The use of polymerase chain reaction for the detection and speciation of bacterial bone and joint infection in children.

We evaluated 36 consecutive patients presenting with signs and symptoms of bacterial bone and joint infection and 10 control patients using bacterial cultures of blood and the presumed site of infection compared with polymerase chain reaction (PCR) techniques using a universal primer and restriction endonuclease digestion. Of the 28 patients with definitive clinical and/or laboratory evidence of bacterial infection, 16 patients had positive bacterial cultures and 12 were PCR-positive. Twenty of 28 patients were either PCR- or culture-positive. Nine of the 16 subjects who had culture-positive samples also had PCR-positive samples (8 positive for the same organism and 1 with 2 organisms identified by culture, but only a single organism by PCR. Six culture positive patients were PCR-negative. Of the 12 patients who were culture-negative, 4 had bacterial genomic material present indicating infection. We conclude that current PCR methods are not superior to standard bacterial culture methods when applied to children with presumed bone or joint infections, but that PCR may complement existing microbiologic cultures for detection of bone and joint infections in children.

Radiographic measures as a predictor of ulcer formation in diabetic charcot midfoot.

BACKGROUND: Plantar midfoot ulceration in diabetic patients with midfoot Charcot neuroarthropathy is a risk factor for infection that can require amputation. The aim of this study was to determine a simple radiographic predictor of the individual risk of subsequent ulcer formation in this group of patients. MATERIALS AND METHODS: A retrospective review of all patients seen at our institution between January 1998 and July 2004 with diabetic Charcot neuroarthropathy was performed. Exclusion criteria were previous reconstructive foot surgery, absence of weightbearing foot radiographs and absent pedal pulses. Patient charts were reviewed for demographics, diabetic co-morbidities, and presence of midfoot skin pathology (plantar callus and/or ulceration). Weightbearing anteroposterior and lateral radiographs were assessed using standard measurements. RESULTS: Nineteen patients with radiographs of 24 feet were included. Fifty-eight percent were female, and the mean age was 54 (SD +/- 13) years. Ninety-five percent had type II diabetes mellitus, and the median duration of illness was 20 (range, 14 to 25) years. Midfoot ulceration and callus formation were seen in 6 (25%) and 2 feet, respectively. When radiographic measures of feet with and without midfoot skin pathology were compared, the lateral talar-first metatarsal angle was significantly associated with skin pathology (p < 0.001). CONCLUSION: The lateral talar-first metatarsal angle measured on weightbearing radiographs is a simple means of monitoring patients' risk of development of midfoot ulceration. Only patients with a lateral talar-first metatarsal angle of greater than -27 degrees had an ulcer. This may be a clinically useful threshold for increased risk of the development of ulceration in midfoot diabetic neuroarthropathy.

Weight-Bearing in the Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Randomized Controlled Trial.

BACKGROUND: The rate of Achilles tendon ruptures is increasing, but there is a lack of consensus on treatment of acute injuries. The purpose of this trial was to compare outcomes of weight-bearing casts with those of traditional casts in the treatment of acute Achilles tendon ruptures. METHODS: Eighty-four patients with an acute Achilles tendon rupture were recruited over a two-year period. Patients were randomized to be treated with either a weight-bearing cast with a Böhler iron or a non-weight-bearing cast for eight weeks. Patients underwent muscle dynamometry testing at six months, with additional follow-up at one and two years. The primary outcomes that were assessed were the rerupture rate and the time taken to return to work. Secondary outcomes included return to sports, ankle pain and stiffness, footwear restrictions, and patient satisfaction. RESULTS: There were no significant differences between groups with regard to patient demographics or activity levels prior to treatment. At the time of follow-up at two years, one (3%) of the thirty-seven patients in the weight-bearing group and two (5%) of the thirty-seven in the non-weight-bearing group had sustained a rerupture (p = 0.62). The patients in the weight-bearing group experienced less subjective stiffness at one year. There were no significant differences in time taken to return to work, Leppilahti scores, patient satisfaction, pain, or return to sports between the groups. CONCLUSIONS: Use of weight-bearing casts for the nonoperative treatment of Achilles tendon ruptures appears to offer outcomes that are at least equivalent to those of non-weight-bearing casts. The overall rerupture rate in this study was low, supporting the continued use of initial nonoperative management for the treatment of acute Achilles tendon ruptures. LEVELS OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Talocalcaneal tarsal coalitions and the calcaneal lengthening osteotomy: the role of deformity correction.

BACKGROUND: Surgical resection of persistently painful talocalcaneal tarsal coalitions may not reliably relieve symptoms in patients with large coalitions associated with excessive hindfoot valgus deformity and subtalar posterior facet narrowing. Since 1991, calcaneal lengthening osteotomy, with or without coalition resection, has been used at our institution to relieve symptoms and to preserve motion at the talonavicular and calcaneocuboid joints. METHODS: We retrospectively reviewed the records for eight patients with thirteen painful talocalcaneal tarsal coalitions who had undergone a calcaneal lengthening osteotomy for deformity correction with or without coalition resection between 1991 and 2005. Preoperative and postoperative clinical, radiographic, and computed tomographic records were reviewed. The duration of clinical follow-up ranged from two to fifteen years. RESULTS: Calcaneal lengthening osteotomy fully corrected the valgus deformity and provided short-to-intermediate term pain relief for the five patients (nine feet) in whom the talocalcaneal tarsal coalition was unresectable. The patient with resectable coalitions but excessive valgus deformities underwent calcaneal lengthening osteotomies along with coalition resections and had excellent deformity correction and pain relief in both feet. One of the two patients who underwent calcaneal lengthening osteotomy years after coalition resection had excellent correction and pain relief. The other patient had a coincident calcaneonavicular coalition and severe degenerative arthritis in the talonavicular joint. He underwent concurrent arthrodesis of the talonavicular joint and, although he had excellent deformity correction, had persistent pain. All feet underwent concurrent gastrocnemius or Achilles tendon lengthening. CONCLUSIONS: It is generally accepted that resection is the treatment of choice for an intractably painful small talocalcaneal tarsal coalition that is associated with a wide, healthy posterior facet and minimal valgus deformity of the hindfoot. Although triple arthrodesis has been recommended for those who do not meet all three criteria, the present study suggests that an algorithmic treatment approach is justified. Treatment of the valgus deformity appears to be as important as that of the coalition. Calcaneal lengthening osteotomy with gastrocnemius or Achilles tendon lengthening is effective for correcting deformity and relieving pain in rigid flatfeet, just as it is in flexible flatfeet.