Late reconstruction of the midfoot and tarsometatarsal region after trauma

The management of painful arthritis and deformity after trauma to the midfoot starts with careful assessment by physical examination and appropriate investigation to identify the affected joints. Conservative treatment may be very effective and includes the use of NSAIDs, custom insoles with arch support, and a rocker-bottom sole with extended steel shank with or without a SACH heel. If this treatment fails, usually a year after the injury, then arthrodesis of all the symptomatic joints with restoration of the arch and alignment of the weight-bearing surface is the recommended treatment. The long-term results of these fusions may be compromised by the subsequent development of arthritis in adjacent joints.

Innervated posterior thigh flap for defects of the sole

We report the use of an innervated posterior thigh flap to reconstruct the sole of a 6-year-old boy. This modification of the posterior thigh flap produced an aesthetically and functionally normal foot, capable of withstanding the stresses of youth and allowing the wearing of normal footwear, with a minimal donor defect.

The modified Pirogoff amputation for traumatic partial foot amputations

OBJECTIVE

To describe our experience with a modification of the Pirogoff amputation, in the treatment of serious injuries to the hind foot.

DESIGN

Retrospective study.

SETTING

University hospital, The Netherlands.

SUBJECTS

Six patients who required amputation of the hind foot after serious injury.

INTERVENTIONS

The modified Pirogoff amputation (amputation of the foot at the ankle with part of the calcaneus left in the lower end of the stump) was done four times as an emergency and twice electively between 1979 and 1991.

RESULTS

All the patients were satisfied with their stumps at follow up (7 months-13 years). None had stump pain or phantom pain and they were able to walk about indoors without using the prosthesis.

CONCLUSION

We recommend the Pirogoff amputation as the treatment of choice in the management of partial traumatic amputation and other injuries of the foot, should a transmetatarsal amputation be impossible and about 5 cm of the sole of the foot can be preserved.

Soft-tissue coverage for lower-extremity trauma

In summary, a rational approach to soft-tissue coverage in the ankle and foot should help lower osteomyelitis and bone nonunion rates and yield an excellent functional result. In addition to adequate fixation, it is crucial to first obtain a clean healthy wound by doing as many debridements as necessary. The goal should be to achieve coverage within the first week of injury to avoid the sequelae of a later closure; i.e., a potentially much higher infection rate and nonunion rate. The reconstructive options range from secondary intention, to primary closure, to skin grafts, to local flaps, to microsurgical free flaps. The choice should be dictated by the health of the patient, the existing bony and neurovascular anatomy, and the desired ultimate objective. Given the currently available orthopedic and plastic surgical techniques, it is possible to salvage almost any foot or ankle; however, we should not be carried away by our surgical armamentorium. If the salvaged extremity will take more than a year to heal, will be barely functional, and will be a constant source of pain, then a below-knee amputation should strongly be considered. The challenge in the coming decade comes both in picking the correct extremity to salvage and in applying the techniques described previously to restore it to its preinjury state.

The management of neuroarthropathic fracture-dislocations in the diabetic patient

Appropriate management for the diabetic patient with a fracture or sprain depends on recognition of "at-risk" factors. For patients with stable, minimally displaced injuries, conservative modalities (prolonged immobilization and non-weight-bearing) are sufficient. For patients with unstable or displaced fracture-dislocations, and whose general condition does not contraindicate surgery, open reduction and internal fixation, at times combined with external fixation, is recommended. Initial aggressive management can avoid or minimize the disastrous sequelae of a destructive neuroarthropathic process and can effect a biomechanically sound plantigrade, braceable, and shoeable lower extremity.

[Continuous cryotherapy--progress in therapy of post-traumatic and postoperative edema]

In patients with foot and ankle trauma, surgery and postoperative mobilization are often delayed owing to swelling. The aim of this study was to assess whether continuous cryotherapy is better than standard therapy with intermittently applied cool packs. For continuous cryotherapy the Polar Care Model 500 (BREG) was used. From May to November 1993, a series of 40 patient (22 ankle fractures, 13 ruptured lateral ankle ligaments, 4 calcaneus fractures, 1 metatarsal fracture) were prospectively randomized to continuous or intermittent cryotherapy. After 24 h treatment the patients with continuous cryotherapy showed an average reduction of 34% in swelling around ankle, midfoot and forefoot. With intermittent cryotherapy the swelling was reduced by 18%. After 4 days of treatment in the postoperative period the swelling subsided by 43% with intermittent cryotherapy, as against 69% with continuous cryotherapy. Continuous cryotherapy proved to be highly effective in treating posttraumatic and postoperative edema. It therefore seems preferable to the therapy with cool packs regarded as standard hitherto.

Compartment syndrome of the foot in children

Compartment syndrome of the foot following trauma is well known in adults but has not been discussed frequently in texts on pediatric trauma. In the current study, seven children and teenagers were identified as having had compartment syndrome of the foot during a five-year period. The average age at the time of the diagnosis was ten years (range, four to sixteen years). The cause of the compartment syndrome was a crush injury in six patients and a motor-vehicle accident in one. All patients had swelling and pain with passive motion, but none had neurovascular deficits. Only the two oldest children had an osseous injury that necessitated open reduction and internal fixation, but all had elevated compartment pressures ranging from thirty-eight to fifty-five millimeters of mercury (5.07 to 7.33 kilopascals). All seven patients had fasciotomies of the nine compartments of the foot, and the skin was closed primarily within five days after the operation. No patient had complications or needed a skin graft. All patients had a good or excellent result after an average duration of follow-up of forty-one months (range, twenty-three to fifty-three months). Orthopaedists managing children who have a traumatic injury of the foot, especially a crush injury, should have a high index of suspicion for compartment syndrome, even in the absence of severe fracture.

A clinical and histologic comparison between free temporoparietal and scapular fascial flaps

It is universally accepted that the fascial flap is one of the best reconstructive strategies for contour and tendon-gliding function. In this study we compare the free temporoparietal fascial flap (n = 20) and the free scapular fascial flap (n = 6) mainly for these reconstructions and discuss their characteristics, including different clinical applications and histologic examination. Our histologic analysis reveals that the free temporoparietal fascial flap has a potential like a muscle flap; moreover, it is very thin. The free scapular fascial flap is very rich in adipose tissues to prevent adhesion between the flap and underlying tissues. Both flaps in our experience can bring satisfaction to the recipient site, but the donor site of the free temporoparietal fascial flap sometimes suffers from conspicuous widened scars in short-haired patients, and the scapular fascia has a tendency to be thicker in obese patients. Therefore, we recommend using the free temporoparietal fascial flap for women, who tend to have more fat and longer hair, and the free scapular fascial flap for men, who tend to be lean and shorten their side hair.

Distal foot coverage with a reverse dorsalis pedis flap

A reverse dorsalis pedis flap based on the proximal communicating branch of the dorsalis pedis artery was successfully used to close distal forefoot defects in two patients. The skin paddle was oriented transversely across the ankle crease, allowing for direct closure of the flap donor site. Both patients maintained full active ankle motion without bowstringing of the dorsal foot tendons and did not require special footwear. Both flaps maintained sensation to light touch and pinprick. We believe that this flap offers a viable alternative when faced with the challenge of a small soft-tissue defect requiring flap reconstruction in the distal foot.

[Loss of cutaneous substances of the foot. Retrograde flaps, apropos of 4 cases]

We report our experience with two retrograde flaps for the treatment of cutaneous tissue loss of the foot. A lateral supramalleolar flap and a medial plantar flap pediculated distally were used, the first to cover the dorsal aspect and the second to cover the forefoot. Indications for local flaps are limited essentially because of the small size. In addition they cannot always be used for local trauma. Retrograde vascularization for the forefoot is an interesting alternative to more invasive salvage procedures involving distant flaps (cross-leg or flee flaps) requiring and uncomfortable position or microsurgery.

[Continuous skin expansion for covering soft tissue defects of the foot sole]

Reconstruction of the weight-bearing area of the sole of the foot is a major surgical problem, regardless of the aetiology of the soft-tissue defects. Numerous reconstruction methods have been described for coverage of plantar defects of the heel with local and free flaps. Skin expansion and skin traction have been described by several authors. According to the Ilizarov technique, a new method has been devised for the closure of posttraumatic soft-tissue defects in the weight-bearing area of the sole by skin stretching with Kirschner wires without the aid of either local or free flaps. The operative procedure is very simple: the sharp ends of Kirschner wires are bent with pliers into hook-shaped semicircles. These ends are then inserted into the skin of the sole at intervals of 3-4 mm, alternately close to and distant from the wound edge. The opposite ends of the K-wires are sandwiched between two small AO plates. These plates are pressed together with screws and nuts; additionally, the ends of the K-wires are bent around the plates to prevent loosening. A frame is set up around the heel and connected to the tibial external fixator. The two plates with the K-wires clamped between are mounted on the threaded rods of an Ilizarov external fixation system. Then the foot is temporarily fixed to the tibia in neutral position by a Schanz screw inserted into the first metatarsal. The soft-tissue defect is treated with moist compresses changed daily.(ABSTRACT TRUNCATED AT 250 WORDS)

Gunshot wounds to the foot

One hundred and one patients who sustained gunshot wounds to their feet were retrospectively reviewed. All patients were treated at King/Drew Medical Center between 1982 and 1994. From the authors' experience, they believe that patients with low-velocity gunshot wounds to the foot should be hospitalized and treated with at least a 3-day course of intravenous antibiotics of a first generation cephalosporin. Low-energy shotgun injuries should be treated the same as low-velocity injuries. Patients with high-velocity and high-energy shotgun wounds should be hospitalized and receive broad-spectrum intravenous antibiotics with multiple irrigation and debridements.

A simplified technique for bending Kirschner wires

Kirschner wires are extremely popular in foot surgery for fixation of osteotomies and digital procedures. Bending the protruding portion of a Kirschner wire used for fixation in foot surgery can sometimes be troublesome. A simplified technique is presented for bending protruding Kirschner wires using a Frazier size 3 suction tube.

Biodegradable internal fixation

The objective of this article was to assess the value of the use of biodegradable materials in internal fracture fixation according to the current literature. Research methods included a computerized Medline search and a hand check of references of identified articles. Also, a complete reference list was obtained from the manufacturer of Biofix (Bioscience Ltd., Tampere, Finland). The reviewers abstracted descriptive information about population, materials, complications, follow-up times in clinical trials and strength of fixation, complications, and population for animal experiments. Results indicated that sterile sinus formation is mostly associated with polyglycolic acid, with rates up to 25%, and to a lesser extent, polylactic acid. Volume of implanted material and vascularity of bone appeared to affect the rate of sinus formation. Absorbable fixation was equivalent to or better than steel fixation for functional outcome refracture rate, and in transepiphyseal femoral and humoral fractures. Polyglycolic acid and polylactic acid both became toxic between 10 days and 4 weeks of hydrolysis. Polyglycolic acid had the highest initial strength at 370 MPa compared with other polymers.

Use of skin grafting in the foot

Skin grafting is a useful adjunct to treating open wounds. It not only provides rapid wound coverage, but also eliminates the pain and the risk of further infection associated with open wounds. A successful skin graft take requires a well vascularized and relatively sterile bed, as well as complete resolution of any surrounding infection. The author reviews the indications and techniques for obtaining a successful skin graft take.

Resurfacing the distal part of the foot with a dorsal foot skin island flap pedicled on the plantar vasculature

The dorsal foot skin island flap pedicled on the plantar vasculature as a reconstructive entity is described. Two successful cases of resurfacing of the distal end of the foot with a dorsal foot island flap pedicled on the proximal communicating vessels and the distal communicating vessels, respectively, are reported, and this type of reconstructive procedure is proposed as an addition to existing procedures for reconstructing the distal end of the foot.

Arterialized venous flaps for reconstructing soft-tissue defects of the extremities

Four cases of soft-tissue defects of the extremities are presented. Each defect was covered by a fasciocutaneous venous free flap in which arterial inflow relied solely on the venous pedicle. India ink injection of the saphenous vein in eight cadaver lower extremities revealed that only the subdermal venous plexus supplies the cutaneous island. Clinically, flaps ranged in size from 4 x 6 cm to 5 x 9 cm. Three flaps survived completely, while one flap lost the cutaneous portion of its skin island. However, the subcutaneous tissue survived. Although free venous fasciocutaneous flaps have a more tenuous blood supply in the immediate postoperative period, this flap can be transferred successfully without the sacrifice of a donor artery.

Evaluation of fasciocutaneous perforators using color duplex imaging

Technological improvements in conventional ultrasound, including color duplex imaging, have greatly facilitated the evaluation of vascular-related problems for virtually every specialty. Higher-frequency transducers now permit the scanning of superficial depths beneath the skin surface with high sensitivity for an analysis specific to the microcirculation. This attribute has already been recognized as a valuable tool for the preoperative mapping of musculocutaneous perforators. A logical extension of this capability would be for the localization and calibration of deep fascial perforators, which may have even greater clinical significance because anomalies at this level are more the rule rather than the the exception. Over the preceding 10-month period, all eight elective fasciocutaneous flaps performed in eight patients had initial scans using color duplex imaging to identify and calibrate all relevant cutaneous perforators. All fasciocutaneous flap subtypes were included. If feasible at the time of flap elevation, all identified perforators were dissected and measured. All were found at the exact site as marked preoperatively, and their diameter closely approximated that predicted. The occasional unanticipated presence in vivo of minor perforators suggests that color duplex imaging may not be reliable for fascial perforators less than 0.5 mm in diameter. Since perforator caliber qualitatively is a major determinant of flow, color duplex imaging can then objectively establish a hierarchy of the importance of perforators in a given region. From such data, the definition of new and more reliable fasciocutaneous flap donor territories should be forthcoming.(ABSTRACT TRUNCATED AT 250 WORDS)

[Preserving the length of amputation stumps by microvascular flap transfer of the lower extremity]

With different case reports we want to show the role of microvascular tissue transfer in preservation of lower extremity amputation length. To salvage amputation stumps after traumatic amputation, as well as in case of chronic soft tissue problems after amputation, the radialis forearm flap is preferred for smaller defects, for example after transmetatarsal amputation, whereas with the latissimus dorsi muscle flap bigger areas can be reconstructed. But also the tensor fascia latae flap and the scapular flap can be used for soft tissue reconstruction. With microvascular soft tissue transfer amputation stump length can be preserved in order to have a better functional outcome, especially for prosthetic rehabilitation.

[Effects of repeated sevoflurane anesthesia on hepatic and renal function in a pediatric patient]

A 10-yr-old boy with an injured lower extremity received sevoflurane anesthesia 5 times within 40 days. Laboratory tests for hepatic and renal function i.e., serum transaminase (glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, gamma-glutamyl transpeptidase), serum cholinesterase, plasma protein, serum cholinesterase, serum bilirubine, serum lactic dehydrogenase, serum prothrombin time, blood urea nitrogen, serum creatinine, beta 2-microglobulin, N-acetyl-D-glucosamidase and 24 hr-creatinine clearance remained within normal ranges throughout his perioperative period. Repeated sevoflurane anesthesia did not exert any adverse effect on hepatic and renal function in this patient.

Proximodorsal first phalanx osteochondral chip fragmentation in 336 horses

The results of arthroscopic surgery in the treatment of osteochondral fragmentation of the proximodorsal aspect of the first phalanx and the influence of other fetlock joint lesions on prognosis were evaluated in 336 horses. Horses were classified as: 1) returning to previous use at the same or higher class of performance; 2) returning to previous use (regardless of class of performance); or 3) failing to return to previous use. Ninety-six horses (29%) had fragmentation alone; 140 horses (42%) had fragmentation and additional fetlock lesions, and 100 horses (29%) underwent concurrent carpal arthroscopy. Of the 100 horses that underwent carpal arthroscopy, 63 had proximodorsal first phalanx fragmentation alone and 37 had other fetlock lesions associated with the fragment. There was significant association between lesion type and return to previous use for the Thoroughbred racehorse group. There was also a significant association between lesion type and return to the same or higher class of racing for the Thoroughbred racehorse group. No significant association in return to previous use existed for racehorses vs. non-racehorses, Thoroughbred racehorses vs. Quarter Horse racehorses, single vs. multiple joint involvement, and single vs multiple fragmentation per joint. The Thoroughbred racehorses in this study were sensitive to additional fetlock or carpal lesions, as was exemplified by the significant effect lesion type had on outcome.

[Repair of heel defect with a free medial plantar flap]

The results of reconstruction of plantar heel defects with a local random flap or an island medial plantar flap have in a majority of cases been satisfactory. However, in cases of extensive plantar defects, local tissue transfers are almost impossible. Since 1988, 8 cases with extensive plantar defects have been treated using free medial plantar cutaneous or musculocutaneous flaps. All flaps survived. Six weeks postoperatively, full weight-bearing was obtained and normal activities were resumed. No ulceration in the flaps has been noted in the follow up period between 6 and 24 months, and the two point discrimination was from 20 to 24 mm. The paper particularly points out the importance of nerve repair in the reconstruction, because recovery of the protective sensation is the most important factor to prevent plantar ulceration, and is the basis for good operative results.

[Free vascularized skin flap from the scapular region for treatment of foot skin loss]

A case of 10 years old boy with foot skin loss due to the traffic accident is presented. Free vascularized skin flap from scapular area has been used. The healing was uneventful. Advantages and disadvantages of this type of flap have been discussed.