Estimation of Patient Acceptable Symptom State (PASS) and Treatment Failure (TF) Threshold Values for the Achilles Tendon Total Rupture Score (ATRS) at 6 Months, 1 Year,and 2 Years After Acute Achilles Tendon Rupture

Interpretation of the Achilles tendon Total Rupture Score (ATRS) is challenging because limited knowledge exists about at which score the patients consider the outcome of treatment as satisfactory. The aims of the study were (1) to describe the proportion of patients who find their symptom levels to be satisfactory, to reflect treatment failure or neither after acute Achilles tendon rupture (ATR), and (2) to estimate the Patient Acceptable Symptom State (PASS) and the Treatment Failure (TF) threshold values for the ATRS at 6 months, 1 year, and 2 years after ATR. The study was based on data extracted from the nationwide Danish Achilles tendon Database which includes patients treated operatively or nonoperatively after ATR. The PASS and TF threshold values for ATRS were estimated using the adjusted predictive modeling method. One hundred and sixty-six patients were included at 6 months, 248 patients at 1 year, and 287 patients at 2 years after ATR. The proportion of patients who considered their symptom level to be satisfactory was 61% at 6 months, 50% at 1 year, and 66% at 2 years, while 5% at 6 months, 11% at 1 year, and 10% at 2 years considered their symptom level to reflect treatment failure. The PASS threshold value for ATRS (95% confidence interval) was 49 (46-52) at 6 months, 57 (54-60) at 1 year, and 52 (49-55) at 2 years. The TF threshold value for ATRS was 30 (23-36) at 6 months, 33 (26-40) at 1 year, and 35 (29-39) at 2 years. The calculated PASS and TF threshold values can help interpret the outcome of ATR when measured with the ATRS. About 50% to 66% of the patients had a satisfactory symptom level after ATR.     

川芎嗪注射液对实验性屈肌腱粘连的影响

本实验观察了川芎嗪注射液对鸡屈深肌腱粘连模型的影响，并与具有抗组织粘连作用的二甲基硅油及生理盐水进行对照。结果显示：川芎嗪与硅油组的损伤肌腱滑动功能好且粘连面积小，与盐水组比较有显著性差异（Ｐ＜０．０５，Ｐ＜０．０１）。而在肌腱的修复方面，川芎嗪又明显优于硅油组。表明：在损伤肌腱的鞘管内局部运用川芎嗪注射液既可减轻其腱周粘连，又不影响肌腱自身的愈合过程。     

The impact of rotator cuff deficiency on structure,mechanical properties,and gene expression profiles of the long head of the biceps tendon (LHBT): Implications for management of the LHBT during primary shoulder arthroplasty

The long head of the biceps tendon (LHBT) occupies a unique proximal intra‐articular and distal extra‐articular position within the human shoulder. In the presence of a rotator cuff (RC) tear, the LHBT is recruited into an accelerated role undergoing potential mechanical and biochemical degeneration. Intra‐articular sections of the LHBT were harvested during primary shoulder arthroplasty from patients with an intact or deficient RC. LHBTs were stained (H&E, Alcian Blue) and subjected to histologic analysis using the semiquantitative Bonar scale and measurement of collagen orientation. LHBTs (n = 12 per group) were also subjected to gene‐expression analyses via an RT²‐PCR Profiler Array quantifying 84 genes associated with cell‐cell and cell‐matrix interactions. LHBTs (n = 18 per group) were biomechanically tested with both stress‐relaxation and load‐to‐failure protocols and subsequently modeled with the Quasilinear Viscoelastic (QLV) and Structural‐Based Elastic (SBE) models. While no histologic differences were observed, significant differences in mechanical testing, and viscoelastic modeling parameters were found. PCR arrays identified five genes that were differentially expressed between RC‐intact and RC‐deficient LHBT groups. LHBTs display signs of pathology regardless of RC status in the arthroplasty population, which may be secondary to both glenohumeral joint arthritis and the additional mechanical role of the LHBT in this population. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:1158–1164, 2015.     

腓肠神经营养血管远端蒂皮瓣修复足踝部软组织缺损

目的：总结应用腓肠神经营养血管远端蒂皮瓣修复足踝部皮肤软组织缺损的经验。方法：从2006年2月～2008年12月,笔者应用腓肠神经营养血管远端蒂皮瓣修复足踝部软组织缺损共12例,皮瓣最大15cm×10cm,最小6cm×5cm,筋膜蒂宽度为4～5cm,皮瓣旋转点至外踝尖距离5～7cm。皮瓣剥离的深度在腓肠肌肌膜深面,将小隐静脉和腓肠神经包含于内。蒂部均留有2cm宽度的皮肤,走明道向受区旋转。结果：12例皮瓣全部成活,无供血不足及静脉回流障碍。结论：腓肠神经营养血管远端蒂皮瓣血运丰富,制作简便,防止蒂部受压是成活率高的保证。     

应用外踝上皮瓣修复足踝部皮肤缺损

目的 探讨外踝上皮瓣修复足踝部皮肤缺损的临床疗效.方法 2008年3月至2012年10月,应用外踝上皮瓣修复外伤性足踝部皮肤缺损15例,其中合并踝关节,蹠跗关节骨折10例.常规清创后二期设计外踝上皮瓣修复缺损创面,皮瓣面积最大10 cm×8 cm,最小5 cm×4cm,平均8 cm×5 cm.结果 所有皮瓣均成活.其中3例术后24 h皮瓣远端出现水泡,经处理后愈合.结论 外踝上皮瓣血管解剖恒定,切取简单,成活率高,是修复足踝部皮肤缺损的一种较好方式.     

Comparison of clinical and radiologic outcomes between non-operative and operative treatment in 5th metatarsal base fractures (Zone 1)

The treatment of Zone 1 fractures of the 5th metatarsal base with >2 mm of displacement remains controversial. We prospectively analyzed 29 patients with 5th metatarsal base fractures (Zone 1) during 2009–2014. Radiography was performed to assess the degree of fracture gap and metatarsal length. Patients with gaps of 2 mm or less were treated conservatively using a short leg cast or splint (Group A), while patients with fracture gap >2 mm were randomly assigned to one of two groups. Group B patients were managed with open reduction and internal fixation (ORIF), and Group C patients were placed in a short leg cast only. Visual analog scale (VAS) score and American orthopedic foot and ankle society (AOFAS) score were obtained at the initial consult and at the last follow-up after treatment; change of the 5th metatarsal length was also measured at the initial consult and after complete bony union. Our study demonstrated that radiographic union of all cases was observed with a significant decrease in VAS and AOFAS scores, regardless of the initial fracture gap and type of management. Additionally, there was no difference seen in final VAS scores for patients with longer metatarsals when compared to those in whom the metatarsals were unchanged or shortened.     

Role of anti-oxidant (vitamin-C) in post-operative pain relief in foot and ankle trauma surgery: A prospective randomized trial

BackgroundPost-operative pain may adversely affect a patient’s quality of life. Studies have shown that vitamin C, being an anti-oxidant and neuro-modulating agent, can help to reduce pain in a variety of clinical settings. The objective of this randomized controlled trial was to assess the effectiveness of vitamin C in reducing post-operative pain, analgesia requirements and improving functional outcome.MethodsPatients with isolated foot and ankle trauma, who had undergone surgery, were randomly assigned to receive either vitamin C 500 mg or a placebo tablet twice a day. VAS score, analgesia requirement and functional outcome were assessed during their regular follow up. Results were compared and analyzed at the end of 3 months.ResultsThe group which received vitamin C, showed improvement in VAS score at the end of second and sixth week of follow up, reduced analgesia requirements and improved functional outcome as compared to the placebo group.ConclusionsThis study shows that the supplementation of vitamin C in patients undergoing surgery for foot and ankle trauma helps to reduce analgesic requirements, improve VAS scores and achieve better functional outcome.     

Peritenolysis and Debridement for Main Body (Mid-Portion) Achilles Tendinopathy in Athletic Patients: Results of 107 Procedures

Achilles tendinopathy in the main body (mid-portion) of the tendon is a common pathologic finding among active and athletic populations and can be debilitating without proper and adequate treatment. Numerous surgical approaches for this common pathologic finding have been reported, with variable outcomes. We evaluated the surgical outcomes of peritenolysis and debridement of main body Achilles tendinopathy among athletic populations using the return to activity (RTA) and decreased desired activity (DDA) as our primary outcome measures. A total of 100 patients underwent 107 procedures by the senior author (A.S.) from January 2001 through December 2015 met the inclusion criteria, 65 (65%) of whom were runners. The mean follow-up duration was 106.6 ± 55.5 months from the index procedure, and the mean interval necessary to RTA for the entire group was 10.9 ± 5.3 weeks. The average RTA after debridement was 14.1 ± 5.2 weeks and after peritenolysis was 7.3 ± 2.0 weeks (p = .00001). Of the 100 patients, 3 (3%) had experienced a DDA at the last follow-up visit. With >97% of the patients able to return to their desired activities, we have concluded that peritenolysis and debridement are favorable surgical techniques for main body Achilles tendinopathy.     

鹿瓜多肽注射液对去势大鼠骨密度和骨力学性能的影响

目的研究鹿瓜多肽注射液对去卵巢大鼠骨骼生物力学性能的影响。方法 3个月龄清洁级雌性Wistar大鼠27只,随机分为假手术（sham group,SHAM）组、去势（ovariectomized,OVX）组、去势＋鹿瓜多肽（cervus and cu-cumis polypeptide,CCP）组,每组9只。OVX＋CCP组大鼠于术后第1天开始按0.6 mL/（kg.d）肌注鹿瓜多肽注射液,术后12周处死所有大鼠,取出股骨及腰椎标本,双能X线吸收仪测量各组大鼠股骨近端、股骨干及全腰椎的骨密度。应用INSTRON 3367电子拉伸试验机检测股骨近端、股骨干和L5的生物力学性能。结果 a）OVX组与SHAM组相比较,大鼠股骨和腰椎最大载荷无明显下降（P〉0.05）,但极限强度明显下降（P〈0.01）;与OVX组相比,OVX＋CCP组的最大载荷无明显增加（P〉0.05）,但极限强度显著高于去势组（P〈0.01）;OVX＋CCP组与SHAM组比,上述检测指标间无统计学差异（P〉0.05）;b）与SHAM组相比,OVX组股骨近端、股骨干及全腰椎的骨密度明显降低（P〈0.01）;与OVX组相比,OVX＋CCP组各部位骨密度明显高于OVX组（P〈0.01）;OVX＋CCP组与SHAM组比,两者各部位骨密度无明显差异（P〉0.05）。结论鹿瓜多肽注射液能保护去势大鼠骨密度和骨骼内在生物力学性能。     

复方芩柏颗粒剂促进创面愈合的研究

目的：研究复方芩柏颗粒剂促进创面愈合的初步机理，为临床应用提供理论依据。方法：实验采用放免法检测小鼠创面肉芽中的表皮生长因子（EGF），并对创面肉芽进行病理切片观察；同时临床对照观察了90例痔瘘术后患者创面愈合的情况。结果：复方芩柏颗粒剂提高创面肉芽中内源性EGF水平，增加小鼠创面肉芽中的微血管数，从而促进创面上皮化，加速创面愈合。结论：复方芩柏颗粒剂促进痔瘘术后创面愈合的机理之一是提高了创面肉芽中EGF水平。     

Efficacy and Safety of Single and Repeated Administration of 1 Gram Intravenous Acetaminophen Injection (Paracetamol) for Pain Management after Major Orthopedic Surgery

Background: Intravenous acetaminophen injection (paracetamol) is marketed in Europe for the management of acute pain. A repeated-dose, randomized, double-blind, placebo-controlled, three-parallel group study was performed to evaluate the analgesic efficacy and safety of intravenous acetaminophen as compared with its prodrug (propacetamol) and placebo. Propacetamol has been available in many European countries for more than 20 yr.

Methods: After orthopedic surgery, patients reporting moderate to severe pain received either 1 g intravenous acetaminophen, 2 g propacetamol, or placebo at 6-h intervals over 24 h. Patients were allowed "rescue" intravenous patient-controlled analgesia morphine. Pain intensity, pain relief, and morphine use were measured at selected intervals. Safety was monitored through adverse event reporting, clinical examination, and laboratory testing.

Results: One hundred fifty-one patients (intravenous acetaminophen: 49; propacetamol: 50; placebo: 52) received at least one dose of study medication. The intravenous acetaminophen and propacetamol groups differed significantly from the placebo group regarding pain relief from 15 min to 6 h (P < 0.05) and median time to morphine rescue (intravenous acetaminophen: 3 h; propacetamol: 2.6 h; placebo: 0.8 h). Intravenous acetaminophen and propacetamol significantly reduced morphine consumption over the 24-h period: The total morphine doses received over 24 h were 38.3 +/- 35.1 mg for intravenous acetaminophen, 40.8 +/- 30.2 mg for propacetamol, and 57. 4 +/- 52.3 mg for placebo, corresponding to decreases of -33% (19 mg) and -29% (17 mg) for intravenous acetaminophen and propacetamol, respectively. Drug-related adverse events were reported in 8.2%, 50% (most of them local), and 17.3% of patients treated with intravenous acetaminophen, propacetamol, and placebo, respectively.     

Rate of COVID-19 infection and 30 day mortality between blue and green (dedicated COVID-19 safe) pathways: Results from phase 1 and 2 of the UK foot and ankle COVID-19 national (UK-FAlCoN) audit

ObjectivesThe primary aim was to determine the differences in COVID-19 infection rate and 30-day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second UK national lockdowns.SettingThis was an ambispective (retrospective Phase 1 and prospective Phase 2) national audit of foot and ankle procedures in the UK in 2020 completed between 13th January 2020 and 30th November 2020.ParticipantsAll adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway (no protocols to prevent COVID-19 infection).Results10,846 patients were included, 6644 from phase 1 and 4202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6470) and 0.21% on a green pathway (9/4280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p = .109), lockdown (p = .923) or post-lockdown (p = .577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p < .001) and lockdown periods (Odd’s Ratio 0.077, p < .001). There was no significant difference in COVID-19 related mortality between pathways.ConclusionsThere was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways over the whole study period; however the success of the pathways only became significant in phase 2 of the study, where there was a 13-fold reduction in infection rate. The study shows a developing success to using green pathways in reducing the risk to patients undergoing foot and ankle surgery.     

Reverse Peroneal Artery Flap—A Workhorse Flap for Reconstruction of Large,Distal Defects of Ankle and Foot

Background  Reconstruction of large foot and ankle defects is a difficult task due to less available local soft tissue and more critical from functional point of view. To overcome the limitations associated with locoregional flaps and free flaps, reverse peroneal artery (RPA) flap was selected and its usefulness in reconstruction of distal large defects of the ankle and foot and its complications were studied. Materials and Methods  This is a prospective observational study done in 20 patients treated as cohort within 2 years and 8 months from January 2018 to August 2020. Large defects of foot and ankle were reconstructed with RPA flap and evaluated for its usefulness. Three cases were evaluated with computed tomography angiography postoperatively, to assess the vascular pattern. Conclusion  RPA flap is a versatile and very reliable flap for the reconstruction of large and distal defects of foot and ankle. It is safely done in children and in acute trauma without any major complications.     

Development and psychometric performance of the French language version of the Manchester-Oxford Foot Questionnaire (MOXFQ)

BackgroundThe Manchester-Oxford Foot Questionnaire (MOXFQ) is a 16-item patient-reported outcome measure (PROM) validated for use in patients with foot and ankle pathologies. It contains three sub-scores for pain, walking/standing and social interaction dimensions. The aim of this study was to develop a French language version of the MOXFQ and to assess its psychometric properties in patients affected by foot and ankle pathologies.MethodsAccording to guidelines, forward and backward independent translations were performed. The final French version was pre-tested in 45 patients. The French MOXFQ and the Short-form 36 Health Survey (SF-36) were filled in by 149 patients. A retest was performed in 39 patients. Internal consistency and test–retest reliability were assessed using Cronbach’s alpha and intraclass correlation coefficient (ICC), respectively. Construct validity was assessed by factor analysis, and through correlations of MOXFQ scales with SF-36 scales.ResultsInternal consistency coefficients were high with Cronbach’s alpha ranging from 0.79 and 0.94. Test-retest ICCs were between 0.74 and 0.93. No floor or ceiling effects were observed. The correlations between French MOXFQ and French SF-36 subscales were moderate ranging from −0.33 to −0.71.ConclusionsThe French translation of the MOXFQ revealed good psychometric properties. Our French version proved to be a reliable instrument which can be used for evaluation of patients with foot and ankle disorders.Level of evidenceII.     

Efficacy and safety of Amphotericin B Lipid Complex Injection (ABLC) in solid-organ transplant recipients with invasive fungal infections

Background: Fungal infections following solid-organ transplantation are a major source of morbidity and mortality. This report describes the efficacy and safety of Amphotericin B Lipid Complex Injection (ABLC) in solid-organ transplant recipients.
Methods: Three open-label, second-line treatment studies evaluated ABLC as a treatment for severe, life-threatening mycoses in patients who were refractory to or intolerant to conventional antifungal (mostly amphotericin B [AmB]) therapy or had pre-existing renal disease.
Results: The 79 solid-organ transplant recipients (25 heart, 20 liver, 17 kidney, 11 lung, 5 multiple, 1 pancreas) who received ABLC in these studies had the following fungal infections: aspergillosis (n=39); candidiasis (n=20); zygomycosis (n=8); cryptococcosis and histoplasmosis (n=3 each); and blastomycosis, cladosporiosis, fusariosis, Bipolaris hawaiiensis , Dactylaria gallopava , and an unspecified fungal infection (n=1 each). The median duration of ABLC therapy was 28 d (1–178 d). The daily dose ranged between 1.6 and 7.4 mg/kg (median, 4.6 mg/kg). The clinical response rate for the patients who could be assessed was 58% (39/67). Clinical response rates for heart, liver, kidney, and lung recipients were 59, 60, 67, and 40%, respectively; response rates for aspergillosis and candidiasis were 47 and 71%, respectively. Forty-six of the 79 patients (58%) survived for more than 28 d after the last dose of ABLC. Mean baseline serum creatinine was 3.2 mg/dL; 64 patients (81%) had stable (n=37) or improved (n=27) serum creatinine at the end of treatment.
Conclusions: ABLC is safe and effective treatment for fungal infections in solid-organ transplant recipients. Its renal-sparing properties are particularly suited for this high-risk population for renal failure.