Mathieu Assal

Complications and failure after total ankle arthroplasty

BACKGROUND Second-generation total ankle arthroplasty has been reported to have good intermediate-term results. The purpose of the present study was to report on the cause and frequency of reoperation and failure after total ankle arthroplasty and to determine demographic and clinical predictors of reoperation and failure. METHODS Three hundred and six consecutive primary total ankle arthroplasties were performed with use of the DePuy Agility Total Ankle System between 1995 and 2001. At a mean of thirty-three months after the arthroplasty, we retrospectively reviewed the records with regard to patient age, gender, the indications for the index procedure, adjuvant procedures, the timing and frequency of reoperation, and the indications for and the type of reoperations performed. Kaplan-Meier analysis was performed to determine the rate of prosthetic survival, and Cox regression analysis was performed to determine predictors of reoperation and failure. RESULTS Eighty-five patients (28%) underwent 127 reoperations (involving 168 procedures) after primary total ankle arthroplasty. The most common procedures at the time of reoperation were débridement of heterotopic bone (fifty-eight), correction of axial malalignment (forty), and component replacement (thirty-one). Eight patients underwent below-the-knee amputation. Age was found to be the only significant predictor of reoperation and failure after total ankle arthroplasty. The five-year survival rate with reoperation as the end point was 54%. The five-year survival rate with failure as the end point was 80% for all patients and 89% for patients who were more than fifty-four years of age. The prosthesis could not be salvaged in nine ankles (2.9%); the inability to salvage the prosthesis was most often due to loosening or infection. CONCLUSIONS We noted a relatively high rate of reoperation after total ankle arthroplasty with this second-generation device. Younger age was found to have a negative effect on the rates of reoperation and failure. Most prostheses could be salvaged; however, the functional outcome of this procedure is uncertain.

Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study

Background: Controversy persists regarding the ideal surgical technique for repair of a ruptured Achilles tendon. We propose a limited open procedure with use of an instrument that provides the advantage of an open repair but avoids the soft-tissue problems with which open repair has been associated.Methods: We first performed a cadaver study in order to develop an instrument and a technique for a limited open repair and then, using this procedure in conjunction with an early functional rehabilitation protocol, we began a prospective multicenter study. We are reporting on the first eighty‐seven patients consecutively treated with the new instrument and followed for an average of twenty‐six months (range, eighteen to forty‐two months). All patients were assessed clinically and with an enhanced American Orthopaedic Foot and Ankle Society (AOFAS) rating score. In addition, all fifty patients who had been followed for at least twenty-four months were further evaluated with isokinetic dynamometry.Results: Four patients were lost to follow‐up and one patient died, which left eighty‐two patients for evaluation. There were no problems with wound-healing, and there were no infections. No patient noted a sensory disturbance in the sural nerve distribution. All patients returned to their previous professional or sporting activities. The mean AOFAS score was 96 points (range, 85 to 100 points). Isokinetic dynamometry showed no significant difference in strength between the injured and uninjured limbs of the fifty patients who were tested. Complications occurred in three patients. Two of them were noncompliant and removed the orthosis, so that the repair was disrupted by a new injury within the first three weeks postoperatively. One patient fell twelve weeks after the surgery and sustained a rerupture. All three new injuries were repaired with an open surgical procedure.Conclusions: This new procedure allows the surgeon to precisely visualize and control the tendon ends while avoiding excessive dissection and disturbance of local vascularity and minimizing nerve and wound-healing problems. Such a technique, along with an early functional rehabilitation program, allowed us to achieve a high rate of successful results with minimal morbidity.

Realignment and Extended Fusion with Use of a Medial Column Screw for Midfoot Deformities Secondary to Diabetic Neuropathy

BACKGROUND The failure of nonsurgical treatment of patients with midfoot and hindfoot deformity secondary to diabetic Charcot arthropathy may lead to a rocker-bottom foot deformity with recurrent or persistent plantar ulceration. We report our experience with realignment and extended fusion with primary use of a medial column screw for this midfoot deformity. METHODS From July 2001 through July 2005, we performed reconstructive surgery on fifteen adults with diabetes mellitus who had a severe neuropathic midfoot deformity consisting of a collapsed plantar arch with a rocker-bottom foot deformity. Thirteen had a nonhealing midfoot plantar ulcer. All underwent realignment and arthrodesis with a medial column screw; some required additional fixation techniques depending on the extent of the deformity. Outcome measures included ulcer and surgical wound-healing, radiographic results, complications, and the need for amputation. RESULTS The mean duration of clinical follow-up was forty-two months. Fourteen patients were able to walk, and there were no recurrent plantar ulcers. Thirteen patients were able to wear custom-made extra-depth, wide-toed shoes with molded inserts. One patient without prior ulceration had development of a deep infection that necessitated an amputation. Four feet had a nonunion, one of which was symptomatic requiring a revision to obtain union. CONCLUSIONS Surgical reconstruction of a collapsed neuropathic foot deformity is technically demanding, but a successful outcome can result in a plantigrade foot that is free of ulceration and abnormal pressure points and a patient who is able to walk. The procedure described has an acceptable degree of complications although it has a high rate of nonunion.

Outcome of orthopedic implant infections due to different staphylococci

BACKGROUND Comparisons of different staphylococci in orthopedic implant infections have rarely been reported. In this study we assessed total joint arthroplasty infections and other orthopedic implant infections due to methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus aureus (MRSA), and coagulase-negative staphylococci (CoNS). METHODS This was a retrospective study performed at the Geneva University Hospitals for the period January 1996 to June 2008. RESULTS There were 44 infections due to MRSA, 58 due to MSSA, and 61 due to CoNS. Overall cure was achieved in 57% (25/44) of MRSA infections, 72% (42/58) of MSSA infections, and 82% (50/61) of CoNS infections, after a minimum follow-up of 1 year. In the subgroup of arthroplasty infections only, cure was achieved in 39% (7/18) of MRSA, 60% (15/25) of MSSA, and 77% (30/39) of CoNS episodes. In multivariate analysis, arthroplasty (odds ratio (OR) 0.2, 95% confidence interval (95% CI) 0.1-0.6) and MRSA infections (OR 0.3, 95% CI 0.1-0.9) were inversely associated with overall cure for all implants. CoNS infection (OR 3.0, 95% CI 1.2-8.0) and the insertion of a new implant (OR 4.5, 95% CI 1.6-13.1) were associated with higher cure results. Methicillin resistance, immunosuppression, sex, age, duration of antibiotic therapy, one-stage revision, rifampin use, and total number of surgical interventions did not influence cure. MRSA-infected patients had more post-infection sequelae than patients with MSSA or CoNS (Chi-square test 13/44 vs. 93/119, OR 3.4, 95% CI 1.3-8.9, p=0.004). CONCLUSIONS In orthopedic implant infections, S. aureus is more virulent than CoNS. MRSA has the worst outcome and CoNS the best.

Six weeks of antibiotic treatment is sufficient following surgery for septic arthroplasty

OBJECTIVES In the treatment of prosthetic joint infections (PJI), the benefit of antibiotic therapy for more than 6 weeks after surgery is uncertain. We compared PJI cure rates according to the duration of antibiotics, 6 versus 12 weeks. METHODS A prospective observational non-randomized study in Geneva University Hospitals 1996-2007. RESULTS A total of 144 PJI (62 hip arthroplasties, 62 knee arthroplasties, and 20 hip hemiarthroplasties) were included with a prolonged follow-up ranging from 26 to 65 months. Surgical treatment included 60 débridements with implant retention, 10 one-stage exchanges of the prosthesis, 57 two-stage exchanges, and 17 Girdlestone procedures or knee arthrodeses. Seventy episodes (49%) received 6 weeks antibiotic therapy and 74 episodes, 12 weeks. Cure was achieved in 115 episodes (80%). Cure rate did not change according to the duration of intravenous antibiotics (>8 days, 8-21 days, >21 days) (Kruskal-Wallis-test; p = 0.37). In multivariate analysis, none of the following parameters was statistically significantly associated with cure: two-stage exchange (odds ratio 1.1,95%CI 0.2-4.8); number of débridements (0.9, 0.4-1.9); six weeks antibiotherapy (2.7, 0.96-8.3); duration of intravenous course (1.0, 0.96-1.03); sinus tract (0.6, 0.2-1.7); or MRSA infection (0.5, 0.2-1.5), although implant retention showed a tendency for less cure (0.3, 0.1-1.1). CONCLUSIONS Following surgery for treatment of PJI, antibiotic therapy appears able to be limited to a 6-week course, with one week of intravenous administration. This approach needs confirmation in randomized trials.

Noninsertional Achilles Tendinopathy Treated with Gastrocnemius Lengthening

Background: Surgery is frequently considered an option for refractory, symptomatic noninsertional Achilles tendinopathy. Gastrocnemius equinus can result in mechanical overload of the Achilles tendon and may be a factor in its etiology. Our hypothesis was that reducing load transmission to the Achilles tendon by gastrocnemius lengthening (Strayer procedure) may be an effective treatment. Materials and Methods: A prospective case series of all patients with a minimum 1-year symptomatic nonin-sertional Achilles tendinopathy who underwent gastrocnemius lengthening was evaluated before surgery, and at 1 and 2 years after surgery. There were 14 patients (17 tendons). Results: One year after surgery, the median American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score was 100 points, as compared to 71 points preoperatively (p< 0.001). The median total Foot Function Index (FFI) decreased significantly from 39 to 12 points at 1 year (p< 0.001) and remained stable (12 points) at 2 years. An electronic goniometer recorded a mean gain in ankle dorsiflexion of 13 degrees. At 1 year after surgery the MRI in all eight patients (ten tendons) with a preoperative MRI demonstrated a decrease in signal hyperintensity and tendon size, signifying an improvement of the tendinopathy. At 2 years after surgery, patient satisfaction assessment revealed that all but one patient was satisfied with the result and 11 of the 14 (79%) patients were able to resume their previous sporting activities. There were no complications. Conclusion: Gastrocne-mius lengthening was an effective treatment for chronic Achilles noninsertional tendinopathy. Two-year results show good to excellent clinical outcome. Level of Evidence: Level IV, Prospective Case Series

Relationship between foot type, foot deformity, and ulcer occurrence in the high-risk diabetic foot

We hypothesized an association between foot type, foot deformity, and foot ulceration and conducted an analysis of a well-characterized, high-risk diabetic population of 398 subjects. The average age was 62 years of age and 74% of the study population were males. Foot-type distributions were 19.5% pes cavus (high arch), 51.5% neutrally aligned (normal arch), and 29.0% pes planus (low arch). We quantified the presence of hallux valgus (23.9%), hammer/claw toes (46.7%), and hallux limitus (24.4%). A significant association was found between foot type and hallux valgus (p = 0.003); pes planus feet had the highest prevalence as compared with neutrally aligned feet (odds ratio [OR] = 2.43, p = 0.0006). Foot type was also significantly associated with fixed hammer/claw toes (p = 0.01); pes cavus feet had the highest prevalence as compared with neutrally aligned feet (OR = 3.89, p = 0.001). Foot type was also significantly associated with hallux limitus (p = 0.006) with pes planus feet having the highest prevalence as compared with neutrally aligned feet (OR = 2.19, p = 0.003). However, foot type was not significantly related to any ulcer outcome (p = 0.7). Fixed hammer/claw toes (OR = 3.91, p = 0.003) and hallux limitus (OR = 3.02, p = 0.006) were associated with increased risk of any ulcer occurrence. This study affirms that foot type and foot deformity are related and that foot deformities are associated with ulcer occurrence.

Low incidence of haematogenous seeding to total hip and knee prostheses in patients with remote infections

OBJECTIVES The exposure of joint prostheses to remote infections is unknown. We wanted to estimate (a) the exposure of arthroplasty patients to severe remote infections, and (b) the incidence of arthroplasty infections associated with remote infections. METHODS Prospective cohort study of all elective hip and knee arthroplasties performed between March 1996 and September 2008, with retrospective documentation of remote infections in hospitalized patients. RESULTS A total of 6101 elective total joint arthroplasties, consisting of 4002 hip replacements (66%) and 2099 knee replacements (34%), were included. The mean follow-up was 70 months. During the study period, the cohort patients experienced 553 remote infections after a median delay of 33 months post-arthroplasty. There were 71 prosthetic infections detected, 7 (total incidence 7/6101, 0.1%) of which were secondary to a remote infection. The ratio of infections associated with remote infections to potential exposure was 1:79. Among hip arthroplasty patients the incidence rate was 1.4 infections associated with remote infections per 10,000 patient-years of follow-up. Infections associated with remote infections occurred later than surgical site infections, (46 months vs. 19 months post-surgery, respectively; mean difference 27 months, 95% CI 8-45 months). CONCLUSIONS Arthroplasty infections associated with remote infections were rare, and occurred like their potential exposure mostly more than 24 months post-arthroplasty.

Total extrusion of the talus: A case report

Total extrusion of the talus with no remaining soft-tissue attachments, and with the talus coming to lie outside the patients body, is an extremely rare injury. We were able to find the cases of only five such patients in the literature1-3, and in only three of them was the talus reimplanted. Other case reports have described patients who had sustained an open total dislocation with a thin soft-tissue connection to the talus remaining4-8, and additional reports have provided no description as to the precise amount of soft-tissue connection remaining9,10. It is important to realize that the many reports of so-called total talar dislocation11-13 do not involve complete extrusion as we have defined it here. Our patient represents the fourth reported case in which the talus was found outside the body with no soft-tissue connections and was replaced following irrigation and debridement of the bone and wound. This report relates the outcome at five years and analyzes previous reports in the literature. Our patient was informed that the data concerning the case would be submitted for publication. The patient was twenty-six years old at the time of the accident, which occurred in December 1998. She was injured when she was struck by an automobile while riding her motorbike. Her only injuries involved the musculoskeletal system. The patient had been wearing boots at the time of the accident. The right boot was in place on the right lower extremity, but the left boot was not attached to her foot and had been brought in separately. The left foot was noted to be in a position of external rotation with respect to the leg and was flaccid. Radiographs of the lower extremity were performed in the Emergency Department …

The extensile approach for the operative treatment of high-energy pilon fractures: surgical technique and soft-tissue healing.

Perhaps the most important advancement in the surgical treatment of high-energy pilon fractures has been the recognition of the need to delay primary surgery. However, at open reduction internal fixation an adequate incision must be made to clearly visualize the articular surface in an attempt to restore intraarticular anatomy. This article illustrates our extensile approach and its effect on soft-tissue healing. The approach allows complete access to the ankle joint to achieve reduction and fixation of the articular surface, as far medially or laterally as is necessary. In addition, it allows for easy placement of plates medially, laterally, or anteriorly. For fractures extending more proximally, plates can be placed subcutaneously from distal to proximal through the open incision.