The cost effective management of diabetic foot infections is a challenge to the Canadian health system. The objective of this study was to predict preoperatively diabetic foot patients who will fail a transmetatarsal amputation (TMA) and end in a costly and disabling below knee amputation (BKA) and hence perform a primary BKA in select patients.

Twenty-one patients failing TMA and revised to BKA within the first year were compared with a matched cohort of twenty-one successful TMA’s. The factors that were selected for comparison were: age at amputation, sex, smoking, type of DM, use of osetoset, presence of charcot fractures, previous contralateral surgery, previous debridement before TMA, debridement after TMA, dialysis, duration of ulcer prior to TMA, hemoglobin level at time of TMA, HbA1C, presence of heel ulcer, prior ipsilateral toe amputation, pulse status prior to TMA, vascular reconstruction and presence of unre-constructable vascular problem. Chi-square was done for group data, and ANOVA for numeric data.

Long-term control of blood glucose level (HbA1C) was found to be significant in predicting the success of TMA. Need of debridement after TMA was found to be a significant predictor of failure of TMA. There was a trend towards duration of ulcer prior to TMA and smoking being significant. All other variables, including vascular status or renal failure were not significantly different between the two groups.

As we have previously achieved a 75% success rate with TMAs in diabetics, we recommend a TMA as the first procedure in all diabetics with major forefoot infection or ulceration instead of a BKA. Obtaining good diabetic control in patients at risk for or requiring amputation for foot infection may prevent the TMA from failing and the subsequent need for BKA.

Patients were randomized between surgeon chosen pressure (control) and an automatically determined tourniquet pressure(study) group. Of the study group 94/106 (88.7%) had good to excellent fields compared to the control group where 100/132 (75.8%) had good to excellent fields (p< 0.05). In the study group, 5% failed to obtain an automatic pressure. Of the remainder, the average tourniquet pressure was 198 +/− 20.2 mHg compared to 259.6 +/− 4.4 mmHg for the control group (p< 0.0001). The automatic measurement of limb occlusion pressure resulted in better operative fields at a lower pressure.

To compare the quality of the operative field that results from using an automatic limb occlusion pressure measurement (study group) versus the tourniquet cuff pressure chosen by the surgeon (control group).

A module allowing rapid determination of tourniquet pressure from limb occlusion pressure was attached to a Zimmer ATS tourniquet machine. Using a coin toss, patients were randomized to the study or control groups. All patients underwent elective foot and ankle operations using a wide contoured tourniquet cuff.

Of two hundred and forty-three patients, one hundred and twelve were assigned to the study (automatic) group and one hundred and thirty-two to the control (surgeon selected) group. Six patients (5.4%) failed to obtain a limb occlusion pressure measurement due to anatomical constraints (toe or thigh shape) or equipment problems, leaving one hundred and six in the study group. The average measurement time to determine limb occlusion pressure was 20 +/− 6 seconds. The mean tourniquet pressure for the study group was 198.5 +/−20.2 mmHg, and 259.6 +/−4.4 mmHg for the control group (p< 0.0001). Of the study group 94 (88.7%) had good to excellent fields compared to the control group where one hundred (75.8%) had good to excellent fields (p< 0.05).

An automatically determined tourniquet pressure reduced the tourniquet pressure and improved the incidence of good to excellent operative fields compared to surgeon chosen pressures. The distribution curve of automatically determined tourniquet pressure indicates that 16% of patients will have a failed field if a standard pre-selected pressure of 250 mmHg is always chosen, in part explaining why pre-selected pressure may cause a poorer operative field.

Introduction and Aims: Stability training on a wobble board is a common method of rehabilitation from lower limb injuries. Injury prevention represents a relatively new application of this exercise but the neural mechanisms underlying its success remain unknown. We hypothesised that a three-week period of wobble board training will result in a decrease in the reflex response in the muscles crossing the left ankle joint.

Method: Fourteen moderately trained university students were randomly assigned to a control and training group. The training group underwent 10-, 20-minute sessions of wobble board training over three weeks. Pre- and post-testing was conducted on an ankle perturbation rig and involved applying various levels of plantar torque to a stable (1DOF) and unstable (3 DOF) footplate. Nine potentiometers measured the position of the footplate, a force transducer measured the applied torque and a dorsiflexing perturbation could be given. Electromyographic data was recorded from four superficial muscles crossing the ankle joint to determine stretch reflex profiles for each muscle. Data was displayed in bar graphs and a two-way ANOVA was used.

Results: No significant difference in the stretch reflex amplitude was noted between the training and control groups in medial gastrocnemius, lateral gastrocnemius, soleus or peroneus longus. A reduction in the amplitude of the stretch reflex in the experimental group was recorded after wobble board training in medial gastrocnemius (35% reduction), lateral gastrocnemius (25% reduction), soleus (15% reduction), and peroneus longus (40% reduction) during post-testing (significant at p < 0.05). There was no significant change in the amplitude of the stretch reflex in any of the four superficial muscles of the ankle joint in the control group between pre- and post-testing sessions.

Conclusion: Presynaptic inhibition represents the most likely neural mechanism responsible for the observed reduction in the stretch reflex amplitude after a brief period of wobble board training. This neuromuscular adaptation may offer dynamic protection prior to and during heel contact, helping to prevent inversion sprains.

Introduction and Aims: The cost-effective management of diabetic foot infections is a challenge to the Canadian health system. The objective of this study was to predict pre-operatively diabetic foot patients who will fail a transmetatarsal amputation (TMA) and end in a costly and disabling below knee amputation (BKA) and hence perform a primary BKA in select patients?

Method: Twenty-one patients failing TMA and revised to BKA within the first year were compared with a matched cohort of 21 successful TMAs. The factors that were selected for comparison were: age at amputation, sex, smoking, type of DM, use of osetoset, presence of charcot fractures, previous contralateral surgery, previous debridement before TMA, debridement after TMA, dialysis, duration of ulcer prior to TMA, hemoglobin level at time of TMA, HbA1C, presence of heel ulcer, prior ipsilateral toe amputation, pulse status prior to TMA, vascular reconstruction and presence of unreconstructable vascular problem. Chi-square was done for group data, and ANOVA for numeric data.

Results: Long-term control of blood glucose level (HbA1C) was found to be significant in predicting the success of TMA. Need of debridement after TMA was found to be a significant predictor of failure of TMA. There was a trend towards duration of ulcer prior to TMA and smoking being significant. All other variables, including vascular status or renal failure were not significantly different between the two groups.

Conclusion: As we have previously achieved a 75% success rate with TMAs in diabetics, we recommend a TMA as the first procedure in all diabetics with major forefoot infection or ulceration instead of a BKA. Obtaining good diabetic control in patients at risk for or requiring amputation for foot infection may prevent the TMA from failing and the subsequent need for BKA.

Introduction and Aims: The transmetatarsal amputation (TMA) is a limb-saving alternative to below knee amputation (BKA) for diabetic patients with forefoot infections. The purpose of this study was to retrospectively review the outcomes of diabetic patients who received a TMA for a non-healing ulcer of the forefoot with or without insertion of antibiotic beads into the surgical wound.

Method: Sixty-five diabetic patients were treated for forefoot ulcers by a single stage TMA and 49 of these patients had insertion of antibiotic pellets into the wound during surgery. A comprehensive chart review was conducted on all patients to gather information on patient age at amputation, sex, smoking, type of diabetes, use of osetoset, time to wound healing, debridement before and after TMA, duration of ulcer prior to TMA, hemoglobin level at time of TMA, HbA1C, presence of heel ulcer, prior ipsilateral toe amputation, pulse status prior to TMA, vascular reconstruction and presence of unreconstructable vascular problem. Outcome follow-up using validated functional outcome questionnaires was completed in 85% of TMA patients.

Results: Healing time was approximately 18 weeks in the antibiotic pellet group, with a BKA rate of 25%. This is in contrast to the literature values of healing times (not isolated to diabetes) for a TMA of 28 weeks and BKA rates of 34–40%. The antibiotic pellet group scored higher than average for bodily pain; social function; role emotional and mental health on the SF-36.

Conclusion: The reduction in time to wound healing and decrease in BKA rates suggests inserting antibiotic pellets into the surgical wound can improve the outcomes of TMAs for patients with non-healing diabetic ulcers of the forefoot. This new procedure could have a significant impact on the management of diabetic foot ulcers by offering an effective limb-saving alternative to the commonly used BKA procedure.