After resection of bone or amputation, postoperative stump breakdown occurs frequently. Furthermore, the altered mechanics with ambulation are difficult to control with bracing and orthoses alone. During the past 10 years, the peroneus brevis tendon has been transferred to various locations in the foot after resection of the fifth metatarsal base in an effort to provide continued balance between the supinatory and pronatory forces needed for a steady gait. In patients who have had a peroneus brevis tendon transfer, the rate of postoperative ulceration and the need for further bony resection is minimal. Analysis of the biomechanical influences and effects of different anatomical placements of the transferred tendon reveals the importance of transfer of the peroneus brevis tendon. (J Am Podiatr Med Assoc 94(6): 594–603, 2004)
Mortality Rates and Diabetic Foot Ulcers
Is it Time to Communicate Mortality Risk to Patients with Diabetic Foot Ulceration?
Five-year mortality rates after new-onset diabetic ulceration have been reported between 43% and 55% and up to 74% for patients with lower-extremity amputation. These rates are higher than those for several types of cancer including prostate, breast, colon, and Hodgkin’s disease. These alarmingly high 5-year mortality rates should be addressed more aggressively by patients and providers alike. Cardiovascular diseases represent the major causal factor, and early preventive interventions to improve life expectancy in this most vulnerable patient cohort are essential. New-onset diabetic foot ulcers should be considered a marker for significantly increased mortality and should be aggressively managed locally, systemically, and psychologically. (J Am Podiatr Med Assoc 98(6): 489–493, 2008)
Squamous cell carcinoma is a common disease of cutaneous tissue with a great ability to form metastases. Squamous cell carcinoma is found most commonly on sun-damaged skin and has a rare occurrence on the toes and feet. The patient was a 68-year-old woman who was seen at a podiatric specialty office with a complaint of pain in her left great toe and toenail. Radiographs displayed erosion of the distal hallux, and magnetic resonance imaging revealed no further spread of disease in the proximal phalanx. An amputation was performed of the hallux interphalangeal joint, and pathology confirmed squamous cell carcinoma of the verrucous type. (J Am Podiatr Med Assoc 103(2): 149–151, 2013)
We report a case of a 40-year-old woman with synovial sarcoma who presented with neural symptoms in the medial aspect of the right foot and ankle. The radiographic appearance of the foot and ankle was unremarkable, but magnetic resonance imaging showed a relatively well-defined enhancing lesion in the plantar soft tissues extending from the master knot of Henry to the posterior tibialis tendon. After orthopedic oncologic evaluation and workup, the patient was ultimately treated with a transtibial amputation, and no evidence of recurrence or metastatic disease was seen at 6-month follow-up. (J Am Podiatr Med Assoc 100(3): 216–219, 2010)
Neuropathic foot ulcers are a common complication in patients with diabetes. These ulcers are often slow to heal and can lead to infection, further tissue destruction, osteomyelitis, and amputation. These patients pose a challenge to clinicians who must determine the best treatment options while balancing the risks, benefits, and costs. Conservative therapies often present disappointing results, and a number of newer “biologic bandages” have been developed to better assist the healing process. We describe results from diabetic patients with neuropathic foot ulcers treated with a new amniotic membrane–based allograft.
We report a case of macrodactyly of the foot in a 3-year-old girl. The standard treatment for this condition has been ablation. Studies of phalangeal resection, phalangeal amputation, syndactylization, digit shortening, tissue debulking, and osteotomy have shown varying results. In the case reported here, debulking combined with a shortening osteotomy was the treatment of choice. Although the pediatric patient may require additional surgeries because the deformity will continue to grow, early treatment has allowed this child the benefit of a functional, cosmetically appealing foot that can be fitted with normal footwear. (J Am Podiatr Med Assoc 94(5): 499–501, 2004)
Background: To evaluate complications and risk factors for nonunion in patients with diabetes after ankle fracture.
Methods: We conducted a retrospective study of 139 patients with diabetes and ankle fractures followed for 1 year. We evaluated the incidence of wounds, infections, nonunions, Charcot’s arthropathy, and amputations. We determined Fracture severity (unimalleolar, bimalleolar, trimalleolar), nonunion, and Charcot’s arthropathy from radiographs. Nonunion was defined as a fracture that did not heal within 6 months of fracture. Analysis of variance was used to compare continuous variables, and χ2 tests to compare dichotomous variables, with α = 0.05. Logistic regression was performed with a binary variable representing nonunions as the dependent variable.
Results: Complications were common: nonunion (24.5%), Charcot’s arthropathy (7.9%), wounds (5.2%), wound site infection (17.3%), and leg amputation (2.2%). Patients with nonunions were more likely to be male (55.9% versus 29.5%; P = .005), have sensory neuropathy (76.5% versus 32.4%; P < .001), have end-stage renal disease (17.6% versus 2.9%; P < .001), and use insulin (73.5% versus 40.1%; P < .001), β-blockers (58.8% versus 39.0%; P = .049), and corticosteroids (26.5% versus 9.5%; P = .02). Among patients with nonunion, there was an increased risk of wounds (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.46–7.73), infection (OR, 2.04; 95% CI, 0.72–5.61), amputation (OR, 7.74; 95% CI, 1.01–100.23), and long-term bracing (OR, 9.51; 95% CI, 3.8–23.8). In the logistic regression analysis, four factors were associated with fracture nonunion: dialysis (OR, 7.7; 95% CI, 1.7–35.2), insulin use (OR, 3.3; 95% CI, 1.5–7.4), corticosteroid use (OR, 4.9; 95% CI, 1.4–18.0), and ankle fracture severity (bimalleolar or trimalleolar fracture) (OR, 2.5; 95% CI, 1.1–5.4).
Conclusions: These results demonstrate risk factors for nonunions: dialysis, insulin use, and fracture severity after ankle fracture in patients with diabetes.
Surgical Treatment of Pressure Ulcers of the Heel in Skilled Nursing Facilities
A 12-Year Retrospective Study of 57 Patients
Background: Chronic nonhealing pressure ulcers of the heel in nursing homes are frequent occurrences among bedridden patients with lower-extremity contractures of varying degrees of severity. Conservative local wound care for these patients can be time consuming, ineffective, costly, and may only delay an eventual major leg amputation. This study evaluates the efficacy of limb salvage surgical procedures, partial calcanectomy, total calcanectomy, and excision of the entire calcaneus and talus, for heel ulcers.
Methods: We performed a retrospective review of 57 nursing home residents who had chronic infected nonhealing pressure ulcers of the heel that we had treated over 12 years. Forty-three patients underwent partial calcanectomy, nine underwent total calcanectomy, and five underwent excision of the entire calcaneus and talus. Average postoperative follow-up was 15 months. Also included in this study are representative surgical cases.
Results: Forty-three patients completed follow-up. Complete healing occurred in 25 patients (58%). Failure to resolve the heel ulcer owing to persistent infection, or recurrence was seen in 18 patients (42%) who eventually had a below-the-knee or above-the-knee amputation. All of the patients with heel pressure ulcers were found to have lower-extremity contractures.
Conclusions: In the nonambulatory contracted patient with a heel ulcer, partial or total calcanectomy or excision of the entire calcaneus and talus offer a viable alternative not only for resolution of infection but also for prevention of limb loss. An aggressive plan must also be instituted to address the lower-extremity contractures in order to prevent recurrence. (J Am Podiatr Med Assoc 101(2): 167–175, 2011)
Cutaneous T-cell lymphoma is a type of non-Hodgkin's lymphoma, which is a neoplasm affecting the lymphatic system. Mycosis fungoides is the most common subset of cutaneous T-cell lymphoma and is often treated conservatively. This neoplasm is most common in adults older than 60 years and does not regularly manifest in the toes. A case is reported of a 70-year-old man seen for a nonhealing hallux ulceration leading to amputation. Histopathologic examination revealed a rare transformed CD30+ high-grade cutaneous T-cell lymphoma. The morbidity of lymphomas is highly dependent on type and grade. Pharmaceutical precision therapies exist that target specific molecular defects or abnormally expressed genes, such as high expression of CD30. This article focuses on treatment protocol and emphasizes the importance of early diagnosis, determination of cell type, and proper referral of atypical dermatologic lesions.
Use of nerve decompression in diabetic sensorimotor polyneuropathy is a controversial treatment characterized as being of unknown scientific effectiveness owing to lack of level I scientific studies.
Herein, long-term follow-up data have been assembled on 65 diabetic patients with 75 legs having previous neuropathic foot ulcer and subsequent operative decompression of the common peroneal and tibial nerve branches in the anatomical fibro-osseous tunnels.
The cohort’s previously reported low recurrence risk of less than 5% annually at a mean of 2.49 years of follow-up has persisted for an additional 3 years, and cumulative risk is now 2.6% per patient-year. Nine of 75 operated legs (12%) have developed an ulcer in 4,218 months (351 patient-years) of follow-up. Of the 53 contralateral legs without decompression, 16 (30%) have ulcerated, of which three have undergone an amputation. Fifty-nine percent of patients are known to be alive with intact feet a mean of 60 months after decompression.
The prospective, objective, statistically significant finding of a large, long-term diminution of diabetic foot ulcer recurrence risk after operative nerve decompression compares very favorably with the historical literature and the contralateral legs of this cohort, which had no decompression. This finding invites prospective randomized controlled studies for validation testing and reconsideration of the frequency and contribution of unrecognized nerve entrapments in diabetic sensorimotor polyneuropathy and diabetic foot complications. (J Am Podiatr Med Assoc 103(5): 380–386, 2013)