Citations

Nineteen distal chevron metatarsal osteotomy operations were performed in 13 patients with painful bunionette. The average duration of follow-up was 7.1 years. Mean forefoot score improved from 35.8 points to 73.9 points out of a possible 75 points. Intermetatarsal 4–5 angle, metatarsophalangeal 5 angle, and forefoot width improved significantly. Overall results were considered good in 17 feet and fair in 2; there were no failures. Complications were transfer metatarsalgia (1 foot) and wound infection (1 foot). Distal chevron fifth metatarsal osteotomy is effective treatment for symptomatic bunionette.

The extraosseous and intraosseous vascular anatomy to the fifth metatarsal as visualized in a group of below-the- knee amputation specimens has been described. The extrinsic circulation to the area is provided by the dorsal metatarsal artery, the plantar metatarsal arteries, and the fibular plantar marginal artery. These three source arteries supply branches to the metatarsal and adjacent joints. The intraosseous vascularity consists of a periosteal plexus, a nutrient artery, and a system of metaphyseal and capital vessels.

Radiographs were studied of 91 feet in 62 patients with the diagnosis of bunionette and no prior bunionette or hallux valgus operations. Various radiologic measurements were compared to a matched control group with no bunionette symptoms or previous forefoot operations. The bunionette group had a significantly increased metatarsophalangeal 5 angle, intermetatarsal 4–5 angle, and intermetatarsal 1–2 angle compared to the control group. Bunionettes were not commonly associated with lateral bowing of the fifth metatarsal or with an increased fifth metatarsal head width. Symmetry was noted between symptomatic and opposite asymptomatic feet, with the exception of an increased intermetatarsal 4–5 angle in the symptomatic feet.

SummaryObjectivesTo describe the experience of a single, tertiary care institution in the care of patients with Fontan physiology undergoing anesthesia for noncardiac surgery.BackgroundThe Fontan procedure was developed in 1971 to palliate patients with univentricular cardiac physiology leading to long‐term survival of these patients, who may now present as adults for noncardiac surgery.MethodsWe retrospectively reviewed the medical records of Fontan patients 16 years and older who underwent general anesthesia for noncardiac surgery at Mayo Clinic in Rochester, Minnesota. Preoperative data, perioperative course, intraoperative and postoperative hemodynamic, pulmonary, cardiovascular, and renal complications were described.ResultsThirty‐nine general anesthetics were administered to 31 patients for noncardiac surgery after Fontan palliation. Perioperative complications occurred in 12 of the 39 (31%) noncardiac surgeries, and there was one postoperative death that occurred on day 13 after ventral hernia repair. The two patients who had complications that did not resolve (long‐term dialysis and death) had ejection fractions well below the mean for the group (22% and 28%).ConclusionIt may be more appropriate for Fontan patients to undergo anesthesia for noncardiac surgery in a tertiary institution, particularly patients with an ejection fraction of <30%. Intraoperative arterial blood pressure monitoring and overnight admission are likely appropriate for most cases.

Background— Use of the left internal mammary artery (LIMA) in multivessel coronary artery disease improves survival after coronary artery bypass graft surgery; however, the survival benefit of multiple arterial (MultArt) grafts is debated. Methods and Results— We reviewed 8622 Mayo Clinic patients who had isolated primary coronary artery bypass graft surgery for multivessel coronary artery disease from 1993 to 2009. Patients were stratified by number of arterial grafts into the LIMA plus saphenous veins (LIMA/SV) group (n=7435) or the MultArt group (n=1187). Propensity score analysis matched 1153 patients. Operative mortality was 0.8% (n=10) in the MultArt and 2.1% (n=154) in the LIMA/SV ( P =0.005) group, which was not statistically different ( P =0.996) in multivariate analysis or the propensity-matched analysis ( P =0.818). Late survival was greater for MultArt versus LIMA/SV (10- and 15-year survival rates were 84% and 71% versus 61% and 36%, respectively [ P <0.001], in unmatched groups and 83% and 70% versus 80% and 60%, respectively [ P =0.0025], in matched groups). MultArt subgroups with bilateral internal mammary artery/SV (n=589) and bilateral internal mammary artery only (n=271) had improved 15-year survival (86% and 76%; 82% and 75% at 10 and 15 years [ P <0.001]), and patients with bilateral internal mammary artery/radial artery (n=147) and LIMA/radial artery (n=169) had greater 10-year survival (84% and 78%; P <0.001) versus LIMA/SV. In multivariate analysis, MultArt grafts remained a strong independent predictor of survival (hazard ratio, 0.79; 95% confidence interval, 0.66–0.94; P =0.007). Conclusions— In patients undergoing isolated coronary artery bypass graft surgery with LIMA to left anterior descending artery, arterial grafting of the non–left anterior descending vessels conferred a survival advantage at 15 years compared with SV grafting. It is still unproven whether these results apply to higher-risk subgroups of patients.

In a 1964 study of the pharmacokinetic determinants of penicillin cure of gonococcal urethritis, 45 male prisoner volunteers were experimentally infected with strains of Neisseria gonorrhoeae having known in vitro penicillin susceptibility. After developing urethritis, subjects received intramuscular penicillin G and had serum samples obtained serially to determine penicillin concentration. Using a multiple regression technique, we studied patient-associated parameters and parameters of the serum penicillin curves to determine the best predictors of treatment results. Cure was best predicted by the time the serum penicillin concentration remained above three to four times the penicillin minimum inhibitory concentration of the infecting strain (probability of correct classification, >0.80). Those cured had serum penicillin concentrations which remained in this range for means of 7 to 10 h. Our findings confirm principles of antimicrobial therapy derived from animal models and may have application in studying therapy of gonorrhea and other infectious diseases.

Background —Genetic defects are being increasingly recognized in the etiology of primary cardiomyopathy (CM). Very-long-chain acyl-CoA dehydrogenase (VLCAD) catalyzes the first step in the β-oxidation spiral of fatty acid metabolism, the crucial pathway for cardiac energy production. Methods and Results —We studied 37 patients with CM, nonketotic hypoglycemia and hepatic dysfunction, skeletal myopathy, or sudden death in infancy with hepatic steatosis, features suggestive of fatty acid oxidation disorders. Single-stranded conformational variance was used to screen genomic DNA. DNA sequencing and mutational analysis revealed 21 different mutations on the VLCAD gene in 18 patients. Of the mutations, 80% were associated with CM. Severe CM in infancy was recognized in most patients (67%) at presentation. Hepatic dysfunction was common (33%). RNA blot analysis and VLCAD enzyme assays showed a severe reduction in VLCAD mRNA in patients with frame-shift or splice-site mutations and absent or severe reduction in enzyme activity in all. Conclusions —Infantile CM is the most common clinical phenotype of VLCAD deficiency. Mutations in the human VLCAD gene are heterogeneous. Although mortality at presentation is high, both the metabolic disorder and cardiomyopathy are reversible.