Permanent Foot Research Articles

Vascular injuries associated with total knee arthroplasty

<div class="Section1"><p class="abstract">Iatrogenic vascular injuries are rare but potentially devastating complications of total knee arthroplasty (TKA). This retrospective study analyzes vascular injuries associated with total knee arthroplasties in an urban, tertiary level referral hospital between 01 April 2010 to 31 March 2020 consisting of 6548 TKAs. Six patients sustained vascular injuries which included five primary, and one revision TKAs. Three patients were bilateral, and two were unilateral primary TKAs. The mean age-adjusted Charlson’s comorbidity index was two (range 1-3). Only two injuries were recognized intraoperatively. They underwent successful vascular repair. The third patient was diagnosed and underwent a vascular repair on the first postoperative day but experienced a permanent foot drop. Two other patients underwent thrombectomy on the fifth postoperative day; one required above-knee amputation, and the other continued to suffer from vascular claudication and paraesthesia. Another patient developed a pseudoaneurysm, which was identified and repaired five months after the primary TKA. The site of vascular injury was popliteal artery in five and superficial femoral artery in one patient. The mechanism of injury was a direct laceration in three, posterior Hohman's retractor in one, the effect of tourniquet on calcified vessels in one, and unknown in one patient. Early recognition was the only factor that significantly altered the functional outcome and limb salvage. Bilateral simultaneous total knee arthroplasties had no higher risks. A mandatory institutional protocol to recognize the early signs of vascular injuries is necessary for successful vascular repair.</p></div>

6.C. The revised EU health security framework

Abstract As a response to the pandemic, the Commission's communication of 11 November 2020 proposed building blocks for a European Health Union (EHU) and advocated the strengthening of existing structures and mechanisms for better EU level protection, prevention, preparedness and response against human health hazards. It recommended a reinforced framework for cross-border cooperation against all health threats to protect better human lives and the internal market as well as to maintain the highest standards in the protection of human rights and civil liberties, and a strengthened EU role in international cooperation to prevent and control cross-border health threats and improve global health security. By upgrading the EU health security framework for cross-border health threats, the building blocks of the European Health Union bring greater overall impact while fully respecting the Member States’ competence in the area of health. Concretely, before the end of 2022, two pieces of legislation will have been adopted: the upgrading of Decision 1082/2013/EU and the strengthened mandate of the European Centre for Disease Prevention and Control (ECDC) and the European Medicines Agency (EMA) that go hand in hand. The new Regulation on serious cross-border threats to health, the overarching legislative piece of the EU Health Union Package, aims at a stronger and more comprehensive legal framework for the Union to better prepare and respond to serious cross-border threats to health and public health emergencies. It better governs actions at Member States and Union level on prevention, preparedness and response, surveillance, risk assessment, and early warning. Further, it ensures better arrangements for joint procurement at EU level. With its revised mandate, the ECDC will be able to issue recommendations to Member States regarding preparedness and response, host a new network of EU reference laboratories and establish an EU Health Task Force for crisis preparedness and rapid public health interventions in case of a major outbreak. The regulation reinforcing EMA's role in crisis preparedness and management of medicinal products and medical devices puts some of the structures and processes established during the COVID-19 pandemic on a permanent footing. EMA is now responsible for monitoring medicine shortages, as well as reporting shortages of critical medicines during a crisis. It will also coordinate responses of EU / EEA countries to shortages of critical medical devices and in-vitro diagnostics in crises. The EU Health Security Framework will link up to IHR (where EU is requesting to become a contracting party) and the pandemic treaty, and the parallel developments to improve pandemic preparedness and response in G7 and G20 framework (also new global health strategy). The revised legislation addresses the weaknesses evidenced by the COVID-19 pandemic and support actions that can be financed via the EU4Health programme and other EU funding instruments. DG SANTE and ECDC will present the new legislation; two Member States will share their views on the newly adopted legislation. HaDEA will present the funding opportunities through EU4Health to support the implementation of th e two new legislation. Speakers/Panellists Ingrid Keller European Commission, Luxembourg, Luxembourg Florina Telea European Commission, Brussels, Belgium

An observational study on congenital talipes equinovarus.

Introduction: Clubfoot or Congenital Talipes Equinovarus (CTEV) is a congenital ab-normality characterized by the permanent foot morphological alteration, conse-quently individual is unable to lean the foot properly on the floor in an appropriate physiological manner.Objective: To execute an observational study on Congenital Talipes Equinovarus (CTEV) in the Orthopedic Department of Indus Medical College Hospital, Tando Mu-hammad Khan.Methodology: Study conducted from Jan 2018 to Jan 2019 at Orthopedic Depart-ment of Indus Medical College Hospital, Tando Muhamad Khan. Medial Crease (MC), Curved Lateral Border (CLB), and Lateral Head of Talus (LHT) assessed based on the Mid Foot Contracture Score (MFCS). Also, an assessment of the Posterior Crease (PC), Empty Heel (EH) and Right Equinus (RE) made as part of the Hind-foot Contracture Score (HFCS). Data collected from 100 participants through conven-ience sampling technique and quantitative analysis performed.Results: Of all participants, Pirani score was calculated from 0 to 1. Scoring is based on the average values. It has been found that the incidence of curved lateral border was 30%, medial crease as 55% and lateral head of talus as 15%. Additionally, it has been found that the empty heel incidence is 35%, posterior crease is 60% and rigid Equinus as 15%. These results reveal that there is a high incidence of CTAV in the given sample.Conclusion: The study revealed that the exact cause (s) of CTEV are still unknown.
 Keywords: Congenital Talipes Equinovarus (CTEV), Pirani score, Pediatric Orthope-dic

The Slow Ascent of Women in Dutch Diplomacy: the Case of Maria Witteveen

Maria Witteveen (1904-1991) started her international career in 1931 at the League of Nations Secretariat in Geneva. From there she was appointed secretary to the Netherlands delegation to the First General Assembly of the UN which met in London in January 1946. This provided Maria with an opening into diplomacy and she joined the Ministry of Foreign Affairs the following year as Counsellor to the Netherlands representation at the UN in New York. Despite an atmosphere that was unfriendly to women, she managed to obtain a permanent footing among Dutch diplomats, evidenced in a posting to Moscow in 1953 and then promotion to become Permanent Representative at the Council of Europe in Strasbourg in 1956. Maria left this post in 1963, not to be re-posted until her retirement from the Dutch foreign service in 1969.

Acquired Dysfibrinogenemia Krakow III after Everolimus Therapy

A 45 yo woman with a medical history of common variable immunodifficiency (CVID) was referred for a bleeding disorder. The bleeding was manifested daily with ecchymosis and epistaxis, but prior to the visit, she developed a lower pelvic mass that was a massive hematoma requiring transfusion. In 2011 she had a splenectomy for thrombocytopenia. After splenectomy, her liver enlarged and one year prior to being seen, she was started on everolimus as part of a protocol to reduce her liver size. Bleeding started 3-6 months after starting everolimus treatment, first manifesting with recurrent lower gastrointestinal hemorrhage. In 2011 she had normal PT and aPTT. At the present time her PT remains normal at 11.43+0.67 (Mean+SD) (normal 9.7-12.7 sec); but her aPTT is abnormal at 43+6.1 (normal 28-38 sec); clottable fibrinogen (Fb) 305+72 (normal 200-400 mg/dl); Fb antigen, 428+115 mg/dl (normal 196-441); ratio of clottable Fb/Fb antigen = 0.71+ 0.06; reptilase time 20+2.2 (normal 14-23 sec); and her thrombin time of 19+1.6 is prolonged (normal 10-16 sec). Blood coagulation factors XI, IX, VIII, VII, X, V, II, and XIII were normal. Further, she did not have excess alpha-1-antitrypin, antithrombin, or protein C to suppress thrombin generation. On a 1:1 mixing study of normal plasma:patient plasma, her thrombin time corrected to normal. Since the patient had an abnormal thrombin time with serious, spontaneous, clinical bleeding with a normal reptilase time, we postulated a fibrin polymerization defect. On a fibrin polymerization assay, the patient required 4-fold greater amounts (32 nM vs 8 nM) of human alpha thrombin to achieve complete fibrin polymerization (See Figure 1 below). On complete fibrinogen sequencing, the patient was found to have a pathologic mutation [Fb gamma chain exon 3, 124G>A, Gly42Ser (Gly16Ser in the mature gamma chain without the signal peptide)]. This defect had been previously described as Fibrinogen Krakow III (Pietrys D et al. Thromb Haemost. 2011;106:558-60). However, neither parent of the patient has a bleeding disorder. Sequencings of her parents' Fb gamma chains show no mutation. Since first being seen, the patient had a serious bleed into her right sacral plexus leaving her with a permanent foot drop. We managed her bleeding with cryoprecipitate replacement acutely and oral tranexamic acid as an outpatient. Everolimus is an mTor inhibitor which is a regulator of protein synthesis. We postulated that everolimus therapy produced the acquired abnormal Fb gamma synthesis, producing the fibrin polymerization defect associated with bleeding. Upon urging, the patient stopped everolimus therapy and has not had a major bleeding incident in 8 months although the abnormal thrombin time persists. Figure 1 Disclosures Wolberg: Novo Nordisk: Research Funding.

Effect of Intermittent Serial Casting on Equinus Ankle Deformity in Children with Hemiplegic Cerebral Palsy

AbstractBackground: Equinus is the most common problem in ambulatory children with spastic hemiplegic cerebral palsy, which results in an unstable and inefficient gait pattern. Without proper management at an early stage, it can lead to permanent foot deformities.Aim of Study: The aim of this study was to evaluate the effect of serial casting on ankle range of motion, tone of the calf muscle and ankle kinematics during gait in children with spastic hemiplegic cerebral palsy.Material and Methods: Twenty-five spastic hemiplegic cerebral palsy children of both sexes (15 boys and 10 girls) participated in this study. Patients were selected at level I according to Gross Motor Function Classification System and the degree of spasticity ranged from 2 to 3 according to Modified Ashworth Scale with true equinus, with their mean age were 4.8±0.8 years. They were randomly assigned to two groups. The first group, 12 children, Group (A) who received a selected physical therapy program once a day/3 times a week for three successive weeks; while the second group, 13 children, Group (B) who received three consecutive casts for five days each and removed in the last two days in each week to conduct the same selected physical therapy program which conducted for the Group (A). Ankle range of motion was assessed by electronic goniometer, calf muscle spasticity was assessed by modified ashworth scale and ankle kinematics during gait was assessed by observational gait scale.Results: The results of the present study revealed that Group (B) showed statistically significant improvement in ankle range of motion, tone of calf muscle and ankle kinematics during gait (p=0.0001 for all) than those of the Group (A).Conclusion: Serial casting of equinus ankle deformity could improve ankle range of motion, tone of calf muscle and ankle kinematics during gait in children with spastic hemiplegic cerebral palsy.

The Interdisciplinary Management of Foot Drop.

Foot drop can be caused by a variety of diseases and injuries. Although it is a common condition, its overall incidence has not been reported to date. Foot drop markedly restricts the everyday activities of persons suffering from it. There is, therefore, a need for an optimized strategy for its diagnosis and treatment that would be standardized across the medical specialties encountering patients with this problem. This article consists of a review on the basis of pertinent publications re- trieved by a search in the Pubmed/MEDLINE and Cochrane databases, as well as a description of the authors' proposed strategy for the diagnosis and treatment of foot drop. Foot drop can be due to a disturbance at any central or peripheral location along the motor neural pathway that terminates in the dorsiflexor muscles of the foot, or at multiple locations in series. Optimal localization of the lesion(s) is a pre- requisite for appropriate treatment and a successful outcome. The most common causes are L5 radiculopathy and peroneal nerve injury. An operation by a neuro- surgeon or spinal surgeon is a reasonable option whenever there is a realistic chance that the nerve will recover. In our opinion, any patient with a subjectively disturbing foot drop and a clinically suspected compressive neuropathy of the peroneal nerve should be informed about the option of surgical decompression of the nerve at the fibular head, which can be performed with little risk. In case of a permanent foot drop, some patients can benefit from muscle-transfer surgery. For spastic foot drop, the option of botulinum toxin injections should be evaluated. The care of patients with foot drop could be optimized by interdisciplin- ary foot-drop clinics involving all of the relevant specialists. The goals of treatment should always be improved mobility in everyday life and the prevention of falls, pain, and abnormal postures.

Initial Diagnosis and Management for Acute Charcot Neuroarthropathy

Charcot neuroarthropathy, also known as Charcot foot, is a complication of diabetes mellitus where there is progressive degeneration of the joints, but it potentially is devastating in its consequences.1 It commonly affects the middle of the foot, hind-foot joints, the ankle, and forefoot joints, and it is believed to result from inflammation in the foot that becomes abnormally protracted due to the underlying neuropathy.2–8 The prevalence of Charcot neuroarthropathy is up to 13% in individuals with diabetes.9–11 Patients with Charcot neuroarthropathy encounter increased morbidity and decreased quality of life and mortality.2,4,5,12,13 If there is a delay in treatment, Charcot neuroarthropathy could result in ulceration and infection which can lead to amputation of the limb.12–16 These patients have a significant financial impact on the health care system through primary care, community care, outpatient costs, increased bed occupancy, and prolonged stays in hospital. Charcot neuroarthropathy poses many clinical challenges in its diagnosis and management. The often asymptomatic nature of the condition is very similar to ankle sprain, cellulitis, venous thrombosis, inflammatory arthritis, or gout in a healthy patient.5,16–22 Missed diagnosis is as high as 79% which ultimately leads to a delay in treatment for an average of 29 weeks.11,16,17,20,23–25 Charcot neuroarthropathy is caused by multiple factors, but essentially it is the result of peripheral neuropathy which is a complication associated with many diseases.2,4,5 The underlying peripheral neuropathy can skew the pain perception the patient experiences and can mislead the clinician on their differential diagnosis of an “inflamed foot”. A thorough neurological examination of the foot can uncover the underlying inflammatory and osteolytic disease process of Charcot neuroarthropathy.2,4,11,19,26–29 Early recognition and intervention is imperative to avoid the rapid progression toward permanent foot deformity, ulceration, and the possibility of limb loss.16,30,31 There are multiple review articles about Charcot neuroarthropathy2,11–13,16,23,25,28,32–34, but a lack of guidance on foot screen strategies for primary care and emergency room physicians. There is a need for a comprehensive guideline for initial diagnoses and management on foot care to advocate for increased awareness, thereby leading to earlier diagnosis and treatment by a multi-disciplinary team. In the current study, a thorough literature review of Charcot neuroarthropathy was conducted to evaluate efficacious methods of protocol design and potential barriers to implementation. The literature review also encompassed treatment goals for patients with Charcot neuroarthropathy. Based on the literature review, a foot screen strategies protocol for Charcot neuroarthropathy was devised by the authors and reported here. This protocol contains three parts: (1) pathophysiology of acute Charcot neuroarthropathy to highlight the relationship between the clinical findings and the development of the disease, (2) a comprehensive guideline on how to screen and evaluate Charcot neuroarthropathy, and (3) a brief overview on prevention of Charcot neuroarthropathy in patients with diabetes and other forms of peripheral neuropathy. Pathophysiology The underlying cause for Charcot neuroarthropathy is due to peripheral neuropathy, which is a loss of function of the nerves in the periphery of the body.2–4 The primary episode of inflammation can result from a number of factors, but ultimately leads to an increase in pro-inflammatory cytokines (interleukin-1β and tumor necrosis factor-α) which leads to receptor activator of the nuclear factor-κB ligand (RANKL-NFκB) pathway. Osteoclasts are activated leading to bone lysis followed by clearing of debris. In the presence of autonomic neuropathy, there is increased blood flow to the area, which acts to clear away bony material demineralizing the bone, cartilage, and soft tissue in the region.3 However, in the presence of diabetic neuropathy, the patient does not have the protective pain perception. Therefore, they continue to walk on the inflamed foot exacerbating the progressive pathway of osteolysis and osteopenia and weakening the pedal skeleton, leading to the high risk for dislocation and/or fracture.5–8,34,35

Experimental and numerical investigations of the behaviour of footing on geosynthetic reinforced fill slope under cyclic loading

This paper investigates the cyclic loading responses of a strip footing supported by a geosynthetic reinforced fill embankment. A series of large-scale model footing tests were conducted first to investigate the accumulation of permanent footing displacement and residual vertical soil stress over large number of load cycles. The embankment fill was a heavily compacted silty sand and the reinforcement was a flexible geogrid, so that the model test configurations were representative of actual field conditions. Both permanent displacement and residual stress accumulated asymptotically with load cycles and majority of the build-up occurred over the first few hundred cycles. The potential effect of load interruptions was part of the study. Depending on how cyclic load interruption was implemented, it may or may not induce a trailing effect on subsequent cyclic loading responses. To have more in-depth understanding, these footing tests were also investigated numerically based on a soil model that can capture the unload-reload stress-strain loop over large number of load cycles. Reasonably good agreement between experimental observations and numerical predictions was also achieved.

The Movements of People between States in the 21st Century: An Agenda for Urgent Institutional Change

The international refugee regime has certainly evolved over the past 65 years, but fundamental challenges remain. On the one hand, an international organization (UNHCR – strictly speaking, a subsidiary organ of the UN General Assembly) with a global mandate to provide protection and seek solutions operates within a widely ratified treaty framework, together with a 98 Member State Executive Committee. On the other hand, notwithstanding the 2003 decision to put UNHCR on a permanent footing (‘until the refugee problem is solved’), the system overall continues very much as if it and the problems of displacement were still temporary. International cooperation is still largely ad hoc and unstructured; funding depends on voluntary contributions; the mechanisms for early warning, conflict prevention, and mediation are insufficient; and viable safe havens as alternatives to displacement are rarely considered, let alone initiated. More significantly, displacement-related challenges are compounded by States’ reluctance to ‘internationalize’ key aspects of the movement of people, with a view to the better and more humane management of migration. This paper proposes some structural changes to bring the international protection mandate into the 21st Century; in particular, the General Assembly should revise UNHCR’s 1950 Statute, not only to reflect its current responsibilities for refugees, internally displaced persons, and the stateless, and to reform the funding base, but also to extend its mandate to migrants without protection. No new treaty or organization is called for and international obligations would remain unchanged. However, working with such an experienced operational partner in the field, States would be free to develop a complementary legal or standards base on migration matters, which, currently, are commonly contested and obstructed by the lack of international cooperation.

Perioperative Complications of Pedicle Subtraction Osteotomy.

Study Design Retrospective case series. Objective To describe the perioperative complications (0 to 90 days) associated with pedicle subtraction osteotomies (PSOs) performed at a tertiary spine center by two experienced spine surgeons who recently adopted the technique. Methods We reviewed all 65 patients (47 women and 18 men; mean age 60 years, range 24 to 80) who underwent a PSO at our institution. Descriptive data and analysis of complications were limited to the perioperative time (within 90 days of surgery). Data analyzed included operative time, length of stay (LOS), estimated blood loss (EBL), blood products, comorbidities, neurologic complications, and medical complications. Complications were rated as major and minor. Radiographic data was also analyzed. Results Ten patients (15.4%) had a major complication, and 15 (23%) had a minor complication. There were three perioperative deaths. The most common major complication was neurologic deficit (6.2%, 4/65), three with a permanent foot drop, and one with paraplegia secondary to postoperative hematoma. There were no differences between patients with and without a major complication in regard to age, gender, comorbidities, operative time, number of levels fused, and EBL (p > 0.05). Patients with a major complication had a longer intensive care unit stay (p = 0.04). There was no difference in the rate of major complications between the initial and later cases performed. Conclusion The major complication rate for pedicle subtraction osteotomy was 15% and the minor complication rate was 23%. The most common major complication was neurologic deficit in 6.2%. The complication rate did not change with increased surgeon experience.

Transport policy and governance in turbulent times: Evidence from Ireland

This paper investigates transport policy in the Republic of Ireland11Henceforth referred to as Ireland. before, during and after the ‘Celtic Tiger’ era (1995–2007), to capture how the prevailing governance system responded to rapid economic, political, and social changes. We argue that a detailed record of changes in Irish transport policy and governance during these turbulent times can offer lessons that are relevant to sustainable transport efforts internationally. Focusing on the development, introduction and subsequent implementation of two transport policy milestones, this paper considers political and institutional conditions that paved the way for both a high-cost approach to transport infrastructure development prior to the financial crisis in 2008 and the subsequent shift in policy discourse towards ‘smarter’ more sustainable travel following the rapid deterioration of public finances in the late 2000s. It then asks what changes (if any) are needed to current political-institutional structures to ensure future implementation of these declaratory commitments to sustainable transport. The concluding section explores whether it would be possible, or indeed desirable, to put current transport policy responses to the economic crisis on a more permanent footing, with a view to advancing the sustainable transport agenda, and uncovers opportunities to promote and implement sustainability initiatives in times of financial restraints.

US Pilot Study of Lumbar to Sacral Nerve Rerouting to Restore Voiding and Bowel Function in Spina Bifida: 3-Year Experience.

Objective. To report our experience with creating a skin-central nervous system-bladder reflex arc with intradural lumbar to sacral motor root microanastomosis to restore bladder/bowel function in spina bifida patients. Methods. Urinary/bowel changes from baseline to three years were evaluated with questionnaires, voiding diaries, urodynamics (UDS), and renal function studies. Treatment response was defined as CIC ≤ once/day with stable renal function, voiding efficiency > 50%, and no worsening of motor function. Results. Of 13 subjects (9 female, median age 8 years), 3 voided small amounts at baseline, one voided 200 cc (voiding efficiency 32%), 4/13 reported normal bowels, and 2/13 were continent of stool. Postoperatively, all had transient lower extremity weakness; one developed permanent foot drop. Over three years, renal function remained stable and mean maximum cystometric capacity (MCC) increased (P = 0.0135). In the 10 that returned at 3 years, 7 were treatment responders and 9 had discontinued antimuscarinics, but most still leaked urine. Only 2/8 with baseline neurogenic detrusor overactivity (NDO) still had NDO, all 3 with compliance <10 mL/cm H2O had normalized, 7/10 considered their bowels normal, 5/10 were continent of stool, and 8/10 would undergo the procedure again. Conclusion. Lumbar to sacral nerve rerouting can improve elimination in spina bifida patients. This trial is registered with ClinicalTrials.gov NCT00378664.

Bilateral gluteal compartment syndrome complicated by rhabdomyolysis and acute kidney injury in a patient with alcohol intoxication

Bilateral gluteal compartment syndrome is a rare clinical entity that can be complicated by rhabdomyolysis or acute kidney injury (AKI). We report the a case of a 30-year-old woman without any comorbid diseases who was diagnosed with bilateral gluteal compartment syndrome complicated by rhabdomyolysis and dialysis-requiring AKI, which was caused by prolonged immobilization under the influence of alcohol. Although the patient’s renal function recovered fully after 5 sessions of hemodialysis, sciatic neuropathy caused by gluteal compartment syndrome led to permanent foot drop.

Coffee Palaces in Australia: A Pub with No Beer

Coffee Palaces in Australia: A Pub with No Beer

1502 THREE-YEAR CLINICAL OUTCOMES WITH LUMBAR TO SACRAL NERVE REROUTING IN SPINA BIFIDA

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Neurogenic Voiding Dysfunction1 Apr 20111502 THREE-YEAR CLINICAL OUTCOMES WITH LUMBAR TO SACRAL NERVE REROUTING IN SPINA BIFIDA Kenneth Peters, Kevin Feber, Benjamin Girdler, William Nantau, Evan Kass, Jose Gonzalez, Gary Trock, and Ananias Diokno Kenneth PetersKenneth Peters Royal Oak, MI More articles by this author , Kevin FeberKevin Feber Royal Oak, MI More articles by this author , Benjamin GirdlerBenjamin Girdler Royal Oak, MI More articles by this author , William NantauWilliam Nantau Royal Oak, MI More articles by this author , Evan KassEvan Kass Royal Oak, MI More articles by this author , Jose GonzalezJose Gonzalez Royal Oak, MI More articles by this author , Gary TrockGary Trock Royal Oak, MI More articles by this author , and Ananias DioknoAnanias Diokno Royal Oak, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1481AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The concept of restoring bladder and bowel function in spina bifida by the creation of a skin-CNS-bladder reflex arc by an intradural lumbar to sacral motor root microanastomosis was introduced by Xiao. We report our three-year experience with the novel procedure. METHODS Nine patients (3 males, 6 females) with median age of 8 (range 6 to 37) years enrolled in this institutional review board approved protocol. After extensive preoperative evaluation, lumbar to sacral nerve rerouting was performed using intraoperative neurophysiological monitoring. Postoperative evaluation included follow-up questionnaires, urodynamic testing (UDT), voiding diaries, renal function studies and bowel assessment. RESULTS Of the 9 patients, 5 patients had defect closure within 24 hours of birth, 3 had intrauterine closure and 1 had no prior surgery. Mean operative time was 183 (range 127–278) minutes. No intraoperative complications occurred. One patient developed permanent foot drop and 8 had transient lower extremity weakness. By 12 months, 7 of 9 had a documented cutaneous to bladder reflex. At 3 years, 2 patients did not return for follow-up and were considered non-responders. Seven patients returned for 36-month evaluation. On UDT, maximum cystometric capacity improved from mean 210 cc to 293 cc. At baseline 4/7 had neurogenic detrusor overactivity (NDO); at 36 months 1/7 had NDO. Median compliance improved from 12.2 ml/H20 to 28.4 ml/H2O and 3 with a baseline compliance of less than 10 had normalization (7 to 34.3, 9.4 to 21.2, and 8.3 to 28.4). At baseline, 2/7 were able to void with an average void of 23 cc. At 36 months, 6/7 no longer required catheterization and 6/7 reported mean voided volume of 156cc on voiding diaries. Uroflow demonstrated a mean voided volume of 248 cc with a 93 cc post void residual and a voiding efficiency of 73%. All 6 patients were voiding > 59% of their bladder capacity. 5 of 7 require some valsalva to void. 6/7 subjects had persistent stress incontinence with 1 subject dry, 3 with occasional leak, 3 frequent leaks. At baseline, 3/7 considered their bowels normal and 1/7 were continent of stool. At 36-months 6/7 considered bowels normal and 4/7 continent of stool. Antimuscarinics were stopped in all subjects except the 1 with persistent NDO. Renal ultrasounds and serum creatinines remained stable. No long-term complications were identified and 6/7 would undergo the procedure again. CONCLUSIONS Lumbar to sacral nerve rerouting can improve bladder and bowel function in patients with neurogenic bladder associated with spina bifida. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited ByRasmussen M, Rawashdeh Y, Clemmensen D, Tankisi H, Fuglsang-Frederiksen A, Krogh K and Christensen P (2018) The Artificial Somato-Autonomic Reflex Arch Does Not Improve Lower Urinary Tract Function in Patients with Spinal Cord LesionsJournal of Urology, VOL. 193, NO. 2, (598-604), Online publication date: 1-Feb-2015. Volume 185Issue 4SApril 2011Page: e602 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kenneth Peters Royal Oak, MI More articles by this author Kevin Feber Royal Oak, MI More articles by this author Benjamin Girdler Royal Oak, MI More articles by this author William Nantau Royal Oak, MI More articles by this author Evan Kass Royal Oak, MI More articles by this author Jose Gonzalez Royal Oak, MI More articles by this author Gary Trock Royal Oak, MI More articles by this author Ananias Diokno Royal Oak, MI More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Assessment of the Effects of Diabetes on Midfoot Joint Pressures Using a Robotic Gait Simulator

One of the more serious diabetic complications is Charcot neuroarthropathy (CN), a disease that results in arch collapse and permanent foot deformity. However, very little is known about the etiology of CN. From a mechanical standpoint, it is likely that there is a ;;vicious circle'' in terms of (i) arch collapse causing increased midfoot joint pressures, and (ii) increased joint contact pressures exacerbating the collapse of midfoot bones. This study focused on assessment of peak joint pressure difference between diabetic and non-diabetic cadaver feet during simulated walking. We hypothesized that joint pressures are higher for diabetics than normal population. Sixteen cadaver foot specimens (eight control and eight diabetic specimens) were used in this study. Human gait at 25% of typical walking speed (averaged stance duration of 3.2s) was simulated by a custom-designed Universal Musculoskeletal Simulator. Four medial midfoot joint pressures (the first metatarsocuneiform, the medial naviculocuneiform, the middle naviculocuneiform, and the first intercuneiform) were measured dynamically during full stance. The pressures in each of the four measured midfoot joints were significantly greater in the diabetic feet (p = 0.015, p = 0.025, p < 0.001, and p = 0.545, respectively). Across all four tested joints, the diabetic cadaver specimens had, on average, 46% higher peak pressures than the control cadaver feet during the simulated stance phase. This finding suggests that diabetic patients could be predisposed to arch collapse even before there are visible signs of bone or joint abnormalities.

Lower extremity compartment syndrome after off-pump aortocoronary bypass

Lower extremity compartment syndrome after off-pump aortocoronary bypass

HapticWalker---a novel haptic foot device

This paper presents a new haptic locomotion interface, which comprises two programmable foot platforms with permanent foot machine contact. It is designed as a scalable and modular system with unit-by-unit extensibility offering up to six plus one degrees of freedom (DOF) per foot. The basic setup comprises three DOF per foot in the sagittal plane.The machine is based on a rigid hybrid parallel-serial robot kinematics structure. It is equipped with electrical direct drive motors, enabling highly dynamic footplate motions. For contact force measurement, six DOF force/torque sensors are mounted under each foot platform. The system was developed for major application in gait rehabilitation, hence great importance was attached to the incorporation of maximum passive and active security measures for machine users and medical operating personnel.The simulator is able to perform walking trajectories with speeds of up to 5 km/h and 120 steps/min. The system is able to simulate not only slow and “smooth” trajectories like walking on an even floor, up/down staircases, but also foot motions like walking on rough ground or even stumbling or sliding, which require high system dynamics.The machine is controlled by a self-developed full-featured robot control whose soft and hardware is based on up-to-date industrial standards and interfaces. The robot control software is based on RTLinux and runs on an industrial PC. The real-time motion generator includes a newly developed Fourier-based algorithm for the interpolation of natural cyclic walking trajectories. For the implementation of asynchronous events (e.g., sliding, stumbling), the controller comprises especially developed algorithms for automatic motion override adaptation. Different modes of haptic behavior needed for gait rehabilitation, ranging from full foot support during swing phase to completely passive behavior, are currently under development.Intuitive and safe machine operation by nontechnical personnel such as clinicians and physiotherapists is achieved via a separate Windows-based graphical user interface software comprising different window areas for machine programming and operation, real-time off-line simulation and online data visualization in two and three dimensions has been developed as well.A working prototype of the system has been built and tested successfully, including all soft and hardware components. Although the machine has been designed and built for major application in gait rehabilitation, its range of applicability is not limited to this area. It could be integrated into any setup requiring a highly dynamic haptic foot interface and permanent foot machine contact if needed.

Surgery for Equinovarus Deformity in Friedreich’s Ataxia Improves Mobility and Independence

Friedreich's ataxia results in morbidity because of many factors; progressive equinovarus deformity is one of these. We studied the risk factors and incidence of this deformity. We sought to assess whether surgical management of fixed equinovarus deformity leads to functional improvement. Thirty-six patients with Friedrich's ataxia were assessed for this deformity. These patients were treated by splinting, botulinum toxin Type A injection, and surgery, as indicated by the severity, followed by an ongoing rehabilitation program. The effect of surgery was assessed using subscales of the Barthel index and functional independence measure. Severe foot deformities in which either surgery or botulinum toxin injection was recommended correlated with current age, years since disease onset, and years that the patient required a wheelchair for mobility, but not with the GAA repeat size or age at disease onset. Function and mobility were improved after surgery compared with a similar period before surgery. Three of seven patients who had surgery had significant complications. Aggressive management of foot deformities should be considered, and active measures to prevent permanent foot deformities should be pursued to maximize quality of life and independence of patients with Friedreich's ataxia. Therapeutic study, Level IV (case series-no, or historical control group).