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Multiple surgical strategies are available for managing the infected diabetic foot at risk for amputation. The authors present their experience with the closed instillation system in the management of 30 such cases in 29 patients over a 5-year period. Data were collected from the hospital records of neuropathic patients presenting with deep-plantar-space infections or presumed acute osteomyelitis. All 29 patients were male; 57% had marginal or poor vascular supply, and 83% were nutritionally compromised or had proteinuria. At the conclusion of the study, 34% of the patients were dead, reflecting the severity of comorbid conditions found in this population. Despite the marginal healing capacity of these patients, the procedure had a 90% success rate, as defined by expeditious return to prior level of functioning and residential living situation without need for re-operation or higher-level amputation.
Leiomyomas are smooth-muscle tumors that may be encountered in the practice of podiatric medicine when they affect the arrector pili muscles or the smooth muscle of a vessel wall. In the present case, the lesion was located on the heel, an area with no hair growth; this further supports the diagnosis, as the most likely origin of the lesion was the smooth muscle of a blood vessel. Vascular leiomyomas show a greater predilection for the lower extremities than their superficial counterparts. Surgical excision is the treatment of choice for these benign lesions, whose prognosis is excellent. When a patient presents with a painful mass in the lower extremity, the diagnosis of leiomyoma should be considered.
The diabetic patient is at high risk for developing long-term medical complications including serious foot problems with potential loss of limb. With today's growing awareness of the importance of curtailing overall health care costs, the importance of comprehensive diabetic patient education programs is academic. It is demonstrated that a multidisciplinary approach to diabetic care management, with foot care assessment encompassing early preventive measures, can serve as a model for other Veterans Affairs Medical Centers to follow. Foot screenings can individualize specific foot problems and provide an understanding of risk factors to prevent complications. Patients with diabetes or peripheral vascular disease and, especially those individuals at risk of foot ulceration, are referred to the appropriate clinic for ongoing management to prevent amputation. Patient education is considered most effective when it is encouraged throughout a diabetic patient's medical care, and it becomes a part of lifestyle habits.
Background
The clinical diagnosis of osteomyelitis is difficult because of neuropathy, vascular disease, and immunodeficiency; also, with no established consensus on the diagnosis of foot osteomyelitis, the reported efficacy of magnetic resonance imaging (MRI) in detecting osteomyelitis and distinguishing it from reactive bone marrow edema is unclear. Herein, we describe a retrospective study on the efficacy of MRI for decision-making accuracy in diagnosing osteomyelitis in diabetic foot ulcers.
Methods
Twelve diabetic patients with infected foot ulcers underwent preoperative MRI between January 1, 2008, and December 31, 2011. The findings were compared with the histopathologic features of 67 parts of 45 resected bones, the cut ends of which were also histopathologically evaluated.
Results
Osteomyelitis was disclosed by MRI and histopathologically confirmed in 30 parts. In contrast, bone marrow edema diagnosed by MRI in 29 parts was confirmed in 23; the other six parts displayed osteomyelitis. Among 17 resected bones, 13 cut ends displayed bone marrow edema and four were normal. All of the wounds healed uneventfully.
Conclusions
In the diagnosis of diabetic foot ulcers, osteomyelitis is often reliably distinguished from reactive bone marrow edema, except in special cases.
Cases must be treated on an individual basis, appreciating the complexity of the syndactyly, considering the patient compliance, and understanding the goals of the surgical correction. Extensive discussion with the patient and parents must occur to clarify the goals of the surgery, the expectations, and possible complications. Careful preoperative planning and incision design is paramount in obtaining satisfactory results. Skin grafting may be required, either full-thickness from a variety of donor sites or split-thickness grafting as in one case study reported. Adjunctively, manipulation and stretching of the web space for 2 to 3 months preoperatively may be helpful to achieve more laxity of the soft tissues. The choice of suture material is of particular concern when dealing with a small child. It is usually wise to use an absorbable suture material for skin closure in a small child to prevent undue emotional stress to the child or even further anesthesia upon suture removal. Vascular compromise caused by soft tissue tension in not an infrequent occurrence. As with any surgery that addresses largely cosmetic deformities, there is no substitute for exact prior planning, meticulous technique, and surgeon experience to optimize results.
A case of progressive congenital hypertrophy of the feet was presented. From a diagnostic standpoint, this case was extremely challenging. Local gigantism was excluded from the diagnosis because the deformity was localized to both feet, with all components showing a concomitant increase in size. Furthermore, there was no evidence of neurofibromatosis or arteriovenous fistula formation. Other conditions leading to lower extremity hypertrophy, ie, Klippel-Trenaunay-Weber syndrome and other diseases associated with angiodystrophy, were excluded because of the absence of varicosities and cutaneous angiomas. There also was no evidence of an adrenal tumor or enchondromas. There was, however, a slight increase in the temperature of the left limb and an increase in the amount of vascular channels of the lower extremity, which may relate to an obscure form of angiodysplasia. Furthermore, the patient's mother took thalidomide during pregnancy, which has been shown to cause a large range of limb deformities. The authors believe that it is appropriate to classify this case as an idiopathic form of progressive congenital hypertrophy, localized to the feet of a 25-year-old Caucasian female. The goal of treatment is primarily two-fold. First, progressive narrowing of the forefoot should be obtained through closing wedge osteotomies. Second, multi-stage debulking of the muscle tissue should be performed, with associated skin reductions. The authors believe that this is the first reported case of bilateral muscular and bony hypertrophy of the feet, which was present at birth and continued to increase after the cessation of skeletal growth.
The purpose of this study was to determine whether Medicare patients at risk for lower-extremity amputation due to complications from diabetes, peripheral vascular disease, and/or gangrene who receive the services classified under Level II code M0101 of the Health Care Financing Administration's Common Procedure Coding System (cutting or removal of corns, calluses, and/or trimming of nails, application of skin creams and other hygienic and preventive maintenance care) have lower rates of lower-extremity amputation than those who do not receive such services. Analysis of the data suggests that those at-risk beneficiaries who received these services were nearly four times less likely to experience lower-extremity amputation than those who did not receive such services. The study has both methodologic limitations (the study considers only one variable, receipt or nonreceipt of certain types of podiatric medical care, while other variables may affect rates of lower-extremity amputation) and technological limitations (attempts to link the 2 years of per case Medicare Part B data were unsuccessful, limiting the length of the study to 1 year). Further research on this topic is encouraged.
From 1982 to 1991, 17 patients underwent a lower extremity arterial bypass to salvage an ischemic transmetatarsal amputation at the New England Deaconess Hospital. Eleven patients were male, and 16 had diabetes for an average of 29 years. The mean age was 71 years. Twelve patients presented with an ischemic ulcer, one had rest pain, and four underwent bypass for failure to heal a transmetatarsal amputation. Twelve patients presented with findings of secondary infection. All 17 patients underwent successful lower extremity bypass procedures to a variety of outflow vessels. Thirteen bypasses were to infrapopliteal arteries, including four to the dorsalis pedis artery. There were no perioperative deaths and all patients were discharged with patent grafts and healing limbs. Actuarial graft patency of the 14 vein grafts was 90% at 2 years. Actuarial limb salvage for the entire group was 93% at 2 years. Thirteen of the 14 patients who maintained patent grafts and healed their transmetatarsal amputations were ambulatory at their last known follow-up examination. Ischemic complications of previously created transmetatarsal amputations are uncommon. However, limb salvage attempts by lower extremity arterial bypass have a high likelihood of success. Major amputation in these patients should not be done without having first undergone a comprehensive vascular evaluation.
The authors present a retrospective study of fifth metatarsal fractures. These fractures include Jones fractures, avulsion fractures, spiral and oblique midshaft fractures, and the author-termed "tulip" fracture (impaction fracture of the fifth metatarsal head). These fractures were fixated with the cannulated screw, Kirschner wires, and cerclage loop wires combined with Kirschner wires. A one-way analysis of variance (ANOVA) was performed on the data to test for any significant difference in the fixation type used and the overall healing time. The ANOVA was found to be nonsignificant, F(2,10) = 0.379, p < 0.05. Therefore, it can be concluded that all three types of fixation work equally well. Other analyses were performed on each of the three specific types of fractures to see if there was any difference in fixating the fracture versus no fixation and immobilization. This information was significant for only the Jones fracture, F(1,5)2.23, p < 0.05, meaning that Jones fractures heal in a significantly shorter amount of time when some type of open reduction internal fixation is used. Since there was no difference in healing time between the different types of fixation, the authors advise that the cannulated screw be strongly considered because of its efficiency of insertion. In addition, because of the vascularity, muscle insertions, and motion related to the fifth metatarsal, the authors recommend that most Jones fractures be fixated for a more rapid return to function.
INTRODUCTION AND OBJECTIVES: The gold standard for the diagnosis of lower extremity deep vein thrombosis (DVT) is reported to be venous duplex ultrasound (VDU) because it is noninvasive, sensitive, relatively inexpensive, and can be performed at a patients bedside. The objective of this investigation was to measure agreement in the interpretation of VDU between multiple medical specialties.
METHODS: Agreement among different physicians who typically interpret VDU images were examined. The physicians were from multiple specialties and included 3 vascular surgeons (VS), 3 emergency medicine physicians (EM), and 1 radiologist. Four complete VDU imaging tests originally obtained for suspected DVT and used for the diagnosis were organized onto a computer program and independently reviewed by the seven physicians. The physicians were asked to review and interpret the VDU imaging test and note whether the test was positive or negative for thrombosis.
RESULTS: For the first case, 2 physicians diagnosed a positive examination while 5 physicians diagnosed a negative examination. For the second case, 4 physicians diagnosed a positive examination while 3 physicians diagnosed a negative examination. For the third case, 4 physicians diagnosed a positive examination while 3 physicians diagnosed a negative examination. For the fourth case, 6 physicians diagnosed a positive examination, while 1 physician diagnosed a negative examination. These findings resulted in an intraclass correlation coefficient (ICC) value of 0.292 indicating a fair degree of agreement.
CONCLUSIONS: We think these findings indicate that VDU may lack the diagnostic accuracy to be considered a gold standard for the diagnosis of lower extremity DVT. We also think this finding highlights the importance of appreciating that VDU is a dynamic evaluation reliant on the clinical knowledge and technical skills of whoever is performing the test. Reviewing static imaging alone may not provide enough information to make the diagnosis consistently.
