Resection Of Infection Research Articles

Deformity and Clinical Outcomes Following Operative Correction of Charcot Foot: A New Classification With Implications for Treatment.

The historic treatment of Charcot foot arthropathy has been immobilization during the active phase of the disease process, followed by accommodative bracing of the acquired deformity. Evidence derived from modern patient-reported outcomes investigations has convinced many surgeons to attempt operative correction of the acquired deformity with a goal of improving quality of life. Over a 12-year period, 214 patients (9 bilateral) underwent reconstruction of the acquired deformity associated with midtarsal Charcot foot arthropathy. Over time, 3 patterns of deformity were observed based on weight-bearing pattern, relationship of the forefoot to the hindfoot, and integrity of the talocalcaneal joint. A valgus deformity pattern was present in 138, varus in 48, and dislocation of the talocalcaneal joint in 37. A consistent operative strategy was employed. Surgery included percutaneous tendon-Achilles lengthening, resection of infection when present, attempted correction of the structural deformity by wedge resection at the apex of the deformity, and immobilization with a 3-level static circular external fixator. Additional deformity pattern-specific procedures were added over time. Clinical outcomes were based on the historic metrics of limb salvage and resolution of infection and the functional metric of the ability to walk with commercially available therapeutic footwear. Seven patients died within a year of surgery, and 15 underwent partial- or whole-foot amputation. Overall, 173 of 223 feet (77.6%) achieved a favorable clinical outcome. Patients with a valgus deformity pattern were most likely to achieve a favorable clinical outcome (120 of 138, 87.0%). Patients with a dislocation pattern were less likely to achieve a favorable clinical outcome (26 of 37, 70.3%), and those with a varus deformity pattern were least likely to achieve a favorable clinical outcome (27 of 48, 56.3%). Operative correction of the acquired deformity of Charcot foot arthropathy was performed with a goal of improving quality of life. Stratification of patients by deformity pattern allowed alterations of the basic surgery to afford improved outcomes. In addition to achieving historic goals of resolution of infection and limb salvage, almost 80% of the patients were able to achieve the functional goal of independent ambulation with commercially available therapeutic footwear. The clinical outcomes achieved in this retrospective case series appear to support the modern paradigm of operative correction of deformity in this complex patient population. This realistic appreciation of outcome expectations should both be helpful in counseling patients on the risk-benefit ratio associated with surgery and provide a benchmark to measure newer strategies of treatment. Level IV, retrospective case series.

External Iliac Artery Injury Complicating Prosthetic Hip Resection for Infection

Vascular injury is a rare but devastating complication of total hip arthroplasty. We present 2 cases of external iliac artery injury that complicated the removal of a chronically infected total hip arthroplasty where the acetabular component had migrated medial to Kohler's line. In both cases, hemostasis and reperfusion were achieved with the assistance of a vascular surgeon. This report describes the diagnosis, treatment, and associated risk factors for this rare complication. The combination of deep infection and medial migration of the acetabular component represents a high-risk situation for vascular injury. We advocate preoperative consultation with a vascular surgeon in this setting.

Acetabular Revision with Metal Mesh, Impaction Bone Grafting, and a Cemented Cup

Impaction grafting is controversial in the presence of segmental and cavitary acetabular defects and requires the use of supplemental devices to close segmental defects. This approach, however, would allow treating combined deficiencies that could not be managed with impacted cancellous bone alone. We raised the following two questions: (1) What is the survival rate in patients with combined deficiencies reconstructed with metal mesh, impaction grafting and a cemented cup and (2) can metal mesh prevent cup migration? We evaluated 23 cavitary uncontained acetabular defects in revision hip arthroplasty. Preoperative diagnoses were aseptic loosening (19 hips) and second-stage reimplantations after resection for infection (four hips). The preoperative Merle D'Aubigné-Postel score averaged 7.4 points. Two patients had reoperations for mechanical failure at 6 and 24 months. The survival rate with further revision as an end point was 90.8% at an average of 36 months (range, 24-56 months; 95% confidence interval, 68.1-97.6). Metal mesh did not prevent cup migration: migration occurred in all patients, averaging 5.1 mm (range, 2-25 mm). Another three patients with severe combined defects had asymptomatic mesh rupture with 3- to 15-mm migration. Postoperative functional score averaged 16.2 points. Metal mesh, impaction grafting, and a cemented cup should be considered for reconstruction of medium uncontained acetabular defects, but not for severe combined deficiencies. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Stability following hip resection for infection

R ESECTION of a hip does not necessariIy result in a weak and unstable joint. Two methods of therapy following resection have been suggested, either external support or reconstructive methods to produce stabiIity. TayIor’ provided a bucket-top caIiper and crutches. Sir Robert Jones2 attached the greater trochanter with its muscles to the remains of the femora1 neck after resection of the head. This procedure was Iater modified by Girdlestone.” M&h4 performed a Schanz osteotomy after excising the femoral head and neck which ensured stabiIity. Another procedure was described by Harmon5 in which the neck of the femur was reconstructed to articulate with the acetabulum. In accordance with the present trend, a prosthesis might be inserted as a substitute. However, no reconstructive procedures were performed foIIowing resection of the hips in the cases presented here because of severe infections of joints. Strong and stable hips developed due to a phenomenon which is described in each case report. These end results were not anticipated, nor were they due to any pIanned treatment or regimen.