Evaluation of the Effectiveness of Remote Foot Temperature Monitoring for Prevention of Amputation in a Large Integrated Health Care System

OBJECTIVE

We evaluated the effectiveness of remote foot temperature monitoring (RTM) in the Veterans Affairs health care system.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study that included 924 eligible patients enrolled in RTM between 2019 and 2021 who were matched up to 3:1 to 2,757 nonenrolled comparison patients. We used conditional Cox regression to estimate adjusted cause-specific hazard ratios (aHRs) and corresponding 95% CIs for lower-extremity amputation (LEA) as the primary outcome and all-cause hospitalization and death as secondary outcomes.

RESULTS

RTM was not associated with LEA incidence (aHR 0.92, 95% CI 0.62-1.37) or all-cause hospitalization (aHR 0.97, 95% CI 0.82-1.14) but was inversely associated (reduced risk) with death (aHR 0.63, 95% CI 0.49-0.82).

CONCLUSIONS

This study does not provide support that RTM reduces the risk of LEA or all-cause hospitalization in individuals with a history of diabetic foot ulcer. Randomized controlled trials can overcome important limitations.

A Prospective Analysis of the SVS WIfI Classification System to Stratify Immediate and 1-Year Patient Outcomes

The purpose of this study was to prospectively enroll patients that presented to the emergency department with a lower extremity infection, stratify risk and record outcomes. Risk stratification was performed based on the Society of Vascular Surgery Wound, foot Infection, and Ischemia (WIfI) classification system. This study aimed to establish the efficacy and validity of this classification in predicting patient outcomes during immediate hospitalization and throughout a 1 year follow up. A total of 152 patients were enrolled in the study and of these, 116 met the inclusion criteria and had at least 1 year of follow up for analysis. Each patient was assigned a WIfI score based on wound, ischemia, and foot infection severity according to the classification guidelines. Patient demographics as well as all podiatric and vascular procedures were recorded. The major end points of the study were rates of proximal amputation, time to wound healing, surgical procedures, surgical dehiscence, readmission rates, and mortality. A difference in rates of healing (p = .04), surgical dehiscence (p < .01), and 1 year mortality (p = .01) with increasing WIfI stage as well as across the individual component scores was noted. This analysis further supports the application of the WIfI classification system early during patient care to stratify risk and identify the need for early intervention and a multispecialty team approach to potentially improve outcomes in the severe multicomorbid patient.

Virtual planning of the anterolateral thigh free flap for heel reconstruction

PURPOSE

three dimensional (3-D) virtual planning is an example of computer assisted surgery that improved management of composite tissue defects. However, converting the 3-D construct into two dimensional format is challenging. The purpose of this study was to assess 3-D virtual planning of complex heel defects for better optimized reconstruction.

PATIENTS AND METHODS

a prospective analysis of 10 patients [9 male and 1 female; mean age = 27.9 years] with post-traumatic heel defects was performed. Heel defects comprised types II (three patients) or III (seven patients) according to Hidalgo and Shaw and were managed using anterolateral thigh (ALT) free flap adopting 3-D virtual planning of the actual defect which was converted into a silicone two dimensional mold. The mean definitive size of the defects was 63.4 cm³ . Functional, aesthetic, and sensory evaluations of both donor and recipient sites were performed 1 year after surgery.

RESULTS

Six patients received thinned ALT (mean size = 139 cm³ ) while four patients received musculofasciocutaneous ALT flap (mean size = 199 cm³ ). One flap exhibited partial skin flap necrosis. Another flap was salvaged after re-exploration secondary to venous congestion. The mean follow-up was 20.2 months. The Maryland foot score showed 4 excellent, 5 good, and 1 fair cases. The mean American Orthopedic Foot and Ankle hind foot scoring was 76.3 (range: 69-86). All patients regained their walking capability.

CONCLUSIONS

3-D virtual planning of complex heel defects facilitates covering non-elliptical defects while harvesting a conventional elliptical flap with providing satisfactory functional outcomes and near-normal contour, volume, and sensibility.

Medial Plantar Artery Common Origin to Determine Incision Placement for the Fasciocutaneous Flap: A Cadaveric Study

Medial plantar artery-based flaps have great value in healing full-thickness wounds of the foot and ankle. The goal of this study was to identify a common location for the origin of the medial plantar artery. Recognition of this anatomic marker will help improve incision placement and increase the success of preserving the artery when performing the medial plantar artery fasciocutaneous flap. This study examined the location of the origin of the medial plantar artery in 40 fresh cadavers. Results were obtained by dissection and macroscopic analysis to document the distance of the origin of the medial plantar artery from the intercollicular groove of the medial malleolus in centimeters. The mean distance was determined to be 3.2 ± 0.4 cm (range 2.7 to 4.5), with a low standard error of 0.0621. This suggests a high statistical probability that the common origin of the medial plantar artery is found 3.2 cm distal to the intercollicular groove of the medial malleolus in the general population.

Membrane-Induced Technique for the Management of Combined Soft Tissue and Osseous Defects

The induced membrane technique is a simple, effective, and reproducible treatment method for segmental bone defects. It is a 2-stage approach that requires eventual autologous bone graft to manage the deficit. The first stage requires debridement of all nonviable tissue while preserving a healthy soft tissue envelope. A polymethylmethacrylate is implanted between the osseous segments to maintain length. The osseous defect can be stabilized internally or externally. During the second stage, a vascularized induced membrane is formed and produces multiple growth factors. The induced membrane technique is a valuable option for limb salvage in cases of segmental bone defects.

A Surgical Approach to Location-specific Neuropathic Foot Ulceration

The management of pedal ulcerations is often challenging because of a failure to correct underlying biomechanical deformities. Without correcting the biomechanical driving force creating the increased plantar pressures, it is unlikely for routine wound care to provide lasting solutions to pedal ulcerations. Patients with diabetes often experience glycosylation of their tendons, leading to contracture and pursuant deformity, creating imbalanced pressure distributions and eventual plantar ulceration. This article evaluates the efficacy of various lower extremity tendon transfers to balance the foot and redistribute plantar pressures to prevent or heal ulceration.

1561. Recurrent Bilateral Culture Negative Abscesses Mimicking a Diabetic Foot Infection

Background

The aim of this study is to present a novel case of recurrent bilateral culture negative pedal abscesses, mimicking a diabetic foot infection, as an extra-intestinal manifestation of previously undiagnosed ulcerative colitis. Culture negative abscesses may develop as a rare sequela of ulcerative colitis, with less than 40 cases documented within current literature. They often demonstrate a large neutrophilic predominance, negative cultures, and negative serology testing. The diagnosis was achieved utilizing a multi-specialty team approach with podiatry serving as the primary service coordinating the patient care.

Methods

Multiple incision and drainage procedures were performed with copious purulence expressed from the plantar medial pedal compartment. The patient was initiated on broad spectrum antibiotics post-operatively without a clinical response. Advanced microbiological and rheumatologic testing was performed.

Results

Serial aerobic, anaerobic, acid fast, and fungal cultures as well as 16s rDNA testing remained negative for infection throughout the admission. Rheumatologic work-up consisted of broad autoimmune serologic testing (Table 1). Greatly elevated levels of calprotectin were identified, resulting in a colonoscopy for confirmation of the diagnosis of ulcerative colitis. The patient was then placed on infliximab and has remained free of recurrent abscesses for the 15 months of follow up.

Table 1: Workup Results

Conclusion

The differential diagnosis of a culture negative abscess is broad and a multi-specialty team approach must be considered. Criteria for the diagnosis has previously been proposed and includes: deep abscess with neutrophilic features, negative serologic testing, failure of broad-spectrum antibiotic therapy, and rapid improvement on steroids or other DMARDs with subsequent radiologic evidence of abscess resolution. To our knowledge no bilateral cases have been documented within the foot.

Disclosures

All Authors: No reported disclosures

The Role of Dermal Regenerative Templates in Complex Lower Extremity Wounds

Dermal regenerative templates (DRTs) provide an option for management of complex lower extremity wounds. DRTs may be used to achieve definitive wound closure by serving as a scaffold for local tissue infiltration. Healing with a DRT interface leads to histologic and structural properties similar to native skin. DRTs can be applied over deep wounds with exposed critical structures that may have required a local or free flap. DRTs are a valuable option for lower extremity limb reconstruction.

The Reverse Sural Artery Flap: A Reliable and Versatile Flap for Wound Coverage of the Distal Lower Extremity and Hindfoot

The reverse sural artery flap is a distally based fasciocutaneous or adipofascial flap used for wound coverage of the distal one-third of the lower extremity, ankle, and posterior heel. The flap harvest can be performed without sacrificing major arteries of the lower extremity. It can be elevated and mobilized with relative ease and a short operative time. It provides a good alternative to free tissue transfer in complex lower-extremity wounds with exposed bone, tendon, or hardware. The surgeon must be familiar with the management of venous congestion to improve the success of the flap.

Distally Based Medial Hemisoleus Muscle Flap for Wound Coverage in the Distal Third of the Leg

Wound healing and coverage of soft tissue defects of distal tibia are challenging. Free tissue transfer is treatment of choice for distal tibial defects. However, resources for free tissue transfer are not readily available and they increase morbidity to host. Local and regional flaps play a key role in management of these defects with less demanding or specialized requirements. The soleus muscle flap is the workhorse flap for midtibia soft tissue defects and is used in reverse fashion to reach the distal third of the tibia. Despite minor complications, distally based medial hemisoleus flap is reliable in limb salvage cases.

Medial Hemisoleus Flap for Middle Third of the Tibia Defects

Covering soft tissue defects of the tibia is challenging, especially in the presence of underlying osseous trauma. The soleus muscle flap remains the treatment of choice for soft tissue defects in the middle third of the tibia. The flap is reliable and requires a relatively short operative time while maintaining minimal donor site morbidity. However, when the muscle flap is performed without a modified fasciocutaneous composite, it requires a split-thickness skin graft. Muscle flaps have the additional advantage of improving vascularity and fighting infection.

First Dorsal Metatarsal Artery Flap for Coverage of Soft Tissue Defects of the Distal Foot: Delayed Technique, Proximal and Distally Based Fasciocutaneous and Adipofascial Variants

Orthoplastic surgeons continue to encounter challenges for both proximal and distal soft issue defects in the foot. Patients with significant comorbidities often are nonideal surgical candidates. Distal free flaps historically have been utilized. The first dorsal metatarsal artery flap is a local flap with several variants, making it a versatile option in the orthoplastic surgeon's armamentarium for treatment of challenging soft tissue defects about the foot and ankle. The vascular tree is variable and preoperative vascular identification is required to determine flap design.

The Distally Based Posterior Tibial Artery Flap

Soft tissue defects to the distal leg and hindfoot are challenging with only the smallest defects closed primarily without tissue transposition. These defects to the distal leg and hindfoot can lead to tendon desiccation, damaged neurovascular structures, and exposed joint surfaces. These wounds can be the result of postoperative dehiscence and exposed orthopedic hardware, with high susceptibility to infection. Pedicled fasciocutaneous flaps of the medial leg provide an excellent solution with good outcomes that do not require microanastomosis and have similar outcomes as compared with free flap reconstruction in the lower extremity.

Medial Plantar Artery Flap for Wound Coverage of the Weight-Bearing Surface of the Heel

Covering soft tissue defects of the heel is particularly challenging because of the highly specialized functional units unique to the plantar fat pad and the shear and compressive forces experienced in this area. The medial plantar artery fasciocutaneous flap provides the unique ability to restore both sensation and the functional units to the plantar heel by taking tissue similar to that which was lost and relocating it from a non-weight-bearing portion of the foot, while maintaining minimal host morbidity. This provides a lasting solution and may prevent future ulcerations from occurring.

Utility of the Digital Fillet Flap

The digital fillet flap provides a good option for coverage of forefoot soft tissue deficits. Understanding of the anatomy, coupled with careful patient selection, improves surgical outcomes. Similar to other fasciocutaneous flaps, the surgeon needs to be familiar with delay techniques and proper inset to minimize complications.

Chondromyxoid fibroma of the calcaneus: two case reports and literature review

Chondromyxoid fibroma occurs primarily in the long tubular bones of the lower extremity, with the foot representing the second most frequent location after the knee. This benign cartilaginous tumor of bone is currently the rarest reported neoplasm of cartilaginous origin. This mass can mimic other benign and malignant bone tumors owing to its variable histologic features. We report 2 cases of chondromyxoid fibroma of the calcaneus with varying presentations. Initially, advanced imaging studies pointed to a diagnosis of a unicameral bone cyst. Pathologic examination is difficult but can be used to differentiate this lesion from more serious conditions. A quick and accurate diagnosis of chondromyxoid fibroma can prevent unnecessary treatment that could be harmful to the patient.

Chondromyxoid fibroma of the calcaneus: two case reports and literature review

Chondromyxoid fibroma occurs primarily in the long tubular bones of the lower extremity, with the foot representing the second most frequent location after the knee. This benign cartilaginous tumor of bone is currently the rarest reported neoplasm of cartilaginous origin. This mass can mimic other benign and malignant bone tumors owing to its variable histologic features. We report 2 cases of chondromyxoid fibroma of the calcaneus with varying presentations. Initially, advanced imaging studies pointed to a diagnosis of a unicameral bone cyst. Pathologic examination is difficult but can be used to differentiate this lesion from more serious conditions. A quick and accurate diagnosis of chondromyxoid fibroma can prevent unnecessary treatment that could be harmful to the patient.