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.

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.

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.

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. 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.

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

The use of marrow-derived stem cells to accelerate healing in chronic wounds.

Adult bone marrow-derived stem cells may aid the healing of chronic lower extremity wounds by transplanting a population of progenitor cells locally into the wound. We present results from three cases in which bone marrow aspirate containing marrow-derived cells was applied/injected locally into complex lower extremity chronic wounds of differing aetiologies. Our case series suggest that bone marrow aspirate, applied topically and injected into the wound periphery, may be a useful and potentially safe adjunct to wound simplification and ultimate closure.

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.

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.

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.

Predictors of postoperative complications of Ilizarov external ring fixators in the foot and ankle.

Our objective was to determine factors associated with complications of Ilizarov external ring fixator surgery for foot and ankle disorders in persons with diabetes mellitus. We reviewed the records of patients who underwent Charcot foot reconstruction or soft tissue offloading surgery over 1 year at a single institution. We compared the association of serious pin tract infection, pin fracture, and surgical wound dehiscence with the patient age, weight, duration device was used, preoperative glucose, preoperative hemoglobin, tourniquet time, and total operating time.

Technique of the sural nerve biopsy.

A sural nerve biopsy may be useful to enable the clinician to diagnose the etiology and underlying pathology of patients presenting with symptoms of a peripheral neuropathy, when no clear underlying cause has been determined with conventional assessment such as electrophysiology or quantitative sensory testing. Given the prevalence of lower extremity neurological pathology, it is surprising that few descriptions in the peer-reviewed medical literature exist on the rationale and technique for biopsy of the sural nerve. We review the usefulness of this procedure, describe the technique, and discuss the potential complications.

Ertapenem for diabetic foot infections.

Foot infections are a common cause of hospitalization in people with diabetes. Diabetic foot infections are associated with increased risk of amputation and death. This monograph reviews the diagnosis and treatment of diabetic foot infections with particular attention to a new carbapenem antibiotic, ertapenem, which has the potential to reduce inpatient length of stay and hospital-associated costs.