Delayed Tibial Osteomyelitis after Anterior Cruciate Ligament Reconstruction with Hamstrings Autograft and Bioabsorbable Interference Screw: A Case Report and Review of the Literature.

Osteomyelitis following arthroscopically assisted anterior cruciate ligament (ACL) reconstruction has rarely been reported in the literature. We report a case of a 20-year-old female who had delayed tibial osteomyelitis and a pretibial cyst with culture-positive, oxacillin sensitive Staphylococcus epidermidis 15 months after an ACL reconstruction with hamstring autograft. Soft tissue fixation within the tibial tunnel was with a poly-L-D-lactic acid (PLDLA) bioabsorbable interference screw. The patient underwent surgical treatment with curettage, debridement, hardware removal, and bone grafting of the tibial tunnel followed by a course of intravenous antibiotics. Arthroscopic evaluation demonstrated an intact ACL graft without any evidence of intra-articular infection. The patient returned to collegiate athletics without any complications. While the most common biologic complications include pretibial cysts, granuloma formation, tunnel widening, and inflammatory reactions, infection is exceedingly rare. Late infection and osteomyelitis are also rare but can occur and should be considered in the differential diagnosis.

Post-traumatic ankle arthritis.

Post-traumatic ankle arthritis can be a very disabling condition especially in young patients. Localization of the pain is important to allow appropriate treatment. Non-surgical treatment options include anti-inflammatory medications and use of bracing. Multiple surgical options range from joint sparing procedures for the younger patient to total ankle replacement for the older, less active patient. Arthrodesis remains the gold standard and is the procedure of choice for younger patients who are heavy laborers and in patients with severe arthritis who are not candidates for a total ankle replacement. Joint sparing operations include allograft resurfacing, arthroscopic debridement and osteophyte resection, joint distraction arthroplasty, and supramalleolar osteotomy. In older low demand patients, the surgeon may consider a total ankle arthroplasty as an alternative to arthrodesis.

Postoperative second metatarsal fractures associated with suture-button implant in hallux valgus surgery.

BACKGROUND: The purpose of this study was to perform a retrospective review of a nonosteotomy technique for the reduction of the intermetatarsal (IM) angle in hallux valgus (HV) surgery using a modified nonabsorbable suture-button implant previously described for ankle syndesmotic injuries and to report on the outcomes and complications associated with this technique. METHODS: A retrospective review was performed of consecutive patients with a minimum follow-up of 1 year. Twenty-five patients, a total of 25 feet, were identified with a mean follow-up of 22.5 months. The mean age was 60 years. The pre- and postoperative HV and IM angles were compared. Each postoperative radiograph was assessed for loss of correction, implant failure, and second metatarsal (MT) stress fracture. The postoperative hallux American Orthopaedic Foot & Ankle Society (AOFAS) scores were obtained at the patient's final follow-up visit. Statistics were performed using the paired Student t test with the P value set at .05 to determine statistical differences. RESULTS: The preoperative mean IM and HV angles were 15.1 and 30.5 degrees, respectively. The postoperative mean IM and HV angles were 8.2 and 10.2 degrees, respectively. The reductions in the IM and HV angles were statistically significant (P < .05). The average postoperative AOFAS hallux score was 85. Two patients developed hallux varus (8%). Eight patients (32%) developed second metatarsal stress fractures. One patient (4%) with a second metatarsal stress fracture had a failure of the implant that required implant removal. The remaining stress fractures healed uneventfully. CONCLUSION: Suture-button fixation in hallux valgus achieved a satisfactory reduction in the first-second intermetatarsal angle compared with first metatarsal osteotomies but was associated with a high rate of second metatarsal stress fractures. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Fibrin glue as interposition graft for tarsal coalition.

We describe a surgical technique and report outcomes for fibrin glue interposition after resection of a tarsal condition. An institutional review board--approved retrospective review of all pediatric patients with a tarsal coalition managed with resection was conducted between January 2002 and July 2010 by a single surgeon. All coalitions were resected with interposition of fibrin glue. Patients were evaluated for postoperative complications, pain, weight-bearing status, return to sports, and ankle and subtalar range of motion. Six feet without a coalition were used as a control group. Nine patients (12 feet) were identified with mean follow-up of 2.1 years (range, 7-72 months). Pre-operative complaints were predominantly foot and ankle pain. Patients also reported flatfeet and recurrent ankle sprains. There were no reported postoperative complications. All 9 patients were weight-bearing as tolerated and returned to sports by 6 months. Fibrin glue is a safe and reliable alternative to tissue grafts for interposition after resection of a tarsal coalition.

Barbed sutures for arthroplasty closure--does it decrease the risk of glove perforation?

Recent resurgence in the interest of barbed suture has extended its application to wound closures in total joint surgery. Improved suture biomaterials and barb geometry has lead to consideration for its use in various orthopedic procedures including arthroplasty. The reported superior wound tensile stress distribution, no need for knots, and ability to close multiple layers with one suture make it an attractive option for deep wound closure after total joint surgery. However, inherent to the design of this suture are barbs that pose a risk of glove perforation and the potential for the transmission of blood borne pathogens. This study reports no increase in the incidence of glove perforation with use of barbed suture for deep wound closure after total joint arthroplasty.

Fractures of the proximal fifth metatarsal: keeping up with the Joneses.

Fractures of the proximal fifth metatarsal are among the most common fractures of the foot. History, physical examination, and subsequent radiographic work-up can help with the diagnosis of such a fracture. Many fractures of the proximal fifth metatarsal can have an associated prodrome, thereby establishing a level of chronicity to the problem. Identification of the location of the fracture plane within the proximal fifth metatarsal can have prognostic implications in regards to fracture union rate and guide treatment options, due to the particular vascular anatomy of the region. Additional findings on physical exam, such as heel varus, can also impact prognosis and treatment options. Treatments can range from nonoperative to operative modalities, and time to weightbearing can vary. Within the realm of operative treatment, identification of certain parameters can aid in successful reduction and fixation of the fracture and thus impact healing. Careful consideration of the patient's particular constellation of social and professional needs, clinical and radiographic parameters, and acceptance of different options can help guide treatment recommendations in the individual patient.

Peroxisome proliferator-activated receptor gamma mediates protection against cyclooxygenase-2-induced gut dysfunction in a rodent model of mesenteric ischemia/reperfusion.

Cyclooxygenase (COX)-2 has been identified as an important mediator elaborated during ischemia/reperfusion, with pro- and anti-inflammatory properties having been reported. As the role of COX-2 in the small intestine remains unclear, we hypothesized that COX-2 expression would mediate mesenteric ischemia/reperfusion-induced gut injury, inflammation, and impaired transit and that these deleterious effects could be reversed by the selective COX-2 inhibitor, N-[2-(cyclohexyloxy)-4-nitrophenyl] methanesulphanamide (NS-398). Additionally, we sought to determine the role of peroxisome proliferator-activated receptor gamma (PPARgamma) in mediating protection by NS-398 in this model. Rats underwent sham surgery or were pretreated with NS-398 (3, 10, or 30 mg/kg) intraperitoneally 1 h before 60 min of superior mesenteric artery occlusion and 30 min to 6 h of reperfusion. In some experiments, NS-398 (30 mg/kg) was administered postischemia. Ileum was harvested for COX-2 mRNA and protein, PGE2, myeloperoxidase (inflammation), histology (injury), intestinal transit and PPARgamma protein expression, and DNA-binding activity. COX-2 expression and PGE2 production increased after mesenteric ischemia/reperfusion and were associated with gut inflammation, injury, and impaired transit. Inhibition of COX-2 by NS-398 (30 mg/kg, but not 3 or 10 mg/kg) not only reversed the deleterious effects of COX-2, but additionally induced expression and nuclear translocation of PPARgamma. NS-398 given postischemia was equally protective. In conclusion, COX-2 may function as a proinflammatory mediator in a rodent model of mesenteric ischemia/reperfusion. Reversal of gut inflammation, injury, and impaired transit by high-dose NS-398 is associated with PPAR activation, suggesting a potential role for PPAR-gamma in shock-induced gut protection.