Weightbearing Computed Tomography for Assessment of Foot and Ankle Deformities: The Iowa Experience

BACKGROUND

Weightbearing computed tomography (WBCT) is a reliable and precise modality for the measurement and analysis of bone position in the foot and ankle, as well as associated deformities. WBCT to assess three dimensional relationships among bones allowed the development of new measurements, as the Foot and Ankle Offset (FAO), which has high inter and intra-rater reliability. This study reports the University of Iowa's experience utilizing WBCT for the care of foot and ankle patients by describing its utility across different orthopedic diseases in improving diagnostic assessment, aiding surgical planning, and expanding the use for objective clinical follow-up.

METHODS

The medical records of consecutive patients with various foot and ankle disorders that underwent WBCT examination as part of the standard of care at a single institution between November 2014 and August 2020 were retrospectively reviewed. Patient factors, including body mass index (BMI), sex, and patient comorbidities were collected. 3D coordinates for calculation of FAO were harvested using the Multiplanar Reconstruction (MPR) views were calculated from the obtained exams. Descriptive statistics were performed with Shapiro-Wilk test and the Anderson-Darling tests.

RESULTS

1175 feet and ankles (820 patients) had a WBCT performed over the studied 68 months. 53% of the subjects were male and 47% female. 588 of the acquisitions were from the right side (50.04%) and 587 from the left side (49.96%). Diabetes was present in 15.47% of, Rheumatic diagnoses in 4.52% and smoking habits in 44.10% of patients. Mean BMI of the sample was found to be 32.47 (32.03-32.90, 95% CI). The mean Foot and Ankle Offset (FAO) encountered in the study's population was 2.43 (2.05-2.82, 95% CI; min -30.8, max 37.65; median 2.39).

CONCLUSION

This study contains the largest cohort of WBCTs with accompanied FAO measurements to date, which can aid with establishing a new baseline FAO measurement for multiple pathological conditions. Acquiring WBCTs resulted in a variety of more specific diagnoses for patient with foot and ankle complaints. The ability to utilize WBCT for presurgical planning, the capability to provide a 3D reconstruction of patient anatomy, and its use for assessment of advanced relational foot and ankle measurements, such as FAO, demonstrate how WBCT may serve as a remarkable utility in clinical practice and has become a standard of care in our practice at the University of Iowa.Level of Evidence: IV.

The Rotational Positioning of the Bones in the Medial Column of the Foot: A Weightbearing CT Analysis

BACKGROUND

Malrotation of medial column bones of the foot has been advocated as an important factor in foot conditions such as hallux valgus and progressive collapsing foot deformity. Although stated as a deformity component, variances of normality in the general population are not completely understood. This study intended to describe the rotational profile of all medial column bones using weightbearing computed tomography (WBCT) images in a cohort of patients with different foot and ankle problems.

METHODS

In this retrospective study, 110 feet of 95 consecutive patients that received a WBCT for assessment of different foot and ankle pathologies were included. Measurements were performed by a blinded fellowship-trained orthopedic foot and ankle surgeon. Rotation of the navicular, medial cuneiform, proximal and distal first metatarsal as well as proximal phalanx of the first toe were recorded. Positive values were considered pronation and negative values were considered supination. Rotational profile of each bone/ segment was assessed by ANOVA and comparison between each segment was performed using Wilcoxon Each-Pair analysis. P-values of less than 0.05 were considered significant.

RESULTS

On average, a rotational positioning in pronation (internal rotation) was observed for all medial column bones. The navicular (43.2°, CI 41.1°-45.3°) and the proximal metatarsal (33.9°, CI 31.8°-36.0°) showed the highest mean rotation values. The medial cuneiform presented the lowest mean pronation (6.1°, CI 4.0°-8.3°). Comparison between each bone segment demonstrated statistically significant differences of rotational alignment for the different bones (p<0.0001), with the exception of the distal metatarsal and proximal phalanx, that had similar amounts of pronation. A zig-zag rotational pattern of alignment was observed from proximal to distal, with relative supination/pronation of adjacent medial column bones.

CONCLUSION

The overall rotational profile of medial column bones was found to be in absolute pronation, most pronounced at the navicular and proximal first metatarsal, with significant differences in the amount of pronation when comparing most of the medial column bones. The presented data may be utilized as reference/ baseline values of medial column rotation, supporting future prospective, comparative and controlled studies.Level of Evidence: IV.

Buprenorphine Treatment for Opioid Use Disorder in Community-Based Settings: Outcome Related to Intensity of Services and Urine Drug Test Results

Background and Objectives

Variables contributing to the outcome of buprenorphine treatment for opiate use disorder have been studied, including patient characteristics and the treatment approach applied. It is also valuable to study the types of clinical facilities that can affect outcome.

Methods

We evaluated patients (N = 20 993) in 573 facilities where buprenorphine was prescribed. Urine drug test results were analyzed for those (N = 13 281) who had buprenorphine prescribed at least twice in the period January 2015 through June 2017. Facilities were divided into three categories: medication management (MM) only, limited psychosocial (LP) therapy, and recovery‐oriented (with more extensive counseling and a 12‐step orientation) (RO).

Results

Urine drug tests negative for other opioids at the time of the second buprenorphine prescription were 34% for MM, 56% for LP, and 62% for RO (P < .001). A comparison was made between the most recent and the established patients at the facilities. The decrement in urinalyses positive for other opioids in this latter comparison was 3% for MM, 7% for LP, and 23% for RO (P < .001).

Discussion and Conclusions

In a large sample of community settings, buprenorphine patients’ urinalyses positive for opioids can vary considerably across treatment facilities, and more intensive recovery orientation may yield a better outcome in terms of secondary opioid use.

Scientific Significance

The majority of buprenorphine patients are treated in community facilities. It is important that research be done by facility type in such settings in order to plan for optimal treatment. (© 2020 The Authors. The American Journal on Addictions published by Wiley Periodicals, Inc.;00:00–00)

Anatomic Syndesmotic and Deltoid Ligament Reconstruction with Flexible Implants: A Technique Description

The optimal fixation method for unstable syndesmosis (SYN) injuries remains a matter of debate between rigid screw fixation that stabilizes all three components of the syndesmosis but prohibits any motion, and flexible implants stabilizing by compression along the axis of the interosseous ligament. More recently additional repairs of the anterior or posterior SYN ligaments have been explored both clinically and biomechanically. The role for deltoid ligament (DL) repair or reconstruction in the setting of SYN injury remains controversial. However, the DL is increasingly recognized as having an important contribution to rotational stability of the ankle. A method of treatment is presented for unstable SYN injuries with flexible implants. An anatomic approach to reconstructing the DL with specific augmentation of the anterior and posterior bands of the deep deltoid ligament (DDL) is described for immediate restoration of medial ankle rotational stability. Level of Evidence: V.

Effect of Lateral Column Lengthening Calcaneal Osteotomy on Radiographic Measurements of Foot Alignment

Category:

Hindfoot

Introduction/Purpose:

Lateral column lengthening (LCL) with calcaneal osteotomy has been increasingly used for reconstruction in flexible flat foot reconstruction. The aims of this study were to 1) evaluate the effects of variably sized LCL blocks on the restoration of alignment in an acute flat foot cadaveric model; 2) create a computer algorithm to more objectively measure foot alignment; and 3) develop an acute flat foot model that does not require cyclic loading for creating a type IIB flat foot. Determining if overcorrection with lateral column lengthening can occur would provide guidance surgeons to avoid lateral column overload. A computer guided measurement program could make studies more comparable. An acute flat foot model would clarify the ligament deficiencies necessary to create a type IIB flat foot.

Methods:

A type IIB flat foot model was used in which the medial and medial-plantar fibers of the calcaneonavicular (CN), the interosseous talo-calcaneal (ITCL) and the cervical (CL) ligaments were transected. Metallic markers were placed in the PF origin. 3D weightbearing CT scans were obtained with the specimens in a custom jig that permitted loading with 100 lbs. (445 N). The jig allowed full pronation under load. Scans were obtained: intact, flat, and with 6, 8 and 10 mm LCL blocks. Simulated AP and lateral radiographs were created using a custom MATLAB program. A custom ImageJ plugin was created which guided measurement of Meary’s angle, naviculo-cuneiform overlap, AP talo-first metatarsal angle, and a novel plantar fascia (PF) distance and PF angle. The program automatically calculated midpoints and perpendicular lines from guided user input. Four observers performed all measurements in blinded and randomized fashion on two occasions greater than 12 weeks apart.

Results:

The ligament sectioning model reliably produced a type IIB flat foot as noted by talo-navicular sag, increased talar head uncovering (forefoot abduction) and divergence of the talus and calcaneus as seen on the AP weightbearing view (Figure 1). Cyclic loading was not required in any specimens and the remaining medial column ligaments were not sectioned. Intraobserver and interobserver comparisons indicated naviculo-cuneiform overlap and plantar fascia distance had excellent interobserver agreement and Meary’s and plantar fascia angle had good interobserver agreement (Figure 1). Lateral column lengthening trended toward overcorrection at 10 mm suggesting a possible threshold for over-correction.

Conclusion:

The trend toward overcorrection with 10 mm LCL may indicate a threshold for lateral column overload. Computer guided measurement may improve consistency when comparing studies. The PF measurements are not possible in vivo. The use of a heel centering ring might be a surrogate for the implanted metallic beads. The CL sectioning was essential for creating type IIB flat foot without cyclic loading. The CL has been noted to be a main subtalar stabilizer, but has not entered into mainstream discussions regarding flat foot. Changes that occurred with cyclic loading performed in other flat foot studies have not been defined.

A Systematic, Intensive Statistical Investigation of Data from the Comprehensive Analysis of Reported Drugs (CARD) for Compliance and Illicit Opioid Abstinence in Substance Addiction Treatment with Buprenorphine/naloxone

BACKGROUND

Buprenorphine and naloxone (bup/nal), a combination partial mu receptor agonist and low-dose delta mu antagonist, is presently recommended and used to treat opioid-use disorder. However, a literature review revealed a paucity of research involving data from urine drug tests that looked at compliance and abstinence in one sample.

METHOD

Statistical analysis of data from the Comprehensive Analysis of Reported Drugs (CARD) was used to assess compliance and abstinence during treatment in a large cohort of bup/nal patients attending chemical-dependency programs from eastern USA in 2010 and 2011.

RESULTS

Part 1: Bup/nal was present in 93.4% of first (n = 1,282; p <.0001) and 92.4% of last (n = 1,268; p <.0001) urine samples. Concomitantly, unreported illicit drugs were present in 47.7% (n = 655, p =.0261) of samples. Patients who were compliant to the bup/nal prescription were more likely than noncompliant patients to be abstinent during treatment (p =.0012; odds ratio = 1.69 with 95% confidence interval (1.210, 2.354). Part 2: An analysis of all samples collected in 2011 revealed a significant improvement in both compliance (p < 2.2 × 10^-16) and abstinence (p < 2.2 × 10^-16) during treatment. Conclusion/Importance: While significant use of illicit opioids during treatment with bup/nal is present, improvements in abstinence and high compliance during maintenance-assisted therapy programs may ameliorate fears of diversion in comprehensive programs. Expanded clinical datasets, the treatment modality, location, and year of sampling are important covariates, for further studies. The potential for long-term antireward effects from bup/nal use requires consideration in future investigations.

Surgical and medical morbidity following failed non-traumatic partial foot amputation in diabetic patients

Category:

Ankle, Diabetes, Lesser Toes, Midfoot/Forefoot

Introduction/Purpose:

Maximal limb preservation is often the goal in choosing partial foot amputation (PFA) as a treat-ment for diabetic foot infections. Some of these patients will go on to experience multiple hospital admissions, IV antibiotic courses, surgical debridements, re-amputations and other medical compli-cations. This study describes the treatment course of these patients starting at second partial foot amputation and ending at 5 year follow-up.

Methods:

A retrospective cohort was built from a database of all amputation procedures performed on diabet-ic patients at the University of Iowa Department of Orthopedics from 2000 – 2015. The cohort was evaluated over time frame starting at second PFA (index procedure) and ending at 5 years after in-dex procedure. Of 264 patients who underwent partial foot amputation, 49 experienced two lower extremities PFA between January 2000 and December 2011 (cut-off used to allow minimum of 5 years post-PFA). Demographic data was recorded at index PFA and included surgical dates, laterali-ty, surgery type, diagnoses at time of initial surgery, and death date. A chart review collected in-formation on 5 year post-index PFA incidence of: non-surgical hospitalizations, antibiotic admin-istrations, total contact cast applications, and complications (such as osteomyelitis and acute renal failure).

Results:

Thirty-two (65%) of the second partial foot amputations (index) were ipsilateral and 17 were con-tralateral to first partial foot amputation (pre-index procedure). Eighteen (37%) of the partial foot amputation patients eventually experienced transtibial / transfemoral amputations in the 5 years fol-lowing index PFA. Eleven (22%) had at least a third partial foot amputation (and as many as 7) dur-ing study period. Sixteen (32%) patients had 17 transtibial / transfemoral amputations within 5 year time frame. 11 of the 17 (65%) TT / TF procedures were ipsilateral to index (second) PFA. Seven (17%) of the patients died.

Conclusion:

Maximal limb preservation may not be beneficial in all cases, particularly in the case of repeat PFAs. This cohort of repeat PFA patients demonstrated a complicated medical course with long pe-riods of hospitalization, leg immobilization in cast, and home-going antibiotics (requiring PICC). This study suggested that over a 5 year period following second PFA, patients on average experi-enced at least 31 days in TCC, 17 days hospitalized and underwent one additional amputation pro-cedure. These are likely underestimates due to follow-up or outside hospital cares. A large number of patients (18 or 37%) ultimately required higher-level amputation. There is a potential morbidity with PFA that may not be communicated to patients when making these decisions. In this cohort, the average days to second PFA was 360 days. 18 of 49 repeat PFA patients underwent tran-stibial or transfemoral amputation within 5 years of their initial PFA. The morbidity of the interim medical course over 5 years added to the poor quality of life after PFA.

Outcomes and Complications of Total Ankle Replacement in Patients with Post-traumatic, Primary, and Inflammatory Ankle Arthritis

Category:

Ankle Arthritis

Introduction/Purpose:

Total ankle replacement has been evolved and proven to be an effective treatment for varieties of ankle arthritis. Previous literatures reported higher complications in patients who underwent total ankle replacement resulted from post-traumatic and inflammatory arthritis compared to primary arthritis. However, there is a lack of comparative studies to demonstrate outcomes and complications among the three groups of patients who underwent total ankle replacement.

Methods:

Retrospective chart review of 247 consecutive patients with 268 ankles who were diagnosed with end-stage ankle arthritis from primary (73 patients /86 ankle), post-traumatic (149 patients/154 ankle), and inflammatory arthritis (25 patients/ 28 ankle) and underwent total ankle replacement between October 1997 and May 2015. Data was collected prospectively and minimum follow-up was 6 months to allow comparison of early complications and longer term survival in all groups (mean, 41.6 months (range, 6 to 132 months), mean 43.4 months (range, 6 to 180 months), and mean 75.1 months (range, 12-162 months) for primary, post-traumatic, and inflammatory arthritis, respectively). The primary outcome was Visual Analogue Scale (VAS), Foot Function Index (FFI, pain, disability, activity limitations, and total scores), Short Form-36 (SF-36, PCS and MCS), and the secondary outcomes included 5-year and 10-year survival rate, the length of hospital stay, time to return to work, sport activity, and activity daily living, ankle range of motion at final post-operative visit, and complications.

Results:

There were post-traumatic (57.5%), primary (32.1%) and inflammatory arthritis (10.4%). Total ankle replacement of all three groups demonstrated significant improvement in the VAS, FFI, SF-36(p < 0.05). However, FFI, SF-36, VAS, ankle dorsiflexion, and ankle plantarflexion were similar among the three groups (p>0.05). Ankle range of motion was significantly improved in both dorsiflexion and plantarflexion in all groups(p < 0.001). The 5-year and 10-year survival rate were lower in the primary arthritis group but it did not reach statistical significance(p>0.05). Tibial subsidence was significantly higher in the inflammatory group compared to the post-traumatic group (p=0.036), but others complications were similar among the three groups.

Conclusion:

Total ankle replacements demonstrated significant improvement in term of functional outcomes, clinical outcomes, and pain relief as measured with FFI, SF-36, VAS scores, and range of motion of the ankle joint for treatment of end-stage ankle arthritis. The functional outcomes and complications were comparable among the primary, post-traumatic, and inflammatory groups except the talar implant subsidence was significant higher in the inflammatory group. Further prospective clinical study is indicated.

Outcomes and Complications of Four Total Ankle Arthroplasty

Category:

Ankle Arthritis

Introduction/Purpose:

Total ankle replacement has been proven to be effective method for treatment of patient with end-stage ankle arthritis alternative to ankle fusion. STAR implant was initially used followed by SALTO, INBONE and ZIMMER implants. While four implants are currently used, there is a paucity of evidence in literature to compare outcomes and complications between them.

Methods:

Retrospective chart review of 247 consecutive patients with 258 arthritic ankles who were diagnosed with end-stage ankle arthritis and underwent total ankle replacement using STAR (98 ankles, 38.0%), SALTO (121 ankles, 46.9%), INBONE (24 ankles, 9.3%), and Zimmer (15 ankles, 5.8%) implants between October 1997 and May 2015. There was prospectively collected data and minimum follow-up for inclusion was 6 months with an average of follow-up of 101.2 months (range, 18 to 211 months), 52.3 (range, 6 to 90 months), 15.3 (range, 6 to 27 months), and 13.7 months (range, 6 to 26 months) for STAR, SALTO, INBONE, and ZIMMER, respectively). The primary outcome was Visual Analogue Scale (VAS), Foot Function Index (FFI, pain, disability, activity limitations, and total scores), Short Form-36 (SF-36, PCS and MCS), and the secondary outcomes included 2- year, 5-year, and 10-year survival rate, ankle range of motion at the final post-operative visit, and complications. Analysis of VAS, SF-36, and FFI was performed between the four groups using one-way ANOVA. Independent Sample T-test, Wilcoxon Rank Sum Test, and Chi-square test were used to compare other parameters and complications.

Results:

All four implants demonstrated significant improvement of functional outcomes (SF-36,FFI,VAS) (p < 0.001); however, there was no significant of outcomes and pain relief between each pair of implants (p > 0.05, all). The 2-year survival rates were 98.9%, 100%, 100%, and 100% for STAR, SALTO, INBONE, and Zimmer implants respectively. The 5-year survival rates were 91.7% and 96.2% and for STAR and SALTO implants respectively but 10-year survival was 86.1% for the STAR implant. Short- term complication for STAR, SALTO, INBONE, and ZIMMER implants were superficial wound infection (8.4%, 8.5%, 0%, and 0%), deep wound infection (2.1%, 1.7%, 0%, and 0%), medial malleolar fracture (6.3%, 6.8%, 0%, and 0%), lateral malleolar fracture (0%, 2%, 0%, and 0%), numbness on the incision (5.3%, 1.7%, 0%, and 0%), stiffness of the ankle joint (1.1%, 1.7%, 0%, and 0%), gutter impingement (14.7%, 2.5%, 0%, and 13.3%), talar component subsidence (9.5%, 0.8%, 0%, and 0%), and tibia component subsidence (4.2%, 3.4%, 0%, and 0%), polyethylene fracture (6.3%, 0%, 0%, and 0%).

Conclusion:

Based on our findings, all implants demonstrated significant improvement in term of functional outcomes, clinical outcomes, and pain relief as measured with FFI, SF-36, VAS scores, and range of motion of the ankle joint for treatment of end- stage ankle arthritis. The functional outcomes were comparable in all four types. Short-term complications were comparable in all groups but long-term complications of INBONE and Zimmer implants required longer follow-up time. Further prospective clinical investigation is important.

Effect of Posterior Malleolus Fracture on Syndesmosis Reduction

Category:

Trauma

Introduction/Purpose:

Syndesmotic malreduction and the presence of posterior malleolus fractures negatively influence outcomes in rotational ankle fractures. While there are no universally accepted criteria for posterior malleolar fixation, it has recently been shown that posterior malleolar fixation contributed to the stability of the syndesmosis. However, little is known if and how anatomic or non-anatomic fixation of the posterior malleolus affects syndesmotic reduction. A study analyzing syndesmotic reduction in specimens with varying in size and quality of reduction of the posterior malleolus was conducted.

Methods:

Nine through-knee cadaveric specimens were randomized into two groups with small (a third of the fibular notch, n=4) and large (two-third of the fibular notch, n=5) posterior malleolar fragments. A model of stage IV supination external rotation injury after fibular repair was created by sharply releasing anterior inferior tibiofibular ligament, superficial and deep deltoid ligaments, and interosseous membrane. Posterior malleolar fracture with predefined sizing was created with preservation of posterior inferior tibiofibular ligament. High resolution CT scan was obtained in each specimen at the four stages; intact, neutral- axis syndesmotic clamping only, with anatomic fixation of the posterior malleolus, and with non-anatomic fixation of the posterior malleolus using a 4.8 mm interposed spacer. Measurement of syndesmotic reduction in both anteroposterior and mediolateral planes was made automatically using a validated technique assisted by custom-developed software at 1 cm proximal to the ankle joint.

Results:

The presence of either a neutral-axis clamping alone or with an anatomically reduced fracture fragment caused a slight anterior shift of the fibula that was more pronounced in the smaller fragment group. Two-way ANOVA indicated no significant effects of fragment size (p=0.73) or reduction (p=0.09) on AP fibular movement. However, presence of non-anatomical fixation caused the fibula to move significantly posteriorly in the presence of a large posterior malleolar fragment (p=0.03 and p=0.01 relative to the intact and clamping only states). In the mediolateral direction, a neutral-axis clamping alone and clamping with an anatomically reduced fracture fragment both increased medial translation of the distal fibula. The non-anatomic reduction model of the posterior malleolus associated with corresponding lateral displacement of the distal fibula.

Conclusion:

The overall anteroposterior reduction of the syndesmosis using neutral-axis clamping was generally not affected by posterior malleolar fracture except in a non-anatomic fixation of large fragments. Mediolateral syndesmotic reduction was affected by the conditions of posterior malleolar fixation with best results in anatomic fixation but the intact state was still not replicated. Malreduction of the posterior malleolus led to a corresponding syndesmotic malreduction. When a posterior malleolar fixation is indicated in cases with syndesmotic injury, anatomic fracture fixation is paramount as it can affect syndesmotic reduction especially with larger fragments.

Tarsal Tunnel Release

Category:

Ankle

Introduction/Purpose:

Tarsal tunnel release is a standard surgical treatment for patients who have tarsal tunnel syndrome and failure of conservative treatment. However, there remains little evidence demonstrating the medium-term of functional outcomes and complications of tarsal tunnel release. The purpose of this study was to report functional outcomes and complications of tarsal tunnel release.

Methods:

Retrospective chart review with prospectively collected data of 79 consecutive patients with 87 feet (primary surgery = 74/80 and revision surgery = 5/5) who were diagnosed with tarsal tunnel syndrome and underwent tarsal tunnel release between 2008 and 2014. Diagnosis bases on history and physical examination. All patients were failure of conservative treatment at least 6 weeks and the minimum follow up to be included in the study was 12 months (mean, 32.2 months; range, 12 to 80 months). The primary outcome was visual analogue scale (VAS), Short Form-36 (SF-36); physical and mental component scores, and Foot Function Index (FFI); pain, disability, activity limitation, and total score. Pre- and post-operative SF-36, and Foot Functional Index (FFI), pain (Visual Analog Scale) were obtained and compared using pair t-test. The secondary outcomes were operative time, time to return to activity of daily living and work, and complications. Mann-Whitney U-test was used to compare non-parametric data and Wilcoxon signed ranks test was used to compare parametric data.

Results:

The VAS was significantly decrease from 7.6 to 2.0(p = 0.001) and SF-36 was significantly improved from 33.2 to 40.2, for PCS (p= 0.001) and 47.7 to 49.7 for MCS (p = 0.005). The FFI was significantly decreased from 63.0 to 36.0, 61.9 to 35, 72.5 to 34.9, and 65.8 to 35.3 for pain, disability, activity limitations, and total scores(p=0.001, all). Mean operative time was 36.1 minutes for primary surgery and 54.8 minutes for the revision surgery. There 45 of 87 feet (51.7%) had positive Tinel test pre-operatively and 9 of 87 feet (10.3%) post-operatively. Revision surgery demonstrated significantly worse outcomes (VAS,SF-36,and FFI) compared to primary surgery(p < 0.05) but duration >12 months and Tinel sign did not affect the outcomes compared to duration >12 months and Tinel sign negative (p>0.05 all). An average time to return to activity of daily living and work was 8.1 and 9.5 weeks. Complications were painful scar(14.9%), wound infection(6.9%), CRPS(2.3%), and paresthesia on the foot(20.7%).

Conclusion:

Tarsal tunnel release demonstrated significant improvement of functional outcomes and pain relief in medium-term follow-up as measured with SF-36, FFI, and VAS. Revision surgery demonstrated less favorable outcomes while pre-operative Tinel test and duration of symptom more than 12 months did not affect the outcome. This procedure was effective and feasible for tarsal tunnel syndrome with minor complications.

Conservative Sharp Wound Debridement by Nurses in the Outpatient Management of Diabetic Foot Ulcers

Category:

Diabetes

Introduction/Purpose:

With approximately 29.1 million diabetics in the United States and estimated total annual cost of $245 billion, diabetes and its associated complications continue to be an increasing burden on society. The management of diabetic foot ulcers accounts for a significant portion of those expenses. We propose a safe, efficacious and economically prudent model for the outpatient treatment of uncomplicated diabetic foot ulcers.

Methods:

Enrolled patients had initial sharp wound debridement by one of two foot and ankle fellowship trained orthopaedic surgeons. Patients were treated with total contact casting and subsequently evaluated every two weeks by nurses who utilized a clinical management algorithm and performed conservative sharp wound debridement (CSWD). Results of healing and complications were recorded. Digital photographs of the ulcers from each clinical encounter were retrospectively reviewed in a blinded fashion by two orthopaedic foot and ankle surgeons and compared to the nursing decisions at the time of treatment. Financial calculations estimated the potential cost savings by having nurses perform CSWD. State boards of nursing were systematically surveyed to assess current policies related to CSWD.

Results:

Average time to clinical healing was 6.03 weeks. There were no identified complications of CSWD performed by nurses. The sensitivity for the timely identification of wound deterioration was 100%, specificity = 86.49%, PPV = 68.75% and NPV = 100% with an overall accuracy of 89.58%. Thirty-six of 51 (70.59%) state boards of nursing responded to the survey with 33 of 36 (91.67%) defining CSWD as within the nursing scope of practice. The estimated cost savings by having nurses perform CSWD over a 6 week treatment period, with all other factors being equal, was $774.60 per patient. When extrapolated to the estimated number of diabetic foot ulcers annually within the United States, this could approach $1.8 to $2.1 billion in potential annual healthcare savings.

Conclusion:

CSWD of diabetic foot ulcers and calluses by trained nurses is a safe, effective and fiscally responsible clinical practice supported by greater than 90% of state boards of nursing. Utilizing a clinical decision algorithm, nursing evaluation and appropriate referral of ulcers at risk demonstrated 100% sensitivity and 89.58% accuracy. There were no complications associated with nurses performing conservative sharp debridement. When considering the most recent CDC estimates of 29.1 million diabetics with an 8% annual incidence of DFU, implementation of this clinical model on a national scale could result in approximately $2 billion in annual healthcare savings.

The Dorsal Intermetatarsal Approach for Plantar Plate and Lateral Collateral Ligament Repair of the Lesser Metatarsophalangeal Joints

Category:

Lesser Toes

Introduction/Purpose:

Access to the plantar plate has been described using either a plantar approach or an extensile dorsal approach that required complete joint destabilization and often a metatarsal osteotomy. Clinical scenarios related to plantar plate tear vary and the pathologies in early stages are frequently limited to unilateral soft tissue structures, a more focused surgical approach deemed appropriate. A novel approach requiring a release of only the lateral collateral ligament and the lateral half of the plantar plate was described and the adequacy of joint exposure was evaluated in a cadaver model. The ability to place a suture through the lateral collateral ligament and the plantar plate were analyzed and validated with pull-out strength.

Methods:

Nine fresh frozen cadaveric specimens were dissected in a randomized fashion across the 2nd to 4th MTP joints through the intermetatarsal space dorsally. Under distraction, soft tissue was sequentially released including dorsal capsule, lateral collateral ligament, and the lateral half of the plantar plate. Integrity of the extensor tendons, deep transverse intermetatarsal ligament, proximal attachment of the plantar plate, and osseous structures was carefully preserved. The joint exposure was quantified after each step with sizing rods. 2/o non-absorbable sutures were passed into the lateral collateral ligament and the plantar plate using a suture passer; and their pullout strength was measured using a tensiometer.

Results:

Progressive increase in mean of joint exposure was noted after each step of soft tissue release with the final exposure of 6mm after release of the lateral half of the plantar plate. Joint exposures after a capsulotomy and a lateral collateral release were 3mm and 4mm, respectively. Under distraction, the unilateral release of soft tissue created a lateral opening of the joint while the proximal phalangeal base adducted and medially deviated. Successful suture passage was noted in all specimens with mean pullout strength of 76 N for the lateral collateral ligament and 67 N for the plantar plate. There was a statistically significant (p < 0.01) higher suture pullout strength for the lateral collateral ligament in males when compared to female specimens

Conclusion:

The dorsal intermetatarsal approached appeared to be feasible for the access to the lateral collateral ligament and the lateral half of the plantar plate. The average joint exposure of 6 mm allowed a quality suture passage by a suture passer in both structures in all specimens without the need of a metatarsal osteotomy.

Variable Volumes of Resected Bone Resulting From Different Total Ankle Arthroplasty Systems

BACKGROUND

The increased popularity and success of total ankle arthroplasty (TAA) has resulted in the development of varying TAA hardware designs, many of which include specific bone-sparing or bone-sacrificing features. The goal of this work was to determine differences in the volume of bone removed for implantation of different total ankle arthroplasty hardware systems.

METHODS

Sixteen cadaveric specimens were computed tomography-scanned preoperatively and after total ankle arthroplasty using either an INBONE II, Salto Talaris, STAR, or Zimmer TMTA implant. Geometries of the talus and the distal tibia were manually segmented and converted to 3D bony surface models. The volume of bone removed for each implant was calculated as the difference in volume between the preoperative and postoperative bone models. To account for differences in specimen size, volume was expressed as a percentage of the intact bone.

RESULTS

There was a significant difference (P = .049) in the average percent of talar bone removed, with the STAR and INBONE II systems requiring removal of greater volumes of bone. The INBONE II system required significantly (P < .004) more tibial bone resection than the other 3 implants when evaluating a long span of the distal tibia. However, most of this increased bone resection was medullary bone. Close to the articular surface, bone volumes removed for the various tibial components were not significantly different (P = .056).

CONCLUSION

Volume and location of bone removed for different implant systems varied with implant design.

CLINICAL RELEVANCE

Primary bone resection associated with different implant hardware systems varied more on the talar side of the articulation, and the stemmed prosthesis did not result in dramatic increases in periarticular bone resection. Clinicians should weigh the effects of greater or lesser bone resection associated with various implant designs against other factors used for hardware selection.

Cortical Bone Thickness of the Distal Part of the Tibia Predicts Bone Mineral Density

BACKGROUND

Poor bone density may affect surgical planning, treatment outcome, and postoperative protocols. Many patients with foot and ankle problems have not undergone a dual x-ray absorptiometry (DXA) scan, which is currently the gold standard for determining bone density. The purpose of this study was to determine if the cortical bone thickness (CBT) of the distal part of the tibia measured on radiographs correlated with bone mineral density.

METHODS

After exclusion criteria were applied, 167 consecutive adult patients (mean age and standard deviation [SD], 62 ± 11.62 years) who had had standardized ankle radiographs and a DXA scan within 6 months of each other were included in this retrospective study. The CBT was measured with both the gauge and the average method on standardized anteroposterior, lateral, and hindfoot alignment radiographs. The relationship between CBT in the distal part of the tibia and DXA findings in the hip, proximal part of the femur, and lumbar spine was assessed with Pearson correlations. The interrater and intrarater reliability of CBT measurements was assessed with intraclass correlation coefficients. Subgroup analysis was performed to determine the ability of CBT thresholds to predict osteoporosis.

RESULTS

Average CBT measurements on the anteroposterior, lateral, and hindfoot alignment views strongly correlated with DXA findings in the proximal part of the femur (r = 0.70, 0.64, and 0.55, respectively; p < 0.0001), the hip (r = 0.74, 0.67, and 0.53; p < 0.0001), and the lumbar spine (r = 0.61, 0.60, and 0.47; p < 0.0001). The interrater and intrarater reliability of the CBT measurements was excellent. Use of a 3.5-mm average CBT of the distal part of the tibia on the anteroposterior view as the threshold value for predicting osteoporosis (T score less than -2.5) had a sensitivity of 100%, a specificity of 25%, an accuracy of 33%, a positive predictive value of 19%, and a negative predictive value of 100%.

CONCLUSIONS

Measurement of the average CBT of the distal part of the tibia is a quick and reliable method for obtaining information on bone quality. CBT measured on standard ankle radiographs correlated strongly with DXA results and may prove to be a useful screening tool for osteoporosis.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Ankle Arthroscopy Simulation Improves Basic Skills, Anatomic Recognition, and Proficiency During Diagnostic Examination of Residents in Training

BACKGROUND

The purpose of this study was to determine whether low-fidelity arthroscopic simulation training improves basic ankle arthroscopy performance and efficiency among orthopedic trainees.

METHODS

Twenty-nine orthopedic surgery trainees with varying levels of experience in ankle arthroscopy were randomized into either simulation or standard practice groups. At baseline testing, all participants performed simulator-based testing and a cadaveric diagnostic ankle arthroscopy with video recording. The simulation group subsequently received 4 one-on-one, 15-minute simulation training sessions over a 4-month period, while the standard practice group received no additional simulation training or exposure. After intervention, both groups were reevaluated with simulator testing and a second recorded cadaveric diagnostic ankle arthroscopy. Two blinded, independent experts evaluated each randomized arthroscopic performance using the 15-point checklist, Arthroscopic Surgery Skill Evaluation Tool (ASSET), and total elapsed time, and all outcome measures were compared within and between groups.

RESULTS

Baseline arthroscopic experience, simulator task performance measures, and ASSET scores were equivalent between the simulation and standard practice groups. After completion of training, the simulation group outscored the control group in total ASSET score (34.9 vs 19.6; P < .001) and checklist score (14.5 vs 8.4; P < .001) and achieved nearly expert ASSET Safety scores (4.7 vs 2.9; P < .001) on the simulator model. Cadaver testing also demonstrated significant improvements in total ASSET score (28.8 vs 16.8; P < .001), checklist score (12.6 vs 7.1; P < .001), and ASSET Safety score (3.9 vs 2.6; P < .001).

CONCLUSION

These results demonstrate that low-fidelity ankle arthroscopy simulation training can improve basic surgical skills, efficiency of movement, and anatomic recognition. The results suggest greater patient safety during ankle arthroscopy following simulation training.

LEVEL OF EVIDENCE

Level I, prospective comparative study.

Neurogenetic and epigenetic correlates of adolescent predisposition to and risk for addictive behaviors as a function of prefrontal cortex dysregulation

As addiction professionals, we are becoming increasingly concerned about preteenagers and young adults' involvement with substance abuse as a way of relieving stress and anger. The turbulent underdeveloped central nervous system, especially in the prefrontal cortex (PFC), provides impetus to not only continue important neuroimaging studies in both human and animal models, but also to encourage preventive measures and cautions embraced by governmental and social media outlets. It is well known that before people reach their 20s, PFC development is undergoing significant changes and, as such, hijacks appropriate decision making in this population. We are further proposing that early genetic testing for addiction risk alleles will offer important information that could potentially be utilized by their parents and caregivers prior to use of psychoactive drugs by these youth. Understandably, family history, parenting styles, and attachment may be modified by various reward genes, including the known bonding substances oxytocin/vasopressin, which effect dopaminergic function. Well-characterized neuroimaging studies continue to reflect region-specific differential responses to drugs and food (including other non-substance-addictive behaviors) via either "surfeit" or "deficit." With this in mind, we hereby propose a "reward deficiency solution system" that combines early genetic risk diagnosis, medical monitoring, and nutrigenomic dopamine agonist modalities to combat this significant global dilemma that is preventing our youth from leading normal productive lives, which will in turn make them happier.

The Molecular Neurobiology of Twelve Steps Program & Fellowship: Connecting the Dots for Recovery

There are some who suggest that alcoholism and drug abuse are not diseases at all and that they are not consequences of a brain disorder as espoused recently by the American Society of Addiction Medicine (ASAM). Some would argue that addicts can quit on their own and moderate their alcohol and drug intake. When they present to a treatment program or enter the 12 Step Program & Fellowship, many addicts finally achieve complete abstinence. However, when controlled drinking fails, there may be successful alternatives that fit particular groups of individuals. In this expert opinion, we attempt to identify personal differences in recovery, by clarifying the molecular neurobiological basis of each step of the 12 Step Program. We explore the impact that the molecular neurobiological basis of the 12 steps can have on Reward Deficiency Syndrome (RDS) despite addiction risk gene polymorphisms. This exploration has already been accomplished in part by Blum and others in a 2013 Springer Neuroscience Brief. The purpose of this expert opinion is to briefly, outline the molecular neurobiological and genetic links, especially as they relate to the role of epigenetic changes that are possible in individuals who regularly attend AA meetings. It begs the question as to whether “12 steps programs and fellowship” does induce neuroplasticity and continued dopamine D2 receptor proliferation despite carrying hypodopaminergic type polymorphisms such as DRD2 A1 allele. “Like-minded” doctors of ASAM are cognizant that patients in treatment without the “psycho-social-spiritual trio,” may not be obtaining the important benefits afforded by adopting 12-step doctrines. Are we better off with coupling medical assisted treatment (MAT) that favors combining dopamine agonist modalities (DAM) as possible histone-deacetylase activators with the 12 steps followed by a program that embraces either one or the other? While there are many unanswered questions, at least we have reached a time when “science meets recovery,” and in doing so, can further redeem joy in recovery.

The effect of suture-button fixation on simulated syndesmotic malreduction: a cadaveric study

BACKGROUND

The accuracy of reduction of distal tibiofibular syndesmosis disruptions has been associated with the clinical outcome. Suture-button fixation of the syndesmosis is a dynamic alternative mode of fixation. We hypothesized that with deliberate clamp-induced malreduction, suture-button fixation of the syndesmosis would allow a more anatomic post-fixation position compared with screw fixation.

METHODS

Forty-eight syndesmotic fixations were performed on twelve through-knee cadaveric specimens. The syndesmosis was destabilized and off-axis clamping was used to produce both anterior and posterior malreduction patterns. In twelve scenarios (six anterior and six posterior malreductions), syndesmotic screw fixation was used, followed by computed tomography. With tenacula holding the malreduction, the syndesmosis screws were exchanged for a suture-button construct and the specimens underwent a subsequent computed tomography scan. In the other twelve scenarios, the suture-button fixation was achieved first, followed by screw fixation. Standardized measurements of anterior-posterior and medial-lateral fibular displacement were performed by two observers blinded to the method of fixation.

RESULTS

With anterior off-axis clamping, the mean sagittal malreduction was 2.7 ± 2.0 mm with screw fixation and 1.0 ± 1.0 mm with suture-button fixation (p = 0.02). With posterior off-axis clamping, the sagittal malreduction was 7.2 ± 2.3 mm with screw fixation and 0.5 ± 1.4 mm with suture-button fixation (p < 0.01). No differences were observed between fixation types in the coronal plane (p = 0.20 for anterior malreductions and p = 0.06 for posterior malreductions).

CONCLUSIONS

With deliberate malreduction in a cadaver model, suture-button fixation of the syndesmosis results in less post-fixation displacement compared with screw fixation. The suture button's ability to allow for natural correction of deliberate malreduction was greatest with posterior off-axis clamping.

CLINICAL RELEVANCE

Although the clinical relevance is unknown, dynamic syndesmotic fixation may mitigate clamp-induced malreduction.

Risks to the blood supply of the talus with four methods of total ankle arthroplasty: a cadaveric injection study

BACKGROUND

Despite the use of contemporary total ankle arthroplasty implant designs, clinical outcomes of total ankle arthroplasty continue to lag behind those of other joint replacement procedures. Disruption of the extraosseous talar blood supply at the time of ankle replacement may be a factor contributing to talar component subsidence-a common mechanism of early failure following ankle replacement. We evaluated the risk of injury to specific extraosseous arteries supplying the talus associated with specific total ankle arthroplasty implants.

METHODS

Sixteen fresh-frozen through-knee cadaveric specimens were injected with latex and barium sulfate distal to the popliteal trifurcation to visualize the arteries. Four specimens each were prepared for implantation of four contemporary total ankle arthroplasty systems: Scandinavian Total Ankle Replacement (STAR), INBONE II, Salto Talaris, and Trabecular Metal Total Ankle (TMTA). Postoperative computed tomography scans and 6% sodium hypochlorite chemical debridement were used to examine, measure, and document the proximity of the total ankle arthroplasty instrumentation to the extraosseous talar blood supply.

RESULTS

All four implant types subjected the extraosseous talar blood supply to the risk of injury. The INBONE subtalar drill hole directly transected the artery of the tarsal canal in three of four specimens. The lateral approach for the TMTA transected the first perforator of the peroneal artery in two of four specimens. The STAR caused medial injury to the deltoid branches in all four specimens, whereas the other three systems did not directly affect this supply (p < 0.005). The Salto Talaris and STAR implants caused injury to the artery of the tarsal canal in one of four specimens.

CONCLUSIONS

All four total ankle arthroplasty systems tested posed a risk of injury to the extraosseous talar blood supply, but the risks of injury to specific arteries were higher for specific implants.

Lateral talar station: a clinically reproducible measure of sagittal talar position

BACKGROUND

The sagittal relationship of the talus to the tibial shaft can prove invaluable to the orthopedist in understanding and effectively treating ankle pathologies such as ligamentous laxity and ankle arthritis. Any useful radiographic analysis tool to assess the lateral position of the talus must be employable reliably in the clinical setting. Previously published measurements to assess the lateral translational relationship of the talus relative to the tibial axis may not be available in the clinical setting or may be subject to significant inaccuracies. We have defined a sagittal talar position measurement (lateral talar station; LTS), which we postulated could be used reproducibly on clinical radiographs by the orthopedist to define the position of the talus as it relates to the anatomic tibial axis. In addition, we defined the normal range of the LTS measurement.

METHODS

A retrospective cohort of patients (121 ankles, 104 patients) who presented to our clinic with foot pain between 2005 and 2011 was evaluated for inclusion in the study. Exclusion criteria included patients with ankle trauma, instability, prior ankle surgery, or radiographic evidence of ankle osteoarthrosis. The final cohort consisted of 82 ankles. The LTS was measured digitally for each subject on weight-bearing lateral ankle radiographs by 3 observers. The mean LTS and standard deviation was determined for the entire cohort. In addition, as a means of validating our methodology, we performed an assessment of interobserver and intraobserver reliability in terms of the LTS measurements.

RESULTS

The LTS measurements for the entire cohort fit a Gaussian distribution with a mean of 1.17 mm (SD = 0.9893 mm). Interobserver intraclass coefficients for 2 observers (medical student and radiologist) and intraobserver intraclass coefficients for 1 reader (orthopaedic surgeon) indicated excellent reliability, being above 0.9.

CONCLUSION

The LTS was a reliable measure that could be used on weight-bearing lateral ankle radiographs to define sagittal position of the talus in a clinical setting. The normal distribution for the LTS was described in our study population.

LEVEL OF EVIDENCE

Level IV, case series.

Withdrawal from Buprenorphine/Naloxone and Maintenance with a Natural Dopaminergic Agonist: A Cautionary Note

BACKGROUND

While numerous studies support the efficacy of methadone and buprenorphine for the stabilization and maintenance of opioid dependence, clinically significant opioid withdrawal symptoms occur upon tapering and cessation of dosage.

METHODS

We present a case study of a 35 year old Caucasian female (Krissie) who was prescribed increasing dosages of prescription opioids after carpel tunnel surgery secondary to chronic pain from reflex sympathetic dystrophy and fibromyalgia. Over the next 5 years, daily dosage requirements increased to over 80 mg of Methadone and 300 ug/hr Fentanyl transdermal patches, along with combinations of 12-14 1600 mcg Actig lollipop and oral 100 mg Morphine and 30 mg oxycodone 1-2 tabs q4-6hr PRN for breakthrough pain. Total monthly prescription costs including supplemental benzodiazepines, hypnotics and stimulants exceeded $50,000. The patient was subsequently transferred to Suboxone® in 2008, and the dosage was gradually tapered until her admission for inpatient detoxification with KB220Z a natural dopaminergic agonist. We carefully documented her withdrawal symptoms when she precipitously stopped taking buprenorphine/naloxone and during follow-up while taking KB220Z daily. We also genotyped the patient using a reward gene panel including (9 genes 18 alleles): DRD 2,3,4; MOA-A; COMT; DAT1; 5HTTLLR; OPRM1; and GABRA3.

FINDINGS

At 432 days post Suboxone® withdrawal the patient is being maintained on KB220Z, has been urine tested and is opioid free. Genotyping data revealed a moderate genetic risk for addiction showing a hypodopaminergic trait. This preliminary case data suggest that the daily use of KB220Z could provide a cost effective alternative substitution adjunctive modality for Suboxone®. We encourage double-blind randomized -placebo controlled studies to test the proposition that KB220Z may act as a putative natural opioid substitution maintenance adjunct.

Genospirituality: Our Beliefs, Our Genomes, and Addictions

Addictions to smoking, alcohol, illicit drugs, and certain behaviors like gambling, overeating, and sex, are prevalent worldwide. These behaviors are highly destructive and costly to individuals and society due to health consequences, criminality and lost productivity. The genetic vulnerability, environmental exposures, and individual behaviors that contribute to the brain dysfunction and compulsive tendencies that mark addiction make it one of the most complicated diseases to study and treat. Although much has been learned about the genetic basis of and biochemical imbalances associated with the addictions, research leading to effective treatments has been slow. Addictions are often accompanied by an inner sense of disintegration, enslavement and meaninglessness that can be viewed in terms of a spiritual craving for wholeness, freedom, and transformation. Arguably, progress towards effective treatment has been retarded by insufficient attention being paid to understanding the role of spirituality in helping to heal addicts. Assuming one accepts the belief that the brain mediates all conscious and unconscious experiences- including spiritually experiences -healing, like addictions, can be related to the processes by which the human brain is organized for controlling pleasure and pain. Here we hypothesize that a healthy spirituality may come more naturally to some individuals because of the unique interaction of their genes and their environments, and we review the evidence in support of this view.

The addictive brain: all roads lead to dopamine

This article will touch on theories, scientific research and conjecture about the evolutionary genetics of the brain function and the impact of genetic variants called polymorphisms on drug-seeking behavior. It will cover the neurological basis of pleasure-seeking and addiction, which affects multitudes in a global atmosphere where people are seeking "pleasure states".

CAM-type impingement in the ankle

BACKGROUND

Anterior ankle impingement with and without ankle osteoarthritis (OA) is a common condition. Bony impingement between the distal tibia and talus aggravated by dorsiflexion has been well described. The etiology of these impingement lesions remains controversial. This study describes a cam-type impingement of the ankle, in which the sagittal contour of the talar dome is a non-circular arc, causing pathologic contact with the anterior aspect of the tibial plafond during dorsiflexion, leading to abnormal ankle joint mechanics by limiting dorsiflexion.

METHODS

A group of 269 consecutive adult patients from the University of Iowa Hospitals and Clinics who were treated for anterior bony impingement syndrome were evaluated as the study population. As a control group, 41 patients without any evidence of impingement or arthrosis were evaluated. Standardized standing lateral ankle radiographs were evaluated to determine the contour of the head/neck relationship in the talus. Two investigators made all the radiographic measurements and intra- and inter-observer reliability were measured.

RESULTS

34% of patients were found to have some anterior extension of the talar dome creating a loss of the normal concavity at the dorsal medial talar neck. A group of 36 patients (13%) were identified as having the most severe cam deformity in order to assess any correlation with coexisting radiographic abnormalities. In these patients, a cavo-varus foot type was more commonly observed. Comparison with a control group showed much lower rates of anterior-medial cam-type deformity of the talus.

CONCLUSIONS

Cam type impingement of the ankle is likely a distinct form of bony impingement of the ankle secondary to a morphological talar bony abnormality. Based on the findings of this study, this form of impingement may be related to a cavovarus foot type. In addition, there may be long term implications in the development of ankle OA.

LEVEL OF EVIDENCE

Level III.

Neurogenetic Impairments of Brain Reward Circuitry Links to Reward Deficiency Syndrome (RDS): Potential Nutrigenomic Induced Dopaminergic Activation

Work from our laboratory in both in-patient and outpatient facilities utilizing the Comprehensive Analysis of Reported Drugs (CARD)(™) found a significant lack of compliance to prescribed treatment medications and a lack of abstinence from drugs of abuse during active recovery. This unpublished, ongoing research provides an impetus to develop accurate genetic diagnosis and holistic approaches that will safely activate brain reward circuitry in the mesolimbic dopamine system. This editorial focuses on the neurogenetics of brain reward systems with particular reference to genes related to dopaminergic function. The terminology "Reward Deficiency Syndrome" (RDS), used to describe behaviors found to have an association with gene-based hypodopaminergic function, is a useful concept to help expand our understanding of Substance Use Disorder (SUD), process addictions, and other obsessive, compulsive and impulsive behaviors. This editorial covers the neurological basis of pleasure and the role of natural and unnatural reward in motivating and reinforcing behaviors. Additionally, it briefly describes the concept of natural dopamine D2 receptor agonist therapy coupled with genetic testing of a panel of reward genes, the Genetic Addiction Risk Score (GARS). It serves as a spring-board for this combination of novel approaches to the prevention and treatment of RDS that was developed from fundamental genomic research. We encourage further required studies.

Generational association studies of dopaminergic genes in reward deficiency syndrome (RDS) subjects: selecting appropriate phenotypes for reward dependence behaviors

Abnormal behaviors involving dopaminergic gene polymorphisms often reflect an insufficiency of usual feelings of satisfaction, or Reward Deficiency Syndrome (RDS). RDS results from a dysfunction in the "brain reward cascade," a complex interaction among neurotransmitters (primarily dopaminergic and opioidergic). Individuals with a family history of alcoholism or other addictions may be born with a deficiency in the ability to produce or use these neurotransmitters. Exposure to prolonged periods of stress and alcohol or other substances also can lead to a corruption of the brain reward cascade function. We evaluated the potential association of four variants of dopaminergic candidate genes in RDS (dopamine D1 receptor gene [DRD1]; dopamine D2 receptor gene [DRD2]; dopamine transporter gene [DAT1]; dopamine beta-hydroxylase gene [DBH]).

METHODOLOGY

We genotyped an experimental group of 55 subjects derived from up to five generations of two independent multiple-affected families compared to rigorously screened control subjects (e.g., N = 30 super controls for DRD2 gene polymorphisms). Data related to RDS behaviors were collected on these subjects plus 13 deceased family members.

RESULTS

Among the genotyped family members, the DRD2 Taq1 and the DAT1 10/10 alleles were significantly (at least p < 0.015) more often found in the RDS families vs. controls. The TaqA1 allele occurred in 100% of Family A individuals (N = 32) and 47.8% of Family B subjects (11 of 23). No significant differences were found between the experimental and control positive rates for the other variants.

CONCLUSIONS

Although our sample size was limited, and linkage analysis is necessary, the results support the putative role of dopaminergic polymorphisms in RDS behaviors. This study shows the importance of a nonspecific RDS phenotype and informs an understanding of how evaluating single subset behaviors of RDS may lead to spurious results. Utilization of a nonspecific "reward" phenotype may be a paradigm shift in future association and linkage studies involving dopaminergic polymorphisms and other neurotransmitter gene candidates.

Can the chronic administration of the combination of buprenorphine and naloxone block dopaminergic activity causing anti-reward and relapse potential?

Opiate addiction is associated with many adverse health and social harms, fatal overdose, infectious disease transmission, elevated health care costs, public disorder, and crime. Although community-based addiction treatment programs continue to reduce the harms of opiate addiction with narcotic substitution therapy such as methadone maintenance, there remains a need to find a substance that not only blocks opiate-type receptors (mu, delta, etc.) but also provides agonistic activity; hence, the impetus arose for the development of a combination of narcotic antagonism and mu receptor agonist therapy. After three decades of extensive research, the federal Drug Abuse Treatment Act 2000 (DATA) opened a window of opportunity for patients with addiction disorders by providing increased access to options for treatment. DATA allows physicians who complete a brief specialty-training course to become certified to prescribe buprenorphine and buprenorphine/naloxone (Subutex, Suboxone) for treatment of patients with opioid dependence. Clinical studies indicate that buprenorphine maintenance is as effective as methadone maintenance in retaining patients in substance abuse treatment and in reducing illicit opioid use. With that stated, we must consider the long-term benefits or potential toxicity attributed to Subutex or Suboxone. We describe a mechanism whereby chronic blockade of opiate receptors, in spite of only partial opiate agonist action, may ultimately block dopaminergic activity causing anti-reward and relapse potential. While the direct comparison is not as yet available, toxicity to buprenorphine can be found in the scientific literature. In considering our cautionary note in this commentary, we are cognizant that, to date, this is what we have available, and until such a time when the real magic bullet is discovered, we will have to endure. However, more than anything else this commentary should at least encourage the development of thoughtful new strategies to target the specific brain regions responsible for relapse prevention.

Arthroscopic debridement of the talonavicular joint using dorsomedial and dorsolateral portals: a cadaveric study of safety and access

PURPOSE

The purpose of this study was to examine the safety and access talonavicular arthroscopy provides for the purpose of arthrodesis through dorsomedial and dorsolateral portals in a cadaveric model.

METHODS

The talonavicular joints of 8 cadaveric specimens were arthroscopically debrided, by use of a dorsomedial instrumentation portal and a dorsolateral visualization portal. The specimens were dissected with the arthroscopic equipment left in place, the distances from the edge of the instrument to the neurovascular structures were measured, and the specimens were then examined for signs of damage. Finally, the naviculars and tali were removed, and the percentage of debrided subchondral bone was determined by use of ImageJ software (National Institutes of Health, Bethesda, MD).

RESULTS

Examination of the talonavicular joint showed mean subchondral debridement of 98.6% of the navicular and 83.2% of the talus. The dorsomedial portal had a median distance of 4.5 mm, 10.5 mm, and 7 mm to the superficial peroneal nerve, the medial terminal branch of the deep peroneal nerve, and the dorsalis pedis, respectively. The dorsolateral portal had a median distance of 1 mm to the lateral branch of the deep peroneal nerve, with the nerve found resting on the arthroscope in 2 specimens.

CONCLUSIONS

Arthroscopic debridement of the talonavicular joint is possible. Because of the risk of damage to the lateral terminal branch of the deep peroneal nerve, an alternative to the dorsolateral portal should be considered.

CLINICAL RELEVANCE

This study provides evidence that arthroscopic assisted talonavicular arthrodesis is possible but that further research is needed to ensure the safety of the technique.

Lisfranc joint displacement following sequential ligament sectioning

BACKGROUND

There are two primary radiographic patterns of Lisfranc instability, transverse and longitudinal. There is no single diagnostic method with which to consistently confirm the diagnosis of an unstable injury. Our purpose was to define which ligament disruptions produce these two injury patterns and to compare the utility of weight-bearing and stress radiographs for detecting each pattern of instability.

METHODS

Ten fresh-frozen cadaveric lower extremities were dissected to expose the dorsal aspect of the midfoot. Radiographic markers were placed at the base of the second metatarsal and the distal borders of the first and second cuneiforms. The specimens underwent sectioning of the interosseous first cuneiform-second metatarsal (Lisfranc) ligament and were then divided into two groups. The transverse group underwent sectioning of the plantar ligament between the first cuneiform and the second and third metatarsals at the plantar aspect of the second cuneiform-second metatarsal joint, whereas the longitudinal group underwent sectioning of the interosseous ligament between the first and second cuneiforms. Weight-bearing, adduction, and abduction stress radiographs were made before and after each ligament was sectioned. The radiographs were digitized, and displacement was recorded. Instability was defined as >or=2 mm of displacement.

RESULTS

Weight-bearing radiographs made after the Lisfranc (first cuneiform-second metatarsal) ligament alone was sectioned were diagnostic (showed instability) for one of ten specimens. Abduction stress radiographs were diagnostic for two of five specimens, and adduction stress radiographs were diagnostic for zero of five specimens. In the transverse group (sectioning of the plantar ligament between the first cuneiform and the second and third metatarsals), weight-bearing radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens but were not diagnostic on the basis of second cuneiform-second metatarsal displacement for any of five specimens. Abduction stress radiographs were diagnostic on the basis of displacement of both the first cuneiform-second metatarsal and the second cuneiform-second metatarsal joints for five of five specimens. In the longitudinal group (sectioning of the interosseous ligament between the first and second cuneiforms), weight-bearing radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens and were diagnostic on the basis of displacement between the first and second cuneiforms for one of five specimens. Adduction stress radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens and were diagnostic on the basis of displacement between the first and second cuneiforms for four of five specimens.

CONCLUSIONS

Transverse instability required sectioning of both the interosseous first cuneiform-second metatarsal ligament and the plantar ligament between the first cuneiform and the second and third metatarsals. Longitudinal instability required sectioning of both the interosseous first cuneiform-second metatarsal ligament and the interosseous ligament between the first and second cuneiforms. Compared with weight-bearing radiographs, injury-specific manual stress radiographs showed qualitatively greater displacement when used to evaluate both patterns of instability.

Alcoholic patients' experience and attitudes on pharmacotherapy for alcoholism

Clinical studies have demonstrated that pharmacotherapies may improve alcoholism treatment, when combined with traditional psychosocial therapies. Recently, the opioid antagonist, naltrexone, has been approved as an adjunct in alcoholism treatment, and several other pharmacotherapies for alcoholism are under development. Because of the abstinence orientation of many patients, we assessed attitudes regarding medications, and explored whether alcoholic patients would consider taking medication as part of their alcoholism treatment. Active patients (n = 127) in three alcohol treatment settings were surveyed with an anonymous questionnaire which asked demographics, personal alcoholism history and questions about medication use. They were asked whether they felt disulfiram and naltrexone were helpful for alcoholics and whether they would take the medications. The findings indicate that the patients were divided about the use of pharmacotherapy for the treatment of alcoholism. The strongest predictor of willingness to take medication was a belief that the medication would be helpful.

Primary Hypothyroidism

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