Kavros, Steven J.

* Repairing skin and soft-tissue loss after severe trauma remains a daunting task because of the complications that arise throughout treatment. Negative-pressure wound therapy (NPWT) has proven to be a useful tool for reducing these complications by facilitating the repair of damaged soft tissue in a variety of scenarios and settings. * The success of NPWT depends on negative pressure, controlling local edema, the removal of inflammatory mediators, revascularization and granulation, and reducing the wound-bed bioburden. * NPWT is a reasonable treatment modality when used appropriately according to recommended indications. * NPWT creates an environment that can help to accelerate healing after devastating soft-tissue loss. * With a high reported rate of success, NPWT can be used in a variety of settings. * NPWT has proven to be useful in conjunction with flaps and grafts to further aid the practitioner in repairing damaged tissue. * NPWT has the potential of eliminating additional surgical procedures and lengthy hospital stays, thus reducing unnecessary costs.

Plantar fasciitis is a common foot disorder that affects more than two million Americans each year. Conservative management of plantar fasciitis is the first line of treatment by the medical specialist who frequently encounters this common foot complaint. In this study, 50 patients with plantar fasciitis of 4 weeks duration but less than 12 weeks were randomized into two groups. One group of 25 patients used the AirHeel (Aircast, Inc.) and the second group of 25 used the 1st Step prefabricated foot insert (Wrymark, Inc). Standardized weight-bearing radiographs were obtained in order to categorize the foot type: normal arch, pes planus, or pes cavus. Patients were initially evaluated and at 12 weeks they returned for a subsequent visit. The contact area of the foot with the AirHeel and 1st Step insert were similar, an increase of 27% and 26%, respectively, over the contact area barefoot. There was a noted difference in force reduction with the two devices. The AirHeel reduced the midstance force by 20.19%, as compared to the 1st Step insert which showed a 1.03% increase in midstance force. Patients with a higher initial pain score seemed to respond better initially to the AirHeel (p= 0.015) than the 1st Step insert (p= 0.035). This study demonstrates the benefits of offloading the foot at midstance with two devices to relieve the discomfort associated with plantar fasciitis. The Aircast AirHeel is a new modality for dynamic, functional treatment of proximal plantar fasciitis.

Background: A feasibility study was conducted to characterize the effects of noncontact low-frequency ultrasound therapy for chronic, recalcitrant lower-leg and foot ulcerations. Methods: The study was an open-label, nonrandomized, baseline-controlled clinical case series. Patients were initially treated with the Mayo Clinic standard of care before the addition of or the switch to noncontact low-frequency ultrasound therapy. We analyzed the medical records of 51 patients (median ± SD age, 72 ± 15 years) with one or more of the following conditions: diabetes mellitus, neuropathy, limb ischemia, chronic renal insufficiency, venous disease, and inflammatory connective tissue disease. All of the patients had lower-extremity ulcers, 20% had a history of amputation, and 65% had diabetes. Of all the wounds, 63% had a multifactorial etiology, and 65% had associated transcutaneous oximetry levels below 30 mm Hg. Results: The mean ± SD treatment time of wounds during the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 9.8 ± 5.5 weeks versus 5.5 ± 2.8 weeks (P < .0001). Initial and end measurements were recorded, and percent volume reduction of the wound was calculated. The mean ± SD percent volume reduction in the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 37.3% ± 18.6% versus 94.9% ± 9.8% (P < .0001). Conclusions: Using noncontact low-frequency ultrasound improved the rate of healing and closure in recalcitrant lower-extremity ulcerations. (J Am Podiatr Med Assoc 97(2): 95–101, 2007)

Background. Gross deformity of the foot in Charcot neuroarthropathy can lead to collapse and subsequent ulceration, infection, amputation, or premature death. This study evaluated healing of midfoot ulcerations of Charcot neuroarthropathy using PriMatrix, a novel acellular fetal bovine dermal matrix. Methods. In this retrospective analysis, 20 patients with ulcerations of the midfoot associated with Charcot neuroarthropathy were treated with either PriMatrix in addition to standard wound care (PriMatrix group,n = 12) or standard wound care alone (control group, n = 8). All patients had chronic, nonhealing foot ulcerations of at least 2250 mm 3 for a minimum of 30 days duration. All foot ulcerations were full thickness with subcutaneous involvement. Ankle brachial index ≥0.90 and/or transcutaneous oximetry (TcPo 2 ) ≥40 mm Hg at the periulcer site was necessary for inclusion. Patients were excluded if they had acute or chronic osteomyelitis of the foot. Results. Demography, risk factors, baseline severity of Charcot neuroarthropathy, and wound volume (control 4078 mm 3 , PriMatrix 3737.5 mm 3 , P = nonsignificant) were similar between treatment groups. Mean time to healing in the PriMatrix group (116 days, 95% CI = 109-123) was significantly shorter than in the control group (180 days, 95% confidence interval [CI] = 171-188); P < .0001. A significantly faster rate of healing was observed with PriMatrix (87.9 mm 3 /wk, 95% CI = 115.2% to 60.6%) compared with control (59.0 mm 3 /wk, 95% CI = 72.8% to 45.3%); P < .0001). Conclusions. The significantly faster rate of healing and steeper slope of volume reduction in the PriMatrix group warrants further investigation into its effects on healing of neuropathic ulcerations and potential limb salvage. Levels of Evidence: Therapeutic, Level IV

Ischemic vascular ulcerations of the upper extremities are an uncommon and frequently painful condition most often associated with scleroderma and small vessel inflammatory diseases. Digital amputation has been advocated as primary therapy because of the poor outcome with medical care. Intermittent pneumatic compression (IPC) pump therapy can improve ulcer healing in lower extremity ischemic ulcerations; however, the value of this treatment in upper extremity ischemic ulcerations is not known. This observational pilot study consisted of a consecutive series of 26 patients with 27 upper extremity ischemic vascular ulcers seen at the Mayo Gonda Vascular Center from 1996 to 2003. Inclusion criteria were documented index of ulcer size and follow-up ulcer size and use of the IPC pump as adjunctive wound treatment. Twenty-six of 27 ulcers (96%) healed with the use of the IPC pump. Mean baseline ulcer size was 1.0 cm 2 (SD=0.3 cm 2 ) and scleroderma was the underlying disease in 65% (17/26) of cases. Laser Doppler blood flow in the affected digit was 7 flux units (normal greater than 100). The mean ulcer duration before IPC treatment was 31 weeks. The average pump use was 5 hours per day. The mean time to wound healing was 25 weeks. Twenty-five of 26 patients reported an improvement in wound pain with pump use. Intensive IPC pump use is feasible and associated with a high rate of healing in upper extremity ischemic ulcers. A prospective, randomized, sham-controlled study of IPC is needed to determine whether IPC treatment improves wound healing compared to standard medical care.