1
|
Nava CM, Martineau J, Suva D, Kalbermatten DF, Oranges CM. Distally based peroneus brevis flap: Reconstruction of complex soft-tissue defects with bony infection of the lateral malleolus. J Plast Reconstr Aesthet Surg 2024; 95:207-215. [PMID: 38936331 DOI: 10.1016/j.bjps.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/02/2024] [Accepted: 06/06/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Managing wounds of the lateral malleolus is challenging owing to limited nearby tissues and possibly injured or inadequate vessels for free flaps, especially in case of underlying infections. Moreover, free flaps require specialized skills and are not suitable for every patient. Therefore, identifying reliable local alternatives is crucial. This retrospective study investigated the efficacy and safety of the distally based peroneus brevis muscle flap in treating complex and infected soft-tissue defects of the lateral malleolus. MATERIALS AND METHODS A retrospective medical chart review of all patients who underwent a distally based peroneus brevis muscle flap reconstruction in the context of an infected lateral malleolus defect at Geneva University Hospitals between October 2020 and January 2024 was performed. RESULTS Ten patients underwent lateral malleolus reconstruction using a distally based peroneus brevis muscle flap primarily to address post-traumatic infections. Flap coverage was performed within 4 weeks of infection onset for post-traumatic cases, alongside antibiotic treatment. The defects were moderate in size, with a median width of 2.5 cm and length of 5.5 cm. There were no complete or partial flap failures. All patients regained the ability to walk within 5 days after surgery. CONCLUSIONS The distally based peroneus brevis muscle flap was efficient in managing complex and infected soft-tissue defects of the lateral malleolus, with control of infection in all patients and minimal donor-site morbidity.
Collapse
Affiliation(s)
- Caterina M Nava
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland; Department of Surgery, HFR Fribourg Cantonal Hospital, 1708 Fribourg, Switzerland
| | - Jérôme Martineau
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Domizio Suva
- Department of Orthopaedic Surgery, Bone Infection Unit, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Carlo M Oranges
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland.
| |
Collapse
|
2
|
Alizade C, Aliyev H, Alizada F. The Concept of Treatment for Surgical Infection in the Hindfoot. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241241058. [PMID: 38623152 PMCID: PMC11017820 DOI: 10.1177/24730114241241058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Background Chronic osteomyelitis of the calcaneus (OC) and open infected calcaneal fractures, especially when complicated by infected soft tissue defects, present significant surgical challenges. Accepted recommendations for the surgical treatment of this pathology are yet to be established. Methods Drawing from our experience and the consensus among experts, we have developed a concept for selecting optimal, well-known surgical approaches based on the specific pathologic presentation. This concept distinguishes 4 main forms of hindfoot infection: infected wounds, open infected fractures, OC, and their mixed forms. Patients with conditions that could confound the treatment outcomes, such as diabetes mellitus and neurotrophic diseases, were excluded from this analysis. We present a retrospective analysis of the treatment outcomes for 44 patients (4 women and 40 men) treated between 2009 and 2022 using some refined surgical techniques. Treatment success was evaluated based on the absence of disease recurrence within a 2-year follow-up, the avoidance of below-knee amputations, and the restoration of weightbearing function. Results The treatment results were considered through the prism of our proposed concept and according to the Cierny-Mader classification. There were 4 instances of disease recurrence, necessitating 6 additional surgeries, 2 of which (4.5% of the patient cohort) resulted in amputations. In the remaining cases, we were able to restore weightbearing function and eliminate the infection through reconstructive surgeries, employing skin grafts when necessary. Conclusion Surgical infections of the hindfoot area remain a significant challenge. The strategic concept we propose for surgical decision making, tailored to the specific pathology, represents a potential advancement in addressing this challenge. This framework could provide valuable guidance for orthopaedic surgeons in their clinical decision-making process. Level of Evidence Level IV, case series.
Collapse
Affiliation(s)
| | - Huseyn Aliyev
- Azerbaijan Scientific Research Institute of Traumatology and Orthopedics, Baku, Azerbaijan
| | - Farhad Alizada
- Klinikum am Gesundbrunnen (SLK-Kliniken Heilbronn GmbH), Am Gesundbrunnen 20-26, 74078 Heilbronn
| |
Collapse
|
3
|
Kong L, Li C, Bai J, Lu J. Surgical treatment of distal radius fractures: impact on forearm rotation in non-elderly patients. Sci Rep 2024; 14:2876. [PMID: 38311631 PMCID: PMC10838908 DOI: 10.1038/s41598-024-53520-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/01/2024] [Indexed: 02/06/2024] Open
Abstract
Forearm rotation restriction (FRR) is common after surgery for distal radius fractures (DRFs). The aim of the current study was to investigate the effect of DRFs on forearm rotation. This retrospective study reviewed patients with DRFs who underwent surgical treatment from January 2019 to December 2021. The patients' basic data and radiographic parameters were analyzed. Forearm rotation, including pronation and supination, was assessed using a standard goniometer. The Patient-Rated Wrist Evaluation (PRWE) score was evaluated, and the incidence of FRR at the 6-month follow-up was recorded. Univariate and multivariate logistic regression analyses were performed to identify risk factors correlated with FRR. A total of 127 patients with DRFs were included in this study. After surgery, 46 cases were considered to have FRR, with a rate of 36.2%, while the remaining 81 cases (63.8%) did not have FRR. The PRWE scores were 22.8 ± 5.2 and 17.9 ± 4.2 in the FRR group and non-FRR group, respectively, and the difference was statistically significant (P < 0.05). Multivariate analysis showed that the involvement of the sigmoid notch (OR, 2.88; 95% CI 1.49-5.56), post-operative volar tilt < 0° (OR, 2.16; 95% CI 1.34-3.50), and post-operative ulnar variance > 0 mm (OR, 1.37; 95% CI 1.06-1.78) were independently associated with the incidence of FRR. The FRR is associated with an increased PRWE score and may have had some impact on the patient's daily life. Fractures involving the sigmoid notch, dorsal angulation, and radial shortening deformity were found to be correlated with the incidence of FRR. Preoperative risk notification and intraoperative preventive measures are necessary for these patients.
Collapse
Affiliation(s)
- Lingde Kong
- Department of Orthopedics, Third Hospital of Hebei Medical University, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Shijiazhuang, 050051, Hebei, China
| | - Chenfei Li
- Department of Orthopedics, Third Hospital of Hebei Medical University, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Shijiazhuang, 050051, Hebei, China
| | - Jiangbo Bai
- Department of Orthopedics, Third Hospital of Hebei Medical University, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Shijiazhuang, 050051, Hebei, China
| | - Jian Lu
- Department of Orthopedics, Third Hospital of Hebei Medical University, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Shijiazhuang, 050051, Hebei, China.
| |
Collapse
|
4
|
Hamrouni N, Højvig JH, Petersen MM, Hettwer W, Jensen LT, Bonde CT. Total calcaneal reconstruction using a massive bone allograft and a distally pedicled osteocutaneous fibula flap: A novel technique to prevent amputation after calcaneal malignancy. J Plast Reconstr Aesthet Surg 2023; 76:44-48. [PMID: 36516510 DOI: 10.1016/j.bjps.2022.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/23/2022] [Accepted: 10/11/2022] [Indexed: 12/14/2022]
Abstract
In patients with primary calcaneal malignancies, such as Ewing's sarcoma, radical treatment with amputation of the foot can result in serious functional impairment and chronic pain. Total calcanectomy followed by the reconstruction of the calcaneal defect offers an alternative treatment to amputation. Capanna et al. described a technique for successfully reconstructing long limb segmental bone defects using a free fibula flap placed within the intramedullary canal of an allograft. We present both a review of the literature on calcaneal reconstruction and describe how the principles of Capanna can be adapted to reconstruct the calcaneus. Total calcanectomy due to Ewing's sarcoma and the subsequent application of this novel reconstructive technique was performed in two young patients aged 5 and 16 years. The reconstruction was achieved by inserting a distally pedicled osteocutaneous fibula flap within the reamed canal of an allograft and placing the composite in the calcaneal defect. Reconstruction was successful with complete bone union between the allograft and the adjacent bone. There were no fractures or infections and both flaps survived. Functional outcome was assessed with a physiotherapist at a follow-up period of 2 years postoperatively, showing near-normal ambulance. This novel technique proved excellent as a limb salvage procedure, avoiding amputation, and offering a satisfactory oncological and functional outcome.
Collapse
Affiliation(s)
- Nizar Hamrouni
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Inge Lehmannsvej 6, 2100 Copenhagen, Denmark.
| | - Jens Hjermind Højvig
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Inge Lehmannsvej 6, 2100 Copenhagen, Denmark
| | - Michael Mørk Petersen
- Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Inge Lehmannsvej 6, 2100 Copenhagen, Denmark
| | - Werner Hettwer
- Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Inge Lehmannsvej 6, 2100 Copenhagen, Denmark
| | - Lisa Toft Jensen
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Inge Lehmannsvej 6, 2100 Copenhagen, Denmark
| | - Christian Torsten Bonde
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Inge Lehmannsvej 6, 2100 Copenhagen, Denmark
| |
Collapse
|
5
|
Vishwanath N, Whitaker C, Allu S, Clippert D, Jouffroy E, Hong J, Stone B, Connolly W, Barrett CC, Antoci V, Born CT, Garcia DR. Silver as an Antibiotic-Independent Antimicrobial: Review of Current Formulations and Clinical Relevance. Surg Infect (Larchmt) 2022; 23:769-780. [PMID: 36178480 DOI: 10.1089/sur.2022.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The increase of multi-drug-resistant organisms has revived the use of silver as an alternative antibiotic-independent antimicrobial. Although silver's multimodal mechanism of action provides low risk for bacterial resistance, high local and uncontrolled concentrations have shown toxicity. This has resulted in efforts to develop novel silver formulations that are safer and more predictable in their application. Optimization of silver as an antimicrobial is crucial given the growing resistance profile against antibiotics. This article reviews formulations of silver used as antimicrobials, focusing on the mechanisms of action, potential for toxicity, and clinical applications. Methods: A search of four electronic databases (PubMed, Embase, MEDLINE, and Cochrane Library) was conducted for relevant studies up to January 2022. Searches were conducted for the following types of silver: ionic, nanoparticles, colloidal, silver nitrate, silver sulfadiazine, silver oxide, silver carboxylate, and AQUACEL® (ConvaTec, Berkshire, UK). Sources were compiled based on title and abstract and screened for inclusion based on relevance and study design. Results: A review of the antimicrobial activity and uses of ionic silver, silver nanoparticles, colloidal silver, silver nitrate, silver sulfadiazine, silver oxide, Aquacel, and silver carboxylate was conducted. The mechanisms of action, clinical uses, and potential for toxicity were studied, and general trends between earlier and more advanced formulations noted. Conclusions: Early forms of silver have more limited utility because of their uncontrolled release of silver ions and potential for systemic toxicity. Multiple new formulations show promise; however, there is a need for more prospective in vivo studies to validate the clinical potential of these formulations.
Collapse
Affiliation(s)
- Neel Vishwanath
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Colin Whitaker
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Sai Allu
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Drew Clippert
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Elia Jouffroy
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - James Hong
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Benjamin Stone
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - William Connolly
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Caitlin C Barrett
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Valentin Antoci
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christopher T Born
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Dioscaris R Garcia
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
6
|
Hu W, Huang C, Zhang Y, Wang X, Jiang Y. A nomogram for predicting post-operative wound complications after open reduction and internal fixation for calcaneal fractures. Int Wound J 2022; 19:2163-2173. [PMID: 35438244 DOI: 10.1111/iwj.13822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 11/28/2022] Open
Abstract
The purpose of our study was to determine the risk factors for post-operative wound complications (PWCs) after open reduction and internal fixation (ORIF) for calcaneal fracture and establish a nomogram prediction model. We retrospectively analysed the clinical data of patients who suffered from calcaneal fractures and had been surgically treated for ORIF in our institution between January 2010 and January 2020. Perioperative information was obtained through the electronic medical record system, univariate and multivariate analyses were performed to determine the risk factors of PWCs, and a nomogram model was constructed to predict the risk of PWCs. The predictive performance and consistency of the model were evaluated by the Hosmer -Lemeshow (H-L) test and the calibration curve. In total, 444 patients were enrolled in our study. Multivariate analysis results showed that smoking, limb swelling, angle of incision, and CRP were independent risk factors for skin necrosis. The AUC value for skin necrosis risk was 0.982 (95%CI 0.97-0.99). The H-L test revealed that the normogram prediction model had good calibration ability (P = .957). Finally, we found a correlation between PWCs and smoking, limb swelling, angle of incision, and CRP after ORIF for calcaneal fracture patients. Our nomogram prediction model might be helpful for clinicians to identify high-risk patients, as interventions could be taken early to reduce the incidence of PWCs.
Collapse
Affiliation(s)
- Wei Hu
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chengbin Huang
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yingying Zhang
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xingyu Wang
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yanshu Jiang
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| |
Collapse
|
7
|
Abstract
BACKGROUND Soft tissue defects of the foot are very common sequelae after trauma and require an individual reconstructive approach. OBJECTIVE Recommendations for the treatment of soft tissue injuries to the foot are given. MATERIAL AND METHODS The criteria of soft tissue reconstruction, postoperative follow-up and complications are first discussed before the therapeutic approach is explained depending on the reconstruction site. Case examples are given for illustration. RESULTS Decision making for soft tissue reconstruction of the foot is based on the location, the 3‑dimensional extent of the defect, the patient requirements and concomitant diseases. Standardized treatment algorithms are usually applied that need to be adapted according to individual patient factors. Randomized and local pedicled flaps can be applied for foot reconstruction; however, these options involve a significant risk of complications. Consequently, free flaps are frequently indicated after appropriate preoperative diagnostics of the perfusion of the foot. Due to the vast variety of donor sites, free flaps allow an individualized reconstruction, which is adapted to local and patient requirements. CONCLUSION Precise preoperative reconstructive planning and analysis of the vascularization form the foundation for a successful soft tissue reconstruction of the foot. The aims of the individualized approach to soft tissue reconstruction of the foot are stable soft tissue coverage, resistance to weight bearing of the sole of the foot, the ability to wear normal shoes and maintenance of sensibility.
Collapse
|
8
|
Liu Y, Cai P, Cheng L, Li Y. Local Random Pattern Flap Coverage for Implant Exposure following Open Reduction Internal Fixation via Extensile Lateral Approach to the Calcaneus. BMC Musculoskelet Disord 2021; 22:567. [PMID: 34154601 PMCID: PMC8218457 DOI: 10.1186/s12891-021-04427-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background Skin necrosis and implant exposure most often appear at the corner of Extensile Lateral Approach for open reduction and internal fixation (ORIF) for displaced intra-articular fracture of the calcaneus. Flap transfer is often used for coverage of this implant exposure. We introduced a new simple local random pattern flap to cover the implant exposure. Methods From March 2017 to March 2020, 12 patients with implant exposure after ORIF for displaced intra-articular fracture of the calcaneus were treated with this procedure. The sizes of the defects ranged from 2 × 2 cm2 to 5 × 2 cm2. A local random pattern flap was designed according to the defect size. The lower edge of the flap was along with the wound upper edge and extended distally. The upper horizontal incision of the flap was made at the lateral malleolus level with a length of 5–7 cm depending on the wound defect. Then the random pattern flap was elevated and transferred to cover the defect area. Results The mean follow-up duration was 6.3 months (ranging 4–13 months). All 12 flaps were uneventfully healed and all patients were able to wear shoes, and no debulking procedures were required. Conclusion The local random pattern flap could be a choice for surgeons when implant exposure at the corner of Extensile Lateral Approach to the Calcaneus occurs.
Collapse
Affiliation(s)
- Yingjie Liu
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan road, Shanghai, 200233, China
| | - Peihua Cai
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan road, Shanghai, 200233, China
| | - Liang Cheng
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan road, Shanghai, 200233, China.
| | - Yanfeng Li
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan road, Shanghai, 200233, China
| |
Collapse
|
9
|
Distally-based Peroneus Brevis Turnover Muscle Flap in the Reconstruction of Soft Tissue Defects. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3290. [PMID: 33425602 PMCID: PMC7787294 DOI: 10.1097/gox.0000000000003290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/30/2020] [Indexed: 11/27/2022]
Abstract
Reconstruction of the distal 3rd of the lower leg requires either local or free flap coverage if tendons or bones are exposed. The distally based, pedicled peroneus brevis (PB) flap has been shown to be a valid option in the management of distal 3rd lower limb injuries. Herein, we present 21 cases treated with distally-based PB muscle flaps between May 2017 and September 2019. The defect location varied, and included defects over the lateral and medial malleolar areas, distal tibia (middle and distal 3rd junction, and the distal 3rd), and Achilles tendon area. Methods The PB was dissected from the lateral fibula and intermuscular septa in a cephalic to caudal direction, to a point no lower than 7 cm proximal to the lateral malleolus tip. This preserved most distal vascular perforators to the muscle, and afforded sufficient mobilization to allow successful turn-over of the muscle, with transposition into the defect within 30 minutes of tourniquet time. A meshed skin graft completed the intervention. Results The metalwork was removed in all chronic cases (10/21), as bone union had occurred. All flaps survived completely. One patient partially lost the skin graft; the wound was healed by secondary intention. No major complications occurred and no significant patient discomfort was noted. All wounds healed completely by 9 weeks of follow-up. Conclusion The PB turnover muscle flap is a versatile flap, ideally suited to manage up to moderately sized defects of the distal 3rd of the lower leg, with negligible postoperative morbidity.
Collapse
|
10
|
Wang JS, Gunsch C, Thompson C, Nigam M, Evans KK, Attinger CE. Proximally Based Split Abductor Hallucis Turnover Flap for Medial Hindfoot Reconstruction: A Case Report. J Foot Ankle Surg 2019; 58:1072-1076. [PMID: 31679661 DOI: 10.1053/j.jfas.2019.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 05/16/2019] [Accepted: 06/13/2019] [Indexed: 02/03/2023]
Abstract
Limited reconstructive options exist for soft tissue defects of the foot and ankle because of a lack of surrounding tissue. Although microsurgical free flaps have become a popular treatment modality for this anatomic region, pedicled muscle flaps can provide robust coverage of small foot wounds with significantly less donor site comorbidity. One such muscle is the abductor hallucis, which can be used as a proximally based turnover flap to cover medial hindfoot defects. However, complete distal disinsertion of the muscle may lead to loss of support over the medial arch and first metatarsophalangeal joint, leading to pes planus and hallux valgus. In this case report, we describe a modified technique of a split abductor hallucis turnover flap for a young patient with a chronic, traumatic medial heel wound complicated by calcaneal osteomyelitis. By preserving part of the muscle's distal tendinous attachment, this technique allows for adequate soft tissue coverage while maintaining long-term biomechanical function.
Collapse
Affiliation(s)
- Jessica S Wang
- Resident, Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Crystal Gunsch
- Resident, Department of Podiatric Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC.
| | - Candice Thompson
- Resident, Department of General Surgery, Medstar Georgetown University Hospital-Washington Hospital Center, Washington, DC
| | - Manas Nigam
- Resident, Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Surgeon, Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Christopher E Attinger
- Surgeon, Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| |
Collapse
|
11
|
Sabater-Martos M, Sigmund IK, Loizou C, McNally M. Surgical Treatment and Outcomes of Calcaneal Osteomyelitis in Adults: A Systematic Review. J Bone Jt Infect 2019; 4:146-154. [PMID: 31192115 PMCID: PMC6536802 DOI: 10.7150/jbji.34452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 03/23/2019] [Indexed: 01/19/2023] Open
Abstract
Introduction: Calcaneal osteomyelitis is an uncommon and challenging condition. In this systematic review we aim to analyse the outcomes from concomitant use of bone debridement and soft tissue management for patients diagnosed with calcaneal osteomyelitis. Materials & Methods: A complete computerised and comprehensive literature search of Pubmed and Cochrane database was undertaken from January 2000 to October 2018. During the review, studies were screened for information about the surgical and antimicrobial treatment, the complications, the reinfection rate and the functional outcome of patients with calcaneal osteomyelitis. Results: Of the 20 eligible studies included, seven (35%) described bone treatment only, six (30%) soft tissue treatment only, five (25%) soft tissue and bone treatment, and two (10%) focused on prognostic factors and differences in outcomes between diabetic and non-diabetic patients. In the studies with bone treatment only, infection recurrence ranged from 0 to 35% and the amputation rate from 0 to 29%. If soft tissue coverage was also needed, both the reinfection rate and amputation rate ranged from 0 to 24%. Studies presenting the functional status generally showed preservation or even improvement of the preoperative ambulatory status. Conclusion: Calcaneal osteomyelitis is difficult to treat. A multidisciplinary approach involving orthopaedic surgeons, plastic surgeons and infectious disease physicians is preferred. The heterogenicity of studies has hindered the development of agreed treatment protocols, which would be useful in clinical practice.
Collapse
Affiliation(s)
- Marta Sabater-Martos
- The Bone Infection Unit, Nuffield Orthopaedic Centre. Windmill Rd, Headington. Oxford OX3 7HE, Oxford University Hospitals Foundation NHS Trust, Oxford, UK.,Department of Orthopaedics and Trauma Surgery. Hospital Universitari Germans Trias i Pujol, Badalona. Carretera del Canyet s/n, 08916 Badalona, Spain
| | - Irene Katharina Sigmund
- The Bone Infection Unit, Nuffield Orthopaedic Centre. Windmill Rd, Headington. Oxford OX3 7HE, Oxford University Hospitals Foundation NHS Trust, Oxford, UK.,Medical University of Vienna, Department of Orthopaedics and Trauma Surgery, Spitalgasse 23, 1090 Vienna, Austria
| | - Constantinos Loizou
- The Bone Infection Unit, Nuffield Orthopaedic Centre. Windmill Rd, Headington. Oxford OX3 7HE, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre. Windmill Rd, Headington. Oxford OX3 7HE, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| |
Collapse
|
12
|
Wound Coverage Options for Soft Tissue Defects Following Calcaneal Fracture Management (Operative/Surgical). Clin Podiatr Med Surg 2019; 36:323-337. [PMID: 30784540 DOI: 10.1016/j.cpm.2018.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Soft tissue defects and wound healing complications related to calcaneus fractures may result in significant morbidity. The management of these soft tissue complications requires following reconstructive principles that provide the requisites for preservation of the injured limb and the maximization of function. Soft tissue complications are addressed with methods that commensurate with the degree of injury, ranging from local wound care to free flap reconstruction. With the orthoplastic approach to both bone and soft tissue plastic reconstruction, outcomes for limb salvage are greatly enhanced. This article discusses in detail the reconstructive ladder for soft tissue injuries associated with calcaneus fractures.
Collapse
|
13
|
Trikha V, Gaba S, Agrawal P, Das S, Kumar A, Chowdhury B. CT based management of high energy tibial plateau fractures: A retrospective review of 53 cases. J Clin Orthop Trauma 2019; 10:201-208. [PMID: 30705560 PMCID: PMC6349673 DOI: 10.1016/j.jcot.2017.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/24/2017] [Accepted: 11/18/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES The management of high energy tibial plateau fractures is a surgical challenge. Recently described Luo's classification is based on CT scans and is more objective with a better inter-observer agreement as compare to Schatzker and AO/OTA classifications. We describe the functional results of a series of 53 cases classified and managed according to the Luo's column concept. METHODS A retrospective review of 53 high energy tibial plateau fractures, operated between January 2012 and March 2015 at a Level I trauma center, was performed. CT scans were used to classify these injuries based on the number of columns involved. Plating configuration and surgical approach were chosen based on the number of independent articular fragments on axial sections at the level of fibular head. RESULTS 1 one-column, 51 two-column and 1 three-column fractures were studied. Triple plating was done in 5 patients. Mean follow-up was 2.7 years and mean Insall Knee score was 95.42. Four patients had varus malalignment and 1 had joint depression in the post-operative period. These were due to imperfect reduction during the surgery itself, and no case of late collapse was detected. CONCLUSION Utilizing Luo's classification for treating these complex injuries will assist in better understanding of fracture pattern and hence help in achieving a better functional outcome. Each fractured column needs to be independently addressed.
Collapse
Affiliation(s)
| | - Sahil Gaba
- Corresponding author at: Room number 113, Trauma Centre Hostel, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | | | | | | | | |
Collapse
|
14
|
Mikami T, Kaida E, Yabuki Y, Kitamura S, Kokubo K, Maegawa J. Negative Pressure Wound Therapy Followed by Basic Fibroblast Growth Factor Spray as a Recovery Technique in Partial Necrosis of Distally Based Sural Flap for Calcaneal Osteomyelitis: A Case Report. J Foot Ankle Surg 2018; 57:816-820. [PMID: 29605553 DOI: 10.1053/j.jfas.2017.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Indexed: 02/03/2023]
Abstract
The distally based sural flap is regarded as the first choice for reconstruction in the distal part of the lower leg because the flap is easy to raise, reliable in its blood supply, and prone to only a few complications. Limited data have investigated the details of treatment in cases of failure of distally based sural flaps. We report a case of calcaneal osteomyelitis in which a successful outcome was finally obtained with a partially necrosed, distally based sural flap using negative pressure wound therapy with basic fibroblast growth factor spray. The 2-year follow-up examination was uneventful. Moreover, the patient was able to walk freely with an ankle-foot orthosis in her house. This technique can be considered as a useful and effective option to recover unfavorable results of distally based sural flaps.
Collapse
Affiliation(s)
- Taro Mikami
- Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Fujisawa Shounandi Hospital, Fujisawa, Kanagawa-ken, Japan; Associate Professor and Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Kanagawa-ken, Japan.
| | - Eriko Kaida
- Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Fujisawa Shounandi Hospital, Fujisawa, Kanagawa-ken, Japan
| | - Yuichiro Yabuki
- Assistant Professor and Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Kanagawa-ken, Japan
| | - Sho Kitamura
- Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Fujisawa Shounandi Hospital, Fujisawa, Kanagawa-ken, Japan
| | - Ken'ichi Kokubo
- Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Fujisawa Shounandi Hospital, Fujisawa, Kanagawa-ken, Japan
| | - Jiro Maegawa
- Professor and Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Kanagawa-ken, Japan
| |
Collapse
|
15
|
Tuzun HY, Kurklu M, Kulahci Y, Turkkan S, Arsenishvili A. Case Report: Late Reconstruction of the Land Mine-Injured Heel With an Osteomyocutaneous Composite Fibular Flap. J Foot Ankle Surg 2018; 57:627-631. [PMID: 29284573 DOI: 10.1053/j.jfas.2017.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Indexed: 02/03/2023]
Abstract
The heel comprises the epidermis, minimal subcutaneous tissue, a dense septum, and the calcaneus. Injury to any of these structures can impair the ability to walk. The soft tissue or calcaneal bone can be injured by trauma. Injuries incurred in war are usually high-energy traumas caused by weapons such as rifles, rockets, and land mines. Such injuries can be life threatening and involve the loss of tissue, including skin, soft tissue, bone, and neurovascular tissue. Two main treatment protocols are used for such injuries with large tissue defects: amputation and reconstruction. We describe a reconstruction with an osteomyocutaneous fibular flap for a heel injury. At the 2-year follow-up point, the patient had 30% loss of ankle range of motion. The visual analog scale score had dramatically decreased from 8 to 1, and the patient was satisfied with the result. In conclusion, patients with significant problems such as infection, pain, and anatomic deterioration of the calcaneus can be successfully treated using an osteomyocutaneous fibular flap in a single surgery.
Collapse
Affiliation(s)
- Harun Yasin Tuzun
- Orthopaedic and Hand Surgeon, Department of Orthopaedics and Traumatology, Division of Hand and Upper Extremity Surgery, SBU Gulhane Training and Research Hospital, Ankara, Turkey.
| | - Mustafa Kurklu
- Associate Professor, Orthopaedic and Hand Surgeon, Department of Orthopaedics and Traumatology, Memorial Hospital, İstanbul, Turkey
| | - Yalcin Kulahci
- Associate Professor, Plastic, Reconstructive and Aesthetic Surgeon, and Hand Surgeon, Ankara, Turkey
| | | | - Arsen Arsenishvili
- Orthopaedic and Hand Surgeon, Department of Orthopaedics and Traumatology, Division of Hand and Upper Extremity Surgery, Ministry of Defence Military Hospital of Georgia, Gori, Georgia
| |
Collapse
|
16
|
Ramanujam CL, Stuto AC, Zgonis T. Use of local intrinsic muscle flaps for diabetic foot and ankle reconstruction: a systematic review. J Wound Care 2018; 27:S22-S28. [DOI: 10.12968/jowc.2018.27.sup9.s22] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Crystal L. Ramanujam
- Assistant Professor/Clinical and Division Chief, Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
| | - Alan C. Stuto
- Specialist and Fellow in Reconstructive Foot and Ankle Surgery, Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
| | - Thomas Zgonis
- Professor and Director, Externship and Reconstructive Foot and Ankle Surgery Fellowship Programs, Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
| |
Collapse
|
17
|
Müller CSL, Burgard B, Zimmerman M, Vogt T, Pföhler C. On the significance of negative-pressure wound therapy with instillation in dermatology. J Dtsch Dermatol Ges 2018; 14:786-95. [PMID: 27509412 DOI: 10.1111/ddg.13038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Methods used in the treatment of acute and chronic wounds undergo constant evolution, reevaluation, and innovation. While negative-pressure wound therapy (NPWT) is an established treatment modality, the combination of NPWT and instillation of normal saline as well as solutions with active antiseptic components for topical treatment of the wound bed represents a novel approach. The well-known effects of NPWT may thus be combined with those of local antisepsis. They include a decrease in wound area, induction of granulation tissue, and reduction in bacterial colonization. To date, studies have focused on NPWT with instillation for orthopedic/surgical indications, whereas clinical data in dermatosurgery is limited to case reports or small case series. There are as yet no randomized prospective studies investigating NPWT with instillation in the treatment of skin disorders. The goal of this review is to present the method of NPWT with instillation, to highlight its mode of action as well as possible complications and contraindications, and to review the recent literature. In summary, there is increasing evidence that both simple and complicated wounds may be effectively treated with NPWT with instillation, resulting in markedly accelerated tissue granulation and thus earlier defect closure.
Collapse
Affiliation(s)
| | - Barbara Burgard
- Department of Dermatology, Allergology, and Venereology, University Hospital of Saarland, Homburg/Saar, Germany
| | - Monika Zimmerman
- Department of Dermatology, Allergology, and Venereology, University Hospital of Saarland, Homburg/Saar, Germany
| | - Thomas Vogt
- Department of Dermatology, Allergology, and Venereology, University Hospital of Saarland, Homburg/Saar, Germany
| | - Claudia Pföhler
- Department of Dermatology, Allergology, and Venereology, University Hospital of Saarland, Homburg/Saar, Germany
| |
Collapse
|
18
|
Müller CSL, Burgard B, Zimmerman M, Vogt T, Pföhler C. Zum Stellenwert der Unterdruck-Instillationstherapie in der Dermatologie. J Dtsch Dermatol Ges 2016; 14:786-96. [PMID: 27509413 DOI: 10.1111/ddg.13038_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Die Methoden zur Behandlung akuter und chronischer Wunden unterliegen einer steten Weiterentwicklung, Reevaluierung und Anwendung innovativer Therapieformen. Die Vakuumtherapie zur Wundbehandlung gehört zu den etablierten Behandlungsmodalitäten. Ein innovatives Verfahren kombiniert die Vakuumtherapie mit der automatisierten, kontrollierten Zufuhr und Drainage wirkstoffhaltiger Lösungen zur topischen Wundbehandlung im Wundbett und auch wirkstofffrei durch Instillation physiologischer Kochsalzlösung (Unterdruck-Instillationstherapie). Hierdurch können die Effekte der konventionellen Vakuumtherapie mit denen der lokalen Antisepsis kombiniert werden. Hierdurch kommt es zu einer Reduktion der Wundfläche, einer Induktion von Granulationsgewebe sowie einer Reduktion der Keimbesiedelung der Wunden. Bisher publizierte Studien konzentrieren sich auf die Anwendung dieses Therapieverfahrens zur Behandlung orthopädisch-chirurgischer Krankheiten. Die Datenlage bezüglich der Vakuum-Instillationstherapie in der Dermatochirurgie beschränkt sich derzeit auf Fallberichte und Einzelfallerfahrungen. Randomisierte, prospektive Studien zum Vergleich der Vakuum-Instillationstherapie zur Behandlung dermatologischer Krankheitsbilder existieren bislang nicht. Ziele des vorliegenden Artikels sind die Vorstellung der Vakuumtherapie mit Instillation einschließlich ihres Wirkprinzips, deren mögliche Komplikationen, die Diskussion erdenklicher Kontraindikationen sowie eine Übersicht über die aktuell verfügbare Datenlage. Zusammenfassend scheint sich die Evidenz zu verdichten, dass mittels Unterdruck-Instillationstherapie sowohl einfache als auch komplizierte Wunden effizient behandelt werden können, was sich in einer deutlichen Beschleunigung der Wundgranulation mit konsekutiv früher möglichem Defektverschluss äußert.
Collapse
Affiliation(s)
| | - Barbara Burgard
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Monika Zimmerman
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Thomas Vogt
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Claudia Pföhler
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum des Saarlandes, Homburg/Saar
| |
Collapse
|
19
|
Abstract
Assessment and treatment of calcaneal fractures have made substantial progress over the last two decades. Open reduction and stable internal fixation without joint transfixation has been established as standard therapy for most displaced intra-articular fractures with good to excellent results in more than two-thirds of patients in larger clinical series. The use of bone grafting or bone substitutes appears unnecessary in most cases. Important prognostic factors are anatomical reduction of subtalar joint congruity and the overall shape of the calcaneus. Therefore, quality of joint reduction should be reliably proved intra-operatively either with open subtalar arthroscopy or high-resolution (3D) fluoroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days, a high body mass index and smoking. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposition of the fractured lateral wall, the subtalar and calcaneocuboid joints in complex fractures. In simple fracture patterns percutaneous screw fixation, supplemented by arthroscopic control if necessary, is a good alternative. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency cases. Early, stable soft tissue coverage exploiting the full armamentarium of pedicled and free tissue transfer appears promising in improving the functional results and infection rates after open fractures. Calcaneal malunions after conservative therapy of displaced fractures are disabling conditions that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, in situ or correctional subtalar arthrodesis and calcaneal osteotomies.
Collapse
Affiliation(s)
- Stefan Rammelt
- Department of Trauma & Reconstructive Surgery, University Hospital ‘Carl Gustav Carus’, Dresden, Germany,
| | - Hans Zwipp
- Department of Trauma & Reconstructive Surgery, University Hospital ‘Carl Gustav Carus’, Dresden, Germany
| |
Collapse
|
20
|
Babiak I, Pędzisz P, Kulig M, Janowicz J, Małdyk P. Comparison of Bone Preserving and Radical Surgical Treatment in 32 Cases of Calcaneal Osteomyelitis. J Bone Jt Infect 2016; 1:10-16. [PMID: 28529846 PMCID: PMC5423567 DOI: 10.7150/jbji.14342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction. Radical procedures like calcanectomy and amputation performed for calcaneal osteomyelitis are regarded as effective in eradication of infection even though potentially functionally disabling. Bone sparing procedures offer better functional result at the expense of potentially worse infection control. The aim of the study has been to assess the influence of the surgical radicalism as much as the extent of bone infection on the final outcome in the surgical therapy of chronic calcaneal osteomyelitis (CO). Material and method. 32 patients with chronic CO have comprised the group under study: 8 with superficial type, 12 localised type and 12 with diffuse type according to Cierny-Mader classification. The aim of the treatment was to heal infection, preserve the heel shape and achieve good skin coverage over the calcaneus. The therapy consisted of 9 debridement surgeries with or without flaps, 8 drilling-operations of the calcaneus with application of collagen-gentamicin-sponge in bore holes, 15 partial and 2 total calcanectomies, and 4 below-the knee amputations. Results. The healing of infection and wound has been achieved after 7 of 9 debridements, 6 of 8 drilling-operations, 13 of 15 partial and all total calcanectomies. Conclusion. Bone preserving operations in chronic calcaneal osteomyelitis provided inferior infection control (76,47% vs 88,24%) and worse patient satisfaction (88,24% vs 100%) and almost camparable ambulation (100% vs 93,33%). Drilling of the calcaneus with application of collagen sponge containing gentamicin performed in chronic diffuse calcaneal osteomyelitis seems to offer a viable alternative to partial or radical calcanectomy. LEVEL OF EVIDENCE V.
Collapse
Affiliation(s)
- Ireneusz Babiak
- Department of Orthopaedics and Traumatology, Medical University of Warsaw, ul. Lindley'a 4, 02-005 Warsaw, Poland
| | | | | | | | | |
Collapse
|
21
|
Rohner-Spengler M, Frotzler A, Honigmann P, Babst R. Effective Treatment of Posttraumatic and Postoperative Edema in Patients with Ankle and Hindfoot Fractures: A Randomized Controlled Trial Comparing Multilayer Compression Therapy and Intermittent Impulse Compression with the Standard Treatment with Ice. J Bone Joint Surg Am 2014; 96:1263-1271. [PMID: 25100773 DOI: 10.2106/jbjs.k.00939] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND After ankle and hindfoot fractures, edema has a major impact on the time for surgical intervention and may increase the risk of wound complications and infection postoperatively. The aim of this study was to evaluate the efficacy of multilayer compression and intermittent impulse compression therapy in reducing ankle and hindfoot edema compared with the standard treatment with elevation and ice. METHODS This was a randomized, controlled, single-blinded clinical trial using a repeated-measures design. Fifty-eight patients with unilateral fractures of the ankle or hindfoot were randomized into the cold pack (control) group, the bandage group, or the impulse compression group and were analyzed according to the intention-to-treat principle. The primary outcome was the reduction of edema as measured with the figure-of-eight-20 method. RESULTS Preoperatively and postoperatively, there were significant differences in edema reduction between the bandage group and the control group. After two days of intervention, the median preoperative edema reduction in the control group was -2.0 mm (-5%) compared with -11.0 mm (-23%) in the bandage group (p < 0.017), and -0.3 mm (0%) in the impulse compression group (p > 0.017). Postoperatively, after two days, the median edema changes were +3.5 mm (+7%) in the control group compared with -7.3 mm (-22%) in the bandage group (p < 0.017) and +5.0 mm (+46%) in the impulse compression group (p > 0.017). CONCLUSIONS Multilayer compression therapy results in a faster reduction of ankle and hindfoot edema, although with less ankle dorsiflexion on postoperative day three than the control group, and can be recommended as an alternative treatment. Intermittent impulse compression applied without any extra compression by stockinette or bandage and without elevation in off-session periods cannot be recommended as a superior alternative to the treatment with ice. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Manuela Rohner-Spengler
- Departments of Rheumatology and Physiotherapy (M.R.-S.) and Trauma Surgery (M.R.-S., P.H., and R.B.), Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland. E-mail address for M. Rohner-Spengler:
| | - Angela Frotzler
- Clinical Trial Unit, Swiss Paraplegic Centre, Guido A. Zäch Strasse 1, 6207 Nottwil, Switzerland
| | - Philipp Honigmann
- Departments of Rheumatology and Physiotherapy (M.R.-S.) and Trauma Surgery (M.R.-S., P.H., and R.B.), Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland. E-mail address for M. Rohner-Spengler:
| | - Reto Babst
- Departments of Rheumatology and Physiotherapy (M.R.-S.) and Trauma Surgery (M.R.-S., P.H., and R.B.), Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland. E-mail address for M. Rohner-Spengler:
| |
Collapse
|
22
|
Shirol SS, Nimbaragi G, Prabhu M, Ratkal J. Abductor digiti minimi muscle flap in reconstruction of diabetic foot ulcers: A case series. EUROPEAN JOURNAL OF PLASTIC SURGERY 2014. [DOI: 10.1007/s00238-013-0923-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
23
|
Use of a Negative Pressure Incisional Dressing After Surgical Treatment of Calcaneal Fractures. TECHNIQUES IN FOOT AND ANKLE SURGERY 2013. [DOI: 10.1097/btf.0b013e3182a2b403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Laporta G, Bock F, Ghate N. Posterior approach for subtalar joint distraction arthrodesis by compact external fixation: a technique guide. J Foot Ankle Surg 2013; 52:547-52. [PMID: 23529016 DOI: 10.1053/j.jfas.2013.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Indexed: 02/03/2023]
Abstract
Subtalar joint arthrodesis is a commonly used surgical procedure for the management of rearfoot pathologic features. We present a technique guide for a posterior incisional approach to subtalar joint arthrodesis for correction of a calcaneal deformity secondary to calcaneal fracture malunion. This technique uses a monolateral external fixation device for controlled distraction and intercallary allograft placement. In contrast to a standard lateral approach, this incision provides better visualization of the joint space, and the use of a distractor enhances access to the joint surfaces for fusion preparation and maintains alignment while internal fixation is applied. A 44-year-old male underwent isolated subtalar joint arthrodesis to repair a malunion of a nonsurgically managed calcaneal fracture sustained 1 year before the surgical intervention. Controlled distraction was applied using a Hoffmann(®) Compact™ MRI external fixation device. This device maintained distraction and tibial-calcaneal alignment until placement of the allograft-bone marrow aspirate. The use of external fixation is a viable option for distraction arthrodesis in subtalar joint fusions. It facilitates frontal plane deformity correction. We have described the surgical technique and presented a case in which the posterior approach with distraction was successfully used in subtalar joint arthrodesis. At 12 weeks postoperatively, serial radiographs displayed incorporation of the graft, with distraction maintained at the subtalar joint arthrodesis site. At the 3-month follow-up visit, the patient had successfully transitioned to weightbearing in a CAM walker without any complications.
Collapse
Affiliation(s)
- Guido Laporta
- Foot and Ankle Surgery, Geisinger Community Medical Center, Scranton, PA 18512, USA.
| | | | | |
Collapse
|
25
|
Endo J, Kuniyoshi K, Mochizuki M, Shimoyama K, Koyama T, Aiba A, Kadota R, Sasaki Y. Two‐staged hindfoot reconstruction with vascularized fibula graft for calcaneal osteomyelitis caused by methicillin‐resistant
Staphylococcus aureus
: A case report. Microsurgery 2013; 33:232-5. [DOI: 10.1002/micr.22070] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 10/30/2012] [Accepted: 11/01/2012] [Indexed: 11/07/2022]
Affiliation(s)
- Jun Endo
- Department of Orthopaedic Surgery, Numazu City Hospital, 550 Higashi‐shiiji, Numazu, Shizuoka, 410‐0302, Japan
| | - Kazuki Kuniyoshi
- Department of Orthopaedic Surgery, Numazu City Hospital, 550 Higashi‐shiiji, Numazu, Shizuoka, 410‐0302, Japan
| | - Makondo Mochizuki
- Department of Orthopaedic Surgery, Numazu City Hospital, 550 Higashi‐shiiji, Numazu, Shizuoka, 410‐0302, Japan
| | - Katsuhito Shimoyama
- Department of Orthopaedic Surgery, Numazu City Hospital, 550 Higashi‐shiiji, Numazu, Shizuoka, 410‐0302, Japan
| | - Tadaaki Koyama
- Department of Orthopaedic Surgery, Numazu City Hospital, 550 Higashi‐shiiji, Numazu, Shizuoka, 410‐0302, Japan
| | - Atsuomi Aiba
- Department of Orthopaedic Surgery, Numazu City Hospital, 550 Higashi‐shiiji, Numazu, Shizuoka, 410‐0302, Japan
| | - Ryo Kadota
- Department of Orthopaedic Surgery, Numazu City Hospital, 550 Higashi‐shiiji, Numazu, Shizuoka, 410‐0302, Japan
| | - Yasuhito Sasaki
- Department of Orthopaedic Surgery, Numazu City Hospital, 550 Higashi‐shiiji, Numazu, Shizuoka, 410‐0302, Japan
| |
Collapse
|
26
|
Tiemann AH, Hofmann GO, Steen M, Schmidt R. Adult calcaneal osteitis: incidence, etiology, diagnostics and therapy. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2012; 1:Doc11. [PMID: 26504695 PMCID: PMC4582472 DOI: 10.3205/iprs000011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Calcaneal osteomyelitis presents a complicated situation. The specific anatomy of the os calcis and its surrounding soft tissues plays an important role in the planning and realization of the procedures needed in order to eradicate the osteomyelitic focus. The calcaneus represents a spongious bone; a fact that supports the developement of an osteomyelitis. It is the strongest bone of the foot and is highly important for the biomechanical features of physiological walking. The surrounding soft tissues are thin and contain various important anatomical structures. These might be damaged during the treatment of the osteomyelitis. In addition the vascularization of the os calcis is delicate and may be compromized during the surgical osteomyelitis treatment. Calcaneus osteomyelitis may be classified based on the routes of infection into exogenous and endogenous forms. Additionally from the clinical point of view acute and chronic forms may be distinguished from an early and a late infection. Exogenous calcaneal osteomyelitis mostly is the result of an infection with S. aureus. The treatment is equal to the therapy in other locations and based on: Eradication of the bone infectionSanitation of the soft tissue infectionReconstruction of bone and soft tissue Especially the preservation and restoration of the soft tissue is important. Thus plastic surgical procedures play an essential role. The main object of treatment is the preservation of a biomechanical functioning foot. This may be impossible due to the local situation. Calcanectomy or even below knee amputation may be needed in those cases.
Collapse
Affiliation(s)
- A. H. Tiemann
- Abteilung für Septische und Rekonstruktive Chirurgie, Klinik für Unfall- und Wiederherstellungschirurgie, BG-Kliniken Bergmannstrost Halle, Deutschland,*To whom correspondence should be addressed: A. H. Tiemann, Abteilung für Septische und Rekonstruktive Chirurgie, Klinik für Unfall- und Wiederherstellungschirurgie, BG-Kliniken Bergmannstrost Halle, Merseburgerstr. 165, 06112 Halle, Deutschland, Tel.: 0345-1326632, E-mail:
| | - G. O. Hofmann
- Abteilung für Septische und Rekonstruktive Chirurgie, Klinik für Unfall- und Wiederherstellungschirurgie, BG-Kliniken Bergmannstrost Halle, Deutschland,Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Friedrich-Schiller Universität Jena, Deutschland
| | - M. Steen
- Klinik für Plastische- und Handchirurgie, Brandverletztenzentrum, BG-Kliniken Bergmannstrost Halle, Deutschland
| | - R. Schmidt
- Klinik für Plastische- und Handchirurgie, Brandverletztenzentrum, BG-Kliniken Bergmannstrost Halle, Deutschland
| |
Collapse
|
27
|
Hersh IR, Fleming JJ. Considerations of a midline posterior approach to the ankle and subtalar joints. J Foot Ankle Surg 2012; 51:482-6. [PMID: 22726652 DOI: 10.1053/j.jfas.2012.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Indexed: 02/03/2023]
Abstract
The standard incisional approaches for ankle and subtalar joint surgery include the medial, lateral, or anterior. However, in patients with a history of traumatic injuries or previous surgery, in which the soft tissues of the foot and ankle have been compromised, a direct midline posterior approach might be preferable. The approach offers unparalleled exposure, provides excellent frontal plane visualization, and reduces the risk of vascular compromise by preserving the surrounding angiosomes. We report on 2 separate cases in which a midline posterior approach to the ankle and subtalar joints was used successfully for fusion procedures of the tibiocalcaneal and subtalar joints.
Collapse
|
28
|
Foot and Ankle Reconstruction: Pedicled Muscle Flaps versus Free Flaps and the Role of Diabetes. Plast Reconstr Surg 2011; 128:173-180. [DOI: 10.1097/prs.0b013e3182173d3a] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
29
|
Ignatiadis IA, Tsiampa VA, Galanakos SP, Georgakopoulos GD, Gerostathopoulos NE, Ionac M, Jiga LP, Polyzois VD. The reverse sural fasciocutaneous flap for the treatment of traumatic, infectious or diabetic foot and ankle wounds: A retrospective review of 16 patients. Diabet Foot Ankle 2011; 2:DFA-2-5653. [PMID: 22396826 PMCID: PMC3284289 DOI: 10.3402/dfa.v2i0.5653] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 11/01/2010] [Accepted: 11/16/2010] [Indexed: 11/14/2022]
Abstract
The authors present their experience with the use of sural fasciocutaneous flaps for the treatment of various soft tissue defects in the lower limb. This paper is a review of these flaps carried out between 2003 and 2008. The series consists of 16 patients, 11 men and 5 women with an average age of 41 years (17-81) and with a follow-up period between 2 and 7 years. The etiology was major velocity accident in six cases, diabetes mellitus with osteomyelitis after ORIF for fractures (2), work accident in five, and another two cases with complications of lower limb injuries. The defect areas were located on calcaneus, malleolar area, tarsal area and lower tibia. Associated risk factors in the patients for the flap performance were diabetes (five patients) and cigarette smoking (ten patients).The technique is based on the use of a reverse-flow island sural flap combined with other flaps in three cases (cross-leg, peroneal, gastrocnemius). The anatomical structures which constituted the pedicle were the superficial and deep fascia, the sural nerve, the lesser saphenous vein and skin.The flap was viable in all 15 patients. On 8 cases was achieved direct closure, on three cases occurred a superficial necrosis and was skin grafted, on one case was observed partial necrosis which was treated with a second flap (posterior tibial perforator flap) and another one occurred delayed skin healing.The sural fasciocutaneous flap is useful for the treatment of severe and complex injuries and their complications in diabetic and non diabetic lower limbs. Its technical advantages are easy dissection, preservation of more important vascular structures in the limb and complete coverage of the soft tissue defects in just one operation without the need of microsurgical anastomosis. Thus this flap offers excellent donor sites for repairing soft tissue defects in foot and ankle.
Collapse
Affiliation(s)
- Ioannis A Ignatiadis
- Hand Surgery-Upper Limb and Microsurgery Department, KAT General Hospital, Athens, Greece
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Capobianco CM, Zgonis T. Abductor hallucis muscle flap and staged medial column arthrodesis for the chronic ulcerated charcot foot with concomitant osteomyelitis. Foot Ankle Spec 2010; 3:269-73. [PMID: 20966453 DOI: 10.1177/1938640010382038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Midfoot ulceration is a common sequela of the diabetic Charcot rocker-bottom deformity. Because redundant soft tissue from a non- weight-bearing area is often scarce in this area of the foot, soft-tissue coverage may be challenging. Wound closure may be difficult to achieve with local wound care and off-loading techniques if the predisposing deformity that caused the ulceration is not addressed. In the same setting, surgical reconstruction is often feared when open wounds are present, given the potential for infection. Approaching these wounds with a rational stepwise and staged approach is prudent to eradicate the underlying infection and also to achieve durable wound closure and long-term deformity correction. The authors present the use of a local muscle flap and circular external fixation for closure of a recalcitrant Charcot plantar-medial midfoot ulceration and also discuss different adjunctive modalities to facilitate soft-tissue reconstruction in the diabetic foot.
Collapse
Affiliation(s)
- Claire M Capobianco
- Division of Podiatric Medicine and Surgery, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, TX 78229, USA
| | | |
Collapse
|
31
|
Abstract
Infections in and around the calcaneus can be quite challenging for the patients and physicians involved. These infections arise because of multiple potential etiologies including chronic pressure, trauma, and postsurgical wound-healing complications. The impediments to healing can be equally as diverse depending on patients' comorbidities, such as smoking, diabetes, and open injury. In this article the authors review the anatomy of the calcaneus and surrounding soft tissue, patient risk factors, and various treatment options that can be used through a multidisciplinary approach. The common limiting factor for most of these patients is the delicate soft-tissue envelope, and occasionally, the lack thereof. The ultimate goal is an infection-free limb with durable soft-tissue coverage and maximal maintenance of function.
Collapse
Affiliation(s)
- Tomiko Fukuda
- Fondren Orthopaedic Group LLC, Pearland, TX 77584, USA
| | | | | |
Collapse
|
32
|
Lorenzetti F, Lazzeri D, Bonini L, Giannotti G, Piolanti N, Lisanti M, Pantaloni M. Distally based peroneus brevis muscle flap in reconstructive surgery of the lower leg: Postoperative ankle function and stability evaluation. J Plast Reconstr Aesthet Surg 2010; 63:1523-33. [DOI: 10.1016/j.bjps.2009.08.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 06/14/2009] [Accepted: 08/09/2009] [Indexed: 10/20/2022]
|
33
|
Abstract
Successful foot and ankle reconstructions require a detailed knowledge of vascular anatomy. This knowledge becomes all the more important in diabetic patients because of healing complications and high incidence of peripheral vascular disease; it allows foot and ankle surgeons to design safe exposures and vascular surgeons to choose effective revascularization strategies. The angiosome concept separates the body into distinct threedimensional blocks of tissue fed by source arteries. This article focuses on the surgical implications of angiosomes of the foot and ankle and their arterial-arterial connections.
Collapse
Affiliation(s)
- Mark W Clemens
- Department of Plastic Surgery, Georgetown University Medical Center, Washington, DC 20007, USA
| | | |
Collapse
|
34
|
Abstract
The diabetic triad of neuropathy, vasculopathy, and foot deformity can be surgically challenging to the reconstructive surgeon. Soft tissue deficits must be closed to protect underlying structures from infection and to provide a stable environment for healing. It is critical to have adequate blood flow and to debride the wound to clean healthy tissue before considering reconstruction. Surgical options commonly used include healing by secondary intention, local flap closure, skin grafts, pedicled flaps, and free tissue transfer. Despite a surgeon's best operative efforts, these strategies may fail perioperatively due to postoperative shear forces created by premature joint motion and/or pressure (either weight bearing or decubitus). In the properly selected patient population, external fixators serve as an indispensable adjunct to wound healing in the Charcot foot by providing temporary but reliable offloading and/or immobilization of joints. Using a team approach is critical to the success of diabetic limb reconstruction.
Collapse
Affiliation(s)
- Mark W. Clemens
- Department of Plastic Surgery, Georgetown University Hospital, Washington, District of Columbia
| | - Christopher E. Attinger
- Department of Plastic Surgery, Georgetown University Hospital, Washington, District of Columbia
| |
Collapse
|
35
|
Abstract
We report a case in which Ilizarov distraction osteogenesis was used to lengthen the portion of calcaneum that remained after a radical debridement for osteomyelitis. The patient was able to walk normally in unmodified shoes at the end of his treatment.
Collapse
Affiliation(s)
- M. R. Brinker
- Center for Problem Fractures and Limb Restoration Fondren Orthopedic Group, 7401 S. Main Street, Houston, Texas 77030, USA
| | - D. P. Loncarich
- Center for Problem Fractures and Limb Restoration Fondren Orthopedic Group, 7401 S. Main Street, Houston, Texas 77030, USA
| | - E. G. Melissinos
- University of Texas Medical School-Houston, 6410 Fannin St Ste 1220, Houston, Texas 77030, USA
| | - D. P. O’Connor
- University of Houston, 3855 Holman GAR 104, Houston, Texas 77204-6015, USA
| |
Collapse
|
36
|
Abstract
This article summarizes the results of a comprehensive review of the literature on the use of negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF) as delivered by V.A.C.(R) Therapy (KCI, San Antonio, TX) in pediatric patients. A review of the literature revealed 20 articles that discussed the use of NPWT/ROCF in exclusively pediatric patients. Nine articles were retrospective reviews, and 11 were case studies. This review discusses the insights from these articles. This review discusses the versatility of NPWT/ROCF for use with pediatric patients with infected wounds; full-thickness burns; open fractures; large soft tissue wounds; surgical wounds of the chest, abdomen, and spine; pilonidal disease; and pressure ulcers. NPWT/ROCF has been used in children as young as a few weeks of age, and in children with comorbidities such as congenital heart disease, immunosuppression, and spina bifida. Wound healing in children can be delayed by impaired perfusion, infection, edema, and poor nutrition. Clinical considerations for using NPWT/ROCF in children can include differences in healing due to higher granulation rates requiring more frequent dressing changes, poor nutritional status, small size, and low weight. With pediatric patients, there is no consensus on foam (white or black) selection, optimum amount of negative pressure, frequency of NPWT/ROCF dressing changes, and interposing contact layer selection. Randomized prospective studies are needed to make recommendations for safe and efficacious clinical practice. Research regarding the effects of dressing types, adjunctive treatment, and wound healing in neonates and children is needed.
Collapse
|
37
|
Athans W, Stephens H. Open calcaneal fractures in diabetic patients with neuropathy: a report of three cases and literature review. Foot Ankle Int 2008; 29:1049-53. [PMID: 18851825 DOI: 10.3113/fai.2008.1049] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Level of Evidence: V, Case Report
Collapse
|
38
|
Gabriel A, Shores J, Heinrich C, Baqai W, Kalina S, Sogioka N, Gupta S. Negative pressure wound therapy with instillation: a pilot study describing a new method for treating infected wounds. Int Wound J 2008; 5:399-413. [PMID: 18593390 DOI: 10.1111/j.1742-481x.2007.00423.x] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This data review reports the results of 15 patients who were treated with Vacuum-Assisted Closure (VAC) negative pressure therapy system in addition to the timed, intermittent delivery of an instilled topical solution for management of their complex, infected wounds. Prospective data for 15 patients treated with negative pressure wound therapy (NPWT)-instillation was recorded and analysed. Primary endpoints were compared to a retrospective control group of 15 patients treated with our institution's standard moist wound-care therapy. Culture-specific systemic antibiotics were prescribed as per specific patient need in both groups. All data were checked for normality of distribution and equality of variance and appropriate parametric and non parametric analyses were conducted. Compared with the standard moist wound-care therapy control group, patients in the NPWT-instillation group required fewer days of treatment (36.5 +/- 13.1 versus 9.9 +/- 4.3 days, P < 0.001), cleared of clinical infection earlier (25.9 +/- 6.6 versus 6.0 +/- 1.5 days, P < 0.001), had wounds close earlier (29.6 +/- 6.5 versus 13.2 +/- 6.8 days, P < 0.001) and had fewer in-hospital stay days (39.2 +/- 12.1 versus 14.7 +/- 9.2 days, P < 0.001). In this pilot study, NPWT instillation showed a significant decrease in the mean time to bioburden reduction, wound closure and hospital discharge compared with traditional wet-to-moist wound care. Outcomes from this study analysis suggest that the use of NPWT instillation may reduce cost and decrease inpatient care requirements for these complex, infected wounds.
Collapse
Affiliation(s)
- Allen Gabriel
- Department of Plastic Surgery, Loma Linda University Medical Center, Loma Linda, CA 92354, USA
| | | | | | | | | | | | | |
Collapse
|
39
|
Spector JA, Levine S, Levine JP. Free Tissue Transfer to the Lower Extremity Distal to the Zone of Injury: Indications and Outcomes over a 25-Year Experience. Plast Reconstr Surg 2007; 120:952-959. [PMID: 17805125 DOI: 10.1097/01.prs.0000255175.92201.c7] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Microvascular free flap anastomoses performed for lower extremity reconstruction are traditionally proximal to the zone of injury. The authors assessed the feasibility and outcomes of microvascular free flaps with anastomoses performed distal to the zone of injury. METHODS The authors retrospectively reviewed all microvascular free flaps performed at their institution over the past 10 years for lower extremity reconstruction and compared this group with their previously published experience (January of 1979 through August of 1995). Between September of 1995 and May of 2005, 119 flap procedures were performed for lower extremity reconstruction. Twenty-eight flaps (24 percent) were anastomosed distal to the zone of injury and 87 (76 percent) were anastomosed proximally. There were insufficient data on the location of the anastomosis for four free flaps (all successful). RESULTS Twenty-seven of 28 distal microvascular free flaps were successful (96 percent); two (7 percent) required emergent postoperative reexploration of the anastomosis. Of the 87 proximal flaps, 79 (91 percent) were successful and eight (9 percent) failed. There was no statistically significant difference in the success rate of microvascular free flaps between the proximal and distal anastomosis groups (p = 0.30, Fisher's exact test). Combined with the data from the authors' previous series (January of 1979 to August of 1995), there were 63 free flaps with anastomosis performed distal to the zone of injury; 61 (97 percent) were successful. CONCLUSION The authors' extensive 25-year experience with lower extremity reconstruction demonstrates that in appropriately selected patients, free tissue transfer to recipient vessels distal to the zone of injury is reliable and in certain cases preferable.
Collapse
Affiliation(s)
- Jason A Spector
- New York, N.Y. From the Division of Plastic Surgery, Weill Cornell Medical College, and Institute of Reconstructive Plastic Surgery, Division of Plastic Surgery, New York University School of Medicine
| | | | | |
Collapse
|
40
|
Bach AD, Leffler M, Kneser U, Kopp J, Horch RE. The Versatility of the Distally Based Peroneus Brevis Muscle Flap in Reconstructive Surgery of the Foot and Lower Leg. Ann Plast Surg 2007; 58:397-404. [PMID: 17413882 DOI: 10.1097/01.sap.0000239842.24021.e4] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Soft tissue and bone defects of the lower leg, ankle, and heel region often require coverage by local or distant flaps. The authors successfully used the distally based peroneus brevis muscle flap for the treatment of 15 patients with osteomyelitis (n = 5), melanoma (n = 1), Achilles tendon defects (n = 6), posttraumatic bone defects (n = 2), and chronic diabetic heel ulcer (n = 1). The size of the defects ranged from 6 to 60 cm. All defects were covered successfully without major complications by the muscle flap. The distally based peroneus brevis muscle represents a very reliable flap for coverage of small and moderate defects of the medial and lateral malleolus, the Achilles tendon, and the heel area. This flap offers a convincing alternative for covering defects in the distal leg region and is often preferable to the use of free flaps because the surgery is rapidly performed and does not require microsurgical expertise.
Collapse
Affiliation(s)
- Alexander D Bach
- Department of Plastic and Hand Surgery, University of Erlangen Medical Center, Erlangen, Germany.
| | | | | | | | | |
Collapse
|
41
|
Papagelopoulos PJ, Mavrogenis AF, Tsiodras S, Vlastou C, Giamarellou H, Soucacos PN. Calcium sulphate delivery system with tobramycin for the treatment of chronic calcaneal osteomyelitis. J Int Med Res 2007; 34:704-12. [PMID: 17295005 DOI: 10.1177/147323000603400618] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The case of a 24-year-old woman with Pseudomonas aeruginosa and Proteus mirabilis chronic calcaneal osteomyelitis is presented. Extensive debridement of the necrotic bone and application of tobramycin-loaded polymethylmethacrylate beads was performed and ciprofloxacin was given post-operatively. Three months later, laboratory tests, including complete blood cell count, erythrocyte sedimentation rate and C-reactive protein, were normal. At this time, extensive surgical debridement and filling of the osseous defect with autologous iliac cancellous bone graft and tobramycin-impregnated calcium sulphate pellets and paste were performed. Oral ciprofloxacin was administered for 3 months after surgery. At the latest follow-up, 2 years later, the patient had full weight-bearing function; there was no recurrence of the infection, and complete incorporation of the autologous bone and calcium sulphate graft with the host bone was observed. This case demonstrates that two-stage surgical treatment with extensive debridement and tobramycin-impregnated calcium sulphate was effective in treating chronic calcaneal osteomyelitis.
Collapse
Affiliation(s)
- P J Papagelopoulos
- First Department of Orthopaedics, Athens University Medical School, Attikon University Hospital, Athens, Greece.
| | | | | | | | | | | |
Collapse
|
42
|
Abstract
Soft tissue complications following calcaneal fractures can be frustrating to the patient and present reconstructive challenges for the surgeon. Preoperative patient assessment may define a group of patients who are best treated nonoperatively in an effort to avoid disastrous soft tissue complications. Late sequelae will continue to be seen and through the use of differential injections, physical exam, and appropriate intervention, the practitioner can usually decrease symptoms and improve a patient's function. Further studies in the treatment of open calcaneal fractures are necessary to better define treatment algorithms. A working knowledge of these complications and their management is necessary for the surgeon treating calcaneal fractures.
Collapse
Affiliation(s)
- Troy S Watson
- Foot and Ankle Institute, Desert Orthopaedic Center, 2800 Desert Inn Road, Suite 100, Las Vegas, NV 89121, USA.
| |
Collapse
|
43
|
Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the Foot and Ankle and Clinical Implications for Limb Salvage: Reconstruction, Incisions, and Revascularization. Plast Reconstr Surg 2006; 117:261S-293S. [PMID: 16799395 DOI: 10.1097/01.prs.0000222582.84385.54] [Citation(s) in RCA: 317] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ian Taylor introduced the angiosome concept, separating the body into distinct three-dimensional blocks of tissue fed by source arteries. Understanding the angiosomes of the foot and ankle and the interaction among their source arteries is clinically useful in surgery of the foot and ankle, especially in the presence of peripheral vascular disease. METHODS In 50 cadaver dissections of the lower extremity, arteries were injected with methyl methacrylate in different colors and dissected. Preoperatively, each reconstructive patient's vascular anatomy was routinely analyzed using a Doppler instrument and the results were evaluated. RESULTS There are six angiosomes of the foot and ankle originating from the three main arteries and their branches to the foot and ankle. The three branches of the posterior tibial artery each supply distinct portions of the plantar foot. The two branches of the peroneal artery supply the anterolateral portion of the ankle and rear foot. The anterior tibial artery supplies the anterior ankle, and its continuation, the dorsalis pedis artery, supplies the dorsum of the foot. Blood flow to the foot and ankle is redundant, because the three major arteries feeding the foot have multiple arterial-arterial connections. By selectively performing a Doppler examination of these connections, it is possible to quickly map the existing vascular tree and the direction of flow. CONCLUSIONS Detailed knowledge of the vascular anatomy of the foot and ankle allows the plastic surgeon to plan vascularly sound reconstructions, the foot and ankle surgeon to design safe exposures of the underlying skeleton, and the vascular surgeon to choose the most effective revascularization for a given wound.
Collapse
|
44
|
Peek A, Giessler GA. Functional Total and Subtotal Heel Reconstruction With Free Composite Osteofasciocutaneous Groin Flaps of the Deep Circumflex Iliac Vessels. Ann Plast Surg 2006; 56:628-34. [PMID: 16721075 DOI: 10.1097/01.sap.0000205768.96705.1e] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Functional and esthetic reconstruction of the bony and tendinous structures with a stable, sensate soft tissue integument after complex posttraumatic defects of the heel is demanding. Cases are rare in the literature and hardly comparable due to their heterogeneity. The reconstructive approach has to consider both patient profile and the reconstructive tree, with free microvascular flaps playing a primary role. The goals are the reconstruction of both osteotendinous structures and slender soft tissue lining for proper shoe fitting for ambulation and mechanical and thermal protection. The flap should be sensate in weightbearing areas to optimize gait and to prevent long-term complications by ulcers. The osteofasciocutaneous deep inferior circumflex artery (DCIA) flap is especially suitable for complex heel defects with subtotal or total loss of the calcaneal bone as all components (iliac bone, groin skin, and fascia lata) can have a wide range of size and shape. We operated on 2 cases with this variable composite flap. One patient had a complete heel defect by war shrapnel. The complete calcaneus, soft heel, and Achilles tendon were reconstructed. The second patient had an empty os calcis after a comminuted fracture and a lateral crush-induced soft tissue defect. In both patients, a stable wound closure, osseous integration, and weightbearing ambulation could be achieved.
Collapse
Affiliation(s)
- Alberto Peek
- Department for Plastic and Hand Surgery, Breast Center, Behandlungszentrum Vogtareuth, Germany
| | | |
Collapse
|
45
|
Abstract
Posttraumatic foot and ankle reconstruction requires careful preoperative planning to reduce wound complications. Systemic and local factors need to be considered. A careful surgical technique can avoid the need for surgical soft tissue coverage. Recognition of the need for coverage preoperatively improves outcomes. Often, dressings and time allow minor wound complications to heal. More severe wound issues require early soft tissue coverage by local or free flaps to prevent failure of the surgery.
Collapse
Affiliation(s)
- Alastair S E Younger
- Department of Orthopaedics, The University of British Columbia, 401-1160 Burrard Street, Vancouver, British Columbia V6Z 2E8, Canada.
| | | |
Collapse
|
46
|
Braga-Silva J. Use of reverse adipofascial flap in cutaneous defects of the distal third of the lower leg. ANN CHIR PLAST ESTH 2006; 51:63-6. [PMID: 16472902 DOI: 10.1016/j.anplas.2004.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2004] [Accepted: 12/09/2004] [Indexed: 10/25/2022]
Abstract
Lower limb reconstruction, especially for the aquilian and calcaneal regions, represent a great challenge for the plastic surgeon. Among the existing options of cutaneous coverage, the distally pedicled adipofascial flap may reach even the most distal zones. From April 1995 to May 2002, 15 adipofascial flaps to the cutaneous coverage of the distal-third leg were performed. The reconstruction was immediate in eight patients. In one case, partial tissue necrosis was observed.
Collapse
Affiliation(s)
- Jefferson Braga-Silva
- Department of Surgery, Division of Hand and Microsurgery, PUCRS University, Centro Cllinico PUCRS conj 216, Jardim Botânico, Porto Alegre, Brazil.
| |
Collapse
|
47
|
Abstract
Calcaneus fractures are a significant burden to society. Assessment and treatment of these injuries has improved significantly. The use of CT scanning has allowed a greater understanding of the pathologic anatomy of these fractures, and has provided for prognostic classification systems with respect to outcome. The treatment options are diverse and are reviewed.
Collapse
Affiliation(s)
- John D Maskill
- Grand Rapids Medical Education and Research Center/Michigan State University Orthopaedic Surgery Residency Program, Grand Rapids, MI 49503, USA
| | | | | |
Collapse
|
48
|
Johnson JE, Rudzki JR, Janisse E, Janisse DJ, Valdez RR, Hanel DP, Gould JS. Hindfoot containment orthosis for management of bone and soft-tissue defects of the heel. Foot Ankle Int 2005; 26:198-203. [PMID: 15766421 DOI: 10.1177/107110070502600303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Bone, soft-tissue, and nerve deficits of the weightbearing surface of the foot are frequent sequelae from foot trauma or diabetes mellitus and present challenging treatment issues. Injury to the specialized, shock-absorbing, heel-pad tissue containing spirally arranged fat chambers is particularly difficult to manage. Appropriate footwear modifications and shoe inserts for protection of this skin are essential to the long-term management of bone and soft-tissue defects of the heel. This study evaluated the performance of a new custom total contact foot orthosis (Hindfoot Containment Orthosis, HCO) which was designed to contain the soft tissues of the heel, reduce shear forces, redistribute weightbearing load, and accommodate bone or soft-tissue deformity of the heel. METHODS Twenty-two patients treated with HCO were retrospectively reviewed. Followup averaged 26 months. The effectiveness of the orthosis was assessed by how well the integrity of the soft tissue was maintained (e.g. the number of ulcerations since dispensing the orthosis), the number of refabrications of the orthosis that were required, and whether or not revision surgery was required. RESULTS Ten patients had superficial ulcerations. No patient required revision surgery. A total of 62 refabrications of the orthoses in 22 patients were required over a 2-year period. Overall results were good in 17 (77%) patients, fair in four (18%), and poor in one. CONCLUSIONS The HCO is effective for preservation of soft-tissue integrity of the heel pad after bony or soft-tissue injury. Important factors in achieving success with the HCO are patient compliance and periodic monitoring for refabrication of the orthosis to accommodate skeletal growth, change in foot size or shape, and compression or wear of insert materials.
Collapse
Affiliation(s)
- Jeffrey E Johnson
- Department of Orthopaedic Surgery, Washington University in St. Louis, School of Medicine, 660 S. Euclid, Campus Box 8233, St. Louis, MO 63110, USA.
| | | | | | | | | | | | | |
Collapse
|
49
|
Abstract
This review article covers the use of small incision open reduction and internal fixation for the treatment of the intra-articular calcaneal fracture. The central concept is to match the fracture anatomy with the appropriate surgical approach. Covered first is the mechanism and pathoanatomy, which produces a stereotypical pattern. The major components to address include the posterior facet, superomedial fragment, anterolateral fragment, and tuberosity. The choices of approaches discussed are percutaneous, lateral, medial, and combined. A reduction strategy follows that of the extensile approach, and the goal is total anatomic restoration. Fixation consists of small fragment implants, minifragment implants, and K wires. Specific fracture patterns amenable to selective small incision approaches are described. Detailed surgical strategies are provided. These techniques will be placed in the context of pertinent literature on this subject.
Collapse
Affiliation(s)
- James B Carr
- Department of Orthopedic Surgery, University of South Carolina, Palmetto Richland Hospital, Columbia, SC 29203, USA.
| |
Collapse
|
50
|
Hausman MR, Rinker BD. Intractable wounds and infections: the role of impaired vascularity and advanced surgical methods for treatment. Am J Surg 2004; 187:44S-55S. [PMID: 15147992 DOI: 10.1016/s0002-9610(03)00304-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fracture nonunion, delayed union, and osteomyelitis remain serious problems with substantial morbidity and mortality rates. Healing promoters, including bone morphogenic proteins, fibroblast growth factors, and transforming growth factor-beta, regulate bone growth in experimental models, such as those employing a "critical gap" to establish nonunion, but have not been effective in clinical situations. This paradox may relate to the fact that such agents target cells, yet in the setting of a clinical nonunion or osteomyelitis, the affected area is frequently hypovascular and therefore deficient in target precursor cells. Wound healing is dependent on local tissue vascularity. Surgical procedures, such as local and remote tissue transfer, which are designed to modify this cell-deficient, poorly vascularized environment, have proved very successful but are often complex and costly. No simple pharmacologic means of upregulating such angiogenesis currently exists.
Collapse
Affiliation(s)
- Michael R Hausman
- Department of Orthopedic Surgery, Mount Sinai Medical Center, 5 East 98th Street, Box 1188, New York, New York 10029, USA.
| | | |
Collapse
|