Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial.

This study compared the treatment of total contact casting (TCC) with traditional dressing treatment (TDT) in the management of diabetic plantar ulcers. Forty patients with diabetes mellitus and a plantar ulcer but with no gross infection, osteomyelitis, or gangrene were randomly assigned to the TCC group (n = 21) or TDT group (n = 19). Age, sex, ratio of insulin-dependent diabetes mellitus to non-insulin-dependent diabetes mellitus, duration of diabetes mellitus, vascular status, size and duration of ulcer, and sensation were not significantly different between groups (P greater than .05). In the experimental group, TCC was applied on the initial visit, and subjects were instructed to limit ambulation to approximately 33% of their usual activity. Subjects in the control group were prescribed dressing changes and accommodative footwear and were instructed to avoid bearing weight on the involved extremity. Ulcers were considered healed if they showed complete skin closure with no drainage. Ulcers were considered not healed if they showed no decrease in size by 6 wk or if infection developed that required hospitalization. In the TCC group, 19 of 21 ulcers healed in 42 +/- 29 days; in the TDT group, 6 of 19 ulcers healed in 65 +/- 29 days. Significantly more ulcers healed (chi 2 = 12.4, P less than .05) and fewer infections developed (chi 2 = 4.1, P less than .05) in the TCC group. We conclude TCC is a successful method of treating diabetic plantar ulcers but requires careful application, close follow-up, and patient compliance with scheduled appointments to minimize complications.

Closed shortening of the femur.

Twenty skeletally mature patients (average age, sixteen years and seven months; range, thirteen years and seven months to twenty-two years and four months) were treated for limb-length inequality by closed shortening of the femur. Preoperatively, the amount of femoral shortening that was necessary to level the pelvis was determined radiographically by balancing the pelvis with calibrated lifts under the shorter extremity. All twenty shortening procedures were performed with an intramedullary cam saw and insertion of an intramedullary rod through a gluteal incision; no additional incisions were needed to complete the procedure. At the most recent follow-up, the limb-length discrepancy was one centimeter or less in all twenty patients. All patients reported that the limbs seemed to be of equal length and that the pelvis felt level.

Relationship of foot deformity to ulcer location in patients with diabetes mellitus.

The purpose of this study was to determine whether a relationship existed between type of foot deformity and the location of ulcers in patients with diabetes and insensitive feet. Forty-two ulcerated feet were examined in 40 patients. All patients had severely decreased or absent sensation. Foot deformities were classified according to operational definitions as 1) Charcot's foot, 2) a compensated forefoot varus, or 3) an uncompensated forefoot varus or forefoot valgus. The plantar surface of the midfoot and forefoot was divided into three regions. Six of the 7 patients with a Charcot's foot showed ulceration at the midfoot. Nine of 18 patients with a compensated forefoot varus showed ulceration at the second, third, or fourth metatarsal head. Fifteen of 17 patients with an uncompensated forefoot varus or forefoot valgus showed ulceration at the first or fifth metatarsal. A significant relationship was found between foot deformity and location of ulcer. These results support the hypotheses 1) that insensitivity, coupled with increased, repetitive pressure, is a primary cause of plantar ulcers and 2) that certain foot types are associated with characteristic patterns of pressure distribution and callus formation.

Diabetic plantar ulcers treated by total contact casting. A clinical report.

The purpose of this clinical report is to describe the healing times of plantar ulcers treated by total contact casting (TCC) in nondiabetic and diabetic patients with and without evidence of severe peripheral vascular disease. Thirty patients with 33 chronic plantar ulcers were treated by applying total contact walking casts. Results demonstrate that 27 of 33 ulcers (81.8%) healed in an average time of 43.6 days. Healing times of patients with severe peripheral vascular disease secondary to diabetes mellitus are similar to those of patients without evidence of vascular disease. These results indicate that TCC is an effective and rapid treatment for chronic plantar ulcers in patients with or without vascular compromise secondary to diabetes mellitus. In addition, the results suggest that pressure reduction on the insensitive foot should be considered in treatment.

Roentgen rounds #81. Posteromedial bowing of the tibia.

Posteromedial bowing of the tibia is a rare deformity which is being recognized more frequently. It is frequently associated with and may be the result of a calcaneovalgus foot deformity. It has a better overall prognosis than the other two categories of congenital angular deformity of the tibia. It does not, however, have a prognosis of normality. The frequent sequelae of LLD and foot hypoplasia should be taken into account when counseling parents of children with PMBT. The need for clinical follow-up with interval scanograms should be emphasized.

Epiphysiodesis: a problem of timing.

A retrospective review of 67 distal femoral and proximal tibial epiphysiodeses, performed over a 14 year period for correction of leg length inequality, revealed only 22 patients with a final discrepancy of less than 1 cm. Ten of the 45 failures were secondary to inadequate surgical epiphysiodesis. The remaining 35 failures were secondary to errors in timing surgery due to incorrect use of Green and Anderson growth prediction tables. The primary causes of failure would have been decreased by more careful follow-up and the use of the Moseley Graph.

Fractures after Wagner limb lengthening.

A retrospective review of our experience with fractures after 27 Wagner limb lengthenings (23 patients) was undertaken. Ten fractures occurred after lengthening in eight patients (six spontaneous, four traumatic). Seven patients fractured despite a "staged" removal of the fixation plate. Seven of 10 fracture patients required open reduction/internal fixation (ORIF) to obtain union and/or satisfactory alignment. Our results indicate that patients with a congenital limb length inequality are prone to spontaneous fracture after Wagner limb lengthening. These results raise serious questions regarding the quality of bone healing after a Wagner-type lengthening for congenital limb length inequality.