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The care of patients at risk for amputation includes the identification of at-risk patients, appropriate follow-up and treatment, and the anticipation of possible complications. Education and long-term follow-up are vital for management of the patient at risk for amputation. (J Am Podiatr Med Assoc 91(1): 2-5, 2001)
The purpose of this article is to present reference guidelines to assist clinicians when treating diabetic patients with foot wounds. Diabetic patients with limb-threatening foot ulcers often have multiple coexisting medical conditions that frequently become impediments to the resolution of foot wounds. Each foot wound is unique and its etiology is multifactorial; therefore, each foot wound should be managed differently. The treatment algorithm presented in this article is divided into three categories: Algorithm I describes the treatment of septic foot wounds, which may be considered true podiatric surgical emergencies; Algorithm II describes the treatment of ischemic foot ulcers or gangrene with or without underlying osteomyelitis; and Algorithm III describes the treatment of neuropathic foot ulcers with or without underlying osteomyelitis. (J Am Podiatr Med Assoc 92(6): 336-349, 2002)
Pernio is an inflammatory condition of the skin associated with cold exposure. The dermatologic manifestations may vary, and this entity is frequently misdiagnosed. Its association with systemic disease underscores the importance of accurate diagnosis. The authors describe a case report in which a patient who, after initially presenting with a complaint of pain and an ingrown toenail, was eventually diagnosed with pernio as well.
Data from 37 patients who underwent a transmetatarsal amputation from January 1993 to April 1996 were reviewed. The mean age and diabetes duration of the subjects were 54.9 (± 13.2) years and 16.6 (± 8.9) years, respectively. The follow-up period averaged 42.1 (± 11.2) months. At the time of follow-up, 29 (78.4%) of the 37 patients still had foot salvage, 8 (21.6%) had progressed to below-the-knee amputation, and 15 (40.5%) had undergone lower-extremity revascularization. Twelve (80%) of the 15 revascularized patients preserved their transmetatarsal amputation level at a follow-up of 36.4 months. The authors concluded that at a maximum of 3 years follow-up after initial amputation, transmetatarsal amputation was a successful amputation level. (J Am Podiatr Med Assoc 91(10): 533-535, 2001)
Decreasing Amputation Rates in Patients with Diabetes Mellitus
An Outcome Study
The lower-extremity amputation rate in people with diabetes mellitus is high, and the wound failure rate at the time of amputation is as high as 28%. Even with successful healing of the primary amputation site, amputation of part of the contralateral limb occurs in 50% of patients within 2 to 5 years. The purpose of this study was to provide valid outcome data before (control period) and 18 months after (test period) implementation of a multidisciplinary team approach using verified methods to improve the institutional care of wounds. Retrospective medical chart review was performed for 118 control patients and 116 test patients. The amputation rate was significantly decreased during the test period, and the amputations that were required were at a significantly more distal level. No above-the-knee amputations were required in 45 patients during the test period, compared with 14 of 76 patients during the control period. These outcome data suggest that unified care is an effective approach for the patient with diabetic foot problems. (J Am Podiatr Med Assoc 92(8): 425-428, 2002)
Diabetic Limb Salvage
A Team Approach at a Teaching Institution
In this retrospective review, 19 diabetic patients with significant lower-extremity pathology were assessed to determine the success of limb salvage in cases of varying complexity. The patients were either scheduled or at risk for below-the-knee amputation before intervention. After the limb-salvage procedure, patients were followed for 4 months to 9 years. Eighteen patients went on to have successful procedures, avoiding below-the-knee amputation; one patient had an above-the-knee amputation. The results demonstrate the benefits of an aggressive team approach with limb salvage as a goal. (J Am Podiatr Med Assoc 92(8): 457-462, 2002)
Classic Kaposi’s sarcoma is one form of Kaposi’s sarcoma. It is usually first seen in the skin of the lower extremities, where it is frequently misdiagnosed as a bruise. As time progresses, the lesions increase in size, number, and color. Early diagnosis is paramount to decrease metastasis to other organ systems such as the lungs, kidneys, and liver. The podiatric physician must take a detailed history, follow the course of the illness, and be aware that definitive diagnosis is made by a skin biopsy. This article provides a case history of Kaposi’s sarcoma and discusses diagnosis and treatment of this disease. (J Am Podiatr Med Assoc 95(6): 586–588, 2005)
There are few documented reports of arteriovenous malformations in the extremities, and even fewer specifically in the foot. Most of the documented cases in the foot present surgical treatments, and there is limited information on the nonsurgical approach. A brief review of the surgical approach to arteriovenous malformations in the foot and hand is presented first, followed by a case report of the nonsurgical treatment of an arteriovenous malformation in the foot, which was initially diagnosed incorrectly.
Background: Transmetatarsal amputations are limb salvage surgical procedures that preserve limb length and functional ankle joints. Indications for transmetatarsal amputations include forefoot trauma, infection, and ischemia. Prior research demonstrates patients who undergo transmetatarsal amputations have a lower 2-year mortality rate compared to those who undergo more proximal amputations. The aim of this study was to determine whether primary closure of a transmetatarsal amputation is a superior treatment compared to secondary healing of a transmetatarsal amputation for forefoot abnormality of infection, gangrene, or chronic ulceration.
Methods: A retrospective chart review was performed on patients aged 18 years or older requiring a transmetatarsal amputation because of forefoot abnormality between September of 2011 and December of 2019. Foot and ankle surgeons performed transmetatarsal amputations. Outcome variables measured included healing time of transmetatarsal amputation site, recurrent infection, recurrent gangrene, and the need for revision surgery or higher level amputations.
Results: Of the original 112 patients, 76 met the inclusion criteria; 47 of these had primary closure of transmetatarsal amputation and 29 of these had an open transmetatarsal amputation performed. Primarily closed transmetatarsal amputations resulted in a significantly greater overall healing rate of 78.8% (37 of 47) compared to open transmetatarsal amputations, with a healing rate of 37.9% (11 of 29) (P < .01). Closed transmetatarsal amputations were statistically significantly less likely than open transmetatarsal amputations to have recurrent gangrene, require revision pedal operations, or progress to higher level amputations.
Conclusions: Our research demonstrated that primary closure of transmetatarsal amputations is a superior treatment compared with secondary healing of transmetatarsal amputations in specific cases of infection, dry gangrene, or chronically nonhealing ulcerations.
