Surgical Reconstruction of the Diabetic Foot and Ankle PDF
Preview Surgical Reconstruction of the Diabetic Foot and Ankle
15833_FM.qxd 4/8/09 7:57 AM Page i Surgical Reconstruction of the Diabetic Foot and Ankle EDITOR Thomas Zgonis, DPM, FACFAS Associate Professor, Department of Orthopaedic Surgery Chief, Division of Podiatric Medicine and Surgery Director, Podiatric Surgical Residency and Fellowship Programs The University of Texas Health Science Center at San Antonio San Antonio, Texas 15833_FM.qxd 4/8/09 11:13 PM Page ii Acquisitions Editor:Robert Hurley Product Manager:David Murphy Jr. Production Manager:Alicia Jackson Senior Manufacturing Manager:Benjamin Rivera Marketing Manager:Lisa Parry Design Coordinator:Teresa Mallon Production Services:Maryland Composition/ASI © 2009 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business 530 Walnut Street Philadelphia, PA 19106 USA LWW.com All rights reserved. This book is protected by copyright. No part of this book may be repro- duced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in the People’s Republic of China Library of Congress Cataloging-in-Publication Data ISBN 978-0-7817-8458-0 Surgical reconstruction of the diabetic foot and ankle / Thomas Zgonis.—1st ed. p. ; cm. Includes bibliographical references and index. 1. Foot—Surgery. 2. Ankle—Surgery. 3. Diabetes—Surgery. I. Zgonis, Thomas. [DNLM: 1. Diabetic Foot—surgery. 2. Limb Salvage. 3. Reconstructive Surgical Procedures—methods. WK 835 S9615 2010] RD563.S88 2010 617.5(cid:2)85059—dc22 2009003111 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsi- ble for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, com- pleteness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and prac- tice at the time of publication. 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Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1 15833_FM.qxd 4/8/09 7:57 AM Page iii Dedication To my parents, grandparents, beautiful wife Kristen, and daughters Labrini and new addition to our family Ioanna Zgonis. With love 15833_FM.qxd 4/8/09 7:57 AM Page iv Contents Contributing Authors vii Foreword x Preface xi Acknowledgment xii 1 The Role of The Multidisciplinary Team Approach to Limb Salvage in Major Academic Healthcare Institutions . . . . . . . . . . . . . . . . . 1 JAMES THOMAS AND RICHARD J. DE ASLA 2 Preoperative and Perioperative Management of the High- Risk Patient with Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 ADAM S. LANDSMAN 3 Utility of Nuclear Medicine Imaging in the Diabetic Foot . . . . . . . . . . . . . . . 13 MOLLY A. SCHNIRRING-JUDGE 4 Elective Surgery for the Neuropathic Diabetic Foot . . . . . . . . . . . . . . . . . . . . 39 JOHN M. GIURINI, JEREMY J. COOK, AND EMILY A. COOK 5 Diabetic Lower Extremity Edema and Venous Insufficiency: Differential Diagnosis and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 CHARLES A. ANDERSEN AND NITEN SINGH 6 Vascular Assessment and Reconstruction of the Ischemic Diabetic Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 CHARLES A. ANDERSEN AND NITEN SINGH 7 Surgical Treatment of Chronic Nerve Compression in the Patient with Diabetic Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 A. LEE DELLON 8 Surgical Management and Stepwise Approach to Diabetic Foot Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 PHILIP BASILE AND BARRY I. ROSENBLUM iv 15833_FM.qxd 4/8/09 7:57 AM Page v Contents v 9 Bioengineered Alternative Tissues for the Surgical Management of Diabetic Foot Ulceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 JOHN S. STEINBERG, BRUCE WERBER, AND PAUL J. KIM 10 Negative Pressure Wound Therapy for the Complicated Diabetic Foot Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 LUKE C. JEFFRIES, ROBERTO H. RODRIGUEZ, RONALD BELCZYK, AND THOMAS ZGONIS 11 Skin Grafting Techniques for Open Diabetic Foot Wounds . . . . . . . . . . . . . 129 THOMAS S. ROUKIS 12 Local Random Flaps for Soft Tissue Coverage of the Diabetic Foot . . . . . . . 140 PETER A. BLUME AND JONATHAN J. KEY 13 Muscle Flaps for Soft Tissue Coverage of the Diabetic Foot . . . . . . . . . . . . . 167 JOHN J. STAPLETON, THOMAS ZGONIS, GARY PETER JOLLY, AND THANOS BADEKAS 14 Local and Distant Pedicle Flaps for Soft Tissue Reconstruction of the Diabetic Foot: A Stepwise Approach with the Use of External Fixation . . . . . 178 THOMAS ZGONIS, JOHN J. STAPLETON, AND IOANNIS PAPAKOSTAS 15 Free Flaps for Soft Tissue Coverage of the Diabetic Foot . . . . . . . . . . . . . . . 193 DEOWALL CHATTAR-CORA, STANLEY A. OKORO, AND DOUGLAS T. CROMACK 16 Equinus Deformity and the Diabetic Foot . . . . . . . . . . . . . . . . . . . . . . . . . . 205 PAUL J. KIM AND THOMAS J. CHANG 17 Surgical Reconstruction of the Failed Tendo-Achilles Lengthening . . . . . . . . 213 NEAL M. BLITZ 18 Surgical Reconstruction and Stepwise Approach to Acute Charcot Neuroarthropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 BRADLEY M. LAMM 19 Surgical Reconstruction and Stepwise Approach to Chronic Charcot Neuroarthropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 WILLIAM P. GRANT AND GLENN M. WEINRAUB 15833_FM.qxd 4/8/09 7:57 AM Page vi vi Contents 20 Intramedullary Nail Fixation for Reconstruction of the Hindfoot and Ankle in Charcot Neuroarthropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 ALAN R. CATANZARITI AND ROBERT W. MENDICINO 21 Surgical Management of Malunions and Nonunions of the Diabetic Neuropathic Lower Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 PATRICK R. BURNS AND RICK L. SCANLAN 22 Bone Grafting and Orthobiologics for Reconstruction of the Diabetic Lower Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 JOHN JOSEPH ANDERSON 23 Bone Growth Stimulation in Complex Diabetic Reconstructive Surgery . . . . 302 JOHN JOSEPH ANDERSON AND THOMAS ZGONIS 24 Revisional and Reconstructive Surgery for the Diabetic Foot and Ankle . . . . 315 THOMAS ZGONIS, JOHN J. STAPLETON, VASILIOS D. POLYZOIS, AND ENZO J. SELLA 25 Diabetic Neuropathic Forefoot, Midfoot, and Hindfoot Osseous Trauma and Dislocations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344 LUIS E. MARIN, LAWRENCE A. DIDOMENICO, VINCENT J. MANDRACCHIA, AND THOMAS ZGONIS 26 Diabetic Neuropathic Pilon and Ankle Osseous Trauma and Dislocations . . . 357 LUIS E. MARIN, LAWRENCE A. DIDOMENICO, EMMANOUIL D. STAMATIS, AND THOMAS ZGONIS 27 Surgical Management of Postoperative Infections and Complications . . . . . . 375 LAURENCE G. RUBIN AND CHARLES M. ZELEN 28 A Stepwise Approach to Diabetic Foot and Ankle Amputations . . . . . . . . . . 392 BORA RHIM, BABAK BARAVARIAN, AND THOMAS ZGONIS 29 Rehabilitation and Therapeutic Footwear for the Reconstructed and Amputee Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 ARMIN KOLLER Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427 15833_FM.qxd 4/22/09 10:13 AM Page vii Contributing Authors Charles A. Andersen, MD, FACS Patrick R. Burns, DPM, FACFAS Chief of Vascular/Endovascular/Limb Preservation Surgery Service Clinical Assistant Professor of Orthopaedic Surgery Department of Surgery Division of Foot and Ankle Surgery Madigan Army Medical Center University of Pittsburgh School of Medicine Tacoma, Washington Director of Podiatric Surgical Training University of Pittsburgh Medical Center South Side Hospital John Joseph Anderson, DPM, FACFAS Pittsburgh, Pennsylvania Chief of Surgery Gerald Champion Regional Medical Center Alan R. Catanzariti, DPM, FACFAS Alamogordo, New Mexico Director of Residency Training Division of Foot and Ankle Surgery Thanos Badekas, MD The Western Pennsylvania Hospital Director of Orthopedic Foot and Ankle Surgery Pittsburgh, Pennsylvania Athineon Hospital Director of Department of Orthopaedics, Police Health Division Thomas J. Chang, DPM, FACFAS Past President, Hellenic Foot and Ankle Society Athens, Greece Clinical Professor and Past Chairman of Podiatric Surgery California College of Podiatric Medicine at Samuel Merritt College Babak Baravarian, DPM, FACFAS Oakland, California Chief of Foot and Ankle Surgery Santa Monica/UCLA and Orthopedic Hospital Deowall Chattar-Cora, MD Assistant Clinical Professor, UCLA School of Medicine Department of Orthopedic Surgery Director, University Foot and Ankle Institute Division of Plastic and Reconstructive Surgery Los Angeles, California University of Texas Health Science Center at San Antonio San Antonio, Texas Philip Basile, DPM, FACFAS Plastic and Reconstructive Surgery of Puerto Rico Clinical Instructor of Surgery San Juan, Puerto Rico Harvard Medical School Co-Director, Harvard Podiatric Reconstructive and Research Emily A. Cook, DPM Fellowship Beth Israel Deaconess Medical Center Clinical Instructor, Surgery Boston, Massachusetts Harvard Medical School Chief of Podiatry Harvard Podiatric Reconstruction and Research Fellow Department of Surgery Beth Israel Deaconess Medical Center Mount Auburn Hospital Boston, Massachusetts Cambridge, Massachusetts Jeremy J. Cook, DPM Ronald Belczyk, DPM Clinical Instructor or Surgery Clinical Instructor of Orthopaedic Surgery Harvard Medical School Division of Podiatric Medicine and Surgery Harvard Podiatric Reconstruction and Research Fellow Fellow in Reconstructive Foot and Ankle Surgery Beth Israel Deaconess Medical Center The University of Texas Health Science Center at San Antonio Boston, Massachusetts San Antonio, Texas Douglas T. Cromack, MD Neal M. Blitz, DPM, FACFAS Assistant Professor of Orthopedic Surgery Chief of Foot Surgery Division of Plastic and Reconstructive Surgery Department of Orthopaedic Surgery University of Texas Health Science Center at San Antonio Bronx-Lebanon Hospital Center San Antonio, Texas Bronx, New York Peter A. Blume, DPM, FACFAS Richard J. de Asla, MD Clinical Assistant Professor of Surgery, Anesthesia, and Co-Director of Foot and Ankle Division Orthopedics/Rehabilitation Department of Orthopaedic Surgery Yale School of Medicine Massachusetts General Hospital Director of North American Center for Limb Preservation Instructor, Harvard Medical School New Haven, Connecticut Boston, Massachusetts vii 15833_FM.qxd 4/22/09 10:13 AM Page viii viii Contributing Authors A. Lee Dellon, MD, PhD Adam S. Landsman, DPM, PhD, FACFAS Professor of Plastic Surgery and Neurosurgery Assistant Professor of Surgery Johns Hopkins University Harvard Medical School Director of Dellon Institutes for Peripheral Nerve Surgery Beth Israel Deaconess Medical Center, Division of Podiatric Surgery Baltimore, Maryland Boston, Massachusetts Lawrence A. DiDomenico, DPM, FACFAS Vincent J. Mandracchia, DPM, MHA, FACFAS Adjunct Professor and Director of Reconstructive Rearfoot and Clinical Professor of Podiatric Medicine and Surgery Ankle Surgical Fellowship Des Moines University Ohio College of Podiatric Medicine Senior Vice President and Chief Medical Officer Cleveland, Ohio Department of Surgery, Foot and Ankle Surgery Broadlawns Medical Center John M. Giurini, DPM, FACFAS Des Moines, Iowa Associate Professor of Surgery Harvard Medical School Chief of Podiatric Surgery Luis E. Marin, DPM, FACFAS Department of Surgery Director of Podiatric Surgical Residency Program Beth Israel Deaconess Medical Center Palmetto General Hospital Boston, Massachusetts Hialeah, Florida William P. Grant, DPM, FACFAS Robert W. Mendicino, DPM, FACFAS Instructor of Surgery Chief of Foot and Ankle Surgery Eastern Virginia Medical School The Western Pennsylvania Hospital Norfolk, Virginia Pittsburgh, Pennsylvania Fellowship Director, Diabetic Limb Salvage Tidewater Foot and Ankle Center Virginia Beach, Virginia Vasilios D. Nicolaides, MD Fourth Department Head, Orthopaedic Surgery Luke C. Jeffries, DPM KAT General Hospital Former Reconstructive Foot and Ankle Surgery Fellow and Clinical Athens, Greece Instructor Department of Orthopaedic Surgery Stanley A. Okoro, MD, FACS Division of Podiatric Medicine and Surgery Division of Plastic and Reconstructive Surgery The University of Texas Health Science Center at San Antonio University of Texas Health Science Center at San Antonio San Antonio, Texas San Antonio, Texas Private Practice Exeter, New Hampshire Ioannis Papakostas, MD, PhD, MSc Gary Peter Jolly, DPM, FACFAS Department of Orthopaedic Surgery Clinical Professor of Surgery Thiva General Hospital Des Moines University, College of Podiatric Medicine and Surgery Thiva, Greece Des Moines, Iowa Director of Reconstructive Foot and Ankle Surgery Vasilios D. Polyzois, MD, PhD New Britain General Hospital Chief of Orthopaedic Traumatology New Britain, Connecticut KAT General Hospital Athens, Greece Jonathan J. Key, DPM, FACFAS Clinical Assistant Professor of Orthopaedics and Rehabilitation Yale University School of Medicine Bora Rhim, DPM New Haven, Connecticut Clinical Instructor, VA Medical Center Staff Physician, University Foot and Ankle Institute Paul J. Kim, DPM Los Angeles, California Assistant Professor of Podiatric Medicine and Surgery Midwestern University Roberto H. Rodriguez, DPM Glendale, Arizona Former Reconstructive Foot and Ankle Surgery Fellow, Clinical Instructor, and Assistant Professor Armin Koller, MD Division of Podiatric Medicine and Surgery Chief of Technical Orthopaedics Department of Orthopaedic Surgery Mathias-Hospital The University of Texas Health Science Center at San Antonio Rheine, Germany San Antonio, Texas Bradley M. Lamm, DPM Head of Podiatry Barry I. Rosenblum, DPM, FACFAS Director of Podiatric Residency Program Assistant Clinical Professor, Surgery Rubin Institute for Advanced Orthopedics Harvard Medical School International Center for Limb Lengthening Director of Podiatric Surgical Residency Sinai Hospital of Baltimore Beth Israel Deaconess Medical Center Baltimore, Maryland Boston, Massachusetts 15833_FM.qxd 6/9/09 9:52 AM Page ix Contributing Authors ix Thomas S. Roukis, DPM, FACFAS John S. Steinberg, DPM, FACFAS Chief of Limb Preservation Service, Vascular, and Endovascular Assistant Professor of Plastic Surgery Surgery Service Georgetown University Hospital Department of Surgery Washington, DC Madigan Army Medical Center Tacoma, Washington James L. Thomas, DPM, FACFAS Associate Professor of Orthopaedic Surgery, Laurence G. Rubin DPM, FACFAS Department of Orthopaedic Surgery, Private Practice West Virginia University School of Medicine, Richmond, Virginia Morgantown, WV Rick L. Scanlan, DPM, FACFAS Glenn M. Weinraub, DPM, FACFAS Chief of Podiatry Section The Permanente Medical Group Faculty of Podiatric Surgical Training Program Department of Orthopaedic Surgery University of Pittsburgh Medical Center South Side Hospital Fremont/Hayward, California Pittsburgh, Pennsylvania Clinical Associate Professor Midwestern University, School of Podiatric Medicine Molly A. Schnirring-Judge, DPM, FACFAS Glendale, Arizona Director of Podiatric Clerkship Program Department of Surgery Bruce Werber, DPM, FACFAS St. Vincent Charity Hospital Associate Professor Cleveland, Ohio Midwestern University Glendale, Arizona Enzo J. Sella, MD Associate Clinical Professor of Orthopaedics and Rehabilitation Charles M. Zelen, DPM, FACFAS Yale University School of Medicine Clinical Assistant Professor of Internal Medicine Co-Director of Foot and Ankle Clinics University of Virginia School of Medicine Yale New Haven Hospital Podiatry Section Chief Section Chief of Orthopaedics Department of Surgery St Raphael Hospital Carilion Medical Center New Haven, Connecticut Podiatry Section Chief Department of Orthopedics Niten Singh, MD HCA Lewis Gale Hospital Chief of Endovascular Surgery Roanoke, Virginia Vascular/Endovascular/Limb Preservation Surgery Service Department of Surgery Thomas Zgonis, DPM, FACFAS Madigan Army Medical Center Associate Professor, Department of Orthopaedic Surgery Tacoma, Washington Chief, Division of Podiatric Medicine and Surgery Director, Podiatric Surgical Residency and Reconstructive Foot and Emmanouil D. Stamatis, MD Ankle Fellowship Department of Orthopaedic Surgery The University of Texas Health Science Center at San Antonio 401 General Army Hospital San Antonio, Texas Athens, Greece John J. Stapleton, DPM Former Reconstructive Foot and Ankle Surgery Fellow and Clinical Instructor Department of Orthopaedic Surgery Division of Podiatric Medicine and Surgery The University of Texas Health Science Center at San Antonio San Antonio, Texas Associate of Foot and Ankle Surgery VSAS Orthopaedics Allentown, Pennsylvania Clinical Assistant Professor of Surgery Pennsylvania State College of Medicine Hershey, Pennsylvania 15833_FM.qxd 4/8/09 7:57 AM Page x Foreword Contemporary medical management of diabetic patients has broad foundation of topics including: pre/perioperative care, become increasingly dependent on the expertise of clinicians use of diagnostic imaging, negative pressure wound therapy, from multiple disciplines. Education and prevention remain management of post operative complications, and a stepwise ap- the foundation of care; however millions of people in this proach to foot and ankle amputations and infections. The eval- country, and round the world live with diabetes every day. uation and treatment of the diabetic neuropathic foot is exten- While we pray for a cure, as clinicians we will continue to face sively covered, particularly the surgical reconstruction of acute the many sequelae of this terrible disease. In this text and chronic neuroarthropathy, nonunions, malunions, and Dr.Zgonis and his distinguished panel of contributing authors management of acute trauma in the neuropathic extremity. have eloquently articulated a detailed, logical, and pragmatic Equal attention is given to the ischemic extremity with in methodology for evaluating and treating diabetic pathology of depth discussion of vascular insufficiency, vascular reconstruc- the foot and ankle. The title, Surgical Reconstruction of the tion, and the entire range of treatment options for soft tissue Diabetic Foot and Ankle may lead the reader to infer that this is coverage. Advances in surgical techniques and fixation have im- purely a surgical text. My primary goal in penning this fore- proved limb salvage rates for diabetic patients. The contribut- word is to accurately convey the truly comprehensive nature of ing authors provide a compelling overview of revisional and re- this tome. constructive surgery for the foot and ankle with an emphasis on It is important to understand the background that inspired external fixation. Dr. Zgonis to embark on this project. Through the leadership For students and experienced clinicians alike, Surgical of Dr. Zgonis, our institution has assembled dozens of faculty Reconstruction of the Diabetic Foot and Anklewill improve the qual- from over 14 disciplines to form a center of excellence for the ity of care and patient outcomes by providing a comprehensive treatment of diabetic foot and ankle disease. stepwise approach for managing even the most complicated di- This text is a natural progression of his efforts to raise aware- abetic patients. ness and educate both patients and clinicians about a patient centric, integrated multi-disciplinary approach to the clinical Daniel W. Carlisle, MD and surgical care of the diabetic patient. The authors cover a Chairman and Orthopaedic Residency Program Director University of Texas Health Science Center at San Antonio x
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