Valerie L. Schade

The Role of Polymethylmethacrylate Antibiotic-loaded Cement in Addition to Debridement for the Treatment of Soft Tissue and Osseous Infections of the Foot and Ankle

Polymethylmethacrylate (PMMA) has been used in skeletal surgery for >40 years as a means of securing prosthetic implants and more recently was used as a delivery agent for local high-dose antibiotics to treat soft tissue and osseous infections. The purpose of this study was to determine the role of PMMA antibiotic-loaded cement (PMMA-ALC) in combination with aggressive debridement for the treatment of foot and ankle soft tissue and osseous infections requiring operative intervention. A retrospective observational cohort study of prospectively collected data was performed for all patients who underwent aggressive debridement with placement of PMMA-ALC for foot and ankle soft tissue and osseous infections between July 2006 and January 2009. There were 35 (29 men, 6 women) patients, 29 who had diabetes, with a mean age of 61 1 13 years (range, 16-86 years). A total of 36 feet/ankles (20 right, 16 left) were involved, and the infections were anatomically divided into 6 groups: (1) toes (n = 9), (2) metatarsalphalangeal joints (MTPJ) (first MTPJ, n = 5; fifth MTPJ, n = 5), (3) forefoot (n = 11), (4) rearfoot (n = 4), and (6) ankle/lower leg (n = 3). All patients had confirmed bacterial infection via microbiologic or pathologic analysis before PMMA-ALC insertion. A total of 73 cultures were obtained at the time of PMMA-ALC removal, with 66 showing no bacterial growth (90.4%) and 7 positive for bacterial growth (9.6%). Methicillin-resistant Staphylococcus aureus was the most commonly cultured organism both preoperatively and postoperatively. When combined with aggressive irrigation and debridement, the use of PMMA-ALC appears to be a beneficial adjunctive therapy for the treatment of foot and ankle soft tissue and osseous infections.

Minimum-Incision Metatarsal Osteotomies

This article focuses on minimal-incision metatarsal osteotomies for treating ulcerative lesions related to hallux valgus deformities and central and fifth metatarsal plantar ulcerations to correct the structural deformity responsible for the ulceration. The authors presented a structured review of the literature regarding complications associated with the use of minimum-incision surgical techniques available for the first, central, and fifth metatarsals and techniques to avoid them. Although a steep learning curve exists with these procedures, the advantage of performing minimum- incision metatarsal osteotomies in high-risk populations allows for rapid and predictable resolution of recalcitrant or recurrent ulcerations through correction of the underlying structural deformity with minimal complications.

Clostridium septicum necrotizing fasciitis of the forefoot secondary to adenocarcinoma of the colon: Case report and review of the literature.

Clostridium septicum accounts for 1% of all reported clostridial infections. C septicum infections are most often nontraumatic in nature and associated with either an occult colonic or hematologic malignancy. The initial presentation of a C septicum infection can be relatively benign with rapid progression to fatality without emergent treatment. Presented is a case of necrotizing fasciitis of the forefoot caused by C septicum associated with an occult adenocarcinoma of the colon in a patient with uncontrolled diabetes. The process we used to achieve successful functional limb preservation based on rapid surgical intervention and use of a multidisciplinary approach to medical and surgical management of this patient is discussed in detail, as well as a through review of the literature regarding the association between malignancies and C septicum infections.

Use of a Surgical Preparation and Sterile Dressing Change During Office Visit Treatment of Chronic Foot and Ankle Wounds Decreases the Incidence of Infection and Treatment Costs

Foot and ankle surgeons work with a patient population burdened by multiple factors that adversely affect wound healing and the ability to combat infection. As a result, many of these patients are seen for treatment of chronic ulcerations on their lower extremities that are highly susceptible to colonization and possible progression to a limb- and/or life-threatening infection. The Limb Preservation Service at the Madigan Army Medical Center hypothesized that implementation of a standardized protocol involving a formal physician-directed surgical preparation of the affected lower extremity and a physician-applied sterile dressing at each outpatient clinic appointment would reduce the incidence of infection, use of systemic antibiosis, and thus the requirement for frequent follow-up office appointments. Initiation of this protocol resulted in the reduction of infection to the extent that antibiotic need was eliminated. The frequency of office visits required for follow-up was also significantly reduced. This is key in treating a patient population in which the financial burden to treat chronic wounds and associated infections represents a large portion of the health care money spent for their medical care.

Percutaneous Bone Marrow Aspirate and Bone Graft Harvesting Techniques in the Lower Extremity

Autogenous bone marrow aspirate and cancellous bone graft represent a useful adjuvant to enhance soft tissue and osseous healing in high-risk patients. The authors present a review of the pertinent literature and step-by-step guidelines for performing reliable, simple, and reproducible percutaneous surgical techniques to harvest autogenous bone marrow aspirate and cancellous bone graft from the proximal medial tibial metaphysis and lateral calcaneus. In addition, these techniques are associated with low morbidity and financial cost.

Use of platelet-rich plasma with split-thickness skin grafts in the high-risk patient.

Split-thickness skin grafting (STSG) is commonly employed for soft-tissue coverage because of its broad application for use, ease of harvest, and universal equipment. STSG healing proceeds through 3 stages: (1) anchorage, (2) inosculation, and (3) maturation. The success of the first 2 stages is critical to the overall success. Bolster dressings of various types are universally applied to create apposition of the skin graft with the granular bed, thereby preventing shearing forces and fluid accumulation until vascular ingrowth can occur. The application of autologous platelet-rich plasma (PRP) to STSG application sites has been recently described and theorized to provide immediate skin graft anchorage as well as inosculation of the STSG with nutrient-rich blood media. This study was performed to report the time to ≥90% primary healing of STSGs augmented with application of PRP in a high-risk patient population. The mean time to ≥90% STSG recipient site healing was 16 ± 4.2 days, as determined by retrospective chart review and digital photograph analysis. The addition of PRP to STSG recipient sites seems to enhance primary healing and reduce healing time, likely as a result of shearing force reduction and enhancement of the wound environment with growth factors.

Antithrombotic Pharmacologic Prophylaxis Use During Conservative and Surgical Management of Foot and Ankle Disorders: A Systematic Review

The use of antithrombotic pharmacologic prophylaxis during conservative or postoperative management of foot and ankle disorders is controversial. This article presents a systematic review of the incidence of deep venous thrombosis (DVT)/pulmonary embolus (PE) during management of foot and ankle disorders in patients who did or did not receive antithrombotic pharmacologic prophylaxis. Incidence of DVT/PE in both groups was low; however, more than half of the patients in both groups received some form of antithrombotic pharmacologic prophylaxis of varying duration, making it difficult to determine the true protective effect of antithrombotic pharmacologic prophylaxis.

Factors associated with successful Chopart amputation in patients with diabetes: a systematic review.

Chopart amputations were first performed for treatment of a non-salvageable distal foot but became unfavorable because of the development of equinovarus contractures and ulcerations. The majority of below-knee amputations today occur in ambulatory patients with diabetes in which a Chopart amputation may be a viable option; however, the durability of the residual limb is questionable. The authors undertook a systematic review of electronic databases and other relevant sources to identify material relating to the factors associated with a successful Chopart amputation in ambulatory patients with diabetes. Studies were eligible for inclusion only if they consecutively enrolled ambulatory patients with diabetes who underwent a Chopart amputation, regardless of etiology, with or without any tendinous or osseous balancing performed and had a mean follow-up of ≥12 months duration. Four studies involving 74 patients/feet were identified that met the inclusion criteria with a weighted mean follow-up of 21.1 months. The efficacy of tendinous and/or osseous balancing could not be assessed because of the lack of comparable techniques. However, review of the included studies supports that a residual functional limb can be maintained for ≥12 months with the use of a properly fitting high-profile prosthetic device for lifelong ambulation.

A literature-based guide to the conservative and surgical management of the acute Charcot foot and ankle

Acute Charcot neuroarthropathy of the foot and ankle presents with the insidious onset of a unilateral acutely edematous, erythematous, and warm lower extremity. The acute stages are typically defined as Eichenholtz Stage 1, or Stage 0, which was first described by Shibata et al. in 1990. The ultimate goal of treatment is maintenance of a stable, plantigrade foot which can be easily shod, minimizing the risk of callus, ulceration, infection, and amputation. The gold standard of treatment is non-weight-bearing immobilization in a total contact cast. Surgical intervention remains controversial. A review of the literature was performed to provide an evidenced-based approach to the conservative and surgical management of acute Charcot neuroarthropathy of the foot and ankle.

V-Y Fasciocutaneous Advancement Flap Coverage of Soft Tissue Defects of the Foot in the Patient at High Risk

This single-center, observational case series involved a review of prospectively collected data pertaining to 16 V-Y fasciocutaneous advancement flaps performed on 16 consecutive patients between August 2006 and December 2008. Each patient underwent primary excision of a foot ulcer with debridement of soft tissue and bone, insertion of polymethylmethacrylate antibiotic-loaded bone cement, and immobilization. At an average of 3 days after the index procedure, soft tissue and osseous deformities were corrected in 13 of the 16 patients, and a V-Y fasciocutaneous advancement flap was used for coverage of the soft tissue defect in all patients. Patients were kept nonweightbearing and were followed up until clinical healing occurred or failure was declared. There were 12 male and 4 female patients with a mean age of 64.0 +/- 7.4 years (range, 48-75 years). Fifteen patients had diabetes mellitus with a mean of 5.1 +/- 1.8 (range, 3-8) medical comorbidities. There were 10 medial forefoot, 3 central forefoot, 2 lateral forefoot, and 1 dorsal midfoot full-thickness soft tissue defects that displayed a mean diameter of 2.3 +/- 1.4 cm (range, 1.0-3.5 cm). All but 4 flaps healed primarily, with each developing marginal dehiscence that healed with local wound care measures. Two deep infections occurred despite healing of the flap, which necessitated transmetatarsal amputation with split-thickness skin graft coverage. When properly performed and after complete resolution of infection, V-Y fasciocutaneous advancement flap coverage of complex foot ulcerations represents a useful and reliable technique even in patients with multiple medical comorbidities.