Verrucous carcinoma of the foot: a review and report of two cases.

Verrucous carcinoma is an uncommon form of squamous cell carcinoma. Clinical and histological features of this condition are reviewed. Excision is the treatment of choice due to local aggressiveness and infrequent metastasis. Two cases involving the foot are presented as well as a survey of previously documented cases of this condition.

The Histologic Spectrum of Apocrine Lesions of the Breast

Apocrine proliferations most often are metaplasia as a component offibrocystic change. However, the appearance of apocrine metaplasia within various breast lesions, such as papillomas, ductal adenomas, and sclerosing adenosis, may complicate their diagnosis. Distinguishing benign from malignant apocrine proliferations can be problematic owing to the nuclear characteristics of apocrine cells. In this article, we characterize the spectrum of apocrine proliferations in the breast ranging from benign to malignant and attempt to clarify the difficult lesions that are intermediate between hyperplasia and ductal carcinoma in situ.

Gamma-glutamyl transpeptidase immunoreactivity in benign and malignant breast tissue.

GGT 129, a polyclonal antibody directed against gamma-glutamyl transpeptidase (GGT), was used to study GGT expression in formalin-fixed paraffin-embedded tissues from normal breast, 24 benign lesions, 27 in situ carcinomas or atypical hyperplasias, and 79 infiltrating mammary carcinomas. Epithelium of the ducts and ductules in normal breast tissue showed immunoreactivity along the apical surface. There was a strong correlation (P < 0.01) between the histologic classification of the tissue and GGT expression. All of the benign breast lesions stained positive for GGT. Among in situ carcinomas and atypical hyperplasias, 5/27 (19%) were negative for GGT while 22/27 were immunopositive. Infiltrating carcinomas showed the greatest deviation from normal tissue with 23/79 (29%) negative for GGT. GGT expression in benign and malignant breast tissue was not correlated with the age of the patient, suggesting that menopausal status does not influence expression of GGT. Correlation of GGT immunoreactivity with tubule formation, nuclear pleomorphism, mitoses, grade, size of tumor, lymph node status, and ER/PR status was performed for 69 cases of infiltrating ductal adenocarcinoma. There were no statistically significant relationships between the level of GGT immunoreactivity and any of the parameters. The loss of GGT in some of the cases is evidence that this enzyme is not required for mammary tumor development or maintenance. However, as GGT is a component of the pathways that metabolize glutathione and glutathione-conjugates, the difference in levels of the enzyme in invasive breast cancers may be one explanation for the variation in chemotherapy response that has been observed in patients treated for advanced mammary cancer.

Deep vein thrombosis in stroke. The use of plasma D-dimer level as a screening test in the rehabilitation setting.

BACKGROUND AND PURPOSE: Venous thromboembolism is a leading cause of morbidity and mortality during the acute recovery period after stroke. This study investigated the utility of plasma D-dimer level as a diagnostic test for deep vein thrombosis (DVT) in patients hospitalized for stroke rehabilitation. METHOD: Plasma samples were drawn from 105 nonambulatory rehabilitation patients with recent ischemic or hemorrhagic stroke and assayed for D-dimer with an enzyme-linked immunosorbent method. Samples were drawn within 24 hours of venous duplex ultrasound (VDU) screening for DVT. Optimal discriminant analysis was used to determine whether plasma D-dimer level, age, sex, days after stroke onset, stroke etiology. National Institutes of Health Stroke Scale score, and ambulatory status could correctly classify patients' DVT status. RESULTS: Fourteen of 105 patients had DVT identified by VDU scan. Of all attributes, only D-dimer level had significant ability to discriminate between patients with or without DVT (P < .0001). The optimal cut point for predicting DVT was D-dimer = 1591 ng/mL, resulting in 79% sensitivity, 78% specificity, 35% positive predictive value, and 96% negative predictive value. Reducing the D-dimer cut point to 1092 ng/mL improved both sensitivity and negative predictive value to 100% but reduced specificity to 66% and positive predictive value to 31%. CONCLUSIONS: A D-dimer level < or = 1092 ng/mL can exclude the presence of DVT in stroke rehabilitation patients. When a D-dimer level > 1092 ng/mL occurs, further diagnostic testing is necessary to confirm DVT. Plasma D-dimer level is a simple and inexpensive screening test for DVT during stroke rehabilitation.

Simultaneous abdominal aortic aneurysm repair and nephrectomy for neoplasm.

BACKGROUND: Abdominal aortic aneurysm and renal neoplasm are occasionally discovered concurrently. Simultaneous operative therapy may be an effective alternate management strategy to a staged procedure. PATIENTS AND METHODS: The medical records of 10 consecutive patients undergoing abdominal aortic aneurysm repair and nephrectomy for renal neoplasm were reviewed. Data collected included mode of presentation, preoperative evaluation, renal pathology, and in-hospital morbidity and mortality. Long-term follow-up was obtained through office records and telephone contact. RESULTS: In 7 patients, the renal mass was identified during evaluation of abdominal aortic aneurysm. The aneurysm was identified during evaluation of hematuria in 2 patients. One patient was discovered to have both conditions simultaneously. All patients underwent successful aneurysm repair and nephrectomy. Pathology revealed 6 renal cell carcinomas, 2 complex cysts, 1 hemangiopericytoma, and 1 oncocytoma. Four patients have died in the follow-up period: 1 of metastatic cancer and 3 of unrelated causes. There have been no cases of graft infection. CONCLUSION: Simultaneous abdominal aortic aneurysm repair and nephrectomy for neoplasm is an appropriate management strategy for selected patients.

Persistence of interstitial inflammation after episodes of cardiac rejection associated with systemic infection.

BACKGROUND: To determine whether systemic infection has an effect on cardiac allografts, we compared heart transplant biopsy specimens showing acute cardiac rejection in patients with and without associated systemic infection. METHODS: Systemic infection was defined as positive bacterial, viral, or fungal cultures with systemic symptoms such as sepsis, fever, or malaise. Patients were identified by chart review to verify the presence or absence of infection and the cardiac biopsy specimens were examined for evidence of rejection. Eight patients (eight episodes of treated acute rejection) with evidence of systemic infection and 11 patients (14 episodes of treated acute rejection) without evidence of systemic infection were identified. RESULTS: Patients with rejection and infection showed persistent interstitial inflammation longer than patients with only rejection and was most often represented by International Society for Heart and Lung Transplantation rejection grade 1B. Days to resolution or last biopsy was 20 to 602 days (mean 196 days) for patients with rejection and infection versus 15 to 133 days (mean 60 days) for patients with rejection alone. Results of two-tailed, unpaired t-test comparing the number of days of persistent inflammatory infiltrates in the patients with and without infection were statistically significant (p = 0.0192). CONCLUSIONS: Heart transplant recipients with treated acute rejection and systemic infection more frequently have persistent interstitial inflammatory infiltrates than do heart cardiac transplant recipients with treated acute rejection and no associated infection. No impact of acute rejection or associated infection on the incidence of allograft coronary artery disease was apparent. Although further evaluation of these findings is necessary, we speculate that heart transplant recipients with systemic infection and acute rejection have greater immunologic activity leading to persistent interstitial inflammation and may possibly be associated with a higher incidence of chronic rejection.

Surgical management of atheroembolization.

PURPOSE: Atheroembolization may cause limb loss or organ failure. Surgical outcome data are limited. We report the largest series of atheroembolization focusing on patterns of disease, surgical treatment and outcome. METHODS: One hundred patients (70 men), mean age 62 +/- 11 years, operated on for lower extremity, visceral, or nonthoracic outlet upper extremity atheroemboli were identified prospectively and monitored over a 12-year period. The atheroembolic source was localized by use of a combination of computed tomography scanning (n = 55), arteriography (n = 93), duplex scanning (n = 25), transesophageal echocardiography (n = 6), and magnetic resonance imaging (n = 4). Occlusive aortoiliac disease (47 patients) and small aortic aneurysms (20 patients; mean aneurysm size 3.5 +/- 0.8 cm) were the most common source of atheroemboli. Imaging studies revealed 12 patients with extensive suprarenal aortic thrombus. Correction of the embolic source was achieved with aortic bypass (n = 52), aortoiliac endarterectomy and patch (n = 11), femoral or popliteal endarterectomy and patch (n = 11), infrainguinal bypass (n = 3), extraanatomic reconstruction (n = 6), graft revision (n = 3), upper extremity bypass (n = 11), or upper extremity endarterectomy and patch (n = 3). RESULTS: All four deaths within 30 days and all seven deaths within the first 6 months after operation were among the 12 patients with suprarenal aortic thrombus. The cumulative survival probabilities for all patients at 1, 3, and 5 years were 89%, 83%, and 73%, respectively. After operation, nine patients required major leg amputations and 10 required toe amputations. Renal atheroemboli led to hemodialysis in 10 patients. Recurrent embolic events occurred in five of 97 patients monitored for a mean of 32 months. All five recurrences occurred in the first 8 months after operation. Three patients with recurrent emboli had suprarenal aortic disease, one of whom had undergone axillofemorofemoral bypass. Four of 15 patients receiving postoperative warfarin anticoagulation had development of recurrent embolism. Only one patient not receiving postoperative warfarin had a recurrent event (p < 0.05 by Fisher exact test). CONCLUSION: The atheroembolic source is the aorta or iliac arteries in two thirds of patients who underwent operation. Computed tomography scanning of the aorta is a useful diagnostic technique. The source of the emboli can be eliminated surgically with low mortality or limb loss rates except when the suprarenal aorta is involved.

Arterial injuries in the thoracic outlet syndrome.

PURPOSE: This article reviews experience with arterial injury caused by thoracic outlet syndrome. Special emphasis is placed on the influence of athletic or work activities on the axillary-subclavian artery system and the mechanism by which the humeral head compresses the axillary artery and the circumflex humeral arterial branches. METHODS: Retrospective review identified 34 patients (age range 13 to 67 years) treated for upper extremity symptoms or ischemic complications of thoracic outlet syndrome from 1983 to 1993. Evaluation included assessment of occupational and recreational activities plus duplex ultrasonography and contrast arteriography with positional maneuvers. RESULTS: Twenty-two patients (27 arms) had subclavian artery injury, which was most commonly caused by compression by a bony abnormality (cervical rib, 16; anomalous first rib, two; cervical rib and anomalous first rib, two). Fourteen of the 27 arms had distal embolization. All 27 had surgical decompression of the subclavian artery; 15 required concomitant arterial reconstruction. Twelve additional patients (nine athletes) had axillary artery involvement, all from arterial compression by the head of the humerus during abduction maneuvers; all had concomitant compression of the posterior circumflex humeral artery. Axillary arterial injury included thrombosis (one), aneurysm (two), and symptomatic extrinsic compression only (nine). Five patients with axillary artery involvement were treated without a surgical procedure; of the remainder, three underwent decompression procedures only, and four had direct arterial repair. In both groups all subclavian and axillary artery reconstructions were patent at last follow-up examination (mean 31 months). CONCLUSION: Most patients with thoracic outlet syndrome who have arterial involvement have a bony anomaly causing subclavian artery compression. This study demonstrates that humeral head compression of the axillary artery and its circumflex branches is a surprisingly common pathologic mechanism. Awareness of this condition affords a better therapeutic approach to arterial injuries caused by thoracic outlet syndrome.

Percutaneous transluminal angioplasty of tibial arteries for limb salvage in the high-risk diabetic patient.

Recent advances in balloon catheter technology allow percutaneous transluminal angioplasty (PTA) of small arteries such as the tibial arteries. PTA can thus be used to treat lower limb ischemia in diabetic patients whose arterial occlusive disease is often localized to the tibial arteries. This series included 14 consecutive diabetic patients who underwent tibial PTA for treatment of limb-threatening ischemia from 1986 to 1992. PTA was selected over conventional bypass procedures because of a lack of autogenous conduit or because of an unacceptably high surgical risk. Limb loss was imminent without prompt improvement in foot perfusion in all patients. Mean follow-up of 17 months demonstrated long-term limb salvage in 10/13 (77%) and "late" cardiac-related death in 3/13 (23%). This series demonstrates that although conventional arterial bypass should routinely supersede angioplasty procedures, tibial PTA offers the opportunity for limb salvage in diabetic patients with inadequate autogenous conduit for distal tibial bypass and may serve as an option for those who are considered too high risk for conventional bypass. Morbidity and mortality rates of tibial PTA parallel those of major amputation in this population with the obvious benefit of achieving limb salvage in carefully selected diabetic patients.

Mesoblastic nephroma of adulthood. Report of three cases.

Mesoblastic nephroma is an uncommon congenital tumor of infancy that rarely occurs in adults. We report three patients (two were female, one was male) who had mesoblastic nephroma of adulthood and who presented at 45, 64, and 66 years of age with hematuria, flank mass, and pain. All underwent nephrectomy without postoperative adjuvant therapy. The tumors were solitary yellow-tan masses with solid and cystic areas involving the renal cortex (three cases) with extension into the renal pelvis and calyces (two) and ureter (one). Microscopically, all consisted of uniform spindle cell proliferations with entrapped dilated renal tubules. Focal necrosis was present in two, but no atypia or mitoses were identified in any case. The spindle cells displayed cytoplasmic immunoreactivity for vimentin, desmin, panmuscle actin (HHF-35), and alpha-smooth-muscle actin, but were nonreactive for keratin (AE1/AE3), epithelial membrane antigen, and S-100 protein. Electron microscopy revealed the presence of smooth-muscle differentiation in two cases and undifferentiated mesenchyme in one. All tumors were DNA diploid by flow cytometry. The patients were free of recurrence 8 months-2 years postoperatively. Because surgical excision may be curative, mesoblastic nephroma in adult patients must be differentiated from spindle cell neoplasms of the kidney that require additional therapy.

Magnetic resonance angiography in the preoperative evaluation of abdominal aortic aneurysms.

Magnetic resonance angiography (MRA) and magnetic resonance imaging (MRI) are noninvasive techniques of visualizing blood vessels without the use of intravenous contrast or ionizing radiation. This prospective study assessed preoperative MRA and MRI in the evaluation of 28 patients with abdominal aortic aneurysm (AAA). MRI and MRA accurately predicted the extent of cephalad AAA, the patency of the superior mesenteric artery, and the course of the left renal vein, but were less accurate in defining the extent of caudal AAA, flow of the inferior mesenteric artery, and multiple renal arteries. This study suggests that MRI and MRA are alternatives to the combination of angiography and computed tomographic scan in the preoperative evaluation of patients with suspected AAA and no evidence of mesenteric or renal ischemia. When combined with preoperative segmental Doppler arterial studies, an accurate surgical plan may be formulated. Further refinements in image acquisition and postprocessing software analysis will advance the use of MRI and MRA for complete evaluation prior to elective AAA repair.

Prospective evaluation of magnetic resonance imaging in the management of acute diabetic foot infections.

Infectious complications of the foot are a major cause of morbidity and mortality in diabetic patients. This prospective study evaluated the ability of MRI to adequately direct the medical and surgical management of 41 diabetic patients with acute foot infections. Forty-seven MRI scans of the foot in question were performed and classified as consistent with osteomyelitis, abscess, cellulitis or diffuse soft tissue infection, or any combination of these. Twenty-seven scans were negative or showed ill-defined soft tissue infection, or superficial cellulitis. Nineteen of these infections were treated nonoperatively and 17 resolved without surgical intervention. MRI was unsuccessful in directing management in one patient in whom an abscess spontaneously drained but was not seen on an MRI scan 4 days earlier. Eight scans revealed focal osteomyelitis and all eight of these patients were successfully managed with one operation. MRI showed a focal abscess in 12 patients, and adequate drainage was achieved without excessive disruption of uninvolved tissue planes in 11 of these patients. The remaining patient required a major amputation from the outset. Based on clinical outcome during the acute hospitalization period, operative findings, and/or pathologic confirmation, the positive predictive value of MRI in defining infectious pathology in the foot was 100% in this series of 20 positive scans. The negative predictive value of MRI was 96%. On the basis of this experience, we conclude that MRI is a diagnostic modality particularly well suited to evaluate acute diabetic foot infections and reliably aids in the management of acute infection to avoid exploration and debridement of uninvolved tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

Safety of simultaneous aortic reconstruction and renal transplantation.

Patients with aortic disease and end-stage renal failure who require both aortic reconstruction and renal transplantation (simultaneously or staged) pose a formidable clinical challenge. Traditionally, the performance of either one of these procedures has been viewed as a relative contraindication to the performance of the other. From 1978 to 1989, eight patients were referred to us with the combination of aortic disease and end-stage renal failure. Seven had aneurysmal disease and one had aorto-iliac occlusive disease. Five patients presented with their diseases sequentially and had two sequential operations, with a mean interval of 4 years between procedures. Three patients presented with their diseases simultaneously and underwent simultaneous aortic reconstruction and living related renal transplantation. All patients were followed up for a mean interval of 4.5 years. By life-table analysis, the 5-year renal graft survival was 100%, the primary aortic graft patency was 82%, and the secondary aortic graft patency was 100%. The only death in this series occurred 11 years after aortic reconstruction and 4 months after a renal transplantation and was due to overwhelming cytomegalovirus sepsis. There were no significant differences between the simultaneous and staged groups in terms of operative mortality, postoperative complications, transplant function, or aortic graft patency. From this experience, we conclude that: (1) patients who present simultaneously with aortic disease and end-stage renal failure can safely undergo simultaneous aortic reconstruction and renal transplantation; (2) patients who present with these two diseases sequentially can undergo a second reconstructive procedure with very low operative morbidity and mortality rates; (3) when these two procedures have been performed sequentially, the second procedure has not significantly altered the 30-day or 5-year results of the first procedure; and (4) the 30-day and 5-year results of each procedure have been excellent regardless of the temporal sequence in which they were performed.

Impact of magnetic resonance imaging on the management of diabetic foot infections.

This combined retrospective/prospective study evaluated the value of magnetic resonance imaging (MRI) in 18 diabetic patients with apparent foot infections. The goal was to define the impact of MRI on directing the expedient and accurate surgical intervention so important in achieving optimal preservation of limb tissue and function. We found that MRI provides a rapid and reliable means of "viewing" the diabetic foot. Unsuspected or poorly localized abscess cavities can be pinpointed for thorough drainage with minimal exploration. An abscess can be differentiated from cellulitis or osteomyelitis. Moreover, persistent fever following drainage of a foot abscess can be reliably evaluated via MRI, obviating the need for empiric surgical reexploration. This exciting noninvasive imaging technique leads to the most accurate surgical drainage of foot abscesses and, at the same time, can prevent unnecessary surgical exploration of the tenuous diabetic foot.

Autogenous vein graft repair of injured extremity arteries: early and late results with 134 consecutive patients.

Autogenous vein tissue is recognized as the preferred material for extremity revascularizations that require the use of a conduit. However, the results after vascular repair of injured extremity arteries with autogenous vein interposition or bypass grafts have not been well defined. This study was done to determine both the early and late patency and limb salvage rates as well as the graft infection rate of autogenous vein repairs of injured extremity arteries. The records of 134 consecutive patients with acute extremity arterial injuries requiring repair with a reversed autogenous vein graft over a recent 5-year period were reviewed. Follow-up graft patency was defined by the presence of a palpable pulse and an extremity Doppler-derived pressure index of greater than or equal to 0.9 distal to the arterial repair. Cumulative patency was assessed by the life-table method. Acute graft thrombosis occurred in two patients, one of whom underwent successful graft thrombectomy. Four patients (3%) required extremity amputation: one patient with a thrombosed vein graft and three patients with patent vein grafts but nonsalvageable limbs as a result of myonecrosis (2) or osteomyelitis (1). No perioperative graft infections occurred. One hundred twenty-eight patients (97%) had an intact extremity and a patent vein graft at the time of hospital discharge. One hundred three patients (80%) were examined at 30 days, and all grafts were patent. Seventy-three patients (57%) were available for follow-up at intervals exceeding 6 months, and 40 patients (31%) were followed-up for periods exceeding 24 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatorenal and splenorenal artery bypass for salvage of renal function.

Hepatic and splenic arteries have been used increasingly as inflow sources to avoid aortorenal bypass in patients whose cardiac dysfunction may be exacerbated by aortic clamping and in patients with previous aortic grafting in whom periaortic dissection is more hazardous than incising undisturbed tissue planes. During an 18-month period, eight patients with atherosclerotic renal artery stenosis and azotemia were treated with six hepatorenal and five splenorenal artery bypasses. Serum creatinine improved initially in all patients. Severe hypertension, present in five patients, improved significantly in four (80%). In one-half the gastroduodenal branch of the hepatic artery was suitable for end-to-end anastomosis to the renal artery, obviating the need for an interposition graft. Hepatorenal bypass is a safe, simple procedure that has been associated with few complications, although occasional transient subclinical evidence of hepatic dysfunction has been reported. Splenorenal bypass requires a relatively more hazardous exposure and is associated with a low risk of splenic and pancreatic injury, especially when the spleen and splenic flexure of the colon are mobilized to expose the splenic artery. The risk of splenic injury is substantially reduced when the splenic artery is approached through the retroperitoneum at the base of the transverse mesocolon as described.

A rapid, accurate, noninvasive technique for diagnosing critical and subcritical stenoses in aortoiliac arteries.

Accurate hemodynamic evaluation of the aortoiliac system for the purpose of determining the need for an inflow procedure currently requires invasive pressure measurements. This study was undertaken to evaluate a noninvasive technique with the aortofemoral transfer function. Twenty-eight human aortoiliac segments were studied with intraarterial pressure measurements, with and without papaverine injection, and by calculation of the Doppler-derived mean power frequency index obtained by digital signal processing of aortic and femoral spectra. The procedure is menu driven and can be performed by any duplex ultrasound technologist. This technique involves recording 20 aortic and 20 femoral Doppler signals, requiring less than 1 minute of data acquisition time. Intraarterial pressure measurements were used to classify arteries into the three following groups: (1) normal arteries, (2) arteries with subcritical stenoses, and (3) arteries with critical stenoses. The mean power frequency index of group 1 arteries (n = 7) was 0.63 +/- 0.04, of group 2 arteries (n = 6) was 0.46 +/- 0.02, and of group 3 arteries (n = 15) was 0.21 +/- 0.05. These mean power frequency index values were significantly different by analysis of variance (ANOVA) (p less than 0.0001). Each group could be differentiated from the other groups with a sensitivity of 0.83 to 1.00, a specificity of 1.00, and an accuracy of 0.92 to 1.00 compared to intraarterial pressure measurements, including papaverine testing. Measurement of the mean power frequency index is a rapid, noninvasive technique that diagnoses and quantifies aortoiliac stenoses with an accuracy similar to intraarterial pressure measurements.

Hollenhorst plaques: retinal manifestations and the role of carotid endarterectomy.

The ocular examinations and hospital records of 64 patients with Hollenhorst plaques were retrospectively reviewed to document any associated visual defects and to determine if carotid endarterectomy prevented the occurrence of new plaques or symptoms. One hundred nine Hollenhorst plaques were seen in 75 eyes; 18 had multiple plaques simultaneously. Visual field defects were noted in 14 eyes, four of which corresponded to the location of Hollenhorst plaques. Twenty-eight carotid endarterectomies were performed ipsilateral to a Hollenhorst plaque: 24 patients had no symptoms; four patients developed new ipsilateral asymptomatic Hollenhorst plaques at 1 to 50 months after operation. Two late strokes occurred, one of which was ipsilateral to a new Hollenhorst plaque, during a mean follow-up of 50 months (range 8 to 102 months). Thirty-seven eyes with asymptomatic Hollenhorst plaques did not undergo ipsilateral operation. Two eyes developed new Hollenhorst plaques during a mean follow-up of 23 months (range 1 to 132 months). Eight eyes in patients with no symptoms had multiple Hollenhorst plaques, one of which was associated with a subsequent stroke. Of the 29 eyes with a single Hollenhorst plaque, one subsequently experienced an ipsilateral stroke, and another had a transient ischemic attack (1 and 3 years later, respectively). Visual field defects infrequently corresponded to locations of Hollenhorst plaques. The cerebral hemisphere ipsilateral to asymptomatic plaques had a slightly increased risk of subsequent transient ischemic attack or stroke compared to the contralateral side without Hollenhorst plaques. The number of simultaneous Hollenhorst plaques in the retinal circulation did not predict clinical outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Open transmetatarsal amputation in the treatment of severe foot infections.

Severe forefoot infections may lead to limb loss, even if addressed aggressively. Infection or gangrene that compromises the plantar skin flap may preclude a standard transmetatarsal or midfoot amputation, thereby culminating in a below-knee amputation. We report a series of forefoot infections with loss of the distal plantar skin. Open or guillotine amputation at the mid-metatarsal level led to a high rate of healing and a durable stump, provided that the level of infection did not extend beyond the metatarsal heads. Wound closure was obtained by wound contracture alone or by use of partial-thickness skin grafting. Rehabilitation was dependable. The association of diabetes mellitus or gangrene did not adversely affect outcome. Open transmetatarsal amputation is a safe surgical option preferable to midfoot or below-knee amputation for the treatment of severe forefoot infection that does not extend proximally beyond the metatarsal heads.

Adventitial cystic disease of the radial artery.

Adventitial cystic disease of arteries is a rare disorder of unknown etiology. While it usually involves the popliteal artery, less common sites of involvement include the external iliac, common femoral, radial, and ulnar arteries. Two cases of adventitial cystic disease of the radial artery are reported herein; each occurred following percutaneous puncture of the radial artery to obtain a blood sample for blood gas analysis. The etiology, modes of presentation, and treatment options are reviewed.