Outcomes in Patients with Heel Ulcerations that Underwent Below the Knee Amputations versus Vertical Contour Calcanectomy: Importance of Selection Criteria.

The aim of the study was to compare preoperative factors and postoperative outcomes in patients with heel ulcerations that primarily had a transtibial (below the knee) amputation (N=38) versus vertical contour calcanectomy (n=62). The groups had no statistical difference between their Charlson Comorbidity Index Score, a prognostic score of ten-year survival in patients with multiple comorbidities. The odds of primary closure was 21.1 times higher in patients that underwent below knee amputation compared to patients that underwent vertical contour calcanectomy [OR 21.1 (95% CI 3.89-114.21)]. The odds of positive soft tissue culture at time of closure were 17.1 times higher for patients that underwent vertical contour calcanectomy [OR 17.1 (95% CI 5.40-54.16)]. The odds of a patent posterior tibial artery was 3.3 times higher for patients that underwent vertical contour calcanectomy [OR 3.3 (95% 1.09-10.09)]. The secondary aim of the study was to evaluate preoperative factors and postoperative outcomes in patients with failed vertical contour calcanectomy, defined as needing a below knee amputation. The odds of vertical contour calcanectomy failure was 13.7 times higher in male patients [OR 13.7 (95% CI 1.80-107.60)]. Vertical contour calcanectomy failure was 5.7 times higher in patients with renal disease [OR 5.7 (95% CI 1.10-30.30)], and vertical contour calcanectomy failure was 16.1 times higher for patients who needed additional surgery post closure [OR 16.1 (95% CI 1.40-183.20)].

The Ankle Joint: Management of Significant Bone Loss with Arthrodesis.

Segmental bone loss of the distal tibia and/or talus presents a challenge to successful reconstruction for the foot and ankle surgeon. When conservative care has been exhausted, multiple surgical treatment options are available including bone transport, bulk allografts, bulk autografts, titanium cages, and external fixation techniques. The primary goals of surgical correction include restoration of limb length as well as a plantigrade, stable lower extremity.

Addressing varus and valgus deformity of the ankle: Algorithmic approach to total ankle arthroplasty.

Total ankle replacements have become increasingly popular, providing a viable alternative to ankle arthrodesis in patients with end stage ankle arthritis. Continued advancements in implant design have substantially improved long term survival outcomes as well as patient pain relief, range of motion, and quality of life. Surgeons continue to advance the indications for implantation of total ankle replacements in patients with more severe varus and valgus coronal plane deformity. This report of twelve cases demonstrates our algorithmic approach to total ankle arthroplasty in patients with deformity of the foot and ankle. By proposing a clinical algorithm with case examples, we aim to aid clinicians in successfully approaching coronal plane deformities of the foot and ankle when using total ankle replacement to ultimately improve clinical outcomes.

Risks Factors Associated With Major Lower Extremity Amputation After Vertical Contour Calcanectomy.

The primary aim of the study is to determine risks for major lower extremity amputation after undergoing Vertical Contour Calcanectomy. Subanalysis was performed comparing patients who underwent Vertical Contour Calcanectomy who were fully ambulatory to those who were partially or nonambulatory postoperatively. Within the cohort of 63 patients included in the Vertical Contour Calcanectomy 85.71% (54/63) of patients had diabetes mellitus, 53.97% (34/63) had peripheral arterial disease, and 19.05% (12/63) had Charcot Neuroarthropathy. Multivariate logistic regression, found that (1) patients that underwent primary closure at the time of the Vertical Contour Calcanectomy, were 79.9% more likely (odds ratio [OR] 0.20; 95% confidence interval [CI] 0.04-0.96) to have limb salvage and that (2) female patients were 85.4% less likely compared to male patients (OR 0.15; 95% CI 0.02-0.99) to undergo major lower extremity amputation. Patients with coronary artery disease were 5.2 times more likely (OR 5.18; 95% CI 1.120-23.94) and patients that were nonambulatory preoperatively, were 10.3 times more likely (OR 10.28; 95% CI 1.60-66.26), to be partially or nonambulatory after Vertical Contour Calcanectomy. Primary closure at time of Vertical Contour Calcanectomy significantly decreases the risk of major lower extremity amputation, and diminished preoperative ambulatory status as well as coronary artery disease makes it less likely that patients return to full ambulation after Vertical Contour Calcanectomy.

Early Clinical, Functional, and Mortality Outcomes for Heel Ulcers Treated With a Vertical Contour Calcanectomy.

Heel ulcerations are common complications seen in patients suffering from chronic conditions such as diabetes mellitus, peripheral vascular disease, and in bed ridden patients. When these systemic pathologies lead to heel ulcers, an increased risk of calcaneal osteomyelitis often significantly limits the benefits of conventional therapeutic interventions and increases risk of major lower extremity amputation. The Vertical Contour Calcanectomy (VCC) is a novel surgical procedure specific for the surgical management of these complex and often recalcitrant heel ulcerations. The VCC was described as a reproducible procedure in which wide excision of both the soft tissue ulceration as well as defined bone cuts of the calcaneus allows for decreased bioburden and in many cases, for primary soft tissue closure. The present study describes the outcomes related to the VCC and provides guidance based on the objective findings detailed herein. This study, at the time of publication, represents the largest collection of patients that have undergone the VCC (N = 51) and their outcomes at 1 year. Those who remained healed without recurrence, amputation, or mortality at 1-year follow-up were 31.4%. Post-VCC total limb salvage rate is 68.6% at one year, mean follow-up 663.9 ± 464.7 days. One-year all-cause mortality post-VCC was 9.8%. Post-VCC function at 1-year follow-up reflects 79.3% of patients having the same or better function that their perioperative state.

A Systematic Review of Angular Deformities in Charcot Neuroarthropathy.

Charcot neuroarthropathy of the foot and ankle is associated with periarticular deformities and progressive radiographic changes. There have been studies analyzing the radiographic angulations and deformity progression in Charcot neuroarthropathy deformity. The aim of this paper is to provide systematic review of studies that evaluate foot and ankle radiographic parameters in patients with Charcot neuroarthropathy. A multidatabase search including, medline, EMBASE, Google Scholar, Cochrane Library, Clinicaltrials.gov and reference lists of included studies, was performed from 1980 to 2020. A total of 7 articles were included that analyzed radiographic angulations in Charcot neuroarthropathy deformity. The articles could be categorized into nonoperative angulation measurements, and pre- versus postoperative angulation measurements. The presence of ulcerations and the severity of the Charcot neuroarthropathy deformity were found to result from predominantly sagittal plane deformity. The deformity initiates with medial column collapse and progresses to continual lateral column collapse. Surgical intervention resulting in immediate postoperative improvement in angular measurements, however, without beaming of both the medial and lateral column, there was recurrence of the lateral column deformity. This systematic review of articles analyzing angular deformities in Charcot neuroarthropathy patients, demonstrates the progressive sagittal plane breakdown patterns of Charcot as well as the benefits of surgical intervention.

Stage-Specific Demethylation in Primordial Germ Cells Safeguards against Precocious Differentiation.

Remodeling DNA methylation in mammalian genomes can be global, as seen in preimplantation embryos and primordial germ cells (PGCs), or locus specific, which can regulate neighboring gene expression. In PGCs, global and locus-specific DNA demethylation occur in sequential stages, with an initial global decrease in methylated cytosines (stage I) followed by a Tet methylcytosine dioxygenase (Tet)-dependent decrease in methylated cytosines that act at imprinting control regions (ICRs) and meiotic genes (stage II). The purpose of the two-stage mechanism is unclear. Here we show that Dnmt1 preserves DNA methylation through stage I at ICRs and meiotic gene promoters and is required for the pericentromeric enrichment of 5hmC. We discovered that the functional consequence of abrogating two-stage DNA demethylation in PGCs was precocious germline differentiation leading to hypogonadism and infertility. Therefore, bypassing stage-specific DNA demethylation has significant consequences for progenitor germ cell differentiation and the ability to transmit DNA from parent to offspring.

The Aorta-Gonad-Mesonephros Organ Culture Recapitulates 5hmC Reorganization and Replication-Dependent and Independent Loss of DNA Methylation in the Germline.

Removal of cytosine methylation from the genome is critical for reprogramming and transdifferentiation and plays a central role in our understanding of the fundamental principles of embryo lineage development. One of the major models for studying cytosine demethylation is the mammalian germ line during the primordial germ cell (PGC) stage of embryo development. It is now understood that oxidation of 5-methylcytosine (5mC) to 5-hydroxymethylcytosine (5hmC) is required to remove cytosine methylation in a locus-specific manner in PGCs; however, the mechanisms downstream of 5hmC are controversial and hypothesized to involve either active demethylation or replication-coupled loss. In the current study, we used the aorta-gonad-mesonephros (AGM) organ culture model to show that this model recapitulates germ line reprogramming, including 5hmC reorganization and loss of cytosine methylation from Snrpn and H19 imprinting control centers (ICCs). To directly address the hypothesis that cell proliferation is required for cytosine demethylation, we blocked PI3-kinase-dependent PGC proliferation and show that this leads to a G1 and G2/M cell cycle arrest in PGCs, together with retained levels of cytosine methylation at the Snrpn ICC, but not at the H19 ICC. Taken together, the AGM organ culture model is an important tool to evaluate mechanisms of locus-specific demethylation and the role of PI3-kinase-dependent PGC proliferation in the locus-specific removal of cytosine methylation from the genome.

Assessing depression in rural communities.

OBJECTIVES: Examined the severity of depressive symptoms and the rates of probable depression assessed by different instruments that were included in two separate surveys of residents in a predominately rural region of the United States. METHOD: Surveys of the Brazos Valley region in south central Texas were conducted and responses to the short form of the Center for Epidemiological Studies-Depression scale (in the 2006 survey) and the Patient Health Questionnaire-9 (in the 2010 survey) were analyzed. RESULTS: Regardless of instrument used, results indicate that women and African Americans are at greater risk for depression in this underserved region, but no unique effects were found for rural residency. IMPLICATIONS: Implications for research, assessment, program planning, and policy are discussed.

Mental health assessment in rehabilitation research.

Assessment in mental health research has evolved from focusing on symptoms and diagnosis to addressing a broad range of change, including psychosocial functioning. This is consistent with developments in the areas of psychosocial rehabilitation and the increase in recovery-oriented intervention models for mental disorders. We reviewed the status of assessment in mental health research, providing an overview of symptom and diagnostic assessment that is the cornerstone of most mental health research assessment. We then focused on measurement that can be applied across diagnostic groups and on functioning as a key mental health outcome. We reviewed the International Classification of Functioning, Disability, and Health and its implications for improvements in assessment. We provided an example of a new assessment, the Inventory of Psychosocial Functioning, which highlights key issues in the measurement of functioning. We then addressed improving research assessment, including issues of assessment in diverse populations and the need to capitalize on new data sources and new assessment technologies to advance assessment in mental health research. Finally, we reviewed and discussed areas for research and quality improvement, drawing on examples from the Department of Veterans Affairs to illustrate potential opportunities.