Weak Responses to Auditory Feedback Perturbation during Articulation in Persons Who Stutter: Evidence for Abnormal Auditory-Motor Transformation

Previous empirical observations have led researchers to propose that auditory feedback (the auditory perception of self-produced sounds when speaking) functions abnormally in the speech motor systems of persons who stutter (PWS). Researchers have theorized that an important neural basis of stuttering is the aberrant integration of auditory information into incipient speech motor commands. Because of the circumstantial support for these hypotheses and the differences and contradictions between them, there is a need for carefully designed experiments that directly examine auditory-motor integration during speech production in PWS. In the current study, we used real-time manipulation of auditory feedback to directly investigate whether the speech motor system of PWS utilizes auditory feedback abnormally during articulation and to characterize potential deficits of this auditory-motor integration. Twenty-one PWS and 18 fluent control participants were recruited. Using a short-latency formant-perturbation system, we examined participants’ compensatory responses to unanticipated perturbation of auditory feedback of the first formant frequency during the production of the monophthong [ε]. The PWS showed compensatory responses that were qualitatively similar to the controls’ and had close-to-normal latencies (~150 ms), but the magnitudes of their responses were substantially and significantly smaller than those of the control participants (by 47% on average, p<0.05). Measurements of auditory acuity indicate that the weaker-than-normal compensatory responses in PWS were not attributable to a deficit in low-level auditory processing. These findings are consistent with the hypothesis that stuttering is associated with functional defects in the inverse models responsible for the transformation from the domain of auditory targets and auditory error information into the domain of speech motor commands

Primary Open vs. Arthroscopic Ankle Arthrodesis

Category: Ankle Arthritis Introduction/Purpose: Ankle arthrodesis is the gold-standard treatment option for patients with end-stage ankle osteoarthritis resulting in measurable improvements in postoperative pain relief. Arthroscopic ankle arthrodesis has gained increasing popularity, however there remains a lack of comparative data with open ankle arthrodesis. The objectives of this retrospective study were to compare (1) demographics, (2) surgical technique, (3) postoperative fusion rates, and (4) postoperative complication rates in patients with primary open vs. arthroscopic tibiotalar arthrodesis. Methods: Between March 2002 and November 2014, 385 primary ankle arthrodeses were performed at our institution. There were 212 male and 173 female patients with a mean age of 56 ± 14.7 years (18.0-88.8). The mean weight, height, and body mass index (BMI) were 89.4 ± 19.7 kg (46-168), 172.9 ± 11.1 cm (147-208), and 29.9 ± 5.8 kg/m2 (18.9-54.9), respectively. There were 322, and 63 patients with primary open and arthroscopic arthrodesis, respectively. Both patient groups were compared with regard to demographics including gender, weight, height, BMI, ASA classification, smoking, alcohol use, and comorbidities. The surgical technique was analyzed in both groups including approach, main fixation type, and allograft/autograft use. Finally, fusion rates and time to complete union were analyzed. Complication rates including wound complications, deep vein thrombosis/pulmonary embolism, and any secondary procedures were described in both groups. The mean time to final follow-up was 37.9 ± 27.0 months (12.0-150.4). Results: Demographics and comorbidities were comparable in both groups. All but one arthroscopy were performed using anterior portals. All arthroscopic ankle arthrodeses were performed using screw fixation, while fixation types varied in open arthrodesis (P < 0.001). Autograft use was higher in open arthrodesis at 84.2% vs. 6.3% (P < 0.001), while allograft was favored for arthroscopic arthrodesis at 66.7% vs. 20.2% (P = 0.101).Osseous union was with 92.2% and 90.5% in patients with open and arthroscopic arthrodesis, respectively (P = 0.529). However, the time to complete osseous fusion was significantly shorter in patients with arthroscopic ankle fusion, at 4.3 vs. 5.1 months (P = 0.034). Wound and thrombembolic complications occurred significantly more often in patients with open ankle arthrodesis. Conclusion: Osseous union rates were comparable in both patient groups,however union time was significantly shorter in the arthroscopic group. Wound healing problems and thrombembolic complications were more common in patients who underwent open ankle arthrodesis

Primary vs. Revision Ankle Arthrodesis

Category: Ankle Arthritis Introduction/Purpose: The current standard treatment for failed ankle arthrodesis is a revision ankle arthrodesis. However, there is limited literature addressing postoperative outcomes in patients with revision tibiotalar arthrodesis. The objectives of the retrospective study were to compare (1) demographics, (2) surgical technique, (3) postoperative fusion rates, and (4) postoperative complication rates in patients with primary vs. revision tibiotalar arthrodesis. Methods: Between March 2002 and November 2014, 455 ankle arthrodeses were performed in our institution. There were 234 male and 221 female patients with a mean age of 55.6 ± 15.1 years (18.0-88.8). The mean weight, height, and body mass index (BMI) were 90.3 ± 21.3 kg (46-218), 172.8 ± 13.6 cm (147-208), and 30.2 ± 6.3 kg/m2 (18.9-61.7), respectively. Both patient groups were compared with regard to demographics including gender, weight, height, BMI, ASA classification, smoking, alcohol use, and comorbidities. The surgical technique has been analyzed in both groups including surgical approach, main fixation type, allograft/autograft use, and use of bone morphogenic protein. Finally, fusion rate and time to complete osseous fusion were analyzed. Complication rates including wound complications, deep vein thrombosis/pulmonary embolism, and any secondary procedures were described in both groups. The mean time to final follow-up was 38.3 ± 27.4 months (12.0-150.4). Results: There were 385 and 70 patients with primary and revision arthrodesis, respectively. Demographics and comorbidities were comparable in both groups. All revision surgeries were open procedures, while 63 of 385 primary ankle arthrodeses were performed arthroscopically. The most common main fixation type in patients with primary ankle arthrodesis was a screw construct, while plates were most common for revisions (P < 0.001). The use of autograft was comparable in both groups (P = 0.886), however allograft was used more frequently in the revision arthrodesis group (P < 0.001). The rate of osseous union was comparable in both groups with 90.4% and 91.4% in patients with primary and revision arthrodesis, respectively (P = 0.735). The complication rate was comparable in both groups. Conclusion: The osseous union rates and complication rates were comparable in both patient groups, with primary and revision ankle arthrodesis

Comparison of Fusion and Complication Rates in Patients with Primary Open Ankle Arthrodesis

Category: Ankle Arthritis Introduction/Purpose: In the last decades, different surgical techniques with various approaches and fixation methods have been described for ankle arthrodesis. Tibiotalar arthrodesis can be performed with or without distal tibiofibular fusion. The objectives of this retrospective study were to compare (1) demographics, (2) surgical techniques, (3) postoperative fusion rates, and (4) postoperative complication rates in patients with primary open tibiotalar arthrodesis with vs. without distal tibiofibular fusion. Methods: Between March 2002 and November 2014, 322 primary open ankle arthrodeses were performed at our institution. There were 183 male and 139 female patients with a mean age of 56.0 ± 14.0 years (18.0-88.8). The mean weight, height, and body mass index (BMI) were 90.0 ± 20.4 kg (46-168), 172.9 ± 11.4 cm (147-208), and 30.0 ± 5.7 kg/m2 (18.9-54.9), respectively. Both patient groups were compared with regard to demographics including gender, weight, height, BMI, ASA classification, smoking, alcohol use, and comorbidities. The surgical technique has been analyzed in both groups including surgical approach, main fixation type, and allograft/autograft use. Finally, fusion rate and time to complete osseous fusion were analyzed. Complication rates including wound complications, deep vein thrombosis/pulmonary embolism, and any secondary procedures were described in both groups. The mean time to final follow-up was 36.7 ± 26.7 months (12.0-150.4). Results: 214 had a combined distal tibiofibular fusion, while 108 did not. The most common surgical approach was lateral and anterior in patients with and without distal tibiofibular fusion, respectively (P < 0.001). The main fixation type was different between groups, with the most common technique being screws for patients with tibiofibular fusion, and plates in those without (P < 0.001). Autograft and allograft were used significantly less frequently in patients without distal tibiofibular fusion. The rate of osseous union was comparable in both groups with 92.2% and 93.0% in patients with and without distal tibiofibular fusion, respectively (P = 0.675). The incidence of wound and thrombembolic complications was similar in both groups. Conclusion: The osseous union rates and complication rates were comparable in both patient groups, with and without distal tibiofibular fusion

Cost Comparison of Operatively Treated Ankle Fractures Managed in an Inpatient versus Outpatient Setting

Category: Trauma Introduction/Purpose: Although choices physicians make profoundly impact the cost of healthcare, few surgeons know actual costs. Without valid cost information, surgeons cannot understand how their choices impact the total cost of care. We leveraged a validated value analytics framework to efficiently allocate clinical care costs to individual patient encounters in an effort to understand the sources and variation of cost of care for a putatively straightforward and common orthopaedic problem. Methods: We conducted a retrospective cost analysis on all isolated, operatively treated ankle fractures from a Level 1 trauma hospital and affiliated outpatient surgery center between 2013 and 2015. Patients were categorized based on whether they were treated on an inpatient or outpatient basis, and records were reviewed to determine the presence of confounding variables as well as readmission and emergency department (ED) visits within 90 days after surgery. Actual costs were determined using a validated episode of care costing system and analyzed using multivariate regression analysis. Results: 148 patients (61 inpatients, 87 outpatients) with isolated, operatively treated ankle fractures were included. After controlling for confounding variables, outpatient care was associated with 31.6% (95% CI: 19.8% - 41.8%) lower costs compared to inpatient care. Obese patients had 21.6% (95% CI: 5.8% - 39.8%) higher costs compared to patients who were not obese. There was no difference in reoperation, readmission or return visits to the ED for patients treated on an inpatient or outpatient basis. Conclusion: Inpatient surgical care is clearly more expensive than outpatient care primarily due to higher facility and labor costs without a clear advantage relative to lower readmission or ER visit rates. Where medically appropriate, this analysis suggests ankle fracture surgery should be provided in an outpatient surgical facility to provide the greatest value to the patient and society

Technique, Complications, and Mid-Term Results of Hindfoot Arthrodesis with a Posterior Blade Plate

Category: Ankle Arthritis Introduction/Purpose: Previous hindfoot surgeries present a unique challenge in performing hindfoot arthrodesis. The use of a blade plate construct is widely accepted, however there is limited data supporting the use of a posterior approach to blade plate arthrodesis. The purpose of this study was to (1) describe demographics of patients who underwent posterior hindfoot arthrodesis using a blade plate, (2) describe our surgical technique, (3) discuss outcomes, and (4) compare patients with and without complications. Methods: Between December 2001 and July 2014, 42 patients underwent hindfoot arthrodesis using a posterior blade plate and 40 patients were included in this study. Demographic data including age, gender, body mass index, smoking status, and comorbidities were analyzed. Surgical data including indication for the surgery, previous surgical treatment, and additional surgical procedures were reviewed. Weight-bearing radiographs were used to assess the fusion rate. Clinic and surgery notes were reviewed for possible intraoperative, perioperative, and postoperative complications. Univariate analysis was performed to compare patients who experienced complications with those who did not. There were 27 male and 13 female patients with a mean age of 56.4 ± 13.4 years. Twenty-eight patients had a tibiotalocalcaneal arthrodesis in a primary (n=6), primary staged (n=10), revision (n=9), or revision staged (n=3) setting. Eleven patients had ankle arthrodesis (primary n=7, revision n=4). The latest follow-up averaged 46.5 ± 27.5 months (range, 13.7-137.2 months). Results: Patients had a median of two previous hindfoot or ankle surgeries (range, 0-9 surgeries). Thirty-three of 40 (82%) procedures fused at an average of 24.4 ± 21.2 weeks. Four patients had a delayed osseous union. Seven patients had a nonunion, including ankle (n=3), subtalar (n=3), and both (n=1) joints. Patient groups with, and without primary solid osseous unions were comparable in terms of demographic data and surgical details. Eighteen major and eight minor complications were observed. Patients with or without complications were comparable in terms of demographic data and surgical characteristics. In total six patients (15%) underwent below knee amputation due to unsatisfactory results. Conclusion: Indications for hindfoot arthrodesis using posterior blade plate fixation include a diverse patient population. These surgeries may be performed as primary, revision, primary staged, or revision staged procedures. Most of the patients in our cohort had previous ankle/hindfoot surgeries. The fusion rate is lower than in primary hindfoot arthrodesis as reported in the current literature. The complications rate is high

In-Vivo Kinematics of the Tibiotalar and Subtalar Joints in Asymptomatic Subjects with Application to Chronic Ankle Instability

Category: Ankle Introduction/Purpose: Measurements of joint angles and translations (i.e. kinematics) are essential to understand the pathomechanics of ankle disease and functional changes following treatment. Traditional motion capture techniques, which track the positions of reflective markers adhered to the skin, cannot measure motion of the tibiotalar and subtalar joints independent of one another. To overcome this limitation, we used high-speed dual fluoroscopy (DF), an x-ray videography technique, to quantify in-vivo kinematics of healthy asymptomatic ankles during activities of daily living. Using these kinematics as baseline data, our secondary objective was to assess preliminary kinematic differences between chronic ankle instability (CAI) patients and asymptomatic control subjects. Methods: High-speed DF images of the hindfoot of ten healthy, asymptomatic adults and four adults with CAI were acquired during treadmill walking at 0.5 m/s and 1.0 m/s and during a single-leg, balanced heel-rise. Three-dimensional (3D) CT models of the calcaneus, tibia, and talus and DF images served as input to the validated model-based markerless tracking software that quantified in vivo kinematics for the tibiotalar and subtalar joints. Dynamic joint kinematics and mean range of motion (ROM) were calculated and reported as dorsi/plantarflexion (D/P), inversion/eversion (In/Ev) and internal/external rotation (IR/ER) angles or translations along the medial/lateral (ML), anterior/posterior (AP), and superior/inferior (SI) directions. Results: During gait, the tibiotalar joint had significantly greater D/P ROM than the subtalar joint (0.5 m/s: p=0.004; 1.0 m/s: p=0.003). The subtalar joint had significantly greater In/Ev (0.5 m/s: p < 0.001; 1.0 m/s: p < 0.001) and IR/ER (0.5 m/s: p=0.01; 1.0 m/s: p=0.02) ROM than the tibiotalar joint. However, during balanced heel-rise, D/P and In/Ev were significantly different between the two joints (p < 0.001; p < 0.001). For AP translation, subtalar ROM was significantly greater than tibiotalar ROM during walking at 0.5m/s (p=0.002). CAI patients often demonstrated rotational profiles with dynamic trends that fell outside the 95% confidence intervals of the asymptomatic subjects (Figure 1). CAI patients exhibited smaller ROM than asymptomatic subjects. However, only 0.5 m/s tibiotalar SI translational (p=0.049) and 1.0 m/s subtalar In/Ev (p=0.03) ROM were significant. Conclusion: To our knowledge, this is the first study to quantify in-vivo joint angles and translations in asymptomatic and CAI subjects. Our results support the belief that the tibiotalar joint is primarily responsible for D/P, while the subtalar joint facilitates In/Ev and IR/ER. Secondary rotational contributions suggest that both joints undergo complex, 3D motion. Our comparison of CAI and asymptomatic subjects is not conclusive, yet suggests that a larger sample size will detect significant differences. With a larger sample size, dual-fluoroscopy may provide insight into the clinical relevance of altered kinematics and the pathomechanics responsible for ankle instability and other pathologies

Interdisciplinary European Guidelines on Metabolic and Bariatric Surgery

In 2012, an outstanding expert panel derived from IFSO-EC (International Federation for the Surgery of Obesity - European Chapter) and EASO (European Association for the Study of Obesity), composed by key representatives of both Societies including past and present presidents together with EASO's OMTF (Obesity Management Task Force) chair, agreed to devote the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery as a pre-satellite of the 2013 European Congress on Obesity (ECO) to be held in Liverpool given the extraordinarily advancement made specifically in this field during the past years. It was further agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced in cooperation of both Societies by focusing in particular on the evidence gathered in relation to the effects on diabetes during this lustrum and the subsequent changes that have taken place in patient eligibility criteria. The expert panel composition allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery