Diabetic foot ulcers combined with ischemia and infection can be difficult to treat. Few studies have quantified the level of blood supply and infection control required to treat such complex diabetic foot ulcers. We aimed to propose an index for ischemia and infection control in diabetic chronic limb-threatening ischemia (CLTI) with forefoot osteomyelitis.
We retrospectively evaluated 30 patients with diabetic CLTI combined with forefoot osteomyelitis who were treated surgically from January 2009 to December 2016. After 44 surgeries, we compared patient background (age, sex, hemodialysis), infection status (preoperative and 1- and 2-week postoperative C-reactive protein [CRP] levels), surgical bone margin (with or without osteomyelitis), vascular supply (skin perfusion pressure), ulcer size (wound grade 0–3 using the Society for Vascular Surgery Wound, Ischemia, and foot Infection classification), and time to wound healing between patients with healing ulcers and those with nonhealing ulcers.
Preoperative CRP levels and the ratio of ulcers classified as wound grade 3 were significantly lower and skin perfusion pressure was significantly higher in the healing group than in the nonhealing group (P < .05). No other significant differences were found between groups.
This study demonstrates that debridement should be performed first to control infection if the preoperative CRP level is greater than 40 mg/L. Skin perfusion pressure of 55 mm Hg is strongly associated with successful treatment. We believe that this research could improve the likelihood of salvaging limbs in patients with diabetes with CLTI.
Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory condition. The lesions are reported to present most frequently in the long bones. This study aimed to review the presenting features of CRMO in a cohort of children diagnosed as having CRMO and to compare the level of agreement between the clinical and published diagnostic criteria.
A case notes review was undertaken of patients with a clinical diagnosis of CRMO. Patients were younger than 16 years at the time of diagnosis. Features were identified in each patient that agreed or disagreed with the published diagnostic criteria. The location of bone lesions in the lower limb at onset and disease progression was recorded.
A total of 37 patients were included. There was a high prevalence in white individuals. Agreement with the diagnostic criteria of Jansson et al and El-Shanti and Ferguson was poor, with levels of agreement of 40.5% and 43%, respectively, and low kappa scores (κ = 0.07 and 0.09, respectively). The lower limb was affected in 49% of patients at onset and in 72% overall.
This study presents one of the largest published cohorts of pediatric patients with CRMO and also presents racial/ethnic group data that have not previously been reported in other studies. Despite being a condition considered to affect the metaphysis of long bones, the ankle area and foot bones were also frequently affected. The agreement between the clinical diagnosis and the published diagnostic criteria was weak.
Background: Fusion of the neuropathic ankle joint is extremely difficult and associated with many complications. The use of the Ilizarov fixator in ankle fusion for patients with neuropathic arthropathy is not clear. We aimed to evaluate the results of the Ilizarov method for ankle arthrodesis in diabetic patients with neuropathic arthropathy.
Methods: We report the results of neuropathic ankle joint arthrodesis performed with the Ilizarov apparatus in 11 patients. The mean age of the patients was 51 years (range, 35–67 years), all patients were diabetic, and they all had a history of ankle trauma unresponsive to conservative treatment. Deformity and instability of the ankle resulting in a nonplantigrade foot was the operative indication.
Results: Solid fusion was obtained in all patients except one, at an average of 16.1 weeks (range, 12–20 weeks). At final follow-up, excellent results were obtained in three patients, good in six, fair in one, and poor in one. No major complication occured.
Conclusions: The Ilizarov fixator may be an alternative and effective means for neuropathic ankle arthrodesis, especially when the usage of internal fixation methods have some limitations. (J Am Podiatr Med Assoc 99(1): 42–48, 2009)
Catfish envenomations represent a relatively rare cause of complications in podiatric medicine. We report a case of an unusual event eliciting a severe soft-tissue necrosis in a 21-year-old man and his complicated wound-healing process. This case reviews the potential complications of catfish envenomations. (J Am Podiatr Med Assoc 100(6): 493–496, 2010)
Osteomyelitis secondary to diabetic foot infections can lead to proximal amputation if not diagnosed in a timely and accurate manner. The authors have found no studies to date that correlate a specific erythrocyte sedimentation rate with osteomyelitis. A retrospective chart review of 29 diabetic patients admitted to the hospital with diagnoses of osteomyelitis or cellulitis of the foot during a 1-year period was performed. Of the various lab values and demographic factors compared, erythrocyte sedimentation rate was the only measure that differed significantly between the two groups. A receiver operating characteristic curve was used to obtain the optimal cutoff value of 70 mm/h, a level above which osteomyelitis was present with the highest sensitivity (89.5%) and highest specificity (100%), along with a positive predictive value of 100% and a negative predictive value of 83%. This study shows that in combination with clinical suspicion in diabetic foot infections, the erythrocyte sedimentation rate is highly predictive of osteomyelitis, and that the value of 70 mm/h is the optimal cutoff to predict accurately the presence or absence of bone infection. (J Am Podiatr Med Assoc 91(9): 445-450, 2001)
The treatment of pilon tibia fractures is challenging. Anatomical reduction of the joint surface is essential. Excessive soft-tissue dissection may interfere with the blood supply and can result in nonunion. We sought to compare the outcomes of distal tibia fractures treated with medial locking plates versus circular external fixators.
We retrospectively evaluated 41 consecutive patients with closed pilon tibia fractures treated with either minimally invasive locking plate osteosynthesis (n = 21) or external fixation (EF) (n = 20). According to the Ruedi and Allgower classification, 23 fractures were type B and 18 were type C. Soft-tissue injury was evaluated according to the Oestern and Tscherne classification. Time to fracture union, complications, and functional outcomes were assessed annually for 3 years with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score.
Mean ± SD values in the plate group were as follows: age, 42.4 ± 14 years; union time, 19.4 ± 2.89 weeks (range, 12–26 weeks); and AOFAS ankle scores, 86.4 ± 2.06, 79.5 ± 1.03, and 77.9 ± 0.80 at 1, 2, and 3 years, respectively. Four patients in the plate group needed secondary bone grafting during follow-up. In the EF group (mean ± SD age, 40.7 ± 12.3 years), all of the patients achieved union without secondary bone grafting at a mean ± SD of 22.1 ± 1.7 weeks (range, 18–24 weeks). In the EF group, mean ± SD AOFAS ankle scores were 86.6 ± 1.69, 82.1 ± 0.77, and 79.7 ± 1.06 at 1, 2, and 3 years, respectively. There were no major complications. However, there were soft-tissue infections over the medial malleolus in five patients in the plate group and grade 1-2 pin-tract infections in 13 patients and grade 3 pin-tract infections in one patient in the EF group. Post-traumatic arthritis was detected in eight plate group patients and seven EF group patients.
Minimally invasive plating and circular EF methods have favorable union rates with fewer complications.
Tedizolid phosphate, the prodrug of the oxazolidinone tedizolid, has been approved in a number of countries, including the United States, those in the European Union, and Canada, for treatment of patients with acute bacterial skin and skin structure infections (ABSSSI). Two phase 3 trials demonstrated the noninferior efficacy of tedizolid (200 mg once daily for 6 days) to linezolid (600 mg twice daily for 10 days) in patients with ABSSSI. Because of the challenges of treating lower-extremity ABSSSI, the efficacy and safety of tedizolid and linezolid for treating lower-extremity versus non–lower-extremity infections were compared.
This was a post hoc analysis of pooled data from patients with lower-extremity infections enrolled in two phase 3 studies, ESTABLISH-1 (NCT01170221) and ESTABLISH-2 (NCT01421511), comparing tedizolid to linezolid in patients with ABSSSI.
Lower-extremity ABSSSI were present in 40.7% of tedizolid-treated and 42.2% of linezolid-treated patients. Methicillin-resistant Staphylococcus aureus (MRSA) was present in 34.7% of all patients with a baseline causative pathogen. Early clinical responses at 48 to 72 hours and investigator-assessed responses at the post-therapy evaluation were similar between tedizolid and linezolid, regardless of ABSSSI type. With both treatments, the early clinical response was slightly higher in patients with non–lower-extremity infection than in those with lower-extremity ABSSSI (tedizolid, 84.8% versus 77.0%; linezolid, 81.4% versus 76.6%, respectively); however, by the post-therapy evaluation visit, response rates were similar (tedizolid, 87.1% versus 86.3%; linezolid, 86.6% versus 87.2%, respectively). Gastrointestinal adverse events and low platelet counts were observed more frequently with linezolid treatment.
Post-therapy evaluations showed that the clinical response of lower-extremity ABSSSI to tedizolid and linezolid was comparable to that of ABSSSI in other locations. A short 6-day course of once-daily tedizolid was as effective as a 10-day course of twice-daily linezolid in treating patients with lower-extremity ABSSSI.
It is well established and accepted that fungi are a major contributing factor in nail dystrophy. It has also been recognized that bacteria play a crucial role in onycholysis. However, the bacteria and fungi that can be grown on culture media in the laboratory are only a small fraction of the total diversity that exists in nature. Contemporary studies have revealed that fungi and bacteria often form physically and metabolically interdependent consortia that harbor properties and pathogenicity distinct from those of their individual components. Metagenomic DNA “shotgun” sequencing has proved useful in determining microbial etiology in clinical samples, effective for not only bacteria but also fungi, archaea, and viruses.
Thirty-nine consecutive nail and subungual debris samples with suspected onychomycosis were sent for laboratory analysis using three examination techniques: DNA sequencing, polymerase chain reaction analysis, and standard fungal culture. The nail plate and surrounding areas were disinfected with an ethyl alcohol swab before nail sampling. Samples from 16 patients were analyzed for suspected onychomycosis with DNA sequencing, searching a database of 25,000 known pathogens. These results were compared with 15 real-time polymerase chain reaction screening assays and eight fungal cultures sampled with the same methods.
The DNA sequencing detected 32 species of bacteria and 28 species of fungi: 50% were solely bacterial, 6.3% were solely fungal, and 43.7% were mixed communities of bacteria and fungi.
Toenails tested with DNA sequencing demonstrated the presence of both bacteria and fungi in many samples. Further work is required to fully investigate its relevance to nail pathology and treatment.
Background: We assessed the tolerability and efficacy of autologous skin cell grafts in older type 2 diabetic patients with chronic foot ulcers.
Methods: Treatment with Hyalograft 3D and Laserskin Autograft was proposed to a consecutive series of type 2 diabetic patients older than 65 years affected by long-standing (>6 months) foot ulcers with an area greater than 15 cm2. Ulcer healing rates and measurements of ulcer area were determined monthly for 12 months.
Results: Seven patients with 12 ulcers, nine of which received the described treatment, were enrolled. During 12-month follow-up, all of the ulcers healed except one. In the remaining eight ulcers, the median healing time was 21 weeks (interquartile range, 4–29 weeks).
Conclusions: Autologous skin cell grafts are feasible, well tolerated, and apparently effective in the treatment of diabetic ulcers of the lower limbs in advanced age. Age did not seem to moderate healing times. (J Am Podiatr Med Assoc 101(1): 55–58, 2011)