Foot and Ankle Surgery

Comp lex regional pain syndrome (CRPS) can be a complication of injury or surgery or have an obscu re etiology. Special precautions are indicated (i.e., preemptive analgesia) when surgery is required with a patient who has been diagnosed with CRPS. The complex case of a 44-year-old female diagnosed with reflex sympathetic dystrophy (RSD) is discussed, including current treatment options. A brief review of the literature as well as the features of complex regional pain syndrome (CRPS IIRSD and CRPS I//causalgia) are presented.

Although functional and clinical outcomes after total ankle arthroplasty have been promising, a steep learning curve has been recognized. In addition, the performance of concomitant hindfoot realignment procedures is controversial. The purpose of this study was to report on a single surgeon's experience with the first 50 total ankle arthroplasty procedures. We wanted to define the characteristics of the learning curve and whether the rate of complications was increased in patients who required complex reconstruction for preexistent foot and ankle deformities. This was a retrospective study of 50 cases with an average follow-up of 24.2 months. The patient population consisted of 18 men and 30 women with an average age of 57.6 years. Twenty-six percent of the cases had concomitant bony realignment procedures, while 20% had prior history of major hindfoot corrective procedures. There were 19 cases with intraoperative malleolar fractures, 12 cases that exhibited some degree of malalignment, and 6 cases of syndesmotic nonunion, and 8 ankles required early component revision. Minor wound complications that resolved with local wound care occurred in 9 cases, while 1 patient had a major wound complication requiring flap coverage. Each of these complications, other than wound complications, decreased with the surgeon's experience. Our results also indicate that the performance of major realignment procedures at the same time of implant arthroplasty is not associated with an increased incidence of complications. The results of this study suggest that total ankle arthroplasty is associated with a learning curve. Perioperative complications may potentially decrease with surgeon experience.

The lower extremity is a frequent site for malignant melanomas. However, skeletal metastases involving the foot and ankle are a rarity. Nearly all documented cases of secondary pedal bone metastasis have originated from a primary subungual melanoma. The following case study illustrates an unusual skeletal metastasis to the foot and ankle arising from a primary malignant melanoma of the torso.

Los huesecillos accesorios del pie son variaciones anatómicas normales de infrecuente importancia clínica. Se sitúan en los sitios de los centros de osificación secundarios del tarso y metatarso. Desde su primera descripción en la literatura científica en 1804, el os trigonum ha sido un frecuente tema de debate por diversos aspectos, de la etiología al tratamiento. Presentamos un raro caso de un os trigonum doloroso con hallazgos clínicos más evidentes que lo habitual. El huesecillo fue extirpado mediante cirugía abierta con alivio completo de los síntomas. Se discuten brevemente algunas peculiaridades históricas, el diagnóstico, el diagnóstico diferencial, los hallazgos clínicos y las modalidades terapéuticas.

Tourniquet use in foot and ankle surgery is common practice; however, the technique varies among foot and ankle surgeons and there are no standard guidelines. To analyze trends in foot and ankle tourniquet use, the authors conducted an e· mail sUlVey. One thousand six hundred sixty-five foot and ankle surgeons were sent a tourniquet-use survey via a-mail, across Canada and the United States. Nineteen percent of the recipients completed and returned the surveys. Eleven (3.4%) rarefy or never use a tourniquet and 8 (2.5%) use an Esmarch bandage toumiquet at the ankle. Most use pneumatic ankle cuffs (92% use, 27% use exclusively); many also use thigh cuffs (69%) and some a/so use calf cuffs (15 %). Most thigh-cuff users (62%) experience problems with cuff fit sometimes or often. All but 3 respondents exsanguinate the limb before tourniquet inflation. Specific devices used for exsanguination varied among surgeons. Most commonly used tourniquet pressures range from s 200 to 350 mm Hg at the ankle and s 200 to 2:.351 mm Hg for the thigh (64% use pressures between 301 and 350 mm Hg). Only 7% of respondents consider limb occlusion pressure when selecting tourniquet cuff pressure. Based on published studies of limb occlusion pressures, these ranges suggest that some of the more common pressure settings may be higher than necessary for many patients. Vascular disease or previous bypass (91 %) and deep vein thrombosis (83%) were the most commonly listed contraindications to tourniquet use. Approximately 10% of respondents have either experienced or learned of skin and nerve injuries secondary to lower extremity tourniquet use at any level. The varied responses show a lack of overall consensus on tourniquet pressure settings. Guidelines for optimizing cuff pressure and technique should be established to minimize the risk of complications.

The purpose of this study was to determine if the relative length of the first metatarsal and the proximal phalanx of the hallux, in respect to the total foot length, were associated with the incidence of hallux rigidus. For this retrospective study, lateral radiographs from 132 cases with hallux rigidus and a control group of 132 normal feet were reviewed.

Patients presenting late for treatment of clubfoot deformity are still common in many parts of the world. These feet are often rigid and severely deformed. Surgical correction is the prevailing option to attain a plantigrade foot, and the extent of correction required predisposes to wound-healing problems. We present the results of treatment of 15 patients (21 feet) with severe, untreated congenital talipes equino varus, who underwent operations using a double zigzag incision as a single-stage procedure. These patients ranged in age from 6 months to 4 years and presented late, having received no treatment or inadequate treatment since birth. The desired end point of the study was a fully corrected foot with a wound that would heal primarily without complications. The etiology was isolated congenital talipes equino varus in 11 patients and arthrogryposis multiplex congenita in 4 patients. Eleven patients were boys and 4 were girls; 6 patients underwent bilateral procedures. The patients were graded preoperatively and postoperatively using the Dimeglio classification, with 10 feet classified preoperatively as grade 3 and 11 graded as grade 4. Desired correction was achieved in all feet, and all wounds healed uneventfully with no complications. This single-stage technique is very safe and cost-effective and is an easy alternative to standard techniques for dealing with late-presenting untreated severe clubfoot deformities.

Tears of the peroneal tendons are not uncommon but remain an underappreciated source of chronic lateral ankle pain. The purpose of this study was to identify the typical patient profile and nature of the injury, to analyze the course of treatment, and to determine the prevalence of complications seen with surgical repair. Forty patients with chronic pain over the peroneal tendons from the Foot and Ankle Institute at the Western Pennsylvania Hospital underwent peroneal tendon repair. During a 3-year period, a retrospective review was performed by evaluating medical records, surgical reports, and radiographs. The average patient age was 42 years (range, 13 to 64 years). The most common cause was an ankle sprain or other traumatic injury (58%). Peroneus brevis tears (35 patients; 88%), peroneus longus tears (5 patients; 13%), combined peroneus brevis and longus tears (15 patients; 37%), low-lying peroneus muscle belly (13 patients; 33%), lateral ankle ligamentous disruptions (13 patients; 33%), and peroneal subluxation (8 patients; 20%) were identified during surgery. The average follow-up was 13 months (range, 9 to 40 months). Ninety-eight percent of the patients were able to return to full activities without pain at final follow-up. The minor complication rate (transient symptoms) was 20%. Clinically significant (major) complications (continued symptoms or revisionary surgery) occurred in 10% of patients. This study indicates that lateral ankle ligamentous incompetence, combined peroneal brevis and longus tears, and low-lying peroneus muscle belly commonly coexist in patients with peroneal tendon injuries. Appropriate surgical intervention of peroneal tendon tears and their coexisting pathology yields successful and predictable results with few clinically significant complications.

Quantitative strength analysis of first metatarsophalangeal joint arthrodesis was performed using two fixation techniques: a small 6-hole plate with an interfragmentary screw or two crossed lag screws. Twelve matched-pair fresh-frozen cadaveric specimens (24 trials) were used for direct comparison of each of the two fixation techniques. All joint surfaces were prepared with power conical reamers utilizing a standard technique. The fixation construct was stressed to failure on each specimen using a computer-integrated materials tester. Fixation stiffness defined as force (load) over displacement and point of ultimate failure was evaluated. The six-hole plate and interfragmentary screw fixation method was a statistically stiff er form of fixation (p > .01) and displayed a greater point of ultimate failure (p > .002) under the laboratory conditions.

Introduction For the quantification of intra-articular fracture of the calcaneus, different types of angles have been mentioned in the literature. Of these, the Bohler's angle (BA) and the critical angle of Gissane (CAG) are used in common practice. However, there is a great paucity of literature conducted on the Indian populace to find out the normal range of BA and CAG. In this article, our objective is to homologate and confirm the normal range of BA and the CAG in the Indian population and compare their values to the published international reference values. Materials and methods It is an observational cross-sectional study done between 2017 and 2019. X-rays were anonymized by hiding the identification data. The BA and CAG were measured together and by two authors simultaneously. Each angle was measured two times. Two-sample T-test was chosen to compare the means of the values and the p value <0.05 was considered significant. Results Three hundred and eighty-four (n = 384...

This is the interim analysis of a prospective, randomized, controlled study comparing diabetic foot ulcer healing in patients being treated with either noncontact normothermic wound therapy (Warm-UP; Augustine Medical Inc. Eden Prairie, MN) applied for 1 hour 3 times daily until healing or 12 weeks, or standard care (saline-moistened gauze applied once a day). Surgical debridement and adequate foot off-loading was provided to both groups. Evaluations were performed weekly and consisted of acetate tracings, wound assessment, and serial photography. Twenty patients have completed the trial and both treatment groups were distributed evenly (N ϭ 10). Ulcers treated with noncontact normothermic wound therapy had a greater mean percent wound closure than control-treated ulcers at each evaluation point (weeks 1-12). After 12 weeks, 70% of the wounds treated with noncontact normothermic wound therapy were healed compared with 40% for the control group. In this subset of patients there have been no adverse events associated with noncontact normothermic wound therapy.

European registers for total ankle replacement Registers for hip and knee replacements have been used for nearly 30 years, starting in Sweden 1975 with the knee arthroplasty register. Many other countries have followed this trend, and the results from the registers give valuable information about survival rates for different devices, detailed information of which patients groups that are at risk of failure, regarding the best technique (for example whether prostheses should be fixed with or without bone cement), and can even differentiate outcomes between centers and surgeons. The value of registries depends on compliance, as many are voluntary, although the UK Department of Health has made submission a mandated requirement for Government hospitals in England and Wales.

A R T I C L E I N F O Keywords: Tendonitis injection hyaluronic acid pain swelling outcomes adverse effects A B S T R A C T Aim: The aim of this study was to evaluate the efficacy and safety of a single, peri-tendinous injection of hyal-uronic acid for mid-portion, non-insertional Achilles tendinopathy. Materials And Methods: A prospective, open labelled, single center, pilot study was conducted. All patients enrolled received a single peri-tendinous injection of Ostenil Tendon™ (40 mg/2 ml 2% HA with 0.5% mannitol). Outcome measures were Visual Analogue Scale (VAS) pain score and Manchester-Oxford Foot Questionnaire (MOxFQ) scores at 2 weeks and at final follow at 12 weeks. Any major and minor adverse effects were recorded. To assess change in VAS and MOxFQ scores, t test and Wilcoxon signed rank test were employed. Results: Seventeen patients were enrolled in this study with a mean follow-up of 12 weeks. Mean pre-injection VAS score was 9.38 cm (9-9.8), which significantly reduced post-injection to a mean score of 4.09 cm (2-8) at week-2 stage, and further improved to 3.01 cm (2-3.9) at the final follow-up (p < 0.0001). MOxFQ score showed a significant improvement from pre-injection value of 67.77 (63.03-72.55) to 31.18 (13-60) at week-2 stage, and further improved to 24.20 (15.73-32.67) at the final follow-up (p < 0.0001). The mean improvement from pre-injection to the final follow up was 43.57 (34.25-52.90). No adverse effects for injections were recorded. Conclusion: This small series suggests an encouraging response of a single injection of HA as an effective and safe option for non-insertional Achilles tendinopathy.

Background: The purpose of this study is to report the short-term complication rates and mid-term subtalar fusion rates following operative management of calcaneal fractures. Methods: This is a retrospective study of Californians undergoing operative treatment of a calaneus fracture from 1995 to 2005. The main outcomes reported are readmission for a short-term complication within 90 days of surgery and reoperation for subtalar fusion during the observation period. Results: We identified 4481 patients who underwent open reduction and internal fixation of their fracture as inpatients within 30 days of the index admission. The short-term rate of complications included a 90-day rate of readmission of 1.03% for wound infection, 0.25% for thromboembolic disease, and 0.22% for mortality. The mid-term rate of subtalar fusion was 3.49% at 5 years post-operatively. Conclusions: This study reports the short-term complication rates and mid-term subtalar fusion rates following operative management of calcaneal fractures using population-based data.

A long-term retrospective review of a long oblique distal osteotomy of the fifth metatarsal for correction of a tailor's bunion deformity is presented. The technique, results, and follow-up of this procedure are described. The long oblique distal osteotomy was performed on 25 feet on 16 patients. Follow-up ranged from 11 to 110 months with an average of 64.4 months. The average preoperative intermetatarsal 4-5 angle and lateral deviation angle improved from 10.88°and 4.24°, respectively, to 5.52°and Ϫ4.24°p ostoperatively, respectively. A modified scoring scale for lesser metatarsal procedures was used, showing an average postoperative score of 94 out of 100 possible points. Subjectively, 96% (24 of 25) of feet that underwent surgery were rated as excellent or good. Complications included one patient with paresthesias, one soft-tissue infection, and 2 patients had irritation from screws. The authors conclude that the long oblique distal osteotomy is a viable alternative in the correction of tailor's bunion deformity.

An understanding of torsion in the human Achilles tendon would assist in more efficient percutaneous tendon lengthening procedures. Tendoachilles torsion was measured on 16 human cadaver specimens. Significant torsion was found in all tendons studied. The authors developed a method to quantify the degree of tendon torsion, explore a possible relationship to external anatomical landmarks, and suggest that the development of tendoachilles torsion closely follows postnatal development of the tibia.

Foot ulcerations and their sequelae remain a major source of morbidity for patients with diabetes mellitus. Often leading to infection, osteomyelitis, or gangrene, these lesions have consistently been ascertained as significant risk factors for subsequent lower extremity amputation. Hence education, appropriate foot care, and early intervention have assumed important roles in programs focused on amputation prevention. Multidisciplinary cooperation has been demonstrated as the most successful approach to the management and prevention of foot lesions in patients with diabetes. This article reviews the epidemiology, current understanding of the underlying pathophysiology, and treatment rationale for diabetic foot ulcerations. Such knowledge is essential in the overall management of these complicated patients and, when incorporated into daily practice, can significantly reduce the incidence and morbidity of foot disease in diabetes.

Self-administered questionnaires have become an important aspect for clinical outcome assessment of foot and ankle-related problems. The Foot and Ankle Ability Measure (FAAM) subjective form is a region-specific questionnaire that is widely used and has sufficient validity and reliability from previous studies. Translate the original English version of FAAM into a Thai version and evaluate the validity and reliability of Thai FAAM in patients with foot and ankle-related problems. The FAAM subjective form was translated into Thai using forward-backward translation protocol. Afterward, reliability and validity were tested. Following responses from 60 consecutive patients on two questionnaires, the Thai FAAM subjective form and the short form (SF)-36, were used. The validity was tested by correlating the scores from both questionnaires. The reliability was adopted by measuring the test-retest reliability and internal consistency. Thai FAAM score including activity of daily life (ADL) a...

We present histopathologic and imaging features, treatment alternatives, and follow-up of a patient with a secondary chondrosarcoma of talus. A 27-year-old man with a chondrosarcoma arising from a preexisting benign tumor was treated by talectomy. At 3 years' follow-up, there is no evidence of recurrence or metastasis. The patient can walk with slight limp without the aid of external support.

Measurement of ground contact forces can be used to assess the loads to which the human body is subjected in normal activities, like walking, or in more demanding situations such as in sports. With regard to clinical problems it is useful to compare the loads in the limb either between injured and non-injured or pre-and posttraumatic or -operative states. Otherwise, comparisons between patients and control groups are necessary. Measurement of the plantar pressure, i.e. the distribution of force over the sole of the foot, is useful as it provides detailed information specific to each region of contact. A wide variety of measurement systems are available on the market. These systems should be considered with respect to their technical specifications and the intended application. In general, one should distinguish between different sensor principles (resistive, capacitive, piezoelectric) and different devices (platform, insole, single transducer system). Platform systems are restricted to use in a laboratory setting (embedded in a walkway) and are used for barefoot measurements. Insole or single transducer systems can be used to record the plantar pressures within the shoe and therefore are appropriate to evaluate the effects of different shoe constructions or modifications like orthotics. Some of the precautions to be taken into account for reproducible measurements and the factors influencing pressure patterns have to be considered. Furthermore, the application of plantar pressure measurements to various clinical problems will be discussed.

Charcot arthropathy, also known as neuroarthropathy, is most commonly associated with diabetes mellitus, despite a variety of other etiologies. A limited number of case reports have been published on neuroarthropathies caused by other forms of neuropathy, including alcoholic peripheral neuropathy. We report 4 cases of neuroarthropathy associated with chronic alcoholism in nondiabetic individuals. Conservative management similar to that afforded diabetic patients was successfully employed in these cases. A review of the clinical presentation and the pathology of alcoholic neuropathy is included in this report. ACFAS

The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, diabetes-associated complications are expected to rise in prevalence.

The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, diabetes-associated complications are expected to rise in prevalence.

The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, diabetes-associated complications are expected to rise in prevalence.

Our purpose was to construct and validate a new score taking into consideration the flaws of existing scores. Methods: A new score named Visual-Analogue-Scale Foot and Ankle (VAS FA) with the following features was constructed: questionnaire based on 20 subjective questions, Visual-Analogue-Scale (VAS) based rating, computerized evaluation. The score was validated in 121 subjects. For validation, SF-36 1 and Hannover Questionnaire (Q) were obtained and correlated with VAS FA. Results: The correlation VAS FA versus SF-36 1 and Q (Pearson, all p-values <0.001, r ! 0.5) was sufficient for the total score and all score categories (pain, function, other complaints).

Extensive tissue resection often mandates unique approaches to complete a functional reconstruction.
While there are numerous options for selecting a donor site for a skin or soft tissue flap, available options
for securing a local flap following midfoot amputation are quite limited. Adequate flap fixation is
essential to maintain its viability, yet this may be challenging to achieve when there is a substantial
residual post debridement requiring coverage and only limited remaining viable surrounding soft tissue
available for anchoring. Over thinning the flap may compromise vital circulation to it from plantar (or
other pertinent) artery perforators. In our experience, the adjunctive use of Kirschner wire(s) to support
external soft-tissue fixation in conjunction with traditional methods has been successful in securing
such tenuous fasciocutaneous flaps. To our knowledge, few alternative techniques have been described
to fasten flaps in instances of compromised surrounding skin and soft tissue integrity in high-risk
patients. This technique offers the surgeon a strong, inexpensive, and versatile solution for soft tissue
anchoring. It allows for mechanical creep and ultimately stress relaxation at a potential wound closure
site. This manuscript reviews several cases, each using this simple, novel approach to fixate an unsecured
flap during the closure of an open amputation.

A retrospective evaluation of 64 randomly selected patients with 100 nonfixated Austin bunionectomy procedures was performed. A radiographic and a clinical evaluation were performed, including an analysis of preoperative and postoperative angles as well as postoperative complications. This study demonstrates a similar complication rate for nonfixated Austin bunionectomies as compared with previous studies with internal fixation. Removal of the fibular sesamoid was performed in 90% of the cases and did not increase the incidence of hallux varus. The nonfixated Austin bunionectomy is an acceptable alternative to the correction of hallux valgus. If internal fixation is utilized, the most cost-effective device should be used.

Non-union of distal fractures of the fibula type Weber B is rare. Undisplaced and minimally displaced isolated lateral malleolar fractures (Weber B) usually unite without operative intervention. We present three cases of lateral malleolus non-union in healthy individuals. Two were treated with internal fixation plus bone grafting. The third patient remained asymptomatic and therefore did not undergo surgery for the fracture.

The authors provide a detailed review of the available literature regarding first ray sagittal plane direction and range of motion with special emphasis on whether or not hypermobility of the first ray can truly be supported as a definable clinical entity. They also describe a novel clinical test for assessing sagittal plane instability of the first ray. The authors believe that this test, when combined with previously defined clinical tests, helps to identify those few patients that would benefit from an arthrodesis procedure of the medial pillar of the foot for the treatment of the hallux valgus deformity.

Keywords: arthritis bunion callus epidemiology hammertoe survey tibialis posterior tendon veteran a b s t r a c t Many factors have been suggested to cause flatfoot deformity. The purpose of this study was to identify risk factors for flatfoot deformity, which itself can be a causative factor for other foot and ankle pathologies. The National Health Interview Survey (Podiatry Supplement) from 1990 was analyzed to determine associations of various demographic factors and other foot and ankle pathologies with self-reported flatfoot deformity. We found statistically significant (P .05) associations of flatfoot with age, male gender, BMI, white-collar occupation, veteran status, bunion, hammertoe, calluses, arthritis, and poor health. Treatment and prevention of flatfoot may have an effect on an individual's overall health and occurrence of other foot and ankle pathologies.

Dactylolysis spontanea is an idiopathic condition affecting the fifth toe, and sometimes other toes, that is frequently bilateral, with lesions in different stages. Between 1977 and 1999, a total 6000 radiographic studies of the feet were reviewed in a mainly African American population in Chicago, J1Jinois. After an initial screening based on the Cole criteria, 581 patients were selected and re-examined, and amplification techniques were performed. After reviewing the complementary exams, 102 patients were diagnosed with dactylolysis spontanea or ainhum. Soft-tissue constriction was the most frequently presented radiological sign on the initial screening. Kurtosis at the digit plantar fold and marked rotation of the fifth toe were normal findings in asymptomatic patients. Demographics, comorbidities, and radiological findings were analyzed in the selected population. Associated diseases occurring in these patients appeared to have no specific etiologic correlation with ainhum. African Americans and the dark-skinned population are affected exclusively by this condition, presumably due to the fibrogenic tendency of these individuals. Early diagnosis and accurate staging of ainhum are facilitated by radiological examination of the feet. The findings suggest that this condition is underdiagnosed and overlooked because its low prevalence and variable clinical presentations that might mimic more common etiologies, including localized trauma.

Although replant of the extruded talus would be preferable at the time of initial management, some patients present with a talus that had not been recovered. A series of 3 cases of the extruded talus that were reconstructed with large allograft interfaces are presented. Two of the cases had femoral head allografts and the other used morcellized cancellous allograft. Several orthobiologic substances were used in various proportions for each case. All 3 resulted in a solid union with minimal shortening of the extremity. 4.

Abstract:
Plantar foot ulcerations in the diabetic population are a significant source of morbidity, mortality, and cost to the healthcare system globally1. The lifetime risk of a patient with diabetic neuropathy developing a foot ulcer is as high as 25%, with rates increasing annually2. It has been previously reported that over 50% of these ulcerations will become infected, with 20-30% of them resulting in lower extremity amputation, likely a transmetatarsal amputation (TMA) or higher3,4. 

The panmetatarsal head resection (PMHR) as originally described by Hoffman in 1911 is a proven alternative to the TMA in the treatment of painful forefoot Rheumatoid Arthritis5. Modifications by Jacobs in 1982 brought the procedure to diabetic feet with chronic neuropathic ulcerations6. Continued improvements, including arthrodesis of the first metatarsophalangeal joint (MTPJ) to the original technique have improved patient outcomes, namely by increasing stability and intrinsic forefoot propulsion capacity5. Additionally, maintenance of the distal toes may allow a patient to wear ‘off the shelf’ extra depth or accommodative athletic shoes, rather than becoming solely dependent on costly, custom-molded shoes7.

Given that multiple isolated metatarsal resections often lead to transfer lesions requiring multiple revisional surgeries in the operating theatre8, the pan-metatarsal head resection may be an excellent alternative for the diabetic patient seeking ulcer prevention following the failure of conservative care. When used in tandem with adequate postoperative offloading, it is our belief that this concept may prevent the need for more proximal amputation such as a TMA.

References:
1. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217-228.
2. Boulton AJM, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719-1724.
3. Lipsky BA, Weigelt JA, Sun X, Johannes RS, Derby KG, Tabak YP. Developing and validating a risk score for lower-extremity amputation in patients hospitalized for a diabetic foot infection. Diabetes Care. 2011;34(8):1695-1700.
4. Lavery LA, Peters EJG, Armstrong DG, Wendel CS, Murdoch DP, Lipsky BA. Risk factors for developing osteomyelitis in patients with diabetic foot wounds. Diabetes Res Clin Pract. 2009;83(3):347-352.
5. Institute TP, Southerland JT, Boberg JS, Downey MS, Nakra A, Rabjohn LV. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Wolters Kluwer Health; 2012.
6. Giurini JM, Basile P, Chrzan JS, Habershaw GM, Rosenblum BI. Panmetatarsal head resection. A viable alternative to the transmetatarsal amputation. J Am Podiatr Med Assoc. 1993;83(2):101-107.
7. Armstrong DG, Fiorito JL, Leykum BJ, Mills JL. Clinical efficacy of the pan metatarsal head resection as a curative procedure in patients with diabetes mellitus and neuropathic forefoot wounds. Foot Ankle Spec. 2012;5(4):235-240.
8. Zgonis T. Surgical Reconstruction of the Diabetic Foot and Ankle. Lippincott Williams & Wilkins; 2009.