Biomedical subjects
Publications and source records attributed to Thomas Zgonis.
Healing of a fracture is a continuous process that involves various types of histologic regeneration at different sites. This article describes current approaches to managing delayed union and non-union of fracture.
Posttraumatic arthrosis is a commonly encountered clinical problem, but the pathoetiology of its development is not yet clarified. Many contributing mechanical biologic factors interplay with the traumatic event that necessarily precedes the posttraumatic syndrome. New biologic concepts involving the ability of the cartilage to repair and how such healing can be promoted are being realized in new modalities of treatment. The traumatic event as such and the resulting pathomechanical consequences require new ways of evaluation.
The surgical repair of acute diabetic neuropathic osteoarthropathy of the midfoot remains a challenge with little guidance available in the medical literature. The authors present a review of the diabetic Charcot neuropathic osteoarthropathy process and proposed surgical intervention techniques with a special emphasis on the available data regarding the use of external fixation. A detailed, step-by-step, guide through the foot-specific Taylor spatial external fixation system is provided. Finally, the authors' preferred technique for these difficult limb salvage cases is presented in detail.
Distal tibial physeal injuries are common in children, accounting for 10% to 40% of all injuries to skeletally immature patients. This article describes the classification, treatment, and complications of distal tibial fractures, fractures of the talus and calcaneus, midfoot and tarsometatarsal injuries, metatarsal fractures, and fractures of the phalanges in children.
Treatment of severely comminuted calcaneal fractures with soft tissue compromise is still a controversial issue among surgeons. Complications of open reduction internal fixation have been well reported in the literature with a fairly high incidence of posttraumatic osteoarthritis of the subtalar joint, symptomatic hindfoot stiffness (especially when fixed in varus), wound dehiscence, and potential for the development of osteomyelitis caused by the extensive soft tissue trauma inherent with these injuries. For these reasons, closed treatment techniques using minimally invasive reduction procedures with application of ring-type fine-wire external fixation have recently gained popularity.
Fractures of the distal tibial articular surface are complex injuries that can destroy the ankle joint. This article discusses the mechanism of injury, classifications and historical means of treating these fractures, the authors' approach to treating low- and high-energy pilon fractures, prognosis, and complications.
Anatomic reduction and restoration of the acute or chronic fracture-dislocation of the tarso-metatarsal joint is essential and needs to be addressed early in the patient's treatment with internal or external fixation. Long-term results following this injury can be associated with chronic instability, posttraumatic arthrosis, and poor functional outcomes. In this article, the authors review the current treatments of internal fixation and introduce new surgical techniques for addressing the acute or chronic tarso-metatarsal injuries with the application of circular multiplane external fixation devices.
Various surgical options beyond implant arthroplasty are available to treat posttraumatic ankle arthrosis. Conservative options are usually employed in combination and include the use of nonsteroidal anti-inflammatories, bracing, and orthoses, as well as injections of intra-articular corticosteroid and hyaluronic acid. If these conservative treatments fail, surgical intervention can be entertained. Alternatives to total ankle implant arthroplasty include (1) arthroscopic debridement, (2) arthrodiastasis, (3) peri-articular resurfacing using allograft or cartilage transplantation, and (4) peri-articular osteotomies to correct angular, rotational, or translational malalignment. However, ankle arthrodesis is the standard technique for end-stage ankle arthrosis. This article reviews the literature and presents an in-depth surgical technique for each procedure. The article also describes how to prevent and address the most common complications.
The minimally invasive "pinless" external fixation device provides soft-tissue immobilization and osseous stabilization while limiting the potential for contiguous spread of bacterial infection.
Plantar fibromatosis is defined as a benign fibrous disorder involving the plantar aponeurosis. Although its incidence is well described on the hands, it is less commonly seen on the feet, and its etiology is unknown. A differential diagnosis for the heel pain along the medial arch could be a benign thickening of the plantar fascia associated with plantar fibromatosis. Its high recurrence after surgical excision and problematic scarring and wound presents a significant challenge to the reconstructive foot and ankle surgeon. This article reviews the history, clinical presentation, pathologic findings, and surgical approaches to the treatment of plantar fibromatosis.
Peroneal tendon pathology is a common entity but is infrequently reported in the literature. The lesion may be due to partial tears, complete ruptures, subluxation, tenosynovitis, a fractured os peroneum, or damage to the peroneal retinacula. Chronic lateral ankle instability and excessive subtalar and ankle varus rotation may cause damage to the peroneal tendons and their associated structures. This article reviews the pathophysiology, diagnostic imaging, and current surgical techniques for the repair of peroneal tendons.
This article establishes a standard approach for the evaluation of patients with heel pain. With this approach, it should become easier for the physician to distinguish between neurogenic and inflammatory heel pain and to devise a more direct plan for definitive treatment.
Heel pain is one of the most common presenting complaints to the foot and ankle specialist. There are many causes for subcalcaneal heel pain, including biomechanical, traumatic, those related to several types of arthritides and tumors, and anatomic causes. This article describes pathologic conditions of the heel, concentrating on tumors and arthritides.
Diabetic forefoot and toe wounds are difficult to heal in a timely fashion. Despite proper continued offloading and protective shoe-gear techniques, these wounds are frequently complicated by recurrent breakdown and adjacent toe deformities. When properly performed, pedicle flaps from the fibular border of the great toe represent viable and cost-effective means of providing early and durable soft tissue coverage and osseous reconstruction of diabetic forefoot and lesser toe wounds. Two modifications of the traditional great toe fibular flap are described: the great toe fibular adipofascio-cutaneous flap and the great toe fibular osteo-cutaneous flap, useful for providing forefoot and toe reconstruction, respectively. Understanding the surgical aspects of the treatment provides insights into overall care for these challenging wounds. Long-term outcomes studies involving these toe reconstruction techniques are needed to fully evaluate their success in preventing recurrent toe deformity and forefoot ulceration.
The use of external fixation in foot and ankle arthrodesis can be beneficial. Its advantages, disadvantages, and indications were reviewed in this article. External fixation offers the surgeon an opportunity to treat complex foot and ankle deformities, trauma, chronic infections, pseudoarthroses, soft tissue contractures, and limb length discrepancies in ways that were unavailable before its advent. The Ilizarov technique requires considerable experience and patient compliance for the best postoperative outcome. An understanding of musculoskeletal physiology and the biomechanics of bone and soft tissue are essential for the competent application of external fixators in general and Ilizarov frames in particular. The surgeon should be aware of all the surgical options before the application of an external complex apparatus.
Fracture-dislocation of the tarsometatarsal joint is a major injury and can be associated with a chronic disability. The incidence is low, but the long-term results can be a devastating problem to the patient. This article reviews the anatomy, mechanism of injury, classifications, diagnostic procedures, treatment, and long-term results of a fracture-dislocation to the tarsometatarsal joint complex.
Distally-based sural artery flaps are used to cover soft tissue defects of the lower leg, ankle, and heel. These flaps are vascularized by septocutaneous perforators of the peroneal artery that anastomose with the perineural and perivenous arterial networks of the sural nerve and the lesser saphenous vein, respectively. A retrospective study of seven patients with a distally-based neurofasciocutaneous sural artery flap for ankle or heel defects that had failed conservative treatment was conducted from 1999 to 2003. The presence of a patent peroneal artery was a requirement for this operation. Among the seven patients, the only flap failure occurred in a renal transplant patient who was immunocompromised. The other six patients healed uneventfully and resumed full weight-bearing status. The mean time to return to shoe was 90.2 days. The average healing time of all seven patients was 3.3 months. Based on these results and other documented successes, the procedure can be considered a viable treatment alternative.
Diabetes mellitus can be a devastating lifelong disease if not treated appropriately. The physician and the patient should be aware of both extremes involved with DM: hyperglycemia and hypoglycemia. Patient education and preventive care are perhaps more important in this disease than many others. A multidisciplinary approach involving the patient, physician, and diabetic educator is best to assure a better quality of life. Enormous advances in the treatment of diabetes have occurred over the past decade and even greater ones can be expected in the future. New drugs, insulin delivery devices, and noninvasive glucose monitoring machines have the potential to normalize blood sugar levels and return diabetics to a near normal lifespan without complications.