Search Results
Background
Toe amputation is the most common partial foot amputation. Controversy exists regarding whether to primarily close toe amputations or to leave them open for secondary healing. The purpose of this study was to evaluate the results of closed toe amputations in diabetic patients, with respect to wound healing, complications, and the need for further higher level amputation.
Methods
We retrospectively reviewed the results of 40 elective or semi-elective toe amputations with primary closure performed in 35 patients treated in a specialized diabetic foot unit. Patients with abscesses or necrotizing fasciitis were treated emergently and were excluded. Patients in whom clean margins could not be achieved due to extensive cellulitis or tenosynovitis and patients requiring vascular intervention were excluded as well. Outcome endpoints included wound healing at 3 weeks, delayed wound healing, or subsequent higher level amputation.
Results
Out of 40 amputations, 38 healed well. Thirty amputations healed by the time of stitch removal at 3 weeks and eight had delayed healing. In two patients the wounds did not heal and subsequent higher level amputation was eventually required.
Conclusions
In carefully selected diabetic foot patients, primary closure of toe amputations is a safe surgical option. We do not recommend primary closure when infection control is not achieved or in patients requiring vascular reconstruction. Careful patient selection, skillful assessment of debridement margins and meticulous technique are required and may be offered by experienced designated surgeons in a specialized diabetic foot unit.
The Role of Interdisciplinary Team Approach in the Management of the Diabetic Foot
A Joint Statement from the Society for Vascular Surgery and the American Podiatric Medical Association
The Society for Vascular Surgery (SVS) and the American Podiatric Medical Association (APMA) recognize the beneficial impact of a multidisciplinary team approach on the care of patients with critical limb ischemia, especially in the diabetic population. As a first step in identifying clinical issues and questions important to both memberships, and to work together to find solutions that will benefit the shared patient, the two organizations appointed a representative group to write a joint statement on the importance of multidisciplinary team approach to the care of the diabetic foot. (J Am Podiatr Med Assoc 100(4): 309–311, 2010)
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)
Digital ring block anesthesia, which is frequently used before surgery for ingrown toenails, is often extremely uncomfortable for patients and can be the most distressing aspect of the procedure. The authors used a novel needleless injection device to induce digital anesthesia before surgery and compared it in terms of patient discomfort and preference with use of a standard needle and syringe for injection in individuals undergoing simultaneous bilateral nail procedures. Use of the needleless device significantly reduced the pain associated with this procedure and was preferred over use of a standard needle and syringe by all individuals. Other potential advantages of a needleless injection system are discussed. (J Am Podiatr Med Assoc 93(1): 23-26, 2003)
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.
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
Plantar Fasciitis
A Degenerative Process (Fasciosis) Without Inflammation
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)
