Association of Demographic Characteristics and Laboratory Values in Diabetic Foot Infections Leading to Lower-Extremity Amputation.

BACKGROUND: Lower-extremity amputations are a common complication of poorly controlled diabetes and contribute to significant morbidity and mortality in diabetic patients. We sought to determine whether objective data points obtained on presentation or hospital admission, including white blood cell (WBC) count, hemoglobin A1c (HbA1c), C-reactive protein (CRP), and descriptive patient demographics allow for the ability to predict optimal amputation levels and outcomes of lower-extremity amputation in the diabetic population. METHODS: A retrospective analysis of 162 patients was performed evaluating laboratory and descriptive values on hospital presentation for lower-extremity infection during a 16-year period. Occurrence of multiple amputations and level of amputation were assessed against laboratory values to determine whether these objective values would provide clinicians with a better understanding of amputations in the diabetic patient. RESULTS: The mean patient age was 60.6 years. A significantly higher percentage of patients who underwent amputations through the tibia and fibula or of the foot midtarsal were male compared with patients who underwent amputations of the thigh through femur. Patients who had amputations through the tibia and fibula had a significantly higher WBC count compared with patients who had a transmetatarsal amputation (P = .03). There was no significant difference in type or quantity of amputations when analyzing HbA1c and CRP levels. CONCLUSIONS: An admission WBC count may be used as a predictor of lower-extremity amputation level and outcomes in diabetic infections. Although a statistically significant difference was not found for CRP or HbA1c levels between amputation procedures and number of procedures performed, these values remain useful in managing lower-extremity infections in diabetic patients.

Operative Ankle Fractures in Complicated Diabetes: Outcomes of Prolonged Non-Weightbearing.

Diabetes increases the risk of developing postoperative complications such as superficial and deep infection, wound dehiscence, and revisional surgery. Prolonged non-weightbearing and/or augmented fixation may reduce postoperative complications in complicated diabetic ankle fractures. This study's purpose was to compare the development of postoperative infection, wound dehiscence, and revisional surgery in complicated diabetic ankle fractures with respect to weightbearing status. We hypothesized that fewer complications would occur in patients with prolonged non-weightbearing. Medical records of 90 surgically treated complicated diabetic ankle fractures were retrospectively reviewed for postoperative radiographs, weightbearing status, and complications. Complicated diabetes was defined as HbA1c ≥ 8% within 1 year of surgery. Twenty-four out of 90 patients had prolonged non-weightbearing status, which was defined as ≥ 8 weeks of non-weightbearing postoperatively. Twelve out of 90 patients had augmented fixation, which was defined as standard open reduction and internal fixation plus ≥ 2 tetra-cortical or > 2 tri-cortical syndesmotic screws with medial plate, external fixation, or other combination. Thirty-three out of 90 patients (36.7%) patients developed complications postoperatively. Patients with prolonged non-weightbearing had less complications (29.2% vs 39.4%, p = .37) and larger HbA1c values compared with early weightbearing patients (10.0 vs 9.3, p = .04). A one-unit increase in creatinine value (mg/dL) revealed a 3.15-fold increase in development of complications (95% confidence interval 1.29-7.65, p = .01). Although not statistically significant, complicated diabetic ankle fractures treated with prolonged non-weightbearing had less complications postoperatively except for ankle Charcot. Creatinine can be utilized as an independent risk factor for postoperative complications in this population.

Nonhealing Wounds with Verrucous Presentation in the Neuropathic Patient: A Report of Two Cases.

Verrucous skin lesions on the feet of diabetic patients in conjunction with a neuropathic foot ulcer is an uncommon incident. Currently, there are approximately 20 reported cases in the literature. Herein we report two cases of verrucous lesions superimposing a chronic diabetic ulcer. Patients failed several conservative treatments, and several biopsies were performed with inconclusive results, suggesting possible underlying verrucous carcinoma. Given the possibility of underlying malignancy, both patients were treated with wide excision, and both were negative for malignancy, thus confirming verrucous skin lesions on the feet in diabetic neuropathy. We also summarize the current literature on verrucous skin lesions on the feet in diabetic neuropathy.

Osteomyelitis of the Calcaneus With Pathologic Fracture.

Pathologic fractures of the calcaneus secondary to osteomyelitis (OM) have rarely been reported in the literature. This case series describes 5 patients who were treated in our institution for chronic OM of the calcaneus and subsequently suffered a fracture of the involved calcaneus in the absence of trauma. All 5 patients had a history of insulin-dependent diabetes mellitus and were treated with a range of surgical treatments including open reduction and internal fixation, external fixation, and excision of the fracture fragment. Three (60%) of the patients required a below-the-knee amputation of the ipsilateral limb, 1 (20%) expired, and 1 (20%) experienced healing of the fracture and the associated heel wound. Pathologic fracture of the calcaneus secondary to OM is a recognized entity, although case descriptions have rarely been reported for this challenging condition.

The Mechanical Axis of the First Ray: A Radiographic Assessment in Hallux Abducto Valgus Evaluation.

The present report describes a new method of hallux abducto valgus deformity correction planning using the mechanical axis of the medial column (mechanical axis planning). This method of radiographic evaluation identifies an ideal position for the first metatarsal after correction and is useful regardless of the surgical procedure chosen. We retrospectively reviewed 200 radiographs to identify a "normal" value for the mechanical axis angle. We reviewed 100 radiographs of patients with hallux abducto valgus deformity (deformity group) and 100 radiographs of patients without hallux abducto valgus deformity (control group). The deformity group revealed an M1-M2 anatomic axis angle of 13.5° ± 2.83° and an M1-M2 mechanical axis angle of 11.58° ± 1°. The control group revealed an M1-M2 anatomic axis angle of 7.5° ± 1.76° and an M1-M2 mechanical axis angle of 11.19° ± 0.9°. The differences in the M1-M2 anatomic axis angle and M1-M2 mechanical axis angle were statistically significant between the control and deformity groups. We sought to provide a reliable method for planning hallux abducto valgus deformity correction by aligning the mechanical axis of the medial column and the mechanical axis of the first ray to the "normal" value of 11° to reduce the deformity.

Medial Column Arthrodesis Using an Anatomic Distal Fibular Locking Plate.

The medial column fusion is performed for a multitude of etiologies, including peritalar subluxation deformity, Charcot arthropathy, trauma, post-traumatic degenerative joint disease, and rheumatoid arthritis. Various surgical techniques have been described for medial column arthrodesis. We describe a new fixation method using an anatomic distal fibular locking plate for medial column arthrodesis. This technique provides a rigid construct in compromised or at risk bone. After a review of the surgical technique, we outline 2 case examples of patients with peritalar subluxation and Charcot arthropathy.

Tibiocalcaneal arthrodesis in the high-risk foot.

The present case series outlines the history and surgical treatment of 6 patients who underwent tibiocalcaneal arthrodesis from April 2002 to May 2012, all with external fixation as the primary or secondary fixation. Surgical intervention was performed by the same surgeon at the same facility. The indication for surgery was a nonbraceable Charcot deformity in 5 (83.3%) patients and bone and soft tissue infection complicating previous intramedullary hindfoot fusion in 1 (16.7%) patient. Talectomy was performed in 2 (33.3%) patients secondary to widespread osteomyelitis of the talus and in 4 (66.7%) patients secondary to avascular necrosis and/or disintegration and fragmentation of the remaining talus. The postoperative complications have been discussed in detail and their management outlined. At the most recent follow-up visit, all patients were independently ambulating on a braceable limb with or without the use of an assistive device. In conclusion, tibiocalcaneal arthrodesis is a reasonable option for limb salvage to produce community ambulators in the high-risk population. We emphasize that although multiple fixation options are available for tibiocalcaneal arthrodesis, a combination of internal and external fixation is vital to its success.