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Teh J, Sharp R, McKean D. Presurgical Perspective and Postsurgical Evaluation of the Diabetic Foot. Semin Musculoskelet Radiol 2022; 26:717-729. [PMID: 36791740 DOI: 10.1055/s-0042-1760219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Management of the diabetic foot is complex and challenging, requiring a multidisciplinary approach. Imaging plays an important role in the decision-making process regarding surgery. This article discusses the presurgical perspective and postsurgical evaluation of the diabetic foot.
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Affiliation(s)
- James Teh
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Robert Sharp
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - David McKean
- Stoke Mandeville Hospital Buckinghamshire Healthcare NHS Trust
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Abstract
The management of ankle fractures in the diabetic population requires special attention as the risks of injury or treatment-related complications are high. Thorough review of clinical history and detailed assessment provide the treating surgeons with key information to guide treatment pathway. Vigilance is required when opting for nonoperative treatment in undisplaced stable ankle fractures in patients with peripheral neuropathy. The presence of critical ischemia in injured limb demands vascular consultation and ultimately, an intervention before surgical fixation of ankle fracture. An extended period of immobilization is one of the key principles in the management of ankle fracture patients with diabetes.
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Affiliation(s)
- Ngwe Phyo
- Department of Trauma and Orthopaedics, Frimley Park Hospital, Frimley Health NHS Foundation Trust, Portsmouth Road, Camberley GU16 7UJ, UK.
| | - Alexander Wee
- Department of Trauma and Orthopaedics, Frimley Park Hospital, Frimley Health NHS Foundation Trust, Portsmouth Road, Camberley GU16 7UJ, UK
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Driessen M, Edwards M, Biert J, Hermans E. Long-term results of displaced intra-articular calcaneal fractures treated with minimal invasive surgery using percutaneous screw fixation. Injury 2021; 52:1054-1059. [PMID: 33388150 DOI: 10.1016/j.injury.2020.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/09/2020] [Accepted: 12/13/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Over the last 20 years, minimally invasive surgery using Percutaneous Screw Fixation (PSF) has been performed increasingly frequently in the treatment of Displaced Intra-Articular Calcaneal Fractures (DIACFs). The purposes of this study were to assess the long-term postoperative outcomes of mobility, foot function, stability, pain and patient satisfaction. METHODS All patients had DIACFs and underwent PSF between 1998 and 2006 according to the method reported by Forgon and Zadravecz. Functional outcomes, range of motion and change in footwear were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). All patients completed a general health status form (Short Form-36 [SF-36]) and visual analogue scale (VAS) for patient satisfaction. Anatomical restoration was assessed based on the pre- and postoperative radiographic images. RESULTS Sixty-six patients with an DIACF were observed in the period 1998-2006. Patients who had open fractures, died or were <18 years of age at trauma were excluded. A total of 46 patients were asked to complete the questionnaires, during the last quarter of 2018. Of these patients, 27 with 29 DIACFs responded (58%). Nineteen were males, and the mean age at trauma was 45 years. Seven cases were classified as Sanders type II, 14 as Sanders type III, and 8 as Sanders type IV. The mean pre- and postoperative Böhler angles were 10 ͦ and 26 ͦ, respectively. The average follow-up period was 16 years, and at the follow-up, the mean AOFAS, MFS, SF-36 and VAS scores were 76, 74, 63 and 7.7 points, respectively. In comparison to the results at 5-10 years postoperatively in a previous study, we observed a decline in the average AOFAS and MFS scores by 8 and 11 points, respectively. Patient satisfaction decreased by 0.1 points and general health by 14 points. CONCLUSION The long-term results of this study show relatively good functional outcomes is two-thirds of the treated patients. According to the reported scores, patients described their level of function as essentially normal. PSF should therefore be considered as a good option in patients with DIAC fractures, especially in patients with Sanders II and III fractures. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Mls Driessen
- Department of surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Mjr Edwards
- Department of surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J Biert
- Department of surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - E Hermans
- Department of surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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Bläsius FM, Link BC, Beeres FJP, Iselin LD, Leu BM, Gueorguiev B, Klos K, Ganse B, Nebelung S, Modabber A, Eschbach D, Weber CD, Horst K, Knobe M. Impact of surgical procedures on soft tissue microcirculation in calcaneal fractures: A prospective longitudinal cohort study. Injury 2019; 50:2332-2338. [PMID: 31630780 DOI: 10.1016/j.injury.2019.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/10/2019] [Accepted: 10/02/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Wound healing complications are a major concern after open reduction and internal fixation (ORIF) in patients with calcaneal fractures. Microcirculation is known to play a key role in bone and soft tissue healing. The present study aimed to characterize and contrast the dynamics of changes in microcirculation comparing two different surgical procedures: A) ORIF and B) a minimally invasive approach (MIA). METHODS Blood flow (BF[AU]), oxygen saturation (sO2[%]) and relative amount of haemoglobin (rHb[AU]) were measured at two depths (2 mm and 8 mm) non-invasively by spectrophotometry (Micro-Lightguide O2C®, LEA Medizintechnik, Giessen, Germany) before surgery and every 24 h after surgery for a duration of six days. A linear mixed model (LMM) was used to analyse longitudinal data and repeated measurements. RESULTS Nineteen patients (44 years, range 21.9-71.0 years) were enrolled in the study. Surgical treatment consisted of ORIF (n = =15) and MIA (n = =9). The postoperative BF and sO2 at the 2 mm and 8 mm depths were higher in the ORIF group (BF: p < 0.001, p = =0.003; sO2: p = =0.001, p = =0.011). The BF at the 2 mm and 8 mm depths increased after surgery (2 mm: p = =0.003, 8 mm: p = =0.001) in both groups. This increase did not correlate with the surgical technique. sO2 and rHb values at the 8 mm depth decreased after surgery (sO2: p = =0.008, rHb: p < 0.001) in both groups, whereas sO2 at the 2 mm depth increased after surgery (p = =0.003). Furthermore, the surgical technique correlated with the postsurgical course of sO2 values at the 2 mm depth (p = =0.042). CONCLUSIONS The spectrophotometry results were in line with the generally accepted phases of soft tissue wound healing. Postsurgical changes in microcirculation are predominantly independent of surgical techniques and may be primarily determined by wound and fracture healing. Future studies should focus on the potential of spectrophotometry to monitor wound healing after surgery. Moreover, studies with longer observation periods are needed in order to examine the changes in microcirculation during all wound-healing phases.
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Affiliation(s)
- Felix M Bläsius
- Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074 Aachen, Germany.
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Switzerland.
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Switzerland.
| | - Lukas D Iselin
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Switzerland.
| | - Benjamin Moritz Leu
- Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074 Aachen, Germany.
| | | | - Kajetan Klos
- Department of Foot and Ankle Surgery, Catholic Hospital Mainz, Germany.
| | - Bergita Ganse
- Research Centre for Musculoskeletal Science & Sports Medicine, Faculty of Science and Engineering, School of Healthcare Science, Manchester Metropolitan University, Manchester, United Kingdom.
| | - Sven Nebelung
- Department of Radiology, University Hospital RWTH Aachen, Germany.
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Germany.
| | - Daphne Eschbach
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, Germany.
| | - Christian David Weber
- Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074 Aachen, Germany.
| | - Klemens Horst
- Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074 Aachen, Germany.
| | - Matthias Knobe
- Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074 Aachen, Germany; Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Switzerland.
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Evers J, Oberste M, Wähnert D, Grüneweller N, Wieskötter B, Milstrey A, Raschke MJ, Ochman S. [Outcome after surgical treatment of calcaneal fractures]. Unfallchirurg 2019; 122:778-783. [PMID: 30402689 DOI: 10.1007/s00113-018-0578-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND After controversial discussions in the literature about therapy regimens for calcaneal fractures, a retrospective study of patients operatively treated in a maximum care trauma center was conducted. OBJECTIVE Investigation of the influencing factors on the treatment quality of operatively treated patients with calcaneal fractures. MATERIAL AND METHODS Between 2005 and 2013 a total of 90 patients with calcaneal fractures were surgically treated in this hospital with locking plate osteosynthesis. A total of 48 patients with 55 fractures were retrospectively investigated. The assessment with respect to posttraumatic arthrosis was made radiologically and Böhler's and Gissane's angles were also determined. Clinically AOFAS and SF-36 scores were documented. The results were statistically tested with respect to possible risk factors. RESULTS A total of 9 patients (18.8%) were found with complications necessitating operative revision, with 8 patients requiring subtalar arthrodesis and 1 patient with a deep wound infection. Nicotine abuse and a long interval between trauma and reconstructive surgery were identified as factors that influenced the development of wound healing problems. The average AOFAS score was 68 points and the SF-36 was 58.86 points. A poor result in the scores was caused by the development of symptomatic arthritis and the type of insurance. In this cohort factors, such as age and complexity of fractures were not correlated with a poor result. CONCLUSION In this patient collective nicotine abuse and a long interval between trauma and surgery were risk factors for development of wound infections. Other factors with an influence on the outcome were the postoperative development of arthritis and the type of health insurance; however, patient age had no impact on the outcome.
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Affiliation(s)
- J Evers
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, W1, 48149, Münster, Deutschland.
| | - M Oberste
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, W1, 48149, Münster, Deutschland
| | - D Wähnert
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, W1, 48149, Münster, Deutschland
| | - N Grüneweller
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, W1, 48149, Münster, Deutschland
| | - B Wieskötter
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, W1, 48149, Münster, Deutschland
| | - A Milstrey
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, W1, 48149, Münster, Deutschland
| | - M J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, W1, 48149, Münster, Deutschland
| | - S Ochman
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, W1, 48149, Münster, Deutschland
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Vasukutty N, Kumar V, Diab M, Moussa W. Operative treatment of calcaneal fractures: improved outcomes and low complications rates with a strict management protocol. Ann R Coll Surg Engl 2016; 99:275-279. [PMID: 27513790 DOI: 10.1308/rcsann.2016.0259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
This is a retrospective review of 80 intra-articular calcaneal fractures treated with open reduction and internal fixation by a specialist team under supervision of a single surgeon in a tertiary centre between 2005 and 2014. The fractures were evaluated with plain radiography and computed tomography, and graded using the Eastwood-Atkins classification. A lateral approach was used and all fractures were fixed with calcaneal plates. All patients had clinical and radiological follow-up. Clinical assessment included foot and ankle disability index, SF-36® and Kerr-Atkins scores. The mean follow-up duration was 72 months (range: 12-130 months). The mean age of patients was 49 years (range: 17-73 years). There were three open fractures and eight patients had other injuries. The mean Bohler's angle improved from 6° preoperatively to 26° postoperatively. The mean foot and ankle disability index score was 78.62, the mean SF-36® scores were 45.5 (physical component) and 52.6 (mental component), and the mean Kerr-Atkins score was 72 (range: 36-100). Early complications included one case of screw protrusion in the subtalar joint (which warranted a repeat procedure), one sural nerve injury and one wound breakdown, which healed with non-operative measures. Twelve patients had symptomatic subtalar joint osteoarthritis. Four of these had subtalar fusion. We believe that our strict protocols of patient selection, intraoperative and postoperative management produced long-term results comparable with those in the peer reviewed literature.
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Affiliation(s)
- N Vasukutty
- University Hospital Southampton NHS Foundation Trust , UK
| | - V Kumar
- University Hospital Southampton NHS Foundation Trust , UK
| | - M Diab
- Dorset County Hospital NHS Foundation Trust , UK
| | - W Moussa
- University Hospital Southampton NHS Foundation Trust , UK
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Abstract
Most intra-articular calcaneal fractures are a result of high-energy trauma. The operative management of calcaneal fractures has been based on achieving anatomic reduction and minimizing complications of the compromised soft tissue envelope. The traditional extensile lateral approach offers advantages of achieving adequate fracture reduction with the risk of wound-healing complications and infection. Limited open reduction and internal fixation techniques with or without using external fixation focuses on achieving fracture reduction with less risk of wound complications but higher risk of malunion. This article discusses key points of operative management for various intra-articular calcaneal fracture patterns and clinical presentations.
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