Tibial Retro-Malleolar Groove Morphology in Patients With Posterior Tibialis Tendon Dysfunction.

The posterior tibial tendon is a gliding tendon which courses around the medial malleolus and fails in posterior tibialis tendon dysfunction (PTTD) leading to a flat foot deformity. Distal tibial bone spurs have been identified as a secondary sign of PTTD although they have not been quantified in detail. The aim of this study was to assess the association of tendon dysfunction with the bony morphology of the tibial retro-malleolar groove. We performed a retrospective review of the clinical presentation, plain radiographs, and 103 magnetic resonance imaging (MRI) scans in 82 consecutive patients with PTTD compared with a non-PTTD group. We carried out a quantitative and qualitative assessment of the presence of plain radiographic bone spurs, stage of PTTD and MRI imaging of the morphology of the tibial bony malleolar groove. Plain radiographic bone spurs, as a secondary sign of PTTD, were present in 21.3% of ankle radiographs. MRI bone spurs were identified in 26/41 (63.4%) for all high-grade partial and complete tears and 7/41 (17.1%) for isolated complete tears compared with only 3.9% of the non-PTTD group. There was a significant association between the presence of bone spurs on MRI imaging and high-grade partial and complete tibialis posterior tears (p < .001; odds ratio of 4.98). Eleven of 103 (10.7%) of spurs were large and in 4/103 (3.9%) were substantial enough to create a tunnel-like hypertrophic groove not previously reported. There is variation in the bony structure of the malleolar groove in PTTD not observed in the non-PTTD group. Further investigation over time may elucidate whether the groove morphology may lead to mechanical attrition of the tibialis posterior tendon and contribute to failure of healing and progressive tendon degeneration.

Characteristics and neuropsychological impact of traumatic brain injury in female prisoners.

Objective: To investigate the characteristics of head injury (HI) and its association with offending behaviour, psychological and neurobehavioral functioning, and cognitive performance in female prisoners.Methods: Using a cross-sectional design, female prisoners in the UK reporting a HI with a loss of consciousness (LOC) over ten minutes (n = 10) were compared with a group without a HI with LOC over ten minutes (n = 41) across a range of measures; including scores on standardized clinical questionnaires and performance-based cognitive assessments. Semi-structured clinical interviews assessed HI and forensic history, with forensic history triangulated against the prison database.Results: Domestic abuse was the most frequently reported cause of HI. The HI with LOC group had been to prison a greater number of times and had committed a greater number violent offences. No significant difference was found on self-reported psychological and neurobehavioral measures, or between the groups' cognitive functioning on neuropsychological tests.Conclusions: Psychosocial factors such as trauma may contribute to higher rates of violent offending and imprisonment in those with a HI with LOC. Domestic abuse is an important factor in HI amongst female prisoners. Forensic screening and interventions need to be designed, adapted and evaluated with consideration of trauma and HI.

Limited plantar incision for flexor digitorum longus tendon harvest in surgical treatment of tibialis posterior tendon insufficiency.

BACKGROUND: Surgical correction of stage II tibialis posterior tendon dysfunction (TPTD) commonly utilises the Flexor Digitorum Longus (FDL) tendon to augment the tibialis posterior tendon. The aim of this study is to present our experience and clinical outcomes harvesting the FDL via a limited plantar incision technique. METHODS: 25 flat foot operations for stage II TPTD were performed harvesting the FDL via a limited plantar incision centred half-way between the base of the heel to the base of the 2nd toe and two-thirds from the lateral border of the foot. RESULTS: The FDL was isolated with no inter-tendonous connections requiring surgical division. There were no recorded cases of plantar nerve injury nor any technique-related complications observed. CONCLUSIONS: The plantar harvest technique for FDL is safe, provides a long tendon graft for transfer and limits the need for an extensive medial midfoot dissection.

The development of the Brain Injury Screening Index (BISI): A self-report measure.

The aim of this study was to investigate the psychometric properties and screening accuracy of the Brain Injury Screening Index (BISI), a self-report questionnaire designed to identify a history of acquired brain injury. The study was conducted in a closed male prison in the UK. The purposive sample comprised 55 male prisoners who arrived at the establishment during the study. A repeated measures design was used, where the Brain Injury Screening Index (BISI) was administered on three occasions. Inter-rater reliability was poor to moderate, but test retest reliability was moderate to good. Medical records were not available for all participants, but the limited number obtained resulted in a sensitivity of .38 to .71 and specificity of .47 to .70 across the three screening administrations of the BISI. The limitations of the present findings are discussed in the context of the use of the tool in custodial environments. It is argued that these results suggest that, when used as recommended, the BISI has acceptable reliability and validity as an initial screen for identifying individuals who should receive support and a comprehensive neuropsychological assessment, and it merits further investigation and development.

Optimizing measurement for neurobehavioural rehabilitation services: A multisite comparison study and response to UKROC.

To evaluate the efficacy of neurobehavioural rehabilitation (NbR) programmes, services should employ valid, reliable assessment tools; the ability to detect change on repeated assessment is a particular requirement. The United Kingdom Rehabilitation Outcomes Collaborative (UKROC) requires neurorehabilitation services to collect data using a standardized basket of measures, but the responsiveness and usefulness of using these in the context of NbR remains unknown. Anonymous data collected at two assessments for 123 people were examined using multiple methods to determine responsiveness of four outcome measures routinely used in NbR (HoNOS-ABI, FIM + FAM UK, MPAI-4, SASNOS). Predictive validity of two measures of rehabilitation complexity (RCS-E, SRS) regarding the extent of difference scores on these outcome measures at reassessment was also determined. All four outcome measures demonstrated responsiveness, with higher levels for SASNOS and MPAI-4 when only participants categorized as "most likely to change" at first assessment were analyzed. Predictive validity of the RCS-E and SRS in estimating the extent of change was variable. SRS was only predictive of improvement on the MPAI-4 whilst RCS-E was not predictive at all. Recommendations are made regarding ideal characteristics of NbR outcome measures, along with the need to develop measures of rehabilitation complexity specifically conceptualized for these programmes.

Utility of the Brain Injury Screening Index in Identifying Female Prisoners With a Traumatic Brain Injury and Associated Cognitive Impairment.

There is a high prevalence of traumatic brain injury (TBI) in prisoners, but screening tools for identifying TBI in female prisoners are not readily available. Using a cross-sectional design, the psychometric properties of the Brain Injury Screening Index (BISI) were investigated in a closed United Kingdom female prison. Purposive sampling comprised 56 females. Assessment included clinical interview, the BISI, self-report measures of mood, and a battery of measures of cognitive functioning. Seven of the 10 clinical indicators on the BISI met test-retest reliability criteria. Two of the three BISI summary variables demonstrated correlations with questionnaires in the hypothesized directions; however, only two BISI variables were associated with cognitive functioning. Findings support further investigation into the validity and reliability of the BISI with a larger sample.

Comparison of Locking Versus Nonlocking Plates for Distal Fibula Fractures.

Locking plates might offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011, our unit introduced a bone-specific locking plate for the distal fibula. The aim of the present study was to compare it against more conventional plating system implants for lateral malleolar fixation in terms of outcomes, crude costs, and complications. We retrospectively reviewed a consecutive cohort of patients with closed ankle fractures who presented within a 24-month period. The clinical and radiographic outcomes were compared among conventional plating using a one-third semitubular plate, a 3.5-mm limited-contact dynamic compression plate, and a 2.7-mm/3.5-mm locking compression distal fibula plate. A total of 145 patients with ankle fractures underwent surgical fixation: 87 (60.0%) with the semitubular plate, 22 (15.2%) with the limited-contact dynamic compression plate, and 36 (24.8%) with the locking compression distal fibula plate. A greater proportion of patients with established osteoporosis or osteoporosis risk factors were in the locking compression distal fibula plate group (27.8% versus 2.3% and 0%). Four patients (2.8%) required washout for infection. No significant differences were found between the sex distribution within the 3 groups (p = .432). No significant difference was found in the complication rate (p = .914) or the reoperation rate (p = .291) among the 3 groups. Although costing >6 times more than a standard fibula fixation construct (implant cost), bone-specific locking compression distal fibula plates add to the portfolio of implants available, especially for unstable fractures with poor bone quality.

Outcome of adult patients with X-linked hypophosphatemia caused by PHEX gene mutations.

X-linked hypophosphatemia (XLH) is the most common monogenic disorder causing hypophosphatemia. This case-note review documents the clinical features and the complications of treatment in 59 adults (19 male, 40 female) with XLH. XLH is associated with a large number of private mutations; 37 different mutations in the PHEX gene were identified in this cohort, 14 of which have not been previously reported. Orthopaedic involvement requiring surgical intervention (osteotomy) was frequent. Joint replacement and decompressive laminectomy were observed in those older than 40 years. Dental disease (63%), nephrocalcinosis (42%), and hearing impairment (14%) were also common. The rarity of the disease and the large number of variants make it difficult to discern specific genotype-phenotype relationships. A new treatment, an anti-FGF23 antibody, that may affect the natural history of the disease is currently being investigated in clinical trials.

Brain Injury and Offending: The Development and Field Testing of a Linkworker Intervention.

Evidence suggests that traumatic brain injury (TBI) is more prevalent amongst offender populations than in the general population, and that it can lead to aggressive behaviour while in custody and impair engagement with offender rehabilitation programmes. The aim of this study was to develop, implement, and evaluate a brain injury Linkworker approach designed to support prisoners who report a significant TBI or multiple mild TBIs. Three clinical case examples are reported to illustrate the conceptual foundations of the approach and to demonstrate the feasibility of the service. Early results showed that engagement with a Linkworker led to effective identification of key areas of intervention and resulted in better integration for prisoners while in custody and in enhancement of the outcomes of offender rehabilitation. These initial findings provide justification for wider implementation and systematic evaluation of the efficacy of this model of service.

The development of a measure of social cognition following acquired brain injury.

Deficits in social cognition following acquired brain injury (ABI) have been found to be both prevalent and disabling. Despite this, relatively little attention has been given to identifying the characteristics of such deficits in a systematic way. We describe the development of self and informant versions of a new questionnaire designed to measure the changes in social cognition that may occur following ABI, the Brain Injury Rehabilitation Trust (BIRT) Social Cognition Questionnaire (BSCQ). Seventy-two participants (Mean age = 36 years, SD = 12), with different forms of ABI (76% traumatic brain injury, 8% cerebrovascular accident, 15% other) and who were on average 20 months post-injury (SD = 16), took part in the study. The measure demonstrates excellent psychometric properties, including high test-retest (.94) and split-half (.92) reliability, high internal consistency (Cronbach's alpha = .92), and good concurrent validity. The questionnaire measures characteristics that are distinguishable from measures of cognitive ability. There was moderate overlap between self-report and informant versions of the questionnaire (r = .50), but the informant version had the strongest predictive value of outcome, measured with the Mayo-Portland Adaptability Inventory III, one year later. The potential uses of the measure in relation to theory and practice are discussed. The results suggest that the BSCQ is a useful screening tool for those with ABI.

Preliminary investigation of the reliability and validity of the BIRT Independent Living Scale.

PURPOSE: Neurorehabilitation aims to increase independence and participation in ordinary life. It is argued that the fundamental indices of this are independent living and engagement in occupational or productive activity. The Brain Injury Rehabilitation Trust Independent Living Scale was designed to capture change in levels of participation and independence following neurorehabilitation. With greater use of outcome measures in health care, it becomes necessary to develop tools which are simple to use and that capture the holistic impact of rehabilitation. This study examines the inter-rater reliability and validity of the Brain Injury Rehabilitation Trust Independent Living Scale, which comprises two single item, multiple-choice sub-scales. METHOD: Inter-rater reliability was assessed by comparing the ratings on the Brain Injury Rehabilitation Trust Independent Living Scale, by five pairs of graduate psychologists, of 37 individuals who had undergone neurorehabilitation. Retrospective data collected by other members of the clinical team for the Mayo-Portland Adaptability Inventory-4, Supervision Rating Scale and Care And Needs Scale were correlated with the Brain Injury Rehabilitation Trust Independent Living Scale to establish concurrent validity. RESULTS: Weighted kappa coefficients revealed moderate (occupation) to strong (accommodation) inter-rater reliability for the two sub-scales. All correlations between the Brain Injury Rehabilitation Trust Independent Living Scale and the Mayo-Portland Adaptability Inventory-4, Supervision Rating Scale and the Care And Needs Scale were high, demonstrating good concurrent validity. CONCLUSIONS: This study highlights some of the psychometric properties of the Brain Injury Rehabilitation Trust Independent Living Scale and demonstrates its utility in assessing independent living ability and level of social participation after neurorehabilitation. Implications for rehabilitation The BIRT Independent Living Scale is a validated method for ranking accommodation and occupation status as an indicator of independent living ability and occupational activity. The two freely available single-item scales emerging from this study provide a brief method for measuring independent living ability and participation following rehabilitation in research and clinical practice. The BIRT Independent Living Scale's simplicity means it does not require specific training to administer, facilitating its use by a wide range of multidisciplinary staff members and researchers.

Do Broken Toes Need Follow-Up in the Fracture Clinic?

Most toe phalangeal fractures can be successfully treated nonoperatively without any residual deformity and are usually clinically asymptomatic. Toe phalangeal fractures are nevertheless common fracture clinic referrals. Our aim was to evaluate the injury characteristics of patients with toe fractures attending a fracture clinic and to understand how current management affects the fracture clinic workload. We retrospectively evaluated all new referrals to a subspecialized foot and ankle fracture clinic during a 12-month period at our institution under the care of 1 consultant. Data were collected regarding patient demographics, fracture type, patient outcome, and the number of clinic appointments attended, cancelled, or not attended. A total of 707 new patients (mean age 39 ± 19 years; 345 males, 362 females) were seen in 47 foot and ankle fracture clinics within the study period. Seventy-four phalangeal fractures were identified in 65 patients. A total of 135 outpatient appointments were scheduled for these patients (initial and follow-up), with 93 (69%) attended, 25 (19%) not attended, and 15 (11%) cancelled and rescheduled at the patient's request. Seventeen patients (13%) failed to attend their first clinic appointment. The results of the present study highlight that 9% of all new patient referrals to a fracture clinic were for toe phalangeal fractures. Only 2 patients required surgery for significant loss of articular congruency or deformity. No patient subsequently developed a symptomatic malunion or required toe surgery during the following 2 years. We believe that undisplaced and stable toe phalangeal fractures do not need to be referred to the fracture clinic. This would result in a reduction of outpatient appointments for toe fractures by 52%.

The Italian version of the Brain Injury Rehabilitation Trust (BIRT) personality questionnaires: five new measures of personality change after acquired brain injury.

The aim of this study was to describe the translation and adaptation of the BIRT personality questionnaires for the Italian population. This included the replication of validity testing and the collection of normative data. Following translation and adaptation according to cross-cultural guidelines, the questionnaires were administered as a pre-test to a sample of 20 healthy subjects and then to 10 patients. The questionnaires were then administered to 120 healthy subjects equally distributed by sex, education, and age, to collect normative data from an Italian population. The questionnaires were easily administered to both healthy subjects and patients. Statistical analysis on normative data was conducted to find the mean value for each questionnaire. This study lays the foundations for using a new instrument to assess behavioral changes after acquired brain injury on the Italian population.

The association between neuropsychological performance and self-reported traumatic brain injury in a sample of adult male prisoners in the UK.

This study employed a correlational and group comparison design to investigate whether self-report of traumatic brain injury (TBI) in a sample of male prisoners screened using the Brain Injury Screening Index (BISI) was associated with impaired cognitive performance on standardised questionnaires and neuropsychological tests. A total of 139 male prisoners who reported having suffered a TBI in the BISI were interviewed, and completed further questionnaires and neuropsychological assessments. Their results were compared to 50 prisoners who had no reported history of TBI. The results of the screening questionnaire correlated with responses in a follow-up interview, with self-report questionnaires of neurobehavioural disorder (.31 to .50) and neuropsychological measures (-.24 to -.45). The "TBI Index", an indicator summarising the number and severity of self-reported injuries in a single score, also correlated well with scores on formal neuropsychological tests (-.20 to -.42). Self-report of traumatic brain injury among prisoners is consistently associated with measurable neuropsychological and neurobehavioural disability. The implications of these findings for current practice in identifying and referring individuals to specialist services are considered.

Head injury and mortality in the homeless.

Risk factors for head injury are also risk factors for becoming homeless but there is little research on this vulnerable group, who can be neglected by health services that specialize in acquired brain injury. This study investigates the prevalence of admissions to hospital with a head injury in the homeless and associations with later mortality. It compares homeless people with and without a record of hospitalized head injury (HHI) and the Glasgow population. Data were obtained from a U.K. National Health Service strategy to enhance care of the homeless. This included development and production of local registers of homeless people. In Glasgow, the initiative took place over a seven-year period (2004-2010) and comprised 40 general practitioner (family practice) services in the locality of 55 homeless hostels. The register was linked to hospital admissions with head injury recorded in Scottish Medical Records and to the General Register of Scotland, which records deaths. A total of 1590 homeless people was registered in general practitioner (family doctor) returns. The prevalence of admission to hospital with head injury in the homeless over a 30-year period (13.5%) was 5.4 times higher than in the Glasgow population. In the homeless with HHI, 33.6% died in the seven-year census period, compared with 13.9% in the homeless with no hospitalized HI (NHHI). The standardized mortality ratio for HHI (4.51) was more than twice that for NHHI (2.08). The standardized mortality ratio for HHI aged 15-34 (17.54) was particularly high. These findings suggest that HHI is common in the homeless relative to the general population and is a risk factor for late mortality in the homeless population.

An unusual cause of an ankle mass.

We report the case of a patient who presented with a 7-year history of a mass over the medial aspect of his right ankle, which had been gradually increasing in size. He had given up his occupation as a bus driver due to decreased movement of his ankle. An initial diagnosis of endemic syphilis was made after treponemal antibody and treponema pallidum particle agglutination tests were positive. However, following surgical debulking, cultures grew Fusarium solani and the diagnosis was changed to eumycetoma. He received prolonged treatment with antifungal agents and at 18 months follow-up remains well.

Osteoid osteoma as a cause of anterior ankle pain in a runner.

We report the case of an osteoid osteoma in the dorsal talar neck of a healthy long-distance runner, masquerading as anterior ankle impingement syndrome. We discuss the diagnosis and successful treatment using percutaneous CT-guided laser photocoagulation. A concise review of the principles of the management of osteoid osteomas is also presented.

Sports injury to a bipartite medial cuneiform in a child.

We report the case of an 11-year-old boy who had sustained a soccer injury to his mid-foot. Plain radiography did not reveal any fracture to account for the severity of his symptoms or his inability to bear weight. Magnetic resonance imaging was undertaken and demonstrated the medial cuneiform to be a bipartite bone consisting of 2 ossicles connected by a synchondrosis. No acute fracture or diastasis of the bipartite bone was demonstrated; however, significant bone marrow edema was noted, corresponding to the site of the injury and his clinical point bony tenderness. This anatomic variant should be considered as a rare differential diagnosis in the skeletally immature foot. The injury was treated nonoperatively with a non-weightbearing cast and pneumatic walker immobilization, with successful resolution of his symptoms and a return to sports activity by 4 months after injury.

Implausible future events in a confabulating patient with an anterior communicating artery aneurysm.

Patient MW, a known confabulator, and healthy age-matched controls produced past and future events. Events were judged on emotional valence and plausibility characteristics. No differences in valence were found between MW and controls, although a positive emotional bias toward the future was observed. Strikingly, MW produced confabulations about future events that were significantly more implausible than those produced by healthy controls whereas MW and healthy controls produced past events comparable in plausibility. A neurocognitive explanation is offered based on differences between remembering and imagining. Possible implications of this single case in relation to confabulation and mental time travel are discussed.