John J. Stapleton

A Stepwise Approach to the Surgical Management of Severe Diabetic Foot Infections.

Foot infections are common among diabetic patients with ulceration and are a major cause of hospitalization and lower extremity amputation. Aggressive and emergent surgical intervention is essential in the face of life- or limb-threatening infection to achieve limb salvage and survival. Critical limb ischemia, neuropathy, and an impaired host complicate the treatment of a severe diabetic foot infection. A severe diabetic foot infection carries a 25% risk of major amputation. For this reason, surgery should be coordinated with a well-functioning multidisciplinary team that specializes in diabetic limb preservation. Timing of surgery and strategies employed should be understood and agreed on by both the surgical and medical disciplines managing the diabetic patient with a limb-threatening infection. The overall strategy for surgically managing a severe diabetic foot infection is as follows: the first step is infection control through aggressive and extensive surgical debridement, the second step is a compre...

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.

Combined lateral column arthrodesis, medial plantar artery flap, and circular external fixation for Charcot midfoot collapse with chronic plantar ulceration.

INTRODUCTION Charcot neuroarthropathy is a progressing debilitating disease that is most commonly seen in patients with diabetes mellitus, especially those with dense peripheral neuropathy. In the disease’s early stages, increased blood flow to the lower extremity leads to generalized osteopenia. Combined with substantial increased weight-bearing activity, this results in a severe deformity with subsequent high plantar pressures, ulceration, and infection. The incidence of Charcot neuroarthropathy and its related complications are increasing in the United States. – 6 The Charcot foot is the greatest single relative risk factor in the development of a foot ulceration when compared with other known risk factors such as insensitivity to a 5.07-g monofilament, obesity, or history of a previous amputation or ulceration. The final common pathway leading to amputation in the diabetic patient typically involves ulceration and subsequent infection. Historically, the treatment for Charcot neuroarthropathy-induced deformity has consisted of bed rest, immobilization, total contact casting, and customized footwear and/or bracing. The goal of any treatment for the diabetic Charcot foot deformity is to create a plantigrade, stable, and braceable foot that will be free from significant risk for further breakdown, ulceration, and/or infection. The actual decision between conservative and surgical intervention depends on the degree of deformity, instability and subluxation, infection, osteomyelitis, patient compliance, medical comorbidities including end-stage renal disease, psychosocial issues, obesity, and life expectancy. Unfortunately, the evidence supporting the more conservative nonoperative treatment option for the Charcot foot is equivocal. The increased risk of amputation related to the nonoperative treatment of Charcot foot should alert wound care practitioners to use caution and close monitoring when conservatively treating Charcot patients with midfoot collapse combined with ulceration. It is estimated that up to 40% of Charcot patients with midfoot collapse will ultimately require surgery to achieve a functional end point that involves the use of commercially available shoe gear and custom in-shoe foot orthoses to decrease the potential for progressive deformity, reulceration, infection, and amputation. Worldwide, surgeons are attempting reconstruction of severe Charcot foot deformities with variable protocols and techniques. – 18 As a result, the literature mainly focuses on small case series or ‘‘how-to’’ manuscripts which, when critically reviewed, produce inconclusive outcomes. The authors believe that these deformities require management by a multidisciplinary diabetic foot team that collectively possesses a comprehensive understanding of the diabetic foot, the whole patient, and the functional deficits associated with the deformed foot. The surgeon, as part of the transdisciplinary team, needs to be well versed in plastic surgery techniques specific to the foot, ankle, and lower leg; various forms and techniques of external fixation; and the principles and application of both acute and chronic deformity correction. A successful outcome can be reached when surgery of the Charcot foot incorporates osseous stability, deformity correction, and concomitant soft tissue reconstruction. This article presents an overview of the surgical techniques used in a lateral column fusion, medial plantar artery flap, and the application of a tensioned ring external fixation device for perioperative and postoperative stability. The authors believe the article is beneficial to all medical and surgical specialties related to the treatment of diabetic limb salvage. It offers an alternative method of treatment to the diabetic Charcot foot ulcer that can be potentially

Surgical Treatment of Calcaneal Fracture Malunions and Posttraumatic Deformities

The surgical management of calcaneal fractures presents with several obstacles to the treating physician. Many experienced surgeons acknowledge a steep and significant learning curve in the operative management of calcaneal fractures. Nonoperative management of displaced intra-articular calcaneal fractures may result in malunion, thereby affecting the function of the ankle and subtalar joint. Although some calcaneal fractures can be treated conservatively, a majority of them require operative intervention. The goal of this article is to bring some insight into the realm of revisional surgery on residual deformity of the calcaneus after operative intervention and also provide a rationale approach to successfully manage failed surgeries for calcaneal fractures.

Complications and Revisional Hallux Valgus Surgery

Complications with hallux valgus surgery can manifest in a variety of ways, but ultimately preventing them depends on the surgeons expertise in patient and procedural selection, ability to perform the surgery selected, and knowledge in dealing with postoperative care and complications if present. In this article, the authors discuss common diagnostic and treatment dilemmas when dealing with recurrent hallux valgus, hallux varus, malunion, and avascular necrosis following bunion surgery.

Use of Circular External Fixation for Combined Subtalar Joint Fusion and Ankle Distraction

The authors discuss a novel technique not previously published that incorporates a subtalar joint arthrodesis with an ankle joint arthrodiastasis as an alternative to a tibiotalocalcaneal arthrodesis. Young and active patients who experience refractory pain and stiffness to the rearfoot and ankle secondary to combined severe subtalar and ankle arthrosis are suitable candidates for this surgical procedure. This new approach is based on sound principles in the treatment of severe arthrosis affecting the ankle and subtalar joint. The authors are currently prospectively reviewing their surgical experience with this procedure and believe that it provides an alternative option for the patient, with potentially promising long-term results.

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.

A case report of a double advancement flap closure combined with an Ilizarov technique for the chronic plantar forefoot ulceration.

Soft tissue closure of defects on the plantar surface of the foot continues to be a challenge for the reconstructive surgeon secondarily to the limited number of surgical options and often difficulty of replacing durable and similar soft tissue coverage. Primary closure and skin grafting may not be suitable for the weight-bearing surfaces of the plantar forefoot area, and closure may then be obtained by other means of plastic surgery techniques.

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.