The utility of wound debridement has expanded to include the management of all chronic wounds, even in the absence of infection and gross necrosis. Biofilms, metalloproteases on the wound base, and senescent cells at the wound edge irreversibly change the physiologic features of wound healing and contribute to a pathologic, chronic inflammatory environment. The objective of this review is to provide surgeons with a basic understanding of the processes of debridement in the noninfected wound. (J Am Podiatr Med Assoc 100(5): 353–359, 2010)
Background: A retrospective review of one surgeon’s practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon.
Methods: We evaluated the incidence of infection and other wound complications, such as suture reactions, scar revision, hematoma, incisional neuromas, and granuloma formation.
Results: A total of 219 surgical cases were available for review (140 males and 70 females; mean ± SD age at the time of surgery, 46.5 ± 12.6 years; age range, 16–75 years). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, for a total complication rate of 10.0%. Six patients had more than one complication; therefore, the percentage of patients with complications was 7.3%. There were no hematomas. Seven patients had additional surgery after their wound complications; some had simple granuloma excision, and one necessitated a flap. Patients with risk factors such as diabetes mellitus, smoking, and rheumatoid arthritis necessitating corticosteroid therapy were more likely to have a wound complication (Fisher exact test, P = .03).
Conclusions: Complications with Achilles tendon surgery may be unavoidable. Suture granulomas may appear in a delayed manner. Absorbable and nonabsorbable sutures can be implicated. (J Am Podiatr Med Assoc 98(2): 95–101, 2008)
Natural disasters, such as hurricanes and severe flooding, pose a threat of increased skin and soft-tissue infections, especially in the event of open fractures and wading through the waters. The purpose of this case study is to present a complex patient sustaining trauma resulting in an open bimalleolar fracture, multiple wounds, and exposure to a variety of water-borne pathogens during Hurricane Harvey in Houston, Texas, in 2017. He underwent multiple incision and drainage procedures, tissue cultures, and placement of antibiotic beads, with an application of external fixation to the left ankle. Several unique multidrug-resistant water-borne pathogens were identified, including Aeromonas hydrophila, Pseudomonas fluorescens/putida, and Serratia marcescens. Once the soft-tissue envelope was restored and infection cleared, a full-thickness rotational flap with tissue expansion was performed. Ultimate reconstruction was delayed several weeks and final left ankle open reduction and internal fixation was performed following antimicrobial treatment with split-thickness skin autograft and wound vacuum-assisted closure application. The patient was discharged after 28 days with no further complications. In instances such as these, all caretakers coming into contact with the patient should be aware of the potential risks of the possible infectious diseases and management to optimize the recovery following hydrologic disasters.
Background: We sought to determine the incidence of tinea pedis in patients with otherwise asymptomatic pedal interdigital macerations. Both diabetic and nondiabetic populations were compared. Age and body mass index were also examined for their significance.
Methods: Fungal cultures of skin scrapings from 80 patients (77 male and 3 female; mean age, 65 years) with interdigital macerations were performed; 40 patients had previously been diagnosed with type 2 diabetes and 40 did not have diabetes.
Results: Cultures revealed a 40% prevalence of tinea pedis in the total study population. The prevalence in the nondiabetic group was 37.5% and 42.5% for the diabetic group. This was not a statistically significant difference. Among patients with interdigital macerations that yielded positive fungal cultures, those in the nondiabetic group were 6.3 years older than those in the diabetic group. It was also observed that the nondiabetic patients with interdigital macerations yielding positive fungal cultures were 9.1 years older than patients with negative fungal cultures in the nondiabetic group.
Conclusion: The results of this study provide the practitioner with a guide for treating pedal interdigital macerations. Because the likelihood of a tinea pedis infection is 40%, it seems prudent to treat these macerations with an antifungal agent. In regard to age, the results suggest that as nondiabetic patients age, the likelihood of an otherwise asymptomatic interdigital maceration yielding a positive fungal culture increases, and that diabetic patients may be susceptible to interdigital fungal infections at a younger age than those without diabetes. (J Am Podiatr Med Assoc 98(5): 353–356, 2008)
A rare and unusual case of plasma cell dyscrasia of the calcaneus is presented. Clinically, the patient had a draining and painful ulcer that was treated with appropriate antibiotics and wound care but failed to show any signs of healing. Radiographic images showed cystic changes of the calcaneus in the vicinity of the ulcer. Blood work was negative for bone and soft-tissue infection, but uric acid and alkaline phosphatase levels were elevated. Nuclear bone scan showed increased uptake in the calcaneus suggestive of osteomyelitis. One possible differential diagnosis was an intraosseous gouty tophus deposit. Not convinced that this was either a bone infection or gout, the author performed a bone biopsy. Pathologic evaluation indicated plasma cell dyscrasia. Continued wound care healed the ulcer completely, with resolution of pain of his heel. Oncology/hematology was consulted, and 16 months after biopsy, he remains asymptomatic.
An increased reliance on vancomycin to treat bacterial infections has led to the emergence of vancomycin-resistant organisms. The podiatric physician must select and use vancomycin with due caution. This article presents a general review of vancomycin’s pharmacology, pharmacokinetics, and dosing recommendations. Literature citations of clinically based evidence regarding the development and use of vancomycin nomograms are also presented. A vancomycin dosing nomogram is introduced as an effective tool for the prescribing podiatric physician. Appropriate use of the information presented may improve patient outcomes and enable the podiatric physician to treat patients with less effort and at a lower cost. (J Am Podiatr Med Assoc 94(4): 389–394, 2004)
Emergency department visits for lower extremity complications of diabetes are extremely common throughout the world. Surprisingly, recent data suggest that such visits generate an 81.2% hospital admission rate with an annual bill of at least $1.2 billion in the United States alone. The likelihood of amputation and other subsequent adverse outcomes is strongly associated with three factors: 1) wound severity (degree of tissue loss), 2) ischemia, and 3) foot infection. Using these factors, this article outlines the basic principles needed to create an evidence-based, rapid foot assessment for diabetic foot ulcers presenting to the emergency department, and suggests the establishment of a “hot foot line” for an organized, expeditious response from limb salvage team members. We present a nearly immediate assessment and referral system for patients with atraumatic tissue loss below the knee that has the potential to vastly expedite lower extremity triage in the emergency room setting through greater collaboration and organization.
Neuropathic foot ulcers are a common complication in patients with diabetes. These ulcers are often slow to heal and can lead to infection, further tissue destruction, osteomyelitis, and amputation. These patients pose a challenge to clinicians who must determine the best treatment options while balancing the risks, benefits, and costs. Conservative therapies often present disappointing results, and a number of newer “biologic bandages” have been developed to better assist the healing process. We describe results from diabetic patients with neuropathic foot ulcers treated with a new amniotic membrane–based allograft.
External fixation was used to reduce or arrest progressive degeneration in 28 patients with Charcot’s foot dislocations. Adjunctive procedures included tendo Achilles lengthening and application of an external bone stimulator. Advantages of using external fixation are that surgeries are usually performed percutaneously and that most patients are weightbearing in 10 to 14 days. There was no incidence of pin tract infection or further foot collapse, with the longest follow-up period being 24 months. The authors propose that use of external fixation with bone stimulation may be an effective alternative method of treating the Charcot foot. (J Am Podiatr Med Assoc 92(8): 429-436, 2002)
Over a time frame of less than 1 year, a 23-year-old competitive horseback rider experienced a midsubstance tear of both the tibialis anterior and extensor hallucis longus tendons without inciting injury. It was after the second spontaneous tear that the patient's recent diagnosis of Lyme disease became the likely culprit. Often, patients with chronic Lyme disease present with an elaborate clinical picture that can mimic many more common diagnoses such as septic arthritis, transient synovitis, ligamentous sprain, and various other traumatic injuries. With the pathognomonic erythema migrans rash reported to be present less than 50% of the time in late-stage infections, the diagnosis of Lyme disease can often be difficult, with a high rate of underdiagnosis. It is important that Lyme disease be included in the differential diagnosis of spontaneous tendon pathology, especially for physicians practicing in highly endemic areas. The treatment is relatively simple and successful—especially for an acute infection—and it is important to initiate treatment promptly to prevent disability.