1/9. Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area.In this study, 12 cases of reconstruction of the heel and plantar area since 1982 are reviewed. Six nonsensate muscle free flaps and six sensate fasciocutaneous flaps were used, respectively. Categories assessed were the time interval for return to daily living activities, sensation to light touch, pinprick, Semmes-Weinstein monofilament test of the reconstructed area for sensory evaluation; and results of pedograms (maximal pressure, pressure distribution, and total contact area of the plantar surface). Follow-up periods were between 2 and 14 years, with an average of 6 years. Better sensory results and early return to daily living activities were observed in the sensate flap group, but the defects were smaller in this group. Despite the slightly longer time to return to daily living activities and worse sensory results, long-term follow-up showed that patients with nonsensate flaps had no difficulty in performing living activities if they continued to be careful and to use some kind of protective shoes. The results of the pedogram analyses were similar between the two groups with regard to total contact area of the reconstructed foot in relation to the healthy foot. pressure values of the reconstructed areas in sensate flaps were found to be close to pressure values in the same weight areas of the normal foot. The differences between pressure values of the sensate and nonsensate flaps were statistically significant (p < 0.001). Therefore, in reconstruction of the weight-bearing surface of the foot, each case should be evaluated individually. The reconstructive method should be chosen according to the location and soft-tissue requirements of the defect.- - - - - - - - - - ranking = 1keywords = difficulty (Clic here for more details about this article) |
2/9. Salter-Harris III stress fracture of the proximal first metatarsal: a case report.An intraarticular, dorsal, proximal epiphyseal stress fracture (Salter-Harris III) of the first metatarsal was identified in a 14-year-old boy. Successful fracture healing was achieved with a rocker sole shoe modification and activity limitation.- - - - - - - - - - ranking = 12.080365975327keywords = limitation (Clic here for more details about this article) |
3/9. rubber foreign bodies in puncture wounds of the foot in patients wearing rubber-soled shoes.We report 8 cases of puncture wound of the foot associated with rubber foreign bodies in patients who were wearing rubber-soled shoes. The difficulty in making the correct diagnosis and the complications arising from these injuries are reviewed. The morbidity associated with these seemingly innocuous puncture wounds can be serious. Infective complications resolved only with removal of all imbedded rubber foreign bodies. A history of wearing rubber-soled shoes during the injury and a high index of suspicion may prevent complications.- - - - - - - - - - ranking = 1keywords = difficulty (Clic here for more details about this article) |
4/9. Determining foot and ankle impairments by the AMA fifth edition guides.The fifth edition of the Guides has been criticized for its failure to provide a comprehensive, valid, reliable, unbiased, and evidenced-based system for rating impairments and the way in which workers' compensation systems use the ratings, resulting in inappropriate compensation [8]. The lower extremity chapter utilizes numerous functional and anatomic methods of assessment, as well as diagnosis-based estimates. Though this process of using multiple approaches to measure impairment increases the chances that an underlying physical impairment may be detected, it is time-consuming and may increase rating variability [9]. McCarthy et al studied the correlation between measures of impairment for patients with fractures of the lower extremity. They found that the anatomic approach of evaluation was better correlated than functional and diagnostic methods with measures of task performance based on direct observations as well as the patient's own assessment of activity limitation and disability. Also, muscle strength assessment as described in the Guides was a more sensitive measure of impairment than range of motion [9]. The most elusive part of the foot and ankle evaluation is the inability to capture the added impairment burden caused by pain. The assessment of pain is the most problematic part of any evaluation. Pain is considered and incorporated into the impairment ratings found in the foot and ankle section, as well as the other individual chapters. chronic pain is often not adequately accounted for, however, and the examiner must evaluate permanent impairment from chronic pain separately. The examiner has the ability to increase the percentage of organ system impairment from 1% to 3% if there is pain-related impairment that increases the burden of illness slightly. If there is significant pain-related impairment, a formal pain assessment is performed. Chapter 18 provides guidance in making these determinations. Impairments for Complex Regional Pain syndrome (CRPS), type 1 (reflex sympathetic dystrophy), and CRPS, type 2 (causalgia) should incorporate the use of a formal pain assessment in addition to the standard methods of assessment. The formal pain evaluation relies mostly on self-reports from the individual and is most heavily weighted for ADL deficits. The physician must make assessments of the individual's pain behavior and credibility for this evaluation. The formal pain assessment classifies the pain-related impairment into categories of mild, moderate, moderately severe, or severe and determines whether this impairment is ratable or not. These categories do not have impairment percentages associated with them. The individual's symptoms or presentation should match known conditions or syndromes in order to be ratable. If not ratable, the examiner should report that the individual has apparent impairment that is not ratable on the basis of current medical knowledge. In the end, pain evaluations are used administratively and, depending on the situation, may be given equal weight with the standard evaluation or may be totally disregarded.- - - - - - - - - - ranking = 12.080365975327keywords = limitation (Clic here for more details about this article) |
5/9. Reconstruction of through-and-through gunshot wounds to the feet with free gracilis muscle flaps.Reconstruction of a through-and-through gunshot wound (GSW) to the foot remains a challenging problem for plastic and orthopedic surgeons, because it is difficult to achieve reliable soft tissue coverage of the foot while at the same time optimizing foot contour and weightbearing. In the past year, four patients with such an injury were treated with initial wound debridement and stabilization of the metatarsals, followed by a free gracilis muscle transfer with a split-thickness skin graft. One patient also had a secondary iliac bone graft to the first metatarsal. All patients have completely healed wounds, are free of osteomyelitis, and have achieved an excellent contour and good ambulation of the foot without donor site problems. Thus, a free gracilis muscle transfer should be considered first for reconstruction of a through-and-through GSW to the foot, because it can provide reliable soft tissue coverage with excellent contour and minimal donor site morbidity.- - - - - - - - - - ranking = 3214.6075151024keywords = ambulation (Clic here for more details about this article) |
6/9. Maggot therapy for wound debridement in a traumatic foot-degloving injury: a case report.A 43-year-old man was treated for a traumatic degloving injury to his foot with a transmetatarsal amputation and wound care because of the extensive soft tissue loss. After biweekly sharp debridements in the office for 4 weeks, very minimal skin ingrowth was noted. Maggot therapy was then implemented for a 48-hour treatment and a second treatment for 72 hours to help reduce excessive fibrosis and to painlessly debride the tissues to expose the granular base. Daily dressing changes for the next 6 weeks successfully allowed complete wound closure without any additional interventions. During the follow-up course, no complications were encountered and the patient has returned to ambulation with the use of a cane.- - - - - - - - - - ranking = 3214.6075151024keywords = ambulation (Clic here for more details about this article) |
7/9. Microvascular free muscle reconstruction of a large plantar defect.Large plantar defects present a difficult problem in reconstructive surgery. skin grafts are not durable and most distant flaps are too bulky to allow for ambulation in conventional footwear. Free muscle transfer with skin graft may represent a modality to provide a contoured and durable reconstruction for large plantar defects when local tissue is not available. This study presents a case of sole of foot and distal heel reconstruction with a free microvascular latissimus muscle transfer. The transfer was contoured to fit the defect and then covered with a split-thickness skin graft. Three months following surgery, the patient was walking without assistive devices and using conventional footwear. Now, two and one-half years after surgery, he is employed full-time in a job that entails walking, and has never experienced a tissue breakdown.- - - - - - - - - - ranking = 3214.6075151024keywords = ambulation (Clic here for more details about this article) |
8/9. Three-dimensional computed tomography reconstruction. A presurgical adjunct in the severely traumatized rearfoot.The use of computed tomography in visualizing the complex anatomy of the foot is well documented in current literature. However, one difficulty with CT films, as well as those of other imaging modalities, is that three-dimensional anatomy is represented in two dimensions. The observer is thus required to assimilate the consecutive film slices into an accurate mental picture of the patient's anatomical structure. Many physicians may find the results of this process unacceptable and inaccurate in select cases of severely abnormal patient anatomy. The authors present a solution, three-dimensional computed tomography reconstruction, and its clinical usefulness in a case presentation.- - - - - - - - - - ranking = 1keywords = difficulty (Clic here for more details about this article) |
9/9. Posterior interosseous free flap: various types.The posterior interosseous artery is located in the intermuscular septum between the extensor carpi ulnaris and extensor digiti minimi muscles. The posterior interosseous artery is anatomically united through two main anastomoses: one proximal (at the level of the distal border of the supinator muscle) and one distal (at the most distal part of the interosseous space). In the distal part, the posterior interosseous artery joins the anterior interosseous artery to form the distal anastomosis between them. The posterior interosseous flap can be widely used as a reverse flow island flap because it is perfused by anastomoses between the anterior and the posterior interosseous arteries at the level of the wrist. The flap is not reliable whenever there is injury to the distal forearm or the wrist. To circumvent this limitation and to increase the versatility of this flap, we have refined its use as a direct flow free flap. The three types of free flaps used were (1) fasciocutaneous, (2) fasciocutaneous-fascia, and (3) fascia only. Described are 23 posterior interosseous free flaps: 13 fasciocutaneous flaps, 6 fasciocutaneous-fascial flaps, and 4 fascial flaps. There were 13 sensory flaps using the posterior antebrachial cutaneous nerve. The length and external diameter of the pedicle were measured in 35 cases. The length of the pedicle was on average 3.5 cm (range, 3.0 to 4.0 cm) and the external diameter of the artery averaged 2.2 mm (range, 2.0 to 2.5 mm). The hand was the recipient in 21 patients, and the foot in 2. All 23 flaps covered the defect successfully.- - - - - - - - - - ranking = 12.080365975327keywords = limitation (Clic here for more details about this article) |