Because neuroischemic complications are associated with a high rate of recurrence, we propose a slight shift in the mechanism by which we counsel and communicate risk daily with our patients. If the epidemiology of this problem is comparable with that of cancer, and recurrences are common, then perhaps language commensurate with such risks should follow. After initial healing of an index wound, our unit now refers to patients not as being cured but rather as being “in remission.” This concept is easy for the patient and the rest of the team to understand. We believe that it powerfully connotes the necessity for frequent follow-up and rapid intervention for inevitable minor and sometimes major complications. (J Am Podiatr Med Assoc 103(2): 161–162, 2013)
Malignant melanoma is responsible for more than three-fourths of skin cancer deaths in the United States. Melanomas presenting on acral surfaces are frequently misdiagnosed initially, leading to progression of disease and worse prognosis. This case is presented to reinforce the significance of careful physical examination and early biopsy of atypical ulcerations of the foot.
There is increasing pressure from industry to use advanced wound care products and technologies. Many are very expensive but promise to reduce overall costs associated with wound care. Compelling anecdotal evidence is provided that inevitably shows wounds that failed all other treatments but responded positively to the subject product. Evidence-based medicine is the standard by which physician-scientists must make their clinical care decisions. In an attempt to provide policy makers with the most current evidence on advanced wound care products, the Department of Veteran Affairs conducted an Evidence-based Synthesis Program review of advanced wound care products. This paper suggests how to take this information and apply it to policy to drive evidence-based care to improve outcomes and fiduciary responsibility.
One hundred eighty-seven type 2 diabetic patients without a history of foot ulceration were followed for a mean period of 3.6 years to investigate the incidence of foot ulceration in a diabetes cohort and to analyze risk factors for foot ulceration by multivariate means. During the study, 10 subjects developed 18 forefoot ulcerations. In multivariate logistic regression, significant predictors for foot ulceration were an elevated vibration perception threshold (VPT) (relative risk [RR] = 25.4), an increased plantar pressure (RR = 6.3), and daily alcohol intake (RR = 5.1). This is the first prospective study to demonstrate plantar pressure and daily alcohol intake as predictors of foot ulceration among patients without previous ulceration. Further, VPT could be confirmed as the strongest predictor for foot ulceration, and it was clearly demonstrated that the more pronounced severity of complications occurred among subjects with elevated VPT. (J Am Podiatr Med Assoc 91(7): 343-350, 2001)
Poorly fitting footwear has frequently been cited as an etiologic factor in the pathway to diabetic foot ulceration. However, we are unaware of any reports in the medical literature specifically measuring shoe size versus foot size in this high-risk population. We assessed the prevalence of poorly fitting footwear in individuals with and without diabetic foot ulceration. We evaluated the shoe size of 440 consecutive patients (94.1% male; mean ± SD age, 67.2 ± 12.5 years) presenting to an interdisciplinary teaching clinic. Of this population, 58.4% were diagnosed as having diabetes, and 6.8% had active diabetic foot ulceration. Only 25.5% of the patients were wearing appropriately sized shoes. Individuals with diabetic foot ulceration were 5.1 times more likely to have poorly fitting shoes than those without a wound (93.3% versus 73.2%; odds ratio [OR], 5.1; 95% confidence interval [CI], 1.2–21.9; P = .02). This association was also evident when assessing only the 32.3% of the total population with diabetes and loss of protective sensation (93.3% versus 75.0%; OR, 4.8; 95% CI, 1.1–20.9; P = .04). Poorly fitting shoes seem to be more prevalent in people with diabetic foot wounds than in those without wounds with or without peripheral neuropathy. This implies that appropriate meticulous screening for shoe-foot mismatches may be useful in reducing the risk of lower-extremity ulceration. (J Am Podiatr Med Assoc 96(4): 290–292, 2006)
Background: Recurrent ulceration is a common problem after partial first-ray amputations. Loss of the first metatarsophalangeal joint contributes to altered biomechanics and increased pressure on the foot. This may increase risk of adjacent ulcerations and additional amputations. Preserving first-ray length maintains the metatarsal parabola and limits transfer lesions, but few data support this. We aimed to evaluate the incidence of ulceration after partial first-ray amputations and to assess the association between metatarsal protrusion distance and recurrent ulceration.
Methods: Thirty-two consecutive patients underwent unilateral partial first-ray amputation at various levels along the first metatarsal, and the metatarsal protrusion distance was measured after surgery. Incidence of ulceration was evaluated on the ipsilateral foot. We hypothesized that patients with a longer first metatarsal were less likely to ulcerate again on the ipsilateral foot.
Results: Fourteen patients (43.8%) ulcerated again after partial first-ray amputation. Mean time to ulceration was 104 days. Active smoking status was associated with increased risk of another ulceration (P = .02), and chronic kidney disease was associated with a decreased risk of recurrent ulceration (P = .03). The average metatarsal protrusion distance for patients who ulcerated again after surgery was 36.1 mm versus 25.9 mm for patients who did not (P = .04). Logistic regression analysis of the receiver operating characteristic curve demonstrated an ideal cutoff length for recurrent ulceration of 37 mm (area under the curve = 0.7381). Patients with a protrusion distance greater than 37 mm were nine times as likely to ulcerate again (95% CI, 1.7–47.0).
Conclusions: Partial first-ray amputations can be a good initial salvage procedure to clear infection and prolong bipedal ambulatory status. Unfortunately, these patients are prone to recurrent ulceration. Significant loss of first metatarsal length is a poor prognostic indicator for recurrent ulceration.