Osteolysis, caused by active resorption of bone matrix by osteoclasts, can be primary or can develop secondary to a variety of disease processes. An elevated level of inflammatory cytokines in the local milieu and increased blood flow secondary to infection or autonomic neuropathy stimulate the osteoclasts and cause bone loss in the diabetic foot. Charcot's neuroarthropathy and osteomyelitis are well-known foot complications of diabetes, and secondary osteolysis has largely been underappreciated and, hence, underreported. Plain radiographs, an initial component in the evaluation of the diabetic foot, may not successfully differentiate secondary osteolysis from osteomyelitis. We describe a patient with phalangeal osteolysis secondary to soft-tissue infection in whom a correct and timely diagnosis helped avoid unnecessary surgical interventions.
Diabetes often causes ulcers on the feet of diabetic patients. A 56-year-old, insulin-dependent, diabetic woman presented to the wound care center with a Wagner grade 3 ulcer of the right heel. She reported a 3-week history of ulceration with moderate drainage and odor and had a history of ulceration and osteomyelitis in the contralateral limb. Rigorous wound care, including hospitalization; surgical incision and drainage; intravenous antibiotic drug therapy; vacuum-assisted therapy; and a new room temperature, sterile, human acellular dermal matrix graft were used to heal the wound, save her limb, and restore her activities of daily living. This case presentation involves alternative treatment of a diabetic foot ulcer with this new acellular dermal matrix, DermACELL.
Ill-fitting shoes may precipitate up to half of all diabetes-related amputations and are often cited as a leading cause of diabetic foot ulcers (DFU), with those patients being 5 to 10 times more likely to present wearing improperly fitting shoes. Among patients with prior DFU, those who self-select their shoe wear are at a three-fold risk for reulceration at 3 years versus those patients wearing prescribed shoes. Properly designed and fitted shoes should then address much of this problem, but evidence supporting the benefit of therapeutic shoe programs is inconclusive. The current study, performed in a male veteran population, is the first such effort to examine the prevalence and extent of change in foot length affecting individuals following skeletal maturity. Nearly half of all participants in our study experienced a ≥1 shoe size change in foot length during adulthood. We suggest that these often unrecognized changes may explain the broad use of improperly sized shoe wear, and its associated sequelae such as DFU and amputation. Regular clinical assessment of shoe fit in at-risk populations is therefore also strongly recommended as part of a comprehensive amputation prevention program.
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.
The talonavicular joint is a rare site of dislocation. Its etiology varies and can be the result of either acute trauma or a chronic degenerative process that most commonly occurs in patients with rheumatoid arthritis or Charcot arthropathy. Our aim is to highlight the relationship between the underlying pathology of talonavicular dislocations and the final outcome in the case of operative management.
We present three cases of talonavicular dislocation with the dislocation itself as the only common denominator, and a completely different etiology, natural history, treatment, and prognosis among them.
There was one case of a traumatic talocalcaneonavicular dislocation in a healthy individual, one case in a rheumatoid arthritis patient, and one case in a patient with diabetes mellitus. All patients were treated surgically. The outcomes were excellent, fair, and poor, respectively.
Among many factors that influence prognosis, it is equally critical to evaluate the overall background in which the dislocation occurs so as to apply the suitable treatment. The surgeon not only needs to treat the local incident but also appreciate the general medical condition to provide the best final outcome to the patient.
Stenotrophomonas maltophilia is an uncommon gram-negative bacterium often found in individuals with long-standing broad-spectrum antibiotic use or catheter use; individuals undergoing hemodialysis; and individuals with prolonged respiratory disease, specifically, cystic fibrosis. To our knowledge, there are few reported cases of S maltophilia being the causative pathogen of infection in a diabetic foot wound.
Following multiple surgical procedures and deep tissue cultures, S maltophilia was determined to be a secondary opportunistic colonizer of the wound, necessitating a change in antibiotic therapy.
The cultured pathogen was sensitive to ceftazidime, levofloxacin, and trimethoprim-sulfamethoxazole. The treatment team chose to use ceftazidime, as it also provided antibiotic coverage for the initial wound and blood cultures. Change in antibiotic therapy was initiated following multiple surgical procedures and angioplasty of the lower limb. The patient was discharged with a peripheral intravenous central catheter for outpatient antibiotic therapy.
Prolonged exposure to broad-spectrum antibiotics in individuals with multiple comorbidities including diabetes mellitus provides an advantageous environment for growth of uncommon multidrug-resistant organisms. Stenotrophomonas maltophilia may complicate the treatment of diabetic foot infections as an opportunistic pathogen. Understanding the implication of long-term broad-spectrum antibiotic treatment in the diabetic patient is important in managing postoperative complications and determining the correct course of treatment. The emergence of atypical pathogens in diabetic wounds must be managed appropriately.
We present a case of a pediatric patient with a history of spina bifida who presented to the emergency department of a large Army medical treatment facility with a partially amputated right fifth digit she sustained while sleeping with the family canine. There are several reports in the popular press that suggest that an animal, particularly a dog, can detect human infection, and it is hypothesized that the toe chewing was triggered by a wound infection. This case provides an opportunity to provide further education in caring for foot wounds in patients with spina bifida.
Focal epileptic seizures can be the first manifestation of a diabetic disorder. Metabolic disturbances, including hyperglycemia, mild hyperosmolality, hyponatremia, and lack of ketoacidosis contribute to the development of partial focal seizures. A review of the medical literature for partial focal seizures is presented, followed by a case study of a patient who developed clonic seizures of the right foot secondary to hyperglycemia, hyponatremia, and hyperosmolality. (J Am Podiatr Med Assoc 92(2): 109-111, 2002)
We report on a 63-year-old male who was found to have an acrochordon on his plantar foot. Although acrochordons constitute a common benign clinical finding, this observation represents, to our knowledge, only the second case reported on the foot and the first occuring on the plantar surface.
Limb salvage for Charcot's neuroarthropathy has been shown to have high complication and failure rates. The aim of our report of two cases it to present a unique complication encountered with staged limb salvage for Charcot's neuroarthropathy. In two cases, patients developed delayed tibial shaft fracture associated with previous wire placement despite insertion of locked intramedullary nail fixation that spanned the delayed fracture. Both patients experienced fractures following advancement of weight after definitive fixation. In both patients, there was noted complication with the sites of the pins and revision of external fixation before fracture. In each case, the fracture was within the construct of the intramedullary fixation and successfully treated with an extended course of nonweightbearing. Complications of external fixation and intramedullary fixation are well reported within the literature; however, tibia fracture is rare. Based on these cases, it would seem prudent to recognize the risk of delayed pin-site complications and ensure adequate length of intramedullary fixation to span the potential areas of stress.