1
|
Lazzarini PA, Armstrong DG, Crews RT, Gooday C, Jarl G, Kirketerp-Moller K, Viswanathan V, Bus SA. Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis. Diabetes Metab Res Rev 2024; 40:e3650. [PMID: 37292021 DOI: 10.1002/dmrr.3650] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/17/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Offloading treatment is crucial to heal diabetes-related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU. METHODS We searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight-bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost-effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta-analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed. RESULTS From 19,923 studies screened, 194 eligible studies were identified (47 controlled, 147 non-controlled), 35 meta-analyses performed, and 128 evidence statements developed. We found non-removable offloading devices likely increase ulcers healed compared to removable offloading devices (risk ratio [RR] 1.24, 95% CI 1.09-1.41; N = 14, n = 1083), and may increase adherence, cost-effectiveness and decrease infections, but may increase new lesions. Removable knee-high offloading devices may make little difference to ulcers healed compared to removable ankle-high offloading devices (RR 1.00, 0.86-1.16; N = 6, n = 439), but may decrease plantar pressure and adherence. Any offloading device may increase ulcers healed (RR 1.39, 0.89-2.18; N = 5, n = 235) and cost-effectiveness compared to therapeutic footwear and may decrease plantar pressure and infections. Digital flexor tenotomies with offloading devices likely increase ulcers healed (RR 2.43, 1.05-5.59; N = 1, n = 16) and sustained healing compared to devices alone, and may decrease plantar pressure and infections, but may increase new transfer lesions. Achilles tendon lengthening with offloading devices likely increase ulcers healed (RR 1.10, 0.97-1.27; N = 1, n = 64) and sustained healing compared to devices alone, but likely increase new heel ulcers. CONCLUSIONS Non-removable offloading devices are likely superior to all other offloading interventions to heal most plantar DFU. Digital flexor tenotomies and Achilles tendon lengthening in combination with offloading devices are likely superior for some specific plantar DFU locations. Otherwise, any offloading device is probably superior to therapeutic footwear and other non-surgical offloading interventions to heal most plantar DFU. However, all these interventions have low-to-moderate certainty of evidence supporting their outcomes and more high-quality trials are needed to improve our certainty for the effectiveness of most offloading interventions.
Collapse
Affiliation(s)
- P A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - D G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, California, USA
| | - R T Crews
- Dr. William M. Scholl College of Podiatric Medicine's Center for Lower Extremity Ambulatory Research (CLEAR), Rosalind Franklin University, North Chicago, Illinois, USA
| | - C Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, Norwich, UK
| | - G Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - K Kirketerp-Moller
- Copenhagen Wound Healing Center, Bispebjerg University Hospital, Copenhagen, Denmark
- Steno Diabetes Center, Copenhagen, Denmark
| | | | - S A Bus
- Amsterdam UMC, University of Amsterdam, Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Mowrer GS, Pilla NI, Sorenson SM, Armstrong DG, Hennrikus WL. Emergency Pediatric Orthopaedic Transfer Criteria: A Pilot Study. J Surg Orthop Adv 2023; 32:182-186. [PMID: 38252606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
The purpose of this study was to define pediatric orthopaedic transfer criteria for patients coming from a smaller facility to a Level I pediatric trauma center. A 10-question phone survey was utilized for every transfer request. Fifty-eight transfer requests were prospectively collected and retrospectively reviewed. The criteria were based on The American Academy of Pediatrics (AAP) guidelines and the expert opinion of the senior author. The AAP criteria included complex fractures/dislocations and bone and joint infections. The expert opinion criteria included a patient requiring admission to the hospital or a patient needing surgery. All centers requesting transfers were staffed by an on-call board-certified general orthopaedic surgeon with the ability to care for pediatric orthopaedic injuries. Of the 58 transfers, 37 (64%) did not meet transfer criteria; 21 (36%) met transfer criteria. Transfer requests came from Emergency Department (ED) physicians in 25/58 cases (43%), physician assistants in 11/58 (19%), orthopaedic attending physicians in 3/58 (5%), and orthopaedic residents in 3/58 (5%). The orthopaedic surgeon at the referring hospital examined the patient in only six instances (10%) prior to transfer. Of the 58 patients, 18 (31%) required a hospital admission, and 17 (29%) patients were indicated for surgery. In the current study, 64% of pediatric orthopaedic transfers did not meet criteria for an inter-facility hospital to hospital transfer and were potentially avoidable. (Journal of Surgical Orthopaedic Advances 32(3):182-186, 2023).
Collapse
Affiliation(s)
- Gregory S Mowrer
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Nicholas I Pilla
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Scott M Sorenson
- Children's Health Orthopaedics, Penn State Milton S. Hershey Medical Center, Hersey, Pennsylvania
| | | | | |
Collapse
|
3
|
Pan T, Armstrong DG, Hennrikus WL. Late presenting developmental dysplasia of the hip after a normal hip ultrasound at 6 weeks of age: A report of two cases. J Paediatr Child Health 2022; 58:1887-1889. [PMID: 35635246 DOI: 10.1111/jpc.16029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/01/2022] [Indexed: 11/27/2022]
Abstract
Developmental hip dysplasia (DDH) is a paediatric condition in which the 'ball and socket' hip joint fails to form properly during infancy. The increased mechanical stress on the hip joint from DDH can contribute to the development of osteoarthritis during adulthood. Therefore, careful physical examination and imaging of all infants to diagnose DDH is critical to provide the best possible functional outcome. Ultrasonography (US) is a useful diagnostic test in providing a real-time evaluation and three-dimensional view of the hip in infants less than 4 months. In infants with a normal hip ultrasound, the risk of subsequent development of hip dysplasia at an older age and the need for further follow-up is assumed to be unnecessary. In the present study, we report 2 cases of late presenting DDH in infant girls born breech with a previous normal hip exam and normal hip ultrasound at 6 weeks of age.
Collapse
Affiliation(s)
- Tommy Pan
- Penn State College of Medicine, Hershey, Pennsylvania, United States
| | - Douglas G Armstrong
- Penn State Hershey Medical Center, Bone and Joint Institute, Hershey, Pennsylvania, United States
| | - William L Hennrikus
- Penn State Hershey Medical Center, Bone and Joint Institute, Hershey, Pennsylvania, United States
| |
Collapse
|
4
|
Pan T, Adeyemo A, Armstrong DG, Petfield JL. Neurophysiological Intraoperative Monitoring in Patients with Cochlear Implant Undergoing Posterior Spinal Fusion: A Case Report. JBJS Case Connect 2022; 12:01709767-202203000-00016. [PMID: 35050944 DOI: 10.2106/jbjs.cc.21.00609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
CASE Transcranial electric stimulation motor-evoked potentials (tcMEPs) are the most sensitive technique in multimodality intraoperative neuromonitoring (IONM) for posterior spinal fusion (PSF). The presence of a cochlear implant (CI) is considered a contraindication to IONM because of theoretical risk of implant device and local tissue damage from voltages induced by tcMEPs. We present the case of a 10-year-old girl with CI who underwent successful PSF with tcMEP and monopolar electrocautery (MoEC) without perioperative complications or CI damage. CONCLUSION With proper precautions, such as MoEC usage at a minimal voltage, motor-evoked potential monitoring can be safely performed in pediatric patients with CI undergoing PSF.
Collapse
Affiliation(s)
- Tommy Pan
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Adeshina Adeyemo
- Penn State Hershey Medical Center, Bone and Joint Institute, Hershey, Pennsylvania
| | - Douglas G Armstrong
- Penn State Hershey Medical Center, Bone and Joint Institute, Hershey, Pennsylvania
| | - Joseph L Petfield
- Penn State Hershey Medical Center, Bone and Joint Institute, Hershey, Pennsylvania
| |
Collapse
|
5
|
Armstrong DG, MacNeille R, Lehman EB, Hennrikus WL. Compartment Syndrome in Children With a Supracondylar Fracture: Not Everyone has Risk Factors. J Orthop Trauma 2021; 35:e298-e303. [PMID: 33252445 DOI: 10.1097/bot.0000000000002030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To clarify the incidence, associated conditions, and timing of fasciotomy for compartment syndrome (CS) in children with a supracondylar (SC) fracture of the humerus. DESIGN A retrospective trauma system database study. SETTING Accredited trauma centers in Pennsylvania. PATIENTS A statewide trauma database was searched for children 2-13 years of age admitted with a SC fracture between January 2001 and December 2015. Four thousand three hundred eight children met inclusion criteria. INTERVENTION Treatment of a SC fracture. MAIN OUTCOME MEASUREMENT Diagnosis of CS/performance of a fasciotomy. RESULTS During the study period, 21 (0.49%) children admitted with a SC fracture of the humerus were treated with fasciotomy. CS/fasciotomy was more likely in males (P = 0.031), those with a nerve injury (P = 0.049), and/or ipsilateral forearm fracture (P < 0.001). Vascular procedure, performed in 18 (0.42%) children, was strongly associated with CS/fasciotomy (P < 0.001). Closed reduction and fixation of a forearm fracture was associated with CS (P = 0.007). Timing of SC fracture treatment did not influence outcome. Fasciotomy was performed subsequent to reduction in 13 subjects; mean interval between procedures was 23.4 hours (r = 4.5-51.3). CONCLUSIONS Risk factors for CS exist; however, they are not required for the condition to develop. CS may develop subsequent to admission and/or SC fracture treatment. In timing of operative management and hospitalization, the results support contemporary practice. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Douglas G Armstrong
- Department of Orthopedics and Rehabilitation, PennState Health Milton S. Hershey Medical Center, Hershey, PA
| | - Rhett MacNeille
- Department of Orthopedic Surgery, Loma Linda University Health, Loma Linda, CA; and
| | - Erik B Lehman
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA
| | - William L Hennrikus
- Department of Orthopedics and Rehabilitation, PennState Health Milton S. Hershey Medical Center, Hershey, PA
| |
Collapse
|
6
|
Abstract
BACKGROUND While supracondylar (SC) fractures are relatively common in children, the incidence of open injuries is believed to be only 1%. Two prior studies on open SC fractures in children reported an increased incidence of vascular injuries. The purposes of our study were to clarify the incidence, associated conditions, and current treatment for open SC fractures. METHODS The Pennsylvania Trauma Outcome Study database was queried. Subjects age 25 to 156 months old admitted to trauma centers between January 2000 and December 2015 with a SC fracture were included. Controls were those with closed fractures and the study group, those with open injuries. Study variables were age, sex, weight, injury severity score, length of stay (LOS), nerve injury, ipsilateral forearm fracture, compartment syndrome/fasciotomy, requirement for a vascular procedure. Other variables were mode of treatment, provisional reduction, repeat reduction, time interval between referring facility admission and operation, and time from emergency department admission to operation. RESULTS A total of 4308 subjects were included, 104 (2.4%) of whom had an open SC fracture. LOS was 2 days for the study group versus 1 day for controls (P<0.001). Open SC fractures were more likely than closed to be associated with a nerve injury (13.5% vs. 3.7%), ipsilateral forearm fracture (18.3% vs. 6.4%) and/or a vascular procedure (6.7% vs. 0.3%) (P<0.001). 5.9% of those in the study group required repeat surgery compared with 0.4% for controls (P<0.001). Time from emergency department admission to operation was 3.2 versus 10.3 hours (P<0.001). CONCLUSIONS We report the largest series to date of open SC fractures in children. Surgeons caring for such patients should be aware of their increased risks for both associated injuries and potential requirement for vascular reconstruction. The majority of children with an open SC fracture are managed with 1 operation and in the absence of vascular injury, seldom require an extended LOS. LEVEL OF EVIDENCE Level III-retrospective cohort study.
Collapse
Affiliation(s)
- Douglas G Armstrong
- Department of Orthopedics and Rehabilitation, PennState Health Milton S. Hershey Medical Center
| | - Kevin Monahan
- Department of Orthopaedic Surgery, Allegheny Health Network, Pittsburgh, PA
| | - Erik B Lehman
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey
| | - William L Hennrikus
- Department of Orthopedics and Rehabilitation, PennState Health Milton S. Hershey Medical Center
| |
Collapse
|
7
|
Patel N, Hatch D, Wells CM, Ahn D, Harris M, Jennings JA, Haggard W, Armstrong DG. Characteristics and clinical assessment of antibiotic delivery by chitosan sponge in the high-risk diabetic foot: a case series. J Wound Care 2019; 26:S32-S38. [PMID: 28379101 DOI: 10.12968/jowc.2017.26.sup4.s32] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The local delivery of antimicrobials is attractive for a number of reasons. Chitosan, a biodegradable polysaccharide sponge material, has been proposed as medium to deliver antibiotics directly to wounds. In this report we evaluate the safety and practicality of antimicrobial delivery via chitosan sponge. METHOD We present the clinical course and systemic absorption characteristics of three cases of people with diabetic foot wounds treated with antibiotic soaked chitosan sponge (Sentrex BioSponge, Bionova Medical, Germantown, TN). The antibiotic sponge was made by reconstituting 1.2g tobramycin or 100mg doxycycline in 10-15ml saline and saturating the sponge with the solution. The sponge was then applied to the wounds. Serum levels of each respective antibiotic were evaluated after application. Additional in vitro studies were conducted evaluating elution of antibiotics from the chitosan sponge at established minimum inhibitory concentrations (MIC) for Staphylococcus aureus over 28 days. RESULTS No patient experienced adverse local or systemic effects due to the sponge treatment. The measured serum levels applied antibiotics remained far less than established minimums after intravenous therapy. Each patient required further treatment, however local infection or contamination resolved during the course of their hospital stay after the chitosan/antibiotic application. CONCLUSION The use of antibiotic-impregnated chitosan sponges appears a safe and effective mechanism of local delivery of antimicrobials in wounds. Future studies and clinical trials are ongoing to confirm these results and to guide clinical applications.
Collapse
Affiliation(s)
- N Patel
- Tucson Medical Center/Midwestern University Podiatry Residency, 5301 E. Grant Road, Tucson Arizona, 85733, US
| | - D Hatch
- Tucson Medical Center/Midwestern University Podiatry Residency, 5301 E. Grant Road, Tucson Arizona, 85733, US
| | - C M Wells
- MS student, The University of Memphis, Department of Biomedical Engineering, 330 Engineering Technology, 3796 Norriswood Avenue, Memphis, TN, 38152, US
| | - D Ahn
- Undergraduate Student, The University of Memphis, Department of Biomedical Engineering, 330 Engineering Technology, 3796 Norriswood Avenue, Memphis, TN, 38152, US
| | - M Harris
- Undergraduate Student, The University of Memphis, Department of Biomedical Engineering, 330 Engineering Technology, 3796 Norriswood Avenue, Memphis, TN, 38152, US
| | - J A Jennings
- The University of Memphis, Department of Biomedical Engineering, 330 Engineering Technology, 3796 Norriswood Avenue, Memphis, TN, 38152, US
| | - W Haggard
- The University of Memphis, Department of Biomedical Engineering, 330 Engineering Technology, 3796 Norriswood Avenue, Memphis, TN, 38152, US
| | - D G Armstrong
- University of Arizona Southern Arizona Limb Salvage Alliance (SALSA), 1501 N. Campbell Ave, PO box 245018, Tucson, AZ, 85724, US
| |
Collapse
|
8
|
Lazzarini PA, Pacella RE, Armstrong DG, van Netten JJ. Diabetes-related lower-extremity complications are a leading cause of the global burden of disability. Diabet Med 2018; 35:1297-1299. [PMID: 29791033 DOI: 10.1111/dme.13680] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2018] [Indexed: 12/15/2022]
Abstract
Globally ~435 million people have diabetes [1], and an estimated 19-34% (~83-148 million people) of those will be expected to develop foot ulcers in their lifetime [2]. Foot ulcers are typically precipitated by other diabetes-related lower-extremity complications, (DRLECs) including peripheral neuropathy and peripheral vascular disease [2,3]. Collectively, DRLECs are a leading cause of infection, hospitalization and amputation outcomes [2-5], yet, these outcomes are readily preventable with evidence-based care [6,7]. This suggests the burden caused by DRLECs is a large, yet reducible, cause of the global burden of disease. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- P A Lazzarini
- School of Clinical Science, Queensland University of Technology
- Allied Health Research Collaborative, Prince Charles Hospital
| | - R E Pacella
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, Queensland University of Technology
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - D G Armstrong
- Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - J J van Netten
- School of Clinical Science, Queensland University of Technology
- Department of Rehabilitation, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
9
|
Awwad AB, Hennrikus WL, Armstrong DG. Pediatric Orthopaedic Consults From Chiropractic Care. J Surg Orthop Adv 2018; 27:58-63. [PMID: 29762118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Alternative medicine in pediatrics is expanding, with chiropractic now a common choice for families seeking alternative medical care. Currently, there is sparse information in the literature exploring the role of chiropractic in orthopaedic pathology. The objective of this case series is to present pediatric patients who received treatment from chiropractors and orthopaedic physicians as well as to review the respective existing research. Data collected included chiropractic diagnosis, orthopaedic diagnosis, imaging studies, treatments, and complications. Twenty-three patients were studied. Scoliosis, Legg-Calvé-Perthes disease, developmental dysplasia of the hip, cerebral palsy, skeletal dysplasia, and slipped capital femoral epiphysis were diagnoses included. Children had multiple sessions of chiropractic for management of these conditions. The parents' perception for chiropractic was positive in every case. Delayed referral, misdiagnosis, adverse events from manipulative therapy, and ineffective treatments were observed in the present study. More research is indicated to validate chiropractic in children with orthopaedic pathology. (Journal of Surgical Orthopaedic Advances 27(1):58-63, 2018).
Collapse
Affiliation(s)
- Andy B Awwad
- Penn State College of Medicine, Hershey, Pennsylvania.
| | - William L Hennrikus
- Department of Orthopaedics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Douglas G Armstrong
- Department of Orthopaedics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| |
Collapse
|
10
|
MacLeod S, Musich S, Hawkins K, Armstrong DG. The growing need for resources to help older adults manage their financial and healthcare choices. BMC Geriatr 2017; 17:84. [PMID: 28399818 PMCID: PMC5387227 DOI: 10.1186/s12877-017-0477-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 04/05/2017] [Indexed: 11/24/2022] Open
Abstract
Background Both financial literacy (managing personal finances) and health literacy (managing personal health) become increasingly important for older adults, potentially impacting their quality of life. Resources in these constructs of literacy tend to be distinct, although the skills and decision-making involved overlap as financial issues impact healthcare choices. Thus the primary purpose of this commentary is to propose a new area of research focus that defines the intersection of financial and health literacy (i.e., financial health literacy). Methods We conducted a limited literature review related to financial, health, and health insurance literacy to demonstrate gaps in the literature and support our position. Online search engines were utilized to identify research in our primary areas of interest. Results We define the intersection of financial and health literacy as an area of need labeled financial health literacy, with a focus on four domains. These include: 1) the ability to manage healthcare expenses; 2) pay medical bills; 3) determine health needs and understand treatment options; and 4) make sound healthcare decisions with financial resources available. Despite some overlap with health insurance literacy, financial health literacy would define an area of need encompassing health management choices and health plan selections integrated with other financial management issues including living arrangements, financial planning, and retirement planning. Conclusions Potential initiatives should be considered to help at-risk older adults find resources to improve their financial health literacy, which in turn will enhance their abilities to manage medical choices in the environment of an increasingly complex healthcare system.
Collapse
Affiliation(s)
- Stephanie MacLeod
- Advanced Analytics, Optum, 315 E. Eisenhower Parkway, Suite 305, Ann Arbor, MI, 48108, USA.
| | - Shirley Musich
- Advanced Analytics, Optum, 315 E. Eisenhower Parkway, Suite 305, Ann Arbor, MI, 48108, USA
| | - Kevin Hawkins
- Advanced Analytics, Optum, 315 E. Eisenhower Parkway, Suite 305, Ann Arbor, MI, 48108, USA
| | | |
Collapse
|
11
|
Garay M, Hennrikus WL, Hess J, Lehman EB, Armstrong DG. Lawnmowers Versus Children: The Devastation Continues. Clin Orthop Relat Res 2017; 475:950-956. [PMID: 27785676 PMCID: PMC5339136 DOI: 10.1007/s11999-016-5132-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 10/14/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Accidents with lawnmowers can cause mutilating injuries to children. Safety guidelines regarding the use of lawnmowers were promoted by professional organizations beginning in 2001. The Pennsylvania Trauma Systems Foundation maintains a database including all admissions to accredited Levels 1 to 4 trauma centers in the state. The annual rates of admission for children in our state and the severity of injuries subsequent to introduction of safety guidelines have not been reported, to our knowledge. Ride-on lawnmowers have been associated with more severe injuries in children. QUESTIONS/PURPOSES We asked: (1) What was the incidence of hospital admissions for children with lawnmower-related injuries during 2002 to 2013 and did the incidence vary by age? (2) What was the severity of injuries and did the severity vary by age? (3) How often did these injuries result in amputation? (4) What types of lawnmowers were involved? METHODS This was a retrospective study using a statewide trauma registry. We queried the Pennsylvania Trauma Outcome Study database for children 0 to 17 years old admitted to trauma centers in Pennsylvania between January 2002 and January 2014 with injuries resulting from lawnmower-related accidents. All accredited Levels 1 to 4 trauma centers in the state are required to submit their data to the Pennsylvania Trauma Systems Foundation which maintains the Pennsylvania Trauma Outcome Study database. Demographic information, Injury Severity Scores, International Classification of Diseases procedure codes, and injury location codes were recorded. Type of lawnmower was determined from the narratives and was identified in 60% (119/199) of patients. Traumatic and surgical amputations performed during the index hospitalization were included in the analysis. Information on later surgeries was not available. Subjects were stratified by age: 0 to 6, 7 to 12, and 13 to 17 years old. RESULTS The incidence of lawnmower injuries in Pennsylvania was a median five of 100,000 children (range, 4-12/100,000) during the study period. The median age was 6 years (range, 1-17 years). The median Injury Severity Score was 4 (range, 1-75). Children 0 to 6 years old had higher median Injury Severity Scores (median, 8; range, 1-75) compared with those 13-17 years old (median, 4; range, 1-20; difference of the medians, 4; p < 0.001). A total of 53% of the patients (106/199) underwent at least one amputation. There were 83 amputations in or of the foot, 18 in the leg, 14 in the hand, and three in the arm. Ride-on lawnmowers accounted for 92% (110/119) of mowers identified by type. CONCLUSIONS The incidence of serious injuries to children owing to lawnmower-related trauma did not change during the 12-year study period. If children younger than 6 years had not been near the lawnmower and those younger than 12 years had not been operating one, at least 69% of the accidents might have been prevented. We recommend annual publicity campaigns during spring to remind the public of the dangers of lawnmowers to children. LEVEL OF EVIDENCE Level IV, therapeutic study.
Collapse
Affiliation(s)
- Mariano Garay
- grid.29857.310000000120974281Penn State Hershey College of Medicine, Hershey, PA USA
| | - William L. Hennrikus
- grid.240473.60000000405439901Department of Orthopaedic Surgery, Penn State Hershey Medical Center, 30 Hope Drive, Building A, Hershey, PA 17033 USA
| | - Joseph Hess
- grid.240473.60000000405439901Division of Pediatric Surgery, Penn State Hershey Children’s Hospital, Hershey, PA USA
| | - Erik B. Lehman
- grid.29857.310000000120974281Department of Public Health Sciences, Pennsylvania State University, Milton Hershey Medical Center, Hershey, PA USA
| | - Douglas G. Armstrong
- grid.240473.60000000405439901Department of Orthopaedic Surgery, Penn State Hershey Medical Center, 30 Hope Drive, Building A, Hershey, PA 17033 USA
| |
Collapse
|
12
|
Deng W, Boey J, Chen B, Byun S, Lew E, Liang Z, Armstrong DG. Platelet-rich plasma, bilayered acellular matrix grafting and negative pressure wound therapy in diabetic foot infection. J Wound Care 2017; 25:393-7. [PMID: 27410393 DOI: 10.12968/jowc.2016.25.7.393] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
UNLABELLED Management and treatment of acute severe diabetic foot disease in patients with suboptimal glycaemic control is a critical issue in wound repair. This paper discusses the clinical efficacy of an aggressive surgical intervention combined with targeted use of regenerative medical therapies in limb preservation. Negative pressure wound therapy (NPWT), platelet-rich plasma (PRP), bilayered acellular matrix grafting and split-thickness skin grafting were combined to treat a patient with diabetes, foot necrotising fasciitis and gaseous gangrene. The wound was completely healed. The clinical outcome revealed that a multi-intervention strategy could be effective for large necrotising fasciitis wounds. Early clinical observation, suggests aggresive surgical intervention preserving intact tissue and targeted use of new regenerative technologies can lead to preservation of a limb. DECLARATION OF INTEREST The authors have received no financial support for the material presented in this study outside of the scope of standard patient care reimbursement. This work was supported by the National Natural Science Foundation of China (NO. 81500596) awarded to Dr Wuquan Deng.
Collapse
Affiliation(s)
- W Deng
- Department of Endocrinology, Diabetic Foot Center, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - J Boey
- Department of Podiatry, Singapore General Hospital, Singapore
| | - B Chen
- Department of Endocrinology, Diabetic Foot Center, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - S Byun
- Department of Surgery, Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | - E Lew
- Department of Surgery, Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | - Z Liang
- Department of Endocrinology, Diabetic Foot Center, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - D G Armstrong
- Department of Surgery, Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona Health Sciences Center, Tucson, Arizona, USA
| |
Collapse
|
13
|
Fanelli MG, Hennrikus WL, Slough Hill JM, Armstrong DG, King SH. The Mini C-arm Adds Quality and Efficiency to the Pediatric Orthopedic Outpatient Clinic. Orthopedics 2016; 39:e1097-e1099. [PMID: 27504650 DOI: 10.3928/01477447-20160808-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/28/2016] [Indexed: 02/03/2023]
Abstract
The mini C-arm has become increasingly popular in the practice of orthopedics. To the authors' knowledge, its use in the pediatric orthopedic outpatient clinic has not been reported. The purpose of this study was to evaluate the practice efficiency and radiation exposure to the patient when the mini C-arm was used in the pediatric orthopedic outpatient clinic. One hundred consecutive midshaft and distal forearm fractures were evaluated by one orthopedic surgeon in follow-up using a mini C-arm. For each case, the radiation physicist calculated the amount of skin exposure in milligray (mGy). The average skin exposure to the patient from the mini C-arm was 0.58 mGy, compared with 0.2 mGy for anteroposterior view and lateral view radiographs. Use of the mini C-arm, in place of plain radiographs obtained in the radiology department, decreased time waiting during clinic visits by 23 minutes. This study reports 2 important findings. First, surprisingly, the mini C-arm used a slightly higher radiation dose than standard imaging with plain radiographs. Second, use of the mini C-arm saved time and improved the efficiency of the clinic visit. Overall, the mini C-arm improves quality and efficiency in the pediatric orthopedic outpatient clinic. [Orthopedics. 2016; 39(6):e1097-e1099.].
Collapse
|
14
|
Armstrong DG. CORR Insights(®): Is Assessment of Femoral Head Perfusion During Modified Dunn for Unstable Slipped Capital Femoral Epiphysis an Accurate Indicator of Osteonecrosis? Clin Orthop Relat Res 2016; 474:1845-6. [PMID: 27146656 PMCID: PMC4925418 DOI: 10.1007/s11999-016-4869-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 04/26/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Douglas G. Armstrong
- Pediatric Orthopaedic Surgery, Hershey Medical Center, 30 Hope Drive, P.O. Box 859, Hershey, PA 17033 USA
| |
Collapse
|
15
|
|
16
|
Bus SA, van Deursen RW, Armstrong DG, Lewis JEA, Caravaggi CF, Cavanagh PR. Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes Metab Res Rev 2016; 32 Suppl 1:99-118. [PMID: 26342178 DOI: 10.1002/dmrr.2702] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Footwear and offloading techniques are commonly used in clinical practice for preventing and healing of foot ulcers in persons with diabetes. The goal of this systematic review is to assess the medical scientific literature on this topic to better inform clinical practice about effective treatment. METHODS We searched the medical scientific literature indexed in PubMed, EMBASE, CINAHL, and the Cochrane database for original research studies published since 1 May 2006 related to four groups of interventions: (1) casting; (2) footwear; (3) surgical offloading; and (4) other offloading interventions. Primary outcomes were ulcer prevention, ulcer healing, and pressure reduction. We reviewed both controlled and non-controlled studies. Controlled studies were assessed for methodological quality, and extracted key data was presented in evidence and risk of bias tables. Uncontrolled studies were assessed and summarized on a narrative basis. Outcomes are presented and discussed in conjunction with data from our previous systematic review covering the literature from before 1 May 2006. RESULTS We included two systematic reviews and meta-analyses, 32 randomized controlled trials, 15 other controlled studies, and another 127 non-controlled studies. Several randomized controlled trials with low risk of bias show the efficacy of therapeutic footwear that demonstrates to relief plantar pressure and is worn by the patient, in the prevention of plantar foot ulcer recurrence. Two meta-analyses show non-removable offloading to be more effective than removable offloading for healing plantar neuropathic forefoot ulcers. Due to the limited number of controlled studies, clear evidence on the efficacy of surgical offloading and felted foam is not yet available. Interestingly, surgical offloading seems more effective in preventing than in healing ulcers. A number of controlled and uncontrolled studies show that plantar pressure can be reduced by several conservative and surgical approaches. CONCLUSIONS Sufficient evidence of good quality supports the use of non-removable offloading to heal plantar neuropathic forefoot ulcers and therapeutic footwear with demonstrated pressure relief that is worn by the patient to prevent plantar foot ulcer recurrence. The evidence base to support the use of other offloading interventions is still limited and of variable quality. The evidence for the use of interventions to prevent a first foot ulcer or heal ischemic, infected, non-plantar, or proximal foot ulcers is practically non-existent. High-quality controlled studies are needed in these areas.
Collapse
Affiliation(s)
- S A Bus
- Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - R W van Deursen
- School of Health Care Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - D G Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, Arizona, USA
| | - J E A Lewis
- Cardiff and Vale University Health Board and Cardiff School of Health Science, Cardiff Metropolitan University, Cardiff, UK
| | - C F Caravaggi
- University Vita Salute San Raffaele and Diabetic Foot Clinic, Istituto Clinico Città, Studi, Milan, Italy
| | - P R Cavanagh
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Centre, Seattle, WA, USA
| |
Collapse
|
17
|
Bus SA, Armstrong DG, van Deursen RW, Lewis JEA, Caravaggi CF, Cavanagh PR. IWGDF guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes. Diabetes Metab Res Rev 2016; 32 Suppl 1:25-36. [PMID: 26813614 DOI: 10.1002/dmrr.2697] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- S A Bus
- Department of Rehabilitation Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - D G Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - R W van Deursen
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - J E A Lewis
- Cardiff and Vale University Health Board and Cardiff School of Health Science, Cardiff Metropolitan University, Cardiff, UK
| | - C F Caravaggi
- Vita-Salute San Raffaele University, Milan, Italy
- Diabetic Foot Clinic, Istituto Clinico Città Studi, Milan, Italy
| | - P R Cavanagh
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
| |
Collapse
|
18
|
Armstrong DG, Hanft JR, Driver VR, Smith APS, Lazaro-Martinez JL, Reyzelman AM, Furst GJ, Vayser DJ, Cervantes HL, Snyder RJ, Moore MF, May PE, Nelson JL, Baggs GE, Voss AC. Effect of oral nutritional supplementation on wound healing in diabetic foot ulcers: a prospective randomized controlled trial. Diabet Med 2014; 31:1069-77. [PMID: 24867069 PMCID: PMC4232867 DOI: 10.1111/dme.12509] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 02/11/2014] [Accepted: 05/21/2014] [Indexed: 12/17/2022]
Abstract
AIMS Among people with diabetes, 10-25% will experience a foot ulcer. Research has shown that supplementation with arginine, glutamine and β-hydroxy-β-methylbutyrate may improve wound repair. This study tested whether such supplementation would improve healing of foot ulcers in persons with diabetes. METHODS Along with standard of care, 270 subjects received, in a double-blinded fashion, (twice per day) either arginine, glutamine and β-hydroxy-β-methylbutyrate or a control drink for 16 weeks. The proportion of subjects with total wound closure and time to complete healing was assessed. In a post-hoc analysis, the interaction of serum albumin or limb perfusion, as measured by ankle-brachial index, and supplementation on healing was investigated. RESULTS Overall, there were no group differences in wound closure or time to wound healing at week 16. However, in subjects with an albumin level of ≤ 40 g/l and/or an ankle-brachial index of < 1.0, a significantly greater proportion of subjects in the arginine, glutamine and β-hydroxy-β-methylbutyrate group healed at week 16 compared with control subjects (P = 0.03 and 0.008, respectively). Those with low albumin or decreased limb perfusion in the supplementation group were 1.70 (95% CI 1.04-2.79) and 1.66 (95% CI 1.15-2.38) times more likely to heal. CONCLUSIONS While no differences in healing were identified with supplementation in non-ischaemic patients or those with normal albumin, addition of arginine, glutamine and β-hydroxy-β-methylbutyrate as an adjunct to standard of care may improve healing of diabetic foot ulcers in patients with risk of poor limb perfusion and/or low albumin levels. Further investigation involving arginine, glutamine and β-hydroxy-β-methylbutyrate in these high-risk subgroups might prove clinically valuable.
Collapse
Affiliation(s)
- D G Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Liu RW, Armstrong DG, Levine AD, Gilmore A, Thompson GH, Cooperman DR. An anatomic study of the epiphyseal tubercle and its importance in the pathogenesis of slipped capital femoral epiphysis. J Bone Joint Surg Am 2013; 95:e341-8. [PMID: 23515995 DOI: 10.2106/jbjs.l.00474] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND It has been proposed that the epiphyseal tubercle on the inferior surface of the capital femoral epiphysis may be responsible for the clinical distinction between a stable and an unstable slipped capital femoral epiphysis (SCFE). The anatomy of the tubercle and its relationship to the lateral epiphyseal vessels have not previously been rigorously defined. METHODS Twenty-two cadaveric capital femoral epiphyses from donors who had been three to seventeen years of age were analyzed and then digitized with use of a high-resolution laser scanner. The height, location, and approximate surface area of the epiphyseal tubercle were measured and were normalized to the size of the entire capital femoral epiphysis. RESULTS In all specimens except that from the youngest donor, the foramina for the lateral epiphyseal vessels were visible and were located directly superior to the epiphyseal tubercle. The height of the epiphyseal tubercle was 4.4 ± 1.1 mm. When normalized to the overall size of the capital femoral epiphysis, the relative height (r = 0.71) and relative area (r = 0.56) of the epiphyseal tubercle decreased with increasing age. The epiphyseal tubercle was consistently located in the posterosuperior quadrant, with its position being more posterior and less superior in specimens from younger donors. CONCLUSIONS The epiphyseal tubercle appears to be a major stabilizer, or keystone, of the capital femoral epiphysis and the lateral epiphyseal vessels. Its relative decrease in height and surface area with increasing age may help explain the susceptibility of individuals to SCFE in adolescence: in a stable SCFE, the physis rotates on the tubercle; however, in an unstable SCFE, the tubercle dislodges, leading to more substantial displacement of the capital femoral epiphysis and the lateral epiphyseal vessels, risking osteonecrosis.
Collapse
Affiliation(s)
- Raymond W Liu
- Division of Pediatric Orthopaedic Surgery, Case Western Reserve University, 11100 Euclid Avenue, RBC 6081, Cleveland, OH 44106, USA.
| | | | | | | | | | | |
Collapse
|
20
|
Game FL, Hinchliffe RJ, Apelqvist J, Armstrong DG, Bakker K, Hartemann A, Löndahl M, Price PE, Jeffcoate WJ. Specific guidelines on wound and wound-bed management 2011. Diabetes Metab Res Rev 2012; 28 Suppl 1:232-3. [PMID: 22271743 DOI: 10.1002/dmrr.2250] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- F L Game
- Foot Ulcer Trials Unit, Nottingham University Hospitals Trust, Nottingham, UK.
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Game FL, Hinchliffe RJ, Apelqvist J, Armstrong DG, Bakker K, Hartemann A, Löndahl M, Price PE, Jeffcoate WJ. A systematic review of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 2012; 28 Suppl 1:119-41. [PMID: 22271737 DOI: 10.1002/dmrr.2246] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The outcome of management of diabetic foot ulcers is poor, and there is continuing uncertainty concerning optimal approaches to management. It was for these reasons that in 2006 the International Working Group of the Diabetic Foot (IWGDF) working group on wound healing undertook a systematic review of the evidence to inform protocols for routine care and to highlight areas which should be considered for further study. The same working group has now updated this review by considering papers on the interventions to improve the healing of chronic ulcers published between December 2006 and June 2010. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network criteria. Selected studies fell into the following ten categories: sharp debridement and wound bed preparation with larvae and hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; hyperbaric oxygen therapy (HBOT); compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, electromagnetic, lasers, shockwaves and ultrasound; other systemic therapies which did not fit in the above categories. Heterogeneity of studies prevented pooled analysis of results. Of the 1322 papers identified, 43 were selected for grading following full text review. The present report is an update of the earlier IWGDF systematic review, but the conclusion is similar: that with the exception of HBOT and, possibly, negative pressure wound therapy, there is little published evidence to justify the use of newer therapies. This echoes the conclusion of a recent Cochrane review and the systematic review undertaken by the National Institute for Health and Clinical Excellence Guidelines Committee in the UK. Analysis of evidence presents considerable difficulties in this field particularly as controlled studies are few and the majority are of poor methodological quality.
Collapse
Affiliation(s)
- F L Game
- Foot Ulcer Trials Unit, Nottingham University Hospitals Trust, Nottingham, UK.
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
AIMS Several authors have discussed an early prodromal state of neuroarthropathy (stage 0 Charcot) prior to the development of frank radiographic changes. However, very few reports are available that detail the outcomes of these patients. The purpose of this study was to report on the outcomes of patients with undetected early Charcot neuroarthropathy of the foot. METHODS Twenty patients, from two health science centres, were diagnosed retrospectively with stage 0 Charcot neuroarthropathy and were managed after referral from outside facilities. We evaluated any complications, including ulcer formation, infection, progression into active Charcot neuroarthropathy and the need for surgical reconstruction. Patients who did not progress to an active Charcot neuroarthropathy (Group I) were compared with those (Group II) who did progress to the destructive phase. RESULTS The diagnosis of Charcot neuroarthropathy was missed in 19 of 20 patients prior to referral. The average delay in treatment in Group I was 4.1±0.7 weeks compared with 8.7±6.8 weeks in Group II (Mann-Whitney U-test=24.5, n(1) =15, n(2) =7, P<0.05 two-tailed). Sixteen of 22 feet (72%) developed a complication during their treatment course. Group II experienced more complications than Group I (66.7% compared with 14.3%). Overall, eleven of 22 feet (50%) required surgical treatment; however, no patient required an amputation during the follow-up course. CONCLUSIONS This study reveals that outcomes of stage 0 Charcot neuroarthropathy feet depend on proper recognition and early management. To reduce the rate of future complications for Charcot foot should be the goal of all treatment.
Collapse
Affiliation(s)
- D K Wukich
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
| | | | | | | |
Collapse
|
23
|
|
24
|
Aragón-Sánchez FJ, Cabrera-Galván JJ, Quintana-Marrero Y, Hernández-Herrero MJ, Lázaro-Martínez JL, García-Morales E, Beneit-Montesinos JV, Armstrong DG. Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement. Diabetologia 2008; 51:1962-70. [PMID: 18719880 DOI: 10.1007/s00125-008-1131-8] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Accepted: 07/25/2008] [Indexed: 12/29/2022]
Abstract
AIMS/HYPOTHESIS We analysed the factors that determine the outcomes of surgical treatment of osteomyelitis of the foot in diabetic patients given early surgical treatment within 12 h of admission and treated with prioritisation of foot-sparing surgery and avoidance of amputation. METHODS A consecutive series of 185 diabetic patients with foot osteomyelitis and histopathological confirmation of bone involvement were followed until healing, amputation or death. RESULTS Probing to bone was positive in 175 cases (94.5%) and radiological signs of osteomyelitis were found in 157 cases (84.8%). Staphylococcus aureus was the organism isolated in the majority of cultures (51.3%), and in 35 cases (36.8%) it proved to be methicillin-resistant. The surgical treatment performed included 91 conservative surgical procedures, which were defined as those where no amputation of any part of the foot was undertaken (49.1%). A total of 94 patients received some degree of amputation, consisting of 79 foot-level (minor) amputations (42.4%) and 15 major amputations (8%). Five patients died during the perioperative period (2.7%). Histopathological analysis revealed 94 cases (50.8%) of acute osteomyelitis, 43 cases (23.2%) of chronic osteomyelitis, 45 cases (24.3%) of acute exacerbation of chronic osteomyelitis and three remaining cases (1.6%) designated as 'other'. The risks of failure in the case of conservative surgery were exposed bone, the presence of ischaemia and necrotising soft tissue infection. CONCLUSIONS/INTERPRETATION Conservative surgery without local or high-level amputation is successful in almost half of the cases of diabetic foot osteomyelitis. Prospective trials should be undertaken to determine the relative roles of conservative surgery versus other approaches.
Collapse
|
25
|
Boulton AJM, Armstrong DG, Baker NR, Rayman G. Diabetic podopathy--no thanks! Diabetologia 2008; 51:1085-6; author reply 1087. [PMID: 18330542 DOI: 10.1007/s00125-008-0978-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Accepted: 02/18/2008] [Indexed: 10/22/2022]
|
26
|
Hinchliffe RJ, Valk GD, Apelqvist J, Armstrong DG, Bakker K, Game FL, Hartemann-Heurtier A, Löndahl M, Price PE, van Houtum WH, Jeffcoate WJ. A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 2008; 24 Suppl 1:S119-44. [PMID: 18442185 DOI: 10.1002/dmrr.825] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The outcome of management of diabetic foot ulcers is poor and there is uncertainty concerning optimal approaches to management. We have undertaken a systematic review to identify interventions for which there is evidence of effectiveness. A search was made for reports of the effectiveness of interventions assessed in terms of healing, ulcer area or amputation in controlled clinical studies published prior to December 2006. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network (SIGN) criteria. Selected studies fell into the following categories: sharp debridement and larvae; antiseptics and dressings; chronic wound resection; hyperbaric oxygen (HBO); reduction of tissue oedema; skin grafts; electrical and magnetic stimulation and ultrasound. Heterogeneity of studies prevented pooled analysis of results. Of the 2251 papers identified, 60 were selected for grading following full text review. Some evidence was found to support hydrogels as desloughing agents and to suggest that a systemic (HBO) therapy may be effective. Topical negative pressure (TNP) may promote healing of post-operative wounds, and resection of neuropathic plantar ulcers may be beneficial. More information was needed to confirm the effectiveness and cost-effectiveness of these and other interventions. No data were found to justify the use of any other topically applied product or dressing, including those with antiseptic properties. Further evidence to substantiate the effect of interventions designed to enhance the healing of chronic ulcers is urgently needed. Until such evidence is available from robust trials, there is limited justification for the use of more expensive treatments and dressings.
Collapse
Affiliation(s)
- R J Hinchliffe
- Department of Vascular Surgery, Nottingham University Hospitals Trust, Nottingham, UK
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Bus SA, Valk GD, van Deursen RW, Armstrong DG, Caravaggi C, Hlavácek P, Bakker K, Cavanagh PR. The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes Metab Res Rev 2008; 24 Suppl 1:S162-80. [PMID: 18442178 DOI: 10.1002/dmrr.850] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Footwear and offloading techniques are commonly used in clinical practice for the prevention and treatment of foot ulcers in diabetes, but the evidence base to support this use is not well known. The goal of this review was to systematically assess the literature and to determine the available evidence on the use of footwear and offloading interventions for ulcer prevention, ulcer treatment, and plantar pressure reduction in the diabetic foot. METHODS A search was made for reports on the effectiveness of footwear and offloading interventions in preventing or healing foot ulcers or reducing plantar foot pressure in diabetic patients published prior to May 2006. Both controlled and uncontrolled studies were included. Assessment of the methodological quality of studies and data extraction was independently performed by two reviewers. Interventions were assigned into four subcategories: casting, footwear, surgical offloading and other offloading techniques. RESULTS Of 1651 articles identified in the baseline search, 21 controlled studies were selected for grading following full text review. Another 108 uncontrolled and cross-sectional studies were examined. The evidence to support the use of footwear and surgical interventions for the prevention of ulceration is meagre. Evidence was found to support the use of total contact casts and other non-removable modalities for treatment of neuropathic plantar ulcers. More studies are needed to support the use of surgical offloading techniques for ulcer healing. Plantar pressure reduction can be achieved by several modalities including casts, walkers, and therapeutic footwear, but the diversity in methods and materials used limits the comparison of study results. CONCLUSIONS This systematic review provides support for the use of non-removable devices for healing plantar foot ulcers. Furthermore, more high-quality studies are urgently needed to confirm the promising effects found in both controlled and uncontrolled studies of footwear and offloading interventions designed to prevent ulcers, heal ulcers, or reduce plantar pressure.
Collapse
Affiliation(s)
- S A Bus
- Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Bus SA, Valk GD, van Deursen RW, Armstrong DG, Caravaggi C, Hlavácek P, Bakker K, Cavanagh PR. Specific guidelines on footwear and offloading. Diabetes Metab Res Rev 2008; 24 Suppl 1:S192-3. [PMID: 18442186 DOI: 10.1002/dmrr.855] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- S A Bus
- Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Hinchliffe RJ, Valk GD, Apelqvist J, Armstrong DG, Bakker K, Game FL, Hartemann-Heurtier A, Löndahl M, Price PE, van Houtum WH, Jeffcoate WJ. Specific guidelines on wound and wound-bed management. Diabetes Metab Res Rev 2008; 24 Suppl 1:S188-9. [PMID: 18442188 DOI: 10.1002/dmrr.854] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- R J Hinchliffe
- Department of Vascular Surgery, Nottingham University Hospitals Trust, Nottingham, UK
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Armstrong DG. Guest Editorial: time and place-shifting the physical examination: technologies are converging to allow more detailed evaluations of the foot and wound. Int Wound J 2008; 4:289-90. [PMID: 18154622 DOI: 10.1111/j.1742-481x.2007.00375.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
|
31
|
Liu RW, Mehta P, Fortuna S, Armstrong DG, Cooperman DR, Thompson GH, Gilmore A. A randomized prospective study of music therapy for reducing anxiety during cast room procedures. J Pediatr Orthop 2008; 27:831-3. [PMID: 17878794 DOI: 10.1097/bpo.0b013e3181558a4e] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cast room procedures, such as cast application and removal, pin removal, and suture removal can cause significant anxiety in young children. The use of music therapy in the cast room to decrease anxiety has not been previously reported. METHODS We performed a randomized, prospective study of soft lullaby music compared with no music in 69 children 10 years or younger undergoing cast room procedures. Heart rates (beats per minute) were recorded in the waiting room and cast room using a pulse oximeter. RESULTS A total of 28 children were randomized to music and 41 children to no music. The mean rise in heart rate between the waiting room and entering the cast room was -2.7 beats/min in the music group and 4.7 beats/min in the no music group (P = 0.001). The mean difference in heart rate between the waiting room and during the procedure was 15.3 beats/min in the music group and 22.5 beats/min in the no music group (P = 0.05). There were 7 patients in the no music group with heart rate increases of greater than 40 beats/min. No patient in the music group had an increase of this magnitude. CONCLUSIONS Playing soft music in the cast room is a simple and inexpensive option for decreasing anxiety in young children during cast room procedures. LEVEL OF EVIDENCE Randomized Clinical Trial, Level II.
Collapse
Affiliation(s)
- Raymond W Liu
- Department of Orthopaedics, Case Western Reserve University, Cleveland, OH 44106, USA
| | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
This retrospective analysis included 36 patients who presented with late-onset tibia vara during a 15-year period. Mean patient age at presentation was 12.8 years. Seventy-eight percent of patients were male, 78% were black, and 72% presented with unilateral deformity. Mean initial varus was 21 degrees with 5.8 degrees at the femur and 12.3 degrees at the tibia. Surgical correction was performed in 31 patients; 5 patients refused surgery. Patients who had osteotomies had a higher rate of complications than those treated with stapling. Epiphyseal stapling has unpredictable results in patients with late-onset tibia vara and is only a temporizing procedure in approximately half of cases. None of the treatments resulted in optimal knee function or alignment, and the long-term prognosis for late-onset tibia vara is guarded at best.
Collapse
Affiliation(s)
- Michael A Rauh
- Department of Orthopedic Surgery, State University of New York at Buffalo, Kaleida Health System, Women's and Children's Hospital of Buffalo, Buffalo, New York, USA
| | | |
Collapse
|
33
|
Armstrong DG. Healing and preventing the diabetic foot wound: where technology, economics and common sense converge. Indian J Med Sci 2007; 61:324-5. [PMID: 17558094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
|
34
|
Janicki JA, Poe-Kochert C, Armstrong DG, Thompson GH. A comparison of the thoracolumbosacral orthoses and providence orthosis in the treatment of adolescent idiopathic scoliosis: results using the new SRS inclusion and assessment criteria for bracing studies. J Pediatr Orthop 2007; 27:369-74. [PMID: 17513954 DOI: 10.1097/01.bpb.0000271331.71857.9a] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
UNLABELLED This is a retrospective cohort study comparing the effectiveness of the thoracolumbosacral orthosis (TLSO) and the Providence orthosis in the treatment of adolescent idiopathic scoliosis (AIS) using the new Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management inclusion and assessment criteria for bracing studies. These new criteria will make future studies comparable and more valid and accurate. METHODS We have used a custom TLSO (duration, 22 hours/day) and the Providence orthosis (duration, 8-10 hours/night) to control progressive AIS curves. Only 83 of 160 patients met the new SRS inclusion criteria: age of 10 years and older at initiation of bracing; initial curve of 25 to 40 degrees; Risser sign 0 to 2; female; premenarcheal or less than 1 year past menarche; and no previous treatment. There were 48 patients in the TLSO group and 35 in the Providence group. The new SRS assessment criteria of effectiveness included the percentage of patients who had 5 degrees or less and 6 degrees or more of curve progression at maturity, the percentage of patients whose curve progressed beyond 45 degrees, the percentage of patients who had surgery recommended or undertaken, and a minimum of 2 years of follow-up beyond maturity in those patients who were thought to have been successfully treated. All patients are evaluated regardless of compliance (intent to treat). RESULTS There were no significant differences in age at brace initiation, initial primary curve magnitude, sex, or initial Risser sign between the 2 groups. In the TLSO group, only 7 patients (15%) did not progress (<or=5 degrees), whereas 41 patients (85%) progressed by 6 degrees or more, including the 30 patients whose curves exceeded 45 degrees. Thirty-eight patients (79%) required surgery. In the Providence group, 11 patients (31%) did not progress, whereas 24 patients (69%) progressed by 6 degrees or more, including 15 patients whose curves exceeded 45 degrees. Twenty-one patients (60%) required surgery. However, when the initial curve at initiation of bracing was 25 to 35 degrees, the results improved. Five (15%) of 34 patients in the TLSO group and 10 (42%) of 24 patients in the Providence group did not progress, whereas 29 patients (85%) and 14 patients (58%), respectively, progressed by 6 degrees or more, and 26 patients (76%) and 11 patients (46%), respectively, required surgery. CONCLUSIONS Using the new SRS bracing criteria, the Providence orthosis was more effective for avoiding surgery and preventing curve progression when the primary initial curves at bracing was 35 degrees or less. However, the overall success of orthotic management for AIS in both groups was inferior to previous studies. Our results raise the question of the effectiveness of orthotic management in AIS and support the need for a multicenter, randomized study using these new criteria.
Collapse
Affiliation(s)
- Joseph A Janicki
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH 44106, USA
| | | | | | | |
Collapse
|
35
|
Abstract
STUDY DESIGN Prospective evaluation of fibrinogen levels before surgery and after surgery in patients with idiopathic scoliosis undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) who received Amicar to decrease perioperative blood loss. OBJECTIVES To assess a possible association between postoperative fibrinogen levels and Amicar administration. SUMMARY OF BACKGROUND DATA Our previous randomized, double-blind (Amicar and control) study demonstrated a rise in fibrinogen levels on the first postoperative day in the Amicar group, but not in the control group. Fibrinogen levels were not measured on the remaining postoperative days. We subsequently measured fibrinogen levels on all postoperative days in 21 consecutive patients with idiopathic scoliosis and found a dramatic increase throughout the postoperative hospitalization. This study is a continuation of our analysis of postoperative fibrinogen levels. METHODS We analyzed fibrinogen levels before surgery and on all postoperative days (4 or 5 days) until discharge in 51 consecutive patients, including our 21 previously reported patients, who received Amicar and underwent a PSF and SSI. We also analyzed the same factors with respect to perioperative blood loss as in our previous Amicar studies. RESULTS There were 41 females and 10 males with a mean age at surgery of 14.2 +/- 1.8 years. Their mean hospitalization was 4.6 +/- 0.8 days. Their mean estimated intraoperative blood loss was 766 +/- 308 mL and postoperative suction drainage 532 +/- 186 mL for a total perioperative blood loss of 1297 +/- 311 mL. The perioperative transfusion requirements were 0.5 +/- 0.6 U per patient. The preoperative fibrinogen was 255.5 +/- 58.3 mg/dL, and it rose steadily throughout the postoperative period to 680.9 +/- 111.9 mg/dL on the fifth postoperative day. There were no complications related to the use of Amicar. CONCLUSIONS Fibrinogen levels rise steadily throughout the postoperative period. The significance of this increase is unknown. Was it due to the use of Amicar or just the effects of surgery itself? Further investigations will be necessary.
Collapse
Affiliation(s)
- George H Thompson
- Division of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH 44106, USA.
| | | | | | | |
Collapse
|
36
|
Wera GD, Friess DM, Getty PO, Armstrong DG, Lacey SH, Baele HR. Fracture of the proximal humerus with injury to the axillary artery in a boy aged 13 years. ACTA ACUST UNITED AC 2006; 88:1521-3. [PMID: 17075102 DOI: 10.1302/0301-620x.88b11.18164] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Fractures of the proximal humerus with concomitant vascular injury are rare in children. We describe the presentation, diagnosis, and treatment of a fracture of the proximal humerus in association with an axillary artery injury in a child.
Collapse
Affiliation(s)
- G D Wera
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, USA.
| | | | | | | | | | | |
Collapse
|
37
|
Abstract
The following finite element study was conducted to determine whether increased body weight, femoral retroversion, and varus hip loading could sufficiently raise physeal shear strains and stresses above the yield point and predispose an adolescent hip to a slip. A computer tomography scan of a 13-year-old child with slipped capital femoral epiphysis was used to generate a solid model of the proximal femur and physis. The model was parameterized using 3-dimensional software to generate three difference angles of femoral neck version-neutral, 15 degrees retroversion, and 15 degrees anteversion. Loads of 2.7 times body weight in a 46- and 86-kg child were applied to the proximal femur to model stance on one leg. In addition, the loading vector was reoriented at various degrees of varus to study the effect of varus loading on physis shear. The results demonstrated that physis stress, strain, and displacement increased with greater body weight, retroversion, and varus displacement of the loading vector. Physis shear strain in hips with a combination of varus loading and femoral neck retroversion exceeded the reported ultimate strain values for cartilaginous soft tissues. The finite element models suggest that in an overweight child, the combination of retroversion and varus hip load may be sufficient to increase physeal strains above the yield point and result in a slip.
Collapse
Affiliation(s)
- Zair Fishkin
- Department of Orthopaedic Surgery, University at Buffalo, Buffalo, NY, and Department of Orthopaedics, Rainbow Babies and Children's Hospital, Cleveland, Ohio 44139, USA
| | | | | | | | | |
Collapse
|
38
|
Abstract
BACKGROUND Various methods of cast immobilization have been recommended for the treatment of distal forearm fractures in children. The purpose of this study was to determine if short arm casts are as effective as long arm casts in the treatment of displaced fractures of the distal third of the forearm in these patients. METHODS In a prospective randomized trial, consecutive patients, four years of age or older, who presented to The Women's and Children's Hospital of Buffalo with a displaced fracture of the distal third of the forearm were randomized to treatment with a short or long arm plaster cast. Radiographs were analyzed for displacement, angulation, and deviation at the time of injury, after reduction, and at subsequent follow-up intervals. The cast index at the fracture level, used to assess the quality of the cast molding, was determined from the postreduction radiographs. Changes between postreduction and final values for displacement, angulation, and deviation; the ranges of motion of both wrists and elbows; the need for physical therapy; and responses to a questionnaire used to evaluate the effects of the cast on activities of daily living were compared between the groups. RESULTS One hundred and thirteen of the 151 patients who were assessed for eligibility were analyzed. The follow-up rate was 92%, and the average duration of follow-up was eight months. Sixty long arm casts and fifty-three short arm casts were used. There were no significant differences between the two groups with regard to patient demographics, initial fracture characteristics, mechanism of injury, cast index, or the change in displacement, angulation, or deviation during treatment. The fractures that lost reduction in the cast had significantly higher cast indices, indicating poor cast-molding. A comparison of partially and completely displaced fractures revealed no difference between the groups with regard to the change between the postreduction and final amount of displacement. Patients treated with a short arm cast missed fewer school days and were less likely to require assistance with various activities of daily living. CONCLUSIONS A well-molded short arm cast can be used as effectively as a long arm cast to treat fractures of the distal third of the forearm in children four years of age and older, and they interfere less with daily activities.
Collapse
Affiliation(s)
- Gavin R Webb
- Seacoast Orthopedics and Sports Medicine, Marsh Brook Professional Center, 237 Route 108, Somersworth, NH 03878-1517, USA.
| | | | | |
Collapse
|
39
|
Watson ED, Bae SE, Al-Zi'abi MO, Hogg CO, Armstrong DG. Expression of mRNA encoding insulin-like growth factor binding protein-2 (IGFBP-2) during induced and natural regression of equine corpora lutea. Theriogenology 2005; 64:1371-80. [PMID: 16139613 DOI: 10.1016/j.theriogenology.2005.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2004] [Revised: 02/21/2005] [Accepted: 02/23/2005] [Indexed: 10/25/2022]
Abstract
The insulin-like growth factors, IGF-I and -II, have been shown to play a key role in luteal function in some species. The IGF binding proteins, IGFBP-2 and -3, have been shown to inhibit binding of IGF-I and -II to bovine luteal cells and decrease progesterone production. We have recently shown that equine follicles have the genetic capacity to produce IGFBP-2, and that levels decrease in healthy preovulatory follicles. In the present study expression of mRNAs encoding IGFBP-2, as well as the rate-limiting steroidogenic enzyme, P450scc, were studied in equine corpora lutea to investigate whether IGFBP-2 might be involved in luteolysis. Corpora lutea were collected from mares in mid-luteal phase (day 10), at early regression (day 14), late regression (day 17), and 12 and 36 h after intramuscular administration of the PGF(2alpha) analogue, cloprostenol (0.5 microg/kg). During early natural regression, and 12 h after administration of cloprostenol on day 10, steady state levels of mRNAs encoding P450scc had decreased significantly compared with day 10 of dioestrus (P < 0.001). Levels of mRNA encoding IGFBP-2 increased significantly between mid-diestrus and early (P < 0.01) and late (P < 0.001) regression, and 36 h after cloprostenol administration (P < 0.001). We conclude that the genetic capacity for increased IGFBP-2 production in the early stages of natural luteolysis in the mare may act to sequester IGF-I in the CL, assisting in inhibition of progesterone production. However the delay in increase in mRNA encoding IGFBP-2 after cloprostenol administration, combined with the sharp fall in expression of P450scc mRNA, suggests that the luteolytic action of a pharmacological dose of cloprostenol may not be mediated via IGFBP-2 in the mare.
Collapse
Affiliation(s)
- E D Watson
- Royal (Dick) School of Veterinary Studies, Department of Veterinary Clinical Studies, Veterinary Field Station, University of Edinburgh, Easter Bush, Midlothian, Scotland EH25 9RG, UK.
| | | | | | | | | |
Collapse
|
40
|
Thompson GH, Akbarnia BA, Kostial P, Poe-Kochert C, Armstrong DG, Roh J, Lowe R, Asher MA, Marks DS. Comparison of single and dual growing rod techniques followed through definitive surgery: a preliminary study. Spine (Phila Pa 1976) 2005; 30:2039-44. [PMID: 16166892 DOI: 10.1097/01.brs.0000179082.92712.89] [Citation(s) in RCA: 217] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of patients treated with single and dual growing rods who had completed their course of treatment, had definitive fusion, and had a minimum of 2 years follow-up. OBJECTIVES To determine which technique was the most effective in the management of severe spinal deformity in young children: control of the spinal deformity, spinal growth, and the incidence of complications. SUMMARY OF BACKGROUND DATA Growing rod techniques provide proximal and distal segmental "claw" foundations, but their overall results through definitive fusion have not been clearly determined. METHODS A total of 28 consecutive patients who had growing rod procedures followed through definitive spinal fusions were analyzed. There were three patient groups: Group 1 (N = 5), single submuscular rod and short apical fusion; Group 2 (N = 16), single growing rod alone; and Group 3 (N = 7), dual growing rods. RESULTS The interval between initial rod insertion and definitive spinal fusion was similar in all three groups. The best overall results occurred in Group 3, whereas the patients in Group 1 had the worse results. Both Groups 2 and 3 provided good initial correction of the spinal deformity and allowed spinal growth. Group 2 had better frontal and sagittal plane balance and the lowest complication rate. CONCLUSION The use of growing rods is effective in controlling severe spinal deformities and allowing spinal growth. Dual rods are stronger than single rods and, therefore, provide better initial correction and maintenance of correction. The use of an apical fusion does not appear to be effective over the course of treatment.
Collapse
Affiliation(s)
- George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, OH 44106, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Abstract
Matrix metalloproteinases (MMPs) degrade the proteinaceous components of the extracellular matrix and are presumably essential for follicular growth culminating in ovulation or atresia. The objectives of this study were to characterize the gelatinolytic and caseinolytic MMPs secreted by cultured bovine thecal and granulosal cells and to determine the effect of luteinizing hormone (LH) on MMP secretion. Thecal and granulosal cells were collected from small bovine follicles (<5 mm) on day 2 or 5 of the estrous cycle (day 0 = estrus). A serum-free culture system was utilized in which bovine thecal and granulosal cells do not spontaneously luteinize, but produce androstenedione and estradiol in response to physiological concentrations of LH and follicle-stimulating hormone (FSH) respectively. The effect of LH (0, 1 or 100 ng/ml) on MMP production was determined in conditioned media collected every 48 h for 144 h. MMPs were detected by gelatin and casein zymography and MMP activity was quantified by image analysis. Thecal and granulosal cell conditioned media contained MMPs that had a relative molecular size (Mr) ranging from 53 000 to 200 000 and addition of 1,10 phenanthroline (MMP inhibitor) blocked gelatinolytic and caseinolytic activity. Patterns of gelatinolytic activity in thecal and granulosal cell conditioned media differed over time with theMr62 000 and 83 000 MMPs being increased (P< 0.05) and theMr53 000 MMP being decreased (P< 0.05) at 96 h of culture. LH (1 or 100 ng/ml) increased (P< 0.05) gelatinolytic activity of theMr53 000 and 62 000 gelatinases within thecal cell conditioned media but not granulosal cell conditioned media. TheMr62 000 and 83 000 gelatinolytic activities corresponded to the active forms of gelatinase A (Mr62 000) and B (Mr, 83 000) and gelatinase A was detected in thecal cell conditioned media by Western blot analysis. Caseinolytic activity (Mr83 000) was detected in both thecal and granulosal cell conditioned media and increased from 48 to 96 h. In summary, thecal and granulosal cells secrete gelatinolytic and caseinolytic MMPs and thecal cell production of gelatinase A was stimulated by LH.
Collapse
Affiliation(s)
- M F Smith
- Department of Animal Science, University of Missouri-Columbia, Columbia MO 65211, USA.
| | | | | | | | | |
Collapse
|
42
|
Brankin V, Hunter MG, Horan TL, Armstrong DG, Webb R. The expression patterns of mRNA-encoding stem cell factor, internal stem cell factor and c-kit in the prepubertal and adult porcine ovary. J Anat 2004; 205:393-403. [PMID: 15575888 PMCID: PMC1571353 DOI: 10.1111/j.0021-8782.2004.00339.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2004] [Indexed: 11/30/2022] Open
Abstract
The receptor, c-kit, and its ligand, stem cell factor (SCF), are important regulators of ovarian follicle growth and development. The aim of this study was to identify the sites of expression of mRNA for c-kit and SCF in prepubertal and mature (pregnant and non-pregnant) animals. Ovaries were recovered from prepubertal animals, non-pregnant sows and five sows at approximately 3 months of gestation. Ovine SCF and c-kit DNA were cloned into plasmid vectors to produce RNA probes. Expression of mRNA encoding SCF and c-kit were detected via in situ hybridization. Both mRNA were detected throughout ovaries from all animals. This study provides evidence that the growth-factor complex is required throughout follicle development, and also for continued maintenance of the corpus luteum (CL) in the mature animal. SCF mRNA was localized to the granulosa cell layer and was also extensively expressed in endothelial tissue and throughout the CL. c-kit mRNA was detected in the theca layer, oocytes and also in CL. In conclusion, expression of SCF and c-kit mRNA in granulosa and theca cells, respectively, indicate an important interaction between somatic cells throughout follicle development and that in the mature animal, SCF and c-kit potentially have a role in maintaining progesterone secretion by the CL. The observations of continued expression of SCF and c-kit throughout development suggest that there may be differences in the role of this receptor-ligand complex between large mono- vs. poly ovulatory species, such as the pig.
Collapse
Affiliation(s)
- V Brankin
- School of Biosciences, University of Nottingham, Leicestershire, UK.
| | | | | | | | | |
Collapse
|
43
|
Watson ED, Bae SE, Thomassen R, Thomson SRM, Woad K, Armstrong DG. Insulin-like growth factors-I and -II and insulin-like growth factor-binding protein-2 in dominant equine follicles during spring transition and the ovulatory season. Reproduction 2004; 128:321-9. [PMID: 15333783 DOI: 10.1530/rep.1.00100] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The period between seasonal anoestrus and cyclicity is characterized in many mares by cyclical growth and regression of large dominant follicles. The insulin-like growth factor (IGF) system plays a key role in follicular growth and regression; therefore, we hypothesized that changes in the IGF system and its binding proteins would modulate onset of cyclicity in mares. Ovaries were obtained from pony mares on the day after detection of an actively growing 30 mm transitional anovulatory follicle, and also at the second or third oestrus of the breeding season on the day after the preovulatory follicle reached 30 mm in diameter. Size of dominant follicles at the time of removal was similar in transition (32 ± 0.8 mm) and at oestrus (34 ± 0.6 mm). IGF-I mRNA was present in granulosa cells, with low thecal expression, whereas IGF-II mRNA was confined to the theca layer. Expression of IGF-I and -II mRNAs, and intrafollicular concentrations of oestradiol, were lower (P < 0.01; paired t test) in transitional anovulatory follicles than in preovulatory follicles. Messenger RNA encoding IGFBP-2 was present in both theca and granulosa layers. Steady-state concentrations of mRNA encoding IGFBP-2 mRNA increased (P < 0.001) in theca in preovulatory follicles. Intrafollicular concentrations of IGFBP-2 were higher (P < 0.001) in transitional than in preovulatory follicles. The similarity in circulating concentrations of IGF-I in transitional and cyclic mares, suggested that the somatotrophic axis is not involved in transition from anovulatory to ovulatory cycles. The results suggest that the increased expression of IGF-I and -II mRNAs in preovulatory follicles, along with the decrease in IGFBP-2 concentrations, could increase the bioavailability of intrafollicular IGF in large follicles during the breeding season, and support our hypothesis that intrafollicular IGF bioavailability must exceed a threshold level before ovulation can occur.
Collapse
Affiliation(s)
- E D Watson
- Department of Veterinary Clinical Studies, University of Edinburgh, Easter Bush, Roslin, Midlothian EH25 9RG, UK.
| | | | | | | | | | | |
Collapse
|
44
|
Abstract
The purpose of this manuscript was to describe a classification of diabetic foot surgery performed in the absence of critical limb ischaemia. The basis of this classification is centered on three fundamental variables which are present in the assessment of risk and indication: 1) the presence or absence of neuropathy (loss of protective sensation); 2) the presence or absence of an open wound; 3) the presence or absence of acute, limb-threatening infection. The conceptual framework for this classification is to define distinct classes of surgery in an order of theoretically increasing risk for high-level amputation. These classes include: Class I: Elective Diabetic Foot Surgery (procedures performed to treat a painful deformity in a patient without loss of protective sensation); Class II: Prophylactic (Procedure performed to reduce risk of ulceration or reulceration in person with loss of protective sensation but without open wound); Class III: Curative (Procedure performed to assist in healing open wound) and Class IV: Emergent (Procedure performed to limit progression of acute infection). The presence of critical ischaemia in any of these classes of surgery should prompt a vascular evaluation to consider a) the urgency of the procedure being considered and b) possible revascularization prior or temporally concomitant with the procedure. It is our hope that this system begins a dialogue amongst physicians and surgeons which can ultimately facilitate communication, enhance perspective, and improve care.
Collapse
Affiliation(s)
- D G Armstrong
- Department of Surgery, Southern Arizona Veterans Affairs Medical Center, Tucson, AZ 85723, USA.
| | | |
Collapse
|
45
|
|
46
|
Webb R, Nicholas B, Gong JG, Campbell BK, Gutierrez CG, Garverick HA, Armstrong DG. Mechanisms regulating follicular development and selection of the dominant follicle. Reprod Suppl 2003; 61:71-90. [PMID: 14635928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Reproductive function is an integrated process encompassing both extra-ovarian signals, such as gonadotrophins, and intrafollicular factors, such as locally produced growth factors. Initiation of primordial follicle growth and the early stages of folliculogenesis can occur without gonadotrophins. However, in vivo and in vitro studies indicate that FSH may stimulate the rate of preantral follicle growth and that it can take only 3 months for a primordial follicle to reach the ovulatory stage. Antral follicle development from 2 and 4 mm in diameter in sheep and cattle, respectively, is gonadotrophin dependent. During the oestrous cycle a transient increase in circulating FSH precedes the recruitment of a group of follicles. Recruited follicles are characterized by induction of expression of mRNAs encoding a range of steroidogenic enzymes, gonadotrophin receptors and local regulatory factors. As follicles continue to mature, there is a transfer of dependency from FSH to LH, which may be part of the mechanism involved in selection of follicles for continued growth. The mechanism of selection of the ovulatory follicle seems to be linked to the timing of mRNA expression encoding LHr and 3beta-hydroxysteroid dehydrogenase (3beta-HSD) in granulosa cells. Locally produced growth factors, such as the insulin-like growth factors (IGFs) and members of the transforming growth factor beta (TGFbeta) superfamily (inhibins, activins and bone morphogenetic proteins (BMPs)), work in concert with gonadotrophins throughout the follicular growth continuum. The roles of growth factors in follicular development and survival are dependent on gonadotrophin status and differentiation state, including morphology. In conclusion, it is the integration of extraovarian signals and intrafollicular factors that determine whether a follicle will continue to develop or be diverted into atretic pathways, as is the case for most of the follicles in monovulatory species, such as cattle.
Collapse
Affiliation(s)
- R Webb
- Division of Agricultural Sciences, School of Biosciences, University of Nottingham, Loughborough LE12 5RD, UK.
| | | | | | | | | | | | | |
Collapse
|
47
|
Armstrong DG, Gong JG, Webb R. Interactions between nutrition and ovarian activity in cattle: physiological, cellular and molecular mechanisms. Reprod Suppl 2003; 61:403-14. [PMID: 14635951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
The effects of acute changes in dietary intake on ovarian activity can be correlated with changes in circulating concentrations of metabolic hormones including insulin, insulin-like growth factor I (IGF-I), growth hormone and leptin. There is no corresponding change in circulating gonadotrophin concentrations and it is proposed that the dietary induced changes in ovarian activity, resulting from acute changes in dietary intake, are a result of direct actions of these metabolic hormones on the ovary. Changes in the peripheral concentrations of insulin, IGF-I and leptin were also associated with the initiation of a synchronized wave of follicle growth and it is hypothesized that oestrogen secreted by the developing follicle is involved in regulating the secretion of these metabolic hormones. At the cellular level, physiological concentrations of insulin and IGF-I interact to stimulate oestradiol production by granulosa cells. In contrast, leptin inhibits FSH-stimulated oestradiol production by granulosa cells and LH-stimulated androstenedione production by theca cells. At the molecular level, dietary energy intake affects the expression of mRNA encoding components of the ovarian IGF system and these changes can directly influence the bioavailability of intrafollicular IGF. This, in turn, can increase the sensitivity or response of follicles to FSH and is one mechanism through which nutrition can directly affect follicle recruitment. Dietary induced increases in intrafollicular IGF bioavailability also have a negative effect on oocyte quality, and diets that are optimal for follicle growth may not necessarily be optimal for oocyte maturation.
Collapse
Affiliation(s)
- D G Armstrong
- Division of Integrative Biology, Roslin Institute (Edinburgh), Roslin, Midlothian EH25 9PS, UK.
| | | | | |
Collapse
|
48
|
Watson ED, Bae SE, Armstrong DG. Molecular and functional characteristics of dominant follicles during spring transition in mares: a review. PFERDEHEILKUNDE 2003. [DOI: 10.21836/pem20030608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
49
|
Armstrong DG, Boulton AJM. Continuous Internet-based activity monitoring provides a surrogate marker for nocturnal polyuria in persons with diabetes mellitus at high risk for foot ulceration. Diabet Med 2002; 19:1034-5. [PMID: 12647847 DOI: 10.1046/j.1464-5491.2002.00696_2.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
50
|
Nicholas B, Scougall RK, Armstrong DG, Webb R. Changes in insulin-like growth factor binding protein (IGFBP) isoforms during bovine follicular development. Reproduction 2002; 124:439-46. [PMID: 12201817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
UThe insulin-like growth factor binding proteins (IGFBPs) bind IGFs with high affinity and so regulate their access to the type 1 and 2 IGF receptors. This is the principal mechanism involved in regulating IGF bioavailability during folliculogenesis. IGFBPs undergo a number of post-translational modifications, including proteolytic cleavage, phosphorylation and glycosylation, which can regulate the affinity of IGFBPs for IGFs. However, the post-translational changes to IGFBPs that occur during folliculogenesis have not been fully characterized. The charge and size variants of the IGFBPs in bovine follicular fluid were examined by two-dimensional non-reducing SDS-PAGE followed by non-isotopic western ligand blot analysis, and immunoblot analysis during follicular development. The results demonstrate the presence of at least 51 IGFBP isoforms corresponding to IGFBP-1 to -6 in bovine follicular fluid from subordinate follicles, many of which were phosphorylated. The total number of IGFBPs was reduced in dominant follicles, whereas no gross changes in isoforms were observed during follicular development. These results demonstrate the high degree of conservation of IGFBP post-translational modifications between species, and from the in vitro dephosphorylation of these proteins it is hypothesized that these modifications may result in changes to IGF binding or susceptibility to proteolytic cleavage.
Collapse
Affiliation(s)
- B Nicholas
- Division of Agricultural Sciences, School of Biosciences, University of Nottingham, Sutton Bonington, Loughborough LE12 5RD, UK
| | | | | | | |
Collapse
|