Search

Background: We aimed to determine the relative risk of pedal vessel calcification (PVC) on major adverse foot events (MAFEs) and chronic kidney disease (CKD) stage in patients with diabetes mellitus (DM) and peripheral neuropathy (PN)., Methods: We retrospectively reviewed electronic medical records of 152 patients with diagnoses of DM, PN, and CKD stages one to five who had at least one foot radiograph obtained. PVC was scored (from 0-4) based on foot anatomic location and radiology reported MAFEs, which includes foot fracture, Charcot neuroarthropathy, foot ulcer, osteomyelitis, or minor amputation. Risk ratios (RR) with 95% confidence intervals (95% CI) and Poisson regressions were performed assessing the risk of sustaining MAFEs with number of PVCs and stage of CKD., Results: The risk of any MAFE increased as PVC score increased (RR = 1.23); the risk of any MAFE increased as CKD stage increased (RR = 1.35); and risk of any PVC increased as CKD stage increased (RR = 1.71)., Conclusions: Pedal vessel calcification on a foot radiograph increases the risk of any MAFE and increases with progressive stage of CKD. Pedal vessel calcification may serve as a gateway to prompt investigation, treatment, or referral for at-risk diabetic neuropathic, nephropathic patients.

Plantar vein thrombosis (PVT) is an atypical cause of plantar heel pain and is seldom reported in the literature. We present a unique, rare case report of a patient exhibiting plantar heel and medial arch pain caused by thrombosis in the plantar medial branch of the posterior tibial vein. The diagnosis was made by means of magnetic resonance imaging, showing lobulated hypointensity in the medial plantar vein, consistent with a PVT. In this article, we provide an overview of the clinical signs of PVT, which is most commonly plantar heel pain. Furthermore, we discuss ultrasound and magnetic resonance imaging as diagnostic modalities, and conservative treatment options, including anti-inflammatory medications, anticoagulation therapy, and compression therapy. As with other types of venous thromboembolism, this condition must also be diagnosed without delay to avoid potential complications.

Background: The deep plantar (D-PL) artery originates from the dorsalis pedis artery in the proximal first intermetatarsal space, an area where many procedures are performed to address deformity, traumatic injury, and infection. The potential risk of injury to the D-PL artery is concerning. The D-PL artery provides vascular contribution to the base of the first metatarsal and forms the D-PL arterial arch with the lateral plantar artery., Methods: In an effort to improve our understanding of the positional relationship of the D-PL artery to the first metatarsal, dissections were performed on 43 embalmed cadaver feet to measure the location of the D-PL artery with respect to the base of the first metatarsal. Digital images of the dissected specimens were acquired and saved for measurement using in-house software. Means, standard deviations, and 95% confidence intervals (CIs) were calculated for all of the measurement parameters., Results: We found that the origin of the D-PL artery was located at a mean ± SD of 11.5 ± 3.9 mm (95% CI, 4.5-24.7 mm) distal to the first metatarsal base and 18.6% ± 6.5% (95% CI, 8.1%-43.4%) of length in reference to the proximal base. The average interrater reliability across all of the measurements was 0.945., Conclusions: This study helps clarify the anatomical location of the D-PL artery by providing parameters to aid the surgeon when performing procedures in the proximal first intermetatarsal space. Care must be taken when performing procedures in the region to avoid unintended vascular injury to the D-PL artery.

Antiphospholipid syndrome is an autoimmune disease characterized by vascular thrombosis involving both the arterial and venous systems that can lead to tissue ischemia or end-organ damage. Much of the literature describes various symptoms at initial presentation, but isolated tissue ischemia manifesting as a solitary blue toe is unusual. We discuss a case of a 23-year-old man who presented to the emergency department with a solitary blue fourth digit with minimal erythema and edema, who was suffering from exquisite pain. Following an extensive workup, the patient was diagnosed with antiphospholipid syndrome with thrombi of the vasculature in their lower extremity. With therapeutic anticoagulation, the patient's symptoms subsided and amputation of the digit was prevented.

Background: We sought to determine the prevalence of lower-extremity arterial calcification in a cohort of patients with diabetes and associated foot pathology receiving inpatient treatment at an urban US tertiary health-care system., Methods: The primary outcome measure was defined as either radiographic evidence of vessel calcification or noninvasive vascular testing that resulted in any reporting of vessel noncompressibility or an ankle-brachial index greater than 1.1. Radiographic evidence of vessel calcification was defined as radiodense calcification in the proximal first intermetatarsal space (deep plantar perforating artery), anterior ankle (anterior tibial artery), or posterior ankle (posterior tibial artery) on dorsoplantar and lateral foot projections., Results: Of the 367 individuals included in the study, 359 underwent radiography, with radiographic evidence of calcification in 192 (53.5%). Noninvasive vascular testing was performed on 265 participants, with any reporting of noncompressibility or an ankle-brachial index greater than 1.1 observed in 153 (57.7%). Ninety-four participants (25.6%) demonstrated evidence of arterial calcification on the radiographs and noninvasive testing, meaning that 251 participants (68.4%) demonstrated evidence of arterial calcification on at least one test, including 63.6% of participants classified as black/African American race, 65.4% as white race, and 78.3% as Hispanic/Latino ethnicity., Conclusions: The results of this investigation increase the body of knowledge with respect to the evaluation and treatment of diabetic foot disease and may lead to future investigations on the topic of lower-extremity arterial calcification.

Background: Spectral Doppler ultrasound examination of pedal arteries is one of the most frequently used noninvasive assessment methods by health-care professionals for the diagnosis and ongoing monitoring of people at risk for or living with peripheral arterial disease. The aim of this study was to determine the interrater reliability of the interpretation of spectral Doppler waveform analysis., Methods: An interrater reliability study was conducted among five experienced podiatric physicians at the University of Malta Research Laboratory (Msida, Malta). A researcher who was not a rater in this study randomly selected 229 printed spectral Doppler waveforms from a database held at the University of Malta. Each rater independently rated the qualitative spectral waveforms., Results: Interrater reliability of the spectral Doppler waveform interpretation was excellent among the five experienced podiatric physicians (α = 0.98). The intraclass correlation coefficient showed a high degree of correlation in waveform interpretation across raters ( P < .001)., Conclusions: This study demonstrates high interrater reliability in visual spectral Doppler interpretation among experienced clinicians. The current foot screening guidelines do not refer to spectral Doppler waveform analysis in their recommendations, which has been shown in studies to be an important modality for the diagnosis of peripheral arterial disease when ankle-brachial pressure indexes are falsely elevated in calcified arteries. If interpreted correctly, the information obtained can provide an indication of the presence of peripheral arterial disease and facilitate early management of this condition.

There are few documented reports of arteriovenous malformations in the extremities, and even fewer specifically in the foot. Most of the documented cases in the foot present surgical treatments, and there is limited information on the nonsurgical approach. A brief review of the surgical approach to arteriovenous malformations in the foot and hand is presented first, followed by a case report of the nonsurgical treatment of an arteriovenous malformation in the foot, which was initially diagnosed incorrectly.

Background: The purpose of this study was to investigate the origin of the arcuate artery., Methods: This cadaveric study was performed on 20 feet from ten cadavers of both sexes (age range, 61-94 years)., Results: The results indicate that the arcuate artery originated from the dorsalis pedis artery in 13 of 20 specimens (65%) and from the lateral tarsal artery in 6 of 20 (30%), and a variation in origination was noted in 1 of 20 specimens (5%)., Conclusions: This cadaveric study demonstrates that the arcuate artery can originate from the dorsalis pedis artery, the lateral tarsal artery, and one other variant. The dorsal arterial network of the lower extremity is important to consider during the overall clinical and surgical assessment of a patient.

Isolated venous aneurysms of the foot are rare. We report a case of venous aneurysm of the dorsal venous arch of the foot with an unusual traumatic etiology. This is a case report of a female patient with a gradually enlarging swelling on the dorsum of her foot located over the pressure area of her sandal straps. A clinical diagnosis of venous aneurysm was made, and she was treated with surgery. Most cases of superficial venous aneurysms only arouse medical interest, with few cosmetic complaints and no complications. This case is unique because it describes a traumatic venous aneurysm associated with repeated trauma caused by inappropriate footwear. All clinicians and allied health-care professionals involved in podiatric medicine should be aware of this clinical condition in the differential diagnosis of soft-tissue swellings in the feet.

Patients with diabetic neuropathy are subject to ulcerations that may be complicated by infection and gangrene, with subsequent risk of amputation. It is the job of the foot specialist to identify and manage these problems early to avoid the unfortunate complication of amputation regardless of the presenting condition of the patient's limb. We shed light on the hypothesis that suggests that infection and gangrene in a diabetic patient aggravate the degree of ischemia (microvascular, macrovascular, or both) already present enough to endanger the viability of the surrounding tissues unless urgent drainage with decompression and debridement of the necrotic sloughs is performed, with consequent reduction of tissue pressure and improvement in circulation to the area. We present cases with severe infections leading to gangrene and ischemia, which were improved following surgical management with consequent improvement in tissue viability. In these cases, we demonstrate that immediate treatment of the wound despite the delayed presentation of the patients resulted in limb salvage with much less soft-tissue loss than expected before treatment.

We report a pseudoaneurysm of the medial plantar artery that developed after percutaneous pinning for a Lisfranc fracture-dislocation in a 68-year-old male. Postembolization ultrasound and arteriography demonstrated successful ablation of the pseudoaneurysm following intra-arterial thrombin injection. Postoperative pulse volume recording and photoplethysmograph of the digits revealed excellent perfusion following ablation.

We report a case of a true plantar artery aneurysm in an adult. True aneurysms of the inframalleolar vessels are rare. The limited literature on the subject is reviewed, including differential diagnosis and suggested treatment.

Nitric oxide is an endogenous gas released by endothelial cells that induces vasodilatation and plays other important roles in the wound-healing process. Nitroglycerin preparations are liberators of nitric oxide. Podiatric physicians have used nitroglycerin paste and patches on patients in an attempt to increase perfusion to the foot. However, the drug's efficacy seems to be largely anecdotal. A prospective, randomized, placebo-controlled, double-blind study was conducted to investigate the efficacy of a nitroglycerin patch in locally increasing perfusion to the foot. Twenty-two healthy subjects were randomly assigned to either a drug group (nitroglycerin patch, 0.2 mg/h) or a placebo group (adhesive patch without active ingredient). The patch was applied to the plantar arch of the foot. Objective and subjective measures were then used to detect changes in perfusion to the foot after a 2-hour experimental period. The objective measures, cutaneous thermometry and photoplethysmography, found no significant measurable difference in perfusion to the foot between the drug and placebo groups (P > .05). A subjective questionnaire used to assess changes in temperature or sensation detected by the subject yielded similar results. Thus a nitroglycerin patch dose of 0.2 mg/h showed no measurable ability to increase perfusion to the foot. Further research is needed to validate the indications for this therapy.

Microvascular dysfunction is an important component of the pathologic processes that occur in diabetic foot disease. The endothelial abnormalities observed in patients with diabetes mellitus are poorly understood, and evidence suggests that endothelial dysfunction could be involved in the pathogenesis of diabetic macroangiopathy and microangiopathy. With the advent of insulin replacement in the early 1900s and increased efforts toward metabolic control of diabetes, long-term complications of this disease have become apparent. These late-term complications are primarily disorders of the vascular system. This article reviews the process of microvascular dysfunction and how it may relate to the pathogenesis of diabetic foot problems.

Vascular anomalies (birthmarks) commonly involve the feet and ankles. Little is known about these anomalies among practicing physicians. In this article, vascular anomalies are described, and detailed information is presented regarding appropriate diagnostic work-up and treatment strategies.

The purpose of this article is to present reference guidelines to assist clinicians when treating diabetic patients with foot wounds. Diabetic patients with limb-threatening foot ulcers often have multiple coexisting medical conditions that frequently become impediments to the resolution of foot wounds. Each foot wound is unique and its etiology is multifactorial; therefore, each foot wound should be managed differently. The treatment algorithm presented in this article is divided into three categories: Algorithm I describes the treatment of septic foot wounds, which may be considered true podiatric surgical emergencies; Algorithm II describes the treatment of ischemic foot ulcers or gangrene with or without underlying osteomyelitis; and Algorithm III describes the treatment of neuropathic foot ulcers with or without underlying osteomyelitis.

The purpose of this study was to quantify the occurrence of the arcuate artery. The arcuate artery was defined as that artery branching off the dorsalis pedis artery at or below the level of the tarsometatarsal joint, tending laterally across the bases of metatarsals 2 through 4, and supplying dorsal metatarsal arteries 2 through 4. The arcuate artery was present in 16.7% of 72 cadaver feet that were dissected and examined, suggesting that the arcuate artery is not the primary blood supply to dorsal metatarsal arteries 2 through 4 as is commonly described. It was determined that the lateral tarsal artery supplied dorsal metatarsal arteries 2 through 4 more frequently (47.2%) than the arcuate artery. The proximal perforating arteries as well as various combinations of all three sources were also found to contribute complete blood supply to dorsal metatarsal arteries 2 through 4. Therefore, a consistent dorsal arterial network, which differentiates throughout development, better explains the blood supply of the dorsal forefoot than the arcuate artery.

Acute arterial occlusion may be caused by an embolus, thrombosis, or trauma. Vascular diseases can involve complications not limited to vascular-related areas and may require a multidisciplinary approach to diagnosis and treatment. An overview of acute arterial occlusion is presented, as well as a case study of an atypical presentation of an arterial embolus of the lower extremity.

Numerous types of soft tissue surgical procedures can be performed using radiowave techniques. The Ellman International Surgitron is a versatile surgical instrument capable of making incisions, excisions, dessication, and coagulation. It converts electrical current into controlled energy in the radiowave frequency of the electromagnetic spectrum. Surgeons can then choose from three surgical currents based on the results they desire.

This study examined the occurrence rate of ten lower extremity anatomical variants occurring over a 6-year period from 1988 to 1994 in a sample range of 166 to 279 cadavers at the University of Osteopathic Medicine and Health Sciences. Literature review of these anomalies shows similar findings for all presented structures with the exception of two. The peroneus quartus muscle was found to be significantly less prevalent than previous studies have indicated. This difference may be attributed to the larger sample size used in this study or differences of interpretation of the definition of the peroneus quartus muscle. Additionally, the flexor digitorum brevis tendon to the fifth digit was found to be absent much more than Sarrafian reports in a total sample size of 926. The importance of these anatomical variants, both in surgery and while using advanced diagnostic imaging such as computed tomography and magnetic resonance imaging, should be realized by the podiatric physician. Awareness of these variants will decrease confusion when considering treatment options.

The history and prosthetic difficulties of a patient with an unusual Chopart amputation variant have been presented. Although it is possible for the Chopart amputee to walk with just a shoe and filler, this patient does best with a formal prosthesis. The Chopart amputation, which has been surgically stabilized with Achilles tendon lengthening to prevent equinus contractures, can be fitted successfully with a lightweight circumferential plastic or silicone prosthesis or more traditionally with a solid ankle foot orthosis with filler. This partial foot prosthesis is worn with a sturdy shoe with a rocker and solid ankle cushion heel or a well constructed running shoe. The Chopart amputee with equinus contractures must be fitted with a Chopart clamshell prosthesis or solid ankle patellar tendon bearing orthosis with filler and the above shoe prescription. Recent variants of the partial foot prosthesis including the Imler partial foot prosthesis, the Lange silicone prosthesis, and the ankle corset prosthesis were described.

The authors present an overview of post-traumatic foot compartment syndrome with an emphasis on the importance of relieving vascular compromise immediately. The incisional approach selected should not only effectively decompress the foot, but also allow for repair of concomitant osseous and soft tissue injury as well. Vascular considerations may dictate the course of simultaneous fracture management.

From 1982 to 1991, 17 patients underwent a lower extremity arterial bypass to salvage an ischemic transmetatarsal amputation at the New England Deaconess Hospital. Eleven patients were male, and 16 had diabetes for an average of 29 years. The mean age was 71 years. Twelve patients presented with an ischemic ulcer, one had rest pain, and four underwent bypass for failure to heal a transmetatarsal amputation. Twelve patients presented with findings of secondary infection. All 17 patients underwent successful lower extremity bypass procedures to a variety of outflow vessels. Thirteen bypasses were to infrapopliteal arteries, including four to the dorsalis pedis artery. There were no perioperative deaths and all patients were discharged with patent grafts and healing limbs. Actuarial graft patency of the 14 vein grafts was 90% at 2 years. Actuarial limb salvage for the entire group was 93% at 2 years. Thirteen of the 14 patients who maintained patent grafts and healed their transmetatarsal amputations were ambulatory at their last known follow-up examination. Ischemic complications of previously created transmetatarsal amputations are uncommon. However, limb salvage attempts by lower extremity arterial bypass have a high likelihood of success. Major amputation in these patients should not be done without having first undergone a comprehensive vascular evaluation.

Reflex sympathetic dystrophy is one of a complex of overlapping, sympathetically maintained pain syndromes which are usually initiated by a minor injury that resolves quickly but leaves behind a persistent pain that generalizes to much or all of the limb. The pathophysiology of reflex sympathetic dystrophy is reviewed to show that the pain is accompanied by cooling of the limb, beginning with the distal end and gradually progressing throughout. Thermography is shown to be an effective way to monitor near-surface blood flow in the limbs and to be sensitive to changes accompanying painful conditions. The usefulness of this technique for early detection of reflex sympathetic dystrophy is demonstrated and illustrated with several examples.

Diabetes mellitus is a disease in which the capillary basement membranes are substantially altered. This diabetic microangiopathy is characterized by a thickening of the basement membrane and changes in its permeability characteristic due to a disturbance in the production and distribution of its functional components. Glucose metabolism and insulin imbalance have been implicated in these basement membrane modifications. The authors describe normal capillary basement membrane architecture and then discuss how pathologic changes caused by diabetes mellitus are related to diabetic foot pathology.

Virtually no attention has been given in public education efforts to the potentially devastating effects of smoking on the lower extremities. An analysis of the epidemiologic studies that have been done by the Office of the Surgeon General and other clinical investigators has been presented, leading to the conclusion that cigarette smoking is the single most powerful risk factor for peripheral vascular disease. In the care of patients with peripheral vascular disease, the podiatric physician has an opportunity to be a participant in efforts to solve one of the nation's major public health problems.

A case report of a heretofore undocumented entity was presented. A brief literature review of associated lesions was included. The authors suggest that pedal varix may be a more common occurrence than previously documented.