Postoperative toxic shock syndrome after excision of a ganglion cyst from the ankle.

Postoperative toxic shock syndrome (PTSS) after orthopedic surgery is rare, but early recognition and prompt intervention are essential to minimize morbidity and potential mortality. The diagnosis should be considered in all postoperative patients presenting with fever, hypotension, and systemic illness. The treating surgeon must have not only knowledge of the clinical entity, but also an extremely high index of suspicion, because the diagnosis can be elusive with surgical wounds appearing deceptively benign. Treatment consists of antibiotics, surgical wound debridement, and, more importantly, aggressive supportive care with intravenous fluids and intensive care surveillance. To date, the literature contains relatively few case reports of PTSS after orthopedic procedures, with even fewer cases encountered after foot and ankle surgery. This report describes a patient who developed the rare complication of PTSS after an elective ganglion cyst excision from the ankle.

Complications after surgery of the hallux.

The great toe is affected by many congenital and acquired conditions including arthritis, hallux valgus, and hallux rigidus and disease of the hallucal sesamoids. Many surgical procedures have been described for the treatment of these conditions. With the increased popularity of forefoot surgery comes the potential for complications even when the surgery is done meticulously by an experienced surgeon under well-planned conditions. When a complication occurs, it can present difficult and challenging problems. It is, therefore, important to recognize a complication early so it may be analyzed and treated successfully. When recognized, a plan should be developed to identify, quantify, control, and resolve the problem. The current review defines some common complications and treatment options. Several problems may exist at the same time. A solution addressing all aspects of the problem must be designed so as not to augment the presenting complications. Salvage operations and long-term treatment are included to provide a perspective on treatment of residual deformity. It is important to realize that there often are several solutions to a difficult problem. Many factors influence the surgeon's choice and implementation of a solution, but the ultimate outcome always depends on a well thought out plan.

Reconstruction of the lateral ankle ligaments using a split peroneus brevis tendon graft.

Thirty-one consecutive ankles in 30 patients with chronic lateral ankle instability were reconstructed using a split peroneus brevis tendon graft. All patients had pain and instability despite adequate treatment and a rehabilitation program. Six patients had clinical and radiographic evidence of associated subtalar laxity. Four patients (four ankles) had prior Brostrom ligament reconstructions. The average time from the initial injury or treatment to surgery was 23 months. At a mean follow-up of 44 months (range, 24-64 months), the functional results included excellent in 20 ankles, good in 9, fair in 1, and poor in 1. Ankle stability, which did not deteriorate with time, was achieved in 30 of 31 ankles. This procedure is simple, safe, and reliable with a 94% good to excellent clinical result and 97% mechanical stability. It is an excellent reconstruction choice for those individuals with high demand ankles, with a longstanding ankle instability with or without subtalar instability, and for failed primary reconstruction.

Oblique metatarsal osteotomy for intractable plantar keratosis: 10-year follow-up.

Twenty patients (14 women and 6 men) (23 feet) had a single oblique osteotomy operation of the 2nd, 3rd, or 4th metatarsal without fixation during an 8-year period. The mean age was 46 years (range, 21-64 years). Each patient had a painful intractable plantar keratosis preoperatively. The average follow-up was 10 years (range, 3-14 years). Postoperatively, reoperation was performed in four feet because of painful callosities. For 13 of the 19 feet that did not have reoperation, patients were limited in footwear or required a shoe insert. Overall results were good for 10 feet, fair for 7 feet, and poor for 6 feet. The only complication was a deep infection that occurred in one foot (good result). Nonunion occurred in one foot and delayed union in one. The average decrease in metatarsal length after osteotomy was 6+/-6 mm. The single oblique lesser metatarsal osteotomy may be successful, but one half of the patients continued to have some degree of pain and most patients had limitations in footwear. Overall results were disappointing, and patients who are offered this procedure should be advised of its limitations.

Long term outcome and survivorship analysis of primary total knee arthroplasty in patients with diabetes mellitus.

Sixty-eight consecutive primary total knee arthroplasties in 51 patients with diabetes mellitus were assessed for long term outcome and risk factors. The mean followup was 8 years. There was a higher complication rate compared with that of a matched control group. Wound complications occurred in 4 knees, deep infection in 1, periprosthetic fractures in 3, and definite aseptic loosening in 5. Urinary tract infections occurred in 4 patients. Radiolucencies of more than 1 mm were observed in 38% of arthroplasties. At last followup, the Hospital for Special Surgery knee score was 77 +/- 12 points, which is worse than the 86 +/- 10 points of the control subjects. Only 74% of the patients had a satisfactory clinical result. Survivorship analysis showed a 91% probability of implant survival at 10 years, which was not significantly different from that of the control subjects. Previous surgery and increased weight were the only risk factors associated with implant failure.

Peroneal nerve palsy after total knee arthroplasty. Assessment of predisposing and prognostic factors.

Thirty-two postoperative peroneal-nerve palsies in thirty patients were documented in a retrospective review of 10,361 consecutive total knee arthroplasties performed at one institution from 1979 through 1992. The mean age of the thirty patients was sixty-five years (range, twenty-eight to seventy-eight years). Four of these patients had had a previous proximal tibial osteotomy and five had had a previous lumbar laminectomy. Ten knees (ten patients) had preoperative valgus alignment of 12 degrees or more. A control group of 100 patients who had had total knee arthroplasty during the same period was computer-matched to the patients by age, sex, and operating surgeon. Comparison of this control group with the thirty patients showed that epidural anesthesia for postoperative control of pain (p < 0.03), previous laminectomy (p < 0.04), and preoperative valgus deformity (p < 0.0001) were significantly associated with peroneal nerve palsy. The relative risk for patients who had had a previous proximal tibial osteotomy was doubled, but this was not significant (p < 0.4). To determine risk factors associated with anesthesia better, a subgroup of 4388 total knee arthroplasties performed during a five-year period (1988 through 1992) was also studied. In this sample, twenty-five peroneal-nerve palsies were documented. Eighteen occurred after epidural anesthesia (p < 0.03); five, after general anesthesia; and two, after spinal anesthesia. An important finding of this study is the high frequency of delayed presentation of peroneal nerve palsy. We believe that epidural anesthesia for postoperative control of pain leads to decreased proprioception and sensation postoperatively. It is postulated that positioning of the limb in this unprotected state may be a factor in the late development of palsy. The concept of the so-called double-crush phenomenon may partially explain the palsy seen in the patients who had had a lumbar laminectomy and asymptomatic peripheral neuropathy.

Gunshot wound injuries. Frequency and cost analyses in south central Los Angeles.

Nine hundred fifty-two patients with gunshot wound injuries admitted between July 1, 1989 and June 30, 1990 in a level one trauma center in South Central Los Angeles were studied retrospectively. The authors attempted to define those periods that gunshot injuries were most likely to occur, to characterize the involved high-risk populations, and to estimate direct and indirect cost of care to society.

Chronic intrastriatal L-pyroglutamate: neuropathology and neuron sparing like Huntington's disease.

Continuous injection of L-pyroglutamate (L-PGA) into the rat striatum induces a lesion with three regions: a necrotic core, a rim of pyknotic cells, and a peripheral spongiose region. The L-PGA was administered through an implanted intrastriatal cannula coupled to an Alzet osmotic pump loaded with one of three doses of L-PGA (3, 5, or 13 times the normal amount of L-PGA/g wet wt rat forebrain (23 nmol/g). The magnitude of the lesion was dependent upon the concentration of buffered L-PGA and the duration of continuous pumping. The necrotic region contained macrophages and neutrophils, while condensed neurons and oligodendroglial cells were present in the pyknotic region. The spongiose region contained vacuolated neuropil and degenerating nerve cells and oligodendroglia. The spongiose region blends with the normal neuropil. A population of aspiny neurons were identified throughout the spongiose region. These neurons stained positive for NADPH diaphorase and demonstrated a somatostatin-like immunoreactivity similar to that of the aspiny neurons spared in Huntington's disease and in the neurotoxin-induced striatal-lesioned rat models of Huntington's disease.