Crystal L. Ramanujam

Split-thickness skin grafts for closure of diabetic foot and ankle wounds: a retrospective review of 83 patients.

The aim of this study was to determine if split-thickness skin grafts could be successfully used for closure of foot and ankle wounds in diabetic patients. The authors retrospectively reviewed the charts of 100 consecutive patients who underwent a soft tissue surgical reconstruction with split-thickness skin grafts to their foot and/or ankle in our institution from 2005 to 2008. After application of inclusion criteria, 83 eligible charts remained. Of the 83 patients, 54 (65%) healed uneventfully, 23 (28%) required regrafting, and 6 (7%) had a complication resolved with conservative management. All patients had a successful surgical outcome, defined as having achieved complete wound closure at the final follow-up. Surgical outcome was not significantly associated with age, gender, race, hemoglobin A1C, wound size, wound location, illicit drug use, amputation history, Charcot history, or preoperative infection. However, postoperative graft complications were significantly associated with current or previous smoking history (P = .016) and the level of previous pedal amputation to which the split-thickness skin graft was applied (P = .009). This study demonstrates that application of split-thickness skin grafts with an appropriate postoperative regimen is a beneficial procedure to achieve foot and ankle wound closure in diabetic patients.

Association of Tibialis Posterior Tendon Pathology with Other Radiographic Findings in the Foot: A Case-Control Study

The purpose of this study was to analyze the prevalence of spring ligament pathology and other radiographic changes related to flatfoot deformity in the presence of different degrees of tibialis posterior tendon pathology. A total of 72 patients (24 with tibialis posterior tendon abnormality and 48 sex- and age-matched controls) were evaluated for tibialis posterior tendon pathology, spring ligament pathology, and plain pedal radiographic angles, including cuboid abduction, talar declination, calcaneal inclination, and Mearys angles. The patients with tibialis posterior tendon pathology were subdivided into either minor (Type I) or severe (Type II/III), according to the Conti classification of tibialis posterior tendon pathology on MRI. All the continuous data of radiographic angles were dichotomized into either a flatfoot group or normal/cavus foot group. Associations between these nominal variables were analyzed. There was no association between Type I tibialis posterior tendon pathology and spring ligament pathologies (OR = 0.8, 95% CI = 0.15-4.65). Conversely, every patient with Type II/III tibialis posterior tendon pathology had spring ligament abnormality. Type II/III group also showed statistically significant associations with both increased talar declination angle (OR = 10.4, 95% CI = 1.62-109.22) and Mearys angle (OR = 7.5, 95% CI = 1.35-51.12), while no such associations were found with Type I tibialis posterior tendon pathology (OR = 1.0, 95% CI = 0.18-6.18 with talar declination angle; OR = 3.9, 95% CI = 0.65-27.71 with Mearys angle). In this investigation, only advanced tibialis posterior tendon pathology was statistically significantly associated with adult-acquired flatfoot deformity and spring ligament pathology.

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

An overview of conservative treatment options for diabetic Charcot foot neuroarthropathy.

Conservative management of Charcot foot neuroarthropathy remains efficacious for certain clinical scenarios. Treatment of the patient should take into account the stage of the Charcot neuroarthopathy, site(s) of involvement, presence or absence of ulceration, presence or absence of infection, overall medical status, and level of compliance. The authors present an overview of evidence-based non-operative treatment for diabetic Charcot neuroarthropathy with an emphasis on the most recent developments in therapy.

External Fixation for Surgical Off-Loading of Diabetic Soft Tissue Reconstruction

Early and aggressive treatment of diabetic foot wounds is imperative for the reduction of amputation risk. Whereas sound local wound care is important for successful management; chronic wounds often reach a stagnant point in healing because of diabetic vasculopathy, immunopathy, or neuropathy. The type, size, shape, and location of wound may not always allow primary closure or grafting. In patients with adequate perfusion and in the absence of infection, local advancement flaps are suitable for durable closure. A review and case report demonstrating the use of these flaps with external fixation as an adjunctive therapy for surgical off-loading is presented.

Negative-pressure wound therapy in the management of diabetic Charcot foot and ankle wounds

As the prevalence of diabetes mellitus continues to rise, innovative medical and surgical treatment options have increased dramatically to address diabetic-related foot and ankle complications. Among the most challenging clinical case scenarios is Charcot neuroarthropathy associated with soft tissue loss and/or osteomyelitis. In this review article, the authors present a review of the most common utilizations of negative-pressure wound therapy as an adjunctive therapy or combined with plastic surgery as it relates to the surgical management of diabetic Charcot foot and ankle wounds.

Combined Circular External Fixation and Open Reduction Internal Fixation with Pro-syndesmotic Screws for Repair of a Diabetic Ankle Fracture.

The surgical management of ankle fractures among the diabetic population is associated with higher complication rates compared to the general population. Efforts toward development of better methods in prevention and treatment are continuously evolving for these injuries. The presence of peripheral neuropathy and the possible development of Charcot neuroarthropathy in this high risk patient population have stimulated much surgical interest to create more stable osseous constructs when open reduction of an ankle fracture/dislocation is required. The utilization of multiple syndesmotic screws (pro-syndesmotic screws) to further stabilize the ankle mortise has been reported by many foot and ankle surgeons. In addition, transarticular Steinmann pins have been described as an adjunct to traditional open reduction with internal fixation (ORIF) of the ankle to better stabilize the talus, thus minimizing risk of further displacement, malunion, and Charcot neuroarthropathy. The authors present a unique technique of ORIF with pro-syndesmotic screws and the application of a multi-plane circular external fixator for management of a neglected diabetic ankle fracture that prevented further deformity while allowing a weight-bearing status. This techniqu may be utilized for the management of complex diabetic ankle fractures that are prone to future complications and possible limb loss.

Impact of Diabetes and Comorbidities on Split-Thickness Skin Grafts for Foot Wounds

BACKGROUND Split-thickness skin grafts can be used for foot wound closure in diabetic and nondiabetic patients. It is unknown whether this procedure is reliable for all diabetic patients, with or without comorbidities of diabetes, including cardiovascular disease, neuropathy, retinopathy, and nephropathy. METHODS We retrospectively reviewed 203 patients who underwent this procedure to determine significant differences in healing time, postoperative infection, and need for revisional surgery and to create a predictive model to identify diabetic patients who are likely to have a successful outcome. RESULTS Overall, compared with nondiabetic patients, diabetic patients experienced a significantly higher risk of delayed healing time and postoperative complication/infection and, hence, are more likely to require revisional surgery after undergoing the initial split-thickness skin graft procedure. These differences seemed to be related more to the presence of comorbidities than to diabetic status itself. Diabetic patients with preexisting comorbidities experienced a significantly increased risk of delayed healing time and postoperative infection and a higher need for revisional surgery compared with nondiabetic patients or diabetic patients without comorbidities. However, there were no significant differences in outcome between diabetic patients without comorbidities and nondiabetic patients. CONCLUSIONS For individuals with diabetes but without exclusionary comorbidities, split-thickness skin grafting may be considered an effective surgical alternative to other prolonged treatment options currently used in this patient population.

An overview of bone grafting techniques for the diabetic Charcot foot and ankle.

Surgical options for diabetic Charcot neuroarthropathy of the foot and ankle must take into consideration the challenging environment for bone healing that accompanies these complex pathologic conditions. Bone grafting has established an important role in reconstructive surgery to promote bone formation, replacement, and repair. This article provides an overview of available bone grafting methods in conjunction with a review of the literature on these techniques as they pertain to diabetic Charcot foot and ankle reconstruction.

Antibiotic-Loaded Cement Beads for Charcot Ankle Osteomyelitis

The concomitant presence of osteomyelitis and diabetic Charcot neuroarthropathy of the foot and ankle places those patients affected at increased risk for limb loss. Antibiotic-loaded cement has been reported to be useful in the treatment of deep soft tissue and joint infections. The authors present an overview of this adjunctive treatment modality and present a case report using antibiotic-loaded cement beads in staged reconstruction for Charcot ankle osteomyelitis.