How multidisciplinary clinics may mitigate socioeconomic barriers to care for chronic limb-threatening ischemia.

OBJECTIVE: Although multidisciplinary clinics improve outcomes in chronic limb-threatening ischemia (CLTI), their role in addressing socioeconomic disparities is unknown. Our institution treats patients with CLTI at both traditional general vascular clinics and a multidisciplinary Limb Preservation Program (LPP). The LPP is in a minority community, providing expedited care at a single facility by a consistent team. We compared outcomes within the LPP with our institution's traditional clinics and explored patients' perspectives on barriers to care to evaluate if the LPP might address them. METHODS: All patients undergoing index revascularization for CLTI from 2014 to 2023 at our institution were stratified by clinic type (LPP or traditional). We collected clinical and socioeconomic variables, including Area Deprivation Index (ADI). Patient characteristics were compared using χ2, Student t, or Mood median tests. Outcomes were compared using log-rank and multivariable Cox analysis. We also conducted semi-structured interviews to understand patient-perceived barriers. RESULTS: From 2014 to 2023, 983 limbs from 871 patients were revascularized; 19.5% of limbs were treated within the LPP. Compared with traditional clinic patients, more LPP patients were non-White (43.75% vs 27.43%; P < .0001), diabetic (82.29% vs 61.19%; P < .0001), dialysis-dependent (29.17% vs 13.40%; P < .0001), had ADI in the most deprived decile (29.38% vs 19.54%; P = .0061), resided closer to clinic (median 6.73 vs 28.84 miles; P = .0120), and had worse Wound, Ischemia, and foot Infection (WIfI) stage (P < .001). There were no differences in freedom from death, major adverse limb event (MALE), or patency loss. Within the most deprived subgroup (ADI >90), traditional clinic patients had earlier patency loss (P = .0108) compared with LPP patients. Multivariable analysis of the entire cohort demonstrated that increasing age, heart failure, dialysis, chronic obstructive pulmonary disease, and increasing WIfI stage were independently associated with earlier death, and male sex was associated with earlier MALE. Ten traditional clinic patients were interviewed via convenience sampling. Emerging themes included difficulty understanding their disease, high visit frequency, transportation barriers, distrust of the health care system, and patient-physician racial discordance. CONCLUSIONS: LPP patients had worse comorbidities and socioeconomic deprivation yet had similar outcomes to healthier, less deprived non-LPP patients. The multidisciplinary clinic's structure addresses several patient-perceived barriers. Its proximity to disadvantaged patients and ability to conduct multiple appointments at a single visit may address transportation and visit frequency barriers, and the consistent team may facilitate patient education and improve trust. Including these elements in a multidisciplinary clinic and locating it in an area of need may mitigate some negative impacts of socioeconomic deprivation on CLTI outcomes.

Quantification of Skeletal Muscle Perfusion in Peripheral Artery Disease Using 18F-Sodium Fluoride Positron Emission Tomography Imaging.

BACKGROUND: Perfusion deficits contribute to symptom severity, morbidity, and death in peripheral artery disease (PAD); however, no standard method for quantifying absolute measures of skeletal muscle perfusion exists. This study sought to preclinically test and clinically translate a positron emission tomography (PET) imaging approach using an atherosclerosis-targeted radionuclide, fluorine-18-sodium fluoride (18F-NaF), to quantify absolute perfusion in PAD. METHODS AND RESULTS: Eight Yorkshire pigs underwent unilateral femoral artery ligation and dynamic 18F-NaF PET/computed tomography imaging on the day of and 2 weeks after occlusion. Following 2-week imaging, calf muscles were harvested to quantify microvascular density. PET methodology was validated with microspheres in 4 additional pig studies and translated to patients with PAD (n=39) to quantify differences in calf perfusion across clinical symptoms/stages and perfusion responses in a case of revascularization. Associations between PET perfusion, ankle-brachial index, toe-brachial index, and toe pressure were assessed in relation to symptoms. 18F-NaF PET/computed tomography quantified significant deficits in calf perfusion in pigs following arterial occlusion and perfusion recovery 2 weeks after occlusion that coincided with increased muscle microvascular density. Additional studies confirmed that PET-derived perfusion measures agreed with microsphere-derived perfusion measures. Translation of imaging methods demonstrated significant decreases in calf perfusion with increasing severity of PAD and quantified perfusion responses to revascularization. Perfusion measures were also significantly associated with symptom severity, whereas traditional hemodynamic measures were not. CONCLUSIONS: 18F-NaF PET imaging quantifies perfusion deficits that correspond to clinical stages of PAD and represents a novel perfusion imaging strategy that could be partnered with atherosclerosis-targeted 18F-NaF PET imaging using a single radioisotope injection. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03622359.

Revascularization Outcomes Stratified by Glycemic Control in Patients with Diabetes Mellitus and Chronic Limb-Threatening Ischemia.

BACKGROUND: The prevalence of chronic limb-threatening ischemia (CLTI) has increased alongside rising rates of diabetes mellitus (DM). While diabetic patients with CLTI have worse outcomes compared to patients without diabetes, conflicting data exist on the relationship between the severity of DM and CLTI outcomes. Close inspection of the relationship between DM severity and outcomes in CLTI may benefit surgical decision-making and patient education. METHODS: We retrospectively reviewed patients who received endovascular intervention or surgical bypass for CLTI at our multidisciplinary Limb Preservation Program from 2013 to 2019 to collect patient characteristics using Society for Vascular Surgery (SVS) reporting standards, arterial lesion characteristics from recorded angiograms, and outcomes, including survival, amputation, wound healing, and revascularization patency. Controlled DM was defined as SVS Grade 1 (controlled, not requiring insulin) and Grade 2 (controlled, requiring insulin), while uncontrolled DM was defined as SVS Grade 3 (uncontrolled), and DM severity was assessed using preoperative hemoglobin A1c (HgbA1c) values. Product-limit Kaplan-Meier was used to estimate survival functions. Univariable Cox proportional hazards analyses guided variable selection for multivariable analyses. RESULTS: Our Limb Preservation Program treated 177 limbs from 141 patients with DM. Patients with uncontrolled DM were younger (60.44 ± 10.67 vs. 65.93 ± 10.89 years old, P = 0.0009) and had higher HgbA1c values (8.97 ± 1.85% vs. 6.79 ± 1.10%, P < 0.0001). Fewer patients with uncontrolled DM were on dialysis compared to patients with controlled DM (15.6% vs. 30.9%, P = 0.0278). By Kaplan-Meier analysis, DM control did not affect time to mortality, limb salvage, wound healing, or loss of patency. However, multivariable proportional hazards analysis demonstrated increased risk of limb loss in patients with increasing HgbA1C (hazard ratio (HR) = 1.96 [1.42-2.80], P < 0.0001) or dialysis dependence (HR = 15.37 [3.44-68.73], P = 0.0003), increased risk of death in patients with worsening pulmonary status (HR = 1.70 [1.20-2.39], P = 0.0026), and increased risk of delayed wound healing in patients who are male (HR = 0.48 [0.29-0.79], P = 0.0495). No independent association existed between loss of patency with any of the variables we collected. CONCLUSIONS: Patients with uncontrolled DM, as defined by SVS reporting standards, do not have worse outcomes following revascularization for CLTI compared to patients with controlled DM. However, increasing HgbA1c is associated with a greater risk for early amputation. Before revascularization, specific attention to the level of glycemic control in patients with DM is important, even if DM is "controlled." In addition to aggressive attempts at improved glycemic control, those with elevated HgbA1c should receive careful education regarding their increased risk of amputation despite revascularization. Future work is necessary to incorporate the severity of DM into risk models of revascularization for the CLTI population.

The natural history of chronic limb-threatening ischemia after technical failure of endovascular intervention.

OBJECTIVES: The treatment for chronic limb-threatening ischemia (CLTI) has changed dramatically in the last few decades with a shift toward an endovascular-first approach and aggressive revascularization to achieve limb salvage. As the size of the CLTI population and intervention rates increase, patients will continue to experience technical failure (TF). Here, we describe the natural history of patients after TF of endovascular intervention for CLTI. METHODS: We conducted a retrospective cohort study of patients with CLTI who attempted endovascular intervention or bypass at our multidisciplinary limb salvage center from 2013 to 2019. Patient characteristics were collected according to the Society for Vascular Surgery's reporting standards. Primary outcomes included survival, limb salvage, wound healing, and revascularization patency. Product-limit Kaplan-Meier estimated survival functions for these outcomes, and between-group comparisons were made using Mantel-Cox log-rank nonparametric tests. RESULTS: We identified 242 limbs from 220 unique patients who underwent primary bypass (n = 30) or attempted endovascular intervention (n = 212) at our limb salvage center. Endovascular intervention was a TF in 31 (14.6%) limbs. After TF, 13 limbs underwent secondary bypass and 18 limbs were managed medically. Patients who experienced TF tended to be older (P < .001), male (P = .003), current tobacco users (P = .014), have longer lesions (P = .001), and have chronic total occlusions of target arteries (P < .001) as compared with those who experienced technical success. Furthermore, the TF group had worse limb salvage (P = .047) and slower wound healing (P = .028), but their survival was not different. Survival, limb salvage, and wound healing were not different in patients who received secondary bypass or medical management after TF. The secondary bypass group was older (P = .012) and had a lower prevalence of tibial disease (P = .049) than the primary bypass group and trended toward decreased survival, limb salvage, and wound healing (P = .059, P = .083, and P = .051, respectively). CONCLUSIONS: Increased age, male sex, current tobacco use, longer arterial lesions, and occluded target arteries are associated with TF of endovascular intervention. Limb salvage and wound healing are relatively poor after TF of endovascular intervention, but survival appears comparable with patients who experience technical success. Secondary bypass may not always rescue patients after TF, though our sample size limits statistical power. Interestingly, patients who received a secondary bypass after TF trended toward decreased survival, limb salvage, and wound healing compared with primary bypass.

Vessel-by-Vessel Computed Tomography Calcium Scoring of the Foot in Peripheral Artery Disease: Association with Patient-Level Factors.

Objective: Peripheral artery disease (PAD) is associated with increased risk of nonhealing ulcers, amputation, and mortality due to occlusive atherosclerotic plaques. Computed tomography (CT) imaging detects vascular calcification in PAD; however, quantitative vessel-by-vessel analysis of calcium burden in the feet of PAD patients has not been assessed. This study sought to perform quantitative analysis of vessel-specific calcium burden and examine the patient-level determinants of foot calcium burden in PAD patients. Approach: PAD patients (n = 41) were prospectively enrolled and underwent CT imaging of the lower extremities. Manual segmentation of the medial plantar, lateral plantar, and dorsalis pedis arteries was performed. CT image Hounsfield units (HUs) were obtained for each artery to quantify vessel-by-vessel calcium mass using a cutoff value of ≥130 HU. Univariate analyses were performed to evaluate patient-level determinants of calcium burden for each foot artery. STROBE guidelines were used for reporting of data. Results: Univariate analyses revealed that body mass index, diabetes mellitus (DM), and chronic kidney disease (CKD) were significant determinants of foot calcium burden in PAD patients. Image analysis demonstrated that PAD patients with DM had significantly higher calcium mass for the medial plantar (p = 0.005), lateral plantar (p = 0.039), and dorsalis pedis (p = 0.001) arteries compared with PAD patients without DM. Innovation: This is the first study to use CT imaging to quantify vessel-specific calcium burden in the feet of patients with PAD and evaluate the patient-level determinants of foot calcium burden in the setting of PAD. Conclusion: CT imaging quantifies vessel-specific calcification in the feet of PAD patients, which is exacerbated with concomitant DM, CKD, and/or obesity.

Vessel-by-vessel analysis of lower extremity 18F-NaF PET/CT imaging quantifies diabetes- and chronic kidney disease-induced active microcalcification in patients with peripheral arterial disease.

BACKGROUND: Positron emission tomography (PET)/computed tomography (CT) imaging with fluorine-18 (18F)-sodium fluoride (NaF) provides assessment of active vascular microcalcification, but its utility for evaluating diabetes mellitus (DM)- and chronic kidney disease (CKD)-induced atherosclerosis in peripheral arterial disease (PAD) has not been comprehensively evaluated. This study sought to use 18F-NaF PET/CT to quantify and compare active microcalcification on an artery-by-artery basis in healthy subjects, PAD patients with or without DM, and PAD patients with or without CKD. Additionally, we evaluated the contributions of DM, CKD, statin use and established CT-detectable calcium to 18F-NaF uptake for each lower extremity artery. METHODS: PAD patients (n = 48) and healthy controls (n = 8) underwent lower extremity 18F-NaF PET/CT imaging. Fused PET/CT images guided segmentation of arteries of interest (i.e., femoral-popliteal, anterior tibial, tibioperoneal trunk, posterior tibial, and peroneal) and quantification of 18F-NaF uptake. 18F-NaF uptake was assessed for each artery and compared between subject groups. Additionally, established calcium burden was quantified for each artery using CT calcium mass score. Univariate and multivariate analyses were performed to evaluate DM, CKD, statin use, and CT calcium mass as predictors of 18F-NaF uptake in PAD. RESULTS: PAD patients with DM or CKD demonstrated significantly higher active microcalcification (i.e., 18F-NaF uptake) for all arteries when compared to PAD patients without DM or CKD. Univariate and multivariate analyses revealed that concomitant DM or CKD was associated with increased microcalcification for all arteries of interest and this increased disease risk remained significant after adjusting for patient age, sex, and body mass index. Statin use was only associated with decreased microcalcification for the femoral-popliteal artery in multivariate analyses. Established CT-detectable calcium was not significantly associated with 18F-NaF uptake for 4 out of 5 arteries of interest. CONCLUSIONS: 18F-NaF PET/CT imaging quantifies vessel-specific active microcalcification in PAD that is increased in multiple lower extremity arteries by DM and CKD and decreased in the femoral-popliteal artery by statin use. 18F-NaF PET imaging is complementary to and largely independent of established CT-detectable arterial calcification. 18F-NaF PET/CT imaging may provide an approach for non-invasively quantifying vessel-specific responses to emerging anti-atherogenic therapies or CKD treatment in patients with PAD.

Novel Application of 18F-NaF PET/CT Imaging for Evaluation of Active Bone Remodeling in Diabetic Patients With Charcot Neuropathy: A Proof-of-Concept Report.

Charcot neuropathic osteoarthropathy (CN) is a serious and potentially limb-threatening complication for patients with diabetes mellitus and peripheral arterial disease. In recent decades, nuclear medicine-based approaches have been used for non-invasive detection of CN; however, to date, a positron emission tomography (PET) radionuclide specifically focused on targeted imaging of active bone remodeling has not been explored or validated for patients with CN. The radionuclide 18F-sodium fluoride (NaF) has historically been used as a bone imaging probe due to its high sensitivity for targeting hydroxyapatite and bone turnover, but has not been applied in the context of CN. Therefore, the present study focused on novel application of 18F-NaF PET/computed tomography (CT) imaging to three clinical cases of CN to evaluate active bone remodeling at various time courses of CN. PET/CT imaging in all 3 cases demonstrated focal uptake of 18F-NaF in the bones of the feet afflicted with CN, with bone retention of 18F-NaF persisting for up to 5 years following surgical reconstruction of the foot in two cases. On a group level, 18F-NaF bone uptake in the CN foot was significantly higher compared to the healthy, non-CN foot (p = 0.039). 18F-NaF PET/CT imaging may provide a non-invasive tool for monitoring active bone remodeling in the setting of CN, thereby offering novel opportunities for tracking disease progression and improving treatment and surgical intervention.

Diagnosis of Hypophosphatasia in Adults Presenting With Metatarsal Stress Fracture: Proof-of-Concept for a Case-Finding Strategy.

Hypophosphatasia (HPP) is caused by loss-of-function mutations in ALPL resulting in decreased alkaline phosphatase (ALP) activity. Metatarsal stress fracture (MSF) is a common clinical feature of hypophosphatasia in adults. In this study, the primary objectives were to determine whether new cases of ALPL variants could be identified in patients with MSF and who also had serum ALP concentration below the reference range and to phenotype their clinical course. Electronic health records were queried for adult patients with MSF using International Classification of Disease codes (ICD-9, ICD-10CM) and ALP measurements. Patients with ALP levels below the normal limit were invited to receive mutational analysis of ALPL and to complete the following surveys: the Short Form 36 version 2 (SF36v2), the Brief Pain Inventory-Short Form (BPI), and the Health Assessment Questionnaire Disability Index (HAQ-DI). Cases with and controls without ALPL pathogenic variants were compared by survey scores and clinical variables relevant to fracture. In 1611 patients with MSF presenting to a podiatry clinic (10/1/2011-10/1/2017), 937 had ALP measurement, of whom 13 (1.4%) had ALP levels below the lower normal limit. In eight patients consenting to participate, two had heterozygous pathogenic ALPL variants. ALPL variants were found in 2 of 1611 patients (0.12%) with MSF, 2 patients of 937 (0.21%) in those with MSF and any ALP measurement, and 2 of 13 patients (15%) in MSF and decreased ALP level. Cases versus controls rated lower scores on eight of eight SF36v2 scales (range, 0-100); higher scores for worst pain (8.0 vs. 0.8) and average pain (6.0 vs. 0.7) on the BPI (range, 0-10); and higher standard disability score (1.4 vs. 0) on the HAQ-DI (range, 0-3). These data provide proof-of-concept for HPP case identification in patients presenting to a podiatry clinic with MSF, suggesting a search for historically low ALP levels may be a useful step for consideration of HPP diagnosis, and supports a prospective study to determine an optimal case-finding strategy. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Intermetatarsal Angle and Hallux Abductus Angle Reduction After First Metatarsophalangeal Joint Arthrodesis in Mild, Moderate, and Severe Hallux Valgus.

BACKGROUND: First metatarsophalangeal joint fusion is a commonly used procedure for treating many pathologic disorders of the first ray. Historically, hallux valgus deformity with severely increased intermetatarsal angle or metatarsus primus adductus indicated need for a proximal metatarsal procedure. However, the effectiveness and reliability of first metatarsophalangeal joint arthrodesis in reducing the intermetatarsal angle has been increasingly described in the literature. We compared findings at our institution with current literature for further validation of this well-accepted procedure in correcting hallux valgus deformity with high intermetatarsal angle. METHODS: Weightbearing preoperative and postoperative radiographs of 43 patients, 31 women and 12 men, meeting the inclusion and exclusion criteria were identified. Two independent investigators measured the hallux abductus and intermetatarsal angles. Preoperative and postoperative measurements for each angle were compared and average reduction calculated. The data were further analyzed by grouping deformities as mild, moderate, and severe. Mean follow-up was 10 months. RESULTS: The overall mean preoperative intermetatarsal and hallux abductus angles decreased significantly (from 13.09° to 9.33° and from 23.72° to 12.19°, respectively; both P < .01). When grouping deformities as mild, moderate, and severe, all of the categories maintained reduction of intermetatarsal and hallux abductus angles (P < .01). Furthermore, the mean reduction of the intermetatarsal and hallux abductus angles seemed to correlate with preoperative deformity severity. CONCLUSIONS: In patients undergoing correction of hallux valgus deformity, first metatarsophalangeal joint arthrodesis produced consistent reductions in the intermetatarsal and hallux abductus angles. Furthermore, these findings are consistent with those reported by other institutions.

SPECT/CT Imaging: A Noninvasive Approach for Evaluating Serial Changes in Angiosome Foot Perfusion in Critical Limb Ischemia.

Objective: To investigate the feasibility of serial radiotracer-based imaging as a noninvasive approach for quantifying volumetric changes in microvascular perfusion within angiosomes of the foot following lower extremity revascularization in the setting of critical limb ischemia (CLI). Approach: A CLI patient with a nonhealing foot ulcer underwent single-photon emission computed tomography (SPECT)/computed tomography (CT) imaging of the feet before and after balloon angioplasty of the superficial femoral artery (SFA) and popliteal artery. SPECT/CT imaging was used to evaluate serial changes in angiosome perfusion, which was compared to quantitative changes in peripheral vascular anatomy and hemodynamics, as assessed by standard clinical tools that included digital subtraction angiography (DSA), ankle-brachial index (ABI), and toe-brachial index (TBI). Results: Following revascularization, upstream quantitative improvements in stenosis of the SFA (pre: 35.4% to post: 11.9%) and popliteal artery (pre: 59.1% to post: 21.7%) shown by DSA were associated with downstream angiosome-dependent improvements in SPECT microvascular foot perfusion that ranged from 2% to 16%. ABI measurement was not possible due to extensive arterial calcification, while TBI values decreased from 0.26 to 0.16 following revascularization. Innovation: This is the first study to demonstrate the feasibility of assessing noninvasive volumetric changes in angiosome foot perfusion in response to lower extremity revascularization in a patient with CLI by utilizing radiotracer-based imaging. Conclusion: SPECT/CT imaging allows for quantification of serial perfusion changes within angiosomes containing nonhealing ulcers and provides physiological assessment that is complementary to conventional anatomical (DSA) and hemodynamic (ABI/TBI) measures in the evaluation of lower extremity revascularization.

Development of Charcot Neuroarthropathy in Diabetic Patients who Received Kidney or Kidney-Pancreas Transplants.

Only a small percentage of the general diabetic population develops Charcot neuroarthropathy. Charcot arthropathy greatly increases the risk of foot complications. At our academic institution, there appeared to be an increased incidence of Charcot arthropathy in transplant patients. We hypothesized that Charcot neuroarthropathy incidence is higher in the diabetic patients who had received kidney or kidney-pancreas transplants. The charts of 1000 patients were reviewed from January 2000 to January 2011. Four hundred and eighty-seven patients were included in the study. Of these diabetic patients, 249 had received a kidney transplant and 238 a kidney-pancreas transplant. The data were analyzed for the incidence of Charcot in each group. Other risk factors and sequelae were also evaluated and analyzed. The incidence of Charcot development in the diabetic patients who had a kidney-pancreas transplant was 18.4%, 44 of 238 patients. This was significantly higher than the incidence in kidney transplant patients, which was 11.2%, 28 of 249 patients (p < .05). Peripheral arterial disease was a statistically significant independent risk factor for developing ulceration, osteomyelitis, and subsequent amputation. Type 1 diabetic patients developed Charcot at a higher rate that was also statistically significant compared with type 2 diabetic patients. In our study, diabetic patients who had undergone kidney-pancreas transplants were associated with higher risk for development of Charcot neuroarthropathy than kidney transplants alone. The incidence of Charcot development in both these transplant groups was also much higher than in the general diabetic population. This is of particular interest to clinicians and surgeons as both transplant groups were found to be high risk for subsequent foot ulceration, infection, and amputation.

Foot measures in patients with pes cavus with and without charcot-marie-tooth disease: A pilot study.

INTRODUCTION: Pes cavus often signals the presence of Charcot-Marie-Tooth (CMT) in adult patients, although its prevalence in the general population makes it a finding of unclear significance. METHODS: We undertook a pilot double cohort study to investigate the feasibility of comparing preselected bedside and radiographic foot measures in pes cavus patients with and without CMT. RESULTS: A total of 16 CMT and 11 non-CMT patients were recruited. Although no findings consistently met statistical significance, recruitment was highly limiting. CONCLUSIONS: Formalized foot measurement comparisons of CMT and non-CMT pes cavus are feasible. Larger studies will be necessary to determine if there are differences in foot structure based on the presence of a hereditary neuropathy. Muscle Nerve 59:122-125, 2019.

Gabapentin as an Adjunct to Standard Postoperative Pain Management Protocol in Lower Extremity Surgery.

Postoperative pain is a problem that plagues physicians and has since the dawn of the surgical arts. Many interventions are available and used as the standard such as preoperative local anesthetic blocks, opiates, both oral and intravenous, and nonsteroidal antiinflammatory drugs. Although the temptation often exists to increase the postoperative opiate dose, opiate abuse is an increasing problem. This abuse has fueled the search for nonopiate pain adjuncts. Gabapentinoids have been shown to both decrease postoperative pain and, secondarily, decrease opiate dependence. This is a growing field in medical research, although it is relatively lacking in the specialty of lower extremity orthopedic surgery. A PubMed query was performed for related articles, which found only 8 related to lower extremity orthopedic surgery, and of these, none addressed the foot or ankle. Studies involving chronic pain, nonorthopedic surgery, orthopedic procedures proximal to and including the hip, studies involving only pregabalin, and studies regarding cancer pain were excluded. The results from our literature review are encouraging regarding the addition of gabapentin as a regular, perioperative adjunctive pain medication because all studied reported data evaluating preoperative administration have shown a statistically significant reduction in postoperative pain and opiate consumption.

Diabetic foot burns: a case series.

Burn injury in diabetic patients has been a recent topic of interest in published studies. Previous studies have shown increased complications in diabetic patients compared with nondiabetic controls who have sustained these injuries. A paucity of research has been devoted to foot-specific diabetic burn injury. We present a case series evaluating the mechanisms and complications of diabetic foot burns.

A clinician's guide to the treatment of foot burns occurring in diabetic patients.

INTRODUCTION: Diabetes mellitus affects 25.8 million Americans and is predicted to almost double by 2050. The presence of diabetes complicates hospital courses because of the microvascular complications associated with disease progression. Patients with diabetes represent 18.3% of annual burn admissions to our unit and 27% have burns to the feet. The purpose of this project was to develop an evidence-based guideline for care of the patient with diabetes and foot burns METHODS: A multidisciplinary group was charged with developing an evidence-based guideline for the treatment of foot burns in patients with diabetes. Evidence was evaluated in the areas of diabetes, burn care, hyperbaric medicine, care of diabetic foot wounds and physical therapy. After guideline development and approval, key aspects were incorporated into order sets. RESULTS: Key aspects of this guideline are the ability to identify patients with undiagnosed diabetes, assess diabetic control, optimize glycemic and metabolic control, optimize burn wound management, treat microvascular disease, and provide education and a discharge plan. Evaluated outcomes are glycemic control, length of stay, complication rates, amputation rates, infection rates and the use of hyperbaric oxygen. CONCLUSIONS: Best outcomes for this high risk population will be attainable with an evidence based guideline.

Reamputation after minor foot amputation in diabetic patients: risk factors leading to limb loss.

The prevalence of lower extremity reamputation in diabetic patients has been well-documented. We sought to determine the risk factors for major lower extremity amputation (LEA) after minor foot amputation in diabetic patients. We studied 163 diabetic patients who had undergone an initial minor foot amputation and then had undergone at least 1 subsequent major or minor LEA. The patients were separated into a minor LEA group (initial minor LEA followed by at least 1 subsequent minor LEA) and a major LEA group (initial minor LEA followed by at least 1 subsequent major LEA). We then studied the possible risk factors for both groups. The possible risk factors analyzed were age, glycemic control, kidney function, previous kidney or kidney-pancreas transplantation, smoking history, and presence and severity of peripheral arterial disease (PAD). No statistical significance was found between the 2 groups for hemoglobin A1c, smoking status, chronic kidney disease, end-stage renal disease requiring dialysis, kidney or kidney-pancreas transplantation, or vascular intervention (peripheral arterial bypass). In the minor group, 22.23% had severe PAD. In the major group, 71.15% had severe PAD. This was statistically significant (p < .001). The average interval to major amputation in those without PAD, mild to moderate PAD, and severe PAD was 1,180.9, 591.0, and 559.6 days, respectively. This demonstrates the importance of assessing the peripheral vascular status in all diabetic patients with minor LEA. Early referral to a vascular surgeon might delay (or prevent) major LEA.

Rate of residual osteomyelitis after partial foot amputation in diabetic patients: a standardized method for evaluating bone margins with intraoperative culture.

The purpose of this study was to determine the rate of residual osteomyelitis after different foot amputations in diabetic patients with a standardized method of determining a clean bone margin. This retrospective observational pilot study evaluated 27 diabetic patients who had a forefoot amputation (toe, partial ray, or transmetatarsal) for osteomyelitis at our institution from January 1, 2010, to August 1, 2011. A standardized method was used intraoperatively to determine if bone margins were negative for residual osteomyelitis. Short-term outcomes were assessed. Negative outcomes included wound dehiscence, re-ulceration, re-amputation, or death. The overall rate of residual osteomyelitis was 40.7% (11/27 patients). Patients who underwent toe amputation with joint disarticulation had a positive margin culture rate of 23.1% (3/13). Patients who underwent partial metatarsal or transmetatarsal amputation had a positive margin culture rate of 57.1% (8/14). Although twice as frequent, this was not considered to be statistically significant (p = .1201). Overall, 48.1% (13/27) of patients were considered to have poor outcomes, and 9/11 (81.8%) patients with a positive bone margin had poor outcomes, whereas only 4/16 (25%) patients with a negative bone margin had poor outcomes. This difference was considered statistically significant (p = .0063). Although this is a pilot study, our results do confirm the high incidence of residual osteomyelitis with associated poor outcomes. Based on our data, we recommend routine standardized bone margin culture after thorough debridement and irrigation.

Metastatic esophageal adenocarcinoma of the great toe: a case report.

Owing to the rarity of metastatic disease to the bones of the foot, the guidelines for the proper care and workup of such conditions are inconsistent. The present case illustrates the evaluation of a patient with established esophageal adenocarcinoma that metastasized to involve the hallux, which had not been confirmed by previous imaging scans. The purpose of reporting the present case was to aid in establishing a protocol for a multidisciplinary approach to patient care and evaluating the entire body when performing metastatic disease treatment. As the present case has shown, evaluation of various abnormalities such as chronic paronychia could mask additional underlying conditions related to the patient's primary cancer.

Early weight bearing of calcaneal fractures fixated with locked plates: a radiographic review.

The use of locked plate technology in the calcaneus has been shown in previous studies to provide greater stability than that of nonlocking plates. The purpose of this study is to examine the radiographic effects of early weight bearing of calcaneal fractures repaired with locked plating. A retrospective review was performed of 17 calcaneal fractures repaired with locked plate fixation over a 2-year period. A chart and radiographic review evaluated the time the patient was kept non-weight bearing and the Bohler's angle at first postoperative visit and final postoperative visit. Change in Bohler's angle was used to evaluate for bone subsidence. Standard reduction and fixation techniques were performed to realign all components of the intra-articular calcaneal fracture using a titanium locking calcaneal fracture plate. Patients returned for follow-up examinations postoperatively and underwent radiographic examination. A weight-bearing short fracture walker boot was applied, and the patient began protected weight bearing at approximately 4 to 5 weeks. The charts and radiographs of 17 intra-articular fractures were reviewed. The average Bohler's angle at first postoperative visit was 30.12° in comparison to the average at final visit of 28.47 °. The average time the patient was kept non-weight bearing after the procedure was 4.8 weeks. The average time of follow-up was 237.7 days. There were no cases of significant bone subsidence or collapse noted. Calcaneal fractures can have significant morbidity associated with the injury and its care. This study examined early weight bearing of calcaneal fractures fixated with locked plating. Under radiographic review, there was no significant loss of calcaneal height, joint reduction, or fixation stability noted. These results are thought to be due to the inherent stability of the locked plate construct.