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.
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)
Radiographic imaging of the foot is commonly performed when medical evaluation is indicated. Angular measurements between bones may be assessed as part of the examination for trauma and foot biomechanics. However, angular relationships between surfaces of the physical bone as they compare with the bone's radiographic image has had limited investigation.
For this study, 54 human feet from amputated limbs were imaged in standard radiographic views and skeletonized. Selected angular measurements were taken on each skeletonized talus and calcaneus and were compared with those taken from radiographic images using paired Student t tests and linear regression analysis.
Transverse plane measurements of the talus were not significantly different (P ≥ .05), associating strongly (r2 = 0.67–0.75; all P < .001). Most transverse and sagittal plane measurements of the calcaneus were not significantly different (P ≥ .05), with transverse plane measurements more strongly associated (r2 = 0.70–0.77; all P < .001) than sagittal plane measurements (r2 = 0.35–0.78; all P < .001).
Selected angular measurements of the talus and calcaneus taken from radiographic images can be compared quantitatively with the physical bone, demonstrating that angular measurements from radiographic images provide useful information concerning both of these bones. This knowledge can be applied to the understanding of the morphology of the calcaneus and talus as it relates to human foot biomechanics and should also be of use in the interpretation of the human fossil pedal record.
Osteomyelitis is one of the most feared sequelae of diabetic foot ulceration, which often leads to lower-extremity amputation and disability. Early diagnosis of osteomyelitis increases the likelihood of successful treatment and may limit the amount of bone resected, preserving ambulatory function. Although a variety of techniques exist for imaging the diabetic foot, standard radiography is still the only in-office imaging modality used today. However, radiographs lack sensitivity and specificity, making it difficult to diagnose bone infection at its early stages. In this report, we describe our initial experience with a cone beam computed tomography (CBCT)–based device, which may serve as an accurate and readily available tool for early diagnosis of osteomyelitis in a patient with diabetes. Two patients with infected diabetic foot ulcers were evaluated for osteomyelitis using radiography and CBCT. Positive imaging findings were confirmed by bone biopsy. In both patients, CBCT captured early osteolytic changes that were not apparent on radiographs, leading to early surgical intervention and successful treatment. The CBCT was helpful in facilitating detection and early clinical intervention for osteomyelitis in two diabetic patients with foot ulcers. These results are encouraging and warrant future evaluation.
Sixty-nine patients who had 96 interspaces decompressed were retrospectively reviewed to assess the efficacy of the endoscopic decompression of the intermetatarsal nerve procedure. Cases were evaluated between October 1, 1993, and December 31, 1999. Of the 69 patients, 14 were men and 55 were women, and their average age was 50.6 years. Of the 96 interspaces released, 39 were second interspaces and 57 were third interspaces. Nine interspaces were lost to follow-up. There were 75 interspaces with excellent or good results (86%) and 12 with poor results (14%). Of the interspaces with poor results, five required further surgery. Those five interspaces, in five patients, were treated with traditional neurectomy. The other patients, accounting for seven interspaces, who classified their result as poor declined any further surgery. Evaluation of these cases was by means of medical chart review only, where the patient’s success or failure was based on the patient’s subjective assessment. None of the patients who underwent decompression developed a true amputation neuroma. (J Am Podiatr Med Assoc 96(1): 19–23, 2006)
People suffering from diabetes are at risk of developing foot ulcerations which, if left untreated, could also lead to amputation. Monitoring of the foot temperature can help in the prevention of these foot complications, and various studies have shown that elevated temperatures may be indicative of ulceration. Over the years, there have been various devices that were designed for foot temperature monitoring, for both clinical and home use. The technologies used included infrared thermometry, liquid crystal thermography, infrared thermography, and a vast range of analogue and digital temperature sensors incorporated into different measurement platforms. All these systems are able to collect thermal data from the foot, with some being able to acquire data only when the foot is stationary and others being able to acquire data from the foot in motion, which can give more in-depth insight into any emerging problems. The aim of this review is to evaluate the available literature related to the technologies used in these systems, outlining the benefits of each and what further developments may be required to make the foot temperature analysis more effective.
Morton's neuroma is a common disease entity of the foot that is often treated with surgical resection. A complication of neuroma resection is recurrence of symptoms as a result of the formation of an amputation neuroma. The authors offer an anatomical and biomechanical explanation for the location of symptomatic amputation neuromas. The neuromas are found on the plantar surface proximal to the condyles of the metatarsal and medial to the interspace where the nerve is resected. The theory is based on intraoperative observations during surgery for recurrent neuromas and on cadaver dissections and offers a method based on this theory to reduce the number of recurrences.
There is evidence to indicate that therapeutic footwear can help prevent lower extremity amputation in patients with diabetes. The primary means of preventing amputation is to protect the insensitive foot from unnoticed trauma and excessive plantar pressures that occur during walking. The specific prescription of the shoe will depend on many foot risk criteria, but particularly on the patient's level of sensation, history of ulceration, and the amount of foot deformity. This article describes the type of footwear recommended for each of these increasing levels of foot risk categories.
A kinetic change in the foot such as altered plantar pressure is the most common etiological risk factor for foot ulcers in people with diabetes mellitus. Kinematic alterations in joint angle and spatiotemporal parameters of gait have also been frequently observed in participants with diabetic peripheral neuropathy (DPN). Diabetic peripheral neuropathy leads to various microvascular and macrovascular complications of the foot in type 2 diabetes mellitus. There is a gap in the literature for biomechanical evaluation and assessment of type 2 diabetes mellitus with DPN in the Indian population. We sought to assess and determine the biomechanical changes, including kinetics and kinematics, of the foot in DPN.
This cross-sectional study was conducted at a diabetic foot clinic in India. Using the purposive sampling method, 120 participants with type 2 diabetes mellitus and DPN were recruited. Participants with active ulceration or amputation were excluded.
The mean ± SD age, height, weight, body mass index, and diabetes duration were 57 ± 14 years, 164 ± 11 cm, 61 ± 18 kg, 24 ± 3 kg/m2, and 12 ± 7 years, respectively. There were significant changes in the overall biomechanical profile and clinical manifestations of DPN. The regression analysis showed statistical significance for dynamic maximum plantar pressure at the forefoot with age, weight, height, diabetes duration, body mass index, knee and ankle joint angle at toe-off, pinprick sensation, and ankle reflex (R = 0.71, R2 = 0.55, F12,108 = 521.9 kPa; P = .002).
People with type 2 diabetes mellitus and DPN have significant changes in their foot kinetic and kinematic parameters. Therefore, they could be at higher risk for foot ulceration, with underlying neuropathy and biomechanically associated problems.
Retrospective and prospective studies have shown that elevated plantar pressure is a causative factor in the development of many plantar ulcers in diabetic patients and that ulceration is often a precursor of lower-extremity amputation. Herein, we review the evidence that relieving areas of elevated plantar pressure (off-loading) can prevent and heal plantar ulceration.
There is no consensus in the literature concerning the role of off-loading through footwear in the primary or secondary prevention of ulcers. This is likely due to the diversity of intervention and control conditions tested, the lack of information about off-loading efficacy of the footwear used, and the absence of a target pressure threshold for off-loading. Uncomplicated plantar ulcers should heal in 6 to 8 weeks with adequate off-loading. Total-contact casts and other nonremovable devices are most effective because they eliminate the problem of nonadherence to recommendations for using a removable device. Conventional or standard therapeutic footwear is not effective in ulcer healing. Recent US and European surveys show that there is a large discrepancy between guidelines and clinical practice in off-loading diabetic foot ulcers. Many clinics continue to use methods that are known to be ineffective or that have not been proved to be effective while ignoring methods that have demonstrated efficacy.
A variety of strategies are proposed to address this situation, notably the adoption and implementation of recently established international guidelines, which are evidence based and specific, by professional societies in the United States and Europe. Such an approach would improve the often poor current expectations for healing diabetic plantar ulcers. (J Am Podiatr Med Assoc 100(5): 360–368, 2010)