Bacterial osteomyelitis in adults: evolving considerations in diagnosis and treatment.

Bacterial osteomyelitis causes substantial morbidity worldwide, despite continued progress toward understanding its pathophysiology and optimal management. The approach to osteomyelitis depends upon the route by which bacteria gained access to bone, bacterial virulence, local and systemic host immune factors, and patient age. While imaging studies and nonspecific blood tests may suggest the diagnosis, an invasive technique is generally required to identify the causative pathogens. Given the paucity of comparative clinical trials, antibacterial regimen selection has been largely guided by knowledge of the relative activities and pharmacokinetics of individual drugs, supported by data from animal models. Definitive therapy often requires a combined medical and surgical approach. Newer microvascular and distraction osteogenesis techniques and the use of laser doppler allow more complete surgical resection of infected material while maintaining function. Despite recent advances, many patients with osteomyelitis fail aggressive medical and surgical therapy. More accurate diagnostic methods, better ways to assess and monitor the effectiveness of therapy, and novel approaches to eradicate sequestered bacteria are needed.

Penetrating orthopedic injuries.

The treatment of gunshot wounds involving bones or joints remains controversial. Antibiotics and thorough debridement may not be necessary for many of these wounds (stable fractures with minimal soft-tissue damage). However, as in the treatment of open fractures and joint injuries from blunt trauma, the damage to the skin frequently is not a good indicator of the amount of soft tissue to be found underneath.

A long-term follow-up of Legg-Calvé-Perthes disease.

In an effort to define the impairment in hips affected by Legg-Calvé-Perthes disease, we attempted to contact 112 patients whose disease had been diagnosed between 1920 and 1940. Data were available on thirty-five patients with thirty-seven affected hips. The average period of follow-up was 47.7 years. Statistically significant correlations were found between clinical outcome (as measured by the Iowa hip rating and by the incidence of arthroplasty) and Catterall head-at-risk signs, femoral head-size ratio, and age at onset of the disease. The measurements of deformity, both femoral and acetabular, and the congruity of the articular surfaces did not change significantly with time. The Catterall classification alone did not correlate well with the clinical outcome. Fifteen affected hips in fourteen patients had undergone hip arthroplasty because of pain and dysfunction. Eleven arthroplasties had been done in the fifth or sixth decade of life and four (three patients), in the third or fourth decade.

Correlation between the measures of impairment, according to the modified system of the American Medical Association, and function.

We performed a prospective study of 302 patients who had a fracture of the lower extremity. Our purpose was to determine whether there was any association between impairment ratings of the lower extremity, derived with use of the Guides to the Evaluation of Permanent Impairment by the American Medical Association, and measurements of task performance based on direct observation as well as the patient's own assessment of activity limitation and disability as recorded on the Sickness Impact Profile. The mean residual impairment of the lower extremity according to the Guides was 27 per cent one year after the injury. Only 130 subjects (43 per cent) could perform all five functional tasks without difficulty. Eighty-four subjects (28 per cent) reported functional limitations that resulted in a score on the Sickness Impact Profile that was more than one standard deviation from the preinjury norm for the sample. Impairment ratings according to a modification of the system of the American Medical Association correlated strongly with the performance of functional tasks (r = 0.57) as well as the patients' reported activity limitations as recorded on the Sickness Impact Profile (r = 0.55). Correlations were highest when measures of impairment were based on strength rather than on range of motion. The relationship between the impairment rating and function (as observed by an examiner and as reported by the patient) was not influenced by the location of the fracture or the receipt of disability compensation. Our results suggest that the American Medical Association developed a valid approach for the measurement of physical impairment after a fracture of the lower extremity. In our study, the anatomical approach of evaluation based on muscle strength that was described in the Guides to the Evaluation of Permanent Impairment was the most sensitive measure of impairment compared with the anatomical measure based on range of motion and compared with the functional and diagnostic methods for the rating of impairment. Until the diagnostic and functional approaches for the measurement of musculoskeletal impairment are refined, we recommend use of the anatomical approach when evaluating impairment after a fracture of the lower extremity.

A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores.

BACKGROUND: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems. METHODS: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation. RESULTS: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation. CONCLUSIONS: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury.

Analysis of the structural behavior of the pelvis during lateral impact using the finite element method.

In this study, three-dimensional finite element models were created from computer tomography data to study lateral impact fractures of the pelvis. The models reflect the complex geometry and material properties of the pelvis. The models were compared to published experimental results for validation. Dynamic analyses of the pelvic structure were performed for different peak forces in the range of 5520 to 15550 N to correspond to the velocities and impulses of real world accidents. The locations of structurally significant regions of the pelvis were identified based upon the stress distribution and upon the energy stored by the pelvis to failure. The impact force which induced fracture of the pelvic bone was 8610 N. The region which failed first in left lateral impact was the right pubic ramus. The fracture pattern was a variant of the lateral compression pelvic injury. The results suggest that the anterior structures of the pelvis are the most sensitive regions. The energy absorbed by the pelvis prior to failure was 8.98 J. The finite element method may be used to determine the strength and energy-absorbing capability of the pelvis for lateral impact loading.

Allografting for traumatic intercalary femoral defects: a report of three cases.

Fewer than 10 cases of allografts used to fill traumatic massive skeletal defects have been reported (10). The threat of infection following an open fracture is the greatest concern when using allografts to fill these defects since allografts are massive necrotic bone fragments and remain so for prolonged periods of time. Three patients with traumatic intercalary femoral defects treated with allograft substitution were followed until bony union. Two of the patients experienced complications related to the allografts. However, both of these patients have returned to work with painless lower limbs. The third has healed and returned to a more sedentary occupation.

Acute anterior compartmental syndrome of the thigh following contusion. A case report and review of the literature.

Contusion is a rare cause of acute compartmental syndrome in the thigh. To date, no case report has described blunt trauma precipitating this limb-threatening condition. The patient in this case report developed rapidly progressive signs and symptoms which required emergency fasciotomy. Delayed primary closure was possible and recovery was complete. The etiologies, diagnosis and management of thigh compartmental syndrome are reviewed.

The reconstruction locked nail for complex fractures of the proximal femur.

Thirty-seven patients with 37 proximal femoral fractures were treated with a reconstruction locked femoral nail. There were four ipsilateral intracapsular femoral neck and shaft fractures, two intertrochanteric fractures, 18 intertrochanteric fractures with diaphyseal extension, eight subtrochanteric fractures with involvement of the lesser trochanter, and five subtrochanteric fractures without involvement of the lesser trochanter. The overall union rate was 92%. Twenty-one complications developed in 13 patients (35%) which included three of the four femoral neck and shaft fractures, and six of 18 intertrochanteric fractures with diaphyseal extension. Of the five intertrochanteric fractures with diaphyseal extension in which anatomic reduction was not achieved, four developed a complication. Of the nine proximal screws in nine fractures, which were placed short (below the subchondral bone of the femoral head), six fractures developed a complication. The complications included three nonunions, one delayed union, two leg-length discrepancies of > 2.5 cm, two cases of varus deformity of > 10 degrees, two varus deformities < 10 degrees, four instances of revision surgery including one broken 13-mm nail, four proximal screws that backed out and required removal, two cases of pudendal nerve palsy, and one case of heterotopic ossification. Seven patients developed more than one complication. Eleven of the 13 patients with complications required a second surgery to treat the complication. We conclude that the reconstruction locked femoral nail is not a good choice for ipsilateral intracapsular neck and shaft fractures. Our recommendation is that anatomic reduction should be achieved for all cases using the reconstruction femoral nail, but it is absolutely required when treating the intertrochanteric fracture with diaphyseal extension. Reconstruction femoral nails have a high rate of complication due to the complex nature of the fractures as well as the device.

Structural allografts for reconstruction of lower extremity open fractures with 10 centimeters or more of acute segmental defects.

Long-term results on the use of structural allografts (> or = 10 cm) to reconstruct large skeletal defects sustained during high-energy, open lower extremity fractures have not been reported. Eight patients are retrospectively reviewed at postallograft time periods ranging from 18 to 93 months. Two patients required reoperation for noninfectious causes, and each healed uneventfully. Four individuals developed infectious complications, but only one required complete allograft removal (amputation). The others remain infection free at follow-up. Using any of three different rating systems, excellent functional outcome results from this method of reconstruction in an otherwise exceptionally challenging extremity for limb salvage.

Successful use of reaming and intramedullary nailing of the tibia.

The records and radiographs of 87 patients with 88 fractures of the tibial diaphysis who underwent intramedullary reaming and nailing were retrospectively reviewed. The mean patient age was 37 years. Seventy fractures were closed, and 18 were open. The indications for nailing were failures of closed treatment (n = 48), nonunions (n = 24), multiple injuries (n = 14), and fixation of osteotomy (n = 2). Seventy-six patients with 77 nails who were followed for an average of 26.2 months were studied. For acute fractures, the average time to complete clinical and radiographic union was 5.3 months. For established nonunions, the average healing time was 9 months. The only fractures that failed to unit were nonunions developing from previously open Type III injuries. Angular deformities greater than 5 degrees did not occur. Significant tibial shortening occurred in only one fracture. Decreased motion in the ankle or knee was present in six patients. Major complications as a result of tibial nailing occurred in three patients: two deep infections and one patellar tendon rupture. Minor complications included 10 patients with pain at the nail insertion site necessitating removal in four patients, three patients with transient sensory peroneal nerve dysesthesias, and one patient with a superficial wound infection that cleared with local care. Nine patients required reoperation. Intramedullary reaming and nailing of the tibia can be used advantageously in the treatment of difficult fractures of the tibial shaft and their sequelae. Attention to the technical details of nail insertion will minimize the most frequent complications.

Tricalcium phosphate as a bone graft substitute in trauma: preliminary report.

Ceramic tricalcium phosphate (TCP) has been implanted in bony defects in 43 patients following trauma. It is an osteoconductive material that facilitates trabecular bone formation. The average follow-up time was 12 months, with a 6-month minimum. There were 33 fractures in 30 patients and 13 nonunions in 13 patients. Three of the patients with acute fractures were unavailable for follow-up observation. Ninety percent of the fractures and 85% of the nonunions were healed at the time of this review. The resorption of TCP was estimated from the roentgenograms to be approximately 10% per month, with complete resorption occurring in 6-24 months. There were eight complications, five among the 30 fractures and three among the 13 nonunions that were observed later. There were three fractures and two nonunions that failed to heal. There were two fractures that had initially been open and one previously infected nonunion that united but were complicated due to infection. These preliminary results demonstrate TCP's usefulness as a substitute for cancellous bone. This is accompanied by other advantages, including increased patient safety, lack of donor site morbidity, unlimited shelf life and reduced operating time.

Outcome validation of the AO/OTA fracture classification system.

OBJECTIVES: To determine whether a greater severity of injury as documented by the AO/OTA code would correlate with poor scores of impairment, functional performance, and self-reported health status. DESIGN: Prospective, functional outcome. SETTING: Three Level One Trauma Centers. PATIENTS/PARTICIPANTS: Two hundred patients with unilateral and isolated lower extremity fractures. MAIN OUTCOME MEASUREMENTS: Six- and twelve-month SIP, AMA impairment, and functional performance measures of self-selected walking speed, stair climbing, heel raises, rising from a chair, balance work. RESULTS: At six months post injury, overall impairment was significantly (p < 0.05) higher for patients with Type C versus Type B fractures. A significant difference was found among the A, B, C types and the ROM impairment rating at six months (p = 0.004). Using the Scheffe method, the significant difference was determined to be between the B- and C-type fractures. Overall functional performance scores at six months were shown to have significant (p = 0.01) variation using an ANOVA with the significant variation being between the B and C type. At twelve months, the overall functional performance was significant (p = 0.05). CONCLUSION: Patients with C-type fractures had significantly worse functional performance and impairment compared with patients with B-type fractures but were not significantly different from patients with A-type fractures. AO/OTA code may not be a good predictor of six- and twelve-month functional performance and impairment for patients with isolated unilateral lower extremity fractures.

Vena caval filter use in orthopaedic trauma patients with recognized preoperative venous thromboembolic disease.

This study comprises a series of 35 patients with pelvic or lower extremity fractures requiring surgery who also had a documented significant acute deep venous thrombosis (DVT). The authors treated these with low-dose Coumadin and 36 vena caval filters, which were used prophylactically prior to surgery. The patients received low-dose warfarin after placement of the vena caval filters and were maintained at 1.3-1.5 times the prothrombin control value for 6 weeks to 3 months. In this group of patients, there were no fatal pulmonary emboli and no clinically significant complications from filter placement. There were nine asymptomatic filter complications demonstrated radiographically in eight patients. Additionally, one patient with a tilted vena caval filter required placement of another filter. The combination of vena caval filters and low-dose warfarin appears to be a successful and relatively safe method of managing those patients who have acute DVT and require surgery for their pelvic or lower extremity fractures.

Patient-oriented functional outcome after unilateral lower extremity fracture.

To determine patient-perceived functional outcome after lower extremity fracture (LEF), a prospective, follow-up study of patients managed at three level I trauma centers was conducted. Patients with unilateral LEF involving the acetabulum and distally were eligible for the study. A total of 444 patients were enrolled. Of these, 363 (82%) were interviewed at 6 months postdischarge. Study patients were predominantly young (mean age 34 years), white (72%) men (71%) who had been working preinjury (78%). Their injuries resulted primarily from motor vehicle crashes (73%); 30% had more than one fracture to the same extremity. Functional status was measured using the Sickness Impact Profile (SIP), a well-validated, general health status instrument. Mean 6-month SIP scores were significantly worse (higher) than those based on preinjury activities (9.8 vs. 2.5) (p < 0.01). Overall disability levels were moderate compared with other health conditions. Analysis of the 12 subscores comprising the SIP indicated particularly high scores in ambulation (16.2 postdischarge vs. 1.1 preinjury), sleep/rest (13.1 vs. 5.1), household management (14.5 vs. 2.6), recreation (17.6 vs. 4.2), emotional well-being (9.9 vs. 2.1), and most significantly work (33.2 vs. 8.8). Of those working preinjury, only 49% had returned by 6 months. SIP scores were highest for persons with three or more fractures to the same extremity and for fracture patterns typical of high-energy forces.

Characterization of patients with high-energy lower extremity trauma.

PURPOSE: (a) to report the demographic, socioeconomic, behavioral, social, and vocational characteristics of patients enrolled in a study to examine outcomes after high-energy lower extremity trauma (HELET) and to compare them with the general population; (b) to determine whether characteristics of patients undergoing limb salvage versus amputation after HELET are significantly different from each other. DESIGN AND STUDY POPULATION: A prospective study of 601 patients admitted with high-energy lower extremity trauma to eight Level I trauma centers. PROCEDURES: Patients were evaluated during the initial hospitalization. They are being followed up for 24 months postinjury. Study patients are compared with the general population by using census information, population survey data, and published norms. Characteristics of patients undergoing limb salvage versus amputation are also compared. RESULTS: Most patients were male (77 percent), white (72 percent), and between the ages of twenty and forty-five years (71 percent). Seventy percent graduated from high school (compared with 86 percent nationally) (p < 0.05). One fourth lived in households with incomes below the federal poverty line, compared with 16 percent nationally (p < 0.05). The percentage with no health insurance (38 percent) was also higher than in the general population (20 percent) (p < .05). The percentage of heavy drinkers was over two times higher than reported nationally (p < 0.01). Study patients were slightly more neurotic and extroverted and less open to new experiences. When patient characteristics were compared for those undergoing amputation versus limb salvage, no significant differences were found among any of the variables (p > 0.05). CONCLUSION: In conclusion, LEAP patients differ in important ways from the general population. However, the decision to amputate verus reconstruct does not appear to be significantly influenced by patient characteristics.

The long-term follow-up of ipsilateral tibial and femoral diaphyseal fractures.

Twenty-nine of 45 patients who had ipsilateral femoral and tibial shaft fractures were evaluated clinically and roentgenographically to correlate treatment method with bony alignment and functional outcome. The results included: (1) limitation of sports activities in patients whose knee ligaments were injured, followed by both instability and thigh atrophy; (2) a direct relationship between the postunion malalignment of the tibia and ankle motion; and (3) a high rate of life threatening complications (thromboembolic, pneumonia, death) and a slower rate of tibial union associated with treatment by closed methods.

Initial care of massively traumatized lower extremities.

From July 1985 through July 1987, 19 patients with 20 massively traumatized lower limbs were treated using a standardized protocol, including early consultation with microvascular and plastic surgeons and a nurse-practitioner. This early consultation allowed for timely reconstruction as well as patient and family counseling. Thirteen of these 20 limbs (65%) were salvaged. Of the seven amputations, one patient died and two patients were lost to follow-up study. The results of the 16 remaining patients with 17 affected limbs were reviewed. Seventy-five percent were ambulatory in less than one year following surgery. All were ambulatory without external aids or orthoses at final follow-up examination. A rapid return to previous activities was a direct result of early decision making.

Vascularized autografts for reconstruction of skeletal defects following lower extremity trauma. A review.

Over the last 15 years, vascularized bone grafts have proved to be a valuable method of reconstructing skeletal defects in the extremities. Successful skeletal reconstruction has been reported following tumor resection, select traumatic skeletal defects, congenital pseudarthrosis, and both infected and uninfected skeletal nonunions unresponsive to conventional methodology. Incorporation of the graft into the recipient is not as dependent on an uninfected well-vascularized host as a conventional avascular autogenous graft is. Vascularized autografts are also capable of achieving union across large skeletal defects with fewer stress fractures than when avascular autografts are used to span a defect greater than 6 cm. With patency of the vascular anastomoses and union at both ends of the graft, hypertrophy of the segmental graft is not unusual. The overall success rate of ultimate bony union is approximately 80% and is mostly dependent on the recipient location. As discussed in this article, vascularized autografts are a salvage procedure to be used in reconstructing extremities in which conventional reconstructive techniques have failed or are not applicable.