The multidisciplinary approach to limb salvage.

There is considerable morbidity and mortality associated with ulcerations of the lower limbs in patients with diabetes as well as non-diabetic patients. The role of the primary care physician and podiatrist in the evaluation, diagnosis, and management of lower extremity wounds is critical. Careful assessment and management of vascular disease by vascular surgeons and interventionalists, biomechanical foot abnormalities by the podiatrist, wound coverage by the plastic surgeons and aggressive treatment of infections and metabolic derangements by the physicians are required. The multidisciplinary approach provides a comprehensive treatment protocol and significantly increases the chances of successfully healing the ulcer and prevents recurrence. It also provides for increased academic output through publications, participation in clinical trials and educational venues.

Surgical débridement. The key to successful wound healing and reconstruction.

No wound can heal in an orderly fashion unless it is clean, healthy, and free of infection. Débridement is key in achieving this goal providing that: (1) the wound is adequately vascularized, (2) the proper antibiotics are on board, and (3) all other medical aspects of the patient have been addressed. Surgical débridement is the quickest and most efficient way of getting the wound ready for healing. Exciting new products such as growth factor, hyperbaric oxygen, skin graft substitutes, and the V.A.C. can then be selectively applied to accelerate wound healing. For those wounds that require more than closure by secondary intention, plastic surgical techniques can then be used to provide a functional and effective wound closure.

Local flaps.

Local flap reconstruction of pedal defects can be accomplished with a variety of techniques. Multiple geometric constructs have been described for closure of foot defects. Each has its own unique principles which can be adapted to certain locations and premorbid conditions. Local flaps considered for closure of foot defects should lie within the higher level of any algorithm, due to their versatility, reproducibility, and long term functional outcomes. In addition, hospitalization, length of anesthesia, and perioperative care can be much less with the use of local flaps.

Skin grafting. Historic and practical approaches.

In this article, the authors have explored the anatomy, physiology, mechanics, and biology of skin grafts. Armed with this knowledge one can predict or anticipate potential complications and thereby avoid them. The authors emphasized the importance of converting chronic infected wounds to acute sterile wounds prior to skin grafting. The authors have discussed the need to assess the patient's vascular status. Skin grafting, when properly used, can be a valuable tool, an adjunct for wound closure and reconstruction.

Pedal macrodactyly: coverage of a large defect with a rectus abdominus free flap.

The authors report a case of a unique reconstructive approach for an isolated macrodactyly of the lower extremity in an otherwise healthy African male. Surgical treatment included excision and local resection of the affected hypertrophied skin, soft tissue, and bone. A rectus abdominis free-tissue transfer and split-thickness skin graft were used for coverage of the defect. The foot healed without complication, and at 2-year follow-up, the patient had an aesthetically pleasing and fully functional result.

Clear cell hidradenoma of the second digit: a review of the literature with case presentation.

Clear cell hidradenoma is a well circumscribed and often encapsulated benign tumor of the dermis and subcutaneous tissue. These tumors have a low tendency toward ulceration, may vary in size, and have a low malignant potential. The treatment of choice is usually surgical excision. A literature review of this soft tissue tumor and a case history are presented.

Fibrosarcoma of the foot: a case presentation and review of the literature.

Fibrosarcomas make up a small percentage of soft somatic tissue malignancies. Fibrosarcomas of the foot and ankle constitute an even smaller percentage of all reported cases with respect to anatomic locations. The postoperative local recurrence is great, and the diagnosis is often difficult to make because of the similar microscopic presentation of plantar fibromatosis and fibrosarcoma. A case presentation of a plantar fibrosarcoma, after two failed attempts at excision, with a review of the literature, is discussed.

Diagnosis of pedal osteomyelitis with Tc-99m HMPAO labeled leukocytes.

The diagnosis of pedal osteomyelitis is often complicated by the presence of pre-existing bony abnormalities. In this study, the utility of radiolabeled white blood cell imaging for the detection of complicated pedal osteomyelitis was evaluated. Twenty-seven men and women were prospectively enrolled and underwent plain film radiography, three-phase bone scan, and Tc-99m hexamethylpropylamine oxine white blood cell scintigraphy of their feet. The presence or absence of osteomyelitis was confirmed in all subjects by microbiologic and histopatholigic analysis of resected bone tissue. The results indicated that white blood cell imaging was more sensitive (90%) and specific (86%) for infection than either bone scan (75% sensitive, 29% specific) or plain film radiography (55% sensitive, 57% specific). This preliminary study suggests that Tc-99m hexamethylpropylamine oxine-labeled white blood cell scintigraphy is a simple, accurate test for the detection of pedal osteomyelitis.