Diabetic foot infections. Bacteriologic analysis.

Diabetic patients with foot infections were prospectively evaluated over a two-year period. Cultures from reliable specimens avoiding contamination with foot ulcers were obtained in 54 infectious episodes. Staphylococcus species, Enterococcus species, Corynebacterium species, and various species of Enterobacteriaceae were commonly isolated. Common anaerobic isolates included Peptostreptococcus magnus, Peptostreptococcus prevotii, and Bacteroides species. Results of cultures from 94 unreliable specimens were similar. Results of reliable and unreliable specimens obtained simultaneously in 26 patients agreed in seven (27%), but antibiotics selected for organisms isolated from unreliable specimens would have adequately covered pathogens found in the reliable culture in 24 (93%). Diabetic foot infections usually involve mixed bacterial flora, including aerobic, facultatively anaerobic, and anaerobic microorganisms. Specimens should be obtained from infected tissue that does not communicate directly with the foot ulcer if possible. If such specimens are not available, cultures of purulent exudate within the foot ulcer or soft-tissue sinuses may provide useful information on which to base decisions about antibiotic therapy. Broad-spectrum beta-lactam antibiotics or a combination of antibiotics active against facultatively anaerobic cocci and bacilli as well as anaerobes provide the best empirical antimicrobial coverage in these patients.

Scintigraphic evaluation of diabetic osteomyelitis: concise communication.

We have reviewed the three-phase bone scans, radiographs, and histologic findings of 39 diabetic patients with serious foot problems. The sensitivity and specificity of bone scans were 83% and 75%, respectively, for osteomyelitis of the small bones of the foot. The positive and negative predictive values were 87% and 69%, respectively. The radiographs were less sensitive (62%) and less specific (69%), with predictive values of 80% (positive) and 47% (negative).

Mortality associated with hip fractures in a single geriatric hospital and residential health facility: a ten-year review.

Mortality in 159 patients who sustained 163 hip fractures in a single geriatric hospital and residential health facility in a ten-year period was studied. This study confirms the major problem of mortality associated with hip fractures in the very elderly. Factors that seemed associated with mortality were preoperative and postoperative ambulatory status and the overall medical condition of the patients, as evidenced by the higher percentage of patients in the hospital who died after sustaining hip fractures. The age of these elderly patients did not seem to affect the type of fracture or the final outcome significantly.

Early scintigraphic findings of occult femoral and tibial fractures in infants.

Differentiation of occult skeletal injuries from early acute osteomyelitis in infants and young children is important clinically. The Tc-99m MDP scintigraphic findings in six patients who had occult femoral or tibial fractures were reviewed. The images obtained early (at 1-4 days from the onset of symptoms) shared the common characteristic finding of a subtle but definite, generalized increased uptake of the tracer along the entire length of the injured bone. This pattern of uptake was similar regardless of the type of fracture. These were different from the focal abnormalities that have been observed in early acute osteomyelitis. In the absence of an extensive cellulitis or a vascular occlusive disease, a bone image showing a mild diffuse uniform increased uptake along the entire length of the tibia or femur in infants and young children with lower extremity pain of less than 1 week's duration should suggest the diagnosis of occult skeletal fractures.

External callus formation of closed femoral shaft fractures treated by medullary fixation.

Various radiographic patterns were observed for external callus formation of closed femoral shaft fractures treated by closed and open medullary Rush pin fixation. Closed pinning tends to form more adequate lateral callus, to have less looping of bridging callus over the cortex, and to form smooth, dense callus. Open pinning tends to form less lateral callus, to have more looping (radiolucent space under callus) of the callus over the cortex and fracture site, and to have areas of exuberant callus with the appearance of myositis ossificans. The circulatory status of the cortex and soft tissues seem to be a factor in these callus patterns. Avascular cortex of shaft fractures is inferred by the radiographic findings of bridging callus loops over the cortex, relative increased density of cortical bone, and resorption of cortical bone.

Osteoid osteoma of the foot: presentation following trauma.

A 15 year old black boy presented with a seven-month history of apparent post traumatic foot pain. Radiologic workup including bone scan, tomograms, and CT scan showed osteoid osteoma, which was treated by surgical excision. This treatment resulted in complete pain relief and return to full activities.

The plight of the traumatic amputee.

This retrospective review of the long-term problems of patients with lower extremity amputation from trauma fails to support the opinion that most traumatic amputees do well. Overall, anatomic problems involved 51% of the amputees, and social problems involved 56%. Attempting limb salvage with subsequent secondary amputation did not seem to compromise the long-term outcome for these problems. The surgeon performing the amputation should try to obtain the best possible stump and insure that the patient gets the careful follow up and multidisciplinary team support needed to manage the anticipated problems.

Orthopedic grand rounds. Retained wooden foreign body in the foot detected by computed tomography.

A 20-year-old female presented with a 12-week history of a penetrating wound by a pointed wooden slat to the dorsum of her right foot. She had persistent pain, swelling, and an open wound. Initial radiographs were normal, and three surgical explorations failed to find a foreign body. Later radiographs showed erosion of the second metatarsal. Computed tomography detected and localized the wooden foreign body. Removal of the foreign body was followed by healing of the foot.

Simultaneous bilateral tibial tubercle avulsion fracture.

Bilateral simultaneous tibial tubercle avulsion fractures are extremely rare. The present case was a 16-year-old boy who sustained bilateral simultaneous tibial tubercle avulsion fractures (Watson-Jones Type III) from jumping while playing basketball. Both fractures were treated successfully by open reduction and internal fixation with screws. Three years later, the patient had the screws removed because of knee pain and tenderness over the screws.

Intrapelvic migration of Knowles pin through external iliac vein.

Intrapelvic migration of a Knowles pin is rare. A case is reported of Knowles pin migration into the pelvis and through the external iliac vein. This was caused by a combination of excessive motion of the femoral neck nonunion and osteoporosis of the femoral head which allowed forward migration of the pin.

Civil War surgery: Gettysburg, summer of 1863.

Gettysburg was the site of a bloody three-day battle starting July 1, 1863. Field hospitals became busy during the battle and were established in churches, schoolhouses, barns and private homes. The Union field hospitals treated 20,500 wounded Union and Confederate soldiers. Civil War surgeons had little equipment and knowledge, but we can appreciate their contributions to surgery and service to country.

Fracture healing in the rat tibia: open medullary pin versus closed medullary pin insertion.

Fracture healing was compared in open medullary pin fixation and closed medullary pin fixation of the rat tibia to determine if the closed method promotes healing faster than the open method. Severe and mild closed tibial fractures were fixed immediately by open and closed medullary pin fixation methods, and fracture healing was tested mechanically. Diaphyseal fractures treated immediately by closed medullary pin fixation healed faster than those treated by the open pinning; the difference was statistically significant in mild fractures, but not in severe fractures.

Simplified two-stage below-knee amputation for unsalvageable diabetic foot infections.

A simplified two-stage below-knee amputation for unsalvageable diabetic foot infections was done on 19 limbs with 84% good results for healing. The first stage was the standard below-knee amputation with a long posterior flap in which the fascia and skin were closed in the central portion with the medial and lateral portions of the wound left open for drainage. The second stage was delayed until closure of the open wounds three to seven days after the first stage. Wagner's classification of diabetic foot lesions was used to stratify these cases. Grades 3 and 4 foot infections had a uniformly good prognosis for healing with this surgical technique. Grade 5 foot infections had a poor prognosis for healing, especially if associated with renal failure and dialysis, even with an initial guillotine amputation.

Scintigraphic evaluation of extremity pain in children: its efficacy and pitfalls.

Early detection of an inflammatory process involving bone and joints is very important in children with extremity pain. We reviewed the efficacy and pitfalls of three-phase bone scans in 100 consecutive children with acute extremity pain. Sixty-one of the subjects showed abnormalities on bone scans. The sensitivity and specificity of three-phase bone scans for acute osteomyelitis were 84% and 97%, respectively. Sensitivity and specificity for both acute septic joint and cellulitis were 93% and 100%, respectively. Pitfalls in interpretation of three-phase bone scans include simulation of infection by fracture and obscuration of osteomyelitis by septic arthritis, prior antibiotic treatment, and the occasional "cold" defect due to ischemia.

Intertrochanteric fractures after hip surface arthroplasty. A report of two cases.

Intertrochanteric fractures of the femur recently occurred following trauma in two young adult patients who had undergone Indiana Conservative Hip (ICH) surface arthroplasty. Although femoral neck fractures have occurred following ICH surface arthroplasty, these are the only two patients treated by the authors for intertrochanteric fractures following ICH surface arthroplasty.