Thomas Zgonis

Autologous platelet-rich plasma for wound and osseous healing: A review of the literature and commercially available products

The application of autologous platelets that have been sequestered, concentrated, and mixed with thrombin to create growth factor-concentrated, autologous platelet-rich plasma for application to soft tissue wounds and for osseous healing has been a subject of great interest for much of the past 2 decades. Autologous platelet-rich plasma, which consists of both quantitative and qualitative components, has the greatest potency or ability to produce the desired effect. Manufacturers prepare autologous platelet-rich plasma with the ultimate goal of maximizing its benefits while minimizing potential risks. Unfortunately, the manufacturing processes for autologous platelet-rich plasma are highly variable, and the types of proprietary systems available on the market for soft tissue and osseous applications are numerous. The authors provide here an in-depth review of commercially available systems for delivery of autologous platelet-rich plasma that emphasizes the subtle yet important differences among systems. In addition, a detailed review of the literature regarding the use of autologous platelet-rich plasma in soft tissue and osseous healing is provided. Although findings are not yet conclusive, autologous platelet-rich plasma has been shown to be safe, reproducible, and effective in mimicking the natural processes of soft tissue wound and osseous healing.

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.

A systematic approach to diabetic foot infections

Foot infection is the most common reason for hospitalization and subsequent lower extremity amputation among persons with diabetes. Foot ulceration caused by diabetic neuropathy, trauma, and peripheral vascular disease can lead to a limb- or life-threatening infection. The optimum treatment of these potentially devastating conditions depends on a multidisciplinary approach that addresses the related or underlying disorders and thus ensures proper wound healing and a positive outcome. In addition to antibiotic therapy, severe soft-tissue or bone infections may necessitate surgical treatment, including drainage, débridement, and vascular reconstruction. Initial (empiric) antibiotic therapy should provide coverage against staphylococci and streptococci and should be revised according culture results. Antibiotic therapy is not indicated in clinically noninfected wounds. The duration of antibiotic treatment can range from 1 week for mild infections to 6 weeks or more for residual osteomyelitis and severe deep tissue infections. Aggressive (and sometimes repeated or staged) surgical intervention and appropriate antibiotic therapy can reduce the likelihood of a major amputation and the duration of hospitalization.

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.

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.

Effect of oral nutritional supplementation on wound healing in diabetic foot ulcers

Among people with diabetes, 10–25% will experience a foot ulcer. Research has shown that supplementation with arginine, glutamine and β‐hydroxy‐β‐methylbutyrate may improve wound repair. This study tested whether such supplementation would improve healing of foot ulcers in persons with diabetes.

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.