Search Results
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)
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)
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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)
Preventive foot-care practices, such as annual foot examinations by a health-care provider, can substantially reduce the risk of lower-extremity amputations. We examined the level of preventive foot-care practices (reported rates of having at least one foot examination by a physician) among patients with diabetes mellitus in North Carolina and determined the factors associated with these practices. Of 1,245 adult respondents to the 1997 to 2001 North Carolina Behavioral Risk Factor Surveillance System, 71.6% reported that they had had their feet examined within the past year, a rate that is much higher than that previously reported by Bell and colleagues in the same population for 1994 to 1995 (61.7%). Foot care was more common among insulin users than nonusers, those having diabetes for 20 years or longer than those having diabetes for less than 10 years, blacks than whites, and those who self-monitored their blood glucose level daily than those who did not. The results of this study indicate that diabetes educational services can be directed at populations at high risk of ignoring the recommended foot-care practices indicated in these analyses, thereby reducing diabetes-related lower-extremity complications. (J Am Podiatr Med Assoc 94(5): 483–491, 2004)
Nevoid melanoma (NeM) is a rare variant of malignant melanoma characterized by slight cellular atypia, polymorphism, and incomplete maturation. It most frequently occurs on the trunk and arms but rarely on the foot. Here, we report a subungual NeM of the right hallux. A 65-year-old man presented with severe pain of 6 months’ duration to his right great toe following self-treatment for an ingrown nail. He was evaluated and treated with debridement of the toenail at an urgent medical center 3 months prior. However, this had not relieved his pain. The patient also noticed discoloration of his distal great toe over the past 3 months. Removal of part of the ingrown nail revealed a pigmented mass extending distally from the matrix. Surgical excision of the mass was performed because of the concern for malignancy. The diagnosis of NeM was based on histologic analysis along with enhanced diagnostic modalities. The patient was further treated with surgical amputation of the great toe and anti–programmed cell death-1 therapy. The patient had no relapse at 1-year follow-up. Nevoid melanoma is a rare variant of malignant melanoma on the toes, which needs to be differentiated from a nevus with atypia, with a variety of modalities including cellular and molecular profiling. The optimal treatment is amputation.
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.
Quality of Life in People with Their First Diabetic Foot Ulcer
A Prospective Cohort Study
Background: People with diabetic foot ulcers report poor quality of life. However, prospective studies that chart quality of life from the onset of diabetic foot ulcers are lacking. We describe change in quality of life in a cohort of people with diabetes and their first foot ulcer during 18 months and its association with adverse outcomes.
Methods: In this prospective cohort study of adults with their first diabetic foot ulcer, the main outcome was change in Medical Outcomes Study 36-Item Short Form Health Survey scores between baseline and 18-month follow-up. We recorded baseline demographics, diabetes characteristics, depression, and diabetic foot outcomes and mortality at 18 months.
Results: In 253 people with diabetes and their first ulcer, there were 40 deaths (15.8%), 36 amputations (15.5%), 99 recurrences (43.2%), and 52 nonhealing ulcers (21.9%). The 36-Item Short Form Health Survey response rate of survivors at 18 months was 78% (n = 157). There was a 5- to 6-point deterioration in mental component summary scores in people who did not heal (adjusted mean difference, −6.54; 95% confidence interval, −12.64 to −0.44) or had recurrent ulcers (adjusted mean difference, −5.30; 95% confidence interval, −9.87 to −0.73) and a nonsignificant reduction in those amputated (adjusted mean difference, −5.00; 95% confidence interval, −11.15 to 1.14).
Conclusions: Quality of life deteriorates in people with diabetes whose first foot ulcer recurs or does not heal within 18 months. (J Am Podiatr Med Assoc 99(5): 406–414, 2009)
The comorbidities of diabetes mellitus were evaluated in an Asian American population with podiatric symptoms living in southern California. The three most common nonpedal complaints in men were blurred vision (73.6%), hypertension (64.1%), and erectile dysfunction (52.3%) and in women were blurred vision (84.5%), incontinence (71.5%), and low-back pain with radiculopathy-like symptoms (56.5%). The most significant finding was that only 3.2% of all patients had any previous knowledge or understanding of the risks of foot infection, ulceration, and amputation secondary to diabetes mellitus. The prevalence of diabetes mellitus in ethnic populations once considered practically exempt continues to rise steadily, and Asians living in the United States are becoming casualties of diabetes mellitus and its complications. (J Am Podiatr Med Assoc 93(1): 37-41, 2003)
Protein S Deficiency and Lower-Extremity Arterial Thrombosis
Complicating a Common Presentation
A 42-year-old woman presented to the emergency department with progressive painful discoloration of the digits of her right foot and symptoms previously diagnosed as neuroma. She was admitted to the hospital for dorsalis pedis arterial occlusion and ischemic foot pain. Despite attempts to restore perfusion to the right leg, ischemia of the right foot persisted and progressed to digital gangrene. The patient subsequently required right transmetatarsal amputation and eventually below-the-knee amputation. After extensive inpatient vascular and hematologic work-up of this otherwise healthy woman, test results revealed that she had protein S deficiency, hepatitis C, and human immunodeficiency virus type 1. In addition to describing this patient’s evaluation and treatment, we review protein S deficiency, including its correlation with human immunodeficiency virus type 1 infection and laboratory diagnosis. This case promotes awareness of protein S deficiency and serves as a reminder to the physician treating patients with vascular compromise and a history of human immunodeficiency virus type 1 to include protein S deficiency in the differential diagnosis. (J Am Podiatr Med Assoc 97(2): 151–155, 2007)
Background
Diabetic foot ulcer (DFU) is a serious health problem. Major amputation increases the risk of mortality in patients with DFU; therefore, treatment methods other than major amputation come to the fore for these patients. Graft applications create an appropriate environment for the reproduction of epithelial cells. Similarly, epidermal growth factor (EGF) also stimulates epithelization and increases epidermis formation. In this study, we aimed to compare patients with DFU treated with EGF and those treated with a split-thickness skin graft.
Methods
Patients who were treated for DFU in the general surgery clinic were included in the study. The patients were evaluated retrospectively according to their demographic characteristics, wound characteristics, duration of treatment, and treatment modalities.
Results
There were 26 patients in the EGF group and 21 patients in the graft group. The mean duration of treatment was 7 weeks (4-8 weeks) in the EGF group and 5.3 weeks (4-8 weeks) in the graft group (P < .05). In the EGF group, wound healing could not be achieved in one patient during the study period. In the graft group, no recovery was achieved in three patients (14.2%) in the donor site. Graft loss was detected in four patients (19%), and partial graft loss was observed in three patients (14.2%). The DFU of these patients were on the soles (85.7%). These patients have multiple comorbidities.
Conclusions
EGF application may be preferred to avoid graft complications in the graft area and the donor site, especially in elderly patients with multiple comorbidities and wounds on the soles.
