Diminished coordination skills may predispose injury to lesser toe fractures-a pilot study.

INTRODUCTION: Lesser toe fractures of the foot are a common lower extremity injury. The common mechanism of injury is a direct impact of force on the toe due to a collision of the toe with an object, often related as accidental injury or clumsiness. MATERIALS AND METHODS: This is a case-control study. We compared patients with lesser toe fractures to a healthy control group. We used a motor imagery tool to evaluate the proprioception and function of the pre-motor, center of motion planning cortex. Forty images of the left/right feet in various positions were incorporated into a dedicated software application. Participant reaction time and accuracy of recognition were recorded. RESULTS: Forty-two adult participants (20 with lesser toe fractures and 22 in the control healthy group) were included in the study. There was no difference in the participant's self-perception of clumsiness or involvement in activities that are related to better coordination. There was no difference in the accuracy or the reaction time in the motor imagery tool. The control group was significantly (p < 0.05) more accurate in recognizing their dominant side, whereas the fracture group was more accurate in recognizing their non-dominant side. CONCLUSIONS: Our findings do not support the premise that diminished coordination skills may predispose to injury to lesser toe fractures. Our findings may suggest that mixed laterality (hand/foot) is related to lesser toe fractures and thus may be related to clumsiness. Whether these alterations in perception bare merit in other types of physical injuries has yet to be explored.

C5 Palsy Following Cervical Spine Decompression.

BACKGROUND: Cervical spinal surgery is considered safe and effective. One of the few specific complications of this procedure is C5 nerve root palsy. Expressed primarily by deltoid muscle and biceps brachii weakness, it is rare and has been related to nerve root traction or to ischemic spinal cord damage. OBJECTIVES: To determine the clinical and epidemiological traits of C5 palsy. To determine whether C5 palsy occurs predominantly in one specific surgical approach compared to others. METHODS: A retrospective study of patients who underwent cervical spine surgery at our medical center during a consecutive 8-year period was conducted. The patient data were analyzed for demographics, diagnosis, and surgery type and approach, as well as for complications, with emphasis on the C5 nerve root palsy. RESULTS: The study group was comprised of 124 patients. Seven (5.6%) developed a C5 palsy following surgery. Interventions were either by anterior, by posterior or by a combined approach. Seven patients developed this complication. All of whom had myelopathy and were older males. A combined anteroposterior (5 patients) and posterior access (2 patients) were the only approaches that were associated with the C5 palsy. None of the patients who were operated via an anterior approach did develop this sequel. CONCLUSIONS: The incidence of the C5 root palsy in our cohort reached 5.6%. Interventions performed through a combined anterior-posterior access in older myelopathic males, may carry the highest risk for this complication.

Conservative treatment for pyogenic flexor tenosynovitis: a single institution experience.

Pyogenic flexor tenosynovitis (PFT) of the hand is a common infection which is clinically diagnosed using Kanavel's signs. Delay in diagnosis and treatment may lead to devastating outcomes, including reduced range of motion (ROM), deformities, tendon impairment or even amputation. While the gold standard for treatment is irrigation and debridement of the flexor sheath, little is known about the outcomes of conservative treatment with intravenous (IV) antibiotics. Patients treated conservatively for PFT between 2000 and 2013 were included. Demographic information, co-morbidities and clinical features at presentation such as Kanavel's signs and inflammatory markers levels were gathered. Treatment course, length of stay (LOS), functional outcomes and complications were collected. Fifty-four (54) patients presented with PFT in the study period. Forty-six (46) patients, ages 19-84 years old, who were treated conservatively were included. Average time from symptoms onset to presentation was 4.6 ± 7.1 days. Fourteen (14) patients failed to improve with course of oral antibiotics prior to presentation. The average number of Kanavel's signs was 3 ± 0.7. Inflammatory markers were elevated in 82.2% of patients. The mean LOS was 4.7 ± 2 days. Forty-four (44) patients continued follow-up for 55 ± 45 months. Final flexion ROM was full or minimally limited in 69% of patients. Three patients were eventually operated. Complication rate for the entire cohort was 4.3% and no fingers were lost. This retrospective case series indicate that inpatient empirical IV antibiotic therapy can be considered for patients presenting with uncomplicated PFT, provided it is practiced under a hand specialist's surveillance.

Long-term Follow-up of Cheilectomy for Treatment of Hallux Rigidus.

BACKGROUND: Hallux rigidus is the most common arthritic condition in the foot. First metatarsophalangeal joint cheilectomy produces satisfactory results in retrospective studies with reported good to excellent results in up to 97% and pain relief and function in 92%. The results of cheilectomy for higher grades of hallux rigidus are less favorable. The purpose of this study was to evaluate the long-term functional results and survivorship of cheilectomy for treatment of hallux rigidus. METHODS: This was a retrospective, questionnaire-based study investigating the long-term results of cheilectomy for treatment of hallux rigidus. The preoperative arthritic grade was graded retrospectively according to the Hattrup and Johnson (H&J) grading system. A questionnaire was administered via email or telephone that included questions regarding pain recurrence following surgery, current functional status, and satisfaction with the operation. Kaplan-Meier survival analysis was performed to estimate survival time between arthritic grades. We reviewed 165 patients (169 feet) with an average follow-up of 6.6 (5.0-10.9) years. RESULTS: The overall survival rate (painless at the time of last follow-up) was 70.4% (119 feet), with no significant difference between the 3 H&J arthritic grades. Most of the recurrences (28 feet, 75%) were at the first 2 years following the surgery. Nine feet (5.3%) had a second procedure at a mean postoperative time of 3.6 (range, 1.6-7.4) years. Of the 169 feet, 117 (69.3%) reported being satisfied or very satisfied and 127 (75.1%) indicated they would repeat the operation under the same circumstances. CONCLUSION: Our study supports the use of cheilectomy for treatment of hallux rigidus (grade 1-3 Coughlin and Shurnas) as a reliable procedure with favorable results. At long-term follow-up, patients who underwent cheilectomy had a low revision rate and a moderately low rate of pain recurrence. LEVEL OF EVIDENCE: Level IV, retrospective case-series.

Prevalence of Neuropathic Pain Symptoms in Foot and Ankle Patients.

BACKGROUND: The management of pain in patients with foot and ankle pathology can be challenging. Cumulative data suggest that, in addition to nociceptive mechanisms, other neuropathic mechanisms can contribute to pain in a subset of people with orthopedic conditions, and can be found in 10.5% to 53% of patients with chronic pain, depending on the location of the pathology. Preoperative diagnosis of neuropathic pain (NP) can potentially change decision making and management of foot and ankle pathologies. METHODS: We used a validated patient-reported pain questionnaire (painDETECT) as a cross-sectional study to investigate the prevalence of NP symptoms in a population of patients undergoing foot and ankle surgery. A total of 533 patients were prospectively included and completed the painDETECT questionnaire. RESULTS: Sixty-six patients (12.4%) were classified as having a component of NP symptoms according to their painDETECT score. Current smokers (23.2%) had a significantly higher rate of developing NP symptoms than current nonsmokers (11.1%) ( P = .016). The location of the pathology and obesity had a moderate effect on the prevalence of NP symptoms. Patients with ankle-level pathology, excluding tarsal tunnel syndrome, had a marginally increased risk of having NP symptoms (15.4%) compared to patients with forefoot pathologies, excluding Morton's neuroma (7.5%, P = 0.06). Obesity also had a moderate effect on the NP risk, with 15.6% risk of NP symptoms for patients with BMI of 30 or more compared to 10% risk for patients with a BMI of less than 30 ( P = .06). Patients with NP symptoms reported significantly higher levels of current pain (7.2 vs 4.6, P < .001). CONCLUSION: A considerable number of patients with foot and ankle problems requiring surgery had a neuropathic component of pain. Evaluation of their risk factors and level of pain may help with the diagnosis, decision making, and pain control. Further research is needed to evaluate the effect of preoperative NP on the short- and long-term results of surgeries. LEVEL OF EVIDENCE: Level II, prospective cohort survey study.

Molecular profile of ultrastructure changes of the ligamentum flavum related to lumbar spinal canal stenosis.

Lumbar spinal canal stenosis (LSCS) is a degenerative disease observed by hypertrophy of the ligamentum flavum (LF) that cause compression of the lumbar neural content. Diabetes mellitus (DM) is a risk factor for the disease and we have shown previously that DM increases the fibrosis and elastic fiber loss in patients with LSCS. The purpose of this study was to find the proteins that play a role in the development of this clinical pathogenesis and the effect of DM on protein expression. LF tissue retrieved from patients diagnosed with LSCS, some were also diagnosed with DM, were compared with LF from patients diagnosed with herniated nucleus pulposus (HNP). The tissues were analyzed by mass spectrometry for proteins profile alteration. We found that LF of LSCS/DM patients exhibited significantly higher levels of proteoglycan proteins and latent transforming growth factor ß-binding protein (LTBP2 and LTBP4). Additionally, an increase of HTRA serine protease 1 and insulin-like growth factor binding protein-5 were noted. The higher fibrosis was also associated with proteins related to inflammation and slower tissue repair. Collagen 6 and transforming growth factor inhibitor are related to activation of the anti-inflammatory M2 pathway that is associated with tissue repair. The decrease of these proteins expression in LSCS/DM is associated with increased levels and activation of M1 pro-inflammatory pathways. Interestingly, C3 and C4b members of the complement complex and mannose receptor-like protein (CLEC18) paralogous proteins were detectable solely at the LSCS/DM patients' samples. Histology analysis shows that inflammatory was induced by the hyperglycemic conditions in diabetic patients involve in altering the matrix compositions. Thus, the protein profiles associated with inflammatory pathways affecting the LF suggested increasing susceptibility of developing the degeneration under hyperglycemic conditions.

Gender Differences in Spinal Injuries: Causes and Location of Injury.

BACKGROUND: Spinal injury is common in trauma suffered by both men and women. A lesser degree of involvement of females with spinal trauma, or at least, the different nature of such injuries, has been suggested. It has been proposed that behavioral and structural characteristics may explain the differential type and severity of spinal injuries in women. We carried out this study to find women-specific divergences in spinal traumatic lesions, including suspected mechanisms for their generation. METHODS: All patients with spinal injury, documented by the Trauma Registry at our Medical Center and using the AIS code 65XXXX.X for spinal fractures and dislocations, were evaluated. The women-associated analysis included data related to: type of spinal lesion, area affected, possible mechanisms, associated damage, surgical procedures, and complications. Male-related data were collected for comparison. RESULTS: Between 2006 and 2010, 546 patients with traumatic spine injuries were documented. Of those, 30.6% were women (F:M-168:378). Average age was 43.5 years (women: 49.6 years and men: 40.1 years). Regarding the mechanisms of injury, women with spinal injuries were susceptible to falls from a standing position or had attempted suicide. However, men with similar lesions had a tendency to be more involved in motorcycle accidents or falls from height. Women involved in motor vehicle crashes showed statistically more significant lumbar spine lesions, whereas men in the same situation developed mainly cervical spine damage to a significant level. CONCLUSIONS: The characteristics of spinal injury in women, as opposed to men, stand out as divergent. The mechanisms of trauma and the site of injury differ significantly. We suggest this variance may be due, in part, to skeletal and muscular structure dissimilarity in women and in part to the spinal kinematics attending each group.

Diabetes mellitus is associated with increased elastin fiber loss in ligamentum flavum of patients with lumbar spinal canal stenosis: results of a pilot histological study.

PURPOSE: Lumbar spinal canal stenosis (LSCS) is associated with fibrosis, decreased elastin-to-collagen ratio, and hypertrophy of the ligamentum flavum (LF). Diabetes mellitus (DM) is known to cause metabolic disturbances within the extracellular matrix in multiple tissues. These alterations may play a major role in the severity of clinical symptoms of LSCS affecting diabetic patients. We aimed to examine the hypothesis that DM may contribute to the LF changes seen in patients with LSCS. METHODS: The study cohort included 29 patients: 23 with LSCS (10 with DM vs. 13 without DM) as well as six patients with lumbar disc herniation (LDH). Surgical LF specimens were retrieved for histological assessment. Morphologic quantification of confocal microscopy images using fast Fourier transform analysis allowed us to compare anisotropy and elastin fiber orientation between groups. RESULTS: There was a significant positive correlation between fasting plasma glucose values and degree of elastin degradation (r = 0.36, p = 0.043). The diabetic patients with LSCS showed a significantly greater loss of elastic fibers (2.3 ± 0.9 vs. 1.5 ± 0.55, p = 0.009), although fibrosis was shown to be similar (1.44 ± 0.7 vs. 1.43 ± 0.88, p = 0.98). There was no significant difference in the degree of calcification in the LSCS group between patients with and without diabetes (1.71 vs. 2.05%, p = 0.653). Fiber orientation was found to be less homogenous in the LSCS compared with the LDH group, although not significantly affected by DM. CONCLUSIONS: The present study points to a significant contribution of DM to the loss of elastin fibers that occurs in the LF of patients with LSCS.

Medial forefoot fillet flap for primary closure of transmetatarsal amputation: A series of four cases.

Amputation of the forefoot is a salvage procedure for several forefoot acute or chronic infection. A good, sensate and durable skin cover is important for quicker and better rehabilitation. The use of filleted flaps (or "spare parts technique") has been published in the past as a creative technique. The purpose of this article is to introduce a reproducible, pre-planned, technique that requires less creativity for the use of the "spare parts". The authors describe a case series of 4 patients with deep infection and osteomyelitis of the forefoot, without involvement of the medial skin that underwent two staged procedure for transmetatarsal amputation with medial forefoot fillet flap. The first procedure was amputation of the 4 lesser metatarsal and the wound was left open. After a few days the second operation was done with amputation of the first metatarsal bone and using the filleted medial skin and subcutaneous tissue for closure of the wound. In conclusion the medial fillet flap is an effective method of covering large wounds after partial, lateral forefoot amputation. This method shortens the healing time of the patient, and in hospital stay. The authors recommend using the staged method when dealing with diabetic patients with partial, central and lateral forefoot deep infection and/or necrosis.

Extended Paratricipital Approach for Intra-articular Fractures of the Distal Humerus.

This article describes an extensile surgical exposure to the distal humerus that is suitable for complex fractures involving the articular surface and extending into the humeral diaphysis proximal to the radial nerve. This method combines 2 approaches: olecranon osteotomy and the lateral paratricipital approach. This combination allows an appropriate exposure of both the articular surface and the humeral diaphysis up to the level of the deltoid tuberosity, while maintaining the extensor mechanism unharmed.

[Posterolateral rotatory instability of the elbow].

The term posterolateral rotatory instability (PLRI) was coined in 1991 by O'Driscoll to describe the instability of the elbow caused by injury to the lateral ulnar collateral ligament (LUCL). This condition, which is usually preceded by a traumatic dislocation of the elbow, is the most common type of chronic instability of the elbow. In this type of instability, the radius and ulna rotate externally in relation to the distal humerus, leading to posterior displacement of the radial head relative to the capitellum. lateral elbow pain, clicking, popping and snapping are possible symptoms. The diagnosis of PLRI relies on a high index of suspicion and on a detailed physical examination. Several tests have been described including apprehension tests and examination under anesthesia. Surgical treatment with reconstruction of the lateral collateral ligament complex yields successful results. In this review we summarize the current knowledge of the pathoanatomy, presentation, physical examination, diagnostic tests and management of chronic posterolateral rotatory instability of the elbow.

Intramedullary nailing without curettage and cement augmentation for the treatment of impending and complete pathological fractures of the proximal or midshaft femur.

Metastases in the proximal femur and in the femoral diaphysis are usually treated with either cephalomedullary or intramedullary nailing. The benefit of curettage and augmentation of the nail with methyl methacrylate remains controversial. The authors retrospectively studied the outcomes with cephalomedullary and intramedullary nailing without curettage and methyl-methacrylate augmentation for lytic metastases of the proximal/diaphyseal femur. Twenty-one complete (11) or impending (10) pathological fractures in 19 consecutive patients were treated between January 2006 and August 2013. There were 11 women and 8 men. Their mean age was 62 years (range, 38 to 87). All patients received adjuvant chemotherapy or radiotherapy.The average postsurgical survival was 9.7 months (range 1-36 months). A single deep infection was debrided. Seventeen out of 19 patients were ambulatory, with or without a walking aid. No implant failure was noted. In other words, patients succumbed to the disease prior to hardware failure. Femoral nail insertion without curettage and cement augmentation provided satisfactory stabilization of proximal and diaphyseal femur fractures, impending or complete, even when there was massive bone destruction.

Accuracy of non assisted glenohumeral joint injection in the office setting.

PURPOSE: The diagnostic and therapeutic success of shoulder joint injection depends on its accuracy. Two recent studies reported high success (93-96%) for non-imaging-assisted anterior injection in anesthetized patients. This study examined the accuracy of anterior shoulder injection in awake patients under conditions similar to the office setting. METHODS: The study group consisted of 166 consecutive patients with shoulder pain who underwent diagnostic magnetic resonance arthrography at a tertiary medical center in 2011-2012. As part of the examination, contrast material was injected into the glenohumeral joint via an anterior approach by a certified musculoskeletal radiologist without any image assistance. Success was defined as contrast material limited to the intra-articular joint on the scan, without scatter to the periauricular tissue. RESULTS: A successful injection was verified by magnetic resonance arthography in 163 patients (98.2%). CONCLUSIONS: Non-assisted anterior shoulder injection is highly accurate (98.2%) in the hands of an experienced radiologist, even in awake patients.

[Metastatic spinal cord compression: diagnosis and treatment].

Metastatic epidural spinal cord compression is a common complication of cancer that can cause pain and potentiaLly irreversible loss of neurologic function. In most cases this syndrome is caused by compression of the thecal sac and the spinal cord by extradural metastatic mass. The most important steps in minimizing the potential neurologic sequelae are early diagnosis and rapid therapeutic intervention. MRI is generally the preferred imaging modality because of its noninvasive ability to study the entire thecal sac. Surgery and radiotherapy are the primary approaches to treat tumor compressing the spinal cord.