The treatment of Johnson stage 2 posterior tibial tendon insufficiency remains controversial. Because the deformities remain flexible in stage 2, bony osteotomies are preferable over fusion operations. It is our contention that operative intervention should address all of the components of the pes planovalgus deformity that exists in stage 2 disease. Seventeen patients with 20 cases of stage 2 posterior tibial tendon insufficiency were treated with heel cord lengthening, flexor digitorum longus to medial cuneiform tendon transfer, lateral column lengthening, and medial displacement calcaneal osteotomy. Preoperative, postoperative, and final radiographs while standing were analyzed to determine radiographic correction of the deformities. In addition, the American Orthopaedic Foot and Ankle Society's ankle/hindfoot rating scale was applied to all patients before surgery and at 6-month intervals after surgery. Currently, the average follow-up is 17.5 months. The average foot rating score preoperatively was 51.4 and has improved to 82.8.Radiograph measurements have demonstrated statistically significant correction of the pes planovalgus deformity, as well as maintenance of the correction to date.It is our conclusion that this combination of surgical procedures provides correction of the symptomatology and deformity associated with stage 2 posterior tibial tendon insufficiency. The long-term result of the procedure is unknown.

The intermediate outcome of patients who underwent a modified Lapidus procedure for the treatment of hallux valgus secondary to a hypermobile first ray was evaluated with an outcome tool to determine if their pain and functional status were improved. We evaluated 31 feet in 26 patients who underwent a modified Lapidus procedure. All working patients (100%) returned to full-time work. Six patients were retired and one was unemployed prior to surgery. There was an average of eight months until sports or unlimited activities were performed, and an average 16 weeks until conventional shoes could be worn. All patients but one (96%) were satisfied with the surgery and knowing their results would have the surgery again. Postoperative pain relief satisfaction was totally satisfied in 19 patients, satisfied with reservations in six patients, and not satisfied in one patient. Postoperative appearance satisfaction was totally satisfied in 21 patients and satisfied with reservations in five patients. Postoperative joint motion was no noticeable stiffness in 22 patients, noticeable stiffness but not bothersome in three patients, and stiffness that impairs activity in one patient (two feet). In the radiographic measurements, there was an average improvement of 10 degrees in the hallux valgus angle, 10 degrees in the intermetatarsal angle, two degrees in the lateral metatarsal-floor angle and two grades in the sesamoid position. Complications experienced were five recurrent deformities, two metatarsalgias, and one deep vein thrombosis. One of the five recurrences became symptomatic and required a revision.

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SUMMARYPolar membrane glycerolipids occur in a mixture of molecular species defined by a polar head group and characteristic acyl groups esterified to a glycerol backbone. A molecular species of phosphatidylglycerol specific to chloroplasts of plants carries a D 3-trans hexadecenoic acid in the sn-2 position of its core glyceryl moiety. The fad4-1 mutant of Arabidopsis thaliana missing this particular phosphatidylglycerol molecular species lacks the necessary fatty acid desaturase, or a component thereof. The overwhelming majority of acyl groups associated with membrane lipids in plants contains double bonds with a cis configuration. However, FAD4 is unusual because it is involved in the formation of a trans double bond introduced close to the carboxyl group of palmitic acid, which is specifically esterified to the sn-2 glyceryl carbon of phosphatidylglycerol. As a first step towards the analysis of this unusual desaturase reaction, the FAD4 gene was identified by mapping of the FAD4 locus and coexpression analysis with known lipid genes. FAD4 encodes a predicted integral membrane protein that appears to be unrelated to classic membrane bound fatty acid desaturases based on overall sequence conservation. However, the FAD4 protein contains two histidine motifs resembling those of metalloproteins such as fatty acid desaturases. FAD4 is targeted to the plastid. Overexpression of the cDNA in transgenic Arabidopsis led to increased accumulation of the D 3-trans hexadecanoyl group in phosphatidylglycerol relative to wild type. Taken together these results are consistent with the hypothesis that FAD4 is the founding member of a novel class of fatty acid desaturases.

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