Integra bilayer wound matrix (IBWM) is a bilayer skin replacement system composed of a dermal regeneration layer and a temporary epidermal layer. It is used to treat various types of deep, large wounds via an inpatient procedure in an operating room. We sought to determine ease of use and effectiveness of IBWM in an outpatient clinical setting when treating diabetic foot ulcers. In addition, no epidermal autografting was performed in conjunction with the IBWM after silicone release, as is common in the inpatient setting.
This 12-week, single-arm, prospective pilot study was conducted in three outpatient clinics. Weekly evaluations included monitoring the wound for signs of infection during the 12-week follow-up phase.
Eleven patients with diabetic foot ulcers who met the inclusion and exclusion criteria were enrolled. One patient was discontinued from the study owing to noncompliance leading to a serious adverse event. Therefore, ten patients who received the study intervention were included in the per-protocol population reported herein. The mean patient age was 60.6 years, with an average 11-year history of diabetes mellitus. Each ulcer was located on the plantar aspect of the foot. No infection was reported during the study. Patients treated with IBWM showed progressive wound healing over time: the greatest mean wound reduction was approximately 95% in week 12. Seven of ten patients (70%) achieved complete wound closure by week 12. No recurrent ulcers were reported during follow-up.
These results are consistent with the hypothesis that IBWM is easy to use, safe, and effective when used on diabetic foot ulcers in an outpatient clinical setting without the secondary procedure of autografting for closure. (J Am Podiatr Med Assoc 103(4): 274–280, 2013)
Use of nerve decompression in diabetic sensorimotor polyneuropathy is a controversial treatment characterized as being of unknown scientific effectiveness owing to lack of level I scientific studies.
Herein, long-term follow-up data have been assembled on 65 diabetic patients with 75 legs having previous neuropathic foot ulcer and subsequent operative decompression of the common peroneal and tibial nerve branches in the anatomical fibro-osseous tunnels.
The cohort’s previously reported low recurrence risk of less than 5% annually at a mean of 2.49 years of follow-up has persisted for an additional 3 years, and cumulative risk is now 2.6% per patient-year. Nine of 75 operated legs (12%) have developed an ulcer in 4,218 months (351 patient-years) of follow-up. Of the 53 contralateral legs without decompression, 16 (30%) have ulcerated, of which three have undergone an amputation. Fifty-nine percent of patients are known to be alive with intact feet a mean of 60 months after decompression.
The prospective, objective, statistically significant finding of a large, long-term diminution of diabetic foot ulcer recurrence risk after operative nerve decompression compares very favorably with the historical literature and the contralateral legs of this cohort, which had no decompression. This finding invites prospective randomized controlled studies for validation testing and reconsideration of the frequency and contribution of unrecognized nerve entrapments in diabetic sensorimotor polyneuropathy and diabetic foot complications. (J Am Podiatr Med Assoc 103(5): 380–386, 2013)
Diabetic foot infections are a common and often serious problem, accounting for more hospital bed days than any other complication of diabetes. Despite advances in antibiotic drug therapy and surgical management, these infections continue to be a major risk factor for amputations of the lower extremity. Although a variety of wound size and depth classification systems have been adapted for use in codifying diabetic foot ulcerations, none are specific to infection. In 2003, the International Working Group on the Diabetic Foot developed guidelines for managing diabetic foot infections, including the first severity scale specific to these infections. The following year, the Infectious Diseases Society of America published their diabetic foot infection guidelines. Herein, we review some of the critical points from the Executive Summary of the Infectious Diseases Society of America document and provide a commentary following each issue to update the reader on any pertinent changes that have occurred since publication of the original document in 2004.
The importance of a multidisciplinary limb salvage team, apropos of this special issue jointly published by the American Podiatric Medical Association and the Society for Vascular Surgery, cannot be overstated. (J Am Podiatr Med Assoc 100(5): 395–400, 2010)
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)
Simulation Improves Podiatry Student Skills and Confidence in Conservative Sharp Debridement on Feet
A Pilot Randomized Controlled Trial
An essential skill for podiatrists is conservative sharp debridement of foot callus. Poor technique can result in lacerations, infections and possible amputation. This pilot trial explored whether adding simulation training to a traditional podiatry clinical placement improved podiatry student skills and confidence in conservative sharp debridement, compared with traditional clinical placement alone.
Twenty-nine podiatry students were allocated randomly to either a control group or an intervention group on day 1 of their clinical placement. On day 4, the intervention group (n = 15) received a 2-hour simulation workshop using a medical foot-care model, and the control group (n = 14) received a 2-hour workshop on compression therapy. Both groups continued to learn debridement skills as opportunities arose while on clinical placement. The participants' debridement skills were rated by an assessor blinded to group allocation on day 1 and day 8 of their clinical placement. Participants also rated their confidence in conservative sharp debridement using a questionnaire. Data were analyzed using logistic regression (skills) and analysis of covariance (confidence), with baseline scores as a covariate.
At day 8, analysis showed that those in the intervention group were 16 times more likely to be assessed as competent (95% confidence interval, 1.6–167.4) in their debridement skills and reported increased confidence in their skills (mean difference, 3.2 units; 95% confidence interval, 0.5–5.9) compared with those in the control group.
This preliminary evidence suggests that incorporating simulation into traditional podiatry clinical placements may improve student skills and confidence with conservative sharp debridement.
The etiology of chronic venous insufficiency is typically neglected or misunderstood when treating lower-extremity edema and venous ulcerations. Despite the high prevalence of venous compression syndromes, it is rarely considered when treating venous ulcers and unresolved venous disease. We report a case of bilateral iliac vein outflow obstruction that prohibited venous ulcer healing until properly treated. This case highlights the importance of properly identifying and treating venous compression syndromes to enhance ulcer healing and decrease the risk of venous ulcer recurrence.
Skin grafting provides an effective means of closing chronic wounds. Autografts and allografts are used most often in skin grafting, but Apligraf, a tissue-engineered bilayered human skin equivalent, provides another safe and effective grafting option for treating diabetic, venous, and pressure ulcers. This skin equivalent has an epidermis and dermis similar to human skin, largely due to its derivation from neonatal foreskin. Apligraf is also easily accessible and has shown little immunoreactivity. (J Am Podiatr Med Assoc 92(1): 19-23, 2002)
Charcot's neuroarthropathy (CN) treatment is still controversial, and the results are controversial. Owing to patient comorbidities, surgical intervention carries a high risk of complications. Thus, foreseeing the possible results of planned treatment is crucial. We retrospectively evaluated the Charcot Reconstruction Preoperative Prognostic Score (CRPPS) in patients with surgically treated CN.
Twenty-two feet of 20 patients were included in the study. Two groups were formed according to their CRPPS. Twelve patients with values less than 4 were defined as group A, and eight patients with values of 4 or greater were defined as group B. Mean follow-up was 61 months (range, 5–131 months). Groups were compared according to American Orthopaedic Foot and Ankle Society (AOFAS) scores, Foot and Ankle Disability Index (FADI) scores, and complication rates.
Group A and B mean AOFAS scores were 76.83 (range, 71–85) and 70.5 (range, 20–85), respectively. All of the patients were improved according to AOFAS and FADI scores, but no correlation was found with the CRPPS. None of the group A patients required additional intervention, but five patients in group B underwent revision surgery. No amputations were performed.
The CRPPS is focused on feasibility. The data needed to fill the scoring system is easily obtainable from medical records even retrospectively, and the score is helpful to predict a patient's outcome after CN-related surgery. Herein, CRPPS values of 4 or greater were related to high complication rates and lower functional outcomes.
Hallux valgus, one of the most common deformities of the great toe, may cause pain, dysfunction, and impaired gait pattern. In this retrospective study we report the results of a new type of distal metatarsal osteotomy combined with distal soft-tissue release in patients with mild-to-moderate hallux valgus deformity.
This new technique was used in the management of 32 feet of 31 patients (eight men and 23 women) with mild-to-moderate hallux valgus. Hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle were measured on preoperative, early postoperative (6–8 weeks), and late (1 year) postoperative radiographs. American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal score was calculated. Sesamoid position, by considering medial sesamoid position, and metatarsal shortness were also measured.
Statistically significant differences were detected between the preoperative and late postoperative measurements of the hallux valgus angle, distal metatarsal articular angle, intermetatarsal angle, and sesamoid position parameters in patients operated on with this technique. Improvement was 14° for the hallux valgus angle, 4° for the distal metatarsal articular angle, and 4° for the intermetatarsal angle. Sesamoid position was also improved, and the mean American Orthopaedic Foot and Ankle Society score was significantly improved. Metatarsal shortness greater than 2 mm was observed in two patients without resulting in any clinical discomfort.
This new technique was easy, safe, and promising in patients diagnosed as having mild-to-moderate hallux valgus deformity.
Fasciotomy and Surgical Tenotomy for Chronic Achilles Insertional Tendinopathy
A Retrospective Study Using Ultrasound-Guided Percutaneous Microresection
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.
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.
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.
Ultrasound-guided percutaneous microresection is a safe and minimally invasive percutaneous alternative that can be used before proceeding to a more invasive open procedure.