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Miller JD, Lew EJ, Giovinco NA, Ochoa C, Rowe VL, Clavijo LC, Weaver F, Armstrong DG. How to Create a Hot Foot Line to Prevent Diabetes-Related Amputations: Instant Triage for Emergency Department and Inpatient Consultations. J Am Podiatr Med Assoc 2019; 109:174-179. [PMID: 31135194 DOI: 10.7547/17-204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Emergency department visits for lower extremity complications of diabetes are extremely common throughout the world. Surprisingly, recent data suggest that such visits generate an 81.2% hospital admission rate with an annual bill of at least $1.2 billion in the United States alone. The likelihood of amputation and other subsequent adverse outcomes is strongly associated with three factors: 1) wound severity (degree of tissue loss), 2) ischemia, and 3) foot infection. Using these factors, this article outlines the basic principles needed to create an evidence-based, rapid foot assessment for diabetic foot ulcers presenting to the emergency department, and suggests the establishment of a "hot foot line" for an organized, expeditious response from limb salvage team members. We present a nearly immediate assessment and referral system for patients with atraumatic tissue loss below the knee that has the potential to vastly expedite lower extremity triage in the emergency room setting through greater collaboration and organization.
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Affiliation(s)
- John D. Miller
- Southwestern Academic Limb Salvage Alliance (SALSA) Department of Surgery, Section of Vascular Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - Eric J. Lew
- Center for the High-Risk Lower Extremity, University of New Mexico College of Medicine, Albuquerque, NM
| | - Nicholas A. Giovinco
- Southwestern Academic Limb Salvage Alliance (SALSA) Department of Surgery, Section of Vascular Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - Christian Ochoa
- Southwestern Academic Limb Salvage Alliance (SALSA) Department of Surgery, Section of Vascular Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - Vincent L. Rowe
- Southwestern Academic Limb Salvage Alliance (SALSA) Department of Surgery, Section of Vascular Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - Leonardo C. Clavijo
- Southwestern Academic Limb Salvage Alliance (SALSA) Department of Surgery, Section of Vascular Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - Fred Weaver
- Southwestern Academic Limb Salvage Alliance (SALSA) Department of Surgery, Section of Vascular Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA) Department of Surgery, Section of Vascular Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA
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Bergeron MC, Ferland J, Malay DS, Lewis SE, Burkmar JA, Giovinco NA. Use of Metatarsophalangeal Joint Dorsal Subluxation in the Diagnosis of Plantar Plate Rupture. J Foot Ankle Surg 2019; 58:27-33. [PMID: 30448184 DOI: 10.1053/j.jfas.2018.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Indexed: 02/03/2023]
Abstract
A dorsal drawer exam, also known as a modified Lachman's test, is a common clinical test for plantar plate insufficiency. This disorder presents as a dislocated metatarsophalangeal joint. The aim of this cadaveric case study was to quantify the degree of the plantar plate pathology necessary to correlate with a positive Lachman's test. The second metatarsophalangeal joint was tested on 18 cadaveric lower extremities. Limbs with previous digital surgery or with an obvious digital deformity were excluded from this study. A plantar linear incision over the plantar aspect of the second metatarsophalangeal joint was performed, and the flexor tendons were retracted to expose the plantar plate. After evaluating the plantar plate's integrity and measuring its width, a Lachman's test was then performed under fluoroscopy. The plantar plate was subsequently severed in a serial manner in 2-mm increments. A modified Lachman's test was performed with the different levels of rupture to assess the degree of dislocation. We found that a tear as small as 2 mm, detected in 12 (66.7%) of 18 specimens, produced gross instability in the second metatarsophalangeal joint. We also showed that a simulated plantar plate tear ≥4 mm but <6 mm resulted in joint subluxation (positive modified Lachman's test) with a sensitivity of 90.3%. This study reinforces the finding that a modified Lachman's test is a clinical exam that demonstrates high sensitivity in diagnosing plantar plate insufficiency.
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Affiliation(s)
- Marie-Christine Bergeron
- Faculty, Department of Surgery, New York College of Podiatric Medicine, New York, NY; Faculty, The Podiatry Institute, Decatur, GA.
| | - Julie Ferland
- Faculty, The Podiatry Institute, Decatur, GA; Staff Surgeon, Kosciusko Community Hospital, Warsaw, IN
| | - D Scot Malay
- Faculty, The Podiatry Institute, Decatur, GA; Staff Surgeon and Director of Podiatric Research, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Sara E Lewis
- Faculty, The Podiatry Institute, Decatur, GA; Staff Surgeon and Director of Podiatric Research, Penn Presbyterian Medical Center, Philadelphia, PA; Fellow, The Southeast Permanente Medical Group, Atlanta, GA
| | | | - Nicholas A Giovinco
- Faculty, The Podiatry Institute, Decatur, GA; Resident, Dekalb Medical Center Podiatry Residency, Decatur, GA; Staff Surgeon, Piedmont Clinics Physician, Newnan, GA
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Rankin TM, Wormer BA, Miller JD, Giovinco NA, Al Kassis S, Armstrong DG. Image once, print thrice? Three-dimensional printing of replacement parts. Br J Radiol 2018; 91:20170374. [PMID: 29091482 DOI: 10.1259/bjr.20170374] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE The last 20 years has seen an exponential increase in 3D printing as it pertains to the medical industry and more specifically surgery. Previous reviews in this domain have chosen to focus on applications within a specific field. To our knowledge, none have evaluated the broad applications of patient-specific or digital imaging and communications in medicine (DICOM) derived applications of this technology. METHODS We searched PUBMED and CINAHL from April 2012 to April 2017. RESULTS 261 studies fulfilled the inclusion criteria. Proportions of articles reviewed: DICOM (5%), CT (38%), MRI (20%), Ultrasonography (28%), and Bio-printing (9%). CONCLUSION There is level IV evidence to support the use of 3D printing for education, pre-operative planning, simulation and implantation. In order to make this technology widely applicable, it will require automation of DICOM to standard tessellation language to implant. Advances in knowledge: Recent lapses in intellectual property and greater familiarity with rapid prototyping in medicine has set the stage for the next generation of custom implants, simulators and autografts. Radiologists may be able to help establish reimbursable procedural terminology.
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Affiliation(s)
- Timothy M Rankin
- 1 Department of Plastic and Reconstructive Surgery, Vanderbilt University , Nashville, TN , USA
| | - Blair A Wormer
- 1 Department of Plastic and Reconstructive Surgery, Vanderbilt University , Nashville, TN , USA
| | - John D Miller
- 2 Baltimore VA Health System, Rubin Institute for Orthopedics , Baltimore, MD , USA
| | | | - Salam Al Kassis
- 1 Department of Plastic and Reconstructive Surgery, Vanderbilt University , Nashville, TN , USA
| | - David G Armstrong
- 4 Department of Surgery, Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine of University of Southern California , Los Angeles, CA , USA
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Miller JD, Carter E, Shih J, Giovinco NA, Boulton AJM, Mills JL, Armstrong DG. Erratum. J Fam Pract 2015; 64:452. [PMID: 26485265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- John D Miller
- The Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, AZ, USA
| | - Elizabeth Carter
- The Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, AZ, USA
| | - Jonathan Shih
- The Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, AZ, USA
| | - Nicholas A Giovinco
- The Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, AZ, USA
| | - Andrew J M Boulton
- Center for Endocrinology and Diabetes, Faculty of Health Sciences, University of Manchester, United Kingdom
| | - Joseph L Mills
- The Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, AZ, USA
| | - David G Armstrong
- The Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, AZ, USA.
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Miller JD, Carter E, Hatch DC, Zhubrak M, Giovinco NA, Armstrong DG. Use of collagenase ointment in conjunction with negative pressure wound therapy in the care of diabetic wounds: a case series of six patients. Diabet Foot Ankle 2015; 6:24999. [PMID: 25630362 PMCID: PMC4309834 DOI: 10.3402/dfa.v6.24999] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 10/11/2014] [Accepted: 10/13/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Diabetic wounds with additional comorbidities are costly, time intensive, and difficult to heal. Often, multiple modalities may be necessary to achieve wound resolution, relying on the synergistic advantage of each therapy to affect wound healing. The selectivity of Clostridium collagenase is physiologically effective at degrading non-viable collagen fibers while preserving living collagen tissue. Additionally, negative pressure wound therapy (NPWT) has long been used to aid wound healing while concurrently depreciating biological wound burden time. METHODS Six patients were selected from those appearing to our university based limb salvage service. Inclusion criteria included patients with a recurrent mixed fibrotic and granular wound base, in which NPWT was indicated, without exclusion criteria. Patients enrolled were administered clostridial collagenase ointment at each regularly scheduled NPWT dressing change. Patients were followed until healing, with visual representations of wound progression and time to full healing recorded. RESULTS Tandem application of these therapies appeared to expedite wound healing by clearing degenerative fibrous tissue and expediting wound granulation without additional complication. Unfortunately, not all patients were able to reach full healing; with two patients experiencing ulcer recurrence, likely a result of their significant comorbid nature. CONCLUSION In our experience, we have noticed a specific subgroup of patients who benefit greatly when collagenase enzymatic debridement therapy is combined with NPWT. It is our belief that this combination therapy combines the molecular clearing of non-viable collagen with the wound granulation necessary to advance complex wounds to the next step in healing despite the current paucity in literature discussing this specific pairing.
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Affiliation(s)
- John D Miller
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Elizabeth Carter
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - David C Hatch
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Michelle Zhubrak
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Nicholas A Giovinco
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - David G Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA;
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Miller JD, Rankin TM, Hua NT, Ontiveros T, Giovinco NA, Mills JL, Armstrong DG. Reduction of pain via platelet-rich plasma in split-thickness skin graft donor sites: a series of matched pairs. Diabet Foot Ankle 2015; 6:24972. [PMID: 25623477 PMCID: PMC4306752 DOI: 10.3402/dfa.v6.24972] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 11/01/2014] [Accepted: 11/09/2014] [Indexed: 11/27/2022]
Abstract
In the past decade, autologous platelet-rich plasma (PRP) therapy has seen increasingly widespread integration into medical specialties. PRP application is known to accelerate wound epithelialization rates, and may also reduce postoperative wound site pain. Recently, we observed an increase in patient satisfaction following PRP gel (Angel, Cytomedix, Rockville, MD) application to split-thickness skin graft (STSG) donor sites. We assessed all patients known to our university-based hospital service who underwent multiple STSGs up to the year 2014, with at least one treated with topical PRP. Based on these criteria, five patients aged 48.4±17.6 (80% male) were identified who could serve as their own control, with mean time of 4.4±5.1 years between operations. In both therapies, initial dressing changes occurred on postoperative day (POD) 7, with donor site pain measured by Likert visual pain scale. Paired t-tests compared the size and thickness of harvested skin graft and patient pain level, and STSG thickness and surface area were comparable between control and PRP interventions (p>0.05 for all). Donor site pain was reduced from an average of 7.2 (±2.6) to 3 (±3.7), an average reduction in pain of 4.2 (standard error 1.1, p=0.0098) following PRP use. Based on these results, the authors suggest PRP as a beneficial adjunct for reducing donor site pain following STSG harvest.
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Affiliation(s)
- John D Miller
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Timothy M Rankin
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Natalie T Hua
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Tina Ontiveros
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Nicholas A Giovinco
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Joseph L Mills
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - David G Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA;
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Miller JD, Carter E, Shih J, Giovinco NA, Boulton AJM, Mills JL, Armstrong DG. How to do a 3-minute diabetic foot exam. J Fam Pract 2014; 63:646-656. [PMID: 25362495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This brief exam will help you to quickly detect major risks and prompt you to refer patients to appropriate specialists.
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Affiliation(s)
- John D Miller
- The Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, AZ, USA.
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Giovinco NA, Sutton SM, Miller JD, Rankin TM, Gonzalez GW, Najafi B, Armstrong DG. A passing glance? Differences in eye tracking and gaze patterns between trainees and experts reading plain film bunion radiographs. J Foot Ankle Surg 2014; 54:382-91. [PMID: 25441848 DOI: 10.1053/j.jfas.2014.08.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Indexed: 02/03/2023]
Abstract
Eye tracking and gaze pattern studies have been used to evaluate human behavior for decades. This is because of its ability to reveal conscious and subconscious behaviors when subjects are tasked with observation, decision making, and surgical performance. Many have popularized the use of this technology for radiographic assessment while evaluating radiologist behaviors, but little has been described for surgeon behavior patterns when evaluating preoperative deformities by radiograph. Because the radiographic assessment strongly influences surgical selection, the present study was designed to evaluate the differences between groups of novice and experienced surgeons' gaze patterns when tasked to describe hallux valgus deformities. The subjects were asked to rate the deformity as "none," "mild," "moderate," or "severe." Using an externally mounted eye tracking system, our study assessed saccades, fixations, overall time spent per radiograph, and the subjects' chosen bunion rating. Both the novice and advanced groups of foot and ankle surgeons were tasked to evaluate 25 total anteroposterior radiographs from patients who presented with a primary complaint of bunion pain. These patients were chosen at random, such that all participating surgeons had no previous patient familiarization. Statistically significant differences were observed with regard to the activity and rating of the moderate bunion films. The experience of surgeons does appear to modify gaze behavior with respect to time and attention, such that less overall time spent per image is needed by the advanced group, with improved efficiency. Future academic curriculum and training techniques could be developed to reflect these potential technical differences in search behavior, diagnostic technique, and surgical selection strategy.
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Affiliation(s)
- Nicholas A Giovinco
- Director of Education, Southern Arizona Limb Salvage Alliance, University of Arizona, Tucson, AZ; Member, Interdisciplinary Consortium of Advanced Motion Performance (iCAMP), University of Arizona, Tucson, AZ; Member, Board of Directors, Freeside Atlanta Technology Space, Atlanta, GA; and Faculty, The Podiatry Institute, Decatur, GA.
| | | | - John D Miller
- Research Associate, Southern Arizona Limb Salvage Alliance, University of Arizona, Tucson, AZ
| | - Timothy M Rankin
- Resident, Southern Arizona Limb Salvage Alliance, University of Arizona, Tucson, AZ
| | | | - Bijan Najafi
- Director of Education, Southern Arizona Limb Salvage Alliance, University of Arizona, Tucson, AZ; Member, Interdisciplinary Consortium of Advanced Motion Performance (iCAMP), University of Arizona, Tucson, AZ; Member, Board of Directors, Freeside Atlanta Technology Space, Atlanta, GA; and Faculty, The Podiatry Institute, Decatur, GA
| | - David G Armstrong
- Member, Interdisciplinary Consortium of Advanced Motion Performance (iCAMP), University of Arizona, Tucson, AZ; and Director of Education, Southern Arizona Limb Salvage Alliance, University of Arizona, Tucson, AZ
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Abstract
Although the use of augmented reality has been well described over the past several years, available devices suffer from high cost, an uncomfortable form factor, suboptimal battery life, and lack an app-based developer ecosystem. This article describes the potential use of a novel, consumer-based, wearable device to assist surgeons in real time during limb preservation surgery and clinical consultation. Using routine intraoperative, clinical, and educational case examples, we describe the use of a wearable augmented reality device (Google Glass; Google, Mountain View, CA). The device facilitated hands-free, rapid communication, documentation, and consultation. An eyeglass-mounted screen form factor has the potential to improve communication, safety, and efficiency of intraoperative and clinical care. We believe this represents a natural progression toward union of medical devices with consumer technology.
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Affiliation(s)
- David G Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, AZ, USA
| | | | - Nicholas A Giovinco
- Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, AZ, USA
| | - Joseph L Mills
- Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, AZ, USA
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Miller JD, Salloum M, Button A, Giovinco NA, Armstrong DG. How Can I Maintain My Patient With Diabetes and History of Foot Ulcer in Remission? INT J LOW EXTR WOUND 2014; 13:371-7. [DOI: 10.1177/1534734614545874] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Patients with diabetes and previous history of ulceration occupy the highest category of risk for reulceration and amputation. Annual recurrence rates of diabetic ulcerations have been reported as high as 34%, 61%, and 70% at 1, 3, and 5 years, respectively, with studies reporting 20% to 58% recurrence rate within 1 year. As the ever growing epidemic of diabetes expands globally, this sequelae of diabetic complication will continue to require increasing resources from the healthcare community to effectively manage. Recent data suggest that removal of preventative podiatric care from statewide reimbursement systems lead to significant and sustained increases in hospital admission (37%), charges (38%), length of stay (23%), and severe aggregate outcomes including amputation, sepsis and death (49%). The addition of comorbidities such as peripheral artery disease, poor nutrition, and non-adherence to preventive therapies not only increase a patient’s likelihood for ulcer recurrence, but also cost of care and certainty of hospital admission. Currently, numerous efforts, guidelines, and industry generated products exist to prolong remission from ulceration; however, the clinical science for treating this patient population calls for much more effort. Despite this, data continue to suggest to demonstrate that appropriate follow-up care, shoe and insole modification, and patient education play a central role in reducing reulceration and amputation. Novel modalities for offloading and wearable sensor technologies offer the advantage of round-the-clock, patient specific and active response healthcare. These have the potential to detect, or even prevent, many wounds before they begin.
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Affiliation(s)
- John D. Miller
- Des Moines University College of Podiatric Medicine, Des Moines, IA, USA
| | | | - Alex Button
- Midwestern College of Podiatric Medicine, Glendale, AZ, USA
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Rankin TM, Giovinco NA, Cucher DJ, Watts G, Hurwitz B, Armstrong DG. Three-dimensional printing surgical instruments: are we there yet? J Surg Res 2014; 189:193-7. [PMID: 24721602 PMCID: PMC4460996 DOI: 10.1016/j.jss.2014.02.020] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 01/28/2014] [Accepted: 02/14/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND The applications for rapid prototyping have expanded dramatically over the last 20 y. In recent years, additive manufacturing has been intensely investigated for surgical implants, tissue scaffolds, and organs. There is, however, scant literature to date that has investigated the viability of three-dimensional (3D) printing of surgical instruments. MATERIALS AND METHODS Using a fused deposition modeling printer, an Army/Navy surgical retractor was replicated from polylactic acid (PLA) filament. The retractor was sterilized using standard Food and Drug Administration approved glutaraldehyde protocols, tested for bacteria by polymerase chain reaction, and stressed until fracture to determine if the printed instrument could tolerate force beyond the demands of an operating room (OR). RESULTS Printing required roughly 90 min. The instrument tolerated 13.6 kg of tangential force before failure, both before and after exposure to the sterilant. Freshly extruded PLA from the printer was sterile and produced no polymerase chain reaction product. Each instrument weighed 16 g and required only $0.46 of PLA. CONCLUSIONS Our estimates place the cost per unit of a 3D-printed retractor to be roughly 1/10th the cost of a stainless steel instrument. The PLA Army/Navy retractor is strong enough for the demands of the OR. Freshly extruded PLA in a clean environment, such as an OR, would produce a sterile ready-to-use instrument. Because of the unprecedented accessibility of 3D printing technology world wide and the cost efficiency of these instruments, there are far reaching implications for surgery in some underserved and less developed parts of the world.
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Affiliation(s)
| | - Nicholas A Giovinco
- Department of Surgery, Southern Arizona Limb Salvage Alliance, Tucson, Arizona.
| | - Daniel J Cucher
- Department of Surgery, University of Arizona, Tucson, Arizona
| | - George Watts
- Department of Surgery, University of Arizona Cancer Center, Tucson, Arizona
| | - Bonnie Hurwitz
- Department of Surgery, University of Arizona, Tucson, Arizona; Office of the Senior Vice President of Health Sciences, College of Agriculture and Life Sciences, University of Arizona, Tucson, Arizona
| | - David G Armstrong
- Department of Surgery, Southern Arizona Limb Salvage Alliance, Tucson, Arizona
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Miller JD, Hua NT, Giovinco NA, Armstrong DG, Mills JL. The SALSA spike: A novel technique using Kirschner wires to anchor tenuous midfoot and forefoot amputation flaps. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.wndm.2014.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Miller JD, Zhubrak M, Giovinco NA, Mills JL, Armstrong DG. The Too Few Toes principle: A formula for limb-sparing low-level amputation planning. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.wndm.2014.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Ankle fractures are a common osteologic outcome from trauma. These fracture patterns include a variety of concomitant soft tissue disruptions, including diastasis. Surgical treatment of a syndesmotic injury can be performed in conjunction with open reduction with internal fixation. The present technique guide demonstrates the use of pre-existing hardware, after open reduction with internal fixation from a previous ankle fracture, with an Ilizarov fixation construct to percutaneously reduce a bimalleolar equivalent fracture and diastasis to the syndesmosis.
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Affiliation(s)
- Robert B Weinstein
- Faculty, Podiatry Institute, Decatur, GA; Private Practice, Ankle and Foot Centers of Georgia, Atlanta, GA
| | - G Clay Taylor
- Faculty, Podiatry Institute, Decatur, GA; Private Practice, Ankle and Foot Centers of Georgia, Atlanta, GA
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Giovinco NA, Dunn SP, Dowling L, Smith C, Trowell L, Ruch JA, Armstrong DG. A novel combination of printed 3-dimensional anatomic templates and computer-assisted surgical simulation for virtual preoperative planning in Charcot foot reconstruction. J Foot Ankle Surg 2012; 51:387-93. [PMID: 22366474 DOI: 10.1053/j.jfas.2012.01.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Indexed: 02/03/2023]
Abstract
Charcot foot syndrome (Charcot neuroarthropathy affecting the foot), particularly in its latter stages, may pose a significant technical challenge to the surgeon. Because of the lack of anatomic consistency, preoperative planning with virtual and physical models of the foot could improve the chances of achieving a predictable intraoperative result. In this report, we describe the use of a novel, inexpensive, 3-dimensional template printing technique that can provide, with just a normal printer, multiple "copies" of the foot to be repaired. Although we depict this method as it pertains to repair of the Charcot foot, it could also be used to plan and practice, or revise, 3-dimensional surgical manipulations of other complex foot deformities.
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Armstrong DG, Giovinco NA. Diagnostics, theragnostics, and the personal health server: fundamental milestones in technology with revolutionary changes in diabetic foot and wound care to come. Foot Ankle Spec 2011; 4:54-60. [PMID: 21364176 DOI: 10.1177/1938640010395750] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Over the past generation, significant advances in care have led to reductions in amputation worldwide. However, it may be argued that the most potent advances in healing have been in organization of care. Technologies are now emerging that may allow further enhancements of organization and integration of care while also bringing in much needed bedside, chairside, and in-home diagnostics to identify key points in healing and potential early warning signs for recurrence. This article reviews what are believed to be 6 key areas of change over the next generation. These include portability, durability, automation, intelligence, ubiquity, and afford-ability, all yielding specific advances in wound diagnostics. The authors believe that devices will be organized into personal health servers in cloud-synchronized devices already existing in the home (eg, a scale), the clinic, and on (or in) the patient.
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Affiliation(s)
- David G Armstrong
- Southern Arizona Limb Salvage Alliance, University of Arizona College of Medicine, Tucson, Arizona, USA.
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Giovinco NA, Bui TD, Fisher T, Mills JL, Armstrong DG. Wound chemotherapy by the use of negative pressure wound therapy and infusion. Eplasty 2010; 10:e9. [PMID: 20090841 PMCID: PMC2806786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Although the use of negative pressure wound therapy (NPWT) is broadly efficacious, it may foster some potentially adverse complications. This is particularly true in patients with diabetes who have a wound colonized with aerobic organisms. Traditional antiseptics have been proven useful to combat such bacteria but require removal of some NPWT devices to be effective. METHODS In this article, we describe a method of "wound chemotherapy" by combining NPWT and a continuous infusion of Dakins' 0.5% solution either as a standardized technique in one device (ITI Sved) or as a modification of standard technique in another (KCI VAC) NPWT device. The twin goals of both techniques are to effectively reduce bacterial burden and to promote progressive wound healing. RESULTS We present several representative case examples of our provisional experience with continuous streaming therapy through 2 foam-based negative pressure devices. DISCUSSION Wound chemotherapy was successfully applied to patients with diabetes, without adverse reactions, complications, or recolonization during the course of treatment. We believe this to be a promising method to derive the benefits of NPWT without the frequent adverse sequela of wound colonization.
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Affiliation(s)
- Nicholas A. Giovinco
- Southern Arizona Limb Salvage Alliance (S.A.L.S.A.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Trung D. Bui
- Southern Arizona Limb Salvage Alliance (S.A.L.S.A.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Timothy Fisher
- Southern Arizona Limb Salvage Alliance (S.A.L.S.A.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Joseph L. Mills
- Southern Arizona Limb Salvage Alliance (S.A.L.S.A.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - David G. Armstrong
- Southern Arizona Limb Salvage Alliance (S.A.L.S.A.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724,Correspondence:
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