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Li KR, Lava CX, Lee SY, Suh J, Berger LE, Attinger CE. Optimizing the Use of Pedicled versus Random Pattern Local Flaps in the Foot and Ankle. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5921. [PMID: 38911575 PMCID: PMC11191039 DOI: 10.1097/gox.0000000000005921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/01/2024] [Indexed: 06/25/2024]
Abstract
Background The aim of this study was to compare the use of pedicled local (PFs) versus random pattern flaps (RpFs) in foot and ankle reconstruction in patients with chronic, nonhealing wounds. Methods A single-center, retrospective review of 204 patients with 118 PFs and 86 RpFs was performed. The primary outcome included rates of limb salvage. Results PFs were used more often in the hindfoot (44.1% versus 30.2%, P = 0.045), lateral and medial surface (39.8% versus 18.6%, P = 0.001), and wounds containing exposed bone and hardware (78.8% versus 62.8%, P = 0.018). RpFs were used more for forefoot (19.8% versus 10.2%, P = 0.053) and plantar defects (58.1% versus 30.3%, P = 0.000). RpFs had a higher rate of immediate success (100% versus 95.8%, P = 0.053), with no significant differences in rate of long-term limb salvage (77.1% versus 69.8%, P = 0.237). PFs had higher rates of ischemia requiring intervention (11.0% versus 3.5%, P = 0.048). RpFs had a higher rate of minor amputations (15.12% versus 6.8%, P = 0.053) but similar rates of major amputation (15.1% versus 16.1%, P = 0.848). There were no significant differences in rates of mortality or ambulatory status. Conclusions Both RpFs and PFs remain reliable options to reconstruct defects of the foot and ankle. Optimizing the use of each flap type should consider wound characteristics. RpFs are preferred for dorsal and plantar defects, whereas PFs are protective for minor infections and preferred for deeper wounds despite a higher rate of partial necrosis.
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Affiliation(s)
- Karen R. Li
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
- Georgetown University School of Medicine, Washington, D.C
| | - Christian X. Lava
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
- Georgetown University School of Medicine, Washington, D.C
| | - Seo Yeon Lee
- Georgetown University School of Medicine, Washington, D.C
| | - Julie Suh
- Georgetown University School of Medicine, Washington, D.C
| | - Lauren E. Berger
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
- Plastic and Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J
| | - Christopher E. Attinger
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
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Moghaddam Ahmadi M, Ashoobi MT, Darabi Z, Ramezannezhad H, Moghaddam Ahmadi M. Characteristics and outcomes of diabetic foot ulcers treated with surgical debridement and standardized wound care. Int Wound J 2024; 21:e14859. [PMID: 38572803 PMCID: PMC10993353 DOI: 10.1111/iwj.14859] [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: 02/25/2024] [Revised: 03/12/2024] [Accepted: 03/12/2024] [Indexed: 04/05/2024] Open
Abstract
Diabetic foot ulcers (DFUs) pose a significant clinical challenge, often leading to amputations and hospitalisation. This study aimed to investigate the characteristics and outcomes of DFUs treated with surgical debridement and standardised wound care. This descriptive cross-sectional study focused on diabetic patients with appropriate vascular conditions, as determined by an Ankle Brachial Index >0.9. Based on their infection status, participants were admitted to Poursina Hospital in Rasht, Iran, and subjected to initial supportive measures, antibiotic therapy and surgical debridement. The study incorporated primary treatment with wet bandages, silver spray and fibrinolysin ointment. Statistical analysis employed SPSS 22 software. Most patients were male (54.7%) and under 60 years old (50.7%). Overweight status was prevalent in 69.3% of diabetic ulcer patients, amongst whom 48% underwent wrist debridement. The 64% and 36% of the cases had grade III and grade II Texas index. Moreover, 96% of patients exhibited signs of infection and were classified as Stage Texas B. Reoperation was necessary for 34.7% of patients. The mean hospital stay was 8.5 ± 7.55 days, and the average recovery time was 15.2 ± 15.19 days. Out of 75 patients, 10 were unable to return to limb function due to disability. In this study, around one-third of patients required secondary repair with grafts and flaps. A small number of them were unable to recover because of underlying disability, and the mean recovery time in other cases was 24 days. Future studies should follow up with patients for longer periods to assess long-term therapeutic outcomes and quality of life.
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Affiliation(s)
- Moein Moghaddam Ahmadi
- Poursina Clinical Research Development UnitGuilan University of Medical SciencesRashtIran
| | - Mohammad Taghi Ashoobi
- Razi Clinical Research Development Unit, Razi HospitalGuilan University of Medical SciencesRashtIran
| | - Zohreh Darabi
- Poursina Clinical Research Development UnitGuilan University of Medical SciencesRashtIran
| | - Hossein Ramezannezhad
- Poursina Clinical Research Development UnitGuilan University of Medical SciencesRashtIran
| | - Mahta Moghaddam Ahmadi
- Poursina Clinical Research Development UnitGuilan University of Medical SciencesRashtIran
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3
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Camilleri-Brennan J, James S, McDaid C, Adamson J, Jones K, O'Carroll G, Akhter Z, Eltayeb M, Sharma H. A scoping review of the outcome reporting following surgery for chronic osteomyelitis of the lower limb. Bone Jt Open 2023; 4:146-157. [PMID: 37051853 PMCID: PMC10041339 DOI: 10.1302/2633-1462.43.bjo-2022-0109.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set. A total of 11 databases were searched. A subset of studies published between 1 October 2020 and 1 January 2011 from a larger review mapping research on limb reconstruction and limb amputation for the management of lower limb COM were eligible. All outcomes were extracted and recorded verbatim. Outcomes were grouped and categorized as per the revised Williamson and Clarke taxonomy. A total of 3,303 records were screened, of which 99 studies were included. Most studies were case series (77/99; 78%) and assessed one method of reconstruction (68/99; 69%). A total of 511 outcomes were reported, which were grouped into 58 distinct outcomes. Overall, 143/511 of all outcomes (28%) were provided with a clear, in-text definition, and 231 outcomes (45%) had details reported of how and when they were measured. The most commonly reported outcome was 'recurrence of osteomyelitis' (62; 12%). The single-most patient-reported outcome measure was 'pain'. This study has highlighted significant inconsistencies in the defining, reporting, and measuring of outcomes across studies investigating surgical management for chronic osteomyelitis of the lower limb in adults. Future studies should clearly report complete details of how outcomes are defined and measured, including timing. The development of a standardized core outcome set would be of significant benefit in order to allow evidence synthesis and comparison across studies.
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Affiliation(s)
| | | | | | - Joy Adamson
- York Trials Unit, University of York, York, UK
| | | | | | | | - Momin Eltayeb
- Hull Limb Reconstruction & Bone Infection Unit, Hull University Teaching Hospitals, Hull, UK
| | - Hemant Sharma
- York Trials Unit, University of York, York, UK
- Hull Limb Reconstruction & Bone Infection Unit, Hull University Teaching Hospitals, Hull, UK
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4
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Frey CB, Park R, Robinson R, Yoder C. Nagging Pain and Foot Ulcers Can be Treated into Remission. Endocrinol Metab Clin North Am 2023; 52:119-133. [PMID: 36754488 DOI: 10.1016/j.ecl.2022.09.003] [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] [Indexed: 12/23/2022]
Abstract
Lower extremity ulcerations are very common in patients with diabetes. These wounds lead to amputation in a surprisingly large percentage of patients with diabetes. The mortality rate following amputation in a patient with diabetes is alarmingly high. Preventive treatment is pivotal to avoid the numerous complications associated with diabetic ulcerations. However, at the onset of ulceration, early treatment under the supervision and guidance of a specialist can result in remission. Diabetic peripheral neuropathy is also a life-altering and debilitating disease. Although some patients experience numbness, some experience pain that can be sharp, shooting, and tingling. Although treatment is challenging and often requires medication, newer modalities, such as stimulation and physical therapy, have shown promise in reversing the devastating effects of peripheral neuropathy.
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Affiliation(s)
- Craig B Frey
- University Hospitals Podiatric Medicine and Surgery, University Hospitals Advanced Limb Salvage and Reconstruction, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Richard Park
- University Hospitals Podiatric Medicine and Surgery, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Rachel Robinson
- University Hospitals Podiatric Medicine and Surgery, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Courtney Yoder
- University Hospitals Podiatric Medicine and Surgery, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Local Random Flaps for the Diabetic Foot. Clin Podiatr Med Surg 2022; 39:321-330. [PMID: 35365329 DOI: 10.1016/j.cpm.2021.11.004] [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: 11/23/2022]
Abstract
Diabetic foot wounds should be treated in a timely fashion to prevent infection and potential limb loss. When local wound care and traditional off-loading fails, surgeons may consider local random flaps for definitive closure. Wound size, location, and type are characteristics that should be considered for selection of the best flap. This article reviews the application of local random flaps in the treatment of diabetic foot wounds.
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Schneider B, Pfaffeneder-Mantai F, Grün P, Meller O, Dobbertin K, Turhani D. Melolabial interpolated island flap for reconstruction of an anterior oronasal fistula after horseshoe Le Fort I osteotomy with iliac bone grafts interposition - A case report. Int J Surg Case Rep 2022; 93:106939. [PMID: 35303603 PMCID: PMC8928081 DOI: 10.1016/j.ijscr.2022.106939] [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] [Received: 01/21/2022] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Horseshoe Le Fort I osteotomy (HLFO) in combination with iliac bone grafts interposition is an established and very effective procedure for reconstructing the severely atrophic maxilla. However potential complications connected to this method, such as oronasal fistula (ONF), have not been described in the literature to date. CASE PRESENTATION We report the case of a female patient with severe atrophy of the edentulous maxillary alveolar ridge with type 2 diabetes (T2D). Initially, a sinus floor augmentation was performed, followed by a failed placement of dental implants. Afterwards, HLFO with simultaneous interposition of iliac bone grafts was conducted. Subsequently, an oronasal communication occurred in the antral maxilla. As several local flaps had not achieved sufficient results, a melolabial interpolated island flap was carried out, yielding satisfactory results. DISCUSSION Failed implant treatment or bone augmentation procedures in combination with T2D may have resulted in significant tissue irritation and subsequent wound healing complications in the antral maxilla, leading to an ONF. CONCLUSION In this case, an ONF occurring after HLFO was described for the first time. The melolabial interpolated island flap proved to be an outstanding long-term solution for the management of an anterior ONF occurring after HLFO over a period of 10 years. Less invasive treatment options including zygomatic implants should be taken into consideration for the treatment of such patients.
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Affiliation(s)
- Benedikt Schneider
- Center for Oral and Maxillofacial Surgery, Faculty of Medicine/Dental Medicine, Danube Private University, Krems, Austria
| | - Florian Pfaffeneder-Mantai
- Center for Oral and Maxillofacial Surgery, Faculty of Medicine/Dental Medicine, Danube Private University, Krems, Austria; Division for Chemistry and Physics of Materials, Faculty of Medicine/Dental Medicine, Danube Private University, Krems, Austria
| | - Pascal Grün
- Center for Oral and Maxillofacial Surgery, Faculty of Medicine/Dental Medicine, Danube Private University, Krems, Austria
| | - Oliver Meller
- Center for Oral and Maxillofacial Surgery, Faculty of Medicine/Dental Medicine, Danube Private University, Krems, Austria
| | - Katharina Dobbertin
- Center for Oral and Maxillofacial Surgery, Faculty of Medicine/Dental Medicine, Danube Private University, Krems, Austria
| | - Dritan Turhani
- Center for Oral and Maxillofacial Surgery, Faculty of Medicine/Dental Medicine, Danube Private University, Krems, Austria.
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Margabandu B, Paramasivam I, Palanisamy P, Christabel P, Sritharan N, Janardhanan J. Applied features of perforasomes in the revascularization and reconstruction of chronic limb-threatening ischemia in the diabetic foot. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_24_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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8
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Ramanujam CL, Zgonis T. Use of Local Flaps for Soft-Tissue Closure in Diabetic Foot Wounds: A Systematic Review. Foot Ankle Spec 2019; 12:286-293. [PMID: 30328715 DOI: 10.1177/1938640018803745] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
"A systematic review was undertaken to assess the outcomes of local random flaps in diabetic foot wound closure. The review was conducted using the following databases: Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, Excerpta Medica dataBASE, Google Scholar, MEDLINE, Ovid, and PubMed. Search terms were local random flap, diabetes, foot, wound, ulceration, neuropathy, tissue transfer, V-Y, bilobed, monolobed, rotational, advancement, transpositional, rhomboid, and Limberg. English language studies, studies published from 1997 to 2017, patients with diabetes mellitus treated for foot wounds, use of local random flaps, follow-up period of 6 months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery were included. Isolated literature reviews and descriptions of only surgical technique and/or cadaveric studies were excluded. The initial search identified 53 eligible studies with 28 being excluded. The remaining 25 studies used for data extraction had a total of 512 patients in which 199 of these underwent 204 local random flap procedures. Average follow-up for the flaps was approximately >2 years, and successful wound closure at last follow-up was demonstrated in 75.5% of the studied population. Studies were found to be of generally low quality, with the majority composed of retrospective case series. Based on current available evidence found in this systematic review, local random flaps demonstrated a relatively high success rate when utilized for the definitive closure of diabetic foot wounds. However, because of a lack of high-quality evidence and substantial heterogeneity among the studies, the results should be interpreted with caution. Levels of Evidence: Level III: Systematic review.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio, San Antonio, Texas
| | - Thomas Zgonis
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio, San Antonio, Texas
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9
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A Novel Surgical Approach to Nasolabial Fistula. Indian J Otolaryngol Head Neck Surg 2018; 71:1854-1858. [PMID: 31763259 DOI: 10.1007/s12070-018-1252-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 01/23/2018] [Indexed: 10/18/2022] Open
Abstract
Infection of hair follicle is commonly called 'boil' or furunculosis. This can result in abscess formation leading to accumulation of pus and necrotic tissue. This can be more common in immunocompromised patients such as uncontrolled diabetes mellitus. Commonest organism to cause furunculosis is believed to be Staphylococcus aureus. We present an elderly patient where multiple nasal vestibular furunculosis suppurated resulting in extensive tissue damage and nasolabial fistula. Reconstruction was delayed to accommodate tissue healing from hyperglycemic insult and necrosis. Alar advancement flap was employed to give a suitable 3 layer closure to the fistula.
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10
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Allahabadi S, Haroun KB, Musher DM, Lipsky BA, Barshes NR. Consensus on surgical aspects of managing osteomyelitis in the diabetic foot. Diabet Foot Ankle 2016; 7:30079. [PMID: 27414481 PMCID: PMC4944594 DOI: 10.3402/dfa.v7.30079] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 04/15/2016] [Accepted: 04/29/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND The aim of this study was to develop consensus statements that may help share or even establish 'best practices' in the surgical aspects of managing diabetic foot osteomyelitis (DFO) that can be applied in appropriate clinical situations pending the publication of more high-quality data. METHODS We asked 14 panelists with expertise in DFO management to participate. Delphi methodology was used to develop consensus statements. First, a questionnaire elicited practices and beliefs concerning various aspects of the surgical management of DFO. Thereafter, we constructed 63 statements for analysis and, using a nine-point Likert scale, asked the panelists to indicate the extent to which they agreed or disagreed with the statements. We defined consensus as a mean score of greater than 7.0. RESULTS The panelists reached consensus on 38 items after three rounds. Among these, seven provide guidance on initial diagnosis of DFO and selection of patients for surgical management. Another 15 statements provide guidance on specific aspects of operative management, including the timing of operations and the type of specimens to be obtained. Ten statements provide guidance on postoperative management, including wound closure and offloading, and six statements summarize the panelists' agreement on general principles for surgical management of DFO. CONCLUSIONS Consensus statement on the perioperative management of DFO were formed with an expert panel comprised of a variety of surgical specialties. We believe these statements may serve as 'best practice' guidelines until properly performed studies provide more robust evidence to support or refute specific surgical management steps in DFO.
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Affiliation(s)
| | | | - Daniel M Musher
- Division of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Benjamin A Lipsky
- Department of Medicine, University of Washington, Seattle.,Department of Medicine (Infectious Diseases), University of Geneva, Geneva, Switzerland.,Department of Medicine, Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine / Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas;
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11
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Multidisciplinary approach to soft-tissue reconstruction of the diabetic Charcot foot. Plast Reconstr Surg 2015; 135:611-616. [PMID: 25357158 DOI: 10.1097/prs.0000000000000861] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diabetics are prone to foot ulceration as a result of local tissue ischemia, immune impairment, and biomechanical derangement in the setting of neuropathy. Healing ulcers in the setting of Charcot neuroarthropathy is challenging, as the skeletal changes usually signify advanced disease. METHODS Records were reviewed for all patients with the diagnosis of Charcot neuroarthropathy and ulceration treated over a 7-year period. Demographic data, anatomical wound location, therapeutic interventions, and wound healing rates were recorded. RESULTS Three hundred fourteen wounds in 259 patients were examined. One hundred ninety-three wounds with documented follow-up data were analyzed. Fifty wounds (25.9 percent) were on the forefoot, 73 (37.8 percent) were on the midfoot, 28 (14.5 percent) were on the hindfoot, and 42 (21.8 percent) were about the ankle. Wounds were débrided surgically an average of four times. Primary closure was attempted in 29 wounds (15.0 percent). Delayed primary closure was attempted in 35 wounds (18.1 percent). Bioengineered alternative tissues were used in 61 wounds (31.6 percent). Autologous skin grafting was performed on 41 wounds (21.2 percent). Fifteen local flaps (7.8 percent) and five free flaps (2.6 percent) were performed. Forty-eight patients (31.6 percent) required a major amputation. Excluding patients who underwent major amputation, 95 wounds (65.1 percent) were healed at the time of final follow-up. CONCLUSIONS The majority of ulcers on Charcot feet required multiple débridements to achieve a clean wound. Multiple therapeutic modalities were used to achieve a 65 percent rate of healing. Despite those efforts, many patients required partial foot or major amputations, with more proximal wounds being at highest risk of the latter.
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12
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Moradian S, Klapper AM. A novel way to treat skin tears. Int Wound J 2015; 13:283-6. [PMID: 25756343 DOI: 10.1111/iwj.12426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 01/12/2015] [Accepted: 01/24/2015] [Indexed: 11/29/2022] Open
Abstract
Skin tears are one of the most commonly treated wounds in the elderly population. In their most basic form, they are essentially traumatic random pattern flaps. We postulate that the injured blood flow to these skin flaps should be ignored and the tissue should be treated as a skin graft. A case report is presented of an 86-year-old female with an 8 × 3·5 cm skin tear to her right upper extremity after a hip fracture. In addition to conventional wound closure strips re-approximating the tissues, a disposable negative pressure wound therapy device was placed to act as bolster. Upon its removal on day 5, the opposed skin tear tissue was found to be 100% viable. We therefore propose that this update may be an improvement over classical skin tear treatments and should be followed up with a case series.
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Affiliation(s)
- Scott Moradian
- Department of General Surgery, Delray Medical Center, Delray Beach, FL, USA
| | - Andrew M Klapper
- Delray Medical Center, Wound Treatment Center, Delray Beach, FL, USA
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13
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Barshes NR, Pisimisis G, Kougias P. Compartment syndrome of the foot associated with a delayed presentation of acute limb ischemia. J Vasc Surg 2015; 63:819-22. [PMID: 25752690 DOI: 10.1016/j.jvs.2015.01.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/26/2015] [Indexed: 10/23/2022]
Abstract
Compartment syndrome of the leg is a well-recognized complication known to follow urgent revascularization done for acute limb ischemia, but compartment syndrome of the foot has not been reported after the ischemia-reperfusion sequence. Herein we report a case of foot fasciotomy done for compartment syndrome that occurred after urgent revascularization. We suggest that foot fasciotomies should be considered in particular circumstances of acute lower leg ischemia, such as infrapopliteal thromboembolic events, prolonged ischemia, and persistent or worsening foot symptoms that follow revascularization and calf fasciotomies.
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Affiliation(s)
- Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
| | - George Pisimisis
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Panos Kougias
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
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14
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Great toe necrosis predicts an unfavorable limb salvage prognosis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2014; 2:e216. [PMID: 25426399 PMCID: PMC4229275 DOI: 10.1097/gox.0000000000000175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 07/11/2014] [Indexed: 11/26/2022]
Abstract
Summary: The initial location of necrosis may affect the limb salvage rate. This study of 130 patients with chronic toe ulcers or gangrene was performed to assess whether the location of initial necrosis in the toes affected limb salvage prognosis. The patients were divided into 2 groups according to whether the initial necrosis was in the great toe or in other toes. Limb salvage prognosis was determined retrospectively. In the great toe group, the rates of total toe loss and major amputation were 50.0% and 24.4%, respectively. When the initial necrosis was in other toes, these rates were 27.3% and 9.3%, respectively. Great toe necrosis is associated with significantly higher rates of total toe loss (odds ratio = 3.10; P = 0.003; 95% confidence interval, 1.43−6.68) and major amputation (odds ratio = 3.66; P = 0.007; 95% confidence interval, 1.37−9.79). The great toe is supplied by 3 source arteries, whereas the lesser toes are fed by 1 or 2 arteries. Therefore, necrosis initiating from the great toe may reflect the presence of severe vascular disorders. The great toe is also anatomically connected to much of the foot via the tendons. Infection is more likely to spread along these tendons, which may reduce limb prognosis. Thus, the initial location of necrosis may be predictive of limb prognosis.
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15
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Radji M, Putri CS, Fauziyah S. Antibiotic therapy for diabetic foot infections in a tertiary care hospital in Jakarta, Indonesia. Diabetes Metab Syndr 2014; 8:221-224. [PMID: 25311820 DOI: 10.1016/j.dsx.2014.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS The purpose of this study was to determine the microbiology of diabetic foot infections and to assess the antibiotic susceptibility patterns. MATERIALS AND METHODS A cross sectional retrospective study of 35 patients with diabetic foot infections hospitalized at the internal medicine clinic of Dr. Mintohardjo Navy Hospital, Jakarta. The data were collected from patient medical records retrospectively. The classification of the diabetic foot infections was evaluated according to Meggit-Wagner's Classification. Identification of causative microorganisms was performed by standard microbiologic methods. Antibiotic susceptibility testing was performed using disk-diffusion method. RESULTS During January to December 2012, a total of 288 of diabetic patients were admitted to hospital, and 35 patients had diabetic foot infections. According to Meggit-Wagner's classification the most common disease was grade 3 in 31.4% patients, followed by grade 2 in 25.7%, and grade 4 in 17.3% of patients. Conservative diabetic control care was carried out in 37.1% of patients, and surgical intervention was carried out in 62.9% of patients. A total of 59 pathogens were identified. The most common infecting microorganism isolated on pus cultures was Staphylococcus aureus (47.5%), followed by Pseudomonas spp (16.9%), E. coli (10.2%), Streptococcus spp. (8.5%), Enterobacter spp. (7.0%), Proteus spp. (6.7%), and Acinetobacter spp. (3.2%). Overall, 37.2% of the diabetic foot infection caused by a single microorganism, and 62.8% had polymicrobial infections. The most frequently administrated antibiotic was ceftriaxone (40.0%), followed by ciprofloxacin (11.4%), and meropenem (8.6%). CONCLUSION Diabetic foot infections (62.8%) were polymicrobial. S. aureus was most commonly found in the foot infection. Most of the microorganisms isolated from diabetic foot infection were resistant to many types of antibiotics.
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Affiliation(s)
- Maksum Radji
- Laboratory of Microbiology and Biotechnology, Faculty of Pharmacy, University of Indonesia, Depok 16424, Indonesia.
| | - Corry Shirleyana Putri
- Laboratory of Microbiology and Biotechnology, Faculty of Pharmacy, University of Indonesia, Depok 16424, Indonesia
| | - Siti Fauziyah
- Department of Pharmacy, Dr. Mintohardjo Navy Hospital, Bendungan Hilir No. 17, Jakarta 10210, Indonesia
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Barshes NR, Bechara CF, Pisimisis G, Kougias P. Preliminary Experiences with Early Primary Closure of Foot Wounds after Lower Extremity Revascularization. Ann Vasc Surg 2014; 28:48-52. [DOI: 10.1016/j.avsg.2013.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 06/04/2013] [Accepted: 06/16/2013] [Indexed: 01/09/2023]
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Mastroianni M, Leto Barone AA, Shanmugarajah K, Leonard DA, Di Rosa L, Feingold RS, Israeli R, Cetrulo CL. Lower extremity soft tissue defect reconstruction with the serratus anterior flap. Microsurgery 2013; 34:183-7. [PMID: 24307318 DOI: 10.1002/micr.22191] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 08/22/2013] [Accepted: 09/04/2013] [Indexed: 11/08/2022]
Abstract
Reconstruction of limb-threatening lower extremity defects presents unique challenges. The selected method must provide adequate coverage of exposed bone, joints, and tendons while maximizing function of the limb. The traditional workhorse flaps, the free latissimus dorsi and rectus abdominis flaps, have been associated with donor site morbidity and bulkiness that can impair rehabilitation. We report a case series (n = 18) in which the free serratus anterior muscle flap and split thickness skin graft (STSG) was used for lower limb soft tissue coverage. Injuries were due to diabetes (9/18), trauma (7/18), and chronic venous stasis (2/18). A 94% flap survival rate was observed and all but one patient was ambulatory. No donor site morbidity was reported. Our series demonstrates that serratus anterior is an advantageous, reliable free flap with minimal donor site morbidity.
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Affiliation(s)
- Melissa Mastroianni
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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18
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Malhotra S, Bello E, Kominsky S. Diabetic foot ulcerations: biomechanics, charcot foot, and total contact cast. Semin Vasc Surg 2012; 25:66-9. [PMID: 22817854 DOI: 10.1053/j.semvascsurg.2012.05.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Diabetes is the seventh leading cause of death in the United States; approximately 6% of the US population has been diagnosed with diabetes. Fifteen percent of all people with diabetes will develop a foot ulceration, and 14% to 20% of them will require an amputation. During the past 25 years, much has been learned and written about lower extremity complications associated with diabetes. The single most significant discovery relative to diabetic foot ulceration is the role of peripheral sensory neuropathy. Once the correlation between the absence of sensation and foot breakdown was made, treatment algorithms began to develop. For the first time, the concept of biomechanics and the role of weight-bearing stress were considered when applying different treatments to the patient with a diabetic foot ulcer. Wound classification systems developed to aid the physician in treating what had been a very frustrating group of patients; those with diabetic foot ulcerations. From that, a myriad of treatments developed. In fact, the technology of wound management became a billion dollar business and, to this day, continues to present the clinician with unending options to effectively manage and heal wounds on the diabetic lower extremity.
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Affiliation(s)
- Sabina Malhotra
- Department of Podiatric Surgery, MedStar Washington Hospital Center, Washington, DC 20010, USA
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19
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Cost-effectiveness in the contemporary management of critical limb ischemia with tissue loss. J Vasc Surg 2012; 56:1015-24.e1. [DOI: 10.1016/j.jvs.2012.02.069] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 02/22/2012] [Accepted: 02/22/2012] [Indexed: 11/23/2022]
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20
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Chan YC, Roy S, Khanna S, Sen CK. Downregulation of endothelial microRNA-200b supports cutaneous wound angiogenesis by desilencing GATA binding protein 2 and vascular endothelial growth factor receptor 2. Arterioscler Thromb Vasc Biol 2012; 32:1372-82. [PMID: 22499991 DOI: 10.1161/atvbaha.112.248583] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE MicroRNAs (miRs) regulate angiogenesis by posttranscriptional silencing of target genes. The significance of angiostatic miR-200b in switching on skin wound angiogenesis was tested. METHODS AND RESULTS Wounding caused imminent and transient downregulation of miR-200b in dermal wound-edge endothelial cells. Derailing this injury response by lentiviral delivery of miR-200b in vivo impaired wound angiogenesis. Computational prediction, target reporter luciferase assay, and Western blot analysis provided first evidence that miR-200b targets globin transcription factor binding protein 2 (GATA2) and vascular endothelial growth factor receptor 2 (VEGFR2). Overexpression of GATA2 or VEGFR2 in endothelial cells rescued the angiostatic effect of miR-200b in vitro. Downregulation of miR-200b derepressed GATA2 and VEGFR2 expression to switch on wound angiogenesis, which was disrupted in diabetic wounds. Treatment of endothelial cells with tumor necrosis factor-α, a proinflammatory cytokine abundant in diabetic wounds, induced miR-200b expression, silenced GATA2 and VEGFR2, and suppressed angiogenesis. These outcomes were attenuated using anti-miR-200b strategy. Neutralization of tumor necrosis factor-α in the diabetic wounds improved wound angiogenesis and closure, which was accompanied by downregulation of miR-200b expression and desilencing of GATA2 and VEGFR2. CONCLUSIONS Injury-induced repression of miR-200b turned on wound angiogenesis. In mice with diabetes mellitus,excessive tumor necrosis factor-α induced miR-200b blunting proangiogenic functions of GATA2 and VEGFR2.
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Affiliation(s)
- Yuk Cheung Chan
- Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University Medical Center, Columbus, OH 43210, USA
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Ramanujam CL, Facaros Z, Zgonis T. Abductor hallucis muscle flap with circular external fixation for Charcot foot osteomyelitis: a case report. Diabet Foot Ankle 2011; 2:DFA-2-6336. [PMID: 22396821 PMCID: PMC3284275 DOI: 10.3402/dfa.v2i0.6336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Complicated soft tissue defects of the diabetic foot often call for alternative methods to traditional primary closure. Despite the popularity of microvascular free flaps, local muscle flaps can offer reliable reconstruction for these challenging wounds with shorter surgical times and reduced complication rates. In this article, the authors describe the successful use of the abductor hallucis muscle flap and external fixation for soft tissue reconstruction of a chronic Charcot foot wound and osteomyelitis in a diabetic patient.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surgery, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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