OKOJ, Volume 9, No. 6

Classification, Diagnosis, and Management of Neuropathic Diabetic Foot Ulcers

Foot ulcers affect 15% of the diabetic population at some time in their lives, and precede 85% of amputations of the diabetic foot or leg. The most important risk factor for ulceration and infection of the diabetic foot appears to be peripheral neuropathy, which, when accompanied by peripheral vascular disease, is highly conducive to failure of the soft-tissue envelope of the foot. Neuropathic ulceration accompanied by impaired arterial inflow can transform a foot wound or infection into gangrene and clinical sepsis. The Wagner-Meggitt classification facilitates treatment of the diabetic foot, and Brodsky’s depth/ischemia classification system extends this to incorporate associated peripheral vascular disease. Dorsal wounds of the foot are generally associated with direct trauma or ill-fitting footwear. Plantar ulcers are typically located over bony prominences. Foot wounds with purulent drainage or necrotic tissue require sharp debridement. If this leaves a nonfunctional foot, amputation should be done. Off-loading is critical to treating diabetic foot wounds and can be accomplished with footwear lined with pressure-dissipating materials or with a total-contact cast. A Charcot deformity may require exostectomy. Numerous dressings and other preparations, skin substitutes, and negative-pressure wound therapy have enhanced the healing of treated diabetic foot wounds. Better evidence is needed before hyperbaric oxygen therapy with total body immersion can be widely applied to the diabetic patient population.

    • Keywords:
    • diabetes mellitus

    • insulin-dependent diabetes mellitus

    • non-insulin-dependent diabetes mellitus

    • juvenile-onset diabetes

    • adult-onset diabetes

    • type 1 diabetes

    • type 2 diabetes

    • diabetic foot

    • neuropathic diabetic foot

    • diabetic foot ulcer

    • diabetic wound

    • neuropathic diabetic foot ulcer

    • Charcot foot

    • Charcot arthropathy

    • diabetic Charcot foot

    • Subspecialty:
    • Foot and Ankle

HOT TOPIC: Ethics and Professionalism for the Orthopaedic Surgeon

Ethical conduct and professionalism are the cornerstones of medical practice for all physicians, including orthopaedic surgeons. It demands placing the interests of patients above those of the physician. It requires establishing and maintaining standards of competence and integrity, and providing authoritative guidance to patients and the community at large about matters of health. The American Academy of Orthopaedic Surgeons (AAOS) developed what has become the Code of Medical Ethics and Professionalism for Orthopaedic Surgeons in 1988 as a guide to define the essentials of honorable conduct for the orthopaedic surgeon in the physician-patient relationship. The American Society for Surgery of the Hand and other orthopaedic specialty societies have followed the lead of the AAOS in the development and implementation of their own codes of ethics and professionalism. The goals of these programs are to strengthen our profession and optimize safe and effective patient care.

    • Keywords:
    • ethics

    • professionalism

    • physician-patient relationship

    • relationships with industry

    • conflicts of interest

    • personal conduct

    • standards of professionalism

    • maintenance of certification

    • Subspecialty:
    • Hand and Wrist

Limb-Length Discrepancy in Children

In children, differences in the lengths of the right and left legs can have effects ranging from cosmetic concerns to severe impairment of mobility. Such differences can be acquired, congenital, or developmental, and can be static or progressive. Growth to skeletal maturity can amplify differences occurring from gestation through adolescence, and several methods can be used to predict limb-length discrepancy at skeletal maturity. A thorough history, physical examination, and radiographic examination are keys to the diagnosis of limb-length discrepancy. Options for treating such discrepancies include nonsurgical treatment, limb shortening through epiphysiodesis or bone resection for discrepancies of 2 to 5 cm, and limb lengthening through distraction osteogenesis for discrepancies exceeding 5 cm. This presentation discusses the contraindications, principles, procedures and equipment, advantages and pitfalls, complications, and postoperative rehabilitation for two types of percutaneous epiphysiodesis, osteotomy for acute limb shortening, and distraction osteogenesis for limb lengthening.

    • Keywords:
    • leg-length discrepancy

    • limb-length discrepancy

    • leg-length inequality

    • limb-length inequality

    • epiphyseal arrest

    • hemihypertrophy

    • epiphysiodesis

    • epiphysiodesis with the drill-and-curettage technique

    • percutaneous epiphysiodesis

    • PETS

    • epiphyseal stapling

    • limb shortening

    • limb lengthening

    • Subspecialty:
    • Pediatric Orthopaedics

Posterior Shoulder Instability

The past decade has seen heightened awareness and interest in posterior glenohumeral instability. In contrast to anterior shoulder instability, posterior instability most often presents with subtle manifestations and symptoms consisting primarily of pain with specific activities. The mechanism of injury may involve an acute traumatic event, but is more often a cumulative effect of repetitive microtrauma. Upon stability testing, patients with posterior shoulder instability have evidence of posterior translation. Radiographic evaluation normally reveals pathology of the posterior labrum, joint capsule, or both, which may be accompanied by bony abnormalities predisposing to posterior instability. Nonsurgical management is the initial treatment of choice, but if this approach fails, surgical intervention may be indicated. Although an open capsular posteroinferior shift has been the historical treatment of choice for posterior shoulder instability, arthroscopic techniques have become increasingly popular among surgeons, and most pathology associated with posterior instability can now be addressed arthroscopically. For patients with more significant deformities, an open procedure involving bone surgery, such as an osteotomy or graft reconstruction, may be necessary.

    • Keywords:
    • posterior shoulder instability

    • Recurrent posterior shoulder instability

    • glenohumeral instability

    • shoulder instability

    • shoulder dislocation

    • shoulder subluxation

    • multidirectional instability

    • arthroscopy

    • Subspecialty:
    • Sports Medicine