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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.
Background: Chronic wounds, especially in patients with diabetes, oftenrepresent clinical challenges. Recently the use of a topically applied blood clot has garnered significant interest. This stromal matrix contains viable cells that are autologous, biocompatible, biological and consistent with a metabolically active scaffold. It has been shown to be safe, effective, and cost efficient. However, the mechanism of action of this modality remains elusive. The objective of this manuscript is to identify a potential mechanism of action of an autologous blood clot.Methods: Review of clinical and scientific literature hypothesizes on how autologous blood clots may stimulate healing and facilitate the movement of critical substrates while lowering bioburden and fostering angiogenesis.Results: Blood serves as a carrier for many components: red blood cells, white blood cells, platelets, proteins, clotting factors, minerals, electrolytes, and dissolved gasses. In response to tissue injury, the hemostatic mechanism employs a host of vascular and extravascular responses initiating primary, secondary, and tertiary hemostasis. The scaffold created by the autologous blood clot tissue provides a medium in which the body can transform the wound from a non-healing chronic condition into a healing "acute" condition. The autologous blood clot tissue also creates a protective setting for the body to utilize its own mechanisms to promote wound healing in an organized manner. This transient scaffold recruits surrounding fibroblasts and promotes cell ingrowth to foster granulation tissue remodeling. Cells in this matrix not only sense soluble factors, but also their physical environments. This well-orchestrated mechanism includes signals from soluble molecules, from the substrate/matrix to which the cell is adherent, from the mechanical or physical forces acting on it, and from contact with other cells. Topically applied autologous blood clot tissue can lower bacterial bioburden while stimulating angiogenesis and fostering the movement of keratinocytes and fibroblasts.Conclusions: Topically applied autologous blood clot tissue represents a formidable cellular and tissue based therapy that has been shown to be safe and effective. Although the central component of this therapy is blood, the autologous clot tissue creates a scaffold that performs as a biologic delivery system that functions to control the release of growth factors and cytokines over several days.
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)
