Peroneus longus tendon transfer; prospective study of treatment outcome of recurrent fixed clubfoot deformities in children after failed surgical treatment

BackgroundIn childhood, for flexible clubfoot deformity, the transfer of the tendon of the tibialis anterior muscle is widely used. In contrast, extensive surgical procedures are required for fixed clubfoot deformities.MethodsWe describe the peroneus longus tendon transfer to the peroneus brevis tendon, additionally to full surgical release, in cases of recurrent fixed clubfoot deformities. The purpose of this surgical technique was to restore and maintain the dynamic balance of foot inversion-eversion during the gait cycle by augmenting the muscular strength of the weak peroneus brevis tendon. We report the prospective study of treatment outcome of twenty recurrent fixed clubfoot deformities in twelve children (20 feet) after failed surgical treatment they had. Anteroposterior and lateral radiographs under full-body weight-bearing and the AOFAS score pre-and postoperatively were used in all patients. For the estimation of the severity of the recurrent clubfoot deformity in each child and to increase the credibility of the AOFAS rating scale, we additionally used a clubfoot sheet score preoperatively and postoperatively (maximum score 100 points for normal foot appearance clinically and radiologically).ResultsThe mean age at surgery was 6,85 (±1,81; 5–11) years. The mean follow-up time was 5,4 (±1,7; 2–8) years. The mean AOFAS ankle-hindfoot rating score increased from 69,85 (±9,51; 53–82) points preoperatively to 94,4 (±2,43; 91–97) points postoperatively. The mean clubfoot sheet rating score increased from 43,00 (±12,18; 15–55) points, preoperatively to 90,0 (±4,58; 80–95) points postoperatively. The two-tailed p-value was < 0,0001.ConclusionsThe transfer of the peroneus longus tendon to the peroneus brevis tendon is a minimal surgical procedure that acts collaboratively in maintaining the correction of foot deformity, achieved by the complete surgical release. Level of Evidence: IV.     

Bipartite os tibiale externum: A rare condition causing foot pain

BackgroundThe accessory navicular (os tibiale externum, prehallux) is a frequent skeletal variation. However, a bipartite os tibiale externum is extremely rare and so far has only be reported in radiologic studies.MethodsWe report on a 30-year old female patient with flexible flatfoot and a bilateral accessory navicular. On the more painful side, a bipartite accessory navicular was resected. The posterior tibial tendon was fixed to the medial aspect of the navicular proper after levelling the prominent tuberosity.Results and conclusionsThe patient was completely pain free after 6 weeks and there was no remaining functional deficit. Bipartite accessory navicular is a very rare variant of a rather frequent accessory bone at the foot. Resection of the ossicle with debridement of the medial aspect of the navicular and attachment of the posterior tibial tendon to the navicular body (modified Kidner procedure) seems to lead to an excellent result also in these cases. In the presence of more severe deformities, treatment has to be adapted to the individual case.     

Peer reviewing in foot and ankle surgery: is there a limit to scientific altruism?

IntroductionComplex foot and ankle trauma surgery is a super-specialization of orthopedic trauma surgery. This topic is gaining in interest, both clinically and in research. The peer review process is the cornerstone of the current scientific model of evaluation of research papers. The burden of peer review activity in foot and ankle trauma surgery is currently unknown.Material and methodA comprehensive Microsoft Outlook® analysis of over seven years’ worth of review invites from one surgical Foot & Ankle specialist working at a Level-1 trauma center was evaluated. The topic of each paper was recorded. Whether or not the journal was specifically foot ankle, orthopedic, general medicine or predatory of origin was noted. In addition, it was recorded if the journal was indexed in Pubmed, Medline, or Scopus. The topic of the paper was scored as being foot and ankle related, and more specifically foot and ankle trauma related. Review of revisions were scored as invites as well.ResultsFrom January 2013 to December 2019 a total of 467 review invites were received. The number of peer review invitations rose from 14 in 2013 to 127 in 2019. The percentage of foot and ankle specific journals was 27.4%. The number of requests from non-indexed (predatory) journals rose from 3.7% in 2014 to 36.2% in 2019, with a decrease in article topics related to the authors subspecialty. The annual absolute number of performed reviews stayed approximately the same throughout the study period (34 on average in the last 5 years).ConclusionThe number of review requests in foot and ankle surgery has increased about 5-fold over the 5 year period evaluated. There is a need for more reviewers to spread the burden. Therefore, foot and ankle specialists who are prepared to publish, should also be prepared to provide peer reviews to maintain a high level of quality in foot and ankle research.     

Relationship of plasma sex hormones to different parameters of obesity in male subjects

Relationships between plasma sex hormones and different parameters of obesity (weight, ideal body weight [IBW], overweight, fat mass, and body surface) were investigated in 70 healthy nonobese and obese males, 20–40 yr of age and with a body weight of 85%–245% of IBW. Plasma sex hormones remained unaffected by weight up to approximately 160% of the IBW. Only in the massively obese subjects was plasma testosterone decreased to 40% of controls (from 6.2 to 2.5 ng/ml), whereas free testosterone remained almost constant. On the other hand, plasma estrone and estradiol exhibited significant increases in obese subjects, ranging from 31.5 ± 5.3 to 52.3 ± 5.8 pg/ml for estrone, and 25.4 ± 5.4 increasing to 44.7 ± 5.0 pg/ml for estradiol. Similarly, free estradiol was shown to significantly increase with obesity in men from 505 ± 118 to 991 ± 123 fg/ml (p < 0.001). The ratios of testosterone/androstenedione, as well as of estradiol/estrone, were not affected by obesity, suggesting that reduction of the 17-oxo-group of the steroids is not influenced by the amount of fat tissue. A significant (p < 0.001) correlation was found between IBW and estrone (r = 0.80) and estradiol (r = 0.75), as well as the ratios of estrone/androstenedione (r = 0.62) and estradiol/testosterone (r = 0.86). This is consistent in its evidence indicating that fat tissue may be able to aromatize androgens. In the obese subjects, there were significant correlations between plasma sex hormones (testosterone, estrone, estradiol, and free estradiol) and the parameters of obesity used. Among these, correlations were best with IBW, overweight, and fat mass (r = 0.74–0.89; p < 0.001); body weight and body surface were less favorable.     

Reduction of creatine kinase and creatine kinase-MB indexes of infarct size by intravenous verapamil

In a prospective, controlled study, 29 patients were randomly allocated to receive intravenous verapamil, 5 to 10 mg/hour, for 2 days starting at a mean of 8 hours after the onset of myocardial infarction. Twenty-five patients received no specific treatment and served as control subjects. Left ventricular (LV) filling pressure in all patients was initially less than 15 mm Hg. Age, infarct localization and hemodynamic values on admission (Swan-Ganz catheter) were comparable in both groups. Maximal creatine kinase (CK) and creatine kinase-MB (CK-MB) values were markedly lower in the verapamil group than in the control group (CK 547 vs 703 U/liter, p less than 0.05; CK-MB 51 vs 68 U/liter, p less than 0.025), as was infarct weight (48 vs 65 g-Eq, p less than 0.03; CK-MB 31 vs 49 g-Eq, p less than 0.005). Arterial blood pressure was 10% lower in the verapamil group than in the control group. Systemic vascular resistance and LV filling pressure remained unchanged. Verapamil reduced myocardial infarction size by about 30% in patients without LV failure and the arterial pressure was reduced.     

Biomaterial-based bone regeneration and soft tissue management of the individualized 3D-titanium mesh: An alternative concept to autologous transplantation and flap mobilization

Three-dimensional augmentation in severely atrophic bone and after cancer resection is a challenging clinical indication that is mostly solved using autologous bone transplantation. The development of the digital technique along with the additive manufacturing and three-dimensional (3D) printing opened new avenues for reconstructive oral and maxillofacial surgery. Therefore, patient-specific titanium mesh is a novel means of stabilizing the augmentation region using particulate bone substitute materials (BSMs) combined with autologous bone as a minimally invasive concept. However, dehiscence is a frequently reported complication in this field. Therefore, the aim of the present case series was to introduce a biomaterial-based regenerative concept in terms of exposed open healing to overcome the dehiscence related to 3D-titanium meshes. Additionally, this case series presents a novel protocol using a combination of xenogeneic BSMs with an autologous blood concentrate system (platelet-rich fibrin [PRF]) and collagen matrices without any autologous transplantation. Seven patients with alveolar ridge atrophy with different etiologies (cancer resection, severe atrophy after tooth loss, aplasia, trauma, implant infections) were treated using the open-healing concept. Therefore, after 3D augmentation using the described biomaterials, the flap margins were approximated, and the gap between the flap margins was bridged using a collagen matrix loaded with liquid PRF that was then covered by either a PTFE-based membrane or sterile latex. No periosteum splitting was performed at any time point. After a healing period of 4–8 months, all patients received dental implants as virtually planned. Bone biopsies were performed during dental insertion for histological evaluation. The augmentation area displayed a vital and well-vascularized newly formed bone that incorporated the BSM granules to build a hybrid bone. Additionally, open healing resulted in newly formed soft tissue without any signs of scar formation or fibrosis. The regenerated soft tissue was used to build a new flap during implant insertion and showed good functional and aesthetic results after implant insertion. The open-healing concept of the regeneration of the soft tissue along with bone tissue to regenerate a harmonic implantation bed is a minimally invasive intervention without periosteum splitting or large flap mobilization. However, further controlled clinical studies are needed to evaluate this concept in a larger patient cohort to outline the potential clinical benefit.