December 2013

   Researchers reviewed 160 percutaneous tenotomies for four indications: 103 tip-of-toe ulcers, 26 cock-up/dorsal ulcers, 21 kissing ulcers and 10 plantar metatarsal ulcers. Healing at four weeks was 98 percent, 96 percent, 81 percent and 0 percent respectively, according to the study.

   Nicholas Bevilacqua, DPM, FACFAS, utilizes percutaneous flexor tenotomy to treat distal tip ulcers in flexible hammertoes. He notes that digital deformities are known to increase pressures and are often associated with neuropathic ulcers.
“(Percutaneous flexor tenotomy) offers a less invasive approach and often affords the necessary intrinsic pressure reduction for ulcer healing,” adds Dr. Bevilacqua. “Outcomes are fairly predictable when patients are properly selected.”

   While the study concludes that percutaneous tenotomy is effective for treating toe ulcers, researchers deem the procedure ineffective for treating plantar metatarsal ulcers.

   Dr. Bevilacqua advises surgeons to consider performing an isolated metatarsal osteotomy or metatarsal head resection for an ulcer below a specific metatarsal head.

   “It is important to maintain a near normal metatarsal parabola to avoid transfer lesions under an adjacent metatarsal head,” explains Dr. Bevilacqua, who is in private practice at North Jersey Orthopaedic Specialists in Teaneck, N.J.

   Dr. Bevilacqua adds that surgeons should also consider an equinus deformity as a contributing factor to plantar metatarsal ulcers.

   “If this is present, a percutaneous Achilles tendon lengthening is an effective procedure to augment the healing of plantar forefoot ulcers,” explains Dr. Bevilacqua.

How Effective Is MRI In Diagnosing Osteomyelitis In Ischemic Feet?

By Brian McCurdy, Senior Editor

A recent study published in the Journal of Foot and Ankle Surgery notes that while magnetic resonance imaging (MRI) is effective in diagnosing osteomyelitis, the modality is less accurate in diagnosing the bone infection in the presence of ischemic ulcers.

   The study compared pre-op MRI results with histopathologic exams of 104 resected bones from 18 diabetic foot ulcers in 16 patients. The authors note that in eight neuropathic ulcers, 29 bones had an accurate diagnosis of osteomyelitis using MRI, even those bones with severe soft tissue infection. Of 75 bones in 10 ischemic ulcers, the study notes only seven bones evaluated by MRI after revascularization had an accurate diagnosis while the other 68 bones could not get an accurate MRI diagnosis. A histopathologic examination found all the bones to be infected through the bone cortex by the surrounding infected soft tissue, notes the study.

   Eric Lullove, DPM, notes that MRI is a very effective tool for delineating the margins and extent of osteolytic destruction of bone as a result of infection. He notes the imaging of the bone marrow contrast enhancement is very specific for osteomyelitis.

   “It is the gold standard in those patients who have normal renal function or slightly impaired renal function, or those patients free of pacemaker devices and recent orthopedic surgery,” says Dr. Lullove, a Fellow of the American College of Certified Wound Specialists, who is in private practice in Boca Raton and Delray Beach, Fla.

   However, Dr. Lullove notes the presence of ischemia does not affect MRI imaging, explaining that the MR spin rates the water in the body, not the blood flow. If one is looking at MR angiography, he says ischemia would be relevant but not as relevant in MRI for osteomyelitis.

   Dr. Lullove notes a computed tomography (CT) scan is not as specific as MRI for osteomyelitis and plain film radiography will show osteolytic processes, but well after the infection process is beyond 14 to 21 days from the onset. He says one can utilize ultrasonography to see periosteal reactions and violations of the cortex in areas where one can use sonographic imaging effectively.

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