Severity rating of specific skin lesions in hidradenitis suppurativa: the ptient perspective

The assessment of physical signs in HS is a very complex matter. This qualitative study investigates how patients with HS themselves would rate the severity of different types of HS lesions, and suggests that the lesion severity weighting in currently used Outcome Measurement Instruments, do not match the patient experience of severity.

Electronic patient-reported outcome measures to enable systematic follow-up in treatment and care of women diagnosed with breast cancer: a feasibility study protocol

INTRODUCTION

The use of patient-reported outcome measures (PROMs) in clinical practice has the potential to promote person-centred care and improve patients' health-related quality of life. We aimed to develop an intervention centred around electronic PROMs (ePROMs) for systematic follow-up in patients diagnosed with breast cancer and to evaluate its feasibility.

METHODS AND ANALYSIS

We developed a nurse-oriented and surgeon-oriented intervention in PROMs, including (1) an education programme for nurses and surgeons; (2) administration of BREAST-Q as proactive ePROMs during follow-up in patients diagnosed with breast cancer and (3) feedback to nurses and surgeons on PROM scores and a guidance manual for healthcare practitioners. Subsequently, we designed a non-controlled feasibility evaluation on the outcomes acceptability, demand, implementation, practicality and integration. The feasibility evaluation includes qualitative ethnographic studies exploring the user perspectives of patients, nurses and surgeons and quantitative studies to explore the characteristics of the patient population regarding demographic background, response rates and response patterns. The feasibility study was initiated in September 2021, will continue until 2024 and will include approximately 900 patients. EPROMs are collected at the following assessment time points: baseline (after diagnosis, before surgery), 1-year follow-up and 3-year endpoint.

ETHICS AND DISSEMINATION

The study will be conducted according to the General Data Protection Regulation and the fifth version of the Helsinki Declaration. The National Committee on Health Research Ethics approved the study according to the law of the Committee § 1, part 4. All data will be anonymised before its publication. The results of the feasibility study will be published in peer-reviewed, international journals.

'At least there is something in my bra': A qualitative study of women's experiences with oncoplastic breast surgery

Aims

This study explores how women diagnosed with breast cancer may be supported by physicians and nurses during physical and existential changes related to oncoplastic breast surgery in Denmark. The following research questions were addressed: (a) how do women experience oncoplastic breast surgery, and (b) how does cancer treatment affect their body image?

Design

A descriptive qualitative study design with a six‐step thematic analysis influenced by Braun and Clarke was applied in this study. This paper has been prepared in accordance with the consolidated criteria for reporting qualitative research.

Methods

Fourteen in‐depth interviews with seven women diagnosed with breast cancer were conducted from August 2018 to March 2019. In this qualitative study, data analysis was performed concurrent with data construction, recognizing that the process of analysis and making sense of data should start during the interviews. We explicitly frame the discussion of the findings in a theory of embodiment influenced by Merleau‐Ponty, consistent with the construct of exploring human experiences to generate meaningful knowledge for applied practice.

Results

Two overall themes with related subthemes were identified: (1) 'Treatment is required for life‐threatening cancer', and (2) 'Striving for a new normal body'. Across both themes, women's experiences reflected a 'time pendulum' as they contemplated their past identity, their current rationale and their transition to a future beyond breast cancer with a changed body.

Conclusion

Participants reflected on their past, present and future when facing an altered body image caused by their breast cancer diagnosis and oncoplastic breast surgery. The participants in the study expressed broad levels of satisfaction with the results of the oncoplastic breast surgery. The reconstructed breast helped them to live normally again, in particular maintaining interpersonal relationships. Breast reconstruction supported participants' embodiment experiences and redefinition of their 'new normal'.

Impact

This study showed the dynamic changes in self‐definition from receiving a breast cancer diagnosis and cancer treatment to oncoplastic breast surgery. The main finding of self‐redefinition was from the perspective of breast cancer women who were in a period of transition between post‐diagnosis and consultation for oncoplastic breast surgery. The findings indicate that advanced nurse specialists in the field of oncoplastic breast surgery can enhance psychosocial wellbeing and support women pre‐ and post‐operatively by focusing on patient experiences of self‐image and embodiment.

User perspectives and preferences regarding a mobile health cough application: A qualitative study during the coronavirus disease pandemic in Denmark

Introduction

Health care systems worldwide are currently facing major challenges because of the coronavirus disease pandemic. When individuals experience coronavirus disease symptoms, they often have to decide whether to seek health care services and render themselves vulnerable to infection or stay home and monitor their condition. Coronavirus disease management strategies should aim to reduce transmission, promote disease control, and facilitate self-monitoring within the population. In this regard, mobile health technologies serve as supportive tools, and acquiring knowledge about user perspectives will facilitate the development and integration of coronavirus disease-related applications. Accordingly, this study aimed to examine user perspectives on applications that monitor coronavirus disease-related physical signs and identify discrepancies between user expectations and developer design perspectives within the Danish context.

Materials and methods

A qualitative research design was adopted. Semi-structured telephone interviews were conducted to examine user expectations during the first wave of the coronavirus disease pandemic in April 2020. The theoretical framework, which was inspired by the concept of health literacy, was developed using a six-step thematic analytic approach.

Results

The analysis yielded two major themes that captured user experiences: (1) coronavirus disease-related applications may serve as digital tools that foster safety when physical signs are monitored and (2) the acceptability of coronavirus disease-related applications depends on the adoption of a personalised and user-friendly design.

On the frontline treating COVID-19: A pendulum experience-from meaningful to overwhelming-for Danish healthcare professionals

OBJECTIVES

In the current study, we aimed to explore the experiences and attitudes among healthcare professionals as they transitioned from their familiar disciplines to respiratory medicine, intensive care or other departments during the first wave of the COVID-19 pandemic.

BACKGROUND

In preparation for the increasing number of patients suspected of having or who would be severely ill from COVID-19, a major reconstruction of the Danish Healthcare System was initiated. The capacity of the healthcare system to respond to the unprecedented situation was dependent on healthcare professionals' willingness and ability to engage in these new circumstances. For some, this may have resulted in uncertainty, anxiety and fear.

DESIGN

The study was a descriptive study using semi-structured focus group interviews. Healthcare professionals (n = 62) from seven departments were included, and 11 focus group interviews were conducted. The focus group interviews took place during June 2020. Analyses was conducted using thematic analysis. The current study was reported using the consolidated criteria for reporting Qualitative research (COREQ).

RESULTS

Healthcare professionals experiences was described by five themes: 1) Voluntary involvement, 2) Changes within the organisation, 3) Risks, 4) Professional identity and 5) Personal investment. Common to all five themes was the feeling of being on a pendulum from a meaningful experience to an experience of mental overload, when situations and decisions no longer seemed to be worthwhile.

CONCLUSIONS

Healthcare professionals experienced a pendulum between a meaningful experience and one of mental overload during the COVID-19 pandemic. The swinging was conditioned by the prevailing context and was unavoidable.

RELEVANCE TO CLINICAL PRACTICE

To balance the continuous pendulum swing, leaders must consider involvement, and to be supportive and appreciative in their leader style. This is consistent with a person-centred leadership that facilitates a well-adjusted work-life balance and may help prevent mental overload developing into burnout.

Improving Person-Centred Leadership: A Qualitative Study of Ward Managers' Experiences During the COVID-19 Crisis

Purpose

In order to provide guidance and prepare ward managers for future crisis situations similar to the COVID-19 pandemic, the aim of this study was to reflect and learn how person-centred nursing leadership may be strengthened in such situations.

Background

The pandemic has forced nurse leaders to face new challenges. Knowledge about their experiences may contribute to advancing leadership practices in times of future crises.

Methods

A qualitative directed content analysis was chosen. The theoretical perspective was person-centred leadership. Thirteen ward managers from a Danish university hospital were included and interviewed using telephone interviews three months after the first national COVID-19 case was confirmed.

Findings

The main findings of the study revealed that the ward managers often experienced a lack of timely, relevant information, involvement in decision-making and acknowledgement from the head nurse of department and the executive management. This was caused by the existing organizational cultures and the traditional hierarchy of communication. This meant that the ward managers' sense of own competences and leadership values and beliefs came under high pressure when they had to balance different stakeholders' needs.

Conclusion

When the experience of ward managers results in them being unable to lead authentically and competently in a crisis like the COVID-19 pandemic, lack of engagement can occur, with serious consequences for patients, staff and the ward managers themselves. Traditional organizational cultures that are hierarchical and controlling needs to be challenged and reoriented towards collaborative, inclusive and participative practices of engagement and involvement. Leadership development must be an established and integrated component of organizations, so that ward managers are able to sustain person-centred ways of being and doing in times of crisis.

Health Professional Frontline Leaders' Experiences During the COVID-19 Pandemic: A Cross-Sectional Study

PURPOSE

The aim was to identify the differences in experiences of Danish healthcare leaders in the beginnning of the coronavirus (COVID-19) pandemic and to generate knowledge for future leadership during and post crises.

BACKGROUND

The global spread of COVID-19 has affected healthcare systems worldwide and has forced healthcare leaders to face challenges few were prepared for. It is expected that the pandemic may hit in several waves within the next year and therefore healthcare leaders must be prepared for these waves.

METHODS

An online survey was developed, and comparative analyses were performed.

RESULTS

One hundred and sixty hospital leaders were invited, and 72% completed the questionnaire. Significant differences were found within three selected characteristics: 1) Management level: significantly more heads of departments experienced taking complex decisions (P=0.05), being able to work in a way consistent with their beliefs and values (P=0.05), and they were less likely to experience that collaboration with other leaders was adversely affected by the COVID-19 situation compared to ward managers (P=0.04). On the other hand, ward managers were significantly more often worried about both their own health (P=0.01) and their family's health (P=0.04). 2) Management education: those with a formal management education more often experienced having the managerial competences to effectively manage the COVID-19 situation (P=0.00), and performing meaningful tasks during the situation (P=0.04). 3) Years of experience: significantly more leaders with more than five years of experience identified having the managerial competences to effectively manage the situation (P=0.01).

CONCLUSION

Leadership support during a healthcare crisis like the COVID-19 pandemic should strategically focus on ward managers, leaders with no formal management education and leaders with less than two years of experience. Hospital leaders may use this knowledge to re-contextualize what is already known about targeted leadership support during healthcare crises and to act accordingly.

User experiences on implementation of patient reported outcome measures (PROMs)in a Haematological outpatient clinic

Background

PROMs can help healthcare professionals gain an improved understanding of patients’ physical burdens, functional levels, and (health-related) quality of life throughout disease and medical treatment. The aim of this study was to investigate the barriers and potential opportunities PROMs may present in a haematological outpatient clinic from three different perspectives: patients, nurses and haematologists.

Methods

The present study synthesizes three previously published studies that separately explored the experiences of patients, nurses and haematologists when implementing PROMs. The studies were all guided by the qualitative methodology Interpretive Description, including a focused ethnographic approach, to develop implications for future practice.

Results

The overall themes that emerged from the analysis were “Structural similarities influence the adoption of PROMs” and “Different perspectives on the potential of PROMs.”

Conclusion

Across the different user groups in the haematological outpatient clinic, the use of PROMs was thwarted due to an unquestioned commitment to biomedical knowledge and the system’s rationality and norms: PROM data was not used in patient consultations. Nurses and haematologists expressed different preferences related to potential future PROMs and different objectives for PROMs in clinical practice. From the different perspectives of the patients, nurses and haematologists, PROMs were not compatible with clinical practice. Further research is recommended to develop PROMs validated for use in haematological outpatient clinics. Moreover, implementation strategies adjusted to the structural barriers of the system are crucial.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s41687-020-00256-z.

Haematologists' experiences implementing patient reported outcome measures (PROMs) in an outpatient clinic: a qualitative study for applied practice

BACKGROUND

The patient-doctor relationship is crucial to provide person-centred care, allowing the alleviation of symptom burden caused by disease or treatment. Implementing Patient Reported Outcome Measures (PROMs) is suggested to inform the decision-making process and lead to initiation of care. Yet there are knowledge gaps regarding how meaningful it is to incorporate PROMs in clinical settings. The aim of this study was to investigate haematologists' experiences when PROMs were implemented in an outpatient setting.

METHODS

Fourteen participant observations, 13 individual interviews and three in-depth interviews were conducted with haematologists, guided by the qualitative methodology Interpretive Description. Analysis was inspired by Habermas' critical theoretical framework.

RESULTS

The haematologists included were characterised by dichotomous experiences with PROMs, either resistant to or supporting their implementation. None were observed to elaborate on PROMs during consultations: instead, primary attention was spent discussing the hematological agenda dictated by the system.

CONCLUSION

The use of PROMs for individualized care was linked with extensive uncertainties and PROMs were not requested by the haematologists. To improve individualized care, other approaches may be more suitable. If PROMs are to be incorporated into future clinical practice, they should be tested tothe specific patient group and involve relevant users.

Surgical management of severe deformity resulting from posterior tibial tendon dysfunction

A retrospective case study format was used to evaluate the results of surgical treatment of severe deformities due to long-standing tibialis posterior tendon dysfunction. To be included in the study, the peri-talar (talonavicular) subluxation on a weight-bearing AP X-ray should have been at least 75%. This criterion limited the field to patients with long-standing, rigid, severe deformities. Surgical correction was obtained through a two-incision approach, dorsomedial and dorsolateral. Significant shortening of the medial column and extensive removal of adaptive bone formation was necessary to allow reduction of the hind- and midfoot deformity. Stable internal fixation using multiple screws was used to secure the reduction. Eleven patients, 12 feet were evaluated. The patients were evaluated using the American Orthopedic Foot and Ankle Society Ankle and Hindfoot Score as well as a questionnaire on footwear and satisfaction rating. The average score improved from 30 points pre-op to 74 points post-op (out of 100). P-value 0.0001. Pain score improved from 11/40 to 33/40. Function improved from 19/50 to 33/50. Alignment improved from 0/10 to 8/10. The radiological parameters showed an average improvement of 31 degrees in the lateral talo-1st metatarsal angle, 11 degrees in the calcaneal pitch, and 35 degrees in the AP talo-1st metatarsal angle. All three parameters were highly significant with P-values of 0.0001. Multiple complications occurred. This included two delayed unions with breakage of screws and partial loss of correction, four wound problems, two sural nerve impairments and three patients requiring hardware removal. Even though it is an extensive procedure with multiple potential complications it still offers a substantial improvement in quality of life.

Salvage or amputation after complex foot and ankle trauma

A treating surgeon must take all the aforementioned ideas and principles into consideration, make a reasoned decision in the first hour of patient evaluation, and proceed with the chosen treatment. When functional salvage is not thought to be possible, it is better simply to let the patient and family know, then proceed directly to the best possible reconstructive amputation. This approach saves the patient, family, friends, and treatment team an enormous amount of anguish and allows for the earliest possible acceptance and positive approach to rehabilitation.

Outcome after open reduction and internal fixation of Lisfranc joint injuries

BACKGROUND

Open reduction and internal fixation has been recommended as the treatment for most unstable injuries of the Lisfranc (tarsometatarsal) joint. It has been thought that purely ligamentous injuries have a poor outcome despite such surgical management.

METHODS

We performed a retrospective study of patients who underwent open reduction and screw fixation of a Lisfranc injury in a seven-year period. Among ninety-two adults treated for that injury, forty-eight patients with forty-eight injuries were followed for an average of fifty-two months (range, thirteen to 114 months). Fifteen injuries were purely ligamentous, and thirty-three were combined ligamentous and osseous. Patient outcome was assessed with use of the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and the long-form Musculoskeletal Function Assessment (MFA) score.

RESULTS

The average AOFAS midfoot score was 77 points (on a scale of 0 to 100 points, with 100 points indicating an excellent outcome), with patients losing points for mild pain, decreased recreational function, and orthotic requirements. The average MFA score was 19 points (on a scale of 0 to 100 points, with 0 points indicating an excellent outcome), with patients losing points because of problems with "leisure activities" and difficulties with "life changes and feelings due to the injury." Twelve patients (25 percent) had posttraumatic osteoarthritis of the tarsometatarsal joints, and six of them required arthrodesis. The major determinant of a good result was anatomical reduction (p = 0.05). The subgroup of patients with purely ligamentous injury showed a trend toward poorer outcomes despite anatomical reduction and screw fixation.

CONCLUSIONS

Our results support the concept that stable anatomical reduction of fracture-dislocations of the Lisfranc joint leads to the best long-term outcomes as patients so treated have less arthritis as well as better AOFAS midfoot scores.

Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot. Early results after distraction arthrodesis of the calcaneocuboid joint in conjunction with stabilization of, and transfer of the flexor digitorum longus tendon to, the midfoot to treat acquired pes planovalgus in adults

BACKGROUND

The successful correction of flatfoot in children through lengthening of the lateral column, osteotomy of the medial cuneiform, and advancement of the posterior tibial tendon led to the introduction of similar procedures to treat acquired pes planovalgus secondary to attrition or rupture of the posterior tibial tendon in adults. However, to our knowledge, no study has been published documenting whether these procedures are effective treatment for acquired flatfoot in adults.

METHODS

The functional and radiographic results of complex reconstruction of a painful, flexible flatfoot associated with attrition or rupture of the posterior tibial tendon were evaluated in thirty-six patients (forty-one feet) with use of a detailed questionnaire, a comprehensive physical examination, and a review of the radiographs and the medical record.

RESULTS

At a mean of thirty-four months (range, twenty-four to fifty months) postoperatively, thirty-six feet (88 percent) were less painful compared with the preoperative status or were pain-free and five of the six parameters that had been used to assess correction of the deformity radiographically had improved significantly (p<0.0001). Eight feet (20 percent) had a non-union at the calcaneocuboid joint, and thirteen feet (32 percent) had anesthesia or paresthesia of the sural nerve. Twenty-nine feet (71 percent) had had additional operations, including removal of hardware from twenty feet; bone-grafting to treat a nonunion at the site of the calcaneocuboid arthrodesis and revision of the internal fixation in four feet; a medial displacement calcaneal osteotomy because of recurrent valgus angulation of the hindfoot in two feet; and a Lapidus procedure because of a hypermobile tarsometatarsal joint with hallux valgus, a triple arthrodesis because of a nonunion at the site of the calcaneocuboid arthrodesis associated with loss of correction, and a dorsiflexion-abduction wedge osteotomy through the site of the calcaneocuboid arthrodesis (which had healed) for alignment of an overcorrected foot in one foot each. The outcomes of the procedures in thirty-five feet (85 percent) were rated by the patients as satisfactory, and thirty-three (92 percent) of the thirty-six patients (thirty-eight [93 percent] of the forty-one feet) stated that they would have the procedure again if the circumstances were similar.

CONCLUSIONS

Despite the high prevalence of postoperative complications, most of our patients were satisfied with the result of the procedure after the short duration of follow-up. We believe that the relief of pain and the restoration of function achieved through effective correction of the severe pes planovalgus deformity account for the satisfactory outcomes in our patients.

Subluxation of the talocalcaneal joint in adults who have symptomatic flatfoot

BACKGROUND

When flatfoot is acquired during adulthood, the shape of the foot changes. In addition to a decreased arch, there may be valgus angulation of the hindfoot or abduction of the forefoot, or both. However, there is little objective information to provide a better understanding of the anatomical or morphological changes that occur in acquired adult flatfoot. We wondered if such an understanding of the three-dimensional anatomy might shed light on the pathway by which these changes occur. We designed this study to measure the three-dimensional position of the talocalcaneal joint in patients who have painful flatfoot.

METHODS

Computed tomography scans of the feet of eight patients who had symptomatic flatfoot were used to construct a model of the talocalcaneal articulation. The scans were performed on a custom loading frame developed to simulate weight-bearing with the foot in a neutral position while a seventy-five-newton axial compressive load was applied. The digital data from the scans were used to make three-dimensional computer models of the articular surfaces of the talus and calcaneus of each foot. These models then were used to calculate the percentage of the articular surface that was in contact and, conversely, the percentage that was subluxated. Two surfaces were modeled for each bone; the posterior facet formed one surface, and the anterior and middle facets were combined to form the second surface. The data were compared, with use of Mann-Whitney nonparametric U analysis, with those derived from scans of the feet of four patients without a deformity of the hindfoot who served as controls.

RESULTS

A mean (and standard deviation) of 68+/-9 percent of the posterior facet of the calcaneus was in contact with the talus in the patients who had flatfoot compared with 92+/-2 percent in the controls, and a mean of 51+/-23 percent of the anterior and middle facets of the calcaneus was in contact with the talus in the patients who had flatfoot compared with 95+/-6 percent in the controls. These differences were significant (p = 0.0066 for both).

CONCLUSIONS

Marked subluxation of the talocalcaneal joint occurs in some patients who have symptomatic planoabductovalgus deformity.

The lateral column lengthening and medial column stabilization procedures

The results of medial column stabilization, lateral column lengthening, and combined medial and lateral procedures were reviewed in the treatment of adult acquired flatfoot secondary to posterior tibialis tendon insufficiency. All bony procedures were accompanied by transfer of the flexor digitorum longus tendon to the medial cuneiform or stump of the posterior tibialis tendon and tendoachilles lengthening or gastrocnemius recession. Medial column fusion was performed for naviculocuneiform and cuneiform first metatarsal sag; lateral column lengthening was performed for calcaneovalgus deformity with a flat pitch angle; and combined procedures were performed for complex combined deformities. At 1 to 4 year followup of 65 feet, 88% of the feet that had lateral column lengthening, 80% that had medial column stabilization, and 88% of the feet that had medial and lateral procedures had a decrease in pain or were pain free. The lateral talar first metatarsal angle improved by 16 degrees in the patients in the lateral column lengthening group, 20 degrees in the patients in the medial column stabilization group, and 24 degrees in the patients in the combined medial and lateral procedures group. The anteroposterior talonavicular coverage angle improved by 14 degrees in the patients in the lateral column lengthening group, 10 degrees in the patients in the medial column stabilization group, and 14 degrees in the patients in the combined medial and lateral procedures group. These techniques effectively correct deformity without disrupting the essential joints of the hindfoot and midfoot.

Biomechanical analysis of the first metatarsocuneiform arthrodesis

This investigation was designed to help define the unique loading characteristics of the first metatarsocuneiform arthrodesis procedure. Part I of this investigation employed nine fresh frozen, matched-pair cadaveric specimens. One specimen in each pair had the subchondral plate removed from the opposing joint surfaces, while the remaining specimen had only the articular cartilage removed. All specimens were stabilized in an identical manner utilizing two 3.5-mm cortical screws. Part II of the investigation also utilized nine fresh frozen, matched-pair cadaveric specimens. Only the articular cartilage was removed prior to placement of fixation. All specimens were stabilized with two crossing 3.5-mm cortical screws. Placement of a third screw was randomized between specimens of a matched pair. Specimens were loaded to failure in cantilever bending utilizing a materials tester. There was a statistically significant (p = .04) greater load to failure and bending moment in specimens with an intact subchondral plate. Values for construct stiffness were not found to be significantly different (p = .95) between specimens with and without a subchondral plate. Although the addition of a third screw increased the load to failure and bending moments, differences were not found to be statistically different (p = .11-.21) from two screws. Preserving the subchondral plate will enhance the stability of the first metatarsocuneiform arthrodesis. Two or three screws can be employed to shield the fusion site from loading; however, three screws were shown to be more effective than two.

Surgery of the rheumatoid foot and ankle

Numerous reconstructive procedures have been used to address the manifestations of rheumatoid arthritis in the foot and ankle. Clinical studies have documented that these procedures relieve pain, however they often sacrifice motion essential to the normal function of the foot. In the forefoot, metatarsophalangeal joint resection arthroplasty shortens the lever arm of the foot, defunctions the toes, and disables the plantar plate and fat pad. Arthrodesis of the ankle and hindfoot alters gait and the effective transmission of weight-bearing stresses through the foot and ankle. These ablative procedures may provoke the deterioration of adjacent joints and may cripple the long-term function of the lower extremity. The introduction of reconstructive procedures designed to preserve motion in joints essential to function and the recognition and treatment of muscle imbalances associated with bone and joint deformities are recent advances in the surgical management of the rheumatoid foot and ankle.

Revision ankle fusion using internal compression arthrodesis with screw fixation

We reviewed 20 revision ankle fusions performed using internal compression arthrodesis with screw fixation. Clinical, functional, and radiographic results were measured at an average follow-up of 30 months (range, 12-50 months). The reasons for the index procedures were nonunion in 11, malunion in 7, infected nonunion in 1, and nonunion associated with avascular necrosis of the talus in 1 case. Fusion occurred in 15 of 20 patients. Two additional patients obtained fusion after subsequent procedures, for a final union rate of 85%. The average time to fusion was 6 months (range, 2-32 months). Nineteen additional operations were necessary in 12 patients, including three amputations for chronic infection (two infected nonunions and one chronic osteomyelitis). All but one patient had a plantigrade limb at follow-up. Seventeen of 20 patients were satisfied with their ultimate outcome, including all three patients with amputations. The three dissatisfied patients were bothered by chronic pain. Revision ankle fusion for nonunion or malunion using internal compression arthrodesis with screw fixation is beneficial for most patients. It is a technically demanding procedure that is associated with a high complication rate. Many patients can be expected to have residual pain. We emphasize the need for accurate alignment and early, aggressive treatment of infectious complications. Amputation should be considered a viable option to improve functional outcome in patients with solid, well-aligned fusions who are disabled by severe chronic pain.

Hallux valgus surgery. Morton and Lapidus were right!

More than 60 years ago an anatomist, Dudley Morton, and an orthopaedic surgeon, Paul Lapidus, independently published similar theories that implicated excessive mobility of the first metatarsal in forefoot dysfunction. Morton first studied in detail the evolution of the foot leading to bipedal gait and then examined the feet of many of his students in an attempt to correlate his tentative assumptions with the presence of or lack of symptoms. Morton's analysis of forefoot dysfunction provides the foundation of modern surgical procedures that restore normal forefoot balance and function to asymptotic feet.

Surgical reconstruction of the diabetic foot: a salvage approach for midfoot collapse

Between 1985 and 1993, 18 patients representing 21 feet underwent surgical reconstruction for diabetic neuroarthropathy with collapse of the midfoot. Forty-seven percent (10/21) of these feet presented with plantar pressure ulcers. Reconstruction involved reduction and fusion of collapsed joints, using internal fixation to restore foot shape and improve weightbearing alignment. The average follow-up in these patients was 28 months (range, 6-84 months). Limb salvage was obtained in 18 of 21 feet. Average time to radiographic union was 5 months (range, 3-9 months). Improvement in shoe fit and ambulatory status was noted for 13 of the 15 patients who had successful reconstruction. Forty-seven percent of the reviewed cases were without any complication throughout their postoperative course. Seventy percent of the presenting ulcers healed without incident. There were no recurrent midfoot ulcers.

Prosthetic history, prosthetic charges, and functional outcome of the isolated, traumatic below-knee amputee

PURPOSE

To review the prosthetic history, prosthetic charges, and functional status of traumatic, isolated, unilateral below-knee amputees at select intervals following amputation.

METHODS

This descriptive study was conducted among patients admitted to Harborview Medical Center between 1980 and 1987 who survived initial trauma, and who required an isolated, below-knee amputation. Hospital and prosthetist records were abstracted to calculate the number of prostheses fabricated and the prosthetic charges since initial amputation. Functional outcomes were determined by personal interview and self-administration of the SF-36 Health Status Profile.

RESULTS

The average age of patients was 36 with the age range extending from 19 to 59 years. The prosthetic history and prosthetic charges were determined from the medical record and the billing records of the prosthetist. Exact charges were determined for 15 of the 20 patients. During the first 3 years, the mean number of prostheses acquired per patient was 3.4 (range 1-5), with average total prosthetic charges of $10,829 (range $2,558-$15,700). Over the first 5 years the mean number of prostheses acquired per patient was 4.4 (range 2-8), with average total prosthetic charges of $13,945 (range $6,203-$20,070). The SF-36 Health Status Profile scores were significantly decreased from published normal aged-matched scores in the categories of physical function and role limitations because of physical health problems and pain. Scores were not significantly different from published normal aged-matched scores in the other five categories: role limitations due to emotional problems, social functioning, mental health, energy/fatigue, and health perception.

Retrograde nailing of femoral shaft fractures

OBJECTIVE

The purpose of the study was to define the outcome following retrograde nailing of the femoral shaft.

DESIGN

Retrospective clinical study.

MATERIALS AND METHODS

Seventeen retrograde intramedullary nailings of the femur were performed in 16 patients for management of complex orthopedic trauma. Thirteen patients were followed for an average of 22.8 months (range from 9 to 72 months). The indications for retrograde nailing were an ipsilateral femoral neck and shaft fracture in eight cases, knee disarticulation or long above knee amputation associated with a femoral shaft fracture in five cases, traumatic arthrotomy of the knee ipsilateral to a shaft fracture in two cases, one case of a shaft fracture ipsilateral to an acetabular fracture that required an extensile exposure, and one case of a femoral nonunion with a knee contracture. In fourteen of the seventeen cases the femur fracture was open including two grade III C injuries.

MEASUREMENTS AND MAIN RESULTS

Two patients died in the early postoperative period due to the severity of the initial trauma and one patient was lost to follow-up. The results were generally poor and postoperative complications were common. There were five nonunions in the group, one which required revision to an above knee amputation for an infected nonunion following a grade III open femur fracture. The average range of motion of the knee was 3 degrees to 110 degrees, and two patients had an extensor lag of 5 degrees or more. Six patients underwent removal of hardware through a second arthrotomy with no significant loss of knee function related to the second procedure.

CONCLUSIONS

The authors concluded that the high complication rate and poor results were related to the severity of the initial injury. An intercondylar starting can be used in properly selected cases with minimal effect on knee function.

Treatment of compartmental liquefaction as a late sequelae of a lower limb compartment syndrome

Symptomatic liquefaction and calcification of muscle tissue as a late sequela of compartment syndrome of the lower leg is rare. The literature shows a high complication rate involved with simple debridement of these compartments. In our limited experience, complete compartmental debridement and immediate introduction of functional viable muscle may prevent the documented complications of chronic drainage and infection.

Continuous regional analgesia by intraneural block: effect on postoperative opioid requirements and phantom limb pain following amputation

The objective of this study was to assess the effectiveness of a previously described technique of regional analgesia (continuous infusion of local anesthetic through a catheter placed at the time of amputation within the exposed sciatic or posterior tibial nerve) on relieving the postoperative pain in a heterogeneous group of patients who underwent lower extremity amputations. A second objective was to determine the effect of such treatment on the incidence and characteristics of phantom limb pain 6 months or more after surgery in the same patients. The study design was retrospective, unblinded, controlled (postoperative pain), and unblinded questionnaire and interview (phantom pain) were utilized. Subjects were inpatients at Harborview Medical Center, University of Washington, Seattle, WA. Nineteen bupivacaine-treated and 40 nonbupivacaine-treated patients who underwent lower extremity amputation subsequent to trauma, infection, long-standing injury (poor or no function), congenital deformity, or burns were evaluated in the postoperative pain management assessment. Nine treated and 12 untreated patients were interviewed in the phantom pain assessment. Bupivacaine 0.5% 2-6 ml/h was infused through a polyamide 20-gauge catheter inserted into the sciatic or posterior tibial nerve sheath under direct vision at the time of surgery. All patients, treated and control, received opioid analgesics systemically during the 72-hour period of study. The postoperative opioid analgesic requirement of treated patients was compared with that of control patients who received opioid analgesics alone. A questionnaire was administered to assess presence, severity, and character of phantom pain.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical, quantitative assessment of first tarsometatarsal mobility in the sagittal plane and its relation to hallux valgus deformity

Today, bunion surgery is still controversial. Considering that a bunion deformity in fact may be a result of multiple causes, the rationale of the currently applied techniques of surgical treatment has not been conclusively demonstrated. In view of the known hypermobility syndrome of the first ray that results in insufficient weightbearing beneath the first metatarsal head, the relationship between this syndrome and hallux valgus deformity has been investigated. The results suggest a direct relationship between painful hallux valgus deformity and hypermobility in extension of the first tarsometatarsal joint. A pathological mechanism of symptomatic hallux valgus is proposed that relates this pathology with primary weightbearing disturbances in the forefoot where angulation of the first metatarsophalangeal joint is one of the consequences. The alignment of the metatarsal heads within the sagittal plane seems to be a main concern in many hallux valgus deformities. As a consequence, treatment includes reestablishing stable sagittal alignment in addition to the horizontal reposition of the metatarsal over the sesamoid complex. As an example, first tarsometatarsal reorientation arthrodesis regulates the elasticity of the multiarticular first ray within the sagittal plane and may be the treatment of choice in many hallux valgus deformities.

Achilles tendon tenodesis to prevent heel pad migration in the Syme's amputation

In an attempt to prevent migration of the heel pad, 11 patients underwent a combined Syme's amputation and Achilles tendon tenodesis between December 1989 and April 1992. Ten patients healed the Syme's amputation, and one patient failed to heal the surgical wounds and required a below-knee amputation. In all 10 successful Syme's cases, the heel pad has remained stable with no migration, and no skin breakdown at an average follow-up of 18.5 months. Published series of Syme's amputations report that the incidence of heel pad migration is between 7.5% and 45%, and occurs primarily in the post-operative or early rehabilitation stage. We believe that tenodesis of the Achilles tendon is a technically easy addition to the Syme's amputation, that it keeps tension off of the incision during healing, and that it prevents migration of the heel pad.

Plate fixation of femoral shaft fractures in multiply injured children

A study was done of twelve patients (seven boys and five girls) who, because of multiple injuries or a head injury, had been managed with compression plating of a unilateral or bilateral femoral-shaft fracture at a level-I trauma center from 1986 through 1990. The patients had a total of fifteen fractures. The average age at the time of the injuries was eight years (range, five years to nine years and eleven months). There were nine closed fractures and six open fractures; three of the open fractures were Grade I; two, Grade II; and one, Grade IIIA, according to the criteria of Gustilo et al. Each patient had an average of three associated injuries. All fifteen fractures had healed clinically and radiographically at an average of eight weeks (range, six to twelve weeks) after the operation. There were no infections. Anatomical alignment was obtained in fourteen limbs. One fracture healed with 13 degrees of anterior angulation. The compression plates were removed at an average of ten months (range, three to twenty-four months) after the index operation. At the latest follow-up evaluation (average, twenty-six months; range, eleven to fifty-seven months), no patient had restriction of activities due to the femoral fracture. Scanograms revealed overgrowth of the injured femur averaging 0.9 centimeter (range, 0.3 to 1.4 centimeters) in seven patients who had an uninjured contralateral femur. We believe that plate fixation of the femur is a good treatment option for children who have a femoral shaft fracture and a major head injury or multiple injuries, or both.

Foot and ankle manifestations of Charcot-Marie-Tooth disease

The term Charcot-Marie-Tooth disease represents a spectrum of neurological dysfunction more recently described as hereditary motor-sensory neuropathies. An abnormality of myelination is thought to be responsible for the clinical manifestations. While histological findings have been well described, the exact biochemical basis for this disorder remains unknown. Over one half of patients with Charcot-Marie-Tooth disease manifest foot and ankle problems, including pain, weakness, deformity, and, rarely, paresthesias. Characteristic patterns of neuromuscular weakness have been identified. Bilateral pes cavovarus is the most common pathologic foot deformity seen. The specific components include hindfoot varus, anterior or forefoot cavus, and, often clawtoes. The etiology of this abnormal foot posture usually results from tibialis posterior overpowering peroneus brevis coupled with peroneus longus overpowering tibialis anterior. Multiple treatment options have been described. Rationale for specific tendon transfers, soft tissue release, osteotomies, and arthrodesis is discussed. Results of surgical intervention are difficult to interpret and compare because of the wide spectrum of both neurological dysfunction and described operative procedures. In the presence of flexible deformity, early soft tissue release and tendon transfers may help prevent or delay more extensive bony procedures. The clinical results of triple arthrodesis in the Charcot-Marie-Tooth disease patient appear to deteriorate with time. Genetic transmission, progression of the neurological dysfunction, flexibility of the deformity, distribution of muscular weakness, and anticipated foot demands vary a great deal within this patient population. Treatment decisions, therefore, must be individualized and based upon a clear history, careful examination, and well-defined patient goals.

Triple arthrodesis using internal fixation in treatment of adult foot disorders

Forty adult patients with 44 fused feet were evaluated at an average of 4.9 years after triple arthrodesis. The average age of the patients at operation was 41 years. All operations were performed by a specific technique using rigid internal fixation with screws. Outcome was graded using the clinical criteria of Hallgrimsson as modified by Angus and Cowell. Function was evaluated according to modified Arthritis Impact Measurement Scales (AIMS). Radiographic evaluation included measurement of lateral talocalcaneal angle, lateral talometatarsal angle, and anteroposterior (AP) talometatarsal angle on standing or simulated weight-bearing radiographs. Thirty-four feet had good results, six had fair results, and there were four failures. The average patient could function painlessly on flat surfaces in nonstrenuous activities and had only occasional mild pain with more vigorous activities. In roentgenographic parameters, there was an average improvement of 17 degrees in the lateral talometatarsal angle, 11 degrees improvement in the lateral talocalcaneal angle, and an improvement of 18 degrees in the AP talometatarsal angle. There were two pseudarthroses, no recurrences, and two unsatisfactory corrections. When carefully done, triple arthrodesis can restore an adult patient with a disabling foot disorder to normal function and minimal pain.

Intraarticular fractures of the foot. Talus and lesser tarsals

In the absence of historical comparative data for the treatment of tarsal fractures, commonly abided maxims of trauma care are noteworthy. A displaced fracture involving an articular surface or a fracture interrupting a mechanical axis is treated by open reduction and internal fixation. Rigid fixation is followed as early as possible with active and passive mobilization. Unlike long bones, whose motion and fracture patterns (i.e., segmental, transverse, and oblique) are understood, the tarsal bones are small bones with complex shapes and restricted motion. As a result, tarsal injuries most often occur with multiple ligamentous and bony injuries. Articular step-off is difficult to establish roentgenographically, the blood supply is tenuous, and fixation is largely dependent on screws and Kirschner wires. Good outcome can be obtained by following principles of internal fixation established in treatment of major joint injuries.

Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity

Nine patients with rigid equinocavovarus contractures of the foot and ankle after ischemic episodes of the leg were treated from 1986 to 1989. The ischemic contractures occurred after tibial and fibular fractures in six cases, and after a trimalleolar ankle fracture, an electrical burn, and cardiac bypass surgery in one case each. Previous tendon and nerve releases had failed. The scarred portion of the various involved muscles of the deep posterior compartment were widely excised along with the respective tendons. A variety of additional foot procedures were generally necessary to obtain a plantigrade foot. Night splinting to maintain a plantigrade foot was prescribed for all patients.

Symmetrical peripheral gangrene (purpura fulminans) complicating pneumococcal sepsis

Bacterial sepsis is only infrequently accompanied by peripheral ischemia. However, we have managed 10 patients with symmetrical peripheral gangrene (purpura fulminans) accompanying pneumococcal sepsis (Streptococcus pneumoniae) during the past 15 years at a single institution. In only two (20%) of these patients could vasoconstrictor administration be implicated as contributory to gangrene. The clinical scenario was characterized by pneumococcal bacteremia, admission to the medical intensive care unit, normal proximal arterial perfusion, and symmetrical full-thickness digital and distal extremity ischemia leading to cutaneous gangrene. Three (30%) of these patients died. The failure of anticoagulant and antiplatelet agents as therapy and the successful reversal of impending digital gangrene in one patient by sympathetic blockade suggest that the initial underlining pathophysiology is vasoconstrictive rather than thrombotic in nature. Effective management includes appropriate antibiotic therapy, avoidance of early operative intervention, conservative local débridement, and secondary skin grafting.

Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot

To better understand the bony component of pes planus and the means by which the Evans calcaneal lengthening corrects them, we studied the standing radiographs of seven adult patients who had undergone calcaneal lengthening to treat symptomatic pes planus. Weightbearing AP and lateral views done preoperatively and postoperatively were used for the study. For each set of films, the following parameters were measured: on the lateral view; overall length of the calcaneus, lateral talometatarsal angle, lateral talocalcaneal angle, and the calcaneal pitch angle; and on the dorsoplantar view, the talometatarsal and talocalcaneal angle. In addition, the relative coverage of the talus by the navicular was described by an angular measurement based on the relationship of the center of the talus to the center of the navicular. The average improvements in lateral talocalcaneal angle (a reflection of hindfoot valgus) was 6.4 degrees when the long axis of the calcaneus was used and 6.8 degrees when the inferior surface of the calcaneous was used for the measurement. The lateral talometatarsal angle improved an average 11.3 degrees (from an average of 19.7 degrees to 8.4 degrees). The dorsoplantar talometatarsal angle (a measure of forefoot adduction/abduction) improved 15.8 degrees (preoperative average 26.8 degrees, postoperative average 11 degrees). The calcaneal pitch angle improved an average 10.8 degrees (preoperative average 3.2 degrees, postoperative average 14 degrees). The relationship between the talus and navicular was defined by an angular measurement based on the center of each articular surface before and after correction using this measurement. An average improvement of 26 degrees occurred in the alignment of these two articular surfaces.(ABSTRACT TRUNCATED AT 250 WORDS)

Traumatic subluxation/dislocation of the peroneal tendons

Traumatic subluxation/dislocation of the peroneal tendons has been reported following a variety of sports-related activities. The peroneal musculature contracts reflexively during the injury and overcomes the restraining soft tissue. The tendons can then dislocate anteriorly from behind the distal fibula. Some patients have anatomical variations of the posterolateral ankle that predispose them to injury. If the physician is unaware of the injury, the diagnosis may be missed in the acute setting and can develop into a chronic, disabling condition. Treatment of the acute injury is controversial because advocates exist for both conservative and surgical therapies. The chronic, painful lesion should be treated operatively. A tremendous number of surgical procedures have been described for the treatment of chronic tendon dislocations. Choice of a surgical procedure depends upon the anatomy of the peroneal groove and the retinaculum, and the nature of the damage to the area.

Ankle arthrodesis using internal screw fixation

Ankle arthrodesis treated by external fixation frequently results in complications from pin tract infections, loss of position, nonunion, and malunion. A method of ankle arthrodesis using 6.5-mm cancellous screws as the primary fixation hardware was developed. The most important screw is placed from the posterior malleolus into the neck and head of the talus, and medial and lateral malleolar screws are added to secure fixation. Near-normal anatomy is maintained with this technique because little or no bone, only cartilage, is removed. Earlier cases were all done through an anterior approach. Later, special techniques were developed for placing screws and strain-relieving bone grafting was added to promote union. Twenty-three cases that were treated by the earlier technique are reviewed. The overall fusion rate was 74%. Three conditions (avascular talus, pyarthrosis, and spasticity) were identified that placed patients at high risk for failure of fusion. Of the patients who were not in a high-risk group, only one had a delayed union. When the high-risk patients were not included in the statistics, the fusion rate was 93%. The evolved technique shows great promise for accurate and trouble-free ankle arthrodesis.

Objective criteria accurately predict amputation following lower extremity trauma

MESS (Mangled Extremity Severity Score) is a simple rating scale for lower extremity trauma, based on skeletal/soft-tissue damage, limb ischemia, shock, and age. Retrospective analysis of severe lower extremity injuries in 25 trauma victims demonstrated a significant difference between MESS values for 17 limbs ultimately salvaged (mean, 4.88 +/- 0.27) and nine requiring amputation (mean, 9.11 +/- 0.51) (p less than 0.01). A prospective trial of MESS in lower extremity injuries managed at two trauma centers again demonstrated a significant difference between MESS values of 14 salvaged (mean, 4.00 +/- 0.28) and 12 doomed (mean, 8.83 +/- 0.53) limbs (p less than 0.01). In both the retrospective survey and the prospective trial, a MESS value greater than or equal to 7 predicted amputation with 100% accuracy. MESS may be useful in selecting trauma victims whose irretrievably injured lower extremities warrant primary amputation.

Internal fixation of children's fractures of the lower extremity

Lower grade fractures are by definition stable and almost always treated with casting or functional splinting. The best kind of fixation for the higher grade fractures, however, differs between adults and children. Appropriate treatments are discussed, and case-study illustrations are provided. Background on the anatomy of the tibia and femur is included.

Salvage of Lisfranc's tarsometatarsal joint by arthrodesis

Sixteen patients with fractures or fracture-dislocations of the tarsometatarsal (Lisfranc) joint who failed initial treatment were salvaged by arthrodesis using a technique of rigid internal fixation. Preoperative symptoms included local pain in all patients, progressive flatfoot deformity with forefoot abduction in 12 patients, and ankle or lateral impingement pain in five. The technique involved exposing the joint, denuding it of cartilage and scar, and reduction and fixation with lag screws. A total of 49 joints were fused. When significant deformity was present, reduction was performed before arthrodesis. Clinically symptomatic and radiographically proven nonunion occurred in four sites in three patients. One healed after revision. Good to excellent results were obtained in 11 patients (69%). Five patients had a fair or poor results. All but one of the patients were subjectively improved. Four patients were symptom free and returned to their preinjury lifestyles. Accurate reduction and early treatment had a significant positive relationship with outcome. Injuries that occurred in the workplace and those that incurred a long delay until treatment showed a significant negative correlation to outcome. Neither the age of the patient nor the number of joints fused had a significant impact on result.

[Thromboxane A2 and granulocyte elastase after severe trauma--relationship to complications and survival rates]

Of 64 polytraumatized patients with a mean injury severity score of 33.1, 42 showed marked systemic release of thromboxane B2 and granulocyte elastase during the initial 18 hours after trauma, reaching peak arterial levels of greater than 1,000 pg/ml and ng/ml, respectively. If those patients ("responders": plasma TXB2 greater than 250 pg/ml) were compared with the remaining 22 ("non-responders": TXB2 less than 250 pg/ml) the following became obvious: "Late" mortality (greater than 3 d) was 31% in responders, which is significantly higher than in non-responders (9%). No correlation was observed between "early" mortality (less than 3 d) and mediator release. There was no difference in the incidence of the adult respiratory distress syndrome (ARDS) (38% versus 32%) or the late sepsis syndrome (17% versus 18%) between responders and non-responders. Morbidity, however, differed markedly in that ARDS in responders was associated with significantly higher elastase levels, a higher mortality and 10 times higher incidence of sepsis as compared to responders without ARDS. ARDS in non-responders, by contrast, did not change elastase maxima or the mortality rate as compared to non-responders without ARDS. It is concluded that TXB2 is not a predictor of posttraumatic ARDS, but is related to a complicated course, in particular to sepsis and mortality. Elastase with high probability predicts ARDS and/or the late sepsis syndrome. Simultaneous determination of TXB2 further enhances the predictive value of elastase.

Displaced intra-articular fractures of the tarsal navicular

Between 1980 and 1987, twenty-one patients who had a displaced fracture of the body of the tarsal navicular were treated with open reduction and internal fixation. A classification system was devised on the basis of the direction of the fracture line, the pattern of disruption of the surrounding joints, and the direction of displacement of the foot. In a Type-1 injury, the fracture line is in the coronal plane and there is no angulation of the fore part of the foot. In a Type-2 fracture, the primary fracture line is dorsal-lateral to plantar-medial, and the major fragment and the fore part of the foot are displaced medially. In a Type-3 injury, there is a comminuted fracture in the sagittal plane of the body of the tarsal navicular, and the fore part of the foot is laterally displaced. Satisfactory reduction, which was defined as restoration of more than 60 per cent of the joint surface in the anteroposterior and lateral planes, was achieved in all Type-1 injuries, 67 per cent of the Type-2 fractures, and 50 per cent of the Type-3 fractures. Radiographic evidence of healing was seen at an average of 8.5 weeks after injury. At an average follow-up of forty-four months (range, twelve to 106 months), a good result was noted in fourteen patients (67 per cent); a fair result, in four (19 per cent); and a poor result, in three (14 per cent). Both the type of fracture and the accuracy of the operative reduction directly correlated with the final clinical outcome.