A clinical perspective on musculoskeletal infection treatment strategies and challenges.

Orthopaedic implants improve the quality of life of patients, but the risk of postoperative surgical site infection poses formidable challenges for clinicians. Future directions need to focus on prevention and treatment of infections associated with common arthroplasty procedures, such as the hip, knee, and shoulder, and nonarthroplasty procedures, including trauma, foot and ankle, and spine. Novel prevention methods, such as nanotechnology and the introduction of antibiotic-coated implants, may aid in the prevention and early treatment of periprosthetic joint infections with goals of improved eradication rates and maintaining patient mobility and satisfaction.

Treatment of Unicameral Bone Cysts of the Calcaneus: A Systematic Review.

The calcaneus is the most common tarsal affected by unicameral bone cysts (UBCs); however, the treatment of calcaneal UBCs remains controversial. The purpose of the present systematic review was to evaluate the treatment modalities for calcaneal UBCs. A systematic review was performed using clinical studies of calcaneal UBCs with a minimum of 1 year of follow-up and level I to IV evidence. Ten studies with 171 patients (181 cysts) were selected. Heel pain and radiographic cyst consolidation were the primary outcomes. A series of Z tests were used to compare the outcomes in the nonoperative and operative groups, cannulated screw and bone augmentation groups, and autografting and allografting groups. All patients treated with open curettage and bone augmentation had significant improvements in heel pain (p < .001). Only 1.1% ± 1.0% of the cysts treated conservatively had healed on radiographs compared with 93.0% ± 13.0% of the cysts after surgery (p < .001). A greater percentage of patients treated with bone augmentation had preoperative heel pain and resolution of that pain than did patients treated with cannulated screws (p < .001). Autografting had a significantly greater percentage of radiographic cyst consolidation than did allografting (97.4% ± 11.1% versus 85.1% ± 15.8%, p < .001, Z = 3.5). Objective outcomes data on calcaneal UBCs are relatively sparse. The results of the present review suggest that open curettage with autograft bone augmentation is the most effective procedure. We would encourage future comparative clinical studies to elucidate differences in UBC treatment modalities.

Characteristics of patients with chronic exertional compartment syndrome.

BACKGROUND: Chronic exertional compartment syndrome (CECS) is a condition that causes reversible ischemia and lower extremity pain during exercise. To date there are few large studies examining the characteristics of patients with CECS. This study aimed to present these characteristics by examining the largest published series of patients with a confirmed diagnosis of the disorder. METHODS: An IRB-approved, retrospective review was undertaken of patients with a suspected diagnosis of CECS undergoing pre- and postexercise compartment pressure testing between 2000 and 2012. Patients were evaluated for gender, age, duration of symptoms, pain level, specific compartments involved, compartment pressure measurements, and participation and type of athletics. RESULTS: Two-hundred twenty-six patients (393 legs) underwent compartment pressure testing. A diagnosis of CECS was made in 153 (67.7%) patients and 250 (63.6%) legs with elevated compartment measurements; average age of the patients was 24 years (range, 13-69 years). Female patients accounted for 92 (60.1%) of those with elevated pressures. Anterior and lateral compartment pressures were elevated most frequently, with 200 (42.5%) and 167 (35.5%) compartments, respectively. One hundred forty-one (92.2%) patients reported participation in sports, with running being the most common individual sport and soccer being the most common team sport. Duration of pain prior to diagnosis averaged 28 months. CONCLUSION: Although there is ample literature pertaining to the diagnostic criteria and treatment algorithm of the condition, few papers have described the type of patient most likely to develop CECS. This is the largest study to date to evaluate the type of patient likely to present with chronic exertional compartment syndrome. LEVEL OF EVIDENCE: Level III, retrospective review.

Conversion arthrodesis for failed first metatarsophalangeal joint hemiarthroplasty.

BACKGROUND: Arthrodesis is currently the most commonly performed surgical procedure for the treatment of arthritis of the first metatarsophalangeal (MTP) joint. Hemiarthroplasty of the first MTP joint has been shown to have inferior clinical results and higher revision rates. The objective of this study was to assess the clinical outcome of the salvage of failed hallux phalangeal hemiarthroplasty with conversion to arthrodesis. METHODS: A retrospective review of patients who underwent salvage of the first MTP joint hemiarthroplasty with conversion to arthrodesis was performed. Preoperative assessment included the visual analog pain (VAP) scale and AOFAS Hallux Metatarsophalangeal Interphalangeal scoring system (AOFAS-HMI). Postoperative outcomes were graded via AOFAS-HMI, VAP, and Foot and Ankle Ability Measure (FAAM). RESULTS: Twenty-one hemiarthroplasties were converted to arthrodesis in 21 patients, with 18 available for follow-up included in the study. There were 13 women and 5 men. Local autologous bone graft was used in 12 cases, while 6 patients required tricortical iliac crest bone graft for the treatment of extensive bone loss. At final follow-up, at a mean of 4.3 years, the average VAS pain score had diminished to 0.75 from 7.8 preoperatively out of 10, while the mean AOFAS-HMI improved from 36.2 out of 100 preoperatively to 85.3 out of 90 (modified to exclude first MTP motion). The mean FAAM ADL/sports were 97.3/91.3, respectively. All patients achieved fusion although at a longer interval than primary fusions. CONCLUSIONS: Conversion from a failed hallux phalangeal hemiarthroplasty to arthrodesis showed similar success to primary arthrodesis which was achieved in the majority of cases with the use of regional bone graft for small defects. However, the time to fusion was longer than that of primary arthrodesis, and it sometimes required structural bone graft for augmentation. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Achilles tendon injuries in a United States population.

BACKGROUND: Most studies on Achilles tendon ruptures involved US military or European populations, which may not translate to the general US population. The current study reviews 406 consecutive Achilles tendon ruptures occurring in the general US population for patterns in a tertiary care subspecialty referral setting. METHODS: An institutional review board-approved, retrospective review of the charts of 331 (83%) males (6 bilateral, nonsimultaneous) and 69 (17%) females diagnosed with Achilles tendon ruptures over a 10-year period was undertaken. Average age was 46.4 years with 310 (76%) ruptures diagnosed and managed acutely (less than 4 weeks), whereas 96 (24%) were chronic (more than 4 weeks since the injury). Patients were assessed for mechanism of injury and previously described underlying risk factors. Results were assessed according to age (greater or less than 55 years), body mass index (BMI), and time to diagnosis. RESULTS: Sporting activity was responsible for 275 ruptures (68%). This was higher in patients younger than 55 years of age (77%) than those older than 55 years (42%). Basketball was the most commonly involved sport, accounting for 132 ruptures (48% of sports ruptures, 32% of all ruptures), followed by tennis in 52 ruptures (13%, 9%), and football in 32 ruptures (12%, 8%). In all, 20 ruptures were reruptures of the same Achilles tendon, of which 17 had previously been treated nonsurgically. In this study, recent quinolone use (2%) and African American race (31%) were not major risk factors for rupture as described in other studies. Older patients and patients with a BMI greater than 30 were more likely to be injured in nonsporting activities and more likely to have their diagnosis initially not recognized resulting in their presentation more than 4 weeks following the injury. CONCLUSION: In this study, sports participation was the most common mechanism, but not to the same extent seen in the European or US military studies. Basketball was the most commonly involved sport, as compared to soccer in Europe. Age and BMI had a directly proportional correlation with time to diagnosis.

Infections in anterior cruciate ligament reconstruction.

CONTEXT: Anterior cruciate ligament (ACL) reconstruction is a safe, common, and effective method of restoring stability to the knee after injury, but evolving techniques of reconstruction carry inherent risk. Infection after ACL reconstruction, while rare, carries a high morbidity, potentially resulting in a poor clinical outcome. EVIDENCE ACQUISITION: Data were obtained from previously published peer-reviewed literature through a search of the entire PubMed database (up to December 2012) as well as from textbook chapters. RESULTS: Treatment with culture-specific antibiotics and debridement with graft retention is recommended as initial treatment, but with persistent infection, consideration should be given to graft removal. Graft type likely has no effect on infection rates. CONCLUSION: The early diagnosis of infection and appropriate treatment are necessary to avoid the complications of articular cartilage damage and arthrofibrosis.

Outcome of modified Kidner procedure with subtalar arthroereisis for painful accessory navicular associated with planovalgus deformity.

BACKGROUND: Type II accessory naviculars are frequently associated with planovalgus deformity. Operative treatment for patients recalcitrant to nonoperative treatment involves resection, with or without takedown, and reattachment of the tibialis posterior tendon as described by Kidner. This does not address the planovalgus deformity. The authors hypothesized that adding a subtalar arthroereisis to the Kidner procedure would lead to improvement of pain and function and correction of the deformity. METHODS: Institutional Review Board-approved, prospectively collected data were reviewed for 20 patients (23 feet), who underwent a combined modified Kidner and subtalar arthroereisis for painful type II accessory navicular with planovalgus deformity recalcitrant to nonoperative treatment. The average age at the time of surgery was 18 years. Patients were evaluated preoperatively and at final follow-up clinically, radiographically, and via the visual analog pain scale (VAPS), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot score, and a satisfaction rating. Mean follow-up was 53.9 months. RESULTS: The mean AOFAS scores improved from 53 preoperatively to 95 at final follow-up and the mean VAPS score decreased from 7.4 preoperatively to 1.7 at final follow-up. Radiographically, the average Meary's angle improved from 18.5° apex plantar preoperatively to 3° apex plantar on weight-bearing lateral radiographs, and the average talar head uncoverage percentage on weight-bearing anteroposterior radiographs improved from 24% preoperatively to 3%. Nineteen of 20 patients reported good or excellent results. Three patients required implant removal because of pain; no recurrence of planovalgus deformity occurred after implant removal. No patients developed subtalar arthritis. CONCLUSION: The modified Kidner procedure combined with a subtalar arthroereisis resulted in significant pain and functional improvement. The deformity correction obtained at surgery was maintained even if the arthroereisis plug was removed. The extra-articular plug did not lead to subtalar arthritis.

MRI is unnecessary for diagnosing acute Achilles tendon ruptures: clinical diagnostic criteria.

BACKGROUND: Achilles tendon ruptures are common in middle-aged athletes. Diagnosis is based on clinical examination or imaging. Although MRI is commonly used to document ruptures, there is no literature supporting its routine use and we wondered whether it was necessary. QUESTIONS/PURPOSES: We (1) determined the sensitivity of physical examination in diagnosing acute Achilles ruptures, (2) compared the sensitivity of physical examination with that of MRI, and (3) assessed care delays and impact attributable to MRI. METHODS: We retrospectively compared 66 patients with surgically confirmed acute Achilles ruptures and preoperative MRI with a control group of 66 patients without preoperative MRI. Clinical diagnostic criteria were an abnormal Thompson test, decreased resting tension, and palpable defect. Time to diagnosis and surgical procedures were compared with those of the control group. RESULTS: All patients had all three clinical findings preoperatively and complete ruptures intraoperatively (sensitivity of 100%). MR images were read as complete tears in 60, partial in four, and inconclusive in two patients. It took a mean of 5.1 days to obtain MRI after the injury, 8.8 days for initial evaluation, and 12.4 days for surgical intervention. In the control group, initial evaluation occurred at 2.5 days and surgical intervention at 5.6 days after injury. Nineteen patients in the MRI group had additional procedures whereas none of the control group patients had additional procedures. CONCLUSIONS: Physical examination findings were more sensitive than MRI. MRI is time consuming, expensive, and can lead to treatment delays. Clinicians should rely on the history and physical examination for accurate diagnosis and reserve MRI for ambiguous presentations and subacute or chronic injuries for preoperative planning. LEVEL OF EVIDENCE: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Single-leg-stance (flamingo) radiographs to assess pelvic instability: how much motion is normal?

BACKGROUND: Chronic pelvic instability is a relatively uncommon cause of pelvic and low-back pain. Patients present with feelings of instability and mechanical symptoms. Static radiographs are often inadequate to detect abnormal relative motion between the hemipelves consistent with chronic pelvic instability; dynamic views of the pelvis are required. We assessed the amount of physiologic motion present at the pubic symphysis in normal adult men and nulliparous and multiparous women with alternating-single-leg-stance radiographs. METHODS: Forty-five asymptomatic adult volunteers (fifteen in each group) were evaluated with a standing anteroposterior pelvic radiograph as well as with anteroposterior pelvic radiographs made with the subjects assuming both right and left single-leg stance. The subjects completed a questionnaire to determine their eligibility for participation in the study, and an examination was performed to exclude certain physical anomalies that might alter the radiographic findings. RESULTS: The mean total translation (and standard deviation) at the pubic symphysis, as measured by three blinded observers, was 1.4 +/- 1.0, 1.6 +/- 0.8, and 3.1 +/- 1.5 mm for the men, nulliparous women, and multiparous women, respectively. With the numbers available, we found no significant difference between the translation in the men and that in the nulliparous women (p = 0.63). The multiparous women had significantly more translation than did either the nulliparous women (p = 0.002) or the men (p = 0.0005). There was a significant positive association between the number of pregnancies and the total translation (p < 0.0001). CONCLUSIONS: The use of anteroposterior pelvic radiographs made with the subject alternating between right and left single-leg stance demonstrated, with high interobserver reliability, that multiparous women had a significantly different physiologic range of pubic translation as compared with men and nulliparous women. The ranges of physiologic motion at the pubic symphysis measured on the single-leg-stance radiographs in this study can be used to identify pathologic amounts of motion at this site. CLINICAL RELEVANCE: This investigation suggests that up to 5 mm of physiologic motion can occur at the pubic symphysis in asymptomatic individuals, as demonstrated by alternating-single-leg-stance radiographs.

Tibiotalocalcaneal arthrodesis: a biomechanical comparision of multiplanar external fixation with intramedullary fixation.

BACKGROUND: Methods of achieving tibiotalocalcaneal arthrodesis include intramedullary nailing, crossed lag screws, blade plates, and external fixation. While reports in the orthopaedic literature have compared the biomechanical properties of some of these fixation techniques, to our knowledge none has evaluated multiplanar external fixation. The purpose of this study was to compare the biomechanical properties of intramedullary nail fixation and external ring fixation for tibiotalocalcaneal arthrodesis. MATERIALS AND METHODS: Tibiotalocalcaneal arthrodesis was performed on ten matched pairs of fresh-frozen human cadaveric legs. A ring fixator stabilized the arthrodesis in one leg from each pair and a 10 mm x 150 mm nail inserted retrograde across the subtalar and ankle joint stabilized the arthrodesis in the contralateral leg. The bending stiffness of the resulting constructs was quantified in plantarflexion, dorsiflexion, inversion, and eversion, and torsional stiffness was measured in internal and external rotation. RESULTS: No difference in bending stiffness between the two constructs was identifiable in any of the four bending directions (p > 0.05). Torsional stiffness was approximately two-fold greater in both internal and external rotation in specimens with the ring fixator arthrodesis than in those with the intramedullary nail (p = 0.002). CONCLUSION: The ring fixator provides a stiffer construct than a 10 mm x 150 mm intramedullary nail in torsion, but no difference in bending stiffness was demonstrable. Both techniques can provide satisfactory fixation; however, the ring fixator may better minimize rotational joint motion. CLINICAL RELEVANCE: This study provides a basis for selecting an arthrodesis method that offers optimized fixation.

Subtalar distraction arthrodesis using interpositional frozen structural allograft.

BACKGROUND: Subtalar bone-block distraction arthrodesis using structural autograft carries the risk of donor site morbidity. Recent reports suggest that structural allograft may be an attractive alternative to structural autograft in subtalar arthrodesis. This prospective study analyzes subtalar distraction arthrodesis using interpositional structural allograft. MATERIALS AND METHODS: Between 2000 and 2006, 22 patients (24 feet; mean age, 45.6 years) underwent subtalar arthrodesis with interpositional fresh-frozen femoral head structural allograft. Indications included subtalar arthrosis, loss of heel height, and anterior ankle impingement. Clinical outcome was assessed using the AOFAS ankle-hindfoot scoring system. Time to union was determined by previously reported clinical findings and radiographic evidence for bridging trabeculation between host bone and structural allograft. RESULTS: Mean followup was 35.8 months for 20 patients (21 feet) available for followup evaluation. Union was achieved in 19 of 21 patients (90%) at a mean of 15.5 (range, 11 to 19) weeks. Mean AOFAS hindfoot score improved from 21 to 71 points (p < 0.05). Radiographic analysis suggested significant (p < 0.05) improvement in all measurements. Complications included nonunion (2), varus malalignment (1), persistent subfibular impingement (1), sural neuralgia (1), and prominent hardware (2). Both patients with nonunions had avascular bone at the arthrodesis site and used tobacco products. CONCLUSION: This study supports recent publications that subtalar arthrodesis using interpositional structural allograft can have a favorable outcome. Our clinical and radiographic results suggest that restoration of hindfoot function and dimensions with structural allograft are comparable to results reported for the same procedure using structural autograft. LEVEL OF EVIDENCE: Level IV, prospective case series.

A quantitative comparison of surgical approaches for posterolateral osteochondral lesions of the talus.

BACKGROUND: Exposure of the posterolateral talar dome for osteochondral autograft transfer can be challenging. The purpose of this study is to compare surgical exposures for perpendicular access to the posterolateral talar dome using osteochondral transfer instrumentation. MATERIALS AND METHODS: Five surgical approaches were performed on each of eight cadaveric ankles. The sequence was: (1) Anterolateral arthrotomy with ATFL release, (2) Anterolateral tibial osteotomy, (3) Fibular osteotomy with ATFL intact, (4) Fibular osteotomy with ATFL release, and (5) Fibular osteotomy with ATFL/CFL release. (ATFL repaired between 1 and 2). While maintaining the orientation of the harvester perpendicular to the talar dome articular surface, osteochondral plugs were harvested as far posteriorly as possible using a 6-mm harvester. Distances from the anterior talar articular surface to the posterior aspect of the recipient site were measured. Statistical analysis used ANOVA and Fisher post hoc tests. RESULTS: Average AP exposure (mm) and percentage of AP talar dome dimensions exposed: (1) Anterolateral arthrotomy with ATFL release: 21.2 mm (43.3%), (2) Anterolateral tibial osteotomy: 33.7 mm (68.5%), (3) Fibular osteotomy(ATFL intact): 43.2 mm (87.8%), (4) Fibular osteotomy with ATFL release: 44.9 mm (91.2%), and (5) Fibular osteotomy with ATFL/CFL release: 46.6 mm (94.6%). All osteotomies provided greater exposure than anterolateral arthrotomy with ATFL release (p < 0.0001). A significant difference was obtained between each of the fibular osteotomies and tibial osteotomy (p < 0.0001). Differences between the fibular osteotomy approaches (3 to 5) were not significant. CONCLUSION: Fibular osteotomy provides the greatest perpendicular exposure to the posterolateral talar dome. Anterolateral tibial osteotomy provides greater exposure than arthrotomy alone. CLINICAL RELEVANCE: This study provides a guide for surgical exposures to the posterolateral talar dome for osteochondral autograft transfer.