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.
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.
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.
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.
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)
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.
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)
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.
Systemic lupus erythematosus is an autoimmune disorder that affects several organs and systems in the human body. Digital gangrene is known to be a rare and severe complication of systemic lupus erythematosus that could lead to amputation. We report a case of an adolescent who presented with an autoimmune disorder and multiple comorbidities and developed gangrenous toes.
Foot ulceration and lower-extremity amputation are devastating end-stage complications of diabetes. Despite agreement that diabetic foot self-care is a key factor in prevention of ulcers and amputation, there has only been limited success in influencing these behaviors among patients with diabetes. While most efforts have focused on increasing patient knowledge, knowledge and behavior are poorly correlated. Knowledge is necessary but rarely sufficient for behavior change. A key determinant to adherence to self-care behavior is clinician counseling style. Podiatrists are the ideal providers to engage in a brief behavioral intervention with a patient. Motivational interviewing is a well-accepted, evidence-based teachable approach that enhances self-efficacy and increases intrinsic motivation for change and adherence to treatment. This article summarizes some key strategies that can be employed by podiatrists to improve foot self-care. (J Am Podiatr Med Assoc 101(1): 78–84, 2011)
Severely comminuted fractures of the metatarsal bones with significant bone and soft-tissue loss have commonly subjected patients to proximal amputation procedures. We describe two patients who experienced high-energy traumatic injuries to their limbs that resulted in significant destruction of their first and second metatarsal bones with overlying soft-tissue trauma not amenable to local coverage. In both cases, a vascularized free fibular osteocutaneous flap was used to reconstruct the metatarsal bone defect and traumatized soft tissues so that a proximal amputation was avoided. At an average of 14 months of follow-up, both patients had recovered well and regained independent ambulation, with one patient being able to play soccer. We show that the free fibular osteoseptocutaneous flap is useful in reconstructing significant metatarsal bone defects and in avoiding amputations in this patient population. The skin component of the flap may be used to fill soft-tissue losses, and the fibula bone may be osteotomized so that more than one ray may be reconstructed. (J Am Podiatr Med Assoc 101(6): 531–536, 2011)
Charcot’s arthropathy is a devastating condition affecting diabetic patients with peripheral neuropathy, resulting in a foot at risk for ulceration and amputation. Early diagnosis is important for the institution of appropriate treatment, which may help prevent disease progression and foot deformity. This article discusses the pathogenesis and treatment options available for the disorder. (J Am Podiatr Med Assoc 92(7): 381-383, 2002)