Skin grafts are a critical part of care for patients suffering from acute wounds, chronic wounds or burns. Currently, a split thickness skin graft is the gold standard for coverage when treating these conditions. However, donor site morbidity or a lack of donor skin due to the size of the wounds needing covered create situations where split thickness skin grafts (or allografts and xenografts) may not be feasible.

At the Orthopedic Foot & Ankle Center, I had the opportunity to be the first in Ohio to use a “Minced” skin autograft for the coverage of chronic wounds. This exciting technique has several advantages over a split thickness skin graft in certain situations. Split thickness skin grafts are usually expanded no more than six times with a maximum of nine times. With a minced skin technique, we’re able to expand the skin autograft up to 100 times, enabling us to effectively to cover much larger wound areas with less donor skin.

THE FOLLOWING PHOTOGRAPHS GIVE YOU A GLIMPSE INTO THE MINCED SKIN AUTOGRAFT TECHNIQUE.

A single-use disposable kit with dermatome and mincer.

The wound bed is prepared in the typical fashion to receive the graft.

The graft is taken with the non-powered dermatome.

The donor site after the graft is taken.

The autograft skin placed on the back table.

The autograft skin is then minced into pieces 0.8mm X 0.8mm.

The minced skin ready to be grafted.

The graft is then inserted into the wound and covered with a non-adherent dressing.

Using this new technique, we’re now able to cover acute and chronic wounds as well as burns while using minimal donor tissue.  We’ll be following this patient and carefully watching his progress. I encourage you to check back often to see the benefits of this technique in treating chronic wounds.

I’ve always wanted to be on the forefront of medical technology and perform the latest procedures – that’s what inspired me to be a surgeon. At OFAC, that’s exactly what I’m able to do every day. I’m glad I can help more patients with the minced skin autograft technique, and I look forward to even more advancements.

Will DeCarbo, DPM, AACFAS – Fellowship Trained Foot & Ankle Surgeon

The OFAC team has three recent publications in scholarly, peer-review medical journals. I’ve posted the title, reference and abstract of each below. In addition to our many lectures at local, regional, national and international medical meetings, our focus on scholarly research and publication of our results continues to forge us ahead of any other foot and ankle practice in the country.

Complications associated with autogenous bone marrow aspirate harvest from the lower extremity: an observational cohort study

J Foot Ankle Surg. 2009 Nov-Dec;48(6):668-71.

Roukis TS, Hyer CF, Philbin TM, Berlet GC, Lee TH

The purpose of this article is to report the complications associated with autogenous bone marrow aspirate harvested from the lower extremity (ie, tibia and/or calcaneus) for soft tissue and/or osseous healing augmentation. This is a multisite, multisurgeon, observational cohort study involving retrospective review of prospectively collected data of 548 autogenous bone marrow aspirate harvests from the lower extremity of 530 consecutive patients between August 2000 and March 2009. Each patient underwent autogenous bone marrow aspirate harvest from the proximal medial tibial metaphysis, distal medial tibial metaphysis, medial malleolus, lateral calcaneus, medial calcaneus, or a combination of both the proximal tibial metaphysis and lateral calcaneus for application to split-thickness skin graft application sites or for mixture with allogeneic bone graft material for osseous defects or arthrodesis. Patients were kept non-weight bearing based on the index procedure and followed until clinical healing occurred or failure was declared. There were 324 female and 206 male patients with a mean age of 54.7 +/- 14.1 years (range: 14 to 84 years). There were 276 left feet/ankles and 272 right feet/ankles undergoing operative interventions with 18 harvests occurring from the proximal medial tibial metaphysis, 183 from the distal medial tibial metaphysis, 11 from the medial malleolus, 325 from the lateral calcaneus, 3 from the medial calcaneus, and 8 from both the proximal tibial metaphysis and lateral calcaneus. All procedures were deemed successful with no nerve-related injury, infection, wound-healing complications, or iatrogenic fracture occurring. When properly performed, autogenous bone marrow aspirate harvest from various locations about the lower extremity as described here represent safe and minimally invasive techniques useful for soft tissue and osseous healing augmentation. Level of Evidence: 4 (Case Series; Therapeutic Study).

Transosseous fixation of the distal tibiofibular syndesmosis: comparison of an interosseous suture and endobutton to traditional screw fixation in 50 cases.

J Foot Ankle Surg. 2009 Nov-Dec;48(6):620-30.

Cottom JM, Hyer CF, Philbin TM, Berlet GC

In this prospective cohort study, we compared screw fixation to interosseous suture with endobutton repair of the syndesmosis. Outcomes of interest included preoperative and postoperative modified American Orthopedic Foot and Ankle Society (AOFAS) hindfoot and ankle scores, and Short Form-12 health status scores, as well as radiographic measurements and the time to full weight bearing. Mean averages and ranges were calculated for numeric variables, and outcomes for each fixation group were compared statistically with Student t test. The cohort consisted of 50 patients; 25 in the screw fixation group and 25 in the interosseous wire with endobuttons group. The mean patient age was 34.68 (15 to 55) years in the interosseous suture endobutton group and 36.68 (17 to 74) years in the screw group, and the mean follow-up was 10.78 (range 6 to 12) months in the interosseous suture endobutton group, and 8.20 (range 4 to 24) months in the screw group. No statistically significant differences (P < or = .05) were noted in regard to age, follow-up duration, time to postoperative weight bearing, or subjective outcome scores between the fixation groups; although statistically significant improvements were noted in the subjective scores for each fixation group between the preoperative and postoperative measurements. The results of this study indicate that the interosseous suture with endobuttons is a reasonable option for repair of ankle syndesmotic injuries, and may be as effective as traditional internal screw fixation. Level of Clinical Evidence: 2.

Results of lapidus arthrodesis and locking plating with early weight bearing.

Foot Ankle Spec. 2009 Oct;2(5):227-33

Sorensen MD, Hyer CF, Berlet GC

In the endeavor toward Lapidus fusion, the authors have studied a new application of locked plating for the first tarsometatarsal joint. The goal was to assess the time to fusion, time to ambulation, rate of delayed union/nonunion, rate of revision, and need for hardware removal following the use of locked-plate technology in the fusion of the first tarsometatarsal joint. The findings denoted an average of 6.95 weeks to radiographic fusion, an average of 2 weeks to ambulation, a 9.52% rate of asymptomatic mal-union, a 0% rate of delayed union or nonunion, and a 0% rate of revision. The rate of need for hardware removal was 4.76%.

Check back often for more updates on our mission on improving foot and ankle education
and outcomes.

Christopher F. Hyer, DPM, FACFAS

The physicians of OFAC recently had their research published in the peer-reviewed journal, Foot and Ankle Specialist. The article demonstrates a new method to correcting severe bunion deformities while safely allowing patients to ambulate much sooner. The procedure, called a Lapidus arthrodesis or fusion, typically required patients to be in a non-weight-bearing cast for at least 6 -8 weeks. New techniques and evidence documented in this study by OFAC has shown a higher healing rate than other published studies and with patients weight-bearing at 2 weeks after the surgery!

Severe Bunion Deformity

Severe Bunion Corrected with Modified Lapidus Technique

With this new technique, patients often can begin protected weight-bearing in a bunion boot walker around 10-12 days. This is an important advance as early weight bearing minimizes time lost from work, eases burdens onto family and friends and is overall much healthier for our patients. 

'Bunion Boot'- protects foot during early weight-bearing.

Not all bunions need to be fixed, but when they do, the physicians of OFAC have the expertise and experience to insure the solution is the right one for you.  I encourage everyone to ask questions, discuss with your doctor and understand what is being recommended and why.

One of our main tenets in practice is to continually educate and strive to improve. I am proud of the research and education efforts our team provides and am confident it is unmatched anywhere. Our new website allows us to quickly broadcast this new information as it becomes available, often before it is even in print.

Check back often as more and more of our work moves toward publication in leading medical journals.

Christopher F. Hyer, DPM, FACFAS

Co-Director, Foot and Ankle Fellowship, Orthopedic Foot & Ankle Center, Westerville, Ohio

Trauma Section Editor, The Journal of Foot and Ankle Surgery

Editorial Board, Foot and Ankle Specialist

A surprise in surgery!

A woman vacations in Costa Rica 6 weeks ago.  When she returns, she notices an itch on her ankle which won’t get better.

A 6 week old itch thats infected

Since it was almost 6 weeks, we got concerned and decided to surgically debride what we thought was an infection.

Within the incision, we found what we thought was a unique abscess or boil.

We thought it was an unusual boil or abscess

As we explored closer, what a surprise! Here’s a close up.

Thomas H. Lee, M.D.