The current review provided a summary of reported outcomes of free heel reconstruction in the literature till date. With the current evidence largely limited to small cohort studies (level IV evidence), there were no significant differences found between reconstructive options. These findings serve as a call to action for more reconstructive surgeons to collaborate on multi-institutional prospective studies with robust outcomes assessment. As such, an ideal flap for reconstruction of the weight-bearing heel has not yet been made clear.
Purpose of Review To provide an overview of patient management and surgical technique regarded as best practice in optimising outcome following primary and secondary amputation in trauma patients. This is supported by evidence where available. Recent Findings There is increasing evidence that primary amputation may offer superior outcome to reconstruction in severe open lower limb injuries, particularly segmental trauma involving the foot and tibia. Similarly, patients considering complex reconstructive procedures for failed trauma management should be counselled that reported outcomes are equivalent or better following amputation and are achieved faster and with less complications. Patients should be fully informed of this when making decisions about management, though this needs to be individualised. Various surgical techniques have been associated with improved outcome and these are described herein. Careful peri-operative pain management has been associated with faster rehabilitation, better psychological response and a reduced risk of chronic pain. On discharge, patients should be linked to rehabilitation, prosthetic and clinical psychology services and these should be integrated where possible. Summary A holistic, multidisciplinary approach is recommended in all aspects of care and should be available from the outset. Patients should be optimised medically and functionally, where possible pre-operatively. Psychological assessment and early information sharing are recommended. Where this is not possible due to acuity, these issues should be addressed as soon as possible post-amputation. Particularly where the limb is severely injured, careful planning and joint operating by senior Orthopaedic, Plastic and Vascular surgeons can achieve the best results.
images in clinical medicineT h e ne w e ngl a nd jou r na l o f m e dic i ne n engl j med 359;23 www.nejm.org december 4, 2008
2477A 56-year-old woman presented to the emergency department with a 3-day history of severe pain in and loss of movement of her right index finger. She reported that for the previous 2 months, she had noted a small, tender lump, with no progression in size, near the finger joint. Marked palmar erythema and a tender, firm swelling overlying the index metacarpophalangeal joint were noted (Panel A). Initially, a flexor-sheath infection was suspected, and antibiotics were administered. However, radiography showed a calcified mass within the flexor digitorum tendon (Panel B, arrow), and calcific tendinitis was diagnosed. Calcific tendinitis may be an acute, intensely painful synovitis of the flexor sheath. It is common in the rotator cuff of the shoulder but rare in the hand. The diagnosis is often overlooked, and differentiation from septic tenosynovitis can be made on the basis of an absence of systemic findings. Initial treatment, which is targeted to alleviate symptoms, consists of elevation of the affected site (e.g., the hand) and the use of antiinflammatory agents. Repeated radiography at 2 to 4 weeks usually shows resolution. Surgery is rarely indicated. At a follow-up visit 6 weeks after the initial presentation, the lump was barely palpable, and the patient had no pain and a normal range of movement.
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