Isolated lateral leg compartment syndrome: A case report

BACKGROUND

Acute leg compartment syndrome is a well-known orthopedic emergency associated with potentially devastating consequences if not treated immediately. Multiple compartments are usually involved with a clear history of trauma and classic symptoms and signs. However, isolated lateral leg compartment syndrome is relatively rare and is often misdiagnosed due to the atypical presentation of no trauma and the lack of pathognomonic signs.

CASE SUMMARY

A 31-year-old male patient presented to our emergency room with excruciating left calf pain and inability to mobilize one-day after participating in a football match despite no clear history of preceding trauma. The patient went to another hospital before presenting to us where he was diagnosed to have a soft tissue injury and was discharged home on simple analgesics. On clinical examination, the left leg showed a tense lateral compartment with severe tenderness. The pain was aggravated by dorsiflexion and ankle inversion. Neurovascular examination of the limb was normal. We suspected a compartment syndrome but as the presentation was atypical and an magnetic resonance imaging (MRI) was readily available in our institution, we immediately performed an MRI and this confirmed a large hematoma in the lateral compartment with a possible partial proximal peroneus longus muscle tear. The patient was taken immediately for an emergency open fasciotomy. The patient is now 18 mo postoperatively having recovered completely and engages fully in sports with no restrictions.

CONCLUSION

Atypical presentation due to the lack of pathognomonic signs makes the diagnosis of isolated lateral leg compartment syndrome difficult. Pain on passive inversion and dorsiflexion and weak active eversion may be suggested as sensitive signs.

Two-stage revision in periprosthetic knee joint infections

Periprosthetic joint infection (PJI) following total knee arthroplasty is one of the most catastrophic and costly complications that carries significant patient wellness as well as economic burdens. The road to efficiently diagnosing and treating PJI is challenging, as there is still no gold standard method to reach the diagnosis as early as desired. There are also international controversies with respect to the best approach to manage PJI cases. In this review, we highlight recent advances in managing PJI following knee arthroplasty surgery and discuss in depth the two-stage revision method.

Randomised controlled trial of triclosan coated vs uncoated sutures in primary hip and knee arthroplasty

BACKGROUND

Triclosan-coated vicryl plus suture (Ethicon, Inc.) was developed to reduce microbial colonisation during surgical procedures. However, its effect on wound healing and surgical site infections remain unclear after hip and knee arthro-plasty surgery.

AIM

To determine the effect of triclosan-coated sutures (TCS) vs non-coated sutures on wound healing, following primary hip and knee arthroplasties.

METHODS

A single-centred, double-blind randomised controlled trial (RCT) was undertaken. We randomly allocated patients to receive either the triclosan-coated sutures (TCS vicryl plus) or non-coated sutures (NCS vicryl) during the closure of unilateral primary hip and knee arthroplasties. We utilised the ASEPSIS wound scoring system to evaluate wound healing for the first 6 weeks post-operatively.

RESULTS

One hundred and fifty patients undergoing primary total hip or knee arthroplasty over a one-year period were included. Eighty-one were randomised to the TCS group and 69 to the NCS group. Despite no statistically significant difference in the ASEPSIS scores among the study groups (P = 0.75), sensitivity analysis using the Mann Whitney test (P = 0.036) as well as assessment of the wound complications at 6 weeks follow up, demonstrated significantly higher wound complication rates in the TCS group (8 vs 1, P = 0.03).

CONCLUSION

No clear advantage was demonstrated for using the TCS. However, larger multi-centred RCTs are required to validate their use in hip and knee arthroplasty surgery.

Periprosthetic joint infections after total hip replacement: an algorithmic approach

An algorithm for managing periprosthetic joint infections (PJIs) after total hip replacement (THR) surgery using a multidisciplinary approach and a clearly defined protocol may improve infection eradication rates. In this article, we present an algorithm for the management of different types of PJIs including the acutely infected cemented and cementless THRs where the components are well-fixed postoperatively and when the infection is secondary to haematogenous spread in previously well-functioning and well-fixed implants. For chronic PJIs where the components are often loose, the standard treatment includes a two-stage revision procedure. However, in a highly selected subset of patients, a single-stage approach has been utilised with high rates of eradicating infections.

Foot and ankle history and clinical examination: A guide to everyday practice

This review summarises the key points in taking a history and performing a comprehensive clinical examination for patients with foot and/or ankle problems. It is a useful guide for residents who are preparing for their specialty exams, as well as family doctors and any other doctor who has to deal with foot and ankle problems in adults.

One-stage Exchange Arthroplasty for Periprosthetic Hip and Knee Joint Infections

Background:

Periprosthetic joint infection (PJI) is a devastating complication of joint replacement surgery. In an aging population of the developed world, the increasing numbers of hip and knee replacements will inevitably lead to increasing incidence of PJI, carrying with (it) significant patient morbidity and cost to the health care system. Two-stage exchange arthroplasty is currently the gold standard but it is associated with multiple operations, prolonged hospitalization and impaired functionality. One-stage exchange arthroplasty is similar to the two-stage procedure but the interval between removal of the prosthesis and reimplantation of a new one is only a few minutes. It has the theoretical benefits of a single anesthetic, shorter hospitalization, less cost and improved function.

Methods:

We reviewed the current literature regarding the outcomes of one-stage exchange arthroplasties focusing on re-infection rates and functional outcomes.

Results:

Current themes around the one-stage exchange procedure include the indications for the procedure, definition of re-infection, surgical techniques used to provide fixation and differences in approach for hip and knee replacements.

Conclusion:

The current literature on one-stage exchange procedure is promising, with comparable results to two-stage revisions for hips and knees in selected patients. However, there is a great need for a large multi-centred randomized control trial, focusing on re-infection rates and functional scores postoperatively, to provide concrete guidelines in managing this complex condition.

Compartment syndrome following total knee replacement: A case report and literature review

Compartment syndrome is a rare complication of total knee replacement (TKR) surgery that needs prompt diagnosis and treatment as it may be associated with high morbidity and mortality. We have found very few reports in the literature describing compartment syndrome after TKRs and therefore, present a relevant case which occurred in the immediate postoperative phase and was treated with fasciotomy and subsequent operations to close the soft tissue defects.

Is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections?

BACKGROUND

The increasing number of patients experiencing periprosthetic total knee arthroplasty (TKA) infections and the cost of treating them suggest that we seek alternatives to two-stage revision. Single-stage revision is a potential alternative to the standard two-stage procedure because it involves only one surgical procedure, so if it is comparably effective, it would be associated with less patient morbidity and lower cost.

QUESTIONS/PURPOSES

We compared (1) the degree to which our protocol of a highly selective single-stage revision approach achieved infection control compared with a two-stage revision approach to TKA infections; and (2) Knee Society scores and radiographic evidence of implant fixation between the single-stage and two-stage patients who were treated for more complicated infections.

METHODS

Between 2004 and 2009, we treated 102 patients for chronic TKA infections, of whom 28 (27%) were treated using a single-stage approach and 74 (73%) were treated using a two-stage approach. All patients were available for followup at a minimum of 3 years (mean, 6.5 years; range, 3-9 years). The indications for using a single-stage approach were minimal/moderate bone loss, the absence of immunocompromise, healthy soft tissues, and a known organism with known sensitivities for which appropriate antibiotics are available. Participants included 38 men and 64 women with a mean age of 65 years (range, 45-87 years). We used the Musculoskeletal Infection Society definition of periprosthetic joint infection to confirm infection control at the last followup appointment. Radiographs were evaluated for signs of loosening, and patients completed Knee Society Scores for clinical evaluation.

RESULTS

None of the patients in the single-stage revision group developed recurrence of infection, and five patients (93%) in the two-stage revision group developed reinfection (p=0.16). Patients treated with a single-stage approach had higher Knee Society scores than did patients treated with the two-stage approach (88 versus 76, p<0.001). However, radiographic findings showed a well-fixed prosthesis in all patients with no evidence of loosening at last followup in either group.

CONCLUSIONS

Our data provide preliminary support to the use of a single-stage approach in highly selected patients with chronically infected TKAs as an alternative to a two-stage procedure. However, larger, multicenter, prospective trials are called for to validate our findings.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Aggressive early débridement for treatment of acutely infected cemented total hip arthroplasty

BACKGROUND

Up to 2% of THAs are complicated by infection, leading to dissatisfied patients with poor function and major social and economic consequences. The challenges are control of infection, restoration of full function, and prevention of recurrence. Irrigation and débridement with or without exchange of modular components remains an attractive alternative to two-stage reimplantation in acutely infected THAs but with variable results from previous studies.

QUESTIONS/PURPOSES

We therefore determined the rate at which aggressive early débridement with exchange of modular components controlled acutely infected cemented THAs.

METHODS

We retrospectively studied all 26 patients presenting with acutely infected cemented THAs (16 primaries, 10 revisions) occurring within 6 weeks of the index operation or of hematogenous spread from a confirmed source of infection elsewhere between 1999 and 2006. Microbiology confirmed bacterial colonization in all patients, with 18 early postoperative infections and eight acute hematogenous infections. Patients underwent aggressive débridement with open complete synovectomy, exchange of all mobile parts, débridement of all aspects of the joint, irrigation with antiseptic solutions, and pulsatile lavage. Minimum followup was 5 years (mean, 6.6 years; range, 5-11 years).

RESULTS

Eight patients had multiple washouts with control of infection in four at latest followup. Five patients underwent two-stage revisions and one patient was placed on long-term antibiotic suppression. Twenty patients returned to their expected functional level with no radiographic evidence of prosthetic failure. At minimum 5-year followup, we had a 77% infection control rate.

CONCLUSIONS

Our data confirm current literature and suggest there may be a role for aggressive early débridement in controlling acute postoperative and hematogenous infections after cemented THA.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Comparing the mid-vastus and medial parapatellar approaches in total knee arthroplasty: a meta-analysis of short term outcomes

PURPOSE

Proponents of a mid-vastus (MV) approach for primary total knee arthroplasties (TKA) stress its importance in preserving function of the extensor mechanism with earlier rehabilitation and decreased prevalence of lateral release. We conducted a meta-analysis of randomised and quasi-randomised controlled trials to compare functional outcomes of the standard medial parapatellar (PP) and mid-vastus (MV) approaches in primary knee arthroplasties.

METHODS

The study was conducted according to the guidelines described in the Cochrane Handbook for Systematic Reviews of Interventions. Methodological features were rated independently by two reviewers.

RESULTS

We included 18 studies involving 1040 patients with mean age of 69 (SD ± 2.7) for the MV and 68.8 (SD ± 2.8) for the PP group. Using a MV approach led to significant improvement in flexion (mean difference (MD) 8.88, 95% confidence interval (CI) 4.50 to 13.25, P<0.01) and visual analogue scale score (MD -1.72 95% CI -2.08 to -1.36, P<0.01) in the first week postoperatively and reduced the number of required lateral releases (risk difference -0.16 95% CI -0.30 to -0.01, P=0.03) with no increase in complication rates.

CONCLUSION

We conclude that the MV approach may provide an alternative to the standard PP approach with earlier rehabilitation and decreased lateral release rates in primary TKA and no increase in complication rates.

Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement

We report a systematic review and meta-analysis of published randomised controlled trials evaluating the efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion in total hip replacement (THR). The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. We identified 11 clinical trials which were suitable for detailed extraction of data. There were no trials that used TXA in revision THR. A total of seven studies (comprising 350 patients) were eligible for the blood loss outcome data. The use of TXA reduced intra-operative blood loss by a mean of 104 ml (95% confidence interval (CI) -164 to -44, p = 0.0006, heterogeneity I(2) 0%), postoperative blood loss by a mean of 172 ml (95% CI -263 to -81, p = 0.0002, heterogeneity I(2) 63%) and total blood loss by a mean of 289 ml (95% CI -440 to -138, p < 0.0002, heterogeneity I(2) 54%). TXA led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion (risk difference -0.20, 95% CI -0.29 to -0.11, p < 0.00001, I(2) 15%). There were no significant differences in deep-vein thrombosis, pulmonary embolism, infection rates or other complications among the study groups.

Two-stage procedure in the treatment of late chronic hip infections--spacer implantation

Infection after total hip arthroplasties (THA) is a devastating complication with significant consequences for both the patients and the healthcare systems. In recent times, a two stage procedure using antibiotic-impregnated interim spacers has become the most popular treatment for late chronic hip joint infections after THA with success rates over 90%. In this review, we discuss the different types of spacers used in the treatment of chronically infected THA and conclude that hip spacers are effective in the treatment of hip joint infections.