An evaluation of dehydrated human amniotic membrane allografts in patients with DFUs.

OBJECTIVE: To evaluate healing of chronic diabetic foot ulcers (DFUs) with use of dehydrated human amniotic membrane (dHAM) in patients failing under standard of care treatment. METHOD: The study population was identified from patients with chronic DFUs enrolled in a randomised trial comparing standard care with standard care with the addition of dHAM. The present study included patients that failed to heal (defined as < 50% decrease in wound size after 6 weeks, or not completely healed by 12 weeks of treatment) with standard care. One week after withdrawal from the randomised trial, these patients were offered treatment with standard care and bi-weekly application of dHAM. Subsequent evaluation of clinical records was made with IRB approval and patient consent. Each patient was used as their own control to compare wound size reduction between treatment periods, and healing rates within the 12-week dHAM treatment period. RESULTS: Eleven patients were included in the study. Mean wound chronicity was 21.1 +/- 12.4 weeks (range 11-54 weeks) and mean wound size was 4.7 +/- 5.0cm2, at baseline. Complete healing was achieved in 55% by 4 weeks, 64% by 6 weeks and 91% by 12 weeks with bi-weekly dHAM application. Mean weeks to complete healing was 4.2 +/- 3.1 weeks for the 10 patients healed. After 4 weeks of standard care, wounds had decreased in size an average of 26.8 +/- 45.3% versus 87.6 +/- 16.0% after 4 weeks of dHAM treatment (two applications; p < 0.001). CONCLUSION: This study provides evidence that the incorporation of dHAM into standard of care for patients with chronic DFUs can be beneficial. The results suggest that dHAM is a viable option for the treatment of recalcitrant DFUs.

The use of local muscle flaps in foot and ankle reconstruction.

Pedicled muscle flaps always should be considered as a reconstructive option when evaluating possible options to filling a defect around the foot and ankle. To gain confidence in using this option, multiple anatomic dissections with special attention to the vascular anatomy are necessary. These dissections also should give the surgeon a feel for the reach of the various flaps and their applicability in various circumstances. For optimal results, the interoperative dissections should be performed with loupes and the Doppler. This allows the surgeon to identify and protect the dominant pedicle. When insetting the flap, special attention is directed to avoid placing excessive torsion or tension on the pedicle so that the blood flow is not compromised. The flow, both arterial and venous, should be assessed after insetting the muscle with a Doppler. Pedicled muscle flaps offer a rapid and easy solution to difficult soft tissue problems around the foot and ankle. The operation can be performed with a regional block in under two hours. The postoperative stay is short, and the donor defect is minimal. Pedicled muscle flaps offer a great alternative to microsurgical free flaps, especially in the sick patient. They should be considered more often when looking at how to fill small defects with exposed bone or osteomyelitis around the foot and ankle.

A new method for reattachment of the tendo Achillis following retrocalcaneal exostectomy.

Currently there are a number of surgical techniques being utilized to address the entity of symptomatic, recalcitrant retrocalcaneal exostosis. This article presents a mechanical study of a modified surgical approach which has been developed at the Northern Virginia Podiatric Residency Program for the purposes of complete resection of all offending exostosis and calcifications, and maintenance of the anatomic configuration of the Achilles tendon with resultant asymptomatic function and cosmetic healing. The centerpiece of the surgical modification is the way in which the portion of reflected Achilles tendon is reattached to the calcaneus, utilizing soft-tissue anchors in combination with a modified Krackow suture technique. In order to delineate the relative strength of this suture technique, a cadaveric study was performed using six specimens. Each specimen underwent tendon repair with both a modified Krackow technique and a modified vertical mattress coaptation technique for a total of 12 studies. The force required to displace the tendon for distances of 0.5 cm and 1.0 cm was then recorded, and the data were statistically analyzed, with the modified Krackow technique proving to have a significantly better ability to resist distractive forces at both 0.5 cm (p = .01) and at 1.0 cm (p = .02) compared to the vertical mattress coaptation technique.