Prognostic factors of calcaneal osteomyelitis.

BACKGROUND: Calcaneal osteomyelitis is difficult to manage and requires a multidisciplinary approach. The aim of this study was to describe the characteristics and outcomes of calcaneal osteomyelitis, and to determine prognostic factors. METHODS: This was an observational and retrospective study including all patients presenting with calcaneal osteomyelitis referred to a tertiary referral centre between January 2005 and December 2010. RESULTS: Forty-two patients (mean age 50.7 y, range 22-89 y) were included. Fifteen were female. The mean duration of follow-up was 20 months (range 12-48 months). Twenty-six (62%) were post-traumatic osteomyelitis and 16 (38%) were secondary to neurological damage (sensitivity or motor impairment). All patients underwent surgical management with bone curettage and appropriate antibiotic therapy. Staphylococcus aureus was the most commonly isolated bacterium and was found in 29 patients. Polymicrobial samples were observed in 29 patients. Pseudomonas aeruginosa was associated with calcaneal osteomyelitis secondary to neurological damage (n = 7; 44% p = 0.045). Twenty-eight patients (66.7%) healed without the need to resort to amputation. The mean time to healing was 29 weeks with a range of 4-144 weeks. Relapse of bone infection occurred in 17 patients (40.5%). Seven patients (16.7%) required amputations. Favourable prognostic factors for healing without amputation were an American Society of Anesthesiologists (ASA) score < 2 (p < 10(-4)), post-traumatic calcaneal osteomyelitis (p = 0.001), age < 65 y (p = 0.02), absence of neuropathy (p = 0.005), and absence of diabetes mellitus (p = 0.02). CONCLUSIONS: Calcaneal osteomyelitis is characterized by frequent relapse with delayed wound healing. Clinicians should take into account the impact of older age, as well as co-morbidities such as diabetes mellitus or the presence of neuropathy, during the routine management of patients with this difficult-to-treat bone infection.

Learning and optimizing arthroscopic knot-tying by surgery residents using procedural simulation.

INTRODUCTION: Procedural training of orthopedic surgery residents includes learning arthroscopic knot-tying. The models used comprise arthroscopy training modules of increasing complexity, although there is no procedural training guide for the acquisition of arthroscopic knot-tying skills. Few studies have focused on how residents learn arthroscopic knot-tying. The aim of our study was to determine the type of arthroscopic knot that is the easiest to perform and learn and that can be done the most successfully by orthopedic surgery residents. MATERIALS AND METHODS: Each participant had to learn five knots in a random order: Tennessee slider, Duncan loop, Revo knot (Surgeon's knot), Nicky knot, and the SMC (Samsung Medical Center) knot. The FAST Arthroscopy Workstation™ (Sawbones, Vashon Island, WA) was used for this study. Each participant could use a FAST Knot Tester™ (Sawbones®, Vashon Island, WA) to evaluate by themselves the biomechanical properties of the knots to optimize learning. Each participant had to rank how easy it was to learn this knot on a visual scale from 0 to 10. They also had to rank the reliability of the knots done on a visual scale from 0 to 10. Then, an independent rater assessed whether the knots were completed successfully; a knot was considered successful if it stretched by less than 3 mm when 60 N of load was applied. RESULTS: Ten participants were included in the study; 250 knots were done and evaluated. When ranked from simplest to most complicated, the easiest knot to learn was the Surgeon's knot, followed by the Duncan loop, Tennessee slider, Nicky knot and SMC knot (p<0.0001). The overall success rate for the knots was 80%. There was a statistical trend for the Nicky being done better than the other arthroscopic knots (88% success rate). CONCLUSION: For orthopedics surgery residents, the surgeon's knot (Revo knot) was the easiest to learn, while the Nicky knot had the highest success rate. LEVEL OF EVIDENCE: II; prospective, randomized study with low power.

Tibiotalocalcaneal arthrodesis using a straight intramedullary nail.

BACKGROUND: Tibiotalocalcaneal (TTC) arthrodesis is a proven solution for severe hindfoot arthropathy that reestablishes stability for plantigrade gait and alleviates pain, while correcting deformity. Intramedullary nailing is an effective option for fixation. The aim of this study was to determine clinical outcome, analyze the fusion rate, and determine final hindfoot alignment in a consecutive series of patients using a single-design straight intramedullary nail. METHODS: This study evaluated 63 patients treated between 2006 and 2010 with at least 36 months of follow-up. Ten patients were excluded because of study inclusion criteria, and 4 were lost to follow-up, leaving 49 patients available for review. The average follow-up was 70.7 ± 15.1 months. RESULTS: The American Orthopaedic Foot and Ankle Society score improved from 29.7 ± 15.1 before arthrodesis to 65.8 ± 14.6 after (P < .001) with 83.7% (41/49) of patients stating they were satisfied or very satisfied with the outcome. The hindfoot angle improved from -3 ± 15 degrees (varus) before the arthrodesis to 3.5 ± 4 degrees (valgus) after; the tibiotalar angle averaged 103 ± 4.2 degrees after the arthrodesis. Fusion occurred in both joints in 86% (42/49) of patients and in 93% (91/98) of all joints. The average time to fusion was 4.5 ± 2 months. Current smokers had a significantly (P = .03) higher risk of complications. Use of an allograft, with or without bone morphogenetic protein 2, led to comparable results even in the presence of a large bone defect. CONCLUSION: These results are comparable to previously published studies using intramedullary nailing to achieve tibiotalocalcaneal arthrodesis. The complication concerns typically associated with straight nails were not found. We recommend using a retrograde intramedullary nail for the fixation of TTC arthrodesis and adding an allograft in cases of significant bone loss. LEVEL OF EVIDENCE: Level IV, consecutive case series.