Effect of oral nutritional supplementation on wound healing in diabetic foot ulcers: a prospective randomized controlled trial.

AIMS: Among people with diabetes, 10-25% will experience a foot ulcer. Research has shown that supplementation with arginine, glutamine and ß-hydroxy-ß-methylbutyrate may improve wound repair. This study tested whether such supplementation would improve healing of foot ulcers in persons with diabetes. METHODS: Along with standard of care, 270 subjects received, in a double-blinded fashion, (twice per day) either arginine, glutamine and ß-hydroxy-ß-methylbutyrate or a control drink for 16 weeks. The proportion of subjects with total wound closure and time to complete healing was assessed. In a post-hoc analysis, the interaction of serum albumin or limb perfusion, as measured by ankle-brachial index, and supplementation on healing was investigated. RESULTS: Overall, there were no group differences in wound closure or time to wound healing at week 16. However, in subjects with an albumin level of ≤ 40 g/l and/or an ankle-brachial index of < 1.0, a significantly greater proportion of subjects in the arginine, glutamine and ß-hydroxy-ß-methylbutyrate group healed at week 16 compared with control subjects (P = 0.03 and 0.008, respectively). Those with low albumin or decreased limb perfusion in the supplementation group were 1.70 (95% CI 1.04-2.79) and 1.66 (95% CI 1.15-2.38) times more likely to heal. CONCLUSIONS: While no differences in healing were identified with supplementation in non-ischaemic patients or those with normal albumin, addition of arginine, glutamine and ß-hydroxy-ß-methylbutyrate as an adjunct to standard of care may improve healing of diabetic foot ulcers in patients with risk of poor limb perfusion and/or low albumin levels. Further investigation involving arginine, glutamine and ß-hydroxy-ß-methylbutyrate in these high-risk subgroups might prove clinically valuable.

Phase I trial on the safety of topical rhVEGF on chronic neuropathic diabetic foot ulcers.

OBJECTIVE: To assess the safety/tolerability and perform a preliminary efficacy evaluation of a multiple-dosing regimen of recombinant human vascular endothelial growth factor (VEGF165 or rhVEGF; telbermin) applied topically to chronic diabetic neuropathic foot ulcers. METHOD: Subjects with type 1 or 2 diabetes mellitus were randomised to receive either topical applied telbermin (72 microg/cm2) (n=29) or placebo (n=26) treatment to the foot ulcer surface in conjunction with standard ulcer care. Subjects received treatment every 48 hours (maximum three doses per week) for up to six weeks. Weekly 35mm photography, quantitative planimetry and physical examinations documented the ulcer appearance, surface area and stage. Safety endpoints included incidence of clinically significant hypotension, adverse events and ulcer infection. Exploratory efficacy endpoints included percentage reduction in total ulcer surface area, incidence of complete ulcer healing and time to complete ulcer healing. RESULTS: Incidence of adverse events was comparable in the two treatment groups. None of the adverse events were attributed to study drug, and no hypotension was observed as a result of telbermin treatment. Occurrence of infected study ulcers appeared to be balanced between the treatment groups. Positive trends suggestive of potential signals of biological activity were observed for incidence of complete ulcer healing (41.4% telbermin versus 26.9% placebo at day 43 [P=0.39]) and time to complete ulcer healing (25th percentile of 32.5 days telbermin versus 43.0 days placebo [log-rank P=0.13]). CONCLUSION: The topical application of telbermin 72 microg/cm2 three times a week for up to six weeks appeared to be well tolerated. Further studies are required to characterise the safety/efficacy of telbermin more completely.

The role of combined magnetic field bone growth stimulation as an adjunct in the treatment of neuroarthropathy/Charcot joint: an expanded pilot study.

This study was designed to assess the value of combined magnetic field (CMF) bone growth stimulation in the treatment of acute, phase 1, Charcot neuroarthopathy. Thirty-one subjects were studied. Initially 10 controls and 11 study patients were examined. When the initial results were analyzed, 10 additional study patients were added. The result was a statistically significant reduction in time to consolidation, 23.8 weeks for the control versus 11 weeks for the study group. Additionally, less destruction of the bony architecture was noted in the study group as compared to the control. Thus the results of this expanded pilot study demonstrate the efficacy of CMF in accelerating the consolidation process of acute, phase 1, Charcot joint, and decreasing the amount of residual deformity.

Angioleiomyoma of the lower extremity.

Angioleiomyomas are benign soft tissue lesions that should be included in the differential diagnosis of any pedal soft tissue mass. There should be an increased index of suspicion for angioleiomyoma, especially when a freely movable subcutaneous mass is encountered in a middle-aged female patient. Treatment of such masses should involve surgical excision to relieve the symptomatology and to obtain tissue for a definitive histologic analysis. If the mass recurs, then the possibility of leiomyosarcoma should be explored.

Wound management in the diabetic foot.

The multiple opinions expressed in this Grand Rounds section make it clear that management of the diabetic patient with a foot wound is complex at best. Several significant points are repeated many times. The need for a detailed history and physical exam, accurate assessment of neurologic, vascular, metabolic status, and addressing the etiologic factor involved are all essential. All authors point to multispecialty integrated treatment protocols to produce the greatest success. Little mention is made of the use of topical agents to accelerate healing. This is due to the lack of unbiased studies, and the many available reports that demonstrate rapid healing when a complete and objective protocol is followed. The aims of this Grand Rounds are to stimulate interest in this important subject, and to provide the practitioner with a scaffold with which to build their own wound care management protocols.

Intraosseous gout of the foot: an unusual case report.

The literature is abundant with cases of crystalline deposition disorders of the lower extremity. Although acute gout and gouty tophi have commonly been described in the medical literature, findings of gouty deposits within the bone itself has been seldom reported. This paper presents an unusual case of intraosseous gout and its etiology and treatment.

Grand rounds: first metatarsophalangeal joint replacement.

For approximately 30 years foot and ankle surgeons have been using a variety of techniques and devices to replace the first metatarsophalangeal joint. During this time there have been a multitude of implant designs and modifications, most attempting to anatomically and functionally replace the natural joint surfaces. The advantages and disadvantages of these many designs and various biomaterials has long been debated in scientific meetings and publications. Surgical technique, implant design, materials, and patient selection remain areas of heated debate and ongoing research. With this in mind, we asked leading foot and ankle surgeons to give their opinions on indications and utilization for joint replacement of the first metatarsophalangeal joint.

Implantable bone substitute materials.

This article focuses on materials used as bone substitutes. The materials may be used as substitutes for autografts or, in some cases, along with autografts. Each material has unique properties that may be beneficial for specific applications. Some future developments in bone substitute materials are also discussed.

Peripheral skeletal tuberculosis of the foot. Etiologic review and case study.

Mycobacterium tuberculosis is a disease that is being reported much more frequently in the literature, primarily because of the rapid increase in severely immunocompromised patients, but also because of the development of multiple drug-resistant tuberculosis strains. Extrapulmonary M. tuberculosis is also reportedly on the rise, and may manifest itself at a number of sites in the body, including the peripheral skeleton. It is important to recognize peripheral tuberculosis osteomyelitis early because early treatment can effectively eliminate long-term morbidity. The authors present a review of the diagnosis and treatment of extrapulmonary M. tuberculosis, with special emphasis on peripheral skeletal tuberculous osteomyelitis. A case study involving peripheral skeletal tuberculous osteomyelitis in the foot is presented.

Arthroscopic lateral ankle stabilization.

The indications for arthroscopic stabilization include those patients with isolated ruptures or strains of the ATF. The procedure is particularly convenient for patients with ankle joint pathology that is already most commonly treated arthroscopically, such as chronic instability, in which inflamed synovium or meniscoid bodies are to be excised. Although significant stability can be gained with this technique, injuries that result in damage to the calcaneofibular ligament may require additional open surgery, since this ligament cannot be visualized arthroscopically. However, the anchoring techniques described in this article can still be used when performing open surgery.

A new radiographic classification for hallux limitus.

A new classification system for hallux limitus that is based on objective radiographic changes around the first metatarsophalangeal joint is introduced. The new system is demonstrated in a 3-year, 110-patient retrospective study. From the information gathered, a surgical algorithm has been developed. Statistical analysis demonstrates an 87% satisfaction rate with the recommended surgical algorithm.

Posterior tibial tendon dysfunction.

Posterior tibial tendon dysfunction, a common entity, frequently is unrecognized and inappropriately managed. Acutely, pain and swelling are present over the medial ankle and longitudinal arch. Long-standing inflammation can lead to tendon rupture, resulting in a progressive planovalgus or "flat foot" deformity. Plain radiographs illustrate the changes in bony anatomy associated with chronic posterior tibial deficiency, while magnetic resonance imaging scans can identify the three stages of posterior tibial tendon pathology. Most cases are amenable to conservative therapy, including rest and administration of nonsteroidal antiflammatory agents. Often a short period of immobilization in a cast or the use of an orthosis is beneficial. In cases with persistent tenosynovitis, complete tendon rupture, or progressive deformity, surgical intervention is indicated.

Rigid internal fixation of the Austin/Chevron osteotomy with Herbert screw fixation: a retrospective study.

One of the adaptations of the Herbert bone screw (Zimmer Corp., Warsaw, Indiana) in podiatric surgery has been in the fixation of the Austin type osteotomy of the first metatarsal, to obtain rigid internal fixation. Technical difficulties in performing the procedure and complications have resulted in the development of several modifications of the original technique to better facilitate application of the Herbert screw. A brief review of the literature including history of distal metaphyseal osteotomies, and the uses of the Herbert screw is included. The purpose of this manuscript is to present utilization of the Herbert bone screw and modified jig in a modified Austin osteotomy, and to produce rigid internal fixation without the disadvantages of other internal fixation techniques.

Modifications of the Regnauld osteochondral autogenous graft for correction of hallux limitus/valgus: a 2-year review.

This study compares modifications of Regnauld's enclavement procedure, the in situ "hat-shaped" and in situ "inverted" osteochondral graft. A 2-year retrospective analysis consisted of patients' satisfaction, activity level, first metatarsophalangeal joint range of motion, and radiographic evaluations. The result of this study demonstrates that both the "hat" and "inverted" type grafts are highly successful and satisfactory procedures. However, the "inverted" technique is found to provide faster healing rates and a broader range of motion of the first metatarsophalangeal joint; it is more stable and technically easier to perform. Therefore, the "inverted" graft provides more consistent and predictable results for the treatment of hallux rigidus and hallux valgus.

Oblique metaphyseal osteotomy for the correction of Tailor's bunions: a 3-year review.

This study presents a 3-year review of patients undergoing a fifth metaphyseal osteotomy for the treatment of Tailor's bunions. Postoperative analysis consisted of patient's subjective appraisal, activity level, physical examination, and radiographic studies. The fifth metaphyseal osteotomy, in this study, reduced lateral deviation and fourth-fifth intermetatarsal angles to less than or equal to normal values, while decreasing intermetatarsal head distance and returning the fifth metatarsophalangeal joint to congruency. Patient satisfaction was high while providing a low incidence of transfer lesions. This manuscript demonstrates the fifth metaphyseal osteotomy to be a viable treatment for Tailor's bunions.

An unusual intermetatarsal coalition.

Synostoses commonly occur in the midfoot and rearfoot. However, metatarsal synostosis is a less common phenomenon. Several etiologies have been described. The authors present a case of a fourth-fifth intermetatarsal bar, which does not fit into one of the established categories, along with the surgical technique used in its correction.

Alternative autogenous bone graft donor sites in brachymetatarsia reconstruction: a review of the literature with clinical presentations.

The authors present a literature review on the surgical treatment of brachymetatarsia. They discuss the identification of donor sites for autogenous bone graft harvesting from the foot. Three case reports of brachymetatarsia, one of iatrogenic, and two of congenital origin are presented.

Pseudogout of the ankle: a case study and arthroscopic-assisted treatment.

Chondrocalcinosis, also known as pseudogout, a calcium pyrophosphate dihydrate crystal deposition disease, has been reported in many joints of the human body. A review of the literature reveals few reported cases of pseudogout of the ankle and various uncertainties of the etiology of pseudogout. The authors offer a review of the disease and a case presentation with the use of arthroscopy to assist in the diagnosis and treatment of pseudogout of the ankle.