Gary Peter Jolly

External fixation in the management of Charcot neuroarthropathy

Charcot neuroarthropathy is a complex sequela of neuropathies associated with diabetes mellitus, syringomyelia, alcoholism, and other disorders. The treatment of deformities associated with Charcot neuroarthropathy is evolving from a passive approach to one in which an earlier recognition of the emergence of the event permits an avoidance of deformity. As the understanding of the etiology and natural history of Charcot neuroarthropathy deepens, it has become apparent that many of the deformities that do develop may be reconstructed expeditiously by the surgeon with a thorough understanding of the diabetic foot and experience in the use of external fixation.

Entrapment neuropathy: The etiology of intractable chronic heel pain syndrome

Chronic heel pain syndrome (CHPS) is a common clinical entity. The etiology of CHPS has never been completely defined and there are no clear treatment regimens in the literature. Most authors agree that nonoperative treatment is effective in most patients. However, in 5%-10% of patients, operative intervention is required. Outcomes for these patients have been inconsistent. A series of 51 patients with intractable CHPS who were diagnosed with an entrapment of the posterior tibial nerve and its terminal branches is presented. Descriptive statistics were obtained for the demographic data and pre and postsurgical start-up and standing pain visual analog scale (VAS) scoring. Statistical testing of the VAS mean scores was performed using a paired t-test at the 0.01 level of significance. Pre- and postsurgical start-up and pre- and postsurgical standing pain VAS means were significantly different from each other (t = 19.6, p = .001 and t = 19.4, p = .001, respectively). Based on subjective and objective criteria, 96% of the patients experienced significant improvement and 90% reported completed resolution of heel pain. The presence of tarsal tunnel syndrome in all 51 patients strongly suggests entrapment neuropathy as the etiology of intractable CHPS.

The accessory soleus and recurrent tarsal tunnel syndrome: Case report of a new surgical approach

The accessory soleus muscle is a rare anatomic variant, which presents as a mass in the posteromedial aspect of the ankle. This anomaly has been linked with compression neuropathy of the posterior tibial nerve. The authors present a case of tarsal tunnel syndrome in which the presence of an accessory soleus was unrecognized at the time of the original procedure, but was utilized during the revisional operation to provide safe coverage of the posterior tibial nerve.

Diabetic foot infections and antibiotic therapy

Diabetic foot infections are associated with high morbidity and mortality rates as well as significant financial impact on the health care system. Improved patient outcomes and intelligent use of resources should determine the selection of diagnostic procedures and the therapeutic modalities used. Diabetic patients who develop lower extremity infections require a multidisciplinary approach in the management of their infections and other disorders. Aggressive surgical debridement and appropriate and adequate antibiotic therapy are necessary to successfully treat severe foot infections and permit faster recovery.

External fixation use in arthrodesis of the foot and ankle

The use of external fixation in foot and ankle arthrodesis can be beneficial. Its advantages, disadvantages, and indications were reviewed in this article. External fixation offers the surgeon an opportunity to treat complex foot and ankle deformities, trauma, chronic infections, pseudoarthroses, soft tissue contractures, and limb length discrepancies in ways that were unavailable before its advent. The Ilizarov technique requires considerable experience and patient compliance for the best postoperative outcome. An understanding of musculoskeletal physiology and the biomechanics of bone and soft tissue are essential for the competent application of external fixators in general and Ilizarov frames in particular. The surgeon should be aware of all the surgical options before the application of an external complex apparatus.

Necrotizing fasciitis in a patient with type 2 diabetes mellitus.

Necrotizing fasciitis is a soft-tissue infection characterized by extensive necrosis of subcutaneous fat, neurovascular structures, and fascia. In general, fascial necrosis precedes muscle and skin involvement, hence its namesake. Initially, this uncommon and rapidly progressive disease process can present as a form of cellulitis or superficial abscess. However, the high morbidity and mortality rates associated with necrotizing fasciitis suggest a more serious, ominous condition. A delay in diagnosis can result in progressive advancement highlighted by widespread infection, multiple-organ involvement, and, ultimately, death. We present a case of limb salvage in a 52-year-old patient with type 2 diabetes mellitus and progressive fascial necrosis. A detailed review of the literature is presented, and current treatment modalities are described. Aggressive surgical debridement, comprehensive medical management of the sepsis and comorbidities, and timely closure of the resultant wound or wounds are essential for a successful outcome.

Soft tissue considerations in partial foot amputations.

Success is possible with partial foot amputations even in the diabetic patient population. Many diabetics who in the past would have undergone a major lower extremity amputation now have successful reconstruction of their complex foot wounds. Even though this article presents the levels of amputation and methods of closure for soft tissue defects in a sequential manner, in many instances, different levels and methods are used for different aspects of the same foot defect (i.e., a TMA may require a fillet of toe, STSG, and TAL for successful closure). Familiarity with the principles advocated in this article and the importance of each member of the multispecialty team involved help to ensure that good outcomes in the immediate postoperative period and in the long-term recovery period are achieved.Success is possible with partial foot amputations even in the diabetic patient population. Many diabetics who in the past would have undergone a major lower extremity amputation now have successful reconstruction of their complex foot wounds. Even though this article presents the levels of amputation and methods of closure for soft tissue defects in a sequential manner, in many instances, different levels and methods are used for different aspects of the same foot defect (i.e., a TMA may require a fillet of toe, STSG, and TAL for successful closure). Familiarity with the principles advocated in this article and the importance of each member of the multispecialty team involved help to ensure that good outcomes in the immediate postoperative period and in the long-term recovery period are achieved.

Digital artery flaps for closure of soft tissue defects of the forefoot

Reconstruction of recalcitrant soft tissue defects in the weightbearing surface of the forefoot can be achieved by using a neurovascular island flap. Island flaps, based on a pedicle from either the proper digital artery or the common digital artery, were used to provide supple and durable coverage. A retrospective analysis was performed on 12 patients who underwent a total of 15 digital artery flaps. There were 7 patients with neuropathic ulcers, 7 with a dysfunctional scar, and 1 with an ischemic ulcer after lower-extremity bypass. There was a failure rate of 13%; 2 flaps fully necrosed, necessitating a revisional digital artery flap. Minor complications were reported in 73% of cases; average time to complete healing was 71 days. All healed flaps have remained viable and durable at an average follow-up of 22.5 months from the date of surgery (range, 3 to 61 months).

High-energy bilateral talar neck fractures secondary to motocross injury

The authors present a case of bilateral Hawkins type II talar neck fractures sustained during a motocross race in a 23 year old man. Due to the complexity of the injuries, open reduction with internal fixation and primary subtalar joint arthrodesis was performed bilaterally. This is one of the few cases of bilateral talar neck fractures reported in the literature in the past 15 years and one of the first utilizing open reduction and internal fixation with concomitant subtalar joint arthrodesis as a primary treatment.

Chapter 21 – Soft tissue considerations in partial-foot amputations

Success is possible with partial foot amputations even in the diabetic patient population. Many diabetics who in the past would have undergone a major lower extremity amputation now have successful reconstruction of their complex foot wounds. Even though this article presents the levels of amputation and methods of closure for soft tissue defects in a sequential manner, in many instances, different levels and methods are used for different aspects of the same foot defect (i.e., a TMA may require a fillet of toe, STSG, and TAL for successful closure). Familiarity with the principles advocated in this article and the importance of each member of the multispecialty team involved help to ensure that good outcomes in the immediate postoperative period and in the long-term recovery period are achieved.Success is possible with partial foot amputations even in the diabetic patient population. Many diabetics who in the past would have undergone a major lower extremity amputation now have successful reconstruction of their complex foot wounds. Even though this article presents the levels of amputation and methods of closure for soft tissue defects in a sequential manner, in many instances, different levels and methods are used for different aspects of the same foot defect (i.e., a TMA may require a fillet of toe, STSG, and TAL for successful closure). Familiarity with the principles advocated in this article and the importance of each member of the multispecialty team involved help to ensure that good outcomes in the immediate postoperative period and in the long-term recovery period are achieved.