Cases reported • Diabetic Foot; Foot Ulcer, Diabetic

1/113. Use of computed tomography and plantar pressure measurement for management of neuropathic ulcers in patients with diabetes.

BACKGROUND AND PURPOSE: Total contact casting is effective at healing neuropathic ulcers, but patients have a high rate (30%-57%) of ulcer recurrence when they resume walking without the cast. The purposes of this case report are to describe how data from plantar pressure measurement and spiral x-ray computed tomography (SXCT) were used to help manage a patient with recurrent plantar ulcers and to discuss potential future benefits of this technology. CASE DESCRIPTION: The patient was a 62-year-old man with type 1 diabetes mellitus (DM) of 34 years' duration, peripheral neuropathy, and a recurrent plantar ulcer. Although total contact casting or relieving weight bearing with crutches apparently allowed the ulcer to heal, the ulcer recurred 3 times in an 18-month period. Spiral x-ray computed tomography and simultaneous pressure measurement were conducted to better understand the mechanism of his ulceration. OUTCOMES: The patient had a severe bony deformity that coincided with the location of highest plantar pressures (886 kPa). The results of the SXCT and pressure measurement convinced the patient to wear his prescribed footwear always, even when getting up in the middle of the night. The ulcer healed in 6 weeks, and the patient resumed his work, which required standing and walking for 8 to 10 hours a day. DISCUSSION: Following intervention, the patient's recurrent ulcer healed and remained healed for several months. Future benefits of these methods may include the ability to define how structural changes of the foot relate to increased plantar pressures and to help design and fabricate optimal orthoses.

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2/113. Use of topical recombinant human platelet-derived growth factor-BB (becaplermin) in healing of chronic mixed arteriovenous lower extremity diabetic ulcers.

lower extremity ulcers cause significant morbidity and mortality in patients with diabetes. The primary factors that contribute to the development of this type of ulcer are peripheral neuropathy and peripheral vascular disease, which are often accompanied by infection. lower extremity diabetic ulcers are chronic and difficult to treat, in part due to underlying pathologic conditions in individuals with diabetes that can contribute to impaired wound healing. This article reports the author's experience with treatment of chronic lower extremity ulcers of mixed etiologies with recombinant human platelet-derived growth factor--BB [rhPDGF-BB, REGRANEX (becaplermin) Gel 0.01%] in a patient with multiple risk factors including long-standing insulin-dependent type 2 diabetes.

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keywords = diabetic, neuropathy
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3/113. Diabetic neuropathic foot ulcer: successful treatment by low-intensity laser therapy.

OBJECTIVE: To evaluate the efficacy of low-intensity laser irradiation for the induction of wound healing of a diabetic neuropathic foot ulcer. CASE: We report a case of a man with insulin-dependent diabetes mellitus, sensory neuropathy, macroangiopathy and microangiopathy who had been suffering from an ulcer of his first left toe accompanied by osteomyelitis for 6 weeks. RESULTS: After a total of 16 sessions of low-intensity laser therapy using a 670-nm diode laser administered within a 4-week period the ulcer healed completely. During a follow-up period of 9 months, there was no recurrence of the ulcer even though the patient's metabolic condition remained unstable. CONCLUSIONS: Although laser therapy was not applied as a monotherapy, the present observation suggests that it might constitute a useful side-effect-free alternative treatment modality for the induction of wound healing of neuropathic ulcers in diabetic patients. Therefore large properly controlled randomized studies seem justified.

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keywords = diabetic, neuropathy
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4/113. Generalized tetanus in a patient with a diabetic foot infection.

tetanus is a preventable disease that continues to affect people in the united states due to poor immunization practices in our health care system. A 57-year-old man with type 2 diabetes mellitus, hypertension, and end-stage renal disease with many hospital admissions came to the hospital emergency department because of a blackened great toe. He denied pain in the toe or knowledge of foot injury. The patient also complained of temporomandibular tenderness accompanied by inability to open his mouth completely. The man's problems progressed to generalized tetanus and required a long hospitalization. clostridium tetani can flourish in the anaerobic environment of a diabetic foot infection. Practitioners should be aware of tetanus as a rare but potentially serious complication of diabetic foot infections.

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5/113. Elevated plantar pressure and ulceration in diabetic patients after panmetatarsal head resection: two case reports.

Panmetatarsal head resection (variously called forefoot arthroplasty, forefoot resection arthroplasty, the Hoffman procedure, and the Fowler procedure) was developed for the relief of pain and deformity in rheumatoid arthritis. Although there are successful retrospective series reported in the literature, such an approach is not supported by carefully designed controlled trials. This procedure has also been advocated by some for the relief of plantar pressure in diabetic patients who are at risk for plantar ulceration. The efficacy of the procedure in this context is not supported by existing pressure measurements on rheumatoid arthritis patients in the literature, which has tended to show that although pain relief is obtained, the procedure results in elevation of forefoot pressure. Case reports are described of two patients (three feet) with sensory neuropathy who presented to our clinic 1 to 2 years after panmetatarsal head resections had been performed. Peak plantar pressures in these feet during first step gait were above the 99th percentile and outside the measuring range of the device used (EMED SF platform; NOVEL electronics Inc., St. Paul, MN). Both patients had also experienced plantar ulcers subsequent to the surgery. Combining the information on patients with rheumatoid arthritis (RA) with that from our two case studies, we conclude that panmetatarsal head resection does not necessarily eliminate focal regions of elevated plantar pressure.

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keywords = diabetic, neuropathy
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6/113. Thermal burns in diabetic feet.

Many patients with diabetes can lead a full life without developing diabetic lesions in their feet. This is because these patients have avoided the precipitating factors of which the most important is mechanical trauma and infections. We present five cases of diabetic patients who, out of ignorance, listened to bad advice by using hot therapy to treat their peripheral neuropathy. This resulted in burns and secondary infections. All of them required large surgical debridement and prolonged costly hospital stay to treat their condition. Fortunately, none of them required amputation. This paper hopes to highlight the dangers of self treatment and medication in diabetic foot lesions.

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7/113. Long-term antibiotic treatment in geriatric diabetic foot infection.

A case report involving a 77-year old diabetic patient with an arterial foot ulcer and subsequent osteomyelitic infection is presented. Due to the patient's ineligibility for surgical intervention, long term antibiotic treatment based upon multiple culture, bone biopsy, radiograms and isotope scanning was initiated. Complete resolution of the osteomyelitis defined by subjective as well as objective criteria was achieved after three months of antibiotic treatment. The common and atypical characteristics of the geriatric population coupled with treatment plan involving a multidisciplinary approach resulted in maintaining foot function and pain-free ambulation in this 77-year old patient.

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8/113. Effects of a tendo-Achilles lengthening procedure on muscle function and gait characteristics in a patient with diabetes mellitus.

STUDY DESIGN: Case report with repeated measures. OBJECTIVES: To describe the effects of a tendo-Achilles lengthening (TAL) and total contact casting (TCC) on wound healing, motion, plantar pressure, and function in a patient with diabetes mellitus, peripheral neuropathy, neuropathic ulcer, and limited dorsiflexion range of motion (DFROM). BACKGROUND: Limited DFROM has been associated with increased forefoot pressures and skin breakdown. A TAL was expected to increase DFROM and reduce forefoot pressures during walking, but the influence on muscle performance and function was unknown. methods AND MEASURES: The patient was a 42-year-old man with a 20-year history of type 1 diabetes (NIDDM) and a recurrent neuropathic plantar ulcer. Outcome measures were DFROM, isokinetic plantar flexor muscle peak torque, in-shoe and barefoot peak plantar pressure, physical performance test (PPT) score, and peak ankle and hip moments during walking obtained from an automated gait analysis. All tests were completed pre-TAL, 8 weeks post-TAL (after immobilization in a TCC), and 7 months post-TAL. RESULTS: The wound healed in 40 days. The TAL resulted in a sustained increase in DFROM (0 to 18 degrees). Plantar flexor peak torque was reduced by 21% 8 weeks after the TAL compared with the torque before surgery but recovered fully at 7 months. Seven months following TAL, in-shoe forefoot peak plantar pressure was reduced by 55%, barefoot pressure decreased by 14%, PPT score increased by 24%, peak ankle plantar flexor moment remained decreased by 30%, and the peak hip flexor moment increased by 41% during walking. CONCLUSION: For this patient, a TAL resulted in short-term deficits in peak plantar flexor torque, but a 7-month follow-up showed improvements in ankle DFROM, walking ability, and a decrease in forefoot in-shoe peak plantar pressure.

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9/113. Filleted toe flap for chronic forefoot ulcer reconstruction.

Chronic plantar and dorsal forefoot ulcer may result from injury, structural deformity, and abnormal sensation or circulation. It is not uncommon that the distal portion of the affected toes is deficient functionally in these patients. A filleted toe flap from the expendable functionless toe can provide a durable, stable, and sensate skin flap of 4 to 5.5 cm for coverage of the forefoot defect. In this report, five cases of dorsal forefoot defects and four cases of plantar forefoot defects due to ischemia (N = 3), trophic change (N = 2), and diabetes (N = 4) were treated with filleted toe flaps. One flap failed due to postoperative deep infection. The other eight filleted toe flaps survived but 2 patients underwent secondary amputations 7 months and 2 two years later because of secondary diabetic foot infections.

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keywords = diabetic
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10/113. Identification of bacteria from a non-healing diabetic foot wound by 16 S rDNA sequencing.

Approximately 10-20% of diabetic foot wounds fail initial antibiotic treatment. It is generally believed that several bacterial species may be present in these types of wounds. Because some of these organisms cannot be easily cultured, proper identification is problematic and thus, appropriate treatment modalities cannot be applied. This report examined the bacterial flora present in a chronic diabetic foot wound that failed antibiotic treatment. A tissue sample was collected from the base of the wound and used for standard microbiological culturing. dna from the sample was used to amplify bacterial 16 S rDNA gene sequences and a library of these sequences was made. The clones were placed into two major groups on the basis of their melting temperatures. Representatives of these groups were sequenced, and information was used to identify the bacteria present in the wound. The culture-based method identified a single anaerobic species, bacteroides fragilis. The method employing rDNA sequencing identified B. fragilis as a dominant organism and pseudomonas (Janthinobacterium) mephitica as a minor component. The results indicate that rDNA sequencing approach can be an important tool in the identification of bacteria from wounds.

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keywords = diabetic
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