Vilray P. Blair

Total Contact Casting in Treatment of Diabetic Plantar Ulcers: Controlled Clinical Trial

This study compared the treatment of total contact casting (TCC) with traditional dressing treatment (TDT) in the management of diabetic plantar ulcers. Forty patients with diabetes mellitus and a plantar ulcer but with nogross infection, osteomyelitis, or gangrene were randomly assigned to the TCC group (n = 21) or TDT group (n = 19). Age, sex, ratio of insulin-dependent diabetes mellitus to non-insulin-dependent diabetes mellitus, duration of diabetes mellitus, vascular status, size and duration of ulcer, and sensation were not significantly different between groups (P > .05). In the experimental group, TCC was applied on the initial visit, and subjects were instructed to limit ambulation to ∼33% of their usual activity. Subjects in the control group were prescribed dressing changes and accommodative footwear and were instructed to avoid bearing weight on the involved extremity. Ulcers were considered healed if they showed complete skin closure with no drainage. Ulcers were considered not healed if they showed no decrease in size by 6 wk or if infection developed that required hospitalization. In the TCC group, 19 of 21 ulcers healed in 42 ± 29 days; in the TDT group, 6 of 19 ulcers healed in 65 ± 29 days. Significantly more ulcers healed (χ2 = 12.4, P < .05) and fewer infections developed (χ2 = 4.1, P < .05) in the TCC group. We conclude TCC is a successful method of treating diabetic plantar ulcers but requires careful application, close follow-up, and patient compliance with scheduled appointments to minimize complications.

Inflammatory Osteolysis in Diabetic Neuropathic (Charcot) Arthropathies of the Foot

Objective: Osteolysis and low bone mineral density (BMD) are underappreciated consequences of several chronic diseases that may elevate the risk for fracture. The purpose of this study was to assess tarsal BMD associated with acute inflammation (ie, inflammatory osteolysis) in individuals with chronic diabetes mellitus (DM), peripheral neuropathy (PN), and recent-onset neuropathic (Charcot) arthropathy (NCA) of the foot. Research Design and Methods: This was a case-control study of 32 people (11 men, 21 women) with DM, PN, and NCA of the foot or ankle. The subjects with DM, PN, and NCA were compared with 64 age-, sex-, and race-matched control subjects (24 men, 40 women) without DM, PN or NCA. Within the first 3 weeks of cast immobilization, BMD was estimated in both calcanei using quantitative ultrasonometry. Acute inflammation was confirmed by comparing skin temperature differences between the feet of the subjects with DM, PN, and NCA and the feet of the control subjects. Results: Skin temperature differences averaged 6.7°F (SD=4.0°F) (involved foot minus noninvolved foot) in the feet of the subjects with DM, PN, and NCA compared with 0.0°F (SD=1.3°F) in the feet of the control subjects. Calcaneal BMD averaged 384 mg/cm2 (SD=110) in the involved feet and 467 mg/cm2 (SD=123) in the noninvolved feet of the subjects with DM, PN, and NCA and 545 mg/cm2 (SD=121) in combined right and left feet of the control subjects. Conclusions: Inflammation in individuals with DM, PN, and NCA may contribute to or exacerbate a rapid loss of BMD. Inflammatory osteolysis may be a prominent factor responsible for both the spontaneous onset of neuropathic fracture and the insidious and progressive foot deformity that is the hallmark of the chronic Charcot foot.

The prevention and correction of facial disfigurement

Abstract To recapitulate, all fractures should be reduced and the fragments held in their normal position before solidification commences. For those of the lower jaw and the tooth-bearing part of the upper jaw the reduction should be as early as possible. Compound fractures of the lower jaw should be drained by external incision. With most injuries of the soft tissue it is better practice to let the wound heal spontaneously than to indulge in early debridement, or run the risk of suture scars. Tattooed wounds, whether from road oil or gunpowder, should have the foreign matter removed early; the former by vigorous scrubbing with a stiff brush after anesthetizing the surface, the latter by cutting out each individual grain with a needle-pointed knife. It might be quite difficult to remove all coloring matter from incised wounds such as come from the edge of a stovepipe, but this can be excised and repaired later. In seeking gross foreign bodies in an open wound, the finger will sometimes detect what x-ray and vision will miss.

The Surgical Treatment of Post-radiation Keratosis1

Pathology WOLBACH (1) has reported clearly the pathologic findings of excessive X-ray exposure from clinical and experimental observations. Our own clinical pathologic findings bear out his conclusions, which he has summarized as follows: “1. Complete loss of appendages of the epidermis. “2. Replacement of the normal collagen (connective tissue constituent) by a peculiar dense hyaline collagen rich in elastic fibers and poor in cells. “3. Obliterative processes in blood vessels of the corium and subcutaneous tissues. “4. Necroses of varying sizes in the corium immediately beneath the epidermis. In the earlier stages these are usually in the region of thrombosed telangiectasis. In the later stages telangiectasis may be nearly entirely absent. “5. In response to necroses of the corium, reparative proliferation on the part of the epidermis,” which may extend beneath the telangiectasis or areas of necrosis. “These small necroses containing the thrombosed telangiectases become completely separated from the ski...

LI. Observations on Sinus Abnormalities in Congenital Total and Hemi-Absence of the Nose

There is an occasional reference made in the literature to the condition shown in Fig. I. There is a woodcut in W. H. A. Jacobson’s “Operations of Surgery,” and we have recently seen a photograph of this condition in an adult, but we have never encountered any very plausible explanation of its “why” or “how.” Certain individual deviations that were found in all our cases suggest that a similar condition had at some earlier period been present in all congenital half-noses.