Search Results
Malignant fibrous histiocytoma of bone is the osseous counterpart of the tumor in soft tissue. It is a rare primary bone tumor, and there have been conflicting reports on its grades of malignancy. The appendicular skeleton, especially the femur, is the most common site of involvement, whereas the calcaneus is rarely involved. We describe a primary malignant fibrous histiocytoma of the calcaneal bone in a 21-year-old man. The patient underwent neoadjuvant and adjuvant chemotherapy and below-the-knee amputation, and no local recurrence or metastasis was noted after 2 years of follow-up. (J Am Podiatr Med Assoc 97(3): 218–222, 2007)
Nerve Decompression After Diabetic Foot Ulceration May Protect Against Recurrence
A 3-Year Controlled, Prospective Analysis
Background
Nerve entrapment, common in diabetes, is considered an associated phenomenon without large consequence in the development of diabetes complications such as ulceration, infection, amputation, and early mortality. This prospective analysis, with controls, of the ulcer recurrence rate after operative nerve decompression (ND) offers an objective perspective on the possibility of frequent occult nerve entrapment in the diabetic foot complication cascade.
Methods
A multicenter cohort of 42 patients with diabetic sensorimotor polyneuropathy, failed pharmacologic pain control, palpable pulses, and at least one positive Tinel's nerve percussion sign was treated with unilateral multiple lower-leg external neurolyses for the indication of pain. All of the patients had healed at least one previous ipsilateral plantar diabetic foot ulceration (DFU). This group was retrospectively evaluated a minimum of 12 months after operative ND and again 3 years later. The recurrence risk of ipsilateral DFU in that period was prospectively analyzed and compared with new ulcer occurrence in the contralateral intact, nonoperated control legs.
Results
Operated legs developed two ulcer recurrences (4.8%), and nine contralateral control legs developed ulcers (21.4%), requiring three amputations. Ulcer risk is 1.6% per patient per year in ND legs and 7% in nonoperated control legs (P = .048).
Conclusions
Adding operative ND at lower-leg fibro-osseous tunnels to standard postulcer treatment resulted in a significantly diminished rate of subsequent DFU in neuropathic high-risk feet. This is prospective, objective evidence that ND can provide valuable ongoing protection from DFU recurrence, even years after primary ulcer healing.
Enchondromas are the most common benign cartilaginous bone tumors of the toe. In contrast, chondrosarcomas are very uncommon in the foot. We report an unusual case of a chondrosarcoma arising in the great toe. The patient was a 62-year-old woman whose chief complaint was swelling of her left great toe. Radiography showed subtle punctate calcification and mild sclerosis and irregularity of the distal phalanx in the great toe. Magnetic resonance imaging showed extraskeletal growth. The distal phalanx was amputated. Histologic examination demonstrated a grade 1 chondrosarcoma. Two years after surgery, the patient was free of recurrence and lung metastasis. (J Am Podiatr Med Assoc 97(2): 156–159, 2007)
Background
We aimed to evaluate surrogate markers commonly used in the literature for diabetic foot osteomyelitis remission after initial treatment for diabetic foot infections (DFIs).
Methods
Thirty-five patients with DFIs were prospectively enrolled and followed for 12 months. Osteomyelitis was determined from bone culture and histologic analysis initially and for recurrence. Fisher exact and χ2 tests were used for dichotomous variables and Student t and Mann-Whitney U tests for continuous variables (α = .05).
Results
Twenty-four patients were diagnosed as having osteomyelitis and 11 as having soft-tissue infections. Four patients (16.7%) with osteomyelitis had reinfection based on bone biopsy. The success of osteomyelitis treatment varied based on the surrogate marker used to define remission: osteomyelitis infection (16.7%), failed wound healing (8.3%), reulceration (20.8%), readmission (16.7%), amputation (12.5%). There was no difference in outcomes among patients who were initially diagnosed as having osteomyelitis versus soft-tissue infections. There were no differences in osteomyelitis reinfection (16.7% versus 45.5%; P = .07), wounds that failed to heal (8.3% versus 9.1%; P = .94), reulceration (20.8% versus 27.3%; P = .67), readmission for DFIs at the same site (16.7% versus 36.4%; P = .20), amputation at the same site after discharge (12.5% versus 36.4%; P = .10). Osteomyelitis at the index site based on bone biopsy indicated that failed therapy was 16.7%. Indirect markers demonstrated a failure rate of 8.3% to 20.8%.
Conclusions
Most osteomyelitis markers were similar to markers in soft-tissue infection. Commonly reported surrogate markers were not shown to be specific to identify patients who failed osteomyelitis treatment compared with patients with soft-tissue infections. Given this, these surrogate markers are not reliable for use in practice to identify osteomyelitis treatment failure.
Maggot Therapy in “Lower-Extremity Hospice” Wound Care
Fewer Amputations and More Antibiotic-Free Days
We sought to assess, in a case-control model, the potential efficacy of maggot debridement therapy in 60 nonambulatory patients (mean ± SD age, 72.2 ± 6.8 years) with neuroischemic diabetic foot wounds (University of Texas grade C or D wounds below the malleoli) and peripheral vascular disease. Twenty-seven of these patients (45%) healed during 6 months of review. There was no significant difference in the proportion of patients healing in the maggot debridement therapy versus control group (57% versus 33%). Of patients who healed, time to healing was significantly shorter in the maggot therapy than in the control group (18.5 ± 4.8 versus 22.4 ± 4.4 weeks). Approximately one in five patients (22%) underwent a high-level (above-the-foot) amputation. Patients in the control group were three times as likely to undergo amputation (33% versus 10%). Although there was no significant difference in infection prevalence in patients undergoing maggot therapy versus controls (80% versus 60%), there were significantly more antibiotic-free days during follow-up in patients who received maggot therapy (126.8 ± 30.3 versus 81.9 ± 42.1 days). Maggot debridement therapy reduces short-term morbidity in nonambulatory patients with diabetic foot wounds. (J Am Podiatr Med Assoc 95(3): 254–257, 2005)
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)
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.
Synovial Sarcoma of the Foot
A Case Report
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)
