Lower extremity vascular prosthesis infection-successful salvage with local muscular flap reconstruction

The development of prosthetic arterial substitute has revolutionized the management of patients with aneurysmal and occlusive disease. Despite the prolonged graft usage and numerous refinements in fabrication, infection remains a disastrous problem. Infected or exposed vascular prosthesis is more encountered in lower extremity bypass operations. Multiple surgical approaches approved its efficacy for treatment of such complication among which is the usage of local muscle flap. To study the effect of local muscle flap [Sartorius] reconstruction for salvaging an infected or exposed vascular prosthesis in the lower extremity. Seventeen patients with infected or exposed vascular prosthesis in the lower extremity were studied during the period 2002-2007. They included 14 patients at the groin incision and three at the supragenicular incision. Their medical records were reviewed. Sartorius myoplasty was performed to all cases. The study was extended to include 17 patients, mean age 55.3 years. There were 12 males and 5 females. The initial operations were recorded. Twelve patients presented by chronic discharging sinus, while exposed grafts were the presentation in 5 patients. Sartorius myoplasty was done for 14 infected prostheses at the groin and for three at supragenicular incision. Follow up to all cases was done with a mean interval time, 16 months, with complete wound healing except in one case. Muscle flap coverage of infected wounds following vascular procedures has been helpful not only for filling large tissue defects but also to assist resolution of limited graft infection. It was performed by Wagensteen in 1940, Numerous advantages attend the use of sartorius muscle flap coverage for vascular graft preservation, Multiple researches were done all over the world and were supporting for its usage. In our study, we reported complete wound healing with graft preservation except in one case. Sartorius myoplasty is a simple effective and durable local reconstructive procedure, for treating infected or exposed graft at the groin or supragenicular incision

Dorsal resection of metatarsal head for diabetic foot plantar ulcers

Treatment of diabetic neuropathic foot ulcers is a difficult challenge for general surgeon. Major changes have taken place in the management of diabetic foot ulcers in the past decade. A full appreciation of the causes of foot ulceration, and accurate categorization of the patient population combined with early, aggressive surgical care have led to a considerable reduction of patient morbidity. The purpose of this study was to assess the effect of surgical excision of the metatarsal head from the dorsal aspect of the foot on healing of diabetic plantar foot ulcers. A prospective study was carried out on 66 diabetic patients with plantar forefoot ulcers. All ulcers had remained unhealed despite intensive conservative treatment. All patients were subjected to metatarsal head resection operation through dorsal incision to alleviate high pressure areas and enable rapid healing of ulcers. The study was performed during the period 2002 - 2007. The mean age was 49.9 +/- 7.2 years. The mean preoperative time for which ulcers had been present was 21.1 +/- 2.3 months. The mean postoperative time was 3.1 +/- 1.2 months without recurrence. The mean follow up period was 12.1 +/- 6.2 months during which we recorded minor complications in seven patients. The numerous manifestations of diabetic neuropathy affect up to 50% of patients but despite much intensive research, the pathophysiology remains unclear. Neurological deficits in combination with prolonged hyperglycemia play an important role in the evolution of these lesions. Creation of high plantar pressure areas with increased shear forces on the sole lead to prominence of metatarsal heads that act as a hummer striking point during ambulation. Metatarsal head resection is designed to reduce the pressure at the ulcer site enabling rapid healing. The results of our study show that all ulcers healed within a short time [3.1 +/- 1.2 month] without recurrence. metatarsal head resection is a simple and reliable procedure for treatment of diabetic neuropathic ulcers