Evaluating the Efficacy of Hyperbaric Oxygen Therapy in Digital Frostbite.

Frostbite is a limb threatening, cold-induced tissue injury most commonly affecting the extremities. Hyperbaric oxygen therapy (HBOT) is a proposed adjunctive treatment for this condition, which acts by increasing cellular oxygen availability in damaged tissues. Currently, there is a lack of data regarding the effectiveness of HBOT. Therefore, the purpose of this study is to further the research as one of the largest retrospective comparative cohort studies to date. We evaluated the efficacy of HBOT in the treatment of digital frostbite compared to a non-HBOT-treated group, with a focus on amputation outcomes between each group. A multicenter retrospective cohort study was performed from January 2016 to August 2021 observing patients seen for frostbite. Amputation characteristics and encounter outcomes of patients treated with HBOT were compared to those in patients treated without HBOT. A one-to-one matching of HBOT-treated and non-HBOT-treated patients was also performed, followed by chi-square and Fisher's exact test statistical analysis. The results of the study found a low overall amputation rate of 5.2% across both cohorts. Comparison between groups identified no statistical difference between HBOT and non-HBOT groups regarding amputation characteristics through matched cohort analysis. However, an increased length of hospital stay in patients treated with HBOT (22.2 days) compared to the non-HBOT group (6.39 days) was identified. Based on this study, recommendations for future HBOT studies should evaluate the efficacy of HBOT for more severe cases of frostbite, with additional consideration for cost analysis studies.

Leclercia Adecarboxylata and Pseudomonas Oryzihabitans Infection after Achilles Tendon Repair: A Case Report and Literature Review.

Leclercia adecarboxylata and Pseudomonas oryzihabitans are two bacteria rarely seen in human infections. We present an unusual case of a patient who developed a localized infection with these bacteria after repair of a ruptured Achilles tendon. We also present a review of the literature regarding infection with these bacteria within the lower extremity.

Treatment of Nonhealing Diabetic Foot Wounds with Vaporous Hyperoxia Therapy in Conjunction with Standard Wound Care.

BACKGROUND: Vaporous hyperoxia therapy (VHT), a patented US Food and Drug Administration 510 (k)-cleared technology, is an adjunct therapy used in conjunction with standard wound care (SWC). Vaporous hyperoxia therapy is said to improve the health of wounded tissue by administering a low-frequency, noncontact, nonthermal, ionic, antimicrobial hydrating mist alternating with concentrated topical oxygen therapy. METHODS: Vaporous hyperoxia therapy was used to treat 36 subjects with chronic diabetic foot ulcers (DFUs) that were previously treated unsuccessfully with SWC. The average age of DFUs in the study was 11 months and the average size was over 3 cm2. Wounds were Wagner grade 2 or 3 and most commonly on the plantar surface around the midfoot. Treatment consisted of twice-weekly applications of VHT and wound debridement. Subjects were followed to wound closure, 20 weeks, or 40 treatments, whichever came first. RESULTS: The combination of SWC and VHT in the group that met and maintained compliance throughout the study period achieved an 83% DFU closure rate within a 20-week period. The average time for DFU closure in this study was 9.4 weeks. CONCLUSIONS: Historical analysis of SWC shows a 30.9% healing rate of all wounds, not differentiating chronic wounds. Accordingly, SWC/VHT increases chronic diabetic foot ulcer healing rates by 2.85 times compared with SWC alone. The purpose of this study was two-fold: first, to observe the effect of VHT on healing rates and time to healing in previously nonhealing DFUs; and second, to compare VHT with SWC, topical oxygen therapy, hyperbaric oxygen therapy, and ultrasound therapy.

Open Tibial Fracture Complicated by Wound Botulism: A Case Study.

Botulism is a neuroparalytic disease most commonly caused by foodborne ingestion of neurotoxin types A, B, and E, and is often fatal if untreated. Clinicians should be able to recognize the classic symptoms of botulinum intoxication (12). Owing to its rarity, there are a limited number of studies evaluating the clinical care of patients with wound botulism (10). We present an infected tibial non-union with botulism who underwent a successful radical excision and bone transport. The patient tolerated the procedure well.

Sagittal Chevron Shortening Osteotomy With Lateral Wedge for Treatment of Lesser Metatarsal Overload: A Case Report.

Metatarsalgia is a common problem that refers to the tenderness and pain beneath the forefoot. Many metatarsal shortening osteotomies have been described to alleviate metatarsal overload; however, these osteotomies have been associated with a high complication rate of floating toe deformity. We present a case study that describes an innovative technique for the treatment of lesser metatarsalgia that allows for the repositioning of the metatarsal head, using a stable screw fixation designed to minimize the common complication of the floating toe.

Primary Tumoral Calcinosis in a Pediatric Patient: A Rare Presentation.

Tumoral calcinosis is a benign, progressive disorder characterized by massive periarticular deposition of calcium salts into subcutaneous and deeper tissue layers. While a majority of cases present secondary to underlying metabolic disorders, it can rarely present as a primary, idiopathic phenomenon. We present an atypical case of a pediatric patient with a large, ulcerated pedal soft tissue mass found to be consistent with primary tumoral calcinosis. This was confirmed by histopathologic analysis and comprehensive metabolic workup. The patient underwent surgical excision of the mass, with complete resolution of symptoms and no recurrence after a 1-year follow-up period.

Isolated Forefoot Juvenile Xanthogranuloma: Unique Case Study and Treatment in a Pediatric Patient.

Juvenile xanthogranuloma is a benign histiocytic cell proliferative disorder that occurs in early childhood. The most common presentation occurs within the first 2 years of life with papular or nodular changes to the skin on the head, neck or upper trunk. This case study documents the findings and treatment of a single solitary soft tissue mass in the forefoot of a 17-year-old patient. Unique to this case, the initial diagnosis of tuberous xanthoma was made and, with referral to an outside hospital, changed to a juvenile xanthogranuloma. In addition, unlike most juvenile xanthogranulomas in the literature, there was no superficial dermatological abnormality seen clinically. This change was not a dramatically different diagnosis, but further immunohistochemical staining was necessary for ultimate diagnosis. The soft tissue mass was self-contained to the deeper tissue layers and not the epidermis. The patient was followed for 12 months for possible recurrence and medical workup, without postoperative complications. The purpose of this study was to report on a unique finding and presentation of a xanthogranulomatous soft tissue mass in the forefoot of a pediatric patient.

Arthroscopic Treatment of Osteochondral Lesions of the Talus Utilizing Juvenile Particulated Cartilage Allograft: A Case Series.

The treatment options for osteochondral lesions of the ankle are scarce, and newer modalities are becoming available. We describe a minimally invasive arthroscopic approach with implantation of juvenile particulated allograft to facilitate the growth of true hyaline cartilage in patients with osteochondral lesions of the talus. The purpose of this study was to subjectively review clinical outcomes using the validated Foot and Ankle Outcomes Score in patients who underwent this technique. Our technique was performed on 82 consecutive patients with average follow-up of 24 (range 9 to 86) months. We found that 28 (88%) of 32 patients who responded to the questionnaire had good or excellent results for activities of daily living; 26 (82%) of 32 patients had at least a good result for both pain and symptoms; and 25 (78%) of 32 had at least a fair result for functional sports and quality of life.

Arthroscopic Implantation of a Cartilage Matrix for an Osteochondral Defect of the Talus: A Case Report.

Advances have been made in the treatment for osteochondral defects of the talus, but these injuries continue to be a challenge for foot and ankle surgeons. We present an arthroscopically assisted technique that uses an allogenic cartilage graft in treating an osteochondral lesion of the medial dome of the talus. A brief discussion on current surgical options for osteochondral defects of the talus is also provided.

Leiomyoma of the Foot: A Case Report and Literature Review.

Leiomyomas within the foot are rare occurrences that are difficult to diagnose clinically and radiographically. They are benign and tend to be slow growing, often with minimal or no pain. We present an unusual case of a worker's compensation patient who presented with a new-onset mass within his foot that was thought to be a fibroma, but was later discovered to be a fast-growing leiomyoma after surgical excision. We also present a review of the literature regarding leiomyomas within the foot and ankle.

Stenotrophomonas maltophilia: A Rare Case of Osteomyelitis After an Open Distal Tibial Fracture.

Stenotrophomonas maltophilia is a gram-negative rod rarely associated with osteomyelitis. To date, only 3 cases of osteomyelitis due to this pathogen have been previously referenced. We describe the case of a 77-year-old male who developed osteomyelitis secondary to S. maltophilia infection after an open distal tibial fracture sustained by falling off a ladder. The purpose of the present case report was to highlight this highly resistant microbe as an infectious etiology.

Surgical Treatment of Bone Marrow Lesion Associated with Recurrent Plantar Fasciitis: A Case Report Describing an Innovative Technique Using Subchondroplasty®.

Plantar fasciitis is one of the most common chief complaints seen in the foot and ankle clinic. With a relatively benign course, most cases are self-limiting or amendable to conservative therapy; ~90% of all plantar fasciitis cases will respond to these methods. When conservative treatment and time fail, surgical intervention can be necessary to improve outcomes. We present a novel method using Subchondroplasty® (SCP®; Zimmer Holdings, Inc.; Warsaw, IN) and revision fasciotomy in a case in which initial fasciotomy had failed. After the patient had failed to improve, a worsening underlying bone marrow lesion was identified at the origin of the plantar fascia; thus, SCP® was used with repeat fasciotomy. SCP® involves injecting calcium phosphate into bone marrow lesions to stimulate long-term bone repair. At 10 months after SCP®, the patient remained pain free and had returned to running at the final follow-up examination. This surgical treatment should be considered as an adjunctive procedure for those patients with plantar fasciitis, identifiable bone marrow lesions on magnetic resonance imaging, and continued pain when other treatment modalities have failed.

Rare Presentation of a Marjolin's Ulcer Secondary to a Post-Traumatic Injury.

Marjolin's ulcer is a rare and aggressive cutaneous malignancy arising from previously traumatized skin, most commonly at the site of previous burns. We present a unique case of Marjolin's ulceration secondary to an orthopedic injury and a nonburn history of trauma. The patient had been involved in a motorcycle accident >20 years earlier. For 17 months, the patient had refused to acknowledge the severity of his disease state. He had refused the standard of care and opted for local wound care only until a minor fall caused a pathologic fracture, leading to an above the knee amputation. Road traffic incidents remain an uncommon cause of subsequent Marjolin's transformation in developed countries. As such, we present the case of a patient with a unique combination of a continued lack of compliance after diagnosis and the unusual cause of his initial trauma.

Nontraumatic Osteonecrosis of the Distal Tibia: A Case Presentation and Review of the Literature.

Osteonecrosis, although commonly occurring in the hip, can also affect the leg and foot. In the foot, it most commonly occurs in the talus. The incidence of osteonecrosis occurring in the tibia is relatively rare. We report a case of a woman who presented to our clinic with ankle pain that was idiopathic in nature. Subsequent magnetic resonance imaging showed findings consistent with osteonecrosis of the bilateral distal tibias and several other lesions located in the shoulder, hip, and calcaneus. The present report also serves as a review of both etiology and treatment of osteonecrosis as it relates to the lower extremity.

Bumble Foot: A Rare Presentation of a Fusobacterium varium Infection of the Heel Pad in a Healthy Female.

Fusobacterium infection is common in herd animals and caged birds; the infection is typically referred to as "bumble foot" or "foot rot." These are opportunistic anaerobic bacteria that cause abscesses in the feet of animals that have developed inflammation in the foot pad secondary to the terrain. In humans, F. varium is known to cause abscesses associated with the oropharynx and gastrointestinal tract, also known as Lemierre's disease. The present study reports the case of a rare presentation of a F. varium soft tissue infection of the heel pad in a healthy young female with no associated oropharynx or gastrointestinal abscesses. Therefore, her presentation and disease course were similar to that described in herd animals. The patient was treated with 3 weeks of intravenous antibiotics, incision and drainage, and a gracilis free flap to the weightbearing surface of the right heel.

Accessory Soleus: A Case Report of Exertional Compartment and Tarsal Tunnel Syndrome Associated With an Accessory Soleus Muscle.

An accessory soleus muscle is a rare anatomic variant that frequently presents as an asymptomatic soft tissue swelling in the posteromedial ankle. Less frequently, the anomalous muscle can cause pain and swelling with activity. We present the case of a 17-year-old male with exertional compartment syndrome and associated tarsal tunnel syndrome secondary to a very large accessory soleus muscle. After surgical excision, the patient was able to return to full activity with complete resolution of symptoms.

Creation and characterization of an ultrasound and CT phantom for noninvasive ultrasound thermometry calibration.

Ultrasound thermometry provides noninvasive 2-D temperature monitoring, and in this paper, we have investigated the use of computed tomography (CT) radiodensity to characterize tissues to improve the accuracy of ultrasound thermometry. Agarose-based tissue-mimicking phantoms were created with glyceryl trioleate (a fat-mimicking material) concentration of 0%, 10%, 20%, 30%, 40%, and 50%. The speed of sound (SOS) of the phantoms was measured over a temperature range of 22.1-41.1 °C. CT images of the phantoms were acquired by a clinical dedicated breast CT scanner, followed by calculation of the Hounsfield units (HU). The phantom was heated with a therapeutic acoustic pulse (1.54 MHz), while RF data were acquired with a 10-MHz linear-array transducer. Two-dimensional speckle tracking was used to calculate the thermal strain offline. The tissue-dependent thermal strain parameter required for ultrasound thermometry was analyzed and correlated with CT radiodensity, followed by the validation of the temperature prediction. Results showed that the change in SOS with the temperature increase was opposite in sign between the 0%-10% and 20%-50% trioleate phantoms. The inverse of the tissue-dependent thermal strain parameter of the phantoms was correlated with the CT radiodensity (R(2) = 0.99). A blinded ultrasound thermometry study on phantoms with a trioleate range of 5%-35% demonstrated the capability to estimate the tissue-dependent thermal strain parameter and estimate temperature with error less than ~1 °C. In conclusion, CT radiodensity may provide a method for improving ultrasound thermometry in heterogeneous tissues.

Acute ischemia after revision hallux valgus surgery leading to amputation.

Acute arterial insufficiency after revision hallux valgus surgery is a rare complication. The identification of surgical candidates who are at risk of vascular complications is of utmost importance. The patient-reported symptoms and physical findings combined with noninvasive vascular studies are generally reliable to assess the vascular status but can fail to identify patients with atypical disease patterns. We present the case of a patient with normal pulses who underwent revision hallux valgus surgery, leading to gangrene of the hallux that required transmetatarsal amputation. We reviewed the vascular evaluation methods and causes of acute ischemia after surgery, including vasculitis.

In vivo validation and 3D visualization of broadband ultrasound molecular imaging.

Ultrasound can selectively and specifically visualize upregulated vascular receptors through the detection of bound microbubbles. However, most current ultrasound molecular imaging methods incur delays that result in longer acquisition times and reduced frame rates. These delays occur for two main reasons: 1) multi-pulse imaging techniques are used to differentiate microbubbles from tissue and 2) acquisition occurs after free bubble clearance (>6 minutes) in order to differentiate bound from freely circulating microbubbles. In this paper, we validate tumor imaging with a broadband single pulse molecular imaging method that is faster than the multi-pulse methods typically implemented on commercial scanners. We also combine the single pulse method with interframe filtering to selectively image targeted microbubbles without waiting for unbound bubble clearance, thereby reducing acquisition time from 10 to 2 minutes. The single pulse imaging method leverages non-linear bubble behavior by transmitting at low and receiving at high frequencies (TLRH). We implemented TLRH imaging and visualized the accumulation of intravenously administrated integrin-targeted microbubbles in a phantom and a Met-1 mouse tumor model. We found that the TLRH contrast imaging has a ~2-fold resolution improvement over standard contrast pulse sequencing (CPS) imaging. By using interframe filtering, the tumor contrast was 24.8±1.6 dB higher after the injection of integrin-targeted microbubbles than non-targeted control MBs, while echoes from regions lacking the target integrin were suppressed by 26.2±2.1 dB as compared with tumor echoes. Since real-time three-dimensional (3D) molecular imaging provides a more comprehensive view of receptor distribution, we generated 3D images of tumors to estimate their volume, and these measurements correlated well with expected tumor sizes. We conclude that TLRH combined with interframe filtering is a feasible method for 3D targeted ultrasound imaging that is faster than current multi-pulse strategies.

A phantom for visualization of three-dimensional drug release by ultrasound-induced mild hyperthermia.

PURPOSE: Ultrasound-induced mild hyperthermia has advantages for noninvasive, localized and controlled drug delivery. In this study, a tissue-mimicking agarose-based phantom with a thermally sensitive indicator was developed for studying the spatial drug delivery profile using ultrasound-induced mild hyperthermia. METHODS: Agarose powder, regular evaporated milk, Dulbecco's phosphate-buffered saline (DPBS), n-propanol, and silicon carbide powder were homogeneously mixed with low temperature sensitive liposomes (LTSLs) loaded with a self-quenched near-infrared (NIR) fluorescent dye. A dual-mode linear array ultrasound transducer was used for insonation at 1.54 MHz with a total acoustic power and acoustic pressure of 2.0 W and 1.5 MPa, respectively. After insonation, the dye release pattern in the phantom was quantified based on optical images, and the three-dimensional release profile was reconstructed and analyzed. A finite-difference time-domain-based algorithm was developed to simulate both the temperature distribution and spatial dye diffusion as a function of time. Finally, the simulated dye diffusion patterns were compared to experimental measurements. RESULTS: Self-quenching of the fluorescent dye in DPBS was substantial at a concentration of 6.25×10(-2) mM or greater. The transition temperature of LTSLs in the phantom was 35 °C, and the release reached 90% at 37 °C. The simulated temperature for hyperthermia correlated with the thermocouple measurements with a mean error between 0.03±0.01 and 0.06±0.02 °C. The R2 value between the experimental and simulated spatial extent of the dye diffusion, defined by the half-peak level in the elevation, lateral and depth directions, was 0.99 (slope=1.08), 0.95 (slope=0.99), and 0.80 (slope=1.04), respectively, indicating the experimental and simulated dye release profiles were similar. CONCLUSIONS: The combination of LTSLs encapsulating a fluorescent dye and an optically transparent phantom is useful for visualizing and modeling drug release in vitro following ultrasound-induced mild hyperthermia. The coupled temperature simulation and dye-diffusion simulation tools were validated with the experimental system and can be used to optimize the thermal dose and spatial and temporal dye release pattern.