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Background: After partial bone resection for osteomyelitis there is a high rate of osteomyelitis occurrence in the remaining bone due to adherent bacterial biofilm, dysvascular infected spongiosum bone, and absence of a surgical technique that can prevent osteomyelitis developing in the remaining bone.
Methods: Presented is a surgical procedure using a dicalcium phosphate bone void filler putty with antibiotics placed into the remaining bone to prevent the development of osteomyelitis, therefore preventing amputation.
Results: This procedure has an osteomyelitis eradication rate of 94.8% and also decreases the rate of lower-extremity amputations.
Conclusions: This procedure provides a single stage surgical technique for infected open bone defects decreasing the previously reported high osteomyelitis reoccurrence rate of 57.1% to 5.2%.
Verrucous Hyperplasia
A Common and Problematic Finding in the High-Risk Diabetic Foot
Although verrucous hyperplasia may be common in high-risk insensitive feet, the literature contains little discussion on this topic. Treatment of verrucous hyperplasia is aimed primarily at reducing the causative forces. In cases that result from edema, external compression has proved to be adequate. If verrucous hyperplasia on the foot results from frictional forces, then shoe modifications with proper fit, accommodative liners, or fillers in the case of amputation are necessary. In recalcitrant cases, excision of the affected tissue with local soft-tissue or graft coverage has been successful. We describe a 56-year-old man with verrucous hyperplasia. (J Am Podiatr Med Assoc 96(4): 348–350, 2006)
Background: Because value-based care is critical to the Affordable Care Act success, we forecasted inpatient costs and the potential impact of podiatric medical care on savings in the diabetic population through improved care quality and decreased resource use during implementation of the health reform initiatives in California.
Methods: We forecasted enrollment of diabetic adults into Medicaid and subsidized health benefit exchange programs using the California Simulation of Insurance Markets (CalSIM) base model. Amputations and admissions per 1,000 diabetic patients and inpatient costs were based on the California Office of Statewide Health Planning and Development 2009-2011 inpatient discharge files. We evaluated cost in three categories: uncomplicated admissions, amputations during admissions, and discharges to a skilled nursing facility. Total costs and projected savings were calculated by applying the metrics and cost to the projected enrollment.
Results: Diabetic patients accounted for 6.6% of those newly eligible for Medicaid or health benefit exchange subsidies, with a 60.8% take-up rate. We project costs to be $24.2 million in the diabetic take-up population from 2014 to 2019. Inpatient costs were 94.3% higher when amputations occurred during the admission and 46.7% higher when discharged to a skilled nursing facility. Meanwhile, 61.0% of costs were attributed to uncomplicated admissions. Podiatric medical services saved 4.1% with a 10% reduction in admissions and amputations and an additional 1% for every 10% improvement in access to podiatric medical care.
Conclusions: When implementing the Affordable Care Act, inclusion of podiatric medical services on multidisciplinary teams and in chronic-care models featuring prevention helps shift care to ambulatory settings to realize the greatest cost savings.
Fibrosarcoma is an uncommon, malignant soft-tissue tumor that is rarely found as a primary neoplasm in the foot. A case report is presented that demonstrates a large, locally invasive fibrosarcoma of the plantar aspect of the foot with initial symptoms consistent with plantar fasciitis. Below-the-knee amputation was performed as curative treatment. (J Am Podiatr Med Assoc 92(9): 507-511, 2002)
Background
Amputation has been most commonly considered the only option to achieve local tumor control for calcaneal malignancies. Advances in oncologic treatment modalities and wide resection have made limb salvage increasingly possible. We retrospectively reviewed nine patients with calcaneal malignancies treated with different surgical options.
Methods
The diagnoses included chondrosarcoma in three patients, Ewing's sarcoma in three, osteosarcoma in two, and small round cell sarcoma in one. Four patients were managed by below-the-knee amputation owing to neurovascular invasion. Five patients were managed by limb salvage procedures. Pedicled osteomyocutaneous fibular grafts were used to reconstruct the defects created after total calcanectomy in limb salvage procedures. Clinical and radiographic evaluations were performed, and functional outcomes were assessed using the Musculoskeletal Tumor Society score.
Results
The patients were followed up for a mean of 42.3 months. Wide resection margins were achieved in all of the patients with limb salvage surgery. At the final follow-up, two patients had died of disease. Lung metastasis was found in two patients who were alive with disease. Five patients had no evidence of disease. No local recurrence occurred in this series. All of the fibular flaps survived, and fibula hypertrophies were observed in three patients. Average Musculoskeletal Tumor Society scores were 74.6% and 83.2% in patients with amputation and limb salvage, respectively.
Conclusions
After wide resection of a calcaneal malignancy, biological reconstruction using pedicled osteocutaneous fibular flaps has proved to be a successful limb salvage procedure, offering a satisfactory oncologic and functional outcome alternative to amputation in selected patients.
Group B and F Beta Streptococcus Necrotizing Infection–Surgical Challenges with a Deep Central Plantar Space Abscess
A Diabetic Limb Salvage Case Report
We present the case of a 66-year-old, type II diabetic male with a deep wound to the plantar-lateral aspect of his right hallux. On examination, the central plantar compartment of his right foot was moderately erythematous and tender on palpation. After obtaining a deep wound culture, treatment was complicated by a progression of a group B and F beta streptococcus, necrotizing infection. The patient underwent a right hallux amputation, followed by a plantar medial incision for drainage of an abscess to the medial and central plantar compartments of the foot. Due to the extent and limb threat of the infection, the patient ultimately underwent a transmetatarsal amputation. Advanced healing modalities were also employed to decrease wound healing times, which allowed the patient to achieve early weightbearing and return to activities of daily living. This study depicts how the astute podiatric surgeon needs to make a decision in a timely manner to surgically debride all nonviable and necrotic tissue in order to minimize further amputation and preserve foot function.
Background: We used a model of lower-extremity ulceration to determine the impact of a podiatric lead limb preservation team on identified relationships among risk factors, predictors of ulceration, amputation, and clinical outcomes of lower-extremity disease in patients with diabetes mellitus.
Methods: A total of 485 patients with diabetes mellitus were randomly selected from the diabetic population and included in this retrospective cohort study. Patients were then stratified into two groups: those who received specialty podiatric medical care and those who did not. Data covering a 5-year period were collected using electronic medical records and chart abstraction to capture detailed treatment characteristics, ulcer status, and surgical outcomes.
Results: Overall, the frequencies of inpatient and outpatient encounters and the durations of hospital stays were significantly greater with increasing wound depth and in the presence of infection. In addition, the overall ulcer incidence was greater in patients with callus (34.3% versus 10.3%, P < .0001) with and without neuropathy (20.4% and 4.1%, P < .0001). Among patients treated in a specialty multidiscipline podiatric medical setting, the proportion of all amputations that were “minor” was significantly increased (33.7% versus 67.3%, P = .0006), and survival was significantly improved (19.5% versus 7.7%, P < .0001).
Conclusions: Early identification of individuals at increased risk for lower-extremity ulceration and subsequent referral for advanced multidiscipline podiatric medical specialty care may decrease rates of ulceration and proximal amputation and improve survival in patients with diabetes mellitus who are at high risk for ulceration and limb loss. (J Am Podiatr Med Assoc 100(4): 235–241, 2010)
A traumatic amputation of a digit as a result of canine mastication and ingestion occurred in a 48-year-old woman with type 2 diabetes and peripheral neuropathy. The injury occurred during sleep and was not felt by the patient. The dangers of sleeping with one’s canine for those with neuropathic wounds are presented, and the literature is reviewed. (J Am Podiatr Med Assoc 101(3): 275–276, 2011)
Verrucous carcinoma of the foot is a rare malignancy, and proper diagnosis can be delayed. Furthermore, misdiagnosis often results in delayed appropriate treatment. Herein, we present an unusual case of verrucous carcinoma of the fifth toe with bone invasion in a 63-year-old woman that was mistaken for a plantar wart for 3 years. The condition was treated by ray amputation. We emphasize the need for appropriate biopsy to achieve an accurate diagnosis.
The Costs of Diabetic Foot
The Economic Case for the Limb Salvage Team
In 2007, the treatment of diabetes and its complications in the United States generated at least $116 billion in direct costs; at least 33% of these costs were linked to the treatment of foot ulcers. Although the team approach to diabetic foot problems is effective in preventing lower-extremity amputations, the costs associated with implementing a diabetic-foot–care team are not well understood. An analysis of these costs provides the basis for this report.
Diabetic foot problems impose a major economic burden, and costs increase disproportionately to the severity of the condition. Compared with diabetic patients without foot ulcers, the cost of care for those with foot ulcers is 5.4 times higher in the year after the first ulcer episode and 2.8 times higher in the second year. Costs for treating the highest-grade ulcers are 8 times higher than are those for treating low-grade ulcers. Patients with diabetic foot ulcers require more frequent emergency department visits and are more commonly admitted to the hospital, requiring longer lengths of stay. Implementation of the team approach to manage diabetic foot ulcers in a given region or health-care system has been reported to reduce long-term amputation rates 62% to 82%. Limb salvage efforts may include aggressive therapy such as revascularization procedures and advanced wound-healing modalities. Although these procedures are costly, the team approach gradually leads to improved screening and prevention programs and earlier interventions and, thus, seems to reduce long-term costs.
To date, aggressive limb preservation management for patients with diabetic foot ulcers has not usually been paired with adequate reimbursement. It is essential to direct efforts in patient-caregiver education to allow early recognition and management of all diabetic foot problems and to build integrated pathways of care that facilitate timely access to limb salvage procedures. Increasing evidence suggests that the costs of implementing diabetic foot teams can be offset in the long term by improved access to care and reductions in foot complications and amputation rates. (J Am Podiatr Med Assoc 100(5): 335–341, 2010)
