Abstract. The aim is to describe the safety and efficacy of TAL in out-patient clinics when managing diabetic forefoot ulcers. Patients and Methods. Consecutive patients, who underwent TAL and had minimum 12m follow-up were analysed. Forceful dorsiflexion of ankle was avoided and patients were encouraged to walk in Total contact cast for 6-weeks and further 4-weeks in walking boot. Results. 142 feet in 126 patients underwent this procedure and 86 feet had minimum follow-up of 12m. None had wound related problems. Complete transection of the tendon was noted in 3 patients and one-patient developed callosity under the heel. Ulcers healed in 82 feet (96%) within 10 weeks however in 12 feet (10%), the ulcer recurred or failed to heal. MRI showed plantar flexed metatarsals with joint subluxation. The ulcer in this subgroup healed following proximal dorsal closing wedge osteotomy. Conclusion. Tightness of gastroc-soleus-Achilles complex and subluxed MTP joint from soft tissue changes due to motor neuropathy result in increased forefoot plantar pressures. A 2-stage approach as described result in long-term healing of forefoot ulcers, and in 96% of patients, the ulcer healed following TAL alone. TAL is a safe and effective out-patient procedure with improved patient satisfaction outcomes

Aim

Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressures. Progressive hindfoot equinus from contraction of gastrocnemius-soleus-tendo-Achilles complex and progressive plantar flexed metatarsal heads secondary to claw toe deformity results callus at the metatarsal heads which break down to ulceration. The aim is to describe 2-stage treatment pathway for managing these ulcers.

Aim

To describe a 2-stage treatment pathway for managing neuropathic forefoot ulcers and the safety and efficacy of percutaneous tendo-Achilles lengthening (TAL) in out-patient clinics.

Percutaneous flexor tenotomy involves cutting the flexor digitorum tendons to correct claw toe deformity to treat apical pressure areas and prevent subsequent infection in patients with peripheral neuropathy. Performing this under ultrasound guidance provides reassurance of complete release of the tendon and increases procedural safety.

This study is a retrospective case series evaluating the effectiveness, safety, and patient satisfaction of performing percutaneous ultrasound-guided flexor tenotomy in an outpatient setting. People with loss of protective sensation, a digital flexion deformity, and an apical toe ulcer or pre-ulcerative lesion who presented to our institution between December 2019 and June 2022 were included in this study. Participants were followed-up at a minimum of 3 months. Time to ulcer healing, re-ulceration rate, patient satisfaction, and complications were recorded. An Australian cost analysis was performed comparing this procedure performed in rooms versus theatres.

There were 28 ulcers and 41 pre-ulcerative lesions. A total of 69 tenotomy procedures were performed on 38 patients across 52 episodes of care. The mean time to ulcer healing was 22.5 +/- 6.4 days. There were 2 cases of re-ulceration. 1 patient sustained a transfer lesion. There were four toes that went onto require amputation, all in the setting of pre-existing osteomyelitis. 94% of patients strongly agreed that they were satisfied with the outcome of the procedure. Costs saved were estimated to be $1426.

Flexor tenotomy is a minimally invasive procedure that can be performed in the outpatient setting, and therefore without delay to treatment, reducing risk of ulcer progression and need for subsequent amputation. This is the first study to report on flexor tenotomy under ultrasound-guidance.

Ultrasound-guided percutaneous flexor tenotomy is safe and effective, with high patient satisfaction and low recurrence rates. This performance in the outpatient setting ensures significant time and cost savings for both the practitioner and patient.

Aims

Local antibiotics are used in the surgical management of foot infection in diabetic patients. This systematic review analyzes the available evidence of the use of local antibiotic delivery systems as an adjunct to surgery.

Charcot arthropathy is a non-infective destructive process manifesting as dislocation, periarticular fracture or a combination of both, in patients with peripheral neuropathy

The classification and staging of charcot arthropathy assists us in decision making and appropriate management of these patients. Clinical presentation and diagnosis will be discussed as well as management techniques for the different stages of arthropathy. Neuropathic ulcer management, including new ideas, will be briefly covered.

We reviewed all patients with a clinically infected foot ulcer attending a specialised neuropathic foot clinic. Neuropathy was confirmed by the inability to feel a 5.07 Semmes-Weinstein hair, areflexia and impaired vibration sense, as measured by a biothesiometer.

Of 40 patients who attended the clinic over a two-year period, six with ischaemic ulcers were excluded. The remaining 34 had plain radiographs of the foot followed by a ^99mTc-MDP bone scan. If the latter was positive, an ¹¹¹In-labelled WBC scan was performed with planar and/or tomographic dual-isotope studies where appropriate. Bone and WBC scans were performed in 31 patients. In ten, isotope imaging showed infection localised to the soft tissues only and conservative treatment was successful in them all. Eighteen patients were treated surgically with excision of the involved bone, which was sent for culture and histological examination.

Dual-isotope scans had a sensitivity of 93% and a specificity of 83%. ^99mTc-MDP bone scans with the appropriate ¹¹¹In-labelled WBC scans can reliably determine the site and extent of osteomyelitis in the neuropathic diabetic foot.

Aim: Analyse the impact of definitive corrective surgery on the course of chronic non-healing diabetic foot ulcers.

Method: The specialist diabetic foot clinic at the Kings College Hospital had six thousand attendees in the period Sept 2007 to Sept 2008. We retrospectively reviewed a group of patients with Neuropathic chronic non-healing diabetic foot ulcers who were referred for surgical correction. They underwent a minimum of twelve months of conservative treatment including pressure-relieving methods such as total contact casts. They were all classified as B3 according to the Texas diabetic wound classification at the time of referral; infection was controlled with antibiotics before correction. Seven ulcers were located over the forefoot, and six over the hind foot. Thirteen patients had definitive corrective surgery. Five using Taylor spatial frames and eight had corrective osteotomies and fusions. The period of ulcer prior to surgery together with the time to healing of the ulcer postoperatively was calculated in each case.

Results: There were ten Males and three Females, with a mean age of 57.4 years ranging from 37 to 75 years. The Mean period of ulceration prior to surgical intervention was 4.2 years. Nine ulcers healed in a mean duration of three months with a maximum of six months. One ulcer is improving and three have failed to heal so far.

Conclusion: Definitive corrective surgery on chronic non-healing diabetic foot ulcers is an important tool to reduce the healing time.

Background and Aims: Patients with a hip fracture often have a poor nutritional status which is associated with increased risk of complications, morbidity and mortality. The aim of this study was to investigate the effects of an improved care intervention in relation to nutritional status and pressure ulcers. An intervention of best practices for patients with hip fracture was introduced, using the available resources effectively and efficiently with a not too complicated or expensive intervention.

Methods: A quasi-experimental study of 478 patients consecutively included between April 1st 2003 and March 31st 2004. A new evidence based clinical pathway was introduced on October 1st 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article.

Results: The total number of patients with a hospital acquired pressure ulcer was in the intervention group, 19 patients, and in the control group 39 patients (p=0.007). No patient younger than 65 years developed a pressure ulcer. There were no statistical significant differences between the groups with respect to blood biochemical variables at inclusion. Patients in the control group had higher arm muscle circumference (AMC) (p=0.05), calf circumference (CC) (p=0.038) and body mass index (BMI) (p=0.043) values. Abnormal anthropometrical tests of BMI, triceps skin fold (TSF) < 10th percentile and AMC < 10th percentile were found in 12 patients in the control group and in 4 patients in the intervention group. None of the four patients in the intervention group developed pressure ulcers. However two of the 12patients in the control group were affected.

Conclusions: It is possible to reduce the development of hospital acquired pressure ulcers among elderly patients with a hip fracture even though they have poor prefracture nutritional status. The results in this study indicate the value of the new clinical pathway, as the number of patients who have developed pressure ulcers during their stay in hospital has been reduced by 50%.

The purpose of this study was to retrospectively review the outcomes of percutaneous flexor tenotomies of diabetic claw toes with ulcers or pending ulcers.

A retrospective chart review between January 1999 and June 2005 was performed to identify those patients that had undergone a percutaneous flexor tenotomy for diabetic claw toe deformities. Thirty-four toes in fourteen patients were identified. Twenty-four toes had ulcerations at the terminal aspect and three of these had radiographic evidence of osteomyelitis of the terminal phalange. All patients had palpable pulses and good capillary refill. A percutaneous flexor tenotomy was performed in an outpatient clinic on all toes, patients with a rigid flexor contracture at the proximal interphalangeal (PIP) joint underwent an osteoclaysis to correct a portion of the deformity.

The average follow-up was thrirteen months, all patients with ulcers healed and there were no significant complications. Those without osteomyelitis healed within an average of three weeks and those with osteomyelitis healed within an average of eight weeks.

A Percutaneous flexor tenotomy with osteoclasis of the PIP joint performed in an outpatient clinic is a safe and effective method to off-load the tip of the toe such that ulcer healing can occur. The presence of osteomyelitis is not a contraindication for this technique; however, an increased healing time can be expected.

Venous ulceration is a chronic disabling complication of deep vein thrombosis. The aim of this study is to estimate the incidence of venous leg ulcers five years or more after total hip replacement, and to investigate some of the clinical features associated with the development of the ulcers. A postal survey of all the patients who had received a total hip replacement 5–12 years previously was done.

Replies from 816 patients yielded 66 patients [8.1.%] with a history of leg ulcers. Prevalence of active ulceration was 2.6%. 43 patients [5.3%] reported ulceration since their hip replacement. A clinical review determined that 31 [3.8%] of these were true venous ulcers. The ulcers occurred with a higher frequency on the operated side, appearing at a mean of 5.8 years after the first lower limb arthroplasty [range 18 months to 12 years]. An average of 1.9 arthroplasties [primary and revision] were carried out prior to the ulcers appearing [max 5, min 1]. Our findings suggest that although the overall incidence rate of leg ulcers was similar to that reported in the general population, we found a tendency for the ulcers to occur on the operated rather than the unoperated leg.

Due to an ageing population the numbers of patients with hip fractures are increasing. They often suffer from concomitant diseases and are therefore prone to be affected by complications such as pressure ulcers. The prevention of pressure ulcers among patients with a hip fracture is crucial. The aim of this study was to improve the quality of care and patient safety in patients with a hip fracture. A new evidence based clinical pathway was introduced to prevent hospital acquired pressure ulcers. Furthermore the purpose was to bring the staff’s attention to pressure ulcer prevention and to facilitate changes in clinical practice to improve quality of care and patient safety. A total of 478 patients with a hip fracture were consecutively included between April 1st 2003 and March 31 st 2004. The new evidence based clinical pathway was introduced on October 1st 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article. In the intervention group hospital acquired pressure ulcers decreased by 50% (p< 0.007). It is possible to reduce the development

Background

Diabetes is bad, common and diabetic foot ulcers (DFU) once established lead to high rates of amputation. In Nottingham our standard management for infected diabetic foot ulcers is surgical debridement, microbiological sampling, packing with gentamicin beads and targeted antibiotic therapy. Recently we have switched to packing with Stimulan, which is a purified synthetic calcium sulphate compound that can be mixed with patient appropriate antibiotics, is biodegradable and delivers better elution characteristics compared to gentamicin beads.

Introduction: Historically, off-loading forefoot neuropathic ulcers with a total contact cast has been an effective treatment method. However, large neuropathic ulcers located on the plantar aspect of the heel or midfoot have been resistant to the off-loading with total contact casting. Therefore, it is not uncommon for these ulcers to persist for several years leading to eventual infection and/or amputation.

Objective: To assesses a new and effective off-loading mode of treatment for hindfoot and midfoot ulcers. The device is composed of a fiberglass cast with a metal stirrup and a window around the ulcer.

Research, Design and Methods: A retrospective study of 14 diabetic and non-diabetic patients was performed. All had a single chronic planter hindfoot or midfoot neuropathic ulcer that failed to heal via the conventional methods. A fiberglass total contact cast with a metal stirrup was applied. A window was made over the ulcer so as to continue with daily ulcer care. The cast was changed every other week.

Results: The average duration of ulcer prior to application of the metal stirrup was 26 ± 13.2 months (range 7 to 52 months). The ulcer completely healed in 12 of the 14 patients (86%) treated. The mean time for healing was 10.8 weeks for the midfoot ulcers and 12.3 weeks for the heel ulcers. Complications developed in 4 patients: 3 developed superficial wounds and 1 developed a full thickness wound. In 3 of these 4 patients, local wound care was initiated and the Stirrup cast was continued to complete healing of the primary ulcer.

Conclusion: The fiberglass cast with a metal stirrup is an effective off-loading device for midfoot and hindfoot ulcers. It is not removable and does not depend on patient’s compliance. The window around the ulcer allows for daily wound care, drainage of secretions and the use of VAC treatment. The complication rate is comparable to that of Total Contact Casting.

Purpose: Since 1996, our multidisciplinary medicosurgical team has decided to propose orthopaedic treatment for diabetic perforating ulcers with osteitis, cellulitis, or necrosis (“cooling down” the acute infected ulcers before programmed surgery) rather than conservative treatment with prolonged antibiotic therapy. We present here a prospective study of 44 cases of diabetic perforating ulcers.

Material and methods: Thirty-two diabetic patients underwent surgery: 77% males, mean age 65.2±8.6 year (range 43–86 years), 87% type 2 diabetes, 52% with a history of perforating ulcers, 45% with minor amputations, and 14% with history of vascular surgery. The lesions—perforating ulcer with osteitis (n=34), vascular necrosis of the toes (n=2), “acute feet” with cellulitis (n=8)—had progressed over 13.2±15.1 weeks. The preoperative work-up included: bacteriology samples 89%; standard x-rays of the foot 100% (osteitis 84%); duplex Doppler of the lower limb arteries 77% (tibial arteriopathy 87%); double bone scintigraphy 34% (osteitis 93%); TcPO2 (40±14mmHg); arteriography 27%; vascular surgery consultation 18%. Before surgery, 77% of the patients were hospitalised in an endocrinology unit (13±3 days) and 88% were on an antibiotic regimen for 26±18 days (50% i.v.).

Orthopaedic surgery (without tourniquet, anaesthesia block, mean duration 53±24 min) involved: partial resection of a toe 23%; amputation of a ray 36% (first ray one, second ray five, third ray one, fourth ray two, fifth ray six); transmetatarsal amputation 32%; resection of the metatarsal heads 4%; calcanectomy (n=1); below knee amputation (n=1); and systematic and multiple samples for bacteriology (deep soft tissue and bone tissue) and for pathology.

Results: Mean hospital stay in the surgery unit was 4±1 days, followed by 18±10 days in the endocrinology unit with antibiotics (oral for 88%) for 34±22 days, 91% of the lesions healed within 33±18 days; four required repeated procedures (two transmetatarsal amputations, one amputation of the first ray, one lower limb amputation); three lesions relapsed.

The peroperative bacteriology samples of the deep soft tissue and bone tissue demonstrated, in comparison with the preoperative samples, that antibiotics had sterilised only 14% of the lesions; with discordant comparison in 40%, partial concordance in 24%, and total concordance in 24%. For the diagnosis of osteitis (confirmed by histology of peroperative bone samples), the x-ray interpretations were largely confirmed (79% exact diagnosis, 87% sensitivity, false positives 12%), as were the bone scintigrams with labelled polymorphonuclears (exact diagnosis 93%, sensitivity 93%, false positives 7%).

Conclusion: This prospective study demonstrated the advantages of programmed surgery over emergency surgery, including for “acute feet”: limited resection, primary suture, rapid wound healing, short antibiotic treatment. It raises some questions concerning the validity of non-surgical bacteriological samples for perforating ulcers, even when performed under rigorous conditions (unique strain isolated from 76% of the samples) and on the possibility of antibiotic pressure on bacterial selection.

Introduction. Diabetic foot disease is a major public health problem with an annual NHS expenditure in excess of £1 billion. Infection increases risk of major amputation fivefold. Due to the polymicrobial nature of diabetic foot infections, it is often difficult to isolate the correct organism with conventional culture techniques, to deliver appropriate narrow spectrum antibiotics. Rapid DNA-based technology using multi-channel arrays presents a quicker alternative and has previously been used effectively in intensive care and respiratory medicine. Methods. We gained institutional and Local Ethics Committee approval for a prospective cohort study of patients with clinically infected diabetic foot wounds. They all had deep tissue samples taken in clinic processed with conventional culture and real-time PCR TaqMan array. Results. 50 samples were taken from 39 patients between October 2020 and March 2022. 84% of patient were male, 88% had type 2 diabetes. The ulcers were of variable chronicity prior to sampling (range 1–113 weeks) and mean HbA1c was 67.2mmol/mol. Ulcers were on the heel (3), midfoot (6) and forefoot (41). Minimum follow up was 3 months. 6 ulcers healed, 24 patients were admitted due to foot disease, there were 2 major amputations and 4 deaths. TaqMan array results were available a mean of 4.3 days earlier than culture results. 9 patients had negative conventional cultures and 8 were negative onarray testing. 17 patients had the same organisms detected on culture and array. 16 of these 17 had additional organisms detected by array. The most frequent organisms detected on array that were not detected by culture were Staphylococcus spp., Enterobacter, Pseudomonas and fungi. Conclusion. TaqMan array shows promise in detecting infecting organisms from diabetic foot wounds and providing earlier results than standard culture, which may enable appropriate and timely antibiotic therapy

Background:. In 1931, Gaenslen reported treatment of haematogenous calcaneal osteomyelitis through an incision on the sole of the heel, without the use of antibiotics. We have modified his approach to allow shorter healing times and early mobilisation in a modern series of cases. Method:. Sixteen patients with Cierny-Mader Stage IIIB chronic osteomyelitis were treated with split-heel incision, calcaneal osteotomy, radical excision, local antibiotics, direct skin closure and parenteral antibiotics. 4 patients had diabetic foot infection with neuropathy, 5 had infection after open injuries, 4 had haematogenous osteomyelitis and 3 had Grade 4 pressure ulceration with bone involvement. 14 had sinuses/ulcers and 12 had undergone previous surgery. Primary outcomes were eradication of infection, time to sinus/ulcer healing, mobility and need for modified shoes. Results:. Mean hospital stay was 19.2 days (7–44). 14 patients had no recurrence of infection at final follow-up (minimum 12 months; mean 53 months). Ulcers healed between 4 and 15 weeks. 2 patients with recurrent infection required amputation. Of the 14 salvaged patients, 10 mobilised unaided. 9 required modified shoes. Conclusion:. This protocol gave effective control of infection, ulcer healing and mobilisation within an acceptable time, but amputation remains a risk

Aims

The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population.

Antibiotic resistance represents a threat to human health. It has been suggested that by 2050, antibiotic-resistant infections could cause ten million deaths each year. In orthopaedics, many patients undergoing surgery suffer from complications resulting from implant-associated infection. In these circumstances secondary surgery is usually required and chronic and/or relapsing disease may ensue. The development of effective treatments for antibiotic-resistant infections is needed. Recent evidence shows that bacteriophage (phages; viruses that infect bacteria) therapy may represent a viable and successful solution. In this review, a brief description of bone and joint infection and the nature of bacteriophages is presented, as well as a summary of our current knowledge on the use of bacteriophages in the treatment of bacterial infections. We present contemporary published in vitro and in vivo data as well as data from clinical trials, as they relate to bone and joint infections. We discuss the potential use of bacteriophage therapy in orthopaedic infections. This area of research is beginning to reveal successful results, but mostly in nonorthopaedic fields. We believe that bacteriophage therapy has potential therapeutic value for implant-associated infections in orthopaedics.

Cite this article: Bone Joint J 2021;103-B(2):234–244.