Transmetatarsal and Minor Amputation Versus Major Leg Amputation: 30-Day Readmissions, Reamputations, and Complications.

AIMS: The optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations. METHODS: Data were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014. Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2 types of amputation patients by propensity score to fairly compare between levels of amputation when either type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients. RESULTS: Major amputation patients were more likely to have dependent functional status, although their surgeries tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or transfusion, respectively. CONCLUSIONS: Although short-term complications, readmissions, and reoperations were more common in distal amputation, UTI and the need for transfusion were higher in major amputation.

Demographic, physical, and radiographic factors associated with functional flatfoot deformity.

In 1 of our previous studies, the occurrence of self-reported flatfoot was associated with self-reported increased age, male gender, Asian and African American races, veteran status, poor health, increased body mass index, callus, bunion, hammertoe, and arthritis. However, we had to rely on survey data to identify these risk factors, and the accuracy of the survey results was unknown. Therefore, we decided to identify the risk factors associated with flatfeet using objectively and more accurately measured data. A total of 94 patients were enrolled in the present study. The demographic data and physical and radiographic examination results were recorded by the investigators in the clinic. The data were then analyzed to identify the factors unique to flatfoot, measured and defined using a plantar pressure measurement system during natural gait. We learned that a painful tibialis posterior tendon was associated with flatfoot. The calcaneal inclination angle was also decreased in the flatfoot group. The talar declination, intermetatarsal, hallux abductus, and calcaneal cuboid angles, and static calcaneal stance eversion were elevated in the flatfoot group compared with the non-flatfoot group. Systematic evaluation of these associated factors will help in the understanding of the functional status of the flatfoot deformity.

The comparison of two negative-pressure wound therapy systems in a porcine model of wound healing.

The purpose of this study was to compare two negative-pressure wound healing systems (NPWT), -75 mmHg with a silicone-coated (SC) dressing and -125 mmHg with polyurethane foam dressing (standard of care). In addition, this study compared the effects of two different dressing interfaces, SC dressing and gauze, with -75 mmHg pressure. For both comparisons, two groups of five pigs were evaluated over a 21-day time course. Two excisional wounds were made on each animal and NPWT dressings were applied. A canvas saddle was constructed to hold the NPWT device so the animal had free range of the pen. Dressings were changed twice a week and wound measurements were taken. Specimens for histology and gene expression analyses were taken on day 7 and 21. These data show that there is increased expression in a few genes associated with remodeling and inflammatory processes in the NPWT-125 with polyurethane foam as compared with the NPWT-75 with SC dressing. These two systems, however, are equivalent with respect to wound healing, histology, and gene expression over 21 days of healing. Further, we demonstrate that there is no difference in measure of healing between the SC dressing and a basic gauze dressing.

Shear-reducing insoles to prevent foot ulceration in high-risk diabetic patients.

PURPOSE: To enhance the learner's competence with knowledge of the effectiveness of shear-reducing insoles for prevention of foot ulceration in patients with high-risk diabetes. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Demonstrate knowledge of foot ulceration risk, risk factors, incidence, and prevention.2. Apply knowledge gained from reviewing this study and a literature review about the use of shear-reducing insoles to patient scenarios. OBJECTIVE: The objective of this study was to evaluate the effectiveness of a shear-reducing insole compared with a standard insole design to prevent foot ulceration in high-risk patients with diabetes. RESEARCH DESIGN AND METHODS: A total of 299 patients with diabetic neuropathy and loss of protective sensation, foot deformity, or history of foot ulceration were randomized into a standard therapy group (n = 150) or a shear-reducing insole group (n = 149). Patients were evaluated for 18 months. Standard therapy group consisted of therapeutic footwear, diabetic foot education, and regular foot evaluation by a podiatrist. The shear-reducing insole group included a novel insole designed to reduce both pressure and shear on the sole of the foot. Insoles were replaced every 4 months in both groups. The primary clinical outcome was foot ulceration. The authors used Cox proportional hazards regression to evaluate time to ulceration. RESULTS: There were 2 significant factors from the Cox regression model: insole treatment and history of a foot complication. The standard therapy group was about 3.5 times more likely to develop an ulcer compared with shear-reducing insole group (hazard ratio, 3.47; 95% confidence interval, 0.96-12.67). CONCLUSIONS: These results suggest that a shear-reducing insole is more effective than traditional insoles to prevent foot ulcers in high-risk persons with diabetes.

Amputation and infection are the greatest fears in patients with diabetes foot complications.

AIMS: To determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications. METHODS: 478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy. RESULTS: Of the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8-4.5), major LEA (OR 2.8, 95 % CI 1.8-4.4), minor LEA (OR 2.3, 95 % CI 1.5-3.5), blindness (OR 2.0, 95 % CI 1.3-3.2), dialysis (OR 2.0, 95 % CI 1.1-3.3), and death (OR 2.4, 95 % CI 1.4-4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation. CONCLUSION: Patients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.

Diabetes as a Risk Factor for Orthopedic Implant Surface Performance: A Retrieval and In Vitro Study.

Orthopedic devices are often associated with increased risk for diabetic patients due to impaired wound healing capabilities. Adverse biological responses for immunocompromised patients at the implant-tissue interface can lead to significant bone resorption that may increase failure rates. The goal of this study was to characterize the surface of implants removed from diabetic patients to determine underlying mechanisms of diabetes-induced impaired osseointegration. Thirty-nine retrieved titanium and stainless-steel orthopedic devices were obtained from diabetic and non-diabetic patients, and compared to non-implanted controls. Optical Microscopy, Scanning Electron Microscopy, Energy Dispersive X-ray Spectroscopy, and X-ray Photoelectron Spectroscopy revealed changes in morphology, chemical composition, oxidation state, and oxide thickness of the retrieval specimens, respectively. Additionally, titanium disks were immersed for 28 days in simulated in vitro diabetic conditions followed by Inductively Coupled Plasma-Optical Emission Spectroscopy to quantify metal dissolution. Electrochemical testing was performed on specimens from retrievals and in vitro study. Aside from biological deposits, retrievals demonstrated surface discoloration, pit-like formations and oxide thinning when compared to non-implanted controls, suggesting exposure to unfavorable acidic conditions. Cyclic load bearing areas on fracture-fixation screws and plates depicted cracking and delamination. The corrosion behavior was not significantly different between diabetic and non-diabetic conditions of immersed disks or implant type. However, simulated diabetic conditions elevated aluminum release. This elucidates orthopedic implant failures that potentially arise from diabetic environments at the implant-tissue interface. Design of new implant surfaces should consider specific strategies to induce constructive healing responses in immunocompromised patients while also mitigating corrosion in acidic diabetic environments.

Electrical stimulation as an adjunctive treatment of painful and sensory diabetic neuropathy.

BACKGROUND: The objective of this review is to evaluate the use of electrical stimulation to treat diabetic neuropathy. Application of electrical stimulation may provide a novel treatment option for large and small fiber neuropathy in persons with diabetes. Large and small nerve neuropathy alters pain, proprioception, touch perception, and motor function, which cause burning foot pain and serve as protective mechanisms from ulcerations. METHODS: A content search for clinical trials involving electrical stimulation, neuropathy, and diabetes was conducted through PubMed. Randomized clinical trials and prospective studies with outcome measures affecting the lower extremity function were selected for review. RESULTS: We identified eight studies in which electrical stimulation was used to treat diabetic neuropathy. Six studies evaluated small fiber neuropathy. Two studies evaluated patients with both small and large fiber neuropathy and reported significant improvement in vibration and monofilament testing and reduction in symptoms in the electrical stimulation treatment group. Six of the eight painful neuropathy studies identified significant improvement in symptoms. There were no studies that evaluated electrical stimulation to treated diabetic motor neuropathy, fall prevention or postural instability. CONCLUSIONS: Electrical stimulation may be an effective alternative and adjunctive therapy to current interventions for diabetic peripheral neuropathy.

Electrical stimulation to accelerate wound healing.

BACKGROUND: There are several applications of electrical stimulation described in medical literature to accelerate wound healing and improve cutaneous perfusion. This is a simple technique that could be incorporated as an adjunctive therapy in plastic surgery. The objective of this review was to evaluate the results of randomized clinical trials that use electrical stimulation for wound healing. METHOD: We identified 21 randomized clinical trials that used electrical stimulation for wound healing. We did not include five studies with treatment groups with less than eight subjects. RESULTS: Electrical stimulation was associated with faster wound area reduction or a higher proportion of wounds that healed in 14 out of 16 wound randomized clinical trials. The type of electrical stimulation, waveform, and duration of therapy vary in the literature. CONCLUSION: Electrical stimulation has been shown to accelerate wound healing and increase cutaneous perfusion in human studies. Electrical stimulation is an adjunctive therapy that is underutilized in plastic surgery and could improve flap and graft survival, accelerate postoperative recovery, and decrease necrosis following foot reconstruction.

Accuracy and durability of Semmes-Weinstein monofilaments: what is the useful service life?

OBJECTIVE: To evaluate the accuracy and effective service life of commercially available Semmes-Weinstein monofilaments with repetitive loading. METHODS: We obtained 6 brands of Semmes-Weinstein monofilaments (SWM) from commercial vendors identified from the Internet and the federal registry. Five monofilaments of each brand were subjected to repeat loading cycles, allowed to rest over night and loaded again the next day. First, sets of five monofilaments were loaded 25 times for each of five days. Then sets of five monofilaments were subjected to 200 loading cycles a day for 15 days. A testing jig ensured each SWM was loaded perpendicular to a digital pressure plate. The buckling force was measured via the pressure plate to determine failure loads. Several statistical techniques were used to examine the behavior of the monofilaments over repeated loadings: time series analysis, ANOVA and nonparametric comparisons of load distributions. RESULTS: The monofilaments tested were neither precise nor accurate. The plasticity of filaments increased with repeated loadings resulting in lower bending forces. Individual and average bending forces varied widely both within and between monofilament brands. All monofilaments showed a typical material failure pattern. Initially the bending force was high but rapidly decreased and then leveled out at levels 1-2g lower than the starting values. After resting over night, the initial bending force was again high but usually not as high as the previous day and bending forces decreased and then leveled out. Most monofilaments did not start at the accepted 10-g buckling force but varied by up to 30% (p<0.01). At best, monofilaments starting at the accepted 10±1g buckling force would remain within a usable range (9-11g) for 7-9 days or to evaluate 70-90 patients. CONCLUSION: Commercially available SWM have significant variability within and between devices from different manufacturers. Their actual bending force varies widely from their designated 10g value. When used they have a short service life where the instrument is within 10% of their initial bending force which is not usually the stated 10g of force.

High levels of foot ulceration and amputation risk in a multiracial cohort of diabetic patients on dialysis therapy.

OBJECTIVE: To evaluate the prevalence of lower-limb complications in a multiracial cohort of patients with diabetes receiving dialysis. RESEARCH DESIGN AND METHODS: This work was a cross-sectional study of lower-limb complications in dialysis-treated patients with diabetes in the U.K. and U.S. RESULTS: We studied 466 patients (139 U.K.; 327 U.S.). The prevalence of lower-limb complications was high (foot ulcers 12%, neuropathy 79%, peripheral arterial disease 57%, history of foot ulceration 34%, and prior amputation 18%), with no significant ethnic variation, except that foot ulcers were more common in whites than in patients of African descent (P = 0.013). Ninety-five percent of patients were at high risk of lower-limb complications. Prior amputation was related to foot ulcer history, peripheral arterial disease, and hemodialysis modality in multivariable analysis. Prevalent ulceration showed independent associations with foot ulcer history and peripheral arterial disease, but not with ethnicity. CONCLUSIONS: All patients with diabetes receiving dialysis are at high risk of lower-limb complications independent of ethnic background.

Diabetic foot prevention: a neglected opportunity in high-risk patients.

OBJECTIVE: To evaluate the frequency of foot prevention strategies among high-risk patients with diabetes. RESEARCH DESIGN AND METHODS: Electronic medical records were used to identify 150 patients on dialysis and 150 patients with previous foot ulceration or amputation with 30 months follow-up to determine the frequency with which patients received education, podiatry care, and therapeutic shoes and insoles as prevention services. RESULTS: Few patients had formal education (1.3%), therapeutic shoes/insoles (7%), or preventative podiatric care (30%). The ulcer incidence density was the same in both groups (210 per 1,000 person-years). In contrast, the amputation incidence density was higher in the dialysis group compared with the ulcer group (58.7 vs. 13.1 per 1,000 person-years, P < 0.001). Patients on dialysis were younger and more likely to be of non-Hispanic white descent (P = 0.006) than patients with a previous history of ulcer or amputation. CONCLUSIONS: Prevention services are infrequently provided to high-risk patients.

First metatarsophalangeal joint dislocation with open fracture of tibial and fibular sesamoids.

Traumatic dislocations of the first metatarsophalangeal joint were first described by Mouchet in 1931. The anatomical complexity of the first metatarsophalangeal joint makes this injury one of a kind. There have been only been a limited number of case reports of this injury, but none in combination with open fractures of both sesamoids. We would like to report 1 case of an open traumatic dislocation of the first metatarsophalangeal joint with open fracture of the fibular and tibial sesamoid. Open reduction and internal fixation of the injury led to a successful outcome.