Background: Many wound assessment systems including the Wagner classification and University of Texas (UT) grading system have been previously described. The authors of this study applied the DIRECT (Debridement of necrosis, Infection control, Revascularization, Exudate control, Chronicity, and Top surface) wound coding system for initial assessment of diabetic foot ulcers (DFUs) to predict limb salvage and prognosis.<br/>Methods: From January 2016 to February 2020, a total of 169 first-time DFU patients were retrospectively evaluated using the DIRECT wound coding assessment system. DFUs were followed up for at least 6 months, and scores in each component of the coding system according to final limb status were statistically evaluated. The coding assessment’s ability to predict major amputation was compared to those of the Wagner classification and the UT grading system.<br/>Results: Subjects were divided into complete healing (n=80, 47.3%), not healed (n=71, 42%), and amputation (n=18, 10.7%) groups. The mean values of each component of DIRECT assessment for the complete healing/amputation groups were D 0.86/1.56 (P<0.001), I 0.46/0.89 (P=0.001), R 0.65/0.94 (P=0.014), E 1.15/1.56 (P=0.049), C 0.69/0.89 (P=0.086), T 0.53/0.72 (P=0.13) and the sum was 3.140/4.741 (P<0.001). The area under the receiver operating characteristic curve of the DIRECT, Wagner, and UT grading systems was 0.722, 0.603, and 0.663, respectively.<br/>Conclusion: The DIRECT coding system shows a greater association with prediction of amputation or complete healing, compared with the Wagner and UT wound classification systems. This more accurate wound assessment system will be helpful in predicting prognosis and planning treatments.

Background Hand fractures can be treated using various operative or nonoperative methods. When an operative technique utilizing fixation is performed, early postoperative mobilization has been advocated. We implemented a protocol involving controlled active exercise in the early postoperative period and analyzed the outcomes.Methods Patients who were diagnosed with proximal phalangeal or metacarpal fractures of the second to fifth digits were included (n=37). Minimally invasive open reduction and internal fixation procedures were performed. At 3 weeks postoperatively, controlled active exercise was initiated, with stress applied against the direction of axial loading. The exercise involved pain-free active traction in three positions (supination, neutral, and pronation) between 3 and 5 weeks postoperatively. Postoperative radiographs and range of motion (ROM) in the interphalangeal and metacarpophalangeal joints were analyzed.Results Significant improvements in ROM were found between 6 and 12 weeks for both proximal phalangeal and metacarpal fractures (P<0.05). At 12 weeks, 26 patients achieved a total ROM of more than 230° in the affected finger. Postoperative radiographic images demonstrated union of the affected proximal phalangeal and metacarpal bones at a 20-week postoperative follow-up.Conclusions Minimally invasive open reduction and internal fixation minimized periosteal and peritendinous dissection in hand fractures. Controlled active exercise utilizing pain-free active traction in three different positions resulted in early functional exercise with an acceptable ROM.

Dermatomyositis (DM) is an autoimmune inflammatory myopathy with some cutaneous manifestations. We present the case of a patient with a bone-depth skin ulceration on the elbow that was well healed with a transposition flap using a dorsal interosseous artery perforator. A 56-year-old man reported difficulties when climbing stairs and diffuse pain of unclear origin throughout his body that started 2 months previously. The patient was diagnosed with DM, and the department of plastic and reconstructive surgery was consulted for the management of an ulcerative skin lesion on the left elbow. The dorsal interosseous artery was first detected by vascular Doppler ultrasonography, and a transposition flap was designed including the pedicle. The flap was transposed to cover the bone exposure over the olecranon. At 4 weeks postoperatively, complete healing of the wound was observed without complications, and the patient had full range of motion of the elbow without pain. Despite major developments in the medical treatment of DM, ulcerative cutaneous lesions remain difficult to treat. Our experience suggests that the use of a transposition flap including the dorsal interosseous artery is suitable for the treatment of ulcerative lesions around the elbow in DM patients.

Venous ulcers, ischemic wounds and skin lesions from autoimmune diseases are some examples of unhealing wounds. Practitioners treating such wounds should consider the possibility of skin metastasis of neoplasms, especially in patients with cancer. Treatment of cutaneous metastasis in cancer must include both surgical resection and chemotherapy. Here we present a patient who had lung cancer with skin metastasis. Though incidence of metastasis from lung cancer is known to be as low as 1% to 12%, its prognosis is poor. Also, the clinical features of these skin lesions tend to vary, often resulting in them being misdiagnosed as benign lesions. The diagnosis of malignancy for this particular case was delayed. After the metastatic lesion was diagnosed as such, surgical resection was performed and the defect caused by wide excision was covered by a superior gluteal artery perforator flap. Though the patient was administered an anticancer drug, the wound healed well after the operation.