353In the neuropathic diabetic foot, high plantar pressure due to structural pathology is a critical causative factor leading to ulceration. 1 To date, a multitude of modalities have been described to externally reduce pressure. [2][3][4] Unfortunately, structural pathology and associated biomechanical abnormalities still exist after the off-loading device is removed. 5 Healing and preventing recidivism after conservative treatment is an ongoing struggle for the clinician treating the diabetic foot. Internal modulation of pressure, or surgical intervention, is sometimes considered to assist in healing and in reducing recurrence. [6][7][8][9][10][11][12] Areas on the forefoot that are prone to ulcerations coincide with biomechanical deformities. Some of the most common areas for ulceration include the plantar aspect of the fifth metatarsophalangeal joint, the hallux, and the first metatarsophalangeal joint. 11,13,14 Previous studies have evaluated various types of forefoot surgery, including various metatarsal procedures. Metatarsal head resections are often lumped into one category despite the fact that each metatarsal may play a very different functional role. Although ulcerations beneath the fifth metatarsal head are common, we are unaware of any reports in the literature that have evaluated the efficacy of isolated fifth metatarsal head resection to treat plantar ulcerations. Furthermore, we are unaware of any studies that have compared patients undergoing resection with similar patients not receiving surgical intervention. Therefore, the purpose of this case-control study was to evaluate outcomes of conservative treatment and surgical intervention for ulcers beneath the fifth metatarsal head. Efficacy of Fifth Metatarsal Head
Poorly fitting footwear has frequently been cited as an etiologic factor in the pathway to diabetic foot ulceration. However, we are unaware of any reports in the medical literature specifically measuring shoe size versus foot size in this high-risk population. We assessed the prevalence of poorly fitting footwear in individuals with and without diabetic foot ulceration. We evaluated the shoe size of 440 consecutive patients (94.1% male; mean +/- SD age, 67.2 +/- 12.5 years) presenting to an interdisciplinary teaching clinic. Of this population, 58.4% were diagnosed as having diabetes, and 6.8% had active diabetic foot ulceration. Only 25.5% of the patients were wearing appropriately sized shoes. Individuals with diabetic foot ulceration were 5.1 times more likely to have poorly fitting shoes than those without a wound (93.3% versus 73.2%; odds ratio [OR], 5.1; 95% confidence interval [CI], 1.2-21.9; P = .02). This association was also evident when assessing only the 32.3% of the total population with diabetes and loss of protective sensation (93.3% versus 75.0%; OR, 4.8; 95% CI, 1.1-20.9; P = .04). Poorly fitting shoes seem to be more prevalent in people with diabetic foot wounds than in those without wounds with or without peripheral neuropathy. This implies that appropriate meticulous screening for shoe-foot mismatches may be useful in reducing the risk of lower-extremity ulceration.
Gamma-irradiated human skin allograft consists of epidermis and dermis. Unlike bioengineered tissues which require cold storage and timely use once received from the manufacturer, gamma-irradiated human skin allograft can be stored for as long as 24 months at room temperature. This modality is applied in a fashion similar to that of bioengineered skin grafts. In this article, we present case studies with concise reviews of the available evidence to discuss the potential use of gamma-irradiated human skin allograft on wounds in the lower extremity.
Although verrucous hyperplasia may be common in high-risk insensitive feet, the literature contains little discussion on this topic. Treatment of verrucous hyperplasia is aimed primarily at reducing the causative forces. In cases that result from edema, external compression has proved to be adequate. If verrucous hyperplasia on the foot results from frictional forces, then shoe modifications with proper fit, accommodative liners, or fillers in the case of amputation are necessary. In recalcitrant cases, excision of the affected tissue with local soft-tissue or graft coverage has been successful. We describe a 56-year-old man with verrucous hyperplasia.
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