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Background: We sought to identify the age-adjusted incidence of lower-extremity amputation (LEA) in Mexican Americans, blacks, and non-Hispanic whites with diabetes in south Texas., Methods: We summarized medical records for hospitalizations for LEAs for 1993 in six metropolitan statistical areas in south Texas., Results: Age-adjusted incidence per 10,000 patients with diabetes was 146.59 in blacks, 60.68 in non-Hispanic whites, and 94.08 in Mexican Americans. Of the patients, 47% of amputees had a history of amputation, and 17.7% were hospitalized more than once during 1993. Mexican Americans had more diabetes-related amputations (85.9%) than blacks (74.7%) or non-Hispanic whites (56.3%)., Conclusions: This study is the first to identify the incidence of diabetes-related lower-extremity amputations in minorities using primary data. Minorities had both a higher incidence and proportion of diabetes-related, LEAs compared with non-Hispanic whites. Public health initiatives and national strategies, such as Healthy People 2000 and 2010, need to specifically focus on high-risk populations and high-risk geographic areas to decrease the frequency of amputation and reamputation.

The objective of this study was to identify the direct cost and length of hospitalization of diabetes-related lower extremity amputations among Hispanics, African Americans, non-Hispanic whites, and Asians. The authors used a database from the office of Statewide Planning and Development in California that identified all hospitalizations for lower extremity amputations in the state in 1991. Amputation level was defined by the ICD-9-CM codes 84.11-84.18. The total hospital charges for diabetes-related lower extremity amputations for the state of California in 1991 was $141 million. The mean hospital charge (HC) per patient with all ethnic groups combined was $27,930; and the mean length of stay (LOS) was 15.9 days. African Americans had significantly higher mean charges ($32,383) and longer stays (17.3 days) compared to all other ethnic groups (p < .05). Toe-level amputations had lower HC (p < .05) and LOS (p < .01) than other amputation levels for all race groups. One-quarter of the population received multiple amputations during their hospital stay. These patients incurred significantly higher hospital charges ($44,731) and stayed in the hospital longer (23.4 days) than those receiving only a single amputation. There was a considerable variation in the HC and LOS among ethnic groups by level of amputation. The direct charges reported in this study suggest considerably higher overall direct costs than have been previously reported in the medical literature. The greater burden of disease experienced by African Americans is probably related to their higher amputation cost and longer hospitalization.

The F-Scan system was used to measure peak plantar pressures in 11 diabetics each with a unilateral great toe amputation and an intact contralateral extremity (nonamputated), to evaluate the effectiveness of five footwear-insole strategies: 1) extra-depth shoes without an insole, 2) extra-depth shoes with a Plastizote insole, 3) extra-depth shoes with a Plastizote insole and a metatarsal pad, 4) extra-depth shoes with a Plastizote insole and a medial longitudinal arch pad, and 5) extra-depth shoes with a Plastizote insole and a combination of metatarsal pad and arch pad. When we compared extra-depth shoes with and without insoles, peak pressures were significantly reduced with insoles under the first metatarsal, the lesser metatarsals, and the heel (p < 0.001) in feet with and without an amputation, as well as under the great toe on the contralateral foot (nonamputated, p < 0.001), but not under the lesser toes (giant toe, p = 0.088; nonamputated, p = 0.763). There was no significant difference between the different insole modifications.

The aim of this study was to identify the age adjusted and level specific mortality rate in African-Americans, Hispanics and non-Hispanic whites (NHW) during the perioperative period following a lower extremity amputation. We identified amputation data obtained from the Office of Statewide Planning and Development in California for 1991 from ICD-9-CM codes 84.11-84.18 and diabetes mellitus from any 250 related code. Amputations were categorized as foot (84.11-84.12), leg (84.13-84.16) or thigh (84.17-84.18). Death was coded under discharge status. Age adjusted and level specific mortality rates per 1000 amputees were calculated for each race/ethnic group. The age adjusted mortality was highest for African-Americans (41.39) compared to Hispanics (19.69) and NHW's (34.98). Mortality was consistently more frequent for proximal amputations. We conclude that mortality rates for persons with diabetes hospitalized for an amputation varied by race, gender and level of amputation. Higher prevalence or severity of risk factors may explain the excess mortality observed in African-Americans.

Viscoelastic inserts are commonly used as artificial shock absorbers to prevent neuropathic foot ulcerations by decreasing pressure on the sole of the foot. Unfortunately, there is little scientific information available to guide physicians in the selection of appropriate insole materials. Therefore, a novel methodology was developed to form a rational platform for biomechanical characterizations of insole material durability, which consisted of in vivo gait analysis and in vitro bioengineering measurements. Results show significant differences in the compressive stiffness of the tested insoles and the rate of change over time in both compressive stiffness and peak pressures measured. Good correlations were found between pressure-time integral and Young's modulus (r2 = 0.93), and total energy applied and Young's modulus (r2 = 0.87).

The purpose of this report is to compare plantar pressures between custom healing sandals and postoperative shoes using unmodified prescription shoe gear as a control. Using a repeat measures design, we recorded the plantar forefoot pressures of eight patients classified as diabetic foot category 1 (neuropathy, no significant deformity, no history of ulceration) with each ambulating in three devices: 1) unmodified prescription shoe gear, 2) postoperative shoe gear, and 3) a custom-fabricated healing sandal. Each subject served as his or her own control. The healing sandal significantly reduced plantar forefoot pressure in all areas of the forefoot except the fifth metatarsal head. The postoperative shoe did not significantly reduce pressure at any site in the forefoot when compared with unmodified prescription shoe gear.

Objective: To identify the age-adjusted and level-specific incidence of amputations associated with diabetes in Hispanics, African-Americans, and non-Hispanic whites., Research Design and Methods: We used a database from the Office of Statewide Planning and Development in California that identified all hospitalizations for lower-extremity amputations in the state in 1991. Amputation level was defined by ICD-9-CM codes 84.11-84.18 and were categorized as toe, foot, leg, and thigh amputations., Results: The age-adjusted incidence of diabetes-related amputation per 10,000 persons with diabetes in 1991 was 95.25 in African-Americans, 55.98 in non-Hispanic whites, and 44.43 in Hispanics. Hispanics had a higher proportion of amputations (82.7%) associated with diabetes than did African-Americans (61.6%) or non-Hispanic whites (56.8%) (P < 0.001). African-Americans had the highest age-adjusted incidence rate for each level in people with and without diabetes. African-Americans underwent more proximal amputations compared with non-Hispanic whites and Hispanics (P < 0.001). Diabetes-related amputations were 1.72 and 2.17 times more likely in African-Americans compared with non-Hispanic whites and Hispanics, respectively., Conclusions: Hispanics had proportionally more amputations associated with diabetes than did African-Americans or non-Hispanic whites. A significant excess incidence of both diabetes- and non-diabetes-related amputations and proportionally more proximal amputations were identified in African-Americans compared with Hispanics and non-Hispanic whites. A possible explanation could be the higher prevalence of peripheral vascular disease in African-Americans. Public health initiatives, which have been demonstrated to reduce the incidence of diabetes-related lower-extremity amputations, should be implemented, and additional work should focus on minority groups.

The structural characteristics of 4.0-mm stainless steel screws compared with 4.0-mm poly-L-lactic acid absorbable screws and 2.0-mm stainless steel Steinmann pins compared with 2.0-mm poly-L-lactic acid absorbable pins in oblique closing base wedge osteotomies of the first metatarsal were evaluated. The authors performed oblique closing base wedge using an osteotomy guide in six matched pairs of fresh frozen first metatarsal bones. Fixation was achieved with either a 4.0-mm stainless steel screw or poly-L-lactic acid absorbable screw. An additional five pairs of matched specimens were used to compare 2.0-mm stainless steel and poly-L-lactic acid absorbable pins with the same approach. Specimens were loaded to failure with the Bionix Material Testing System at a constant rate of 0.166 mm/sec. A Student's t-test for paired samples was used with a 95% confidence interval to measure differences in ultimate load, ultimate displacement, and structural stiffness. There was not a significant difference in any of the parameters evaluated in the 4.0-mm poly-L-lactic acid absorbable versus stainless steel screw comparison (P > 0.05). Stainless steel 2.0-mm pins had significantly greater structural stiffness (P = 0.032) and less ultimate displacement (P = 0.021) than their poly-L-lactic acid absorbable counterparts. There was not a significant difference in ultimate load in poly-L-lactic acid absorbable and stainless steel pins (P = 0.59).

This article discusses various aspects of mechanical testing for podiatric applications. Included is a brief overview of the terminology used to describe a variety of mechanical tests, suggestions for the preparation and storage of specimens, and an overview of various mechanical testing techniques that have been used to collect data on internal fixation and osteotomy stability.

Topical treatment of wounds is an important aspect of wound care, although secondary to surgical and systemic care. Dressing materials come in many forms to suit wound types and preferences. No hard evidence exists to place any one approach above another. All wounds deserve individualized attention and care plans. Likewise, a plethora of solutions exist to augment dressing materials in cleansing, antibiosis, and débridement. Traditional agents, including hydrogen peroxide, Dakin's solution, and povidone-iodine, are more tissue toxic than their common usage would indicate. We prefer frequent dressing changes with natural fiber gauze and nontoxic solutions such as saline. The scalpel, curette, and rongeur are, in our experience, much preferred to enzymatic agents when débridement is needed. We encourage scrutiny of commercial products based on clinical merit and effectiveness as documented in the medical literature. Platelet derived growth factors are an effective adjunct to wound healing and are primarily indicated when the condition of patients and their wounds has otherwise been optimized.

The purpose of this study was to investigate factors that contribute to the development of osteomyelitis of the foot after a puncture wound in patients with diabetes. Forty-five male and 21 female adults with diabetes that were admitted to the hospital for a foot infection precipitated by a puncture were included in the study. Twenty-two (33%) patients had osteomyelitis (O) based on either a positive bone culture or pathology report. Forty-four patients had soft tissue infections (ST). Age and duration of diabetes were similar in both groups. Patients with osteomyelitis received medical treatment later than patients with soft tissue infections. A significant difference was identified when comparing the time interval from the time of the injury until patients were hospitalized and until they had the puncture wound surgically debrided, and when comparing the interval from when patients first received initial professional medical evaluation until they were hospitalized and until they had the puncture wound surgically debrided. Patients with punctures involving the forefoot (FF) and patients that wore shoes (S) at the time of the injury were more likely to develop osteomyelitis than patients that had rearfoot (RF) injuries O: FF = 20, 90%, RF = 2, 10%, ST: FF = 30, 70%, RF = 13, 30%, p < 0.05) and patients that were barefoot (B) at the time of injury (O: S = 15, 88%, B = 2, 12%, ST: S = 21, 57%, B = 16, 43%, p < 0.05). Osteomyelitis is a common complication in patients with diabetes with a foot infection following a puncture wound.(ABSTRACT TRUNCATED AT 250 WORDS)

The purpose of this article is to review the English language medical literature involving intraosseous ganglia and to report the rare finding of a histologically proven intraosseous ganglion found in the calcaneus. Intraosseous ganglia are rare lesions of bone seen in the metaphyses or epiphyses of long bones. The lesion is more common in the lower extremity; however, very few have been reported in the foot. The lesion is usually in close proximity to a joint, but rarely has any communication with it. The intact intraosseous ganglion is smooth and round in shape, with an opalescent color indistinguishable from soft tissue ganglia. The contents of the cyst are of a gelatinous consistency and have mucoid centers with a yellowish color. Patients commonly present with intermittent pain that increases with activity. Radiographically, the lesion appears as a well-defined circular to oval radiolucent defect surrounded by a thin rim of sclerotic bone. Bone lesions with a similar radiographic appearance (giant cell tumors, aneurysmal bone cyst, and enchondromas) must be differentiated from intraosseous ganglia. Curretage of the cyst followed by packing of the defect with bone graft is the treatment most often used.

The purpose of this study is to evaluate the structural characteristics of 3.5-mm. stainless steel cortical screws and poly-L-lactic acid (PLA) absorbable screws in oblique closing base wedge osteotomies of the first metatarsal. Six pairs of frozen first metatarsal bones were excised from the specimen group. An oblique base wedge osteotomy was performed and fixated with either a 3.5-mm. stainless steel or PLA screw. Specimens were loaded to failure with the Bionix Material Testing System at a constant rate of 0.166 mm./sec. A Student's t test for paired samples with a 95% confidence interval was used to measure differences in ultimate load, ultimate displacement, and structural stiffness. The following results (mean +/- standard deviation) were obtained: Structural stiffness, PLA 12.35 +/- 3.82 N/mm. and stainless steel 10.13 +/- 5.74 N/mm.: ultimate displacement, PLA 7.39 +/- 3.23 mm. and stainless steel 10.89 +/- 7.91 mm.; ultimate load, PLA 57.95 +/- 1.01 N and stainless steel 51.49 +/- 5.22 N. In this fracture model, there were no statistically significant differences in the structural characteristics of PLA 3.5-mm. screws and stainless steel screws in oblique closing base wedge osteotomies of the first metatarsal.

The purpose of this study was to compare the structural characteristics of 2.0-mm polyglycolic acid pins and 2.0-mm Steinmann pins in oblique closing base wedge osteotomies of the first metatarsal bone commonly used to correct metatarsus primus varus. Six pairs of fresh frozen cadaveric first metatarsal bones were osteotomized, fixated with either absorbable or stainless steel 2.0-mm pins, cemented in a specimen-holding jig, and tested with the Bionix Material Testing System. There was no significant difference in the mean ultimate force, ultimate displacement, or structural stiffness when comparing 2.0-mm polyglycolic acid pins and Steinmann pins in this model. The structural characteristics of 2.0-mm absorbable pins were the same as stainless steel pins at the time of initial placement in the oblique closing base wedge osteotomy of the first metatarsal.