Foot complications are common in diabetic patients; foot ulcers are among the more serious consequences. These ulcers frequently become infected, and if not treated promptly and appropriately, diabetic foot infections can lead to septic gangrene and amputation. Foot infections may be classified as mild, moderate, or severe; this largely determines the approach to therapy. Staphylococcus aureus is the most common pathogen in these infections, and the increasing incidence of methicillin-resistant S aureus during the past two decades has further complicated antibiotic treatment. Chronic infections are often polymicrobial. Physiologic changes, and local and systemic inflammation, can affect the plasma and tissue pharmacokinetics of antimicrobial agents in diabetic patients, leading to impaired target-site penetration. Knowledge of the serum and tissue concentrations of antibiotics in diabetic patients is, therefore, important for choosing the optimal drug and dose. This article reviews the commonly used therapeutic options for treatment, including many newer antibiotics developed to target multidrug-resistant gram-positive bacteria, and includes available data relating specifically to the tissue penetration of these agents. (J Am Podiatr Med Assoc 100(1): 52–63, 2010)
Studies have been conducted to evaluate the efficacy of dehydrated human amnion chorion membrane (dHACM) in treating recalcitrant diabetic foot ulcers. A literature search was performed to review the data collected from the use of dHACM allografts. Two products were explicitly named in these publications, EpiFix and AmnioBand Membrane. Relevant results included the healing rate, number of wounds healed, and number of grafts used. Data had supported the potential of lowering the overall cost to manage a wound despite a relatively higher cost per dressing. However, discrepancy was observed in the rate of healing between several of the studies. Nonetheless, dHACM had demonstrated improvement in healing of recalcitrant diabetic foot ulcers compared to standard of care alone. These results provide grounds for more inclusive research on dHACM in the future.
Remote ischemic conditioning involves the use of a blood pressure cuff or similar device to induce brief (3–5 min) episodes of limb ischemia. This, in turn, seems to activate a group of distress signals that has shown the potential ability to improve healing of the heart muscle and other organ systems. Until recently, this has not been tested in people with diabetic foot ulcers. The purpose of this review was to provide background on remote ischemic conditioning and recent data to potentially support its use as an adjunct to healing diabetic foot ulcers and other types of tissue loss. We believe that this inexpensive therapy has the potential to be deployed and incorporated into a variety of other therapies to prime patients for healing and to reduce morbidity in patients with this common, complex, and costly complication.
This literature review sought to evaluate the current state of knowledge and guidelines surrounding the role of pH in the recovery of chronic nonhealing wounds. A systematic review of PubMed examining the relationship between pH and wound healing was completed. Seven sources were retrieved for review. The development of a highly structured and reproducible system of pH-driven therapy may add to the treatment algorithm for chronic nonhealing wounds.
Vitamin D is an essential vitamin that targets several tissues and organs and plays an important role in calcium homeostasis. Vitamin D deficiency is common, particularly at higher latitudes, where there is reduced exposure to ultraviolet B radiation. We reviewed the role of vitamin D and its deficiency in foot and ankle pathology.
The effects of vitamin D deficiency have been extensively studied, but only a small portion of the literature has focused on the foot and ankle. Most evidence regarding the foot and ankle consists of retrospective studies, which cannot determine whether vitamin D deficiency is, in fact, the cause of the pathologies being investigated.
The available evidence suggests that insufficient vitamin D levels may result in an increased incidence of foot and ankle fractures. The effects of vitamin D deficiency on fracture healing, bone marrow edema syndrome, osteochondral lesions of the talus, strength around the foot and ankle, tendon disorders, elective foot and ankle surgery, and other foot and ankle conditions are less clear.
Based on the available evidence, we cannot recommend routine testing or supplementation of vitamin D in patients with foot and ankle pathology. However, supplementation is cheap, safe, and may be of benefit in patients at high risk for deficiency. When vitamin D is supplemented, the evidence suggests that calcium should be co-supplemented. Further high-quality research is needed into the effect of vitamin D in the foot and ankle. Cost-benefit analyses of routine testing and supplementation of vitamin D for foot and ankle pathology are also required.
The discovery of antibiotic drugs was one of the most significant medical achievements of the 20th century. The improper use of antibiotic drugs to prevent and treat infections has resulted in the emergence of resistance. Antimicrobic stewardship programs are becoming a mainstay in the fight against multidrug-resistant organisms. Individual clinicians should be encouraged to adopt the principles of antibiotic stewardship when treating lower-extremity infections in their scope of practice. First, a review of the available literature outlining the concept and practice of antibiotic stewardship is offered. Second, a discussion describing how to adopt and apply these principles to the individual clinician's practice as it applies to lower-extremity infections is offered. Finally, specific antimicrobial pharmacologic spectra and antibiogram information are offered.
The effect of lower-extremity pathology and surgical intervention on automobile driving function has been a topic of contemporary interest in the medical literature. The objective of this review was to summarize the topic of driving function in the setting of lower-extremity impairment. Included studies involved lower-extremity immobilization devices, elective and traumatic lower-limb surgery, chronic musculoskeletal pathology, and diabetes as it relates to the foot and ankle, focusing on the effect each may have on driving function. We also discuss the basic US state regulations with respect to impaired driving and changes to automobile structure that can be made in the setting of lower-extremity pathology.
Onychomycosis is a chronic fungal infection of the nail that is recalcitrant to treatment. It is unclear why normally effective antifungal therapy results in low cure rates. Evidence suggests that there may be a plethora of reasons that include the limited immune presence in the nail, reduced circulation, presence of commensal microbes, and fungal influence on immune signaling. Therefore, treatment should be designed to address these possibilities and work synergistically with both the innate and adaptive immune responses.
Equinus is characterized by reduced dorsiflexion of the ankle joint, but there is a lack of consensus regarding criteria for definition and diagnosis. This review examines the literature relating to the definition, assessment, diagnosis, prevalence, and complications of equinus. Articles on equinus and assessment of ankle joint range of motion were identified by searching the EMBASE, Medline, PubMed, EBSCOhost, Cinahl, and Cochrane databases and by examining the reference lists of the articles found. There is inconsistency regarding the magnitude of reduction in dorsiflexion required to constitute a diagnosis of equinus and no standard method for assessment; hence, the prevalence of equinus is unknown. Goniometric assessment of ankle joint range of motion was shown to be unreliable, whereas purpose-built tools demonstrated good reliability. Reduced dorsiflexion is associated with alterations in gait, increased forefoot pressure, and ankle injury, the magnitude of reduction in range of motion required to predispose to foot or lower-limb abnormalities is not known. In the absence of definitive data, we propose a two-stage definition of equinus: the first stage would reflect dorsiflexion of less than 10° with minor compensation and a minor increase in forefoot pressure, and the second stage would reflect dorsiflexion of less than 5° with major compensation and a major increase in forefoot pressure. This proposed definition of equinus will assist with standardizing the diagnosis and will provide a basis for future studies of the prevalence, causes, and complications of this condition. (J Am Podiatr Med Assoc 100(3): 195–203, 2010)
Ankle dorsiflexion measurement is important for clinical and research use. With so much evidence on the unreliability of goniometric measurements, a systematic review was performed to investigate various alternative techniques for measuring ankle dorsiflexion in the nonneurologic patient. All of the major databases were queried electronically to identify studies that used any method of ankle dorsiflexion measurement in the nonneurologic subject. Keywords included ankle dorsiflexion NOT cerebral palsy NOT stroke, the latter to exclude neurologic conditions. In 755 studies that used some form of ankle joint dorsiflexion measurement, ten different techniques were identified that included various apparatuses designed specifically for this purpose. Reliability testing of these techniques involved test-retest trials with small student populations as subjects, which returned high intraclass correlation coefficient scores. However, their methodological quality would have benefitted from the use of an actual patient population and comparison with a reference standard. When validating ankle dorsiflexion measurement techniques, actual patient populations should be used, otherwise papers would score poorly on methodological quality assessment. Standardizing patient position, foot posture, amount of moment applied, and reference landmarks will ensure that various trial results can be compared directly. (J Am Podiatr Med Assoc 101(1): 59–69, 2011)