Malignant transformation of plantar ulcers in leprosy

Malignant transformation of plantar ulcers in leprosy is not uncommon. The apparent rarity of these neoplasms could be because many observed cases are not reported. To determine the extent of the problem, 133 consecutive cases of plantar ulcers seen over two years were studied clinically as well as histologically. Plantar ulcers were more common in the distal third of foot (64.67%) but malignant transformation was seen more often in plantar ulcers of proximal third of foot (64.29%). Malignant transformation was more common in plantar ulcers of long duration. Histologically, most of the lesions were benign, being instances of pseudo-epitheliomatous hyperplasia (57.89%) or atypical pseudo-epitheliomatous hyperplasia (13.53%). However, squamous cell carcinoma was observed in 10.53% cases. Thus it may be that more cases with this complication will be detected if it is borne in mind that malignant change may be encountered in such ulcers.

[Symmetric multiple lipomatosis with Charcot's joint and neuropathic ulcer. Description of a clinical case]

Multiple symmetric lipomatosis (MSL) (or Madelung's disease or Launois-Bensaude syndrome) is a rare inherited disease clinically characterized by a massive development of large symmetric unencapsulated lipomas on the subcutaneous tissue of face, neck, trunk and arms, resulting in a grotesque aspect of the patient. Less frequently the accumulation of excessive fatty tissue can spread deeply to the superficial fascia. Peripheral neuropathy, macrocytic anemia and chronic hepatopathy have been reported to cohesist. Macrocytic anaemia and chronic hepatopathy are probably secondary to high alcohol consumption, that is frequently associated. MSL, that was first described by Sir Benjamin Brodie in 1846, affects mainly the men (ratio man/woman 30:1), with an incidence in Mediterranean area of 1:25.000 men; the ages at onset range from 20 to 50 years. It is not known yet the pathway of inheritance and the molecular basis of the genetic defect responsible for the development of fat accumulation. It has been postulated a defective lipolytic response to catecholamines; this altered response could be due to an abnormal amount or a defective function of Gs-protein, the coupler between beta-adrenergic receptors on the surface of adipocytes and adenylate cyclase, or, alternatively, the defect could be in the catalytic unit of adenylate cyclase. The number and function of alpha- and beta-adrenergic receptors and the lipolytic response to cAMP (the second messenger) are normal. Recently it has been hypothesized that the defective lipolysis is due to a disorder in the mitochondria of brown fat, whose distribution is similar to the peculiar position of the lipomas in this pathology; the brown fat, unlike white adipose tissue, has abundant mitochondria. The alcohol abuse, frequently present in these subjects, might facilitate the clinical expression of the molecular defect. The therapy of lipomas is essentially surgical, but this approach is not easy, because the lipomas are not capsulated and extremely vascularized. Moreover the surgical excision is not always a successful treatment for the lipomas as they frequently recurrent after a short period from the exeresis. In this report we describe a 59-years old white man, alcohol abuser, with a typical clinical picture of MSL, developed when he was 37 years old. The patient presented multiple lipomas around the shoulders, face, neck and arms, that had been surgically excised eight times. Magnetic resonance imaging showed the presence of fat deposits also in the mediastinum, that caused a tracheal compression. Hepatic cirrhosis and serious side effects from peripheral neuropathy, represented by Charcot's joint and neuropathic ulcer on the sole foot were observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Leg and foot ulcer prevalence and investigation of the peripheral arterial and venous circulation in a randomised elderly population. An epidemiological survey and clinical investigation

Five thousand one hundred and forty questionnaires concerning leg ulcers were sent to a randomly selected population aged 65 years and older in Gothenburg in April 1989. The response rate was 89%. Ninety-seven individuals answered affirmatively, that they had leg ulcers, which corresponds to a prevalence of 2.15 +/- 0.42 per cent. These 97 individuals and the same number of controls were asked to come for a medical examination with tests of the peripheral circulation and an interview. Seventy-five (of the 97) were examined. Thirty-five had leg or foot ulcers caused by vascular insufficiency and/or diabetes and the true prevalence was estimated to be 1.02 +/- 0.29 per cent.

[Non-familial ulcero-mutilating acro-osteopathy of the foot (Bureau-Barrière syndrome)]

We report on a case of severe acro-osteopathia ulcero-mutilans complicated by lethal endocarditis. The clinical course is presented with emphasis on the typical signs and symptoms. Diagnosis and treatment require a multidisciplinary approach to such patients.

A survey of lower limb amputation in diabetic patients

A retrospective survey of non-traumatic and non-neoplastic lower limb amputations in Newcastle upon Tyne during 1989-91 was performed. Hospital data were cross-checked with the local limb fitting centre to ensure 100% ascertainment. The diabetic patients were found to be 39% of amputees and 42% of operations (all levels). Incidence of diabetes amputation was 5.7 per 100,000 population per year. Fifteen percent of the diabetic patients had diabetes first diagnosed when they were admitted for amputation. For the known diabetes patients, 46% were under diabetes care by general practitioners only. Forty-seven percent of the patients who were under the care of a hospital service for diabetes had incomplete foot examination and assessment. Mortality rate within 30 days after diabetic amputation was 10% and median life expectancy following amputation was 22 months. It seems likely that assessment and management of the diabetic foot remains suboptimal in Newcastle, and that protocols and audit of care could lead to improvements without additional resources.

Leukocyte scanning with 111In is superior to magnetic resonance imaging in diagnosis of clinically unsuspected osteomyelitis in diabetic foot ulcers

OBJECTIVE

To compare the accuracies of MRI and leukocyte scanning in diagnosing clinically unsuspected osteomyelitis in diabetic foot ulcers.

RESEARCH DESIGN AND METHODS

A prospective study of 16 diabetic foot ulcers in 12 patients, including both ambulatory and hospitalized patients, was performed at a university medical center. Pedal images were obtained by leukocyte scanning with [111In]oxyquinoline and MRI. Definitive diagnosis of osteomyelitis then was determined by bone biopsy for culture and histology.

RESULTS

Biopsy-proven osteomyelitis was present in 7 (44%) of the 16 foot ulcers. The diagnosis was suspected clinically in 0%. Leukocyte scanning was 100% sensitive, whereas MRI was only 29% sensitive in diagnosing osteomyelitis in diabetic foot ulcers. Specificities were 67 and 78%, respectively. The positive and negative predictive values (70 and 100%, respectively) for the leukocyte scan also were greater than those of MRI (50 and 58%, respectively).

CONCLUSIONS

Leukocyte scanning is superior to MRI in detecting clinically unsuspected osteomyelitis in diabetic foot ulcers.

Infected pressure and diabetic ulcers

Infected pressure and diabetic ulcers are encountered frequently by clinicians caring for the geriatric population. These infections are polymicrobial and are often complicated by sepsis syndrome and osteomyelitis. Together, these infections account for significant morbidity and mortality in elderly persons. A team approach to management is essential for the clinician, and efforts should focus primarily on prevention.

Foot infections in diabetes are rarely due to a single microorganism

The purpose of this study was to investigate the frequency with which multiple organisms can be isolated from severe foot infections in diabetic patients with carefully planned techniques of collection and processing of specimens. One hundred and seventy-seven organisms were isolated from 52 patient admissions (mean 3.4 per infection) at a district hospital. This was compared to a mean of 2.1 organisms per lesion at a local university hospital and 2.3 at a smaller community hospital. Staphylococcus aureus was isolated in about half of all lesions at the three hospitals, while anaerobic organisms were isolated from 30 at the district hospital, 10 at the university hospital, and 4 at the community hospital. This study concludes that, firstly, proper techniques for collection, transportation and examination of culture specimens are important in the isolation of multiple organisms from foot infections in diabetes, and secondly, Staphylococcus aureus is often absent while anaerobic organisms are common.

Medical risk factors in diabetic patients with foot ulcers and severe peripheral vascular disease and their influence on outcome

The association between medical risk factors and the outcome of foot ulcers was evaluated in 208 consecutive diabetic patients with severe peripheral vascular disease (systolic toe blood pressure < or = 45 mm Hg). All patients were treated and followed by the same foot care team. Eighty patients healed primarily, 83 healed after a minor or major amputation, and 45 died. The systolic toe blood pressure was higher among primary healed (30 +/- 13 mm Hg) compared with amputated (22 +/- 15 mm Hg; p < 0.001) and deceased patients (20 +/- 14 mm Hg; p < 0.001). The patients were comparable regarding age, sex, and diabetes and wound duration. Only 41 (19%) patients had intermitten claudication, whereas 153 (77%) lacked palapble pedal pulses, 36% of whom healed primarily. Rest pain occurred in 72 (33%) patients, 38 (47%) of whom had an amputation and 18 (25%) who healed primarily (p < 0.01). Peripheral edema and proteinuria were more common among patients who healed after amputation compared with those who healed primarily (p < 0.001 and p < 0.01, respectively). Signs of sensory neuropathy were found in 158 (77%) patients. There were no differences concerning cardiovascular disease, smoking habits, or short-term metabolic control between patients who healed primarily or after an amputation. In conclusion, diabetic patients with foot ulcers and severe peripheral vascular disease with low systolic toe blood pressure were not excluded from the possibility of primary healing. The most important risk factors for amputation were a systolic toe pressure of less than 30 mm Hg, peripheral edema, rest pain, and proteinuria.

Partial calcanectomy for the treatment of large ulcerations of the heel and calcaneal osteomyelitis. An amputation of the back of the foot

Twelve patients who had a large ulceration over the heel were managed with a partial calcanectomy, in lieu of a below-the-knee amputation, after unsuccessful non-operative treatment of the ulcer. Only patients who had an ankle-arm index (the ratio of blood pressure at the ankle to the brachial blood pressure) of more than 0.45, a transcutaneous PO2 of more than twenty-eight millimeters of mercury (3.7 kilopascals), a level of albumin of more than 3.0 grams per deciliter (thirty grams per liter), and a total lymphocyte count of more than 1500 were managed with a partial calcanectomy. The primary diagnosis was diabetes in seven patients, peripheral vascular disease in three, quadriplegia in one, and myelodysplasia in one. The duration of follow-up averaged thirty-three months and ranged from seven to sixty-four months. The wound healed after the partial calcanectomy in ten of the twelve patients. Nine of these ten patients maintained the level of mobility that they had had preoperatively. (One patient was unable to walk because he was quadriplegic before the operation). The wound did not heal in two patients, and those patients ultimately had a below-the-knee amputation and a decrease of one grade on the scale that was used to evaluate walking ability.

Indication, technique, and results of plantaris medialis neurovascular island flaps

Treatment of soft tissue defects in the heel often causes problems because of the anatomical structures of the foot and the foot's function in bearing the entire weight of the body. Various types of flap surgery have been tried, to deal with these problem areas. As ever, all the skin flaps lacked the normal quality of the plantar skin, which has fibrous septa with reduced flexibility. In view of the quality of the skin and subcutaneous tissue and the quality of the nerve supply, the technique of neurovascular island flaps for the plantaris medialis was used over the last 4 years in 14 patients, to conceal small to medium-sized heel defects. In this report, we examine anatomy, indication, technique, and results with regard to plantaris medialis island flaps. Their use is discussed in comparison with other types of flaps already used in this region.