Effectiveness of foot fasciotomies in foot and ankle trauma.

BACKGROUND: Foot compartment syndrome (FCS) has been reported to cause neuropathic pain, claw or hammer toes, and motor and sensory disturbances. The optimal treatment of FCS is controversial. The purpose of this study was to determine if foot fasciotomies improve patient outcomes in high-energy, combat-related lower extremity trauma. METHODS: Medical records of patients with documented FCS from May 2007 to January 2009 were retrospectively reviewed. Consecutive, matched control patients were identified based on similar hindfoot, mid-foot and/or forefoot injuries who did not undergo foot fasciotomy during the same period. The primary outcomes analysed were the development of claw or hammer toes and neuropathic pain. RESULTS: 19 patients with foot fasctiotomies were identified and matched with 19 controls. Median follow-up was 19.5 months (range, 3.5-47.5 months) for the combined cohorts. The most common mechanism of injury was an explosive blast. Nine fasciotomy and nine control patients sustained open foot fractures. Significantly more patients with foot fasciotomies developed claw toes (50% vs 17%, p=0.03). There were no significant differences in the development of neuropathic pain, sensory deficits, motor deficits, chronic pain, stiffness or infection. The fasciotomy patients underwent an average of 5.5 surgeries per patient versus 4 surgeries per patient in the control group. CONCLUSIONS: Fasciotomy of the foot did not prevent neuropathic pain and deformities in patients with FCS in this study.

Development of a hematogenous implant-related infection in a rat model.

BACKGROUND: Implant-related osteomyelitis is a major complication that requires immediate treatment, often involving removal of the implant, prolonging patient recovery and inflating expenses. Current research involving interventions to diminish the prevalence of such measures include investigating prophylactic and therapeutic remedies. A proper and accurate animal model is needed to thoroughly investigate such treatments. The scope of this project was to develop an animal model in which a consistent and measurable infection can be formed on an orthopedic implant when bacteria is introduced via a hematogenous source. METHODS: Titanium Kirschner-wires were implanted into the intramedullary canals of both femurs. Staphylococcus aureus, ranging from10(4) to 10(9) colony forming units, was injected into a tail vessel. After a designated time (3, 7, 14, or 42 days) the femurs were harvested and bacterial numbers determined for both the femur and the implanted K-wire. In addition, histology and micro-computed tomography were used as subjective tools to further characterize the infection. RESULTS: Consistent infection, that is infection of ≥75% of the femurs, wasn't achieved until 10(7) CFU S. aureus was injected. At 10(7) CFU, the femurs contained 4.6x10(6) CFU/g bone tissue at day 3 and 4.8×10(8) CFU/g bone tissue by day 14. The wire showed comparable contamination with 4.8×10(4) CFU/mm(2) at day 3 and 3.7×10(5)/mm(2) by day 14. After 42 days, the bacteria number decreased but was still occupying at 1.9×10(5) CFU/g bone tissue. There were morphological changes to the bone as well. At day 42, there were signs of osteonecrosis and active bone formation when compared to control animals that received a K-wire but were inoculated with saline. CONCLUSIONS: A model for hematogenous osteomyelitis, a common complication associated with implants, has been introduced. A reproducible, preclinical model is essential to evaluate future methods used to mitigate blood-borne bacteria hardware and bone infections.

Can an integrated orthotic and rehabilitation program decrease pain and improve function after lower extremity trauma?

BACKGROUND: Patients with severe lower extremity trauma have significant disability 2 years after injury that worsens by 7 years. Up to 15% seek late amputation. Recently, an energy-storing orthosis demonstrated improved function compared with standard orthoses; however, the effect when integrated with rehabilitation over time is unknown. QUESTIONS/PURPOSES: (1) Does an 8-week integrated orthotic and rehabilitation initiative improve physical performance, pain, and outcomes in patients with lower extremity functional deficits or pain? (2) Is the magnitude of recovery different if enrolled more than 2 years after their injury versus earlier? (3) Does participation decrease the number considering late amputation? METHODS: We prospectively evaluated 84 service members (53 less than and 31 > 2 years after injury) who enrolled in the initiative. Fifty-eight sustained fractures, 53 sustained nerve injuries with weakness, and six had arthritis (there was some overlap in the patients with fractures and nerve injuries, which resulted in a total of > 84). They completed 4 weeks of physical therapy without the orthosis followed by 4 weeks with it. Testing was conducted at Weeks 0, 4, and 8. Validated physical performance tests and patient-reported outcome surveys were used as well as questions pertaining to whether patients were considering an amputation. RESULTS: By 8 weeks, patients improved in all physical performance measures and all relevant patient-reported outcomes. Patients less than and greater than 2 years after injury improved similarly. Forty-one of 50 patients initially considering amputation favored limb salvage at the end of 8 weeks. CONCLUSIONS: We found this integrated orthotic and rehabilitation initiative improved physical performance, pain, and patient-reported outcomes in patients with severe, traumatic lower extremity deficits and that these improvements were sustained for > 2 years after injury. Efforts are underway to determine whether the Return to Run clinical pathway with the Intrepid Dynamic Exoskeletal Orthosis (IDEO) can be successfully implemented at additional military centers in patients > 2 years from injury while sustaining similar improvements in patient outcomes. The ability to translate this integrated orthotic and rehabilitation program into the civilian setting is unknown and warrants further investigation.

2011 Marshall Urist Young Investigator Award: when to release patients to high-impact activities after hip resurfacing.

BACKGROUND: Surface replacement arthroplasties are commonly performed in young, active patients who desire return to high-impact activities including heavy manual labor and recreational sports. Femoral neck fracture is an arthroplasty-related complication unique to surface replacement arthroplasty. However, it is unclear regarding whether patients are at lower risk for fracture after a certain postoperative time. QUESTIONS/PURPOSES: We therefore raised the following questions: (1) does stress shielding occur after surface replacement arthroplasty, and (2) when does bone mineral density return to normal so patients can return to high-impact activities without excessive risk of fracture? PATIENTS AND METHODS: We prospectively enrolled 90 patients (96 hips) with either surface replacement arthroplasty or THA, and performed dual energy x-ray absorptiometry scans at 6 weeks, 6 months, 1 year, and 2 years. We analyzed bone density by Gruen zone in both groups, and six femoral neck zones in the patients who had surface replacement arthroplasties. We calculated 6-month, 1-year, and 2-year ratios for the change in bone density compared with baseline. RESULTS: Bone density was greater in patients who had surface replacement arthroplasties than for patients who had THAs at 6 months and 1 year in Gruen Zones 1, 2, 6, and 7, with the largest increase in femoral neck bone density on the tension side at 6 months in Zone L1. We saw no decrease in bone density in patients who had surface replacement arthroplasties in any Gruen zone at any time, and observed no decrease in bone density in female patients. CONCLUSIONS: Increased bone density at 6 months postoperatively in patients who had surface replacement arthroplasties provides evidence that clinically relevant stress shielding does not occur after surface replacement arthroplasty. Owing to the increased bone mineral density at 6 months, we believe patients who underwent surface replacement arthroplasties may to return to high-impact activities at that time without increased risk of fracture.

Comparison of Calcaneal Exposure Through the Extensile Lateral and Sinus Tarsi Approaches.

The purpose of this study was to compare the exposure of the posterior facet with the extensile lateral (EL) approach compared with the sinus tarsi (ST) approach. We hypothesized that the ST approach will provide a similar exposure of the posterior calcaneal facet. A total of 8 sequential ST then EL approaches were performed on cadavers. Calcaneal landmarks were identified by visualization or palpation. Calibrated digital photographs of the posterior facet and lateral calcaneal body were obtained from standardized positions and used to calculate the exposed surface area. No significant difference was found in the average square area of the posterior facet exposed with the 2 approaches. Significantly more of the lateral calcaneal body was seen with the EL approach. Excluding the posterior facet superomedial quadrant, all the landmarks were visualized in 100% of approaches. The superomedial corner was visualized in significantly more of the cadavers with the EL approach and was palpable in 12.5% of the remaining cadavers in both approaches. Whereas the ST approach exposes less of the lateral wall of the calcaneus, it exposes similar amounts of the posterior facet when compared with the EL approach. LEVELS OF EVIDENCE: Therapeutic, Level V.