A case report is presented of a 65-year-old diabetic woman with an 18-month history of a penetrating ulcer of the plantar aspect of the first metatarsal head with associated sepsis of the first metatarsophalangeal joint and adjacent underlying osteomyelitis. Salvage of the first metatarsophalangeal joint was performed through aggressive soft-tissue and osseous debridement, external fixation with antibiotic-loaded polymethyl methacrylate bone cement, and delayed interpositional autogenous iliac crest bone graft arthrodesis. Osseous incorporation of the interposed bone graft occurred 12 weeks postoperatively. No soft-tissue or osseous complications occurred during the postoperative period, and at 1-year follow-up there was no evidence of ulceration recurrence, transfer ulceration, shoe-fit problems, or gait abnormalities. A detailed review of the literature on the use of external fixation and interpositional bone graft distraction arthrodesis of the first metatarsophalangeal joint is presented. (J Am Podiatr Med Assoc 94(5): 492–498, 2004)
This randomized, prospective, multicenter, open-label study was designed to test whether a topical, electrolyzed, superoxidized solution (Microcyn Rx) is a safe and effective treatment for mildly infected diabetic foot ulcers.
Sixty-seven patients with ulcers were randomized into three groups. Patients with wounds irrigated with Microcyn Rx alone were compared with patients treated with oral levofloxacin plus normal saline wound irrigation and with patients treated with oral levofloxacin plus Microcyn Rx wound irrigation. Patients were evaluated on day 3, at the end of treatment on day 10 (visit 3), and 14 days after completion of therapy for test of cure (visit 4).
In the intention-to-treat sample at visit 3, the clinical success rate was higher in the Microcyn Rx alone group (75.0%) than in the saline plus levofloxacin group (57.1%) or in the Microcyn Rx plus levofloxacin group (64.0%). Results at visit 4 were similar. In the clinically evaluable population, the clinical success rate at visit 3 (end of treatment) for patients treated with Microcyn Rx alone was 77.8% versus 61.1% for the levofloxacin group. The clinical success rate at visit 4 (test of cure) for patients treated with Microcyn Rx alone was 93.3% versus 56.3% for levofloxacin plus saline–treated patients. This study was not statistically powered, but the high clinical success rate (93.3%) and the P value (P = .033) suggest that the difference is meaningfully positive for Microcyn Rx–treated patients.
Microcyn Rx is safe and at least as effective as oral levofloxacin for mild diabetic foot infections. (J Am Podiatr Med Assoc 101(6): 484–496, 2011)
We report an unusual case of Aeromonas hydrophilia septicemia in a nonmobile diabetic patient secondary to contaminated well water used for bathing with a portal of entry through chronic forefoot and heel ulcers. To date, there are no documented cases similar to this patient's presentation. Aeromonas hydrophilia is commonly distributed among aquatic environments and tends to be found during warmer months. It is a rare cause of disease but can be life threatening and deadly, as in our case, in immunocompromised individuals. As podiatric physicians, we must remain diligent and have a high index of suspicion to identify patients at risk for this rare but serious infection and administer treatment aggressively to limit morbidity and mortality.
The structure, classification, function, and regulation of matrix metalloproteinases in normal and abnormal wound healing is discussed. Results from key studies suggest that neutrophil-derived matrix metalloproteinase 8 (MMP-8) is the predominant collagenase present in normal healing wounds, and that overexpression and activation of this collagenase may be involved in the pathogenesis of nonhealing chronic leg ulcers. Excessive collagenolytic activity in these chronic wounds is possible because of the reduced levels of tissue inhibitor metalloproteinase 1 (TIMP-1). However, until recently, there have been no studies evaluating levels of matrix metalloproteinase or tissue inhibitors of metalloproteinase activity in chronic diabetic foot wounds. Improving basic knowledge and pharmaceutical intervention in this area ultimately may help clinicians identify and proactively intervene in an effort to prevent normal wounds from becoming chronic. This may prevent the high prevalence of morbidity associated with this significant health problem. (J Am Podiatr Med Assoc 92(1): 12-18, 2002)
Background: Treatment of diabetic foot wounds remains a major health-care issue, with diabetic foot ulcers representing the most common causal pathway to lower-extremity amputation. Although several investigations have examined topical collagen-based dressings, none have specifically looked at equine pericardium. We, therefore, evaluated the effect of the equine pericardium dressing on neuropathic foot wounds.
Methods: Twenty-three consecutive patients with 34 neuropathic foot wounds were evaluated as part of a pilot study. An equine pericardium dressing was applied in a standard manner, and the patients followed a standard postapplication treatment protocol. Changes in wound size were recorded when the equine dressing was removed and 4 and 12 weeks after application. Patients underwent dressing changes every 3 to 4 days until healed or for 12 weeks.
Results: Thirty-two wounds in 22 patients were prospectively available for evaluation. On enrollment, the median wound size was 299 mm2. When the equine material was removed (mean, 2.9 weeks), 30 of the wounds (94%) had improved, with a median size of 115 mm2 and an average reduction in size of 44.3% (P < .0001). At 4 weeks, the average decrease in wound size was 52.3% (P < .0001). At 12 weeks, 15 wounds (47%) had healed.
Conclusions: This first report of equine pericardium used to treat neuropathic foot ulcerations demonstrates that the equine pericardium dressing is a safe and beneficial treatment for neuropathic wounds. (J Am Podiatr Med Assoc 99(4): 301–305, 2009)
Foot ulceration and lower-extremity amputation are devastating end-stage complications of diabetes. Despite agreement that diabetic foot self-care is a key factor in prevention of ulcers and amputation, there has only been limited success in influencing these behaviors among patients with diabetes. While most efforts have focused on increasing patient knowledge, knowledge and behavior are poorly correlated. Knowledge is necessary but rarely sufficient for behavior change. A key determinant to adherence to self-care behavior is clinician counseling style. Podiatrists are the ideal providers to engage in a brief behavioral intervention with a patient. Motivational interviewing is a well-accepted, evidence-based teachable approach that enhances self-efficacy and increases intrinsic motivation for change and adherence to treatment. This article summarizes some key strategies that can be employed by podiatrists to improve foot self-care. (J Am Podiatr Med Assoc 101(1): 78–84, 2011)
Background: Total-contact casting is an effective method to treat various pathologic abnormalities in patients with diabetic neuropathy, but its use is frequently associated with iatrogenic complications.
Methods: The largest retrospective review to date of iatrogenic complications of total-contact casts was conducted over an 8-year period at Cleveland Clinic.
Results: In the past 8 years, 23% of patients developed complications, and the most common complication was a new heel ulcer formation. Of these complications, 92.1% resolved, 6.4% were lost to follow-up, and 1.4% resulted in a partial foot amputation. Mean cast duration was 10.3 days for patients who developed a total-contact cast iatrogenic complication. The most common indication for the use of a total-contact cast was a neuropathic foot ulceration.
Conclusions: The results of this study support the use of total-contact casting in the insensate patient with diabetes. However, adequate staff training in total-contact cast application is recommended to reduce complications.
Since 2006 there have been increased reports of severe agranulocytosis and vasculitis associated with levamisole use. Historically, levamisole was an immunomodulatory agent used in various cancer treatments in the United States. Currently the drug is used as an antihelminthic veterinary medication, but it is also used as an additive in freebase cocaine. There are multiple reports of levamisole-induced vasculitis in the head and neck but limited reported cases in the lower extremities. This article describes a 60-year-old woman who presented to the emergency department with multiple painful lower-extremity ulcerations.
Radiographs, laboratory studies, and punch biopsy were performed. Physical examination findings and laboratory results were negative for signs of infection. Treatment included local wound care and education on cocaine cessation, and the patient was transferred to a skilled nursing facility. Her continued use of cocaine, however, prevented her ulcers from healing.
Local wound care and cocaine cessation is the optimal treatment for levamisole-induced lesions. With the increase in the number of patients with levamisole-induced vasculitis, podiatric physicians and surgeons would benefit from the immediate identification of these ulcerations, as their appearance alone can be distinct and pathognomonic. Early identification of levamisole-induced ulcers is important for favorable treatment outcomes. A complete medical and social history is necessary for physicians to treat these lesions with local wound care and provide therapy for patients with addictions.
Background: Individuals with diabetic neuropathy may experience plantar ulcers and postural instability. Although use of an insole with arch support has the potential to decrease the incidence of plantar ulcers, the choice of proper design and material density concerning postural stability is challenging. The objective of this pilot study was to conduct a preliminary evaluation of the immediate effects of custom-made ethyl vinyl acetate insoles with arch support and Shore A values of 30 or 50 on static balance in patients with diabetes and neuropathic foot/feet.
Methods: Ten women with diabetes participated in this study. Static balance was analyzed while in double-limb standing with eyes closed and eyes open and while standing on a dominant limb with eyes open wearing shoes only and wearing shoes and insoles with Shore A values of 30 and 50.
Results: With insole, the mean values of center of pressure excursions decreased significantly while standing on double limbs with eyes closed. The improvement in static balance was greater while using the insole with greater density; however, the difference was not statistically significant.
Conclusions: An insole with arch support made of ethyl vinyl acetate Shore A of 30 and 50, which could decrease plantar pressure concentration, had no negative effect on the static balance of diabetes. Therefore, further research on the long-term effects of such insoles on the static balance of diabetes is suggested.
Foot complications are common in diabetic patients; foot ulcers are among the more serious consequences. These ulcers frequently become infected, and if not treated promptly and appropriately, diabetic foot infections can lead to septic gangrene and amputation. Foot infections may be classified as mild, moderate, or severe; this largely determines the approach to therapy. Staphylococcus aureus is the most common pathogen in these infections, and the increasing incidence of methicillin-resistant S aureus during the past two decades has further complicated antibiotic treatment. Chronic infections are often polymicrobial. Physiologic changes, and local and systemic inflammation, can affect the plasma and tissue pharmacokinetics of antimicrobial agents in diabetic patients, leading to impaired target-site penetration. Knowledge of the serum and tissue concentrations of antibiotics in diabetic patients is, therefore, important for choosing the optimal drug and dose. This article reviews the commonly used therapeutic options for treatment, including many newer antibiotics developed to target multidrug-resistant gram-positive bacteria, and includes available data relating specifically to the tissue penetration of these agents. (J Am Podiatr Med Assoc 100(1): 52–63, 2010)