Abductor hallucis muscle flap and staged medial column arthrodesis for the chronic ulcerated charcot foot with concomitant osteomyelitis

Does the Application of a Semiocclusive Dressing Alter the Microflora of Healthy Intact Skin on the Foot?

BACKGROUND

The skin on human feet presents unique environments for the proliferation of potentially pathogenic commensals. This study examined microflora changes on healthy intact skin under a semiocclusive dressing on the medial longitudinal arch of the foot to determine changes in growth, distribution, and frequency of microflora under the dressing.

METHODS

Nine human participants wore a low-adherent, absorbent, semiocclusive dressing on the medial longitudinal arch of the left foot for 2 weeks. An identical location on the right foot was swabbed and used as a control. Each foot was swabbed at baseline, week 1, and week 2. The swabs were cultured for 48 hours. Visual identification, Gram staining, DNase test agar, and a latex slide agglutination test were used to identify genera and species.

RESULTS

Microflora growth was categorized as scant (0-10 colony-forming units [CFU]), light (11-50 CFU), moderate (51-100 CFU), or heavy (>100 CFU). Scant and light growth decreased and moderate and heavy growth increased under the dressing compared with the control. Seven different genera of bacteria were identified. Coagulase-negative Staphylococcus spp appeared most frequently, followed by Corynebacterium spp.

CONCLUSIONS

Changes in microflora distribution, frequency, and growth were found under the dressing, supporting historical studies. Microflora changes were identified as an increase in bioburden and reduction in diversity. The application of similar methods, using more sophisticated identification and analysis techniques and a variety of dressings, could lead to a better understanding of bacterial and fungal growth under dressings, informing better dressing selection to assist the healing process of wounds and prevent infection.

Surgical treatment of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes: a systematic review

OBJECTIVE

A wide range of clinical presentations of Charcot neuroarthropathy of the foot with concomitant osteomyelitis in patients with diabetes has been described. Existing literature provides an equally diverse list of treatment options. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes.

METHOD

A systematic review was conducted by three independent reviewers using the following databases and search engines: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, EMBASE (Excerpta Medica dataBASE), Google Scholar, Ovid, PubMed and Scopus. Search terms used were: Charcot neuroarthropathy, osteoarthropathy, neuro-osteoarthropathy, neurogenic arthropathy, osteomyelitis, midfoot, foot, ankle, diabetes mellitus, ulceration, wound, infection, surgical offloading, diabetic reconstruction, internal fixation, external fixation. Studies meeting the following criteria were included: English language studies, studies published from 1997-2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, follow-up period of six months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery. Studies which were entirely literature reviews, descriptions of surgical-only technique and/or cadaveric studies, patients without diabetes, studies that did not specify location of osteomyelitis and Charcot neuroarthropathy, and treatment proximal to and including Chopart's/midtarsal joint specifically talonavicular, calcaneocuboid, subtalar, ankle were excluded.

RESULTS

A total of 13 selected studies, with a total of 114 patients with diabetes of which 56 had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis, met the above inclusion criteria and were used for data extraction.

CONCLUSION

Surgical intervention for midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal or external fixation, and advanced soft tissue reconstruction. However, this systematic review emphasises the need for larger, better designed studies to investigate the efficacy and failure rates of surgical treatment in this group of patients.

Soft Tissue Reconstruction Pyramid for the Diabetic Charcot Foot

Foot and ankle ulcerations in patients with diabetic Charcot neuroarthropathy (DCN) occur frequently and can be challenging to address surgically when conservative care fails. Patients with acute or chronic diabetic foot ulcers (DFU) are at continued risk for development of osteomyelitis, septic arthritis, gas gangrene, and potential lower extremity amputation. Concurrent vasculopathy and peripheral neuropathy as well as uncontrolled medical comorbidities complicate the treatment approach. In addition, pathomechanical forces left untreated may contribute to DFU recurrence in this patient population. This article outlines in detail the stepwise approach and options available for durable soft tissue coverage in the DCN patient.

Abductor hallucis muscle flap with circular external fixation for Charcot foot osteomyelitis: a case report

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.