The February 2024 Foot & Ankle Roundup³⁶⁰ looks at: Survival of revision ankle arthroplasty; Tibiotalocalcaneal nail for the management of open ankle fractures in the elderly patient; Accuracy of a patient-specific total ankle arthroplasty instrumentation; Fusion after failed primary ankle arthroplasty: can it work?; Treatment options for osteochondral lesions of the talus; Managing hair tourniquet syndrome of toe: a rare emergency; Ultrasound-guided collagenase therapy for recurrent plantar fibromatosis: a promising line of therapy?.

Aims

The duration of systemic antibiotic treatment following first-stage revision surgery for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is contentious. Our philosophy is to perform an aggressive debridement, and to use a high local concentration of targeted antibiotics in cement beads and systemic prophylactic antibiotics alone. The aim of this study was to assess the success of this philosophy in the management of PJI of the hip using our two-stage protocol.

Aims

To explore the effect of different durations of antibiotics after stage II reimplantation on the prognosis of two-stage revision for chronic periprosthetic joint infection (PJI).

Aims

The mainstay of surgical correction of hallux valgus is first metatarsal osteotomy, either proximally or distally. We present a technique of combining a distal chevron osteotomy with a proximal opening wedge osteotomy, for the correction of moderate to severe hallux valgus.

Spondylodiscitis is an uncommon condition with an incidence of 1:100,000 to 1:250,000 in developed countries. Diagnosis and treatment can be delayed resulting in poor outcomes. A high index of suspicion is necessary considering the associated mortality, reported at 2–17%. Establishing a diagnosis can be challenging as features are non-specific and onset may be insidious. While treatment is usually conservative, certain situations require surgery. All patients however require careful assessment and monitoring for complications that may require further intervention. A review of our practice in Wexham Park and Heatherwood Hospital NHS Trust from 2009 to 2013 produced a guideline suggesting the need for blood cultures, imaging with MRI and involvement of the infectious diseases and spinal teams. We re-audited (20 cases) to assess compliance with the guidelines, which were in place to reduce the delay in diagnosis. Recurrent presentation, infections of unknown origin and deterioration after a short course of antibiotics were indicators for triggering imaging of the spine for discitis. Delays in diagnosis were more marked in bacterial cases rather than tuberculosis. It was impossible to predetermine patients that would require surgical intervention. Our compliance with the guideline had improved from 70 to over 90% and there were no relapses or mortality

We herein report a case of isolated hip pain in a four year old boy. The importance of this project is the unusual history, presentation, ultrasound, MRI and blood culture results and treatment, which lead to the diagnosis of adductor pyomyositis with a rare organism (Streptococcus Mitis) in a temperate country. The patient presented with a one day history of malaise, fever, left groin pain and inability to weight bear on the left leg. There was no history of any predisposing infections or recent travel. A working diagnosis of transient synovitis / septic arthritis of the hip was made on clinical examination. Plain radiograph and ultrasound of the hip was normal with no effusion. Two consecutive blood cultures suggested Streptococcus Mitis bacteriaemia and MRI scan confirmed pyomyositis of the left hip adductors that was too small to drain. Streptococcus Mitis is a normal commensal organism of the oral cavity however it can lead to opportunistic infections particularly endocarditis. Echocardiogram revealed no cardiac complications, in particular no endocarditic vegetation. Patient was treated with intravenous benzylpenicillin for a week followed by oral phenoxymethylpenicillin for a week. As it was a soft tissue infection, a short course of antibiotics was sufficient and he made a complete recovery. Adductor pyomyositis must be considered as a differential diagnosis in a child with unusual presentation of hip pain. When an ultrasound is normal, MRI scan is warranted to confirm diagnosis. Septic screen should include blood cultures. The commonest organisms are the Staphylococcus family. However if Streptococcus Mitis is isolated, cardiac sources of infection resulting in septic emboli must be investigated. Repeated MRI scans are required particularly if the patient does not respond to medical management

Little information is available about several important aspects of the treatment of melioidosis osteomyelitis and septic arthritis.

We undertook a retrospective review of 50 patients with these conditions in an attempt to determine the effect of location of the disease, type of surgical intervention and duration of antibiotic treatment on outcome, particularly complications and relapse.

We found that there was a 27.5% risk of osteomyelitis of the adjacent bone in patients with septic arthritis in the lower limb. Patients with septic arthritis and osteomyelitis of an adjacent bone were in hospital significantly longer (p = 0.001), needed more operations (p = 0.031) and had a significantly higher rate of complications and re-presentation (p = 0.048).

More than half the patients (61%), most particularly those with multifocal bone and joint involvement, and those with septic arthritis and osteomyelitis of an adjacent bone who were treated operatively, needed more visits to theatre.

Cite this article: Bone Joint J 2015;97-B:277–82.

The June 2013 Shoulder & Elbow Roundup³⁶⁰ looks at: whether suture anchors are still the gold standard; infection and revision elbow arthroplasty; the variable success of elbow replacements; sliding knots; neurologic cuff pain and the suprascapular nerve; lies, damn lies and statistics; osteoarthritis; and one- or two-stage treatment for the infected shoulder revision.

The purpose of this study was to assess the impact of Ilizarov frame fixation and total contact casting on the complications of Charcot arthropathy. The diabetic charcot foot or ankle is a potentially limb threatening disorder. This progressive disorder is characterised by osteopenia, bone fragmentation and joint subluxation. The risk of significant deformity and osteomyelitis lead to high rates of amputation in these patients. We analysed patients with acute charcot arthropathy attending the Rowley Bristow Unit between 2008 and 2012. We assessed 48 patients with a mean age of 59 years. Mean follow up was 24 months. 12 patients were managed with Ilizarov frame fixation and 36 using total contact casting. The duration of management was determined using serial infrared temperature monitoring to ensure the temperature of the limb normalised before patients were deemed safe to remove their immobilisation. The mean duration of Iliazarov frame fixation was 6.2 months and 5.3 months duration for total contact casting. In the Ilizarov group pin site infections were common and treated with a short course of antibiotics. In total one patient required below knee amputation following Ilizarov frame fixation. No patients suffered with osteomyelitis. We feel that prompt management of acute charcot arthropathy with either total contact casting where appropriate or Ilizarov frame fixation can reduce serious complications of this disorder

We present a series of 11 patients with infected tibial intramedullary nails which were treated at our tertiary referral centre from January 2000 to November 2009. All of them were males and the mean age was 36 years (26 to 47 years). All the patients had sustained post traumatic fractures which were treated with intramedullary nail. Four patients (36%) had sustained open fractures in whom adequate soft tissue cover was provided by plastic surgeons. Five of them (45%) were smokers. All of them underwent surgical debridement. Nine out of 11 patients had removal of metal work followed by one or more of the following procedures such as reaming, exchange nailing, excision of sequestrum, application of antibiotic beads and stabilisation with a frame with or without several bone grafts at a later date. Out of 11 patients six (55%) had no further episodes of infection, three (27%) still need short courses of antibiotics when the disease flares up and two (18%) underwent amputation. Causative organisms were isolated in all the patients. Commonest organism was MRSA. Overall, most of the organisms were sensitive to Vancomycin and resistant to Penicillin. Despite exploring most of the surgical procedures described for infected tibial intramedullary nails we have potentially eradicated infection only in about half of our patients. Hence we would like to emphasise that this condition still remains a serious problem and demands further insight in its management

There are 33 million people worldwide currently infected with human immunodeficiency virus (HIV). This complex disease affects many of the processes involved in wound and fracture healing, and there is little evidence available to guide the management of open fractures in these patients. Fears of acute and delayed infection often inhibit the use of fixation, which may be the most effective way of achieving union.

This study compared fixation of open fractures in HIV-positive and -negative patients in South Africa, a country with very high rates of both HIV and high-energy trauma. A total of 133 patients (33 HIV-positive) with 135 open fractures fulfilled the inclusion criteria. This cohort is three times larger than in any similar previously published study.

The results suggest that HIV is not a contraindication to internal or external fixation of open fractures in this population, as HIV is not a significant risk factor for acute wound/implant infection. However, subgroup analysis of grade I open fractures in patients with advanced HIV and a low CD4 count (< 350) showed an increased risk of infection; we suggest that grade I open fractures in patients with advanced HIV should be treated by early debridement followed by fixation at an appropriate time.

Purpose: Proximal tibia fractures present a difficult treatment challenge with historically high complication rates. The purpose of this study is to report the clinical outcome of proximal tibial fractures treated with of a variable-axis locking plate. Patients and Methods: Between 2004 and 2007, 42 patients (23 males) with a mean age of 50 (21–67) with a total of 42 proximal tibia fractures were included in this prospective documented study. Fractures were classified according to the OTA system. All fractures were treated with the polyaxial locked-plate fixation system (DePuy, Warsaw, Indiana). Besides radiography, CT scanning was obtained for type B and C fractures. Clinical and radiographic data, including fracture pattern, changes in alignment, local and systemic complications, hardware failure and time to union were recorded. Functional outcome was measured using the Knee Society Score. Malalingment was defined the presence of more than 5°angulation in any plane at the post-op X-ray and at the final F.U. The mean follow up was 11 months (6–36). Results: According to the OTA classification, there were 7 41-A, 11 41-B and 24 41-C fractures. There were 6 open and 36 closed fractures. The majority were isolated injuries 38/42. 19 cases required bone grafting. Fractures were treated percutaneously in 30% of the cases (MIPO). Double plating was utilised in 8 cases. All fractures but 2 progressed to union at a mean time of 3.8 months (3–5). The two fractures who failed to unite were complicated by deep sepsis and required further intervention. One patient required fasciotomies for compartment syndrome. Superficial infection was treated successfully with a short course of antibiotics in 2 cases. There was no evidence of varus collapse as a result of polyaxial screw failure. No plate fractured, and no screw cut out was noted. There was 1 case of lateral joint collapse (more than 10o) in a patient with open bicondylar plateau fracture. The mean Knee society score at the time of final follow-up was 89 points (59 – 100) and the mean functional score was 83 points. Conclusion: The polyaxial locking plates provided stable fixation of extra-articular and intra-articular proximal tibia fractures and good functional outcomes with a low complication rate. These plates offer more fixation options without an apparent increase in mechanical complications or loss of reduction

Aim: To review our practice of performing two-stage revision for infected total knee arthroplasty by using articulating interval prosthesis and short course parenteral antibiotic therapy. Patients and Methods: We included 70 patients treated by a single surgeon using a uniform protocol since 2001. All patients were planned to have two- stage revision for infected total knee arthroplasty with an articulating interval prosthesis made up of cruciate retaining femur and all poly tibia at stage one. All patients were given short course parenteral antibiotic therapy (5 days IV) followed by and 6 weeks dual oral therapy. Results: The average age was 68 yrs at the time of first stage. Five patients required repeat of 1st stage procedure because of persistent infection. Twenty six (40%) patients opted not to have a 2nd stage procedure because of eradication of infection after 1st stage and good functional result with interval prosthesis. We had recurrence of infection in 6 patients after two-stage procedure at a mean follow up of 42 months. Four patients out of these six had multiple surgeries for infection before our two-stage protocol. Conclusion: Articulating interval prosthesis gives excellent function and also makes subsequent revision easier with well preserved soft tissue balance. It also takes pressure off on the time constraint for the 2nd stage and good number of them may not require a 2nd stage at all. Our results of recurrence are comparable with published literature evidence and we don’t think that prolonged parenteral antibiotics therapy is required provided adequate surgical debridement has been performed

We describe the results of 287 intra-articular fractures of the calcaneum in 247 patients treated by minimally-invasive reduction and K-wire fixation between 1994 and 2003. There were 210 men (85%) and 37 women (15%). The most common cause of injury was a fall from a height in 237 patients (96%). Fracture classification was based on the method described by Sanders and Essex-Lopresti. All patients were operated on within 21 days of injury and 89% (220) within 48 hours. The reduction was graded as nearly anatomical (less than 2 mm residual articular displacement and satisfactory overall alignment) in 212 (73.9%) fractures.

There were 20 cases (7%) of superficial pin-track infection and five (1.7%) of deep infection. All healed at a mean of 6 weeks (3 to 19). Loss of reduction was observed in 13 fractures (4.5%) and a musculocutaneous flap was needed in three (1%).

The results were evaluated in 176 patients (205 fractures) with a mean age of 44.3 years (13 to 67), available for follow-up at a mean of 43.4 months (25 to 87) using the Creighton-Nebraska Health Foundation Assessment score. The mean score was 83.9 points (63 to 100). There were 29 (16.5%) excellent, 98 (55.7%) good, 26 (14.8%) fair and 23 (13%) poor results. A total of 130 patients (73.9%) were able to return to their original occupation at a mean of 5.6 months (3.2 to 12.5) after the injury.

Semi-open reduction and percutaneous fixation is an effective treatment for displaced intra-articular fractures of the calcaneum.

Background/objective: Although several prospective trials have shown the efficacy of sequential intravenous followed by oral antimicrobial regimen in treatment of bone and joint infections, considerable uncertainty exists about ideal antibiotic regimen and optimal duration of antibiotic therapy. The aim of this study was to demonstrate that short course antibiotic therapy combined with surgical drainage and followed by oral antibiotic therapy is quite adequate and suggested a scoring system as a comfortable and reliable tool to adjust the route of drug administration. Methods: Thirty-three cases of acute hematogenous bone or joint infection were randomly treated with short term (7 days for joint infection, l0 days for bone infection) or a long-term (14 days and 21 days, respectively) intravenous antibiotics after surgical drainage. The treatment outcome was measured through a detailed scoring system that included the ability to eradicate infection, the functional status of the limb, and the radiological appearance of the bone and joint. Criteria for discontinuation of parenteral antibiotic Scoring criteriapoints. Clinical evaluation. A: improved active motion of the joint: l. B: Painless active motion of the joint: 2. C: improvement in A & B:3. Radiological findings. A: progressive osteolysis ormultifocal involvement: 0. B: absence of the above findings*: 1. Laboratory evaluation. A: drop of 50.00/mm3 in WBC count or return to normal range (5.000–10.000 /mni3): 0.5. B: drop in ESR of 30 mm/hr or return to level of 30 mm/hr or less: 0.5. Total score: 5. *Pure periosteal elevation received a score of 1. Patients with a score > or equal to 4 would be switched to oral antibiotic. Results: The average follow up was 19 months. The scoring system had the following results: Infection was eradicated in both groups. Radiological scoring for septic arthritis was full for both groups and had a non-significant difference P> 0.05 between the 2 groups for osteomyelitis. The mean functional scoring between the short-term group and long-term group were similar P> 0.05. Overall, excellent or good results were achieved in both groups. No fair or poor results were observed. The average hospital cost for a patient in long-term group was twice that of a patient in short-term group. Conclusion: It is concluded that for bone or joint infection in children who have received appropriate and early surgical treatment, intravenous antibiotics given for 7 days in joint infections and 10 days in bone infections, followed by 4 weeks of oral antibiotics, is an adequate treatment. A decision on prolonging the duration of parenteral antibiotics should be based on a combination of clear clinical, laboratory, and radiographic criteria, such us the scoring system presented in this article

To assess the outcome of bicondylar tibial fractures, treated prospectively with fine wire fixation in the Limb Reconstruction Service. Twenty patients with mean age 56 years with bicondylar tibial plateau fractures, were treated at the author’s institution with fine wire fixation over a three-year period. Ten followed road traffic accidents and four followed high-energy falls; The remainder mainly in the elderly resulted from a simple fall. There were four Schatzeker type V, and sixteen type VI. Four were open fractures (Gustilo grade III); Seven patients sustained associated fractures at the same time. They were treated according to a prospective protocol and were followed up for an average of thirty months, (11 – 51). The protocol included CT Scan Guided planning, closed reduction if possible and percutaneous interfragmentary screw fixation to reconstruct the articular surface, under image intensifier control; The external fixator was applied in neutralization. Mobilization and full weight bearing was encouraged as early as possible. Ten patients started full weight bearing between four and six weeks post operatively, in nine cases with other injuries weight bearing was delayed. All patients healed with an average time in the fixator of eighteen weeks, (9–25). Fifteen patients had a range of movement from Zero to at least 120 degrees flexion. Using Rasmussen’s functional and radiological scoring system, fifteen out of twenty scored good or excellent. Complications included deep vein thrombosis in one patient, loss of fracture reduction in three, superficial pin tract infection which resolved with local pin care and a short courses of antibiotic in five patients, there was no deep infection. The Sheffield hybrid external fixator is strong, permits early fracture recovery and weight bearing and may have significantly contributed to the high rate of good results in this group, of which more than 50% were over sixty years old. This technique is recommended for treatment of this difficult fracture