Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a systematic review.

The outcome of management of diabetic foot ulcers remains a challenge, and there remains continuing uncertainty concerning optimal approaches to management. It is for these reasons that in 2008 and 2012, the International Working Group of the Diabetic Foot (IWGDF) working group on wound healing published systematic reviews of the evidence to inform protocols for routine care and to highlight areas, which should be considered for further study. The same working group has now updated this review by considering papers on the interventions to improve the healing of chronic ulcers published between June 2010 and June 2014. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network criteria. Selected studies fell into the following ten categories: sharp debridement and wound bed preparation with larvae or hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; oxygen and other gases, compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, electromagnetic, lasers, shockwaves and ultrasound and other systemic therapies, which did not fit in the aforementioned categories. Heterogeneity of studies prevented pooled analysis of results. Of the 2161 papers identified, 30 were selected for grading following full text review. The present report is an update of the earlier IWGDF systematic reviews, and the conclusion is similar: that with the possible exception of negative pressure wound therapy in post-operative wounds, there is little published evidence to justify the use of newer therapies. Analysis of the evidence continues to present difficulties in this field as controlled studies remain few and the majority continue to be of poor methodological quality.

Candida fasciitis following renal transplantation.

BACKGROUND: We describe a rare case of necrotizing fasciitis involving Candida albicans, an organism that has been reported to have a minimal potential for invasive soft tissue infection. In this case, immunosuppression, chronic renal failure, and a history of diabetes mellitus were predisposing factors. METHODS: The medical record and histopathologic material were examined. The clinical literature was reviewed for previous cases of C albicans necrotizing fasciitis. RESULTS: A review of the literature showed that in solid organ transplant recipients, localized fungal soft tissue infection is infrequent, with only 35 cases reported between 1974 and 1992. Necrotizing fasciitis caused by C albicans is extremely rare in the modern era of solid organ transplantation. CONCLUSIONS: The management of transplant patients at risk for invasive fungal infection warrants a high index of suspicion for fungal necrotizing fasciitis in the setting of wound infection and merits a thorough investigation for atypical pathogens.

Soft tissue reconstruction for calcaneal fractures or osteomyelitis.

A systematic approach of the surgical management of a calcaneal fracture can minimize the potential of soft tissue complications. When reducing a closed calcaneal fracture, the incision used affects the postoperative complications. The L-shaped incision with the horizontal limb lying on the lateral glabrous junction ensures maximum blood flow to either side of the incision. Whether or not the wound can be closed primarily depends on the preexisting edema, the lost calcaneal height, and the delay between the fracture and reduction (Fig. 20). The wrinkle test is a good indicator that the incision can be closed primarily if the amount of height restored is minimal. If the edema is too great, steps should be taken to reduce it sufficiently to allow successful wound closure. If the wound, after reduction, is too wide to allow primary closure, an ADM flap laterally or an AHM flap medially should be used. For larger defects, a free flap should be considered. The three important steps to reconstruction of soft tissue defects around the calcaneus include good blood supply, a infection-free wound, and the simplest soft tissue reconstructive option that covers the wound successfully. Adequate blood supply can be determined by the use of Doppler. If the supply is inadequate, revascularization is necessary before proceeding. Achieving a clean wound requires aggressive debridement, intravenous antibiotics, and good wound care. Adjuncts that can help in achieving a clean wound include topical antibiotics (silver sulfadiazine), the VAC, and hyperbaric oxygen. Osteomyelitis has to be treated aggressively. Any suspicious bone has to be removed. Only clean, healthy, bleeding bone is left behind. Antibiotic beads can be useful when there is doubt as to whether the cancellous bone is infection-free. The beads are not a substitute for good debridement, however. Soft tissue reconstruction ranges from delayed primary closure to the use of microsurgical free flaps (Fig. 21). When bone or hardware is exposed, a muscle flap should cover the wound because of the extra blood supply it carries with it. The soft tissue option depends on the width of the wound. For wounds 1 cm wide or less, the options include allowing the wound to close by secondary intention (VAC), delayed primary closure, or a local muscle flap. For wounds 2 cm wide or less, allowing the wound to close by secondary intention (VAC) and a local muscle flap are the best options. For wider wounds, one has to assess whether the local muscle flap has sufficient bulk to close the defect. If it does, it is the simplest solution. If the local muscle is inadequate, a microsurgical free flap has to be used. The VAC sometimes can convert a large wound to a smaller wound so that a local muscle flap can be used. This procedure takes time, however, and adds to the cost of the repair.

Débridement. The key initial first step in wound healing.

Before addressing a wound, whether it is chronic or acute, clinicians must thoroughly assess the wound and the patient. An acute wound in a patient with normal blood flow and good medical and nutritional condition should go on to heal if appropriate care is given. This means that the wound has to be débrided adequately, dressed, and closed when appropriate. Getting back to healthy tissue is the key. In chronic wounds, healing is more difficult because the etiology of the wound is harder to determine, and the measures to reverse the medical abnormalities are often complex. When these have been sorted out and addressed, however, débridement again plays the key role. It converts the chronic wound into an acute wound so that it can then progress through the normal stages of healing. The key is for clinicians to be aggressive and not let concerns about the residual defect limit débridement. Subsequent healing then can be achieved by use of wound-healing adjuncts such as the V.A.C. device, hyperbaric oxygen, skin substitutes, growth factor, or plastic surgical techniques.

Adjuncts to preparing wounds for closure: hyperbaric oxygen, growth factors, skin substitutes, negative pressure wound therapy (vacuum-assisted closure).

Achieving closure in a chronic wound requires provision of adequate oxygen delivery to the tissue, adequate protein and other nutritional factors, a moist environment, an appropriate inflammatory milieu, dèbridement, and correction of contributing medical diagnoses. In some patients, these conditions are achieved easily, whereas in others, greater effort is required. Adjunctive treatments, including HBO2, growth factors, skin substitutes, and negative-pressure wound therapy (e.g., V.A.C.) can provide the proper conditions for healing in appropriately selected patients.

The safest surgical incisions and amputations applying the angiosome principles and using the Doppler to assess the arterial-arterial connections of the foot and ankle.

Knowing the arterial anatomy of the foot and ankle in addition to understanding the angiosome concept provides the basis for careful and safe planning of incisions. The Doppler allows the surgeon to map out the actual vascular anatomy that exists preoperatively and therefore allows for appropriate adjustment to the planned incisions. If the vascular flow is inadequate for the planned surgery, then the vascular surgeon has to intervene to improve the existing blood flow. If the vascular tree is so compromised that successful revascularization of the affected angiosome is impossible, then the revascularization is likely to fail. Serious consideration to a below-knee amputation should then enter the decision tree at that time. Most of the time, however, the blood flow is adequate or can be sufficiently augmented with vascular surgery. The foot and ankle surgeon can then perform preoperative mapping of the arterial blood supply with the Doppler. By making the necessary adjustments to the planned incision, surgery can proceed safely with uneventful healing.

Surgical débridement. The key to successful wound healing and reconstruction.

No wound can heal in an orderly fashion unless it is clean, healthy, and free of infection. Débridement is key in achieving this goal providing that: (1) the wound is adequately vascularized, (2) the proper antibiotics are on board, and (3) all other medical aspects of the patient have been addressed. Surgical débridement is the quickest and most efficient way of getting the wound ready for healing. Exciting new products such as growth factor, hyperbaric oxygen, skin graft substitutes, and the V.A.C. can then be selectively applied to accelerate wound healing. For those wounds that require more than closure by secondary intention, plastic surgical techniques can then be used to provide a functional and effective wound closure.

The role of microsurgical free flaps in foot and ankle surgery.

Microsurgery is clearly an extremely useful adjunct in foot and ankle reconstruction. It requires careful planning between the microsurgeon and vascular, podiatric, and orthopedic surgeons. Ideally, each member of the team should have a special focus on limb salvage. The more experienced the microsurgeon and the better the planning the higher the chance of success. Current success rates in large microsurgical centers exceed 95% free flap survival. Skill in choosing the appropriate flap and optimizing how it is inset ensure an optimal aesthetic and functional result while minimizing the need for later revisions. Adding microsurgical free flaps to the armamentarium of limb salvage surgeons ensures a much higher salvage rate in limbs that heretofore posed too large of a reconstructive challenge and, therefore, were amputated. Current efforts should be directed toward the salvage of only those feet that will be functional, while avoiding limb salvage surgery in other cases. Microsurgical salvage should not be undertaken simply because it is technically feasible. The patient who undergoes 10 to 15 procedures over a 2 to 3 year interval and has a viable, but minimally functional, limb has not been helped. One, therefore, must be sure that the functional salvage can be performed within a defined number of operations in a given time. If not, a below-knee amputation should be considered strongly.

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.

Local flaps.

Local flap reconstruction of pedal defects can be accomplished with a variety of techniques. Multiple geometric constructs have been described for closure of foot defects. Each has its own unique principles which can be adapted to certain locations and premorbid conditions. Local flaps considered for closure of foot defects should lie within the higher level of any algorithm, due to their versatility, reproducibility, and long term functional outcomes. In addition, hospitalization, length of anesthesia, and perioperative care can be much less with the use of local flaps.

Prosthetic bypass with a distal vein patch for limb salvage.

BACKGROUND: Certain patients require tibial bypass for limb salvage without adequate vein available as the conduit. Polytetrafluoroethylene (PTFE) bypasses result in decreased patency prompting the addition of venous tissue at the distal anastomosis as cuffs, collars, and boots. We assessed feasibility and graft patency of a distal vein patch (DVP) interposed between PTFE and the tibial artery. METHODS: Between 7/93 and 7/96, 148 tibial bypasses were performed with 25 (17%) using PTFE/DVP as the conduit. Patient demographics (n = 24) were 11 males and 13 females, mean age of 67, diabetes (n = 15, 57%), renal failure (n = 8, 31%), and excessive cardiac risk (n = 20, 83%). All patients had limb-threatening ischemia with rest pain in 14 (58%) and gangrene/nonhealing ulcer in 10 (42%). Lack of vein was due to previous failed bypass (15,63%), cardiac surgery (5,21%), and unsuitable vein (4,21%). Patients were discharged on coumadin with follow-up at 1 month, 6 months, and annually. RESULTS: PTFE/DVP bypasses originated from the CFA (13,48%), the SFA (3,11 %) and the external iliac artery due to previous groin dissection (9,41 %). Recipient arteries included anterior tibial (7), posterior tibial (8), and peroneal (10). Follow-up ranged from 1 to 36 months. Cumulative graft patency at 6 months and 3 years was 91% and 78%, respectively, by life table analysis. Limb salvage was 91%. CONCLUSION: These early data indicate that tibial bypass with PTFE/DVP as the conduit results in acceptable patency and limb salvage. In the patient without adequate vein, PTFE bypasses to tibial arteries for limb salvage may be improved with a distal vein patch.

Chest wall fibromatosis associated with silicone breast implants.

Aggressive fibromatosis is a well described locally destructive benign lesion, comprising 0.3% of all solid tumors. Although the chest wall is a common location, this tumour has rarely been associated with breast tissue or breast implants. Herein is only the fourth case described in conjunction with a breast implant and the only case linked to a ruptured silicone implant. This tumour was locally aggressive and required wide surgical resection, including removal of the chest wall, to gain control. Wide surgical resection is recommended with the application of adjuvant radiation therapy being more controversial.

Salvage of traumatic below-knee amputation stumps utilizing the filet of foot free flap: critical evaluation of six cases.

Over a 12-year period between 1979 and 1991, 27 patients were operated on at the New York University Medical Center for salvage of below-knee amputation stumps utilizing free flaps. Six different donor sites were used. In 6 patients, the amputated foot was the donor site for a free flap to cover the tibial stump. There were 3 males and 3 females in this group. Five of the patients underwent immediate filet of foot reconstructions, while 1 patient had a reconstruction performed 69 days after injury, electively, when it was determined that below-knee amputation was the best option. All foot flaps survived and ultimately provided the major soft-tissue coverage for the below-knee amputation stump. The length of hospitalization ranged from 24 to 118 days. The time required from foot filet procedure to ambulation was 2, 4, 6, 7, 9, and 12 months in the 6 patients. Five of the 6 patients have resumed work or school after their injury. Foot flaps were based on the posterior tibial artery, anterior tibial artery, or both vessels. Nerve anastomosis of the posterior tibial nerve was performed in 5 patients. In 1 patient it was possible to maintain the continuity of the posterior tibial nerve. Five of the 6 patients were tested over a year after the flap, and all have good cold, pressure, and vibration sensation. Two of the 5 patients have heat sensation, and all 5 patients have at least protective pressure sensation. All the patients ambulate well with a below-knee prosthesis.

Soft-tissue coverage for lower-extremity trauma.

In summary, a rational approach to soft-tissue coverage in the ankle and foot should help lower osteomyelitis and bone nonunion rates and yield an excellent functional result. In addition to adequate fixation, it is crucial to first obtain a clean healthy wound by doing as many debridements as necessary. The goal should be to achieve coverage within the first week of injury to avoid the sequelae of a later closure; i.e., a potentially much higher infection rate and nonunion rate. The reconstructive options range from secondary intention, to primary closure, to skin grafts, to local flaps, to microsurgical free flaps. The choice should be dictated by the health of the patient, the existing bony and neurovascular anatomy, and the desired ultimate objective. Given the currently available orthopedic and plastic surgical techniques, it is possible to salvage almost any foot or ankle; however, we should not be carried away by our surgical armamentorium. If the salvaged extremity will take more than a year to heal, will be barely functional, and will be a constant source of pain, then a below-knee amputation should strongly be considered. The challenge in the coming decade comes both in picking the correct extremity to salvage and in applying the techniques described previously to restore it to its preinjury state.

Use of skin grafting in the foot.

Skin grafting is a useful adjunct to treating open wounds. It not only provides rapid wound coverage, but also eliminates the pain and the risk of further infection associated with open wounds. A successful skin graft take requires a well vascularized and relatively sterile bed, as well as complete resolution of any surrounding infection. The author reviews the indications and techniques for obtaining a successful skin graft take.

Vulvar reconstruction using a mons pubis flap.

A mons pubis flap was used to reconstruct vulvar defects in 4 patients. This is an axial-pattern flap based on the superficial external pudendal vessels. Our cadaver injection studies demonstrated the vascular anatomy of the flap, which encompasses both a primary and a secondary vascular territory. Four patients were reconstructed, with excellent cosmetic results. The flap provides pliable, hair-bearing skin that resembles the normal vulva. The donor defect is inconspicuous and well hidden in the pubic hair. The flap is a reconstructive option for appropriate patients with full-thickness vulvar defects.

Selected benefits of thoracotomy and chemotherapy for sarcoma metastatic to the lung.

To determine the benefit of aggressive surgical therapy, we studied 77 consecutive patients presenting to our sarcoma registry with pulmonary metastases. Detailed follow-up was available on all patients; the median follow-up of the 13 long-term survivors was 72 months from the date of diagnosis of the primary tumor. Survival of these 77 patients with metastatic disease was independent of the size, location, and histology of the primary tumor. Once metastases developed, survival of patients with pulmonary metastases was not influenced by the extent of surgical resection of the primary tumor or by the use of radiation therapy. Pulmonary metastases were initially treated with thoracotomy and metastasectomy in 34 patients. The median survival after thoracotomy was 26 months. Seven patients were alive more than 4 years after their diagnosis. Pulmonary metastases were treated with chemotherapy alone in 43 patients. Although the survival was shorter (median survival 14 months) in patients treated with chemotherapy, an objective response to chemotherapy was obtained in 13 (30%) patients. Four of these patients were alive 4 years after their diagnosis. These data demonstrate that both thoracotomy and chemotherapy are associated with long-term survival of patients with sarcoma metastatic to the lung.