Mechanical Testing of Seven Fixation Methods for Generation of Compression Across a Midtarsal Osteotomy: A Comparison of Internal and External Fixation Devices

The purpose of this study was to assess 7 methods of fixation for a midtarsal osteotomy. Polyurethane foam models (N = 6) and cadaver specimens (N = 4-7) were used to examine the force generated by the different constructs of fixation. A midtarsal osteotomy was performed on each specimen in the test groups. The osteotomies were fixated either with 2 parallel 0.062-in Kirschner wires and 40-mm-long, 4-mm partially threaded, cancellous, cannulated titanium screws, an external ring fixator (frame), a frame with wires tensioned (tension), a frame with wires tensioned and compressed toward the osteotomy (tension and compression), a frame with tension, compression, and parallel Kirschner wires, or a frame with tension, compression, and two 4.0 cannulated parallel screws, respectively. Each model was fixated, and the force generated by the construct across the osteotomy was recorded via the use of pressure-sensitive film. Statistical analysis of the data in the polyurethane foam group determined that the use of frame with tension, compression, and two 4.0 parallel cannulated screws was statistically superior to 1) frame, 2) frame with tension, 3) 2 parallel Kirschner wires, 4) two 4.0 cannulated parallel screws, and 5) frame with tension and compression. A cadaver study determined that the frame with tension, compression, and 2 parallel Kirschner wires was statistically superior to 1) frame and 2) two parallel Kirschner wires. These findings suggest that there is a difference in the force generated by the type of fixation construct across a midtarsal osteotomy.     

Independent and court-ordered forensic neuropsychological examinations: Official statement of the National Academy of Neuropsychology

Independent forensic neuropsychological examinations are performed by neuropsychologists who are hired as independent contractors by third parties to make determinations regarding neuropsychological functioning. The responsibilities of neuropsychologists when performing independent or court-ordered forensic examinations differ from those of clinical examinations. Because neuropsychological training typically occurs in clinical contexts, the transition to forensic contexts may result in uncertainty about how to negotiate the unique responsibilities of the forensic examiner role. Neuropsychologists are responsible for maintaining the highest standards of professional practice when performing independent and court-ordered forensic examinations. To reach and maintain the highest standards of practice, neuropsychologists must understand the unique relationships with retaining parties and examinees and strive to maintain true independence and objectivity. Although a true neuropsychologist-patient relationship is not considered to exist within the context of a forensic neuropsychological evaluation, neuropsychologists have ethical responsibilities to both the retaining party and the examinee.     

Freiberg’s Infraction in Identical Twins: A Case Report

Freiberg's infraction is an ostechondrosis of a lesser metatarsal head resulting in degeneration of the metatarsophalangeal joint. Several mechanisms have been suggested in its pathenogenesis. Freiberg first described the entity and believed single impact trauma was the underlying cause. Repetitive biomechanical microtrauma is the most widely accepted etiologic theory. Other factors contributing to its development include aseptic necrosis, ischemia, and a congenital predisposition. We present a case report of Freiberg's infraction occurring in identical twins involving multiple metatarsals in various stages of degeneration. One of the twins was affected unilaterally whereas the other twin was affected bilaterally. Both twins had involvement of the second metatarsal on the same side extremity. The occurrence of Freiberg's infraction in identical twins suggests that an underlying congenital predisposition to the condition may play more of a role than previously considered.     

CHILDREN'S CONSENT TO PSYCHIATRIC TREATMENT: ALL OR NOTHING?

An adolescent with a history of attempted suicide who refused to involve his father in the treatment plan is presented. Issues surrounding consent to psychiatric treatment in childhood are discussed and the assessment process outlined. Contributions by primary healthcare professionals are emphasised.     

Early Results of the Mau Osteotomy for Correction of Moderate to Severe Hallux Valgus: A Review of 24 Cases

In our retrospective study, we report the objective results of the Mau osteotomy in the treatment of hallux valgus. We reviewed the results of 24 cases of moderate to severe hallux valgus deformities corrected with the Mau osteotomy of the first metatarsal combined with a distal soft-tissue procedure. Follow-up was possible in 24 cases. Preoperatively the mean hallux valgus and first intermetatarsal angles were 31.3 degrees and 16.6 degrees respectively, and were corrected postoperatively to an average of 13.00 degrees+/-7.15 degrees and 9.80 degrees+/-2.43 degrees respectively (P< .001). In the sagittal plane, the first metatarsal was shortened by an average of 2.00 mm. Two (8.3%) cases had dorsal elevation of the osteotomy fragment. Complications included 3 recurrences of the deformity, 1 frank nonunion, 8 dorsal cortical nonunions, 5 cases of undercorrection, and 1 case of broken hardware that was present in the nonunion that went on to revision. There were no superficial or deep infections, and no cases of transfer metatarsalgia were noted. In this series, the use of an oblique first metatarsal osteotomy with a dorsal shelf resulted in reliable and powerful correction of the first intermetatarsal angle in patients with moderate to severe hallux valgus. Particular attention should be paid to severe IM angles and the possibility of undercorrections. Despite ambulation postoperatively, the Mau osteotomy minimized dorsal malunion and the incidence of transfer metatarsalgia. LEVEL OF CLINICAL EVIDENCE: 4.     

Digital mucoid cyst excision by using the bilobed flap technique and arthroplastic resection

There are a number of proposed causes and treatment approaches for digital mucoid cysts. The described treatment outcomes for this cyst have been variable, with the highest success rate reported with complete excision and single-lobe skin flap closure. This report describes a bilobed flap reconstruction in conjunction with resection of the head of the middle phalanx. A retrospective review was undertaken to evaluate the recurrence rate, complications, and patient satisfaction with this combined procedure. Fifteen patients with an average follow-up of 4.6 years were evaluated. There were no recurrences, flap failures, or other major complications. The use of this flap allows for greater exposure than traditional semi-elliptical incisions while allowing the wide excisional defects to be closed primarily.