High Rates of Psychiatric Disorders and Below Normal Mental Capacity Associated With Spastic Peroneal Flatfoot: A New Relationship

Evaluation and Management of Adolescents With a Stiff Flatfoot

While flatfeet are normal in children, persistence into adolescence with associated pain or asymmetry warrants additional evaluation. Rigidity of a flatfoot deformity, whether a clinical report or evident on examination, should raise suspicion for pathology. The differential diagnosis includes tarsal coalition, neurogenic planovalgus, and peroneal spasticity. History must include pointed inquiry into birth and neurologic histories to probe for a source of central spasticity. Examination must include standing assessment of hindfoot and midfoot alignment. Hindfoot rigidity may be assessed by the double limb heel rise test and manual examination. Radiographs should include standing ankle (anterior-posterior and mortise) and whole foot (anterior-posterior, external rotation oblique, and lateral) images. Magnetic resonance imaging is more sensitive for identifying coalitions and better characterizes adjacent cartilage, subchondral edema, and tendon pathology, yet CT better characterizes the anatomy of a bony coalition. Conservative treatments are pathology-dependent and play a more prominent role in neurogenic or peroneal spastic flatfoot. Surgical management of coalitions is centered on coalition resection coupled with arthrodesis in the case of a talocalcaneal coalition with a dysplastic subtalar joint; concomitant planovalgus reconstruction is considered on a case-by-case basis.

Refractory peroneal spastic flat foot successfully treated with a cast in a girl

An 11-year-old girl presented with pain in the sinus tarsi and a foot deformity after spraining her left foot. She had flat foot due to spasticity of the peroneal tendon, which was difficult to correct manually. An imaging study revealed an accessory anterolateral talar facet (AALTF) and bone marrow oedema at the lateral aspect of the posterior talocalcaneal joint. We diagnosed peroneal spastic flat foot with possible involvement of sinus tarsi syndrome and AALTF. When conservative therapy failed, we applied a cast with the foot in full plantar flexion and an inverted position. After 4 weeks, the patient had a normal range of motion in the foot, the pain had resolved completely and the peroneal spasticity had disappeared. Orthopaedic treatment with a cast may be worth attempting before surgery in such cases.

Insulin resistance induced by olanzapine and other second-generation antipsychotics in Chinese patients with schizophrenia: a comparative review and meta-analysis

PURPOSE

This systematic review aimed to determine whether olanzapine is more likely than other second-generation antipsychotics (SGAs) to induce insulin resistance in patients with schizophrenia in China.

METHODS

We reviewed all randomized controlled trials on insulin resistance and metabolic abnormalities caused by SGAs in the PubMed, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang databases. Retrieved articles were published on or before December 2018. Meta-analysis was performed to determine the effect size of the treatment on the insulin resistance index (IRI), fasting blood glucose (FBG), and fasting insulin (FINS).

RESULTS

Forty studies (3725 participants in total) were included. All studies contained data suitable for comparing aripiprazole vs. olanzapine, ziprasidone vs. olanzapine, and risperidone vs. olanzapine. Patients treated with olanzapine had higher IRI, FBG, and FINS levels than did patients treated with aripiprazole, ziprasidone, or risperidone, with significant differences (aripiprazole vs. olanzapine: FBG: standardized mean difference [SMD] = 0.72, 95% confidence interval [95%CI] - 0.82, - 0.61; FINS: SMD = - 0.8, 95%CI - 1.00, - 0.61; IRI: SMD = - 0.80, 95%CI - 0.99, - 0.61; ziprasidone vs. olanzapine: FBG: SMD = - 1.19, 95%CI - 1.30, - 1.08; FINS: SMD = - 0.66, 95%CI - 0.85, - 0.47; IRI: SMD = - 0.71, 95%CI - 0.88, - 0.55; risperidone vs. olanzapine: FBG: SMD = - 0.17, 95%CI - 0.34, - 0.00).

CONCLUSIONS

Existing data suggest that olanzapine is associated with a significantly greater risk of IRI, FBG, and FINS, while other agents are associated with relatively lower risks. Thus, olanzapine is more likely to induce insulin resistance than are other SGAs in schizophrenic patients in China.