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Syme's amputations can provide a reliable alternative to more proximal amputations, but they are not without their occasional complication. Varus heel pad migration has been well documented as a complication following Syme's amputations. We describe a technique of resection of soft tissue and bone combined with anchoring of the lateral band of the plantar fascia in order to treat patients with the complication of varus heel pad migration.

Partial foot amputations are frequently performed to salvage significant portions of the lower extremity affected by limb-threatening infection. Once healed, the residual foot is at high risk for reulceration. Careful long-term follow-up and appropriate interventions can lower this risk.

A retrospective chart review was performed on 11 patients (13 feet) who underwent a modified Keller procedure for the treatment of recalcitrant neuropathic diabetic ulcers to the plantar aspect of the hallux between 1994 and 1998 to evaluate the postoperative results and complications. Diabetic patients with hallux rigidus, adequate vascular status, documented peripheral neuropathy, and at least 6 months of conservative care for treatment of a Wagner grade I and II ulceration were included in the study. Patients with active soft tissue infections or osteomyelitis were excluded. All primary ulcers healed within 6 months postoperatively. After 1-year of follow-up, 8 feet remained completely free of ulcers and 5 transfer ulcers occurred. Four infections developed; 3 from the surgical wound and 1 from a transfer ulcer. Based on these findings, the modified Keller procedure may be an appropriate intervention for hallux ulcerations provided the surgeon and the patient are aware of its limitations and possible outcomes.

Malignant melanoma is increasing at a rate faster than any other cancer in the United States. Location of the primary tumor on the foot is associated with poorer prognosis. This study evaluates a cohort of 148 patients with melanoma of the lower extremity (37 foot or ankle and 111 leg, knee, or thigh) diagnosed at a university medical center during a 32-year period. The mean follow-up for the foot/ankle patients was 44 months. The overall 5-year survival rate was 52% for patients with a primary melanoma of the foot/ankle compared with 84% for patients with a primary melanoma elsewhere on the lower extremity. Although the study period extended over 32 years, nearly 65% of the foot/ankle patients were diagnosed in the last decade. This increase is most likely because of the documented increase in incidence of melanoma in the United States and an increasing referral pattern at our institution.

Evidence at the scene of death and the postmortem examination led the pathologist to conclude suicide by intentional insulin overdose. The examination was conducted one day after the patient's death. The amount of insulin injected is not known, but levels of insulin in the vitreous gel were extremely high. While glucose and insulin are more stable in vitreous than in postmortem blood, the longer the delay between death and sample collection, the greater the uncertainty of the exact concentrations of substances at the time of death [42]. Patients with diabetes may have at their disposal the resources to end their lives; misuse of insulin and suicide by insulin overdose are presumably underreported events. Not only do diabetics have insulin available, but they may also have narcotics, tricyclic antidepressants or other drugs that are toxic at high doses. Even in the absence of depression, all patients with diabetes face multiple emotional issues related to the diagnosis and course of the disease. Diabetes often requires significant lifestyle changes, such as diet and physical activity, upon its diagnosis. Patients face the possibility of long-term, possibly debilitating, complications: vision loss, sexual dysfunction, and amputation. Any podiatrist who treats a large number of diabetic patients will encounter the situation of a patient at risk of losing a limb. A patient may consciously or unconsciously view amputation as punishment; limb loss interferes physically with bodily function and has extensive emotional consequences as well. It is important for patients to be involved with a healthcare team (including primary care physician, nurse educator, ophthalmologist, and podiatrist) that provides support throughout their lives [3]. As learned early on in podiatry school, podiatric physicians don't treat feet; they treat patients who have foot problems. It is as important to know when to refer a patient to the primary care physician or a psychiatrist for mental health complaints as it is to know when to refer a patient to an orthopedic surgeon for hip pain or to an ophthalmologist for vision problems. We do not propose that this patient's diabetic foot disease was the direct cause of his depression and suicide; however, the prevalence of depression in the general population and its even higher rates in patients with chronic medical illness require awareness of these problems by all members of the medical profession.

A retrospective evaluation of first metatarsophalangeal joint arthrodesis was performed on nine patients (12 feet) using two fixation techniques: a small compression plate and screws or two crossed lag screws. The joint surfaces were prepared with power conical reamers to allow for joint alignment and subsequent fusion. The average follow-up time was 6.9 months (range, 1.3 to 15 months) and, to date, all feet are successfully fused. No major postoperative complications or removal of internal fixation devices were noted in our retrospective study. This surgical technique was effective and reliable in achieving first metatarsophalangeal joint fusion, and it may serve as an alternative procedure to silicone implant or resection joint arthroplasty.