BACKGROUND:Neonatal surgical injury triggers developmentally regulated long-term changes that include enhanced hyperalgesia and spinal microglial reactivity after reinjury. To further evaluate ...priming of response by neonatal hindpaw incision, the authors investigated the functional role of spinal microglial p38 mitogen-activated protein kinase after reincision in adult rodents.
METHODS:Plantar hindpaw incision was performed in anesthetized adult rats, with or without previous incision on postnatal day 3. Numbers and distribution of phosphorylated-p38 (1, 3, 24 h) and phosphorylated extracellular signal-regulated kinase (15 min, 24 h) immunoreactive cells in the lumbar dorsal horn were compared after adult or neonatal plus adult incision. Withdrawal thresholds evaluated reversal of incision-induced hyperalgesia by p38 inhibition with intrathecal SB203850.
RESULTS:Neonatal injury significantly increased phosphorylated-p38 expression 3 h after adult incision (55 ± 4 vs. 35 ± 4 cells per section, mean ± SEM, n = 6 to 7, P < 0.01). Increased expression was restricted to microglia, maintained across lumbar segments, and also apparent at 1 and 24 h. Preincision intrathecal SB203850 prevented the enhanced mechanical hyperalgesia in adults with previous neonatal injury and was effective at a lower dose (0.2 vs. 1 mg/kg, n = 8, P < 0.05) and for a longer duration (10 vs. 3 days). Lumbar neuronal phosphorylated extracellular signal-regulated kinase expression reflected the distribution of hindpaw primary afferents, but was not significantly altered by previous incision.
CONCLUSIONS:Neonatal incision primes spinal neuroglial signaling, and reincision in adult rats unmasks centrally mediated increases in functional microglial reactivity and persistent hyperalgesia. After early life injury, p38 inhibitors may have specific benefit as part of multimodal analgesic regimes to reduce the risk of persistent postsurgical pain.
OBJECTIVES:To characterize the return-to-duty (RTD) rates and disability outcomes for soldiers who sustained combat-related hindfoot injuries that were treated with either reconstruction or ...transtibial amputation (TTA).
DESIGN:Retrospective cohort series.
SETTING:Tertiary trauma center.
PATIENTS/PARTICIPANTS:All patients treated for combat-related hindfoot injuries between May 2005 and July 2011.
INTERVENTION:TTA or hindfoot reconstruction/ankle fusion.
MAIN OUTCOME MEASUREMENTS:Age, RTD rate, combined disability, and associated disabling conditions.
RESULTS:One hundred twenty-two patients underwent treatment for combat-related hindfoot injuries. Fifty-seven patients were treated with amputation, and 65 patients were treated with hindfoot reconstruction or ankle fusion. The overall RTD rate was 20%. Amputees had a RTD rate of 12%, which was lower than those who had a fusion or hindfoot repair 26% (P < 0.06). The disability ratings of amputees were significantly higher than those patients undergoing either ankle fusion or primary hindfoot repair 75% and 62%, respectively (P < 0.006).
DISCUSSION:While RTD rates were higher for hindfoot reconstruction or ankle fusion compared with TTA, psychiatric conditions were more common among these patients. Although there were clear differences between both groups, the relationship between true functional outcomes and disability ratings remains unclear and both treatment groups seem to do poorly in terms of returning to active duty.
LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
•Puncture wounds, while at times seemingly benign, can cause significant morbidity, especially in the diabetic host.•In this case, damage to the pedal perfusion that was not initially apparent, ...coupled with pre-existing peripheral vascular disease, ultimately necessitated transmetatarsal amputation.•This case is an excellent example in peripheral vascular disease and the angiosomal principles of the lower extremity.
Pedal puncture wounds can precipitate a variety of complications, often resulting from a delay in treatment. Although the risk of infection predominates, direct vascular insult and subsequent ischemia is a lesser reported complication of these injuries. Consequently, this may have morbid results, especially on a background of pre-existing peripheral vascular disease. A case involving a small, plantar forefoot puncture wound, ultimately resulting in transmetatarsal amputation due to ischemic dry gangrene in an uncontrolled, but sensate, diabetic with profound vasculopathy is presented. This presentation highlights the importance of considering the potential for macrovascular damage via pedal puncture, and the potentially magnified complications in patients with dependent retrograde angiosomal flow and compromised collateral circulation. Based on a thorough analysis of the literature and the findings in this clinical example, a detailed investigation of angiosomal blood supply through direct and indirect vessel flow in patients with peripheral arterial disease incurring puncture wounds is advocated. In these patients, lack of compensatory avenues of the pedal circulation may portend significant tissue loss in an otherwise inoffensive situation. Knowledge of this complication, although rare, may prompt the clinician to assess for its potential, and emphasize a preference for direct revascularization in those with critical limb ischemia.
Level of Clinical Evidence: 4
Disorders of the lesser toes Smith, Bertil W; Coughlin, Michael J
Sports medicine and arthroscopy review,
09/2009, Letnik:
17, Številka:
3
Journal Article
Recenzirano
Lesser toe disorders are an often under-appreciated source of pain and disability in athletes. Patients may have significant symptoms from corns, hammertoe and mallet toe deformities, and ...metatarsalgia resulting from neuromas and metatarsophalangeal joint instability. Although patients may present with vague symptoms, a careful history and physical examination will point a clinician to an accurate diagnosis. Treatment of these lesser toe disorders is straightforward and leads to predictably good results.
BackgroundOpen 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.MethodsWe 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.ResultsThe 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.ConclusionsOur 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.
Stingray spine injuries are among the most common marine animal injuries in humans. While most resolve with immersion in warm water, a few become infected and require antibiotics. We present a case ...report of a presumptive stingray injury that evolved to a major slough and which required prolonged healing in a patient with diabetes mellitus. Our literature review was unable to find a similarly reported case.
A co-author was asked to evaluate and manage an ominous-appearing wound on the right foot of a diabetic. The problem developed after the individual had been wading in shallow ocean beach water. The patient's diabetic sensory neuropathy obscured the immediate association of the problem with a stingray injury, but this became the presumptive diagnosis when pain developed and necessitated that he seek medical care.
After an initial urgent care visit, increasing pain and worsening appearance of the patient's foot necessitated a visit to our emergency department. The patient was admitted the next day due to symptoms of systemic sepsis. On the fourth hospital day, a large bulla on the lateral side of the right foot was excised. This unroofed a full-thickness slough to the periosteum level of the underlying bones. Not until the 16th hospital day had enough improvement occurred to discharge the patient. Over the next 16 weeks, the wound improved, developed a vascular base and epithelialized.
With a dearth of literature about stingray injuries in patients with diabetes mellitus reported, our case is unique: The patient's wound course more closely resembled a toxic inoculation than the typical puncture wound-cellulitis presentations associated with stingray injuries.
Foot injuries in runners Kindred, Jeff; Trubey, Cameron; Simons, Stephen M
Current sports medicine reports,
2011 Sep-Oct, 2011-09-00, 20110901, Letnik:
10, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Injuries of the foot are common among both elite and recreational runners. Overuse accounts for most of these injuries. Plantar fasciitis and tendinopathies of the midfoot and forefoot have a high ...incidence in running athletes. These injuries may present with significant pain but often resolve with rest and rehabilitation. Bone injuries caused by overuse also have a high prevalence among runners. The metatarsals, tarsal navicular, and sesamoids are most at risk for stress damage. Most running injuries are self-limited and pose little detriment if diagnosis is delayed. Navicular and sesamoid stress fractures may impart significant long-term consequences, and thus, a clinical suspicion of either fracture warrants definitive diagnosis and treatment. Barefoot running recently has garnered increased attention, but currently, there is a lack of prospective studies regarding its injury reduction.
Purpose
A novel percutaneous distractor with the advantage of axial and direct distraction was designed for the minimally invasive treatment of calcaneal fractures. The purpose of this study was to ...investigate the clinical results and complications of a novel distractor combined with sinus tarsi approach (STA) in treatment of the joint depression-type of calcaneal fractures.
Methods
Fifty-four patients with the depression-type of calcaneal fractures (30 Sanders type II, 22 Sanders type III, 2 Sanders type IV) who were subjected to the novel distractor combined with STA were retrospectively assessed. Calcaneal height, width, and length; Bohler’s angle; and the Gissane angle were evaluated pre-operatively and post-operatively. Clinical outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) pain scores from the last follow-up. Complications were also recorded.
Results
Fifty-two patients achieved an average follow-up of 24.3 months (range 18 to 34 months), and two patients were lost to follow-up six months post-operatively. There was significant difference between pre-operative and post-operative calcaneal height, width, and length; Bohler’s angle; and Gissane angle (
p
< 0.01), but no significant difference was detected between the post-operative and normal side Bohler’s angle (
p
> 0.05). The AOFAS ankle and hind foot score was 88.4 ± 6.6, and the VAS score was 1.9 ± 0.7 at the last follow-up. Nine (17.3%) patients developed complications: One experienced skin necrosis and two had screws loosening; three patients developed early degenerative changes of the subtalar joint; two had no symptoms; one had light pain around the subtalar joint without medical treatment; complex regional pain syndrome (CRPS) developed in one patient after seven months post-operatively; and two developed transient ankle stiffness.
Conclusion
The novel distractor combined with the STA effectively reconstructs the facet depression-type of calcaneal fractures (sanders type II and III) with minimal complications.
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