Caleb Jones

Cigarette smoke induces systemic defects in cystic fibrosis transmembrane conductance regulator function.

RATIONALE Several extrapulmonary disorders have been linked to cigarette smoking. Smoking is reported to cause cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction in the airway, and is also associated with pancreatitis, male infertility, and cachexia, features characteristic of cystic fibrosis and suggestive of an etiological role for CFTR. OBJECTIVES To study the effect of cigarette smoke on extrapulmonary CFTR function. METHODS Demographics, spirometry, exercise tolerance, symptom questionnaires, CFTR genetics, and sweat chloride analysis were obtained in smokers with and without chronic obstructive pulmonary disease (COPD). CFTR activity was measured by nasal potential difference in mice and by Ussing chamber electrophysiology in vitro. Serum acrolein levels were estimated with mass spectroscopy. MEASUREMENTS AND MAIN RESULTS Healthy smokers (29.45 ± 13.90 mEq), smokers with COPD (31.89 ± 13.9 mEq), and former smokers with COPD (25.07 ± 10.92 mEq) had elevated sweat chloride levels compared with normal control subjects (14.5 ± 7.77 mEq), indicating reduced CFTR activity in a nonrespiratory organ. Intestinal current measurements also demonstrated a 65% decrease in CFTR function in smokers compared with never smokers. CFTR activity was decreased by 68% in normal human bronchial epithelial cells exposed to plasma from smokers, suggesting that one or more circulating agents could confer CFTR dysfunction. Cigarette smoke-exposed mice had decreased CFTR activity in intestinal epithelium (84.3 and 45%, after 5 and 17 wk, respectively). Acrolein, a component of cigarette smoke, was higher in smokers, blocked CFTR by inhibiting channel gating, and was attenuated by antioxidant N-acetylcysteine, a known scavenger of acrolein. CONCLUSIONS Smoking causes systemic CFTR dysfunction. Acrolein present in cigarette smoke mediates CFTR defects in extrapulmonary tissues in smokers.

Collagen degradation and neutrophilic infiltration: a vicious circle in inflammatory bowel disease

Objective Proline–glycine–proline (PGP) has been shown to have chemotactic effects on neutrophils via CXCR2 in several lung diseases. PGP is derived from collagen by the combined action of matrix metalloproteinase (MMP) 8 and/or MMP9 and prolyl endopeptidase (PE). We investigated the role of PGP in inflammatory bowel disease (IBD). Design In intestinal tissue from patients with IBD and mice with dextran sodium sulfate (DSS)-induced colitis, MMP8, MMP9 and PE were evaluated by ELISA, immunoblot and immunohistochemistry. Peripheral blood polymorphonuclear cell (PMN) supernatants were also analysed accordingly and incubated with collagen to assess PGP generation ex vivo. PGP levels were measured by mass spectrometry, and PGP neutralisation was achieved with a PGP antagonist and PGP antibodies. Results In the intestine of patients with IBD, MMP8 and MMP9 levels were elevated, while PE was expressed at similar levels to control tissue. PGP levels were increased in intestinal tissue of patients with IBD. Similar results were obtained in intestine from DSS-treated mice. PMN supernatants from patients with IBD were far more capable of generating PGP from collagen ex vivo than healthy controls. Furthermore, PGP neutralisation during DSS-induced colitis led to a significant reduction in neutrophil infiltration in the intestine. Conclusions The proteolytic cascade that generates PGP from collagen, as well as the tripeptide itself, is present in the intestine of patients with IBD and mice with DSS-induced colitis. PGP neutralisation in DSS-treated mice showed the importance of PGP-guided neutrophilic infiltration in the intestine and indicates a vicious circle in neutrophilic inflammation in IBD.

Isolated Gastrocnemius Recession for the Treatment of Achilles Tendinopathy

Background: Various treatment modalities have been described for Achilles tendinopathy with varying degrees of success. The rationale for the gastrocnemius recession procedure is to decrease the mechanical overload of the Achilles tendon arising from an equinus contracture. Methods: We retrospectively reviewed 25 patients who underwent an isolated gastrocnemius recession procedure at our institution between May 2013 and April 2015 by a single surgeon. Clinical outcome was evaluated on the basis of pain, utilizing visual analog scale (VAS) scores and the Foot Function Index (FFI) by telephonic interview. Student’s t test and one-way analysis of variance were used for statistical analysis. Results: The average age of patients was 53.2 years with an average body mass index of 35.8 kg/m2. The average follow-up was 13.1 months. All 25 patients had a decrease in VAS scores from an average of 8.9 preoperatively to 2.0 at the 6-week visit. The average FFI went from 73.5 preoperatively to 27.4 at final follow-up. Two out of 25 patients had a postoperative sural neuritis with a total complication rate of 12%. Twenty-one of 25 patients (84%) reported total or significant pain relief. Conclusion: The medium-term results of our study suggest that an isolated gastrocnemius recession is a simple, effective, and safe surgical procedure for the treatment of Achilles tendinopathy. Levels of Evidence: Therapeutic, Level IV: Retrospective

Tibiotalocalcaneal Arthrodesis With Intramedullary Fibular Strut Graft With Adjuvant Hardware Fixation

ABSTRACT Tibiotalocalcaneal arthrodesis (TTCA) is a well‐established operative procedure for different severe pathologic conditions of the ankle and hindfoot joints. We present our results with a modified technique of TTCA using an intramedullary fibular strut graft in a series of complex cases of patients treated for multiple etiologies shown to have improved union rates. The technique involves inserting the fibular strut graft intramedullary after joint preparation and the use of either a Taylor spatial frame or plate and screws for definitive fixation. We reviewed the records of 16 patients who had undergone TTCA with this technique at our hospital from September 2013 to April 2015. Sixteen patients (10 males [62.5%] and 6 females [37.5%]) were included in the present study. These patients had complex cases and multiple risk factors, including diabetes, smoking, poor bone stock, and a history of previous surgeries. The mean follow‐up time was 9.1 (range 9 to 18) months. Thirteen patients (81.2%) subsequently achieved union. The mean visual analog scale scores at the final follow‐up examination had improved from 6.9 to 1.2. We suggest that our technique of TTCA with intramedullary fibular strut graft with fixation is a reasonable option to salvage complex cases with risk factors for operative complications.

Outcomes of Locking-Plate Fixation for Hindfoot Fusion Procedures in 15 Patients

ABSTRACT Tibiotalocalcaneal arthrodesis is a salvage procedure for various end‐stage foot and ankle pathologic entities. Several factors are known to influence the union rate after these procedures, including construct rigidity. The data on locked plates as a fixation technique have been inconclusive, with variable union rates reported. One recent study suggested that locking plates can lead to high nonunion rates owing to excessive rigidity. The purpose of the present study was to retrospectively examine the outcomes of locking plate fixation. We retrospectively reviewed the cases of 15 patients (7 [46.7%] male, 8 [53.3%] female) who underwent tibiotalocalcaneal, tibiocalcaneal, or tibiotalar arthrodesis fixed with a locking plate from January 2013 to January 2014. The average age was 52.19 ± 5.8 years. The mean follow‐up period was 17 ± 5.3 months. We examined the overall union rates and the effects of smoking, diabetes, and rheumatologic status on the union rate. Of the 15 cases, 11 (73.3%) did not achieve union. The mean time to failure was 10 ± 5.3 months. Age, gender, smoking, diabetes, use of augmentation screws outside the plate, and operating surgeon did not have an effect on the failure rate (p > .50). In addition, gender, smoking, and diabetes did not predict for nonunion. The high failure rate of rigid locking plate fixation reported might be attributable to the high incidence of smoking and diabetic comorbidities in our study. However, excessive construct rigidity might play an important role. Larger studies are needed to establish more reliable union rates with the use of locking plates in foot and ankle fusion.

A Prospective Study: Driving After Gastrocnemius Recession. When Is It Safe To Return?

Category: Post-surgical Lifestyle Introduction/Purpose: Gastrocnemius recession is the most common surgical procedure in the foot and ankle orthopaedic community. After surgery, patients ask their surgeons when they can safely resume day-to-day activities such as driving. Most times, the surgeon responds with generalized instructions using pain and patient comfort level as benchmarks for when the patient can return to driving. Several studies have identified safe return times for driving after traumatic injuries. However, a safe return time for gastrocnemius recession patients has never been studied. Given the safety concerns and risk associated with driving after surgery, it is important to have evidence-based advice for patients. The purpose of this study is to determine when a patient can safely return to driving after gastrocnemius recession. Methods: IRB approval has already been obtained for this study. 20 patients undergoing right-sided gastrocnemius recession will be identified in the Foot and Ankle clinic. Inclusion criteria will include first time isolated gastrocnemius recession surgery, licensed driver, and age between 18 and 65. Exclusion criteria will include failure to meet inclusion criteria, inability to return for follow-up testing, non-active driver status, medical contraindication to driving, history of any prior foot and ankle surgeries, and performance of any concurrent foot and ankle surgical procedures alongside gastrocnemius recession. Study participants will attend a driving simulator session prior to undergoing their procedure and will follow-up with repeat simulations at 1, 2, and 4 weeks postoperatively. Collected data will include braking reaction time, total braking time, speed stability, and number of traffic violations. A matched healthy control dataset will be used for comparison. Results: There was no detailed data available at the time of writing this abstract. We anticipate data availability over the next couple of months. Conclusion: We anticipate conclusions on the safe time to resume driving in gastrocnemius recession patients after gathering and processing detailed data. This is the first prospective study to guide counseling for patients undergoing gastrocnemius recession regarding a safe time to resume driving.

Calcaneal Osteotomies in the treatment of Hindfoot Deformities: Comparison between One Screw vs Two Screws fixation technique

Category: Hindfoot Introduction/Purpose: Calcaneal osteotomy is a common procedure for hindfoot deformities correction. Screw fixation is the most common technique used to stabilize these osteotomies. The clinical decision regarding the number of screws used is frequently based on the surgeon’s experience without sufficient data regarding outcomes and complications. The aim of this study was to compare the outcomes and complications of one versus two screws fixation technique of sliding calcaneal osteotomies. Methods: We reviewed 190 patients (112 female, 78 male) who underwent corrective calcaneal osteotomy for hind-foot angular deformity between 2010-2016. The average age was 48.4 years (18-83), and mean follow-up was 28 weeks (4-150). We divided patients into two groups, according to the number of screws used in the osteotomy fixation (one or two). 85 osteotomies were fixed by one screw and 105 by two screws. We compared both groups regarding incision type, positioning and type of the screws (headed or headless) and complications (non-union, infection, hardware related heel pain). Results: The average time for radiographic union was similar between the groups, around 5.6 weeks (4-10 weeks). Non-unions were not found. The overall Incidence of complications was not significant different in the one screw group compare two screw group (12.7% x 8%, p-value 0.465). Infection rate was similar in both groups (4.7% vs 3.5%, p-value 0.674). There was not significant difference of hardware related heel pain between two groups (15.2% vs 8.5%, p-value 0.149). Similarly, no difference in incidence of hardware related symptoms between patients who used headed screw when comparing with headless screws. Conclusion: Our study compared results in the use of one screw versus two screws fixation technique for sliding calcaneal osteotomies. We found similar time for union. Base of date there was no significant difference of complications, infection, and hardware related heel pain between patients who used one screw when comparing two screws fixation technique for corrective calcaneal osteotomy.

Effectiveness of Lateral Soft Tissue Release of the 1st Metatarsophalangeal Joint Through a Medial Transarticular Approach – A Cadaver Study

Category: Bunion Introduction/Purpose: First metatarsophalangeal joint lateral soft tissue release is frequently performed during corrective surgery for hallux valgus deformity. Surgical approaches include an open dorsal approach as well as a medial transarticular approach. The medial transarticular approach avoids the need for a second incision while also attenuating the risk of avascular necrosis of the first metatarsal head. However, this method is limited by the poor visualization of the lateral structures through the joint. The objective of this study was to evaluate the effectiveness of the medial transarticular approach for lateral soft tissue release in the 1st metatarsophalangeal joint. Methods: Ten below-the-knee fresh-frozen cadaveric specimens were used (6 females, 4 males). The mean age was 73.4 years. Two specimens had moderate hallux valgus deformity. None of the samples had considerable degenerative changes of the first metatarsophalangeal joint. Lateral soft tissue release was performed using a single 2.5 cm medial incision. Lateral soft tissue release targeted the lateral collateral ligament, lateral capsule, adductor hallucis muscle tendon and lateral metatarsosesamoid suspensory ligament. A single surgeon performed all procedures. An extended lateral dissection of the 1st intermetatarsal space was carried out to examine the accuracy of the technique. Successful release of each targeted structure (4 total) was recorded for each specimen. Thus, the percentage of successful release was computed for each specimen. Injuries to important non-targeted structures were also registered. Results: All four targeted structures were successfully released (100%) in seven of the ten cadavers. Three out of four structures were released (75%) in one cadaver, while two of the four and one of the four targeted structures were successfully released in the other two cadavers (50% and 25% success respectively). Lateral collateral ligament was successfully released in all cadavers. Lateral joint capsule, adductor hallucis muscle tendon, and lateral metatarsosesamoid suspensory ligament were released in 80% of the specimens. 1st metatarsal head chondral and unintended release of lateral head of the flexor hallucis brevis occurred respectively in 40% and 50% of the procedures. No injuries to the flexor hallucis longus tendon, neurovascular bundle, deep transverse metatarsal ligament or chondral damage to the proximal phalanx were recorded. Conclusion: Lateral soft tissue release of the first metatarsophalangeal joint can be successfully performed through a medial transarticular approach. Inadvertent release of the lateral head of the flexor hallux brevis and chondral damage of the 1st metatarsal head are complications to be considered.

Lateral Ankle Instability Surgical Treatment: A Comparison Between Primary Repair and Revision Surgery

Category: Ankle, Sports Introduction/Purpose: Lateral ankle instability is a common cause of disability in the active population. Although the majority of patients can be treated conservatively, surgical repair of the ligaments, with or without reinforcement, represents an excellent option for refractory cases. Failed primary surgical repair, recurrence of the ankle instability and need for revision surgery can rarely happen and is probably affected by multiple variables. That includes patient’s characteristics such as BMI and comorbidities and surgical aspects such as the use of suture anchors and soft-tissue reinforcement. The purpose of this study was to compare patient’s characteristics and complication rates of primary repair and revision procedures. Methods: We retrospectively reviewed 231 patients (160 Female, 71 Male) who underwent surgical treatment for lateral ankle instability between 2010-2016. Thirty-two were revision cases (14.2%), including 24 females and 8 males, and 199 were primary direct repairs (85.8%). The mean age at the time of the surgery was 39 (19-65)years, and average follow-up was 9 (2-55) months. The procedures were performed by four different surgeons. All cases were reviewed based on age, gender, BMI, procedure type and number of incisions, comorbidities, and complications. Data found was compared between the two groups (primary repair and revision surgery) by T-test. A p-value <0.05 was considered significant. Results: The Brostrom-Gould procedure was used in 69.5% of the primary repairs and 63.6% of the revision cases. The use of suture anchors was also similar in both groups (51%). Repair of the calcaneofibular ligament was performed in 68% of primary repairs and 81.8% of the revisions. We didn’t find significant differences regarding comorbidities between two groups: smoking (23.4% x 27.2%, p-value 0.371); diabetes (6.8% x 6%, p-value 0.951) and body mass index above 30 (28.5% x 24.2%, p-value 0.347). We found significant difference in the complication rate of the procedures, with a higher incidence in the revision group (48.4%) when compared to the primary repair group (24%). That included: sural neuritis (15.1% x 3.4%), superficial peroneal neuritis (12.1% x 4.5%), skin problems (9% x 7.4%). Conclusion: Our study of 231 patients that underwent surgical treatment for lateral ankle instability found significant higher incidence of complications in patients who had revision procedures when compared to primary repair. No differences regarding smoking status, diabetes and BMI were found.

Revisiting the Prevalence of Associated Co-Pathologies in Chronic Lateral Ankle Instability

Category: Ankle, Hindfoot, Sports Introduction/Purpose: Ankle sprains are the most common athletic injury with an estimated 30% risk of developing chronic lateral ankle instability. Up to 20% of these patients will require surgical management after trial of conservative treatment for chronic disease. Current literature suggests that the presence and type of co-pathologies associated with chronic lateral ankle instability can serve as important predictors of surgical outcomes. As the occurrence of these co-pathologies varies in the literature, providers may underestimate their presence which may lead to suboptimal surgical approach. The purpose of this study is to re-examine the prevalence of common associated lesions in patients who underwent surgical treatment for chronic lateral ankle instability. Methods: We retrospectively reviewed medical charts for 389 cases of lateral ankle instability repair surgery at our institution between June 2006 and November 2016. All patients had undergone at least 6 months of conservative therapy such as ankle stabilizing orthosis or physical therapy with no improvement. All operations were performed by senior orthopaedic surgeons. Exclusion criteria included age less than 18 at time of surgery, gross traumatic event, and history of ipsilateral subtalar arthrodesis. Demographic information such as age, gender, body mass index, and race/ethnicity were collected. 166 surgical notes accessible through the electronic medical record were reviewed for specific intra-operative findings including presence of peroneal pathology (including tendon split lesion), talar osteochondral defects, anterior or posterior ankle impingement, low lying muscle belly of the peroneus brevis and surgical approach. Simple descriptive statistics were used to examine means and frequencies of the collected data. Results: 166 cases (48 males, 118 females) were included (mean age = 39 ±13.4 years, mean body mass index = 31.41 ± 7.5 kg/m2, mean follow-up = 44 ± 46 weeks). 95 cases involved the left foot while 71 cases involved the right foot. Two senior surgeons accounted for 87% (145/166) of the cases. 20 cases were revisions. 72.3% (120/166) of all cases had associated peroneal pathology (36.6% (44/120) peroneus brevis split lesion and 5.8% (7/120) with peroneus longus split lesion). 41% (69/166) of the patients had ankle impingement (anterior = 32; posterior = 19. combined = 17), 37% (62/166) had a low lying muscle belly of the peroneus brevis and 19% (32/166) had osteochondral lesions of the talus. Conclusion: Surgical approach and long-term outcomes can be affected by the knowledge and proper diagnosis of chronic lateral ankle instability associated lesions. Our study reinforces the need for vigilant exploration of chronic ankle instability patients who require surgical treatment. More specifically, surgical exploration for peroneal pathology and ankle impingement may be crucial as our findings reveal a high intraoperative rate of their occurrence. While the role of a low-lying peroneus brevis muscle belly in the development or course of chronic lateral ankle instability remains to be elucidated, we report a significant percentage of its occurrence.