Đang chuẩn bị liên kết để tải về tài liệu:
The Foot in Diabetes - part 9

Cắt bỏ đầu tiên Metatarsophalangeal phần Có những trường hợp trong đó một vết loét thâm nhập đã bị phá hủy ® rst metatarsophalangeal doanh, để lại ngón chân cái khả thi. Trong trường hợp này | 296 The Foot in Diabetes Excision of First Metatarsophalangeal Joint There are instances in which a penetrating ulcer has destroyed the first metatarsophalangeal joint leaving the great toe viable. In this instance in lieu of a first ray amputation the joint alone can be removed through a medial longitudinal incision. Of course all relatively avascular tissues including the sesamoid complex remaining articular cartilage joint capsule and flexor tendons as well as infected cancellous bone should be removed Figure 19.8 . If the wound is sufficiently clean at the conclusion of the procedure it can be closed loosely over the Kritter flow-through irrigation system as described above. The cosmetic result is much better than following great toe amputation although the stabilizing windlass mechanism is lost with the excision of the flexor hallucis brevis complex. Active dorsiflexion of the great toe is retained by preservation of the extensor hallucis longus tendon Figure 19.9 . Transmetatarsal Amputation Method This should be considered whenever most or all of the first metatarsal bone must be removed or two or more medial rays or more than one central ray must be excised to control infection. For maximum function it is important to save all metatarsal shaft length that can be covered with good plantar skin distally Figure 19.10A B . Residual dorsal defects can be easily closed with split skin grafts. With avoidance of shear forces and with properly fitted footwear these dorsal grafts rarely ulcerate. To assist in preserving forefoot length and in assuring distal coverage of the metatarsal shafts with a durable soft tissue envelope the transverse plantar and dorsal incisions are made at the base of the toes. The metatarsal shafts should be bevelled on the plantar surface to reduce distal plantar peak pressures during roll-over. In addition if passive ankle dorsiflexion is absent with the knee extended a concomitant percutaneous fractional lengthening of the Achilles .