The use of indocyanine green fluorescence angiography to assess perfusion of chronic wounds undergoing hyperbaric oxygen therapy.

OBJECTIVE: The purpose of this study is to determine the utility of using indocyanine green fluorescence angiography (IGFA) in assessing perfusion of chronic wounds after hyperbaric oxygen (HBO2) therapy. METHODS: From May 2016 to January 2018, 26 patients underwent both HBO2 and IGFA. A near-infrared charge-coupled camera measured the flow of intravenous indocyanine green into the wound. IGFA was done pre-HBO2, after approximately 10 HBO2 sessions, and upon completion of HBO2. The ingress rate at baseline, mid-therapy and post-HBO2 values were compared using descriptive statistics. RESULTS: A total of 26 chronic wounds were identified. Baseline median ingress rate was 0.90 units/second (IQR: 0.28 to 6.10). Median ingress rate after approximately of 10 HBO2 sessions was 2.45 units/sec (IQR: 0.48 to 6.35). Six of 11 patients, however, exhibited a decrease in ingress rate from baseline to mid-therapy. Finally, median ingress rate post-HBO2 was 3.70 units/second (IQR: 0.30 to 9.90). Median increase in ingress and rate from baseline to mid-HBO2 treatment 0.30 units/second (IQR: -0.25 to 3.10) and from mid- to post-HBO2 was -0.40 units/second (IQR: -1.50 to 2.60). CONCLUSIONS: This preliminary study shows capability of IGFA to detect changes in blood flow to wounds following HBO2 therapy. Results support the use of IGFA to evaluate the changes in perfusion of patients undergoing HBO2 for chronic wounds. A larger sample size may help clarify the benefit of IGFA to predict potential for wound healing.

Osseous Healing in Foot and Ankle Surgery with Autograft, Allograft, and Other Orthobiologics.

In the surgical treatment of foot and ankle abnormality, many problems require bone grafting for successful osseous union. Nonunion, reconstruction, and arthrodesis procedures pose specific challenges due to bony defects secondary to trauma, malunions, or previous surgery. Nonunion in foot and ankle arthrodesis is a significant risk and is well documented in recent literature. This article is a review of the recent literature regarding the use of bone graft and orthobiologics in foot and ankle surgery.

Acupuncture Treatment of a Metatarsus Proximal End Fracture: A Case Report.

A tuberosity fracture is an avulsion fracture in an area 1.5 cm proximal to the fifth metatarsus. Six to eight weeks of immobilization may be required. A patient with a short leg plaster splint came to our clinic because of pain. The patient had a diagnosis of a fifth metatarsus fracture. Significant edema, fluctuation on the dorsolateral section of the left foot, and red color changes (0.2- to 0.3-cm diameter) on the skin of the anterolateral tibial area of the affected leg were noted. The locations of these skin changes corresponded to the GB34 (Yanglingguan) and the ST37 (Shanqiuxu) acupoints. The patient was successfully treated with acupuncture at these and several other acupoints. After 3 weeks (i.e., eight sessions), the patient returned to her routine life without any pain. This interesting case of metatarsus proximal end fracture shows that some acupoints may be visible during the progress of the disease. We used these acupoints in acupuncture treatment. Pain and edema were rapidly relieved, which may be attributable to the recovery of the lymphatic system in the affected area via acupuncture treatment.

Evaluation of TCOM/HBOT practice guideline for the treatment of foot burns occurring in diabetic patients.

OBJECTIVES: A multidisciplinary team developed an evidence-based guideline for the management of foot burns occurring in diabetic patients that included transcutaneous oxygen measurements (TCOM) and application of hyperbaric oxygen therapy (HBOT) to selected patients. This report represents an evaluation of preliminary TCOM/HBOT data. METHODS: This is a retrospective review of patients with diabetes mellitus (DM) who were admitted to a single American Burn Association (ABA) verified burn center for the treatment of foot burns. Patients were treated via the guideline if they were over the age of 16, admitted for the initial care of burns involving the feet between 4/01/2012 and 7/22/2013, and had a known or new diagnosis of DM. RESULTS: Eighteen patients were treated according to the guideline, 14 men and 4 women. Average age was 54 years+14.78. Average BMI was 30.63+6.34. Median burn size was 0.88% TBSA (median partial thickness of 1% and median full thickness of 0.5%). The average HbA1c was 9.08+2.42. Seven patients received pre-operative HBOT, two received post-operative HBOT and three patients healed their wounds with HBOT alone. Average hospital length of stay was 13.39 days+9.94 and was significantly longer for the group receiving HBOT. Admission HbA1c was not a predictor of the need for HBOT. CONCLUSIONS: While TCOM/HBOT therapy has not been widely applied to the management of diabetic foot burns, the use of an evidence-based guideline incorporating TCOM/HBOT can provide a systematic way to evaluate the patients' microcirculation and ability to heal burns of the foot. The incorporation of TCOM determination and application of HBOT in selected patients with DM and burns of the feet warrant continued study.

Mind body medicine in the care of a U.S. Marine with chronic pain: a case report.

Many service members suffer from chronic pain that can be difficult to adequately treat. Frustration has led to more openness among service members to complementary and alternative medicine modalities. This report follows JK, a Marine with chronic pain related to an injury while on combat deployment through participation in a 6-week self-care-based Mind Body Medicine program and for 7 months after completion of the program. JK developed and sustained a regular meditation practice throughout the follow-up period. JK showed a noticeable reduction in perceived disability and improvements in psychological health, sleep latency/duration and quality of life. This report supports further study into the efficacy and feasibility of self-care-based mind body medicine in the treatment of chronic pain in the military medical setting.

A clinician's guide to the treatment of foot burns occurring in diabetic patients.

INTRODUCTION: Diabetes mellitus affects 25.8 million Americans and is predicted to almost double by 2050. The presence of diabetes complicates hospital courses because of the microvascular complications associated with disease progression. Patients with diabetes represent 18.3% of annual burn admissions to our unit and 27% have burns to the feet. The purpose of this project was to develop an evidence-based guideline for care of the patient with diabetes and foot burns METHODS: A multidisciplinary group was charged with developing an evidence-based guideline for the treatment of foot burns in patients with diabetes. Evidence was evaluated in the areas of diabetes, burn care, hyperbaric medicine, care of diabetic foot wounds and physical therapy. After guideline development and approval, key aspects were incorporated into order sets. RESULTS: Key aspects of this guideline are the ability to identify patients with undiagnosed diabetes, assess diabetic control, optimize glycemic and metabolic control, optimize burn wound management, treat microvascular disease, and provide education and a discharge plan. Evaluated outcomes are glycemic control, length of stay, complication rates, amputation rates, infection rates and the use of hyperbaric oxygen. CONCLUSIONS: Best outcomes for this high risk population will be attainable with an evidence based guideline.

Severe lower limb crush injury and the role of hyperbaric oxygen treatment: a case report.

Open fractures with severe soft-tissue injury and critical local ischaemia of the lower limbs are usually difficult to treat and require a multidisciplinary approach. A 33-year-old Caucasian female with crush injury of the right foot (Gustillo IIIC) was admitted to hospital after a car accident. Despite surgical interventions, a persistent state of hypoxia was present because of the severe vessel injury, and amputation was suggested. Seventy-two hours after admission she was referred to the hyperbaric medicine unit for hyperbaric oxygen treatment (HBOT) to define the limits of viable tissues prior to amputation. After six sessions, clinical improvement was so obvious that the decision to amputate was rejected and she underwent a total of 32 HBOT in addition to frequent debridement and administration of antibiotics. After the HBOT course, she underwent successful surgical reconstruction with a vascularised cutaneous flap. Full healing was achieved. Given the fact that hyperbaric oxygen mechanisms of action target the pathophysiology of crush injuries it should be considered not only for the definition of viable tissue limits but also to enhance viability, even in the most serious situations. HBOT may prove a valuable supplement in the therapeutic armamentarium of these patients.

Treating envenomation caused by fish sting.

The lesser weever fish is found around the coastline of the UK, particularly in the south and west of England. The spines on the fish's first dorsal fin and gill covers release a poison that can cause excruciating pain in anyone who stands on them. Emergency staff should be aware, therefore, of the symptoms of lesser weever fish stings in patients who present with severe pain in the foot. Immersion of the foot in hot water is the most effective treatment.

The epidemiology of foot wounds in patients with diabetes: a description of 600 consecutive patients in Turkey.

Epidemiological studies describing demographic, clinical, and surgical characteristics of diabetic foot wounds are lacking in Turkey. To further describe the epidemiology of diabetic foot wounds in Turkey, we developed an evaluation form and performed a retrospective cohort study that entailed 600 diabetic patients who were admitted to the hospital for treatment of their foot wound(s). The mean age of the cohort was 62.3 ± 10.3 (range 23-92) years, and their mean duration of diabetes was 17.4 ± 7.4 years. Males accounted for 68.17% of the cohort, and 96.83% of the cohort had type 2 diabetes. Prevalences for lower extremity arterial pulses and peripheral neuropathy, as well as the location, depth, microbiology, and surgical treatment of the pedal wounds are also presented. In conclusion, diabetic foot wounds are common in Turkey, and the morbidity associated with these lesions is generally substantial. Although our investigation aimed primarily at describing risk factors associated with diabetic foot wounds, we believe that the findings of this investigation can be used in the development of prospective cohort studies and randomized controlled trials that focus on foot wounds in diabetic patients in Turkey, and may be useful to investigators in other parts of the world.

Stimulation of the medial plantar nerve for complex regional pain syndrome.

We describe a 47-year old male with complex regional pain syndrome II in the distribution of the medial plantar nerve following metatarsal fracture, which was treated with peripheral nerve stimulation. Using a new technique of nerve stimulation with a percutaneous-type electrode, the patient experienced sustained relief at 12 months follow-up. To our knowledge, this is the first report of peripheral neurostimulation effectively managing pain for the medial plantar nerve.

Cold damage to the extremities: frostbite and non-freezing cold injuries.

The treatment of cold injuries to the periphery has advanced substantially in the last 10 years and optimal outcomes are only likely to be achieved if a multidisciplinary team uses the full range of diagnostic and treatment modalities that are now available. The internet and satellite phones with digital images allow immediate access by patients from remote geographical locations to hospital based specialists who can assess cold injuries and advise on early field care. The severity of frostbite injuries can now be assessed with triple phase bone scanning, allowing early prediction of likely subsequent tissue loss. Early hyperbaric oxygen therapy appears to improve outcome and the use of intravenous drugs such as synthetic prostaglandin analogues infusions and tissue plasminogen activator have been shown to reduce amputation rates. In non-freezing cold injuries the early administration of analgesia, the avoidance of secondary exposure, and the use of infrared thermography to assess the injuries are among newer approaches being introduced.

Bone growth stimulation for foot and ankle nonunions.

During the last few decades, electrical current stimulation has gone from an investigational modality to an accepted method of treatment to assist with bone healing. This article provides an overview of electrical bone stimulation for nonunions in the foot and ankle.

Spinal cord stimulation in the treatment of complex regional pain syndrome (CRPS) of the lower extremity: a case report.

UNLABELLED: Complex regional pain syndrome (CRPS) is a condition that is often associated with the extremities. This chronic pain syndrome, when localized to the lower extremity, includes peripheral changes such as edema, temperature alterations, limited range of motion, loss of or excessive perspiration, pain out of proportion to any stimulus, and trophic alterations of the skin, hair, and nails. In this report, we describe the case of a patient who developed complex regional pain syndrome following an ankle injury and surgery. This case report highlights treatment options that are available to patients experiencing complex regional pain, including the use of a spinal cord stimulator. LEVEL OF CLINICAL EVIDENCE: 4.

A review of the clinical significance of tissue hypoxia measurements in lower extremity wound management.

The aim of this paper is to review techniques that are currently available to measure tissue hypoxia in order to benefit the management of wounds. Direct measurement of tissue partial oxygen pressure (PO(2)) is invasive and therefore unappealing in clinical practice. Several techniques (PET scans, MRI derived techniques) are primarily applicable to research rather than clinical applications. Imaging techniques (duplex ultrasonography, arteriography, MRI techniques) are recommended only as part of the workup for revascularisation. Techniques that assess local perfusion include clearance methods, transcutaneous O(2) and CO( 2) pressure measurement, and laser Doppler flowmetry and imaging. These techniques permit interpretation of altered perfusion states. Each technique offers subtly different information concerning microvascular function. All these techniques require strict protocols to derive reliable data. The potential of the promising near infrared reflectance spectroscopy (NIRS) technique is yet to be determined.

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.

[Regional circulation in gunshot wounds of the ankle joint and foot]. / Regionarnoe krovoobrashchenie pri ognestrel'nykh raneniiakh golenostopnogo sustava i stopy.

Problems of treatment of battle injuries of the ankle joint and foot are discussed. These injuries are characterized with severe disturbances of regional circulation and microcirculation causing hypoxia and metabolic disorders both in soft tissues and in bones. Digital substraction angiography (DSA) was used in 7 wounded (7.53%) of all patients with battle injuries of the foot and ankle joint. Combined treatment including surgery, drugs, physical and exercise therapy, hyperbaric oxygenation was used in all the patients. Prolonged intraarterial infusion of drugs was carried out in 4 of 7 patients. It is concluded that early evaluation of regional circulation permits to clarify expediency of applied combined treatment. Injury of three arteries is the indication for amputation, but even one functioning artery enables use of combined therapy with intraarterial infusion for extremity salvage.