Consumer Interest in Total Ankle Replacements Over the Last 10 Years: A Google Trends™ Analysis From 2009 to 2019

With an aging population, the incidence of osteoarthritis (OA) continues to grow. After exhausting conservative therapy for many forms of OA, patients regularly opt for surgical intervention in the form of total joint replacement surgery. One form, total ankle replacement, has continued to gain favorability in the medical community. Improved implant design and surgical technique have enabled success rates of total ankle replacements to approach those of the hip and knee. As a new and improving therapy to address end-stage ankle OA, knowledge of patient-interest has yet to be determined. We used search inquiry data for the keywords "ankle arthritis" "ankle replacement" and "ankle fusion" available from Google Trends™ to identify trends in patient and geographic interest from 2009 to 2019. Search inquiries significantly increased for all keywords over time (p < .001). Trend analysis over this 10-year period revealed a strong correlation for ankle arthritis (0.88) and ankle replacement (0.76). Moreover, the correlation between "ankle arthritis" and "ankle replacement" was strong (0.83) during this period. The geographic distribution of these search terms showed the greatest increase in interest for the keywords "ankle arthritis" "ankle replacement" and "ankle fusion" in Arizona, New York, and Virginia respectively. Results of this study illustrate a similar increasing patient interest in ankle arthritis and ankle replacements. This data can be used effectively identify, educate, and treat populations interested in ankle replacements. To the best of our knowledge, this is the first study to utilize Google Trends™ to analyze patient interest in foot and ankle surgery.

Preliminary Report of a Hybrid Total Ankle Arthroplasty Combining a Stemmed Intramedullary Tibial Component With Chamfer-Cut Talar Dome

Total ankle arthroplasty (TAA) is a viable treatment for end-stage ankle arthritis. In our experience, a stemmed intramedullary tibial component combined with a chamfer-cut talar component provides the most stable construct for TAA. We present our technique for placement of this hybrid prosthesis utilizing the INBONE tibial component in combination with the INFINITY talar component. This technique differs from the standard protocol by minimizing use of both patient-specific and standard intraoperative guides. The primary aim of this study is to report our preliminary outcomes with our novel technique. Secondarily, we aim to demonstrate that placement of this hybrid prosthesis is radiographically reproducible and accurate. The first 10 patients undergoing this technique with at least 1 year of follow-up were retrospectively reviewed. Average visual analog pain scale decreased from 7.4 preoperatively to 0.5 at 1 year postoperatively. The average time to weightbearing was 6.4 weeks. Complications were minimal, and no implant-related complications were encountered. First weightbearing ankle radiographs postoperatively were evaluated by 3 reviewers to determine accuracy of the tibial intramedullary stem in relation to the anatomical axis of the tibia. We found that the deviation of the tibial implant from the anatomic axis was on average 0.9°± 0.5° in the coronal plane, and 2.2°± 2.7° in the sagittal plane. Inter-rater reliability was 83%. We conclude that this hybrid technique utilizing a stemmed intramedullary tibial component in combination with a chamfer-cut talar component for TAA is reproducible, accurate, and safe.

Risk Stratification for Revision Surgery Following Total Ankle Replacement

As a result of improved implants total ankle replacement (TAR) is becoming a more reliable option for end stage ankle arthritis. As with any surgery there are numerous complications that can occur intraoperatively and postoperatively with TAR. The primary aim of this study is to use recent data on implants currently on the market to develop a well-defined and comprehensive complication classification system which stratifies risk of subsequent surgery for TAR. A systematic review of studies on TARs from 2013 to 2018 was performed. Inclusion criteria were studies published between 2013 and August 2018, studies having at least 20 patients, data with at least 1-year follow-up and use of implants currently on the market. Studies were excluded if they involved revision cases, case reports, basic science articles and studies published in non-peer-reviewed journals. Sixteen studies fit inclusion criteria involving 3,305 implants. Overall survival of all implants was found to be 93% with a pooled complication rate of 75.6% using criteria for classifying complications by Glazebrook et al. Previously published classification systems did not clearly define complication categories leading to inconsistency in complication reporting and inaccurate complication rates. There are also several complications that are unclassifiable with the classifications developed by Gadd et al and Glazebrook et al. Our proposed updated classification system provides more inclusive tier profiles to capture the complications that can occur with implants currently on the market. Furthermore, this system provides a stratification of risk that these complications pose to ultimate procedure success.

Imaging pitfalls in paediatric posterior fossa neoplastic and non-neoplastic lesions

Paediatric posterior fossa lesions can have much overlap in their clinical and radiological presentation. There are, however, a number of key imaging features that can help the reading radiologist to distinguish tumours from important tumour mimics which are often inflammatory or metabolic entities. This pictorial review provides a number of important cases that proved challenging on imaging and illustrates some common pitfalls when interpreting lesions in the posterior fossa in children. Not everything that is abnormal will be a tumour, but often other causes are overlooked and misinterpreted as tumours, leading to great morbidity for that child. This article highlights some lesions that were mistaken as tumours and will introduce the reader to less commonly seen pathologies which are important to consider on a differential list for this location.

One-Year Outcome Study of Anatomic Reconstruction of Lesser Metatarsophalangeal Joints

Background: Lesser metatarsophalangeal joint (MTPJ) and plantar plate pathologies are commonly seen forefoot conditions. Traditional rebalancing techniques are commonly used but can have concerning adverse effects. The purpose of this study was to analyze the 1-year outcomes of a new technique consisting of anatomic repair of the plantar plate and collateral ligaments involving lesser MTPJs. Methodology: A retrospective cohort study of 50 consecutive patients treated with anatomic plantar plate and collateral ligament reconstruction were evaluated for lesser MTPJ imbalances between 2013 and 2016. The primary outcome was postoperative digital stability defined as a normal dorsal drawer test and normal paper pull-out test. Secondary outcomes included pre- and postoperative visual analogue scale pain measurements, MTPJ radiographic alignment, and ACFAS Forefoot module scores. Results: All patients had digital instability prior to the surgical intervention. Final follow-up revealed that 92% of patients showed improved digital stability, P = .0005. Multivariate regression found statistically significant improvement in pain reduction via the visual analogue scale of 51.2 mm (P < .0001) and ACFAS Forefoot module scores improved to 92 (P < .0001). The 45 joints with preoperative abnormal transverse plane deformity, had either complete (n = 29) or partial (n = 16) radiographic MTPJ correction. Conclusion: These results suggest that anatomic repair of lesser MTPJ improved digital stability, pain, function and radiographic alignment with greater than one year of follow-up.Levels of Evidence: Level IV: Retrospective cohort study.

Long-Term Outcomes of Corrective Osteotomies Using Porous Titanium Wedges for Flexible Flatfoot Deformity Correction

Common corrective osteotomies used in flexible flatfoot deformity reconstruction include Cotton and Evans osteotomies, which require structural graft to maintain correction. Auto-, allo-, and xenografts are associated with a number of limitations, including disease transmission, rejection, donor site morbidity, technical challenges related to graft fashioning, and graft resorption. Porous titanium is a synthetic substance designed to address these flaws; however, few studies have been reported on the efficacy, safety, and long-term outcomes. A multicenter retrospective cohort of 63 consecutive preconfigured porous titanium wedges (PTWs) used in flexible flatfoot reconstructions from June 1, 2009 to June 30, 2015 was evaluated. The primary outcome measure was the pre- to postdeformity correction efficacy. The secondary outcomes included maintenance of correction at a minimum follow-up point of 12 months, complications, graft incorporation, and graft safety profile. Multivariate linear regression found a statistically significant improvement in all radiographic parameters from preoperatively to the final weightbearing radiographs (calcaneocuboid 18.850 ± 4.020 SE, p < .0001; Kite's, 7.810 ± 3.660 SE, p = .04; Meary's 13.910 ± 3.100 SE, p = .0001; calcaneal inclination, 5.550 ± 2.140 SE, p = .015). When restricted to patients with >4 years of follow-up data, maintenance of correction appeared robust in all 4 measurements, demonstrating a lack of bone or graft resorption. No patients were lost to follow-up, no major complications or implant explantation or migration occurred, and all implants were incorporated. Minor complications included hardware pain from plates over grafts (8%), 1 case of scar neuritis, and a 5% table incidence of transfer pain associated with the PTWs. These results support the use of PTWs for safety and degree and maintenance of correction in flatfoot reconstruction.

Reproducibility and Reliability of the Radiographic Angles Used to Assess Tailor's Bunions

BACKGROUND

Tailor's bunion, or bunionette, deformity is a common condition of the lateral forefoot. To aid in assessing the deformity, radiographic angular measurements are frequently used. The objective of this study was to determine the reliability and reproducibility of these angular measurements.

METHODS

Thirty unique weightbearing dorsoplantar digital radiographs of pathologic feet were compiled. For these 30 radiographs and for ten repeated radiographs, six practicing clinicians measured the following angles: the fourth to fifth intermetatarsal angle, the lateral deviation angle, and the fifth metatarsophalangeal angle. Both traditional and modified versions of the fourth to fifth intermetatarsal angle were included.

RESULTS

Intraclass correlation coefficient values were calculated for each of the angles studied. Intrarater reliability was highest for the fifth metatarsophalangeal angle and lowest for the lateral deviation angle. Intrarater reliability was higher for the traditional fourth to fifth intermetatarsal angle than for the modified version. The interrater reliability calculations revealed parallel findings.

CONCLUSIONS

Accurate assessment is critical when planning for surgical intervention. Awareness of the relative reliability of these radiographic angular measurements can aid in preoperative planning and may be of benefit in procedure selection.

Amnion: The Ideal Scaffold for Treating Full-Thickness Wounds of the Lower Extremity

Amnion and amniotic tissue has been studied for more than 100 years in the treatment of acute and chronic wounds. Recent studies have focused on the use of amnion tissue in the management of full-thickness diabetic wounds, particularly of the lower extremities. With new harvesting, processing, and distribution technologies, amnion is increasingly available in treating these wounds. Current data and research show increased healing potential and decreased healing times, pain, drainage, and infection in wounds treated with amnion products. There are a variety of amnion products with varying differences and purposes, requiring additional research and comparison trials.

Changing trends in postoperative cataract care: impact of electronic patient records in optometrist-delivered shared care

BACKGROUND

This study evaluates a community optometrist-delivered postoperative care scheme in patients discharged from the hospital ophthalmology department following uncomplicated cataract surgery.

AIM

The aim of this study is to assess the efficacy of electronic patient records (EPR) in facilitating co-managed cataract care.

METHODS

We performed a retrospective analysis of a prospectively maintained Medisoft EPR database of postoperative cataract review data at a single centre, Sligo University Hospital (SUH), which serves a large and predominantly rural catchment area. All patients undergoing cataract surgery at SUH from October 2012 to September 2013 were included in this study. A total of 39 optometric practices, all with access to the Medisoft EPR software, participated in this pilot co-management scheme.

RESULTS

One thousand four hundred and twenty-two cataract surgeries were performed in SUH (55% female, 45% male); 1011 patients (71%) were discharged to the community on the day of cataract surgery. Complete postoperative feedback (i.e. data on refraction, visual acuity and intraocular pressure) was available in 97% of these patients compared to 50% of patients reviewed in the hospital. Patients followed up by optometrists were twice as likely to have complete postoperative clinical details (RR = 1.934, 95% CI: 1.759-2.126, p < 0.0001). Overall, 65% of operations were performed on first eyes. Hospital doctors were more likely to document requirement for second eye surgery compared to community optometrists (RR = 1.434, 95% CI: 1.302-1.580, p < 0.0001).

CONCLUSIONS

Optometrists provided an excellent postoperative care service with superior postoperative feedback rates compared to hospital doctors. EPRs facilitate a postoperative shared-care pathway that is of high quality and efficiency with major economic advantages.

Implementation of CFD modeling in the performance assessment and optimization of secondary clarifiers: the PVSC case study

The water industry and especially the wastewater treatment sector has come under steadily increasing pressure to optimize their existing and new facilities to meet their discharge limits and reduce overall cost. Gravity separation of solids, producing clarified overflow and thickened solids underflow has long been one of the principal separation processes used in treating secondary effluent. Final settling tanks (FSTs) are a central link in the treatment process and often times act as the limiting step to the maximum solids handling capacity when high throughput requirements need to be met. The Passaic Valley Sewerage Commission (PVSC) is interested in using a computational fluid dynamics (CFD) modeling approach to explore any further FST retrofit alternatives to sustain significantly higher plant influent flows, especially under wet weather conditions. In detail there is an interest in modifying and/or upgrading/optimizing the existing FSTs to handle flows in the range of 280-720 million gallons per day (MGD) (12.25-31.55 m(3)/s) in compliance with the plant's effluent discharge limits for total suspended solids (TSS). The CFD model development for this specific plant will be discussed, 2D and 3D simulation results will be presented and initial results of a sensitivity study between two FST effluent weir structure designs will be reviewed at a flow of 550 MGD (∼24 m(3)/s) and 1,800 mg/L MLSS (mixed liquor suspended solids). The latter will provide useful information in determining whether the existing retrofit of one of the FSTs would enable compliance under wet weather conditions and warrants further consideration for implementing it in the remaining FSTs.

Dielectric and thermophysical properties of meat batters over a temperature range of 5-85 °C

Dielectric (dielectric constant (ε(')) and loss factor (ε″)) and thermal (heat capacity (c), thermal conductivity (k) and thermal diffusivity (α))) properties of two meat batters (pork luncheon roll (PLR) and white pudding (WP)) were measured between 5 and 85 °C. Radio frequency (RF) and microwave (MW) ε″ values varied across 5-85 °C (P<0.05). MW ε(') and ε″ values for WP tended to peak at 45 °C and decrease thereafter, whereas for PLR, ε(') and ε″ peaked at 65 °C which appeared to match potato starch gelatinisation within this product. WP and PLR had significantly higher c values at 25 °C, which corresponded to the MP of pork fat. For PLR, an additional c peak was noted at 65 °C, which appeared to correspond to potato starch gelatinisation. At 85 °C, k values were higher (P<0.05) than at 5, 25 and 45 °C but were not higher than values at 65 °C. α values increased with temperature (P<0.05).

Cell Culture Evaluation of the Semliki Forest Virus Expression System As a Novel Approach for Antigen Delivery and Expression in Fish

Heterologous gene expression by Semliki Forest virus (SFV) expression vectors was investigated in fish cell culture. Experiments performed using an infectious strain of SFV, replication-defective SFV particles, and recombinant SFV RNA constructs encoding the Escherchia coli LacZ or firefly luciferase reporter genes indicated that levels of SFV-mediated expression in fish cells were dependent on cell type and temperature. Maximal expression levels were observed in the two salmonid-derived cell lines CHSE-214 and F95/9 at 25 degrees C and 20 degrees C. As the temperature was lowered to 15 degrees C or below, levels of reporter gene expression were reduced up to 1000-fold, indicating that the SFV replication complex functioned inefficiently at low temperatures. The ability of SFV expression systems to function in fish cells was further investigated by analyzing the expression of the protective VP2 antigen of infectious pancreatic necrosis virus (IPNV) from the various constructs, including a novel DNA-based SFV plasmid. The VP2 protein produced in CHSE-214 and F95/9 cells transfected or infected with the recombinant SFV-IPNV VP2 constructs appeared to be synthesized in an antigenically correct form, as evidenced by the ability to react with several conformation-dependent IPNV-specific monoclonal antibodies. Whether the temperature-restricted replication and expression displayed by SFV-based constructs in fish cell culture also occurs in vivo remains to be determined.

Continuous infusion cyclosporine and nifedipine to day +100 with short methotrexate and steroids as GVHD prophylaxis in unrelated donor transplants

Unrelated donor marrow transplantation is associated with an increased incidence of graft-versus-host disease (GVHD) compared with sibling donor transplants. Forty-one patients undergoing unrelated donor transplants were treated with a GVHD prophylaxis regimen that consisted of continuous infusion cyclosporine from day -1 to 100 days post transplant along with nifedipine, glucocorticoids and short-course methotrexate. The regimen was well-tolerated in this cohort with mostly high risk disease. Fifty-one percent of patients developed acute GVHD, which was grade III-IV in 22% of patients. Six of 22 patients at risk for chronic GVHD developed extensive chronic GVHD, five of whom were adults. In patients <18 years of age, there was a >40% chance of 2 year disease-free survival. Use of continuous infusion cyclosporine with nifedipine as an immunosuppressant and protectant against cyclosporine-induced toxicities in unrelated donor transplants is well-tolerated, and results in acute GVHD incidence favorable to that reported with bolus cyclosporine.

Bridging the theory-practice gap

In New Zealand, there is a festering debate over a "theory-practice gap" in nursing. Joint appointments may be a potential solution to this issue. Joint appointments refer to a variety of arrangements whereby concurrent employment occurs within an educational institution and a clinical setting. Advantages for the appointees include job satisfaction and professional growth. Clinical credibility for nurse educators enables improved facilitation of student learning. In clinical areas, benefits in patient care are associated with the marrying of academic rigour with clinical practice. Some appointees assist with staff development, act as consultants on nursing issues and undertake research. Disadvantages in the concept focus on role conflict, i.e. incongruity between the roles and role ambiguity, i.e. lack of clarity concerning expectations. Success depends upon the personal attributes of appointees; realistic expectations; flexibility to allow the concept to evolve; and support from colleagues and management. This research describes a case study of a joint appointment between a nurse lecturer and a staff nurse in an acute forensic psychiatry unit. Advantages, disadvantages and reasons for success are discussed in relation to the literature findings. (See p15-15) The discussion focuses on the need to develop research methodology to further clarify potential benefits and advantages.

Emergent cervical cerclage: predictors of success or failure

Emergent cervical cerclage is a procedure not commonly performed in general clinical practice. The outcome of pregnancies requiring emergent cerclage is based on limited information. The factors that predict success are not well known. Previous studies have suggested that advanced cervical dilation, significant cervical effacement, and the presence of prolapsed membranes are correlated with cerclage failure. We present a retrospective review of maternal characteristics predictive of perinatal survival. Analysis showed the presence of membrane prolapse to be the strongest predictor of poor outcome. Analysis also reveals a significant association between initial white blood cell count and perinatal outcome. This information may be helpful in decision making regarding adjunctive procedures such as amniocentesis and counseling patients regarding the likely outcome.

Clinical pathway development: the Overlake Model

Overlake Hospital Medical Center has developed a multi-faceted Care Management Model to improve clinical and fiscal outcomes for selected patient populations. The Clinical Pathway Component of this model has been applied to high-volume, high-loss DRG groups. Success of the program can be attributed to the unique multidisciplinary problem solving approach, team building and a focus beyond the inpatient hospital stay.

CEA-like material in cytosols from human breast carcinomas. Correlation with biochemical and pathologic parameters

CEA-like material was found in 51 of 62 primary human breast carcinomas and in only 2 of 12 fibroadenomas. Levels of carcinoma CEA-like material correlated weakly with cytoplasmic estradiol receptor levels, total cytosol estrogens, and cytosol progesterone. Levels of CEA-like material showed no significant correlation with carcinoma stage, grade, cellularity, size or histologic type. Levels, however, correlated inversely with lymphocyte infiltration.

The role of methionine in the intracellular accumulation and function of folates

It is suggested that mammalian cells have evolved to respond to methionine deficiency since in such circumstances vital methylation reactions are put at risk, due to decreased levels of S-adenosyl-methionine. Enzymatic changes occurring as a result of decreased methionine, S-adenosylmethionine and S-adenosylhomocysteine, optimize the remethylation of homocysteine to methionine by decreasing homocysteine catabolism and channelling cellular folates into 5-methyltetrahydropteroylglutamate (5-CH3-H4 PteGlu). The latter, in addition to optimising the remethylation cycle, directs the folate cofactors away from purine and pyrimidine biosynthesis and decreases the rate of proliferation of rapidly dividing cells thus reducing competition for methionine incorporation into proteins. Decreased cellular homocysteine, as a result of decreased methionine, would also restrict cell division by decreased conversion of plasma 5-CH3-H4PteGlu into intracellular polyglutamates. Cobalamin deficiency, either nutritional or due to exposure to the Co (I) cobalamin inactivating agent nitrous oxide, prevents the demethylation of 5-CH3-H4PteGlu, which even in the presence of adequate amounts of homocysteine and methionine prevents rapidly proliferating cells from converting enough of the plasma 5-CH3-H4 PteGlu into folylpolyglutamate forms to permit normal DNA biosynthesis and cell replication. This, together with the trapping of the cellular folate cofactors in the 5-CH3-H4PteGlu form, results in megaloblastic changes occurring in tissues such as the marrow. The vital role of the methylation reactions was demonstrated by exposing monkeys to nitrous oxide which inactivated their methionine synthetase. The resultant ataxia and severe demyelination was prevented and diminished by methionine supplementation. When methionine synthetase was similarly inactivated in mice it was shown that while 5-CH3-H4PteGlu enters mammalian cells, it is not converted into a polyglutamyl form and subsequently leaves the cell unmetabolised. In similar experiments in rats methionine was found to have only a small effect in restoring folylpolyglutamate biosynthesis, contrary to previous reports using nutritionally cobalamin deficient animals. It was found that a decrease in the deoxythymidine salvage pathway by methionine, under the experimental conditions used, has led others to the mistaken conclusion that methionine has an 'anti-folate' effect in bone marrow, i.e. that it decreases folate availability for thymidylate synthetase.