Reconstruction of the Pediatric Lateral Malleolus and Physis by Free Microvascular Transfer of the Proximal Fibular Physis

Traumatic injury to the pediatric growth plate can result in growth disturbances, late angular deformity, and limb length inequalities. Complete traumatic loss the entire growth plate complex (physis, epiphysis, and distal metaphysis) of the ankle can lead to severe joint instability and loss of function. In the growing child, physeal preservation is paramount; however, the reconstructive options are limited. We report a case of post-traumatic loss of the distal fibular physis resulting in severe ankle valgus in a pediatric patient after a Gustilo grade 3B open injury. Ankle valgus secondary to post-traumatic necrosis of the lateral ankle physeal complex was successfully managed by microvascular free transfer of the ipsilateral proximal fibula physis. The 24-month follow-up examination demonstrated continued growth of the free vascularized physeal graft and a stable ankle. The donor site had healed without incident. The patient was able to return to age-appropriate play, sports, and social integration.

Bone morphogenetic proteins: indications and uses

The BMPs are a group of growth factors that have varied roles in the development and maintenance of many organ systems. Several of the BMPs have osteogenic potential, and exert their effects via complex and highly regulated pathways. At present, only rhBMP-2 and rhBMP-7 are available for clinical use, but only rhBMP-2 is readily available, and from a practical standpoint is considered the only commercially available BMP. Only a few studies exist on BMP use in foot and ankle surgery, but these have shown promising results with low complication rates. BMP is an adjuvant to bone healing,and does not substitute for structural bone needs. In addition, rhBMP-2 outside spinal fusions is considered to be US Food and Drug Administration off-label, and should be used only in patients who are at high risk for bone healing problems.

Low Wound Complication Rates for the Lateral Extensile Approach for Calcaneal ORIF When the Lateral Calcaneal Artery Is Patent

BACKGROUND

Historically, the lateral extensile approach for calcaneal fracture osteosynthesis has had relatively high rates of wound healing problems. The vascular territory (angiosome) of the lateral foot is now known to be dependent upon the lateral calcaneal branch of the peroneal artery (LCBP artery). We postulated that patency of the LCBP artery may have a profound positive impact on incisional wound healing for calcaneal open reduction and internal fixation (ORIF).

METHODS

Ninety consecutive calcaneal fractures that met operative criteria were preoperatively evaluated for the presence of a Doppler signal in the LCBP artery and were followed for the development of wound healing problems.

RESULTS

Among these 90 fractures, 85 had a positive preoperative Doppler signal along the course of the LCBP artery (94%) and 5 had no Doppler signal (6%). All patients underwent ORIF via a lateral extensile approach. Overall, incisional wound healing problems occurred in 6 of 90 calcaneal incisions (6.5%). All 5 feet that exhibited an absent Doppler signal in the LCPB artery developed an incisional wound healing complication (5/6, approximately 83%): 2 large apical wounds and 3 major dehiscence/slough. However, among the 84 feet that possessed a positive preoperative Doppler signal in the LCBP artery, there was only 1 (1/84, approximately 1%) incisional wound healing problem (P < .0001, Fischer's exact test). Smokers with a positive Doppler signal in the LCBP artery did not develop a wound healing complication.

CONCLUSIONS

This study suggests a strong link to low incisional wound healing complications for the lateral extensile approach to the calcaneus when a preoperative Doppler signal is present in the LCBP artery. We believe this simple examination should be routinely performed prior to calcaneal ORIF.

LEVEL OF EVIDENCE

Level III, comparative case series.

Successful salvage of complicated calcaneal blastomycosis in disseminated disease with staged surgical reconstruction and local-systemic antifungal therapy

Disseminated blastomycosis can be a devastating disease, affecting multiple organ systems, including the musculoskeletal system. Osteomyelitis from disseminated disease can be difficult to eradicate but is particularly important to successfully manage in the load-bearing bones of the lower extremity. We present a staged protocol for salvage of blastomycotic calcaneal osteomyelitis in the presence of disseminated disease.

Reverse sural flap with bifocal Ilizarov technique for tibial osteomyelitis with bone and soft tissue defects

Tibial osteomyelitis, in association with bone loss and a soft tissue defect, poses a significant reconstructive challenge, especially in high-risk patients. We describe a case of methicillin-resistant Staphylococcus aureus tibial osteomyelitis with intercalary bone loss successfully managed with bifocal Ilizarov compression osteogenesis at the bone resection site and proximal distraction osteogenesis, accompanied by a reverse sural fasciocutaneous flap performed with a delayed technique. When free tissue transfer is not a reconstructive option owing to medical comorbidities or patient refusal, the reverse sural flap combined with bifocal Ilizarov compression and distraction osteogenesis can provide a reconstructive option to achieve limb salvage for these challenging cases.

Modification of the Syme amputation to prevent postoperative heel pad migration

The Syme amputation (ankle disarticulation level amputation) can be a valuable procedure for properly selected patients but might be underused owing to the problem of postoperative migration of the heel pad cushion. The present report presents a modification of the Syme amputation technique to prevent postoperative heel pad migration. The technique was performed in 12 patients, most of whom were male patients with diabetic foot infections. At an average follow-up of 7 years, the soft tissue cushion remained in a stable position, without ulceration. Also, patient satisfaction was high with the Syme level of amputation using the modified technique.

Temporary cementation in total ankle arthroplasty

Total ankle arthroplasty can be technically demanding in patients with poor bone quality. In bone fragile patients, the use of a temporary cementation technique ("biocementation") can assist in providing a stable, secure implant interface with native bone that is of poor quality. I report the short-term results of 9 ankles (7 consecutive patients) undergoing total ankle replacement with temporary cementation using a slowly resorbable injectable bone graft substitute composed of 75% calcium sulfate and 25% calcium phosphate.

Flap infection associated with medicinal leeches in reconstructive surgery: two new drug-resistant organisms

The use of medicinal leeches in reconstructive surgery has proven value for the salvage of flaps with venous congestion but is associated with a risk of leech-acquired infection. The most common leech-associated organism is Aeromonas hydrophila, which antibiotic prophylaxis is typically directed against. The authors describe two new multidrug-resistant organisms acquired from medicinal leech therapy that resulted in flap infection. The evaluation of suspected leech-borne infection and management protocol for this leech-acquired resistant multi-organism infection is presented.

The reverse peroneus brevis muscle flap for ankle wound coverage

Coverage of lower extremity wounds, especially those in the ankle region, presents a challenge to the foot and ankle surgeon. The present case illustrates a surgical technique for the use of the reverse (distally based) peroneus brevis muscle flap for coverage of a postoperative ankle wound with exposed bone. The reverse peroneus brevis muscle flap provides an option for wound coverage in the ankle region in limb salvage cases in medically frail patients.

Posterior approach for total ankle arthroplasty

Total ankle arthroplasty is a technically challenging reconstruction, with soft tissue complications posing potential significant morbidity, especially when the anterior ankle soft tissue envelope is not pristine. Alternate approaches to the ankle for arthroplasty may need to be sought in unique cases. The author describes a posterior surgical approach for total ankle arthroplasty.

A modified anterior approach to the ankle

The anterior approach to the ankle is frequently used in fracture fixation, ankle arthroplasty, and various tendon reconstructive procedures. However, wound complications and trauma may lead to scarring and a suboptimal anterior ankle soft tissue envelope for healing. The author presents a modified approach to the anterior ankle in cases where scarring and soft tissue injury preclude a direct anterior incision.

Plantar heel reconstruction with a sensate plantar medial artery musculocutaneous pedicled island flap after wide excision of melanoma

Reconstruction of soft tissue defects in the plantar heel pad presents a surgical challenge that requires replacing the lost tissue with another tissue having similarly unique physical characteristics. This case report describes a reconstruction of the plantar heel pad after wide excision of a heel melanoma, using a sensate plantar medial artery musculocutaneous pedicled island flap.

Reduction calcaneoplasty and local muscle rotation flap as a salvage option for calcaneal osteomyelitis with soft tissue defect

Plantar heel wounds with infection remain a surgical challenge. Reduction calcaneoplasty combined with local muscle flap is an alternative technique to achieve limb salvage when standard wound therapy fails to resolve complex wounds of the plantar heel complicated by osteomyelitis of the calcaneus.

Tumoral calcinosis of the foot: a radiologic case study

Tumoral calcinosis is a disorder characterized by deposits of calcium phosphate in the subcutaneous tissues near large joints. While often resembling a neoplasm, the soft tissue deposits of tumoral calcinosis are benign in nature. The deposits can, however, cause significant morbidity to patients due to tissue pressure or impingement. The focus of this case report will include the presentation, radiographic examinations, clinical course, and treatment of a 90-year-old female patient presenting for evaluation of a painful plantar right foot soft tissue mass associated with chronic renal failure and secondary hyperparathyroidism.

Combined total ankle replacement and modified bridle tendon transfer for end-stage ankle joint arthrosis with paralytic dropfoot: report of an unusual case

In recent years, total ankle replacement has become a reasonable option for many patients with end-stage ankle arthrosis. In order to be successful, total ankle replacement requires a relatively balanced alignment of the foot in relation to the leg. Such alignment is traditionally achieved surgically by means of stabilization of the hindfoot in conjunction with relocation osteotomy of the calcaneus and/or tibia. In this report, we describe the unconventional combination of total ankle replacement in an adult patient with concomitant paralysis that was addressed by means of tendon transfer.

Review of vascular leiomyosarcoma and report of a case localized to the greater saphenous vein of the ankle

Smooth muscle sarcomas involving blood vessels, leiomyosarcomas, are rare, making up less than 2% of all leiomyosarcomas. Leiomyosarcoma of the saphenous vein is even more uncommon, with nearly all cases reported occurring in the thigh. This article reviews leiomyosarcoma of blood vessels and reports on a 62-year-old woman with an extremely rare case of a leiomyosarcoma of the distal portion of the greater saphenous at the ankle.

Platelet-rich plasma concentrate to augment bone fusion

Within the foot and ankle literature, there exists only a handful of basic science and clinical articles reporting on the efficacy and clinical utility of platelet-rich plasma (PRP). This article discusses the concept and basic science of PRP, and clinical applications of PRP for the augmentation of bone healing in foot and ankle surgery. The authors also provide a classification system that assesses relative risks for poor bone healing and the need for orthobiologic augmentation.

Lower extremity manifestations and treatment of heparin-induced thrombocytopenia syndromes: a cohort study

Heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia with thrombosis (HITT) syndromes are the result of an adverse reaction to heparin that results in a spectrum of laboratory and end-organ manifestations secondary to thrombosis of both arterial and venous small and large vessels. HITT most often manifests in the extremities as acral ischemia and necrosis, with a spectrum of severity. The lower extremity surgical patient is at risk for deep venous thrombosis, and when exposed to heparin products, is also at risk for the development of a heparin-induced thrombocytopenic syndrome. This article reports on a cohort of patients from a tertiary referral lower extremity reconstruction practice with the HIT/HITT syndromes, with an analysis of the frequency, medical characteristics, clinical settings, lower extremity manifestations, management, and outcomes of patients with HIT/HITT.).

Complications of digital and lesser metatarsal surgery

Complications associated with digital and lesser metatarsal surgical procedures have been well documented in the literature. These complications may stem from systemic medical, structural, biologic, biomechanical, or iatrogenic causes. The surgeon must be cognizant of all potential complications, including ways to prevent them from occurring and how to manage them when they do occur. This article discusses preventative measures through the preoperative evaluation of the patient, and examines the subsets of complications that may occur after lesser ray surgery that pose a particular management challenge, as well as special complications specific to particular operative techniques.

Metatarsal giant cell tumor in adolescents

Level of Evidence: V, Expert Opinion

Ilizarov wound closure method for traumatic soft tissue defects

Level of Evidence: V, Expert Opinion

VERSAJET hydrosurgery technique for the preparation of full thickness skin grafts and the creation of retrograde split thickness skin grafts

Full- and split-thickness skin grafts continue to serve a vital role in lower extremity wound coverage, and meticulous preparation of the recipient site is vital to incorporation of the transplanted skin. A technique for the rapid, controlled preparation of full-thickness skin grafts and creation of thick-split thickness skin grafts from full-thickness donor tissue, using a high-pressure stream of saline solution, is described.

Prevention and management of complications arising from external fixation pin sites

The use of external fixation devices to assist in the management of lower extremity trauma and reconstruction continues to rise. Despite the distinct advantages of external fixation, complications from external fixators continue to exist. The complicated external fixator-associated pin site may be a potential source of significant morbidity, especially in the at-risk patient, which may lead to soft tissue healing problems and infections, as well as osteomyelitis. This article describes both simple as well as more complex techniques that the authors use in the prevention and management of complications arising from external fixator pin sites, and solutions to the difficult task of incorporating external fixator wires into negative-pressure dressings.