Diabetic osteolysis. A case report.
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Aged↗
Biomedical subjects
L B Harkless
Publications and source records attributed to L B Harkless.
Painful heel syndrome. A case presentation.
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Aged↗
Are antibiotics necessary in the treatment of locally infected ingrown toenails?
CONTEXT: A wide variety of generalists and specialists treat locally infected ingrown toenails, with perhaps the most common treatment regimen including resection of the nail border coupled with oral antibiotics. OBJECTIVE: To determine whether oral antibiotic therapy is beneficial as an adjunct to the phenol chemical matrixectomy in the treatment of infected ingrown toenails. DESIGN: We prospectively enrolled healthy patients with infected ingrown toenails. Each patient was randomly assigned to 1 of 3 groups that received either 1 week of antibiotics and a chemical matrixectomy simultaneously (group 1), antibiotics for 1 week and then a matrixectomy (group 2), or a matrixectomy alone (group 3). SETTING: Institutional ambulatory outpatient clinic. PATIENTS: Fifty-four healthy patients with infected ingrown toenails were studied. Patients with immunocompromised states, peripheral vascular disease, or cellulitis proximal to the hallux interphalangeal joint were excluded. Groups were age matched for comparison. RESULTS: Mean healing times for groups 1, 2, and 3 were 1.9, 2.3, and 2.0 weeks, respectively. Subjects receiving antibiotics and a simultaneous chemical matrixectomy (group 1) healed significantly sooner than those receiving a 1-week course of antibiotics followed by a matrixectomy (group 2). There was not a significant difference in healing time between those that received a chemical matrixectomy alone (group 3) and those that received a matrixectomy coupled with a course of oral antibiotics (group 1). CONCLUSION: The use of oral antibiotics as an adjunctive therapy in treating ingrown toenails does not play a role in decreasing the healing time or postprocedure morbidity.
Adolescent↗
The impact of diabetes-related lower-extremity amputations in The Netherlands.
The purpose of this study is to identify the incidence of diabetes-related lower-extremity amputations in the Netherlands. We used discharge records from SIG Health Care Information for every hospitalization for a lower-extremity amputation in all hospitals in the Netherlands in 1992. Age- and gender-specific population figures and diagnosed cases of diabetes were obtained from the Central Bureau of Statistics. Age- and gender-adjusted amputation incidences were identified at four different levels (toe, foot, leg, and thigh). Multiple amputations were analyzed by the highest level. Of all lower-extremity amputations, 1,575 (47%) were in persons with diabetes mellitus. Age- and gender-adjusted lower-extremity amputation rates per 10,000 persons with diabetes by level were the following: toe 12.39, foot 2.42, leg 7.82, thigh 2.54, and total 25.17. People with diabetes were 20.3 times more likely to experience a lower-extremity amputation than people without diabetes. Males were at a significantly higher risk of experiencing an amputation than females. There was a significant increase in the age-specific incidence of amputations as age increased. The most common amputation procedure performed was the toe amputation. There was a significant increase in thigh amputations as age increased, indicating that as people get older they suffer higher levels of amputations. Although the incidence of lower-extremity amputations was lower than previous reports, they still have a serious impact on the health-care system in the Netherlands.
Adult↗
Microbiology of osteomyelitis in diabetic foot infections.
The objective of this report is to describe the bacterial pathogens in diabetic patients with osteomyelitis due to neuropathic foot ulcerations. The authors reviewed the records of 36 diabetic patients with osteomyelitis of the foot due to neuropathic ulceration. Intraoperative deep soft tissue and bone specimens were obtained from each patient. The mean age of patients was 56.7 years, and the mean duration of diabetes was 14.9 years. Streptococcus species (61%) and Staphylococcus aureus (47%) were the most common organisms identified. Gram-negative aerobes were found in 18 cultures (50%). Only five patients' cultures (14%) were identified with anaerobic pathogens. The average number of pathogens per patient was 2.25. The most common bacterial pathogens in bone infections in diabetics were Streptococcus species and Staphylococcus aureus. Anaerobes were uncommon.
Adult↗
Classification of diabetic foot wounds.
Foot ulcers in persons with diabetes are one of the most common precursors to lower extremity amputation. Appropriate care of the diabetic foot ulceration requires a clear, descriptive classification system that may be used to direct appropriate therapy and possibly predict outcome. Ideally, this system would be used by all participants in a multidisciplinary limb salvage team. We describe a clinical classification system for diabetic foot wounds that evaluates wound depth, the presence of infection, and peripheral arterial occlusive disease in every category of the wound assessment. The goal of this system is to improve communication, leading to a less complex, more predictable treatment course and, ultimately, an improved result.
Diabetic Foot↗
Is prophylactic diabetic foot surgery dangerous?
Any treatment rendered to the deformed, insensate foot should be undertaken with the prime intentions of reducing the potential for future limb-threatening events and allowing the patient to continue as an ambulatory, productive member of society. The purpose of this article is to compare morbidity and outcomes of elective foot surgery among diabetics and nondiabetics with isolated toe deformities. We compared the prevalence of infection, wound complication, and recurrence of ulcers in 31 diabetics and 33 nondiabetics. All of these patients received a single proximal interphalangeal joint arthroplasty with a mean follow-up of 3 years (range 12 to 61 months). The diabetic group was divided into two subgroups: 1) insensate with deformity, but no history of ulceration, and 2) insensate with deformity and a previous history of ulceration. Diabetics with a history of ulceration were more likely to experience a postoperative infection (14.3%) than neuropathic diabetic patients with no history of ulceration (0%) and nondiabetic subjects (0%) (p = 0.04, Cl = 3.1 to 8.6). There was not a significant difference in prevalence of dehiscence among diabetic and nondiabetic groups (16.1% versus 9.1%, respectively, Cl = 0.4 to 8.8). The long-term outcomes after prophylactic surgery at a site of previous ulceration were uniformly good, with 96.3% of patients remaining ulcer-free a mean of 3 years postoperatively.
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A quantitative assessment of healing sandals and postoperative shoes in offloading the neuropathic diabetic foot.
The purpose of this report is to compare plantar pressures between custom healing sandals and postoperative shoes using unmodified prescription shoe gear as a control. Using a repeat measures design, we recorded the plantar forefoot pressures of eight patients classified as diabetic foot category 1 (neuropathy, no significant deformity, no history of ulceration) with each ambulating in three devices: 1) unmodified prescription shoe gear, 2) postoperative shoe gear, and 3) a custom-fabricated healing sandal. Each subject served as his or her own control. The healing sandal significantly reduced plantar forefoot pressure in all areas of the forefoot except the fifth metatarsal head. The postoperative shoe did not significantly reduce pressure at any site in the forefoot when compared with unmodified prescription shoe gear.
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The impact of gender on amputation.
The purpose of this report is to compare the proportion of lower extremity amputations among men and women with and without diabetes mellitus. We abstracted data from a database supplied by the State of New York for 14,555 nontraumatic amputations performed from 1990 through 1991, 58.8% of which were performed on patients with diabetes mellitus. We categorized amputations into three different levels (foot, leg, and thigh). Fifty-seven percent of the diabetes mellitus group were male, compared with 50% of the nondiabetic group. Men were younger than women regardless of the level of amputation in both the diabetic and nondiabetic population. Men with and without diabetes were significantly more likely to have a foot amputation, while diabetic and nondiabetic women were more likely to have a thigh amputation. When controlling for age, prevalence of vascular disease was not significantly different by gender in diabetic and nondiabetic groups at all amputation levels.
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Our fixation with fixation: are screws clinically superior to external wires in distal first metatarsal osteotomies?
The purpose of this study was to evaluate the immediate postoperative morbidity, the structural correction attained, and the long-term range of motion following fixation with a single external Kirschner wire and an internal cortical screw. We abstracted records for 69 patients undergoing, distal unicorrectional chevron osteotomies. Thirty-three patients received percutaneous 0.062-inch K-wire fixation and 36 patients received single 2.7-mm. cortical screw fixation. Among these age- and sex-matched subjects, there was not a significant difference between any of the correctional or morbid outcomes measured in this study on the basis of type of fixation employed. Patients with rigid internal screw fixation did not return to shoe gear sooner, develop fewer postoperative infections, or have increased long-term range of motion than the group receiving external fixation with a single K-wire. Surgical time was significantly longer for those patients undergoing rigid internal fixation with a screw (42.5 +/- 9.5 vs. 35.1 +/- 6.6 minutes, p < 0.001). We conclude that there is no significant difference in postoperative infection, dehiscence, long-term structural correction attained, or range of motion achieved between rigid internal screws and external K-wires used to fixate distal metatarsal osteotomies.
Bone Screws↗
Seasonal variations in lower extremity amputation.
The purpose of this study was to examine seasonal variations in nontraumatic amputation among diabetic and nondiabetic adults. We abstracted data from a database supplied by the state of New York for 14,555 amputations performed in 1990 and 1991. We categorized amputations into three different levels (foot, leg, and thigh). The most common season for a patient with diabetes to receive a lower-extremity amputation was spring (27.0%, p < 0.004; odds ratio 1.1, confidence interval 1.0 to 1.2), while winter was the most common in nondiabetic patients (27.3%, p < 0.005; odds ratio 1.1, confidence interval 1.0 to 1.2). When stratified by amputation level, fewer amputations at the level of the foot occurred during winter in patients with diabetes compared with those without diabetes (24.5% vs. 28.2%, p < 0.002; chi 2MM = 193.1, odds ratio = 1.2, confidence interval = 1.1 to 1.4). Fall was the least common season for amputation at nearly every level for both diabetic and nondiabetic groups, and more diabetic patients presented with an admission diagnosis of vascular disease (74.6% vs. 54.9%, p < 0.0001; chi 2MM = 612.3, odds ratio = 2.4, confidence interval = 2.3 to 2.6). In most diabetic patients, a primary etiologic factor for amputation is an infected neuropathic ulceration brought about or exacerbated by increased activity. By limiting activity, cold weather should act as a protective measure. The data in this study seem to support this notion.
Adult↗
Outcomes of preventative care in a diabetic foot specialty clinic.
The purpose of the study was to report the incidence of ulceration, reulceration, and amputation in 341 patients treated in a multidisciplinary clinic over the course of 3 years. Patients enrolled were 57.8% male, with a mean age of 53.2 +/- 11.8 years. All were assessed using the University of Texas Diabetic Foot Classification System. Of these patients, 118 fell into category 0 (protective sensation intact), 98 into category 1 (loss of protective sensation, LOPS), 77 into category 2 (LOPS with deformity), and 48 into category 3 (LOPS, deformity, previous history of ulcer or amputation). Outcomes assessed included any incident ulcerations or amputations. The authors stratified patients based on their compliance to follow up appointments. Non compliance was defined as missing > 50% of scheduled appointments in any calendar year. Thirty of the above subjects were classified as noncompliant. Prior to analysis, the authors initially stratified subjects into compliant and noncompliant groups. If further stratified by foot category, the incidence of ulceration in the compliant group was 0 for diabetic foot categories 0 and 1, 3.5/1,000/year for category 2, and 18/1,000/year for category 3. One category 3 patient required a partial first-ray amputation. The yearly incidence of amputation for the entire cohort was therefore 1.1/1,000/year. For categories 0-2 the incidence was 0, and for category 3, it was 9/1,000/year. Patients stratified into the noncompliant group were approximately 54 times more likely to ulcerate than patients who returned regularly for their scheduled care (81.8% ulcer prevalence vs. 5.4%, p < .0001, OR = 54.0, Cl = 7.5-1,425.0). Additionally, noncompliant category 3 patients were over 20 times more likely to receive an amputation than their compliant counterparts (45.5% amputation prevalence vs. 2.7%, p < .002, OR = 2.5-819.0). The study concluded that multidisciplinary diabetes care team, which includes aggressive foot care and consistent treatment-based risk classification, may be effective in profoundly mitigating the occurrence and recurrence of diabetic foot sequelae, including ulceration and amputation. Furthermore, patient noncompliance to routine preventative care appears to be associated with a significantly higher prevalence of ulceration and amputation.
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Preoperative assessment of the transplant patient.
In the authors' university medical center, there are an increasing number of transplant patients presenting for foot surgery. Newer immunosuppressive agents are largely responsible for improvement of graft and patient survival and hence more patients requiring and wanting foot surgery. Podiatric surgeons must approach these patients with caution, but not fear. Transplant patients are more susceptible to infection, have altered response to stress from surgery, and may have delayed wound healing. Preoperative assessment and planning are imperative when considering surgery for transplant patients.
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The role of revascularization in transmetatarsal amputations.
Data from 37 patients who underwent a transmetatarsal amputation from January 1993 to April 1996 were reviewed. The mean age and diabetes duration of the subjects were 54.9 (+/- 13.2) years and 16.6 (+/- 8.9) years, respectively. The follow-up period averaged 42.1 (+/- 11.2) months. At the time of follow-up, 29 (78.4%) of the 37 patients still had foot salvage, 8 (21.6%) had progressed to below-the-knee amputation, and 15 (40.5%) had undergone lower-extremity revascularization. Twelve (80%) of the 15 revascularized patients preserved their transmetatarsal amputation level at a follow-up of 36.4 months. The authors concluded that at a maximum of 3 years follow-up after initial amputation, transmetatarsal amputation was a successful amputation level.
Adult↗
One of the most feared complications of surgery is infection.
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Foot↗
The interpositional arthroplasty procedure in treatment of degenerative arthritis of the second metatarsophalangeal joint.
A description of subjective and objective results in patients that received an interpositional arthroplasty procedure of the second metatarsophalangeal joint is presented. The authors evaluated nine patients using an observational, descriptive design. An independent examiner administered a subjective questionnaire at the same time a physical examination was performed. The average follow-up period was 35.5 months, with a range of 7 to 142 months. All patients showed an improvement in postoperative pain and activity. All but one of the patients rated their results as good or excellent. Additionally, the patient population demonstrated limited motion of the second metatarsophalangeal joint without pain or crepitus postoperatively. The subjective and objective results from this small case series were consistently good.
Adolescent↗
Long-term follow-up of Morton's neuroma.
The long-term results of neurectomy are evaluated in 70 symptomatic Morton's neuromas in 53 patients with an average postoperative follow-up of 4.8 years, and a maximum of 8.6 years. The presentation, number, and location of neuromas in this series, in some instances, coincides with previous publications. Neurectomy, by means of a dorsal approach, provided 93% patient satisfaction at long-term follow-up.
Adult↗
Retrospective statistical analysis of factors influencing the formation of long-term complications following hallux abducto valgus surgery.
A retrospective analysis was performed to determine the long-term results of hallux abducto valgus surgery done under the auspices of the Texas Health Science Center at San Antonio and its teaching hospitals. Two hundred eighty-five patients with a postoperative follow-up ranging from 3 to 10 years were studied. Attempts were made to study many of the patient demographic factors and perioperative procedures that acted to affect the development of a long-term complication. It was found that type of procedure, past medical history, age, medical control, and location of the surgical suite were all important variables to consider in this regard.
Adolescent↗