Search Results
Precise comprehensive imaging of arterial circulation is the cornerstone of successful revascularization of the ischemic extremity in patients with diabetes mellitus. Arterial imaging is challenging in these patients because the disease is often multisegmental, with a predilection for the distal tibial and peroneal arteries. Occlusive lesions and the arterial wall itself are often calcified, and patients with ischemic complications frequently have underlying renal insufficiency. Intra-arterial digital subtraction angiography, contrast-enhanced magnetic resonance angiography, and, more recently, computed tomographic angiography have been used as imaging modalities in lower-extremity ischemia. Each modality has specific advantages and shortcomings in this patient population, which are summarized and contrasted in this review. (J Am Podiatr Med Assoc 100(5): 412–423, 2010)
Background:
Below-the-knee amputations are regarded as definitive treatment for calcaneal osteomyelitis. They may be less than desirable in patients with a viable midfoot and forefoot. Partial and total calcanectomies have been reported as an alternative for limb salvage. However, the durability of the residual limb is questionable.
Methods:
A systematic review was undertaken to identify material relating to the potential for limb salvage with partial or total calcanectomy in ambulatory patients with calcaneal osteomyelitis. Studies eligible for inclusion consecutively enrolled ambulatory patients older than 18 years who underwent partial or total calcanectomy without adjunctive free tissue transfer for the treatment of calcaneal osteomyelitis and had a mean follow-up of 12 months or longer.
Results:
Sixteen studies involving 100 patients (76 partial and 28 total calcanectomies) met all of the inclusion criteria. Weighted mean follow-up was 33 months. Minor complications with subsequent healing occurred in less than 24% of patients. Most major complications were related to residual soft-tissue infection and osteomyelitis. Approximately 10% of patients required a major lower-extremity amputation. Major complications and major lower-extremity amputations occurred more frequently after total calcanectomy and in patients with a diagnosis of diabetes. Eighty-five percent of patients maintained or improved their ambulatory status postoperatively. Only 3% of patients decreased their ambulatory status postoperatively, becoming unlimited household ambulators.
Conclusions:
This systematic review provides evidence that partial or total calcanectomy is a viable option for limb salvage in ambulatory patients with calcaneal osteomyelitis. (J Am Podiatr Med Assoc 102(5): 396–405, 2012)
Letter to the Editor
Maggot Therapy in “Lower-Extremity Hospice” Wound Care
Background: We evaluated adverse short-term outcomes after open lower-extremity bypass surgery in patients with diabetes mellitus with a comparison performed based on patient height.
Methods: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed to select patients with Current Procedural Terminology codes 35533, 35540, 35556, 35558, 35565, 35566, 35570, and 35571 and with the diagnosis of diabetes mellitus. This resulted in 83 patients 60 inches or less in height, 1,084 between 60 and 72 inches, and 211 patients 72 inches and taller.
Results: No differences were observed among groups with respect to the development of a superficial surgical site infection (9.6% versus 6.4% versus 5.7%; P = .458), deep incisional infection (1.2% versus 1.4% versus 2.8%; P = .289), sepsis (2.4% versus 2.0% versus 2.8%; P = .751), unplanned reoperation (19.3% versus 15.6% versus 21.8%; P = .071), or unplanned hospital readmission (19.3% versus 14.8% versus 17.1%; P = .573). A significant difference was observed among groups in the development of a wound disruption (4.8% versus 1.3% versus 4.7%; P = .001). A multivariate regression analysis was performed of the wound disruption outcome with the variables of age, sex, race, ethnicity, height, weight, current smoker, and open wound/wound infection. Race (P = .025) and weight (P = .003) were found to be independently associated with wound disruption, but height was not (P = .701).
Conclusions: The results of this investigation demonstrate no significant differences in short-term adverse outcomes after lower-extremity bypass surgery based on patient height.
Background:
One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis. This retrospective, observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital.
Methods:
A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation.
Results:
The overall rate of ambulation in a prosthesis was 29.94% (50.0% of those with unilateral below-the-knee amputation [BKA] and 20.0% of those with unilateral above-the-knee amputation [AKA]). In 24.81% of patients with unilateral BKA or AKA, a secondary surgical procedure of the amputation site was required. In those with unilateral BKA or AKA, statistically significant factors associated with ambulation included male sex (odds ratio [OR] = 2.50) and at least 6 months of outpatient follow-up (OR = 8.10), survival for at least 1 postoperative year (OR = 8.98), ambulatory preamputation (OR = 14.40), returned home after the amputation (OR = 6.12), and healing of the amputation primarily without a secondary surgical procedure (OR = 3.62). Those who had a history of dementia (OR = 0.00), a history of peripheral arterial disease (OR = 0.35), and a preamputation history of ipsilateral limb revascularization (OR = 0.14) were less likely to walk. We also observed that patients with a history of outpatient evaluation by a podiatric physician before major amputation were 2.63 times as likely to undergo BKA as opposed to AKA and were 2.90 times as likely to walk after these procedures.
Conclusions:
These results add to the body of knowledge regarding outcomes after major amputation and could be useful in the education and consent of patients faced with major amputation.
Emergency department visits for lower extremity complications of diabetes are extremely common throughout the world. Surprisingly, recent data suggest that such visits generate an 81.2% hospital admission rate with an annual bill of at least $1.2 billion in the United States alone. The likelihood of amputation and other subsequent adverse outcomes is strongly associated with three factors: 1) wound severity (degree of tissue loss), 2) ischemia, and 3) foot infection. Using these factors, this article outlines the basic principles needed to create an evidence-based, rapid foot assessment for diabetic foot ulcers presenting to the emergency department, and suggests the establishment of a “hot foot line” for an organized, expeditious response from limb salvage team members. We present a nearly immediate assessment and referral system for patients with atraumatic tissue loss below the knee that has the potential to vastly expedite lower extremity triage in the emergency room setting through greater collaboration and organization.
Lateral Plantar Artery Aneurysm
A Case Report
We report a case of a true plantar artery aneurysm in an adult. True aneurysms of the inframalleolar vessels are rare. The limited literature on the subject is reviewed, including differential diagnosis and suggested treatment. (J Am Podiatr Med Assoc 97(6): 480–482, 2007)
Background: We used a model of lower-extremity ulceration to determine the impact of a podiatric lead limb preservation team on identified relationships among risk factors, predictors of ulceration, amputation, and clinical outcomes of lower-extremity disease in patients with diabetes mellitus.
Methods: A total of 485 patients with diabetes mellitus were randomly selected from the diabetic population and included in this retrospective cohort study. Patients were then stratified into two groups: those who received specialty podiatric medical care and those who did not. Data covering a 5-year period were collected using electronic medical records and chart abstraction to capture detailed treatment characteristics, ulcer status, and surgical outcomes.
Results: Overall, the frequencies of inpatient and outpatient encounters and the durations of hospital stays were significantly greater with increasing wound depth and in the presence of infection. In addition, the overall ulcer incidence was greater in patients with callus (34.3% versus 10.3%, P < .0001) with and without neuropathy (20.4% and 4.1%, P < .0001). Among patients treated in a specialty multidiscipline podiatric medical setting, the proportion of all amputations that were “minor” was significantly increased (33.7% versus 67.3%, P = .0006), and survival was significantly improved (19.5% versus 7.7%, P < .0001).
Conclusions: Early identification of individuals at increased risk for lower-extremity ulceration and subsequent referral for advanced multidiscipline podiatric medical specialty care may decrease rates of ulceration and proximal amputation and improve survival in patients with diabetes mellitus who are at high risk for ulceration and limb loss. (J Am Podiatr Med Assoc 100(4): 235–241, 2010)
