A RARE CASE OF OXYTOCIN-INDUCED MATERNAL CARDIAC BRADYARRHYTHMIA DURING LABOUR

The report a rare case of oxytocin-induced severe maternal bradyarrhythmia of a young healthy term primigravida with a singleton pregnancy in spontaneous labour. Augmentation of labour was initiated immediately following the diagnosis of poor progression of labour at four centimetres dilatation. An oxytocin infusion was administered as per standard hospital titration protocol. The patient developed ongoing, persistent episodes of severe bradycardia within six hours of commencement of the oxytocin infusion, as detected by routine pulse oximeter for maternal heart rate monitoring and confirmed manually. Oxytocin was ceased as soon this was recognised, and delivery was expedited by emergency caesarean section both for inadequate progress in labour and the inability to continue oxytocin infusion. Despite being theoretically known to cause cardiac arrhythmias, as a side effect, to our knowledge this is the first reported case in published literature of oxytocin-induced maternal bradycardia.

AtSUC2 has a role for sucrose retrieval along the phloem pathway: evidence from carbon-11 tracer studies

The location of the phloem within a plant, and its vulnerability to disruption, make it a difficult tissue to study and therefore non-invasive studies of phloem functionality are important. Here we compare, phloem transport, measured non-invasively, in wild type Arabidopsis thaliana, and transposon-insertion mutants for AtSUC1 or AtSUC2, giving in vivo information on the importance of these sucrose transporters for phloem transport. The suc2 mutant showed an increase in both phloem leakage and transport time, consistent with reduced sucrose uptake into both transport and collection phloem. The results are consistent with the AtSUC2 transporter being important for retrieval of leaked sucrose in the transport phloem of Arabidopsis. There was no difference in phloem transport properties between the wild type and the suc1 mutants, implying that the AtSUC1 transporter does not play a significant role within the transport phloem of Arabidopsis under the conditions of our study.

The mediation of construction disputes: recent research

Mediation can no longer be said to be a new phenomenon for the resolution of construction disputes. It has been used, in the commercial context, for the resolution of disputes in a wide range of industry sectors both before the commencement of and during formal proceedings. There are some useful data in respect of the use and effectiveness of mediation in the construction industry and court-annexed mediation services, however these are mainly anecdotal. In order properly to assess the effectiveness and cost savings associated with mediation in the construction industry, an industry-based survey was developed between King’s College London and the Technology and Construction Court. This paper explores the results of that survey which indicate that the court appears to be dealing with fewer disputes which relate to changes in the scope of works, project delays and site conditions than those generally arising 10 years ago. The incentives to consider mediation provided for by the Civil Procedure Rules appear to be effective; and that those advising the parties to construction disputes now routinely consider mediation to try and bring about a resolution of the dispute. It is clear that mediation has transformed from a novel idea to an indispensable tool for construction litigators.

The commutability of external quality assurance serum and reference serum materials between the VITROS® Albumin Slide and four other routine albumin methods

Background

Between-method differences in external quality assurance schemes (EQAS) are assumed to be indicative of between-method differences in results for fresh diagnostic serum samples. However, this assumption is only valid if the EQAS fluid is shown to be commutable between methods with the fresh human samples. Using fresh human serum samples, we studied the commutability of six UK National EQAS (UKNEQAS) samples and two reference serum preparations using five methods for the measurement of albumin.

Methods

The VITROS® Albumin Slide was compared with two liquid reagent bromocresol green-based methods and two immunoturbidimetric methods. Thirty fresh human serum samples, six UKNEQAS samples and two reference materials were analysed over a period of five days by all methods. The reference materials were: a certified protein reference material, CRM470 (protein reference preparation) and the Scandinavian NFKK Reference Serum X.

Results

A concentration-dependent tendency towards non-commutability was seen for the six UKNEQAS samples. Two of the methods recovered the CRM470 above the upper limit of the expected range and the remaining three were within the expected range.

Conclusions

Assessment of commutability is important in the investigation of between-method differences in EQAS. External quality assurance and reference materials should have been demonstrated to be commutable and be available at multiple concentrations, before they may be considered appropriate for the assessment of accuracy.

Predictors of complications after inguinal lymphadenectomy

OBJECTIVE

The aim of this study was to identify predictors of complications in patients undergoing inguinal lymphadenectomy (LND) in the treatment of vulvar carcinoma.

METHODS

Clinical information was abstracted from records of patients with invasive vulvar cancer. All patients underwent LND. Closed suction drains were placed in groin incisions and removed when output was less than 30 ml/24 h. Associations between variables were studied by chi(2) and t tests.

RESULTS

Sixty-seven patients undergoing 112 LND were evaluated. Eighty-eight percent of patients underwent radical vulvar surgery and LND while 12% underwent LND alone. Patients were treated with either unilateral (22) or bilateral (45) LND. Seventy-three percent received extended postoperative prophylactic antibiotics. The median duration of suction drainage was 15 days for one drain and 14 days for two drains. Early postoperative cellulitis (<30 days after surgery) developed in 35.4%, early wound breakdown in 19.4%, early lymphedema in 4.8%, and early lymphocyst formation in 13.1%. Late cellulitis (>30 days after surgery) developed in 22.2%, late wound breakdown in 3.2%, late lymphedema in 29.5%, and late lymphocysts in 5%. Patients developing early cellulitis were more likely to have early wound breakdown (P = <0.001, RR 14.2) or early lymphocyst formation (P = 0.016, RR 7.6). Type of procedure, antibiotic use, need for adjuvant therapy, and duration of suction drainage did not influence early complications. Early complications and management strategies did not predict late complications.

CONCLUSIONS

Chronic lymphedema occurs in nearly 30% of patients after LND. Late complications after LND were not predicted by early complications. New strategies for prevention of chronic lymphedema are needed.

A Retrospective Analysis of Radical Hysterectomies Done for Cervical Cancer: Is There a Role for the Pfannenstiel Incision?

OBJECTIVE

The goal of this work was to review patients with early-stage cervical cancer undergoing radical hysterectomy, comparing Pfannenstiel and vertical midline incisions for surgical feasibility, complications, and length of stay.

METHODS

Patients were identified by searching our institutional database. Data were collected from review of each patient's medical record, including demographics, cancer stage, histology, procedural information, length of stay, and complications. Associations between variables were studied using chi(2) and two-tailed t tests. Multivariate analysis was performed using logistic regression.

RESULTS

Between March 1996 and June 2000, 113 patients from the University and Presbyterian Hospitals, Oklahoma City, Oklahoma, underwent radical hysterectomy and pelvic and paraortic lymph node dissection with records available for review. Group 1 consisted of 40 patients who had vertical incisions and group 2 consisted of 73 patients who had Pfannenstiel incisions. There was no difference in race, number of previous abdominal surgeries, distribution of stage, histology, percentage of type III hysterectomies, estimated blood loss, nodal counts, pathologic margin positivity, and postoperative complications among the two groups. Group 2 were younger (41.6 vs 46.5, P = 0.02) and had a lower average QI than group 1 (24.9 vs 28.9, P = 0.001). Group 2 also had a shorter average hospital stay (4.6 days vs 5.8 days, P = 0.04) and shorter operative time (215 min vs 273 min, P = 0.09). Multivariate analysis resulted in Pfannenstiel incisions (P = 0.002), younger age (P = 0.004), and smaller body mass index (P = 0.01) being significant predictors of length of stay.

CONCLUSIONS

Pfannenstiel incisions are feasible without increased morbidity and equal nodal retrieval as compared with vertical midline incisions in patients with early-stage cervical cancer. Pfannenstiel incisions may offer an advantage besides cosmesis in the form of shorter operating room time and earlier discharge from the hospital.

Non-immune hydrops after 20 weeks' gestation: review of 10 years' experience with suggestions for management

OBJECTIVE

To analyze the etiologies and outcomes for a southeastern section of the United States, and to organize an efficient approach to evaluation.

METHODS

We reviewed 82 cases of non-immune hydrops presenting after 20 weeks' gestation over a 10-year period.

RESULTS

Overall perinatal mortality was 86.6%. Fetuses diagnosed with hydrops before 24 weeks' gestation had a perinatal mortality of 95%, with nearly one-third having abnormal karyotypes. The etiology of hydrops diagnosed after 24 weeks' gestation was more likely to remain idiopathic or to be related to cardiothoracic abnormalities.

CONCLUSION

Before 24 weeks' gestation, the high risk of mortality and abnormal karyotype justifies offering families funipuncture in the hope of finding a treatable cause of non-immune hydrops. After 24 weeks' gestation, when fewer abnormal karyotypes are found, funipuncture may also be pivotal in diagnosing the cause of non-immune hydrops.

Rapid computer-assisted infrared analysis of urinary calculi using photoacoustic detection

The application of commercial spectrum-analysing software to quantitative analysis of urinary stones by Fourier transform infrared spectrophotometry is described. The infrared technique is straightforward in comparison with other stone analysis procedures of similar scope and affords significant time savings. The use of partial least squares regression in the analysis program enables better quantitation of stone components than has been hitherto possible using infrared methods. All the principal and many less common stone constituents can be detected and measured. Photoacoustic detection was employed, thus enabling non-destructive analysis with minimal sample preparation. A comparison is made between the infrared procedure and the hybrid thermogravimetric plus "wet" chemistry technique, which it has superseded for routine urinary stone analysis in the author's department.

Effectiveness of combined limonene and 4-hydroxyandrostenedione in the treatment of NMU-induced rat mammary tumours

Limonene, a monocyclic monoterpene, occurs naturally in orange peel oil. It has been shown to exhibit both chemopreventive and chemotherapeutic activity without toxicity in rodent models. In this study we examined the effect of limonene both at maximally optimal and suboptimal doses and in combination with suboptimal doses of 4-hydroxyandrostrenedione on nitrosmethylurea-induced rat mammary tumours. A 10% limonene dose mixed in the diet caused tumour regression in all animals. A 5% limonene dose was only able to cause regression in 50% of the rats (P < 0.05). A suboptimal dose of 4-hydroxyandrostrenedione (12.5 mg kg-1) resulted in tumour regression in 75% of rats. A combination of 5% limonene with 4-hydroxyandrostrenedione (12.5 mg kg-1) resulted in a greater tumour regression (83.3%) than either agent given individually (P < 0.001 and 0.006 for limonene/4-hydroxyandrostrenedione vs limonene alone and 4-hydroxyandrostrenedione alone respectively.

Left ventricular free wall rupture following acute myocardial infarction and cardiac amyloid

A 74-year-old man died of left ventricular free wall rupture 6 days following an acute inferoposterior wall myocardial infarction. His hospital course was complicated by pump failure which proved resistant to inotropic support, diuresis, and percutaneous transluminal coronary angioplasty. At necropsy, extensive amyloid deposition was noted. This case constitutes an unusual clinical setting for myocardial rupture because of the severity of systolic left ventricular dysfunction as well as cardiac amyloidosis.

Foot growth in children age one to five years

As part of the protocol on the Development of the Child's Arch, foot growth studies were monitored prospectively in 107 children from 1 year of age till 5 years of age. Under 15 months of age, growth necessitated a 1/2 size footwear change in less than 2 months; from 15 months to 2 years of age, 1/2 size increase occurred every 2 to 3 months; from 2 to 3 years of age, 1/2 size change every 3 to 4 months; and from 3 to 5 years of age, 1/2 size change every 4 months. Although foot growth in boys and girls is parallel, boys' feet tend to average one size longer and one size wider. Width growth remained proportional to length growth throughout the study.

Development of the child's arch

The purposes of the project were to monitor the development of the lower extremities and the longitudinal arch of the foot and to determine whether or not arch support footwear (three types) affected development of a neutral arch in toddlers 11 to 14 months of age until age 5 years. A total of 125 beginner walkers were recruited through the pediatrics department during a period of 1 1/2 years and divided by lot into four different footwear groups (one nonarch supportive). The group was studied for 4 years by physical examinations, x-ray films, and pedotopography (a Moire fringe technique of photography). At initial examination all of the apparently normal toddlers had pes planus by all clinical, roentgenographic, and photographic measurements. There were no cavus feet at that time or at 5 years of age. Arches developed regardless of the footwear worn but development was faster during the first 2 years (until age 3 years) with arch support footwear. The rapidity of arch development until 5 years of age continued in those children who wore longitudinal arch cookies. Ossification of the sustentaculum tali begins at approximately 5 years of age but is not complete for at least another 1 to 2 years. Hyperpronation was present in 77.9% and genu valgum in 92.3% of the 5-year-old children. These conditions are apparently the norm at this age in both boys and girls.

Post-fracture, late debridement resection arthroplasty of the ankle

Seven patients (three male and four female), aged 10 to 45 years (average, 36 years), who suffered fractures at the ankle (three right and four left) from 6 months to 20 years ago (average, 7.6 years), underwent late debridement resection arthroplasty. Follow-up ranged from 3.5 to 7 years (average, 5 years). Six patients improved in range of motion, endurance, and freedom from pain and swelling and were able to engage thereafter in increased activities, including sports. The oldest female (aged 45), because of continual pain 15 months later, had an ankle arthrodesis. No "normal" ankles resulted, but final rating determinations based on range of motion, endurance, swelling, pain, and subjective analyses were: excellent (1), good (3), fair (2), poor (1) (arthrodesis patient). Results of the 5-year follow-ups suggest that this type of surgery in selected cases is a feasible, at least interim, alternative to more radical total ankle arthroplasty or ankle arthrodesis.

Shoes versus sneakers in toddler ambulation

The purpose of this study was to determine the relative values and differences between shoes and sneakers for young children just learning to walk. In phase 1 of the study, 79 toddlers (47 females and 32 males), ranging in age from 11 months to 3 years, were carefully measured for footwear. Only 15 toddlers (19%) could be properly fitted in the medium-width sneakers that are currently available on the market. The majority of the measured toddlers required widths greater than D, and to accommodate these wider feet, it was necessary to fit them with longer sneakers than they actually needed otherwise, thus making ambulation a bit more difficult and clumsy. In phase 2, eight toddlers, randomly selected except for sex (four male and four female), ranging in age from 11 to 16 months who had been ambulating 2 weeks to 5 months, were tagged with an identifying letter and videotaped in four walking situations: sneakers on tile, shoes on tile, sneakers on rugging, and shoes on rugging. Four hours of video taping was edited down to one-half hour. Twenty-three observers (orthopaedic surgeons, pediatricians, and shoe fitters) carefully reviewed the tape on multiple occasions and came to the following conclusions: better fit, stance, gait, cadence, and stability were noted with shoes in all the toddlers and in all situations. Falls were three times more frequent in sneakers as compared to shoes on tile surfaces and five times more frequent on rugging. It was concluded that the slight economic advantage of sneakers over shoes was not that great to warrant jeopardizing the capabilities of the toddler in the earliest stages of ambulation.

Osteochondritis dissecans of the talus (transchondral fractures of the talus): review of the literature and new surgical approach for medial dome lesions

A retrospective study of 22 ankles in 22 patients with osteochondral talar dome lesions between 1975 and 1983 has indicated that surgical treatment yields superior results to conservative therapy. Thirteen male and 9 female patients, ages 9 to 72 years, average age 28 years, showed 10 medical lesions (Berndt and Harty classification (stage I (one); stage II/III (nine)) and 12 lateral lesions (stage II/III (5), stage IV (7)). Examination follow-up on 19 patients (86%) has averaged 24 months. The initial diagnosis seen retrospectively on x-rays was missed 43% of the time by emergency room physicians. A history of trauma was verified in 100% of the lateral lesions and 80% of the medial talar dome lesions. Of the 22 ankles, 14 lesions were isolated injuries, while 8 had concomitant fractures, lateral ligament, or peroneal tendon damage. Surgical treatment consisted of removal of the osteochondral fragment, curettage, and drilling of its bed. Two distinct surgical approaches were utilized. Lateral dome lesions were approached through the standard anterolateral incision, while medial dome lesions were approached through the anterior tibial tendon sheath with grooving of the anteromedial distal tibia articular surface. The medial approach allowed the somewhat posteriorly placed medial lesions to be reached, negating the need for a medial malleolar osteotomy and postoperative immobilization. On follow-up, no untoward ankle arthrosis was noted as a result of the grooving of the anteromedial distal tibia. Nineteen of the 22 patients had surgical therapy with 79% excellent or good, 21% fair, and no poor results. Five of the eight patients who elected prolonged conservative therapy finally had surgery. Of the three remaining patients conservatively treated, there were two fair results and one poor result.

The simple bunion: anatomy at the metatarsophalangeal joint of the great toe

The pathomechanics for the development of the hallux valgus deformity takes place at the first metatarsophalangeal joint--the sesamoid complex. The sesamoid complex consists of seven muscles, eight ligaments, and two sesamoid bones. When the first metatarsal escapes the complex and drifts medially, the sesamoids remain twisted in situ, several of the ligaments "fail," and others contract. The authors propose reduction of the metatarsus primus varus by first metatarsal osteotomy and appropriate ligament releases and plications to restore alignment. A detailed understanding of the pathomechanics is essential for proper interpretation of the problems and anticipated lasting surgeries.

Surgery in advanced Charcot-Marie-Tooth disease

Crippling equinocavovarus position of the foot in advanced Charcot-Marie-Tooth disease with its attendant metatarsalgia tender calluses and rigidity creates painful, limited, hobbling ambulation with lowered work and general activity tolerance. The object of the surgeries is to convert this foot into a plantigrade , more flexible, painless unit. Surgery consists of plantar fasciotomies off the tubercle of the os calcis and also transversely through the middle of the longitudinal arch. Dorsally angulated green-stick osteotomies are performed at the bases of all the metatarsals. A Jones operation with transfer of the long extensor great toe tendon through the neck and head of the first metatarsal and arthrodesis of the IP joint of the great toe complete the surgery. Often it is necessary to do Bunnell repair lengthening of the flexor hallucis longus tendon. Occasionally, the first metatarsophalangeal joint needs dorsal capsulotomy and lengthening of the short extensor tendon. Variations in and simplicity of techniques are demonstrated with a case report. Ten patients (eight men and two women: 18 feet), ranging in age from 18 to 46 years (average age, 29 years), with a 3- to 6-year follow-up are herein reported. Correction has been maintained in the oldest case.

Warburg syndrome

Warburg syndrome is a congenital oculocerebral disorder. It is caused by a genetic defect that simultaneously affects ocular and cerebral embryogenesis. The characteristic ophthalmic findings reflect the cerebral malformation (agyria or lissencephaly). Two cases, siblings, have been described. The characteristic bilateral ocular findings (leukocoria with microphthalmia) have been discussed and contrasted with simulating entities. Since Warburg syndrome is a lethal disorder, it is important to distinguish these affected infants from those with hydrocephalus with a known better prognosis. Lastly, the early recognition of this autosomal recessive disorder should prompt genetic parental counseling.

Evaluation of hyperpronation and pes planus in adults

Pes planus and hyperpronation of the hindfoot and midfoot are differentiated, and the numerous methods available for the clinical evaluation of both (including their norms) in the adult are presented. Pedotopography, a moiré fringe technique, is currently used in the clinical evaluation, along with "eyeball" visualization, tape measurement, ink mats, and roentgenography. Static deformities of the lower limbs and their joints are frequently responsible for manifestations of hyperpronation in the feet. Trauma and disease to bone, joints, or tendons in the region of the hindfoot or ankle can result in spastic pes planus with hyperpronation. Hyperpronation (excessive medial rotation of the talus) may exist without pes planus, but pes planus rarely is present without some degree of hyperpronation.

Transcutaneous muscle stimulation to retard disuse atrophy after open meniscectomy

Immobilization of an extremity inevitably results in disuse muscle atrophy. The effectiveness of transcutaneous muscle stimulation by a portable device in preventing atrophy has been determined. Ten patients treated by open meniscectomy and given the usual isometric training were matched with ten patients in whom electrostimulation, consisting of a strong, tetanizing, five-second sustained muscular contraction about 400 times/day, was used for two weeks. Muscular strength and leg circumference were measured before surgery and four weeks after surgery. The electrically stimulated group had a significantly smaller loss of muscle volume and muscle strength, were able to walk earlier without crutches, had a greater range of knee motion, had much less postoperative knee swelling, and used significantly less pain medication. Transcutaneous electrical stimulation may prevent muscle atrophy due to immobilization, thereby shortening rehabilitation time.

Bilateral tarsal tunnel syndrome caused by varicosities

The authors present a case report of bilateral tarsal tunnel syndrome occurring in a 39-year-old, slightly overweight female with a long history of varicose veins of her legs. Symptomatology suggestive of tarsal tunnel syndrome was present over the left heel. Vein stripping was done on both legs. When the burning discomfort at the inner aspect of the left heel continued in spite of the strippings, she presented at our Foot Clinic. Surgery on the left heel revealed varicosities overlying the medial and lateral plantar nerves near their origin, and removal of these resulted in prompt relief of her complaints. Nine months later and 10 months following the venous stripping of her right leg, medial right heel pain, burning, paresthesias, and a positive Tinel sign appeared over the inner aspect of her right heel. There was prompt subsidence of these complaints when again varicosities were found and removed.

Surgery of the forepart of the foot in rheumatoid arthritis

The purpose of this paper is to introduce a surgical approach to treatment of severe forefoot deformities of rheumatoid arthritis. Briefly, the surgery consists of base of the first metatarsal osteotomy to correct metatarsus primus varus, and metatarsal head resection beginning with the fifth metatarsal and carried around in crescentic fashion through the necks of the other metatarsals, so that as an end result the great toe is the longest, the second next to the longest, etc. The short extensor tendons are dissected to their insertions and, since they have drifted laterally into the "valleys" pulling the toes into lateral drift with them, they are usually sacrificed. The long extensor tendons are appropriately lengthened to proper tension. All the toes are straightened by plantar capsulotomies, dermotomies, and long flexor tenotomies, and the toes held straight with C-.045 wire in shishkabob fashion. Then, under direct vision, each wire is drilled up into the metatarsal shaft, aligning the toes into parallel cosmetic fashion. In the early cases, a single stem silastic implant was utilized but for the past 5 years now the double stem silastic implant is employed for the first MTP joint and is inserted "upside down" in order to give its greater power towards the floor. A cast is not used, but the patient ambulates on a well-padded bandaged foot by the second or third day. Twenty patients (40 feet) were operated upon (17 females and 3 males, ages 28 to 72 years, average 47 years), with a follow-up of 3 to 5 years. Pain relief has been remarkable. Good great toe function has been obtained in all cases with excellent power to the floor and a satisfactory range of dorsiflexion ability. About 67% have developed some mild recurrence of hallux valgus, but none so severe that it has been disabling. All patients have been pleased with their final results.

Transcutaneous muscle stimulation as a method to retard disuse atrophy

Thirty healthy, young adults (18 to 25 years of age), were volunteers in a three-group study to determine the efficacy of transcutaneous electrostimulation as a means of preventing atrophy of normal musculature on wearing a long-leg cast. Each group of ten subjects (five males and five females) were chosen by lot: Group I, nonisometric, Group II, isometric, Group III, TMS electrostimulated thigh and calf muscles. There was little difference in the findings in Groups I and II, and each lost an appreciable amount of muscle mass and power after just two weeks of immobilization. However, in the electrostimulated group muscle atrophy was one-half that of the other groups in the thigh area and one-fifth that of the others in the calf area. In addition, the calf musculature retained its bulk and power with actual increase in a few of the less athletic individuals. Trancutaneous muscle stimulation offers great promise for surgically treated or impaired extremities, enabling early return to activity with optimal function.

Graphing the adult foot and ankle

When the patient appears in your office with foot and/or ankle complaints, what will be your standard routine X-rays for those areas and what information can you glean from your careful study of these films? What views portray the areas in question and what are suggestive pathognomonic signs? The author has attempted to outline some of the roentgenological approaches to diagnosis of ailments of the foot and ankle and to point out some of the clues that can be found with their interpretations. Many of the signs have, hitherto, not been recognized or are buried in the voluminous orthopaedic literature.

Sural nerve entrapment by avulsion fracture of the base of the fifth metatarsal bone

Three cases of sural nerve entrapment by an avulsion fracture of the base of the fifth metatarsal bone are reported. The fracture was incurred while running, the foot twisting in a depression in the ground. The fracture included a fairly large piece of bone which avulsed and strutted the overlying sural nerve causing continued pain and dysesthesias for months following the injury. All patients promptly recovered completely following removal of the incriminating, ununited fragment and neurolysis of the sural nerve.

Surgical treatment of stenosing tenosynovitis at the ankle

Twelve cases of stenosing tenosynovitis about the ankle (eight posterior tibial and four peroneal), with at least 2 to 4 years of follow-up, have been successfully relieved of their symptoms and returned to increased activity by utilizing a simplified comprehensive surgical technique. Surgery consists of: 1) appropriate treatment to the tendon itself whether intact, partially ruptured, or completely ruptured; 2) deepening of the constricted groove; 3) fashioning of new pulleys from available sheath and retinaculum; and 4) construction of a new sheath from regional deep fascia. Postoperative management includes non-weightbearing, soft bandages, and home exercise therapy for 1 month, followed thereafter by intensive home therapy buildup of the involved muscle and orthoses. Pathology findings included thickening of the tendon sheath, varying degrees of fibrosis of the tendon itself, with or without rupture, and reactive hypertrophy of the bone at the involved groove.

Stenosing tenosynovitis of the flexor hallucis longus tendon at the great toe

The purpose of this paper is to call attention to the previously overlooked entity, stenosing tenosynovitis of the flexor hallucis longus tendon in the sesamoid area of the great toe. Nine patients have been tabulated and successfully treated during the past 4 years, with an average 2 1/2-year follow-up. Trauma seems to be the causative factor. Five cases had accompanying pathology. Three cases responded to inflation of the tendon sheath with 1% lidocaine anesthesia, but the remainder required tenolysis of the sheath plus surgery to the accompanying pathology for relief. Early recognition of this problem and prompt inflation with lidocaine may be the only required treatment if this is the only entity. Chronic cases will respond to tenolysis. A plantar full visualization surgical approach is recommended.

Hallux rigidus: cheilotomy or implant?

Fifty-one feet in 42 patients with varying degrees of symptomatic hallux rigidus and with 2 years of follow-up have been operated with excellent results. Cheilotomy was performed in all cases with only cheilotomy employed in the young patients and implant surgery (single-stem silicone) reserved for the older and more advanced arthritis cases. Pain generally disappeared within 3 months. Range of toe motion in dorsiflexion increased. All patients returned to their activity of choice. All patients were able to utilize off-the-shelf footwear postoperatively. There have been no fractures or inflammatory reactions of the implants as yet, including those inserted 4 or more years ago.

Articular osteoid osteoma of the talus: a case report

A case report of an occult articular osteoid osteoma of the talus is presented that remained undiagnosed for 4 1/2 years despite repeated X-rays, bone scan, tomography, and surgical exploration. The problems of the surgical approach are also detailed.

Stenosing tenosynovitis of the pseudosheath of the tendo Achilles

This entity consists of a chronic inflammatory process of peritenon of the tendo Achilles (usually bilateral) at variable points of the tendon itself but usually near the insertion in the Achilles. Its occurrence, but not only in runners but in relatively sedentary individuals of both sexes, seems to be the result of microtrauma of stress with insidious onset of local pain in increasing degree with physical activity. Clinically, in the advanced cases, fibrillation, nodulation, and "yellowing" of the edematous tendon occur and probably are a precursor to later ruptures. Pathological changes consist of one or more of the following: a myxomatous degeneration of collagenous tissue; fibrosis; round cell inflammatory infiltrate; and proliferation of fibrovascular connective tissue. The use of steroid injections seems to be of no help and probably is contraindicated. Surgery consists of excision of the entire pseudosheath, allowing the tendon to assume a new, nonconstricting alignment. All but one of the nine patients with a follow-up of at least 1 year went on to clinical, painless recovery, with unrestricted future activity, in just a few months.

Early and late repair of lateral ligament of the ankle

Utilizing an apparatus for separately testing the status of the anterior talofibular and the calaneofibular ligaments of the ankle in 25 healthy, 15- to 30-year-old adults, it became apparent that the stability of the ankle depends primarily upon the integrity of the anterior talofibular ligament. When the "fore n' aft" stress measurement exceeds 4 mm, a positive anterior drawer test is elicited, and the ankle ligament needs surgical repair. Tibial talar tilt normals ranged up to 18 degrees. Repair (early and late) is accomplished by suturing what one finds (there is always some ligament present) and reinforcing the anterior talofibular ligament repair with overlap of the nearby lateral talocalcaneal ligament plus the marginal ankle retinaculum. Four weeks in a plaster of paris walking cast are followed by use of Ace bandages of 2 weeks. Light activity is begun 6 weeks after repair, and activity of choice is begun 8 weeks after repair. Repeat stress testing is performed at 3 months postsurgery, and a questionnaire is completed at the same time. On a point system (1 to 10) reviewing pain, stability, and swelling, the results in 50 cases rate from 8 to 10, with a lower rating improving with more time. Surgical time is approximately 30 minutes. There seems to be no need for more radical surgery utilizing other muscles. The senior author has employed this surgery for the past 19 years with approximately 165 cases. Only 50 patients with proper 3-month postoperative stress testing and questionnaire follow-up, who were operated upon 1 or more years ago, area recorded here.

Early and late repair of lateral ligament of the ankle

Utilizing an apparatus for separately testing the status of the anterior talofibular and the calaneofibular ligaments of the ankle in 25 healthy, 15- to 30-year-old adults, it became apparent that the stability of the ankle depends primarily upon the integrity of the anterior talofibular ligament. When the "fore n' aft" stress measurement exceeds 4 mm, a positive anterior drawer test is elicited, and the ankle ligament needs surgical repair. Tibial talar tilt normals ranged up to 18 degrees. Repair (early and late) is accomplished by suturing what one finds (there is always some ligament present) and reinforcing the anterior talofibular ligament repair with overlap of the nearby lateral talocalcaneal ligament plus the marginal ankle retinaculum. Four weeks in a plaster of paris walking cast are followed by use of Ace bandages of 2 weeks. Light activity is begun 6 weeks after repair, and activity of choice is begun 8 weeks after repair. Repeat stress testing is performed at 3 months postsurgery, and a questionnaire is completed at the same time. On a point system (1 to 10) reviewing pain, stability, and swelling, the results in 50 cases rate from 8 to 10, with a lower rating improving with more time. Surgical time is approximately 30 minutes. There seems to be no need for more radical surgery utilizing other muscles. The senior author has employed this surgery for the past 19 years with approximately 165 cases. Only 50 patients with proper 3-month postoperative stress testing and questionnaire follow-up, who were operated upon 1 or more years ago, area recorded here.

Epidemiological survey of foot problems in the continental United States: 1978-1979

Questionnaire cards were sent to 45,000 family shoe store customers; 15,000 cards were completed and returned, thereby permitting a broad statistical base in respect to the incidence and types of foot problems encountered in the United States. The incidence of corns, calluses, warts, ingrown toenails, bunions, hallux rigidus, hammer toes, cavus, and pes planus were correlated with age, sex, race, and demographic background, along with the incidence of surgery, conservative treatment, or no treatment. The extrapolated data indicated that 40% of the population have foot problems, of which 12% had surgery and 7% have been untreated.