Role of regenerative therapies on erectile dysfunction after radical prostatectomy.

The present study provides a review of stem cell therapy as a treatment of erectile dysfunction from peer-reviewed human and animal trials. A literature search was conducted in PubMed-Medline, Scopus, Embase, and Cochrane databases. Tweenty-three animal studies and seven human studies in the period from 1st of January 2000 to 1st of Mai 2020 were included. The seven included human studies are primary phase one trials, and most of them treat erectile dysfunction following radical prostatectomy by injection of stem cells into the corpus cavernosum. The primary outcome measure in all human trials is safety and secondary can stem cells play a role in the recovery of erectile function. All studies conclude that it is safe to use stem cells and the majority of the studies demonstrate an improvement in erectile function. The results from both animal and human trials are promising for stem cells as a restorative treatment, but data from large randomized human phase two trials is missing before it can be concluded, that stem cells is an effective treatment for erectile dysfunction in humans.

Salvage or amputation after complex foot and ankle trauma.

A treating surgeon must take all the aforementioned ideas and principles into consideration, make a reasoned decision in the first hour of patient evaluation, and proceed with the chosen treatment. When functional salvage is not thought to be possible, it is better simply to let the patient and family know, then proceed directly to the best possible reconstructive amputation. This approach saves the patient, family, friends, and treatment team an enormous amount of anguish and allows for the earliest possible acceptance and positive approach to rehabilitation.

Surgical management of severe deformity resulting from posterior tibial tendon dysfunction.

A retrospective case study format was used to evaluate the results of surgical treatment of severe deformities due to long-standing tibialis posterior tendon dysfunction. To be included in the study, the peri-talar (talonavicular) subluxation on a weight-bearing AP X-ray should have been at least 75%. This criterion limited the field to patients with long-standing, rigid, severe deformities. Surgical correction was obtained through a two-incision approach, dorsomedial and dorsolateral. Significant shortening of the medial column and extensive removal of adaptive bone formation was necessary to allow reduction of the hind- and midfoot deformity. Stable internal fixation using multiple screws was used to secure the reduction. Eleven patients, 12 feet were evaluated. The patients were evaluated using the American Orthopedic Foot and Ankle Society Ankle and Hindfoot Score as well as a questionnaire on footwear and satisfaction rating. The average score improved from 30 points pre-op to 74 points post-op (out of 100). P-value 0.0001. Pain score improved from 11/40 to 33/40. Function improved from 19/50 to 33/50. Alignment improved from 0/10 to 8/10. The radiological parameters showed an average improvement of 31 degrees in the lateral talo-1st metatarsal angle, 11 degrees in the calcaneal pitch, and 35 degrees in the AP talo-1st metatarsal angle. All three parameters were highly significant with P-values of 0.0001. Multiple complications occurred. This included two delayed unions with breakage of screws and partial loss of correction, four wound problems, two sural nerve impairments and three patients requiring hardware removal. Even though it is an extensive procedure with multiple potential complications it still offers a substantial improvement in quality of life.

Outcome after open reduction and internal fixation of Lisfranc joint injuries.

BACKGROUND: Open reduction and internal fixation has been recommended as the treatment for most unstable injuries of the Lisfranc (tarsometatarsal) joint. It has been thought that purely ligamentous injuries have a poor outcome despite such surgical management. METHODS: We performed a retrospective study of patients who underwent open reduction and screw fixation of a Lisfranc injury in a seven-year period. Among ninety-two adults treated for that injury, forty-eight patients with forty-eight injuries were followed for an average of fifty-two months (range, thirteen to 114 months). Fifteen injuries were purely ligamentous, and thirty-three were combined ligamentous and osseous. Patient outcome was assessed with use of the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and the long-form Musculoskeletal Function Assessment (MFA) score. RESULTS: The average AOFAS midfoot score was 77 points (on a scale of 0 to 100 points, with 100 points indicating an excellent outcome), with patients losing points for mild pain, decreased recreational function, and orthotic requirements. The average MFA score was 19 points (on a scale of 0 to 100 points, with 0 points indicating an excellent outcome), with patients losing points because of problems with "leisure activities" and difficulties with "life changes and feelings due to the injury." Twelve patients (25 percent) had posttraumatic osteoarthritis of the tarsometatarsal joints, and six of them required arthrodesis. The major determinant of a good result was anatomical reduction (p = 0.05). The subgroup of patients with purely ligamentous injury showed a trend toward poorer outcomes despite anatomical reduction and screw fixation. CONCLUSIONS: Our results support the concept that stable anatomical reduction of fracture-dislocations of the Lisfranc joint leads to the best long-term outcomes as patients so treated have less arthritis as well as better AOFAS midfoot scores.

Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot. Early results after distraction arthrodesis of the calcaneocuboid joint in conjunction with stabilization of, and transfer of the flexor digitorum longus tendon to, the midfoot to treat acquired pes planovalgus in adults.

BACKGROUND: The successful correction of flatfoot in children through lengthening of the lateral column, osteotomy of the medial cuneiform, and advancement of the posterior tibial tendon led to the introduction of similar procedures to treat acquired pes planovalgus secondary to attrition or rupture of the posterior tibial tendon in adults. However, to our knowledge, no study has been published documenting whether these procedures are effective treatment for acquired flatfoot in adults. METHODS: The functional and radiographic results of complex reconstruction of a painful, flexible flatfoot associated with attrition or rupture of the posterior tibial tendon were evaluated in thirty-six patients (forty-one feet) with use of a detailed questionnaire, a comprehensive physical examination, and a review of the radiographs and the medical record. RESULTS: At a mean of thirty-four months (range, twenty-four to fifty months) postoperatively, thirty-six feet (88 percent) were less painful compared with the preoperative status or were pain-free and five of the six parameters that had been used to assess correction of the deformity radiographically had improved significantly (p<0.0001). Eight feet (20 percent) had a non-union at the calcaneocuboid joint, and thirteen feet (32 percent) had anesthesia or paresthesia of the sural nerve. Twenty-nine feet (71 percent) had had additional operations, including removal of hardware from twenty feet; bone-grafting to treat a nonunion at the site of the calcaneocuboid arthrodesis and revision of the internal fixation in four feet; a medial displacement calcaneal osteotomy because of recurrent valgus angulation of the hindfoot in two feet; and a Lapidus procedure because of a hypermobile tarsometatarsal joint with hallux valgus, a triple arthrodesis because of a nonunion at the site of the calcaneocuboid arthrodesis associated with loss of correction, and a dorsiflexion-abduction wedge osteotomy through the site of the calcaneocuboid arthrodesis (which had healed) for alignment of an overcorrected foot in one foot each. The outcomes of the procedures in thirty-five feet (85 percent) were rated by the patients as satisfactory, and thirty-three (92 percent) of the thirty-six patients (thirty-eight [93 percent] of the forty-one feet) stated that they would have the procedure again if the circumstances were similar. CONCLUSIONS: Despite the high prevalence of postoperative complications, most of our patients were satisfied with the result of the procedure after the short duration of follow-up. We believe that the relief of pain and the restoration of function achieved through effective correction of the severe pes planovalgus deformity account for the satisfactory outcomes in our patients.

Subluxation of the talocalcaneal joint in adults who have symptomatic flatfoot.

BACKGROUND: When flatfoot is acquired during adulthood, the shape of the foot changes. In addition to a decreased arch, there may be valgus angulation of the hindfoot or abduction of the forefoot, or both. However, there is little objective information to provide a better understanding of the anatomical or morphological changes that occur in acquired adult flatfoot. We wondered if such an understanding of the three-dimensional anatomy might shed light on the pathway by which these changes occur. We designed this study to measure the three-dimensional position of the talocalcaneal joint in patients who have painful flatfoot. METHODS: Computed tomography scans of the feet of eight patients who had symptomatic flatfoot were used to construct a model of the talocalcaneal articulation. The scans were performed on a custom loading frame developed to simulate weight-bearing with the foot in a neutral position while a seventy-five-newton axial compressive load was applied. The digital data from the scans were used to make three-dimensional computer models of the articular surfaces of the talus and calcaneus of each foot. These models then were used to calculate the percentage of the articular surface that was in contact and, conversely, the percentage that was subluxated. Two surfaces were modeled for each bone; the posterior facet formed one surface, and the anterior and middle facets were combined to form the second surface. The data were compared, with use of Mann-Whitney nonparametric U analysis, with those derived from scans of the feet of four patients without a deformity of the hindfoot who served as controls. RESULTS: A mean (and standard deviation) of 68+/-9 percent of the posterior facet of the calcaneus was in contact with the talus in the patients who had flatfoot compared with 92+/-2 percent in the controls, and a mean of 51+/-23 percent of the anterior and middle facets of the calcaneus was in contact with the talus in the patients who had flatfoot compared with 95+/-6 percent in the controls. These differences were significant (p = 0.0066 for both). CONCLUSIONS: Marked subluxation of the talocalcaneal joint occurs in some patients who have symptomatic planoabductovalgus deformity.

The lateral column lengthening and medial column stabilization procedures.

The results of medial column stabilization, lateral column lengthening, and combined medial and lateral procedures were reviewed in the treatment of adult acquired flatfoot secondary to posterior tibialis tendon insufficiency. All bony procedures were accompanied by transfer of the flexor digitorum longus tendon to the medial cuneiform or stump of the posterior tibialis tendon and tendoachilles lengthening or gastrocnemius recession. Medial column fusion was performed for naviculocuneiform and cuneiform first metatarsal sag; lateral column lengthening was performed for calcaneovalgus deformity with a flat pitch angle; and combined procedures were performed for complex combined deformities. At 1 to 4 year followup of 65 feet, 88% of the feet that had lateral column lengthening, 80% that had medial column stabilization, and 88% of the feet that had medial and lateral procedures had a decrease in pain or were pain free. The lateral talar first metatarsal angle improved by 16 degrees in the patients in the lateral column lengthening group, 20 degrees in the patients in the medial column stabilization group, and 24 degrees in the patients in the combined medial and lateral procedures group. The anteroposterior talonavicular coverage angle improved by 14 degrees in the patients in the lateral column lengthening group, 10 degrees in the patients in the medial column stabilization group, and 14 degrees in the patients in the combined medial and lateral procedures group. These techniques effectively correct deformity without disrupting the essential joints of the hindfoot and midfoot.

Biomechanical analysis of the first metatarsocuneiform arthrodesis.

This investigation was designed to help define the unique loading characteristics of the first metatarsocuneiform arthrodesis procedure. Part I of this investigation employed nine fresh frozen, matched-pair cadaveric specimens. One specimen in each pair had the subchondral plate removed from the opposing joint surfaces, while the remaining specimen had only the articular cartilage removed. All specimens were stabilized in an identical manner utilizing two 3.5-mm cortical screws. Part II of the investigation also utilized nine fresh frozen, matched-pair cadaveric specimens. Only the articular cartilage was removed prior to placement of fixation. All specimens were stabilized with two crossing 3.5-mm cortical screws. Placement of a third screw was randomized between specimens of a matched pair. Specimens were loaded to failure in cantilever bending utilizing a materials tester. There was a statistically significant (p = .04) greater load to failure and bending moment in specimens with an intact subchondral plate. Values for construct stiffness were not found to be significantly different (p = .95) between specimens with and without a subchondral plate. Although the addition of a third screw increased the load to failure and bending moments, differences were not found to be statistically different (p = .11-.21) from two screws. Preserving the subchondral plate will enhance the stability of the first metatarsocuneiform arthrodesis. Two or three screws can be employed to shield the fusion site from loading; however, three screws were shown to be more effective than two.

Surgery of the rheumatoid foot and ankle.

Numerous reconstructive procedures have been used to address the manifestations of rheumatoid arthritis in the foot and ankle. Clinical studies have documented that these procedures relieve pain, however they often sacrifice motion essential to the normal function of the foot. In the forefoot, metatarsophalangeal joint resection arthroplasty shortens the lever arm of the foot, defunctions the toes, and disables the plantar plate and fat pad. Arthrodesis of the ankle and hindfoot alters gait and the effective transmission of weight-bearing stresses through the foot and ankle. These ablative procedures may provoke the deterioration of adjacent joints and may cripple the long-term function of the lower extremity. The introduction of reconstructive procedures designed to preserve motion in joints essential to function and the recognition and treatment of muscle imbalances associated with bone and joint deformities are recent advances in the surgical management of the rheumatoid foot and ankle.

Revision ankle fusion using internal compression arthrodesis with screw fixation.

We reviewed 20 revision ankle fusions performed using internal compression arthrodesis with screw fixation. Clinical, functional, and radiographic results were measured at an average follow-up of 30 months (range, 12-50 months). The reasons for the index procedures were nonunion in 11, malunion in 7, infected nonunion in 1, and nonunion associated with avascular necrosis of the talus in 1 case. Fusion occurred in 15 of 20 patients. Two additional patients obtained fusion after subsequent procedures, for a final union rate of 85%. The average time to fusion was 6 months (range, 2-32 months). Nineteen additional operations were necessary in 12 patients, including three amputations for chronic infection (two infected nonunions and one chronic osteomyelitis). All but one patient had a plantigrade limb at follow-up. Seventeen of 20 patients were satisfied with their ultimate outcome, including all three patients with amputations. The three dissatisfied patients were bothered by chronic pain. Revision ankle fusion for nonunion or malunion using internal compression arthrodesis with screw fixation is beneficial for most patients. It is a technically demanding procedure that is associated with a high complication rate. Many patients can be expected to have residual pain. We emphasize the need for accurate alignment and early, aggressive treatment of infectious complications. Amputation should be considered a viable option to improve functional outcome in patients with solid, well-aligned fusions who are disabled by severe chronic pain.

Hallux valgus surgery. Morton and Lapidus were right!

More than 60 years ago an anatomist, Dudley Morton, and an orthopaedic surgeon, Paul Lapidus, independently published similar theories that implicated excessive mobility of the first metatarsal in forefoot dysfunction. Morton first studied in detail the evolution of the foot leading to bipedal gait and then examined the feet of many of his students in an attempt to correlate his tentative assumptions with the presence of or lack of symptoms. Morton's analysis of forefoot dysfunction provides the foundation of modern surgical procedures that restore normal forefoot balance and function to asymptotic feet.

Surgical reconstruction of the diabetic foot: a salvage approach for midfoot collapse.

Between 1985 and 1993, 18 patients representing 21 feet underwent surgical reconstruction for diabetic neuroarthropathy with collapse of the midfoot. Forty-seven percent (10/21) of these feet presented with plantar pressure ulcers. Reconstruction involved reduction and fusion of collapsed joints, using internal fixation to restore foot shape and improve weightbearing alignment. The average follow-up in these patients was 28 months (range, 6-84 months). Limb salvage was obtained in 18 of 21 feet. Average time to radiographic union was 5 months (range, 3-9 months). Improvement in shoe fit and ambulatory status was noted for 13 of the 15 patients who had successful reconstruction. Forty-seven percent of the reviewed cases were without any complication throughout their postoperative course. Seventy percent of the presenting ulcers healed without incident. There were no recurrent midfoot ulcers.

Retrograde nailing of femoral shaft fractures.

OBJECTIVE: The purpose of the study was to define the outcome following retrograde nailing of the femoral shaft. DESIGN: Retrospective clinical study. MATERIALS AND METHODS: Seventeen retrograde intramedullary nailings of the femur were performed in 16 patients for management of complex orthopedic trauma. Thirteen patients were followed for an average of 22.8 months (range from 9 to 72 months). The indications for retrograde nailing were an ipsilateral femoral neck and shaft fracture in eight cases, knee disarticulation or long above knee amputation associated with a femoral shaft fracture in five cases, traumatic arthrotomy of the knee ipsilateral to a shaft fracture in two cases, one case of a shaft fracture ipsilateral to an acetabular fracture that required an extensile exposure, and one case of a femoral nonunion with a knee contracture. In fourteen of the seventeen cases the femur fracture was open including two grade III C injuries. MEASUREMENTS AND MAIN RESULTS: Two patients died in the early postoperative period due to the severity of the initial trauma and one patient was lost to follow-up. The results were generally poor and postoperative complications were common. There were five nonunions in the group, one which required revision to an above knee amputation for an infected nonunion following a grade III open femur fracture. The average range of motion of the knee was 3 degrees to 110 degrees, and two patients had an extensor lag of 5 degrees or more. Six patients underwent removal of hardware through a second arthrotomy with no significant loss of knee function related to the second procedure. CONCLUSIONS: The authors concluded that the high complication rate and poor results were related to the severity of the initial injury. An intercondylar starting can be used in properly selected cases with minimal effect on knee function.

Prosthetic history, prosthetic charges, and functional outcome of the isolated, traumatic below-knee amputee.

PURPOSE: To review the prosthetic history, prosthetic charges, and functional status of traumatic, isolated, unilateral below-knee amputees at select intervals following amputation. METHODS: This descriptive study was conducted among patients admitted to Harborview Medical Center between 1980 and 1987 who survived initial trauma, and who required an isolated, below-knee amputation. Hospital and prosthetist records were abstracted to calculate the number of prostheses fabricated and the prosthetic charges since initial amputation. Functional outcomes were determined by personal interview and self-administration of the SF-36 Health Status Profile. RESULTS: The average age of patients was 36 with the age range extending from 19 to 59 years. The prosthetic history and prosthetic charges were determined from the medical record and the billing records of the prosthetist. Exact charges were determined for 15 of the 20 patients. During the first 3 years, the mean number of prostheses acquired per patient was 3.4 (range 1-5), with average total prosthetic charges of $10,829 (range $2,558-$15,700). Over the first 5 years the mean number of prostheses acquired per patient was 4.4 (range 2-8), with average total prosthetic charges of $13,945 (range $6,203-$20,070). The SF-36 Health Status Profile scores were significantly decreased from published normal aged-matched scores in the categories of physical function and role limitations because of physical health problems and pain. Scores were not significantly different from published normal aged-matched scores in the other five categories: role limitations due to emotional problems, social functioning, mental health, energy/fatigue, and health perception.

Treatment of compartmental liquefaction as a late sequelae of a lower limb compartment syndrome.

Symptomatic liquefaction and calcification of muscle tissue as a late sequela of compartment syndrome of the lower leg is rare. The literature shows a high complication rate involved with simple debridement of these compartments. In our limited experience, complete compartmental debridement and immediate introduction of functional viable muscle may prevent the documented complications of chronic drainage and infection.

Continuous regional analgesia by intraneural block: effect on postoperative opioid requirements and phantom limb pain following amputation.

The objective of this study was to assess the effectiveness of a previously described technique of regional analgesia (continuous infusion of local anesthetic through a catheter placed at the time of amputation within the exposed sciatic or posterior tibial nerve) on relieving the postoperative pain in a heterogeneous group of patients who underwent lower extremity amputations. A second objective was to determine the effect of such treatment on the incidence and characteristics of phantom limb pain 6 months or more after surgery in the same patients. The study design was retrospective, unblinded, controlled (postoperative pain), and unblinded questionnaire and interview (phantom pain) were utilized. Subjects were inpatients at Harborview Medical Center, University of Washington, Seattle, WA. Nineteen bupivacaine-treated and 40 nonbupivacaine-treated patients who underwent lower extremity amputation subsequent to trauma, infection, long-standing injury (poor or no function), congenital deformity, or burns were evaluated in the postoperative pain management assessment. Nine treated and 12 untreated patients were interviewed in the phantom pain assessment. Bupivacaine 0.5% 2-6 ml/h was infused through a polyamide 20-gauge catheter inserted into the sciatic or posterior tibial nerve sheath under direct vision at the time of surgery. All patients, treated and control, received opioid analgesics systemically during the 72-hour period of study. The postoperative opioid analgesic requirement of treated patients was compared with that of control patients who received opioid analgesics alone. A questionnaire was administered to assess presence, severity, and character of phantom pain.(ABSTRACT TRUNCATED AT 250 WORDS)