Delay in presentation due to confusion between blood blister and wet necrosis
A 67-year-old man with type 2 diabetes which had not previously been diagnosed, developed what he took to be a blood blister on his left hallux. The lesion was not painful, he felt well, and he did not seek treatment until he noticed an unpleasant odour and went to casualty. The toe was infected and necrotic. Pedal pulses were bounding. His vibration perception threshold was 45 volts Fig. 6.3 . He underwent amputation of the hallux and the foot healed in 4 months. Three weeks after he was...
Preoperative preparation for neuropathic and neuroischaemic patients needing
On admission, these patients should be regarded as medical and surgical emergencies. The following investigations should be carried out Full blood count and typing Serum electrolytes and creatinine Fig. 5.23 a Small ulcer on 5th toe with associated blistering. Photograph by Mark O'Brien. b Extensive debridement. Photograph by Mark O'Brien. c The patient is wearing a patellar-tendon bearing weight-relieving orthosis. Table 5.5 Insulin sliding scale. Adjust volume of fluids according to clinical...
Rigid hammer toe deformity
A 64-year-old man, a retired pilot, with type 2 diabetes of 16 years' duration, was followed regularly in the diabetic foot clinic for treatment of a rigid hammer toe deformity of his right 2nd toe, with recurrent ulceration over the proximal interphalangeal joint. The patient underwent an elective proximal interphalangeal joint arthroplasty, with lengthening of the extensor hallucis longus tendon and dorsal capsulotomy of the metatarsophalangeal joint. A Kirschner wire was not used in this...
Ray amputations
A ray resection consists of excision of a toe and its corres Fig. 8.23 A full-thickness neuropathic plantar ulcer developed beneath the 1st metatarsal, as a complication of amputation of the hallux with resectionofthelst metatarsal head. Fig. 8.23 A full-thickness neuropathic plantar ulcer developed beneath the 1st metatarsal, as a complication of amputation of the hallux with resectionofthelst metatarsal head. ponding metatarsal. The most frequent complication of a ray resection is transfer...
Partial digital amputation of the hallux
Distal amputation of the hallux, sometimes referred to as a terminal Symes amputation, is indicated for lesions of the distal toe or nail bed, e.g. osteomyelitis of the distal phalangeal tuft, ulceration of the nail bed or tumour. The procedure employs either resection of the tuft of the distal phalanx or disarticulation of the toe at the interphalangeal joint. This procedure preserves acceptable length and function of the hallux. A similar surgical approach can be modified for the lesser toes.
Surgical reconstruction of Charcots osteoarthropathy of the hindfoot
A 61 -year-old lady with type 1 diabetes of 40 years' duration developed a hot, red, swollen foot and ankle, and Charcot's osteoarthropathy was diagnosed. She was unwilling to wear a total-contact cast, but agreed to wear an Aircast. One month later she attended a wedding and discarded the Aircast for 1 day. She returned to the foot clinic the following week with an unstable flail ankle. She underwent surgical reconstruction Fig. 3.26 and returned to the foot clinic in a non-weightbearing...
Preoperative care
The following points should be recognized Admission to hospital is always an anxious time, especially for patients fearing or facing a major amputation When patients are worried and anxious they may not retain information Information should be repeated several times and reinforced with the written word Patients like to feel that their limb is valuable, and that initial investigations and interventions are made in an effort to try and save the limb Patients want to know the reason why the leg...
Lisfranc amputation
A 50-year-old man with a history of IV drug abuse and type 2 diabetes underwent amputation of his right 2nd toe and was referred to us for surgical management of his infected right foot. Examination revealed several draining ulcers and sinus tracts, extending from the site of his amputated 2nd toe, to beneath the 2nd and 3rd metatarsal heads and into the central plantar space Fig. 8.33a . Radiographs revealed osteolytic changes in the 2nd and 3rd metatarsals consistent with osteomyelitis. The...
Partial calcanectomy
Partial calcanectomy is indicated for the surgical management of large non-healing wounds located over the heel, with or without osteomyelitis. These wounds are typically chronic decubitus ulcers located on the posterior aspect of the heel, or neuropathic ulcers on the plantar surface of the heel. Regardless of the aetiology, heel ulcers are often unresponsive to conservative therapy and are frustrating to treat. Partial calcanectomy is a viable alternative to below-knee amputation for these...
Mechanical control Ikn
Armstrong DG, Lavery LA. Evidence-based options for offloading diabetic wounds. Clin Podiatr Med Surg 1998 15 95-104. Armstrong DG, Nguyen HC, Lavery LA etal. Off-loading the diabetic foot wound a randomized clinical trial. Diabetes Care 2001 24 1019-22. Baumhauer JF, Wervey R, McWilliams J etal. A comparison study of plantar foot pressure in a standardised shoe, total contact cast and prefabricated pneumatic walking brace. Foot AnkleInt 1997 18 26-33. Boninger ML, Leonard JA. Use of bivalved...
Case Study Kxv
A 50-year-old female with undiagnosed type 2 diabetes, applied Bazooker, a proprietary wart remedy, to a small brown tender papule over her right third metatarsal head. Within a few days she developed a cutaneous erosion which failed to heal for 9 months and became increasingly painful Fig. 2.13a,b . Diabetes was diagnosed by her Fig. 2.13 a Ulcer following application of a proprietary wart remedy which proved to be a squamous cell carcinoma, b Close-up of lesion. Fig. 2.13 a Ulcer following...
Modified Lisfranc amputation
Modifications of the Lisfranc amputation include preservation of the 5th metatarsal base, and the 2nd metatarsal base, in its intercuneiform mortise. The patient is placed in a supine position with the foot and lower half of the leg prepared and draped in the usual manner. This procedure is performed in a manner similar to the transmetatarsal amputation, with the development of a longer plantar flap and short dorsal flap. The dorsal skin incision is made just distal to the 1st...
Achilles tendon lengthening
Increased pressure on the plantar aspect of the forefoot has been shown to be associated with limited joint mobility and with equinus deformity of the ankle. In the Fig. 8.16 Technique for 5th metatarsal head resection. Before and after removal of the metatarsal head. Note that the osteotomy is angled in an oblique manner at the surgical neck of the metatarsal. Fig. 8.17 a Preoperative anteroposterior radiograph reveals deformity of the right 5th metatarsophalangeal joint with lateral bowing...
Fifth metatarsal head resection
This procedure is well suited for older sedentary individuals, and for patients with osteopenia or osteomyelitis of the metatarsal head, where a transpositional osteotomy is not appropriate. Although transfer lesions callus or ulcer have been reported to occur beneath adjacent Fig. 8.15 The Weil lesser metatarsal shortening osteotomy, a The lesser toe is plantarflexed, and the oblique osteotomy cut begins at the distal dorsal edge of the articular cartilage, b Proximal displacement of the...
Hallux amputation Fig 822ab
Amputation of the great toe invariably results in biomech-anical dysfunction of the foot. The degree to which this occurs depends upon whether or not a portion of the 1st metatarsal has also been removed. The loss of propulsive function is not detrimental to neuropathic patients who already have an apropulsive gait. Of greater concern, however, are the following postoperative sequelae Compensatory flexion contracture of the 2nd toe Ulceration at the tip of the 2nd toe Ulceration beneath the 1st...
Wet necrosis
The microbiological principles of managing wet necrosis are similar to those for the management of infection of the foot with extensive soft tissue infection or the foot with blue discolouration as described in Chapter 5. When the patient initially presents, deep wound swabs and tissue specimens are sent off for microbiology. Deep tissue taken at operative debridement must also go for culture. Intravenous antibiotic therapy Both neuropathic and neuroischaemic patients need parenteral therapy....
Practice Points 1
The basic approach to the diabetic foot is assessment, classification, staging and multidisciplinary management Diabetic feet can be classified into neuropathic and neuroischaemic feet The natural history of the diabetic foot falls into six stages normal, high risk, ulcerated, infected, necrotic and unsalvageable Multidisciplinary management consists of mechanical, wound, microbiological, vascular, metabolic and educational control The multidisciplinary foot care service should include...
Classification
The simple staging system differentiates between ulcers on neuropathic feet and ulcers on ischaemic feet. The basis of this classification is the presence or absence of ischaemia in the common background of neuropathy. The majority of ischaemic feet in diabetes will also have neuropathy and therefore we describe the ischaemic foot as neuroischaemic. However, there may be some ischaemic feet with minimal or no neuropathy and the ulcers in these feet are perhaps more accurately called ischaemic....
Dressings and postoperative care Lun
The decision to close the wound primarily or to pack it open will vary with each case. Infected or contaminated wounds should be packed open, and either allowed to heal by secondary intention or brought back to the operating theatre for delayed wound closure. Dressings consist of a dry sterile compression gauze bandage with the hallux splinted in its proper alignment. The patient is instructed to rest at home, remain non-weightbearing and elevate his feet for 48 h. If the wound was packed open,...
Practical Assessment
This can be divided into three parts Every attempt should be made to encourage the patient to be open and non-defensive. The history can be divided into the following sections Be aware that some patients may be asymptomatic due to neuropathy. The presenting complaint is usually one or more of the following For skin breakdown, swelling and colour change or any other presenting complaints, the following questions may be helpful As regards pain, this maybe a specific complaint alone or it may...
Case Study Fyl
A 44-year-old woman with type 2 diabetes of 6 years' duration developed itchy vesicles on the border of her foot associated with dry skin, desquamation and pruritus Fig. 2.11 . We prescribed Whitfield's ointment which she used for 1 week. Three weeks later the problem recurred. She was advised to continue using the Whitfield's ointment until 2 weeks after the symptoms had resolved, and then to apply surgical spirit to the previously affected areas after washing them daily and drying them...
Acknowledgements
Ali Foster and Mike Edmonds offer special thanks first to their co-author, Lee Sanders, who contributed the chapter on surgical management of the diabetic foot and also cast a critical and helpful eye over the other chapters giving an American perspective. His advice was invaluable. For sections of the chapter on the management of diabetic major amputees we owe a great deal to Christian Pankhurst and Alan Tanner for details of prosthetic and orthotic management. We are also grateful to Rosalind...
Advances In Diabetic Foot Care
The diabetic foot has become a major area of interest, and insight has been gained into the reasons why diabetic feet go wrong and the ways in which patients can be helped. Of all the complications of diabetes, the diabetic foot is probably the easiest to prevent and treat. The groundswell of interest in the diabetic foot surged in the 1980s, and developments in foot care included the setting up of multidisciplinary diabetic foot clinics Fig. 6 and the pioneering educational work of Jean...
Historical Background
The last century made great inroads into improving the management of diabetes. The early work of pioneers such as Nicolas Paulesco in Rumania and Georg Zuelzer in Germany culminated in the work of Banting, Best, Collip and Macleod in Canada who produced a pancreatic extract which was used successfully in patients and ended the Fig. 6 International visitors at the King's Diabetic Foot Clinic left to right, Dr Kamenov Bulgaria , the Authors, Dr Harkless USA and Dr Plamen Bulgaria . Fig. 7 The...
Prologue
He's both their parent and he is their grave, And gives them what he will, not what they crave. Pericles, Prince of Tyre, II, iii, William Shakespeare Fig. 1 Foot from the UK. This 85-year-old man with type 2 diabetes of 8 years' duration received regular dressings of his ulcerated ischaemic foot for 9 months, but was not referred until extensive gangrene had developed. Fig. 2 Foot from Ukraine. This 48-year-old man with type 2 diabetes of 12 years' duration trod on a nail and developed severe...
The Scope Of The Problem
Diabetic foot complications are a major global public health problem. Amputation rates vary throughout the world but are always increased in people with diabetes compared to those without diabetes. Amputations are increasing in diabetic patients. Throughout the world, health-care systems, both public and private, have been unsuccessful in managing the overwhelming problems of patients suffering with diabetic foot complications. The results of this failure are shown in the following case...