Pseudoaneurysms are created by a traumatic or iatrogenic perforation of an artery, resulting in accumulation of blood between the two outermost layers of a blood vessel, the tunica media and tunica adventitia. Pedal artery pseudoaneurysms are an extremely uncommon complication of foot and ankle surgery; therefore, few cases have been reported in the literature. Early diagnosis is important to ensure timely treatment of this condition. Once clinical suspicion has been established, urgent referral to the vascular surgery clinic for prompt surgical evaluation is required to prevent potentially harmful sequelae. We present the case of a 70-year-old woman who developed a pseudoaneurysm of the dorsalis pedis artery 33 days after undergoing open reduction and internal fixation of a second metatarsal fracture. Her treatment included urgent referral to the vascular surgery clinic with subsequent surgical repair of the pseudoaneurysm by means of ligation of the medial dorsal branch of the dorsalis pedis artery. At 10-month follow-up, she denied any pain, sensory deficits, or functional disability and had returned to all preinjury activities, with no recurrence of the pseudoaneurysm. Our case study demonstrates early diagnosis and successful treatment of a pseudoaneurysm of the dorsalis pedis artery that developed shorty after open reduction and internal fixation of a second metatarsal fracture.
Intraosseous epidermoid inclusion cysts are rare benign bone lesions that occur most commonly in the skull and in the distal phalanges of the fingers. Herein we report a case of an intraosseous epidermoid inclusion cyst occurring in the distal phalanx of the left hallux. Only six occurrences of this lesion have been described in the foot. This patient’s presentation, with active drainage (initially appearing as purulent discharge from an acutely tender ingrown hallux nail) and a known inoculation event accompanied by severe peripheral vascular disease, make this case unique. (J Am Podiatr Med Assoc 100(2): 133–137, 2010)
Nail pyogenic granulomas are common benign vascular lesions often occurring after trauma. A variety of treatment modalities exist, including topical therapies and surgical excision, although both have their pros and cons. In this communication, we describe the case of a 7-year-old boy with repeated toe trauma, who developed a large nail bed pyogenic granuloma after undergoing surgical debridement and nail bed repair. He was treated with 3 months of topical 0.5% timolol maleate, resulting in complete resolution of the pyogenic granuloma and minimal nail deformity.
We sought to determine the prevalence of lower-extremity arterial calcification in a cohort of patients with diabetes and associated foot pathology receiving inpatient treatment at an urban US tertiary health-care system.
The primary outcome measure was defined as either radiographic evidence of vessel calcification or noninvasive vascular testing that resulted in any reporting of vessel noncompressibility or an ankle-brachial index greater than 1.1. Radiographic evidence of vessel calcification was defined as radiodense calcification in the proximal first intermetatarsal space (deep plantar perforating artery), anterior ankle (anterior tibial artery), or posterior ankle (posterior tibial artery) on dorsoplantar and lateral foot projections.
Of the 367 individuals included in the study, 359 underwent radiography, with radiographic evidence of calcification in 192 (53.5%). Noninvasive vascular testing was performed on 265 participants, with any reporting of noncompressibility or an ankle-brachial index greater than 1.1 observed in 153 (57.7%). Ninety-four participants (25.6%) demonstrated evidence of arterial calcification on the radiographs and noninvasive testing, meaning that 251 participants (68.4%) demonstrated evidence of arterial calcification on at least one test, including 63.6% of participants classified as black/African American race, 65.4% as white race, and 78.3% as Hispanic/Latino ethnicity.
The results of this investigation increase the body of knowledge with respect to the evaluation and treatment of diabetic foot disease and may lead to future investigations on the topic of lower-extremity arterial calcification.
Persons with diabetes have a higher incidence of fractures compared with persons without diabetes. However, there is little published information concerning the deleterious effect of late-stage diabetes on fracture healing. There are no studies using animal models that evaluate the effect of advanced diabetes on fracture healing. The purpose of our study was to evaluate cytokine expression, specifically macrophage inflammatory protein 1 (MIP-1) and vascular endothelial growth factor, in fracture healing in a type 2 diabetes rat model.
We evaluated biomarker expression after femur fracture using a rat model. The two groups consisted of 24 Zucker diabetic rats (study group) and 12 Zucker lean rats (control group). An independent reviewer was used to assess delayed union. We evaluated serum samples 2, 4, 7, and 14 days after surgery for MIP-1, vascular endothelial growth factor, leptin, and other cytokine levels.
At 3 weeks, Kaplan-Meier estimates showed that 45.8% of femur fractures in Zucker diabetic rats had healed, whereas 81.8% of those in Zucker lean rats had healed (P = .02). A logistic regression model to predict fast healing that included the three cytokines and diabetes status showed that the only factor achieving significance was MIP-1α. Vascular endothelial growth factor was the only biomarker to show significance compared with delayed healing.
These results confirm significant differences in biomarker expression between diabetic and nondiabetic rats during bone healing. The key factors for bone healing may appear early in the healing process, whereas differences in diabetes versus nondiabetes are seen later in the healing process. Increased levels of MIP-1α were associated with the likelihood of delayed healing.
Angioleiomyomas are benign tumefactions that originate from smooth muscle in vascular structures and are difficult to definitively diagnose preoperatively. Although these lesions are rarely encountered in the foot, the lower extremity is the most common site of occurrence. An angioleiomyoma typically manifests as a small, painful, solitary, mobile lesion. This case report describes a lateral retromalleolar para–Achilles tendon insertional location for a moderately sized immobile solid tumefaction in the subcutaneous tissues. The lesion was nonpainful and progressively enlarged over 5 years. An excisional biopsy was performed, and the nodular lesion was subsequently diagnosed histopathologically as an angioleiomyoma. Owing to the ambiguous nature of the clinical findings, angioleiomyoma should be included in the differential diagnosis of lower-extremity soft-tissue manifestations.
The authors review histologic findings from 50 cases of heel spur surgery for chronic plantar fasciitis. Findings include myxoid degeneration with fragmentation and degeneration of the plantar fascia and bone marrow vascular ectasia. Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis without inflammation, not a fasciitis. These findings suggest that treatment regimens such as serial corticosteroid injections into the plantar fascia should be reevaluated in the absence of inflammation and in light of their potential to induce plantar fascial rupture. (J Am Podiatr Med Assoc 93(3): 234-237, 2003)
Diabetic foot ulcers combined with ischemia and infection can be difficult to treat. Few studies have quantified the level of blood supply and infection control required to treat such complex diabetic foot ulcers. We aimed to propose an index for ischemia and infection control in diabetic chronic limb-threatening ischemia (CLTI) with forefoot osteomyelitis.
We retrospectively evaluated 30 patients with diabetic CLTI combined with forefoot osteomyelitis who were treated surgically from January 2009 to December 2016. After 44 surgeries, we compared patient background (age, sex, hemodialysis), infection status (preoperative and 1- and 2-week postoperative C-reactive protein [CRP] levels), surgical bone margin (with or without osteomyelitis), vascular supply (skin perfusion pressure), ulcer size (wound grade 0–3 using the Society for Vascular Surgery Wound, Ischemia, and foot Infection classification), and time to wound healing between patients with healing ulcers and those with nonhealing ulcers.
Preoperative CRP levels and the ratio of ulcers classified as wound grade 3 were significantly lower and skin perfusion pressure was significantly higher in the healing group than in the nonhealing group (P < .05). No other significant differences were found between groups.
This study demonstrates that debridement should be performed first to control infection if the preoperative CRP level is greater than 40 mg/L. Skin perfusion pressure of 55 mm Hg is strongly associated with successful treatment. We believe that this research could improve the likelihood of salvaging limbs in patients with diabetes with CLTI.
Background: Adhesions after tendinopathy in individuals who perform physical work and those physically active in middle age are a challenging problem for orthopedic surgeons. We evaluated the effects of human-derivated amniotic membrane on tendon healing, adhesions, angiogenesis, and the inflammatory process.
Methods: Thirty-five rats were divided evenly into five groups, and the left lower extremity was used in this study. No interventions were applied to the control group (group 5). In the other groups, Achilles tendons were partially cut to the midline. Then, primary repair (group 1), amniotic membrane treatment with no repair (group 2), primary repair and amniotic membrane treatment (group 3), or secondary healing with no repair (group 4) was performed.
Results: Use of amniotic membrane in tendon healing resulted in decreased adhesion formation and positive effects on collagen sequencing and anti-inflammatory effects. In addition, for the vascular endothelial growth factor evaluation there was no difference among the amniotic membrane repair groups, but there was an increase in vascular endothelial growth factor positivity compared with the control group.
Conclusions: These data show that amniotic membrane treatment can alter biological behavior and induce surface-dependent angiogenesis and can have angiogenetic effects on ischemia and inflammation.
Lower-Extremity Infections Caused by Serratia marcescens
A Report of Three Cases and a Literature Review
Serratia marcescens is a ubiquitous, facultatively anaerobic, gram-negative bacillus that has been cited to cause infection in immunocompromised populations. In the literature, S marcescens infections of the lower extremity have presented as granulomatous ulceration, abscess, bullous cellulitis, and necrotizing fasciitis. Herein we present a series of three cases of lower-extremity infections in which S marcescens was the sole or a contributing pathogen. We discuss the commonalities of these three cases as well as with those previously cited. All three patients presented with some combination of a similar set of clinical characteristics, including bullae formation, liquefactive necrosis, and black necrotic eschar. All three patients were diabetic and had peripheral vascular disease.