Tarsometatarsal Arthrodesis for Lisfranc Injuries.

This article discusses tarsometatarsal arthrodesis for Lisfranc injuries. Although open reduction and internal fixation has traditionally been the treatment of choice for most Lisfranc fracture-dislocations, there is a trend toward primary fusion, especially for purely ligamentous injuries. Consideration should be made for primary fusion in select fracture-dislocation cases. Primary fusion offers a single-stage alternative with potentially more stable, predictable results overtime.

Gastrocnemius recession or tendo-achilles lengthening for equinus deformity in the diabetic foot?

Contracture of the Achilles-gastrocnemius-soleus complex leading to ankle equinus has been linked to the development of various foot disorders. Decrease in ankle dorsiflexion results in an increase in plantar pressures and in diabetes and neuropathy, increased pressures can lead to ulceration and possibly the formation of Charcot foot. Surgical management of the equinus deformity corrects this abnormality and has the potential to avert the development of Charcot foot or ankle. Gastrocnemius recession, tendo-Achilles lengthening, and Achilles tenotomy have all been offered as surgical solutions to this condition. This article reviews ankle equinus and compares the treatment options available. A video of Hoke's triple hemisection has been included with this article and can be viewed at www.podiatric.theclinics.com.

Treatment of the neglected Achilles tendon rupture.

Achilles tendon ruptures are best managed acutely. Neglected Achilles tendon ruptures are debilitating injuries and the increased complexity of the situation must be appreciated. Surgical management is recommended, and only in the poorest surgical candidate is conservative treatment entertained. Numerous treatment algorithms and surgical techniques have been described. A V-Y advancement flap and flexor halluces longus tendon transfer have been found to be reliable and achieve good clinical outcomes for defects ranging from 2 cm to 8 cm. This article focuses on the treatment options for the neglected Achilles tendon rupture.

Advanced foot and ankle fixation techniques in patients with diabetes.

This article presents advanced techniques and current fixation constructs that are advantageous for the management of diabetic foot and ankle trauma and Charcot neuroarthropathy. Both these pathologies are often intimately related, and the fixation constructs that are required often require sound biomechanical concepts coupled with innovative approaches to achieve bone healing and limb salvage.

Human digit partially consumed by a canine during sleep in a patient with neuropathy and diabetes.

A traumatic amputation of a digit as a result of canine mastication and ingestion occurred in a 48-year-old woman with type 2 diabetes and peripheral neuropathy. The injury occurred during sleep and was not felt by the patient. The dangers of sleeping with one's canine for those with neuropathic wounds are presented, and the literature is reviewed.

Surgical off-loading of the diabetic foot.

Surgical intervention for chronic deformities and ulcerations has become an important component in the management of patients with diabetes mellitus. These patients are no longer relegated to wearing cumbersome braces or footwear for deformities that might otherwise be easily corrected. Although surgical intervention in these often high-risk individuals is not without risk, the outcomes are fairly predictable when patients are properly selected and evaluated. In this brief review, we discuss the rationale and indications for diabetic foot surgery, focusing on the surgical decompression of deformities that frequently lead to foot ulcers.

Surgical off-loading of the diabetic foot.

Surgical intervention for chronic deformities and ulcerations has become an important component in the management of patients with diabetes mellitus. Such patients are no longer relegated to wearing cumbersome braces or footwear for deformities that might otherwise be easily corrected. Although surgical intervention in these often high-risk individuals is not without risk, the outcomes are fairly predictable when patients are properly selected and evaluated. In this brief review, we discuss the rationale and indications for diabetic foot surgery, focusing on the surgical decompression of deformities that frequently lead to foot ulcers.

Digital planimetry results in more accurate wound measurements: a comparison to standard ruler measurements.

BACKGROUND: Cutaneous wound measurements are important to track the healing of a wound and direct appropriate therapy. The most commonly used method to calculate wound area is an estimation by multiplying the longest length by the widest width. Other devices can provide an accurate and precise measurement of the true area (TA). This study aim was to compare wound areas calculated by computerized planimetry with standard area estimation by multiplying the longest length by the widest width (l x w). METHODS: We reviewed the wound records of 10 patients with circular or oval wounds and estimated the area with the l x w method. We compared this with the TA obtained by a specialized planimetric camera. RESULTS: Average wound size was 4.3 cm(2) by l x w estimation and 3 cm(2) by TA calculation. We found the l x w method overestimated wound area an average of 41%. CONCLUSIONS: Standard, manual (l x w) measurement of cutaneous wounds inaccurately overestimates wound area by roughly 40%.

Smoking cessation: the role of the foot and ankle surgeon.

Tobacco cigarette smoking causes many negative effects on the body, and it is the leading preventable cause of death in the United States. These negative effects are a concern for the foot and ankle surgeon, as smoking can increase the risk of diabetes and peripheral artery disease and delay healing of surgical incisions and ulcerations of the lower extremities. Tobacco cigarette smoking can also increase the risk of avascular necrosis and delayed union and nonunions of fractures and osteotomies. Smoking cessation is an important component in the overall treatment of conditions affecting the foot and ankle. Smoking cessation can be a difficult goal to achieve, but proper education and support can help patients reach this goal.

Organized programs to prevent lower-extremity amputations.

BACKGROUND: Diabetes-related lower-extremity amputations are largely preventable. Eighty-five percent of amputations are preceded by a foot ulcer. Effective management of ulcers, which leads to healing, can prevent limb loss. METHODS: In a county hospital, we implemented a six-step approach to the diabetic limb at risk. We calculated the frequency and level of lower-extremity amputations for 12 months before and 12 months after implementation of the amputation prevention program. We also calculated the high-low amputation ratio for the years reviewed. The high-low amputation ratio is a quality measure for the success of amputation prevention measures and is calculated as the ratio of the number of high amputations (limb losses) over the number of low (partial foot) amputations. RESULTS: The frequency of total amputations increased from 24 in year 1 to 46 in year 2. However, the number of limb losses decreased from 7 to 2 (72%). The high-low amputation ratio decreased eightfold in 1 year, which serves as a marker for limb salvage success. CONCLUSIONS: Improvement in care organization and multidisciplinary-centered protocols can substantially reduce limb losses.

Gastrocnemius recession as an alternative to tendoAchillis lengthening for relief of forefoot pressure in a patient with peripheral neuropathy: a case report and description of a technical modification.

The gastrocnemius recession is a popular surgical procedure for the treatment of equinus contracture. Lengthening the gastrocnemius tendon has been show to be an effective means of reducing pressure to the plantar forefoot by weakening the triceps surae complex. The more traditional method of weakening the triceps surae is a modification of Hoke's triple hemisection through the tendoAchillis. This technique unfortunately carries a serious risk of the development of a calcaneal gait. The purpose of this case report is to demonstrate that the gastrocnemius recession is an effective and safe alternative to the traditional tendoAchillis lengthening. The authors also describe a minimally invasive technique that uses a pediatric speculum for a self-retrained retractor and portal for instrumentation and visualization.

Neuropathy in diabetes: not a knee-jerk diagnosis.

Neuropathic symptoms in patients with diabetes occur commonly and are most often a consequence of the diabetes. Up to 10% of patients with diabetes and neuropathy have an etiology other than diabetes as a cause of their nerve dysfunction. Herein we present a case of vasculitic neuropathy initially misdiagnosed as diabetic neuropathy that led to separate amputations of two toes. This case emphasizes the importance of considering alternative, potentially treatable, causes of peripheral neuropathy in patients with diabetes.

Diabetic foot surgery: classifying patients to predict complications.

The purpose of this article is to describe a classification of diabetic foot surgery performed in the absence of critical limb ischaemia. The basis of this classification is centred on three fundamental variables that are present in the assessment of risk and indication: (1) presence or absence of neuropathy (the loss of protective sensation); (2) presence or absence of an open wound; (3) presence or absence of acute limb-threatening infection. The conceptual framework for this classification is to define distinct classes of surgery in an order of theoretically increasing risk for high-level amputation. These include: Class I: elective diabetic foot surgery (procedures performed to treat a painful deformity in a patient without the loss of protective sensation); Class II: prophylactic (procedure performed to reduce the risk of ulceration or reulceration in a person with the loss of protective sensation but without an open wound); Class III: curative (procedure performed to assist in healing an open wound); and Class IV: emergency (procedure performed to limit the progression of acute infection). The presence of critical ischaemia in any of these classes of surgery should prompt a vascular evaluation to consider (1) the urgency of the procedure being considered and (2) possible revascularization prior to or temporally concomitant with the procedure. It is our hope that this system begins a dialogue amongst physicians and surgeons which can ultimately facilitate communication, enhance perspective, and improve care.

Imaging of the Charcot foot.

Charcot foot is a serious problem that causes considerable morbidity and may lead to limb loss. Arriving at a definitive diagnosis can be challenging. Given the progressive, destructive nature of Charcot's arthropathy, this delay can result advancing deformity, ulceration, infection, and place the limb at risk for amputation. Although clinical signs and symptoms and historical information are crucial, this article focuses on the imaging modalities that can aid practitioners in arriving at an early diagnosis, and how to differentiate Charcot's arthropathy from osteomyelitis of the feet.

Restoration and preservation of first metatarsal length using the distraction scarf osteotomy.

The authors reviewed the records of 8 patients who underwent a distraction scarf osteotomy of the first metatarsal, and report the radiographic outcomes achieved with this procedure. The osteotomy was used to reestablish or maintain the length of the first metatarsal, without the use of a structural bone graft. The osteotomy was used as part of a revisional procedure for a failed bunionectomy in 4 patients. In the remaining patients, the procedure was used to preserve the length of the first metatarsal in conjunction with a Lapidus arthrodesis. The first and second metatarsals were measured radiographically, and the length of the first metatarsal was expressed as a percentage of the length of the second metatarsal. The average proportional increase in first metatarsal length obtained in the patients undergoing correction of the shortened first metatarsal was 7.08%, and the difference between the pre- and postoperative length of the first metatarsal was statistically significant (P = .0013) in these patients. Relative shortening of the first metatarsal was avoided in those patients undergoing distraction scarf osteotomy in conjunction with Lapidus arthrodesis. ACFAS Level of Clinical Evidence: 4.

A technique to protect external fixation devices.

The indications for external fixation in foot and ankle surgery are expanding and now include the use on patients with significant comorbidities. Protecting the contralateral limb from inadvertant injury is important especially in patients with diabetes where the contralateral limb is already "at risk". The authors describe a simple and inexpensive technique to protect the external fixator and the contralateral limb from potential injury.

Charcot's arthropathy in a patient with HIV-associated neuropathy.

Charcot's arthropathy is a destructive arthritis that can occur in patients with peripheral neuropathies of various etiologies. This report describes a rare case of Charcot's arthropathy attributable to the distal sensory polyneuropathy associated with HIV infection. As treatments for HIV/AIDS advance and life expectancy increases, cases of end-organ sequelae, such as Charcot foot, may become more common.

The diagnosis of Charcot foot.

Charcot foot is a rapidly progressive disease process occurring in those with peripheral neuropathy. The disease is frequently misdiagnosed resulting in a delay of appropriate treatment, worsening the outcome. We present the hallmarks for diagnosis of Charcot foot based on the clinical examination and imaging studies. We provide a simple algorithm based on evidence and experience for the investigation of the foot when Charcot arthropathy is suspected. Additionally, we propose a new classification that accounts for the degree of complications in the Charcot joint. This new system considers deformity, ulceration, and osteomyelitis, which may help to predict amputation.

Surgical management of Charcot midfoot deformities.

Diagnosing Charcot neuroarthropathy requires a heightened index of suspicion. Early recognition and intervention can limit deformity. Aggressive conservative management should be initiated early in the treatment plan to minimize the devastating effects often seen with this condition. Any delay in therapy can result in severe foot and ankle deformity in which traditional nonoperative methods alone may be inadequate. These deformities may lead to ulcerations and ultimately progress to amputation of the lower extremity. Surgical correction and stabilization is an effective method to prevent further deformity and ulcer recurrence. If performed in the appropriate setting and for the right indications, Charcot foot reconstruction is a better alternative to lower limb amputation.

The narrowed forefoot at 1 year: an advanced approach for wound closure after central ray amputations.

Central ray resections often result in a biomechanically unsound forefoot often accompanied by a cleft wound that is difficult to heal. Narrowing the forefoot enables the surgeon to close the plantar defect primarily, foregoing prolonged wound care and lowering the risk for postoperative complications. The authors present a technique of narrowing the forefoot using a small light-weight external fixation device that allows for immediate wound closure without adjacent metatarsal osteotomies. Four patients were treated with this technique, and all four healed in a timely fashion and resumed their previous lifestyle without skin breakdown. The forefoot narrowing technique results in a stable plantigrade forefoot in individuals at high risk for diabetes-related lower extremity reulceration and amputation.