A Guide To Closure Techniques For Open Wounds

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In the diabetic foot, split thickness skin grafts are frequently used in non-weightbearing areas or to cover donor sites of locally raised flaps.
Here one can see a rhomboid flap over the Achilles tendon. The rhomboid flap is one of a number of modifications that have been made to the standard transposition flap. Other modifications include bilobed flaps and Z plasties.
Another view of a rhomboid flap over the Achilles tendon.
For this patient, the authors used an island flap based on the lateral digital artery to the great toe.
Another view of an island flap based on the lateral digital artery to the great toe.
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Author(s): 
By Thomas Zgonis, DPM, Gary Peter Jolly, DPM, and Peter Blume, DPM

The soft tissue envelope of the foot resists severe mechanical stresses on a daily basis and protects the underlying structures from injury. However, an injury to the foot or a chronic ulcer can cause a defect in the soft tissues and presents a daunting challenge for the foot and ankle specialist. When the defect is on the sole of the foot, the injury may be disastrous.
Historically, soft tissue lesions have been treated conservatively via various techniques of offloading, local wound care, molded shoes, inserts and orthoses. While some wounds lend themselves well to non-operative treatment, there are many wounds that either refuse to close or close with a resultant scar that is so unstable that recurrence of the ulcer is all but assured.
Since the 1980s, there has been an emerging body of literature reporting on outcomes from reconstruction of the soft tissues of the foot. Historically, these procedures were the domain of the plastic surgeon, but as the training of foot and ankle surgeons has increased in duration and scope, these procedures are now being taught in a podiatric surgical fellowship.
The ability of a surgeon to close a wound, which has been open for months and sometimes years, gives new hope to many patients and their families, whose lives revolve around the long-term treatment of these wounds. The majority of foot and ankle wounds are seen in the diabetic population, and many of the comorbidities associated with diabetes (such as peripheral vascular disease, Charcot neuroarthropathy and the loss of protective threshold) make it quite challenging to close wounds in these individuals.
Since many of the ulcers are linked to acquired deformities associated with Charcot neuroarthropathy, one must integrate soft tissue reconstruction and the management of Charcot deformities into any treatment plan. Competency in using multiplanar external fixators is essential in treating these complex patients.

How Do Skin Grafts Facilitate Closure?
Soft tissue reconstruction of the foot and ankle includes the use of skin grafts, local flaps and pedicle flaps. The use of free flaps, once essential in the treatment of defects of the hindfoot and ankle, has waned with the advent of reverse flow neurocutaneous flaps harvested from the lower leg. Let’s begin by taking a closer look at skin grafts.

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