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      A salvage strategy for heel pad degloving injury : A case report

      case-report
      , BS, , MD, , MD
      OTA International
      Wolters Kluwer Health
      degloving, heel pad, limb salvage

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          Abstract

          Case:

          A 50-year-old female experienced a crush injury to the foot resulting in open degloving of her heel pad. This study details a surgical strategy to achieve healing and limb salvage.

          Conclusion:

          Heel pad injuries with degloving are difficult to salvage and have a poor prognosis. Amputation is often the only therapeutic option, unless part of the blood supply to the heel pad is intact, rendering limb salvage a possibility.

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          Most cited references11

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          Comparison of the mechanical properties of the heel pad between young and elderly adults.

          To compare the mechanical properties of the human heel pad between young and aged adults. A 7.5-MHz linear-array ultrasound transducer was incorporated into a specially designed device to measure the thickness of the heel pad under different loads. The heel pad was compressed with serial increments of 0.5kg to a maximum of 3kg and then relaxed sequentially. Then the load-displacement curve of the heel pad during a loading-unloading cycle was plotted. Convenience sample of 33 volunteers without heel problems, aged 18 to 78 years, were divided into young (less than 40 years) and elderly (older than 60 years) groups. Unloaded heel-pad thickness, compressibility index, stiffness, and energy dissipation ratio were calculated from the load-displacement curves. Student's t-test was used to compare the mechanical properties of the heel between these two groups. The average unloaded heel-pad thickness was 1.76+/-.20cm in the young group and 2.01+/-.24cm in the elderly group (p < .001). The average compressibility index was 53.3%+/-7.7% in the young group and 61.3%+/-5.5% in the elderly group (p < .001). Energy dissipation ratio representing shock absorbency of the heel pad, was 23.7%+/-6.9% in the young group and 35.3%+/-10% in the elderly group (p < .001). Unloaded heel-pad thickness, compressibility index, and energy dissipation ratio of the heel pad were significantly increased in the elderly group, indicating loss of the elasticity of the heel pad. The loss of elasticity may be responsible for the higher incidence of heel injury in elderly individuals.
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            Soft tissue defects of the heel: a surgical reconstruction algorithm based on a retrospective cohort study.

            The hindfoot is a special anatomical location, requiring unique forms of reconstruction of the thick, durable heel pad, the underlying calcaneus, and the Achilles tendon and its thin, pliable soft tissue envelope. Perhaps more than in any other region of the foot, the heel poses a reconstructive challenge to the surgeon who must consider both form and function when repairing wounds in this location. There are many possible reconstructive options, including local, distant, and free flaps. These flaps could be of muscular, myocutaneous or fasciocutaneous tissues. We reconstructed heel defects in 46 consecutive patients using several reconstructive options, and reviewed the results. Patients were classified according to preoperative demographic variables, including size, depth, site, etiology, age, vascularity, sensation, Achilles tendon condition, bone exposure or bone loss, and the patient's functional needs. Neither partial nor total flap losses were observed; the reconstructions were evaluated and considered satisfactory both by surgeons and patients if they fulfilled certain criteria, namely complete coverage, durability upon weight bearing and walking, sensation, donor site morbidity, and cosmetic appearance. No recurrences of the defects were observed during the follow-up period. Heel reconstruction is a challenging task for foot and ankle reconstructive surgeons. Every step should be taken to avoid recurrences and ulcerations. In this article we present a surgical reconstruction algorithm that may allow easy and reliable decision making based on the preoperative assessment of the defect and other clinical features.
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              Angiosome theory: fact or fiction?

              The angiosome concept delineates the human body into three-dimensional blocks of tissue fed by specific arterial and venous sources named "angiosomes." Adjacent angiosomes are connected by a vast compensatory collateral web, or "choke vessels." This concept may provide new information applicable to improving targeted revascularization of ischemic tissue lesions. A few dedicated studies available seem to favor this strategy, as encouraging ulcer healing and limb preservation are reported in connection with both bypass and endovascular techniques based on these principles. The theory on the angiosome model of revascularization (AMV) may help the clinician to better refine vessel selection, vascular access, and specific strategies in the revascularization of critically ischemic legs with tissue lesions. Specific applications of angiosome-guided revascularization were recently suggested for patients with diabetes or renal insufficiency, with ischemic tissue lesions of the lower limb, and extended large- and medium-size collateral network decay. For these cases, the concept may allow deliberate arterial reconstruction following individual wound topographies in specific ischemic areas, although deprived from "rescue-vessel" supply. The AMV theory may contribute to a shift in common reperfusion options. However, the data available is suggestive and does not provide strong evidence as factors such as case mix and the severity of ischemia are unsatisfactorily controlled. At present, the evidence is scarce as to the effect of the severity of the arterial disease. In all comparisons, the groups treated are likely to be dissimilar and mismatched. The angiosome concept is postulated to be valid especially in diabetics, whose ischemic lesions tend to heal worse than those of non-diabetics.
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                Author and article information

                Journal
                OTA Int
                OTA Int
                oi9
                OTA International
                Wolters Kluwer Health
                2574-2167
                September 2018
                13 September 2020
                : 1
                : 2
                : e007
                Affiliations
                MetroHealth Medical Center, Affiliated with Case Western Reserve University, Cleveland, OH
                Author notes
                []Corresponding author. Address: Department of Orthopaedic Surgery, 2500 MetroHealth Drive, Cleveland, OH 44109. Tel: +216-778-7361; fax: +216-778-4690, E-mail address: hvallier@ 123456metrohealth.org (H.A. Vallier).

                All devices used in this study are FDA approved.

                The patient provided informed consent for the content of this paper.

                Conflicts of interest and sources of funding: The authors disclose no conflicts related to the study. The project was not externally funded.

                Article
                OTAI-D-17-00003 007
                10.1097/OI9.0000000000000007
                7953521
                33937645
                dcf75010-ecb9-44b1-9b7f-ece6ee4d3234
                Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.

                This is an open access article distributed under the Creative Commons Attribution-NoDerivatives License 4.0, which allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author. http://creativecommons.org/licenses/by-nd/4.0

                History
                : 09 November 2017
                : 19 May 2018
                : 12 June 2018
                Categories
                Case Report
                Custom metadata
                TRUE

                degloving,heel pad,limb salvage
                degloving, heel pad, limb salvage

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