Complications of Percutaneous Tendo-Achilles Lengthening for Treatment and Prevention of Diabetic Foot Ulcers: A Systematic Review.

Percutaneous Achilles tendon lengthening is an effective surgical procedure to treat and prevent forefoot and midfoot ulcerations in patients with diabetes. Patients with diabetes are prone to plantar ulcerations due to a combination of factors, such as peripheral neuropathy, decreased tendon elasticity, peripheral vascular disease, and hyperglycemia. Complications such as re-ulceration and transfer lesion to the heel, associated with a calcaneal gait secondary to over-lengthening, are possible with percutaneous Achilles tendon lengthening. Although percutaneous Achilles tendon lengthening is well accepted, the overall incidence of complication has not been well described. A systematic review of the reported data was performed to determine the incidence of complication for percutaneous tendo-Achilles lengthening when used for the treatment and prevention of diabetic plantar ulcerations. Nine studies involving 490 percutaneous lengthening procedures met the inclusion criteria. The overall complication rate was 27.8% (8% with transfer heel ulcerations). Given the high rate of complications associated with a percutaneous Achilles tendon lengthening, careful patient selection and consideration of these risks should be considered prior to proceeding with this procedure. Additional prospective comparative analyses with standardization of surgical technique, degrees of lengthening achieved, and post-operative weightbearing and immobilization modalities are needed to decrease incidence of complication and achieve higher healing rates.

A Prospective Analysis of the SVS WIfI Classification System to Stratify Immediate and 1-Year Patient Outcomes.

The purpose of this study was to prospectively enroll patients that presented to the emergency department with a lower extremity infection, stratify risk and record outcomes. Risk stratification was performed based on the Society of Vascular Surgery Wound, foot Infection, and Ischemia (WIfI) classification system. This study aimed to establish the efficacy and validity of this classification in predicting patient outcomes during immediate hospitalization and throughout a 1 year follow up. A total of 152 patients were enrolled in the study and of these, 116 met the inclusion criteria and had at least 1 year of follow up for analysis. Each patient was assigned a WIfI score based on wound, ischemia, and foot infection severity according to the classification guidelines. Patient demographics as well as all podiatric and vascular procedures were recorded. The major end points of the study were rates of proximal amputation, time to wound healing, surgical procedures, surgical dehiscence, readmission rates, and mortality. A difference in rates of healing (p = .04), surgical dehiscence (p < .01), and 1 year mortality (p = .01) with increasing WIfI stage as well as across the individual component scores was noted. This analysis further supports the application of the WIfI classification system early during patient care to stratify risk and identify the need for early intervention and a multispecialty team approach to potentially improve outcomes in the severe multicomorbid patient.

A Surgical Approach to Location-specific Neuropathic Foot Ulceration.

The management of pedal ulcerations is often challenging because of a failure to correct underlying biomechanical deformities. Without correcting the biomechanical driving force creating the increased plantar pressures, it is unlikely for routine wound care to provide lasting solutions to pedal ulcerations. Patients with diabetes often experience glycosylation of their tendons, leading to contracture and pursuant deformity, creating imbalanced pressure distributions and eventual plantar ulceration. This article evaluates the efficacy of various lower extremity tendon transfers to balance the foot and redistribute plantar pressures to prevent or heal ulceration.

Evaluation of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for detecting necrotizing soft tissue infections in patients with diabetes and lower extremity infection.

AIMS: The aim of this pilot study was to assess the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC), a scoring system for Necrotizing Soft Tissue Infections, to diagnose Necrotizing Soft Tissue Infections of the lower extremity in patients with diabetes. METHODS: Sixty-nine patients with lower extremity infections were prospectively enrolled. The Laboratory Risk Indicator for Necrotizing Fasciitis was calculated and logistic regression was performed for each laboratory value. RESULTS: The Laboratory Risk Indicator for Necrotizing Fasciitis was associated with Necrotizing Soft Tissue Infection diagnosis in patients with diabetes (p = 0.01). Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 69%, 16.6%, and 100% respectively. Elevated C-reactive protein (OR 1.01, p = 0.02, 95% CI [1.002-1.23]) and white blood cell count (OR 1.34, p < 0.01, 95% CI [1.1-1.7]) were associated with Necrotizing Soft Tissue Infection. CONCLUSIONS: The Laboratory Risk Indicator for Necrotizing Fasciitis was useful as a negative predictor of Necrotizing Soft Tissue Infection while C- reactive protein and white blood cell count may have value as individual predictors. We recommend high clinical suspicion of Necrotizing Soft Tissue Infections in diabetics as laboratory evaluation may be non-specific.

Primary Invasive Squamous Cell Carcinoma of the Foot.

Malignant transformation of wounds is a rare complication that if missed can lead to loss of life or limb. This case report presents a rare invasive variant of squamous cell carcinoma presenting in the setting of a chronic wound complicated by osteomyelitis. This aggressive form of squamous cell carcinoma has a high growth rate and a high propensity for metastasis and recurrence. Early intervention greatly decreases the risk of metastasis and recurrence. We present the systematic evaluation and surgical management of an aggressive primary tumor occurring in the forefoot.

The Role of Dermal Regenerative Templates in Complex Lower Extremity Wounds.

Dermal regenerative templates (DRTs) provide an option for management of complex lower extremity wounds. DRTs may be used to achieve definitive wound closure by serving as a scaffold for local tissue infiltration. Healing with a DRT interface leads to histologic and structural properties similar to native skin. DRTs can be applied over deep wounds with exposed critical structures that may have required a local or free flap. DRTs are a valuable option for lower extremity limb reconstruction.

Vertical Wire Forefoot Fixation: An Advanced Technique for the Dynamic External Fixation Apparatus.

External fixation is used for the correction of select foot and ankle deformities. We have found the traditional forefoot crossing wire technique to be insufficient in terms of both individual metatarsal control and forefoot manipulation when using a dynamic ring fixator to correct forefoot deformities. We developed a forefoot fixation technique at the University of Cincinnati Medical Center, using 5 vertical wires to gain greater forefoot control while performing more precise skeletal manipulation for multiplanar deformity correction. The associated risks of infection, neurovascular injury, and other soft-tissue injury should be further investigated. This proposed vertical wire construct is an advanced method with which the foot and ankle surgeon can correct complex lower limb deformities.

Patterns in Opioid Prescription for Patients Operatively Treated for Ankle Fractures Following Implementation of 2017 Ohio Opioid Prescriber Law.

BACKGROUND: The purpose of this study was to report patterns of opioid prescription for patients treated operatively for ankle fractures after implementation of the 2017 Ohio Opioid Prescriber Law in comparison to the previous year. METHODS: A total of 144 patients operatively treated for isolated ankle fractures during two 6-month periods, January 2017 to July 2017 (pre-law) and January 2018 to July 2018 (post-law), were retrospectively identified. Preoperative and postoperative patient narcotic use was reviewed using a legal prescriber database. Total number of prescriptions, quantity of pills, and morphine milligram equivalents (MMEs) per patient prescribed during the 90-day postoperative period were compared between those treated before and those treated after implementation of the Ohio prescriber law. RESULTS: The average number of opioid prescriptions prescribed per patient in the 90-day postoperative period was 2.3 in the pre-law group and 2.1 in the post-law group (P = .625). The average MMEs prescribed per patient dropped from 942.4 MME pre-law to 700.5 MME post-law (P = .295). Differences in the average number of pills per prescription pre- and post-law (49.7 vs 36.2) and average MME per prescription (382.1 mg vs 275.2 mg) were statistically significant (P < .001 and P = .016, respectively). CONCLUSION: Following the implementation of the 2017 Ohio Opioid Prescriber Law, there was a downward trend in the number of pills per prescription and MMEs per prescription in patients operatively treated for isolated ankle fractures. The presence of a downward trend in the quantity of opioids prescribed in this patient cohort suggests the effectiveness of the state law. LEVEL OF EVIDENCE: Level III, comparative study.