The ultimate goal of soft-tissue coverage is to restore form and function, and this is especially... more The ultimate goal of soft-tissue coverage is to restore form and function, and this is especially true of plantar foot wounds. Ideally, coverage would be in primary fashion under minimal tension, utilising adjacent, sensate native tissue that is capable of withstanding the shear and tangential forces sustained during ambulation. Soft-tissue wound coverage employs conservative and surgical techniques aimed at providing the most appropriate means of creating rapid, durable and functional closure using the simplest and least invasive modalities. These include delayed primary closure, skin grafting, local, pedicle or free-tissue transfer.
Patients with severe acute and chronic lower extremity wounds often present a significant challen... more Patients with severe acute and chronic lower extremity wounds often present a significant challenge in terms of limb salvage. In addition to control of infection, assuring adequate perfusion and providing standard wound care, advanced modalities are often required to facilitate final wound closure. We herein present a case study on a diabetic patient with gangrene and necrotising soft‐tissue infection who underwent a forefoot pedal amputation to control the sepsis. Despite his non invasive vascular studies demonstrating poor healing potential at this level, he was not deemed suitable for revascularisation by our vascular surgeons and ankle‐level amputation was recommended. Nonetheless, over a 5‐month period using multiple advanced wound care therapies, wound closure was ultimately achieved.
The Charcot foot is a devastating but oftentimes preventable complication of diabetes with periph... more The Charcot foot is a devastating but oftentimes preventable complication of diabetes with peripheral neuropathy. The condition has several synonyms including Charcot’s arthropathy, Charcot joint disease, Charcot syndrome, tabetic arthropathy, diabetic neuropathic osteoarthropathy, and many derivations or combinations thereof. It is named after Jean-Martin Charcot (1825–1893), a French neurologist who first described the joint disease associated with tabes dorsalis and named it the “arthropathy of locomotor ataxia.” In 1881, J-M Charcot presented his findings at the 7th International Medical Congress in London which was attended by many acclaimed physicians of the era. During this meeting the eponym “Charcot’s Disease” was designated by Sir James Paget to these degenerative neuropathic changes in bones and joints. Although W. Musgrave in 1703 and later J.K. Mitchell in 1831 ostensibly described osteoarthropathy associated with venereal disease and spinal cord lesions, respectively, Charcot’s name remains synonymous with neuropathic arthropathies regardless of etiology.
Clinics in Podiatric Medicine and Surgery, Oct 1, 2006
The infected or ulcerated diabetic foot is a suitable environment for Clostridium tetani. Tetanus... more The infected or ulcerated diabetic foot is a suitable environment for Clostridium tetani. Tetanus intoxication as a result of foot ulcer has been described in the literature. Immunopathy, vasculopathy, and ulceration place the diabetic patient at risk for developing tetanus. Of diabetic patients who contract generalized tetanus in the United States, foot ulcer or gangrene are responsible for 25% of cases. Patients who have diabetic wounds should receive tetanus prophylaxis. The prophylaxis should follow the "tetanus-prone" wound recommendations as set by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.
Early diagnosis and a multidisciplinary team approach to managing comorbidities are essential in ... more Early diagnosis and a multidisciplinary team approach to managing comorbidities are essential in treating foot ulcerations.
Diabetic foot problems are a major cause of hospitalization, with immense personal and economic c... more Diabetic foot problems are a major cause of hospitalization, with immense personal and economic consequences. Twenty percent of all diabetic patients enter the hospital due to foot problems at a certain point in their lifetime. Foot ulcers are the most representative lesions and are responsible for one out of four hospitalizations in subjects with diabetes (1-4). These lesions are most often the result of peripheral neuropathy, autonomic neuropathy, and peripheral vascular disease. Infection is a very frequent component of them and it is certainly a significant determinant of outcome. In a case control study by Reiber et aI., infection was a significant predisposing factor for amputation in 68% of the cases (5). In a study conducted by Pecoraro et al, in a series of 80 male veterans, it was determined that infection played a role in the need for lower extremity amputation in 59% of the cases (6). Therefore, infected ulcers, especially in combination with peripheral vascular disease, can sometimes evolve to limbor life-threatening events which frequently result in amputation of the lower extremity. The risk of amputation is in fact 15-40 times higher in diabetic patients than in the nondiabetic population, and 40%-45% of patients undergoing nontraumatic amputation are diabetic (1). Surgical complications and mortality are also increased in diabetic patients: Half of those who undergo amputation die within 3 years (2). The economic costs associated with diabetic foot complications and amputations are astronomical. Direct hospital costs alone in the United States exceeded $200 million a year in 1980. This figure does not include other direct medical expenses or indirect costs due to disability
Of the 16 million people in the United States with diagnosed or undiagnosed diabetes, many will s... more Of the 16 million people in the United States with diagnosed or undiagnosed diabetes, many will suffer the long-term complications of the disease affecting their lower extremities including peripheral neuropathy and vascular disease. When combined with physical or mechanical trauma, these important predisposing risk factors can frequently lead to infection, ulceration, or gangrene. In fact, each of these events are, in turn, major risk factors for diabetic lower-extremity amputation (LEA), perhaps the most feared of all complications attendant with diabetes mellitus.
The diabetic Charcot foot is rare, but a life-changing event affecting quality of life, and it ri... more The diabetic Charcot foot is rare, but a life-changing event affecting quality of life, and it risks amputation of the limb. There is no high quality evidence base governing treatment, causing clinicians to rely on low-quality, underpowered studies and expert opinion. However, CN is a treatable condition and, with lifestyle modifications and proper footwear, it does not shorten the life span of those afflicted.
Journal of the American Podiatric Medical Association, Jul 1, 1997
Through a discussion of the etiology and pathology of diabetic foot lesions with particular empha... more Through a discussion of the etiology and pathology of diabetic foot lesions with particular emphasis on ulceration and osteoarthropathy, the author will develop a plan for treatment and prevention using a multidisciplinary approach to such problems. Underlying risk factors including neuropathy, ischemia, infection, and, especially high pressures must be evaluated and appropriately ameliorated in order to promote resolution and avoidance of recidivism. Accordingly, conservative management with pressure-relieving devices, topical therapies, and prophylactic surgery on structural deformities plays an integral part in the overall podiatric management of the high-risk foot in diabetes mellitus.
The ultimate goal of soft-tissue coverage is to restore form and function, and this is especially... more The ultimate goal of soft-tissue coverage is to restore form and function, and this is especially true of plantar foot wounds. Ideally, coverage would be in primary fashion under minimal tension, utilising adjacent, sensate native tissue that is capable of withstanding the shear and tangential forces sustained during ambulation. Soft-tissue wound coverage employs conservative and surgical techniques aimed at providing the most appropriate means of creating rapid, durable and functional closure using the simplest and least invasive modalities. These include delayed primary closure, skin grafting, local, pedicle or free-tissue transfer.
Patients with severe acute and chronic lower extremity wounds often present a significant challen... more Patients with severe acute and chronic lower extremity wounds often present a significant challenge in terms of limb salvage. In addition to control of infection, assuring adequate perfusion and providing standard wound care, advanced modalities are often required to facilitate final wound closure. We herein present a case study on a diabetic patient with gangrene and necrotising soft‐tissue infection who underwent a forefoot pedal amputation to control the sepsis. Despite his non invasive vascular studies demonstrating poor healing potential at this level, he was not deemed suitable for revascularisation by our vascular surgeons and ankle‐level amputation was recommended. Nonetheless, over a 5‐month period using multiple advanced wound care therapies, wound closure was ultimately achieved.
The Charcot foot is a devastating but oftentimes preventable complication of diabetes with periph... more The Charcot foot is a devastating but oftentimes preventable complication of diabetes with peripheral neuropathy. The condition has several synonyms including Charcot’s arthropathy, Charcot joint disease, Charcot syndrome, tabetic arthropathy, diabetic neuropathic osteoarthropathy, and many derivations or combinations thereof. It is named after Jean-Martin Charcot (1825–1893), a French neurologist who first described the joint disease associated with tabes dorsalis and named it the “arthropathy of locomotor ataxia.” In 1881, J-M Charcot presented his findings at the 7th International Medical Congress in London which was attended by many acclaimed physicians of the era. During this meeting the eponym “Charcot’s Disease” was designated by Sir James Paget to these degenerative neuropathic changes in bones and joints. Although W. Musgrave in 1703 and later J.K. Mitchell in 1831 ostensibly described osteoarthropathy associated with venereal disease and spinal cord lesions, respectively, Charcot’s name remains synonymous with neuropathic arthropathies regardless of etiology.
Clinics in Podiatric Medicine and Surgery, Oct 1, 2006
The infected or ulcerated diabetic foot is a suitable environment for Clostridium tetani. Tetanus... more The infected or ulcerated diabetic foot is a suitable environment for Clostridium tetani. Tetanus intoxication as a result of foot ulcer has been described in the literature. Immunopathy, vasculopathy, and ulceration place the diabetic patient at risk for developing tetanus. Of diabetic patients who contract generalized tetanus in the United States, foot ulcer or gangrene are responsible for 25% of cases. Patients who have diabetic wounds should receive tetanus prophylaxis. The prophylaxis should follow the "tetanus-prone" wound recommendations as set by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.
Early diagnosis and a multidisciplinary team approach to managing comorbidities are essential in ... more Early diagnosis and a multidisciplinary team approach to managing comorbidities are essential in treating foot ulcerations.
Diabetic foot problems are a major cause of hospitalization, with immense personal and economic c... more Diabetic foot problems are a major cause of hospitalization, with immense personal and economic consequences. Twenty percent of all diabetic patients enter the hospital due to foot problems at a certain point in their lifetime. Foot ulcers are the most representative lesions and are responsible for one out of four hospitalizations in subjects with diabetes (1-4). These lesions are most often the result of peripheral neuropathy, autonomic neuropathy, and peripheral vascular disease. Infection is a very frequent component of them and it is certainly a significant determinant of outcome. In a case control study by Reiber et aI., infection was a significant predisposing factor for amputation in 68% of the cases (5). In a study conducted by Pecoraro et al, in a series of 80 male veterans, it was determined that infection played a role in the need for lower extremity amputation in 59% of the cases (6). Therefore, infected ulcers, especially in combination with peripheral vascular disease, can sometimes evolve to limbor life-threatening events which frequently result in amputation of the lower extremity. The risk of amputation is in fact 15-40 times higher in diabetic patients than in the nondiabetic population, and 40%-45% of patients undergoing nontraumatic amputation are diabetic (1). Surgical complications and mortality are also increased in diabetic patients: Half of those who undergo amputation die within 3 years (2). The economic costs associated with diabetic foot complications and amputations are astronomical. Direct hospital costs alone in the United States exceeded $200 million a year in 1980. This figure does not include other direct medical expenses or indirect costs due to disability
Of the 16 million people in the United States with diagnosed or undiagnosed diabetes, many will s... more Of the 16 million people in the United States with diagnosed or undiagnosed diabetes, many will suffer the long-term complications of the disease affecting their lower extremities including peripheral neuropathy and vascular disease. When combined with physical or mechanical trauma, these important predisposing risk factors can frequently lead to infection, ulceration, or gangrene. In fact, each of these events are, in turn, major risk factors for diabetic lower-extremity amputation (LEA), perhaps the most feared of all complications attendant with diabetes mellitus.
The diabetic Charcot foot is rare, but a life-changing event affecting quality of life, and it ri... more The diabetic Charcot foot is rare, but a life-changing event affecting quality of life, and it risks amputation of the limb. There is no high quality evidence base governing treatment, causing clinicians to rely on low-quality, underpowered studies and expert opinion. However, CN is a treatable condition and, with lifestyle modifications and proper footwear, it does not shorten the life span of those afflicted.
Journal of the American Podiatric Medical Association, Jul 1, 1997
Through a discussion of the etiology and pathology of diabetic foot lesions with particular empha... more Through a discussion of the etiology and pathology of diabetic foot lesions with particular emphasis on ulceration and osteoarthropathy, the author will develop a plan for treatment and prevention using a multidisciplinary approach to such problems. Underlying risk factors including neuropathy, ischemia, infection, and, especially high pressures must be evaluated and appropriately ameliorated in order to promote resolution and avoidance of recidivism. Accordingly, conservative management with pressure-relieving devices, topical therapies, and prophylactic surgery on structural deformities plays an integral part in the overall podiatric management of the high-risk foot in diabetes mellitus.
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