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.
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.
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.
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.
Reflex sympathetic dystrophy syndrome is a troublesome, complex disorder that presents with chronic, unexplained aching or burning pain, the intensity of which is incommensurable with the original injury. Six diagnostic criteria have been described by Genant et al: pain and tenderness in the extremities; swelling of soft tissue; diminished motor function; trophic skin changes; vasomotor instability; and patchy osteoporosis. Currently, the most widely accepted etiology is an initial vasomotor reflex spasm occurring after an injury to the extremity, followed by a loss of vascular tone, persistent vasodilation, and rapid bone resorption.
Administration of air under the skin produced a pouch wall that closely resembled a synovium in that the inner lining was made up of macrophages and fibroblasts. Administration of 1% carrageenan directly into the 7-day-old air pouch produced an inflammation characterized by an increased number of mast cells in pouch fluid as well as an increase in wall vascularity. A punch biopsy weight of the pouch wall did not reveal an increase in 1% carrageenan-treated animals. However, a 10% Aloe vera treatment of carrageenan-inflamed synovial pouches reduced the vascularity 50% and the number of mast cells in synovial fluid 48%. The pouch wall punch biopsy weight was increased by A. vera, which was verified by histologic examination of the inner synovial lining. Aloe vera stimulated the synovial-like membrane, as evidenced by an increased number of fibroblasts, suggesting that A. vera stimulated fibroblasts for growth and repair of the synovial model. The synovial air pouch can be used to study simultaneously the acute anti-inflammatory and fibroblast stimulating activities of A. vera.
Fifteen percent of individuals with diabetes will likely develop foot ulcers in their lifetime, and approximately 15% to 20% of these ulcers are estimated to result in lower extremity amputation. Techniques to prevent lower extremity amputation range from the simple but often neglected foot inspection to complicated vascular and reconstructive foot surgery. Appropriate management can prevent and heal diabetic foot ulcers, thereby greatly decreasing the amputation rate and medical care costs. Prevention is the key to treatment. The author discusses general guidelines for foot screening and identifies three specific goals for prevention of amputation: 1) identification of at risk individuals needing prevention and the specific factors placing them at risk; 2) protection of the foot against the adverse effects of external forces (pressure, friction, and shear); and 3) reduction of the incidence of diabetic foot ulcers through educational programs.
The authors presented an overview of the development of antibiotic-loaded bone cement beads and their indications for usage, method of application, advantages, disadvantages, and causes of failure. This method of treatment for bone and soft tissue infections of the foot is not a panacea and should be used only in selected cases. The vascular status and the physiologic ability of the patient to heal a peripheral wound or infection are the basis for the success of this method of therapy. European literature makes little mention of adjunctive systemic antibiotic therapy with local antibiotic-loaded bone cement bead use. It is the authors' opinion that clinical judgment should be used to determine the necessity for such therapy.
This article discusses the advantages and disadvantages of primary wound healing as compared with primary amputation in individuals with chronic diabetic foot wounds. The authors review the potential benefits of vascular surgical procedures and advanced dressings, including two of the most promising modalities in modern wound care: growth factors and bioengineered skin. In this era of cost-conscious health-care administration, it is incumbent on the practitioner to consider not only the basic science of wound care, but also the economic aspect of treatment rendered. These various interventions, dressings, growth factor delivery systems, and new modalities could significantly reduce healing time, thereby reducing the risk of infection, hospitalization, and amputation while improving quality of life. If so, they may be truly cost-effective.
Multiple surgical strategies are available for managing the infected diabetic foot at risk for amputation. The authors present their experience with the closed instillation system in the management of 30 such cases in 29 patients over a 5-year period. Data were collected from the hospital records of neuropathic patients presenting with deep-plantar-space infections or presumed acute osteomyelitis. All 29 patients were male; 57% had marginal or poor vascular supply, and 83% were nutritionally compromised or had proteinuria. At the conclusion of the study, 34% of the patients were dead, reflecting the severity of comorbid conditions found in this population. Despite the marginal healing capacity of these patients, the procedure had a 90% success rate, as defined by expeditious return to prior level of functioning and residential living situation without need for re-operation or higher-level amputation.