Kutler repair for amputated fingertip

485

Kutler repair for amputated fingertip J E Crockett MBE FRCS Midland, Western Australia I must congratulate Mr M Gaber (Annals, July I979, vol 6i, p 298) on his clear delineation of the operative details of the Kutler repair for the amputated fingertip. I have used this method for many years now and would corroborate the excellent results obtained. The main advantages are a well-padded bone end with normal sensation and a minimum of hypersensitivity. Some patients have had minor problems with reorientation (as

with a neurovascular island transfer and the Moberg slide). I use the Kutler method as the preferred method of closure for digital amputations at all levels. In the face of infection or possible infection it can be used as a delayed primary or secondary method of closure. There is considerable flexibility with regard to symmetry of the flaps which can be an advantage. Even with asymmetry the cosmetic result is good.

Management of the diabetic foot J H Newman FRCS Consultant Orthopaedic Surgeon, Bristol Royal Infirmary

I was pleased to read Mr J A Dormandy's article (Annals, July 1979, vol. 6i, p 305) on the 'Management of the diabetic foot' not only because it draws attention to an important but unglamorous area of medicine but also because he stresses the importance of team work. Unfortunately, relatively little attention was given to the management of local foot complications and osteomyelitis. He mentions the occasional finding of air in tissue planes as an alarm signal of gas gangrene. Gas gangrene is usually thought of as a rare, life-threatening, clostridial infection which generally requires urgent radical amputation. However, in diabetes subcutaneous gas in association with infected feet is not uncommon, being seen by Bessman and Wagner' in I77o of diabetics admitted with orthopaedic vascular problems. These authors also found that 48 of their 49 patients in fact had nonclostridial gas-forming infections which were usually due to mixed Gram-negative organisms. Most of the patients responded to treatment with cephalosporins or kanamycin in addition to relatively conservative surgery. Only 7 patients required through-knee or aboveknee amputations. It is, therefore, important to bear in mind the possibility of non-clostridial gas-forming infection since a more distal

amputation can be performed than would be the case with a clostridial infection. No mention is made by Mr Dor-mandy of the development of Charcot joints in diabetic feet. The incidence of this complication is variably reported as o.i % and 77o2 and has a twofold significance. Firstly, pain may be complained of in the initial stages and, secondly, rapid changes in the shape of the foot may occur. Extra care is then needed to prevent ulceration over a bony prominence, for once an ulcer is present surgery becomes necessary to remove the underlying bony lump before the ulcer will heal3. Finally, no reference is made to the use of controlled environment treatment4, which probably helps to control the oedema involved with foot infection and is also beneficial in healing amputation wounds.

References Bessman, A N, and Wagner, F W (3975) Journal of the American Medical Association, 233, 958. 2 Bruckner, F E, and Howell, A (1972), Seminars in Arthritis and Rheumatism, 2, 47. 3 Newman, J H, and Wagner, F W (I978) Journal of Bone and Joint Surgery, 6oB, 142. 4 Redhead, R G, and Snowdon, C (1978) Prosthetics and Orthotics International, 2, 148. I

Management of the diabetic foot.

Kutler repair for amputated fingertip 485 Kutler repair for amputated fingertip J E Crockett MBE FRCS Midland, Western Australia I must congratulate...
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