Background: We aim to share our popliteal sciatic nerve block (PSB) experience, which we applied to diabetic and nondiabetic patients in the operating room of our hospital.
Methods: The patients who underwent PSB for foot and ankle surgery between October 1, 2021, and December 31, 2021, in Sakarya University Training and Research Hospital were evaluated retrospectively. All nerve blocks were administered by a single anesthesiologist. Demographic data of the patients and the duration of the operation, the type of operation, the time of application of the nerve block, whether it was single or bifurcation block, and the onset times of motor and sensory block were also recorded in the perioperative period.
Results: It was determined that PSB was applied to 49 patients over a 3-month period. The mean age of the patients was 61.33 ± 14.03 years, and 12 patients (24.5%) were women. The reason why the patients were operated on was amputation in 21 (42.9%) and wound debridement in 27 (55.1%). There were 37 patients in the diabetic group and 12 patients in the nondiabetic group. There was no significant difference between the two groups in terms of demographic data and operation characteristics, but it was observed that there was a significant difference in both sensory and motor block formation times between the two groups (P < .001).
Conclusions: In conclusion, we think that popliteal sciatic nerve block is easy to apply, the complication rate is low, and it is a suitable anesthesia method for patients who will undergo day surgery for foot ulcer.
Background: More than half of opioid misusers last obtained opioids from a friend or relative, a problematic reflection of the commonly known opioid reservoir maintained by variable prescription rates and, notably, excessive postoperative prescription. We examined the postoperative opioid-prescribing approaches among podiatric physicians.
Methods: We administered a scenario-based, anonymous, online questionnaire via an online survey platform. The questionnaire consisted of five patient–foot surgery scenarios aimed at discerning opioid-prescribing approaches. Respondents were asked how many opioid “pills” (dosage units) that they would prescribe at the time of surgery. We divided respondents into two opioid-prescribing approach groups: one-size-fits-all (prescribed the same dosage units regardless of the scenario) and patient-centric and procedure-focused (prescribed varied amounts of opioid dosage units based on the patient’s opioid history and the procedure provided in each scenario). We used the Mann-Whitney U test to determine the difference between the opioid dosage units prescribed at the time of surgery by the two groups.
Results: Approximately half of the respondents used a one-size-fits-all postoperative opioid-prescribing approach. Podiatric physicians who used a patient-centric and procedure-focused approach reported prescribing significantly fewer opioid dosage units in scenarios 1 (partial toe amputation; –9.1; P = .0087) and 2 (incision and drainage with partial fifth-ray resection; –12.3; P = .0024), which represented minor procedures with opioid-naive patients.
Conclusions: Podiatric physicians who used a one-size-fits-all opioid-prescribing approach prescribed more postoperative opioid dosage units regardless of the scenario. Given that the patient population requiring foot surgery is diverse and may have multiple comorbidities, the management of postoperative pain, likewise, should be diverse and nuanced. The patient-centric and procedure-focused approach is suited to limit excess prescribing while defending the physician-patient relationship.
On a national level, heroin-related hospital admissions have reached an all-time high. With the foot being the fourth most common injection site, heroin-related lower-extremity infections have become more prevalent owing to many factors, including drug preparation, injection practices, and unknown additives.
We present a 16-month case series in which eight patients with lower-extremity infections secondary to heroin abuse presented to The Jewish Hospital in Cincinnati, Ohio.
Three cases of osteomyelitis were seen. All of the infections were cultured and yielded a wide array of microbes, including Staphyloccoccus, Streptococcus, Bacillus, Serratia, Prevotella, and Eikenella. All of the patients were treated with intravenous antibiotic agents, with nearly all receiving combination therapy. Seven of the eight patients underwent surgery during their hospital stay, with two undergoing amputation. Only half of the patients followed up after discharge.
This case series brings to light many considerations in the diagnosis and management of the heroin user, including multivariable attenuation of immunity, existing predisposition to infection backed by unsterile drug preparation and injection practices, innocuous presentation of deep infections, microbial spectrum, and recommendations on antimicrobial intervention, noncompliance, and poor follow-up. By having greater knowledge in unique considerations of diagnosis and treatment, more efficient care can be provided to this unique patient population.
Diabetic foot wounds remain a significant health-care issue. Healing these wounds in a timely manner is of paramount importance because the duration of ulceration correlates with increased rates of infection and amputation, costing billions of dollars yearly. Collagen-based matrices have been used as wound covers and have been shown to improve and expedite healing. We present our experience with equine pericardium biomatrix for the treatment of neuropathic foot wounds.
Thirty-four patients with 37 diabetic foot wounds were evaluated at two institutions prospectively. All of the wounds were debrided, and equine pericardium biomatrix was applied. Secondary dressings were changed every 48 to 72 hours until healed or for 12 weeks after application. Healing rate at 12 weeks, time to wound closure, and complications were evaluated.
Twenty-two men and 12 women (mean age, 56.9 years) were treated and evaluated. Mean and median wound sizes at initial treatment were 715.8 and 440 mm2, respectively. The overall wound healing rate by 12 weeks was 75.7% (n =28). Mean and median times to wound closure were 7.2 and 7.0 weeks, respectively. No device or procedure-related complications were reported.
The use of equine pericardium as a temporary biological scaffold is safe and effective for the treatment of chronic neuropathic foot wounds. (J Am Podiatr Med Assoc 102(5): 352–358, 2012)
Diabetic foot infections are a common and often serious problem, accounting for more hospital bed days than any other complication of diabetes. Despite advances in antibiotic drug therapy and surgical management, these infections continue to be a major risk factor for amputations of the lower extremity. Although a variety of wound size and depth classification systems have been adapted for use in codifying diabetic foot ulcerations, none are specific to infection. In 2003, the International Working Group on the Diabetic Foot developed guidelines for managing diabetic foot infections, including the first severity scale specific to these infections. The following year, the Infectious Diseases Society of America published their diabetic foot infection guidelines. Herein, we review some of the critical points from the Executive Summary of the Infectious Diseases Society of America document and provide a commentary following each issue to update the reader on any pertinent changes that have occurred since publication of the original document in 2004.
The importance of a multidisciplinary limb salvage team, apropos of this special issue jointly published by the American Podiatric Medical Association and the Society for Vascular Surgery, cannot be overstated. (J Am Podiatr Med Assoc 100(5): 395–400, 2010)
Osteomyelitis is a common complication in the diabetic foot that can conclude with amputation. The purpose of this study was to evaluate the role of diffusion-weighted magnetic resonance imaging (DWI) in the diagnosis of osteomyelitis in diabetic foot ulcer (DFU).
Thirty patients with type 2 diabetes mellitus and a DFU were enrolled. Both DWIs and conventional MRIs were obtained. Apparent diffusion coefficient (ADC) measurements were made by transferring the images to a workstation. The measurements were made both from bone with osteomyelitis, or nearest to the injured area if osteomyelitis is not available, and from the adjacent soft tissue.
The patients comprised nine women (30%) and 21 men (70%) with a mean age of 58.7 years (range, 41–78 years). The levels of ADC were significantly low (P = .022) and the erythrocyte sedimentation rates were significantly high (P = .014) in patients with osteomyelitis (n = 9) compared with patients without osteomyelitis (n = 21). The mean ± SD bone ADC value (0.75 ± 0.16 × 10–3 mm2/sec) was significantly lower than the adjacent soft-tissue ADC value (0.90 ± 0.15 × 10–3 mm2/sec) in patients with osteomyelitis (P = .04).
It is suggested that DWI contributes to conventional MRI with short imaging time and no requirement for contrast agent. Therefore, DWI may be an alternative diagnostic method for the evaluation of DFU and the detection of osteomyelitis.
This prospective longitudinal study assessed whether baseline mean skin temperature measurements are useful in predicting the most common foot-related complications of diabetes mellitus. We evaluated the mean of baseline skin temperatures taken bilaterally from six plantar sites in 1,588 patients with diabetes. There was no difference in skin temperature based on neuropathy, foot laterality, or foot risk category or between people with and without foot deformity and elevated plantar foot pressure. Whereas people with Charcot’s arthropathy had slightly but significantly higher mean temperatures (84.8° ± 3.5° F versus 82.5° ± 4.7° F), this was not true for those who developed ulcers or infections or who underwent amputations. The presence of vascular disease was not associated with lower skin temperatures. Mexican Americans (83.0° ± 4.6° F) and blacks (83.6° ± 4.5° F) had higher mean skin temperatures at baseline than did non-Hispanic whites (81.8° ± 4.6° F). Baseline measurement of nonfocal mean skin temperatures is not an effective means of screening people for future events. Regular assessment of skin temperatures, using the contralateral site as a physiologic control, may be a better use of this technology. (J Am Podiatr Med Assoc 93(6): 443-447, 2003)
Background: We sought to determine the similarity of pathogens isolated from soft tissue and bone in patients with diabetic foot infections. It is widely believed that soft-tissue cultures are adequate in the determination of causative bacteria in patients with diabetic foot osteomyelitis. The culture results of specimens taken concurrently from soft-tissue and bone infections show that the former does not predict the latter with sufficient reliability. We sought to determine the similarity of pathogens isolated from soft tissue and bone in patients with diabetic foot infections.
Methods: Forty-five patients with diabetic foot infections were enrolled in the study. Patients had to have clinically suspected foot lesions of grade 3 or higher on the Wagner classification system. In patients with clinically suspected osteomyelitis, magnetic resonance imaging, scintigraphy, or histopathologic examination were performed. Bone and deep soft tissue specimens were obtained from all patients by open surgical procedures under aseptic conditions during debridement or amputation. The specimens were compared only with the other specimens taken from the same patients.
Results: The results of bone and soft-tissue cultures were identical in 49% (n = 22) of cases. In 11% (n = 5) of cases there were no common pathogens. In 29% (n = 13) of cases there were more pathogens in the soft-tissue specimens; these microorganisms included microbes isolated from bone cultures. In four patients (9%) with culture-positive soft-tissue specimens, bone culture specimens remained sterile. In one patient (2%) with culture-positive bone specimen, soft-tissue specimen remained sterile.
Conclusion: Culture specimens should be obtained from both the bone and the overlying deep soft tissue in patients with suspected osteomyelitis whose clinical conditions are suitable. The decision to administer antibiotic therapy should depend on these results. (J Am Podiatr Med Assoc 98(4): 290–295, 2008)
In spite of the most vigorous efforts to intervene medically and surgically when peripheral vascular disease threatens a patient, amputation of the extremity may be the only option left to arrest the progression of the disease. In a previous study, the authors assessed amputations, examined gross pathology, and identified scanning electron microscopic features associated with atherosclerotic disease. In the present study, the authors discuss this disease in terms of conventional light microscopy and transmission electron microscopy.
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)