Vascular Assessment of the Foot Surgery Patient.

Foot surgery is common. Orthopaedic nurses charged with evaluating and treating patients who have undergone foot surgery are required to evaluate the vascular status of the patient's foot (or feet). As a result, these nurses are often the first to identify vascular issues. This article provides orthopaedic nurses with the background to understand how the patient's history, the procedure(s) performed, and a thorough assessment of the foot's circulation will allow them to promptly identify circulatory problems and potentially save a patient from having a serious complication.

Vitamin D and foot and ankle trauma: An individual or societal problem.

BACKGROUND: Vitamin D deficiency is a worldwide health concern. Hypovitaminosis D may adversely affect recovery from bone injury. The authors aimed to perform an audit of the Vitamin D status of patients in three centres in the United Kingdom presenting with foot and ankle osseous damage. METHODS: Serum 25-hydroxyvitamin-D (vitamin D) levels were obtained in patients presenting with imaging confirmed foot and ankle osseous trauma. Variables including age, gender, ethnicity, location, season, month, anatomical location and type of bone injury were recorded. RESULTS: 308 patients were included from three different centres. 66.6% were female. The average age was 47.7 (range; 10-85). The mean hydroxyvitamin-D levels were 52.0 nmol/L (SD 28.5). 18.8% were grossly deficient, 23.7% deficient, 34.7% insufficient and 22.7% within normal range. 351 separate bone injuries were identified of which 104 were categorised as stress reactions, 134 as stress fractures, 105 as fractures and 8 non-unions. Age, gender, anatomical location and fracture type did not statistically affect vitamin D levels. Ethnicity did affect Vitamin D levels: non-Caucasians mean levels were 32.4 nmols/L compared to Caucasian levels of 53.2 nmol/L (p=0.0026). CONCLUSION: Only 18.8% of our trauma patients had a normal Vitamin D level and 22.7% were grossly deficient. Patient age, gender, anatomical location and injury type did not statistically affect vitamin D levels. No difference between trauma and elective patients were found. Hypovitaminosis D is a problem of society in general rather than specific to certain foot and ankle injury patterns or particular patient groups sustaining trauma. LEVEL OF EVIDENCE: 2b.

Can we use biomarkers of coagulation to predict which patients with foot and ankle injury will develop deep vein thrombosis?

BACKGROUND: Our aim was to determine whether plasma levels of Tissue Factor (TF), Vascular Cell Adhesion Molecule 1 (VCAM-1), Interleukin 6 (IL-6) or D-dimer after foot and ankle injury could predict which patients would develop deep vein thrombosis (DVT). METHODS: Patients aged 18-60 years with acute foot and ankle injury had venous blood sample to measure TF, VCAM-1, IL-6 and D-dimer within 3 days of injury. Patients had bilateral lower limb venous ultrasound to assess for DVT on discharge from clinic. RESULTS: 21 of 77 patients were found to have DVT (27%). There was no statistically significant association between levels of TF, VCAM-1, IL-6 or D-dimer and subsequent development of DVT. CONCLUSION: Tissue Factor (TF), Vascular Cell Adhesion Molecule-1 (VCAM-1), Interleukin-6 (IL-6) and D-dimer levels were not associated with development deep vein thrombosis in patients with acute foot and ankle injury.

Evaluation of TCOM/HBOT practice guideline for the treatment of foot burns occurring in diabetic patients.

OBJECTIVES: A multidisciplinary team developed an evidence-based guideline for the management of foot burns occurring in diabetic patients that included transcutaneous oxygen measurements (TCOM) and application of hyperbaric oxygen therapy (HBOT) to selected patients. This report represents an evaluation of preliminary TCOM/HBOT data. METHODS: This is a retrospective review of patients with diabetes mellitus (DM) who were admitted to a single American Burn Association (ABA) verified burn center for the treatment of foot burns. Patients were treated via the guideline if they were over the age of 16, admitted for the initial care of burns involving the feet between 4/01/2012 and 7/22/2013, and had a known or new diagnosis of DM. RESULTS: Eighteen patients were treated according to the guideline, 14 men and 4 women. Average age was 54 years+14.78. Average BMI was 30.63+6.34. Median burn size was 0.88% TBSA (median partial thickness of 1% and median full thickness of 0.5%). The average HbA1c was 9.08+2.42. Seven patients received pre-operative HBOT, two received post-operative HBOT and three patients healed their wounds with HBOT alone. Average hospital length of stay was 13.39 days+9.94 and was significantly longer for the group receiving HBOT. Admission HbA1c was not a predictor of the need for HBOT. CONCLUSIONS: While TCOM/HBOT therapy has not been widely applied to the management of diabetic foot burns, the use of an evidence-based guideline incorporating TCOM/HBOT can provide a systematic way to evaluate the patients' microcirculation and ability to heal burns of the foot. The incorporation of TCOM determination and application of HBOT in selected patients with DM and burns of the feet warrant continued study.

Transcutaneous oxygen measurements under hyperbaric oxygen conditions as a predictor for healing of problem wounds.

Controversy exists as to what transcutaneous oxygen (P(tc)O2) levels are required for wound healing and what role hyperbaric oxygen has for this. Current information suggests that 30 to 40 mmHg juxta-wound oxygen tensions in room air are required. We recorded P(tc)O2 measurements in room air and with hyperbaric oxygen in 190 patients with foot wounds; then looked retrospectively and prospectively whether there was any effect on healing. Transcutaneous oxygen measurements under hyperbaric oxygen conditions defined a responder group (P(tc)O2 > 200 mmHg) with a sensitivity of 0.80 and a positive predictive value of 0.88 for healing, regardless of room air measurements when hyperbaric oxygen was used as an adjunct to wound management. This information helps to objectify the indications for hyperbaric oxygen and predict healing especially in those patients with problem wounds of the foot and ankle.