Search

One of the most challenging problems facing orthopedic surgeons is persistent pain after surgery and certainly is just as frustrating following hindfoot fusion. The hindfoot joints consist of the subtalar, talonavicular, and calcaneocuboid (CC) joints. These joints are commonly fused for degenerative changes, deformity correction, inflammatory or neuropathic arthropathy, tarsal coalition, or primarily after trauma. Goals of hindfoot fusion are a painless plantigrade foot capable of fitting in shoes without orthotics or a brace. Many believe that deformity correction is achievable without inclusion of the CC joint. Managing patient expectations is important when counseling a patient especially regarding potential complications.

Objective To evaluate the rate of subtalar arthrodesis based on a computed tomography (CT) scan after open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneal fractures. Design Retrospective chart review. Setting Single tertiary care practice. Patients A retrospective chart review was performed to identify patients who sustained an acute, displaced, intra-articular calcaneal fracture and underwent open reduction and primary subtalar arthrodesis. Thirty-five patients participated in the study. Intervention Each patient included in the study was treated with open reduction and primary subtalar arthrodesis. Main outcome measures All patients were evaluated with CT for arthrodesis of the posterior facet of the subtalar joint, which was quantitated. Other outcome measures included radiographic parameters, the Veterans RAND Item Health Survey, and the Foot and Ankle Ability Measure. Results The median patient age was 47.8 years (range 21.5-79.5 years). The median patient follow-up was 34.4 months (range 4.6-104.1 months). The Sanders classification was as follows: 3% (1/35) type II, 40% (14/35) type III, and 57% (20/35) type IV. Based on a CT scan, primary subtalar union occurred in 94.3% (33/35) of patients. Conclusions Open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneus fractures has a high rate of union and good pain and function outcomes. It should be strongly considered for patients with significant cartilage injury and comminution of the posterior facet. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Posterior tarsal tunnel syndrome is the result of compression of the posterior tibial nerve. Anterior tarsal tunnel syndrome (entrapment of the deep peroneal nerve) typically presents with pain radiating to the first dorsal web space. Distal tarsal tunnel syndrome results from entrapment of the first branch of the lateral plantar nerve and is often misdiagnosed initially as plantar fasciitis. Medial plantar nerve compression is seen most often in running athletes, typically with pain radiating to the medial arch. Morton neuroma is often seen in athletes who place their metatarsal arches repetitively in excessive hyperextension.

Hallux rigidus is marked by degenerative osteoarthritis of the first metatarsophalangeal (MTP) joint with pain and stiffness in the joint, with first ray plantarflexion and dorsiflexion, swelling and inflammation surrounding the first MTP joint, and reduced sagittal plane motion. Treatment of mild cases of hallux rigidus focuses on conservative, nonsurgical treatments such as rigid orthotic devices, physical therapy, pain relievers, and corticosteroid injections. Hallux rigidus recalcitrant to conservative management can be treated with dorsal cheilectomy to palliate pain at extremes of motion. Post-cheilectomy scarring and stiffness of the joint result in a diminished arc of motion over time. This clinical problem is not readily addressed by current treatment methods. Amniotic membrane/umbilical cord has the potential to modulate adult wound healing by suppressing stromal cellular-based inflammation and reducing scarring. Cryopreserved amniotic membrane/umbilical cord (AM/UC) tissue has been successfully used for minimizing postoperative inflammation, pain, and adhesion formation following various soft tissue reconstructive procedures, particularly in ophthalmology. Recently, the therapeutic potential of cryopreserved AM/UC has been expanded for use in lower extremity reconstructive procedures, specifically where wound healing and adhesion prevention are of clinical significance. This article reviews a bilateral case report experience of the novel utility of cryopreserved AM/UC tissue as an adhesion barrier and inflammatory modulator in conjunction with dorsal cheilectomy for treatment of hallux rigidus.

Staphylococcus aureusinvades osteoblasts and can persist in the intracellular environment. The present study examined the role of osteoblast mitogen-activated protein kinase (MAPK) pathways in bacterial invasion.S. aureusinfection of normal human and mouse osteoblasts resulted in an increase in the phosphorylation of the extracellular signal-regulated protein kinases (ERK 1 and 2). This stimulation of ERK 1 and 2 correlated with the time course ofS. aureusinvasion, and bacterial adherence induced the MAPK pathway. ERK 1 and 2 phosphorylation was time and dose dependent and required activeS. aureusgene expression for maximal induction. The nonpathogenicStaphylococcus carnosuswas also able to induce ERK 1 and 2 phosphorylation, albeit at lower levels thanS. aureus. Phosphorylation of the stress-activated protein kinases was increased in both infected human and mouse osteoblasts; however, the p38 MAPK pathway was not activated in response toS. aureus. Finally, the transcription factor c-Jun, but not Elk-1 or ATF-2, was phosphorylated in response toS. aureusinfection.

Staphylococcus aureusandSalmonellaspp. are common causes of bone diseases; however, the immune response during such infections is not well understood. Colony-stimulating factors (CSF) have a profound influence on osteoclastogenesis, as well as the development of immune responses following infection. Therefore, we questioned whether interaction of osteoblasts with two very different bacterial pathogens could affect CSF expression by these cells. Cultured mouse and human osteoblasts were exposed to various numbers ofS. aureusorSalmonella dublinbacteria, and a comprehensive analysis of granulocyte-macrophage (GM)-CSF, granulocyte (G)-CSF, macrophage (M)-CSF, and interleukin-3 (IL-3) mRNA expression and cytokine secretion was performed. Expression of M-CSF and IL-3 mRNAs by mouse osteoblasts was constitutive and did not increase significantly following bacterial exposure. In contrast, GM-CSF and G-CSF mRNA expression by mouse osteoblasts was dramatically upregulated following interaction with either viableS. aureusorSalmonella. This increased mRNA expression also translated into high levels of GM-CSF and G-CSF secretion by mouse and human osteoblasts following bacterial exposure. ViableS. aureusandSalmonellainduced maximal levels of CSF mRNA expression and cytokine secretion compared to UV-killed bacteria. Furthermore, GM-CSF and G-CSF mRNA expression could be induced in unexposed osteoblasts separated by a permeable Transwell membrane from bacterially exposed osteoblasts. M-CSF secretion was increased in cultures of exposed human osteoblasts but not in exposed mouse osteoblast cultures. Together, these studies are the first to define CSF expression and suggest that, following bacterial exposure, osteoblasts may influence osteoclastogenesis, as well as the development of an immune response, via the production of these cytokines.

Staphylococcus aureus is a bacterial pathogen causing approximately 80% of all cases of human osteomyelitis. This bacterium can adhere to and become internalized by osteoblasts and previous studies indicate that osteoblasts are active in the internalization process. In the current study, we examined the roles of microfilaments, microtubules and clathrin-dependent receptor-mediated endocytosis in the internalization of S. aureus by MC3T3-E1 mouse osteoblast cells. Microfilament and microtubule polymerization was inhibited with cytochalasin D and colchicine. Clathrin-coated pit formation was examined by using the transaminase inhibitor, monodanslycadaverine. The results of this study indicate that mouse osteoblasts utilize actin microfilaments, microtubules and clathrin-coated pits in the internalization of S. aureus; however, microfilaments seem to play the most significant role in the invasion process.