The diabetic foot and ankle

Diabetes mellitus is a common malady of our time with ever increasing numbers of patients presenting with diabetic foot and ankle pathology. Diabetes requires treatment by a multidisciplinary team and vascular disease requires management involving vascular surgeons. There is, however, an increasing burden on the orthopaedic surgeon with ulceration, foot deformity, osteomyelitis and Charcot osteo-arthropathy being direct complications of diabetes. Potential severe complications following fracture and elective surgery require an understanding of diabetes and its effects on soft tissue and bone. The key topics are: Pathophysiology - effects of hyperglycaemia on vascular, neuronal and immune systems, Assessment - examination of diabetic foot pathology and how to spot the ‘at risk foot’, Ulceration - management of foot and ankle ulceration and indications for intervention, Charcot osteo-arthropathy - brief overview of Charcot-type foot and ankle disease, and Management of ankle fractures - overview of current trends in options for conservative and surgical intervention.     

Classification and management of the midfoot Charcot diabetic foot

Charcot neuroarthropathy adversely affects the quality of life of diabetic patients with peripheral neuropathy and therefore early diagnosis is essential. The midfoot is the commonest site for Charcot deformity and can lead to ulceration, deep infection and amputation. The goal of treatment in Charcot arthropathy is to achieve a stable, plantigrade foot without infection and ulceration to allow for ambulation in the long term. The aim of this article is to review the classification of Charcot midfoot deformity and assess the role of non-operative and surgical measures in the management of these patients. We specifically reviewed the indications and literature around surgical exostectomy.     

Oral health care in diabetes mellitus.

Diabetes mellitus produces many complex changes in the lives of those affected. Elevated blood glucose levels, which may occur in the absence of symptoms, lead to late complications from tissue damage. There is an increased susceptibility to infection, poor wound healing and periodontal disease. Furthermore, chronic oral infection itself may contribute to raised blood glucose levels and hence to the later complications of diabetes. Acute infection in the oral cavity needs specific and aggressive management, just as in the acutely infected diabetic foot.' The dental team may not have made a significant contribution to the shared management of the person with diabetes in the past; however, recent findings suggest that the dental team may contribute greatly to the shared care of diabetes with the diabetic team itself, and regular liaison is strongly recommended.     

Oral health care in diabetes mellitus

Diabetes mellitus produces many complex changes in the lives of those affected. Elevated blood glucose levels, which may occur in the absence of symptoms, lead to late complications from tissue damage. There is an increased susceptibility to infection, poor wound healing and periodontal disease. Furthermore, chronic oral infection itself may contribute to raised blood glucose levels and hence to the later complications of diabetes. Acute infection in the oral cavity needs specific and aggressive management, just as in the acutely infected diabetic foot. The dental team may not have made a significant contribution to the shared management of the person with diabetes in the past; however, recent findings suggests that the dental team may contribute greatly to the shared care of diabetes with the diabetic team itself, and regular liaison is strongly recommended.     

(ii) The cavo-varus foot

Cavo-varus foot deformity has many causes but the final common pathway is an imbalance of the muscles acting on the foot. The commonest cause of bilateral deformity is Charcot Marie Tooth disease. Unilateral deformity may arise from spinal pathology. Symptoms range from ankle instability and fatigue fractures to abnormal gait and the effects of joint overload.As well a clinical assessment, patients may require neuro-physiological investigation, and foot and spinal imaging. Treatment ranges from footwear modifications and orthoses to surgical treatment which may include combination of soft tissue releases, tendon transfers or a variety of osteotomies. Severe or recurrent deformities may require joint arthrodesis.     

Presentation of bone tumours: clinical findings and initial management of patients

Bone tumours are uncommon diagnoses and there is often a delay from first presentation to a healthcare professional (HCP) to definitive diagnosis and management. Patients may present to secondary care in a number of ways. Patients may present acutely with pathological (or impending) fractures, patients may present as urgent 2-week referral from primary care or patients may present with incidental findings on radiological investigations. A thorough history and examination is essential, followed by radiological investigations. Common clinical findings include pain, which is usually the main reason for patient presentation to an HCP. Other reasons include limp or loss of function of limb, swelling or lump, or pathological fracture. As part of the work-up, it is important to ask about constitutional symptoms, past history of malignancy and family history of known syndromes. Plain radiographs are vital for diagnosis. The patient's age is important for the differential diagnosis. The location, morphology and how the tumour is affecting the bone, periosteum and soft tissues are key to the diagnosis. For patients presenting with bone lesions, it is essential to follow the bone sarcoma referral guidelines so that patients are promptly diagnosed and treated.     

Management of severe odontogenic infections in pregnancy

Background: The objective of this study was to review the management of patients presenting with severe odontogenic infections and who are also pregnant. Methods: A retrospective clinical audit was conducted of all female patients admitted to the Royal Adelaide Hospital by the Oral and Maxillofacial Surgery Unit from 1999 to 2009 with severe odontogenic infections. Pregnant patients were identified and their age, medical history, previous obstetric and gynaecological history, stage of current pregnancy, presenting infection, diagnosis and management were recorded, as well as the outcome of the pregnancy. Results: A total of 346 female patients were admitted to the Royal Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with an admission diagnosis of severe odontogenic infection and five were pregnant. Besides surgical and anaesthetic assessment, mother and foetus were assessed by the Obstetric and Gynaecology Unit. In all, five with severe infection were successfully resolved and four proceeded to a normal delivery with a healthy child. The remaining patient had an already planned therapeutic abortion. Conclusions: Pregnant patients with severe odontogenic infections require urgent referral to a tertiary hospital with full surgical, anaesthetic and obstetric services. This allows appropriate management of the complex requirements of mother and foetus.     

Diabetes and orthopaedic surgery: a review

Diabetes mellitus (DM) is common, estimated to affect 425 million people worldwide in 2017. It is a condition that is continually growing in prevalence and is often associated with multiple co-morbidities. Its multi-system effects on the body mean that its management can pose a challenge, even to more experienced clinicians. In orthopaedic practice, diabetic patients are commonly encountered owing to their increased fracture risk and complications of the disease such as diabetic foot. An appropriate knowledge of diabetes, its pathophysiology, immunology and the pharmacology of medications used in its treatment is essential, as the consequences of mismanagement can be grave. Optimal treatment of diabetics can often require the involvement of a wider multidisciplinary team. Complications that can be encountered in the perioperative and postoperative periods include, diabetic ketoacidosis, hyperosmolar hyperglycaemic state, surgical site infection and venous thromboembolism. This review outlines current concepts in the perioperative management of diabetes and its manifestations within orthopaedic surgery, with a focus on outcomes and complications. A review of the available literature reveals conflicting conclusions between studies, with no clear effect or consensus yet established for many issues. There is a need for a greater number of well-designed, high-quality, appropriately powered trials to establish the true effect of diabetes on outcomes in orthopaedic surgery.     

Arthroscopic diagnosis and medical management of calcium pyrophosphate deposition disease in the temporomandibular joint

Calcium pyrophosphate deposition disease (CPPD) is a crystal arthropathy that can involve the temporomandibular joint. It is known to accelerate the osteoarthritic process, often initially presenting with advanced level of disease. The management of CPPD in the rheumatology and orthopedic literature is one of early diagnosis and medical management of acute attacks. The cases of three patients who presented with initial complaints of joint pain and limited mouth opening are presented. Preoperative imaging identified calcifications in two of these patients. Definitive diagnosis was achieved through arthroscopic-assisted biopsy. Rheumatology referrals revealed chondrocalcinosis of the knee in one patient. All patients had improved mouth opening and pain.     

Anaphylaxis: an update for dental practitioners

Anaphylaxis is an acutely presenting life‐threatening medical emergency. Surveys indicate that dentists feel inadequately able to recognize and treat anaphylaxis. This paper reviews the terminology and pathophysiology of anaphylaxis, and describes the recognition and initial management of anaphylaxis for dentists. Dentists should be able to administer intramuscular adrenaline during anaphylaxis at the appropriate dose. The role of further medical care is also explained. Six cases of anaphylaxis arising from dental oral maxillofacial surgery practice are discussed.     

Falls in elderly people that result in facial injuries

Falls in elderly people are increasing. Injuries of the upper limb that result from a fall usually suggest that an outstretched hand was used to curb the fall. Conversely, maxillofacial injuries in elderly people may result from alterations in consciousness as a result of a pre-existing medical condition. We investigated the nature of falls in an elderly population and compared two cohorts of patients-those presenting with maxillofacial injuries, and those with isolated upper limb injuries, and there were 25 patients in each cohort. Comprehensive personal data and medical history were recorded together with details of the fall. We found a significant correlation between the nature of the injury and recollection of the event (P <0.01). Patients who sustain facial injuries are less likely to recall the event. This may be the result of the injury itself, but an underlying medical condition may have been responsible for the fall and should be excluded.     

Rare presentation of Mycobacterium avium-intracellulare infection

Mycobacterium avium-intracellulare causes clinical disease mainly in immunocompromised patients with long-standing pulmonary disease, the symptoms of which are identical to those of pulmonary tuberculosis. In patients with AIDS the infection is typically disseminated. Extrapulmonary infection by M. avium-intracellulare is seen in children aged 1-5 years as cervicofacial lymphadenitis. Other extrapulmonary sites are less common and include musculoskeletal, maxillary sinus, mastoid, breast, small bowel, genitourinary tract and cornea. Such infection of the hard palate is rare. We present an unusual case of infection of the palate by M. avium-intracellulare in a 53-year-old diabetic man. To our knowledge, this infection presenting as a palatal lump in a patient without HIV or pre-existing lung disease has not been previously reported.     

The impact of COVID-19 on cervicofacial infection of dental aetiology

Cervicofacial infections of dental aetiology can be life-threatening and with the closure of dental practices following the onset of the COVID-19, it would be anticipated that their prevalence presenting to maxillofacial surgery would increase and services may be overwhelmed, with patients presenting later with a potential subsequent increase in morbidity. A retrospective analysis of patients with cervicofacial infection of dental aetiology referred to maxillofacial surgery during the initial six weeks of COVID-19 lockdown in 2020 was carried out and compared with the equivalent period in the two preceding years. Unexpectedly, during COVID-19 lockdown, there was a reduction in patients seen with cervicofacial infection of dental aetiology. This may have resulted from patient adherence to government guidelines “Stay at home”, successful triaging of patients in primary care and emergency treatment provided by urgent dental care centres. Proportionally more patients who presented to hospital had received prior antibiotic therapy and required in-patient admission. All patients admitted received incision and drainage, with an increase extraoral drainage and an associated reduction in length of stay. During COVID-19 lockdown, maxillofacial managed a reduced number of patients with cervicofacial infection, likely resulting from primary and secondary dental care working together. The rate of incision and drainage of patients not admitted increased under local anaesthesia with increase of extraoral drainage and reduced length of stay for those admitted.     

(i) Disorders of the first ray

Musculoskeletal conditions are a common presentation in primary care, and almost one third of these are related to the foot and ankle. Of these, the most common pathologies are disorders of the first ray, which includes hallux valgus and hallux rigidus. Pain in the first ray, which forms the weight-bearing medial column of the foot, can significantly impact on a patient's quality of life. Diagnosis is often not difficult, but it is important to examine for pathologies in the lesser rays that coexist with the presenting disorder. Initial treatment is with physiotherapy and orthotics, but surgical treatment of degenerative change and valgus deformity yields good outcomes and patient satisfaction. This article reviews the common conditions affecting the first ray, their assessment and their management.     

An evaluation of complications following dental extractions using either sterile or clean gloves

This randomized prospective study aims to evaluate any differences in the postoperative infection rate from dental extraction using either sterile or clean surgical gloves and to determine any predisposing factors that may complicate socket healing. A total of 609 patients were randomly assigned to two groups, with the operators wearing either sterile or clean gloves in performing forcep extractions. 551 patients, who had 811 extractions performed, returned for the postoperative assessment visit. There was no difference in the incidence of an acutely inflamed socket, acutely infected socket and dry socket and also no significant predisposing factors found between the sterile and clean glove groups. The pre-operative diagnosis of caries, periodontal disease or retained root had a higher tendency of producing an acute-inflamed socket, whereas an acutely infected socket only developed in the cases of retained root. On the pain intensity level, an acutely inflamed socket caused mild to moderate pain, on acutely infected socket caused moderate to severe pain; and a dry socket caused severe pain in the majority of cases. The study concluded that the use of sterile surgical gloves does not offer an advantage over clean gloves in minimizing socket inflammation, infection, as well as a dry socket following dental extraction.     

An update on tarsal coalitions

Tarsal coalitions are anomalous connections between two or more bones in the hindfoot or midfoot secondary to embryonic failure of segmentation and differentiation of the mesenchyme. Calcaneonavicular and talocalcaneal coalitions are the most common. Although it is a congenital deformity, presentation is usually in adolescence which coincides with ossification of the coalition. Patients typically present with diffuse foot pain, calf muscle pain, recurrent ankle ligament sprains and a rigid hindfoot valgus deformity. Initial management is non-operative and may involve activity reduction, a trial of immobilization in a walking boot or cast, physiotherapy, corticosteroid injections and regular analgesia. Close to a third of patients experience symptom relief but the remaining patients with persistent symptoms will require operative intervention. Patients without degenerative joint disease undergo resection of the coalition. It is now established that an associated severe hindfoot valgus foot should be addressed at this stage to prevent inevitable future joint degeneration. The indications for joint fusion remain unclear and the tendency is to postpone this when possible until a later age. In recent years, arthroscopic resection of talocalcaneal coalitions has gained popularity, despite being technically demanding. It gives good visualization of the coalition, better postoperative pain relief and quicker improvement of the hindfoot stiffness.     

Hemophilic arthropathy of the temporomandibular joint: Review of the literature,a case report,and discussion

Hemarthrosis of extremity joints in patients with hemophilia has been well documented. However, hemarthrosis of the temporomandibular joint in patients with coagulopathies appears to be rare. Consequently, management of a temporomandibular joint hemarthrosis is difficult because of the lack of treatment guidelines. The purpose of this article is to review the pathophysiology of hemophilic arthropathy and its management. A case of temporomandibular joint hemophilic arthropathy in a patient with a factor XI deficiency will be presented. A brief review of factor XI deficiency and a hypothetical pathophysiological mechanism for internal derangement induced by myofascial pain dysfunction are included.     

Management of tooth resorption

A correct diagnosis and an understanding of the aetiology and dynamics of the processes involved in tooth resorption is critical to effective management. Tooth resorptions can be classified as: (1) trauma induced; (2) infection induced; or (3) hyperplastic invasive. Some transient trauma induced resorptions require no treatment but must be carefully monitored to check that there are no complicating issues such as infection. In cases of trauma induced replacement resorption, a multidisciplinary approach is usually necessary to ensure an optimal long-term solution. Infection induced tooth resorptions require the removal of the invading micro-organisms by endodontic therapy including intra-canal medication which can also facilitate repair of the resorbed tooth structure. The hyperplastic invasive tooth resorptions pose considerable challenges in management due to the complexity and aggressive nature of the resorptive process. With careful case selection and complete inactivation of resorptive tissue successful management can be achieved.     

牙周病与糖尿病足临床相关性研究

目的 调查糖尿病足的风险是否与牙周病（PD）相关。方法 选择110例糖尿病足伴牙周病患者,及项目协作组医院口腔科就诊的条件相近的102名非糖尿病的牙周病患者为对照组。采用logistic回归模型,对潜在的混杂因素进行了调整,对本研究中所见的PD危险因素如：高龄、糖尿病病程、口腔保健和患者受教育水平等,采用SPSS 12.0作统计分析。结果 年龄、糖尿病病程、口腔保健和教育水平具统计学意义。在调整性别、年龄、糖尿病病程、口腔保健和教育后,PD和牙列缺损与糖尿病足有独立相关。结论 糖尿病足的风险与牙周病高度相关。     

Primary syphilis remains a cause of oral ulceration

After many years the incidence of infective syphilis (infection with Treponema pallidum) is increasing in the United Kingdom. This may reflect changes in sexual attitudes and behaviour, altering trends in HIV disease, and increased foreign travel. Oral disease as a consequence of primary syphilis is rare. The present report details two patients presenting to an oral medicine clinic in London, within a 6-month period in 1999, with oral ulceration as their only clinical manifestation of undiagnosed primary syphilis. The oral aspects of early syphilis and the need for dentists to be aware of changing epidemiological trends in relevant infectious diseases are highlighted.