Recipient Vessel Dissection Technique in Diabetic Foot Patients with Perivascular Fibrosis.

Diabetic foot ulcers are becoming more prevalent, and microsurgical free flaps are gaining popularity in salvaging the foot after postdebridement. The perivascular fibrosis around the recipient vessels often makes the dissection of vessels difficult. In this article, we describe a technique of dissection in such situations where fibrosis and dissection of vessels are fraught with danger. In the period from November 2020 to May 2023, 72 free flap reconstructions of the diabetic foot were done at our institute using this technique, with a success rate of 95.8%.

Outcomes of Keller Gap Arthroplasty for Plantar Hallux Interphalangeal Joint Ulcers in Patients With Diabetes Mellitus.

BACKGROUND: Hallux ulcers are known for their recurrence and associated risk for future amputations. Traditional nonsurgical external offloading methods have poor compliance rates, and the data is sparse on surgical offloading of hallux ulcers. We performed this study to analyze the outcomes of Keller excision gap arthroplasty of the first metatarsophalangeal joint in patients with a neuropathic plantar hallux interphalangeal joint (IPJ) ulcer in patients with diabetes mellitus. METHODS: A retrospective study of 105 diabetic patients with a plantar hallux IPJ ulcer who underwent a Keller excision gap arthroplasty between December 2014 and June 2020 was done. A total of 122 great toes had been operated upon for hallux IPJ ulcers. We studied the long-term wound healing rates from patient records and then did a prospective survey of the postreview period. RESULTS: All the hallux IPJ ulcers healed well in the immediate postoperative period. Six patients reported a recurrence of the ulcer at the original site during a mean follow-up period of 30 months. For these 6 patients, the mean time to recurrence of ulcer after operation was 2.5 years. CONCLUSION: At an average of 30 months, we found the Keller gap arthroplasty for treatment of noninfected and nonischemic diabetic foot hallux IPJ ulcers was associated with an ulcer recurrence rate of 5%. LEVEL OF EVIDENCE: Level IV, cohort study.

Single-stage Flexor Hallucis Longus transfer and Gracilis free flap cover for failed Achilles tendon repair with soft tissue defect.

INTRODUCTION: Reconstruction of failed Achilles tendon repair, with infection and loss of overlying skin, is a surgical challenge. This paper aims to deal with the technical considerations and study the outcome of reconstructing such defects by radical debridement and reconstruction with combined Flexor hallucis longus (FHL) transfer and free Gracilis flap cover. MATERIALS AND METHODS: A retrospective study of six patients with failed Achilles tendon repair with overlying skin and soft tissue loss reconstructed by FHL transfer and free Gracilis flap cover performed between January 2017 and August 2020 was conducted. Postoperatively, they were assessed with the Mean Functional Gait Assessment score(MFGA), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, the Achilles tendon Total Rupture Score (ATRS), and Modified Vancouver scar scale score (mVSS). RESULTS: All six patients reported a good gait at nine months of follow-up. The MFGA score at six months was 24.8. The mean ankle plantar flexion at nine months follow up was 39.1° . The mean nine-month postoperative AOFAS and ATRS scores were 86.33 ± 2.654 and 88.5 ± 5.54, respectively. At nine months, all the patients could perform a single-leg heel raise on the operated foot. The overall mean mVSS score was 1.41. In about 12 months, the peak forefoot to hindfoot ratio matched the uninjured opposite foot. CONCLUSION: Simultaneous reconstruction of the Achilles tendon with FHL transfer with free Gracilis flap for the coverage of overlying soft tissue loss is a good management option for failed Achilles tendon repair with overlying skin loss.

Parachute Method: A Novel Method to Retrieve a Stuck Degloved Finger.

An entrapped finger is a relatively uncommon domestic injury. When the finger gets stuck proximal to the proximal interphalangeal joint, the resultant distal edema and inappropriate attempts at retrieval can result in circumferential degloving of the skin and injury to the neurovascular structures. We report a technique that can be used in such circumstances. Strategically placed skin sutures are used to get the skin through the constricting ring, and retrieval is aided by a cut finger glove that wraps the finger and can be lubricated. This non-cutting technique is named as the parachute technique since the withdrawn skin sutures look like the strings of the parachute. This technique is valuable when the finger gets stuck in an idli plate, a common South Indian kitchen utensil, where there is difficulty of access to cutting equipment and where inappropriate attempts at retrieval can result in skin injury making further attempts more difficult.

Diabetic Hand Infections: Factors at Presentation Influencing Amputation and Number of Surgical Procedures.

Background Diabetic hand infections are associated with significant morbidity and disability. Amputations cause permanent disability, and multiple surgical procedures lead to morbidity. Diabetic foot infections have been well-studied but literature on hand infections is limited. We undertook a retrospective study of patients with diabetic hand infections operated at our center to study the factors at presentation with significant association with amputation and number of surgical procedures. Patients and Methods Demographic data of 51 patients was collected. The six parameters, namely, duration of diabetes, "onset of symptoms to presentation" interval, presence of comorbidities, HbA1c level, random blood sugar (RBS) levels at admission, and culture characteristics were selected for statistical analysis to find a relationship with the two outcome variables: number of procedures done and need for amputation. Results On bivariate analysis, Gram-negative infection was found to have a significant relationship with the need for multiple of procedures ( p = 0 . 014). The mean difference between the "onset of symptoms to presentation" interval between the amputation/non-amputation groups (2.9 days, p = 0 . 04) and the multiple procedures/non-multiple procedure groups (4.4 days, p = 0 . 02) was found to be statistically significant. Presence of comorbidities, long duration of diabetes, HbA1c, and RBS levels at admission did not show any statistically significant association with the two outcome variables studied. Conclusion In the present study, we found that infection with Gram-negative organisms is significantly related to the need for multiple surgical procedures. A delay in presentation can influence the risk of amputation as well as multiple procedures. Institution of early appropriate care is important to get a good outcome.

Management of Chronic Achilles Tendon Injuries-Review of Current Protocols and Surgical Options.

Chronic Achilles tendon injury is a challenging problem. A review of the different options available and their technical considerations is required. Reconstruction of the Achilles tendon depends on numerous factors such as the gap between the debrided tendon ends, the presence of a distal stump, and the and presence of scar tissue. Various protocols have been described for reconstruction. Methods of reconstruction vary from direct repair, bridging of the tendon gap with tendon grafts or tendon transfers. We review and enumerate the different protocols enumerated for the reconstruction of chronic Achilles tendon lesions in the literature and look at the authors preferred methods of reconstruction.

Healing ulcers and preventing their recurrences in the diabetic foot.

Fifteen percent of people with diabetes develop an ulcer in the course of their lifetime. Eighty-five percent of the major amputations in diabetes mellitus are preceded by an ulcer. Management of ulcers and preventing their recurrence is important for the quality of life of the individual and reducing the cost of care of treatment. The main causative factors of ulceration are neuropathy, vasculopathy and limited joint mobility. Altered bio-mechanics due to the deformities secondary to neuropathy and limited joint mobility leads to focal points of increased pressure, which compromises circulation leading to ulcers. Ulcer management must not only address the healing of ulcers but also should correct the altered bio-mechanics to reduce the focal pressure points and prevent recurrence. An analysis of 700 patients presenting with foot problems to the Diabetic Clinic of Ganga Hospital led to the stratification of these patients into four classes of incremental severity. Class 1 - the foot at risk, Class 2 - superficial ulcers without infection, Class 3 - the crippled foot and Class 4 - the critical foot. Almost 77.5% presented in either Class 3 or 4 with complicated foot ulcers requiring major reconstruction or amputation. Class 1 foot can be managed conservatively with foot care and appropriate foot wear. Class 2 in addition to measures for ulcer healing would need surgery to correct the altered bio-mechanics to prevent the recurrence. The procedures called surgical offloading would depend on the site of the ulcer and would need an in-depth clinical study of the foot. Class 3 would need major reconstructive procedures and Class 4 would need amputation since it may be life-threatening. As clinicians, our main efforts must be focused towards identifying patients in Class 1 and offer advice on foot care and Class 2 where appropriate surgical offloading procedure would help preserve the foot.

Primary Index Finger Pollicization for Thumb Reconstruction Following Soft Tissue Sarcoma Excision.

Soft tissue sarcomas in the thumb are rare, but often require amputation to ensure tumour clearance. This can severely impair the use of the entire upper limb and negatively impact quality of life. We describe a 63-year-old male patient with a large malignant fibrous histiocytoma affecting the base of his dominant right thumb. A wide resection of this tumour was performed, followed immediately by index finger pollicization and first web space reconstruction with a reverse pedicled posterior interosseous artery flap. The patient was able to continue using his right hand for functions of daily living and was free from local recurrence until he died from distant metastases 2 years later. Primary thumb reconstruction following amputation for sarcoma can allow a patient to retain useful hand function postoperatively. Provided that strict principles of tumour clearance are adhered to, this need not compromise local recurrence rates.