Clinics in podiatry最新文献

A summary of the phalangeal set procedure has been given with indications, significance of the correction, contraindications, biomechanical factors, operative procedure, and the acceptance in many podiatric and orthopedic surgery circles. This is an ambulatory procedure for toe deformities which allows for release of toe contractures, reduction of superimposition of phalanges, increased joint space, and correction of malalignment.

We have attempted to delineate a logical and rational approach to the recognition and management of postoperative infections. The reader is urged to use the tenets presented strictly as guidelines. Each and every treatment regimen must be tailored to the individual case. The priorities of early detection and treatment as well as the routine ordering of Gram stain and culture and sensitivity studies must never be ignored. The best prevention of bone infection is high serum levels of antibiotic in the early stages of management. Also, medications should have a high osseous perfusion rate. Among these are the cephalosporins, oxacillins, cloxacillins, and penicillins. After making a definitive diagnosis of osteomyelitis, radiographic evidence may be anticipated from 21 days after the start of infection. Bone scans will demonstrate this condition much sooner and allow for earlier treatment. There are two basic requirements for effective antibiotic therapy. The antibiotic chosen must be capable of inhibiting the growth of the agent or agents causing the infection (this requires an identification of the infecting bacteria and the selection of an antibiotic effective against that organism). Secondly, a therapeutically effective concentration of the antibiotic must reach the infected tissues for a sufficient period of time to allow the antimicrobial activity of the compound to be effective. This requires a blood supply capable of delivering the antibiotic in the blood to the affected tissues. Furthermore, the physiologic state of the patient, the nutritional status, and the immunosuppressive systems should be supported by the means necessary to initiate host reactions against the invading organism. Three last principles may be added to this antibiotic prescribing regimen. (1) When using broad-spectrum antibiotics, be constantly aware of the likelihood of superinfection. This is the overgrowth of bacterial organisms present on the skin as normal flora that multiply rapidly when the surrounding flora is destroyed by the broad-spectrum antibiotic. (2) Ancillary measures including heat, elevation, and immobilization should be employed when conditions permit. (3) Always check for allergy before prescribing an antibiotic. There are no certainties in the treatment of infections; the regimens may change daily as newer and more effective medications are marketed. Nonetheless, the principles remain unchanged. Clinical disease results only when the invading agent evokes anatomic and functional damage in the course of obtaining the necessary requirements for survival.(ABSTRACT TRUNCATED AT 400 WORDS)

The closing base wedge osteotomy will consistently yield excellent prognostic results when performed as described. The technique should be used when an angular change at the first metatarsal base is needed in any direction.

Minimal traumatic surgery is considered the preferred treatment for painful digital deformities including hammertoes, overlapping toes, mallet toes, underlapping toes, and painful corns. With the introduction of technology such as intraoperative x-ray monitoring, these procedures can be performed more efficiently, safely, and without unnecessary hospitalization in most cases. Mobility is kept to a minimum, yet the patients can be comfortably mobile while they are recovering.

The CO2 laser has several distinct advantages in its application to soft tissue lesions of the foot. A dry field is obtained with good hemostasis and clear vision, with easy access in confined areas. The laser beam sterilizes as it cuts, reducing the incidence of infection. In sealing lymphatic channels, it may theoretically diminish the risk of metastasis in malignant lesions. Healing occurs with minimal postoperative swelling, scarring, or pain, leading to increased patient comfort. Other areas in which the laser can be helpful are porokeratosis, keloids, spider web varicosities, and tattoos.

A historical review of osteotomies of the proximal phalanx has been presented. The techniques have remained relatively unchanged since their introduction by O. F. Akin in 1925. This article describes a minimal incision osteotomy technique using a medial approach to the hallux and wedge-shaped burs. The results suggest that the procedure produces good clinical results and is highly accepted by the patient. The procedure is compatible with a hospital or outpatient surgical facility. The procedure is recommended to those surgeons who are well-trained in ambulatory foot surgery. A statistical survey of the end-results is not available at the present time.

The importance of correction of the high proximal articular set angle with a subluxed joint in hallux abducto valgus for long-term correction is cited. I have shown that if the laterally deviated facet is not corrected, pronatory forces continue to act on the first ray. When force is applied to a still laterally tilted first metatarsophalangeal joint, further side-slipping of the joint will occur even though modification of the Silver, McBride, or osteotomy procedures of the first metatarsal have been performed successfully. A review of the standard procedures for the correction of a high proximal set angle alone usually did not correct the high intermetatarsal angle usually associated with this problem. Combination procedures sometimes created complications. These include dorsal dislocation of the distal fragment in correction of the sagittal plane deformity causing metatarsalgia, limited dorsal range of motion, and damage to the sesamoids or sesamoid grooves on the plantar aspect of the first metatarsal. Angulational transpositional derotation and hallux set (ATDH) is offered to correct four deformities using one or two 1-cm incisions together with "stab" incisions. This method overcomes the many disadvantages of previous procedures and can be used in the presence of biomechanical pronatory forces to reduce the proximal articular set and intermetatarsal angles; to derotate the hallux; to neutralize the forces that pull the proximal phalanx off the first metatarsal head; and if necessary, to correct the sagittal plane deformity of the first metatarsal so that weight bearing is not disturbed.(ABSTRACT TRUNCATED AT 250 WORDS)

No matter what the underlying podiatric problem, if surgical correction is considered, a good preoperative work-up is essential. This article deals with the preoperative work-up and criteria for a variety of ambulatory surgical procedures.

It is clear from this study that the majority of foot surgical cases being done in the United States may be performed in an office-based surgical setting when individual case considerations are made on a case-by-case basis. This entire study reflects the importance of physician preference relative to selecting a surgical environment for management of disorders and surgery of the foot. In some areas, a strong consensus of opinion existed concerning one surgical location or the other, but the overwhelming majority of responses indicated a case-by-case evaluation prior to physician selection of the surgical environment. The Delphi study was well validated by the survey of Alabama podiatrists in this regard. Traditionally, within the United States, the physician has acted as an agent to the patient and as an allocator of health care resources. Perhaps current concepts regarding patient hospitalization for certain surgical procedures would change if the physician were motivated (either intellectually or financially) toward office-based surgery on a individual case basis. Perhaps, in selected elective surgical procedures, patients could be sufficiently informed so that they could voice an opinion or preference relative to selection of the surgical environment. Additional research in this area is necessary. Expanded insight into established patterns of patient hospitalization practices and general anesthesia usage on these hospitalized patients may also be in order. Realizing full well the role of independent physician judgment in these matters, it may be that selection of general anesthesia and hospitalization for some elective surgery procedures reflects the physician's training rather than his appreciation of alternate routes for rendering reasonable and responsible care.(ABSTRACT TRUNCATED AT 250 WORDS)