Foot and ankle survey in adults with diabetes mellitus.

The purpose of this study was to examine the foot and ankle care patterns and shoe wear habits in patients with clinically proven diabetes mellitus who were attending diabetes education classes for the first time. One hundred subjects were recruited from outpatient adult diabetes education classes. No attempts were made to select patients on the basis of disease duration or severity. Each subject completed a questionnaire assessing life-style, shoe wear habits, health care status and interaction with healthcare providers. Thirty-seven percent of the subjects reported prior foot problems. Twenty percent had their feet examined regularly and 59% had never had their feet examined. Foot problems reported were: corns 11%, calluses 11%, bunions 3%, ulcers 1%, gout 1%. Sensation was tested using the 5.07 Semmes Weinstein monofilament across seven zones of the plantar surface of the foot. Subjects unable to feel this varied from 5% to 20% in each of the zones. Shoe wear was assessed for fit and style. Thirty percent of the patients had shoes that were too narrow and 81% of the patients with poorly fitting shoes were women. Shoe wear history and factors influencing shoe selection were recorded. Diabetes mellitus is a common disease, often affecting the feet. Preventive care can help patients deal with the manifestations of diabetic neuropathy. This study showed that a low percentage of subjects with diabetes regularly have their feet examined and that a relatively high percentage (31%) wear shoes that are too narrow. Identifying these patients early may allow modification of habits that put their feet at risk.

Foot pressures during gait: a comparison of techniques for reducing pressure points.

PURPOSE: Various methods have been used to redistribute plantar surface foot pressure in patients with foot ulcers. This study was conducted to determine the effectiveness of four modalities (fracture walker, fracture walker with insert, and open and closed toe total contact casts) in reducing plantar foot pressure. METHODS: Ten healthy, normal volunteer subjects had an F-scan sensor (ultra thin shoe insert pressure monitor) placed under the right foot. They then ambulated on a flat surface, maintaining their normal gait. Dynamic plantar pressures were averaged over 10 steps at four different sites (plantar surface of great toe, first metatarsal head, base of fifth metatarsal, and plantar heel). All subjects repeated this sequence under five different testing conditions (barefoot, with a fracture walker, fracture walker with arch support insert, open and closed toe total contact cast). Each subject's barefoot pressures were then compared with the pressures during the different modalities. RESULTS: All four treatment modalities significantly reduced (p < 0.05) plantar pressure at the first metatarsal head (no method was superior). The fracture walker, fracture walker with insert, and open toe total contact cast significantly reduced pressure at the heel. Pressures at the base of the fifth metatarsal and great toe were not significantly reduced with any treatment form. CONCLUSION: The fracture walker, with and without arch support, and total contact cast can effectively reduce plantar pressure at the heel and first metatarsal head.

Calcaneal osteomyelitis caused by nail puncture wounds.

Plantar puncture wounds to the foot are a common injury. A small number (1.8%) of these puncture wounds become infected and progress to osteomyelitis. The purpose of this article is to report the cases of six patients who developed osteomyelitis of the calcaneus after a puncture wound to the heel caused by a nail. The characteristics of the patients, the pathogenic organism, and the outcome were studied. Patients who were healthy and had no systemic illness (N = 4) had only one pathogenic organism cultured, whereas patients who had systemic illness (diabetes mellitus, N = 2) had more than one pathogenic organism cultured. The only amputation in this group occurred in a patient with diabetes mellitus. It was concluded that diabetic patients who develop calcaneal osteomyelitis from a nail puncture wound are more likely to have multiple pathogens cultured. Furthermore, if a diabetic neuropathy is also present, the nail puncture wound may be the initial injury leading to a chronic ulceration, increasing the risk of amputation.

Endoscopic plantar fascia release: a cross-sectional anatomic study.

Endoscopic plantar fascia release is a new procedure proposed to treat heel pain and plantar fasciitis. The purpose of this study was to assess the structures at risk during plantar fascia release using this method. Ten fresh-frozen cadaver feet were divided into two groups. All specimens underwent cannula placement inferior to the plantar fascia. Five-of the specimens had plantar fascia release using the endoscopic technique. Six of the specimens were then frozen and cut in transverse, sagittal, and coronal sections to visualize the relationship between the cannula and plantar fascia and surrounding structures. Gross dissection was performed on the remaining four specimens. The amount of plantar fascia released, the relationship to the nerve to abductor digiti minimi, and the fascia of the abductor hallucis muscle were assessed. The average distance from the cannula margin to the nerve to the abductor digiti minimi was 6 mm at the medial border of the plantar fascia. The average amount of plantar fascia released was 90%. Although a complete release was attempted, the fascia to the abductor hallucis was not released in any of the specimens. The nerve to the abductor digiti minimi was not damaged in any of the specimens. On coronal sections, the nerve was closer to the cannula and plantar fascia release than previously reported.

Patellar tilt in total knee arthroplasty.

Eighty-nine consecutive primary total knee arthroplasties performed for osteoarthrosis were evaluated to determine the effect of patellar thickness, alignment, joint line, patellar height, type of patellar prosthesis, and length of follow-up on patellar tilt. Preoperatively, 62% of the patellae were tilted neutrally and 38% tilted laterally on standard 45 degrees Merchant-view radiographs. At 3-week follow-up, 52% were neutral, 32% tilted laterally and 16% tilted medially. At the most recent follow-up (mean 36 months), 41% were neutral, 46% tilted laterally and 13% tilted medially. Five (5.6%) required reoperation for patellar complications. Change in joint line, in alignment, and in patellar height had no effect on postoperative patellar tilt. Patients who required a lateral release had postoperative patellar tilt measurements that were not statistically different from those who did not require a lateral release. Metal-back domed patellae were more likely to tilt laterally than all-polyethylene domed patellae; however, the metal-back patellae had a longer mean follow-up (41 months) compared with the all-polyethylene patellae (27 months). The positive correlation between preoperative patellar thickness and postoperative patellar tilt was statistically significant. The negative correlation between change in patellar thickness and postoperative patellar tilt also was statistically significant. Finally, postoperative medically tilted patellae moved toward neutral with time and laterally tilted patellae not only remained laterally tilted but also the tilt increased with time.

Displaced intra-articular calcaneus fractures treated with the Galveston plate.

From January 1992 to August 1993, 59 calcaneal fractures in 48 patients were treated. Thirty-three fractures in 31 patients were displaced intra-articular fractures and were treated with open reduction and internal fixation through an extensile lateral approach with the Galveston plate (Smith and Nephew, Richards, Memphis, TN). Complete radiographs and CT scans were available for 32 of the fractures. The CT scan classification of Sanders was used. The distribution of the fractures was: IIA, N = 17; IIB, N = 2; IIC, N = 2; IIIAB, N = 7; IIIAC, N = 2; IV, N = 2. Sixteen (50%) had calcaneocuboid joint involvement. Preoperative and postoperative radiographic measurements of Bohler's angle, Gissane's angle, talocalcaneal angle, and Achilles tendon fulcrum distance were made. Clinical follow-up on 23 fractures in 22 patients at an average of 21 months is presented. Seventy percent of the patients have no pain or only occasional pain not requiring medication. Using the Maryland Foot Score for assessment, 78% of the patients had a good or excellent result. The Galveston plate was useful for maintaining reduction of intra-articular calcaneus fractures treated operatively and provided results comparable to other reported series.

Pelvic and bladder trauma: a case report and subject review.

Pelvic fracture and bladder rupture resulted in bladder wall entrapment in the fracture site of a patient involved in a severe motor vehicle accident. Although hematuria and bladder rupture are known to occur after fracture of the pelvis, our literature review showed no reports of this type of injury or management. Bladder extravasation was managed with catheter drainage and surgical extraction; viscus repair was performed for the bladder rupture. Fracture healing and bladder continuity resolved uneventfully.

Osteomyelitis.

The complexities of osteomyelitis make its diagnosis and treatment challenging. Current trends emphasize early diagnosis and aggressive treatment. Imaging has improved, with nuclear scans and magnetic resonance imaging, and technique modifications have enhanced the specificity of these tests. Treatment depends on thorough debridement of necrotic bone and tissue, accurate cultures and administration of culture, and sensitivity-specific antibiotics. Antibiotic delivery has expanded to include effective oral agents and local agents mixed with polymethylmethacrylate or a biodegradable substance. Success rates in treating this disease have improved with the use of a systematic approach, making outcome more predictable.

Ring fixators for reconstruction of traumatic disorders of the foot and ankle.

External fixation methods have an accepted place in orthopedic management of problems involving the foot and ankle. Traditionally, reconstruction and correction of deformity have been managed with extensive soft-tissue release, osteotomies, and arthrodeses. Methods of external fixation have evolved dramatically over the past decade with the introduction of the techniques of Ilizarov to the Western World. This article covers ankle arthrodesis, burn scar contracture, distal tibial deformity, and fractures.

Osteomyelitis.

Osteomyelitis can be difficult to treat. Current trends emphasize early diagnosis and aggressive treatment. Imaging has improved with nuclear scans and magnetic resonance imaging, and recent modifications in technique have enhanced the specificity. Treatment depends on debridement of necrotic bone and tissue, obtaining accurate cultures, and administration of culture- and sensitivity-directed antibiotics. Antibiotic delivery has expanded to include effective oral agents and local agents mixed with polymethylmethacrylate or a biodegradable substance. Success rates in treating this disease have improved with a systematic approach, making outcome more predictable.

Syme amputation in patients with severe diabetes mellitus.

Surgical results and functional outcome of 52 patients treated with Syme amputations for forefoot gangrene between 1986 and 1988 were retrospectively reviewed with reference to the predictive value of posterior tibial artery Doppler examination. Wound healing was correlated with the preoperative status of the posterior tibial artery. Functional outcome was assessed by the ability to wear a prosthesis, ambulatory capabilities, episodes of ulceration, and revision surgery. Follow-up averaged 27 months. Twenty-nine patients had a posterior tibial artery with either a triphasic waveform (N = 23) or a normal pulse (6). Twenty-six (90%) of these achieved a healed wound suitable for prosthetic wear. Twenty-three patients had monophasic flow in the posterior tibial artery. Thirteen (57%) of these achieved a healed wound. Ninety percent of the patients who achieved healed wounds were fit with a prosthesis. Functional level of ambulation was assessed in 20 patients. Eighteen were community level ambulators, 11 could walk three or more blocks, and 16 could climb stairs. Eighteen wore their prosthesis all day. These findings indicate that posterior tibial artery Doppler examination is predictive of healing in the Syme amputation performed on diabetics. Furthermore, diabetics can attain a functional level of ambulation with a Syme amputation.

Late functional outcome in patients with tibia fractures covered with free muscle flaps.

The functional outcome and work capacity of patients treated with a free muscle flap to cover open grade III tibial fractures was assessed. The conditions of patients, eight with grade IIIB and six with grade IIIC isolated open tibia fractures, treated with a free muscle flap transfer less than 3 months after their injury, were retrospectively reviewed. Flap survival was 86%. Twelve of the 14 were contacted, with follow-up time averaging 7 years. Four of the 14 eventually had below-knee amputations and one of the 10 patients with a successful limb salvage died of unrelated causes. All nine surviving patients with salvaged limbs had healed fractures in an average of 15 months (range, 8-23). Six were initially infected, but drainage had stopped an average of 13.5 months after flap coverage. No wounds were draining at last follow-up observation. Those tibias that were initially infected have been drainage free for an average of 78 months. The average total hospital cost of reconstruction was $48,996.40. The functional outcome in 12 patients was assessed. Eight of the nine patients whose limbs were salvaged returned to work, six to jobs with demands similar to their preinjury occupation. Three of the four patients with limb amputations were also able to return to jobs similar to their preinjury occupation. Patients must be made aware of the expected course of reconstruction and anticipated final outcome. Despite rarely achieving normal function, returning to work is a reasonable goal.

Displacement of an uncemented acetabular component after dislocation of a total hip prosthesis. A case report.

Review of the literature reveals few reports of complications encountered with noncemented acetabular components; most concern problems with screw or cup placement, component wear or migration, or disassembly of modular components. No reports involving the displacement of a noncemented acetabular component were found. This is a case report of a patient in whom a noncemented acetabular component was dislodged after the closed reduction of a dislocated total hip prosthesis 4.5 weeks after surgery. In light of this case, the authors believe these reductions should be performed under general anesthesia with fluoroscopic guidance. Care must be taken at surgery to ream sufficiently and obtain proper cup fit and position. Finally, the authors recommend bicortical screw fixation to provide maximum contact and rigid fixation in the early postoperative period.