After resection of bone or amputation, postoperative stump breakdown occurs frequently. Furthermore, the altered mechanics with ambulation are difficult to control with bracing and orthoses alone. During the past 10 years, the peroneus brevis tendon has been transferred to various locations in the foot after resection of the fifth metatarsal base in an effort to provide continued balance between the supinatory and pronatory forces needed for a steady gait. In patients who have had a peroneus brevis tendon transfer, the rate of postoperative ulceration and the need for further bony resection is minimal. Analysis of the biomechanical influences and effects of different anatomical placements of the transferred tendon reveals the importance of transfer of the peroneus brevis tendon.

Low molecular weight heparins (LMWHs) are commonly employed as a substitute for unfractionated heparin (UFH) in the treatment of venous thromboembolic events. Despite their higher cost, the preferential use of LMWHs seemed justified initially as, based on the results of earlier meta-analyses, these compounds were deemed to be more effective and safer than UFH. Although, in this respect, their purported superiority over UFH could not be confirmed by subsequent large, randomised trials and updated meta-analyses, other peculiar features of LMWHs were highlighted, favouring their preferential utilisation in patients with venous thromboembolism. Among these, the possibility of once-daily administration on an out-patient basis, the lower incidence of Type II heparin-induced thrombocytopenia and the lower likelihood of osteoporosis after prolonged treatment periods, appear to be especially prominent. This review attempts to evaluate the available evidence focusing on the safety of LMWHs for the treatment of venous thromboembolism and the current therapeutic options and potential advantages of LMWHs, either in general or in selected patient populations.

BACKGROUND:Patients who have had major trauma are at very high risk for venous thromboembolism if they do not receive thromboprophylaxis. We compared low-dose heparin and a low-molecular-weight heparin with regard to efficacy and safety in a randomized clinical trial in patients with trauma.METHODS:Consecutive adult patients admitted to a trauma center who had Injury Severity Scores of at least 9 and no intracranial bleeding were randomly assigned to heparin (5000 units) or enoxaprin (30 mg), each given subcutaneously every 12 hours in a double-blind manner, beginning within 36 hours after the injury. The primary outcome was deep-vein thrombosis as assessed by contrast venography performed on or before day 14 after randomization.RESULTS:Among 344 randomized patients, 136 who received low-dose heparin and 129 who received enoxaparin had venograms adequate for analysis. Sixty patients given heparin (44 percent) and 40 patients given enoxaparin (31 percent) had deep-vein thrombosis (P=0.014). The rates of proximal-vein thrombosis were 15 percent and 6 percent, respectively (P=0.012). The reductions in risk with enoxaparin as compared with heparin were 30 percent (95 percent confidence interval, 4 to 50 percent) for all deep-vein thrombosis and 58 percent (95 percent confidence interval, 12 to 87 percent) for proximal-vein thrombosis. Only six patients (1.7 percent) had major bleeding (one in the heparin group and five in the enoxaparin group, P=0.12).CONCLUSIONS:Low-molecular-weight heparin was more effective than low-dose heparin in preventing venous thromboembolism after major trauma. Both interventions were safe.

Background The study objective was to determine the relative efficacy and safety of a low-molecular-weight heparinoid (Orgaran) compared with aspirin for the prevention of postoperative venous thromboembolism in patients undergoing surgery for fractured hips. A double-blind, randomized, controlled trial was used to study 251 consecutive eligible and consenting patients undergoing surgery for hip fracture in seven participating hospitals. Methods and Results Patients received either fixed-dose Orgaran by subcutaneous injection every 12 hours in a dose of 750 anti–Factor Xa units or aspirin 100 mg orally twice daily; both regimens were started 12 to 24 hours after surgery and continued for 14 days or until discharge, if sooner. All patients had postoperative 125 I-fibrinogen leg scanning and impedance plethysmography. If the results of one or both tests were positive, then venography was performed. Otherwise, venography was done at day 14, or sooner if the patient was ready for discharge. Pulmonary embolism in symptomatic patients was diagnosed on the basis of a high probability perfusion/ventilation lung scan, a positive angiogram, or a clinically significant embolism detected at autopsy. Evaluable venograms were obtained in 90 of the 125 patients randomly assigned to receive Orgaran and in 87 of the 126 patients assigned to receive aspirin. Venous thromboembolism was detected in 25 (27.8%) patients in the Orgaran group and in 39 (44.3%) patients in the aspirin group. Thus, there was a relative risk reduction of 37% with Orgaran ( P =.028; 95% confidence interval, 3.7% to 59.7%). Six (6.8%) of 88 patients in the Orgaran group and 12 (14.3%) of 84 patients in the aspirin group developed proximal deep vein thrombosis or pulmonary embolism, a relative risk reduction of 52% with Orgaran ( P =.137; 95% confidence interval, −30.7% to 84.6%). Hemorrhagic complications occurred in 2 (1.6%) patients given Orgaran and 8 (6.4%) patients given aspirin ( P =.10). There was one major bleed in the Orgaran group compared with four in the aspirin group. Conclusions This study demonstrates that Orgaran is significantly more efficacious than aspirin in preventing postoperative venous thromboembolism in patients undergoing surgery for fractured hips, with no evidence of any increase in hemorrhagic complications.

An orthotic device, which prevents hyperpronation of a human foot, has an offset, deep heel seat to cup the calcaneus. It maintains the calcaneus in approximately 5 degrees of varus with high medial and lateral flanges, which prevents lateral transverse drift of the first and fifth metatarsals.

BACKGROUNDAlthough deep-vein thrombosis and pulmonary embolism are considered common complications after major trauma, their frequency and the associated risk factors have not been carefully quantified.METHODSWe performed serial impedance plethysmography and lower-extremity contrast venography to detect deep-vein thrombosis in a cohort of 716 patients admitted to a regional trauma unit. Prophylaxis against thromboembolism was not used.RESULTSDeep-vein thrombosis in the lower extremities was found in 201 of the 349 patients (58 percent) with adequate venographic studies, and proximal-vein thrombosis was found in 63 (18 percent). Three patients died of massive pulmonary embolism before venography could be performed. Before venography, only three of the patients with deep-vein thrombosis had clinical features suggestive of the condition. Deep-vein thrombosis was found in 65 of the 129 patients with major injuries involving the face, chest, or abdomen (50 percent); in 49 of the 91 patients with major head injuries (53.8 percent); in 41 of the 66 with spinal injuries (62 percent); and in 126 of the 182 with lower-extremity orthopedic injuries (69 percent). Thrombi were detected in 61 of the 100 patients with pelvic fractures (61 percent), in 59 of the 74 with femoral fractures (80 percent), and in 66 of the 86 with tibial fractures (77 percent). A multivariate analysis identified five independent risk factors for deep-vein thrombosis: older age (odds ratio, 1.05 per year of age; 95 percent confidence interval, 1.03 to 1.06), blood transfusion (odds ratio, 1.74; 95 percent confidence interval, 1.03 to 2.93), surgery (odds ratio, 2.30; 95 percent confidence interval, 1.08 to 4.89), fracture of the femur or tibia (odds ratio, 4.82; 95 percent confidence interval, 2.79 to 8.33), and spinal cord injury (odds ratio, 8.59; 95 percent confidence interval, 2.92 to 25.28).CONCLUSIONSVenous thromboembolism is a common complication in patients with major trauma, and effective, safe prophylactic regimens are needed.

Medical care of the hospital patient has become increasingly complicated due to the rising incidence of risk factors for opportunistic infection. With intravenous drug use, HIV infection, and alcoholism complicating an immunocompromised host such as a diabetic, fungal and mycobacterial infections are no longer as rare as in previous reports. The authors present a case of Candida osteomyelitis in a patient with multiple risk factors for opportunistic infection.

Magnetic resonance (MR) arthrography is a useful technique in evaluating the articular structures of the ankle. With intra-articular administration of gadolinium-DTPA (Gd-DTPA), visualization and delineation of anatomic structures, that would not be depicted by other traditional imaging techniques, are achieved. It is a technique that proves to be advantageous as it does not require the use of ionizing radiation, nor iodinated contrast material as other conventional diagnostic modalities. MR arthrography also allows multiplanar imaging and provides excellent resolution.

Apophysitis of the fifth metatarsal base, or Iselin's disease, is an overuse osteochondrosis seen in growing children. Although amenable to treatment, it is a self-limiting disorder, disappearing spontaneously with completion of growth.

Objective: To determine the relative efficacy and safety of low molecular weight (LMW) heparin (Enoxaparin) compared with standard calcium heparin for the prevention of postoperative deep vein thrombosis in patients undergoing elective hip surgery.Design: A double-blind, randomized, controlled trial.Patients: Six hundred sixty-five consecutive patients undergoing hip replacement at five participating hospitals.Interventions: Patients received either fixed-dose LMW heparin, 30 mg subcutaneously twice daily, or fixed-dose standard calcium heparin, 7500 units subcutaneously twice daily; both regimens were started 12 to 24 hours after surgery and continued for 14 days or until discharge if sooner.Measurements: All patients had postoperative I-125-fibrinogen leg scanning and impedance plethysmography. If results of one or both tests were positive, then venography was done. Otherwise, venography was done between day 10 and day 14, or sooner if the patient was ready for discharge.Results: Evaluable venograms were obtained in 258 of the 333 patients randomly assigned to receive LMW heparin and in 263 of the 332 patients assigned to receive calcium heparin. For patients with evaluable venograms, thrombosis was detected in 50 patients (19.4%) who received LMW heparin compared with 61 patients (23.2%) who received standard heparin (difference, - 3.8%; 95% CI, - 11.1% to 3.6%) (P > 0.2). Proximal deep vein thrombosis was detected in 5.4% of the patients receiving LMW heparin and in 6.5% of the patients receiving standard heparin (difference, - 1.1%; CI, - 5.2% to 3.3%) (P > 0.2). For the entire group of 665 patients, venous thrombosis occurred in 17.1% given LMW heparin and in 19.0% given standard heparin. Hemorrhagic complications occurred in 31 patients (9.3%) given standard heparin and in 17 patients (5.1%) given LMW heparin (difference, 4.2%; CI, 0.3% to 8.2%) (P = 0.035). The relative risk reduction was 45%. The rate of major bleeding in the standard heparin group was 5.7% compared with 3.3% in the LMW heparin group (difference, 2.4%; CI, - 1.0% to 5.4%) (P = 0.13). The relative risk reduction was 42%.Conclusion: Low molecular weight heparin is significantly less hemorrhagic than standard unfractionated heparin; the difference in the rate of deep vein thrombosis, although not statistically significant (P > 0.2), favors the use of LMW heparin.

The literature is complete in its review of osteoid osteoma and benign bone-forming tumors. When present in a child, the clinical and radiographic picture is not that clear and often is missed diagnosed. Routine radiographs may not offer a complete diagnosis in this young patient and additional studies are indicated. Tomograms and computerized tomographic (CT) scans, as well as bone scans, provide more information in determining the presence of absence of a bone lesion in the child. A case is presented of an 8-year-old female with pain for over 10 months, eventually diagnosed as an osteoid osteoma. A surgical procedure was performed to excise the lesion and replace it with a corticocancellous bone graft. The child has been followed for the past 5 years and has remained asymptomatic.

A crescentic osteotomy of the first metatarsal is unstable during the preliminary healing stage. The authors present a modification in the direction of the cut of the osteotomy. This alteration increases stability at the first metatarsal base.

Geerts, William H.; Nanez, H.; Pagliarello, G.; Saibil, E.; Szalai, J. P. Author Information

The juvenile fracture of Tillaux is a Salter-Harris type III fracture of the distal tibial epiphysis. The mechanism of injury is an external rotational force of the foot. The fracture fragment is avulsed from the anterolateral aspect of the distal tibial epiphysis by the anteroinferior tibiofibular ligament. Treatment is based on the amount of displacement after closed reduction techniques are attempted. If complete anatomical reduction cannot be obtained, the authors recommend open reduction with internal fixation. The method of internal fixation should be based on the skeletal maturity of the distal tibial epiphysis. The prognosis usually is good if anatomical reduction is performed. The most serious complication reported is pain and stiffness secondary to articular incongruity following inadequate closed reduction techniques. The case of a 14-year-old girl with a juvenile Tillaux fracture treated by open reduction with excellent functional results at 11 months follow-up was presented.