Partial calcanectomy: A procedure to cherish or to reject?

BACKGROUND: Large ulcers on the heel often lead to major amputations. When a conservative treatment fails, a partial or subtotal calcanectomy is a possible treatment option. METHODS: 24 Patients were evaluated regarding limb salvage and infection eradication. Fourteen of these completed a questionnaire regarding functional outcome and satisfaction. RESULTS: Only 1 of 24 patients needed a below-knee amputation. Three patients did not heal and still have minor drainage of the wounds. However, hospital stay was long and in many cases additional surgery was necessary. Recurrences are seen, especially in patients with impaired sensation of the foot. In the fourteen patients who completed the questionnaire, pain was not a major problem. Many patients use orthotics and external support. The majority, however, is satisfied with the procedure and would consider the same treatment again. CONCLUSION: Calcanectomy still has a place in the treatment of osteitis of the calcaneus.

Clinical evaluation of the Copan ESwab for methicillin-resistant Staphylococcus aureus detection and culture of wounds.

The screening for and diagnosis of bacteriological infections often involves the collection and transportation of swab samples. The Copan ESwab was compared with the dry cotton Copan swab for methicillin-resistant Staphylococcus aureus (MRSA) screening (n = 200 paired samples) and with the Amies agar gel swab (Copan) for the sampling of burn and orthopaedic wounds (n = 203 paired samples) in terms of Gram staining and bacterial recovery. Gram stains performed with ESwab liquid showed significantly more Gram-negative rods, streptococci, Gram-positive cocci, Gram-positive rods, polymorphonuclear cells, lymphocytes and red blood cells than Gram stains from dry swabs. Bacterial recovery was significantly higher with ESwab (p < 0.01, for both MRSA screening and wounds, quantitative/semi-quantitative method). This lead to a slightly higher detection rate of MRSA (128 vs. 124 MRSA-positive ESwabs and dry swabs, respectively, p = 0.50) and a higher detection rate of coagulase-negative Staphylococcus spp. (44 isolates with ESwab vs. 29 with Amies gel swab, p = 0.001) and Enterococcus spp. (15 isolates with ESwab vs. 7 isolates with Amies gel swab, p = 0.005) with ESwab (quantitative method). We confirmed that ESwab has a high performance for Gram stains and a higher bacterial recovery than dry and Amies gel swabs when using clinical samples for MRSA screening and wound sampling.

Macroparasites of Pallas's squirrels (Callosciurus erythraeus) introduced into Europe.

Introduced pets released in natura can lead to sanitary risks for native fauna and humans. We analysed the macroparasite fauna of a total of 49 Pallas's squirrels, Callosciurus erythraeus, from two populations introduced into urbanised areas in Europe (n=16 female symbol and 13 male symbol from Antibes, France, 43 degrees 33'N-7 degrees 7'E; n=11 female symbol and 9 male symbol in from Dadizele, Belgium, 50 degrees 52'N-3 degrees 5'E). Of the 185 identified ectoparasites from Antibes, 183 were sucking lice Enderleinellus kumadai, with male squirrels 10 times more intensely infested than females. The flea Nosopsyllus fasciatus was found on two hosts. No hard ticks were recovered. Of the 131 arthropods specimens from Dadizele, 45 belonged to E. kumadai, with male squirrels three times more intensely infested than females. Eighty-six arthropods belonged to another sucking louse, Hoplopleura erismata, with males infested twice as intensely as females. No fleas or hard ticks were found. We only found 12 immature Hymenolepis sp. cestodes in the small intestine of three squirrels from Antibes and two immature Mastophorus sp. female nematodes in the stomach of a squirrel from Dadizele. We found no other helminths in the body cavity, heart, lung, liver, kidney or bladder. The macroparasite fauna of these two squirrel populations is consistent with what is expected from an introduced host, i.e., a few species dominated by specialist taxa imported with founders. The scarcity of other rodent species in the urbanized areas where Pallas's squirrels were sampled may explain the low variety of newly acquired macroparasites. The discrepancy in sucking lice infestations between males and females could be due to differences in either behaviour or physiology in this non-sexually dimorphic host. Based on the macroparasites found in this study, we expect minimal sanitary risks for both native fauna and humans in urbanized habitats such as those in our study.

Serological and genetic evidence for the presence of Seoul hantavirus in Rattus norvegicus in Flanders, Belgium.

Seoul hantavirus (SEOV), carried by Rattus rattus (black rat) and R. norvegicus (Norway, brown rat), was reported to circulate as well as cause HFRS cases in Asia. As Rattus sp. are present worldwide, SEOV has the potential to cause human disease worldwide. In Europe however, only SEOV prevalence in rats from France was reported and no confirmed cases of SEOV infection were published. We here report genetic and serological evidence for the presence of SEOV virus in brown rat populations in Belgium. We also serologically screened an at-risk group that was in contact with R. norvegicus on a daily basis and found no evidence for SEOV infection.

Free myocutaneous latissimus dorsi flap transfer in total knee arthroplasty.

The purpose of this article is to present our experience with free myocutaneous latissimus dorsi flap transfer in total knee arthroplasty in case of insufficient soft tissue prior to operation ('prophylactic indication'). Fourteen patients who underwent simultaneous flap surgery in the context of total knee arthroplasty because of insufficient soft tissue are reviewed in a retrospective clinical study. The following criteria were examined: (1) aetiology of the soft-tissue defect, (2) number of previous operations, (3) status of the knee extensor mechanism classified as complete, partial or missing, (4) primary wound healing, (5) complications and (6) active range of motion (ROM). Insufficient soft tissue resulted from multiple previous operations in 10 patients and large post-traumatic defects in four patients. All patients had 5-23 (mean 10.2) previous operations before free latissimus dorsi transfer. The status of the extensor mechanism was complete in one, partial in nine and missing in four patients. Primary wound healing could be achieved in eight patients. After free latissimus dorsi transfer, skin breakdown at the recipient site occurred in five patients. Secondary skin grafting was carried out in four patients and a fasciocutaneous flap in one patient. There were three late recurrences of infection, with ultimate removal of the knee prosthesis and conversion to arthrodesis. Average active ROM prior to surgery was for extension/flexion 0-9-28 degrees . One year after surgery the average active ROM was 0-6-75 degrees . A free myocutaneous latissimus dorsi flap transfer is rarely indicated in total knee arthroplasty and should only be considered for defects which cannot be covered by a pedicled (medial gastrocnemius) flap. Free latissimus dorsi transfer makes prosthesis implantation possible, prevents postoperative knee stiffness because of soft tissue and/or scar constriction and shows a low rate of severe complications in patients with a high risk of wound-healing problems. Moreover, transfer of well-vascularised tissue will improve trophicity in the knee region, and thus make future operations in this region easier.

Ilizarov's method: a solution for infected bone loss.

We report the results of 22 infected nonunions treated by radical resection and bone transport technique according to Ilizarov with a minimal follow-up period of 2 years. This series involves four fractures of the femur diaphysis, ten at tibial level, four defects of the knee and four of the upper limb. The mean length of the bone defect was 7.7 cm. The mean time from the transport procedure to frame removal was 14.5 months. In 15 cases the docking site was reviewed to refresh the bone ends at the end of the transport procedure, of which eight had a bone graft performed. Five refractures were noticed at the docking site in the nonrevised group and one in the other group. Two of them were treated conservatively and four with a new external fixator. Consolidation was achieved in all but two nonunions at the knee level, which means a succesrate of 91%. The infection could be eradicated in all 22 patients. A revision of the docking site at the end of the bone transport procedure with or without bone grafting is recommended.

FDG-PET, 99mtc-HMPAO white blood cell SPET and bone scintigraphy in the evaluation of painful total knee arthroplasties.

Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET), technetium-99m hexamethylpropylene amine oxime (HMPAO)-labelled white blood cell (WBC) scintigraphy and bone scintigraphy were used in the evaluation of total knee arthroplasties (TKAs). We prospectively included 21 patients who had a three-phase bone scan for exclusion of infection of TKAs. Four hours after injection of 185 MBq 99mTc-HMPAO-labelled WBCs, planar and single-photon emission tomographic (SPET) imaging was performed. Planar imaging was repeated at 24 h p.i. Consecutively images of the knees were obtained with a dedicated PET system 60 min following the injection of 370 MBq of FDG. Focal tracer uptake was scored on SPET and PET visually (0=no uptake, 4=intense uptake). In addition, SUV (standardised uptake value) per voxel was calculated from attenuation-corrected PET images using the MLAA algorithm. Focal uptake at the bone-prosthesis interface was used as the criterion for infection before and after correlation with the third phase of the bone scan. Final diagnosis was based on operative findings, culture and clinical outcome. In the infected TKAs, the WBC scan showed focal activity of grade 2 (n=2), 3 (n=l) or 4 (n=2). PET scan revealed focal activity of grade 4 (n=5) or 3 (n=1). WBC scan alone had a specificity for infection of 53% [positive predictive value (PPV) 42%, sensitivity 100%], compared with 73% for PET scan (PPV 60%, sensitivity 100%). Considering only lesions at the bone-prosthesis interface that were also present on the third phase of the bone scan, we found a specificity of 93% (PPV 83%) for WBC scan. Using these criteria, a specificity of 80% (PPV 67%) was obtained for PET scan. Two out of three false-positive PET scans were due to loosening of the TKA. It is concluded that WBC scintigraphy in combination with bone scintigraphy has a high specificity in the detection of infected TKAs. FDG-PET seems to offer no additional benefit.

Core decompression for avascular necrosis of the femoral head.

The results of core decompression as the sole treatment for Ficat stages 1, 2 and 3 avascular necrosis of 51 femoral heads in 39 patients were studied. The mean follow-up time was 24 months (6-47 months); 19 hips (38.8%) were good and 30 hips (61.2%) had failed (two hips were lost to follow-up). The good results as stated in the literature could not be obtained, but we believe core decompression can delay the need for total hip replacement in avascular necrosis of the femoral head.

Treatment of nonunion of the humerus using the Ilizarov external fixator.

Ilizarov's method of monofocal compression was used in 30 humeri with a diaphyseal pseudarthrosis. Twenty-one patients had previous surgery but had loosening of the osteosynthesis material. Nine patients initially were treated with a hanging cast, resulting in interfragmentary distraction. Fourteen nonunions were hypertrophic, and 16 were atrophic, of which six were infected. A complete circular frame was used only in the first nine patients, whereas the remaining 21 patients were treated with the modified semicircular fixator. Union was obtained in all but two patients, with an average consolidation time of 4.5 months (range, 2.5-10 months). No patient required additional bone grafting. Apart from superficial pin tract infection seen in most of the patients, three had a minor temporary sensory neurologic problem. Four patients experienced a second fracture after removal of the fixator that required a second application of an Ilizarov frame. Although similar results with regard to union are reported after plate osteosynthesis, there was no radial nerve palsy or deep infection in this series, indicating that the treatment by the Ilizarov technique is associated with less complications. The authors' findings suggest that the Ilizarov method is a reliable treatment for humeral nonunions, even after multiple previous operations or in the event of infection.

Conservative treatment of femoral shaft fractures in patients with total hip arthroplasty.

Over a period of 20 years, 34 patients with a total hip arthroplasty were treated conservatively for a femoral shaft fracture. Thirty-five fractures were treated by traction followed by cast-brace or by cast-brace alone. Sound healing was obtained in 33 fractures. Problems were angular malalignment jeopardizing revision surgery in cases of loosening, long hospitalization, and a considerable complication rate. As a consequence, the authors no longer recommend conservative treatment as the first choice for these difficult fractures.

Chronic osteomyelitis: diagnosis with technetium-99m-d, l-hexamethylpropylene amine oxime labelled leucocytes.

To evaluate the diagnostic value of technetium-99m d, l-hexamethylpropylene amine oxime (HMPAO) labelled leucocytes in combination with a 99mTc-methylene diphosphonate (MDP) bone scan in the detection of chronic osteomyelitis, we retrospectively reviewed 55 patients. Prior to the 99mTc-d,l-HMPAO labelled leucocyte scan, all patients underwent a 99mTc-MDP bone scan. The correct diagnosis was confirmed by long-term clinical follow-up (n=29) or by bacteriological cultures (n=26). We found an overall sensitivity of 94%, a specificity of 91% and an accuracy of 92% for 99mTc-d,l-HMPAO labelled leucocyte scintigraphy in the diagnosis of chronic osteomyelitis. When the patients were divided into three groups according to the location of the infection, our study results showed a sensitivity and specificity for the central location (containing active bone marrow) of 94% and 100% respectively; for the peripheral location (hands and feet) both parameters were 100%, and for the middle location (all sites between the central and the peripheral location) the values were 92% and 81% respectively. Specificity and accuracy were significantly lower in the middle location than in the central and peripheral locations. The results of our study confirm that a 99mTc-d,l-HMPAO labelled leucocyte scan in combination with an 99mTc-MDP bone scan is a reliable way to diagnose chronic osteomyelitis, except for vertebral osteomyelitis.

Ectopic bone formation due to a distal venting hole in intramedullary nailing.

A case report is presented on ectopic bone formation around a distal venting hole drilled in the femur to prevent pulmonary embolism. We no longer recommend this technique, because it is ineffective and has its own complications.

Salmonella typhi osteomyelitis.

Salmonella infections in man can be divided in five clinical groups: enteric fever, septicaemia without localization, focal disease, gastroenteritis and the carrier state. Salmonella typhi is mostly associated with enteric fever and the carrier state. Bone infections due to S. typhi have been reported relatively seldom. They usually occur as the result of metastatic spread during septicaemia or, more rarely, after direct inoculation. Two patients with S. typhi osteomyelitis of the forearm without evidence of a primary infection or direct inoculation are presented here.

Subtrochanteric fractures of the femur treated with the Zickel nail.

In a retrospective study of 41 subtrochanteric fractures treated with Zickel intramedullary nails (with a follow-up period of at least 1 year) there was a union rate of 100% (39/39). Union occurred between 4 and 7 months (average healing time 5.2 months). There were no implant failures. To date 4 patients have had their Zickel nails successfully removed. In 48% of the cases we had some difficulties with the stability of the fracture, and in 12% there was a need for additional cast immobilization. In 9 cases there was shortening of 1.5 to 4 cm (average shortening of 2 cm). Therefore we no longer recommend use of the Zickel nail in the treatment of acute subtrochanteric femur fractures.

Subtrochanteric fractures of the femur treated with the Zickel nail.

In a retrospective study of 41 subtrochanteric fractures treated with Zickel intramedullary nails (with a follow-up period of at least 1 year) there was a union rate of 100 per cent (39/39). Union occurred between 4 and 7 months (average healing time 5.2 months). There were no implant failures. Four patients have had their Zickel nails successfully removed. In 48 per cent of the cases we had some difficulties with the stability of the fracture, and in 14 per cent, all of them long oblique comminuted fractures, skeletal traction was needed for 6 weeks. In nine cases there was a shortening of 1.5-4 cm (average 2 cm). Although our overall experience with the Zickel nail has been favourable in the treatment of non-union of subtrochanteric fractures, and with the elderly patients who had a simple subtrochanteric fracture secondary to minor trauma, we no longer recommend its use in the treatment of subtrochanteric fractures with marked comminution, because it does not give sufficient rotational and axial stability.

Conservative treatment of acromioclavicular dislocation. Evaluation of functional and radiological results after six years follow-up.

Fifty-eight patients with acute acromioclavicular dislocations of Type III, IV and V (Rockwood classification) were examined to assess the late results of conservative treatment. The average age of the patients was 31 years, and the interval between injury and final review was 6.3 years. Seventy-nine percent of the patients had excellent or good late results. Surprisingly the age and activity level of the patients did not influence our late results, nor did the radiological appearance of acromioclavicular osteoarthritis or periarticular calcification. The radiological appearance of the acromioclavicular joint improved in 41% of patients. In 10 failed cases, excision of the distal end of the clavicle with reconstruction of the coracoclavicular ligament (Weaver and Dunn procedure) resulted in 90% excellent or good results after a 3-year follow-up. A high percentage of excellent results can be expected after this procedure, as long as it is correctly performed.

Isolated posterior dislocation of the radial head without fracture of the ulna in a child.

An isolated posterior dislocation of the radial head is a rare injury. We present a case report on an 11-year-old boy with a traumatic posterior radial head dislocation without fracture or bending of the ulna. The diagnosis can be difficult and should be supported with good radiographic images, since clinically the injury can be missed or misdiagnosed.

Acute colonic pseudo-obstruction.

We present two cases of acute colonic pseudo-obstruction, one complicated with perforation. Orthopedic surgery was the pathogenetic factor in both cases. Recovery was successful in both patients after appropriate treatment. The importance of conventional X-ray techniques, and more specially the plain X-ray of the abdomen, is stressed regarding early diagnosis and follow-up.

Corrective osteotomy for mal- and nonunion of the tibia using the posterolateral approach.

An analysis of the results of 9 patients with a post-traumatic malalignment of the tibia, treated by an osteotomy and immediate bone grafting through a posterolateral approach is presented. Fixation was obtained with an external fixator in 8 cases and with a fibular plate in one case. Union was obtained in all cases after an average of 4.8 months. A significant improvement in the malalignment was obtained, especially in the frontal plane and somewhat less in the sagittal plane. Permanent sequellae due to the procedure were not noted.