Using cement plugs in soft tissue infection and osteomyelitis

Operative foot and ankle osteomyelitis is challenging for orthopedic surgeons because of the area’s unique anatomy, high trauma incidence, local and systemic disease effects, and often limited space. Standard treatment includes aggressive operative debridement with local and systemic antibiotic administration to control infection. Dead space management is critical yet technically demanding. The authors report a modified antibiotic cement bead therapy technique in which antibiotic sticks, minnows, and mushroom-shaped plugs are used to strike a balance between the stability of the load-bearing unit and radical removal of infection to preserve a functional foot. Three cases are presented.

Charcot neuroarthropathy triggered and complicated by osteomyelitis. How limb salvage can be achieved

BACKGROUND

Charcot neuroarthropathy is a severe complication in the feet of patients with diabetes, which can lead to a major amputation. Osteomyelitis and surgery for osteomyelitis have been reported as trigger mechanisms of developing Charcot neuroarthropathy. However, the development of acute Charcot neuroarthropathy triggered by osteomyelitis during conservative antibiotic treatment is not well outlined in the medical literature.

CASE REPORTS

Two patients apparently developed mid and rear foot Charcot neuroarthropathy, which was clinically suspected while being treated with antibiotics for osteomyelitis. One of them presented osteomyelitis of the navicular bone and subsequently developed acute Charcot neuroarthropathy of the tarsometatarsal joints. The other presented calcaneal osteomyelitis with pathological fracture and developed Charcot neuroarthropathy of the transverse tarsal joint. No offloading had been implemented in either case. A major amputation had been indicated in both cases in their teaching hospitals. Limb salvage was achieved in both cases by means of surgery, culture-guided post-operative antibiotics, intraosseus instillation of super-oxidized solution, bed rest before placing a total contact cast and stabilization of the unstable foot with a total contact cast with an opening for checking the healing course and to detect any complications. The mechanisms of the development of acute Charcot neuroarthropathy in a patient with osteomyelitis are discussed.

CONCLUSIONS

Osteomyelitis in the feet of patients with diabetes and neuropathy may trigger the development of acute Charcot neuroarthropathy. Fractures and dislocated joints may subsequently become infected from the index focus, producing a severe infected and unstable foot that may require a major amputation. Limb salvage can be achieved in specialized departments.

Feet and fabrication: footbinding and early twentieth-century rural women's labor in Shaanxi

The early twentieth-century transformations of rural Chinese women’s work have received relatively little direct attention. By contrast, the former custom of footbinding continues to fascinate and is often used to illustrate or contest theories about Chinese women’s status. Arguing that for rural women at least, footbinding needs to be understood in relation to rural economic conditions, the authors focus on changes in textile production and in footbinding in two counties in Shaanxi province. Drawing on historical sources and their own interview data from rural women who grew up in this period, the authors find evidence that transformations in textile production undercut the custom of footbinding and contributed to its rapid demise.

Chondrosarcoma of the distal phalanx of the great toe

Enchondromas are the most common benign cartilaginous bone tumors of the toe. In contrast, chondrosarcomas are very uncommon in the foot. We report an unusual case of a chondrosarcoma arising in the great toe. The patient was a 62-year-old woman whose chief complaint was swelling of her left great toe. Radiography showed subtle punctate calcification and mild sclerosis and irregularity of the distal phalanx in the great toe. Magnetic resonance imaging showed extraskeletal growth. The distal phalanx was amputated. Histologic examination demonstrated a grade 1 chondrosarcoma. Two years after surgery, the patient was free of recurrence and lung metastasis.

"Silent" bone stress injuries in the feet of diabetic patients with polyneuropathy: a report on 12 cases

BACKGROUND

Bone stress injuries are rarely being diagnosed in patients with sensory neuropathy, most likely because they may be silent in terms of pain. Load-related pain is considered a key feature of any bone stress injury, a symptom, which may be partially or completely absent in subjects with sensory neuropathy (loss of protective sensation). We evaluated the clinical course of bone stress injuries in insensitive feet in diabetic patients with polyneuropathy.

METHODS

We investigated 12 consecutive diabetic patients with bone stress injuries of the foot (bone marrow edema, bone bruise and microtrabecular fractures, on magnetic resonance imaging MRI), which were undetectable on plain X-ray. All patients suffered from diabetic polyneuropathy, none of them had an active foot ulcer.

RESULTS

The patients presented with a swollen foot, which was only mildly painful and did not prevent them from walking. Complaints were related to the swelling, which increased during load-bearing. In seven cases, a traumatic event preceding the onset of symptoms could be ascertained. MRI disclosed stress injuries in 2.5 (1-8) [median (range)] bones per foot. In 11 patients, treatment was started immediately by off-loading with total contact cast for 17 (8-52) weeks, followed by gradual increase in weight bearing. One patient unfortunately received off-loading treatment only after deforming fractures had developed. All bone injuries healed uneventuelly in eight patients, and with residual mild osteoarthrosis in three patients without gross deformities. However, the untreated patient developed severe Charcot foot deformity.

CONCLUSIONS

In diabetic patients with polyneuropathy, symptoms of bone stress injuries of the foot are atypical, in that there is load-related swelling rather than load-related pain. Immediate diagnosis, and treatment with off-loading, leads to a restitutio ad integrum like in non-neuropathic patients. Delayed cessation of overuse, however, may cause irreversible joint and bone damage (Charcot foot).

Secularizing the pain of footbinding in China: missionary and medical stagings of the universal body

How did foreign Christian anti-footbinding activists treat the distinctive forms of human embodiment they encountered in China? What were their assumptions? How should we understand the transition from religious to secular imaginings of the body and its pains? Here I discuss late nineteenth and early twentieth century religion and medicalized hygiene through the voices of two English people who campaigned against and wrote extensively about footbinding. Not an easy story about God traded for Nature, but a far more uneasy and subliminal borrowing and cross-fertilization of tropes between the religious and the scientific. In both evangelical religion and biological science our protagonists created powerful narrative technologies for making cultural process disappear into nature, and thus to re-channel agency, making it available for new projects. Here we see the secular and the religious informing and reinforcing one another as moments in the creation of the modern.

Differentiating clinical and radiographic features of enchondroma and secondary chondrosarcoma in the foot

BACKGROUND

Enchondroma is the most common benign tumor of the bones of the foot. Chondrosarcoma in this area is relatively rare with malignant transformation from enchondroma occurring rarely. In contrast to similar tumors in the appendicular skeleton, it is difficult to distinguish between these two tumors when they occur in the foot.

METHODS

We reviewed the medical records and radiographs of all patients with enchondroma and chondrosarcoma arising from enchondroma (secondary chondrosarcoma) from the radiologic archives at the Armed Forces Institute of Pathology (AFIP) and identified those patients with tumors involving the bones of the foot. There were 755 patients with enchondroma of which 34 (4.8%) involved the foot; there were 340 patients with secondary chondrosarcoma and 14 (4.1%) involved the foot. We compared clinical and radiographic features of both these lesions. We also compared interobserver differences not only for diagnosis but also for the presence of scalloping, fracture, cortical destruction, and mineralized matrix.

RESULTS

Size and location were statistically significant variables differentiating the two tumors (p = 0.03). Enchondromas had a mean size of 2.7 cm(2). Lesions that occurred in the hindfoot and midfoot were more likely to be malignant compared to those in the forefoot. In comparing interobserver reliability, most disagreement occurred regarding the presence or absence of matrix with the examiners concurring only 51% of the time. With regard to diagnosis, the examiners' accuracy was 71% and 80%. Their accuracy increased only to 83% when they agreed.

CONCLUSION

Our findings suggest that it is difficult to differentiate enchondroma from secondary chondrosarcoma in the foot. Concern for malignant change is warranted for cartilage bone tumors of the foot if they exceed 5 cm(2), or if they arise in the midfoot or hindfoot. In these cases, we recommend either biopsy or close clinical followup.

Easily identifiable bony landmarks as an aid in targeted regional ankle blockade

Regional anesthesia around the ankle joint is well suited to a large number of surgical procedures of the foot. Previous studies have alluded to the variable nerve distribution of the foot, which may result in incomplete blocks. The aim of the study was to determine the position of the nerves in relation to the ankle joint to easily identifiable bony and prominent soft tissue landmarks to aid more accurate targeting of these nerves. A number of 94 ankles (47 left; 47 right) were dissected to expose the tibial, sural, deep fibular (peroneal), superficial fibular (peroneal), and saphenous nerves. The distance of the nerves relative to easy to find bony landmarks was measured. A distance (alpha) was measured from the middle of the tibial nerve to the most medial aspect of the medial malleolus. Measurement beta was considered from the inferior tip of the lateral malleolus to the anterior border of the sural nerve on a horizontal plane. Measurement delta was taken from the medial border of the deep fibular (peroneal) nerve to the most anterior aspect of the medial malleolus. epsilon was measured from the middle of the superficial fibular (peroneal) nerve to the most anterior aspect of the medial malleolus on a horizontal plane. The saphenous nerve was measured (gamma) from its medial border to the most anterior aspect of the medial malleolus on a horizontal plane. Factors such as sex, length, and ankle side were also analyzed concerning their influence on the position of the nerves. This study suggests that a greater degree of certainty may possibly be attained when palpable and easy to find bony landmarks are used to determine the position of the nerves around the ankle and ensure a simple to perform, predictable, and selectively targeted block.

What are the effects of obesity in children on plantar pressure distributions?

OBJECTIVE

This study examined the effects of obesity on static and dynamic plantar pressure distributions displayed by children.

DESIGN

Field-based experimental data on body mass index (BMI) and plantar pressures were collected for 10 obese children and 10 nonobese controls.

SUBJECTS

In all, 10 obese (age 8.8+/-2.0 y, BMI 25.8+/-3.8 kg m(-2)) children matched to 10 nonobese children (age 8.9+/-2.1 y, BMI 16.8+/-2.0 kg m(-2)), for gender, age and height.

MEASUREMENTS

Height and weight were measured to calculate BMI. Right and left foot plantar pressures were obtained using an AT-4 emed pressure platform (Novel(gmbh), Munich) to calculate the peak force and pressure experienced under areas of each child's feet during static and dynamic conditions.

RESULTS

While standing, the obese children generated significantly higher forces over a larger foot area and experienced significantly higher plantar pressures compared to their nonobese counterparts (41.8+/-17.7; 30.1+/-12.0 N cm(-2), respectively; P<0.022). Similarly, while walking, the obese children generated significantly higher forces over all areas of their feet, except the toes. Despite distributing these higher forces over a significantly larger foot area when walking, the obese children experienced significantly higher plantar pressures in the midfoot (P<0.003) and under the second to fifth metatarsal heads (P<0.006) compared to the nonobese children.

CONCLUSIONS

It is postulated that obese children are at an increased risk of developing foot discomfort and/or foot pathologies due to increased plantar loads being borne by the small forefoot bones. Furthermore, continual bearing of excessive mass by children appears to flatten the medial midfoot region during walking. As the long-term consequences of these increased plantar loads are currently unknown, it is recommended that the effects of obesity on the structural and functional characteristics of obese children's feet be further investigated.

Distal lower extremity sarcomas: frequency of occurrence and patient survival rate

BACKGROUND

Primary sarcomas in the distal leg, tibia, fibula, ankle, and foot are uncommon and are believed to be less malignant than those that arise in other sites, but only limited information is available to support this contention.

METHODS

Using a computerized system containing extensive information regarding over 14,000 patients, mostly with tumors treated by our center over a 25-year period, 175 sarcomatous lesions with MSTS stage I, II, and III were located in the distal lower extremity. These were compared with 2367 lesions of similar diagnoses in other body parts. The principal studies included diagnostic distribution and outcome (recorded as death as a result of disease). Data were compared for diagnosis, gender, age, Musculoskeletal Tumor Society (MSTS) stage, anatomic site, and treatment methods and evaluated statistically by chi-square methods.

RESULTS

The most frequent distal lower limb tumors were synovial cell sarcoma, osteosarcoma, and Ewing's tumor and the percentage distribution of the various tumors for that site as compared with the rest of the body was quite different. Of even more importance was the remarkable difference in outcome with the death rate for the lower limb tumors set at 10%, while the same tumors at other sites had a death rate of 27% (p <.000002). Furthermore, gender, stage, age, and the type of operative procedure showed highly significant differences between the tumors of the lower leg and those of the remainder of the body.

CONCLUSIONS

On the basis of these data, it is evident that far fewer sarcomas occur in the lower leg, tibia, fibula, ankle, and foot than in other body sites and that their diagnostic distribution is different. Of perhaps greater interest is the fact that the rate of metastasis and death is markedly reduced for this site as compared with others. The authors speculate on the causes of this remarkable alteration in numbers and outcome.

[Unusual parosteal osteochondromatous proliferation or Nora's tumor. A clinicopathological analysis of 4 cases]

Nora's lesion, also known as bizarre parosteal osteochondromatous proliferation (B.P.O.P.), involves mostly the small tubular bones of the hands and feet. Histologically, it is characterized by a proliferation of chondroid, bony and fibrous tissues, sometimes with high cellular density, bizarre chondrocytes but is devoid of cellular atypia and necrosis. Distinct blue color is noted at the interface of bone and cartilage. The most important lesions that present differential diagnostic problems are chondrosarcoma, parosteal osteosarcoma and florid reactive periostitis. The lesion is benign but may recur locally in as many as 55%. The clinical and pathological findings of four cases of Nora's lesion are presented.

Primary bone tumors of the lower extremities

The key to adequate and accurate evaluation, diagnosis, and treatment of bone tumors is an organized and integrated approach involving the surgeon, radiologist, and pathologist. The radiologist plays not only a valuable role in the diagnosis and preoperative staging of bone tumors but may also play a role in biopsy and treatment. Despite the wide variety of imaging modalities available today, radiographs remain the mainstay in the evaluation of osseous neoplasms. Advanced imaging is. however. very useful for staging purposes and for characterization of the internal characteristics of tumors and may aid significantly in limiting the differential diagnosis. Although a detailed discussion of all ofthe various bone tumors of the lower extremities is beyond the scope of this article, an attempt is made to provide a framework for a rational and comprehensive approach to these complicated but relatively uncommon lesions. Certain lesions with unique characteristics are discussed to facilitate the diagnostic process.

Complications of ring fixators in the foot and ankle

The current review reports the author's 12-year experience with the Ilizarov ring external fixator for the treatment of foot and ankle disorders. The complications caused by the use of this apparatus also will be presented. In the beginning, the complications were attributable to inexperience and the lack of literature available at that time (1987); afterward, the complications were attributable to excess of confidence and the belief that the external fixator could be the universal solution for all patients. The current review has two main purposes: to show the more frequent complications that arise during the use of the external fixators, and to present methods on how to prevent the complications and how to manage them once they occur. The majority of complications presented in the current review are related directly to the use of the external fixator. These complications could be called minor complications that frequently are seen during treatment. However, there are major complications that can be avoided with adequate application and control of the external fixator during treatment.

Complications in foot and ankle arthroscopy

Arthroscopy of the foot and ankle has become an important diagnostic and therapeutic tool for the orthopaedic surgeon. A thorough knowledge of foot and ankle anatomy and intraarticular anatomy is critical to avoid complications in foot and ankle arthroscopy. Numerous complications can occur in foot and ankle arthroscopy, such as neurologic, tendon, and ligament injuries, wound complications, infections, and instrument breakage. The most common complication is neurologic injury. The overall complication rate is 9%. Most complications associated with foot and ankle arthroscopy are transient and tend to resolve within 6 months. The only complication that persisted at 10 years followup was a neurologic injury, specifically, numbness at the incision site. Because the difficulty of procedures has increased, so has the complication rate. Knowledge of the more common complications in foot and ankle arthroscopy and improved techniques and instruments may reduce the overall complication rate.

Treatment of epithelioid hemangioendothelioma of bone using a novel combined approach

Radiofrequency (RF) treatment has been used for a variety of malignant and benign conditions. However, treatment of a bone malignancy has yet to be reported. The authors present a 21-year old woman with multifocal epithelioid hemangioendothelioma (EH) treated by a combination of surgical excision, chemotherapy and four RF ablations. Follow-up radiographs of the RF-treated sites reveal no evidence of recurrent disease 71, 58, 49 and 33 months, respectively, after treatment.

Bone and joint manifestations of systemic infectious diseases

Bone and joint infections can occur as the consequence of a wide variety of systemic diseases. Disseminated fungal and mycobacterial infections, hepatitis, syphilis, gonorrhea, Lyme disease, and AIDS can all have osteoarticular manifestations. A thorough knowledge of the wide range of potential pathogens is key to establishing a correct diagnosis and instituting appropriate treatment.

Osteochondral lesions of the proximal phalanx of the great toe: a report of two cases

Two cases of osteochondral lesions of the proximal phalanx of the great toe at the interphalangeal joint are presented. This condition is characterized by pain, swelling, and tenderness at the interphalangeal joint. The roentgenographic characteristics resemble osteochondritis dissecans. Curettage and bone grafting to the lesion is effective. These conditions in adolescent soccer players may be caused by chronic repetitive overloading of the interphalangeal joint using soccer shoes with soft, supple, and narrow toe boxes.

Ape-like or hominid-like? The positional behavior of Oreopithecus bambolii reconsidered

Comparative morphological and functional analyses of the skeletal remains of Oreopithecus bambolii, a hominoid from the Miocene Mediterranean island of Tuscany-Sardinia (Italy), provides evidence that bipedal activities made up a significant part of the positional behavior of this primate. The mosaic pattern of its postcranial morphology is to some degree convergent with that of Australopithecus and functionally intermediate between apes and early hominids. Some unique traits could have been selected only under insular conditions where the absence of predators and the limitation of trophic resources play a crucial role in mammalian evolution.

Osteitis caused by bacille Calmette-Guérin vaccination: an emergent problem in Chile?

SETTING

Osteitis caused by bacille Calmette-Guérin (BCGOST) vaccination has not been described in Latin American countries.

OBJECTIVE

To evaluate the incidence, clinical features and prognosis of patients with BCGOST in one of the most populated areas of Santiago, Chile.

DESIGN

A retrospective analysis of medical records kept over twenty years (1976-1995).

RESULTS

In ten children (four in the last five years), diagnostic criteria of BCGOST were fulfilled. Six were boys, the mean age was 11 months (range 6.5-21), symptoms were present with a mean of 31 days (range 15-60) before diagnosis and the sites of predilection of osteitis were the lower extremity (8/10 cases). Culture was positive in one case, and nine patients had typical histopathological lesions (two with acid-fast bacilli). All had normal chest X-ray. Mantoux testing was performed in four cases (mean 21.5 mm, range 16-28). None of the ten patients had a history of underlying immunodeficiency. In this area BCG coverage was 90.2 +/- 9.7% of all newborn infants, and the annual risk of tuberculosis infection was 24.6/100,000 population per year.

CONCLUSION

Our study demonstrated an estimated incidence for BCGOST in this area of 3.2/100,000 vaccinated newborns. Based on the epidemiological situation of tuberculosis in Chile (29.5/100,000), universal BCG vaccination in newborns should be encouraged.

[Simultaneous occurrence of localized plasmacytoma in hands and feet bones]

Localized plasmacytomas in the bones account for less than 10% of all myelomas. Axial skeletal bones are most commonly affected, while isolated lesions in the hands and feet are very rare. Simultaneous occurrence of localized lesions on both hands and feet has not been reported so far. We repor on a female patient, 40 years old, whose symptoms developed simultaneosly: pain and deformity of the hands and feet were radiologically confirmed as numerous cystic transilluminations and destruction of the bones. Specific diagnostic procedures in the affected bones showed moderately differentiated plasmacytoma with lamda light-chains. Serum and urine analysis revealed a monoclonal component (lambda light-chains). The patient received local radiotherapy and combined chemotherapy. Subsequently, bone changes regressed, and monoclonal protein disappeared from both serum and urine. Four years after the onset of the disease the phalanx of the left hand was punctured confirming the absence of plasmacytoma.