Pediatric and adolescent intra-articular fractures of the calcaneus

Calcaneal fractures in childhood are very rare, whereas particularly intra-articular displaced fractures are not typical in skeletally immature children. Various techniques of osteosynthesis have been described. This study aimed to determine clinical and radiological outcome after surgical treatment of intra-articular calcaneal fractures. Fourteen intra-articular fractures of the calcaneus were included in this retrospective study. Eleven children (2 girls and 9 boys) aged 6-16 years (average age 11.5 years) underwent surgical treatment. One child sustained a Type II open fracture of both calcanei. All injuries occurred after a high-energy trauma; 3 patients had multiple additional fractures. The clinical and radiological postoperative follow up was an average 44 months. In 4 cases, a reduction through a minimally invasive approach and fixation with K-wires or screws could be achieved. Eleven fractures were treated with open reduction and internal fixation with plate osteosynthesis, K-wires or screws. In one case with open fractures of both heel bones, an additional external fixator was applied. The surgical treatment approach adopted enabled the pre-operative Boehler’s angle (average 16°) to be improved to an average 30°. In all cases, except for the patient with open fractures, a good functional result and outcome could be achieved. In calcaneal fractures in childhood, anatomical reduction is the determining factor, as in fractures in adults, whereas the surgical technique seems to have no influence on clinical outcome in children. The wound healing problems that have often been described were not observed in this age group

Three-stage revision arthroplasty for the treatment of fungal periprosthetic joint infection: outcome analysis of a novel treatment algorithm : a prospective study.

Aims: Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI. Methods: From 2015 to 2018, a total of 18 patients with fPJI were included in a prospective, single-centre study (DKRS-ID 00020409). The diagnosis of PJI is based on the European Bone and Joint Infection Society definition of periprosthetic joint infections. The baseline parameters (age, sex, and BMI) and additional data (previous surgeries, pathogen spectrum, and Charlson Comorbidity Index) were recorded. A therapy protocol with three-stage revision, including a scheduled spacer exchange, was implemented. Systemic antifungal medication was administered throughout the entire treatment period and continued for six months after reimplantation. A minimum follow-up of 24 months was defined. Results: Eradication of infection was achieved in 16 out of 18 patients (88.8%), with a mean follow-up of 35 months (25 to 54). Mixed bacterial and fungal infections were present in seven cases (39%). The interval period, defined as the period of time from explantation to reimplantation, was 119 days (55 to 202). In five patients, a salvage procedure was performed (three cementless modular knee arthrodesis, and two Girdlestone procedures). Conclusion: Therapy for fPJI is complex, with low cure rates according to the literature. No uniform treatment recommendations presently exist for fPJI. Three-stage revision arthroplasty with prolonged systemic antifungal therapy showed promising results. Cite this article: Bone Jt Open 2021;2(8):671-678

Facing multidrug-resistant pathogens in periprosthetic joint infections with self-administered outpatient parenteral antimicrobial therapy-A prospective cohort study.

A key factor in the successful management of periprosthetic joint infection (PJI) besides the surgical regime is a consistent antimicrobial therapy. Recently, oral versus intravenous (IV) antibiotics for bone and joint infection trial demonstrated the noninferiority of oral antimicrobial therapy compared to IV, implying that an early transition to oral administration is reasonable. It is likely that the international consensus meeting of musculoskeletal Infections and the European Bone and Joint Infection Society will consider these findings. However, rising levels of antimicrobial resistance are challenging and recommendations for dealing with multidrug-resistant (MDR) pathogens resistant to oral antibiotics are lacking. This study focuses on establishing guidance towards their management in PJI. From December 2015 to June 2019, patients with MDR pathogens were included in a single-center prospective cohort study and treated with self-administered outpatient parenteral antimicrobial therapy (S-OPAT) based on a two-stage revision strategy. Demographics, pathogens, antimicrobial agents, and outcomes were recorded. A total of 1738 outpatient days in 26 patients were analyzed. The incidence of pathogens resistant to oral antibiotics in PJI was 4%, most frequently encountered were staphylococcus epidermidis. The Kaplan-Meier-estimated infection-free survival after 3 years was 90% (95% confidence interval, 84.6%-95.5%). We recorded adverse events in 6 of 54 (11%) S-OPAT episodes (3.45/1000 S-OPAT days). (i) S-OPAT in two-stage revision arthroplasty to counter increasing numbers of MDR pathogens resistant to oral agents can achieve a high infection eradication rate and (ii) should therefore be taken into account at the next society\u27s consensus treatment updates

Anatomical repair and ligament bracing of Schenck III and IV knee joint dislocations leads to acceptable subjective and kinematic outcomes

Purpose!#!The aim of this study was to analyze the outcomes of anatomical repair and ligament bracing for Schenck III and IV knee dislocation (KD).!##!Methods!#!The results of 27 patients (15 and 12 cases of Schenck III and IV KD, respectively) after a mean follow-up of 18.1 ± 12.1 months (range 6-45 months) were retrospectively reviewed. Twenty-two patients suffered high-kinetic-energy accidents, whereas five patients suffered ultralow-velocity (ULV) trauma due to obesity. The outcome measures were the Lysholm score, Hospital for Special Surgery (HSS) knee score, Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Short Form 36 (SF-36) score. A kinematic 3D gait analysis with five walking trials was performed to compare the patients and healthy controls.!##!Results!#!The mean KSS, HSS score, Lysholm score, and KOOS were 77.4 ± 14.4, 84.6 ± 11.2, 81.5 ± 10.4, and 67.3 ± 16.8, respectively. No intra- or postoperative complications occurred. The mean range of motion deficiency compared to the healthy side was 24.4 ± 18.5°. Ten patients had first-degree residual laxity of the anterior cruciate ligament; 12 and 2 patients had first- and second-degree residual laxity of the collateral ligament, respectively. Five patients underwent additional arthroscopic arthrolysis due to arthrofibrosis at an average of 6.2 ± 1.9 months (range 4-9 months) after the initial surgery. The 3D gait analysis showed no major differences in joint stability or movement between the patients and healthy controls. Only the ULV trauma patients had significantly lower outcome scores and showed larger kinematic deviations in joint movement during the gait analysis.!##!Conclusion!#!Anatomical repair with ligament bracing is a suitable surgical procedure in the treatment of KD and provides evidence in clinical practice with the benefit of early, definitive repair and preservation of the native ligaments. Patients reach acceptable subjective and objective functional outcomes, including mainly normalized gait patterns during short-term follow-up, with only minor changes in kinematics and spatial-temporal characteristics. Obese patients who suffered ULV trauma showed significantly inferior outcomes with larger deviations in joint kinematics.!##!Level of evidence!#!Level III

Surgical management of sternoclavicular joint septic arthritis.

Introduction: Infections of the sternoclavicular joint (SCJ) account for less than 1% of all joint infections. There are no standardized diagnostic and therapeutic algorithms defined in literature. This study intended to report the risk factors, the bacterial spectrum, the extent and localization and the clinical outcome of SCJ infections. Patients and methods: We retrospectively reviewed the medical charts of 13 patients (8 men, five women, mean age 37.6 years) with SCJ infections between Januray 1st 2008 and October 30th 2015 for clinical parameters and radiological studies. All patients were interviewed during their follow-up along with clinical examination and assessing the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Results: Nine patients presented with local chest pain and swelling; in 4 patients, the prevalent symptom was pain without local signs of inflammation. Full blood count revealed a mean leukocytosis of 15 × 10 Conclusion: CT should be routinely obtained to recognize the possible extends to the surrounding structures. SCJ resection can result in satisfactory clinical results and should be considered in cases of extended infections including the surrounding structures. Empiric antibiotic coverage should contain cephalosporin or extended-spectrum penicillin. Inappropriate or less-invasive surgical procedures may cause recurrencent infections, especially in cases of osteomyelitis

Semitendinosus autograft augmentation after bilateral patellar tendon re-rupture: a case report and technique note.

BACKGROUND: Acute bilateral patellar tendon rupture is a rare occurrence, especially in young patients in the absence of comorbidities. We describe a case of bilateral patellar tendon re-rupture in a young patient without predisposing factors. Further, we explain a technique for autograft augmented patellar tendon repair with bidirectional fixation using an ipsilateral semitendinosus graft in transosseous patellar and tibia bone tunnels. CASE PRESENTATION: We present the case of a 40-year-old healthy worker with bilateral acute on chronic patellar tendon rupture maintained following initial trauma and Krackow repair 2 years ago. He underwent bilateral reconstruction using semitendinosus autograft. At 1 year postoperatively, he has maintained the full range of motion and strength without re-rupture. CONCLUSION: This is the first case describing a new fixation technique after bilateral patellar tendon re-rupture. The use of semitendinosus autograft for reconstruction of the patellar tendon after re-rupture is a viable and effective option

Biomechanical comparison of screw osteosyntheses and anatomical plating for coronoid shear fractures of the ulna

Introduction!#!Among the few techniques described for the treatment of coronoid fractures, osteosynthesis techniques include screw osteosynthesis from anterior to posterior (AP) or from posterior to anterior (PA) and plate osteosynthesis. The aim of this study was to test the biomechanical stability of screw osteosynthesis and plate osteosynthesis using anatomical plates in coronoid process fractures.!##!Materials and methods!#!On a total of 25 biomechanical synthetical ulnae, a coronoid shear fracture including 70% of the coronoid height was simulated. Osteosynthesis was then performed using two 2.7 mm screws from anterior, posterior and with use of three different anatomical plates of the coronoid process. For the biomechanical testing, axial load was applied to the fragment with 1000 cycles from 5 to 250 N, load to failure and load at 100 µm displacement. Displacements were measured using a point-based three-dimensional motion analysis system.!##!Results!#!Osteosynthesis using the PA-screw showed significant more displacement during cyclic loading compared with all other osteosyntheses (0.99 mm), whereas AP-screw showed the smallest displacement (0.10 mm) during cyclic loading. The PA-screw technique showed a significant lower load to failure compared to all other osteosynthesis with the highest load in AP-screw osteosynthesis. The load for 100 µm displacement was the smallest in PA-screw with a significant difference to the AP-screw and one plate osteosynthesis.!##!Conclusion!#!Osteosynthesis of large coronoid shear fractures with two small-fragment screws from anterior allows stable fixation that is not inferior to anterior plate osteosynthesis and might be an alternative in specific fracture types. Posterior screw fixation was found as the weakest fixation method.!##!Level of evidence!#!Basic science study

Revision of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screw

$\bf Background:$ Nonunions of the subtrochanteric region of the femur after previous intramedullary nailing can be difficult to address. Implant failure and bone defects around the implant significantly complicate the therapy, and complex surgical procedures with implant removal, extensive debridement of the nonunion site, bone grafting and reosteosynthesis usually become necessary. The purpose of this study was to evaluate the records of a series of patients with subtrochanteric femoral nonunions who were treated with dynamic condylar screws (DCS) regarding their healing rate, subsequent revision surgeries and implant-related complications. $\bf Methods:$ We conducted a retrospective chart review of patients with aseptic femoral subtrochanteric nonunions after failed intramedullary nailing. Nonunion treatment consisted of nail removal, debridement of the nonunion, and restoration of the neck shaft angle (CCD), followed by DCS plating. Supplemental bone grafting was performed in all atrophic nonunions. All patients were followed for at least six months after DCS plating. $\bf Results:$ Between 2002 and 2017, we identified 40 patients with a mean age of 65.4 years (range 34–91 years) who met the inclusion criteria. At a mean follow-up period of 26.3 months (range 6–173), 37 of the 40 (92.5%) nonunions healed successfully (secondary procedures included). The mean healing time of the 37 patients was 11.63 months (± 12.4 months). A total of 13 of the 40 (32.5%) patients needed a secondary revision surgery; one patient had a persistent nonunion, nine patients had persistent nonunions leading to hardware failure, two patients had deep infections requiring revision surgery, and one patient had a peri-implant fracture due to low-energy trauma four days after the index surgery. $\bf Conclusions:$ The results indicate that revision surgery of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screws is a reliable treatment option overall. However, secondary revision surgery may be indicated before final healing of the nonunion

Tibiocalcaneal arthrodesis using the Ilizarov fixator in compromised hosts: an analysis of 19 patients

Introduction!#!Salvage of joint destruction of the tibiotalar and subtalar joint with necrosis or infection of the talus in compromised hosts is a challenging problem. In these cases, tibiocalcaneal arthrodesis using the Ilizarov external fixator represents a possible alternative to amputation. This retrospective study presents the results and complications of this salvage procedure.!##!Materials and methods!#!Between 2005 and 2015, 19 patients were treated with tibiocalcaneal arthrodesis using the Ilizarov external fixator. Ten patients received tibiocalcaneal arthrodesis due to an acute or chronic infection with joint destruction. The other nine patients presented posttraumatic necrosis of the talus or Charcot arthropathy. In addition to demographic data, the time spent in the fixator, the major and minor complications and the endpoint of the consolidation were evaluated retrospectively. Furthermore, clinical outcomes were measured using the modified American Orthopedic Foot and Ankle Society (AOFAS) score.!##!Results!#!The average time spent in the fixator was 22 (range 14-34) weeks. The average follow-up in 17 patients was 116 (range 4-542) weeks. Two patients were lost to follow-up. Complete osseous consolidation was achieved in 14 out of 19 patients. One patient presented partial consolidation, and in four patients, pseudarthrosis could be detected. The mean modified AOFAS score at the final follow-up was 53 out of 86 possible points.!##!Conclusion!#!Tibiocalcaneal arthrodesis using the Ilizarov fixator is a possible salvage procedure even in compromised hosts. However, the healing rates are below the rates reported in the literature for tibiotalar arthrodesis in comparable clinical situations