Aims

Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below-knee amputation, particularly in the presence of severe soft-tissue destruction. This study assesses the outcomes of single-stage orthoplastic surgical treatment of calcaneal osteomyelitis with large soft-tissue defects.

We present a novel approach to the management of patients with longstanding heel ulcers complicated by open calcaneal fractures. The principles of management of diabetic foot ulcers were combined with applied physiology of fracture healing. Case notes of 6 consecutive patients who presented to our diabetic foot clinic between January 2009 and December 2009 were reviewed. Type of diabetes, duration of heel ulcer, type of fracture and treatment given were recorded. Initial treatment consisted of regular local debridement and application of dressing. Vacuum Assisted Continuous (VAC) pump application was deferred until 6 weeks to preserve fracture hematoma and thereby initiate fracture healing. In all patients, VAC pump was started at 6 weeks and continued till healing of ulcer to adequate depth. Infection was treated aggressively with appropriate antibiotics according to the microbiology results. The average age was 53 (40-60) and the mean duration of follow up was 6 months. All wound healed completely, fractures united and patients returned to previous function. An open calcaneal fracture presents a severe injury likely to be complicated by infection and consequent osteomyelitis leading to amputations. In our group of patients, a novel treatment approach consisting of multidisciplinary model resulted in successful limb preservation and return to function

Introduction: Polymodal anaesthesia has become the core approach for the modern anaesthetist. Femoral, sciatic and obturator nerve blockade, individually or in combination, by means of either single shot or continuous infusion, are often used as adjuncts to general anaesthesia in knee arthroplasty. Methods: We examine the outcome of 2 groups of 100 patients from 2 surgeons and their anaesthetists. All patients received a general anaesthetic. The first group receive a single shot femoral and sciatic nerve block, the second group a standard GA and local infiltration of the surgical field. Post operatively, both groups received identical analgesic regimes and rehabilitation programmes. Results: Length of stay was prolonged in the nerve blockade group, with 21 of the 100 patients still in hospital on day 6 versus 9 patients in the local infiltration group. An initial advantage in flexion and extension in the nerve blockade group was reversed by day 2 and persisted thereafter. Motor dysfunction was seen to be more prevalent and of longer duration in the nerve blockade group. Muscle groups supplied by the sciatic nerve were 4 times more likely to be involved than those supplied by the femoral nerve. Dysaesthesia in the sciatic nerve dermatomes was 5 times more likely within the nerve blockade group, but less likely in the local infiltration group. No significant difference in rates of VTE. Pain control was superior and less analgesia was required in the nerve blockade group. Fewer patients required urethral catheterisation in the local infiltration group. One heel ulcer occurred in the nerve blockade group. Tourniquet time, significant as a possible contributor to nerve injury, was similar. Conclusion: Nerve blockade in knee arthroplasty not recommended

The cost effective management of diabetic foot infections is a challenge to the Canadian health system. The objective of this study was to predict preoperatively diabetic foot patients who will fail a transmetatarsal amputation (TMA) and end in a costly and disabling below knee amputation (BKA) and hence perform a primary BKA in select patients. Twenty-one patients failing TMA and revised to BKA within the first year were compared with a matched cohort of twenty-one successful TMA’s. The factors that were selected for comparison were: age at amputation, sex, smoking, type of DM, use of osetoset, presence of charcot fractures, previous contralateral surgery, previous debridement before TMA, debridement after TMA, dialysis, duration of ulcer prior to TMA, hemoglobin level at time of TMA, HbA1C, presence of heel ulcer, prior ipsilateral toe amputation, pulse status prior to TMA, vascular reconstruction and presence of unre-constructable vascular problem. Chi-square was done for group data, and ANOVA for numeric data. Long-term control of blood glucose level (HbA1C) was found to be significant in predicting the success of TMA. Need of debridement after TMA was found to be a significant predictor of failure of TMA. There was a trend towards duration of ulcer prior to TMA and smoking being significant. All other variables, including vascular status or renal failure were not significantly different between the two groups. As we have previously achieved a 75% success rate with TMAs in diabetics, we recommend a TMA as the first procedure in all diabetics with major forefoot infection or ulceration instead of a BKA. Obtaining good diabetic control in patients at risk for or requiring amputation for foot infection may prevent the TMA from failing and the subsequent need for BKA

Introduction and Aims: The cost-effective management of diabetic foot infections is a challenge to the Canadian health system. The objective of this study was to predict pre-operatively diabetic foot patients who will fail a transmetatarsal amputation (TMA) and end in a costly and disabling below knee amputation (BKA) and hence perform a primary BKA in select patients?. Method: Twenty-one patients failing TMA and revised to BKA within the first year were compared with a matched cohort of 21 successful TMAs. The factors that were selected for comparison were: age at amputation, sex, smoking, type of DM, use of osetoset, presence of charcot fractures, previous contralateral surgery, previous debridement before TMA, debridement after TMA, dialysis, duration of ulcer prior to TMA, hemoglobin level at time of TMA, HbA1C, presence of heel ulcer, prior ipsilateral toe amputation, pulse status prior to TMA, vascular reconstruction and presence of unreconstructable vascular problem. Chi-square was done for group data, and ANOVA for numeric data. Results: Long-term control of blood glucose level (HbA1C) was found to be significant in predicting the success of TMA. Need of debridement after TMA was found to be a significant predictor of failure of TMA. There was a trend towards duration of ulcer prior to TMA and smoking being significant. All other variables, including vascular status or renal failure were not significantly different between the two groups. Conclusion: As we have previously achieved a 75% success rate with TMAs in diabetics, we recommend a TMA as the first procedure in all diabetics with major forefoot infection or ulceration instead of a BKA. Obtaining good diabetic control in patients at risk for or requiring amputation for foot infection may prevent the TMA from failing and the subsequent need for BKA

Introduction and Aims: The transmetatarsal amputation (TMA) is a limb-saving alternative to below knee amputation (BKA) for diabetic patients with forefoot infections. The purpose of this study was to retrospectively review the outcomes of diabetic patients who received a TMA for a non-healing ulcer of the forefoot with or without insertion of antibiotic beads into the surgical wound. Method: Sixty-five diabetic patients were treated for forefoot ulcers by a single stage TMA and 49 of these patients had insertion of antibiotic pellets into the wound during surgery. A comprehensive chart review was conducted on all patients to gather information on patient age at amputation, sex, smoking, type of diabetes, use of osetoset, time to wound healing, debridement before and after TMA, duration of ulcer prior to TMA, hemoglobin level at time of TMA, HbA1C, presence of heel ulcer, prior ipsilateral toe amputation, pulse status prior to TMA, vascular reconstruction and presence of unreconstructable vascular problem. Outcome follow-up using validated functional outcome questionnaires was completed in 85% of TMA patients. Results: Healing time was approximately 18 weeks in the antibiotic pellet group, with a BKA rate of 25%. This is in contrast to the literature values of healing times (not isolated to diabetes) for a TMA of 28 weeks and BKA rates of 34–40%. The antibiotic pellet group scored higher than average for bodily pain; social function; role emotional and mental health on the SF-36. Conclusion: The reduction in time to wound healing and decrease in BKA rates suggests inserting antibiotic pellets into the surgical wound can improve the outcomes of TMAs for patients with non-healing diabetic ulcers of the forefoot. This new procedure could have a significant impact on the management of diabetic foot ulcers by offering an effective limb-saving alternative to the commonly used BKA procedure

Introduction: Historically, off-loading forefoot neuropathic ulcers with a total contact cast has been an effective treatment method. However, large neuropathic ulcers located on the plantar aspect of the heel or midfoot have been resistant to the off-loading with total contact casting. Therefore, it is not uncommon for these ulcers to persist for several years leading to eventual infection and/or amputation. Objective: To assesses a new and effective off-loading mode of treatment for hindfoot and midfoot ulcers. The device is composed of a fiberglass cast with a metal stirrup and a window around the ulcer. Research, Design and Methods: A retrospective study of 14 diabetic and non-diabetic patients was performed. All had a single chronic planter hindfoot or midfoot neuropathic ulcer that failed to heal via the conventional methods. A fiberglass total contact cast with a metal stirrup was applied. A window was made over the ulcer so as to continue with daily ulcer care. The cast was changed every other week. Results: The average duration of ulcer prior to application of the metal stirrup was 26 ± 13.2 months (range 7 to 52 months). The ulcer completely healed in 12 of the 14 patients (86%) treated. The mean time for healing was 10.8 weeks for the midfoot ulcers and 12.3 weeks for the heel ulcers. Complications developed in 4 patients: 3 developed superficial wounds and 1 developed a full thickness wound. In 3 of these 4 patients, local wound care was initiated and the Stirrup cast was continued to complete healing of the primary ulcer. Conclusion: The fiberglass cast with a metal stirrup is an effective off-loading device for midfoot and hindfoot ulcers. It is not removable and does not depend on patient’s compliance. The window around the ulcer allows for daily wound care, drainage of secretions and the use of VAC treatment. The complication rate is comparable to that of Total Contact Casting

Aims

Local antibiotics are used in the surgical management of foot infection in diabetic patients. This systematic review analyzes the available evidence of the use of local antibiotic delivery systems as an adjunct to surgery.

We report a case in which Ilizarov distraction osteogenesis was used to lengthen the portion of calcaneum that remained after a radical debridement for osteomyelitis. The patient was able to walk normally in unmodified shoes at the end of his treatment.

Periprosthetic femoral fracture (PFF) is a potentially devastating complication after total hip arthroplasty, with historically high rates of complication and failure because of the technical challenges of surgery, as well as the prevalence of advanced age and comorbidity in the patients at risk.

This study describes the short-term outcome after revision arthroplasty using a modular, titanium, tapered, conical stem for PFF in a series of 38 fractures in 37 patients.

The mean age of the cohort was 77 years (47 to 96). A total of 27 patients had an American Society of Anesthesiologists grade of at least 3. At a mean follow-up of 35 months (4 to 66) the mean Oxford Hip Score (OHS) was 35 (15 to 48) and comorbidity was significantly associated with a poorer OHS. All fractures united and no stem needed to be revised. Three hips in three patients required further surgery for infection, recurrent PFF and recurrent dislocation and three other patients required closed manipulation for a single dislocation. One stem subsided more than 5 mm but then stabilised and required no further intervention.

In this series, a modular, tapered, conical stem provided a versatile reconstruction solution with a low rate of complications.

Cite this article: Bone Joint J 2015;97-B:1031–7.