Outpatient care and morbidity reduction in diabetic foot ulcers associated with chronic pressure callus.

In a retrospective review of 233 cases of diabetic foot ulceration preceded by minor trauma, 192 ulcerations exhibited focal pressure keratosis as the preceding traumatic event. The frequency of outpatient visits and other foot care interventions were correlated with the occurrence and severity of ulceration. Patients seen more frequently in an outpatient foot clinic had less severe ulcers and were less likely to undergo surgical treatment than those with less frequent visits.

First metatarsophalangeal joint arthrodesis: quantitative mechanical testing of six-hole dorsal plate versus crossed screw fixation in cadaveric specimens.

Quantitative strength analysis of first metatarsophalangeal joint arthrodesis was performed using two fixation techniques: a small 6-hole plate with an interfragmentary screw or two crossed lag screws. Twelve matched-pair fresh-frozen cadaveric specimens (24 trials) were used for direct comparison of each of the two fixation techniques. All joint surfaces were prepared with power conical reamers utilizing a standard technique. The fixation construct was stressed to failure on each specimen using a computer-integrated materials tester. Fixation stiffness defined as force (load) over displacement and point of ultimate failure was evaluated. The six-hole plate and interfragmentary screw fixation method was a statistically stiffer form of fixation (p > .01) and displayed a greater point of ultimate failure (p > .002) under the laboratory conditions.

Triple arthrodesis stabilization: a quantitative analysis of screw versus staple fixation in fresh cadaveric matched-pair specimens.

Qualitative analyses of midfoot stabilization in triple arthrodeses utilizing bone staple versus 4.5-mm cannulated cancellous screw fixation, with and without washers, were performed in fresh cadaveric specimens. Twenty-two trials (11 matched-pair feet) were used for direct comparison. Stiffness, defined as force/displacement, was determined at each talonavicular and calcaneocuboid joint. Ultimate load failure points of each specimen were also calculated. Trial results showed no statistically significant difference in stiffness or ultimate failure between these two forms of midfoot fixation for triple arthrodeses.

Tumor as an indication for amputation in the foot.

When a benign or malignant tumor presents itself in the foot, amputation may, at times, be necessary for complete eradication. Suspected malignancies require detailed general evaluation and oncology consultation. Biopsy is the gold standard for diagnosis. Depending on the type of tumor identified, resection margins of varying degrees may be necessary. Cases are used to illustrate the principles of tumor care.

Enlarged peroneal process with peroneus longus tendon entrapment.

A 50-year-old man was treated conservatively for chronic bilateral ankle pain for several years. Plain radiographs obtained following exacerbation of symptoms showed bilateral enlarged peroneal processes. CT and MRI demonstrated bony detail of the unusual processes and also showed isolation of the peroneus longus tendons and associated tendinitis and partial tears.

Retrospective analysis of first metatarsal phalangeal arthrodesis.

A retrospective evaluation of first metatarsophalangeal joint arthrodesis was performed on nine patients (12 feet) using two fixation techniques: a small compression plate and screws or two crossed lag screws. The joint surfaces were prepared with power conical reamers to allow for joint alignment and subsequent fusion. The average follow-up time was 6.9 months (range, 1.3 to 15 months) and, to date, all feet are successfully fused. No major postoperative complications or removal of internal fixation devices were noted in our retrospective study. This surgical technique was effective and reliable in achieving first metatarsophalangeal joint fusion, and it may serve as an alternative procedure to silicone implant or resection joint arthroplasty.

The foot as a primary site for distant metastatic infection.

Localized foot infection can lead to generalized sepsis under certain conditions. Two diabetic patients who suffered from infected foot ulcers, even after treatment with debridement and appropriate antibiotics, developed distant site infection. Another diabetic patient developed a distant site abscess from a chronic foot infection, for which he initially sought no medical treatment. Evaluation revealed that one patient had a psoas muscle abscess, one a renal abscess, and one an epidural abscess. All three patients were treated aggressively for their infections. One recovered fully, while two expired from septic complications associated with their illnesses. These case histories, along with the chronology of the development of sepsis from a foot infection are presented.

Postgraduate podiatric medical educational resources in the Department of Veterans Affairs.

The existing podiatric medical residencies in the Department of Veterans Affairs are reviewed. The suitability of these residencies to fill a potential need for entry level programs is discussed. The financial implications of providing such training are reviewed and a plan for implementation is presented. Ninety-eight rotating podiatric residency positions currently available in Department of Veterans Affairs hospitals are prime candidates to serve as entry level PGY-1 positions. Assurances will need to be given that implementation of the PGY-1 concept must serve the best interests of the veteran patient population, and that funds will need to be allocated to pay faculty salaries and resident stipends. Congressional review of student loan forbearance policies affecting podiatric medical residents is also needed.

Diabetic ulcers: evaluation and management.

Four factors are necessary for healing any diabetic ulceration. First, the vascular supply must be adequate. Second, any infection must be controlled. Third, pressure that is contributing to the formation of the ulceration must be eliminated. Lastly, adequate nutritional status must be maintained. With the variety of ulcer treatments that appear on a regular basis, it is frequently difficult to evaluate one method versus another. Any treatment regimen that is advised must ultimately depend on these basic building blocks for success. It is frequently difficult and sometimes impossible to control each of these factors, but an understanding of their mechanisms and contribution to ulcer healing allows the clinician to plan therapy and develop an ultimate prognosis for each case he encounters. Tables 1 and 2 contain guidelines for evaluation and treatment based on these principles.