Aims

Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below-knee amputation, particularly in the presence of severe soft-tissue destruction. This study assesses the outcomes of single-stage orthoplastic surgical treatment of calcaneal osteomyelitis with large soft-tissue defects.

Background. The treatment of chronic calcaneal osteomyelitis is a challenging and increasing problem because of the high prevalence of diabetes mellitus and operative fixation of heel fractures. In 1931, Gaenslen reported treatment of hematogenous calcaneal osteomyelitis by surgical excision through a midline, sagittal plantar incision. We have refined this approach to allow successful healing and early mobilization in a modern series of complex patients with hematogenous, diabetic, and postsurgical osteomyelitis. Methods. Twenty-eight patients (mean age 54.6 years, range 20–94) with Cierny-Mader stage IIIB chronic osteomyelitis were treated with sagittal incision and calcaneal osteotomy, excision of infected bone, and wound closure. All patients received antibiotics for at least 6 weeks, and bone defects were filled with an antibiotic carrier in 20 patients. Patients were followed for a mean of 31 months (SD 25.4). Primary outcome measures were recurrence of calcaneal osteomyelitis and below-knee amputation. Secondary outcome measures included 30-day postoperative mortality and complications, duration of postoperative inpatient stay, footwear adaptions, mobility, and use of walking aids. Results. All 28 patients had failed previous medical and surgical treatment. Eighteen patients (64%) had significant comorbidities. The commonest causes of infection were diabetes ± ulceration (11 patients), fracture-related infection (4 patients), pressure ulceration, hematogenous spread, and penetrating soft tissue trauma. The overall recurrence rate of calcaneal osteomyelitis was 18% (5 patients) over the follow-up period, of which 2 patients (7%) required a below-knee amputation. Eighteen patients (64%) had a foot that comfortably fitted into a normal shoe with a custom insole. A further 6 patients (21%) required a custom-made shoe, and only 3 patients required a custom-made boot. Conclusion. Our results show that a repurposed Gaenslen calcanectomy is simple, safe, and effective in treating this difficult condition in a patient group with significant local and systemic comorbidities

Purpose and background:. Sacroiliitis identified by MRI is considered as a keystone in the diagnosis of spondyloarthritis. To reduce the number of unnecessary MRI scans it would be ideal if sacroiliac (SI) joint pain provocation tests could be used to identify patients at risk of having sacroiliitis. The aim of the current study was to investigate the diagnostic value of three pain provocation SI-joint tests for sacroiliitis identified by MRI. Methods:. Patients (n=454, mean age 32 years, 54% women) without clinical signs of nerve root compression were selected from a cohort consisting of patients with persistent low back pain referred to an outpatient spine clinic. Data from the Gaenslen's Test, Thigh Thrust Test and Long Dorsal Sacroiliac Ligaments Test and sacroiliitis identified by MRI were analysed. Results:. The prevalence of SI-joints with sacroiliitis was 5%. In the whole study group, only the Thigh Trust Test was associated with sacroiliitis, ROC area 0.58 (95% CI 0.51–0.65), sensitivity 31% (18–47) and specificity 85% (82–87). In men, sacroiliitis was associated with all three SI joint tests and multitest regimens, with the greatest ROC area found for ≥ 1 positive out of 3 tests, (0.68 (0.56–0.80)), sensitivity 56% (31–79) and specificity 81% (77–85). In women, no significant associations were observed between the assessed SI joint tests and sacroiliitis. Conclusions:. Only in men were the performed SI-joint tests found to be associated with sacroiliitis identified by MRI. Although, the diagnostic value was limited, the results indicate that the use of SI joint tests for sacroiliitis may be optimised by gender-separated analyses

Background:. In 1931, Gaenslen reported treatment of haematogenous calcaneal osteomyelitis through an incision on the sole of the heel, without the use of antibiotics. We have modified his approach to allow shorter healing times and early mobilisation in a modern series of cases. Method:. Sixteen patients with Cierny-Mader Stage IIIB chronic osteomyelitis were treated with split-heel incision, calcaneal osteotomy, radical excision, local antibiotics, direct skin closure and parenteral antibiotics. 4 patients had diabetic foot infection with neuropathy, 5 had infection after open injuries, 4 had haematogenous osteomyelitis and 3 had Grade 4 pressure ulceration with bone involvement. 14 had sinuses/ulcers and 12 had undergone previous surgery. Primary outcomes were eradication of infection, time to sinus/ulcer healing, mobility and need for modified shoes. Results:. Mean hospital stay was 19.2 days (7–44). 14 patients had no recurrence of infection at final follow-up (minimum 12 months; mean 53 months). Ulcers healed between 4 and 15 weeks. 2 patients with recurrent infection required amputation. Of the 14 salvaged patients, 10 mobilised unaided. 9 required modified shoes. Conclusion:. This protocol gave effective control of infection, ulcer healing and mobilisation within an acceptable time, but amputation remains a risk

The purpose of this study is to present the surgical and functional results of a partial and total calcanectomy procedure as a foot salvage alternative in patients with extensive chronic osteomyelitis of the calcaneus. Material: A retrospective review identified 19 calcanectomies in 16 patients: 5 partial, 11 total and 3 partial to total. The primary diagnosis was insulin-dependent diabetes mellitus (3 patients), neurophatic ulceration (2 patients), infected osteosynthesis (4 patients) and open fracture (7 patients). The average age of the patients was 42.36 years (range from 22 to 60). Prior procedures included removal of osteosynthesis, debridement, Gaenslen’s procedure and skin grafting. Operation was based in Martini’s technique. Most common bacteria were Staphylococcus aureus. Antibiotic treatment was based in cultures and has changed during this period of time. Results: Four patients were lost (2 died) and the rest average follow-up was 9.8 years (range from 1 to 19 years). Recurrence of infection was present in 3/5 partial calcanectomies and in 1/14 of total calcanectomies. Talonavicular subluxation occurred as a late complication in the patient with recurrence after total calcanectomy and underwent a below-knee amputation. An assessment of functional ambulation was performed in all 16 patients according Volpicelli scale; the lost patients were recorded last time they were visited. All ambulatory patients needed a modified heel-containment orthosis. Conclusions: Total calcanectomy is an alternative procedure to a bellow-knee amputation in patients with chronic osteomyelitis of the calcaneus. In our hands, partial calcanectomy has worse results in eradication of infection and we have left it

We reviewed 15 consecutive patients, 11 women and four men, with a mean age of 48.7 years (37.3 to 62.6), who between July 2004 and August 2007 had undergone percutaneous sacroiliac fusion using hollow modular anchorage screws filled with demineralised bone matrix.

Each patient was carefully assessed to exclude other conditions and underwent pre-operative CT and MR scans. The diagnosis of symptomatic sacroiliac disease was confirmed by an injection of local anaesthetic and steroid under image intensifier control.

The short form-36 questionnaire and Majeed’s scoring system were used for pre- and post-operative functional evaluation. Post-operative radiological evaluation was performed using plain radiographs.

Intra-operative blood loss was minimal and there were no post-operative clinical or radiological complications. The mean follow-up was for 17 months (9 to 39). The mean short form-36 scores improved from 37 (23 to 51) to 80 (67 to 92) for physical function and from 53 (34 to 73) to 86 (70 to 98) for general health (p = 0.037). The mean Majeed’s score improved from 37 (18 to 54) pre-operatively to 79 (63 to 96) post-operatively (p = 0.014). There were 13 good to excellent results. The remaining two patients improved in short form-36 from a mean of 29 (26 to 35) to 48 (44 to 52). Their persistent pain was probably due to concurrent lumbar pathology.

We conclude that percutaneous hollow modular anchorage screws are a satisfactory method of achieving sacroiliac fusion.

We report the management of an adult patient with septic sacroiliitis. This is an uncommon condition. Debridement, decompression and spontaneous fusion are the treatment of choice when symptoms do not resolve with routine initial intravenous antibiotic therapy. A percutaneous technique is described, using the principles of sacroiliac screw insertion commonly used for pelvic reconstruction surgery. After successful evacuation of the infected joint, fusion was observed in our patient.

Tuberculous sacro-iliitis occurs in fewer than 10% of cases of skeletal tuberculosis. The diagnosis is usually delayed as more common causes of low back pain are sought. Treatment is mainly conservative, with very few patients requiring surgery. In a retrospective analysis from 1994 to 2004, we reviewed 15 patients, ranging in age from 15 to 60 years, 13 of whom presented with lower back pain and difficulty with walking. Two patients had an abscess over the affected sacro-iliac joint. All patients had tenderness over the sacro-iliac joint. The Gaenslen and FABER stress tests were positive in all patients. Radiographs showed joint space widening, marginal sclerosis of the joints and peri-articular osteopoenia. Technetium 99 bone scan revealed increased uptake in the region of the sacro-iliac joint. CT scan revealed joint space widening, sclerosis and sequestra in the joint space. Only one patient had bilateral tuberculous infection. Two had had an associated lumbar spine lesion. All 15 patients underwent open biopsy. Histological and microbiological reports revealed chronic infection, with Mycobacterium tuberculosis the causative organism. An 18-month program of antituberculous medication was initiated. Ambulation followed wound healing. Follow-up ranged from 5 to 8 years. All 15 patients responded well to this conservative approach. In patients with low back pain, sacro-iliac disease should always be included in the differential diagnosis. Thorough clinical and radiological examination and laboratory diagnosis is essential to exclude pyogenic infection and tumours