Effect of Obesity on Clinical and Radiographic Outcomes Following Reconstruction of Stage II Adult Acquired Flatfoot Deformity.

BACKGROUND: Obesity is a known risk factor for the development of adult acquired flatfoot deformity (AAFD), but obesity's effects on outcomes following AAFD reconstruction are unknown. We hypothesized that obesity would negatively impact outcomes following joint-preserving stage II AAFD reconstruction. METHODS: This retrospective study compared the outcomes of normal-weight (18.5 kg/m(2) ≤ BMI < 25 kg/m(2)), overweight (25 kg/m(2) ≤ BMI < 30 kg/m(2)), and obese (BMI ≥ 30 kg/m(2)) patients after AAFD reconstruction. Clinical outcome measures included the Foot and Ankle Outcome Score (FAOS), Short-Form 12 (SF-12), and Numeric Rating Scale of Pain (NRS Pain) administered preoperatively and at least 1 year postoperatively. Anteroposterior and lateral radiographs were taken preoperatively and at least 6 months postoperatively. Pre- to postoperative changes in outcome measures were assessed within BMI classes. Preoperative, postoperative, and pre- to postoperative changes in outcomes were compared among BMI classes. There were 41 normal-weight patients, 39 overweight patients, and 44 obese patients with a mean age of 56 years, FAOS follow-up of 2.9 years, and radiographic follow-up of 2.1 years. Demographics and reconstructive procedures were comparable among the 3 BMI classes. RESULTS: All outcomes significantly increased pre- to postoperatively in the 3 groups with the exception of the FAOS Symptoms subscale for normal-weight patients (P = .340) and SF-12 Mental Component score for all 3 BMI classes (P > .999). Preoperatively, obese patients had more symptoms than normal-weight patients, scoring 12 points lower on the FAOS Symptoms subscore (P = .008). Obese patients also scored 11 points lower preoperatively on the SF-12 Overall score (P = .028) and had 31% greater pain than normal-weight patients (P = .003). There were no differences among the 3 BMI classes in any postoperative outcomes assessed. CONCLUSION: Although obese patients had significantly worse symptoms, overall health, and NRS pain scores preoperatively, the short-term clinical and radiographic outcomes of stage II AAFD reconstruction were similar for normal-weight, overweight, and obese patients. We suggest that joint-preserving reconstruction remains a viable alternative to fusion of the triple joint complex for the treatment of overweight and obese stage II AAFD patients. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Return to Sports and Physical Activities After the Modified Lapidus Procedure for Hallux Valgus in Young Patients.

BACKGROUND: The modified Lapidus procedure has successfully relieved pain and corrected deformity in patients with hallux valgus, but its effect on participation in specific sports and physical activities remains unclear. Our goals were to assess sports and physical activities in young patients following the modified Lapidus procedure and to compare these with clinical outcomes. METHODS: Fifty-eight eligible patients were identified from a retrospective registry review. Of these, 48 (83%) were reached for follow-up at a mean of 2.8 (range, 1.0 to 6.1) years and had a mean age at surgery of 37.3 (range, 14.1 to 49.3) years. Physical activity participation was evaluated with a new sports-specific, patient-administered questionnaire. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score (FAOS) and compared to sports outcomes. RESULTS: Patients participated in 26 different physical activities, consisting of 212 total physical activities preoperatively and 209 total postoperatively. The most common were walking, running, bicycling, and swimming. Compared to preoperatively, patients rated 29% of activities as less difficult, 52% as the same, and 19% as more difficult and rated participation levels as improved in 40%, the same in 41%, and impaired in 19%. Eighty-one percent of patients were satisfied with their operative outcome in regard to return to physical activity. Changes in the FAOS Pain subscore were significantly associated with improvements in physical activity difficulty (P < .05), and changes in the Pain, Sports, and QOL subscores were significantly associated with changes in physical activity participation levels (P < .05). CONCLUSION: Four in 5 patients were able to participate in previous sports and physical activities, including high-impact activities, at their preoperative participation level or better after the modified Lapidus procedure, and were satisfied with surgery in regard to return to previous activity. However, several patients had increased difficulty and impaired participation in physical activity postoperatively. Altogether, this suggests that the procedure is a viable treatment option for hallux valgus in young, active patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Assessment of coronal plane subtalar joint alignment in peritalar subluxation via weight-bearing multiplanar imaging.

BACKGROUND: Patients with adult-acquired flatfoot deformity (AAFD) develop peritalar subluxation, which may stem from valgus inclination of the inferior surface of the talus. We hypothesized that patients with AAFD would have an increased valgus tilt of the subtalar joint in the coronal plane compared to controls when assessed with a novel multiplanar weight-bearing imaging (MP-WB). METHODS: Eighteen normal and 36 stage II AAFD patients scheduled to undergo operative reconstruction were evaluated by MP-WB through measuring 3 novel angles of the subtalar joint in the coronal view: (1) angle between inferior facet of the talus and the horizontal/floor (inftal-hor), (2) angle between inferior and superior facets of the talus (inftal-suptal), and (3) angle between inferior facet of the talus and superior facet of the calcaneus (inftal-supcal). Intra- and interobserver reliability were evaluated via intraclass correlation coefficients (ICCs). Differences in angles between AAFD patients and controls were evaluated using Wilcoxon rank-sum test. RESULTS: Intra- and interobserver reliability were excellent for inftal-hor (ICC .942 and .991, respectively) and inftal-suptal (ICC .948 and .989, respectively), and moderate-good for inftal-supcal (ICC .604 and .742, respectively). Inftal-hor and inftal-suptal angles were found to be significantly greater in AAFD patients (P < 0.001) at all 3 locations along the posterior subtalar joint, while inftal-supcal did not demonstrate a significant difference (P = .741). While controls exhibited varus orientation at the anterior aspect of the joint, AAFD patients maintained a valgus orientation throughout. CONCLUSION: Inftal-hor and inftal-suptal angles provided a reliable means of evaluating the orientation of the subtalar joint axis in AAFD via MP-WB, and showed that the subtalar joint had increased valgus orientation in AAFD compared to controls. This may allow for identification of patients at risk for developing AAFD, and could potentially be used in guiding operative reconstruction.

Delta-6-desaturase activity and arachidonic acid synthesis are increased in human breast cancer tissue.

Omega-6 (n-6) arachidonic acid (AA) and its pro-inflammatory metabolites, including prostaglandin E2 (PGE(2)), are known to promote tumorigenesis. Delta-6 desaturase (D6D) is the rate-limiting enzyme for converting n-6 linoleic acid (LA) to AA. Our objective was to determine if AA synthesis, specifically D6D activity, and PGE(2) levels are increased in cancerous breast tissue, and whether these variables differ between estrogen receptor positive (ER+) and negative (ER-) breast cancers. Gas chromatography was performed on surgical breast tissue samples collected from 69 women with breast cancer. Fifty-four had ER+ breast cancer, and 15 had ER- breast cancer. Liquid chromatography-mass spectrometry was used to determine PGE(2) levels. Lipid analysis revealed higher levels of LA metabolites (C18:3 n-6, C20:3 n-6, and AA) in cancerous tissue than in adjacent noncancerous tissue (P < 0.01). The ratio of LA metabolites to LA, a measure of D6D activity, was increased in cancerous tissue, suggesting greater conversion of LA to AA (P < 0.001), and was higher in ER- than in ER+ patients, indicating genotype-related trends. Similarly, PGE(2) levels were increased in cancerous tissue, particularly in ER- patients. The results showed that the endogenous AA synthetic pathway, D6D activity, and PGE(2) levels are increased in breast tumors, particularly those of the ER- genotype. These findings suggest that the AA synthetic pathway and the D6D enzyme in particular may be involved in the pathogenesis of breast cancer. The development of drugs and nutritional interventions to alter this pathway may provide new strategies for breast cancer prevention and treatment.

Is the "10% rule" equally valid for all subsets of sentinel-node-positive breast cancer patients?

BACKGROUND: In breast cancer, a combination of radioisotope and blue dye mapping maximizes the success and accuracy of sentinel node (SLN) biopsy. When multiple radioactive nodes are present, there is no single definition of isotope success, but the popular "10% rule" dictates removal of all SLN with counts >10% of the most radioactive node. Here we determine how frequently a positive SLN would be missed by the 10% rule. METHODS: Between 9/96 and 12/04, we performed 6,369 successful SLN biopsies using (99m)Tc sulfur colloid and isosulfan blue dye, removing as SLN all radioactive and/or blue nodes, and taking counts from each node ex vivo. Standard processing of all SLNs with a benign frozen section included hematoxylin and eosin (H&E) staining, serial sectioning, and immunohistochemistry (IHC). RESULTS: 33% of patients (2,130/6,369) had positive SLNs. Of these patients, 1,387/2,130 (65%) had >1 SLN identified. The most radioactive SLN was benign in 29% (398/1,387), and 107/1,387 (8%) had a positive SLN that was neither blue nor the hottest. From this group 1.7% (24/1387) of patients had positive SLN with counts <10% radioactive counts of the hottest node. The 10% rule captured 98.3% of positive nodes in patients with multiple SLNs. No patient characteristics were predictive of failure of the 10% rule. CONCLUSION: With combined isotope and blue dye mapping, the 10% rule is a robust guideline and fails to identify only 1.7% (24/1387) of all SLN-positive patients with multiple SLNs. This guideline appears to be equally valid for all subsets of patients.

MRI screening in a clinic population with a family history of breast cancer.

BACKGROUND: Breast MRI is increasingly being used in patients at increased risk for breast cancer; however, guidelines for MRI screening are inadequately defined. We describe our experience with MRI screening in a large population of women with a family history of breast cancer. METHODS: We retrospectively reviewed the Memorial Sloan-Kettering breast cancer surveillance program prospective database from April 1999 to July 2006. Patients with a family history of breast cancer and at least 1 year follow-up were identified. All patients were offered biannual clinical breast examination (CBE) and annual mammography (MMG). MRI screening was performed at the discretion of the physician and patient. RESULTS: Family history profiles revealed 1,019 eligible patients; median follow-up was 5.0 years. MRI screening was performed in 374 (37%) patients resulting in a total of 976 MRIs during the study period. Cancer was detected in 9/374 patients (2%) undergoing MRI screening. Seven cancers were detected by MRI only, for a cancer detection rate of 0.7% (7/976) for screening MRI. When stratified by family risk profile, the positive predictive value (PPV) of MRI was higher (13%) in those patients with the strongest family histories and lower (6%) in patients with less significant family histories. CONCLUSIONS: MRI screening can be a useful adjunct to CBE and MMG in patients with high-risk family histories of breast cancer, yet it has low yield in patients with lower-risk family histories. These data suggest that MRI screening should be reserved for those at highest risk.

Bone marrow micrometastases and adjuvant treatment of breast cancer.

The immunohistochemical detection of epithelially derived cells in the bone marrow of patients with primary breast cancer has been shown to be associated with increased risk of distant relapse as well as higher rates of cancer-related death. Despite the correlation between bone marrow micrometastases and poor outcome in breast cancer patients, bone marrow status does not yet have an established role in patient management. In this prospective study, adjuvant therapy recommendations for 43 patients with stage I, II, or III breast cancer treated with lumpectomy or mastectomy, sentinel lymph node biopsy and/or axillary dissection, and intraoperative bone marrow aspiration were recorded. Recommendations were made by a multidisciplinary tumor board both blinded and unblinded to the results of the bone marrow aspiration. In our study, 10 of the 43 breast cancer patients were found to have bone marrow micrometastases. Four of these patients (40%) had axillary lymph node metastases. When blinded to the results of the bone marrow aspiration, the tumor board recommended adjuvant chemotherapy for these four node-positive patients, as well as two node-negative patients. When unblinded to the results of the bone marrow aspiration, the tumor board did not change its recommendations for any of these six patients. The remaining four node-negative, bone marrow-positive patients were not advised to have adjuvant chemotherapy by the tumor board when blinded to bone marrow status. However, once the tumor board was informed of the presence of bone marrow micrometastases, adjuvant chemotherapy was recommended for all of these patients. The results of this pilot study indicate that the presence of bone marrow micrometastases in breast cancer patients with stage I, II, or III disease does influence recommendations for adjuvant chemotherapy, particularly in patients with node-negative disease.