Lymphoma masquerading as infection.

During surgical training, medical students and residents constantly are reminded to culture every suspected tumor and send tissue for pathologic evaluation for every suspected abscess. A diagnosis of cancer can be missed easily if this procedure is not followed, delaying the diagnosis and possibly adversely affecting the patient's prognosis. The confusion also may be compounded by a sterile abscess, positive culture results or a negative biopsy specimen. Therefore it is imperative to do a biopsy and a culture on any suspect lesion. An additional workup and possible biopsy may be warranted for a nonhealing wound that has been treated appropriately. The cases of three patients with lymphoma that were treated as infectious processes are presented. In all three instances, the appropriate treatment was delayed because of a delay in diagnosis.

Effects of immobilization on plantar-flexion torque, fatigue resistance, and functional ability following an ankle fracture.

BACKGROUND AND PURPOSE: The goal of this investigation was to study the recovery of ankle plantar-flexor peak torque, fatigue resistance, and functional ability (stair climbing, walking) following cast immobilization in patients with ankle fractures. SUBJECTS: The participants were 10 patients who underwent open reduction-internal fixation and 8 weeks of cast immobilization following a fracture of the ankle mortise and 10 age- and sex-matched, noninjured comparison subjects. METHODS: Plantar-flexor torque and fatigue resistance were measured at 1, 5, and 10 weeks of rehabilitation using an isokinetic dynamometer. Ankle plantar-flexor peak torque and fatigue resistance were correlated to timed ambulation, timed stair climbing, and unilateral heel-rises. RESULTS: Following immobilization, plantar-flexor peak torque was decreased at all angular speeds and positions. The decrease in peak torque was associated with an increase in fatigue resistance. With rehabilitation, ankle plantar-flexor torque and fatigue resistance normalized. Regression analysis revealed a strong relationship between plantar-flexor peak torque and functional measures. By 10 weeks post-immobilization, peak torque, fatigue resistance, and all measures of functional performance had returned to control levels. CONCLUSION AND DISCUSSION: The decrease in muscle performance, functional ability, and fatigue resistance induced by 8 weeks of cast immobilization can be reversed with 10 weeks of supervised physical therapy. In addition, this study demonstrated that ankle-plantar flexor torque is a good predictor of stair-climbing and walking performance in patients with ankle fractures.

Well-leg compartment pressures during hemilithotomy position for fracture fixation.

OBJECTIVE: To evaluate the relationship between the well-leg compartment pressures and time during hemilithotomy position for fracture fixation. DESIGN: Prospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Ten patients who underwent intramedullary nailing of a fractured femur in the hemilithotomy position (with a well-leg holder). INTERVENTION: Continuous pressure monitoring was achieved with in-dwelling slit catheters inserted into the calf compartments of the well leg. Baseline measurements were obtained in the supine position. After the leg was placed in the hemilithotomy position, compartment pressures were monitored throughout surgery. MAIN OUTCOME MEASUREMENTS: Calf compartment pressures at baseline, during hemilithotomy position, and post-hemilithotomy were compared. The association between body mass index and compartment pressure was analyzed. RESULTS: A consistent pattern was observed between compartment pressures and time. The curve was that of a step function in which the pressure increased as soon as the leg was placed in the well-leg holder and remained elevated until the leg was taken down. The pressure jumped from a baseline of 9.2 to 27.3 millimeters of mercury (mm Hg) (p<0.0001). While in the hemilithotomy position, the leg pressure trended slightly upward. Once the leg was taken down, the pressure immediately returned to a near-baseline level of 8.1 mm Hg (p<0.0001). A significant correlation was also found between the body mass index and leg pressure (R2 = 0.713; F = 0.002). CONCLUSIONS: The use of the well-leg holder to maintain hemilithotomy position increases the calf compartment pressures dramatically and significantly. Therefore, we recommend avoiding this position for fracture fixation in at-risk patients.

Orthotic management for posttraumatic nonunion of the tibia complicated by osteomyelitis.

Frequently, patients undergoing complex bone reconstructions for the treatment of osteomyelitis complicating tibial nonunion require extended exoskeletal support. Once the need for strict, continuous cast immobilization has passed, the patient can be fitted with a removable orthosis. Although prefabricated ankle foot orthoses are available, the purpose of this paper is to highlight the sophisticated new custom orthotic options available to the physician for the patient. Difficult to fit limbs now can be accommodated. Access to a skilled orthotist is the sine qua non of success.

Prosthetic options for below knee amputations after osteomyelitis and nonunion of the tibia.

Below the knee amputation after trauma is an appropriate option for many patients with recalcitrant infection and nonunion of the tibia. Patients who have had transtibial amputations have lower energy expenditure, heart rate, and oxygen cost when ambulating with their prostheses than when using a three-point gait with crutches without their artificial limb. Innovative prosthetists have improved each of the five essential components of the limb amputated below the knee: socket, insert, shaft and pylon, foot and ankle assembly, and suspension system. Prosthetists are integral members of the patient's healthcare team. Their recommendations and direct patient care are essential to optimizing the functional ability of patients who have had amputations.

Longitudinal study of skeletal muscle adaptations during immobilization and rehabilitation.

This study describes the metabolic, morphologic, neurologic, and functional adaptations observed in the plantar flexors during 8 weeks of lower leg immobilization and 10 weeks of physical therapy following ankle surgery. A combination of magnetic resonance imaging and spectroscopy, isokinetic and isometric muscle testing, and simple functional tests revealed many adaptive changes due to immobilization, including atrophy, loss of muscle strength, reduced central activation, increase in fatigue resistance, and an increase in inorganic phosphate content. After 10 weeks of physical therapy all alterations were reversed, with the exception of a remaining 5.5% deficit in total muscle cross-sectional area.

Pathophysiology of delayed healing.

Delayed union represents an ongoing failure of initial fracture management. It still occurs partly because the precise reason why a patient's fracture does not heal frequently is unknown. This article aims to outline the limited material available on the pathophysiology of delayed healing. The systemic status of the patient, local limb status before injury, the nature of the traumatic injury, local host response to the injury, potential negative impact of orthopaedic fracture care, and pharmacologic variables are considered.

Impact of CT scan on treatment plan and fracture classification of tibial plateau fractures.

OBJECTIVE: To evaluate the interobserver and intraobserver agreement for both treatment plan and fracture classification of tibial plateau fractures using plain films alone and with computed tomography (CT) scans. DESIGN: Prospective study to assess the impact of an advanced radiologic study on the agreement of treatment plan and fracture classification of tibial plateau fractures. SETTING/PARTICIPANTS: Two orthopaedic traumatologists, two orthopaedic residents, and two skeletal radiologists were presented with twenty-one cases of tibial plateau fractures imaged with plain films and with CT scans. MAIN OUTCOME MEASURES: Agreement was measured using kappa coefficients. RESULTS: Using plain films alone, the mean interobserver kappa coefficient for classification was 0.62, which decreased to 0.61 after addition of CT scans. Using plain films alone for formulating a treatment plan, the mean interobserver kappa coefficient was 0.58, which increased to 0.71 after addition of CT scans. The mean intraobserver kappa coefficient for fracture classification using plain films was 0.70, which increased to 0.80 with addition of CT scans. The mean intraobserver kappa coefficient for treatment plan based on plain films alone was 0.62, which increased to 0.82 after addition of CT scans. Class was changed in an average of 12 percent of cases after addition of CT scans. Treatment plan was changed an average of 26 percent of the time after addition of CT scans. CONCLUSION: Addition of CT scans to plain roentgenograms increases the interobserver and intraobserver agreement on treatment plan.

Treatment of considerations in patients with compartment syndrome and an inherited bleeding disorder.

In addition to consultation with an experienced hematologist, the following are recommendations regarding compartment syndrome in a patient with an inherited bleeding disorder. Von Willebrand's Disease. Humate-P (rich in von Willebrand factor) is the replacement therapy of choice for surgical procedures in patients with von Willebrand's disease. In general, in the perioperative period, factor VIII levels between 50% and 100% are ideal with a gradual tapering to maintain levels at 50% for approximately 2 weeks. Adjuncts to therapy are DDAVP and EACA. Hemophilia A. During the initial evaluation and with measurement of compartment pressures, factor VIII replacement to levels in the range of 40% to 60% of normal is appropriate replacement therapy. For fasciotomy, however, factor VIII levels greater than 50% to 100% are required. In patients who have developed antibodies to factor VIII, a number of options are available. With low titers of factor VIII inhibitor, higher doses of factor VIII may be successful in overriding the inhibitor. In patients with higher titers of inhibitor, activated factor VII or porcine factor VIII is recommended. Hemophilia B. Highly purified factor IX replacement aimed at keeping factor levels between 50% and 100% in the perioperative period, followed by maintenance at 50% for approximately 2 weeks, is optimal management. Treatment Algorithm: The Figure outlines an algorithm to aid in the diagnosis and treatment of compartment syndrome in the patient with an inherited bleeding disorder. In a suspected case of compartment syndrome due to a soft-tissue hemorrhage or injury, factor replacement as outlined above should be initiated. Unequivocal clinical findings in the normal patient usually would be an indication to proceed to fasciotomy without obtaining compartment pressures. In the patient with an inherited bleeding disorder, however, factor replacement and subsequent normalization of the clotting cascade may help lowe compartment pressures. Therefore, we advocate obtaining initial pressures even with clinical findings of an acute compartment syndrome. At our institution, we advocate using an automated handheld pressure monitor (Stryker, Ontario, Canada) or the needle injection technique as described by Whitesides et al. In interpreting the obtained pressures, we choose to use the guidelines as described by Heppenstall et al. Briefly, Heppenstall et al determined that the pressure threshold at which cellular damage occurred was related more closely to the difference between the mean arterial blood pressure and compartment pressure than with the absolute compartment pressure alone; this measurement is called delta P. If delta P is > 30 mm Hg, then one should continue factor replacements and perform serial clinical and pressure examinations. Pressures should be taken every hour for 2 hours total. If the patient worsens in either respect, then the physician should enter the other limb of the algorithm for delta P < 30 mm Hg. For the patient with a delta P < 30 mm Hg, the amount of time since onset of symptoms must be considered. Since the patient may improve with adequate factor replacement, a delta P < 30 mm Hg mercury does not dictate automatic fasciotomy. An adequate time trial of replacement therapy may be attempted. In patients whose pressures do not begin normalizing, we advocate proceeding to fasciotomy. Patients who begin to normalize pressures during a 2-hour trial can be followed with serial clinical and pressure examinations. Any worsening in either scenario is an indication for fasciotomy; otherwise, observation and factor replacement may be continued. After initial decompression, staples may be placed in both wound edges with an elastic vascular loop woven between the two edges in a "shoelace" pattern. Then while waiting for closure, the loops can be gradually tightened at the bedside. Definitive closure should be attempted around the fifth postoperative day. All closure techniques should be pre

Goal setting as a predictor of return to work in a population of chronic musculoskeletal pain patients.

To assess prospectively the association between personal attributes, vocational factors, and the return to work outcome for patients with chronic, nonmalignant, musculoskeletal pain, we assessed return to work (RTW) motivation though an open-format listing of treatment goals in 59 chronic pain patients admitted to a university pain management program. Patients were then followed (average of 17.9 months) in the posttreatment period to determine whether they had in fact returned to employment. Results indicated that a number of pretreatment factors predicted future employment status in this patient population. Age, marital status, education and decreased length of unemployment were predictive of RTW outcome. Overall, RTW goal was the single best predictor of return to work outcome. In contrast, increased number of premorbid jobs, compensation status, patient's race and sex were not predictive. The present study suggests that the assessment of an individual's motivation as defined by goal-setting may be a key factor in predicting a favorable outcome in this typically refractory population of patients.

Hazards to the orthopaedic trauma surgeon: occupational exposure to tuberculosis. Risk reduction, testing, and treatment (a review article).

Infection with tuberculosis (TB) in the United States has risen over the last decade. In the past 5 years, health care worker exposure to multidrug-resistant TB has lead to more than 100 skin-test conversions, 17 cases of active TB, and at least six deaths. As with human immunodeficiency virus, hepatitis B virus, and hepatitis C virus, the orthopaedic traumatologist is at risk of exposure and infection because, in many cases, the medical histories of patients encountered in the trauma bay cannot be determined until well into the course of care. Risk depends principally on two factors: (a) likelihood of exposure (large urban settings, prisons, concentration of persons from countries with high TB prevalence), and (b) immune status of the surgeon. Prompt recognition, isolation, and appropriate treatment of patients with infectious TB; engineering controls; and the use of personal protective respiratory equipment can help prevent the transmission of TB to health care workers.

Hazards to the orthopaedic trauma surgeon: occupational exposure to HIV and viral hepatitis (a review article).

The risk of transmission of blood-borne pathogens is directly related to the prevalence of the infectious disease in the physician's patient population, the infectivity after a single exposure, and the frequency and nature of exposure. After reading this material the reader should understand the guidelines for risk prevention of human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C virus transmission as published by the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) and be better able to evaluate and choose personal protective devices for use while caring for patients. To date there have been no documented cases of HIV seroconversion from solid-bore needle puncture or aerosolized transmission from an HIV-positive patient to a physician in the operating room. However, the authors and the Orthopaedic Trauma Association urge all physicians who have sustained an occupational seroconversion to communicate with the CDC so that prevention guidelines and health-care worker protection can be improved. Regardless, all physicians performing invasive procedures must reevaluate their techniques to determine what procedures can be modified or new instruments developed to reduce the risk of exposure.

Tibial nonunion treated with direct current, capacitive coupling, or bone graft.

Two hundred seventy-one tibial nonunions of average duration of 23.5 months (range, 9-69 months) were treated with direct current (167 patients), capacitive coupled electrical stimulation (56 patients), or bone graft surgery (48 patients). Logistic regression analysis was used to compare heal rates among the 3 treatment methods, to identify risk factors adversely affecting the heal rate, and to predict the probability of successful healing of a nonunion of any given risk profile treated with each of the 3 forms of therapy. Seven risk factors were identified: duration of nonunion, prior bone graft surgery, prior electrical treatment, open fracture, osteomyelitis, comminuted or oblique fracture, and atrophic nonunion. When no risk factors were present, there were no significant differences among the 3 treatment methods. As progressively more risk factors were present, the predicted heal rates decreased significantly regardless of the treatment method. Some differences among the treatment groups did appear in the heal rates: bone graft surgery yielded a worse heal rate when there was a previous bone graft failure, and capacitive coupling had a worse heal rate in the presence of an atrophic nonunion.

Veillonella myositis in an immunocompromised patient.

Infectious myositis is rather uncommon. When caused by anaerobic organisms, myositis is usually polymicrobial. Trauma, ischemia, or a contiguous focus of infection is often an antecedent of myositis. We report a case of monomicrobial veillonella myositis in an immunocompromised patient. The infection responded to debridement and therapy with metronidazole.

Osteonecrosis of the knee following laser-assisted arthroscopic surgery: a report of six cases.

We report six cases where significant postoperative pain persisted in individuals following arthroscopic surgery augmented with the use of lasers. Subsequent magnetic resonance images showed lesions with signal changes compatible with the diagnosis of osteonecrosis in areas directly addressed with laser energy.

Magnetic resonance imaging for the diagnosis of osteomyelitis in the diabetic patient with a foot ulcer.

Twenty-seven diabetic patients (12 males and 15 females) with clinically suspected osteomyelitis complicating soft tissue infection of the foot underwent 29 magnetic resonance imaging studies of the suspected lesion. Of these patients, 26 had plain film radiographs, 11 had technetium bone scanning, and 12 had indium-labeled leukocyte scintigraphy performed within 2 weeks of the magnetic resonance imaging. Definitive diagnosis of the presence or absence of osteomyelitis was obtained on the basis of surgical findings, histological evidence, or resolution with nonoperative therapy. Magnetic resonance imaging was 90% accurate (sensitivity 77%, specificity 100%) in the diagnosis of osteomyelitis in this patient population. Technetium bone scan was 45% accurate (sensitivity 100%, specificity 25%); indium-labeled leukocyte scintigraphy was 50% accurate (80% sensitivity, 29% specificity); and plain film roentgenography was 73% accurate (60% sensitivity, 81% specificity). Magnetic resonance imaging is a powerful, noninvasive tool for determining the presence or absence of osteomyelitis in the patient with a diabetic foot ulcer.

Immediate internal fixation of low-velocity gunshot-related femoral fractures.

Fractures caused by gunshots are increasingly common in urban hospitals and trauma centers. The rising incidence and complexity of these injuries present difficult management problems and health care burdens. In a 3-year period, from 1989 through 1991, 21 patients with femoral shaft fractures from low-velocity bullets were treated with intramedullary fixation within 15 hours of admission. Eighteen patients were available for follow-up. The fractures had healed in all patients. Average hospitalization for an isolated injury was 7 days. There were no complications related to immediate internal fixation. Immediate internal fixation of femoral shaft fractures caused by low-velocity gunshots can be performed in an efficient and cost effective manner.

Quality of life assessment of patients with posttraumatic fracture nonunion, chronic refractory osteomyelitis, and lower-extremity amputation.

One hundred nine patients with long-bone fracture nonunion, chronic refractory osteomyelitis, and posttraumatic amputation were evaluated to assess the impact of chronic disability on the quality of life. The quality of life parameters were defined by a functional assessment instrument, the Arthritis Impact Measurement Scale (AIMS), and a Psychosocial Adjustment to Illness Scale (PAIS). A spouse PAIS self-report instrument was administered to assess the psychosocial adjustment of spouses or significant others. A final questionnaire was developed to determine the reasons, in order of their importance, for either continuing medical therapy or accepting amputation. The PAIS scores differed significantly between osteomyelitis patients and nonunion or amputation patients. The presence or absence of pain produced significant differences in AIMS and PAIS scores of nonunion and osteomyelitis patients. Subscale analysis of AIMS scores showed significant differences among the three groups with respect to health perception and scale of orthopaedic problem. The osteomyelitis patients were more severely affected than the nonunion or amputation patients. The PAIS was unable to detect any statistically significant differences in psychosocial adjustment of the spouses of patients in each of the three population groups. The most frequent reason for continuing medical and surgical management of nonunion and osteomyelitis was hopeful expectation for cure. The group who chose amputation did so in an attempt to put an end to the need for medical and surgical treatment. Differences in psychosocial and functional ability were related to disease diagnosis, pain, status of fracture healing, and timing of amputation. This study provides further insight into the quality of life experience for patients with long-term orthopaedic problems.

Diagnoses and staging. Osteomyelitis and prosthetic joint infections.

The diagnoses of osteomyelitis and prosthetic joint infections are usually made on the basis of clinical, laboratory, and radiographic examination. The diagnostic studies presently employed to diagnosis and assess osteomyelitis and prosthetic joint infections are described. A universally applied classification system for stratifying osteomyelitis and prosthetic joint infection would provide a framework for the evaluation of medical and surgical treatment efficacy. Such a system would enable treatment results to be compared among institutions. Staging systems currently being used are described.

Comparison of the clinical efficacy and tolerance of gentamicin PMMA beads on surgical wire versus combined and systemic therapy for osteomyelitis.

These data do not prove a statistical superiority of conventional antibiotics or Septopal in the treatment of chronic osteomyelitis. This result, however, is complicated by the biased data set represented by the combined treatment. The data do suggest that cost of treatment is considerably less in patients who are treated with local antibiotics (i.e., Septopal) alone. The rate of adverse experiences was directly related to the use of parenteral antibiotics, with higher rates of adverse experiences in the conventional and combined treatment groups. Furthermore, the Cierny-Mader Physiologic Class had the best correlation with outcome, suggesting that host factors are probably of critical importance in inducing remission of chronic osteomyelitis. This protocol was not designed to test the role of debridement in the treatment of osteomyelitis: it was assumed that debridement would be the same in both groups. It is the investigators' strong opinion, however, that adequacy of debridement was an important determinant in quiescence or recurrence in the study patients. Similarly, there was no strict control for adequacy of soft-tissue coverage provided by local or distant tissue transfer. Again, the investigators believe that adequacy, including viability and durability, of soft-tissue covering was an important determinant for the end result in these patients. Other covariants such as smoking, history, nutritional status, and other measures of general health will be added to this model when data are available. This analysis will allow definition of the appropriate clinical situations in which use of Septopal alone or combined with parenteral antibiotic is indicated.