Human skin allograft used to treat open wounds after club foot release

The inversion deformity of club foot is characterized by shortened ligaments and tendons on the medial side of the foot. The condition, when refractory to castings, is treated easily by operative intervention with neutralization of the foot and ankle. Closure of the resulting incision creates tension on the skin that is well tolerated in most children. Correction of severe deformities leaves incisions that will not close primarily, leaving tendons and neurovascular structures exposed on the posteromedial aspect of the foot. Free tissue transfer or spontaneous secondary closure are 2 options that have drawbacks. Application of human skin allograft affords protection to underlying tissue while allowing granulation tissue formation and wound contraction. Subsequent skin autograft and secondary skin contraction and epithelialization provide satisfactory wound closure with normal foot contour and preservation of ankle correction. Complete healing is achieved by the time cast immobilization is discontinued 6 weeks after surgery.     

Can a Tissue-Engineered Skin Graft Improve Healing of Lower Extremity Foot Wounds after Revascularization?

p < 0.01) and the median time to complete wound closure (7 vs. 15 weeks, p= 0.0021, rank-sum test). There was no difference in the wound closure rate of meshed and unmeshed graft at 4, 8, 12, or 24 weeks (p > 0.05). Three indolent localized wound infections in the tissue-engineered skin graft group were the only complication. Tissue-engineered skin grafting can be used safely in previously ischemic wounds after lower extremity revascularization. Treatment with this graft promotes healing more rapidly and in more patients than standard moist dressings. It obviates the risk, inconvenience, and expense of donor skin harvesting, anesthesia, and hospitalization associated with autologous skin grafting. This graft may represent an advance in the treatment of previously ischemic lower extremity foot wounds.     

Erbium: YAG Laser-Assisted Preparation of a Combined Dermal/Full Thickness Sandwich Skin Graft

BACKGROUND: Skin grafting is a common procedure to close defects after tumor resection. However, delicate areas such as the heel or the sole of the foot can be closed with a specially designed graft as described in this article. OBJECTIVE: To describe a surgical technique by means of erbium:YAG laser-assisted preparation of a combined dermal/full-thickness sandwich skin graft that facilitates the closure of defects, especially at mechanically stressed anatomic sites. METHODS: Tumor defects on the sole of the foot of 28 patients were closed with a new dermal/full-thickness sandwich skin graft. To obtain this special graft, half of a full-thickness skin graft twice the size of the wound defect was deepithelialized with an erbium:YAG laser. After complete defatting of the transplant, the deepithelialized part was folded beneath the full-thickness part (upside down) resulting in a sandwich graft, enabling contact of the papillary dermis with the wound surface. Graft results were graded as excellent when more than 75%, good if 50-75%, fair if 25-50%, and poor if less than 25% of the transplant healed. RESULTS: Results were graded as excellent in 32%, good in 54%, fair in 11%, and poor in 3% of the patients. Total graft loss was experienced in 1 of 28 patients. Complications such as bulky margins or infection were encountered in 14% of the patients. CONCLUSION: The laser-assisted preparation of the combined dermal/full-thickness sandwich skin graft is a new technique that facilitates the closure of defects in delicate anatomic locations with high mechanical stress like the plantar sole.     

Combined transfer by several perforator skin flaps to cover an extensive and multiplanar wound on the foot and ankle

BackgroundThis study aimed to assess the feasibility and effectiveness of using combined transfer by two or three large skin flaps to cover a single extensive and multiplanar wound on the foot and ankle to achieve full coverage of the wound and primary donor-site closure.Patients and methodsSeventeen patients with extensive wounds around their foot and ankle were treated. The flap could either be anterolateral femoral perforator (ALTP) flap, deep inferior epigastric artery perforator (DIEP) flap, or thoracodorsal artery perforator (TDAP) flap. According to the dimensions and shape of the wound and the availability of donor sites, we classified the reconstruction into three different types. Based on the type, the soft-tissue defect was divided into two or three parts to guide the corresponding perforator skin flaps to be harvested within the maximum width and length of the donor sites.ResultsAll 17 patients were successfully reconstructed, with a total of 35 flaps in 37 paddles. Vascular compromise occurred in one patient and was saved by venous thrombectomy. In total, four flaps experienced a partial loss and were treated either conservatively or by a skin graft. No ulceration due to abrasion occurred on any flap during the entire follow-up. All donor sites were directly closed and healed uneventfully, except for one needing coverage by a skin graft and another experiencing dehiscence and scar widening.ConclusionCombined transfer by several skin perforator flaps is a flexible reconstructive option for resurfacing extensive and multiplanar wounds on the foot and ankle. The benefit lies in a well-reconstructed contour, an anti-frictional property, a permission of a normal shoe wearing in the reconstructed foot, and meanwhile a primary closure on donor site.     

油调膏配合负压封闭引流治疗湿热毒盛型糖尿病足疗效分析

目的:总结油调膏配合负压封闭引流治疗湿热毒盛型糖尿病足的疗效.方法:回顾40例湿热毒盛型糖尿病足患者的临床资料,均采用油调膏外用、创面清创后负压封闭引流治疗.结果:40例患者中38例创面愈合出院,愈合时间14～30天,平均(16.58±1.60)天.住院时间15～33天,平均(18.58±4.12)天.未愈合2例,出院...     

Severe Post-Burn Hyperextension of Metatarsophalangeal Joints in a Child With Bilateral Foot Contracture

Achieving a stable plantigrade foot after repair of complex post-burn deformities poses a particularly difficult challenge for the foot and ankle surgeon. We report an unusual case of a child with severe bilateral forefoot contracture deformities treated by soft tissue release and lengthening, and conventional wound coverage with split-thickness skin grafting.     

超长蒂岛状皮瓣修复足部大面积组织缺损

目的 探讨超长血管蒂岛状皮瓣修复足跟部大面积组织缺损的临床效果。方法 2012年1月至2014年12月,选择12例因外伤等原因造成足部较大面积软组织缺损患者,设计小腿、足背的神经营养血管蒂超长岛状皮瓣,旋转后修复足跟部巨大创面,供区植皮闭合创面。结果 术后移植皮瓣外观及形态良好,耐磨,无明显臃肿和色素沉着。术后随访6~12个月,供区无明显继发畸形与并发症。结论 超长血管蒂岛状皮瓣血供可靠,可超长转移,是修复足跟部创面的理想选择。     

Application of external fixators for management of Charcot deformities of the foot and ankle

External fixators have been used effectively for a variety of traumatic, congenital, and neuromuscular conditions of the lower extremity for many decades. The transition to management of Charcot foot and ankle deformities in the diabetic neuropathic patient is a logical application. External fixation can address the unique challenges in the Charcot foot, including osteoporosis, osteomyelitis, wound healing, and compliance issues. The author's experience has lead to abandoning other methods of fixation in favor of external fixation for most infected and noninfected Charcot deformities of the foot and ankle.     

小腿开放性骨折伤口处理

目的 报道开放性小腿骨折伤口闭合的处理经验。方法 清创和处理骨折后，直接缝合伤口时应无张力，否则行关系和缝合，创面有软组织，可游离植皮。套状４撕脱皮肤可修得成中厚皮片行原位缝合。理宜延期Ⅰ期闭合。对骨质外露，宜采用筋膜皮瓣，肌（皮）瓣。感染创口需炎症控制后行伤口闭合。结果 新鲜创口２８例伤口闭合。仅皮片原位缝合出现７例坏死，经第二次手术创口闭合。６３例感染创面经抗炎、植皮和组织瓣方法闭合。结论 伤     

中西医结合点状植皮治疗糖尿病足溃疡

目的：观察中西医结合点状植皮法对糖尿病足溃疡的修复作用。方法：在174例糖尿病足溃疡患者创面肉芽组织较新鲜,质地坚实,无明显水肿,分泌物较少,周围无急性炎症时植皮,在局麻下,用锐刀切取点状皮片,将皮片均匀置于创面肉芽组织,使皮片深层与肉芽底部紧密接触,皮片间距0.5--1 cm,无菌网眼纱布覆盖固定,敷以生肌象皮膏纱条,无菌干纱布稍加压包扎。结果：植皮数8--60片,平均成活率80%;创面痊愈时间7--28 d,平均18.7 d。结论：中西医结合点状植皮法治疗糖尿病足溃疡,操作简便,疗效显著,创伤小,不需要特殊技术及设备器械。     

Mu甲皮瓣供区创面的处理

目的 探讨提高Mu甲皮瓣供瓣区植皮成活的治疗措施。方法 1982年6月-1998年4月对252例带趾骨片Mu甲皮瓣,18例单纯Mu甲皮瓣供区创面采用游离皮片覆盖,植皮区适当加压包扎处理,术后2周拆线,对较厚的移植皮片或皮片未完全成活的则需延长包扎时间,避免过早下床行走,结果 共有66例植皮坏死,其中38例需再次植皮,28例经换药愈合,在纵劈Mu趾骨髓腔面上植皮比在裸露骨膜上植皮的成活率明显提高,术后皮片的收缩使Mu趾跖内侧保留皮肤组织向跖外侧扩展,能覆盖整个Mu趾跖侧面,结论 采用改进Mu甲皮瓣的剥取、注意皮片切取及植皮区包扎等治疗措施后,提高了供足植皮的成活率,游离皮片移植应作为Mu甲皮瓣供瓣区创面修复的理想选择。     

Clinical Classification of Bioengineered Skin Use and Its Correlation with Healing of Diabetic and Venous Ulcers

BACKGROUND: Chronic wounds are being treated with bioengineering skin constructs. Yet, there is no standard way of assessing these wounds. We developed a classification system to evaluate wounds after construct application. The classification system evaluates the early clinical effect of bioengineered skin and early construct appearance giving a total score named the skin substitute score. OBJECTIVE: Apply classification system to both venous and diabetic foot ulcers and determine whether classification system has validity and predictability for healing. METHODS: Evaluated serial photographs in 83 and 78 patients with diabetic foot ulcers and in 84 and 83 patients with venous ulcer on Days 7 and 14, respectively, treated with a bilayered bioengineered skin construct. Applied the classification system and determined the percentages of healed patients. RESULTS: There was a significant correlation between better skin substitute score and complete wound closure for both venous ulcers p=0.002 on Day 7 and p=0.01 on Day 14) and diabetic foot ulcers p=0.0005 on Day 7 and p<0.0001 on Day 14). CONCLUSION: Optimal clinical effect was associated with complete wound closure. As the clinical effect becomes less than optimal continued clinical persistence of the construct becomes important. This classification system seems to have validity in predicting complete wound closure in wounds treated with a bilayered bioengineered skin construct.     

人组织工程全层皮肤在烧伤创面中厚供皮区的应用

目的观察人组织工程全层皮肤(ActivSkin)在中厚供皮区临床应用效果.方法 9例患者,年龄17～43岁.其中5例1%～6%总体表面积烧伤,深Ⅱ度～Ⅲ度;4例烧伤后瘢痕.每例患者2个部位创面,均使用自体中厚皮片修复.切取皮片后供区遗留创面随机分为试验组和对照组,行自体对照观察.试验组创面采用ActivSkin修复,对照组创面采用凡士林油纱覆盖.术后观察创面疼痛、愈合时间及治愈率;术后7～30 d每日观察创面愈合情况,1、3、6个月定期随访.结果试验组创面术后疼痛明显减轻,愈合时间为9.67±2.92 d,比对照组16.56±2.96 d提前,差异有统计学意义(P＜0.05);治愈率均为100%.术后随访试验组创面供皮区愈合后未见水疱、残余创面发生,瘢痕形成减轻;对照组创面4例于术后3个月内有水泡形成,残余创面发生. 结论ActivSkin可减轻中厚供皮区创面疼痛,加速愈合,并能预防供皮区愈合后水疱、残余创面发生,降低瘢痕形成.     

人工真皮修复手足部肌腱和骨外露创面

目的观察应用人工真皮联合自体皮片移植修复手足部肌腱和骨外露创面的临床疗效。方法对14例手足部皮肤缺损伴肌腱、骨外露患者采用清创人工真皮覆盖治疗,3周后采用自体中厚皮片移植修复创面。结果除1例边缘坏死经局部换药愈合外,13例植皮全部成活。患者均获得随访,时间6~24个月。创面愈合外观满意,局部无明显疼痛和增生性瘢痕,移植皮肤柔软,有弹性,色素沉着不明显。结论人工真皮联合二期植皮是修复手足部肌腱和骨外露创面的一种简单、有效的方法。     

Extra-articular arthrodesis of the subtalar joint: a clinical study and review

A series of 73 Grice extra-articular arthrodeses in 54 children with hind foot valgus is presented with an overall satisfactory result in 79% of these cases. The diagnostic categories in which we have used this procedure include: cerebral palsy, poliomyelitis, meningomyelocele, pes plano valgus, convex pes valgus, osteogenesis imperfecta, congenital hydrocephalus, partial adactylia, and congenital calcaneovalgus. The results with 11 meningomyelocele deformities are encouraging as only 2 of these children required a triple arthrodesis; 5 out of 6 patients in whom the opposite foot could serve as a control developed a smaller foot on the opposite extremity as a result of this procedure. This operative procedure was considered definitive treatment in 47% of the cases (264 operative feet) and produced satisfactory results in 74% of the cases (573 operative feet) reported in the literature.     

Soft Tissue Management and Tibialis Posterior Tendon Transfer in Acute Correction for Neglected Drop Foot Deformity

Acute correction of rigid drop foot deformity can be problematic due to the skin defect that may occur in the medial part of the ankle. The purpose of this study is to present an innovative solution for this problem. We hypothesized that acute correction for rigid ankle contractures without arthrosis might be possible if the medial skin defect could be closed. Therefore, we described a surgical technique for acute functional correction of rigid drop foot deformities. The closure of the medial defect was performed by applying a flap and partial-thickness skin graft. We have retrospectively evaluated the results of 18 patients who were treated between 2010 and 2016 with this technique. The mean age of the patients was 37 ± 9.5 (22-56) years. Foot drop etiology was firearm-related nerve injury. Corrections were performed after 14.6 ± 7.9 (8-38) months following the injury. At the end of an average follow-up period of 44.4 ± 6.2 (37-60) months, 14 of 18 patients (78%) recovered without complications, 3 patients experienced partial loss in the medial skin graft region, and 1 patient developed a superficial infection. None of the patients have developed pes planus. We observed that the ankle flexion contracture, which was 34° ± 9.2° (20°-50°) preoperatively, could reach an average of 2.2° ± 2.5° (0°-6°) dorsiflexion after surgery. We suggest that acute correction and tibialis posterior tendon transfer in the treatment of rigid foot drop deformity can be performed with an effective skin closure with low soft tissue complications.     

Recurrent diabetic foot ulcers: Results of a maximal multidisciplinary approach including reconstructive foot/ankle surgery

The diabetic foot ulcer (DFU) and Charcot Neuroarthropathy (CN) are serious complications of diabetes mellitus in which wound closure is complex to achieve. Treating recurrent DFU in patients with a combination of infection, ischemia, and deformities is extremely challenging and this group of patients has a very poor outcome. This case series describes the outcomes of patients with a recurrent DFU and CN, with a mean SINBAD score of 4 and of which 40% had a TCS of D3, using a multidisciplinary protocol that includes reconstructive foot and ankle surgery. In 24/35 (69%) of patients, wound closure was achieved after a mean of 75 days postoperatively. The mean ulcer-free period was 358 days. The mean number of interventions was 6.7 (range 3–9). Post treatment 27/35 (77%) of patients was mobile, without additional amputation or ulcer recurrence. This study shows that wound closure and a long ulcer-free period can be achieved in patients with a DFU and CN and its multifactorial underlying diseases when treated in a multidisciplinary team, including reconstructive foot and ankle surgery.     

甲皮瓣供区创面的处理

目的　探讨提高口止母甲皮瓣供瓣区植皮成活的治疗措施。方法　 1982年 6月～ 1998年 4月对 2 5 2例带趾骨片口止母甲皮瓣 ,18例单纯口止母甲皮瓣供区创面采用游离皮片覆盖 ,植皮区适当加压包扎处理。术后 2周拆线 ,对较厚的移植皮片或皮片未完全成活的则需延长包扎时间 ,避免过早下床行走。结果　共有 6 6例植皮坏死 ,其中38例需再次植皮 ,2 8例经换药愈合。在纵劈口止母趾骨髓腔面上植皮比在裸露骨膜上植皮的成活率明显提高。术后皮片的收缩使口止母趾跖内侧保留皮肤组织向跖外侧扩展 ,能覆盖整个口止母趾跖侧面。结论　采用改进口止母甲皮瓣的剥取、注意皮片切取及植皮区包扎等治疗措施后 ,提高了供足植皮的成活率。游离皮片移植应作为口止母甲皮瓣供瓣区创面修复的理想选择。     

The Keystone Design Perforator Island Flap in reconstructive surgery

Background: A surgical technique for closing skin defects following skin cancer (particularly melanoma) removal is described in the present paper. Its use is illustrated in five patients. The technique has been used in 300 cases over the past 7 years and is suitable for all areas of the body from scalp to foot. We have coined the term Keystone Design Perforator Island Flap (KDPIF) because of its curvilinear shaped trapezoidal design borrowed from architectural terminology. It is essentially elliptical in shape with its long axis adjacent to the long axis of the defect. The flap is based on randomly located vascular perforators. The wound is closed directly, the mid‐line area is the line of maximum tension and by V‐Y advancement of each end of the flap, the ‘islanded’ flap fills the defect. This allows the secondary defect on the opposite side to be closed, exploiting the mobility of the adjacent surrounding tissue. The importance of blunt dissection is emphasized in raising these perforator island flaps as it preserves the vascular integrity of the musculocutaneous and fasciocutaneous perforators together with venous and neural connections. The keystone flap minimizes the need for skin grafting in the majority of cases and produces excellent aesthetic results. Four types of flaps are described: Type I (direct closure), Type II (with or without grafting), Type III (employs a double island flap technique), and Type IV (involves rotation and advancement with or without grafting). The patient is almost pain free in the postoperative phase. Early mobilization is possible, allowing this technique to be used in short stay patients. Results: In a series of 300 patients with flaps situated over the extremities, trunk and facial region, primary wound healing was achieved in 99.6% with one out of 300 developing partial necrosis of the flap. Conclusions: The technique described in the present article offers a simple and effective method of wound closure in situations that would otherwise have required complex flap closure or skin grafting particularly for melanoma.     

应用皮肤牵张带延期闭合骨筋膜室减张切口

目的观察应用皮肤牵张带延期直接缝合骨筋膜室减张切口的效果。方法因骨筋膜室综合征而行切开减压术导致皮肤缺损患者 21例,年龄 7～ 36岁,小腿皮肤缺损 17例、前臂皮肤缺损 3例、足部皮肤缺损 1例。缺损区最小 5 cm× 15 cm,最大 11 cm× 28 cm,合并骨外露和肌腱外露者各 1例。于骨筋膜室切开减压后第 4～ 7 d放置皮肤牵张带,此后 3～ 7 d天待牵拉至两侧皮缘靠近时延期缝合伤口, 2周后拆线。结果 21例患者, 20例伤口一期愈合,形成线状瘢痕; 1例在放置皮肤牵张带之前伤口红肿,有较多分泌物,置皮肤牵张带 2 d后分泌物仍较多,故拆除 3根硅胶带,伤口引流,遗留 2 cm× 5 cm创面,经换药、小块游离皮片植皮后伤口愈合。 2例合并骨外露和肌腱外露者伤口愈合良好。随访 3～ 15个月,患肢远端关节活动自如,无肌肉挛缩现象。结论急性骨筋膜室综合征切开减压后,使用皮肤牵张带延期缝合伤口,安全、有效。其优点 :(1)操作方法简便、快速,病程短,费用相对较低; (2)无需游离皮片植皮,愈合后形成线状瘢痕,局部皮肤质量较好,对美观影响小; (3)同样适用于伴骨外露和肌腱外露者,可避免施行皮瓣转移覆盖手术。