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Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_2 | Pages 21 - 21
1 Jan 2014
Ribee H Bhalla A Patel A Johnson B Leah J Bailey A Chapman C Bing A Hill S Laing P Makwana N Thomason K Marquis C
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Introduction:

Plantar Fasciitis is an extremely common and challenging problem that presents itself to foot and ankle practitioners. Many different treatment modalities are available for this condition, with little proven benefit. ECSWT was approved for use by the FDA for the treatment of chronic proximal plantar fasciitis in 2002 and NICE published guidance in 2009 recommending its use in refractory cases.

Methods:

Patients who diagnosed with ultrasound scan, and for whom other treatments were unsuccessful, underwent treatment on an outpatient basis. They had three 4–5 minute sessions, once a week. A Spectrum machine was used delivering 10 Hz waves in 500 preset pulses at 2 bar pressure, followed by 2000 preset pulses at 2.5 bar pressure. Pre- and 3 month post-treatment pain levels were recorded using a 10 point Visual Analogue Scale.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_21 | Pages 17 - 17
1 Apr 2013
Stevenson J Tong A Joshi Y Laing P Makwana N
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Introduction

Patients who present with atypical foot pain in a non specific sensory distribution may benefit from having nerve conduction studies (NCS). The aim of this study was to confirm whether NCS is a useful tool.

Methods

Between July 2005 and March 2011, 78 patients had NCS to investigate foot pain. The management following NCS was compared with the initial management plan.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 58 - 58
1 Sep 2012
Lever C Bing A Hill S Laing P Makwana N
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Introduction

Forefoot deformities are common in the rheumatoid population and lead to abnormal loading, plantar callosities and metatarsalgia. First MTP joint arthrodesis with lesser toe Stainsby procedures has become a popular method of reconstructing the rheumatoid forefoot but there is little data that reviews the clinical or biomechanical results of combining the two procedures.

Materials & Methods

A prospective observational study was set up to review 10 rheumatoid patients (20 feet) undergoing bilateral first MTP joint arthrodesis via a medial approach with Stainsby procedures to all lesser toes via curved incisions with resection of two thirds of the proximal phalanx, repositioning of plantar fat pad, extensor to flexor interposition and temporary stabilisation with k wires. Clinical scoring and dynamic pedobarograph pressure measurements were taken pre operatively and at one year post surgery.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXII | Pages 63 - 63
1 May 2012
Malhotra A Gallacher P Makwana N Laing P Hill S Bing A
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Background

Salvage procedures on the 1st MTPJ following failed arthroplasty, arthrodesis or hallux valgus surgery are difficult and complicated by bone loss. This results in shortened first ray and transfer metatarsalgia. We present our experience of using tri-cortical interposition grafts to manage this challenging problem.

Methods

Between 2002 and 2009 our department performed 21, 1st MTPJ arthrodeses using a tri-cortical iliac crest interposition graft. Surgical fixation was achieved with a compact foot plate. We performed a retrospective review from the medical notes and radiographs along with American Foot and Ankle scores which were collected prospectively.

We analysed the following parameters: time to radiological, requirement for further surgery, lengthening of 1st ray and any post operative complications.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 9 - 9
1 Jan 2011
Prasad V Whittaker J Makwana N Laing P Harrison P Richardson J Smith G Robinson E Kuiper J Roberts S
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We aimed to assess the long term results of patients who underwent Autologous Chondrocyte Implantation (ACI) for osteochondral lesions of the talus. Between 1998 and 2006, 28 patients underwent ACI for osteochondral lesions of the talus. All these patients were prospectively reviewed and assessed for long term results. Outcomes were assessed using satisfaction scores, Mazur ankle score and the AOFAS score, and Lysholm knee score for donor site morbidity.

The 28 patients who underwent the procedure included 18 males and 10 females. Follow up ranged from 1–9 years. In all patients, there was an improvement in the Mazur and AOFAS ankle scores and the Lysholm scores showed minimal donor site morbidity. Improvement in ankle score was independent of age and gender. The better the pre-op score the less the difference in post-op ankle scores. Patients were unlikely to benefit with pre-op ankle scores over 75.

The mid to long term results of ACIs in the treatment of localised, contained cartilage defects of the talus are encouraging and prove that it is a satisfactory treatment modality for symptomatic osteochondral lesions of the talus. Complications are limited. However, in view of limited number of patients, a multi-centre randomised controlled study is required for further assessment.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_II | Pages 362 - 362
1 May 2009
Kulshreshtha R Makwana N Laing P
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Introduction: The treatment of stage 3 hallux rigidus is controversial. Cheilectomy, fusion and total joint replacement have all been advocated. No consensus is agreed on the best optimal management. We present our results of a ceramic on ceramic MOJE metatarsophalangeal (MTP) joint replacement.

Aim: To find out the medium to long term outcome following MOJE MTP joint replacement.

Material and Methods: A sample of 95 patients was identified, between January 1999 to July 2006 from our data base who underwent MOJE metatarsophalangeal joint replacement. We divided these patients into three groups. First group had screw fit ceramic MOJE joint replacement; second group Mark 1 ceramic on ceramic press fit MOJE joint replacement and third group Mark 2. Indications of the surgery were osteoarthritis (primary or secondary), osteochondral defects, inflammatory arthropahty, previous infections and previously failed surgery. The outcome was analysed clinically, radiologically and functionally (using AOFAS and QALY scoring system).

Results: This study shows that the early results are promising but the medium and long term results show early radiological loosing. The significance of this is not known but based on these results we would advice caution on the use of these implants and further long term studies are required.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 226 - 226
1 Jul 2008
Winson I Laing P Makawana N Hepple S Harries W
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Introduction: Osteochondral lesions of the Talar Dome(OCD) remain a difficult therapeutic problem. One solution has been to consider using autologous chondrocyte implants. Though initial results of this technique are interesting the donor sites have always been in a normal knee. The presence of knee symptoms subsequently in some patients might be regarded as inevitable. This paper reports on the viabilty of donor material taken from the ankle.

Materials: Twenty four patients have been recruited to a pilot study of the viability of obtaining donated chondral material for Matrix Autologous Condrocyte Implantation. There were 14 men and 10 women. Their mean age was 37.3 years (range 17–63). All were complaining of presistent symptoms of pain and some insecurity following previous conventional surgery for treatment of a symptomatic OCD. All had MRI evidence of ongoing changes in keeping with persistent problems related to an OCD.

Methods: All patients had an initial arthroscopy of the affected ankle to reassess the state of the joint surface. Donor articular cartilage was obtained from one of three sites. The anterior part of the joint surface on the talar neck, from the medial articular facet of the talus or rarely from an area of articular cartilage on the edge of the lesion. The mean weight of the donor harvest was 133 micrograms(range51–450).

Results: All donated graft material produced viable implantable graft material between 5 and 7 weeks from harvest. Cell counts ranged from 12.3 million to 20 million with cell viabilities of 98% or above. These figures are directly comparable with the results obtained from the knee despite the original donor weights being less.

Conclusion: If this technique is contemplated the use of the affected ankle as a donor site is a viable alternative to the knee.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 227 - 228
1 Jul 2008
Malviya A Ashton B Kuiper J Makwana N Laing P
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Aim: Concerns have been expressed that DMARDS may interfere with bone healing. Previous studies give conflicting advise and no consensus exist in current practise especially with the newer DMARDS such as Leflunomide, Etanercept, and Infliximab. The aim of this study was to assess the in-vitro effect of DMARDS and cox-2 inhibitors on Osteoblast activity.

Method: Osteoblasts were cultured from femoral heads obtained from five young otherwise healthy patients undergoing total hip replacement The cells were cultured using techniques that have been previously described. A computer aided design of experiment was used as a model for setting up the experiment on samples obtained from the five patients. Normal therapeutic concentration of the various DMARDS was added alone and in combination to the media. The cell growth was estimated after two weeks using spectrophotometric technique using Roche Cell proliferation Kit. Multiple regression analysis was used to estimate the best predictor of the final result.

Results: The most significant factor (p< 0.001) in predicting the ultimate response was the patient themselves. Cox-2 inhibitor (Etoricoxib) was found to have the most consistent effect although always in combination with some other drug which varied amogst different patients. Etoricoxib in fact had a stimulatory effect (R=0.219) on the osteoblast growth.

Conclusion: Different patients respond differently to the drugs. None of the DMARDS tested inhibit osteoblast proliferation and differentiation in-vitro. If osteoblastic activity is considered to be the primary factor responsible for bone healing, then an inhibition should not result in patients who are on these drugs.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_III | Pages 412 - 412
1 Oct 2006
Malviya A Ashton B Kuiper J Makwana N Laing P
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Methotrexate and Cox-2 inhibitors are thought to interfere with bone healing. There have been controversial results published in the literature. The effect of newer antirheumatoids (Leflunomide, Etanercept, Infliximab) has not been studied. The aim of this study was to find the in-vitro effect of methotrexate, newer anti-rheumatoids, steroids and cox-2 inhibitors on Osteoblasts. Osteoblasts were cultured from femoral heads obtained from young otherwise healthy patients undergoing total hip replacement. The cells were cultured using techniques that have been previously described. A computer aided design of experiment was used as a model for setting up the experiment on samples obtained from five patients. Normal therapeutic concentration of the various antirheumatoids was added alone and in combination to the media. The cell growth was estimated after two weeks using spectrophotometric technique using Roche Cell proliferation Kit. Multiple regression analysis was done to estimate the best predictor of the final result. Patient was found to be the most significant factor (p< 0.001) in predicting the ultimate response. Cox-2 inhibitor (Etoricoxib) was found to be the next best predictor (p=0.043). Etoricoxib in fact had a stimulatory effect (R=0.219) on the osteoblast growth, which was accentuated in the presence of other agents that varied amongst different patients. Different patients respond differently to the drugs. None of the antirheumatoids inhibit osteoblast proliferation and differentiation in-vitro. If osteoblastic activity is considered to be the primary factor responsible for bone healing, then an inhibition should not result in patients who are on these drugs.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_I | Pages 26 - 26
1 Mar 2006
Malviya A Makwana N Laing P
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Aims: Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all structurally unstable joints require stabilisation. The aim of this study was to find out the role of EUA & Arthroscopy in the management of these problems.

Methods: We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation programme. All patients underwent an examination under anaesthesia with stress views to determine instability proceeded by arthroscopic examination of the ankle.

Results: Intra-articular bony lesion was seen in 41.8% of cases. 79.1% had fibrosis in the anterolateral gutter, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%. Arthroscopy demonstrated attenuation of the Anterior Talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14(32.5%). 23 patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction.

Conclusion: Arthroscopic assessment and treatment of intraarticular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 374 - 374
1 Sep 2005
Malviya A Makwana N Laing P
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Aims Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all structurally unstable joints require stabilisation. The aim of this study was to find out the role of examination under anaesthesia (EUA) and arthroscopy in the management of these problems.

Method We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation programme. All patients underwent an EUA with stress views to determine instability, proceeded by arthroscopic examination of the ankle.

Results Intra-articular bony lesion was seen in 41.8% of cases. Fibrosis in the anterolateral gutter was found in 79.1%, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%. Arthroscopy demonstrated attenuation of the anterior talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14 (32.5%). Twenty-three patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction. Three patients (6.9%) needed supplementary procedures for other associated problems.

Conclusion Arthroscopic assessment and treatment of intraarticular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 375 - 375
1 Sep 2005
Malviya A Makwana N Laing P
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Background The American Orthopaedic Foot and Ankle Society (AOFAS) score is one scoring system used to evaluate and monitor the progress of patients following foot and ankle surgery. The aim of this study was to evaluate the trend of AOFAS score over a period of time and correlate with quality-adjusted life-year (QALY) score, which is a valid and reliable scoring system.

Method All patients undergoing surgery under one foot and ankle surgeon from a period of January 2001 to July 2003 were reviewed. The pre-operative AOFAS and QALY scores and post-operative at 3, 6, 12 months and yearly were collected prospectively.

Results This study includes 205 surgical procedures in 159 patients. This included 40 patients with 41 feet in the ankle-hindfoot group; 15 patients with 15 feet in the midfoot group; 83 patients with 114 feet in the hallux group and 29 patients with 35 feet in the lesser toes group. The mean age of the patients was 51.9 yrs.

The general trend of the AOFAS graph shows a mean of 45.3 pre-operatively which rises to 72.4 at 3 month and a peak of 77.1 at 6 months only to fall to 75.7 at 12 months. This fall though seemingly marginal was significant (p< 0.001) Kendall’s rank correlation was used to correlate the AOFAS and QALY score. The 6-month AOFAS score was found to have higher correlation with the final QALY score (τ =0.423) than the 12-month AOFAS score (τ =0.236).

Conclusion AOFAS score correlates with subjective and functional results as determined by QALY score. The role of assessing AOFAS at 3 months does not seem to be justified. There is a deterioration in score at 12 months. Post-operative scores at 6 months should be sufficient to assess the outcome.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 289 - 289
1 Sep 2005
Malviya A Makwana N Laing P
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Introduction and Aims: Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all the structurally unstable joints require stabilisation.

Method: We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation program. All patients underwent an examination under anaesthesia with or without stress views to determine instability and this was preceded by arthroscopic examination of the ankle.

Results: Intra-articular lesion was seen in 41.8% of cases. 79.1% had fibrosis in the anterolateral gutter, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%.

Arthroscopy demonstrated attenuation of the Anterior Talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14 (32.5%). Twenty-three patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction. Three patients (6.9%) were lost to follow-up and three (6.9%) needed further procedures.

Conclusion: Arthroscopic assessment and treatment of intra-articular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 2 | Pages 179 - 183
1 Feb 2005
Whittaker J Smith G Makwana N Roberts S Harrison PE Laing P Richardson JB

Autologous chondrocyte implantation (ACI) has been used most commonly as a treatment for cartilage defects in the knee and there are few studies of its use in other joints. We describe ten patients with an osteochondral lesion of the talus who underwent ACI using cartilage taken from the knee and were prospectively reviewed with a mean follow-up of 23 months. In nine patients the satisfaction score was ‘pleased’ or ‘extremely pleased’, which was sustained at four years. The mean Mazur ankle score increased by 23 points at a mean follow-up of 23 months. The Lysholm knee score returned to the pre-operative level at one year in three patients, with the remaining seven showing a reduction of 15% at 12 months, suggesting donor-site morbidity. Nine patients underwent arthroscopic examination at one year and all were shown to have filled defects and stable cartilage. Biopsies taken from graft sites showed mostly fibrocartilage with some hyaline cartilage. The short-term results of ACI for osteochondral lesions of the talus are good despite some morbidity at the donor site.


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_III | Pages 267 - 267
1 Mar 2004
Tanaka H Laing P
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Aim: To identify factors which improved outcome following surgery. Method: Between 1994–2000, 28 patients with 30 displaced intra-articular fractures of the calcaneum were treated with open reduction and internal fix-ation at our hospital (mean, 45 years). We reviewed 20 patients within the Shropshire region over a 3.6 average follow-up period using 4 recognised hindfoot scoring systems. Patients were classified according to Sander’s classification with preoperative CT scans. The mechanism of injury and postoperative management was recorded. Clinical and radiographic assessments were also made. Results: Average follow up was 3.6 years. The overall surgical results were comparable of similar studies based upon the Maryland Foot Score (30% excellent, 35% good, 30% fair, 5% poor). 75% of our patients returned back to work within 6 months with an average of 5 months. 3 patients developed a superficial wound infection. Data analysis revealed that neither the age, energy of injury, time to surgery, time spent in plaster nor the time that physiotherapy was commenced had any significant bearing on functional outcome. However, early weightbearing at 6 weeks positively influenced outcome with all 4 scoring systems (p=0.01, 0.01, 0.02, 0.05) with a deterioration of outcome with delayed weightbearing. This was shown to be due to loss of sub-talar joint mobility (r=−0.74, p=0.001). Conclusions: We propose that good results can be obtained from internal fixation of intra-articular calcaneal fractures with a high probability of early return back to work. We recommend that patients be encouraged to weightbear at 6 weeks to optimise mobility at the subtalar joint.


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_III | Pages 245 - 246
1 Mar 2003
Whittaker J Makwana N Smith G Laing P Richardson J Ashton B Harrison P
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Patients with osteochondral lesions of the talus have traditionally been difficult to treat. Autologous chondrocyte implantion (ACI) may provide predictable repair through restoring an articular surface. We reviewed our results of Ankle ACI in eight ACI plus two ACI and mosaicplasty combined with an average age of 40 years (32 to 62) performed over four years.

The patients were assessed with a modified Mazur ankle score, patient satisfaction score and Lysholm knee score, pre- and post-operatively. Ankle arthroscopic assessment was performed in patients at 12 months post surgery. The average time to follow up was 24 months (range two to 52). The osteochondral lesions were post traumatic in seven cases, with seven lesions situated medially and three anterolaterally. The average size of the talar defects at surgery was 2.25cm (range 1 to 4 cm.)

Patient satisfaction scores in eight patients were either “extremely pleased” or “pleased” with the operation which was sustained in the patients at up to four years follow up. The Mazur scores increased by 23 points at mean 24 months follow up. Six patients with over 12 months follow up maintained a markedly improved ankle score. Patients were noted to rehabilitate twice as quickly as patients receiving ACI to the knee.

The Lysholm knee scores returned to the preoperative level in four patients, with the remaining six patients showing a reduced score (mean 12 points), suggesting there may be some donor site morbidity. Five had ankle arthroscopy at one year and were shown to have filled defects and stable cartilage. A biopsy taken from the graft site showed hyaline like cartilage and fibrocartilage to be present These early results suggest that ankle ACI is an appropriate treatment for large symptomatic osteochondral lesions in the talus.


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_II | Pages 128 - 128
1 Feb 2003
Tanaka H Laing P
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Introduction

Considerable controversy exists with regard to the surgical management of displaced intra-articular calcaneal fractures. Protagonists for internal fixation would suggest there is sufficient evidence to expect better functional outcomes with surgery. However, this is not conclusive.

Aim

To identify factors which improved outcome following surgery.

Method

Between 1994–2000, 28 patients with 30 displaced intra-articular fractures of the calcaneum were treated with open reduction and internal fixation at our hospital (mean age 45 years). We reviewed 20 patients within the Shropshire region using four recognised hindfoot scoring systems. Patients were classified according to Sanders’ classification with pre-operative CT scans. The mechanism of injury and post-operative management were recorded. Clinical and radiographic assessments were also made.

Results

Average follow-up was 3.6 years. The overall surgical results were comparable with similar studies based upon the Maryland Foot Score (30% excellent, 35% good, 30% fair, 5% poor). Seventy-five percent of our patients returned to work within six months at an average of five months. Three patients developed a superficial wound infection. Age, energy of injury, time to surgery, time spent in plaster and time to commencing physiotherapy had no significant bearing on functional outcome. However, early weightbearing at six weeks positively influenced outcome with all four scoring systems (p=0.01, 0.01, 0.02, 0.05) with a deterioration of outcome with delayed weightbearing. This was shown to be due to loss of subtalar joint mobility (r=−0.74, p=0.001).

Conclusions

We propose that good results can be obtained from internal fixation of intra-articular calcaneal fractures with a high probability of early return to work. We recommend that patients be encouraged to weightbear at 6 weeks to optimise mobility at the subtalar joint.


The Journal of Bone & Joint Surgery British Volume
Vol. 78-B, Issue 1 | Pages 51 - 55
1 Jan 1996
Crerand S Dolan M Laing P Bird M Smith ML Klenerman L

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.


The Journal of Bone & Joint Surgery British Volume
Vol. 75-B, Issue 6 | Pages 967 - 971
1 Nov 1993
Kumar P Laing P Klenerman L

In the 1950s Frederick Dwyer evolved the concept of treating resistant and relapsed clubfoot by osteotomy of the calcaneum. He published the results of his medial opening wedge procedure in 1963 with a mean follow-up of five years. We present the structured, radiographic and functional results at a mean elapsed time of 27 years of 36 feet (26 patients) all operated on by Dwyer. Their mean Laaveg and Ponseti (1980) grading was 83.7%. In 94% the heel was in neutral or valgus and 86% of the feet were plantigrade. A good range of movement was present in the ankle and subtalar joints in 83%.


The Journal of Bone & Joint Surgery British Volume
Vol. 74-B, Issue 1 | Pages 133 - 136
1 Jan 1992
Laing P Cogley D Klenerman L

Ulceration of the insensitive foot continues to cause great morbidity in diabetic patients. We treated 46 patients with neuropathic ulceration by applying total contact casts. Most neuropathic ulcers healed within six weeks but ischaemic ulcers did not heal. One patient developed gangrene and required partial amputation of the foot.