The authors evaluated the time to healing and prevalence of complications in patients undergoing mechanically assisted, delayed primary closure of diabetic foot wounds compared with a similar population who received standard wound care. A total of 55 patients were enrolled for study, with 25 in the experimental group and 30 in the control group. Patients in the experimental (stretch) group underwent mechanically assisted primary closure of their wounds using a skin-stretching device. There was no difference between the stretch and control groups with regard to any descriptive characteristics, including wound chronicity. Although the wounds were over three times as large on average in the stretch group (P < .001), the stretch group reached full epithelialization approximately 40% sooner than the control group (26.4 +/- 16.0 versus 42.5 +/- 19.9 days; P < .002). Eighty-eight percent of patients in the stretch group experienced wound dehiscence, at a mean time of 1.8 +/- 0.6 weeks following mechanically assisted closure. However, patients who experienced dehiscence in the stretch group healed significantly faster than patients in the control group (27.4 +/- 16.7 versus 42.5 +/- 19.9 days; P < .007). The results of this study suggest that mechanically assisted closure of diabetic foot wounds may result in reduced healing time compared with healing by secondary intention.
Few scientific data are available on the effectiveness of commonly used modalities for reducing pressure at the site of neuropathic ulcers in persons with diabetes mellitus. The authors' aim was to compare the effectiveness of total contact casts, half-shoes, rigid-soled postoperative shoes, accommodative dressings made of felt and polyethylene foam, and removable walking casts in reducing peak plantar foot pressures at the site of neuropathic ulcerations in diabetics. Using an in-shoe pressure-measurement system, data from 32 midgait steps were collected for each treatment. There was a consistent pattern in the devices' effectiveness in reducing foot pressures at ulcer sites under the great toe and ball of the foot. Removable walking casts were as effective as or more effective than total contact casts. Half-shoes were consistently the third most effective modality, followed by accommodative dressings and rigid-soled postoperative shoes.
Appropriate care of feet of patients with diabetes requires a clear, descriptive classification system that may be used to direct appropriate therapy and possibly predict outcome. Ideally, this system would be used by all participants in a multidisciplinary limb-salvage team. The authors report on a logical, treatment-oriented system that may improve communication, leading to a less complex, more predictable treatment course and, ultimately, an improved result.
The complications of elevation and shortening in the oblique closing base wedge osteotomy of the first metatarsal fixated with either a single AO screw or two 0.062 Kirschner wires were compared. Thirty-three consecutive oblique closing base wedge osteotomies of the first metatarsal bone are evaluated. With the exception of fixation, which is examined as an independent variable, the patients are managed identically with respect to osteotomy technique and postoperative care. The Reese osteotomy guide is used to normalize osteotomy configuration. The authors found no difference in elevation or shortening when comparing an AO screw with 0.062 Kirschner wire fixation. When other variables are controlled, fixation type does not lead to a statistical difference in elevation or shortening.
The authors present two cases of resultant hallux hammer toe secondary to the definitive treatment of hallux sesamoidal osteomyelitis. Pseudomonas osteomyelitis developed in both cases following puncture wounds to the first metatarsophalangeal joint complex. The authors also review the literature on pseudomonas osteomyelitis secondary to puncture wounds and the development of hallux hammer toe after removal of the involved sesamoid bones.
The purpose of this study was to compare the structural characteristics of 2.0-mm polyglycolic acid pins and 2.0-mm Steinmann pins in oblique closing base wedge osteotomies of the first metatarsal bone commonly used to correct metatarsus primus varus. Six pairs of fresh frozen cadaveric first metatarsal bones were osteotomized, fixated with either absorbable or stainless steel 2.0-mm pins, cemented in a specimen-holding jig, and tested with the Bionix Material Testing System. There was no significant difference in the mean ultimate force, ultimate displacement, or structural stiffness when comparing 2.0-mm polyglycolic acid pins and Steinmann pins in this model. The structural characteristics of 2.0-mm absorbable pins were the same as stainless steel pins at the time of initial placement in the oblique closing base wedge osteotomy of the first metatarsal.
The authors compare the level of foot amputation by age, prevalence of arterial disease as a precipitating factor, gender, and ethnicity in persons with diabetes mellitus. Medical records were abstracted for each hospitalization for a lower extremity amputation from January 1 to December 31, 1993, in six metropolitan statistical areas in south Texas. Amputation level was defined by ICD-9-CM codes and were categorized as foot, leg, and thigh amputations. Foot-level amputations were further subcategorized as hallux or first ray, middle, fifth, multiple digit or ray, and midfoot amputations. Only the highest amputation level for each individual was used in the analysis. Of 1,043 subjects undergoing a lower extremity amputation in south Texas in the year 1993, 477 received their amputation at the level of the foot. African-Americans requiring a foot-level amputation were at significantly higher risk to undergo a midfoot-level amputation than was the rest of the population. Nearly 40% of all subjects undergoing a foot-level amputation had a previous history of amputation. However, nearly 40% of subjects undergoing foot amputations had not been diagnosed either before or during admission with peripheral arterial occlusive disease, suggesting a causal pathway dependent primarily on neuropathy. This implies that better screening of diabetic patients with appropriate risk-directed treatment at the primary care level may significantly impact the large number of preventable diabetes-related lower extremity amputations.
To evaluate the standard of evaluation and treatment of the infected diabetic foot ulceration at a 551-bed university teaching institution.
A retrospective review of a 4-year consecutive sample (1991-1994).
Two hundred fifty-five patients who were admitted to a hospital for care of an infected diabetic foot ulceration. Patients were subdivided into the following 4 dichotomous variables: (1) whether the patient underwent a lower-extremity amputation, (2) whether the patient was admitted once or multiple times, (3) whether the patient underwent intraoperative debridement, and (4) whether the patient was admitted to medical or surgical services.
All groups that were evaluated had undergone a less than adequate foot examination. Of the admitted patients, 31.4% did not have their pedal pulses documented; 59.7% of the admitted patients were not evaluated for the presence or absence of protective sensation. Nearly 90% of the wounds were not evaluated for involvement of underlying structures, and foot radiographs were not performed in 32.9% of the patients. There were more blood cultures ordered (62.0%) than wound cultures (51.4%).
The results of this study highlight the need for a systematic, detailed lower-extremity examination for every diabetic patient who is admitted to a hospital, particularly those who are admitted with a primary diagnosis that involves a foot complication.