Membrane Flow Drives an Adhesion-Independent Amoeboid Cell Migration Mode.

Cells migrate by applying rearward forces against extracellular media. It is unclear how this is achieved in amoeboid migration, which lacks adhesions typical of lamellipodia-driven mesenchymal migration. To address this question, we developed optogenetically controlled models of lamellipodia-driven and amoeboid migration. On a two-dimensional surface, migration speeds in both modes were similar. However, when suspended in liquid, only amoeboid cells exhibited rapid migration accompanied by rearward membrane flow. These cells exhibited increased endocytosis at the back and membrane trafficking from back to front. Genetic or pharmacological perturbation of this polarized trafficking inhibited migration. The ratio of cell migration and membrane flow speeds matched the predicted value from a model where viscous forces tangential to the cell-liquid interface propel the cell forward. Since this mechanism does not require specific molecular interactions with the surrounding medium, it can facilitate amoeboid migration observed in diverse microenvironments during immune function and cancer metastasis.

Short-Course Antimicrobial Therapy Does Not Increase Treatment Failure Rate in Patients with Intra-Abdominal Infection Involving Fungal Organisms.

BACKGROUND: Fungi frequently are isolated in intra-abdominal infections (IAI). The Study to Optimize Peritoneal Infection Therapy (STOP-IT) recently suggested short-course treatment for patients with IAI. It remains unclear whether the presence of fungi in IAI affects the optimal duration of Antimicrobial therapy. We hypothesized that a shorter treatment course in IAI with fungal organisms would be associated with a higher rate of treatment failure. METHODS: Patients enrolled in the STOP-IT trial were stratified according to the presence or absence of a fungal isolate. They were analyzed as a subgroup based on original randomization to either the control group or an experimental group that received a four-day course of Antimicrobial therapy and by comparison with those without a fungal component to their infection. Descriptive comparisons were performed using a χ2, Fisher exact, or Kruskal-Wallis test as appropriate. The primary outcome was a composite of recurrent IAI, surgical site infection, and death. RESULTS: A total of 411 patients in the study (79%) had available culture data, of which 58 (14%) had positive fungal cultures. The most common organisms were Candida albicans and C. glabrata. The treatment failure rate was equivalent in the experimental and control arms (29.6% vs. 22.6%; p = 0.54). Patients with fungal isolates were more likely to have malignant disease (25.9% vs. 9.6%; p = 0.0004) and coronary artery disease (22% vs. 12%; p = 0.04), but were otherwise similar to those without fungal isolates. Patients with fungal isolates had more hospital days (median 10 vs. 7; p < 0.0001) and more days to resumption of enteral intake (median 5 vs. 3; p = 0.0006), but there was no difference in the composite outcome. CONCLUSIONS: Patients with IAI involving fungal organisms randomized to a shorter course of Antimicrobial therapy had no difference in the rate of treatment failure. These results suggest that the presence of fungi in IAI may not indicate independently the need for a longer course of Antimicrobial therapy.

Surgical Infection Society Curriculum Development Symposium: An Overview.

Hospital-acquired infections, sepsis, and critically ill patients cost the healthcare system billions of dollars every year. Many factors contribute to these problems, and the remedies are multifactorial. Education is an important component in resolving many of the issues related to better combating the economic, social, and personal costs associated with surgical infections. The Surgical Infection Society (SIS) convened a symposium to begin a dialogue on how the SIS can facilitate a better understanding of how to educate the surgical infection professionals and trainees. The following report summarizes the presentations and commentary presented at the 2013 Annual Meeting.

Does Self-Assessment Improve the Effectiveness of Grand Rounds Lectures in a Community-Based Teaching Hospital?

OBJECTIVE: To determine whether use of self-assessment (SA) questions affects the effectiveness of weekly didactic grand rounds presentations. DESIGN: From 26 consecutive grand rounds presentations from August 2013 to April 2014, a 52-question multiple-choice test was administered based on 2 questions from each presentation. SETTING: Community teaching institution. PARTICIPANTS: General surgery residents, students, and attending physicians. RESULTS: The test was administered to 66 participants. The mean score was 41.8%. There was no difference in test score based on experience with similar scores for junior residents, senior residents, and attending surgeons (43%, 46%, and 44%; p = 0.13). Most participants felt they would be most interested in presentations directly related to their surgical specialty. Participants, however, did not score differently on topics which were the focus of the program (40% vs. 42%; p = 0.85). Journal club presentations (39% vs. others 42%; p = 0.33) also did not affect the score. The Pearson correlation coefficient for attendance was 0.49 (p < 0.0001) demonstrated that attendance was very important. Participation in the weekly SA was significantly associated with improved score as those who participated in SA scored over 20% higher than those who did not (59% vs. 38%; p < 0.0001). Based on multiple linear regression for mean score, SA explained the variation in score more than attendance. CONCLUSIONS: The current study found that without preparation approximately 40% of material presented is retained after 10 months. Participation in weekly SA significantly improved retention of information from grand rounds presentations.

BIITE: A Tool to Determine HLA Class II Epitopes from T Cell ELISpot Data.

Activation of CD4+ T cells requires the recognition of peptides that are presented by HLA class II molecules and can be assessed experimentally using the ELISpot assay. However, even given an individual's HLA class II genotype, identifying which class II molecule is responsible for a positive ELISpot response to a given peptide is not trivial. The two main difficulties are the number of HLA class II molecules that can potentially be formed in a single individual (3-14) and the lack of clear peptide binding motifs for class II molecules. Here, we present a Bayesian framework to interpret ELISpot data (BIITE: Bayesian Immunogenicity Inference Tool for ELISpot); specifically BIITE identifies which HLA-II:peptide combination(s) are immunogenic based on cohort ELISpot data. We apply BIITE to two ELISpot datasets and explore the expected performance using simulations. We show this method can reach high accuracies, depending on the cohort size and the success rate of the ELISpot assay within the cohort.

Diagnostic yield of targeted next generation sequencing in various cancer types: an information-theoretic approach.

The information-theoretic concept of Shannon entropy can be used to quantify the information provided by a diagnostic test. We hypothesized that in tumor types with stereotyped mutational profiles, the results of NGS testing would yield lower average information than in tumors with more diverse mutations. To test this hypothesis, we estimated the entropy of NGS testing in various cancer types, using results obtained from clinical sequencing. A set of 238 tumors were subjected to clinical targeted NGS across all exons of 27 genes. There were 120 actionable variants in 109 cases, occurring in the genes KRAS, EGFR, PTEN, PIK3CA, KIT, BRAF, NRAS, IDH1, and JAK2. Sequencing results for each tumor were modeled as a dichotomized genotype (actionable mutation detected or not detected) for each of the 27 genes. Based upon the entropy of these genotypes, sequencing was most informative for colorectal cancer (3.235 bits of information/case) followed by high grade glioma (2.938 bits), lung cancer (2.197 bits), pancreatic cancer (1.339 bits), and sarcoma/STTs (1.289 bits). In the most informative cancer types, the information content of NGS was similar to surgical pathology examination (modeled at approximately 2-3 bits). Entropy provides a novel measure of utility for laboratory testing in general and for NGS in particular. This metric is, however, purely analytical and does not capture the relative clinical significance of the identified variants, which may also differ across tumor types.

Management of idiopathic granulomatous mastitis with observation.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is becoming more commonly recognized and reported more often. Currently, many recommend corticosteroids in its management. METHODS: A retrospective chart review was conducted from January 2002 to June 2013. Data were collected regarding sociodemographic information, clinical history, treatment, and outcomes. RESULTS: Thirty-seven patients were found with IGM. Thirty-five patients were Hispanic born outside the United States. Early in the time period reviewed, 5 patients had masses excised and 5 patients were lost to follow-up. Twenty-seven cases of IGM resolved with observation. Corticosteroids were not used in the management. The average time to resolution was 7.4 months. Three patients (11%) had recurrent episodes after resolution. CONCLUSIONS: IGM is a self-limited benign condition that will resolve spontaneously without treatment. Patience with the natural history of IGM is important, as the process often includes periods of exacerbation before resolution.

Temporal resolution of idiopathic granulomatous mastitis with resumption of bromocriptine therapy for prolactinoma.

INTRODUCTION: Idiopathic granulomatous mastitis (IGM) is becoming more commonly recognized and reported more often. Currently, many recommend corticosteroids in its management. PRESENTATION OF CASE: A 34-year-old G3P2 Hispanic female, 28 weeks pregnant, presented with a 19cm right breast mass. She had a known prolactinoma treated with bromocriptine which was discontinued during her pregnancy. Ultrasound guided core biopsy procedure revealed granulomatous mastitis. The patient was told that the mass would resolve with observation. The patient seen at another institution by an infectious disease specialist who started treatment with amphotericin for presumptive disseminated coccidioidomycosis. Repeated titers were negative for coccidioides antibody. Repeat cultures were negative as well. Due to the persistence of the infectious disease specialist, tissue cultures were performed on fresh tissue specimens, which did not grow bacterial, fungal, nor acid fast organisms. The amphotericin regimen resulted in no improvement of her breast mass after 10 weeks. Within two weeks of stopping the antifungal therapy, however, the mass diminished to 6cm. The patient delivered at 39 weeks. Bromocriptine was restarted, and within 4 weeks, the lesion was no longer palpable. She had not shown signs of recurrence for 32 months. DISCUSSION: Treatment recommendations for IGM vary widely but antibiotics and antifungal medications are not recommended. Corticosteroid treatment is most commonly recommended, however, outcomes may not be different from management with observation. Prolactin may be involved in the pathophysiology of the process. CONCLUSION: IGM is becoming recognized more frequently. Observation and patience with natural history can be an effective management.

The effect of an evidence-based medicine curriculum on breast cancer knowledge and satisfaction of surgical residents.

OBJECTIVE: The current study was performed to determine if evidence-based medicine (EBM) curriculum would affect education of surgical residents. DESIGN: A 5-year prospective study was designed to determine if EBM curriculum could improve residents' satisfaction and understanding of breast cancer management during a breast surgical oncology rotation. During the first 2 years, 45 journal articles were used. During the subsequent 3 years, journal articles were not used. The proportion of patients seen in clinic was collected as an objective measure of the "effort" made by the resident. The final assessment was a 120-question examination. SETTING: Maricopa Medical Center, Phoenix, AZ. Safety net institution with General Surgery residency program. PARTICIPANTS: Postgraduate year 2 general surgery residents. RESULTS: Over 5 years, 30 postgraduate year 2 residents were involved. Univariate analysis showed that female sex (p = 0.04), residents with peer-reviewed publications (p = 0.03), younger age (p = 0.04), American Board of Surgery in-service training examination score (p = 0.01), and clinical effort (p < 0.01) were associated with higher scores. Although residents taught using the journal articles scored 7 points higher on the final examination, this was not significant (p = 0.10). Multivariate analysis showed that American Board of Surgery in-service training examination score and clinic efficiency remained statistically significant. Residents who were taught using the EBM curriculum had significantly higher satisfaction (4.4 vs 3.5, p = 0.001) compared with those who did not go through the EBM curriculum. CONCLUSIONS: The current study demonstrates that an EBM curriculum significantly improved resident satisfaction with the rotation. The EBM curriculum may improve residents' breast cancer knowledge. The most important predictor of resident performance was the effort of resident.

Predictive Value of Nutritional Markers for Wound Healing Complications in Bariatric Patients Undergoing Panniculectomy.

BACKGROUND: Hypoproteinemia and nutritional deficiencies are common after bariatric surgery, and although massive weight loss (MWL) patients experience increased wound complication rates, the association has not been causatively determined. OBJECTIVES: This study investigated preoperative nutritional parameters and wound complications in MWL patients (postbariatric and diet-controlled) undergoing panniculectomy at 2 academic institutions. METHODS: One hundred sixty-one consecutive patients undergoing elective panniculectomy after bariatric surgery or diet-controlled weight loss were identified. Patient demographics and nutritional indices (serum protein, albumin, and micronutrient levels) were analyzed. Complications including wound separation, infection, and operative debridements were compared. Post hoc comparisons tested for correlation between complications and nutritional markers. RESULTS: Postbariatric patients lost an average of 151 lb and presented at an average of 32 months after gastric bypass. Diet-controlled weight loss patients lost an average of 124 lb. Despite MWL, albumin levels were higher in the bariatric group (3.8 vs 3.4 g/dL, P < 0.05). Conversely, bariatric patients experienced increased wound complications (27% vs 14%; P < 0.05). Factors which were found to correlate to increased risk of wound dehiscence and infection were elevated body mass index at time of panniculectomy and amount of tissue removed. Multivariate analysis did not show serum albumin or percent weight loss to independently predict complications. CONCLUSIONS: Bariatric patients presenting for elective operations are at risk for protein and micronutrient deficiency. Despite aggressive replacement and normalization of nutritional markers, bariatric patients experience increased wound complications when compared to nonbariatric patients and traditional measures of nutritional evaluation for surgery may be insufficient in bariatric patients.

Intra-abdominal Infections.

Intra-abdominal infections are multifactorial, but all require prompt identification, diagnosis, and treatment. Resuscitation, early antibiotic administration, and source control are crucial. Antibiotic administration should initially be broad spectrum and target the most likely pathogens. When cultures are available, antibiotics should be narrowed and limited in duration. The method of source control depends on the anatomic site, site accessibility, and the patient's clinical condition. Patient-specific factors (advanced age and chronic medical conditions) as well as disease-specific factors (health care-associated infections and inability to obtain source control) combine to affect patient morbidity and mortality.

Decompressive craniectomy or medical management for refractory intracranial hypertension: an AAST-MIT propensity score analysis.

BACKGROUND: Moderate/severe traumatic brain injury (TBI) management involves minimizing cerebral edema to maintain brain oxygen delivery. While medical therapy (MT) consisting of diuresis, hyperosmolar therapy, ventriculostomy, and barbiturate coma is the standard of care, decompressive craniectomy (DC) for refractory intracranial hypertension (ICH) has gained renewed interest. Since TBI treatment guidelines consider DC a second-tier intervention after MT failure, we sought to determine if early DC (<48 hours) was associated with improved survival in patients with refractory ICH. METHODS: Eleven Level 1 trauma centers provided clinical data and head computed tomographic scans for patients with a Glasgow Coma Scale (GCS) score of 13 or less and radiographic evidence of TBI excluding deaths within 48 hours. Computed tomographic scans were graded according to the Marshall classification. A propensity score to receive DC (regardless of whether DC was performed) was calculated for each patient based on patient characteristics, physiology, injury severity, GCS, severity of intracranial injury, and treatment center. Patients who actually received a DC were matched to patients with similar propensity scores who received MT for analysis. Outcomes were compared between early (<48 hours of injury) primary or secondary DC and matched controls and then between early primary DC only and matched controls. RESULTS: There were 2,602 patients who met the inclusion criteria ,of whom 264 (10.1%) received DC (either primary or secondary to another cranial procedure) and 109 (5%) had a DC that was primary. Variables associated with performing a DC included sex, race, intracranial pressure monitor placement, in-house trauma attending, traumatic subarachnoid hemorrhage, midline shift, and basal cistern compression. There was no survival benefit with early primary DC compared with the controls (relative risk, 1.07; 95% confidence interval, 0.67-1.73; p = 0.77), and resource use was higher. CONCLUSION: Early DC does not seem to significantly improve mortality in patients with refractory ICH compared with MT. Neurosurgeons should pause before entertaining this resource-demanding form of therapy. LEVEL OF EVIDENCE: Therapeutic care/management, level III.

Local BLyS production by T follicular cells mediates retention of high affinity B cells during affinity maturation.

We have assessed the role of B lymphocyte stimulator (BLyS) and its receptors in the germinal center (GC) reaction and affinity maturation. Despite ample BLyS retention on B cells in follicular (FO) regions, the GC microenvironment lacks substantial BLyS. This reflects IL-21-mediated down-regulation of the BLyS receptor TACI (transmembrane activator and calcium modulator and cyclophilin ligand interactor) on GC B cells, thus limiting their capacity for BLyS binding and retention. Within the GC, FO helper T cells (TFH cells) provide a local source of BLyS. Whereas T cell-derived BLyS is dispensable for normal GC cellularity and somatic hypermutation, it is required for the efficient selection of high affinity GC B cell clones. These findings suggest that during affinity maturation, high affinity clones rely on TFH-derived BLyS for their persistence.

Alternative dosing of prophylactic enoxaparin in the trauma patient: is more the answer?

BACKGROUND: Inadequate anti-factor Xa levels and increased venous thromboembolic events occur in trauma patients receiving standard prophylactic enoxaparin dosing. The aim of this study was to test the hypothesis that higher dosing (40 mg twice daily) would improve peak anti-Xa levels and decrease venous thromboembolism. METHODS: A retrospective review was performed of trauma patients who received prophylactic enoxaparin and peak anti-Xa levels over 27 months. Patients were divided on the basis of dose: group A received 30 mg twice daily, and group B received 40 mg twice daily. Demographics and rates of venous thromboembolism were compared between dose groups and patients with inadequate or adequate anti-Xa levels. RESULTS: One hundred twenty-four patients were included, 90 in group A and 34 in group B. Demographics were similar, except that patients in group B had a higher mean body weight. Despite this, only 9% of group B patients had inadequate anti-Xa levels, compared with 33% of those in group A (P = .01). Imaging studies were available in 69 patients and revealed 8 venous thromboembolic events (P = NS, group A vs group B) with significantly more venous thromboembolic events occurring in patients with low anti-Xa levels (P = .02). CONCLUSIONS: Although higher dosing of enoxaparin led to improved anti-Xa levels, this did not equate to a statistical decrease in venous thromboembolism.

Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis.

BACKGROUND: This study aimed to evaluate if variation in management of blunt splenic injury (BSI) among Level I trauma centers is associated with different outcomes related to the use of splenic artery embolization (SAE). METHODS: All adult patients admitted for BSI from 2008 to 2010 at 4 Level I trauma centers were reviewed. Use of SAE was determined, and outcomes of spleen salvage and nonoperative management (NOM) failure were evaluated. A priori, a 10% SAE rate was used to group centers into high- or low-use groups. RESULTS: There were 1,275 BSI patients. There were intercenter differences in age, injury severity, and grade of spleen injury (Spleen Injury Scale [SIS]). Mortality was similar by center; however, BSI treatment varied significantly by center. Overall, SAE use was highest at center A compared with B, C, and D (19%, 11%, 1%, and 4%, respectively; p < 0.01). High SAE use centers had significantly higher spleen salvage rates and fewer NOM failures. Differences in the use of SAE (25% vs. 2%, p < 0.01) and salvage rate (67% vs. 56%, p = 0.03) were most dramatic between high- and low-use SAE centers for Grade 3 and 4 injured spleens. In patients who received initial NOM, multivariate logistic regression analysis showed that SAE was an independent predictor of spleen salvage (odds ratio, 5; 95% confidence interval, 1.8-13.5; p < 0.01) as were lower age, lower SIS, and Injury Severity Score (ISS). Patients treated at high SAE use centers were more likely to leave the hospital with their spleen in situ (odds ratio, 3; 95% confidence interval, 1.7-6.3; p < 0.01). CONCLUSION: Significant practice variation exists in the use of SAE in treating BSI at Level I trauma centers. Centers with higher rates of SAE use have higher spleen salvage and less NOM failure. SAE was shown to be an independent predictor of spleen salvage. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Chronic spinal cord injury impairs primary antibody responses but spares existing humoral immunity in mice.

Spinal cord injury (SCI) results in immune depression. To better understand how injury inhibits humoral immunity, the effects of chronic thoracic SCI on B cell development and immune responses to thymus-independent type 2 and thymus-dependent Ags were determined. Mice received complete crush injury or control laminectomy at either thoracic level 3, which disrupts descending autonomic control of the spleen, or at thoracic level 9, which conserves most splenic sympathetic activity. Although mature B cell numbers were only mildly reduced, bone marrow B cell production was transiently but profoundly depressed immediately after injury. Despite the return of normal B cell production 4 wk after SCI, mice receiving thoracic level 3 injury showed a significant reduction in their ability to mount primary thymus-independent type 2 or thymus-dependent immune responses. The latter were marked by decreases in germinal center B cells as well as class-switched high-affinity Ab-secreting cells. Importantly, injury did not affect affinity maturation per se, pre-existing B cell memory, or secondary humoral immune responses. Taken together, these findings show that chronic high thoracic SCI impairs the ability to mount optimal Ab responses to new antigenic challenges, but spares previously established humoral immunity.

Incidence of blunt cerebrovascular injury in low-risk cervical spine fractures.

BACKGROUND: It has been suggested that specific cervical spine fractures (CSfx) (location at upper cervical spine [CS], subluxation, or involvement of the transverse foramen) are predictive of blunt cerebrovascular injury (BCVI). We sought to determine the incidence of BCVI with CSfx in the absence of high-risk injury patterns. METHODS: We performed a retrospective study in patients with CSfx who underwent evaluation for BCVI. The presence of recognized CS risk factors for BCVI and other risk factors (Glasgow coma score ≤ 8, skull-based fracture, complex facial fractures, soft-tissue neck injury) were reviewed. Patients were divided into 2 groups based on the presence/absence of risk factors. RESULTS: A total of 260 patients had CSfx. When screened for high-risk pattern of injury for BCVI, 168 patients were identified and 13 had a BCVI (8%). The remaining 92 patients had isolated low CSfx (C4-C7) without other risk factors for BCVI. In this group, 2 patients were diagnosed with BCVI (2%). Failure to screen all patients with CSfx would have missed 2 of 15 BCVIs (13%). CONCLUSIONS: We propose that all CS fracture patterns warrant screening for BCVI.

Use of computed tomography in the initial evaluation of anterior abdominal stab wounds.

BACKGROUND: The purpose of this study was to assess the ability of computed tomography (CT) to facilitate initial management decisions in patients with anterior abdominal stab wounds. METHODS: A retrospective review was conducted of patients with anterior abdominal stab wounds who underwent CT over 4.5 years. Any abnormality suspicious for intra-abdominal injury was considered a positive finding on CT. RESULTS: Ninety-eight patients met the study's inclusion criteria. Positive findings on CT were noted in 30 patients (31%), leading to operative intervention in 67%. Injuries were confirmed in 95% of cases, but only 70% were therapeutic. Ten patients had nonoperative management despite positive findings on CT, including 5 patients with solid organ injuries. One patient underwent operative intervention for clinical deterioration, with negative findings. No computed tomographic evidence of injury was noted in the remaining 68 patients (69%), but 1 patient was noted to have a splenic injury while undergoing operative evaluation of the diaphragm. All remaining patients were treated nonoperatively with success. CONCLUSIONS: In patients with anterior abdominal stab wounds, CT should be considered to facilitate initial management decisions, as it has the ability to delineate abnormalities suspicious for injury.

Risk factors for blunt cerebrovascular injury in children: do they mimic those seen in adults?

BACKGROUND: Eastern Association for the Surgery of Trauma guideline for the evaluation of blunt cerebrovascular injury (BCVI) states that pediatric trauma patients should be evaluated using the same criteria as the adult population. The purpose of our study was to determine whether adult criteria translate to the pediatric population. METHODS: Retrospective evaluation was performed at a Level I trauma center of blunt pediatric trauma patients (age <15 years) presenting over a 5-year period. Data obtained included patient demographics, presence of adult risk factors for BCVI (Glasgow coma scale ≤8, skull base fracture, cervical spine fracture, complex facial fractures, and soft tissue injury to the neck), presence of signs/symptoms of BCVI, method of evaluation, treatment, and outcome. RESULTS: A total of 1,209 pediatric trauma patients were admitted during the study period. While 128 patients met criteria on retrospective review for evaluation based on Eastern Association for the Surgery of Trauma criteria, only 52 patients (42%) received subsequent radiographic evaluation. In all, 14 carotid artery or vertebral artery injuries were identified in 11 patients (all admissions, 0.9% incidence; all screened, 21% incidence). Adult risk factors were present in 91% of patients diagnosed with an injury. Major thoracic injury was found in 67% of patients with carotid artery injuries. Cervical spine fracture was found in 100% of patients with vertebral artery injuries. Stroke occurred in four patients (36%). Stroke rate after admission for untreated patients was 38% (3/8) versus 0.0% in those treated (0/2). Mortality was 27% because of concomitant severe traumatic brain injury. CONCLUSION: Risk factors for BCVI in the pediatric trauma patient appear to mimic those of the adult patient.

Calcaneal reconstruction with free fibular osteocutaneous flap.

Due to the role of the calcaneus in weight bearing, soft tissue coverage along with proper reduction of the fracture is the treatment following open calcaneal injury. Intra-articular calcaneal fractures present a very difficult management problem, as the lack of soft tissue and the intricate vascularity in this area pose a risk of complications. Coverage with local and free muscle flaps following excision of infected structures is a common approach for the treatment of chronic osteomyelitis. However, it is unknown which type of flap is optimal for the treatment of lateral foot wounds, especially when complicated by calcaneal osteomyelitis. A patient presented with an open wound over the lateral aspect of the heel with exposed hardware and chronic osteomyelitis of the calcaneus. Following multiple debridements, an ipsilateral osteocutaneous free fibular flap was transferred to the bony defect. Weight bearing was initiated at 2 months postoperatively, and he now ambulates with a normal gait, has normal plantar sensation, and has no difficulty maneuvering stairs. The patient has done well postoperatively and has recovered full range of motion and complete mobility. In this case report, an osteocutaneous free flap provided an excellent outcome for an active patient with a very complex and complicated condition.