Claire M. Capobianco

An overview of negative pressure wound therapy for the lower extremity.

Since its introduction into the market, negative pressure wound therapy (NPWT), also known as topical negative pressure, has become an important adjuvant therapy for the treatment of many types of wounds. Surgeons and physicians of all subspecialties have adopted NPWT into their practices. NPWT has become a mainstay in the management of lower extremity soft tissue pathology, especially in patients with traumatic, diabetic, postsurgical, and peripheral vascular disease-associated wounds. This article reviews the background, currently understood mechanisms of action, applications, contraindications, reported complications, advantages, criticisms, and techniques in the lower extremity.

Combined Midfoot Arthrodesis, Muscle Flap Coverage, and Circular External Fixation for the Chronic Ulcerated Charcot Deformity

If the FDB muscle is not clearly visualized, then another method of closure should be considered.” “ L ateral column plantar ulcerations associated with chronic Charcot foot deformity are often difficult to heal and can be complicated in the presence of osteomyelitis. Charcot neuroarthropathy of the foot may result in rigid varus malunion deformities that may ulcerate frequently despite aggressive attempts in offloading with bracing or accommodative shoe gear. Collapse of the lateral column of the Charcot foot is a difficult pathological entity to treat, and longstanding ulcerations frequently become complicated with soft tissue and/ or osseous infection. These patients often present after failure of prior surgical debridements and soft tissue coverage attempts. Proper management of an ulcerated Charcot foot deformity and concomitant osteomyelitis involve removal of all infected bone and soft tissue, eradication of dead space, and prolonged antibiotic therapy. Adequate debridement of soft tissue can be aided by quantitative soft tissue cultures because greater than 10 organisms per gram of tissue cannot sustain a skin graft or flap and will require further debridement before definitive coverage. Chronic osteomyelitis is frequently associated with significant surrounding soft tissue loss and a tunneling, draining ulceration. When osteomyelitis involves the cortical surface and the medullary cavity, sequestrae are typically present. Infected nonunion or malunions of Charcot foot deformities may be treated with isolated resection of the infected bone, but sufficient debridement of plantar lateral midfoot ulcers may result in potential destabilization of the longitudinal arches of the foot. In addition, suboptimal resection of necrotic or infected bone will preclude successful resolution of infection, contribute to chronic nonhealing ulcers, and ultimately result in failure of attempted reconstruction. Resected joint space from osteomyelitis can be managed initially with locally placed antibiotic beads or spacers, vacuumassisted negative pressure therapy, or soft tissue coverage with pliable vascularized local flaps. Antibiotic beads or spacers can be placed beneath a flap after saucerization to help decrease bacterial counts and may be later replaced with

Soft tissue reconstruction pyramid in the diabetic foot.

Foot complications and ulceration are well-known sequelae to uncontrolled diabetes. Patients with chronic foot ulcers or wounds resulting from surgical debridement of deep-space infections are at continued risk for development of osteomyelitis and potential amputation. Moreover, these wounds often necessitate multiple outpatient clinic visits, daily dressing care, and prolonged periods of non—weight bearing, all of which have been shown to adversely affect the patient’s quality of life. After a prudent period of wound-healing response, the authors believe that early and aggressive soft tissue reconstruction is in the patient’s best interest and is crucial for resolution of the chronic nonhealing wound. The options for soft tissue coverage and the logical progression of application of these techniques in the diabetic foot will be described.

The role of an extended medial column arthrodesis for Charcot midfoot neuroarthropathy

The etiology of diabetic Charcot neuroarthropathy involving the midfoot often includes an inciting traumatic event or repetitive micro-trauma from an uncompensated biomechanical imbalance that potentiates an incompletely understood pathway leading to a rocker-bottom foot deformity and ulceration. In the setting of a severe Charcot foot fracture and/or dislocation with obvious osseous instability, diagnostic delay can potentiate the limb-threatening sequelae of infected midfoot ulcerations in this patient population. In this article, the authors discuss the thought process as well as the advantages of performing an extended medial column arthrodesis for selected Charcot midfoot deformities.

Surgical Management of Diabetic Foot and Ankle Infections

Delayed treatment of any diabetic foot infection can lead to a limb- or life-threatening scenario. Urgent and/or emergent surgery may be necessary in the early diagnosis of a severe diabetic foot infection that is fol- lowed by staged reconstructive proce- dures. This article provides the reader with a thorough understanding of the surgical management of severe dia- betic foot infections and describes and guides treatment based on a rational schematic approach that identifies the anatomic location of the diabetic foot infection

Diabetic foot infections: a team-oriented review of medical and surgical management.

As the domestic and international incidence of diabetes and metabolic syndrome continues to rise, health care providers need to continue improving management of the long-term complications of the disease. Emergency department visits and hospital admissions for diabetic foot infections are increasingly commonplace, and a like-minded multidisciplinary team approach is needed to optimize patient care. Early recognition of severe infections, medical stabilization, appropriate antibiotic selection, early surgical intervention, and strategic plans for delayed reconstruction are crucial components of managing diabetic foot infections. The authors review initial medical and surgical management and staged surgical reconstruction of diabetic foot infections in the inpatient setting.

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

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.

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.

Ilizarov External Fixation Technique for Repair of a Calcaneal Avulsion Fracture and Achilles Tendon Rupture

In this unique subset of calcaneal fractures, our technique accomplishes the primary goals of repair: to maintain functional length of the Achilles tendon and prevent loss of reduction.” “ A lthough the calcaneus is the most commonly fractured tarsal bone, avulsion fractures of the calcaneal tuberosity account for only 1.3% to 2.7% of all calcaneal fractures. Because of their rare occurrence, the literature has few options in the surgical management of these fractures. Essex-Lopresti first sought to distinguish intra-articular from extra-articular fractures of the calcaneus, whereas Bohler more specifically reported on avulsion-type fractures. Lowy described the anatomical relationships associated with these fractures and stressed the importance of open reduction with internal fixation as closed manipulation often failed to achieve adequate reduction. Lag screw fixation followed by non–weight bearing in a short leg cast has been the most common operative technique reported. Alternative fixation techniques described include the use of Steinmann pins, cerclage wire, and suture anchors. Avulsion fractures of the calcaneal tuberosity comprise only a small percentage of all calcaneal fractures and are found to occur more frequently in the diabetic, osteoporotic, elderly, and neuropathic populations as well as those on long-term immunosuppressive therapy. The mechanism of injury for avulsion fractures is commonly described as a combination of direct trauma and muscular contraction with the heel fixed on the ground, usually consisting of a fall from a small height, as seen in our case presentation. The popular classification systems for calcaneal fractures such as those by Bohler, Essex-Lopresti, and Watson-Jones provide little focus on avulsion fractures. In 1969, Lowy and Protheroe separately presented several case reports, which detailed the anatomy of these fractures as well as the importance of accurate operative reduction and fixation for favorable outcomes. More recently, Beavis et al proposed a classification system for 3 subtypes of calcaneal avulsion fractures: “sleeve” fracture, classical “beak” fracture, and infrabursal fracture from the middle third of the posterior tuberosity. Despite the large amount of literature that exists on surgical management of intra-articular calcaneal fractures, there is limited information regarding the treatment options available for avulsion fractures. These fractures often pose a challenge to the surgeon as the force exerted by the Achilles tendon must be neutralized to prevent loss of reduction and subsequent failure of fracture repair.

Surgical Equinus Correction for the Diabetic Charcot Foot: What the Evidence Reveals.

Triceps surae contracture, or equinus, is a known deforming force in the foot and ankle. Biomechanical studies have shown that ankle equinus significantly alters gait and plantar pressures, and in the diabetic neuropathic patient population, this can propagate plantar ulceration and/or Charcot neuroarthropathy (CN). Surgical correction of equinus is globally and frequently used to aid in plantar wound healing in the neuropathic diabetic patient, with and without CN. Treatment guidelines for equinus correction in this medically complex population are undefined and lack evidence from high-quality published peer-reviewed studies.