Extensive Foot Research Articles

Anterolateral thigh free flap surgery for medial malleoli fracture with extensive dorsal foot skin defect: A case report

Severe foot deformities, especially those affecting the dorsum of the foot, can make it difficult to perform daily activities. For example, mild pain when walking can be felt on the dorsal aspect of the foot, and toe contractures can make it difficult to wear non supportive shoes. Reconstructive surgeons face a great deal of difficulty in providing a suitable flap in accordance with the "like for like" reconstructive principle. The best outcomes for reconstructing small- to medium-sized dorsal foot lesions have been reported using local flaps and pedicled flaps. Reconstruction of large dorsal foot deformities is, however, hardly studied. In this work, we report our experience reconstructing large dorsal foot lesions using the free anterolateral thigh (ALT) flap.

The Protective Role of KANK1 in Podocyte Injury.

Approximately 30% of steroid-resistant nephrotic syndromes are attributed to monogenic disorders that involve 27 genes. Mutations in KANK family members have also been linked to nephrotic syndrome; however, the precise mechanism remains elusive. To investigate this, podocyte-specific Kank1 knockout mice were generated to examine phenotypic changes. In the initial assessment under normal conditions, Kank1 knockout mice showed no significant differences in the urinary albumin-creatinine ratio, blood urea nitrogen, serum creatinine levels, or histological features compared to controls. However, following kidney injury with adriamycin, podocyte-specific Kank1 knockout mice exhibited a significantly higher albumin-creatinine ratio and a significantly greater sclerotic index than control mice. Electron microscopy revealed more extensive foot process effacement in the knockout mice than in control mice. In addition, KANK1-deficient human podocytes showed increased detachment and apoptosis following adriamycin exposure. These findings suggest that KANK1 may play a protective role in mitigating podocyte damage under pathological conditions.

Diabetic foot gangrene - A case study

Diabetic foot is a major public health issue which may lead to leg amputation and thus resulting in disability, reduction in the quality of life and high treatment cost. Non healing ulcer turning into gangrene is a common consequence of diabetic foot. Thus, saving the limb and healing of the leg ulcer are the major challenges faced in case of diabetic foot disease. In this case study, Conservative Ayurveda surgical management was followed in the case of diabetic foot gangrene. A 60 year old female patient, a known case of diabetes mellitus since three years presented with sudden onset of blackish discoloration, pus discharge in the left foot since two weeks. She was diagnosed as diabetic gangrene of left foot. She was advised amputation of foot by 3 contemporary surgeons. Patient had uncontrolled diabetes mellitus and sepsis, which was effectively managed. Once the patient was hemodynamically stable, amputation of left great toe and debridement of left foot ulcer was done. Following this treatment, extensive diabetic foot ulcer healed with formation of healthy granulation tissue with the help of internal medications and local wound care. Complete ulcer healing was noted in a span of four months without any complications, conservative Ayurveda Surgical intervention has proven very helpful to save the foot and complete healing of the ulcer in this case study.

Hand, Foot, and Mouth Disease: Extensive Facial Involvement Preceding Hand and Foot Lesions

Hand, Foot, and Mouth Disease: Extensive Facial Involvement Preceding Hand and Foot Lesions

Sulforaphane ameliorated podocyte injury according to regulation of the Nrf2/PINK1 pathway for mitophagy in diabetic kidney disease

Mitophagy, a mechanism of self-protection against oxidative stress, plays a critical role in podocyte injury caused by diabetic kidney disease (DKD). Sulforaphane (SFN), an isothiocyanate compound, is a potent antioxidant that affords protection against diabetes mellitus-mediated podocyte injury. However, its role and underlying mechanism in DKD especially in diabetic podocytopathy is not clearly defined. In the current study, we demonstrated SFN remarkably activated mitophagy in podocytes, restored urine albumin to creatinine ration, and prevented the glomerular hypertrophy and extensive foot process fusion in diabetic mice. Simultaneously, nephroprotective effects of SFN on kidney injury were abolished in podocyte-specific Nuclear factor erythroid 2-related factor 2 (Nrf2) conditional knockout mouse (cKO), indicating that SFN alleviating DM-induced podocyte injury dependent on Nrf2. In vitro study, supplement with SFN augmented the expression of PTEN induced kinase 1(PINK1) and mediated the activation of mitophagy in podocytes treated with high glucose. Further study revealed that SFN treatment enabled Nrf2 translocate into nuclear and bind to the specific site of PINK1 promoter, ultimately reinforcing the transcription of PINK1. Moreover, SFN failed to confer protection to podocytes treated with high glucose in presence of PINK1 knockdown. On the contrary, exogenous overexpression of PINK1 reversed mitochondrial abnormalities in Nrf2 cKO diabetic mice. In conclusion, SFN alleviated podocyte injury in DKD through activating Nrf2/PINK1 signaling pathway and balancing mitophagy, thus maintaining the mitochondrial homeostasis.

Diagnosis and treatment of Minimal Change Disease in adults-2023

Minimal change disease is aglomerulopathy that clinically manifests as acute onset nephrotic syndrome. Adiagnosis is made by renal biopsy, implying the absence of glomerular lesions on light microscopy but detection of extensive podocyte foot process effacement on electron miscroscopy. Considering the typically excellent response to immunosuppressive measures (especially to glucocorticoids), an autoimmune pathogenesis is assumed. Although general prognosis is overall beneficial, steroid-dependent, steroid-resistant and frequently-relapsing disease courses may complicate the management of these patients and necessitate the use of alternative immunosuppressive treatment strategies. Here, the Austrian Society of Nephrology (ÖGN) provides aconsensus on how to best diagnose and manage adult patients with minimal change disease.

Skin and soft-tissue coverage for limb salvage in extensive diabetic foot ulcers: An institutional experience

Background: Extensive diabetic foot ulcers (DFUs) with skin and soft-tissue defects need prompt coverage of the defect using plastic surgical means. The indication, timing, and techniques of wound coverage in DFUs are not adequately understood by all. Hence, an institutional experience of providing skin and soft-tissue coverage to extensive DFUs is reported. Aims and Objectives: The aims of this study were to study the various types of DFU that needs surgical wound coverage and to understand the types of wound coverage surgeries, their timings, success rates, and final outcomes. Materials and Methods: A retrospective-prospective study of all the DFUs managed using skin and soft-tissue coverage was conducted. Surgical and medical management and their outcomes were studied. Results: Sixteen patients underwent skin graft or flap surgery for their DFU. All the limbs were salvaged and all wounds were covered with two reports of ulcer recurrences. Conclusion: For optimal care of DFUs, the possible need for wound coverage, it’s timing, and aftercare are to be understood by all involved.

Adult-Onset Genetic Focal Segmental Glomerulosclerosis: A Tale of Two Mutations

Focal segmental glomerulosclerosis (FSGS) is a kidney histologic lesion that may be caused by multiple aetiologies and pathophysiological mechanisms, with podocyte injury and depletion as the common denominator. FSGS may be subdivided into different subclasses: primary, secondary, genetic and unknown forms. Notwithstanding the overlapping clinical and histological characteristics across the different forms of FSGS, their management and response to treatment are strikingly different. Genetic FSGS may be suggested by the appearance of nephrotic syndrome during childhood, but it may also present in adulthood, where the diagnosis is rather challenging due to widely variable clinical and histological phenotypes. Herein we present the case of a 34-year-old female with a family history of chronic kidney disease of undetermined aetiology, referred for a Nephrology consultation due to haematoproteinuria and de novo arterial hypertension. Complementary evaluation revealed a urinary protein/creatinine ratio of 4.3 g/g and albumin/creatinine ratio of 3.9 g/g with hypoalbuminaemia. Kidney biopsy revealed lesions of FSGS, associated with extensive foot process effacement. The constellation of findings and family history of kidney disease raised the suspicion of a genetic cause, therefore genetic testing was performed. Two variants in the NPHS2 gene [c.686G>A, p.(Arg229Gln) and c.855_856del, p(Arg286Thrfs*17)] were found in compound heterozygosity, compatible with the diagnosis of genetic FSGS. This case highlights the importance of a detailed evaluation of patients with FSGS lesions in order to identify the FSGS form, given its therapeutic and prognostic impact, including after kidney transplantation.

Two stages of salvaging an extensively necrotic foot with chronic limb‐threatening ischemia by arterialization of great saphenous vein and free latissimus dorsi musculocutaneous flap transfer for wound coverage with the arterialized vein as the recipient vessel: A case report

Patients with chronic limb-threatening ischemia (CLTI) without other options for adequate arterial revascularization could undergo deep (or distal) venous arterialization for limb salvage. Additionally, patients with extensive foot wound with CLTI sometimes require free flap transfer for limb salvage. We herein report a case of successful reconstructive limb-salvage surgery for an extensively necrotic foot with CLTI, using a two-stage operation involving venous arterialization using foot-perforating veins and subsequent free flap transfer (with preservation of the arterialized vein). The patient was a 59-year-old man with CLTI. The patient's right foot had dry necrotic tissue after Lisfranc joint amputation. Only one straight-line to the posterior tibial artery was achieved after endovascular therapies (four times). At the first stage of surgery, an arterial-venous shunt bypass from the superficial femoral artery to the distal great saphenous vein (GSV) (near the foot-perforating vein) was created. Arterial blood supply reached the necrotic area via the foot venous circulation system. At the second stage of surgery, free latissimus dorsi musculocutaneous flap (8 × 27 cm) transfer with preservation of the arterialized vein was performed. The pedicle artery was anastomosed to the bypass graft (end-to-side). The pedicle vein was anastomosed to the proximal stump of the GSV (end-to-end). The flap and residual foot survived completely, at a one-year follow-up postoperatively. An indocyanine green bypass-through angiography revealed the angiosome through the venous arterialization bypass graft, which included the flap; entire forefoot; and partial regions of the midfoot and heel. This two-stage operation might be considered a useful option for limb-salvage and complete wound-healing in patients with severe non-healing wound with CLTI. The two methods could compensate and overcome the problems of either method: incomplete wound-healing after venous arterialization, and the absence of a recipient artery for free flap transfer.

485-P: DFUCare Deep-Learning–Based Mobile App for Diabetic Foot Ulcer Monitoring

In 2021, 1 out of adults suffered from diabetes mellitus globally. A major complication resulting from this is diabetic foot ulcers (DFU) , which can lead to amputation if improperly managed. Current clinical approaches to DFU have significant limitations, such as the high cost involved in the diagnosis and time-consuming care. In light of this, we have developed DFUCare, a mobile app that uses the built-in camera and deep learning to diagnose and quantify patients' diabetic foot ulcers. DFUCare is trained on an extensive foot dataset containing over 5000 images of normal and infected DFU patients. For binary classification of infected and non-infected patients, we use a combination of transfer and ensemble learning. Using transfer learning, DFUCare uses the pretrained InceptionResNetV2 model for deep learning derived feature extraction. With an ensemble approach, we compare the deep learning derived feature extraction results to handcrafted color and textural feature extraction results to come up with a final prediction of infected vs. non-infected patients. In the end, we achieved top-level results with a binary accuracy of .9014, AUC of .9437, specificity of .9023, and precision of .8901. In addition, using standardized metrics and computer vision algorithms, DFUCare can determine the dimensions of the DFU to quantify the severity over time. With all of the information stored in the cloud, doctors and patients can use the share feature in the mobile app to send medical reports to anyone in the world. In the future, we are planning to add clinical, biological, and epidemiological features along with macroscopic image features to improve the performance of the tool in predicting infection and healing. This novel approach has the potential to deliver a paradigm shift in diabetic foot care among patients by being a cost-effective, remote, and convenient healthcare solution. Disclosure V.Sendilraj: None. W.C.Pilcher: None. M.K.Bhasin: None.

Pharmacological Melanocortin 5 Receptor Activation Attenuates Glomerular Injury and Proteinuria in Rats With Puromycin Aminonucleoside Nephrosis.

Clinical evidence indicates that the melanocortin peptide ACTH is effective in inducing remission of nephrotic glomerulopathies like minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS), including those resistant to steroids. This suggests that a steroid-independent melancortinergic mechanism may contribute. However, the type of melanocortin receptor (MCR) that conveys this beneficial effect as well as the underlying mechanisms remain controversial. Burgeoning evidence suggests that MC5R is expressed in glomeruli and may be involved in glomerular pathobiology. This study aims to test the effectiveness of a novel highly selective MC5R agonist (MC5R-A) in puromycin aminonucleoside (PAN) nephrosis. Upon PAN injury, rats developed evident proteinuria on day 5, denoting an established nephrotic glomerulopathy. Following vehicle treatment, proteinuria continued to persist on day 14 with prominent histologic signs of podocytopathy, marked by ultrastructural glomerular lesions, including extensive podocyte foot process effacement. Concomitantly, there was loss of podocyte homeostatic markers, such as synaptopodin and podocin, and de novo expression of the podocyte injury marker desmin. Treatment with MC5R-A attenuated urine protein excretion and mitigated the loss of podocyte marker proteins, resulting in improved podocyte ultrastructural changes. In vitro in cultured podocytes, MC5R-A prevented the PAN-induced disruption of actin cytoskeleton integrity and apoptosis. MC5R-A treatment in PAN-injured podocytes also reinstated inhibitory phosphorylation and thus averted hyperactivity of GSK3β, a convergent point of multiple podocytopathic pathways. Collectively, pharmacologic activation of MC5R by using the highly selective small-molecule agonist is likely a promising therapeutic strategy to improve proteinuria and glomerular injury in protenuric nephropathies.

Reverse sural flap as an alternative to microsurgical reconstruction of extensive foot wound after electrical burn: case report

A Revista Brasileira de Cirurgia Plástica é o órgão oficial de divulgação da Sociedade Brasileira de Cirurgia Plástica (SBCP), tem como objetivo registrar a produção científica em Cirurgia Plástica, fomentar o estudo, aperfeiçoamento e atualização dos profissionais da especialidade.

Podocyte Foot Process Effacement Precedes Albuminuria and Glomerular Hypertrophy in CD2-Associated Protein Deficient Mice.

Background: Podocyte foot process effacement is a key histologic finding in proteinuric kidney disease. We previously showed that 3-week old CD2AP-deficient mice have significant proteinuria, glomerular hypertrophy and mesangial expansion. The goal of this study is to use morphometry to establish the temporal sequence of podocyte foot process effacement, glomerular volume expansion and albuminuria in Cd2ap−/− mice by measuring these parameters at the 2-week time point.Methods: Wild-type mice age 14 ± 1 days with the Cd2ap gene (WT, N = 5) and mice deficient for Cd2ap (Cd2ap KO, N = 5) were generated. Kidneys were harvested and fixed in 2.5% glutaraldehyde and processed for examination by light and electron microscopy. An average of 415.2 (range 268–716) grid points were counted for all the glomeruli, and quantification of glomerular volume from each kidney. Urine was collected the day prior to sacrifice for urine albumin-to-creatinine ratio (ACR) measurements.Results: There was no difference in albuminuria [median (range) mg/g] between WT [212.2 (177.6–388.4) mg/g] vs. Cd2ap KO mice [203.3 (164.7–910.2) mg/g], P = 0.89; or glomerular volume 68,307[10,931] vs. 66,844[13,022] μm3, p = 0.92. The volume densities of glomerular components of the podocyte, capillary lumen and mesangium were not different for the two groups, P = 0.14, 0.14 and 0.17 respectively. However, foot process width was increased in Cd2ap KO 1128[286] vs. WT [374 ± 42] nm, P = 0.02.Conclusion: Here we show that while 2-week old WT and Cd2ap KO mice have similar levels of albuminuria, glomerular and mesangial volume, Cd2ap KO mice have more extensive podocyte foot process effacement. The data suggests that podocyte injury is the initiating event leading to mesangial expansion and albuminuria in this model.

Outcome of percutaneous transluminal angioplasty for subacute lower limb ischemia

Context Management of acute limb ischemia ( Aim The aim of this study was to evaluate the clinical and hemodynamic outcome of percutaneous transluminal angioplasty for subacute lower limb ischemia. Settings and design A total of 22 limbs that presented with subacute leg ischemia admitted to Alexandria Main University Hospital have been studied prospectively. All patients had femoro-popliteal occlusions shown by multislice computed tomographic angiography and severe leg ischemic pain +/− crippling claudication. Patients with acute leg ischemia or extensive foot necrosis necessitating amputation were excluded from the study. Patients and methods All patients were subjected to ankle-brachial index (ABI) measurement, color duplex ultrasound (CDU) scan, and multislice computed tomographic angiography before intervention. Percutaneous transluminal angioplasty (balloon angioplasty +/− stent deployment) was performed for all participants. Clinical follow-up with ABI measurement was done at 1-, 3-, and 6-month intervals. CDU after 6 months for patency and restenosis was performed. Statistical analysis Statistical Package for the Social Sciences, version 15.0 was used. Values were compared with a paired samples t test. P values less than 0.05 were considered significant. Results Mean follow-up period was 6.2 months. The mean (±SD) ABI before and at 1-, 3-, and 6-month interval was 0.4 (±0.2), 0.53 (±0.11), 0.62 (±0.12), and 0.86 (±0.16), respectively, with P value less than 0.0001. Limb salvage rate for those patients who had constant ischemic pain and had primary technical success was 89%. As for those patients who had severe claudication, at 6-month follow-up, they had no complaint. Primary patency rate by CDU was 95%. Conclusions Balloon angioplasty is a safe and effective tool for management of subacute leg ischemia. It avoids high surgical risks and carries promising patency and limb salvage rates.

A case of minimal change disease after the administration of anti receptor activator of nuclear factor kappa B ligand (RANKL) monoclonal antibody: a case report

BackgroundMinimal change disease (MCD) is one of the causes of idiopathic nephrotic syndrome in adults. The pathogenesis of proteinuria in MCD has not been fully understood. Recently, it has been reported that the receptor activator of nuclear factor-kappa B (RANK)/RANK ligand (RANKL) may contribute to the podocyte biology in kidney diseases. Denosumab is a human anti-RANKL monoclonal antibody used to treat osteoporosis. Here we report a case of MCD after denosumab administration.Case presentationA 59-year-old male without any episodes of proteinuria was given denosumab to treat osteoporosis. Two weeks after its administration, he noticed a foamy urine and bilateral pretibial edema. Laboratory tests revealed that he had severe proteinuria (15g/g Cr), hypoproteinemia (4.0g/dL), and hypoalbuminemia (1.5g/dL). Based on the results, he was diagnosed with nephrotic syndrome. The proteinuria selectivity index was 0.05, indicating selective proteinuria. Renal biopsy showed minor glomerular abnormality with less tubulointerstitial damage, and electron microscopy showed extensive foot process effacement, indicating MCD. With all these results, glucocorticoid therapy of 50mg/day prednisolone was started. After 4weeks of treatment, the urinary protein level remains high (3.1g/g Cr). Prednisolone therapy was continued, and the levels of proteinuria decreased gradually to the range of partial remission (1.2g/g Cr) with another 7weeks of prednisolone treatment, but complete remission was not achieved.ConclusionsThis might be a case wherein RANKL inhibition is associated with the pathogenesis of MCD. Further studies will be needed to elucidate the causal relationship of RANK-RANKL signaling to the pathogenesis of MCD.

AKI and Collapsing Glomerulopathy Associated with COVID-19 and APOL 1 High-Risk Genotype.

Kidney involvement is a feature of COVID-19 and it can be severe in Black patients. Previous research linked increased susceptibility to collapsing glomerulopathy, including in patients with HIV-associated nephropathy, to apo L1 (APOL1) variants that are more common in those of African descent. To investigate genetic, histopathologic, and molecular features in six Black patients with COVID-19 presenting with AKI and de novo nephrotic-range proteinuria, we obtained biopsied kidney tissue, which was examined by in situ hybridization for viral detection and by NanoString for COVID-19 and acute tubular injury-associated genes. We also collected peripheral blood for APOL1 genotyping. This case series included six Black patients with COVID-19 (four men, two women), mean age 55 years. At biopsy day, mean serum creatinine was 6.5 mg/dl and mean urine protein-creatinine ratio was 11.5 g. Kidney biopsy specimens showed collapsing glomerulopathy, extensive foot process effacement, and focal/diffuse acute tubular injury. Three patients had endothelial reticular aggregates. We found no evidence of viral particles or SARS-CoV-2 RNA. NanoString showed elevated chemokine gene expression and changes in expression of genes associated with acute tubular injury compared with controls. All six patients had an APOL1 high-risk genotype. Five patients needed dialysis (two of whom died); one partially recovered without dialysis. Collapsing glomerulopathy in Black patients with COVID-19 was associated with high-risk APOL1 variants. We found no direct viral infection in the kidneys, suggesting a possible alternative mechanism: a "two-hit" combination of genetic predisposition and cytokine-mediated host response to SARS-CoV-2 infection. Given this entity's resemblance with HIV-associated nephropathy, we propose the term COVID-19-associated nephropathy to describe it.

Melanocortin therapy ameliorates podocytopathy and proteinuria in experimental focal segmental glomerulosclerosis involving a podocyte specific non-MC1R-mediated melanocortinergic signaling.

The clinical effectiveness of adrenocorticotropin in inducing remission of steroid-resistant nephrotic syndrome points to a steroidogenic-independent anti-proteinuric activity of melanocortins. However, which melanocortin receptors (MCR) convey this beneficial effect and if systemic or podocyte-specific mechanisms are involved remain uncertain. In vivo, wild-type (WT) mice developed heavy proteinuria and kidney dysfunction following Adriamycin insult, concomitant with focal segmental glomerulosclerosis (FSGS) and podocytopathy, marked by loss of podocin and synaptopodin, podocytopenia and extensive foot process effacement on electron microscopy. All these pathologic findings were prominently attenuated by NDP-MSH, a potent non-steroidogenic pan-MCR agonist. Surprisingly, MC1R deficiency in MC1R-null mice barely affected the severity of Adriamycin-elicited injury. Moreover, the beneficial effect of NDP-MSH was completely preserved in MC1R-null mice, suggesting that MC1R is likely non-essential for the protective action. A direct podocyte effect seems to contribute to the beneficial effect of NDP-MSH, because Adriamycin-inflicted cytopathic signs in primary podocytes prepared from WT mice were all mitigated by NDP-MSH, including apoptosis, loss of podocyte markers, de novo expression of the podocyte injury marker desmin, actin cytoskeleton derangement and podocyte hypermotility. Consistent with in vivo findings, the podoprotective activity of NDP-MSH was fully preserved in MC1R-null podocytes. Mechanistically, MC1R expression was predominantly distributed to glomerular endothelial cells in glomeruli but negligibly noted in podocytes in vivo and in vitro, suggesting that MC1R signaling is unlikely involved in direct podocyte protection. Ergo, melanocortin therapy protects against podocyte injury and ameliorates proteinuria and glomerulopathy in experimental FSGS, at least in part, via a podocyte-specific non-MC1R-mediated melanocortinergic signaling.

Pirogoff Amputation with a Disappointing Outcome: A Case Report

Case Presentation: A 53-year-old motorcyclist suffered trauma with an extensive foot injury. A Pirogoff amputation was performed. A hindfoot amputation might be considered as an alternative option rather than directly proceeding to a trans-tibial amputation. Results: A Pirogoff amputation was performed with a disappointing course afterward. Subsequently, we performed a literature search on the Pirogoff amputation. Conclusion: Further research is needed concerning the optimal amputation level for patients who need a hindfoot amputation since good studies are lacking. In general, a major advantage of the Pirogoff amputation is the possibility of some barefoot mobility. The disadvantages are fitting problems due to a bulbous stump and limited installation height for the incorporation of a prosthesis. A trans-tibial amputation might be considered in young and healthy patients because of the extensive possibilities for prosthetic fitting. The final decision of the amputation level should be made by an experienced surgical and rehabilitation team discussing the advantages and disadvantages with the patient involved. Currently, evidence from the literature is too limited to guide this discussion and the decision-making process.

Predictors of Major Adverse Limb Events after Open Forefoot Amputation in Patients with Chronic Limb-Threatening Ischemia

Management of patients with chronic limb-threatening ischemia (CLTI) and extensive foot necrosis presents a challenge for limb salvage. Our study evaluates preoperative risk factors that contributed to durability and efficacy of limb salvage after open transmetatarsal amputation (TMA) in patients with critical limb-threatening ischemia. We abstracted data from patients who underwent open TMA at Los Angeles County-University of Southern California Medical Center and Keck Hospital of University of Southern California from 2009 to 2018. Multivariable logistic regression analysis, adjusting for preoperative risk factors, was used to examine predictors of major adverse limb events (MALE). The aim was to evaluate outcomes following open TMA with MALE as the primary outcome. Our hypotheses were that outcomes would be worse for patients with foot infections and renal failure. Forty-three open TMAs were done in 39 patients during the study period. The cohort had a mean age of 63 ± 11.6years, 89% had a history of diabetes, 95% hypertension (HTN), 54% had end-stage renal disease (ESRD), and 26% were current smokers. MALE occurred in 39% of the cohort. Sex, race, indication, HTN, smoking status, and history of prior ipsilateral revascularization or minor amputations were not associated with MALE (P>0.05). Multivariate logistic regression found ESRD to be an independent predictor of MALE (odds ratio 7.43, 95% confidence interval 1.12-49.17, P=0.038) after adjusting for clinically significant covariates. Open TMA provides acceptable rates of limb salvage for complex patients with CLTI. ESRD is an independent risk factor for MALE following open TMA in these patients. Vigilant follow-up is essential for this morbid patient population given poorer outcomes after forefoot amputation.

Der Einsatz des Neuro-Fasziokutanen Suralisinsellappens zur Defektdeckung im Bereich des Unterschenkels und des Fußes

BackgroundThe closure of soft tissue defects in areas of the distal third lower leg anterior, ankle, heel and foot dorsum especially with exposed bony or tendinous tissue, in case of infections or difficult healing tendency is still challenging. These defects need a stable and sufficient soft tissue cover.With the introduction of the Neuro-Fasciocutaneus suralis island flap (hereinafter called suralis flap) we do have a good alternative with stable results and less operation complexity. Material and methodsSince 2005 we are using this technique for the coverage of complicated defect wounds, especially for complete heel and extensive foot dorsum defects.The most frequent area was the lateral malleolus and the Achilles tendon area with and maximum dimension of 7cm by 11cm. Results2 suralis flaps get lost; in 6 cases we saw superficial skin necrosis.In most of the harvest areas we could directly close the defects, in 7 cases we had to close the defects with split skin grafts.Technically it is easy to learn the harvest of the suralis flap and none of ourpatient's complaint about the reduces sensitivity after necessitated cutting of the suralis nerve. ConclusionDefects in areas of the distal third lower leg anterior, ankle, heel and foot dorsum does need a stable and sufficient soft tissue cover, especially with exposed bony or tendinous tissue or in case of infections or difficult healing tendency.The suralis flap as an alternative to the commonly used free flaps and reduces the surgical effort.