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.

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.

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.

The relative roles of aggressive wound care versus revascularization in salvage of the threatened lower extremity in the renal failure diabetic patient.

Current literature indicates poor survival and limb salvage rates in renal failure diabetic patients who present with ulcerated or gangrenous lower extremities. Even in those limbs that were successfully revascularized, the amputation rate was as high as 37 percent. This has led some to advocate immediate amputation when treating the threatened limb of a renal failure diabetic patient.

Single-stage surgical treatment of noninfected diabetic foot ulcers.

A retrospective study was undertaken to evaluate a single-stage approach in the treatment of noninfected, chronic, well-perfused diabetic foot wounds. This single-stage approach consisted of total excision of the ulcer with broad exposure, correction of the underlying osseous deformity, and immediate primary closure using a local random flap. Four hundred cases of pedal ulcers were analyzed by chart review.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Comparative response of muscle and subcutaneous tissue pH during arterial and venous occlusion in musculocutaneous flaps.

Clinical measures often fail to detect early tissue ischemia in inadequately perfused flaps. This study investigates the application of a new pH electrode system to monitor tissue metabolism continuously in porcine and human musculocutaneous flaps. Bilateral rectus abdominis flaps based on the deep inferior epigastric pedicle were elevated in eight mixed-breed pigs.

Femoropopliteal reconstruction for claudication. The risk to life and limb.

The current study was undertaken to examine the results of femoropopliteal bypass grafting with intermittent claudication as the indication. Of 1173 infrainguinal reconstructions carried out on our service during the past decade, 249 (21%) consecutive femoropopliteal grafts were performed for disabling claudication in 191 patients. The primary five-year cumulative patency rates were 78% for autogenous vein and 52% for polytetrafluoroethylene grafts.