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Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Progressive Collapsing Foot Deformity (PCFD) can present with independent deformities, characterized by five classes: hindfoot valgus (Class A), midfoot abduction (Class B), forefoot varus (Class C), Peritalar Subluxation (PTS) (Class D) and ankle valgus (Class E). Conservative treatment includes the use of corrective insoles and orthotics. Arch support inflatable Ankle-Foot orthoses (IAFO) can help control symptoms in PCFD patients. However, the ability of IAFOs to correct deformities in PCFD is unknown. The aim of this prospective comparative and controlled study was to assess the ability of arch support IAFOs to correct 3D overall PCFD alignment as well as the five different PCFD classes independently. We hypothesized that IAFOs would correct PCFD 3D overall alignment as well as the five independent classes of deformity. Methods: After IRB approval, we enrolled 24 symptomatic PCFD and 24 controls matched on age, sex, and BMI. Flexible PCFD patients and controls were scanned using Weight-Bearing CT (WBCT) with and without an arch support IAFO. The Foot and Ankle Offset (FAO) was used to assess the 3D foot overall alignment. We measured the Hindfoot moment arm (HMA, Class A), the Talonavicular coverage angle (TNCA, Class B), the Meary’s angle and medial cuneiform-to-floor distance (C1-floor) for the Class C and the middle facet uncoverage (MFunco, Class D). No Class E patients were included. Measurements were performed by two fellowship-trained surgeons. A power-analysis hypothesizing that IAFOs would be two times less efficient than the PCFD surgery in correcting the FAO, the requisite number of subjects was 24 per group. Data normality was assessed by Shapiro-Wilk test. Comparisons used normality based paired T-tests or paired-Wilcoxon tests. P-values < 0.05 were considered significant. Results: PCFD measurements performed in controls were all significantly less pronounced than unbraced PCFD patients, confirming the presence of collapse (ps < 0.0001). Comparing PCFD without and with IAFO, the FAO did not show significant improvement (respectively 6.6+/-3.7% vs 5.5+/-4.2%, p=0.101). The HMA (8.8+/-5.8 vs 8.1+/-5.8, p=0.66), the TNCA (24.2+/-10.6 vs 21.9+/-9.7, p=0.44) and the MFunco (37+/-12% vs 31+/-18%, p=0.17) also did not portray significant improvements when applying the IAFOs. The Meary’s angle (17.6+/-7.2 vs 10.8+/-7.3, p=0.002) and C1-floor (17.2+/-3.3mm vs 24.1+/-5.3mm, p< 0.001) were the only to improve significantly with use of IAFOs. When comparing braced PCFD and controls, the only measurement that improved to normal values, similar to controls, in braced PCFD was the C1-floor (24.1+/-5.3mm in PCFD with IAFO vs 25.7+/- 5.4mm in controls, p=0.31). Conclusion: In this prospective comparative and controlled study, we found that arch support IAFOs was not able to correct overall 3D deformity and most of the specific classes in PCFD. The orthosis did not improve hindfoot valgus (Class A), midfoot abduction (Class B) or peritalar subluxation (Class D) in PCFD. The only deformity pattern to improve with the use of IAFOs was the medial longitudinal arch height (Class C). These improvements were expected by the presence of the inflatable bladder of the IAFO on the plantar aspect of the foot, pushing the longitunal arch up but not correcting the entire PCFD.

Category: Ankle; Sports Introduction/Purpose: Syndesmotic injuries and residual chronic subtle distal tibiofibular syndesmotic instability (DTFSI) are relatively common injuries, especially in athletes prone to suffering high ankle sprains. The diagnosis of subtle DTFSI remains challenging, with a high prevalence of false-negative results using conventional non-invasive clinical-radiographical diagnostic tools. The current gold standard for diagnosis, arthroscopy, is a surgical operation, which is invasive and, therefore, not ideal. Weightbearing Computed-Tomography (WBCT) has emerged as a possible dynamic non-invasive alternative diagnostic option, with proven high diagnostic accuracy for syndesmotic incisura area measurements in major DTFSI. Our study aimed to assess the capability of semiautomatic weight-bearing computed tomography (WBCT) syndesmotic incisura area in diagnosing subtle chronic syndesmotic instability. Methods: In this diagnostic case-control study, patients with suspected unilateral chronic subtle DTFSI underwent bilateral standing weight-bearing CT (WBCT) before surgical treatment. All patients had gold-standard arthroscopic assessment for DTFSI, introducing a 3mm diameter arthroscopic sphere into the syndesmotic incisura for diagnosis. Bilateral syndesmotic incisura areas were measured 10mm proximally to the apex of the distal tibia articular dome using a semiautomatic measurement algorithm. Two tangent lines marked the anterior and posterior borders of the syndesmotic incisura to the anterior and posterior edges of the distal tibia and fibula. Once borders were marked, the incisura area was automatically calculated by the software based on a Hounsfield units (HU) contrast algorithm. A HU threshold of 200HU was utilized. Measurements were done independently by two fellowship-trained readers. Comparisons between injured and control ankles were made using Student T-test or Wilcoxon, according to normality. Measurements' reliability was assessed with the Intraclass Correlation Coefficient (ICC). Results: From an initial sample of 32 patients, 20 patients (12 female) with arthroscopically confirmed DTFSI (11 right sides) with a mean age of 31.7 years (range 18 to 55 years) and a mean BMI of 30.35kg/m² (SD +/-8.29 kg/m²) were included in the study. All patients had a history of an old ankle sprain 6 to 182 months before the assessment, and athletic lesions were reported in 53% of the population. ICCs were above 0.98 for both intra and interobserver reliability. The average syndesmotic area was 96.91mm 2 (SD +/-27.9mm 2 ) in injured ankles compared to 84.61mm 2 (SD +/-26.9 mm 2 ) in uninjured ankles. The difference between injured and non-injured tibiofibular areas was 12.31mm 2 (95%CI: 9.04-15.58mm 2 ), which was shown statistically significant (p < 0.001; effect size: 1.43). Conclusion: In this case-control study, we assessed the accuracy of semiautomatic WBCT syndesmotic incisura area measurements in diagnosing subtle chronic DTFSI. We found an increased syndesmotic area in injured ankles that reached statistical significance. Due to the minimal differences between injured and uninjured contralateral ankles, larger cohorts would likely solidify this study's findings further. The use of external rotation stress, volumetric assessment, distance, and coverage maps could increase the diagnostic accuracy in DTFSI. However, automatic area measurements have a higher overall reproducibility and applicability in the clinical setting, which could help providers make therapeutic decisions.

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: Decision regarding ankle osteoarthritis (OA) management varies depending on the severity and distribution of the associated joint degeneration. Disease staging is typically based on subjective grading of appearance on conventional plain radiographs, with reported sub-par reproducibility and reliability. Weight-bearing computed tomography (WBCT) offers clinical advantages in the setting of OA, where thinning of the ankle cartilage, softening of the cartilage, and other deformities become more apparent under load. WBCT also provides a better geometric representation of the ankle and allows for more accurate measurements when compared to a conventional radiograph. The purpose of this study was to develop and describe computational methods to objectively quantify radiographic changes associated with ankle OA apparent on low-dose WBCT images. Methods: We analyzed two patients with ankle OA and one healthy control that had all undergone WBCT of the foot and ankle. The severity of OA in the ankle of each patient was scored using the Kellgren-Lawrence (KL) classification by plain weight-bearing radiographs. For each ankle, the subsequent analysis focused on a volume of interest (VOI) centered on the tibiotalar joint. Within the VOI, the initial computational analysis focused on measuring the 3D joint space width (JSW). Subsequent analyses utilized WBCT image intensity (Hounsfield Unit, or HU) profiles along lines perpendicular to the subchondral bone/cartilage interface of the distal tibia extending across the entire VOI. The HU intensity profiles were recorded, and graphical plots of the HU distributions were generated for each line. These plots were then used to calculate the HU contrast, a novel measure of the regional variation in bone density. Results: The average JSW was 3.89 mm for the healthy control ankle, 2.69 mm for the mildly arthritic ankle (KL 2), and 1.57 mm for the severely arthritic ankle (KL 4). The average HU contrast was 72.31 for the healthy control ankle, 62.69 for the mildly arthritic ankle, and 33.98 for the severely arthritic ankle. The use of four projections at different locations throughout the joint allowed us to visualize specifically which quadrants have reduced joint space width and contrast. One projection in the severely arthritic ankle had JSW and contrast values of 0 due to complete joint space loss along with projection 4, which corresponds in this case to the posterolateral part of the joint (Figure). Conclusion: We presented a novel computational assessment of ankle osteoarthritis using low-dose WBCT imaging. We were able to demonstrate differences between normal ankles and ankles with mild and severe OA using JSW and HU contrast measurements. This methodology represents an important step towards a more reliable OA assessment when compared to the current standard qualitative evaluations, potentially serving as a starting point for the development of a more robust osteoarthritis staging system. Additional studies are needed to assess the algorithm more rigorously over a variety of radiographic presentations.

Category: Ankle; Ankle Arthritis; Hindfoot; Other Introduction/Purpose: Total ankle replacement (TAR) has been shown as a viable surgical option to reduce pain, improve function, and preserve ankle joint range of motion in patients with Ankle osteoarthritis (AO). Standard anterior approach TAR capability in correcting deformities is already established by several studies. However, there is a paucity of literature evaluating patient outcomes as well as the potential to correct alignment using a lateral approach TAR. Therefore, the primary objective of this study was to assess the capability of lateral trans-fibular approach TAR in correcting coronal and sagittal plane deformity and secondarily to report the ability to improve patient-reported outcomes (PROs) following lateral TAR. Methods: This IRB-approved, retrospective comparative study included 14 consecutive patients that underwent lateral trans- fibular approach TAR for end-stage AO. Average age and BMI were 63.9 years (range 43-83) and 32.7 kg/m2 (SD 7.5). All patients had received pre- and post-operative weight-bearing CT imaging on the affected foot and ankle. Foot and Ankle Offset (FAO), Talar Tilt Angle (TTA), Hindfoot Moment Arm (HMA), and Lateral Talar Station (LTS) were performed. PROs were collected pre- and post-operatively at the latest clinical follow-up including: PROMIS Global Physical Health score, the Tampa Scale of Kinesiophobia (TSK), the European Foot and Ankle Society (EFAS) score, the Pain Catastrophizing Scale (PCS) and the Foot and Ankle Ability Measure (FAAM) Daily Living Score. One-way ANOVA and Wilcoxon tests were used for comparison at each interval time period. A multivariate regression analysis was then performed to evaluate the association between change in alignment and improvements of PROs. Results: Three of 14 patients (21.4%) underwent a concomitant osseous re-alignment procedure. At an average of 16.1 months (range 11 to 24), all patients demonstrated a significant deformity correction in measurements performed: FAO (7.73% - 3.63%, p=0.031), HMA (10.93mm - 5.10mm, p=0.037), TTA (7.9o - 1.5o, p=0.003), and LTS (5.25mm - 2.83mm, p=0.018). Four of the PROs demonstrated significant improvement postoperatively: TSK (42.7-34.5, p=0.012), PROMIS Global Physical Health (46.1- 54.5, p=0.011), EFAS (5-10.3, p=0.004), and FAAM (60.5-79.7, p=0.04). PROMIS was associated (p=0.0015) with optimization of FAO (p=0.00065) and LTS (p=0.00436), R2 of 0.98). Improvements in TSK were associated with changes in the HMA (p=0.0074), R2 of 0.66. Improvements in FAAM correlated (p=0.048) with improvements in FAO (p=0.023) and TTA (p=0.029), and an R2 of 0.78. Conclusion: In this retrospective comparative cohort study, the results suggest that the lateral trans-fibular TAR can correct different aspects of AO deformity. Clinical benefit was also demonstrated by the impacted PROs, particularly TSK, PROMIS Global Physical Health, EFAS, and FAAM Daily Living. Direct and strong correlations between deformity correction measurements and the significantly improved PROs were found. The obtained data might help surgeons when planning treatment and may serve as the basis for future comparative prospective studies.

Category: Basic Sciences/Biologics; Hindfoot; Other Introduction/Purpose: The use of bio-integrative implants in orthopedic surgery is growing rapidly. While many biomechanical and histological studies have been able to demonstrate their structural and biological properties, few clinical reports are available to support their advantages, such as good osteosynthesis, lower rates of removal, and diminished implant-related artifact in imaging studies. This clinical information is vital to providers when choosing the proper material and planning postoperative treatment. Hounsfield Units (HU) algorithms have been used as an objective assessment of joint space width. This pilot data analysis intends to test the capacity of the bio-integrative screws in reaching similar radiographical outcomes of the current metallic screws when analyzing medial displacement calcaneus osteotomies (MDCO). Our hypothesis is that both types of implants would present similar results. Methods: In this prospective comparative IRB-approved study, three patients undergoing MDCO with bio-integrative screws were compared to two patients undergoing the same surgery with metallic screws. Surgeon, primary diagnosis, technique, and displacement were the same for both groups. Patients were assessed using weight-bearing computed tomography at weeks 2, 6, and 12 postoperatively. Using a dedicated software, a 40x40x40mm cube, which defines a volume of interest (VOI), is centered at the osteotomy site. Within the VOI, initial computational analysis focused on image intensity (Hounsfield Units) profiles along lines perpendicular to the osteotomy line, crossing the osteotomy line and spanning approximately 8mm on either side. The HU intensity profiles were recorded, and graphical plots of the HU distributions were generated for each line. The plots were then used to calculate the HU contrast, a proxy for bone healing at the osteotomy site. Results: At 2 weeks, mean HU intensity in the metallic and bio-integrative were respectively 403.25 and 416.28 at the centerline (p=0.312), 513.24 and 386.57 at the inferior (p

Category: Midfoot/Forefoot; Ankle; Hindfoot Introduction/Purpose: Progressive Collapsing Foot Deformity (PCFD) comprises five independent deformities represented by five classes: hindfoot valgus (class A), midfoot abduction (class B), forefoot varus (class C), peritalar subluxation (class D) and ankle valgus (class E). Conservative treatment includes the use of corrective insoles and orthotics. Longitudinal arch support inflatable ankle-foot orthoses (IAFO) help control pain in PCFD patients. But we have no knowledge about the ability of IAFOs to correct deformities in PCFD. The aim of this prospective case-controlled study was to assess the ability of longitudinal arch support IAFOs to correct 3D overall PCFD alignment as well as the five different PCFD classes independently. We hypothesized that IAFOs will correct PCFD 3D overall alignment as well as the five independent classes. Methods: After IRB approval we enrolled 24 symptomatic flexible PCFD and 24 controls matched on age, sex, and BMI. Patients were scanned using Weight-Bearing CT with and without a longitudinal arch support IAFO. The Foot and Ankle Offset (FAO) was used to assess the 3D foot overall alignment. We measured the Hindfoot moment arm (HMA, Class A), the Talonavicular coverage angle (TNCA, Class B), the Meary's angle and the distance between the floor and the medial cuneiform (C1-floor) for the Class C and the middle facet uncoverage (MFunco, Class D). We did not have any Class E deformity in our PCFD cohort. Data normality was assessed by Shapiro-Wilk test. Comparisons used normality based paired T-tests or paired-Wilcoxon tests. Hypothesizing that the IAFOs would be two times less efficient than the surgery (Day et al.) in correcting the FAO in PCFD, the requisite number of subjects was 24 per group. Results: Control measurements were all significantly different than unbraced PCFD measurements confirming our PCFD selection process. Comparing PCFD without and with IAFO via FAO did not show significant improvement (respectively 6.6+/- 3.7% vs 5.5+/-4.2%, p=0.101). The HMA (8.8+/-5.8 vs 8.1+/-5.8, p=0.66), the TNCA (24.2+/-10.6 vs 21.9+/-9.7, p=0.44) and the MFunco (37+/-12% vs 31+/-18%, p=0.17) did not show any significant improvement when applying the IAFOs. The Meary's angle (17.6+/-7.2 vs 10.8+/-7.3, p=0.002) and the C1-floor (17.2+/-3.3mm vs 24.1+/-5.3mm, p

Background: The treatment of ankle osteoarthritis (OA) varies depending on the severity and distribution of the associated joint degeneration. Disease staging is typically based on subjective grading of appearance on conventional plain radiographs, with reported subpar reproducibility and reliability. The purpose of this study was to develop and describe computational methods to objectively quantify radiographic changes associated with ankle OA apparent on low-dose weightbearing CT (WBCT). Methods: Two patients with ankle OA and 1 healthy control who had all undergone WBCT of the foot and ankle were analyzed. The severity of OA in the ankle of each patient was scored using the Kellgren-Lawrence (KL) classification using plain radiographs. For each ankle, a volume of interest (VOI) was centered on the tibiotalar joint. Initial computation analysis used WBCT image intensity (Hounsfield units [HU]) profiles along lines perpendicular to the subchondral bone/cartilage interface of the distal tibia extending across the entire VOI. Graphical plots of the HU distributions were generated and recorded for each line. These plots were then used to calculate the joint space width (JSW) and HU contrast. Results: The average JSW was 3.89 mm for the control ankle, 3.06 mm for mild arthritis (KL 2), and 1.57 mm for severe arthritis (KL 4). The average HU contrast was 72.31 for control, 62.69 for mild arthritis, and 33.98 for severe arthritis. The use of 4 projections at different locations throughout the joint allowed us to visualize specifically which quadrants have reduced joint space width and contrast. Conclusion: In this technique report, we describe a novel methodology for objective quantitative assessment of OA using JSW and HU contrast. Clinical Relevance: Objective, software-based measurements are generally more reliable than subjective qualitative evaluations. This method may offer a starting point for the development of a more robust OA classification system or deeper understanding of the pathogenesis and response to ankle OA treatment.

Abstract Background Symptom assessment is essential in palliative care, but holds challenges concerning implementation and relevance. This study aims to evaluate patients’ main symptoms and problems at admission to a specialist inpatient palliative care (SIPC) ward using physician proxy- and patient self-assessment, and aims to identify their prognostic impact as well as the agreement between both assessments. Methods Within 12 h after admission, palliative care specialists completed the Symptom and Problem Checklist of the German Hospice and Palliative Care Evaluation (HOPE-SP-CL). Patients either used the new version of the minimal documentation system for patients in palliative care (MIDOS) or the Integrated Palliative Care Outcome Scale (IPOS) plus the Distress Thermometer (DT). Results Between 01.01.2016–30.09.2018, 1206 patients were included (HOPE-SP-CL 98%; MIDOS 21%, IPOS 34%, DT 27%) whereof 59% died on the ward. Proxy-assessment showed a mean HOPE-SP-CL Total Score of 24.6 ± 5.9 of 45. Most frequent symptoms/problems of at least moderate intensity were weakness (95%), needs of assistance with activities of daily living (88%), overburdening of family caregivers (83%), and tiredness (75%). Factor analysis identified four symptom clusters (SCs): (1) Deteriorated Physical Condition/Decompensation of Home Care, (2) Emotional Problems, (3) Gastrointestinal Symptoms and (4) Other Symptoms. Self-assessment showed a mean MIDOS Total Score of 11.3 ± 5.3 of 30, a mean IPOS Total Score of 32.0 ± 9.0 of 68, and a mean distress of 6.6 ± 2.5 of 10. Agreement of self- and proxy-assessment was moderate for pain (ƙ = 0.438) and dyspnea (ƙ = 0.503), fair for other physical (ƙ = 0.297 to 0.394) and poor for psychological symptoms (ƙ = 0.101 to 0.202). Multivariate regression analyses for single symptoms and SCs revealed that predictors for dying on the SIPC ward included impaired ECOG performance status, moderate/severe dyspnea, appetite loss, tiredness, disorientation/confusion, and the SC Deteriorated Physical Condition/Decompensation of Home Care. Conclusion Admissions to a SIPC ward are mainly caused by problems impairing mobility and autonomy. Results demonstrate that implementation of self- and reliability of proxy- and self-assessment is challenging, especially concerning non-physical symptoms/problems. We identified, specific symptoms and problems that might provide information needed for treatment discussions regarding the medical prognosis.

Category: Ankle; Arthroscopy; Sports; Trauma Introduction/Purpose: Improving the diagnosis of subtle syndesmotic instability (SSI) represents one of the most challenging missions in orthopedic surgery, since undiagnosed instability frequently leads to posttraumatic ankle arthritis. Stressed conventional radiographs, ultrasonography, bilateral comparative conventional CT and MRI serve as important diagnostic tools, however, the current diagnostic gold-standard is arthroscopic assessment, an invasive surgical method. The advent of weight- bearing computed tomography (WBCT) brought hope for improved non-invasive SSI diagnosis, particularly by utilizing distal tibiofibular syndesmotic (DTFS) area and volume measurements. However, to date, no studies assessed WBCT diagnostic accuracy for chronic SSI. The purpose of this study was to prospectively evaluate the diagnostic accuracy of WBCT area and volumetric measurements in patients with suspected chronic SSI, when compared to the gold-standard arthroscopic assessment. Methods: In this IRB-approved prospective comparative study, 11 patients with suspected SSI were enrolled from July 2019 to December 2020. Patients were assessed preoperatively by bilateral standing WBCT. Raw 3D WBCT was automatically segmented by dedicated software. WBCT measurements performed: semi-automatic DTFS area (1cm proximally to tibial dome apex); DTFS volumes (1, 3 and 5cm proximally to tibial dome apex). Threshold values for WBCT abnormality were defined based on currently available data (area>105mm 2 and volumes>796mm 3 , >3062 mm 3 , and >6733 mm 3 for 1, 3 and 5cm, respectively). Subjects underwent surgical treatment including DTFS instability arthroscopic assessment, defined as positive when a 3mm diameter sphere could enter the syndesmotic incisura. Confirmed unstable cases were treated with open reduction/internal fixation. WBCT measurements sensitivity, specificity, positive and negative predictive values (PPV/NPV) and accuracy were calculated using confirmed arthroscopic instability as diagnostic gold standard. Paired t-tests/Wilcoxon analysis was used to compare measurements. P-values105mm 2 ), including 3 true positives (+WBCT/+Arthroscopy), 1 false positive (+WBCT/-Arthroscopy), 6 false negatives (-WBCT/+Arthroscopy), and 1 true negative (-WBCT/-Arthroscopy), leading to a 33.3% sensitivity, 50%, specificity, 75% PPV 75%, 14.3% NPV and 36% accuracy. When analysing WBCT DTFS volumes (1cm), 3/11 patients were found positive (>796mm 3 ), depicting 3 true positives, 0 false positives, 2 true negatives and 6 false negatives, with resultant diagnostic accuracy of: 33.3% sensitivity, 100% specificity, 100% PPV, 25% NPV 25%, and 45% accuracy. Conclusion: This is the first study to prospectively assess WBCT diagnostic accuracy of area and volume measurements in detecting chronic SSI, comparing it to arthroscopic diagnostic standard. When compared to uninjured side, DTFS area and volumetric measurements were significantly increased in injured sides of patients with suspected SSI, including medial gutter volumes, consistent with associated deltoid ligament instability. However, interestingly, we observed a diagnostic accuracy for WBCT area and volumetric measurements to be lower than initially expected. Further incorporation of additional patients, as well as introduction of an external rotational stress can potentially optimize the WBCT diagnostic accuracy for chronic SSI.

Objective: To assess the degree of implant-related artifacts (IRA) around metallic and bio-integrative (BI) cannulated screws using Hounsfield units (HU) on computed tomography (CT). Our hypothesis was that BI implants would demonstrate significantly decreased IRA around the inserted screws. Methods: In this cadaveric CT imaging study, we used 2 below-knee specimens. Medial displacement calcaneal osteotomy was performed, and the specimens were fixed with either metallic or BI screws. HU values were measured over 4 different lines that crossed the osteotomy position. Results: The mean HU value was decreased in the BI implants compared to the metallic ones in 3 different positions: near the screw, directly over the screw, and inside the screw cannula. At the line placed 1 cm dorsal to the screw, the HU value for the metallic screw was lower than that for the BI screw. Conclusions: We found metallic implants to demonstrate significantly increased HU values in regions close to the implant and significantly decreased values 1 cm away from the implant, when compared to the BI screw. The decreased HU values 1 cm away from the implant could be due to a shielding effect of the surrounding bone, hindering the assessment of union and healing. BI implants represent an alternative to decrease these IRA effects. Level of Evidence III; Case-Control Study.

Peroneal tendon instability is a common injury that occurs in physically active individuals, often as a result of trauma and in the context of an anatomically shallow distal fibular groove. Subluxation of these tendons over the lateral malleolus is accompanied by superior peroneal retinaculum injury. Several techniques have been described in the literature, including fibular groove deepening and retinaculum repair, but few reconstruction techniques are available for cases with insufficient residual retinaculum. We report the case of a 53-year-old man, without a history of trauma, who presented with chronic peroneal instability with a completely obliterated, unsalvageable retinaculum which we treated with a combination of fibular groove deepening and fibular periosteal flap to reconstruct the superior peroneal retinaculum. Level of Evidence V; Case Report; Expert Opinion.

We present a technical surgical description of a 36-year-old female diagnosed with Progressive Collapsing Foot Deformity (PCFD) treated with a medial displacement calcaneus osteotomy, a lateral column lengthening, and a modified Lapidus fusion. In order to increase the plantar flexion power of this arthrodesis and minimize the loss in ray length with joint preparation, a bone block structured graft was used. Fixation was performed using a post implant in the medial cuneiform with crossing screws though the surfaces and the graft. Forefoot varus was properly corrected intraoperatively by using the described surgical technique. Satisfactory functional short-term results and an excellent alignment was accomplished. Level of Evidence V; Therapeutic Studies; Expert Opinion.

INTRODUCTION:Healthcare personnel are at high risk for exposure to influenza by direct and indirect contact, droplets and aerosols, and by aerosol generating procedures. Information on air and surface influenza contamination is needed to assist in developing guidance for proper prevention and control strategies. To understand the vulnerabilities of healthcare personnel, we measured influenza in the breathing zone of healthcare personnel, in air and on surfaces within a healthcare setting, and on filtering facepiece respirators worn by healthcare personnel when conducting patient care. METHODS:Thirty participants were recruited from an adult emergency department during the 2015 influenza season. Participants wore personal bioaerosol samplers for six hours of their work shift, submitted used filtering facepiece respirators and medical masks and completed questionnaires to assess frequency and types of interactions with potentially infected patients. Room air samples were collected using bioaerosol samplers, and surface swabs were collected from high-contact surfaces within the adult emergency department. Personal and room bioaerosol samples, surface swabs, and filtering facepiece respirators were analyzed for influenza A by polymerase chain reaction. RESULTS:Influenza was identified in 42% (53/125) of personal bioaerosol samples, 43% (28/ 96) of room bioaerosol samples, 76% (23/30) of pooled surface samples, and 25% (3/12) of the filtering facepiece respirators analyzed. Influenza copy numbers were greater in personal bioaerosol samples (17 to 631 copies) compared to room bioaerosol samples (16 to 323 copies). Regression analysis suggested that the amount of influenza in personal samples was approximately 2.3 times the amount in room samples (Wald χ2 = 16.21, p

Describes the process of acquisition in learner varieties with respect to reference and referential movement in the domain of modality. Findings are based on data from the longitudinal ESF and P-Moll projects and on cross-sectional data of Italian learners of German. (Author/VWL)

Youdas JW, Hollman JH, Aalbers MJ, Ahrenholz HN, Aten RA, Cremers JJ. Agreement between the GAITRite walkway system and a stopwatch-footfall count method for measurement of temporal and spatial gait parameters. OBJECTIVE: To determine the agreement for measurements of stride length, cadence, and walking speed obtained from the GAITRite system and the stopwatch-footfall count technique. DESIGN: Criterion standard. SETTING: Research laboratory in a physical therapy education program. PARTICIPANTS: Forty healthy volunteers (13 men, 27 women) without lower-extremity injury. INTERVENTIONS: Participants walked across a GAITRite mat with embedded pressure sensors at their self-selected walking speed. Simultaneously, an examiner used a stopwatch to record the elapsed time necessary to cross the mat and counted the number of complete footfalls. MAIN OUTCOME MEASURES: Walking speed, cadence, and stride-length measures were compared between the GAITRite system and the stopwatch-footfall count technique. RESULTS: Correlation coefficients comparing both systems were .97 for walking speed, .75 for cadence, and .85 for stride length. Ninety-five percent of the time we would expect the between-methods differences to range between .09 and -.05m/s for walking speed, between -1.5 and -24.3 steps/min for cadence, and between .01 and .37m for stride length. CONCLUSIONS: This study shows that the GAITRite and stopwatch-footfall count methods lack clinically acceptable agreement for the measurements of cadence and stride length in a group of healthy volunteers walking at their self-selected speeds. Clinicians who require precise measurement of cadence and stride length should consider using the GAITRite system instead of the stopwatch-footfall count technique. Copyright © 2006 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation [ABSTRACT FROM AUTHOR]

We demonstrate temperature-influenced increment spacing in the sagittal otoliths of juvenile Atlantic menhaden Brevoortia tyrannus reared at different temperatures and describe otolith increment patterns from wild juveniles born in different months. Tank-reared individuals completed metamorphosis a month earlier at 25°C than at ambient temperatures (10-14°C). We identified several patterns from the sectioned otoliths, including reduced time to metamorphosis, faster transition to the juvenile stage, and increased increment spacing after onset of metamorphosis for those individuals exposed to warmer temperatures. For wild individuals that could be accurately aged, mean otolith increment spacing in the zone from 70 to 80 increments increased 1-2 μm for fish born in November and December to more than 3 μm for fish born in February. The increase in increment spacing is consistent with the arrival of individuals across seasonally warming temperatures in the estuary. A discriminant analysis based on otolith increment spacing and metamorphic patterns successfully classified birth month for 59-100% (65% overall) of Atlantic menhaden spawned between November-February. This approach is being developed ultimately to identify the birth month of wild Atlantic menhaden adults in order to test for differential survival among cohorts born in different months that recruit to the fishery. [ABSTRACT FROM AUTHOR]