Inpatient management of diabetic foot disorders: a clinical guide

The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.

Complications encountered with circular ring fixation in persons with diabetes mellitus

BACKGROUND

The purpose of this study was to identify and report the complications associated with the use of circular ring fixation in diabetic patients, and to compare the frequency of complications in patients without diabetes. We hypothesized that complications with circular ring fixation occurred more frequently in patients with diabetes than patients without diabetes.

MATERIALS AND METHODS

Institutional Review Board approval was obtained and patient charts were retrospectively reviewed from June 2004 and February 2007. Fifty six consecutive patients undergoing midfoot, hindfoot and/or ankle surgery were treated with circular ring fixation which included 33 diabetic patients in the study group and 23 non-diabetic patients in the control group. Patient demographics, the duration of treatment with the external fixator, and complications were recorded.

RESULTS

Males had a greater number of complications compared to females (p = 0.0014). The total number of complications was statistically greater in diabetic patients (study group) versus non-diabetic patients (control group) (p = 0.003). In multivariate logistic regression, diabetes and male sex were the only significant variables associated with wire complications (OR 7.35, 95% CI 1.93-28.04 and OR 0.22, 95% CI 0.05-8584111, respectively).

CONCLUSION

Women are protected from wire complications with a risk reduction of 78% compared to males. Diabetics have a 7-fold risk for any wire complication compared to patients without diabetes. We found no adverse effects of BMI, obesity, age, smoking, neuropathy, or Charcot neuroarthropathy on a satisfactory recovery.

Surgical reconstruction of the Charcot rearfoot and ankle

Charcot arthropathy of the rearfoot and ankle is a complex disorder. To date there are no evidence-based, universally agreed upon treatment protocols. As the number of patients who have these deformities continues to increase, surgeons' skill levels and experience grow as well. With increased technical skill, knowledge, and advances in fixation, these deformities are becoming more manageable. In the future this experience should afford the general community with evidenced-based protocols. This article discusses basic techniques in deformity planning and current uses of internal and external fixation techniques for rearfoot and ankle limb salvage.

Improvements in confidence, sexual relationship and satisfaction measures: results of a randomized trial of tadalafil 5 mg taken once daily

An efficacy study of tadalafil (5 mg once daily) for treating erectile dysfunction included sexual satisfaction and psychosocial outcome measures such as Treatment satisfaction (THX) domain of Sexual Life Quality Questionnaire, Self-Esteem And Relationship (SEAR) questionnaire, Sexual Encounter Profile questions 4 (SEP4; hardness satisfaction) and 5 (SEP5; overall satisfaction), intercourse satisfaction (IS) and overall satisfaction (OS) domains of International Index of Erectile Function (IIEF), and partner SEP question 3 (pSEP3). After a 4-week run-in phase, participants were randomized to receive either tadalafil (N=264) or placebo (N=78) for 12 weeks. Participants and partners were more satisfied (THX) with tadalafil (75 and 73, respectively) than with placebo (51 and 55, respectively, P<0.001). Statistically significant improvements in sexual relationship, confidence, self-esteem and overall relationship (SEAR), in addition to IS, OS, SEP5 and pSEP3 for tadalafil compared with placebo (P<0.001) correlated with erectile function (EF) improvement (assessed by change from baseline in IIEF-EF score). Tadalafil significantly improved treatment and sexual satisfaction, while improving multiple outcomes measured by SEAR.

Intermediate and long-term outcomes of the suture bridge technique for the management of insertional achilles tendinopathy

INTRODUCTION

Insertional Achilles tendinopathy is a problem frequently encountered by the foot and ankle surgeon. Conservative care yields mixed results, and this condition is often treated surgically. Our hypothesis is that the suture bridge technique through a central posterior incision allows adequate visualization for thorough debridement and exostectomy and provides a stable tendon-to-bone interface for healing.

MATERIAL AND METHODS

The medical records of 35 patients who underwent surgical treatment for insertional Achilles tendinopathy with the suture bridge technique, by a single surgeon, between 2006 and 2012 were retrospectively reviewed. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot instruments as well as a subjective questionnaire were utilized.

RESULTS

In all, 30 individuals who met the inclusion criteria for the treatment of insertional Achilles tendinopathy were evaluated at a mean follow-up of 28.93 ± 16.99 months. We included 10 men and 20 women, with a mean age of 49.1 ± 9.2 years. The mean preoperative AOFAS score was 56.6 ± 14.0. The average postoperative AOFAS score significantly increased to 91.7 ± 10.4 (P < .0001). One participant required revisional surgery, consisting of a flexor hallucis longus transfer performed by another physician. There were no wound complications or infections. Overall, there was a 97% (28/29) satisfaction rate.

CONCLUSION

The central incision with complete detachment of the Achilles tendon and reattachment with the suture bridge technique for the treatment of insertional Achilles tendinopathy provides an effective treatment with good to excellent clinical outcomes in 97% of patients, with a mean follow-up of 29 months.

The pathogenesis of Charcot neuroarthropathy: current concepts

The pathogenesis of Charcot neuroarthropathy (CN) has been poorly understood by clinicians and scientists alike. Current researchers have made progress toward understanding the cause of CN and possible treatment options. The authors review the current literature on the pathogenesis of this debilitating disorder and attempt to explain the roles of inflammation, bone metabolism, and advanced glycation end products.

Double row anchor fixation: a novel technique for a diabetic calanceal insufficiency avulsion fracture

Avulsion fractures of the calcaneal tuberosity represent only 1.3% to 2.7% of calcaneal fractures. These fractures are common pathologically in nature and attributed to decreased bone mineral density. Calcaneal insufficiency avulsion (CIA) fracture in patients with diabetes mellitus is most likely due to Charcot neuroarthropathy (CN) as described by the Brodsky classification (Brodsky 3B). Traditional open reduction and internal fixation is difficult in all calcaneal avulsion fractures because of poor bone quality. The authors report the first known description of the use of fracture fragment excision and double row anchor fixation.A 39-year-old woman with type I diabetes mellitus and a history of CN presented with an avulsion fracture of the calcaneal tuberosity. Excision of the fracture fragment and a gastrocnemius recession and reattachment of the Achilles tendon with double row anchor fixation to the calcaneus were performed. At 1 year, the patient's American Orthopaedic Foot & Ankle Society rearfoot score improved from 27/100 to 88/100. CIA fractures are an infrequently described injury. Because diabetes mellitus is frequently associated with this disease, it most likely represents a CN event. Traditionally, CIA fractures have been operatively treated with open reduction internal fixation. Previous authors have described difficulty with fixation because of poor quality. In the current report, the authors describe a novel operative approach to CIA fractures through the use of double row anchor fixation and excision of the fracture fragments. The authors feel that this previously undescribed treatment is superior to traditional methods and may serve as a new treatment option for all patients who have sustained this unusual pathology regardless of the underlying cause. The current authors provide a novel operative technique that provides inherent advantages to the traditional repair of CIA fractures. We believe CIA fractures represent a CN-type event and care should be taken when evaluating and treating these patients to prevent further sequelae.

Technical guide: transfibular ankle arthrodesis with fibular-onlay strut graft

A wide range of techniques have been described for ankle arthrodesis, and although all of these have been shown to provide stability, few have been shown to achieve a solid construct in patients at risk of nonunion. In this technical guide, we describe a modified transfibular approach to ankle arthrodesis that uses a fibular-onlay strut graft for use in patients at high risk for nonunion. In our experience, the technique has been effective and reliable.

Prognostic Scoring System for Patients Undergoing Reconstructive Foot and Ankle Surgery for Charcot Neuroarthropathy: The Charcot Reconstruction Preoperative Prognostic Score

Charcot neuroarthropathy is a destructive process that occurs in patients with peripheral neuropathy, often due to poorly controlled diabetes mellitus. Surgical reconstruction can be necessary to provide a plantigrade foot that is wound free. A risk of major amputation exists after a Charcot event and after attempted reconstruction. We retrospectively reviewed the data from 34 patients (36 reconstructions) who had undergone reconstructive surgery for Charcot neuroarthropathy. The mean patient age was 56.44 years. The mean follow-up period was 56 months. We collected patient age, body mass index, presence of wound or osteomyelitis, anatomic location, activity of disease, and hemoglobin A1c. Using these data, each patient was given a score using our novel prognostic scoring system, the Charcot Reconstruction Preoperative Prognostic Score (CRPPS). Our primary outcome measure was no wound and no major amputation at the final follow-up visit. The limb salvage rate was 89% (32 of 36), and 78% (28 of 36) had no wound at the final follow-up examination. For patients without a wound or major amputation at the final follow-up visit, the mean CRPPS was 2.96 ± 1.23. The mean CRPPS for those with a wound or major amputation at the final follow-up visit was 4.33 ± 1.07 (p = .0024). Univariate logistic regression revealed 2 statistically significant predictors of wound and/or amputation: anatomic location (odds ratio [OR] 5.0, 95% confidence interval [CI] 1.051 to 23.789; p = .043) and CRPPS (OR 2.724, 95% CI 1.274 to 5.823, p = .01). A CRPPS of ≥4 was also predictive of a negative outcome (OR 7.286, 95% CI 1.508 to 35.211; p = .013). This scoring system, with a sensitivity of 75%, specificity of 71%, and negative predictive value of 85%, is a potential starting point when educating patients and making treatment decisions in this exceptionally challenging group.

A return to normal erectile function with tadalafil once daily after an incomplete response to as-needed PDE5 inhibitor therapy

INTRODUCTION

An optimal outcome of an erectile dysfunction (ED) treatment is to enable a return to normal erectile function (as defined by an International Index of Erectile Function-Erectile Function [IIEF-EF] domain score ≥ 26). As-needed (PRN) phosphodiesterase type 5 (PDE5) inhibitor treatment does not always result in a return-to-normal erectile function.

AIM

The combined studies evaluated whether treatment with tadalafil once daily would allow men to return to normal erectile function who had less than normal IIEF-EF domain scores while using a maximum dose of a PRN PDE5 inhibitor treatment.

METHODS

Men were ≥ 18 years of age, sexually active, reported a ≥ 3-month history of ED, and had been taking the maximum dose of sildenafil citrate, vardenafil, or tadalafil PRN. Randomization to once-daily therapy with tadalafil 2.5 mg to 5 mg (N = 207), tadalafil 5 mg (N = 207), or placebo (N = 209) for 12 weeks followed a 4-week maximum dose PRN PDE5 treatment and 4-week nondrug lead periods. Two identical double-blind, randomized, placebo-controlled studies were conducted; combined results are reported.

MAIN OUTCOME MEASURE

The main outcome measure was the percentage of subjects with a return-to-normal erectile function (IIEF-EF domain score ≥ 26) when treated with tadalafil once daily compared with placebo.

RESULTS

In subjects not achieving normal erectile function with the maximum dose of a PRN PDE5 inhibitor, a higher percentage of subjects treated with tadalafil had an IIEF-EF domain score ≥ 26 at end point (tadalafil 2.5- to 5-mg group [39%]; tadalafil 5-mg group [40%]) compared with the placebo group (12.1%; P < 0.001). Tadalafil was generally well tolerated and adverse events observed were consistent with previous reports of tadalafil once daily.

CONCLUSIONS

Treatment with tadalafil once daily significantly improved erectile function in men with mild to mild-moderate impairments in erectile function following PRN PDE5 inhibitor treatment.

Tibiotalocalcaneal Arthrodesis for Foot and Ankle Deformities

Tibiotalocalcaneal arthrodesis is a safe and viable option to treat patients with arthridities affecting ankle and subtalar joints, neuromuscular disorders, avascular necrosis of the talus, failed ankle arthrodesis, instability, and Charcot neuroarthropathy. Choice of incision and fixation is based on deformity, pathology, prior surgery and hardware, and surgeon comfort and preference. Intramedullary nails offer high primary stability, reduce sustained soft tissue damage, and may allow for earlier return to activities than traditional plate or screw constructs. Peri- and postoperative fractures, malunion, nonunion, and infections are potential complications. Postoperative recovery is a vital component for an overall successful outcome.

Tibiotalocalcaneal arthrodesis with the use of a humeral locking plate

Combined arthrosis or deformity of the subtalar and ankle joints presents a challenge to the foot and ankle specialist. Tibiotalocalcaneal arthrodesis is a well-described surgical technique used for resolution of deformity and end-stage arthrosis of the ankle and subtalar joints and is currently the standard of care for this condition. This article highlights the technique of insertion of the humeral locking plate for the stabilization of tibiotalocalcaneal arthrodesis. A case study is provided to serve as an example of the technique.

Two functionally distinct forms of guanosine cyclic 3',5'-phosphate stimulated cation channels in a bovine rod photoreceptor disk preparation

Cyclic nucleotide stimulated efflux of 22Na+ and 45Ca2+ from a purified bovine rod outer segment disk preparation was measured on the 25-100-ms time scale by a novel rapid superfusion method. Activation of cation efflux by 8-bromoguanosine cyclic 3',5'-phosphate (8-Br-cGMP) was maximal within 25 ms. Over a wide range of concentrations of 8-Br-cGMP, the kinetics of termination of efflux precisely conformed to the sum of two exponential decay processes: a rapid phase (decay constant of 200 ms) and a slower phase (decay constant of 1.6 s). The kinetics of the biphasic decay of efflux cannot be explained by depletion of a pool of releasable 22Na but appear to reflect an intrinsic process for inactivation of the channels. 8-Br-cGMP-stimulated release of actively accumulated 45Ca exhibited identical biphasic decay kinetics. The maximum rate of Ca release [5 nmol.(mg of disk protein)-1.min-1] may be sufficient to produce a 1 microM change in local cytoplasmic [Ca] within 20 ms. The Ca:Na selectivity ratio is approximately 0.5:1 for both decay phases. 8-Br-cGMP demonstrated a lower potency (EC50 of 8.4 microM vs 2.8 microM) but a higher degree of cooperativity in its activation of the rapid vs the slower decay phase of 22Na efflux. The slower phase of decay was selectively inhibited by 25 microM l-cis-diltiazem, a relatively weak inhibitor of the rapid decay phase. Sodium ion (5-10 mM) selectively inhibited the rapid decay phase of 8-Br-cGMP-stimulated 45Ca release. These two kinetically and pharmacologically distinct phases of decay are hypothesized to represent two functionally distinct forms of cGMP-stimulated cation channels.

Technique tip: subtalar joint fusion using a parallel guide and double screw fixation

A wide range of techniques has been described to achieve subtalar (talocalcaneal) arthrodesis using interfragmental screw fixation. In this technical report, we describe a method that enables us to accurately position 2 screws across the subtalar joint in order to achieve arthrodesis between the talus and calcaneus. Careful attention to the tips described in this report should minimize the risk of aberrant placement of the screws while expediting the process of osteosynthesis.

Bilateral osteonecrosis of the navicular and medial cuneiform in a patient with systemic lupus erythematosus: a case report

INTRODUCTION

Atraumatic avascular necrosis (AVN) is an unusual pathology to the foot. Risk factors include the use of corticosteroids, smoking, alcohol, rheumatologic disorders, hematologic disorders, and metabolic disorders. To the authors' knowledge, this study presents the first case of bilateral atraumatic AVN to the navicular and medial cuneiform in a patient with systemic lupus erythamatosus (SLE).

CASE DESCRIPTION

A 40-year-old man presented with a past medical history of SLE in which he developed AVN of the tarsal navicular and medial cuneiform. This occurred first on the subject's right foot and then while recovering from surgical intervention, on his left foot. Talonaviculocuneiform arthrodesis was performed with the use of distal tibial autograft on both extremities. The subject's American Orthopaedic Foot and Ankle Society midfoot score improved from 34 to 80 at 21 months on the right and 37 to 90 at 15 months to the left.

DISCUSSION

Patients with SLE carry a significant risk of developing AVN. Comorbidities such as vasculitis, corticosteroid use, cytotoxic medication, and peripheral neuropathy are known risk factors in the development of AVN. Unusual features such as multifocal AVN and unusual anatomic locations can occur with SLE. AVN of the foot is generally treated with surgical intervention. Treatments such as core decompression, open reduction and internal fixation, and arthrodesis have been recommended based on the symptoms and presentation.

CONCLUSION

The authors present a very rare presentation of bilateral osteonecrosis of the tarsal navicular and first cuneiform in a patient with SLE. The patient was treated with bilateral talonaviculocuneiform arthrodesis. The patient demonstrated considerable improvement to both extremities.

LEVELS OF EVIDENCE

Therapeutic, Level IV.

Permanent antibiotic impregnated intramedullary nail in diabetic limb salvage: a case report and literature review

Managing complications after attempted hind foot and ankle arthrodesis with intramedullary nail fixation is a challenge. This situation becomes more problematic in the patient with diabetes mellitus and multiple comorbidities. Infection and subsequent osteomyelitis can be a devastating, limb threatening complication associated with these procedures. The surgeon must manage both the infectious process and the skeletal instability concurrently. This article provides a literature review and detailed management strategies for a modified technique of employing antibiotic impregnated polymethylmethacrylate-coated intramedullary nailing.

Periprosthetic fracture after femoral intramedullary nail use in two cases of tibiotalocalcaneal arthrodesis

Tibiotalocalcaneal arthrodesis using intramedullary nail fixation is a technically demanding procedure. Periprosthetic fracture in association with tibiotalocalcaneal arthrodesis is a rare occurrence, with relatively few instances reported. The present report describes 2 such instances that occurred after tibiotalocalcaneal arthrodesis using retrograde femoral intramedullary nail fixation. Studies have suggested that a longer nail might decrease the incidence of periprosthetic fracture. Other factors could also have an influence, including the proximal screw orientation and the presence of medical comorbidities, such as osteopenia.

Advances in intramedullary nail fixation in foot and ankle surgery

Tibiotalocalcaneal arthrodesis for the treatment of complex foot and ankle deformities are extremely challenging cases. Technological advances in intramedullary nail fixation have improved the biomechanical properties of available fixation constructs in recent years. Nails designed specifically to accommodate hindfoot anatomy, advancement in the understanding of optimal screw orientation, fixed angle technology, the availability of spiral blade screws, and features designed to achieve compression across the arthrodesis site have provided the foot and ankle surgeon with a greater armamentarium for performing tibiotalocalneal arthrodesis. Although advances may help to improve clinical results, small sample sizes and the low-level evidence of study designs limit the evaluation of how these advances affect clinical outcomes.

Biodynamics of hallux abductovalgus etiology and preoperative evaluation

Hallux abductovalgus (HAV) is a common but complex deformity. HAV is a combination of deformities and abnormalities. Because HAV is not from a single cause or pathologic process, controversies in description and potential treatments exist. Although many HAV deformities appear similar, no two are the same and thus cannot be treated the same surgically.

Subtalar Distraction Arthrodesis with Fresh Frozen Femoral Neck Allograft: A Retrospective Case Series

Subtalar joint distraction arthrodesis has been well reported with use of structural iliac crest or local autologous bone graft for malunited calcaneal fractures. Early reports for structural allograft did not yield good, consistent results, leading to a subsequent lack of recommendation in previous literature. Newer studies have had promising results utilizing femoral allograft as an alternative to autogenous bone graft. We performed a retrospective chart review on 10 patients (12 feet) undergoing subtalar joint distraction arthrodesis with femoral neck allograft for malunited calcaneal fractures. The primary aim of this study was to report on successful union rates and, in addition, outline any consistent complications. Twelve of the 12 procedures (100%) yielded successful fusion with a mean final follow-up of 7.7 months (range = 2.2-35.1 months). The mean increase in talocalcaneal height was 4 mm (range = 2-6 mm). The overall complication rate was 16.6%, including one superficial wound complication that healed uneventfully and one hardware removal. In conclusion, the current study reports a 100% successful fusion rate with interpositional structural femoral neck allograft in treatment for malunited calcaneal fractures.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

Soft tissue fixation with a cortical button and interference screw: a novel technique in foot and ankle surgery

Tendon transfers are commonly performed procedures in the foot and ankle. They have been described for multiple tendons and a myriad of pathologies. One issue with these procedures has always been inadequate fixation with several methods available to the surgeon. In this report, we describe a novel technique in foot and ankle surgery using a cortical button and an interference screw.

Acute Compartment Syndrome of the Foot Due To Frostbite: Literature Review and Case Report

Acute compartment syndrome of the foot and ankle is a relatively rare clinical finding. Lower extremity compartment syndrome is customarily due to vascular or orthopedic traumatic limb-threatening pathologic issues. Clinical correlation and measurement of intracompartmental pressure are paramount to efficient diagnosis and treatment. Delayed treatment can lead to local and systemically adverse consequences. Frostbite, a comparatively more common pathologic entity of the distal extremities, occurs when tissues are exposed to freezing temperatures. Previously found in military populations, frostbite has become increasingly prevalent in the general population, leading to more clinical presentations to foot and ankle specialists. We present a review of the published data of acute foot compartment syndrome and pedal frostbite, with pathogenesis, treatment, and subsequent sequelae. A case report illustrating 1 example of bilateral foot, atraumatic compartment syndrome, is highlighted in the present report. The patient presented with changes consistent with distal bilateral forefoot frostbite, along with gangrenous changes to the distal tuft of each hallux. At admission and evaluation, the patient had increasing rhabdomyolysis with no other clear etiology. Compartment pressures were measured in the emergency room and were >100 mm Hg in the medial compartment and 50 mm Hg dorsally. The patient was taken to the operating room urgently for bilateral pedal compartment release. Both pathologic entities have detrimental outcomes if not treated in a timely and appropriate manner, with amputation rates increasing with increasing delay.

Isolated first metatarsocuneiform joint fusion for correction of metatarsus primus varus deformity and literature review

Correction of a bunion deformity with the use of proximal first ray procedures has historically included additional distal soft tissue and bone work about the first metatarsophalangeal joint. We report the case of a young adult female who underwent isolated first tarsometatarsal fusion for correction of a bunion deformity. Moreover, we describe the published data related to this approach. This technique could have the potential to improve patient outcomes by avoiding postoperative arthrofibrosis of the first metatarsophalangeal joint.