Search Results
Background:
We investigated the validity of probe-to-bone testing in the diagnosis of osteomyelitis in a selected subgroup of patients clinically suspected of having diabetic foot osteomyelitis.
Methods:
Between January 1, 2007, and December 31, 2008, inpatients and outpatients with a diabetic foot ulcer were prospectively evaluated, and those having a clinical diagnosis of foot infection and at least one of the osteomyelitis clinical suspicion criteria were consecutively included in this study.
Results:
Sixty-five patients met the inclusion criteria and were prospectively enrolled in the study. Forty-nine patients (75.4%) were hospitalized, and the remaining 16 (24.6%) were followed as outpatients. Osteomyelitis was diagnosed in 39 patients (60.0%). Probe-to-bone test results were positive in 30 patients (46.1%). The positive predictive value for the probe-to-bone test was fairly high (87%), but the negative predictive value was only 62%. The sensitivity and specificity of the test were 66% and 84%, respectively. White blood cell counts and mean C-reactive protein levels did not statistically significantly differ between groups. However, erythrocyte sedimentation rates greater than 70 mm/h reached statistical significance between groups. Wound area and depth were not found to be statistically significantly different between groups.
Conclusions:
Positive probe-to-bone test results and erythrocyte sedimentation rates greater than 70 mm/h provide some support for the diagnosis of diabetic foot osteomyelitis, but it is not strong; magnetic resonance imaging or bone biopsy will probably be required in cases of doubt. (J Am Podiatr Med Assoc 102(5): 369–373, 2012)
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)
Fasciotomy and Surgical Tenotomy for Chronic Achilles Insertional Tendinopathy
A Retrospective Study Using Ultrasound-Guided Percutaneous Microresection
Background:
Achilles insertional tendon pathology is a common condition affecting a broad range of patients. When conservative treatments are unsuccessful, the traditional open resection, debridement, and reattachment of the Achilles tendon is a variably reliable procedure with significant risk of morbidity. Fasciotomy and surgical tenotomy using ultrasound-guided percutaneous microresection is used on various tendons in the body, but the efficacy has not been examined specifically for the Achilles tendon.
Methods:
A retrospective review evaluated 26 procedures in 25 patients who underwent Achilles fasciotomy and surgical tenotomy. The Foot Function Index was used to quantify pain, disability, activity limitation, and overall scores.
Results:
Mean Foot Function Index scores were as follows: pain, 8.53%; disability, 7.91%; activity limitation, 2.50%; and overall, 6.97%. Twenty index procedures were successful, and two patients repeated the procedure successfully for an overall 84.6% success rate in patients with chronic insertional pathology with mean surveillance of 16 months. There were no infections or systemic complications.
Conclusions:
Ultrasound-guided percutaneous microresection is a safe and minimally invasive percutaneous alternative that can be used before proceeding to a more invasive open procedure.
Fungal Diversity and Onychomycosis
An Analysis of 8,816 Toenail Samples Using Quantitative PCR and Next-Generation Sequencing
Background:
Onychomycosis is a fungal infection of the nail that is often recalcitrant to treatment and prone to relapse. Traditional potassium hydroxide and culture diagnosis is costly and time-consuming. Therefore, molecular methods were investigated to demonstrate effectiveness in diagnosis and to quantify the microbial flora present that may be contributing to disease.
Methods:
A total of 8,816 clinically suspicious toenail samples were collected by podiatric physicians across the United States from patients aged 0 to 103 years and compared with a control population (N = 20). Next-generation sequencing and quantitative polymerase chain reaction were used to identify and quantify dermatophytes, nondermatophyte molds, and bacteria.
Results:
Approximately 50% of suspicious toenails contained both fungi and bacteria, with the dermatophyte Trichophyton rubrum contributing the highest relative abundance and presence in 40% of these samples. Of the remaining 50% of samples, 34% had bacterial species present and 16% had neither. Fungi only were present in less than 1% of samples. Nondermatophyte molds contributed to 11.0% of occurrences in fungus-positive samples. All of the control samples were negative for fungi, with commensal bacterial species composing most of the flora population.
Conclusions:
Molecular methods were successful in efficiently quantifying microbial and mycologic presence in the nail. Contributions from dermatophytes were lower than expected, whereas the opposite was true for nondermatophyte molds. The clinical significance of these results is currently unknown.
Phaeohyphomycosis is a spectrum of subcutaneous and systemic infections caused by a variety of dematiaceous fungi. It is an opportunistic disease with an increased incidence in immunocompromised patients. We report a case of a pedal phaeohyphomycotic cyst in an immunocompetent adult male immigrant with the goal of highlighting its clinical presentation, diagnosis, and optimal treatment. A 57-year-old male immigrant from Panama presented with a painless, gradually increasing, large cystic lesion in his left foot, first intermetatarsal space, which had been present for many years. The patient was treated with surgical excision without antifungal therapy. Histologic analysis showed multiple granulomas composed of fibrin and necrosis in the centers surrounded by proliferative palisading fibroblasts admixed with heavily infiltrated neutrophils, plasma cells, macrophages, lymphocytes, and eosinophils. Periodic acid-Schiff and Fontana-Masson stains revealed sporadic, scattered dematiaceous fungal hyphae and pseudohyphae among granulomatous tissues. The mass was diagnosed as a phaeohyphomycotic cyst. Polymerase chain reaction–based sequencing failed to identify the fungal species because of the rarity of the fungal elements in the granulomatous tissues. The patient had no recurrence at a follow-up of 2 years. A phaeohyphomycotic cyst is a rare entity that needs to be differentiated from other benign and malignant lesions. Multiple modalities, including clinical evaluation, radiography, histologic analysis, microbiological culture, and nucleic acid sequencing, should be used for the final diagnosis. Surgical excision is an optimal treatment. Antifungal therapy should be considered based on the patient’s clinical manifestation, surgical excision, and immune functional status.
Background: Kaposi sarcoma (KS) has multiple clinical variants, and most frequently presents on the lower extremities. Anti–human immunodeficiency virus (HIV) therapy has significantly reduced the incidence of KS. However, KS is still prevalent in both HIV-infected and HIV-uninfected patients. This case series analysis aims to reveal the clinical presentations, differential diagnosis, and treatment options of KS on the foot and ankle.
Methods: Eleven cases of KS involving the foot and ankle were retrieved from our patient database, and their clinicopathologic features were analyzed.
Results: All patients were men, aged 29 to 85 years. Two types of KS were found: classic and acquired immunodeficiency syndrome–associated epidemic. The average ages of classic and epidemic KS were 65.7 and 41.8 years, respectively. Clinically, three patients manifested multiple erythematous or deep violaceous, or blue-violaceous macules on either the dorsal or plantar surfaces of both feet. Eight patients showed exophytic, pyogenic granuloma-like nodules on the plantar surface, heels, and toes. Histologically, all KSs had uniform intervening fascicles of elongated spindle cells with slit-like vascular spaces filled with red blood cells and immunoreactivity with human herpesvirus-8. The patients were treated according to HIV infection status. Human immunodeficiency virus–infected patients were treated with anti-HIV therapy after primary surgical excision or biopsy. Human immunodeficiency virus–negative patients were treated with either surgical excision, Mohs surgery, or a combination of surgical excision and local radiotherapy according to individual patient clinical presentation.
Conclusions: Kaposi sarcoma is still prevalent in both HIV-infected and HIV-uninfected patients with a variety of clinical presentations. Biopsy, with histologic evaluation, in combination with immunohistochemistry is essential for the differential diagnosis. The patient should be treated according their clinical manifestation, staging, comorbidity, and immune function.
Nerve Decompression After Diabetic Foot Ulceration May Protect Against Recurrence
A 3-Year Controlled, Prospective Analysis
Background
Nerve entrapment, common in diabetes, is considered an associated phenomenon without large consequence in the development of diabetes complications such as ulceration, infection, amputation, and early mortality. This prospective analysis, with controls, of the ulcer recurrence rate after operative nerve decompression (ND) offers an objective perspective on the possibility of frequent occult nerve entrapment in the diabetic foot complication cascade.
Methods
A multicenter cohort of 42 patients with diabetic sensorimotor polyneuropathy, failed pharmacologic pain control, palpable pulses, and at least one positive Tinel's nerve percussion sign was treated with unilateral multiple lower-leg external neurolyses for the indication of pain. All of the patients had healed at least one previous ipsilateral plantar diabetic foot ulceration (DFU). This group was retrospectively evaluated a minimum of 12 months after operative ND and again 3 years later. The recurrence risk of ipsilateral DFU in that period was prospectively analyzed and compared with new ulcer occurrence in the contralateral intact, nonoperated control legs.
Results
Operated legs developed two ulcer recurrences (4.8%), and nine contralateral control legs developed ulcers (21.4%), requiring three amputations. Ulcer risk is 1.6% per patient per year in ND legs and 7% in nonoperated control legs (P = .048).
Conclusions
Adding operative ND at lower-leg fibro-osseous tunnels to standard postulcer treatment resulted in a significantly diminished rate of subsequent DFU in neuropathic high-risk feet. This is prospective, objective evidence that ND can provide valuable ongoing protection from DFU recurrence, even years after primary ulcer healing.
The Percutaneous Surgical Approach for Repairing Acute Achilles Tendon Rupture
A Comprehensive Outcome Assessment
Background: Treatment modalities for acute Achilles tendon rupture can be divided into operative and nonoperative. The main concern with nonoperative treatment is the high incidence of repeated ruptures; operative treatment is associated with risk of infection, sural nerve injury, and wound-healing sequelae. We assessed our experience with a percutaneous operative approach for treating acute Achilles tendon rupture.
Methods: The outcomes of percutaneous surgery in 29 patients (25 men; age range, 24–58 years) who underwent percutaneous surgery for Achilles tendon rupture between 1997 and 2004 were retrospectively evaluated. Their demographic data, subjective and objective evaluation findings, and isokinetic evaluation results were retrieved, and they were assessed with the modified Boyden score and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale.
Results: All 29 patients demonstrated good functional outcome, with no- to mild-limitations in recreational activities and high patient satisfaction. Mean follow-up was 31.8 months. Changes in ankle range of motion in the operated leg were minimal. Strength and power testing revealed a significant difference at 90°/sec for plantarflexion power between the injured and healthy legs but no difference at 30° and 240°/sec or in dorsiflexion. The mean modified Boyden score was 74.3, and the mean Ankle-Hindfoot Scale score was 94.5.
Conclusions: Percutaneous surgery for Achilles tendon rupture is easily executed and has excellent functional results and low complication rates. It is an appealing alternative to either nonoperative or open surgery treatments. (J Am Podiatr Med Assoc 100(4): 270–275, 2010)
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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)
Background: The aim of this study was to share the clinical results of open calcaneus fractures, which are extremely rare and have become the fearful nightmare of orthopedic surgeons.
Methods: Between June of 2014 and June of 2020, of 196 patients with the diagnosis of calcaneus fracture, Gustilo-Anderson type IIIB, 17 patients (11 men and six women; mean age, 36.2 ± 4.6 years; range, 22–56 years) under prospective follow-up were retrospectively screened and included in the study. Patients were recorded in terms of classification of fracture, mechanism of injury, comorbidities, surgical progress, complications, and associated orthopedic and nonorthopedic injuries. Functional clinical results and quality of life of the patients were evaluated at the 6-month follow-up with the American Orthopedic Foot and Ankle Society score and the 36-Item Short Form Health Survey questionnaire.
Results: The most common etiologic factor was work-related injuries, with 29.4%. Although triple arthrodesis surgery was performed in three cases because of pseudoarthrosis, amputation was performed in one case because of deep infection. The most common soft-tissue defect was located at the medial aspect of the foot, which was commonly reconstructed with the used of reverse flow island sural flap. The average total American Orthopedic Foot and Ankle Society hindfoot score was 51.6 (range, 48–74) and similarly, physical component, pain, and social parameters on the 36-Item Short Form Health Survey were statistically significant compared to Turkish population normal scores.
Conclusions: A long and laborious process is required for both the patient and the surgeon in the treatment of open calcaneal fractures. However, it is possible to obtain good results with soft-tissue reconstructions.
