The Use of Cryopreserved Human Skin Allograft for the Treatment of Wounds With Exposed Muscle, Tendon, and Bone.

BACKGROUND: Wounds with exposed bone or tendon continue to be a challenge for wound care physicians, and there is little research pertaining to the treatment of these particular wounds with allograft skin. The purpose of this study was to evaluate the effectiveness and safety of a biologically active cryopreserved human skin allograft for treating wounds with exposed bone and/or tendon in the lower extremities. METHODS: Fifteen patients with 15 wounds at a single hospital-based wound care center were included in the study. Eleven wounds had exposed bone, 1 wound had exposed ten- don, and 3 wounds had exposed bone and tendon. Standard treatment principles with adjunctive cadaveric allograft application were performed on all wounds in the study. RESULTS: In this study 14/15 (93.3%) of the wounds healed completely. The mean duration of days until coverage of the bone and/or tendon with granulation tissue was 36.14 (5.16 weeks) (range 5-117 days). Mean duration to complete healing of the wound was 133 days (19 weeks) (range 53-311 days). The mean number of grafts applied was 2. There were no adverse events directly related to the graft. Zero major amputations and 1 minor amputation occurred. CONCLUSION: This study found biologically active cryopreserved human skin allografts to be safe and effective in treating difficult wounds with exposed bone and/or tendon. To the authors' knowledge, this is the largest study to date focused on the utilization of allograft skin as an adjunct therapy for lower extremity wounds with exposed tendon and/or bone.

Fibular Strut Graft for Revisional Tibiotalocalcaneal Arthrodesis.

Tibiotalocalcaneal arthrodesis with an intramedullary nail is a procedure reserved for patients who have conditions affecting the ankle joint and subtalar joint. The most common complications include nonunion, malunion, delayed union, infection, periprosthetic fracture, hardware failure, lateral plantar nerve injury, and wound healing. Significant bone void may result if the hardware requires removal secondary to one of these complications. The purpose of this article is to report on 2 cases of infected intramedullary nails, which were revised with fibular inlay strut grafts. Both cases were augmented with either internal or external fixation. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case report.

Neuropathy and poorly controlled diabetes increase the rate of surgical site infection after foot and ankle surgery.

BACKGROUND: This prospective study was designed to evaluate the frequency of surgical site infection in patients treated with foot and ankle surgery. Our hypothesis was that patients with complications of diabetes are at increased risk for surgical site infection compared with patients without diabetes and patients with diabetes who do not have diabetic complications. Another goal was to compare the association of neuropathy with surgical site infection in both nondiabetic and diabetic patients. METHODS: Two thousand and sixty consecutive surgical cases were evaluated. Group 1 included nondiabetic patients without neuropathy, Group 2 included nondiabetic patients with neuropathy, Group 3 included patients with diabetes but no diabetic complications, and Group 4 included patients with diabetes who had at least one complication of diabetes. RESULTS: The surgical site infection rate in this study was 3.1%. Patients with complicated diabetes had a 7.25-fold increased risk of surgical site infection compared with nondiabetic patients without neuropathy and a 3.72-fold increased risk compared with patients with uncomplicated diabetes. Patients with complicated diabetes had a nonsignificant 1.54-fold higher rate of surgical site infection compared with nondiabetic patients with neuropathy. Nondiabetic patients with neuropathy had a significant 4.72-fold increased risk of surgical site infection compared with nondiabetic patients without neuropathy. Despite this, nondiabetic patients with neuropathy did not have a significantly higher rate of surgical site infection than patients with uncomplicated diabetes, and the frequency of surgical site infection in the group with uncomplicated diabetes was not significantly different from that in the nondiabetic patients without neuropathy. Multivariable logistic regression analysis demonstrated that peripheral neuropathy and a hemoglobin A1c of ≥8% were independently associated with surgical site infection. CONCLUSIONS: Complicated diabetes increases the risk of surgical site infection after foot and ankle surgery. Patients who had diabetes without complications did not have a greater risk of surgical site infection compared with nondiabetic patients without neuropathy. The presence of neuropathy increases the risk of surgical site infection even in patients without diabetes. Poor long-term glycemic control is also associated with an increased risk of surgical site infection. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Lawn mower injuries to the lower extremity: a 10-year retrospective review.

INTRODUCTION: Lawn mower injuries occur frequently in the United States and oftentimes result in extensive trauma to the lower extremities. These injuries can be quite devastating and cause there to be loss of function and amputation. The purpose of this study was to determine if there are specific factors that would help determine the best treatment protocol, patient outcomes, and prognosis after lawn mower injury to the foot and ankle. MATERIAL AND METHODS: A retrospective review of medical records was performed on all patients treated at a university level 1 trauma center from 2000 to 2010. Only subjects 18 years or older who sustained an injury below the level of the knee were included for review. RESULTS: Seventy-three patients were included in this review. The results revealed that patients who developed a complication were significantly older than the group of patients without complications (P = .03). Digits were found to be injured most often but the odds of developing a complication were much higher if these injuries involved the plantar foot, dorsal foot, or ankle. Interestingly, patients on prolonged antibiotic therapy had a significantly higher risk of developing complications. The presence of comorbidities significantly increased the risk of complication (P = .008); the greatest risk factors were cardiovascular disease (P = .001) and diabetes (P = .06). DISCUSSION: The authors present the largest cohort of lawn mower injuries in the medical literature, which demonstrates that factors such as age, location of injury, and the presence of comorbidities influence the outcome and increase the risk of injury to the foot and ankle. These results may be useful in determining the best treatment plan possible for patients with these severe injuries. LEVELS OF EVIDENCE: Therapeutic, Level IV, Retrospective case series.

Bilateral osteonecrosis of the navicular and medial cuneiform in a patient with systemic lupus erythematosus: a case report.

INTRODUCTION: Atraumatic avascular necrosis (AVN) is an unusual pathology to the foot. Risk factors include the use of corticosteroids, smoking, alcohol, rheumatologic disorders, hematologic disorders, and metabolic disorders. To the authors' knowledge, this study presents the first case of bilateral atraumatic AVN to the navicular and medial cuneiform in a patient with systemic lupus erythamatosus (SLE). CASE DESCRIPTION: A 40-year-old man presented with a past medical history of SLE in which he developed AVN of the tarsal navicular and medial cuneiform. This occurred first on the subject's right foot and then while recovering from surgical intervention, on his left foot. Talonaviculocuneiform arthrodesis was performed with the use of distal tibial autograft on both extremities. The subject's American Orthopaedic Foot and Ankle Society midfoot score improved from 34 to 80 at 21 months on the right and 37 to 90 at 15 months to the left. DISCUSSION: Patients with SLE carry a significant risk of developing AVN. Comorbidities such as vasculitis, corticosteroid use, cytotoxic medication, and peripheral neuropathy are known risk factors in the development of AVN. Unusual features such as multifocal AVN and unusual anatomic locations can occur with SLE. AVN of the foot is generally treated with surgical intervention. Treatments such as core decompression, open reduction and internal fixation, and arthrodesis have been recommended based on the symptoms and presentation. CONCLUSION: The authors present a very rare presentation of bilateral osteonecrosis of the tarsal navicular and first cuneiform in a patient with SLE. The patient was treated with bilateral talonaviculocuneiform arthrodesis. The patient demonstrated considerable improvement to both extremities. LEVELS OF EVIDENCE: Therapeutic, Level IV.

Internal fixation techniques for midfoot charcot neuroarthropathy in patients with diabetes.

Charcot neuropathic osteoarthropathy (CN) of the foot and ankle is a poorly understood destructive process that poses a great clinical challenge to foot and ankle specialists. Neuropathic fractures or dislocations in the foot and ankle predispose patients to increased morbidity, premature mortality, and can greatly decrease quality of life. Early recognition and treatment of CN is imperative to prevent the development of permanent deformities. The purpose of this article is to review the history, cause, and classification of CN and to discuss commonly used internal fixation techniques and their indications.

Technique tip: subtalar joint fusion using a parallel guide and double screw fixation.

A wide range of techniques has been described to achieve subtalar (talocalcaneal) arthrodesis using interfragmental screw fixation. In this technical report, we describe a method that enables us to accurately position 2 screws across the subtalar joint in order to achieve arthrodesis between the talus and calcaneus. Careful attention to the tips described in this report should minimize the risk of aberrant placement of the screws while expediting the process of osteosynthesis.