The role of revascularization in transmetatarsal amputations.

Data from 37 patients who underwent a transmetatarsal amputation from January 1993 to April 1996 were reviewed. The mean age and diabetes duration of the subjects were 54.9 (+/- 13.2) years and 16.6 (+/- 8.9) years, respectively. The follow-up period averaged 42.1 (+/- 11.2) months. At the time of follow-up, 29 (78.4%) of the 37 patients still had foot salvage, 8 (21.6%) had progressed to below-the-knee amputation, and 15 (40.5%) had undergone lower-extremity revascularization. Twelve (80%) of the 15 revascularized patients preserved their transmetatarsal amputation level at a follow-up of 36.4 months. The authors concluded that at a maximum of 3 years follow-up after initial amputation, transmetatarsal amputation was a successful amputation level.

Functional status of persons with diabetes-related lower-extremity amputations.

OBJECTIVE: It is reasonable to predict that diabetes-related lower-extremity amputations have a detrimental impact on quality of life. However, we are unaware of any study in the medical literature describing the functional level of diabetic patients with amputations. The objective of this study was to evaluate amputations among diabetic patients and to determine the functional level of these patients with the Sickness Impact Profile (SIP). RESEARCH DESIGN AND METHODS: We enrolled 124 patients with diabetes. Case subjects (n = 35) were defined as patients who had undergone amputation of the lower-extremity, and control subjects (n = 89) were defined as patients who had not undergone amputation. Study participants received a standard history and physical examination. RESULTS: Both the physical dimension scores (33.5 +/- 14.9 vs. 22.3 +/- 14.7, P < 0.001) and the total SIP scores (27.6 +/- 9.9 vs. 22.5 +/- 10.3, P = 0.013) were significantly higher for amputees. However, the psychosocial dimension scores were not significantly different between case and control subjects (14.9 +/- 8.9 vs. 15.2 +/- 10.0, P > 0.05). Post hoc analysis showed that the group of patients who had undergone transtibial amputation had a significantly higher total impairment score than patients who had not undergone amputation (P = 0.039). This is in contrast to patients with toe or midfoot amputations, for whom total impairment scores were not significantly higher than those for the control subjects. Interestingly, bilateral amputees did not have significantly higher scores on either SIP dimension compared with unilateral amputees. CONCLUSIONS: These findings exemplify the detrimental physical and psychosocial health status of patients with diabetes-related lower-extremity amputation.

Off-loading the diabetic foot wound: a randomized clinical trial.

OBJECTIVE: To compare the effectiveness of total-contact casts (TCCs), removable cast walkers (RCWs), and half-shoes to heal neuropathic foot ulcerations in individuals with diabetes. RESEARCH DESIGN AND METHODS: In this prospective clinical trial, 63 patients with superficial noninfected, nonischemic diabetic plantar foot ulcers were randomized to one of three off-loading modalities: TCC, half-shoe, or RCW. Outcomes were assessed at wound healing or at 12 weeks, whichever came first. Primary outcome measures included proportion of complete wound healing at 12 weeks and activity (defined as steps per day). RESULTS: The proportions of healing for patients treated with TCC, RCW, and half-shoe were 89.5, 65.0, and 58.3%, respectively. A significantly higher proportion of patients were healed by 12 weeks in the TCC group when compared with the two other modalities (89.5 vs. 61.4%, P = 0.026, odds ratio 5.4, 95% CI 1.1-26.1). There was also a significant difference in survival distribution (time to healing) between patients treated with a TCC and both an RCW (P = 0.033) and half-shoe (P = 0.012). Patients were significantly less active in the TCC (600.1 +/- 320.0 daily steps) compared with the half-shoe (1,461.8 +/- 1,452.3 daily steps, P = 0.04). There was no significant difference in the average number of steps between the TCC and the RCW (767.6 +/- 563.3 daily steps, P = 0.67) or the RCW and the half-shoe (P = 0.15). CONCLUSIONS: The TCC seems to heal a higher proportion of wounds in a shorter amount of time than two other widely used off-loading modalities, the RCW and the half-shoe.

The effects of ulcer size and site, patient's age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers.

AIMS: The outcome of foot ulcers is affected by wound depth, infection, ischaemia and glycaemic control. The aim of this study was to determine the effects of ulcer size, site, patient's age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers. METHODS: Diabetic patients with new foot ulcers presenting during a 12-month period had demographics and ulcer characteristics recorded at presentation. Ulcers were followed-up until an outcome was noted. RESULTS: One hundred and ninety-four patients (77% males) with a mean (+/- SD) age and duration of diabetes of 56.6 +/- 12.6 and 15.4 +/- 9.9 years, respectively, were included in the study. The majority of ulcers were neuropathic (67.0%) and present on the forefoot (77.8%) with a median (interquartile range) area of 1.5 (0.6-4.0) cm2. Amputations were performed for 15% of ulcers; 65% healed; 16% remained unhealed and 4% of patients died. The median (95% confidence interval) time to healing was 10 (8.8-11.6) weeks. Ulcer area at presentation was greater in the amputation group compared to healed ulcers (3.9 vs. 1.2 cm2, P < 0.0001). Ulcer area correlated with healing time (rs = 0.27, P < 0.0001) and predicted healing (P = 0.04). Patient's age, sex, duration/type of diabetes, and ulcer site had no effect on outcome. CONCLUSIONS: Ulcer area, a measure of ulcer size, predicts the outcome of foot ulcers. Its inclusion into a diabetic wound classification system will make that system a better predictor of outcome.

A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems.

OBJECTIVE: In this study the following two ulcer classification systems were applied to new foot ulcers to compare them as predictors of outcome: the Wagner (grade) and the University of Texas (LT) (grade and stage) wound classification systems. RESEARCH DESIGN AND METHODS: Ulcer size, appearance, clinical evidence of infection, ischemia, and neuropathy at presentation were recorded, and patients were followed up until healing or for 6 months. RESULTS: Of 194 patients with new foot ulcers, 67.0% were neuropathic, 26.3% were neuroischemic, 1.0% were ischemic, and 5.7% had no identified underlying factors. Median (interquartile range [IQR]) ulcer size at presentation was 1.5 cm2 (0.6-4.0). Lower-limb amputations were performed for 15% of ulcers, whereas 65% healed [median (IQR) healing time 5 (3-10) weeks] and 16% were not healed at study termination; 4% of patients died. Wagner grade (P < 0.0001), and UT grade (P < 0.0001) and stage (P < 0.001) showed positive trends with increased number of amputations. For UT stage, the risk of amputation increased with infection both alone (odds ratio [OR] = 11.1, P < 0.0001) and in combination with ischemia (OR = 14.7, P < 0.0001), but not significantly with ischemia alone (OR = 4.6, P = 0.09). Healing times were not significantly different for each grade of the Wagner (P = 0.1) or the UT system (P = 0.07), but there was a significant stepwise increase in healing time with each stage of the UT system (P < 0.05), and stage predicted healing (P < 0.05). CONCLUSIONS: Increasing stage, regardless of grade, is associated with increased risk of amputation and prolonged ulcer healing time. The UT system's inclusion of stage makes it a better predictor of outcome.

Are antibiotics necessary in the treatment of locally infected ingrown toenails?

CONTEXT: A wide variety of generalists and specialists treat locally infected ingrown toenails, with perhaps the most common treatment regimen including resection of the nail border coupled with oral antibiotics. OBJECTIVE: To determine whether oral antibiotic therapy is beneficial as an adjunct to the phenol chemical matrixectomy in the treatment of infected ingrown toenails. DESIGN: We prospectively enrolled healthy patients with infected ingrown toenails. Each patient was randomly assigned to 1 of 3 groups that received either 1 week of antibiotics and a chemical matrixectomy simultaneously (group 1), antibiotics for 1 week and then a matrixectomy (group 2), or a matrixectomy alone (group 3). SETTING: Institutional ambulatory outpatient clinic. PATIENTS: Fifty-four healthy patients with infected ingrown toenails were studied. Patients with immunocompromised states, peripheral vascular disease, or cellulitis proximal to the hallux interphalangeal joint were excluded. Groups were age matched for comparison. RESULTS: Mean healing times for groups 1, 2, and 3 were 1.9, 2.3, and 2.0 weeks, respectively. Subjects receiving antibiotics and a simultaneous chemical matrixectomy (group 1) healed significantly sooner than those receiving a 1-week course of antibiotics followed by a matrixectomy (group 2). There was not a significant difference in healing time between those that received a chemical matrixectomy alone (group 3) and those that received a matrixectomy coupled with a course of oral antibiotics (group 1). CONCLUSION: The use of oral antibiotics as an adjunctive therapy in treating ingrown toenails does not play a role in decreasing the healing time or postprocedure morbidity.

Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial.

OBJECTIVE: Diabetic foot ulceration is a preventable long-term complication of diabetes. A multicenter prospective follow-up study was conducted to determine which risk factors in foot screening have a high association with the development of foot ulceration. RESEARCH DESIGN AND METHODS: A total of 248 patients from 3 large diabetic foot centers were enrolled in a prospective study. Neuropathy symptom score, neuropathy disability score (NDS), vibration perception threshold (VPT), Semmes-Weinstein monofilaments (SWFs), joint mobility, peak plantar foot pressures, and vascular status were evaluated in all patients at the beginning of the study. Patients were followed-up every 6 months for a mean period of 30 months (range 6-40), and all new foot ulcers were recorded. The sensitivity, specificity, and positive predictive value of each risk factor were evaluated. RESULTS: Foot ulcers developed in 95 feet (19%) or 73 patients (29%) during the study. Patients who developed foot ulcers were more frequently men, had diabetes for a longer duration, had nonpalpable pedal pulses, had reduced joint mobility, had a high NDS, had a high VPT, and had an inability to feel a 5.07 SWE NDS alone had the best sensitivity, whereas the combination of the NDS and the inability to feel a 5.07 SWF reached a sensitivity of 99%. On the other hand, the best specificity for a single factor was offered by foot pressures, and the best combination was that of NDS and foot pressures. Univariate logistical regression analysis yielded a statistically significant odds ratio (OR) for sex, race, duration of diabetes, palpable pulses, history of foot ulceration, high NDSs, high VPTs, high SWFs, and high foot pressures. In addition, 94 (99%) of the 95 ulcerated feet had a high NDS and/or SWF which resulted in the highest OR of 26.2 (95% CI 3.6-190). Furthermore, in multivariate logistical regression analysis, the only significant factors were high NDSs, VPTs, SWFs, and foot pressures. CONCLUSIONS: Clinical examination and a 5.07 SWF test are the two most sensitive tests in identifying patients at risk for foot ulceration, especially when the tests are used in conjunction with each other. VPT measurements are also helpful and can be used as an alternative. Finally, foot pressure measurements offer a substantially higher specificity and can be used as a postscreening test in conjunction with providing appropriate footwear.

The potential benefits of advanced therapeutic modalities in the treatment of diabetic foot wounds.

This article discusses the advantages and disadvantages of primary wound healing as compared with primary amputation in individuals with chronic diabetic foot wounds. The authors review the potential benefits of vascular surgical procedures and advanced dressings, including two of the most promising modalities in modern wound care: growth factors and bioengineered skin. In this era of cost-conscious health-care administration, it is incumbent on the practitioner to consider not only the basic science of wound care, but also the economic aspect of treatment rendered. These various interventions, dressings, growth factor delivery systems, and new modalities could significantly reduce healing time, thereby reducing the risk of infection, hospitalization, and amputation while improving quality of life. If so, they may be truly cost-effective.

Factors associated with bone regrowth following diabetes-related partial amputation of the foot.

BACKGROUND: The formation of hypertrophic bone after partial resection of metatarsal bone has the potential to cause abnormal foci of high pressure in people who have diabetes mellitus; this may increase the risk of reulceration and reamputation. However, we are not aware of previous studies evaluating the risk factors for this entity. METHODS: The records of ninety-two adults (mean age, 54+/-10.1 years; range, thirty to seventy-four years) with diabetes who had had an isolated partial amputation of a ray were abstracted. Repeat radiographs were made for all of these subjects at a mean of 22+/-6.1 months (range, thirteen to thirty-five months) after the initial procedure. The formation of hypertrophic bone was defined as more than three millimeters of regrowth. RESULTS: A total of forty-one (45 percent) of the subjects had formation of hypertrophic bone at the time of radiographic analysis after isolated partial amputation of a ray. On multivariate analysis, the factors that were significantly associated with this regrowth of bone were male gender (88 percent [thirty-six] of the forty-one patients who had bone regrowth were male compared with 51 percent [twenty-six] of the fifty-one patients who did not have bone regrowth; p<0.01, odds ratio = 5.7, 95 percent confidence interval = 1.8 to 18.9), the use of manual bone-cutting instruments (used in 56 percent [twenty-three] of the forty-one patients who had bone regrowth compared with 16 percent [eight] of the fifty-one who did not; p<0.01, odds ratio = 4.7, 95 percent confidence interval = 1.6 to 13.8), and a resection made distal to the surgical neck of the metatarsal (used in 34 percent [fourteen] of the forty-one patients who had bone regrowth compared with 12 percent [six] of the fifty-one who did not; p<0.03, odds ratio = 4.5, 95 percent confidence interval = 1.2 to 16.9). The patients who had regrowth of bone were approximately eight times more likely to have reulceration at the site of the amputation than were those who did not have regrowth (24 percent [ten] of the patients with regrowth had reulceration compared with 4 percent [two] of the patients without regrowth; p<0.01, chi square = 8.4, odds ratio = 7.9, 95 percent confidence interval = 1.6 to 38.5). CONCLUSIONS: Overgrowth of the bone of a transected metatarsal predisposes patients to ulceration. Male gender, the use of manual bone-cutting instruments, and metaphyseal amputation may be associated with long-term regrowth of bone following isolated partial amputation of a ray. The use of power instruments during these procedures may lead to a lower prevalence of this reaction, thereby potentially reducing the risk of ulceration, infection, and reamputation.

The increased prevalence of severe necrotizing infections caused by non-group A streptococci.

The authors report on 20 patients who were admitted to the University of Texas Health Science Center at San Antonio during a recent 4-month period with foot infections caused predominantly by non-group A streptococci. This number of patients was significantly greater than the number admitted to the same institution with the same diagnosis during the preceding 3 years. All patients had type 2 diabetes mellitus. In each case, a rapidly spreading cellulitis followed trauma to the foot, which necessitated emergent incision and drainage. Five patients required extensive fascial and skin debridement because of soft-tissue destruction, and two patients needed below-the-knee amputation because of uncontrolled infection. These cases suggest that non-group A streptococci, like group A streptococci, can cause serious skin and soft-tissue infections in patients with diabetes that may require aggressive surgical debridement despite appropriate antibiotic therapy.

Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot.

BACKGROUND: The purpose of this study was to determine the degree to which pressure on the plantar aspect of the forefoot is reduced following percutaneous lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. METHODS: Ten diabetic patients who had a history of neuropathic plantar ulceration of the forefoot were enrolled in a laboratory gait trial. A repeated-measures design and a computer analysis of force-plate data were used to examine dynamic pressures on the forefoot, with the patient walking barefoot, immediately before percutaneous lengthening of the Achilles tendon and at eight weeks afterward. Although the wound in each patient had healed at least one month before the operation, we considered the patients to be at high risk for ulceration because they had had an ulcer previously. RESULTS: The mean peak pressure (and standard deviation) on the plantar aspect of the forefoot decreased significantly from 86+/-9.4 newtons per square centimeter preoperatively to 63+/-13.2 newtons per square centimeter at eight weeks postoperatively (p<0.001). Commensurately, the mean dorsiflexion of the ankle joint increased significantly from 0+/-3.1 degrees preoperatively to 9+/-2.3 degrees at eight weeks post-operatively (p<0.001). CONCLUSIONS: The results of this study suggest that peak pressures on the plantar aspect of the forefoot are significantly reduced following percutaneous lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. We are unaware of any other reports in the medical literature that describe such findings. These data may lend support to studies that have indicated that this procedure should be used as an adjunctive therapeutic or prophylactic measure to reduce the risk of neuropathic ulceration.

Is intermittent pulsatile pressure a valuable adjunct in healing the complicated diabetic wound?

Diabetic neuropathic ulceration and subsequent lower extremity amputation are a significant cause of chronic disability. High-risk diabetic patients with infected foot wounds, poor lower extremity blood flow, and inadequately controlled blood glucose require prompt action by clinicians in order to successfully avoid more severe sequelae. Dysvascular patients who are poor candidates for arterial bypass surgery may benefit from adjunctive treatment with a pneumatic pedal compression device. The authors discuss the rationale behind this unique treatment modality and present a case report illustrating a successful outcome in a high-risk diabetic patient.

Role of neuropathy and high foot pressures in diabetic foot ulceration.

OBJECTIVE: High plantar foot pressures in association with peripheral neuropathy have been ascertained to be important risk factors for ulceration in the diabetic foot. Most studies investigating these parameters have been limited by their size and the homogeneity of study subjects. The objective of this study was therefore to ascertain the risk of ulceration associated with high foot pressures and peripheral neuropathy in a large and diverse diabetic population. RESEARCH DESIGN AND METHODS: We studied a cross-sectional group of 251 diabetic patients of Caucasian (group C) (n=121), black (group B) (n=36), and Hispanic (group H) (n=94) racial origins with an overall age of 58.5+/-12.5 years (range 20-83). There was an equal distribution of men and women across the entire study population. All patients underwent a complete medical history and lower extremity evaluation for neuropathy and foot pressures. Neuropathic parameters were dichotomized (0/1) into two high-risk variables: patients with a vibration perception threshold (VPT) > or =25 V were categorized as HiVPT (n=132) and those with Semmes-Weinstein monofilament tests > or =5.07 were classified as HiSWF (n=190). The mean dynamic foot pressures of three footsteps were measured using the F-scan mat system with patients walking without shoes. Maximum plantar pressures were dichotomized into a high-pressure variable (Pmax6) indicating those subjects with pressures > or =6 kg/cm2 (n=96). A total of 99 patients had a current or prior history of ulceration at baseline. RESULTS: Joint mobility was significantly greater in the Hispanic cohort compared with the other groups at the first metatarsal-phalangeal joint (C 67+/-23 degrees, B 69+/-23 degrees, H 82+/-23 degrees, P=0.000), while the subtalar joint mobility was reduced in the Caucasian group (C 21+/-8 degrees, B 26+/-7 degrees, H 27+/-11 degrees, P=0.000). Maximum plantar foot pressures were significantly higher in the Caucasian group (C 6.7+/-2.9 kg/cm2, B 5.7+/-2.8 kg/cm2, H 4.4+/-1.9 kg/cm2, P=0.000). Univariate logistic regression for Pmax6 on the history of ulceration yielded an odds ratio (OR) of 3.9 (P=0.000). For HiVPT, the OR was 11.7 (P=0.000), and for HiSWF the OR was 9.6 (P=0.000). Controlling for age, diabetes duration, sex, and race (all P < 0.05), multivariate logistic regression yielded the following significant associations with ulceration: Pmax6 (OR=2.1, P=0.002), HiVPT (OR=4.4, P=0.000), and HiSWF (OR=4.1, P=0.000). CONCLUSIONS: We conclude that both high foot pressures (> or =6 kg/cm2) and neuropathy are independently associated with ulceration in a diverse diabetic population, with the latter having the greater magnitude of effect. In black and Hispanic diabetic patients especially, joint mobility and plantar pressures are less predictive of ulceration than in Caucasians.

Preoperative assessment of the transplant patient.

In the authors' university medical center, there are an increasing number of transplant patients presenting for foot surgery. Newer immunosuppressive agents are largely responsible for improvement of graft and patient survival and hence more patients requiring and wanting foot surgery. Podiatric surgeons must approach these patients with caution, but not fear. Transplant patients are more susceptible to infection, have altered response to stress from surgery, and may have delayed wound healing. Preoperative assessment and planning are imperative when considering surgery for transplant patients.

Emergence of non-group A streptococcal necrotizing diabetic foot infections.

Recently the authors have noted a disturbing trend toward an increased incidence of necrotizing infections caused by non-group A streptococcal species. This article describes the typical clinical course of such an infection. Prompt surgical intervention, coupled with an antibiotic regimen aimed at mitigating exotoxin release, may be both limb- and life-preserving.

Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation.

OBJECTIVE: To validate a wound classification instrument that includes assessment of depth, infection, and ischemia based on the eventual outcome of the wound. RESEARCH DESIGN AND METHODS: We evaluated the medical records of 360 diabetic patients presenting for care of foot wounds at a multidisciplinary tertiary care foot clinic. As per protocol, all patients had a standardized evaluation to assess wound depth, sensory neuropathy, vascular insufficiency, and infection. Patients were assessed at 6 months after their initial evaluation to see whether an amputation had been performed. RESULTS: There was a significant overall trend toward increased prevalence of amputations as wounds increased in both depth (chi 2trend = 143.1, P < 0.001) and stage (chi 2trend = 91.0, P < 0.001). This was true for every subcategory as well with the exception of noninfected, nonischemic ulcers. There were no amputations performed within this stage during the follow-up period. Patients were more than 11 times more likely to receive a midfoot or higher level amputation if their wound probed to bone (18.3 vs. 2.0%, P < 0.001, chi 2 = 31.5, odds ratio (OR) = 11.1, CI = 4.0-30.3). Patients with infection and ischemia were nearly 90 times more likely to receive a midfoot or higher amputation compared with patients in less advanced wound stages (76.5 vs. 3.5%, P < 0.001, chi 2 = 133.5, OR = 89.6, CI = 25-316). CONCLUSIONS: Outcomes deteriorated with increasing grade and stage of wounds when measured using the University of Texas Wound Classification System.

Who is at risk for diabetic foot ulceration?

Diabetic foot ulceration is the most common cause of nontraumatic, lower-extremity amputation throughout the developed world. This article reviews recent data that report on various risk factors for ulceration. Subsequently, it discusses appropriate risk stratification for both the neuropathic ulcer specifically and the diabetic foot in general, using The University of Texas Diabetic Foot and Diabetic Wound Classification Systems. We believe that knowledge and communication of the most common risk factors precipitating ulceration and subsequent amputation lead to more consistent treatment of the diabetic foot, and, ultimately, to a reduction of its prevalence.

Outcomes of preventative care in a diabetic foot specialty clinic.

The purpose of the study was to report the incidence of ulceration, reulceration, and amputation in 341 patients treated in a multidisciplinary clinic over the course of 3 years. Patients enrolled were 57.8% male, with a mean age of 53.2 +/- 11.8 years. All were assessed using the University of Texas Diabetic Foot Classification System. Of these patients, 118 fell into category 0 (protective sensation intact), 98 into category 1 (loss of protective sensation, LOPS), 77 into category 2 (LOPS with deformity), and 48 into category 3 (LOPS, deformity, previous history of ulcer or amputation). Outcomes assessed included any incident ulcerations or amputations. The authors stratified patients based on their compliance to follow up appointments. Non compliance was defined as missing > 50% of scheduled appointments in any calendar year. Thirty of the above subjects were classified as noncompliant. Prior to analysis, the authors initially stratified subjects into compliant and noncompliant groups. If further stratified by foot category, the incidence of ulceration in the compliant group was 0 for diabetic foot categories 0 and 1, 3.5/1,000/year for category 2, and 18/1,000/year for category 3. One category 3 patient required a partial first-ray amputation. The yearly incidence of amputation for the entire cohort was therefore 1.1/1,000/year. For categories 0-2 the incidence was 0, and for category 3, it was 9/1,000/year. Patients stratified into the noncompliant group were approximately 54 times more likely to ulcerate than patients who returned regularly for their scheduled care (81.8% ulcer prevalence vs. 5.4%, p < .0001, OR = 54.0, Cl = 7.5-1,425.0). Additionally, noncompliant category 3 patients were over 20 times more likely to receive an amputation than their compliant counterparts (45.5% amputation prevalence vs. 2.7%, p < .002, OR = 2.5-819.0). The study concluded that multidisciplinary diabetes care team, which includes aggressive foot care and consistent treatment-based risk classification, may be effective in profoundly mitigating the occurrence and recurrence of diabetic foot sequelae, including ulceration and amputation. Furthermore, patient noncompliance to routine preventative care appears to be associated with a significantly higher prevalence of ulceration and amputation.

Our fixation with fixation: are screws clinically superior to external wires in distal first metatarsal osteotomies?

The purpose of this study was to evaluate the immediate postoperative morbidity, the structural correction attained, and the long-term range of motion following fixation with a single external Kirschner wire and an internal cortical screw. We abstracted records for 69 patients undergoing, distal unicorrectional chevron osteotomies. Thirty-three patients received percutaneous 0.062-inch K-wire fixation and 36 patients received single 2.7-mm. cortical screw fixation. Among these age- and sex-matched subjects, there was not a significant difference between any of the correctional or morbid outcomes measured in this study on the basis of type of fixation employed. Patients with rigid internal screw fixation did not return to shoe gear sooner, develop fewer postoperative infections, or have increased long-term range of motion than the group receiving external fixation with a single K-wire. Surgical time was significantly longer for those patients undergoing rigid internal fixation with a screw (42.5 +/- 9.5 vs. 35.1 +/- 6.6 minutes, p < 0.001). We conclude that there is no significant difference in postoperative infection, dehiscence, long-term structural correction attained, or range of motion achieved between rigid internal screws and external K-wires used to fixate distal metatarsal osteotomies.