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Fractures of the talus are significant injuries and are usually intra-articular. The authors discuss the evaluation and management of a patient with a delayed union of a talar body fracture. Assessment of talar vascularity and joint integrity should be performed preoperatively. The role of internal fixation and continuous passive motion is discussed.
People at risk for diabetic foot ulcer (DFU) often misunderstand why foot ulcers develop and what self-care strategies may help prevent them. The etiology of DFU is complex and difficult to communicate to patients, which may hinder effective self-care. Thus, we propose a simplified model of DFU etiology and prevention to aid communication with patients. The Fragile Feet & Trivial Trauma model focuses on two broad sets of risk factors: predisposing and precipitating. Predisposing risk factors (eg, neuropathy, angiopathy, and foot deformity) are usually lifelong and result in “fragile feet.” Precipitating risk factors are usually different forms of everyday trauma (eg, mechanical, thermal, and chemical) and can be summarized as “trivial trauma.” We suggest that the clinician consider discussing this model with their patient in three steps: 1) explain how a patient’s specific predisposing risk factors result in fragile feet for the rest of life, 2) explain how specific risk factors in a patient’s environment can be the trivial trauma that triggers development of a DFU, and 3) discuss and agree on with the patient measures to reduce the fragility of the feet (eg, vascular surgery) and prevent trivial trauma (eg, wear therapeutic footwear). By this, the model supports the communication of two essential messages: that patients may have a lifelong risk of ulceration but that there are health-care interventions and self-care practices that can reduce these risks. The Fragile Feet & Trivial Trauma model is a promising tool for aiding communication of foot ulcer etiology to patients. Future studies should investigate whether using the model results in improved patient understanding and self-care and, in turn, contributes to lower ulceration rates.
Proposed Mechanism of Action of Topically Applied Autologous Blood Clot Tissue
A Quintessential Cellular and Tissue-Based Therapy
Background: Chronic wounds, especially in patients with diabetes, often represent clinical challenges. Recently, the use of a topically applied blood clot has garnered significant interest. This stromal matrix contains viable cells that are autologous, biocompatible, biological, and consistent with a metabolically active scaffold. It has been shown to be safe, effective, and cost-efficient. However, the mechanism of action of this modality remains elusive. We sought to identify a potential mechanism of action of an autologous blood clot.
Methods: Review of clinical and scientific literature hypothesizes on how autologous blood clots may stimulate healing and facilitate the movement of critical substrates while lowering bioburden and fostering angiogenesis.
Results: Blood serves as a carrier for many components: red blood cells, white blood cells, platelets, proteins, clotting factors, minerals, electrolytes, and dissolved gasses. In response to tissue injury, the hemostatic mechanism uses a host of vascular and extravascular responses initiating primary, secondary, and tertiary hemostasis. The scaffold created by the autologous blood clot tissue provides a medium in which the body can transform the wound from a nonhealing chronic condition into a healing acute condition. The autologous blood clot tissue also creates a protective setting for the body to use its own mechanisms to promote wound healing in an organized manner. This transient scaffold recruits surrounding fibroblasts and promotes cell ingrowth to foster granulation tissue remodeling. Cells in this matrix sense not only soluble factors but also their physical environments. This well-orchestrated mechanism includes signals from soluble molecules, from the substrate/matrix to which the cell is adherent, from the mechanical or physical forces acting on it, and from contact with other cells. Topically applied autologous blood clot tissue can lower bacterial bioburden while stimulating angiogenesis and fostering the movement of keratinocytes and fibroblasts.
Conclusions: Topically applied autologous blood clot tissue is a formidable cellular and tissue-based therapy that has been shown to be safe and effective. Although the central component of this therapy is blood, the autologous clot tissue creates a scaffold that performs as a biological delivery system that functions to control the release of growth factors and cytokines over several days.
Surgical matrixectomies and phenol alcohol matrixectomies have been effective in eliminating certain nail conditions. The complication rate is at an acceptable level; however, there is a need for comparison to other techniques, such as negative galvanism, trephine, osteotripsy, and laser ablation. Of the 353 patients in this study, two were known diabetics who were seen preoperatively by a vascular surgeon for vascular studies and by their internist. Both consultants agreed that the patients would heal. Both patients healed without complications. The author described the use of a modified Frost partial matrixectomy and modified Fowler total matrixectomy in this review. The phenol alcohol technique had a total complication rate of 9.6%, as did the partial matrixectomy. The total matrixectomy had an overall complication rate of 10.9%.
Acute dysvascular limb in young adults is a rare entity. Diagnosis is often difficult because symptoms are not recognized as ischemic. The most common causes of this condition are premature atherosclerosis, thromboangiitis obliterans, microemboli, popliteal entrapment syndrome, collagen vascular disease, Takaysu's arteritis, and coagulopathy. A case study is presented to illustrate the disease process. A systematic approach to diagnosis, consisting of history and physical examination, palpation and auscultation of peripheral pulses at rest and following exercise, and noninvasive vascular examination at rest and following exercise, is recommended. Suggestion of an ischemic condition following noninvasive studies should be followed up with an arteriogram. The prognosis is dependent on the underlying etiology of the ischemia, early detection, and appropriate treatment.
A second case of compartment syndrome affecting the dorsal aspect of the foot has been presented. The syndrome was arrested by fasciotomy. There were no permanent neurologic, vascular, or musculoskeletal sequelae. Although techniques exist to obtain quantitative measurements of intracompartmental pressure, the diagnosis rests heavily on clinical assessment. Practitioners who encounter trauma victims must recognize the symptoms of the condition and be familiar with the procedures necessary to interrupt it.
A pedal complication of Milroy's disease has been presented. With a history of multiple debridement procedures as in this case, there is the risk of recurrent infections and the possibility of permanent vascular compromise, particularly with respect to the thin pedal skin on the dorsal aspect. When the toes are recurrently involved with infection, a patient may be best served with a transmetatarsal amputation using a skin flap on the plantar aspect.
Skin grafting is a useful adjunct to treating open wounds. It not only provides rapid wound coverage, but also eliminates the pain and the risk of further infection associated with open wounds. A successful skin graft take requires a well vascularized and relatively sterile bed, as well as complete resolution of any surrounding infection. The author reviews the indications and techniques for obtaining a successful skin graft take.
Theories about the nature of cavernous hemangiomas have been reviewed. Most authors believe that such vascular tumors are congenital. The influence of pregnancy on the growth of these tumors was exemplified in a case report, and explanatory mechanisms were offered. Occurrences of cavernous hemangiomas that involve the foot were reported in the literature, ranging from 4.9% to 28.5% of all cases reviewed. X-ray findings of phleboliths and the importance of angiography in planning treatment were emphasized. In the authors' case report, a satisfactory surgical result was obtained in a plantar foot lesion that would otherwise have required amputation.
Dermatologic, vascular, neurologic, and musculoskeletal complications are common among persons with acquired immunodeficiency syndrome (AIDS). These manifestations frequently involve the lower extremities and may be the initial presenting symptoms of human immunodeficiency virus (HIV) infection. It is important that practitioners of podiatric medicine be aware of these syndromes to facilitate early diagnosis of AIDS and to provide the best possible care for immunodeficient patients. The author provides a review of the manifestations of AIDS frequently encountered in podiatric practice, along with guidelines for treatment.
