This video depicts an Ilizarov style external fixation construct. It reveals the typical location of most rings and half rings, as well as posts, struts, pins, and dynamic natures. This may help patients to visualize the procedure and post operative course to be followed. These constructs are often placed for several months at a time. Patient education is a high consideration before undertaking such a procedure.
Nicholas Giovinco
© 2012 DrGlass.org
-Nicholas Giovinco
www.DrGlass.org
Project Summary:
-Used the Logo Raiford sent along as a template to create the 3D model.
-The animation and modeling was done in Lightwave 10 &10.1 (midproject upgrade...)
-Sound Fx are public domain media from Freesound.org (about 14 clips in all with lots of fades/layers)
-Editing and compositing via Final Cut Pro
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© 2011www.DrGlass.orgglass.dpm@gmail.com
This illustration depicts the architectural restoration provided by an Evans calcaneal osteotomy.
Producer:Nicholas Giovinco
© 2011www.DrGlass.orgglass.dpm@gmail.com
© 2011
www.DrGlass.org
glass.dpm@gmail.com
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© 2011
www.DrGlass.org
glass.dpm@gmail.com
Happy Halloween from the Dr. Glass DPM Video Podcast
Nicholas Giovinco
www.NicholasGiovinco.com
Southern Arizona Limb Salvage Alliance (SALSA)
www.ToeAndFlow.com
Authorship:
Nicholas A. Giovinco
Julia Bernardini
David G. Armstrong
The Receptor Activator for Nuclear Factor kappa B Ligand is believed to be an important molecule of bone metabolism. This is a natural and necessary surface-bound molecule on several types of cells, and serves to activate osteoclasts.
Overproduction of RANKL is implicated in a variety of degenerative diseases. In patients with neuropathy, the RANKL/OPG pathway is thought to mediate the development of Neuropathic Osteoarthropathy or "Charcot Joint"
An illustrative depiction of the RANKL pathway is as follows:
Cellular stress or injury may result in expression of RANK Ligand on the surface of activated ostoblasts and T cells. In this example, an activated T cell is contacting a pre-osteoclast. Because this RANKL presenting cell is in an activated form, RANKL will become expressed, thus activate an uninhibited RANK receptor on the Surface of an Osteoclast.
What is important to note, is that osteoprotegerin is a natural inhibitor of RANK and is thought to mediate a protective balance. Denosumab, and several other drugs, are being studied for their effects in preventing further transduction on the RANKL pathway and could prove to be useful in preventing disease progression.
As the transduction cascade continues, IkB kinase is activated and subsequently phosphorylates the Inhibitor of kappa B, leaving Nuclear Factor kappa B free to diffuse uninhibited. Upon entering the nuclear membrane, Nuclear Factor kappa B will serve as a rapid-acting transcription factor, and will contribute to a variety of changes in gene expression.
This gene expression, is correlated with the progression of Preosteoclastic species in becoming activated as osteoclasts. When the overproduction and/or expression of RANKL is seen, increased osteoclastogenesis will arise. Osteoclastogenesis is one of the fundamental elements in normal bone development and maturation.
However, in Neuropathic Osteoarthropathy, over abundance of osteoclastic activity will result in osteopenia or bone wasting. With compromised bone strength, osteolysis and fragmentation will be observed.
In addition to osseous destruction, the RANKL pathway has been correlated with macroangiopathic disfunction. The RANKL signaling pathway serves a regulatory role in the expression of bone matrix proteins in Vascular smooth muscle cells. A phenomenon that is naturally observed in many patients with Charcot joint destruction is vascular smooth muscle calcification. This presentation is often referred to as Monckeberg's arteriosclerosis.
One important note is that neuropathic osteoarthropathy or "Charcot Foot" is seen in nearly every sort of disease that results in peripheral neuropathy. The exact mechanisms of this correlation are still not entirely understood, but neuropathic degeneration itself serves a presumable teleological role in permitting both an increase in blood flow and vascular permeability into the bone as well as a decreased sensation and detection of boney destruction in patients.
When considering the supporting evidence of these two factors, the emergence of the indpendent, Neurovascular (French theory) and the Neurotraumatic (German theory), may possibly hold a similar etiology which is reflective of a common underlying cause. Because of the varying causes of peripheral neuropathy, the specific role the RANKL signal pathway merits more investigation at this time, and is needed to fully understand the process of neuropathic osteoarthropathy.
When observing Charcot foot on a macro anatomic level, evidence of destruction may be visualized on plain film xray. Vascular calcification is reported in nearly 90% of all diabetics with Charcot foot, and is often seen prior to joint or bone involvement. As Charcot joint progresses through the acute phase, destruction and dislocation will be observed with severe osteopenia. Although this phase will eventually subside, resulting in a coalescence of fragments and overall stability of architecture, the foot is often permanently deformed.
Deformations such as these, when accompanied by peripheral neuropathy and possible microangiopathological status, are often what lead to ulceration and infection. Although Neuropathic Osteoarthropathy is not directly responsible for the loss of limb or even death, the "Stairway to Amputation" is a perilous progression that must be curbed in all patients afflicted with this condition.
Authorship:
Nicholas A. Giovinco
Julia Bernardini
David G. Armstrong
Doxycycline is a semi-synthetic tetracycline compound. Classically, this drug is used in podiatry and wound care for its properties of antibiosis and antisepsis. There have, however, been some investigations of doxycycline and other chemically modified tetracycline species (CMTS), which demonstrate its potential as an inflammatory modulator. These qualities may prove useful within a wound environment. This is particularly so, as an inhibitor of nitric oxide (NO) production, matrix metalloprotease (MMP) activity, and tissue necrosis factor alpha converting enzyme (TACE).
MMP activity has been identified as a key player in the environment of chronic wounds as well. Although MMP's are part of the normal breakdown and remodeling of tissues within the human body, non-healing ulcers are particularly less governed by regulatory mechanisms and therefore see an overabundance of MMP activity, and consequently lead to the persistence of inflammation and degradation of the epithelial matrix in situ. The chemical structure of doxycycline has been investigated, and demonstrates satisfactory results as an inhibitor of such zinc catalyzed protease activity. By inhibiting the activity of various MMP species in a wound bed, the breakdown of wound matrix may be prevented.
Similar to MMP inhibition, TACE (otherwise known as ADAM17) is a member of the same metalloprotease superfamily and thus inhibition works by zinc binding as well. As a surface bound enzymatic protein, TACE degrades pre-TNF-a, thereby converting it to a biologically active form. Doxycycline has demonstrated convincing results in lowering the conversion of pre-TNF-a to its active form. Because TNF-a has long been known as a powerful member of the entourage of inflammatory cytokines of chronic wounds, the ability to suppress its expression could potentially be to the patient's advantage.
Next, the presence of Nitric Oxide within a wound environment is made possible by its production via the iNOS enzyme. The mRNA molecule which codes for iNOS is expressed during times of cytokine and inflammatory stimulation. This mRNA molecule has a relatively short half life, which is presumed to be for regulatory purposes, and is stabilized by the presence of p38 MAPK binding to one of several 'AUUA' motifs. When Doxycycline prevents p38 MAPK from stabilizing iNOS mRNA, via competitive binding to metallic ions, subsequent degradation of the iNOS mRNA molecule takes place and therefore acts to decrease the concentration of Nitric Oxide within the wound environment.
Although further investigation is needed to ascertain the true beneficial value of Doxycycline as a wound chemotherapeutic agent, laboratory data is highly suggestive of this possibility.
References:
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Project Lead: Samir Lalani
Producer: Nicholas Giovinco
This video depicts a traumatic laceration of the Anterior Tibial Tendon. This may happen with either blunt or sharp insult.
Note: with traumatic ruptures, it is important to look for TA ruptures, b/c when foot is in neutral, the tendon may be distal from laceration site, if the injury took place when the foot was in a DF position
]]>Project Lead: Scott Crismon
Producer: Nicholas Giovinco
We interrupt this podcast episode to bring you a message from our sponsor.
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Project Leads:
William Hoffman
Hummira Hassani
Contributing Authors:
Julia Bernardini
Scott Crismon
Technical Advisor:
Thomas Vitale
Narration:
Matrona Giakoumis
Producer:
Nicholas Giovinco
With the foot in a fixed pronated position the forces start along the medial axis of the tibia. The leg undergoes an internal rotation creating tension on the deltoid ligament complex.
In a Stage 1 injury, one of two pathologies may occur; rupture of the deltoid ligament complex or a transverse fracture of the medial malleolus.
As the injury progresses forward into Stage 2 the talus rotates further laterally putting tension on the anterior inferior tibiofibular ligament resulting in either a rupture of this ligament or an avulsion fracture off the anterior portion of the fibula or tibia.
As the forces continue past stage 2 rupture of the interosseus membrane begins to occur distally at the level of the anke joint. The exit point of this rupture creates a Stage 3 injury, described as a high short oblique fracture of the fibula beginning above the level of syndesmois. This fracture can be at various levels on the fibula. The most proximal fracture pattern occurs at the head and neck of the fibula which is described as a Maisonneuve fracture.
If the force progress into Stage 4 either a rupture of the posterior tibio-fibular ligament or a fracture of the posterior malleolus (Volkman’s fracture) will occur.
Note: The combined rupture of the anterior inferior tibiofibular ligament, the posterior inferior tibiofibular ligament, and the interosseus membrane results in a true ankle diastasis.
(Take home points)
-The injury begins along the medial axis of the tibia.
-Rupture of the interosseus membrane in conjunction with the rupture of the anterior inferior tibiofibular ligament, and the posterior inferior tibiofibular ligament creates a true ankle diastasis.
-The high fibular spiral fracture (Maisonneuve fracture) seen in stage 3 is unique to pronation external rotational injuires. It is important to always take proximal tibio-fibular x-rays when pronation external rotation injuries are suspected especially in the presence of posterior malleolar fracture with diastasis, because the high fibular fracture can be easily missed on a standard ankle x-ray series.
Project Leads:
William Hoffman
Hummira Hassani
Contributing Authors:
Julia Bernardini
Scott Crismon
Technical Advisor:
Thomas Vitale
Narration:
Matrona Giakoumis
Producer:
Nicholas Giovinco
With the foot in a fixed supinated position the forces start along the lateral axis of the fibula. The leg undergoes an internal rotation creating tension on the anterior inferior tibio-fibular ligament. In a Stage 1 injury, one of two pathologies may occur; rupture of the anterior inferior tibio-fibular ligament or a fracture of the distal lateral tibia (aka Tillaux-chaput fracture).
As the leg continues to internally rotate the talus collides with the distal fibula, creating a spiral fracture of the fibula beginning at the level of the syndesmosis. This describes a Stage 2 injury, which is the most commonly encountered ankle fracture. A Wagstaffe fracture can also occur during this stage.
As the force progresses a Stage 3 injury will either involve a rupture of the posterior tibio-fibular ligament or fracture of the posterior malleolus of the tibia (aka Volkman’s fracture).
Supination external rotation injuries that reach stage 3 rarely stop at this point and usually progresses to the final stage. Continued unrestrained lateral rotation of the talus will result in a Stage 4 injury involving either a rupture of the deltoid ligament complex or a transverse fracture of the medial malleolus.
(Take home points)
-The injury begins along the lateral axis of the fibula.
-The spiral fracture seen in stage 2 is unique to supination-external rotation injuries
Project Leads:
William Hoffman
Hummira Hassani
Contributing Authors:
Julia Bernardini
Scott Crismon
Technical Advisor:
Thomas Vitale
Narration:
Matrona Giakoumis
Producer:
Nicholas Giovinco
With the foot in a fixed pronated position, an abductory force is placed along the medial aspect of the medial malleolus; creating either a TRANSVERSE medial malleolar fracture and/or deltoid ligament failure, this is described as a STAGE 1 injury. As the abductory force continues to push the talus laterally the talus is driven into the tibio-fibular syndesmotic joint creating injury to BOTH the ANTERIOR & POSTERIOR-inferior TIBIO-FIBULAR ligaments creating a stage 2 injury. (Note: With the interosseus ligament still intact one cannot call this a true diastasis).
In STAGE 3: The ABductory force has continued into the fibula creating a fracture at or above the ankle joint that is short and OBLIQUE on the AP view but appears transverse on a lateral x-ray. Since the talus is driven in an inferomedial to superiorlateral direction a LATERAL SPIKE of cortex from the fibula may be visualized on an AP x-ray. Lateral comminution is quite common. One must remember to take a Lateral x-ray of the ankle joint to adequately differentiate this fracture from the posterior spike of the fibula seen with supination external rotation injuries. This is important for fixation purposes.
(Take home points)
The SHORT OBLIQUE fracture of the lateral malleolus seen in stage 3 will appear oblique on an AP x-ray, but transverse on a Lateral x-ray. This is unique to pronation- Abduction injuries.
Project Leads:
William Hoffman
Hummira Hassani
Contributing Authors:
Julia Bernardini
Scott Crismon
Technical Advisor:
Thomas Vitale
Narration:
Matrona Giakoumis
Producer:
Nicholas Giovinco
With the foot in a fixed supinated position a lateral Adductory force is exerted along the lateral malleolus as the talus inverts with-in the ankle mortise. In Stage 1, one of three injuries may occur, a rupture of the lateral collateral ligaments, an avulsion fracture the lateral malleolus, or a transverse fracture of the distal fibula below or at the level of the ankle joint. (Note: The syndesmotic ligaments are not involved with Supination ADduction injuries). If the ADductory force continues medially the talus will abut against the tibia and progress to a Stage 2 injury resulting in an oblique to near vertical fracture of the medial malleolus.
One must note that this is a multi-factorial injury; the relative position of the foot, the amount of force involved, and the inherent strength of both the ligamentous and osseous structures all play an intricate role in the development of this type of injury.
(Take home points)
Rupture of the lateral collateral ligaments or a fracture of the fibula below the level of the ankle joint in stage 1. Oblique to near vertical fracture of the medial malleolus seen in stage 2.
SALSA (Southern Arizona Limb Salvage Alliance)
ToeAndFlow.com
Project Leads:
Nicholas A. Giovinco
Timothy Fisher
Julia Bernardini
David G. Armstrong
Chemotherapy is classically defined as the treatment of disease by use of chemicals. In addition to microbial management of a wound environment, this term has recently become adopted in the field of wound healing for several additional purposes. Wound chemotherapy is best seen as an enabling factor, which further extends the clinicians ability to manipulate a wound environment on a biochemical level.
The benefits of maintaining cleanliness, regular lavage, irrigation, and drainage of open wounds and compound fractures has long been appreciated in medicine. In recent decades, the advent and application of Negative Pressure Wound Therapy (NPWT) has been further augmented with the instillation of chemotherapeutic agents.
Stepwise Technique which has been Shown to Provide Sufficient Results at the Southern Arizona Limb Salvage Alliance:
As one might imagine, the use of chemotherapeutic modalities is generally easy to perform. Topical applications and traditional dressing modifications are, in many instances, technically unchanged from standard practice. Our experience with the application of chemovac dressings has underscored the importance of careful technique for optimal results. Many of these techniques are listed in the product instructions and have been previously discussed in various literary mediums. We have found that they are useful in order to avoid the potential for complications from dressing adherence, leakage, durability, and subsequent maceration.
We therefore recommend that the wound area be thoroughly cleaned and dried between dressing changes. Adhesive tinctures such as benzoin or mastisol are useful in increasing the ability for the plastic dressing to hold a tighter and more rigorous seal.
It has also proven useful to 'Window' the wound edges with smaller strips of dressing seal in order to create more exact boundaries. This is helpful for wounds with irregular borders, the need for bridging two or more wound beds, and to prevent excessive contact between viable surrounding skin with the foam sponge. In addition, we recommend precise trimming of the foam sponge with shears or even a scalpel blade. This further prevents the potential for maceration of surrounding skin.
When the top cover is place over the sponge, it is important to do so in a manner which allows a flat and uniform contact across the sponge and skin. By preventing wrinkles, tracks, or 'Cigar Rolls' one can minimize leakage and non-uniform distribution of negative pressure.
The next step will depend on the type of negative pressure device and dressing being used. The dual port dressings such as ITI Sved units contain both ingress and egress interfaces, which are simply applied in the same manner as one would expect. However, when modifying or augmenting a standard VAC dressing with a make-shift ingress port, it is important to utilize IV tubing which can be inserted directly into the dressing. For this, we recommend a minimal incision. Additional seal or Tegaderm dressing material must then be used to seal this interface, and thus decrease leakage or loss of pressurization.
To our knowledge, the specific arrangement of the ingress and egress ports is of little importance. By this, we have not experienced any notable effects from gravity or direction of flow. It appears that the chemotherapeutic agent perfuses the sponge and is thus 'delivered' to the entire wound bed without prejudice. Therefore, merely spacing a reasonable difference between the two interfaces is more than sufficient at achieving satisfactory distribution.
At this point, negative pressure should be initiated. It is important to identify and eliminate any breaks in seal and loss of pressure. Once a satisfactory seal has been established, the chemotherapeutic input should be initiated. By initiating the negative pressure component PRIOR to chemotherapeutic input, one can ensure a consistent and predictable rate of infusion. In our experience, most dressing configurations merit this process as a 'Best Practice' in avoidance of leakage and maceration, due to a compromised dressing assembly.
Many hospital and care facilities possess automated IV infusion apparatuses. These devices allow for programmable infusion cycles to be administered. This is undoubtedly a convenience to care providers, but is not necessary to deliver infusion. A manual regulator is capable delivering a consistent and reliable infusion rate. Depending on several factors, typical rates of infusion range from 1-3 drops per 10 second interval, or a total of 25 cc's per hour.
One notable observation about the use of foam dressings with infusion ports, both modified as well as designed, is the increased reliance on patient compliance. This is seen, more so, with the use of such chemovac devices outside of hospital and specialized care facilities, where strict adherence to therapeutic instructions, weight bearing status, and foam dressing application is not always satisfied. In this event, the discontinuation of chemovac therapy may need to be considered, in favor of standard dressings or negative pressure wound therapy. After all, wounds have been healed for many years, long before vacuums.
Project Leads:
William Hoffman
Hummira Hassani
Contributing Authors:
Julia Bernardini
Scott Crismon
Technical Advisor:
Thomas Vitale
Narration:
Matrona Giakoumis
Producer:
Nicholas Giovinco
Lauge-Hansen is perhaps one of the most commonly utilized classifications for ankle fractures. Dr. Lauge-Hansen in 1948, broke down the mechanism of injury into two simplistic terms for a complicated three-dimensional fracture. The first term describes the position of the foot at the time of injury. The second term was originally described as the direction and/or force in which the talus moves relative to the tibia and the fibula. Since, the original classification was based off of a cadaver study the second term has been modified to describe the way the tibia moves relative to the talus, which is what occurs in a weight-bearing individual.
Lauge-Hansen's classification is a numerical system which describes a step-wise approach through the injuries progression. One must look at rotational injuries in a clockwise fashion while direct blow injuries must be looked at in a transverse abductory /adductory fashion. Generally pronation injuries will start at the medial aspect of the ankle joint while supination injuries will start at the lateral aspect of the ankle joint. This classification not only allows you to visualize the osseous injury to the tibia & fibula but also incorporates the ligamentous structures that may become damaged within the ankle joint. The Lauge-Hansen system can provide insight into the proper maneuvers required for closed reduction.
Another classification that is commonly correlated with the Lauge-Hansen classification system is the Danis Weber classification. Danis Weber is based on the fibular fracture line's relationship to the ankle joint. Danis Weber type A injury starts below the level of the ankle joint and corresponds with a Lauge-Hansen Supination Adduction injury. Danis Weber type B starts at the level of the ankle joint and correspond with Lauge-Hansen Supination External rotation and Pronation Abduction injuries. Last but not least, Danis Weber type C injuries start above the level of the ankle joint and correspond with a Lauge-Hansen Pronation External Rotation injury. The Danis Weber classification although more simplistic in nature than the Lauge Hansen classification, is limited by its anatomical focus on the fibula. Danis Weber also fails to take into consideration the soft tissue structures that are often associated with these injuries. The AO group has expanded this classification to include some of the shortfalls of this system.
It is important remember that these classification systems are guidelines and atypical fracture patterns do occur.
Project Lead: Nicholas Giovinco
This video illustrates both the functional anatomy of the plantar plate during Metatarsal Phalangeal Joint Dorsiflexion while intact, as well as when a full rupture has occurred. This positive finding can be demonstrated with a failed Lachman’s test.
Project Lead: Nicholas Giovinco
This video illustrates the idea of using an external fixator device to perform a callus distraction to correct a Charcot foot collapse.
Project Lead:
Nicholas Giovinco
Contributing Authors:
Kristen Diehl
Doug Doxey
Resource Consultant:
Kelly Powers
Producer:
Nicholas Giovinco
A "Hammer-Toe" deformity, describes a pathological condition of abnormal or exaggerated contracture at the metatarsal-phalangeal and inter-phalangeal joints of the toes. This is mainly due to an imbalance between the muscular flexors and extensors as well as intrinsic interossei and lumbrical muscles within the forefoot.
A hammer toe deformity may present as one of three morphological variations. A true hammer-toe deformity will exhibit dorsiflexion at the metatarsal-phalangeal joint and plantar flexion at the proximal interphalangeal joint. Whereas a mallet toe solely results from a plantarflexory contracture of the distal interphalangeal joint. A simultaneous combination of these two conditions is thus known as a claw toe.
Clinically, a hammer toe may present with hypertrophic callosities on the plantar surface of the corresponding metatarsal head and the distal/plantar tip of the toe in addition to a painful corn over the proximal interphalangeal joint.
A radiographic analysis of a hammer-toe deformity in the Anterior/Posterior or Dorsal/Plantar view will reveal a hallowed point or gun barrel appearance of the middle phalanx.
Although conservative care may involve shoe modifications, padding, strapping, and custom orthosis; surgical reconstruction may be required to alleviate painful and immobilizing hammer-toe conditions.
This surgical management of the hammer-toe deformity is performed by variable means of "Sequential Reduction." By this, a hammer-toe contracture is alleviated through various procedures in order to re-establish a functional position during active motion as well as rest.
This process may include, a lengthening of the extensor tendons, followed by a resection of the extensor hood. An "Arthroplasty" may be utilized to increase useable joint space within the proximal inter-phalangeal joint by removing the head of the proximal phalanx.
In more extreme deformities, a tenotomy of the flexor tendon may be utilized. This may be accompanied by a fusion of the joint itself, known as an "Arthrodesis," whereby the base of the middle phalanx and the head of the proximal phalanx are combined to form one continuous bone mass.
By balancing the forces of plantarflexion and dorsiflexion at the joints of the toe, a Hammer-toe operation may result in a drastic improvement of the functional mobility of the foot and leg during gait.
Script Lead:
Nicholas Adams
Contributing Authors: (Alphabetical Order)
Matrona Giakoumis
James Sills-Powell
Eugene Timpano
Jackie Schwartz
Technical Advisor:
Carl Kihm
Key Grip:
Irina Gelman
Narration:
Timmy Teck
Producer(s):
Bradley Hart
Nicholas Giovinco
Dr. Glass Team Members:
Kelly Powers
Shane Baker
Nicholas Giovinco
This video should make you do two things; laugh and think.
Charcot foot (as it's properly spelled) is a serious condition of the lower extremity, whereby the foot is ultimately deformed and is threatened by the increased potential for infection and amputation. Although the causes of Charcot foot are not clearly understood, it is almost always associated with neuropathology.
Limb Salvage, as it pertains to amputation prevention, is a powerful field of medicine which utilizes a number of subspecialties to improve a patient's longevity as well as quality of life. Diabetic limb salvage and wound care are some of the fastest growing and evolving medical fields, which every diabetic could stand to gain from.
Transcript:
In a world swimming with peril,
The threat of neuropathy treads closer than ever.
Where diabetes claims the limbs of over 200 thousand people every year,
...There exists something far more frightening...
This summer!
Prepare to have your vision disturbed
Your kidneys fail,
And your sensations left bobbing out at sea...
Rocker-bottom studios brings you one whale of an arch-buster that will throw your A1C.... overboard...
Consult your local Podiatric limb salvage experts, or else...
(Musgrave was on to something big...)
Shark-O-Foot 2.... This time it's chronic!!
For more information, please visit:
Diabetes.org - American Diabetes Association
APMA.org - American Podiatric Medical Association
VascularWeb.org - Society of Vascular Surgeons
DiabeticFootOnline.com - Southern Arizona Limb Salvage Alliance
ToeAndFlow.com - Diabetic Foot Blog
LEInfections.com - Handbook of Lower Extremity Infections
DrGlass.org - Dr. Glass Learning Resource Network
Thank You! :-)
Project Lead: Nicholas Giovinco
This is a demo of the arteries and veins within the lower extremity. Visit www.ToeAndFlow.com for more information about limb salvage.
Project Lead: Nicholas Giovinco
Illustrated here is midfoot collapse, due to an Equinas Contracture. This causes a rocker bottom foot over months or years. This illustration is exaggerated for diagrammatical effect.
Project Lead: Nicholas Giovinco
This is an example of a reverse cole osteotomy, which is used to treat severely collapsed, rocker bottom feet. Most often, this procedure is utilized for a Charcot deformity in the mid foot. The use of an external fixator is then used over a course of several weeks/months to gain correction and length.
Project Lead: Nicholas Giovinco
Illustrated here is a Cole osteotomy, whereby a dorsiflexory wedge is removed from the midfoot to eliminate a high arched Cavus foot type.
Project Lead: Nicholas Giovinco
This is an example of a procedure which is performed in sever deformities and complications of the forefoot. In Rheumatoid patients, the fibular deviation and dorsal subluxation of the digits is noted. The modification demonstrated here, is a Keller arthroplasty of the 1st metatarsal-phalangeal joint (MTPJ). By performing these osteotomies to all the MTPJs in the forefoot, an increase in the range of motion is observed post operatively.
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