Adam Schiff

The Impact of School Daily Schedule on Adolescent Sleep

Objectives. This study was initiated to examine the impact of starting school on adolescent sleep, to compare weekday and weekend sleep times, and to attempt to normalize the timing of the circadian sleep/wake cycle by administering bright light in the morning. This was a collaborative project involving high school students and their parents, as well as high school and university faculty members, for the purpose of contributing information to the scientific community while educating students about research processes and their own sleep/wake cycles and patterns. Methods. Sixty incoming high school seniors kept sleep/wake diaries beginning in August and continuing through 2 weeks after the start of school in September. Sleep diaries were also kept for 1 month in November and 1 month in February. Early-morning light treatments were given to 19 students in the last 2 weeks of November and the last 2 weeks of February. Neuropsychologic performance was measured with computer-administered tests. Paper-and-pencil tests were used for assessment of mood and vigor. A testing period consisted of 2 consecutive days at the beginning and end of November and at the beginning and end of February. Tests were given 3 times per day, ie, in the morning before school (6:30–8:00 am), during midday lunch periods (11:30 am to 1:00 pm), and in the afternoon (3:00–4:30 pm), on each of the test days. Results. Adolescents lost as much as 120 minutes of sleep per night during the week after the start of school, and weekend sleep time was also significantly longer (∼30 minutes) than that seen before the start of school (August). No significant differences were found between weekday sleep in the summer and weekend sleep during the school year. Early-morning light treatments did not modify total minutes of sleep per night, mood, or computer-administered vigilance test results. All students performed better in the afternoon than in the morning. Students in early morning classes reported being wearier, being less alert, and having to expend greater effort. Conclusions. The results of this study demonstrated that current high school start times contribute to sleep deprivation among adolescents. Consistent with a delay in circadian sleep phase, students performed better later in the day than in the early morning. However, exposure to bright light in the morning did not change the sleep/wake cycle or improve daytime performance during weekdays. Both short-term and long-term strategies that address the epidemic of sleep deprivation among adolescents will be necessary to improve health and maximize school performance.

Cost Comparison Limb Salvage Versus Amputation in Diabetic Patients With Charcot Foot

Background: The negative impact on health-related quality of life in patients with Charcot foot has prompted operative correction of the acquired deformity. Comparative effectiveness financial models are being introduced to provide valuable information to assist clinical decision making. Methods: Seventy-six patients with Charcot foot underwent operative correction with the use of circular external fixation. Thirty-eight (50%) had osteomyelitis. A control group was created from 17 diabetic patients who successfully underwent transtibial amputation and prosthetic fitting during the same period. Cost of care during the 12 months following surgery was derived from inpatient hospitalization, placement in a rehabilitation unit or skilled nursing facility, home health care including parenteral antibiotic therapy, physical therapy, and purchase of prosthetic devices or footwear. Results: Fifty-three of the patients with limb salvage (69.7%) did not require inpatient rehabilitation. Their average cost of care was

Conversion of Tibiotalar Arthrodesis to Total Ankle Arthroplasty

56,712. Fourteen of the patients with amputation (82.4%) required inpatient rehabilitation, with an average cost of

Outcomes of Tibiotalocalcaneal Arthrodesis Through a Posterior Achilles Tendon–Splitting Approach

49,251. Conclusions: Many surgeons now favor operative correction of Charcot foot deformity. This investigation provides preliminary data on the relative cost of transtibial amputation and prosthetic limb fitting compared with limb salvage. The use of comparative effectiveness models such as this simple attempt may provide valuable information in planning resource allocation for similar complex groups of patients. Level of Evidence: Level III, economic and decision analysis.

Short and long term failure of the modular oncology knee prosthesis.

BACKGROUND Conversion of ankle arthrodesis to total ankle arthroplasty remains controversial. Although satisfactory outcomes have been published, not all foot and ankle surgeons performing total ankle arthroplasty have embraced this modality. METHODS Twenty-three total ankle arthroplasties were performed in patients who had undergone a prior or an attempted ankle arthrodesis. The mean age at surgery was fifty-nine years (range, forty-one to eighty years), and the mean duration of follow-up was 33.1 months (minimum, twelve months). Indications for the procedure were symptomatic adjacent hindfoot arthritis (twelve patients) or symptomatic tibiotalar or subtalar nonunion (eleven) after tibiotalocalcaneal arthrodesis. We performed concomitant surgical procedures in eighteen ankles (78%), with the most common procedure being prophylactic malleolar fixation (70%). We prospectively evaluated clinical outcomes using the Short Form-36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), and visual analog scale (VAS) for pain and assessed initial weight-bearing radiographs and those made at the most recent follow-up evaluation. RESULTS The mean VAS pain score (and standard deviation) improved from 65.7 ± 21.8 preoperatively to 18.3 ± 17.6 at the most recent follow-up evaluation (p < 0.001), with five patients being pain-free (VAS score = 0). The mean SMFA bother and function indexes improved from 55 ± 22.9 and 46.7 ± 12.6 preoperatively to 30.6 ± 22.7 and 25.4 ± 17.4 at the most recent follow-up visit (p = 0.001 and p < 0.001, respectively). The mean SF-36 total score improved from 37.7 ± 19.3 to 56.4 ± 23.1 (p = 0.002). The implant survival rate was 87%. Four (20%) of the tibial components and fourteen (70%) of the talar components that were not revised exhibited initial settling and then were seen to be stabilized radiographically without further change in implant position. Three total ankle replacements (13%) showed progressive talar subsidence, prompting revision. Ten patients (43%) had minor complications not requiring repeat surgery. CONCLUSIONS Short-term follow-up after conversion of ankle arthrodesis to total ankle arthroplasty demonstrated pain relief and improved function in a majority of patients. Patients who undergo this surgery frequently require concomitant procedures; we recommend prophylactic malleolar fixation when performing conversion total ankle arthroplasty. The rate of complications, particularly talar component settling and migration, is cause for concern. We do not recommend the procedure for ankle arthrodeses that included distal fibulectomy.

Pin Tract Infection Following Correction of Charcot Foot With Static Circular Fixation

Background: A number of operative approaches have been described to perform a tibiotalocalcaneal (TTC) arthrodesis. Here we present the largest reported series of a posterior Achilles tendon–splitting approach for TTC fusion. Methods: With institutional review board approval, a retrospective review of the TTC fusions performed at a single academic institution was carried out. Orthopedic surgeons specializing in foot and ankle surgery performed all procedures. Eligible patients included all those who underwent a TTC fusion via a posterior approach and had at least a 2-year follow-up. Forty-one patients underwent TTC arthrodesis through a posterior Achilles tendon–splitting approach. Mean age at surgery was 56.9±15.0 years. There were 21 female and 20 male patients. Preoperative diagnoses included arthritis (n = 13 patients), failed total ankle arthroplasty (9), avascular necrosis of the talus (9), prior nonunion of the ankle and/or subtalar joint (6), Charcot neuro-arthropathy (2), and stage IV flatfoot deformity (2). In 37 patients (90.2%), a hindfoot intramedullary arthrodesis nail was used, with posterior plate or supplemental screw augmentation in 17 patients. Posterior plate stabilization alone was utilized in 4 cases (9.8%). Results: The fusion rate was 80.4%. Eight patients developed a nonunion of the subtalar, tibiotalar, or both joints. Complications were observed in 17 patients (41.4%). Of these, ankle nonunion (19.5%), tibial stress fracture (17%), postoperative cellulitis and superficial wound breakdown (9.7%), subtalar nonunion (4.8%), and TTC malunion (2.4%) were the most frequently identified. One patient eventually underwent amputation (2.4%). Conclusion: We believe that posterior Achilles tendon–splitting approach for tibiotalocalcaneal arthrodesis was a safe and effective method, with similar union and complications rates to some previously described techniques. We believe the posterior approach is advantageous as it provides simultaneous access to both the ankle and subtalar joints and allows for dissection to occur between angiosomes, which may preserve blood supply to the skin. Level of Evidence: Level IV, retrospective case series.

Functional Impairment of Patients Undergoing Surgical Correction for Charcot Foot Arthropathy

This retrospective study investigated the modes of implant failure in 80 patients with modular oncology knee prostheses. Twenty patients (25%) required revision: 12 (60%) for stem loosening, 6 (30%) for bearing failure, and 2 (10%) for infection. Patients with bone sarcomas survived longer; however, long-term prosthetic survivorship was a problem. A higher failure rate was found in patients with tibial tumors and with adjuvant treatment of chemotherapy. This study demonstrates for improved long-term survivorship of modular oncology knee prostheses, there must be improvement in the methods of stem fixation, prosthetic materials, and bearing mechanics.

Quantification of Shear Stresses Within a Transtibial Prosthetic Socket

Background: The traditional nonsurgical accommodative treatment for diabetes-associated Charcot foot arthropathy has been unsuccessful in improving the quality of life in affected individuals. This has led to the growing interest in surgical correction of the acquired deformity with either “super construct” internal fixation implants or fine-wire static circular external fixation. The use of static circular external fixation without implants has been demonstrated to achieve high rates of deformity correction with low complication rates. The goal of this investigation was to assess the risk of pin site infection in this high-risk patient population. Methods: Over an 11-year period, 283 consecutive diabetic patients underwent single-stage correction of Charcot foot deformity with static fine-wire circular external fixation and no internal fixation devices. Pin care was minimal. Results: Fifty-nine (20.8%) patients developed clinical signs of pin tract infection in at least 1 pin site. Forty-nine occurred in patients undergoing surgical correction of deformity in the foot. Eight occurred in patients undergoing surgical correction at the ankle level and 2 in patients undergoing complex reconstruction for combined foot and ankle deformity. Higher rates of pin site infections were observed in patients with osteomyelitis present at the time of surgery (25.6%) as compared with patients without evidence of infection (17.8%), although the difference was not statistically significant (P = .1184). There was no correlation between body mass index and pin site infection (P = .288). There was a statistically significant trend (P < .05) for higher rates of pin site infection in patients with elevated hemoglobin A1C levels. Erythema and drainage resolved in all patients with local pin care and empiric oral antibiotic therapy. None of the wires were removed prematurely, and all infections resolved following removal of the circular external fixator at the scheduled time for removal. Conclusions: Pin site infection was common following surgical correction of the acquired deformity associated with Charcot foot. These acquired pin site infections were a nuisance but did not appear to add permanent morbidity or require additional surgery to resolve. Level of Evidence: Level IV, retrospective case series.

Tibiotalar Arthrodesis Conversion to Total Ankle Arthroplasty

Background: Investigations using the Medical Outcomes Study Short Form 36 Healthy Survey (SF-36) and the American Orthopaedic Foot & Ankle Society Diabetic Foot Questionnaire (AOFAS-DFQ) have demonstrated a poor quality of life in patients with Charcot foot arthropathy. The Short Musculoskeletal Function Assessment (SMFA) questionnaire has been widely used in patients with a broad range of musculoskeletal disorders. Methods: Twenty-five consecutive patients undergoing operative correction for diabetes-related Charcot foot arthropathy of the midfoot completed the SMFA prior to undergoing surgery. There were 16 males and 9 females. The average body mass index (BMI) was 37.4 (range 25.8-50.2), and the average hemoglobin A1c was 7.5 (range 5.3-10.1) prior to surgery. Results: All 25 patients exhibited significant impairment in all 6 domains of the SMFA (P < .0001) as compared to the normative data. There was a high correlation between each of the 6 domains of the SMFA, even after correcting for BMI. Conclusion: Charcot foot severely impaired the quality of life in patients beyond the impact of morbid obesity. This impairment equally impacted all of the functional and emotional domains measured with the SMFA as compared with population norms. This investigation provides a benchmark for measuring the impact of operative correction of the deformity. In addition, the SMFA appears to be a valid tool for measuring impairment in this complex patient population. Level of Evidence: Level II, prospective comparative investigation

Effectiveness of Allograft Reconstruction vs Tenodesis for Irreparable Peroneus Brevis Tears A Cadaveric Model

Background: There is a paucity of objectively recorded data delineating the pattern of weightbearing distribution within the prosthetic socket of patients with transtibial amputation. Our current knowledge is based primarily on information obtained from finite element analysis computer models. Methods: Four high-functioning transtibial amputees were fit with similar custom prosthetic sockets. Three load cells were incorporated into each socket at high stress contact areas predicted by computer modeling. Dynamic recording of prosthetic socket loading was accomplished during rising from a sitting position, stepping from a 2-leg stance to a 1-leg stance, and during the initiation of walking. By comparing the loads measured at each of the 3 critical locations, anterior/posterior shear, superior/inferior shear, and end weightbearing were recorded. Results: The same load pattern in all 4 subjects was found during each of the 3 functional activities. The load transmission at the distal end of the amputation residual limbs was negligible. Consistent forces were observed in both the anterior/posterior and superior/inferior planes. Correlation coefficients were used to compare the loads measured in each of the 4 subjects, which ranged from a low of .82 to a high of .98, where a value approaching 1.0 implies a linear relationship amongst subjects. Conclusion: This experimental model appears to have accurately recorded loading within a transtibial prosthetic socket consistent with previously reported finite element analysis computer models. Clinical Relevance: This clinical model will allow objective measurement of weightbearing within the prosthetic socket of transtibial amputees and allow objective comparison of weightbearing distribution within the prosthetic sockets of patients who have undergone creation of different versions of a transtibial amputation residual limb and prosthetic socket designs.