available that detail the outcomes of these patients. The purpose of this study was to report on the outcomes of patients with undetected early Charcot neuroarthropathy of the foot. METHODS: Twenty patients, from two health science centres, were diagnosed retrospectively with stage 0 Charcot neuroarthropathy and were managed after referral from outside facilities. We evaluated any complications, including ulcer formation, infection, progression into active Charcot neuroarthropathy and the need for surgical reconstruction. Patients who did not progress to an active Charcot neuroarthropathy (Group I) were compared with those (Group II) who did progress to the destructive phase. RESULTS: The diagnosis of Charcot neuroarthropathy was missed in 19 of 20 patients prior to referral. The average delay in treatment in Group I was 4.1±0.7 weeks compared with 8.7±6.8 weeks in Group II (Mann-Whitney U-test=24.5, n(1) =15, n(2) =7, P<0.05 two-tailed). Sixteen of 22 feet (72%) developed a complication during their treatment course. Group II experienced more complications than Group I (66.7% compared with 14.3%). Overall, eleven of 22 feet (50%) required surgical treatment; however, no patient required an amputation during the follow-up course. CONCLUSIONS: This study reveals that outcomes of stage 0 Charcot neuroarthropathy feet depend on proper recognition and early management. To reduce the rate of future complications for Charcot foot should be the goal of all treatment.

Elevated levels of peripheral serum creatine phosphokinase with strangulated small bowel obstruction.

Experimental arterial bowel infarction can cause elevations in levels of peripheral serum creatine phosphokinase (CPK), lactic dehydrogenase (LDH), and their isoenzymes. To test whether these changes would occur in strangulated small bowel infarctions, 18 dogs were placed under general anesthesia and randomized to one of three categories: laparotomy alone, simple mechanical small bowel obstruction, or strangulated small bowel infarction induced by incarcerating bowel in a surgically created ventral hernia. Serum samples were drawn for 48 hours postoperatively. Total CPK and LDH activity were determined by automated spectrophotometry; isoenzyme levels were determined by agarose gel electrophoresis. Levels of peripheral serum CPK and each of its isoenzymes became significantly elevated in the dogs with strangulated infarction. Such elevations did not occur with LDH. The findings suggest that changes in peripheral serum CPK could prove helpful in evaluating bowel viability in cases of intestinal obstruction.

Diagnosis of infection by preoperative scintigraphy with indium-labeled white blood cells.

Scintigraphy with indium-labeled white blood cells has been reported to be sensitive and specific in the diagnosis of low-grade sepsis of the musculoskeletal system. We reviewed the records of fifty patients who had suspected osteomyelitis or suspected infection about a total joint prosthesis and who underwent scintigraphy with technetium-99m methylene diphosphonate and scintigraphy with indium-111 oxine-labeled white blood cells before an open surgical procedure. Any patient who received preoperative antibiotics was not included in the study. For all of the patients, gram-stain examination of smears, evaluation of a culture of material from the operative site, and histological examination were done. The patients were divided into two groups. Group I was composed of twenty-four patients, each of whom had a prosthesis in place and complained of pain. Group II was composed of twenty-six patients for whom a diagnosis of chronic osteomyelitis had to be considered. With the indium scans alone, there was only one false-negative result (in Group II), but there were eighteen false-positive results (eight patients in Group II and ten patients in Group I). Although scintigraphy with indium-labeled white blood cells is quite sensitive, it is not specific in detecting chronic osteomyelitis; a negative scan should be considered highly suggestive that osteomyelitis is not present. Specificity can be increased by interpreting the indium scan in conjunction with the technetium scan.

Preoperative indium-labeled white blood cell scintigraphy in suspected osteomyelitis of the axial skeleton.

The cases of six patients with suspected osteomyelitis of the axial skeleton who underwent preoperative indium-labeled white blood cell scintigraphy (In-WBC) were reviewed retrospectively. Five of these patients had undergone previous spinal surgery, and all six patients complained of back pain. Four of these six patients were proven to have osteomyelitis by culture and histopathology. The sensitivity, specificity, and accuracy of In-WBC scintigraphy in detecting osteomyelitis of the axial skeleton was 25%, 50%, and 33%, respectively. Our preliminary experience in six patients with suspected osteomyelitis of the axial skeleton suggests that In-WBC scintigraphy is neither sensitive nor specific in predicting infection.

Serum creatine kinase and lactate dehydrogenase changes after anterior approaches to the thoracic and lumbar spine.

Ten patients undergoing anterior approaches to the thoracic and lumbar spine had prospective determinations of serum creatine kinase, lactate dehydrogenase, and their myocardial-associated isoenzymes (CK-MB and the LD-1/LD-2 ratio). None of these patients experienced postoperative myocardial infarction. Skeletal muscle injury associated with anterior spinal surgery resulted in significant elevations of serum CK-MB on postoperative Day 1; however, the LD-1/LD-2 ratio did not change significantly. Although false-positive elevations of serum CK-MB occurred, no patient had a CK-MB value exceeding 50 IU/liter combined with an LD-1/LD-2 ratio exceeding 1.0 (so-called "flipped LD" pattern). In evaluating suspected postoperative myocardial infarction, the authors recommend determining the isoenzymes of both serum creatine kinase and lactate dehydrogenase. In postoperative patients, elevations of CK-MB exceeding 50 IU/liter combined with an LD-1/LD-2 ratio exceeding 1.0 should not be attributed to skeletal muscle injury alone after anterior approaches to the thoracic and lumbar spine.

A long-term study of triple arthrodesis for correction of pes cavovarus in Charcot-Marie-Tooth disease.

Twenty-two patients with severe pes cavovarus secondary to Charcot-Marie-Tooth disease who underwent triple arthrodesis were retrospectively reviewed with an average follow-up period of 12 years, 4 months. Although only 32% of the patients had good objective results, 88% had good or excellent function and 86% were satisfied with their result. Radiographic follow-up averaged 10 years, 4 months. Talonavicular pseudarthroses were present in 15% of the feet and were symptomatic in all but one foot. Twenty-four percent of the ankles and 62% of the feet demonstrated radiographic evidence of degenerative joint disease.

Major neurovascular complications of endoscopic carpal tunnel release.

Endoscopic carpal tunnel release is becoming an increasingly popular method of surgically correcting median nerve compression. Several complications have been suggested as possibilities following the technique; however, to date, there have been only isolated reports of iatrogenic injury to major neurovascular structures in the hand. We report both a case of transection of the median nerve and a pseudoaneurysm of the superficial palmar arch following endoscopic carpal tunnel release.

Operative treatment of acute hip fractures: its effect on serum creatine kinase, lactate dehydrogenase and their isoenzymes.

Serum creatine kinase, lactate dehydrogenase, and their isoenzymes were prospectively studied in 16 patients who underwent operative treatment of acute hip fractures. No perioperative myocardial infarctions occurred; however, two patients died of noncardiac causes. We found that skeletal muscle injury associated with operative treatment of acute hip fractures did not result in significant elevations of serum CK-MB or the LD-1/LD-2 ratio. CK-MB activity exceeding 5% of total CK activity was observed in five patients who did not experience acute perioperative myocardial infarction; however, no patient had an absolute CK-MB value exceeding 50 IU/L. Elevations of serum CK-MB exceeding 50 IU/L and a LD-1/LD-2 ratio exceeding 1.0, therefore, should not be attributed to skeletal muscle injury alone following the operative treatment of acute hip fractures.

Cardiac isoenzyme values after total joint arthroplasty.

The purpose of this study was to prospectively determine what effect total joint arthroplasty had on the myocardial-associated isoenzymes of serum creatine kinase (CK-MB) and lactate dehydrogenase (LD-1:LD-2). Fifty patients treated with total joint arthroplasty of the hip or knee had isoenzyme determinations using automated spectrophotometry and agarose gel electrophoresis. Skeletal muscle injury associated with the trauma of surgery resulted in significant elevations of the absolute value of CK-MB; however, the percentage of CK-MB comprising total CK activity and LD-1:LD-2 did not rise significantly in patients who did not experience postoperative myocardial infarction. It is important to determine both serum CK-MB and LD-1:LD-2 in suspected postoperative myocardial infarction since false positive elevations of CK-MB can occur. Elevations of CK-MB exceeding 50 International Units/liter or 5% of the total CK activity combined with LD-1:LD-2 exceeding 1.0 should not be attributed to skeletal muscle injury alone following total joint arthroplasty of the hip or knee.

Changes in peripheral serum creatine phosphokinase (CPK) and lactic dehydrogenase (LDH) in acute experimental colonic infarction.

No satisfactory laboratory test for the early diagnosis of bowel infarction exists at this time. We have delineated changes in serum CPK levels after acute superior mesenteric artery infarction; whether or not comparable changes occur with inferior mesenteric artery infarction has not yet been determined. Furthermore, the changes in LDH associated with acute bowel infarction have not been documented. To determine the changes in serum CPK and LDH in acute colonic infarction, laparotomies were performed on dogs after peripheral baseline blood samples were drawn and each subject was randomly placed in one of three groups: laparotomy alone, acute colonic obstruction, and acute colonic infarction by ligation of the inferior mesenteric artery. The marginal artery of the colon was ligated at the peritoneal reflection and at the cecum to interrupt arterial collaterals. Blood samples were taken from each subject at intervals of three hours for 48 hours after injury. Serum from each sample was analyzed for total CPK and LDH by automated spectrophotometry. Isoenzymes were determined by agarose gel electrophoresis. Necropsies were conducted on all the dogs to confirm that the intended condition had been produced and that no intercurrent disease was present. The data support the conclusion that total CPK, total LDH and their isoenzymes become elevated in the peripheral serum after colonic infarction. The maximal elevations were all seen within the first 12 hours after acute colonic infarction. Total LDH and LDH(3), the most prevalent isoenzyme of LDH in bowel, do not become elevated in the serum to as high a level as CPK, but the combination of serum elevations in both enzyme systems may prove to be of diagnostic significance.