Necrotizing fasciitis in a patient with type 2 diabetes mellitus.

Necrotizing fasciitis is a soft-tissue infection characterized by extensive necrosis of subcutaneous fat, neurovascular structures, and fascia. In general, fascial necrosis precedes muscle and skin involvement, hence its namesake. Initially, this uncommon and rapidly progressive disease process can present as a form of cellulitis or superficial abscess. However, the high morbidity and mortality rates associated with necrotizing fasciitis suggest a more serious, ominous condition. A delay in diagnosis can result in progressive advancement highlighted by widespread infection, multiple-organ involvement, and, ultimately, death. We present a case of limb salvage in a 52-year-old patient with type 2 diabetes mellitus and progressive fascial necrosis. A detailed review of the literature is presented, and current treatment modalities are described. Aggressive surgical debridement, comprehensive medical management of the sepsis and comorbidities, and timely closure of the resultant wound or wounds are essential for a successful outcome.

The value of radiographic parameters in the surgical treatment of hallux rigidus.

The purpose of this study was to determine if metatarsal protrusion or the length of the first and second rays were associated with the incidence of hallux rigidus. For this retrospective study, anteroposterior radiographs from 51 patients diagnosed with hallux rigidus and 51 patients without evidence of hallux rigidus were selected for review as a control group. Radiographs were randomly assigned to one of two raters who determined the metatarsal protrusion distance, first metatarsal length, second metatarsal length, length of the proximal phalanx of the hallux, length of the proximal phalanx of the second toe, and overall hallux length. A statistical comparison of these radiographic measurements showed only first metatarsal length to significantly differ (P = .05) between the two groups (65.4 +/- 5.3 mm and 67.7 +/- 5.9 mm for the hallux rigidus and control groups, respectively). The findings of this study suggest the need to revisit the role that metatarsal protrusion distance and first metatarsal length play in the etiology of hallux rigidus. In addition the need to surgically correct a long first metatarsal should be further evaluated.

Plantar fibromatosis.

Plantar fibromatosis is defined as a benign fibrous disorder involving the plantar aponeurosis. Although its incidence is well described on the hands, it is less commonly seen on the feet, and its etiology is unknown. A differential diagnosis for the heel pain along the medial arch could be a benign thickening of the plantar fascia associated with plantar fibromatosis. Its high recurrence after surgical excision and problematic scarring and wound presents a significant challenge to the reconstructive foot and ankle surgeon. This article reviews the history, clinical presentation, pathologic findings, and surgical approaches to the treatment of plantar fibromatosis.

Peroneal tendon pathology.

Peroneal tendon pathology is a common entity but is infrequently reported in the literature. The lesion may be due to partial tears, complete ruptures, subluxation, tenosynovitis, a fractured os peroneum, or damage to the peroneal retinacula. Chronic lateral ankle instability and excessive subtalar and ankle varus rotation may cause damage to the peroneal tendons and their associated structures. This article reviews the pathophysiology, diagnostic imaging, and current surgical techniques for the repair of peroneal tendons.

Neurogenic heel pain.

This article establishes a standard approach for the evaluation of patients with heel pain. With this approach, it should become easier for the physician to distinguish between neurogenic and inflammatory heel pain and to devise a more direct plan for definitive treatment.

Soft tissue reconstruction of the foot with a reverse flow sural artery neurofasciocutaneous flap.

Distally-based sural artery flaps are used to cover soft tissue defects of the lower leg, ankle, and heel. These flaps are vascularized by septocutaneous perforators of the peroneal artery that anastomose with the perineural and perivenous arterial networks of the sural nerve and the lesser saphenous vein, respectively. A retrospective study of seven patients with a distally-based neurofasciocutaneous sural artery flap for ankle or heel defects that had failed conservative treatment was conducted from 1999 to 2003. The presence of a patent peroneal artery was a requirement for this operation. Among the seven patients, the only flap failure occurred in a renal transplant patient who was immunocompromised. The other six patients healed uneventfully and resumed full weight-bearing status. The mean time to return to shoe was 90.2 days. The average healing time of all seven patients was 3.3 months. Based on these results and other documented successes, the procedure can be considered a viable treatment alternative.

The efficacy of prophylactic intravenous antibiotics in elective foot and ankle surgery.

A retrospective chart review of 555 patients who received elective foot and ankle surgeries between 1995 and 2001 at 1 outpatient podiatric hospital clinic was performed to evaluate the efficacy of preoperative intravenous antibiotic use. Only those patients who were having elective foot or ankle surgery for the first time, were being followed up at the hospital's outpatient clinic, and had a nontraumatic cause for their surgery were included in this study. A wound was considered infected when purulent material from the wound sites was noted and an organism(s) was cultured. A wound complication was defined as a superficial dehiscence, edema, erythema, or stitch abscess. Three hundred six (55.1%) patients received a preoperative antibiotic and 249 (44.9%) patients did not. Of the 306 patients who received a preoperative antibiotic, 9 (1.6%) acquired a postoperative wound infection, whereas 8 (1.4%) of the 249 patients who did not receive preoperative antibiotics acquired a postoperative infection. A logistic regression model and chi square tests of association were used to determine if preoperative antibiotic use, age, gender, type of surgical procedure, operative time, tourniquet use, past medical history, and internal fixation were predictive of or associated with postoperative wound infection or complication. None of the study factors was predictive of postoperative wound infection or complication (P >.01). Preoperative antibiotic use was associated with surgical category and internal fixation use (P <.001) but not postoperative wound infection or complication (P >.01). The results suggest that prophylactic intravenous antibiotic use in routine elective foot and ankle surgery is not warranted.

Diabetes mellitus and pharmacological therapy.

Diabetes mellitus can be a devastating lifelong disease if not treated appropriately. The physician and the patient should be aware of both extremes involved with DM: hyperglycemia and hypoglycemia. Patient education and preventive care are perhaps more important in this disease than many others. A multidisciplinary approach involving the patient, physician, and diabetic educator is best to assure a better quality of life. Enormous advances in the treatment of diabetes have occurred over the past decade and even greater ones can be expected in the future. New drugs, insulin delivery devices, and noninvasive glucose monitoring machines have the potential to normalize blood sugar levels and return diabetics to a near normal lifespan without complications.

Diabetic foot infections and antibiotic therapy.

Diabetic foot infections are associated with high morbidity and mortality rates as well as significant financial impact on the health care system. Improved patient outcomes and intelligent use of resources should determine the selection of diagnostic procedures and the therapeutic modalities used. Diabetic patients who develop lower extremity infections require a multidisciplinary approach in the management of their infections and other disorders. Aggressive surgical debridement and appropriate and adequate antibiotic therapy are necessary to successfully treat severe foot infections and permit faster recovery.

External fixation in the management of Charcot neuroarthropathy.

Charcot neuroarthropathy is a complex sequela of neuropathies associated with diabetes mellitus, syringomyelia, alcoholism, and other disorders. The treatment of deformities associated with Charcot neuroarthropathy is evolving from a passive approach to one in which an earlier recognition of the emergence of the event permits an avoidance of deformity. As the understanding of the etiology and natural history of Charcot neuroarthropathy deepens, it has become apparent that many of the deformities that do develop may be reconstructed expeditiously by the surgeon with a thorough understanding of the diabetic foot and experience in the use of external fixation.

Soft tissue reconstruction of the diabetic foot.

Treatment of wounds in the diabetic foot presents a set of difficult problems that requires "out of the box" thinking. The traditional approach of off-loading these wounds is often expensive, time-consuming, and in some cases seemingly never ending. The literature speaks loudly for a change in the philosophy of treating chronic wounds. When developing a team to treat chronic diabetic wounds, a reconstructive foot and ankle surgeon trained in these techniques is an appropriate addition to the team.

Digital artery flaps for closure of soft tissue defects of the forefoot.

Reconstruction of recalcitrant soft tissue defects in the weightbearing surface of the forefoot can be achieved by using a neurovascular island flap. Island flaps, based on a pedicle from either the proper digital artery or the common digital artery, were used to provide supple and durable coverage. A retrospective analysis was performed on 12 patients who underwent a total of 15 digital artery flaps. There were 7 patients with neuropathic ulcers, 7 with a dysfunctional scar, and 1 with an ischemic ulcer after lower-extremity bypass. There was a failure rate of 13%; 2 flaps fully necrosed, necessitating a revisional digital artery flap. Minor complications were reported in 73% of cases; average time to complete healing was 71 days. All healed flaps have remained viable and durable at an average follow-up of 22.5 months from the date of surgery (range, 3 to 61 months).