Reconstruction After Osteomyelitis of the Midfoot From High-Pressure Washer Injury.

Reports of ballistic injures to the extremities typically include those involving gunshot wounds. However, high-pressure washer injuries frequently lead to equally damaging injuries. These injuries should not be overlooked, because they can result in high morbidity and complication rates. Similar to the open fracture protocol, these injuries require prompt debridement and irrigation with administration of antibiotics to avoid limb loss. The present case report identified a delay in the treatment protocol that left limited options for the patient. However, the patient agreed to undergo staged reconstruction consisting of serial debridement, implantation of a polymethylmethacrylate antibiotic spacer, and eventual interpositional iliac crest arthrodesis of the midfoot. At a follow-up point >5 years from the initial injury, the patient was walking with minimal pain and no limitations in his daily activities.

Procalcitonin as a Biomarker for Predicting Amputation Level in Lower Extremity Infections.

Inflammatory markers are essential tools in the decision-making process for lower extremity infections. When coupled with objective findings, clinicians can more accurately diagnose and treat these entities. Typically, markers such as the white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are used to initially assess these patients or monitor the progression of medical or surgical therapy. Procalcitonin is a newer inflammatory marker that is specific for an infectious process. Originally, procalcitonin was used to monitor antibiotic therapy and sepsis for patients in the intensive care setting, but it has now been expanded to other facets of medicine. The utility of procalcitonin has been described for diagnosing infection or osteomyelitis in diabetic foot ulcers. However, limited research has compared inflammatory marker levels and the level of amputation. A retrospective inpatient medical record review was performed of 156 consecutive patient occurrences during 25 months in which surgical intervention was required for a lower extremity infection and an initial procalcitonin level had been obtained. This initial procalcitonin value was then compared with the level of amputation at the final surgical intervention. A highly statistically significant difference was found when comparing those who underwent a below-the-knee or above-the-knee amputation (median procalcitonin 1.72 ng/mL) and those who did not (median procalcitonin 0.105 ng/mL; p < .001). Therefore, patients with higher initial procalcitonin values were more likely to undergo below-the-knee or above-the-knee amputation or require aggressive surgical intervention. Thus, the procalcitonin level can provide valuable initial information to the clinician.

Management of failed and infected first metatarsophalangeal joint implant arthroplasty by reconstruction with an acellular dermal matrix: a case report.

Management of failed first metatarsophalangeal joint implant arthroplasty, especially in the face of infection, is an area of debate without a clear consensus. The purpose of the present report was to explore a new option of reconstructing the joint with an acellular dermal matrix substance in a single case study during a 12-month follow-up period. A staged approach that began with removal of the failed 2-component great toe implant, Koenig(®), excisional debridement of the wound with resection of the necrotic bone (proximal phalanx and distal portion of the first metatarsal bones), and culture-specific antibiosis therapy. The final stage included incorporating the acellular dermal matrix, Graftjacket(®) into the joint in an accordion-type fashion, and reconstruction of the joint capsule. Postoperative radiographs revealed a more rectus joint with some improvement in length. At 6 months postoperatively, magnetic resonance imaging revealed incorporation of the graft material into the joint. Finally, at the 1-year mark, the patient was pain free with satisfactory function at the first metatarsophalangeal joint during gait. This is the first reported case of salvaging failed and infected first metatarsophalangeal joint implant arthroplasty with incorporation of the acellular dermal matrix and provides a new option to consider in the future.

The Jones compression bandage. Review and clinical applications.

Lower-extremity edema is a common condition that can be caused by many pathophysiologic processes. Control of edema associated with surgery or trauma is important and will help minimize pain and discomfort and prevent wound complications and blisters. Many techniques are used to control edema. The Jones compression dressing is an excellent tool that has been used successfully by the senior author for 18 years. It continues to be a primary treatment technique for the control of edema.

Techniques of digital arthrodesis: revisiting the old and discovering the new.

Digital surgery is commonplace for foot and ankle surgeons. The techniques of arthrodesis are more exacting and complex than techniques of arthroplasty. They are generally performed in cases of more severe deformity or underlying biomechanical abnormalities, which strongly influence the development and propagation of the deformity. When performed properly in a patient with good compliance, the results are consistently good and rewarding to patients and surgeons. Attention to detail cannot be overemphasized in managing digital deformities. Failure to do so is likely to result in a less than satisfactory outcome for physician and patient. Traditional techniques are proven effective approaches. Meticulous attention to detail and precise execution of the procedure will minimize complications. The exact role of newer implants for fusion is yet to be determined. Further short-term and long-term experience will determine their role in foot surgery.