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Background: In foot and ankle surgery, there are multiple sites used for autologous bone graft, including the proximal (PT) or distal tibia (DT), calcaneus (C), and iliac crest (ICBG). There has been no comparison between these anatomic areas and the potential for acute or persistent pain at 1 year. The purpose of this study was to prospectively compare patient-reported outcomes of acute and persistent pain at 1 year after surgery to determine if harvest site selection made a difference., Methods: As part of a clinical trial examining ankle and hindfoot fusion rates with autograft compared with synthetic graft, the autologous bone graft harvest sites were assessed with visual analog pain outcome scores at 3, 24, 36, and 52 weeks after surgery. Patients with a score of 20+ defined clinically significant pain. Four harvest sites were compared: ICBG, PT, DT, and C. Fisher exact test was used to compare the graft site pain between locations., Results: Twelve percent of subjects reported clinically significant pain at 24 weeks and 8.5% at 52 weeks postoperatively. Each lower extremity harvest site (C, DT, PT) showed higher rates of clinically significant graft harvest site pain than the ICBG at 52 weeks., Conclusions: Autologous bone graft harvest carried a risk of persistent pain at up to 1 year (weeks 24-52) in 18% of patients. Lower-extremity bone graft sites had the greatest risk for persistent pain at 1 year., Level of Evidence: Level II, prospective comparative study.

Fifty strains of Branhamella catarrhalis were examined for susceptibility to sulphamethoxazole, trimethoprim and a combination of the two by determinating minimum inhibitory concentrations (MICs) and fractional inhibitory concentrations (FICs). All strains were susceptible to sulphamethoxazole and resistant to trimethoprim. On the basis of the MIC results it was predicted that greater synergy between sulphamethoxazole and trimethoprim would be observed with approximately equal proportions of each component. The lowest FIC values were obtained with a ratio of 1:1 and the greatest synergy was observed at this ratio with 39 strains (78%). Only seven strains were most synergistically inhibited at the ratio of 20:1 (sulphamethoxazole: trimethoprim) although this ratio was still synergic for most strains. Overall the 1:20 ratio was not synergic. [ABSTRACT FROM AUTHOR]

The Lisfranc joints make up the bony structural support of the transverse arch in the midfoot and account for approximately 0.2% of all fractures. Early recognition and treatment of this injury are paramount to preserving normal foot biomechanics and function. Controversy exists regarding the optimal treatment of patients with Lisfranc injuries, particularly when the instability is entirely ligamentous.The authors performed a qualitative, systematic review of the literature to compare the 2 most common procedures for Lisfranc fractures: primary arthrodesis and open reduction and internal fixation (ORIF). Six articles with a total of 193 patients met the inclusion criteria. At 1-year follow-up, the mean American Orthopaedic Foot and Ankle Society score of ORIF patients was 72.5 and of arthrodesis patients was 88.0. Fisher's exact test revealed no significant effect of treatment group on the percentage on patients who had an anatomic reduction (P=.319).This study highlights that both procedures yield satisfactory and equivalent results. A slight advantage may exist in performing a primary arthrodesis for Lisfranc joint injuries in terms of clinical outcomes., (Copyright 2012, SLACK Incorporated.)

Due in part to an emphasis on quality and cost control within healthcare institutions, protocols for healthcare practice are increasingly being developed in an effort to maintain normative guidelines and set acceptable standards. For example, the Association of periOperative Registered Nurses, the National Quality Forum, and the Association of Surgical Technologists have made recommendations regarding tourniquet use. In the institution of the senior authors (C.D. and E.A.), an effort to establish a protocol for tourniquet use prompted a review of the evidence behind standard practices and existing recommendations for safe tourniquet use in the upper and lower extremities. Sparse evidence exists in support of strict limits for tourniquet use, including tourniquet duration, inflation pressure, and reperfusion periods. However, simple principles and general guidelines regarding tourniquet use can be extrapolated to guide safe practice.

Background: Augment Bone Graft, a fully synthetic bone graft material composed of recombinant human PDGF and a calcium phosphate matrix (rhPDGF/TCP), has been considered as a possible alternative to autogenous bone graft. Before proceeding with randomized control studies comparing rhPDGF/TCP to autograft bone, a human trial to assess efficacy and safety was required., Materials and Methods: The current study was a prospective, open-label, multi-center trial designed to evaluate rhPDGF in a calcium phosphate matrix (Augment Bone Graft). Sixty patients requiring hindfoot or midfoot fusion were prospectively followed for 36 weeks. All patients received 0.9 to 2.7 mg of rhPDGF at the fusion sites and returned for clinical and radiographic review at Day 7 to 14 and Weeks 6, 9, 12, 16, 24, and 36. Computerized tomography (CT) scans of the fusion site were obtained at the 6- and 12-week postoperative appointment, with an additional CT scan at 16 weeks if required., Results: No patients suffered a serious adverse event caused by rhPDGF. CT scan evaluation at 12- to 16-week time periods revealed moderate or complete osseous bridging of 75% (44/59) at 36 weeks., Conclusion: These results indicate that rhPDGF is a safe product and provides clinical/radiographic outcomes that justify the pursuit of randomized controlled studies comparing rhPDGF/TCP to autograft.

Recent epidemiologic studies highlight lateral talar process fractures as snowboarder's fracture or snowboarder's ankle. Snowboarding is the fastest growing sport worldwide, so lateral talar process fractures are increasing in frequency and mandating a more careful assessment of injury patterns, surrounding tissue involvement, and treatment strategy. In this study, we evaluated the effects of lateral talar process fracture on the footprints of 3 lateral stabilizing ligaments of the ankle and subtalar joint-the lateral talocalcaneal ligament (LTCL), the anterior talofibular ligament (ATFL), and the posterior talofibular ligament (PTFL). The musculotendinous structures from 10 fresh cadaveric limbs were removed and the distal fibula reflected to provide visualization of the lateral talar process and ligamentous attachments. Length and width of the LTCL, ATFL, and PTFL footprints on the lateral process of the talus were measured with calipers before and after removal of a 1-cm(3) simulated fracture fragment. Relative changes in the attachment site areas for the 3 ligaments were determined. Mean pre-excision footprint areas were 80.57 mm(2) (LTCL), 224.38 mm(2) (ATFL), and 394.18 mm(2) (PTFL); mean postexcision footprint areas were 2.10 mm(2) (LTCL), 194.89 mm(2) (ATFL), and 335.18 mm(2) (PTFL); and mean decreases calculated as percentages of the original areas were 97.5% +/- 3.5% (LTCL), 11.7% +/- 13.0% (ATFL), and 14.3% +/- 12.3% (PTFL). Removal of a 1-cm(3) bony fragment from the lateral talar process involves 3 of the major lateral stabilizing ligaments: approximately 100% of LTCL and approximately 10% to 15% of ATFL and PTFL.

Fractures of the lateral process of the talus have historically been considered unusual. This study sought to more precisely define the typical lateral talar process fracture pattern and its incidence in general trauma patients. Such information may have implications for the clinical treatment of these seemingly increasingly recognized injuries. A retrospective review was performed at our level I trauma center of the x-rays and available computed tomography scans of all talus fractures treated between 2000 and 2005 to identify the respective incidence and variation in fracture configuration of all isolated lateral process injuries. The incidence was 10.4%. The fractures were most commonly single large fragments closely followed in frequency by nonarticular chip patterns.

We studied nonpharmaceutical interventions used to mitigate the second, and most deadly, wave of the 1918-1920 influenza pandemic in the United States. We conclude that several small communities implemented potentially successful attempts at preventing the introduction of influenza.

This study analyzed tourniquets used for orthopedic surgery in our hospital to determine the frequency and type of microbial contamination. Group A tourniquets were from our main operating room, Group B tourniquets were from our ambulatory surgicenter, Group C tourniquets were unused, prepackaged, sterile tourniquets from our main operating room, and Group D tourniquets were sterilely packed tourniquets from our ambulatory surgicenter. Tourniquets from Groups A, B, C, and D had 100%, 40%, 0%, and 0% microbial growth, respectively. For Group A tourniquets, coagulase-negative staphylococci, Bacillus, and Staphylococcus aureus were present in 100%, 60%, and 20% of tourniquets, respectively. Twenty percent were contaminated either with Streptococcus sanguis, Aerococcus viridans, or Cornyebacterium species. Coagulase-negative staphylococci and Bacillus were present in 40% and 30% of Group B tourniquets, respectively. Tourniquet contamination may be a risk factor for the development of surgical site infection in orthopedic surgery.

A 1-day table-top exercise in San Diego, California, in December 2004 emphasized voluntary compliance with home quarantine to control an emerging infectious disease outbreak. The exercise heightened local civilian-military collaboration in public health emergency management. Addressing concerns about lost income by residents in quarantine was particularly challenging.

Background: Historically, the standard of care for minimally or nondisplaced, closed, distal fibula fractures has been short-term immobilization and progressive weightbearing. The vast majority of such patients are expected to heal with excellent functional outcome after such treatment. There exists a subpopulation of patients sustaining these fibular fractures who develop symptomatic incomplete union or nonunion despite appropriate management, and later require operative intervention to eliminate pain., Methods: A retrospective review of 17 referred patients with rotational fibular fractures between August 1999 and July 2003 identified six persistently symptomatic distal fibular fractures after an adequate trial of conservative treatment. Due to their persistent localized pain and difficulty with ambulation, five patients underwent operative treatment of the nonunion with autologous bone grafting with plate and screw osteosynthesis. The sixth patient has refused operative intervention despite persistent symptoms., Results: All six of these patients were identified as low risk for nonunion. Two fibular nonunions were found to be complete and four were partial nonunions. One hundred percent of these patients presented with a chief complaint of pain, had reproducible tenderness with palpation directly at the fracture site, and exhibited a persistent antalgic gait pattern. Four of six patients who underwent surgery noticed complete resolution of their pain and return of their normal gait within an average of 2.3 months postoperatively, with an average follow-up of 19.5 months (range, 2-53 months)., Conclusions: Distal fibula nonunion appears to be a relatively common cause of persistent lateral ankle symptoms in patients who do not enjoy a satisfactory recovery after appropriate conservative treatment. The authors believe that the persistent lateral pain in such patients results from micromotion strain at the incomplete fracture union site. Surgical stabilization of fibular nonunion seems to be a reliable means of resolving these symptoms when conservative measures fail.

The purpose of this study was to cull lessons from Toronto's experiences with large-scale quarantine during the outbreak of Severe Acute Respiratory Syndrome in early 2003. We focused on issues that affected the population's willingness to comply with quarantine. Information was acquired from interviews, telephone polling, and focus groups. Issues of quarantine legitimacy, criteria for quarantine, and the need to allow some quarantined healthcare workers to leave their homes to go to work were identified. Also important was the need to answer questions from people entering quarantine about the continuation of their wages, salaries, and other forms of income while they were not working, and about the means by which they would be supplied with groceries and other services necessary for daily living. The threat of enforcement had less effect on compliance than did the credibility of compliance-monitoring. Fighting boredom and other psychological stresses of quarantine, muting the forces of stigma against those in quarantine, and crafting and delivering effective and believable communications to a population of mixed cultures and languages also were critical. The need for officials to develop consistent quarantine policies, procedures, and public messages across jurisdictional boundaries was paramount.

Residents of a community who are intentionally exposed to a hazardous biological, chemical, or radiological agent (including medical first-responders and other civil defense personnel who live in that community) will exhibit a spectrum of psychological reactions that will impact the management of the incident. These reactions will range from a variety of behaviors of normal people under abnormal circumstances that either will help or hinder efforts to contain the threatening agent, deliver medical care, and reduce the morbidity, mortality, and costs associated with the disaster, to the development of new, or exacerbation of preexisting, mental disorders. Anticipating the decisions that people will make and actions they will take as the crisis develops is hindered by the limited number of previous disasters that bear crucial similarities to a terrorist attack with a weapon of mass destruction. Such actions, therefore, could serve as models to predict community reactions. One result of a study that attempted to fill in these gaps suggested that medical first-responders and their spouses/significant others may require separately crafted information and advice to reduce the potential for disharmony within the family that could affect job performance during the crisis. For those persons who exhibit emotional lability or cognitive deficits, evaluation of their psychiatric signs and symptoms may be more difficult than imagined, especially with exposure to nerve agents. Appreciation of these difficulties, and possession of the skill to sort through them, will be required of those assigned to triage stations. The allocation and utilization of mental health resources as the incident unfolds will be the responsibility of local consequence managers; these managers should be aware of the results of a recently-held workshop that attempted to reach consensus among experts in disaster mental health, based on the peer-reviewed literature, on the efficacy and safety of various approaches to early psychological interventions for victims of mass trauma and disasters. Thus, psychological factors are likely to be significant in the management of a terrorist incident that involves an agent of mass destruction. Emergency medical workers with managerial responsibilities, whether limited in scope or community-wide, should be aware of these factors, and should train to handle them through effective risk communication as part of their planning and preparation.

To assess community needs for public information during a bioterrorism-related crisis, we simulated an intentional Rift Valley fever outbreak in a community in the southern part of the United States. We videotaped a series of simulated print and television "news reports" over a fictional 9-day crisis period and invited various groups (e.g., first-responders and their spouses or partners, journalists) within the selected community to view the videotape and respond to questions about their reactions. All responses were given anonymously. First-responders and their spouses or partners varied in their reactions about how the crisis affected family harmony and job performance. Local journalists exhibited considerable personal fear and confusion. All groups demanded, and put more trust in, information from local sources. These findings may have implications for risk communication during bioterrorism-related outbreaks.

Gastrocnemius contracture may be a significant cause of many foot disorders. Gastrocnemius tension can be estimated clinically by measuring maximum ankle dorsiflexion during full knee extension. Such measurements, when made with currently available goniometric devices, are subject to high levels of intra- and inter-observer variability. We have designed a device to more consistently measure ankle dorsiflexion, using three dimensional tracking sensors on the leg and foot. The applied dorsiflexion torque is kept constant by a computer, and the computer also monitors hindfoot position to maintain a neutrally aligned foot during testing. Repeated measurements on 26 feet were taken to determine the consistency of the device. The correlation coefficient for the measurements was 0.96, indicating very low intra-observer variability. The standard deviation of the repeated measures was 2 degrees. Based on the 95% confidence interval, the device can be considered accurate to within 4 degrees. Given this accuracy, this instrument could be used to assess gastrocnemius tension, its role in foot pathology, and the effectiveness of surgical lengthening. Compared to other currently available measuring devices, this instrument is the most reliable in estimating ankle dorsiflexion, since it is capable of controlling hindfoot position and applied dorsiflexion torque, and it can be easily constructed by other laboratories.

Objective: This article highlights the mental health consequences of a domestic terrorist incident involving chemical or biological weapons., Method: The author reviews the literature on the neuropsychiatric effects of selected chemical and biological weapon agents, on the psychological sequelae of mass disasters, and on approaches to crisis intervention., Results: Disturbances of behavior, affect, and cognition can result directly from the pharmacological actions of some chemical and biological weapon agents. In addition, an incident involving these agents can have considerable psychological effects on individuals and the community. In either case, some disorders are acute and others are prolonged or delayed in onset. Effective therapeutic intervention involves a broad range of clinical, social, and administrative actions., Conclusions: Psychiatrists have an important role in the management of a chemical or biological terrorist incident and, along with their other medical colleagues, should train and prepare for it.

This is a retrospective review of 49 subtalar arthroscopies performed between 1989 and 1996. Patients were evaluated in the following areas: (1) preoperative diagnosis, (2) preoperative tests and clinical evaluation, (3) intraoperative findings, (4) postoperative diagnosis,(5) complications, and (6) clinical outcome. Particular attention was paid to the accuracy of the preoperative diagnosis, subtalar instability, intraoperative findings in sinus tarsi syndrome, and clinical outcome. Overall, this study demonstrated a success rate of 94% good and excellent results in the treatment of various types of subtalar pathologic conditions with arthroscopic techniques. The Workers' Compensation cases reported 90% good and excellent results. The complication rate was low, with five minor complications reported. The most common complication was a transient neuropraxia involving branches of the superficial peroneal nerve. Of the 14 feet that had a preoperative diagnosis of sinus tarsi syndrome, all the diagnoses were changed at the time of arthroscopy. The postoperative diagnoses included 10 interosseous ligament tears, two cases of arthrofibrosis, and two degenerative joints. Based on these findings, "sinus tarsi syndrome" seems to be an inaccurate term that should be replaced with a specific diagnosis. Arthroscopy is the tool that will allow the orthopaedic surgeon to make a more accurate diagnosis.

Because Armed Forces Reserve members, especially combat support units, were rapidly mobilized during Operation Desert Shield/Desert Storm, they were at higher risk for anxiety and stress-related disorders. Personnel in reserve units in the military force structure are at greater risk for psychologic stress due to rapid mobilization and demobilization, which allows minimal time to process adverse experiences or fears. The unexpected disruption of families and careers and resulting financial pressures are magnified in older age groups who have increased personal and family commitments. Personnel in combat support units are at greatest risk when they lack necessary training, cohesion, and leadership. Prevention efforts in reserve units should involve education regarding the potential for activation and associated disruption of family and career plans. Support networks for reserve families should be encouraged. Additional training in an appropriate context regarding risks of biologic and chemical exposure, with the goal of developing confidence in training and equipment, should be stressed. Finally, group processing before demobilization and recall within 90 days of return to emphasize unit cohesion and readjustment to civilian life may be of benefit.

During a 3-year period Branhamella catarrhalis was isolated in significant numbers from 239 (1.3%) of 19,488 specimens of sputum sent for routine microbiological examination at a 700-bed general hospital. The majority of patients (83%) were over 60 years of age and 65% were male. There was a distinct seasonal variation in isolations with a peak incidence during the winter and early spring, a pattern not found with other pathogens. Susceptibility to amoxycillin decreased by approximately 50% over the 3 years, corresponding to an increased incidence of beta-lactamase-producing strains. There were minimal changes in susceptibility to other antimicrobial agents. Underlying pulmonary disease was the major factor predisposing to B. catarrhalis infection, and 71% of patients were smokers or ex-smokers.

Aims: Many advocate screw fixation of fractures to the metaphyseal-diaphyseal junction of the fifth metatarsal base, better known as Jones fractures (JF), to facilitate quicker ambulation and return to sport. Maximizing screw parameters based on fifth metatarsal (MT5) anatomy, alongside understanding the anatomic structures compromised by screw insertion, may optimize surgical outcomes. This study aims to (1) correlate the proximity of JF to the peroneus brevis (PB) and plantar fascia (PF) footprints and (2) quantify optimal screw parameters given MT5 anatomy.Materials and Methods: 3D CT-scan reconstructions were made of 21 cadaveric MT5s, followed by meticulous mapping of the PB and PF onto the reconstructions. Based on bone length, shape, narrowest intramedullary canal (IMC) diameter, and surrounding anatomy, two traditional debated screw positions were modeled for each reconstruction: (1) an anatomically positioned screw (AP), predicated on maximizing screw length by following the IMC for as long as possible, and (2) a clinically achievable screw (CA), predicated on maximizing screw length without violating the fifth tarso-metatarsal joint or adjacent cuboid bone. Fixation parameters were calculated for all models.Results: The PB and PF extended into the JF site in 29% and 43%, respectively. AP's did not affect PB and PF footprint but required screw entry through the cuboid and fifth tarso-metatarsal joint in all specimens. CA screw entry sites, avoiding the cuboid and fifth tarso-metatarsal joint, partially compromised the PB and PF insertions in 33% and 62% with a median surface loss of 1.6%%(range 0.2-3.2%) and 0.81%%(range 0.05-1.6%), respectively. Mean AP screw length was 64±3.6mm and thread length 49±4.2mm. Mean CA screw length was 48±5.8mm and thread length 28±6.9mm.Conclusion: This study underscores the challenges associated with surrounding MT5 anatomy as they relate to optimal JF treatment. Both the extent of JF as well as a clinically achievable positioned screw violate the PB and PF footprints - although the degree to which even partial disruption of these footprints has on outcome remains unclear. To minimize damage to surrounding structures, including the PB and PF footprint, while allowing a screw length approximately two thirds of the metatarsal length, the CA screw position is recommended. This position balances the desire to maximize pull out strength while avoiding cortical penetration or inadvertent fracture site distraction. [ABSTRACT FROM AUTHOR]