Biomedical subjects
Publications and source records attributed to L J Sanders.
A number of effective, low-cost strategies are available to identify and treat the person at risk for diabetic foot ulcers and lower-extremity amputation. These strategies must be more widely adopted by all diabetic care providers to maintain the integrity and function of the lower limb, and thus improve the quality of life for people with diabetes.
We present an unusual complication of chronic tophaceous gout in a 63-year-old man with a 27-year history of gout, who could not be treated with allopurinol due to previous allopurinol-induced neutropenia. The patient presented with a progressively enlarging, painful mass on the bottom of his right foot, which caused difficulty wearing shoes and walking. Extirpation of the tophus and first metatarsophalangeal joint arthroplasty were successfully employed for management of this condition.
This article discusses transmetatarsal and midfoot amputations, selection of level, criteria for wound healing, surgical techniques, and functional considerations. Amputations through the middle of the foot include the Lisfranc amputation at the tarsometatarsal joints and the Chopart amputation at the midtarsal joints. Both of these procedures result in the development of equinovarus deformity, and require lengthening of the Achilles tendon. Transmetatarsal amputation preserves foot function, is cosmetically acceptable and does not require a prosthesis. Satisfactory limb salvage can be achieved by the motivated patient and knowledgeable surgeon when these procedures are employed.
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Fifteen percent of individuals with diabetes will likely develop foot ulcers in their lifetime, and approximately 15% to 20% of these ulcers are estimated to result in lower extremity amputation. Techniques to prevent lower extremity amputation range from the simple but often neglected foot inspection to complicated vascular and reconstructive foot surgery. Appropriate management can prevent and heal diabetic foot ulcers, thereby greatly decreasing the amputation rate and medical care costs. Prevention is the key to treatment. The author discusses general guidelines for foot screening and identifies three specific goals for prevention of amputation: 1) identification of at risk individuals needing prevention and the specific factors placing them at risk; 2) protection of the foot against the adverse effects of external forces (pressure, friction, and shear); and 3) reduction of the incidence of diabetic foot ulcers through educational programs.
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To assess the outcome of transmetatarsal amputations of the foot, data were analyzed for all transmetatarsal and midfoot amputations performed at the Lebanon Veterans Health Administration Medical Center for the period 1984 to 1990. During this 6-year period, 42 consecutive transmetatarsal and midfoot amputations were performed on 39 patients. Patient demographics, factors leading to amputation, level of amputation, outcome, function, and long-term complications were analyzed. Overall healing rate was 83.3%, with an average length of hospital stay of 35.7 days (range 3 to 96 days). Average follow-up period was 30.2 months (range 2 to 65 months).
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OBJECTIVE: To examine the relationship between peak plantar pressure during walking and body mass in diabetic patients and age-matched control subjects. RESEARCH DESIGN AND METHODS: A volunteer sample of 56 male diabetic veterans (12 insulin dependent, 44 non-insulin dependent) with a mean age of 58.9 yr, mean duration of diabetes of 16.9 yr, and mean vibration perception threshold of 30.8 and 27 age-matched nondiabetic control subjects comprised the study. RESULTS: Peak plantar pressure was measured with a 1000-element piezoelectric platform during the first step of gait. The correlation between body mass and peak pressure was found to be only 0.37 in the patients with diabetes and 0.36 in the control subjects, indicating that body mass accounts for less than 14% of the variance in peak plantar pressure. The body mass and peak plantar pressure of the 14 patients who experienced plantar ulcers was not significantly different from those who did not ulcerate, but vibration perception thresholds and monofilament perception thresholds of the ulcer patients were significantly higher. CONCLUSIONS: Although the correlation between body mass and peak plantar pressure is statistically significant, the functional relationship between the two variables is weak. Elevated plantar pressures are as likely to occur in small individuals as they are in those with large body mass. Foot deformity, in the presence of neuropathy and other permissive factors, is itself likely to be an important risk factor for plantar ulceration in diabetes, and this hypothesis deserves further exploration.
A case of human myiasis caused by the black blowfly, P. regina, has been presented. Although various reports have documented the therapeutic effects of maggot infestation, infection and mortality by gas-forming anaerobic organisms also have been reported. The removal of maggots from a wound can be accomplished using various methods. The authors successfully used topical application of dichlorotetrafluoroethane.
A rare case of benign fibrous histiocytoma involving the foot of a sixty-three-year-old white man is presented, with a review of the literature. The histopathologic appearance of benign fibrous histiocytoma, differential diagnosis, and surgical management are discussed. Fibrous histiocytomas are characteristically nonencapsulated tumors composed of a mixture of fibroblastic and histiocytic cells arranged in a storiform or cartwheel pattern.
Pachyonychia congenita is a rare genodermatosis characterized by symmetrical thickening and discoloration of the nails with a wedge-shaped, pinched-up, or claw-like appearance. Subungual hyperkeratosis results in a lifting up of the free edge of the nail. Nail changes may be seen alone or in combination with a variety of other cutaneous findings. The authors present a kindred with fifteen cases of pachyonychia congenita in four generations, in Lebanon County, Pennsylvania.
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An eight-year follow-up of a progressive case of nonfilarial elephantiasis affecting the lower extremity and a review of the literature is presented. The natural history and management of this disorder are discussed, together with recommendations to assist the clinician in early identification an treatment. Elephantiasis nostras is characterized by chronic enlargement of a limb, resulting from lymphatic blockage secondary to recurrent attacks of streptococcal lymphangitis. Each subsequent attack results in greater edema of the limb. Without appropriate intervention the cycle continues until the deformity is greatly exaggerated. Control of edema an infection is important in preventing the recurrent lymphangitis that will eventually result in grotesque enlargement of the limb. Photographic documentation and serial circumferential limb measurements are recommended to document progression of the disease and effectiveness of treatment.
This article presents an overview of the pathogenesis of diabetic foot lesions that lead to lower extremity amputation surgery. The magnitude of this problem is presented together with a brief historical perspective. Indications for "local amputation" of the foot are discussed as well as preoperative noninvasive hemodynamic evaluation of the patient, with determination of level of amputation. Surgical management is covered in detail, with discussion of factors important for amputation wound healing, selection of anesthesia and operative technique, use of tourniquet, and antibiotic considerations.
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A case of subungual lentigo maligna and a review of the literature is presented. Pigmented lesions involving the nail bed are rare, and should arouse clinical suspicion. Examination of biopsy specimens of these lesions is essential to rule out malignancy. The treatment of choice of lentigo maligna is surgical excision.