Richard L. Jacobs

Surgical Arthrodesis of the Neuropathic Foot: A Salvage Procedure

Reconstructive foot and ankle surgery is a salvage procedure in the deformed neuropathic foot, despite condemnation by some authors. Clinical union and stability was achieved in 91% of the patients, and soft-tissue coverage without skin breakdown was achieved in 100% of the cases. Although one patient had moderate to severe pain in her ankle after operation and was able to do only bed-to-wheelchair transfers, she had good clinical stability, no skin ulceration, and was satisfied overall with the procedure. In addition, a significant component of her pain was believed to be from diabetic neuropathy and not pain that was directly attributable to her reconstructive surgery. All other patients were able to ambulate to some degree. More than half had unlimited use of the affected lower extremity. More than half of the patients had mild or no pain, and all patients had a functional limb. Surgical arthrodesis of the deformed neuropathic foot as a salvage procedure can preserve the limb as a stable functional unit, and create an acceptable alignment of the ankle-foot complex that will promote viability of the overlying soft-tissue structures.

Chopart Amputation With Percutaneous Heel Cord Lengthening

When amputation becomes necessary in a patient with peripheral vascular disease, it is important to preserve as much tissue as possible to preserve maximum function. This is especially important because the other extremity may have similar involvement in the future. With appropriate care, an amputation at the Chopart (calcaneocuboid-talonavicular) level can give a good functional result.

Pseudoaneurysm of the Dorsalis Pedis Artery After Lisfranc Amputation

Pseudoaneurysm formation is usually associated with laceration, fracture, or iatrogenic arterial injury. 2 However, it may also develop as a result of blunt trauma. 5 We report the case of a pseudoaneurysm of the dorsalis pedis artery after a Lisfranc amputation in an individual with diabetes mellitus, Charcot joint changes in the left forefoot, and atherosclerosis of the distal vessels.

Triple Arthrodesis through a Single Lateral Approach: A Cadaveric Experiment*

Using a single lateral approach, triple arthrodesis was performed on six cadaveric feet. An attempt was made to obliterate the talocalcaneal, talonavicular, and calcaneocuboid joints. The limbs were subsequently disarticulated to allow for an inspection of the talonavicular, talocalcaneal, and calcaneocuboid joints. An estimate of cartilage and subchondral bone removed from each articular surface was made by a single observer (J.V.B.) by direct visual inspection. Results were as follows: calcaneocuboid joint, 90% of cartilage removed; talocalcaneal joint, 80% of cartilage removed; talonavicular joint, 38% of cartilage removed. Failures at the talonavicular joint were attributed to a poor appreciation of the anatomy of the talar head and poor observation. Complications involved in obliteration of the talonavicular joint from a single lateral approach included: inadvertent division of the talar neck; inadvertent division of the talar head; removal of excessive bone stock; medial skin punctures; and creation of an iatrogenic cut through the talar dome. Therefore, a triple arthrodesis through a single lateral approach, as described by Ryerson, 8 Hoke, 5 and Campbell, 2 cannot be recommended. The talonavicular joint should be approached through an auxiliary medial incision, as recommended by Cracchiolo. 3 This paper documents the experience of a beginner with this operation, and demonstrates the value of using the anatomy laboratory.

Hoffman Procedure in the Ulcerated Diabetic Neuropathic Foot

Twelve diabetic patients with varying degrees of insen-sitivity of the foot presented with problems of forefoot ulceration beneath one or more metatarsal heads. This was associated with local abscess formation. Some of these patients had previously been subjected to surgical procedures such as ray resection or single metatarsal head resection for earlier problems and were left with areas of increased pressure in the weightbearing surface of the forefoot. Appropriate antibiotic therapy was started by the Infectious Diseases service in each case. Blood flow to the extremity was evaluated by pulse volume recordings and measurement of Doppler pressures at various levels down the extremity. Vascular reconstruction was indicated in two of these patients. After this reconstruction, circulation was deemed adequate to perform the Clayton (Clayton, M.L.: Surgery of the forefoot in Rheumatoid Arthritis. Clin. Orthop. 16:136–140, 1960) modification of the Hoffman (Hoffman, P.: An operation for severe grades of contracted or clawed toes. Am. J. Orthop. 9:441–449, 1911) procedure. This procedure was also done on 10 other patients with more adequate circulation. Although the time of healing was prolonged in some instances, all feet healed and the patients were successfully graduated to full weightbearing with extra depth shoes with soft neoprene rubber insoles. This procedure should be considered instead of transmetatarsal amputation in some patients with problems of ulceration and abscess formation of the forefoot if circulation is adequate, or can be restored to adequate levels by vascular reconstruction.

Occult Foreign Bodies of the Foot

This article illustrates several case reports of occult foreign bodies of the foot. The patients came for treatment from weeks to years after the inciting incident with chronic, sterile, draining wounds. The diagnosis of these foreign bodies can be quite difficult. Several radiographic and clinical clues are included, yet the single most valuable tool for the physician remains a high index of suspicion.

Healing of foot ulcers in immunosuppressed renal transplant patients

Sixteen renal transplant patients were retrospectively studied to determine the time foot ulcerations healed. All patients were taking imuran and medrol. More recently, patients were also on cyclosporine. All were insulin-dependent diabetics. A control group was established from a pool of randomly selected, age-matched, insulin-dependent diabetics who were also observed for foot ulcerations. All treatment was given by one physician. Pulse volume recordings were obtained in all but eight patients, who were clinically believed to have normal vascular supply to the affected extremity. No statistically significant difference was found between these groups in this regard. Cultures were obtained in all patients when indicated; appropriate antibiotics were started. No major differences were noted with respect to infecting organism. The immunosuppressed group had no excellent results, and three good, 14 fair, and 23 poor results. The control group had ten excellent, 14 good, 11 fair, and 17 poor results. A higher failure rate may occur with limb-salvage surgery in the immunosuppressed patient. This observation confirms a long-held clinical suspicion.

Plantar Abscess in the Diabetic Patient

This is a report on 42 plantar abscesses in 40 patients with diabetes mellitus. Data concerning the mode of origin, the microorganisms involved, the antibiotics used, the end results or treatment, and the length of stay are given. Several typical cases are presented. Below-knee amputation can usually be avoided in diabetic patients with plantar abscess. The extremity can often be saved by a team consisting of specialists in infectious diseases, vascular surgery, and orthopaedic surgery.

Treatment of the diabetic foot with exposed os calcis.

With improved methods of medical care, the survival rates in all types of diabetes are improving. There are increasing numbers of older diabetics with complicated soft tissue problems. This is a report of our experiences in treating 15 consecutive patients with soft tissue defects involving the hindfoot. Each of these patients had an intact forefoot.

Molded foot orthosis after great toe or medial ray amputations in diabetic feet.

Necrosis of the tip of the next lateral remaining toe has been found to be a late complication of great toe and medial ray amputations in diabetic feet. The use of custom-molded insert foot orthoses helps avoid this complication.