The diagnosis of osteomyelitis in diabetes using erythrocyte sedimentation rate: a pilot study.

Osteomyelitis secondary to diabetic foot infections can lead to proximal amputation if not diagnosed in a timely and accurate manner. The authors have found no studies to date that correlate a specific erythrocyte sedimentation rate with osteomyelitis. A retrospective chart review of 29 diabetic patients admitted to the hospital with diagnoses of osteomyelitis or cellulitis of the foot during a 1-year period was performed. Of the various lab values and demographic factors compared, erythrocyte sedimentation rate was the only measure that differed significantly between the two groups. A receiver operating characteristic curve was used to obtain the optimal cutoff value of 70 mm/h, a level above which osteomyelitis was present with the highest sensitivity (89.5%) and highest specificity (100%), along with a positive predictive value of 100% and a negative predictive value of 83%. This study shows that in combination with clinical suspicion in diabetic foot infections, the erythrocyte sedimentation rate is highly predictive of osteomyelitis, and that the value of 70 mm/h is the optimal cutoff to predict accurately the presence or absence of bone infection.

Treatment of posterior tibial tendon dysfunction with tendon procedures from the posterior muscle group.

The use of tendons from the posterior muscle group, specifically the FDL, as a means to repair PTTD is useful for the early stages of the deformity. Once the patient has reached the later stages and the foot becomes rigidly deformed with loss of the medial longitudinal arch, however, any attempt to reconstruct the area with tendon work alone fails. Tendon repair, tenodesis, and tendon transfer are attractive treatment options for PTTD, but care should be taken in choosing the correct patient for these procedures. Some authors note that side-to-side tenodesis does not address arch realignment. Other procedures combined with tendon work perhaps can help to reduce the shortcomings of isolated tendon procedures. Subtalar joint arthroeresis in combination with the tendon work seems to solve this problem. The authors have begun to explore this option and have performed this procedure on some patients. It is premature to address the effectiveness of this combined procedure. Similarly, tendon procedures augmented with other soft-tissue-type procedures also remains an option and is mostly ignored in the medical literature. Deland et al experimented with reconstruction of the spring ligament in a cadaver study, and believed that it should be considered in any reconstructive flatfoot surgery. Likewise, Myerson used some capsular reefing of the talonavicular joint in his tendon reconstruction to aid the correction of the forefoot-to-rearfoot relationship. The treatment of the patient with PTTD remains driven by the surgeon's preference, with little scientific research to guide him or her. There is much controversy regarding the efficacy of tendon procedures and the specific surgical technique of each procedure. Some variations may prove inconsequential, whereas others may prove revolutionary. The authors believe that the use of the tendon work as a means of treatment for PTTD is viable alone or in combination with other procedures. Much research is still needed to identify the best technique for each stage of the deformity. Wiekland has attempted to do this, but unfortunately has not offered any long-term follow-up to justify his treatment algorithms. Foot and ankle specialists should strive for clinical research, which allows better understanding of the appropriate treatment options for each progressive stage of PTTD.

Use of postoperative steroids to reduce pain and inflammation.

Postoperative injection of a steroid is used by many podiatric surgeons to reduce pain and inflammation after foot surgery. The authors present a review of the literature on postoperative steroid use from many medical specialties as well as a review of wound and bone healing. The literature indicates that using a steroid is a safe and effective means to reduce postoperative pain and edema. Studies have shown steroids to delay healing, inhibit collagen synthesis, and increase the risk of postoperative infection. No author reported a delay in wound or bone healing or increased infection rate in patients in which a steroid was used. Although there is literature to support this practice, many questions remain and further investigation is needed.