Novel PEM-enhancement of a FDL tendon transfer procedure holds promise as a method for improved treatment of AAFD. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

BACKGROUNDPyoderma gangrenosum (PG) is a noninfectious inflammatory condition of the skin that results in rapidly progressing necrotic, ulcerative lesions. 1,2 It is rare, affecting three to 10 patients per million, and is often misdiagnosed as an infection. 3,4 PG is a clinical diagnosis of exclusion and can only be made after infection, vasculitis, and neoplasm have been ruled out. 5 Although underlying systemic inflammation, neutrophil malfunction, and genetic predispositions are thought to be linked to the development of PG, the exact cause is

Background Few studies have examined the impact of abdominoplasty on chronic back pain. Objectives The aim of this study was to test our hypothesis that patients undergoing abdominoplasty with anterior abdominal wall plication will show significant improvements in back pain and physical function compared with those without plication. Methods We utilized Current Procedural Terminology (CPT) codes to identify patients who underwent abdominoplasty with the senior author over a 10-year period. The Oswestry Disability Index (ODI) and the RAND 36-Item Short-Form Health Survey (SF-36) were administered. All patients indicating preoperative back pain were reviewed. Results Of 338 patients, 143 surveys (42.3%) were returned; 51 patients (35.7%; n = 28 aesthetic, n = 23 massive weight loss) reported preoperative back pain on the ODI. Paired t tests compared overall and strata-specific changes in ODI and SF-36 pre- and postsurgery. Multivariable linear regression models were fitted to model relations between scores and plication, adjusting for presurgery scores and patient variables. There were significant improvements in overall patient cohort in ODI (–15.14), SF-36 physical function (19.92), and pain (17.42) (P < 0.001), as well as when patients were stratified by plication status. However, outcomes between those with plication and those without were not significantly different. Conclusions Abdominoplasty with and without anterior abdominal wall plication significantly improves ODI and SF-36 scores relating to physical function and pain, in both aesthetic and massive weight loss patients. Outcomes did not differ based on plication status. All patients with preoperative back pain showed improvement regardless of operation performed, suggesting that abdominoplasty with or without abdominal wall plication improves chronic back pain in this patient population. Level of Evidence: 4

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Category: Ankle, Basic Sciences/Biologics, Hindfoot, Midfoot/Forefoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) associated with posterior tibial tendon (PTT) dysfunction remains a common orthopaedic problem for which a definitive solution has yet to be identified. Controversy has surrounded the diversity of treatment approaches utilized in current practice, which collectively fail to restore physiologic posterior tibial tendon function. In this proof-of-concept study we proposed a novel passive engineering mechanism (PEM) enhanced flexor digitorum longus (FDL) tendon transfer to address this deficiency. The objective of this study was to determine if PEM-enhancement would better restore physiologic PTT function and gait using a biomechanical flatfoot model. We hypothesized that compared to standard treatment, PEM-enhancement would increase applied FDL tendon force and improve pedobarographic and kinematic gait parameters. Methods: An AAFD model consistent with stage II PTT dysfunction was induced in 8 cadaveric lower-limb specimens. Specimens were tested using a robotic gait simulator (RGS) under conditions in randomized order simulating flatfoot, standard treatment, and PEM-enhanced treatment. Three trials were performed for each condition per specimen for a total of 120 trials. In PEM conditions, a custom pulley was fixed in series to the PT tendon along its normal line of action to provide biorealistic passive mechanical advantage (Fig. 1). Pedobarographic (plantar pressures and CoP) and foot bone kinematics during the stance phase of gait were assessed with a RGS-integrated pressure mat and motion capture system respectively. Twenty-five independent RGS trials were completed to measure PEM force scaling using a custom load cell. For statistical analysis, a linear mixed-effects regression was used to determine if mean biomechanical outcome differed by condition. Significance was set at p = 0.05. Results: Cadaveric flatfoot induction and robotic gait simulation produced a statistically validated biomechanical AAFD model. Throughout stance phase, PEM-enhancement significantly increased applied FDL tendon forces while reflecting physiologic tendon action, with mean FDL force increased 32.6 ± 10.7% at the physiologic force peak. Pedobarographic data demonstrated that PEM- enhancement consistently increased lateral pressure and decreased medial pressure during stance phase, with significantly decreased hindfoot pressure (-21 to -24 kPa) and laterally shifted CoP (3.9 to 4.8 mm) observed in comparison to standard treatment. Kinematic data generally showed that PEM-enhancement caused adduction, inversion, and elevation of the medial longitudinal arch during stance phase, with significant joint motion differences (~1 to 2 degrees) observed from standard treatment for the tibiotalar, naviculocuneiform, and first MTP. Conclusion: Using a well-documented biomechanical flatfoot model, we demonstrated that an innovative PEM-enhanced FDL tendon transfer better restored physiologic PTT force and...

Category: Ankle, Trauma Introduction/Purpose: As medical imaging of the syndesmosis prior to ankle injury is usually not available, researchers have diagnosed and surgically reduced syndesmotic disruptions based on presumed symmetry with the healthy contralateral limb. The purposes of this study are to quantify the degree of symmetry present in the DTFS using 3D CT modeling, and to compare the accuracy of common clinical two-dimensional (2D) measurements to 3D CT measurements for assessing syndesmotic symmetry and measuring diastasis. Methods: Bilateral lower limb CT (n=65) were assessed, were segmented, and reconstructed into 3D surface models, and an anatomically-defined coordinate system was applied to orient the 3D models uniformly. Symmetry was assessed three- dimensionally to overlap the left and right. The relative differences between the two fibulae were quantified in six degrees of freedom. For comparative purposes, four 2D measures were also measured. These measures included anteroposterior (AP), mediolateral (ML), and rotational displacement of the fibula relative to the tibia, measured using axial CT, and longitudinal displacement, measured using coronal radiographs. The four measures were automatically calculated using custom software to reduce the influence of inter- and intra-rater variability. The absolute difference was calculated for each 3D and 2D measure. The differences measured represent the amount of translation or rotation needed to match the position of the left fibula to the position of the right fibula after reflection and optimal tibial alignment. Results: The mean difference in AP displacement was approximately double the mean difference in ML displacement for the 2D measurements (1.65 mm vs 0.71 mm), while AP and ML displacement differences for the 3D measurements were comparable (0.57 mm and 0.44 mm). As a general trend, the 2D measurements exhibited larger values of absolute differences than the 3D measurements. The average difference in fibular rotation detected was larger for the 2D measurements (6.1°) than the 3D measurements (0.59°). . The 2D AP displacement differences varied between 1.41 -1.95 mm (95% CI), which is beyond the suggested 1 mm tolerance level. The 3D analog of this measurement varied between 0.47-0.70 mm (95% CI), which is within the suggested threshold. Conclusion: Some clinical reports suggest that 1 mm misalignment can cause pain and require surgical revision, but detecting asymmetry below 1 mm is limited by the quality of clinical 2D imaging. Our findings suggest that the current standard practice of using 2D measures to assess the DTFS may exaggerate the amount of asymmetry present, which may lead to misdiagnoses and subsequent surgical revisions. Natural symmetry exists in uninjured syndesmoses. More accurate comparisons of syndesmotic alignment may be needed to determine the accuracy of DTFS diastasis.

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