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Squamous cell carcinoma is a malignant tumor of the squamous epithelium and can occur in many different organs. We present a case of a 61-year-old veteran with metastatic squamous cell carcinoma of the bladder with distal metastasis to the middle phalanx of the fourth toe, which is a rare occurrence in the literature. (J Am Podiatr Med Assoc 99(3): 251–253, 2009)

This case report presents a rare postoperative dislocation of the fifth metatarsal base following a healed open partial fourth and fifth ray amputation of a 62-year-old male veteran with poorly controlled diabetes mellitus. The dislocated fifth metatarsal base subsequently created a chronic ulceration and an inhibition of normal gait. The patient was taken to the operating room where the fifth metatarsal base was resected with transfer of the peroneus brevis tendon to the cuboid to maintain biomechanical stability. (J Am Podiatr Med Assoc 102(1): 71–74, 2012)

Forty-nine feet in 47 patients with midfoot neuropathic foot deformity were referred for care to a comprehensive foot salvage clinic and followed for an average of 3.6 years. Twenty-three initially presented without open ulcers. Two underwent elective Syme's ankle disarticulation amputation, and the others were kept ambulatory with a combination of periods of nonweightbearing cast immobilization, accommodative extra-depth shoes with custom orthotics, and ankle-foot orthoses. Twenty-six of the feet initially presented for care with open ulcers and/or chronic osteomyelitis. Twenty-two of these patients underwent 32 surgical procedures. Sixteen underwent debridement of the infected bone and surrounding soft tissues. Excision of large, nonaccommodative boney prominence, termed ex-ostectomy, was performed in eight. Partial excision of the deformed midfoot combined with boney stabilization and attempted arthrodesis, termed partial tarsectomy, were performed in seven. All surgical patients were managed postoperatively with long-term custom accommodative bracing. Follow-up at an average of 3.6 years revealed that all but one of the patients remained ambulatory. Six walk with accommodative shoe gear and persistent stable chronic open ulcers. None required below-knee amputation. Five amputations were performed, three at the Syme's ankle disarticulation level, one at the Chopart's hind-foot level, and one at the mid-foot level. Neuropathic midfoot deformity is a disabling disorder that requires thorough patient education and compliance, prolonged palliative monitoring and care, accommodative orthotic shoe management, and selective surgery. It can markedly limit the patient's walking ability and independence. With careful monitoring and selective surgery to maintain a plantigrade foot, foot salvage and walking ability can be maintained. A treatment algorithm is presented to guide patient care.

The etiology of ulcerations related to increased plantar pressure in patients with diabetes mellitus is complex but frequently includes a component of gastrocnemius soleus equinus. One viable treatment option is percutaneous tendo Achillis lengthening as a means of increasing dorsiflexory range of motion and decreasing forefoot shear forces. This article presents three case reports illustrating the importance of reducing plantar pressure as a crucial component of treatment of diabetic forefoot ulcerations. (J Am Podiatr Med Assoc 95(3): 281–284, 2005)

Syme ankle disarticulation is an amputation level that minimizes disability and preserves function, but it has been used sparingly in patients with diabetes mellitus. Surgeons have avoided this level because of the perceived high risk for wound failure, wound infection, or migration of the heel pad, which makes prosthesis use difficult.Ninety-seven adult patients with diabetes mellitus who underwent Syme ankle disarticulation because of a neuropathic foot with an infection or gangrene, or both, during an eleven-year period were studied retrospectively. Selection of the amputation level was made on the basis of clinical examination and an assessment of the wound-healing parameters, i.e., vascular inflow, tissue nutrition, and immunocompetence. The average age of the patients was 53.2 +/- 17.5 years.Eighty-two patients (84.5%) ultimately achieved wound-healing. When threshold levels for vascular inflow (ultrasound Doppler ischemic index of 0.5 or transcutaneous partial pressure of oxygen between 20 and 30 mm Hg) and tissue nutrition (serum albumin of 2.5 g/dL) were met, an overall success rate of 88% was achieved. Total lymphocyte count (an absolute lymphocyte count of 1500) and the smoking of cigarettes during the study period did not appear to impact wound-healing rates. The overall infection rate was 23%, and it was three times greater in smokers. Most infections were managed with local wound care and antibiotic therapy. At a minimum follow-up of two years, all but two patients were able to walk with a prosthesis. Thirty of the ninety-seven patients died at an average of 57.1 months following surgery.The results of this retrospective review support the value of Syme ankle disarticulation in diabetic patients with infection or gangrene. This function-sparing amputation can be successfully performed with a reasonable risk. Patients managed with a Syme ankle disarticulation appeared to remain able to walk better and to survive longer than similar patients who had a transtibial amputation and served as historical controls. In diabetic patients with dysvascular disease who have adequate vascular inflow to support wound-healing (an ultrasound Doppler ischemic index of 0.5 or a transcutaneous partial pressure of oxygen between 20 and 30 mm Hg), the threshold for the wound-healing parameter of serum albumin appears to be as low as 2.5 g/dL.

In a retrospective review of 233 cases of diabetic foot ulceration preceded by minor trauma, 192 ulcerations exhibited focal pressure keratosis as the preceding traumatic event. The frequency of outpatient visits and other foot care interventions were correlated with the occurrence and severity of ulceration. Patients seen more frequently in an outpatient foot clinic had less severe ulcers and were less likely to undergo surgical treatment than those with less frequent visits. (J Am Podiatr Med Assoc 91(6): 275-279, 2001)

Scientific structured foot salvage clinics will provide surgeons with a large population of peripheral vascular insufficiency patients who may someday become candidates for salvage amputation at the foot or ankle level. This article presents the technology of functional amputation levels.

Four diabetic patients with gangrene of the forefoot and infection ascending above the ankle were treated with open amputation of the foot combined with open fasciotomy and debridement of the involved proximal muscle compartments. All four patients healed their wounds and returned to their premorbid community ambulation status. The management and indications in these unusual patients are discussed.

A review of 64 midfoot amputations performed between 1980 and 1985 revealed that complications occurred in 42% of the series. These included early wound dehiscence and late re-ulceration after the patient began walking again. By providing aggressive management and appropriate local revisions, 84% of the original group's limbs were salvaged at a functionally significant level. These findings underscore the fact that midfoot amputation requires diligent immediate and long-term follow-up if an acceptable success rate is to be achieved.

Recent trends in amputation surgery favor amputation at the most distal level to preserve the patient's ability to walk. This paper reports the results of sixty-four amputations performed at the level of the middle of the foot in fifty-eight patients. All were performed in patients with peripheral vascular disease who had a diagnosis of either gangrene or resistant, nonhealing ulcers. Forty-three patients (74 per cent) had diabetes. Nutritional evaluation of the patient was used to improve the potential for healing. In the initial forty-six patients, a retrospective review of the serum albumin level, the blood total-lymphocyte count, and the Doppler ischemic index was performed. A prospective study was performed in the final twelve patients, in whom a minimum level in each of these three factors was required before the distal amputation was done. The healing rate for all sixty-four amputations was 81 per cent. When all three factors were above the minimum level, the healing rate was increased to 92.2 per cent. When one or two of the factors was below the minimum level, the rate of healing decreased to 38.5 per cent. Aggressive distal amputation can be performed with a high rate of success when the factors influencing the decision on the amputation level include non-invasive vascular testing and nutritional evaluation.

Twenty-nine ray resection amputations of the lower extremity were performed in 25 dysvascular patients during a four-year period. The indications for amputation were localized gangrene, resistant localized osteomyelitis of a metatarsal, or both. Specific criteria included: (1) foot Doppler pressure of 70 mm Hg, (2) ankle-arm Doppler arterial pressure ratio of at least 0.5, (3) lateral ray resection only when healthy tissue margins could easily be produced, and (4) central ray resection only for persistent deep infection resistant to local treatment. Only 31% healed without further amputation or ulceration. Analyzed retrospectively, the results demonstrate that ray resection has a poor potential for success in the presence of "localized" gangrene and is only moderately successful in the treatment of chronic resistant localized infection.