Biomedical subjects
Publications and source records attributed to Charles L Saltzman.
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Mobility of the first-ray is associated with several common lower extremity disorders. However, the reliability and validity of clinical measurement remains unclear. In this study we examined first-ray mobility by using one hand to stabilize the lesser metatarsals while the clinician's other hand applied a displacement force to the head of the first metatarsal. The amount of mobility was graded as stiff, normal or hypermobile. We then used a well-validated mechanical device to perform similar tests and assessed validity, intrarater reliability and interrater reliability. Three clinicians having varied levels of experience graded first-ray mobility on 15 subjects. A separate investigator measured dorsal mobility with a mechanical device. Both methods of testing were repeated to assess measurement reliability. Reliability was estimated by kappa (K) statistics. Spearman correlation assessed the relationship between mobility graded manually and dorsal mobility measured by device. Manual examination intrarater K values ranged from 0.50 to 0.85, and interrater agreement from 0.09 to 0.16. Manual grading was not related (r = -0.21) to the absolute measure of total dorsal mobility made by device. This brings into question the validity and reliability of manual estimates of first-ray mobility.
Total contact casts (TCC) are commonly used in the treatment of neuropathic ulcers of the foot related to diabetes. However, casts may alter the gait pattern and increase loading parameters of the contralateral foot. We determined the effects of total contact casting on plantar pressure parameters for the contralateral extremity. Ten healthy subjects consented to walk, for four consecutive trials, along a 25-meter corridor while wearing a running shoe (RS), fiberglass TCC and a traditional TCC. Parameters of peak pressure, contact time and pressure-time integrals for the contralateral forefoot, metatarsal V area and heel were recorded using the novel Pedar system of plantar pressure measurement. Repeated measures analyses of variance (footwear x region) were used to analyze the recorded parameters with post-hoc Tukeys selected for follow-up analysis. Each of the measured parameters for the forefoot, lateral foot over metatarsal V and heel regions on the contralateral foot were similar regardless of footwear worn. Use of a TCC does not appear to affect contralateral foot contact pressure parameters and likely does not increase the risk of contralateral ulceration.
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The Agility Total Ankle System can be used in most arthritic conditions that involve the ankle joint, including many angular deformities that result from trauma or degenerative wear. The surgeon must be prepared to realign the ankle and to achieve soft-tissue balancing at the time of the surgery to avoid late failures. Proper patient selection is very important, and certain conditions, including diabetes with peripheral neuropathy, poor skin quality or poor circulation, and deficient bone stock, must be avoided to achieve a successful outcome. The surgical procedure must be done in a precise manner, with selection of the proper size of prosthesis and accurate insertion of the components in all directions. Proper tensioning of the joint is also paramount to achieve long-term stability. The precise degree of tensioning is still somewhat controversial, although with experience the deltoid end point can be readily determined in most patients. The follow-up care of these patients is very important, not only from the standpoint of compliance but also because any long-term problems must be recognized and treated before the implant is lost.
There remains vast truth in the statement "neuropathy causes diabetic foot pathology." However, if it were really that straightforward and if our understanding were complete, it is doubtful that ulceration and neuroarthropathy would be the public health problems that they are today. Diabetes is an insidious disease, and almost every component of the spectrum of hyperglycemic complications is active in creating foot lesions. These include dramatic alterations in all components of the peripheral nerves, the mechanical characteristics of bones and soft tissues, gait kinematics, the vasculature at both a microscopic and a macroscopic level, the immune system, and the fundamental processes of wound healing. Clinical treatments that address the biologic aspects of the problem without considering the mechanics, or vice versa, can sometimes be effective but fail to take advantage of all of the potential means to succeed. The greatest potential for future clinical advance lies in understanding and simultaneously addressing the many synergistic factors that cause both ulceration and neuroarthropathy.
Ankle arthroplasty for post-traumatic tibiotalar arthritis remains controversial. The current literature strongly recommends arthrodesis, especially in those patients who will overload the joint: the young, the active and the overweight patients. The case described here is a 40-year follow up. A 31-year old man underwent talar dome resurfacing with a custom Vitallium implant for post-traumatic arthritis in 1962. He continued to work as a heavy laborer until retirement in 1987 and presently remains virtually asymptomatic with regard to his foot and ankle. The longevity of this individual implant has been remarkable. The unique design, minimal resection, surgical approach and remarkable success merit discussion in the light of publication of predominantly bleak reports of arthroplasty in this patient population.
Although posttraumatic osteoarthritis (OA) is a common and important entity in orthopedic practice, no data presently exist regarding its prevalence or its relative burden of disease. A population-based estimate was formulated, based on one large institution's experience in terms of its fraction of patients with OA presenting to lower-extremity adult reconstructive clinics with OA of posttraumatic origin. The relative proportion of these patients undergoing total joint replacement provided a basis for extrapolating institutional experience with posttraumatic OA to a populationwide estimate because the numbers of lower-extremity total joint arthroplasty procedures performed were reliably tabulated both within the institution and populationwide. By this methodology, approximately 12% of the overall prevalence of symptomatic OA is attributable to posttraumatic OA of the hip, knee, or ankle. This corresponds to approximately 5.6 million individuals in the United States being affected by posttraumatic OA sufficiently severe to have caused them to present for care by an orthopedic lower-extremity adult reconstructive surgeon. Further, based on the relative prevalence of OA versus rheumatoid arthritis, and their relative impacts as assessed by the SF-36 (Short-Form 36) lower-extremity physical composite scores, about 85.5% of the societal costs of arthritis are attributable to OA. The corresponding aggregate financial burden specifically of posttraumatic OA is Dollars 3.06 billion annually, or approximately 0.15% of the total U.S. health care direct cost outlay.
This study examined the diagnostic validity of three different swab techniques in identifying chronic wound infection. Concurrent swab specimens of chronic wounds were obtained using wound exudate, the Z-technique, and the Levine technique, along with a specimen of viable wound tissue. Swab and tissue specimens were cultured using quantitative and qualitative laboratory procedures. Infected wounds were defined as those containing 1 x 10(6) or more organisms per gram of tissue. Accuracy was determined by associating the quantitative cultures of swab specimens with the cultures from tissue specimens using receiver operating characteristic curves. Of the 83 study wounds, 30 (36%) were infected. Accuracy was the highest for swab specimens obtained using Levine's technique at 0.80. Based on Levine's technique, a critical threshold of 37,000 organisms per swab provided a sensitivity of 90% and a specificity of 57%. The mean concordance between swab specimens obtained using Levine's technique and tissue specimens was 78%. The findings suggest that swab specimens collected using Levine's technique provide a reasonably accurate measure of wound bioburden, given that they are more widely applicable than tissue cultures. The diagnostic validity of Levine's technique needs further study using an alternative reference standard, such as the development of infection-related complications.