Category: Basic Sciences/Biologics, Diabetes Introduction/Purpose: Bone infection in the foot is a challenging pathology that frequently leads to amputation and major disability. Agent identification and antimicrobial susceptibility-guided therapy is the key for a successful treatment. Standard culture methods for bone tissue have demonstrated poor sensitivity. It has been reported that synovial fluid culture sensitivity is enhanced when seeded into pediatric blood culture bottles (PBCB), however, its performance for bone infection has yet to be determined. The aim of this study was to evaluate a novel method to obtain and process infected bone tissue using PBCB and comparing it with the standard technique. Methods: Patients admitted at a single university hospital with foot osteomyelitis between 2008 and 2017 were recruited prospectively. The diagnosis was made by clinical, laboratory and imaging findings. A representative sample of infected bone tissue was obtained for each patient and simultaneously processed using the standard technique for solid tissue cultures (SCM) and a morselized bone sample that was seeded into a PBCB (BacT/ALERT® PF). Culture sensitivity and number of agents detected for each technique were compared using the McNemar and the Mann Whitney tests respectively. Results: Over the period studied, 107 patients fitted the inclusion criteria. Of these, 63 patients had a diabetic-related infection. The causative agent was identified in 60.7% using the SCM and in 97.2% using PBCB (p < 0.001). We detected a mean of 1.05 bacteria species using SCM and 1.67 using PBCB (p<0.01). PBCB retrieved 1 bacterial species in 50.5% of the samples and 2 or more bacterial species in 46.7%. The SCM detected 1 bacterial species in 29% of the samples and 2 or more bacterial species in 31.7%. Conclusion: In this cohort, culture technique using morselized bone tissue seeded in PBCB identified the causative agent in a significantly larger percentage than SCM. Additionally, this method identified a larger number of agents. These findings demonstrate that this novel, simple and reproducible technique for culturing bone tissue samples allows a better microbiological diagnosis, without additional intraoperative risks, compared with standard methods.

Macrodystrophia lipomatosa (ML) is a rare cause of local gigantism affecting hands or feet of congenital non-hereditary origin and unknown etiology. The main characteristic of this disease is the overgrowth of the mesenchymal structures as bone, tendons, vessels, nerves and, predominantly, the fibroadipose tissue. The low frequency of this pathology implies a difficulty to establish management guidelines. The most recommended treatment for this condition is the reductive surgery as an alternative to amputation of the affected segment. Our objective is to report the clinical results of the reductive surgery in four patients with ML in the forefoot. Methods: Four cases of ML surgically treated in our center between 2008 and 2016 were retrospectively analyzed after approval from our institutional review board. For each case, clinical history at admission, pre and post-operative radiographs and pre and post-operative clinical images were obtained. Results: Patients were adults between 28 and 38 years old and followed between 1 and 4 years. The toes involved were: 1 hallux, 2 second toes and 1 fourth toe. All had failed conservative treatment prior to surgery. SURGICAL TECHNIQUE: An extensile dorsal approach preserving the neurovascular bundles was performed. Bone was resected until a harmonic appearance of the toe related to the rest of the foot was obtained. In one case, removal of the distal phalanx was necessary to achieve adequate reduction. The remnant soft tissue was resected from dorsal and distal. Skin was closed using non-absorbable sutures. Wound dehiscence was observed in 2 patients and managed conservatively. No major complications were observed. All the patients were satisfied and able to wear regular shoes postoperatively. Conclusion: The reductive surgery for adults with symptomatic ML of the foot offers good functional results. The extensile dorsal approach allows an excellent surgical exposure, preservation of neurovascular supply and adequate tissue resection. Based on our clinical results and the high satisfaction observed in our 4 patients, we suggest reductive surgery as a good alternative to amputation in selected patients with ML.

Category: Ankle, Trauma Introduction/Purpose: Dislocation of the proximal tibiofibular joint (PTFJ) in association with ankle fracture is an infrequent injury. The mechanism involves a pronation-external rotation injury in which the energy exits through the PTFJ instead of the proximal fibula, like in a Maissoneuve fracture. Early diagnosis and treatment is of paramount importance to avoid complications such as pain, posterolateral knee instability and peroneal nerve injury due to chronic traction by the dislocated fibular head. In addition, an anatomical reduction of the PTFJ is mandatory to restore the fibular length in order to obtain anatomic reduction at the ankle. The objective is to report 3 cases with PTFJ dislocation in association with ankle fracture and to provide a treatment guide based on the management of these patients. Methods: Three cases of PTFJ dislocation in association with ankle fracture, surgically treated in our institution between 2009 and 2016, were retrospectively analyzed. For each case, clinical history at admission, pre and post operative radiographs and computed tomography (CT) were obtained. Clinical follow up time was between 1 and 6 years. Results: Diagnosis of the PTFJ dislocation required a high degree of suspicion. All the patients had subtle radiographic abnormalities at the PTFJ, thus requiring a CT of the knee to confirm the diagnosis. The first surgical step was to perform an open reduction of the PTFJ. Common peroneal nerve was identified and retracted. Reduction was performed with a clamp and for fixation we used one cortical positioning screw from the fibula to the tibia. After the achievement of an anatomic reduction, the second step was to approach the ankle according the specific fracture pattern. Anatomical reduction was obtained in all the patients checked by ankle and knee CT. At final follow up none of the patients had knee pain, and all returned to their activities. Conclusion: The PTFJ dislocation in association with ankle fracture is an infrequent injury and should be considered as a Maissoneuve equivalent fracture in terms of mechanism and diagnosis. A high index of suspicion is needed and the diagnosis is confirmed with a knee CT. As the Essex Lopresti injury of the upper extremity, this type of lesion requires proximal and distal stabilization. Our recommended treatment, based on the good clinical results of our 3 patient, is open reduction and screw fixation of the PTFJ as the first step in order to allow anatomical reduction of the distal injury at the ankle.