Screening for patients at risk of diabetic foot ulceration in a general diabetic outpatient clinic.

An examination of the reproducibility of three tests for identifying patients at risk of diabetic foot complications is reported. One thousand and one patients attending a general diabetic outpatient clinic at the Royal Liverpool University Hospital underwent screening using the Semmes-Weinstein monofilaments, the biothesiometer, and palpation of pedal pulses. Two hundred and fifty-nine patients who were found to have a deficit on at least one of these tests were given a second appointment where the tests were repeated. Two hundred and twenty-nine patients attended for their second appointment. The expected range of variation in readings for the biothesiometer was 5 log hertz, sufficient variation to make the biothesiometer unacceptable as a screening instrument. The range of reproducibility for the four pedal pulses was from 68% to 81%, also an unacceptable level of variation. Over 85% of the results for the Semmes-Weinstein monofilaments were the same on the first and second measurement. Of the three instruments examined in this study, only the Semmes-Weinstein monofilaments have sufficient reproducibility in the clinical setting for them to be recommended for general use as a screening test for risk of diabetic foot complications.

Risks of radiation exposure to orthopaedic surgeons.

The risks of occupational radiation exposure for orthopaedic surgeons has not been well documented. The use of fluoroscopy in orthopaedics has reduced morbidity and by reducing operative time and by reducing the invasiveness of procedures. Increasingly procedures requiring the use of fluoroscopy are being developed. In a prospective study we have monitored cumulative radiation exposure over a 6-month period. The exposure levels are well below the maximum dose limits for ionizing radiation as recommended by European Economic Communities EURATOM directives. Experimentally using a phantom patient it was shown that the exposure to ionizing radiation during the insertion of a dynamic hip screw was minimal. Despite the low level of exposure care should be exercised when using fluoroscopy.

Diagnosis of osteomyelitis in neuropathic foot ulcers.

We reviewed all patients with a clinically infected foot ulcer attending a specialised neuropathic foot clinic. Neuropathy was confirmed by the inability to feel a 5.07 Semmes-Weinstein hair, areflexia and impaired vibration sense, as measured by a biothesiometer. Of 40 patients who attended the clinic over a two-year period, six with ischaemic ulcers were excluded. The remaining 34 had plain radiographs of the foot followed by a 99mTc-MDP bone scan. If the latter was positive, an 111In-labelled WBC scan was performed with planar and/or tomographic dual-isotope studies where appropriate. Bone and WBC scans were performed in 31 patients. In ten, isotope imaging showed infection localised to the soft tissues only and conservative treatment was successful in them all. Eighteen patients were treated surgically with excision of the involved bone, which was sent for culture and histological examination. Dual-isotope scans had a sensitivity of 93% and a specificity of 83%. 99mTc-MDP bone scans with the appropriate In-labelled WBC scans can reliably determine the site and extent of osteomyelitis in the neuropathic diabetic foot.

The development of the low profile Liverpool shear transducer.

The development of a shear transducer, small enough to be worn comfortably under a normal foot, is described, along with a microcomputer controlled data logger. Walks up to 8 s can be recorded and the information downloaded to any IBM compatible computer. Software then allows easy analysis of the peak shear stresses. Calibration curves show the transducers to have a linear response up to 35N and preliminary data from the measurement of shear stresses under the normal foot, and their relationship to vertical pressures, is presented. A patent application (number 9109463.1) has been filed for the device in the United Kingdom.

Colorectal carcinoma over 30 years at one hospital: no evidence for a shift to the right.

Many recent reports in the North American literature have documented an increase in the ratio of proximal to distal colorectal cancers with an increase in right-sided lesions. In order to assess trends in the distribution of large bowel carcinoma at our hospital we reviewed the files of 1553 patients who presented with primary colorectal carcinoma over a 30-year period. Thirty-nine percent of patients were over 70 years old and 51% were in the 50-69 year age group. Seventy five percent of the carcinomas were left-sided, 22% right-sided and caecal carcinomas accounted for 18%. This distribution varied only slightly over the study period. Left-sided lesions were more common in males (55%: p less than 0.005), and right-sided lesions were more common in females (57%: p less than 0.005). Caecal carcinoma was more common in patients over 69 years old than in younger patients (p less than 0.001). In elderly females (greater than 69 years) 30% of colorectal carcinomas occurred in the caecum. These findings may have important implications for the investigation of patients with suspected colorectal disease or for screening programmes.

Hypertrophic callus formation leading to high-output cardiac failure in a patient with osteogenesis imperfecta.

A 4-year old child with osteogenesis imperfecta developed high-output cardiac failure secondary to hypertrophic callus formation in four long bones. The association of hypertrophic callus formation with fracture and operative intervention is well known, but the role of infection in the aetiology of his condition is not well defined.