Nucleotides regulate secretion of the inflammatory chemokine CCL2 from human macrophages and monocytes.

CCL2 is an important inflammatory chemokine involved in monocyte recruitment to inflamed tissues. The extracellular nucleotide signalling molecules UTP and ATP acting via the P2Y2 receptor are known to induce CCL2 secretion in macrophages. We confirmed this in the human THP-1 monocytic cell line showing that UTP is as efficient as LPS at inducing CCL2 at early time points (2-6 hours). Expression and calcium mobilisation experiments confirmed the presence of functional P2Y2 receptors on THP-1 cells. UTP stimulation of human peripheral CD14+ monocytes showed low responses to LPS (4-hour stimulation) but a significant increase above background following 6 hours of treatment. The response to UTP in human monocytes was variable and required stimulation >6 hours. With such variability in response we looked for single nucleotide polymorphisms in P2RY2 that could affect the functional response. Sequencing of P2RY2 from THP-1 cells revealed the presence of a single nucleotide polymorphism altering amino acid 312 from arginine to serine (rs3741156). This polymorphism is relatively common at a frequency of 0.276 (n = 404 subjects). Finally, we investigated CCL2 secretion in response to LPS or UTP in human macrophages expressing 312Arg-P2Y2 or 312Ser-P2Y2 where only the latter exhibited significant UTP-induced CCL2 secretion (n = 5 donors per group).

Maternal kangaroo (skin-to-skin) care in the NICU beginning 4 hours postbirth.

Kangaroo care (KC) for preterm infants is becoming well known in the United States. Typically, KC is given by mothers in the neonatal intensive care unit (NICU) beginning days or weeks postbirth. This case report documents KC beginning at 4.5 hours postbirth with a healthy mother whose 32-week, 1,953 gram infant required initial care in the NICU. The nurse's role in supporting this care is described. Both parents experienced KC with their son and were soon convinced of the exceptional benefits he received. The infant was transferred to intermediate care on Day 2, regained his birth weight by Day 12, was discharged home on Day 21. He was breast-feeding exclusively at 40 weeks corrected age, and had Bayley mental and motor development scores within normal limits at 6 months corrected age.

Review of the effect of fixation on complication rate in the base wedge osteotomy.

The complications of elevation and shortening in the oblique closing base wedge osteotomy of the first metatarsal fixated with either a single AO screw or two 0.062 Kirschner wires were compared. Thirty-three consecutive oblique closing base wedge osteotomies of the first metatarsal bone are evaluated. With the exception of fixation, which is examined as an independent variable, the patients are managed identically with respect to osteotomy technique and postoperative care. The Reese osteotomy guide is used to normalize osteotomy configuration. The authors found no difference in elevation or shortening when comparing an AO screw with 0.062 Kirschner wire fixation. When other variables are controlled, fixation type does not lead to a statistical difference in elevation or shortening.

1993 William J. Stickel Gold Award. Stability of absorbable fixation in basilar first metatarsal osteotomies.

The purpose of this study was to compare the structural characteristics of 2.0-mm polyglycolic acid pins and 2.0-mm Steinmann pins in oblique closing base wedge osteotomies of the first metatarsal bone commonly used to correct metatarsus primus varus. Six pairs of fresh frozen cadaveric first metatarsal bones were osteotomized, fixated with either absorbable or stainless steel 2.0-mm pins, cemented in a specimen-holding jig, and tested with the Bionix Material Testing System. There was no significant difference in the mean ultimate force, ultimate displacement, or structural stiffness when comparing 2.0-mm polyglycolic acid pins and Steinmann pins in this model. The structural characteristics of 2.0-mm absorbable pins were the same as stainless steel pins at the time of initial placement in the oblique closing base wedge osteotomy of the first metatarsal.

1995 William J. Stickel Silver Award. Structural analysis of absorbable pin and screw fixation in first metatarsal osteotomies.

The structural characteristics of 4.0-mm stainless steel screws compared with 4.0-mm poly-L-lactic acid absorbable screws and 2.0-mm stainless steel Steinmann pins compared with 2.0-mm poly-L-lactic acid absorbable pins in oblique closing base wedge osteotomies of the first metatarsal were evaluated. The authors performed oblique closing base wedge using an osteotomy guide in six matched pairs of fresh frozen first metatarsal bones. Fixation was achieved with either a 4.0-mm stainless steel screw or poly-L-lactic acid absorbable screw. An additional five pairs of matched specimens were used to compare 2.0-mm stainless steel and poly-L-lactic acid absorbable pins with the same approach. Specimens were loaded to failure with the Bionix Material Testing System at a constant rate of 0.166 mm/sec. A Student's t-test for paired samples was used with a 95% confidence interval to measure differences in ultimate load, ultimate displacement, and structural stiffness. There was not a significant difference in any of the parameters evaluated in the 4.0-mm poly-L-lactic acid absorbable versus stainless steel screw comparison (P > 0.05). Stainless steel 2.0-mm pins had significantly greater structural stiffness (P = 0.032) and less ultimate displacement (P = 0.021) than their poly-L-lactic acid absorbable counterparts. There was not a significant difference in ultimate load in poly-L-lactic acid absorbable and stainless steel pins (P = 0.59).

Lesser metatarsalgia. Rheumatologic considerations.

The differential diagnosis for metatarsalgia should include rheumatoid arthritis, SLE, mixed connective tissue disease, psoriatic arthritis, Reiter's syndrome, fibromyalgic syndrome, gout, post-traumatic joint disease, and septic arthritis. When the patient's symptoms are approached systematically an accurate diagnosis can lead to implementation of an appropriate treatment plan. Multidisciplinary treatment approaches often lead to the most satisfying therapeutic outcomes.

Wound dressings and topical agents.

Topical treatment of wounds is an important aspect of wound care, although secondary to surgical and systemic care. Dressing materials come in many forms to suit wound types and preferences. No hard evidence exists to place any one approach above another. All wounds deserve individualized attention and care plans. Likewise, a plethora of solutions exist to augment dressing materials in cleansing, antibiosis, and débridement. Traditional agents, including hydrogen peroxide, Dakin's solution, and povidone-iodine, are more tissue toxic than their common usage would indicate. We prefer frequent dressing changes with natural fiber gauze and nontoxic solutions such as saline. The scalpel, curette, and rongeur are, in our experience, much preferred to enzymatic agents when débridement is needed. We encourage scrutiny of commercial products based on clinical merit and effectiveness as documented in the medical literature. Platelet derived growth factors are an effective adjunct to wound healing and are primarily indicated when the condition of patients and their wounds has otherwise been optimized.

Research perspectives in first metatarsal osteotomy and fixation stability.

Well-designated research is required to provide clinical guidance by validation of old and new methods. Variables, including technologic advancement in surgical techniques, diagnosis, shoe design, and immobilization all contribute to the challenge of investigating surgical procedures of the foot. This article highlights some of the relevant research pertaining to first metatarsal osteotomies and internal fixation and provides direction for potential, future research. Numerous aspects about the research techniques involved are discussed.

Arthrodesis of the first metatarsophalangeal joint: a review of the literature and long-term retrospective analysis.

A retrospective analysis of arthrodesis of the first metatarsophalangeal joint was done to determine the procedure's long-term subjective and objective results. The authors reviewed the long-term results of arthrodesis in 25 patients with 32 operated feet. The average age was 54.8 years (range 22 to 72 years), and the average length of follow-up was 31.9 months (range 12 to 84 months). The patients were questioned regarding pain, activity, cosmesis, and willingness to have the operation performed again. The subjective results were good or excellent in 26 feet (81% success rate). The primary postoperative complaints were pain in the interphalangeal joint (four feet), and a callosity or pain under the first metatarsal head (four feet). Radiographic examination revealed that the procedure provided a good reduction of the hallux valgus angle (preoperative average 33.7 degrees; postoperative average 17.4 degrees) and intermetatarsal angle (preoperative average 16.2 degrees; postoperative average 12.0 degrees). The authors believe that this procedure is a reliable, effective treatment whenever stability is required at the first metatarsophalangeal joint.

Seronegative rheumatoid arthritis and Morton's neuroma.

The authors present a case of seronegative rheumatoid arthritis and symptomatic Morton's neuroma. The thought process of the differential diagnosis is explored extensively with substantial support and review of existing literature.

Mechanical characteristics of poly-L-lactic acid absorbable screws and stainless steel screws in basilar osteotomies of the first metatarsal.

The purpose of this study is to evaluate the structural characteristics of 3.5-mm. stainless steel cortical screws and poly-L-lactic acid (PLA) absorbable screws in oblique closing base wedge osteotomies of the first metatarsal. Six pairs of frozen first metatarsal bones were excised from the specimen group. An oblique base wedge osteotomy was performed and fixated with either a 3.5-mm. stainless steel or PLA screw. Specimens were loaded to failure with the Bionix Material Testing System at a constant rate of 0.166 mm./sec. A Student's t test for paired samples with a 95% confidence interval was used to measure differences in ultimate load, ultimate displacement, and structural stiffness. The following results (mean +/- standard deviation) were obtained: Structural stiffness, PLA 12.35 +/- 3.82 N/mm. and stainless steel 10.13 +/- 5.74 N/mm.: ultimate displacement, PLA 7.39 +/- 3.23 mm. and stainless steel 10.89 +/- 7.91 mm.; ultimate load, PLA 57.95 +/- 1.01 N and stainless steel 51.49 +/- 5.22 N. In this fracture model, there were no statistically significant differences in the structural characteristics of PLA 3.5-mm. screws and stainless steel screws in oblique closing base wedge osteotomies of the first metatarsal.

Risk of complications of first metatarsal head osteotomies with biodegradable pin fixation: Biofix versus Orthosorb.

Bioabsorbable materials for fracture repair have recently become available in the United States. These products have been especially attractive to surgeons that perform elective foot surgeries because an additional surgery is not required to remove internal fixation, and exposed pins and their complications can be avoided. The aim of this study was to compare complications in distal first metatarsal head osteotomies fixed with Biofix, polyglycolide pins and Orthosorb, polydioxanon pins. The authors identified nine patients with 11 distal first metatarsal osteotomies repaired with Biofix and 28 patients with 34 osteotomies repaired with Orthosorb from surgery logs for a 2-year period. The authors abstracted medical records and radiographs to identify sterile sinus formation, non-unions, malunions, and osteolytic lesions. The age and gender of patients in the Orthosorb and Biofix groups were similar. Six osteotomies in five patients in the Biofix group demonstrated bone resorption and osteolytic changes involving the osteotomy. Two of these patients also had a dorsally subluxed malunion of the first metatarsal head. There was one dorsally subluxed malunion in the Orthosorb group. No sterile sinus tracts were identified in either group. Complications were more common in distal first metatarsal osteotomies fixed with Biofix compared with Orthosorb (Biofix 55%, Orthosorb 3%, p < 0.001, odds ratio: 39.6, confidence interval (CI) = 3.9-401.6). Complications in the Biofix group were significantly more common in patients 50 years of age and older (p < 0.05).

Long-term follow-up of Morton's neuroma.

The long-term results of neurectomy are evaluated in 70 symptomatic Morton's neuromas in 53 patients with an average postoperative follow-up of 4.8 years, and a maximum of 8.6 years. The presentation, number, and location of neuromas in this series, in some instances, coincides with previous publications. Neurectomy, by means of a dorsal approach, provided 93% patient satisfaction at long-term follow-up.

Critical evaluation of the short "Z" bunionectomy.

The authors reviewed 120 "short Z" bunionectomy operations and, on the basis of available clinical and radiographic data, selected 50 osteotomies in 36 patients for review. Follow-up averaged 21 months and ranged from 13 to 26 months. Excellent and good results were found in 92%, while fair and poor results were obtained in 8% of patients. Although seven fractures occurred in the 50 osteotomy sites, most of these resolved without sequellae after appropriate treatment.