Biomedical subjects
Publications and source records attributed to Christopher Bibbo.
In this review, an in-depth anatomic and molecular pathogenesis of diabetic neuropathy is provided. Classifications and clinical manifestations of diabetic neuropathy are discussed. The current modalities of treatment and clinical research on this disorder are summarized.
BACKGROUND: Displaced intra-articular calcaneal fractures may have a central cancellous bone defect area. We hypothesized that human demineralized bone matrix (DBM) calcium sulfate (CaSO(4)) might act as a reasonable alternative to autograft in calcaneal fractures. When combined with antibiotic powder, this bone graft substitute also may act as a local antibiotic delivery device. This is the first clinical study evaluating bone healing and complications associated with DBM-calcium sulfate bone graft substitute in the treatment of displaced intra-articular calcaneal fractures with a central cancellous bone defect. METHODS: Over a 29-month period, 33 displaced intra-articular calcaneal fractures with central cancellous defects were treated with open reduction and internal fixation (ORIF) and grafting with vancomycin/DBM-calcium sulfate bone graft substitute. Eleven fractures without bone defects were treated with ORIF only. Patient demographics, medical history, and CT fracture classification were recorded. Postoperatively, fractures were monitored every 2 weeks for healing and complications. RESULTS: The mean time to union was 8.2 weeks in the grafted, while the control group mean time to union was 10.4 weeks (p = 0.0117). Wound problems occurred in five (15%) of the 33 patients with grafting, all in type III fractures with severe soft-tissue swelling, and included two minor wound healing delays, and three serious wound problems. At a mean followup time of 22.4 months, no DBM-calcium sulfate grafted calcaneus demonstrated evidence of osteomyelitis. CONCLUSIONS: This is the first study examining human DBM-calcium sulfate bone graft substitute to treat displaced intra-articular calcaneal fractures. Based on these initial data, human DBM-calcium sulfate acted as an acceptable and safe autograft alternative in displaced intra-articular calcaneal fractures with moderate (5 cc to 10 cc) central cancellous bone defects.
Platelet-rich plasma (PRP), derived from autologous blood, is defined as a volume of plasma that has a platelet concentration that typically is five times greater (approximately 1,000,000/microl) than physiologic levels. PRP serves as a reservoir of critical growth factors, including platelet-derived growth factor, transforming growth factor-beta, and insulin-like growth factor-I. Although there is an abundance of literature pertaining to dental applications, this article highlights the use of PRP in orthopedic applications, ranging from PRP preparation to in vitro and in vivo studies to clinical research.
UNLABELLED: Feet are prone to bacterial contamination. We hypothesized that chlorhexidine scrub and isopropyl alcohol paint provide superior local flora reduction than povidone-iodine scrub and paint. Patients with intact, uninfected skin having clean elective foot and ankle surgery were prospectively enrolled and randomly assigned to skin preparation with povidone-iodine (Group 1) or chlorhexidine scrub and isopropyl alcohol paint (Group 2). Culture swabs (aerobic, anaerobic, acid fast, fungus, and routine antibiotic sensitivity) were taken from all web spaces, nail folds, toe surfaces, and proposed surgical incision sites. One-hundred twenty-seven patients were enrolled (mean age, 46 years; range, 16-85 years). Sixty-seven patients were assigned to Group 1; 60 patients were assigned to Group 2. In Group 1, 53 of 67 patients (79%) had positive cultures; in Group 2, 23 of 60 patients (38%) had positive cultures. These data indicate that chlorhexidine and alcohol provide better reduction in bacterial carriage than povidone-iodine. Based on these data, we recommended chlorhexidine as the surgical preparatory agent for the foot and ankle. LEVEL OF EVIDENCE: Therapeutic study, Level I-1a (significant difference). See the Guidelines for Authors for a complete description of levels of evidence.
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Adjuvant use of autologous platelet concentrate (APC) to assist bone healing in foot and ankle surgery has not been reported. This study examined the clinical results and complications after the adjuvant use of APC in high-risk patients undergoing elective foot and ankle surgery. Patients at risk for bone-healing complications were prospectively enrolled over a 6-month period for the intraoperative application of APC. Patients were followed every 2 weeks for radiographic union and complications. Sixty-two high-risk patients were enrolled, totaling 123 procedures. Mean patient age was 51 years (range, 16-76), there were 36 females and 26 males, and 24 patients were smokers. Overall, a 94% union rate was achieved at a mean of 41 days. For APC alone, the mean time to union was 40 days; when APC was used with autograft, the mean time to union was 45 days (p = .173, two-tailed t test). These data suggest that adjuvant APC results in an acceptable time to union and may be a useful adjunct to promote osseous healing in high-risk patients undergoing elective foot and ankle surgery.
Ankle injuries are common in the general and athletic populations. These injuries constitute 21% of all sports-related injuries. The wide spectrum of sports-related ankle injuries includes ligamentous injuries, soft-tissue and osseous impingement, osteochondral lesions of the talus, tendon injuries, and fractures. Occult lesions (eg, fractures of the lateral process of the talus, fractures of the anterior process of the calcaneus, fractures of the base of the fifth metatarsal, os trigonum, stress fractures) may be missed on initial physical examination, and patients with such injuries often present to a sports clinic with persistent pain around the ankle. Because of increasing participation in sporting events, health care professionals involved in the care of athletes at all levels must have a thorough understanding of the anatomy, pathophysiology, and initial management of ankle injuries. In this review, we describe the pertinent anatomy, pathology, diagnosis, and treatment of sports-related injuries of the ankle.
The records of 47 consecutive patients with metastatic pathologic fractures of the lower extremity were analyzed with respect to thromboembolic complications. All patients were unable to receive pharmacologic deep venous thrombosis prophylaxis, and were stratified into two groups, based on use of an inferior vena cava filter. Group I (n = 24) consisted of patients who had an inferior vena cava filter plus mechanical deep venous thrombosis prophylaxis (compression stockings and sequential compression boots); Group II (n = 23) consisted of a group of patients receiving only mechanical deep venous thrombosis prophylaxis. All patients had routine lower extremity venous duplex imaging preoperatively, postoperatively, and before hospital discharge. At final followup, patients were examined for deep venous thrombosis and reviewed for thromboembolic events. At a mean followup of 11.5 months, Group I had two detectable deep venous thromboses and no pulmonary emboli; Group II had one detectable deep venous thrombosis and five pulmonary embolisms. In Group II, 40% (two of five) of pulmonary embolisms were fatal, yielding an 8.7% (two of 23) group mortality rate. Overall, the entire group had an approximately 17% deep venous thrombosis rate. Only 6.4% (three of 47) of deep venous thromboses were detectable by standard duplex imaging. The majority of deep venous thromboses (five of eight, 62.5%) were nondetectable by duplex imaging. Overall, a 4.3% (two of 47) death rate was attributable to pulmonary embolism. In contrast, an 8.6% (four of 47) mortality rate occurred in Group II alone. All pulmonary embolisms occurred in patients who did not receive an inferior vena cava filter. The majority of venous thromboses (62.5%) were not detectable on duplex scanning, therefore were thought to arise from the pelvic venous system. Complications related to inferior vena cava filter insertion were minimal. For patients with metastatic pathologic fractures of the lower extremities who are unable to receive pharmacologic deep venous thrombosis prophylaxis, the use of inferior vena cava filters, in conjunction with standard mechanical deep venous thrombosis prophylaxis, is a procedure that has a low risk and is useful adjunct to prevent fatal pulmonary embolisms.
BACKGROUND: Biologic response modifiers are assuming a larger role in the management of patients with rheumatoid arthritis. The tumor necrosis factor-alpha (TNF-alpha) inhibitors etanercept and infliximab improve patient symptoms and function. However, these agents have been associated with a risk for healing and infectious complications due to systemic blockade of TNF-alpha, a ubiquitous mediator required in the normal inflammatory response in tissue healing and infection surveillance. This study analyzed the risk of healing/infectious complications in patients undergoing elective foot and ankle surgery while being treated with TNF-alpha inhibitors etanercept and infliximab. METHODS: Patients with rheumatoid arthritis undergoing elective foot and ankle surgery over a 12-month period were prospectively followed for the development of complications in the postoperative period. All patients continued their antirheumatic medication schedule unaltered in the perioperative period. Data collected included sex, age, all medications used to treat rheumatoid arthritis, smoking history, and number of orthopaedic foot and ankle procedures performed. Patients were then stratified into two groups based on the use of immunomodulation via TNF-alpha inhibition (group 1) versus patients who did not receive TNF-alpha inhibition therapy (group 2). Groups 1 and 2 were followed and compared for the development of infectious/healing complications. RESULTS: Thirty-one patients were enrolled in the study. Group 1 (n = 16) and group 2 (n = 15) patients were comparable for sex distribution, number of orthopaedic procedures performed, and use of steroids, methotrexate, leflunamide, and nonsteroidal anti-inflammatory drugs. Group 1 contained six times the number of smokers in group 2. At mean follow-up of 10.6 months (group 1) and 9.7 months (group 2), healing or infectious complications were similar in both groups. However, when total complications (healing + infection) were analyzed, group 1 (TNF-alpha inhibition, "higher risk") patients demonstrated a lower complication rate (p =.033). CONCLUSIONS: The data suggest that in patients with rheumatoid arthritis undergoing elective foot and ankle surgery, the use of TNF-alpha inhibition agents may be safely undertaken in the perioperative period without increasing the risk of healing or infectious complications.
The accessory extensor tendon of the first metatarsophalangeal joint (1st MTPJ) was evaluated in 32 cadaver feet. Eighty-one percent of feet possessed an accessory tendon to the 1st MTPJ. Of those feet possessing an accessory tendon to the 1st MTPJ, approximately 92% originated from the extensor hallucis longus muscle-tendon unit, while approximately 8% originated from the tibialis anterior muscle-tendon unit. All accessory tendons inserted onto the dorsal/dorsomedial capsule of the 1st MTPJ. Accessory tendons were found to be bilateral in the majority (87.5%) of specimens. Differences in sex distribution of the accessory tendon of the 1st MTPJ were not statistically significant. The difference in distribution of an accessory tendon to the 1st MTPJ in those feet that demonstrated clinical hallux valgus versus those that did not demonstrate hallux valgus was not statistically significant (p = 1.0000, respectively, Fisher's exact test). This tendon is unique to the human foot (lacking in primates) and is a fairly constant structure (80%). The data presented do not lend support for the accessory tendon of the 1st MTPJ to play a role in the development of hallux valgus. At the present time, the role of this accessory tendon on the biomechanics of the 1st MTPJ remains unknown.
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BACKGROUND: Appropriate suture selection is necessary in providing mechanical stability to soft tissue reconstructions. Caprolactone/glycolide (Panacryltrade mark) became a popular suture, possessing excellent handling properties; however, clinical observations questioned the knot security of caprolactone/glycolide. Caprolactone/glycolide is still available on many commercial suture anchor systems. This study compared the security of the knots and ultimate tensile strength of braided caprolactone/glycolide suture to that of a commonly used suture material, braided polyester (Ethibondtrade mark). MATERIALS: Suture knots of No. 2 braided polyester suture and No. 2 braided caprolactone/glycolide suture were submersed in a physiologic saline solution and stressed using a continuous (non-cyclic) load, simulating a single maximal loading event in a clinical setting. Continuous loading was done to achieve clinical suture knot failure (3-mm knot slippage), then continued until catastrophic suture failure (suture breakage) occurred. Ten trials of each suture were tested. RESULTS: Force required to cause knot slippage of 3 mm was greater for braided polyester than for braided caprolactone/glycolide (p <. 0001, unpaired Students' t-test). Forces resulting in catastrophic failure were greater for braided polyester than braided caprolactone/glycolide (p = .0284, unpaired Students' t-test). CONCLUSIONS: These data have important implications in the selection of suture materials for repair of soft tissue injuries. In the clinical setting, a single maximal loading event may result in suture failure. These data indicate that braided polyester possesses superior in-vitro mechanical properties and suggest that braided polyester may provide greater security in-vivo than braided caprolactone/glycolide suture.
The remarkable rise in popularity of mini scooters has been accompanied by an increase in the number of foot and ankle injuries. We have observed unique pediatric foot injuries related to the use of mini scooters. An association may be present linking the design of the mini scooter and the riding practices of children. We report on two unique midfoot injuries in children occurring with mini scooter use and discuss how these foot injuries may be related to scooter design and children's riding practices. Safety guidelines aimed at the prevention of foot and ankle injuries while riding mini scooters are outlined.
The records of 104 patients who underwent reconstructive foot and ankle surgery for deformities secondary to rheumatoid arthritis were reviewed. The use of rheumatoid chemotherapeutic agents, age, sex, rheumatoid nodule status, and the number of concurrent surgical procedures performed was analyzed to determine any association with the postoperative outcome for wound healing and infectious complications. The 104 patients, ranging in age from 23 to 83 years, underwent 725 operative procedures. An overall 32% complication rate was recorded. Analysis of five specific rheumatoid chemotherapeutic agents (NSAIDs, steroids, methotrexate, hydroxychloroquine, gold), age, sex, number of operative procedures performed, and presence of rheumatoid nodules, either alone or in combination, failed to prove a statistical association with either a healing or infectious postoperative complication.
UNLABELLED: The objective of this study was to determine the mechanisms of injury and pattern of associated foot and ankle injuries and systemic injuries associated with subtalar dislocations, and, correlate these data with the radiographic and clinical/functional outcome of patients after subtalar dislocation. RESULTS: Twenty-five patients with a subtalar dislocation were identified over a seven year period. The mean patient age was 38 years. Males (n=19) comprised 76% of patients, with a mean age of 36 years. High energy mechanisms (motor vehicle accidents, falls) accounted for 68% of subtalar dislocations. Although high energy mechanisms showed a strong trend toward open subtalar dislocations, the association was not statistically significant (p=0.0573, Fisher's exact test). Closed dislocations predominated (75%). Left and right-sided dislocations were nearly equally distributed, even among motor vehicle accidents. Medial dislocations predominated (65%): these were not influenced by mechanism of injury and did not result in statistically lower AOFAS ankle/hindfoot scores. Subtalar dislocation was irreducible (requiring open reduction) in 32%, with higher energy mechanisms of injury being statistically associated with an irreducible subtalar dislocation (p=0.0261, Fisher's exact test). Block to reduction was evenly distributed among soft tissue elements (posterior tibial tendon, flexor hallucis longus tendon, capsule, extensor retinaculum) and osseous elements. Eighty-eight percent of patients incurred concomitant injuries to the foot and ankle (95% of which were closed injuries), namely, the ankle and talus. Systemic injuries occurred in 88% of patients. At a mean follow-up of five years, the mean AOFAS score of the subtalar dislocation side was significantly lower (mean=71 vs. 93, p=0.0007, unpaired Student's t-test). No statistical relation was found between the number of associated extremity injuries and AOFAS score (Spearman correlation coefficient, r=(-)0.236, p=0.331). Radiographic follow-up demonstrated 89% of ankles with radiographic changes (31% symptomatic); however, the majority of these patients (61%) had an associated ankle injury. The subtalar joint demonstrated radiographic changes in 89% of patients, with 63% being symptomatic; 75% of patients with subtalar joint changes incurred a fracture about the subtalar joint at the time of dislocation. Four patients went on to subtalar fusion at an average of 8.8 months post-dislocation. The midfoot showed radiographic changes in 72% of patients, with only 15% of these patients being symptomatic. All patients with midfoot symptoms were well controlled by nonsurgical measures.
Tibiotalocalcaneal arthrodesis utilizing a retrograde intramedullary nail has been used for nearly a decade. The indications for retrograde intramedullary nailing to achieve a tibiotalocalcaneal arthrodesis have expanded from systemic arthritides and post-traumatic arthritis to use in diabetic patients with severe Charcot neurarthropathy and hindfoot malalignment. Results with this procedure have been good, with low infection rates when used in nonimmunocompromised hosts. As indications have expanded to include diabetic deformities, infection rates may increase. We report on the results of a salvage technique and management plan utilized in the treatment of infected tibiotalocalcaneal arthrodesis in five high-risk (immunocompromised) patients. The majority of these patients had diabetes with Cierny-Mader IVB osteomyelitis, and would have required an above-knee or below-knee amputation due to their infection.
The clinical characteristics of patients with a nonbony avulsion of the Achilles tendon from its calcaneal insertion (Achilles "sleeve" avulsions) along with the results of operative treatment via a transcalcaneal suture repair technique are presented. Analysis of functional outcome was measured by the AOFAS ankle/hindfoot score and quantitative peak strength by Cybex testing. The results of AOFAS ankle/hindfoot scoring demonstrated no statistically significant difference in AOFAS ankle/hindfoot score between the operative limb and the control (unaffected) limb (mean values = 98.83 vs. 96.67, respectively, p = .5232, unpaired Student t test). Cybex testing for peak strength generated during plantarflexion was performed on all operative limbs and compared to the matching control (unaffected) limb. Cybex testing results demonstrated no statistically significant difference in maximum peak strength between the operative limb and the matched control (unaffected) limb (mean values: 43 ft-lbs vs. 46 ft-lbs, respectively, p = .2818, paired Student t test). All patients were satisfied with their result. This technique was successful in repairing Achilles sleeve avulsions in a variety of patients, ranging from professional and recreational athletes to lower-demand patients with diabetes, allowing them to return to work and full recreational activities. Based on our data, we conclude that the transcalcaneal suture repair technique for the Achilles tendon sleeve avulsion is a reliable reconstruction technique for these otherwise difficult-to-repair osseous-tendinous disruptions at the Achilles tendon insertion.
Repeat episodes of musculoskeletal infarction coupled with immunosuppression predispose sickle cell patients to infectious complications throughout their lives. Osteomyelitis is a familiar complication of sickle cell disease, and it may result in significant morbidity, especially when occurring in multiple sites. Staphylococcus and Salmonella remain the most common causes of osteomyelitis in sickle cell patients. Vancomycin-resistant enterococcus (VRE) infections have been reported mainly in connection with bacteremias and infections outside of the musculoskeletal system. To our knowledge, only a few cases of VRE long bone osteomyelitis have been reported in the literature. A few antimicrobial agents are available to treat VRE infections. The occurrence of VRE osteomyelitis is a major clinical concern, especially in an immunocompromised host, such as a sickle cell patient. We present a case of multiple long bone vancomycin-resistant Enterococcus faecium (mixed organisms) osteomyelitis in a sickle cell patient, and we report on a new method of using quinupristin-dalfopristin as part of the management plan to treat a complicated VRE infection successfully. We discuss the mechanism of action of anti-VRE drugs and the future direction to combat VRE in orthopedic infections.