Isolated dislocation of the ankle with grade III open fracture has been scarcely reported. These ankle injuries usually involved mortise fractures, complete dislocation of the tibial astragaloid joint, capsuloligamentous structure disruption, and severe soft-tissue damage. There is no well-recognized regimen that would result in desirable outcomes.
Sixteen patients with grade III open dislocated ankle fractures were treated immediately with bioabsorbable implants and an external fixator between January 2003 and June 2007. According to the classification system of Gustilo and Anderson, five patients were grade IIIA, seven were grade IIIB, and four were grade IIIC. Surgical interventions included combined internal fixation with bioabsorbable screws/rods and external fixation.
Patients underwent clinical and radiologic examination at an average of 18.1 months after surgery. Outcomes were excellent in seven patients (three IIIA, three IIIB, and one IIIC), good in four (one IIIA, two IIIB, and one IIIC), fair in three (one IIIA, one IIIB, and one IIIC), and poor in two (one IIIB, and one IIIC). In the two patients with poor outcomes, bone defect and cartilage exfoliating in the distal tibia were found during surgery. Painful osteoarthritis in the ankle was discovered 2 years after surgery. Another case had pin tract infections in the external fixator 3 months after surgery. There was no case of late deep infection.
It may be a reasonable and desirable option that bioabsorbable implants combined with an external fixator be applied for treatment of severe open dislocated ankle fractures. (J Am Podiatr Med Assoc 101(4): 307–315, 2011)
Background: We used a model of lower-extremity ulceration to determine the impact of a podiatric lead limb preservation team on identified relationships among risk factors, predictors of ulceration, amputation, and clinical outcomes of lower-extremity disease in patients with diabetes mellitus.
Methods: A total of 485 patients with diabetes mellitus were randomly selected from the diabetic population and included in this retrospective cohort study. Patients were then stratified into two groups: those who received specialty podiatric medical care and those who did not. Data covering a 5-year period were collected using electronic medical records and chart abstraction to capture detailed treatment characteristics, ulcer status, and surgical outcomes.
Results: Overall, the frequencies of inpatient and outpatient encounters and the durations of hospital stays were significantly greater with increasing wound depth and in the presence of infection. In addition, the overall ulcer incidence was greater in patients with callus (34.3% versus 10.3%, P < .0001) with and without neuropathy (20.4% and 4.1%, P < .0001). Among patients treated in a specialty multidiscipline podiatric medical setting, the proportion of all amputations that were “minor” was significantly increased (33.7% versus 67.3%, P = .0006), and survival was significantly improved (19.5% versus 7.7%, P < .0001).
Conclusions: Early identification of individuals at increased risk for lower-extremity ulceration and subsequent referral for advanced multidiscipline podiatric medical specialty care may decrease rates of ulceration and proximal amputation and improve survival in patients with diabetes mellitus who are at high risk for ulceration and limb loss. (J Am Podiatr Med Assoc 100(4): 235–241, 2010)
Background: This retrospective study of a case series analyzed the results from the application of a distally based adipofascial sural flap for nonweightbearing defects of the foot and ankle.
Methods: Twenty-eight patients with post-traumatic ankle and foot defects (ten women and 18 men; age range, 17–63 years) underwent surgery between November 1, 2003, and November 30, 2008. Distally based adipofascial sural flaps were used in ten open fractures, 14 soft-tissue post-traumatic defects, and four deep burns. Defects were on the dorsal side of the foot (eight cases), the lateral malleolus (four cases), the medial malleolus and inframalleolar region (four cases), the Achilles tendon region (eight cases), and the anterior surface of the ankle (four cases). Surgical procedures were performed by a single surgeon (A.M.).
Results: All of the flaps healed uneventfully. There was no partial or total flap loss. All 28 patients walked normally at the time of follow-up. Three delayed healings occurred at the donor site.
Conclusions: This is a homogeneous series of lower-limb reconstructions with the distally based adipofascial sural flap, which permits better analysis of the results. This flap has a constant and reliable blood supply. It can be used for the reconstruction of nonweightbearing foot and ankle regions to avoid the bulky volume of the fasciocutaneous flap in this area and to minimize the donor site scar. (J Am Podiatr Med Assoc 101(1): 41–48, 2011)
Vancomycin is a common treatment option for skin and skin structure infections caused by methicillin-resistant Staphylococcus aureus (MRSA). Given the increasing prevalence of MRSA, vancomycin is widely used as empirical therapy. In patients with lower-limb infections, antimicrobial penetration is often reduced because of decreased vascular perfusion. In this study, we evaluated the tissue concentrations of vancomycin in hospitalized patients with lower-limb infections.
An in vivo microdialysis catheter was inserted near the margin of the wound and was perfused with lactated Ringer's solution. Tissue and serum samples were obtained after steady state for one dosing interval. Tissue concentrations were corrected for percentage of in vivo recovery using the retrodialysis technique.
Nine patients were enrolled (mean ± SD: age, 54 ± 19 years; weight, 105.6 ± 31.5 kg). Patients received a mean of 12.8 mg/kg of vancomycin every 12 hours (n = 7), every 8 hours (n = 1), or every 24 hours (n = 1). Mean ± SD steady-state trough vancomycin concentrations in serum and tissue were 11.1 ± 3.3 and 6.0 ± 2.6 μg/mL. The mean ± SD 24-hour free drug areas under the curve for serum and wound were 283.7 ± 89.4 and 232.8 ± 75.7 μg*h/mL, respectively. The mean ± SD tissue penetration ratio was 0.8 ± 0.2.
These data suggest that against MRSA with minimum inhibitory concentrations of 1 μg/mL or less, vancomycin achieved blood pharmacodynamic targets required for the likelihood of success. Reduced concentrations may contribute to poor outcomes and the development of resistance. As other literature suggests, alternative agents may be needed when the pathogen of interest has a minimum inhibitory concentration greater than 1 μg/mL.
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)
Serratia marcescens is a ubiquitous, facultatively anaerobic, gram-negative bacillus that has been cited to cause infection in immunocompromised populations. In the literature, S marcescens infections of the lower extremity have presented as granulomatous ulceration, abscess, bullous cellulitis, and necrotizing fasciitis. Herein we present a series of three cases of lower-extremity infections in which S marcescens was the sole or a contributing pathogen. We discuss the commonalities of these three cases as well as with those previously cited. All three patients presented with some combination of a similar set of clinical characteristics, including bullae formation, liquefactive necrosis, and black necrotic eschar. All three patients were diabetic and had peripheral vascular disease.
Achieving timely healing of foot ulcers can help avoid complications such as infection and amputation; topical oxygen therapy has shown promise in achieving this. We evaluated the clinical effectiveness of Granulox, a hemoglobin spray device designed to deliver oxygen to the surface of wounds, for the healing of foot ulcers.
We conducted a single-center, prospective, randomized controlled trial comparing standard of care (once-weekly podiatric medical clinic visits) versus standard care plus adjunct Granulox therapy twice weekly in adults with foot ulcers. After a 2-week screening phase, patients in whom the index wound had healed by less than 50% were randomized 1:1. Outcome measures were collated during the trial phase at 6 and 12 weeks.
Of 79 patients enrolled, 38 were randomized. After 12 weeks, the median percentage wound size reduction compared with the size of the ulcer at the start of the trial phase was 100% for the control arm and 48% for the Granulox arm (P = .21, Mann-Whitney U test). In the former, eight of 14 foot ulcers had healed; in the latter, four of 15 (P = .14, Fisher exact test). In the control arm, two amputations and one withdrawal occurred, whereas in the Granulox arm, one unrelated death and five withdrawals were recorded.
We could not replicate the favorable healing associated with use of Granulox as published by others. Differences in wound chronicity and frequency of Granulox application might have influenced differences in study results. Granulox might perform best when used as an adjunct for treatment of chronic wounds at least 8 weeks old.
The purpose of this study was to report the management and outcomes of ten patients with chronic Achilles tendon rupture treated with a turndown gastrocnemius-soleus fascial flap wrapped with a surgical mesh (Hyalonect).
Ten men with neglected Achilles tendon rupture were treated with a centrally based turndown gastrocnemius fascial flap wrapped with Hyalonect. Hyalonect is a knitted mesh composed of HYAFF, a benzyl ester of hyaluronic acid. The Achilles tendon ruptures were diagnosed more than 1 month after injury. The mean patient age was 41 years. All of the patients had weakness of active plantarflexion. The mean preoperative American Orthopaedic Foot and Ankle Society score was 64.8.
The functional outcome was excellent. The mean American Orthopaedic Foot and Ankle Society score was 97.8 at the latest follow-up. There were significant differences between the preoperative and postoperative scores. Ankle range of motion was similar in both ankles. Neither rerupture nor major complication, particularly of wound healing, was observed.
For patients with chronic Achilles tendon rupture with a rupture gap of at least 5 cm, surgical repair using a single turndown fascial flap covered with Hyalonect achieved excellent outcomes.
This randomized, prospective, multicenter, open-label study was designed to test whether a topical, electrolyzed, superoxidized solution (Microcyn Rx) is a safe and effective treatment for mildly infected diabetic foot ulcers.
Sixty-seven patients with ulcers were randomized into three groups. Patients with wounds irrigated with Microcyn Rx alone were compared with patients treated with oral levofloxacin plus normal saline wound irrigation and with patients treated with oral levofloxacin plus Microcyn Rx wound irrigation. Patients were evaluated on day 3, at the end of treatment on day 10 (visit 3), and 14 days after completion of therapy for test of cure (visit 4).
In the intention-to-treat sample at visit 3, the clinical success rate was higher in the Microcyn Rx alone group (75.0%) than in the saline plus levofloxacin group (57.1%) or in the Microcyn Rx plus levofloxacin group (64.0%). Results at visit 4 were similar. In the clinically evaluable population, the clinical success rate at visit 3 (end of treatment) for patients treated with Microcyn Rx alone was 77.8% versus 61.1% for the levofloxacin group. The clinical success rate at visit 4 (test of cure) for patients treated with Microcyn Rx alone was 93.3% versus 56.3% for levofloxacin plus saline–treated patients. This study was not statistically powered, but the high clinical success rate (93.3%) and the P value (P = .033) suggest that the difference is meaningfully positive for Microcyn Rx–treated patients.
Microcyn Rx is safe and at least as effective as oral levofloxacin for mild diabetic foot infections. (J Am Podiatr Med Assoc 101(6): 484–496, 2011)
The authors reviewed 91 surgical procedures in 87 patients with chronic Achilles tendinopathy. There were 62 males and 25 females (mean age, 44.9 years). The average interval between surgery and review for the group was 4.2 years (range, 1 to 10 years). Twenty patients underwent peritenolysis, with a mean return-to-activity time of 7.7 weeks. Four patients with concomitant bony procedures had significantly longer return-to-activity times than 16 patients who underwent peritenolysis only. The mean return-to-activity time was 13.2 weeks in 15 patients who had Achilles debridement for mucoid degeneration, 14.4 weeks in 32 Achilles tendocalcinosis repair patients, 18.6 weeks in 24 patients who had retrocalcaneal exostectomy procedures, and 34.0 weeks in 5 patients who had chronic Achilles rupture repair. Athletic patients (n = 47) had significantly shorter return-to-activity times than active (n = 38) and sedentary (n = 6) patients. Males returned to activity faster than females. Runners returned to activity faster than other patients. (J Am Podiatr Med Assoc 93(4): 283-291, 2003)