Investigation and management of diabetic foot osteomyelitis: An update for the foot and ankle orthopaedic surgeon.

Diabetic foot osteomyelitis (DFO) poses a significant challenge in the management of diabetic patients, often leading to severe complications and increased morbidity. Effective management of DFO requires a multidisciplinary approach, involving endocrinologists, infectious disease specialists, vascular surgeons, orthopaedic surgeons, and wound care experts. Early diagnosis is paramount, facilitated by advanced imaging techniques such as magnetic resonance imaging (MRI) and bone scintigraphy. Once diagnosed, the treatment strategy hinges on a combination of medical and surgical interventions. Antibiotic therapy, guided by culture results, plays a central role in managing DFO. Tailored regimens targeting the specific pathogens involved are administered, often for prolonged durations. Surgical intervention becomes necessary when conservative measures fall short. Surgical approaches range from minimally invasive procedures, like percutaneous drainage, to more extensive interventions like debridement and bone resection. Prevention of DFO recurrence is equally vital, emphasising glycemic control, meticulous foot care, patient education, monitoring of at-risk signs, revascularization and early intervention when indicated. The management of diabetic foot osteomyelitis mandates a comprehensive strategy that addresses both the infectious and surgical aspects of the condition. A collaborative, interdisciplinary approach ensures timely diagnosis, tailored treatment, and holistic care. Further research into novel therapeutic modalities and long-term outcomes remains essential in refining the management of this complex and debilitating complication of diabetes.

To plate, or not to plate? A systematic review of functional outcomes and complications of plate fixation in patellar fractures.

PURPOSE: Poor outcomes and high complication and reoperation rates have been reported with tension-band wiring (TBW) in the management of patellar fractures and particularly the comminuted ones. The purpose of this study was to investigate the functional outcomes and complication rates of patellar fractures managed with open reduction and internal fixation (ORIF) with a plate. METHODS: MEDLINE, EMCare, CINAHL, AMED and HMIC were searched, and the PRISMA guidelines were followed. Two independent reviewers extracted the data from the included studies and assessed them for the risk of bias. RESULTS: Plating of patellar fractures is associated with satisfactory range of movement (ROM) and postoperative function and low pain levels. We found a 10.44% complication rate and a low reoperation rate. Reoperations were mainly performed for metalwork removal. CONCLUSION: ORIF with plating of patellar fractures is a safe alternative in the management of patellar fractures and may be associated with a lower complication and reoperation rate compared to TBW. Future randomized prospective studies are needed to validated the results of the present systematic review.

Combined Charcot hindfoot and midfoot reconstruction using internal fixation method-surgical technique and single surgeon series.

Isolated midfoot and hindfoot Charcot reconstruction using internal fixation is increasingly a common procedure in multidisciplinary diabetic foot units, and the surgical techniques using internal fixation have well been described. However, about a third of Charcot deformities that require surgical limb salvage present with the involvement of midfoot and hindfoot. Surgical reconstruction of a combined hindfoot and midfoot deformity is an evolving technique and technically challenging. We present the surgical technique of deformity correction and stabilisation using internal fixation, developed by the senior author (VK), and present the outcomes. All patients that had undergone combined hindfoot and midfoot reconstruction to address a limb threatening deformity due to Charcot neuroarthropathy, performed by the senior author, with a minimum follow-up of 12 months, have been included in this study. The principles of surgical reconstruction included adequate pre-operative optimisation of the patient, sequential deformity correction and stabilisation of the hindfoot followed by midfoot using the principle of long-segment rigid internal fixation with optimal bone opposition. Standard post-operative regime, including offloading, has been used in all patients. A total of 34 patients (35 feet) had undergone combined midfoot and hindfoot Charcot reconstruction between January 2009 and December 2019. Active ulcers were noted in 13 feet at the time of the procedure. Eleven reconstructions were performed as two-stage procedures due to the presence of active infection. At a mean follow-up of 53 months, 11/13 ulcer healed, and 32 patients (33 feet) were full weightbearing in surgical shoes or a brace at the latest follow-up. Bone fusion was noted in 28 feet in the hindfoot region and 32 feet in the midfoot. Metal work failure was noted in 5 feet requiring removal in 3 feet. Revision procedures were required in 4 patients. Our newly described technique of combined hindfoot and midfoot Charcot has provided functional limb salvage in majority of presentations, with an acceptable level of complications, at a medium-term follow-up of 53 months.

Etiology, Epidemiology, and Outcomes of Managing Charcot Arthropathy.

Surgical intervention for Charcot arthropathy is becoming more common; this is driven by an increased prevalence, better understanding of the cause, identifying patient risk factors that influence outcomes, and how to best optimize these. This article aims to summarize the cause of Charcot, look at the factors that influence the outcomes, and the financial cost of managing what is a very challenging condition.

Predictors of metalwork failure and nonunion after hindfoot Charcot reconstruction.

AIMS: Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions. METHODS: We retrospectively analyzed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between January 2007 and December 2019 in our unit. Patient demographic details, comorbidities, weightbearing status, and postoperative complications were noted. Metalwork breakage, nonunion, deformity recurrence, concurrent midfoot reconstruction, and the measurements related to intramedullary nail were also recorded. RESULTS: There were 70 patients with mean follow-up of 54 months (SD 26). Overall, 51 patients (72%) and 52 patients (74%) were fully weightbearing at one year postoperatively and at final follow-up, respectively. The overall hindfoot union rate was 83% (58/70 patients). Age, BMI, glycated haemoglobin, and prior revascularization did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the nonunited group (0.90 (SD 0.06) and 0.86 (SD 0.09), respectively; p = 0.034). In those with a supplementary hindfoot compression screw, there was a 95% union rate (19/20 patients), compared to 78% in those without screws (39/50 patients; p = 0.038). All patients with a miss-a-nail hindfoot compression screw went on to union. Hindfoot metalwork failure was seen in 13 patients (19%). An intact medial malleolus was found more frequently in those with intact metalwork ((77% (44/57 patients) vs 54% (7/13 patients); p = 0.022) and in those with union ((76% (44/58 patients) vs 50% (6/12 patients); p = 0.018). Broken metalwork occurred more frequently in patients with nonunions (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001) and midfoot deformity recurrence (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001). CONCLUSION: Rates of hindfoot union and intact metalwork were noted in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail and supplementary hindfoot screws. An intact medial malleolus is protective against nonunion and hindfoot metalwork failure. Cite this article: Bone Joint J 2022;104-B(6):703-708.

Visualising the Future of Orthopaedic Surgery: A Novel Application of Wireless Smart Glasses to Visualise Intraoperative Imaging.

Smart glasses can provide a heads-up display of advanced imaging intraoperatively. In recent years, growing attention has been drawn to the use of smart glasses as an assistive technology to improve both efficiency and ergonomics in a surgical setting. Previous studies have reported improved surgical accuracy, efficiency, and ergonomics with its usage, but its effectiveness as a form of intraoperative heads-up display remains elusive in the context of orthopaedics. This study provides a novel account of a wireless set-up of the Moverio BT-35E Smart Glasses (Suwa, Japan: Epson Inc.), incorporated in a complex orthopaedic procedure. Hind-foot nailing was performed on a patient with a complex open ankle fracture and multiple co-morbidities. Smart glasses were worn by the primary surgeon throughout the procedure to provide heads-up visualisation of the intraoperative fluoroscopy. In our surgical case, the surgeon experienced improved ergonomics and reduced disruption to focus with the use of smart glasses. The wireless set-up provided excellent signal transmission throughout the duration of the procedure. The wireless set-up of smart glasses is a potential solution for common occupational risks imposed on orthopaedic surgeons. Smart glasses minimise musculoskeletal strain from switching of vision from monitor to patient, whilst the wireless set-up allows for efficient use of space in an operating theatre and may potentially limit radiation exposure. Lastly, ergonomic benefits may increase the efficiency of movement for the surgeon, decreasing operative duration, and in turn minimising the risk of surgical complications for patients.

Opportunities and challenges of using augmented reality and heads-up display in orthopaedic surgery: A narrative review.

BACKGROUND & AIM: Utilization of augmented reality (AR) and heads-up displays (HUD) to aid orthopaedic surgery has the potential to benefit surgeons and patients alike through improved accuracy, safety, and educational benefits. With the COVID-19 pandemic, the opportunity for adoption of novel technology is more relevant. The aims are to assess the technology available, to understand the current evidence regarding the benefit and to consider challenges to implementation in clinical practice. METHODS & RESULTS: PRISMA guidelines were used to filter the literature. Of 1004 articles returned the following exclusion criteria were applied: 1) reviews/commentaries 2) unrelated to orthopaedic surgery 3) use of other AR wearables beyond visual aids leaving 42 papers for review.This review illustrates benefits including enhanced accuracy and reduced time of surgery, reduced radiation exposure and educational benefits. CONCLUSION: Whilst there are obstacles to overcome, there are already reports of technology being used. As with all novel technologies, a greater understanding of the learning curve is crucial, in addition to shielding our patients from this learning curve. Improvements in usability and implementing surgeons' specific needs should increase uptake.

Current concepts and challenges in managing ankle fractures in the presence of diabetes: A systematic review of the literature.

BACKGROUND: Ankle fractures in diabetic patients are known to have an increased morbidity. This systematic review aims to evaluate the current evidence in terms of risk profile and inform treatment options. METHODS: Following the methodology of the Cochrane collaboration, an extensive literature search was conducted. Outcomes included, complications, operative and non-operative management and early weight-bearing. RESULTS: A total of 40 studies were included. Complication rates were higher in diabetic patients and more so in poorly controlled diabetes, IDDM, or "complicated" diabetes. Supplementary fixation was associated with lower complication rates. Regarding early weight-bearing, similar results to non-diabetics in the stable fracture pattern were found providing there was no evidence of neuropathy. CONCLUSION: Diabetes, especially complicated diabetes, presents an increased risk of complications. However non operative management of diabetic ankle fractures do poorly, and with the use of 'ORIF plus' techniques there is no increase in complications from early fixation. The use of external fixation for definitive fixation should be minimised as it is associated with high complication rates.

Charcot hindfoot deformity reconstruction using a hindfoot nail- surgical technique.

Various techniques of reconstruction of deformed Charcot hindfoot using different internal fixation devices have been described in the literature. We present our surgical technique using specific principles that has resulted in improved outcomes to allow correction of deformity, obtain stability and allow progression to weightbearing in orthotic shoes. We describe our preoperative evaluation, planning and surgical timing. We also hope to share some technical pearls and details on the finer points to achieve a satisfactory correction and reduce the learning curve.

Increasing Access to Specialized Dermatology Care: A Retrospective Study Investigating Clinical Operation and Impact of a University-Affiliated Free Clinic.

INTRODUCTION: Our objective was to study the impact and clinical operation of an integrated model for free specialized dermatology care via collaboration between an academic institution and a nonprofit outpatient clinic through an analysis of patient demographics and care provided. METHODS: Hope@UMHS is a partnership between the University of Michigan Health System (UMHS) and Hope Clinic (HC) which provides free specialty consultations to uninsured residents of Southeast Michigan. A retrospective chart review was completed for patients referred to the UMHS Dermatology clinic as part of the HOPE@UMHS collaboration from April 2012 through February 2020. RESULTS: Of the 294 referred patients, 264 were managed in 30 clinic sessions over 8 years, staffed by 92 unique volunteers. Patients most commonly presented with atopic dermatitis (10.5%), seborrheic dermatitis (7.9%), and actinic keratosis (7.4%). The majority of patients (68.2%) were prescribed at least one new medication. Nine skin cancers, including one melanoma, were diagnosed and treated. There were 102 procedures performed. Eighty-seven percent of patients received conclusive evaluation and treatment at the time of their consultation. CONCLUSION: Our experience illustrates that providing free, comprehensive dermatology care in a university hospital by partnering with a nonprofit clinic is both feasible and beneficial to the greater community.

Charcot foot reconstruction outcomes: A systematic review.

BACKGROUND: Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications. METHODS: We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques. RESULTS: A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation. CONCLUSIONS: Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.

Does 3D CT reconstruction help the surgeon to preoperatively assess calcaneal fractures?

BACKGROUND: With the advent of 3D volume rendered CT scans, more information is potentially available to aid the surgeon in complex calcaneal fractures. The primary aim was to determine if there is a difference in inter-observer and intra-observer reliability of 3D CT reconstructions compared to 2D CTs of calcaneus fractures based on classification, identification of specific fracture characteristics and proposed treatment. It is hypothesized that the correlation will be greater between experienced surgeons and trainees when using 3D CT. As a secondary aim, the authors wished to investigate the surgeons' satisfaction with 3D CT. PATIENTS AND METHODS: There were six raters, split into 2 groups: high and low surgical experience. Both 2D and 3D scans (10 patients) were reviewed by each rater by filling out a validated questionnaire. This sitting was over a period of six months and all scans were sent separately and randomly by our research coordinator. This process was repeated after a four-week break. RESULTS: The overall evaluation and satisfaction of CT scans of calcaneal fractures was improved by the additional use of volume rendered 3D images. Inexperienced surgeons benefited more than experienced surgeons in terms of reliabilities with fracture configuration. 3D CTs were more likely to change the surgeons' operative strategy. The consistency of deciding on the fracture classification and satisfaction was more uniform between all the raters when 3D CT was used. CONCLUSION: Inter-observer and intra-observer reliability of 3D CT reconstructions compared to 2D CTs of calcaneus fractures was greater based on classification, identification of specific fracture characteristics and proposed treatment. Inexperienced surgeons were more consistent when interpreting the scans using 3D CTs (improved inter-observer reliability) and were always more satisfied using the 3D CTs. As there is no extra cost or radiation exposure, we propose that 3D CTs may be valuable with preoperative teaching and planning.

Training and Deployment of Medical Students as Respiratory Therapist Extenders during COVID-19.

Background: Early experience during the coronavirus disease (COVID-19) pandemic and predictive modeling indicate that the need for respiratory therapists (RTs) will exceed the current supply. Objective: We present an implemented model to train and deploy medical students in the novel role of "respiratory therapist extender" (RTE) to address respiratory therapist shortage during the COVID-19 pandemic. Methods: The RTE role was formulated through discussions with respiratory therapists. A three-part training, with both online and in-person components, was developed and delivered to 25 University of Michigan Medical Students. RTEs were trained in basic respiratory care, documentation, equipment preparation, and equipment processing for clinically stable patients. They operate in a tiered staffing model in which RTEs report to a single RT, thereby extending his/her initial capacity. Results: The first cohort of safely trained RTEs was deployed to provide patient care within 1 week of volunteer recruitment. Conclusion: Our experience has demonstrated that healthcare professionals, including medical students, can be quickly trained and deployed in the novel RTE role as a surge strategy during the COVID-19 pandemic. Because we urgently developed and implemented the RTE role, we recognize the need for ongoing monitoring and adaptation to ensure patient and volunteer safety. We are sharing the RTE concept and training openly to help address RT shortages as the pandemic evolves.

Formation of a Spin-Forbidden Product, (1)[MnO4](-), from Gas-Phase Decomposition of (6)[Mn(NO3)3](.).

The manganese nitrate complex, [Mn(NO3)3](-), was generated via electrospray ionization and studied by tandem quadrupole mass spectrometry. The complex is assumed to decompose into [MnO(NO3)2](-) by elimination of NO2(•). The [MnO(NO3)2](-) product undergoes elimination of NO2(•) to yield [MnO2(NO3)](-), or elimination of NO(•) to yield [MnO3(NO3)](-). Both [MnO2(NO3)](-) and [MnO3(NO3)](-) yield [MnO4](-) via the transfer of oxygen atoms from the remaining nitrate ligand. The mechanism of permanganate formation is interesting because it can be generated through two competing pathways, and because the singlet ground state is spin-forbidden from the high-spin sextet [Mn(NO3)3](-) precursor. Theory and experiment suggest [MnO2(NO3)](-) is the major intermediate leading to formation of [MnO4](-). Theoretical studies show crossing from the high-spin to low-spin surface upon neutral oxygen atom transfer from the nitrate ligand in [MnO2(NO3)](-) allows formation of (1)[MnO4](-). Relative energy differences for the formation of (1)[MnO4](-) and (1)[MnO3](-) predicted by theory agree with experiment.

Fragmentation of [Ni(NO3)3](-): A Study of Nickel-Oxygen Bonding and Oxidation States in Nickel Oxide Fragments.

Gas-phase nickel nitrate anions are known to produce nickel oxide nitrate anions, [NiOx(NO3)y](-) upon fragmentation. The goal of this study was to investigate the properties of nickel oxide nitrate complexes generated by electrospray ionization using a tandem quadrupole mass spectrometer and theoretical calculations. The [Ni(NO3)3](-) ion undergoes sequential NO2(•) elimination to yield [NiO(NO3)2](-) and [NiO2(NO3)](-), followed by elimination of O2. The electronic structure of the nickel oxide core influences decomposition. Calculations indicate electron density from oxygen is delocalized onto the metal, yielding a partially oxidized oxygen in [NiO(NO3)2](-). Theoretical studies suggest the mechanism for O2 elimination from [NiO2(NO3)](-) involves oxygen atom transfer from a nitrate ligand to yield an intermediate, [NiO(O2)(NO2)](-), containing an oxygen radical anion ligand, O(•-), a superoxide ligand, O2(•-), and a nitrite ligand bound to Ni(2+). Electron transfer from superoxide partially reduces both the metal and oxygen and yields the energetically favored [NiO(NO2)](-) + O2 products.

Gas-Phase Fragmentation of Aluminum Oxide Nitrate Anions Driven by Reactive Oxygen Radical Ligands.

Gas-phase metal nitrate anions are known to yield a variety of interesting metal oxides upon fragmentation. The aluminum nitrate anion complexes, Al(NO3)4(-) and AlO(NO3)3(-) were generated by electrospray ionization and studied with collision-induced dissociation and energy-resolved mass spectrometry. Four different decomposition processes were observed, the loss of NO3(-), NO3(•), NO2(•), and O2. The oxygen radical ligand in AlO(NO3)3(-) is highly reactive and drives the formation of AlO(NO3)2(-) upon loss of NO3(•), AlO2(NO3)2(-) upon NO2(•) loss, or Al(NO2)(NO3)2(-) upon abstraction of an oxygen atom from a neighboring nitrate ligand followed by loss of O2. The AlO2(NO3)2(-) fragment also undergoes elimination of O2. The mechanism for O2 elimination requires oxygen atom abstraction from a nitrate ligand in both AlO(NO3)3(-) and AlO2(NO3)2(-), revealing the hidden complexity in the fragmentation of these clusters.

An Unusual Prepatellar Bursa Swelling: Patellar Button Dissociation and Migration.

Implant loosening is not a new phenomenon, nor is implant migration; however they are rarely seen after knee arthroplasty surgery. Complications with patellar buttons have been reported before with peg failure, loosening, and patella fracture; however extra-articular migration is extremely rare. We report an unusual case of patellar button migration 11 years after total knee arthroplasty to the prepatellar bursa.

Simultaneous bilateral total hip arthroplasty dislocation with unilateral foot drop following closed reduction.

Dislocation following primary and revision arthroplasty is a well-recognised complication with an estimated incidence rate of 0.2-10%. We present a rare case of simultaneous bilateral total hip replacement dislocation, complicated by unilateral foot drop following closed reduction, with no improvement in neurological function at 6-month follow-up.

Modern Orthopedic Inpatient Care of the Orthopedic Patient With Diabetic Foot Disease.

In this article, we describe emergency and elective pathways within our orthopedic multidisciplinary inpatient care of patients with diabetic foot problems. We performed a retrospective cohort review of 19 complex patients requiring orthopedic surgical treatment of infected ulceration or Charcot feet or deformity at our institution. A total of 30 admissions (19 emergency, 11 elective) were included. The pathways were coordinated by a multidisciplinary team and comprised initial assessment and investigation and a series of key events, which consisted of emergency and elective surgery together with the introduction, and change of intravenous antibiotics when indicated. Patients had rigorous microbiological assessment, in the form of deep ulcer swabs, operative tissue specimens, joint aspirates, and blood cultures according to their clinical presentation as well as close clinical and biochemical surveillance, which expedited the prompt institution of key events. Outcomes were assessed using amputation rates and patient satisfaction. In the emergency group, there were 5.6 ± 3.0 (mean ± SD) key events per admission, including 4.2 ± 2.1 antibiotic changes. In the elective group, there were 4.8 ± 1.4 key events per inpatient episode, with 3.7 ± 1.3 antibiotic changes. Overall, there were 3 minor amputations, and no major amputations. The podiatric and surgical tissue specimens showed a wide array of Gram-positive, Gram-negative, aerobic and anaerobic isolates and 15% of blood cultures showed bacteremia. When 9 podiatric specimens were compared with 9 contemporaneous surgical samples, there was concordance in 2 out of 9 pairs. We have described the successful modern care of the orthopedic diabetic foot patient, which involves close clinical, microbiological, and biochemical surveillance by the multidisciplinary team directing patients through emergency and elective pathways. This has enabled successful surgical intervention involving debridement, pressure relief, and stabilization, with low rates of amputation.