Orthopaedics and Trauma最新文献

Achilles tendon rupture is a common injury and its incidence is increasing. There is a large body of literature on the subject and much of it debates the influence of management on re-rupture rates. Operative treatment was thought to be superior in reducing the risk of re-rupture. However, it must be balanced against the risks, in particularly wound infection and breakdown, and sural nerve injury. Minimally invasive surgery aimed to reduce wound complications but has frequently been associated with a higher risk of sural nerve damage and irritation. The introduction of functional rehabilitation, which includes early weight bearing and range of motion within an orthosis, has been pivotal in improving outcomes particularly in non-operatively managed patients. More recent evidence suggests that re-rupture rates are now similar between operatively and non-operatively managed patients when incorporating a functional rehabilitation protocol. The publication of the Achilles Tendon Rupture Score, which has been validated specifically for this injury, has been helpful in providing a more detailed picture of post-injury symptoms and function. The studies which have included this as an outcome measure have also shown comparable results between operatively and non-operatively treated patients.

Turf toe is characterized by sprain or disruption of the plantar capsuloligamentous structures of the first metatarsophalangeal joint and usually occurs due to injury during contact sports such as rugby and American football. The clinical presentation typically includes pain, swelling, and ecchymosis at the plantar surface of the first metatarsophalangeal joint, with associated weakness during push off. Diagnostic evaluation involves thorough physical examination, stressing of ligaments, and imaging with radiographs and magnetic resonance imaging. Treatment is based on classification, but is generally conservative, with surgical management being reserved for patients who fail to improve with non-operative methods. Chronic injuries may be associated with worse outcomes, and therefore early diagnosis and treatment is vital.

Metatarsal fractures sustained in sport can either be acute, or stress fractures. The aim of treatment of any fracture of the metatarsals in an athlete should be to achieve bony union, allow return to play quickly and at the same level as prior to the injury with few complications. In addition, further injuries should be prevented. Up to 9% of metatarsal fractures occur in sport. The majority of these involve the fifth metatarsal, particularly the proximal aspect of it. This location has a problematic blood supply and has a high rate of non-union. There is a wealth of information published about proximal fifth metatarsal fractures in the sporting population, with a consensus that surgical management provides the best outcomes. The second to fourth metatarsals are most likely to sustain stress fractures. These are likely to heal with non-operative treatment with good outcomes. Stress fractures of the fifth metatarsal are at high risk for fracture propagation, displacement and non-union so are best managed surgically. These injuries can be effectively prevented by improving bone health and biomechanics.

Exertional leg pain is a common problem in the athletic population, presenting with a constellation of similar symptoms. Delayed or incorrect diagnosis and treatment may result in significant morbidity and avoidable cessation of activity. Multiple causes such as chronic exertional compartment syndrome (CECS), medial tibial stress syndrome (MTSS), nerve or vascular entrapment syndromes may be responsible. A thorough history and focused clinical examination is mandated, and may yield clues as to the definitive diagnosis. Investigative adjuncts include imaging, compartment pressure measurement and electrodiagnostic studies. Whilst specific management depends on the underlying cause, the mainstay of initial management is activity modification, with surgery reserved for those who fail to respond to conservative measures.

Paediatric bone and joint infections (PBJI) can be challenging to diagnose due to their non-specific symptoms including fever, pain, swelling, and limited range of motion of the limb. The diagnosis involves a combination of clinical evaluation, laboratory tests, and imaging studies. Plain radiographs, ultrasound, and MRI can aid in the diagnosis of these infections. The approach to treating PBJI is multidisciplinary, involving paediatricians, infectious disease specialists, orthopaedic surgeons, and radiologists. Family-centred care and close follow-up are crucial to ensure optimal outcomes for children with bone infections. Management involves a combination of medical treatment with intravenous and oral antibiotics, and, if required, surgical interventions centred around debriding all dead bone and soft tissue, draining intra- or extra-osseus abscesses, stabilizing pathological fractures and delivering high doses of local antibiotics. Early diagnosis and prompt initiation of appropriate treatment are crucial to prevent long-term complications such as chronic osteomyelitis, septic arthritis, growth disturbances and limb length discrepancies.

Diagnosis of bone and joint infections can be difficult. In recent years there has been great progress in defining how we diagnose fracture-related infection (FRI) and prosthetic joint infection (PJI). Definitions have been proposed based on the best evidence from the literature, including well-established tests performed before and during surgery. These allow surgeons to make better decisions for treatment and to counsel patients. This paper presents the elements of the International Consensus Definition of FRI and the European Bone & Joint Infection Society Definition of Prosthetic Joint Infection (PJI), together with the current knowledge on how these definitions can help in clinical practice.

Prosthetic joint infection (PJI) is one of the worst complications of joint arthroplasty with an incidence of around 1% following primary arthroplasty, 3% following aseptic revision, and 20% following septic revision. It can occur following direct inoculation, haematogenous or contiguous spread. The majority of PJIs are secondary to bacterial infection although fungal PJI may be seen in multiply operated or immune compromised patients. Risk factors for PJI include patient, pathology and procedure-related factors which, where possible, should be optimized prior to surgery. The diagnosis of PJI remains a challenge and is based on patient history, clinical examination, laboratory tests, and imaging studies. No diagnostic assessment is 100% accurate with various diagnostic criteria used clinically. Investigation and treatment of PJI should be guided by a multi-disciplinary team. Surgical treatment remains the gold standard with the aim of eradicating infection. During surgery the causative organism is sought through a rigorous standardized tissue sampling technique. Surgical approaches including debridement, antibiotics and implant retention (DAIR), single-stage revision, two-stage revision, excision arthroplasty, arthrodesis and amputation. The approach used is tailored to the individual patient with the optimum surgical strategy being one that successfully eradicates the infection, but at the same time minimizes morbidity to the patient.

Recently, bone and joint infections such as fracture-related infection (FRI) and prosthetic joint infections (PJI) have been defined for clinical and research purposes. National and international guidelines are being produced to guide clinicians towards what is considered best practice. However, much of what we do regarding the microbiological diagnosis and management of orthopaedic infection is based on expert opinion, rather than evidence-based medicine. This is largely because, prior to the publication of the clinical definitions of orthopaedic infection, studies included a heterogeneous population making comparisons between them difficult. More recently the publication of large clinical trials in the antimicrobial management of orthopaedic infection has demonstrated that such clinical research is possible, and can both challenge the existing dogma in this field and lead to universal changes in clinical practice. There is robust evidence for microbiological sampling techniques and their interpretation in diagnosis of orthopaedic infection, as well as the choice of empiric broad-spectrum antibiotics and the non-inferiority of oral versus intravenous systemic antibiotics. For other elements of the diagnosis and management of orthopaedic infection this is not the case. For example, there are limited or no data to support recommendations regarding time off antibiotics prior to microbiological sampling, systemic antibiotic duration, when to do a joint aspirate in PJI revisions or the timing of definitive joint implantation in the two-stage management of PJI. In summary, this review highlights what is currently considered best practice within the field of orthopaedic infection and discusses both the evidence behind it and where there is controversy or where further research is warranted.

Bone and joint infections can present in many ways. It is important to understand the features of the infection which contribute to the complexity of the condition and affect the outcome of treatment for the patient. Classification systems can do this but are often ignored in clinical decision-making and design of research projects. Recent work has better documented the key features of the patient and limb which must be considered when treatment is planned. This paper reviews the available classifications and their application to clinical practice. The Cierny and Mader and JS-BACH classifications offer useful information for stratifying cases and provide evidence-based advice on outcome from treatment for patients. Both have been validated in well-defined patient cohorts.