External thermoregulation using noncontact normothermic wound therapy accelerates wound closure by second intention in areas of existing osteomyelitis before surgical excision compared with standard wound care. This pilot study consisted of two arms. The control arm received standard wound care, which resulted in complete ulcer healing at an average of 127 days. The treatment arm received noncontact normothermic wound therapy, which resulted in complete ulcer healing at an average of 59 days, or 54% faster than in the control arm. This new treatment allows the physician to decrease the rate of limb loss and recurrent osteomyelitis by decreasing the morbidity of bone reinfection through the wound bed. There have been no published studies or case presentations addressing thermoregulation in the management of wounds associated with osteomyelitis. Although noncontact normothermic wound therapy is not a direct treatment for osteomyelitis, this new treatment option results in significantly accelerated healing of wounds associated with osteomyelitis. (J Am Podiatr Med Assoc 93(1): 18-22, 2003)
A prospective study was performed to examine the performance of bone scintigraphy in the earliest stage of soft-tissue foot ulceration with potential risk for progression to osteomyelitis. Twenty-three podiatry clinic patients with new or recurrent foot ulcers but negative plain film radiographs of the foot underwent 24 (one patient was studied twice) multiphase bone scans (flow, blood pool, and 3- and 24-hour delayed images) that were visually scored for severity of increased uptake on a scale of 0 to 3+, with 0 indicating normal and 3+ indicating severe. Twenty-one scans (88%) showed abnormal uptake on at least one phase, with 17 (71%) having increased bone uptake on late images. Ulcer healing without complications occurred in 20 cases (83%), whereas 4 cases had adverse outcomes, 3 requiring surgical resection for failure to heal and 1 having radiographic progression to frank osteomyelitis. All three patients whose bone scans showed severe abnormal uptake had an adverse clinical outcome. (J Am Podiatr Med Assoc 93(2): 91-96, 2003)
Chemical matrixectomy for ingrown toenails is one of the most common surgical procedures performed on the foot. The procedure was first described in 1945 by Otto Boll, who discussed the use of phenol to correct ingrown toenails. In the years that followed, many variations of technique and method have been described. This article reviews the pertinent literature detailing chemical matrixectomies and advocates the use of an evidence basis for care. (J Am Podiatr Med Assoc 92(5): 287-295, 2002)
Pressure ulcers of the heel are a major and growing health-care problem. Although prevention and aggressive local wound care and pressure reduction remain the gold standard for treatment of most heel ulcers, recalcitrant wounds may require surgical intervention. Limb salvage when dealing with heel ulcers remains a challenge. Nine feet (eight patients) that underwent partial calcanectomy for chronic nonhealing heel ulcers were evaluated retrospectively. Complete healing occurred in seven of nine feet. Patients who were ambulatory before surgery remained ambulatory after healing. (J Am Podiatr Med Assoc 95(4): 335–341, 2005)
Background: The removal of necrotic tissue from chronic wounds is required for wound healing to occur. Hydrodebridement (jet lavage) and superoxidized aqueous solution have been independently used for debriding wounds. We sought to investigate the use of superoxidized aqueous solution with a jet lavage system.
Methods: Twenty patients with diabetic foot ulcers were randomly assigned in a 1:1 ratio to receive jet lavage debridement with either superoxidized aqueous solution or standard saline weekly.
Results: There was no significant difference between the two treatments in the reduction of bacterial load or wound size in 4 weeks. No adverse reactions were reported for either treatment.
Conclusions: The use of superoxidized aqueous solution for jet lavage debridement seemed to be as safe and effective as saline. Future investigations should concentrate on whether superoxidized aqueous solution may reduce the bacterial air contamination associated with hydrodebridement. (J Am Podiatr Med Assoc 101(2): 124–126, 2011)
Relationship Between Onychocryptosis and Foot Type and Treatment with Toe Spacer
A Preliminary Investigation
The relationship between onychocryptosis and foot type was investigated in a series of 512 patients. Of these patients, 124 had signs or a history of onychocryptosis. Among the nine foot types identified by digital and metatarsal formulas, the Greek index minus and squared index minus types showed the strongest association with onychocryptosis, which was present in more than one-third of such feet. When anteroposterior radiographs of each type of foot were taken after binding the first and second toes together to simulate a tight shoe, the enlargement of bony structures of the second toe at the distal interphalangeal level in the Greek and squared index minus feet moved toward the distal enlargement of the distal phalanx of the first toe where the ingrowing occurs. Ten cases of stage I and four cases of stage II onychocryptosis were treated by placing a toe spacer between the first and second toes; all healed in about 3 weeks, suggesting that counterpressure of the second toe in tight shoes is a factor in the development of onychocryptosis. (J Am Podiatr Med Assoc 93(1): 33-36, 2003)
We conducted a post-hoc retrospective analysis of patients enrolled in a randomized controlled trial to evaluate overall costs of negative pressure wound therapy (NPWT; V.A.C. Therapy; KCI USA, Inc, San Antonio, Texas) versus advanced moist wound therapy (AMWT) in treating grade 2 and 3 diabetic foot wounds during a 12-week therapy course.
Data from two study arms (NPWT [n = 169] or AMWT [n = 166]) originating from Protocol VAC2001-08 were collected from patient records and used as the basis of the calculations performed in our cost analysis.
A total of 324 patient records (NPWT = 162; AMWT = 162) were analyzed. There was a median wound area reduction of 85.0% from baseline in patients treated with NPWT compared to a 61.8% reduction in those treated with AMWT. The total cost for all patients, regardless of closure, was $1,941,472.07 in the NPWT group compared to $2,196,315.86 in the AMWT group. In patients who achieved complete wound closure, the mean cost per patient in the NPWT group was $10,172 compared to $9,505 in the AMWT group; the median cost per 1 cm2 of closure was $1,227 with NPWT and $1,695 with AMWT. In patients who did not achieve complete wound closure, the mean total wound care cost per patient in the NPWT group was $13,262, compared to $15,069 in the AMWT group. The median cost to close 1 cm2 in wounds that didn't heal using NPWT was $1,633, compared to $2,927 with AMWT.
Our results show greater cost effectiveness with NPWT versus AMWT in recalcitrant wounds that didn't close during a 12-week period, due to lower expenditures on procedures and use of health-care resources.
Homeless people live in poverty, with limited access to public health services. They are likely to experience chronic medical conditions, such as diabetes mellitus; however, they do not always receive the necessary services to prevent complications. This study was designed to determine the effectiveness of a volunteer health service outreach to reduce disparity in diabetic foot care for homeless people.
The research was conducted on 21 patients with diabetic ulcers of 930 homeless people visited between 2008 and 2013. Each ulcer was treated with regular medication every week for a mean ± SD of 17.6 ± 12 months. The inclusion criteria were 1) homeless with a previous diagnosis of diabetes or a blood glucose level greater than 126 mg/dL at first check and 2) foot ulcer caused by diabetic vasculopathy or neuropathy. The efficacy of the interventions was assessed against the number of successfully cured diabetic feet based on a reduced initial Wagner classification score for each ulcer.
Clinical improvement was observed in 18 patients (86%), whose pathologic condition was completely resolved after 3 years and, therefore, no longer needed medication. One patient died of septic shock and kidney failure, and two patients needed amputation owing to clinical worsening of ulcers (Wagner class 4 at the last visit).
Most homeless people who have diabetes and diabetic foot encounter many difficulties managing their disease, and a volunteer health-care unit could be a suitable option to bridge these gaps.
Background: We sought to report the clinical results of a new conservative treatment modality that uses a shape memory alloy device in patients with ingrown toenail.
Methods: A retrospective review was performed on 41 patients with ingrown toenail treated with the K-D device (S&C Biotech, Seoul, South Korea) between April 2013 and July 2014. Recurrence rate, cosmetic results, pain during the treatment period, and patient satisfaction were the major outcome measures.
Results: Patients were followed for at least 6 months (mean ± SD, 8.6 ± 2.1 months; range, 6–12 months). Recurrence was seen in eight patients (19.5%). Mean time to recurrence was 6.2 months (range, 3–10 months). Thirty-one patients (75.6%) were satisfied with the treatment. Thirty-five patients (85.4%) rated the application and treatment period as painless, and the remaining six (14.6%) noted pain particularly during shoe wearing. Thirty-one patients (75.6%) rated the cosmetic results as “excellent,” four (9.8%) as “acceptable,” and six (14.6%) as “poor.” Satisfaction with the treatment, the cosmetic results, and pain were significantly worse in patients with recurrence (P = .0001 for all). All of the patients returned to their work immediately after application of the device. No complications occurred.
Conclusions: The K-D device is a safe and effective treatment method for ingrown toenail. Although the recurrence rate is higher than for surgical treatment methods, the K-D device is a practical and painless method that provides immediate return to work and daily activities and excellent or acceptable cosmesis in most patients.
Background: Several studies have shown a significant relationship between depressive symptoms and wound healing, but these studies have not assessed the effects of depressive symptoms on diabetic foot prognosis. We specifically designed our study to assess the role of depressive symptoms in healing and recurrence of diabetic foot ulcers.
Methods: A consecutive series of 80 type 2 diabetic patients aged 60 years and older with foot ulcers was enrolled in a cohort observational study with a 6-month follow-up. Patients who healed within 6 months of enrollment were included in a 12-month follow-up study for assessment of ulcer recurrence. Depressive symptoms were assessed with the geriatric depression scale.
Results: Healing was associated with a smaller ulcer area, shorter delay between ulcer onset and treatment, lower glycosylated hemoglobin, and higher ankle-brachial index. Both smoking status and Texas and Wagner scores also had a significant impact on healing. Patients who healed had significantly lower scores on the geriatric depression scale, and those with scores = 10 had a significantly higher risk of not healing at 6 months (relative risk, 3.57; 95% confidence interval, 1.05–12.2). Patients with a recurrent ulcer (59.3%) showed significantly higher total cholesterol levels, higher scores on the Greenfield index of disease severity and geriatric depression scale, and a higher prevalence of cerebrovascular disease. Depressive symptoms maintained a significant association with persistence and recurrence of ulcer even after adjustment for confounders.
Conclusions: Depressive symptoms are associated with impaired healing and recurrence of ulcers in elderly type 2 diabetic patients. (J Am Podiatr Med Assoc 98(2): 130–136, 2008)