Treatment of diabetic (neuropathic) foot ulcers with two-stage debridement and closure.

We reviewed 33 patients with 37 wounds treated between November of 1991 and December of 1995 in the Wound Care Center. A two-stage debridement and closure technique for neuropathic foot ulcers was performed. Patients selected included those with obvious osteomyelitis and those who had failed nonsurgical treatment. The approach included initial surgical excision of the ulcer with biopsy, bone resection with biopsy, and deep culture. The second-stage procedure 4 to 8 days later included debridement of the wound and delayed closure. Intravenous antibiotic treatment using a central line was given postoperatively in patients with documented osteomyelitis for at least 6 weeks and in patients with infected soft tissues only for about 4 weeks. All patients remained nonweightbearing for 4 weeks; this was felt necessary to prevent separation of the wound edges. Four wounds in four patients failed to heal, and two of these went on to amputation. Satisfactory healing occurred in 29 of 33 patients and in 33 of 37 wounds. The authors conclude that two-stage surgical debridement and closure is an acceptable treatment in selected nonhealing diabetic (neuropathic) foot ulcers.

Chopart's fracture dislocation: a case report and review of the literature.

The prompt identification of peri-talar dislocation with immediate reduction and early range of motion will generally result in a good outcome. Higher energy injury with greater soft tissue compromise and associated fractures worsen the prognosis. Salvage procedure for post-traumatic degenerative changes require arthrodesis for relief of pain. The deformity is usually apparent on physical examination, but occasionally is masked by marked early swelling. A high index of suspicion should be maintained with high or low energy injury to the foot and ankle with normal ankle radiographs. This particular case is unusual in that the patient was able to function as a farmer even with the fracture dislocation. This again is probably explained by his mild peripheral neuropathy. This case, however, does demonstrate the difficulty in making the diagnosis.

Melorheostosis of the foot: a case report and review of the literature.

As seen in the case presented, melorheostosis is a bony dysplasia showing irregular wavy lines of hyperostotic bone. Clinically, patients present variably, ranging from incidental radiographic discovery of the syndrome to severe deformities and pain. Subsequently, diagnosis is often delayed or missed. Treatment is usually symptomatic, although surgical correction of deformities is often pursued. Unfortunately, these surgeries may be complicated with frequent vascular problems and deformities usually recur. Thus, treatment of melorheostosis should be individualized based on the patient's lifestyle, progression of disease and age.

Heel Pain in an Active Adolescent?

In brief Calcaneal apophysitis, a condition commonly seen in active adolescents, results in pain in the posterior aspect of the os calcis, or heel. Radiographic findings sometimes noted at the calcaneal apophysis, including fragmentation and increased density of the apophysis, were once thought to be evidence of osteochondrosis. These findings are now recognized as a normal stage of apophysis development and appear to be unrelated to the symptoms. Teatment, which generally produces excellent results, includes restriction of physical activity, nonsteroidal anti-inflammatory medication, icing, a heel lift, and a stretching program.