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A 34-year-old patient is noted to have a lack of ankle dorsiflexion by 5 degrees with knee extension as seen in Figure A. However, the ankle dorsiflexion improves to 20 degrees with knee flexion as seen in Figure B. Which of the following diagnoses would benefit MOST from a gastrocnemius recession (Strayer procedure)?
Chronic peroneal tendonitis
Chronic retrocalcaneal bursitis
Chronic calcaneal osteomyelitis
Chronic plantar forefoot ulcer
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A 65-year-old patient with poorly controlled diabetes develops 2nd metatarsal head osteomyelitis deep to a superficial ulcer. Which of the following treatment modalities would have the highest chance of success?
IV antibiotics based on ulcer swab culture sensitivity
IV antibiotics based on percutaneous bone biopsy culture sensitivity
Elevation and non-weight bearing
A 57-year-old man taking metformin for diabetes and gabapentin for peripheral neuropathy has a superficial plantar midfoot ulcer with a clean, noninfected appearance. Total contact casting is implemented for mechanical relief. Which of the following radiographs most likely corresponds to the clinical situation described?
A diabetic ulcer shown in Figure A probes down to bone when a cotton-tipped applicator is used. What is the approximate likelihood this patient has osteomyelitis?
A 44-year-old man with diabetes mellitus has a non-healing Wagner grade 1 ulcer shown in Figure A for the past 8 months. Conservative management with total contact casting has not resolved the ulcer. Physical examination reveals loss of protective sensation by Semmes-Weinstein testing, no signs of infection, positive Silfverskiold test indicating gastrocnemius contracture, and palpable pedal pulses. What is the next most appropriate step in management?
Integra artificial dermis placement followed by split thickness skin grafting
Continued total contact casting
Split thickness skin grafting to ulcer
Strayer procedure (gastrocnemius lengthening)
Weil metatarsal decompression osteotomy
A 65-year-old diabetic male presents with the foot ulcer shown in Figure A. There is no exposed bone, and no signs of infection. Pulses are palpable. What additional information should be obtained next to help guide this patient's treatment?
MRI scan with contrast
Results of Silverskiold test
Transcutaneous oxygen measurements of the toes
Hemoglobin A1C level
You are caring for a 72-year-old male with diabetes and peripheral neuropathy with a non-healing forefoot ulcer as shown in Figure A. To reduce the plantar pressure on his forefoot, which of the following shoe modifications would you suggest?
Polyethylene foam insole
Open toe sandals
Rocker sole shoes
Custom indepth shoes
Hard postoperative shoe
A 66-year-old male with a known history of uncontrolled Type 2 diabetes presents for follow up of a forefoot ulcer that is seen in Figure A. All of the following are strong prognostic indicators of osteomyelitis EXCEPT:
Exposed bone at ulcer site
Periarticular erosions at 1st MTP joint
Increased signal within metatarsal diaphysis on T2 weighted MRI
Increased signal within indium labeled WBC scan
Positive wound culture
A 37-year-old man with type-1 diabetes mellitus reports a 3-month history of a plantar foot ulcer shown in Figure A. His pulses are palpable and sensation to a 5.07 Semmes-Weinstein monofilament is absent on the entire plantar surface of the foot. There is no erythema or drainage and there is no bone encountered during probing of the ulcer. There is no fever and the white blood cell count is normal. The C-reactive protein and erythrocyte sedimentation rate are normal. What is the most appropriate next step in treatment?
Total contact casting and empiric IV antibiotics
Surgical debridement, dressing changes, and empiric IV antibiotics
Charcot restraint orthotic walker (CROW)
Surgical debridement, dressing changes, biopsy, and culture specific IV antibiotics
Total contact casting
Which of the following is least likely to predict future amputation in diabetic patients?
Diabetic foot ulceration
Loss of sensation with 5.07 Semmes-Weinstein monofillament testing
Hemoglobin A1c level of 10.7
Ankle-brachial index of 1.07
Which of the following is not financially covered during one calendar year for Medicare patients under the United States Therapeutic Shoe Bill?
Three pair of inserts for extra-depth shoes
Inserts for missing toes
Two pairs of custom-molded shoes
Velcro closure shoe modification
A 62-year-old diabetic female presents with a Wagner grade 1 foot ulcer. Upon examination of the foot, no dorsalis pedis pulse is palpable. Each of the following noninvasive vascular tests indicate a good prognosis for ulcer healing EXCEPT:
Ankle-brachial indices (ABI) of 0.72
Absolute toe pressure of 45 mm Hg
Transcutaneous oxygen measurements (pO2) of 15mm Hg
Presence of hair on the toes
Which of the following variables is not predictive of poor healing of diabetic foot ulcers?
Transcutaneous oxygen pressure < 20 mmHg
Systolic blood pressure > 140 mmHg
Ankle-brachial index < 0.45
Albumin < 3.0 g/dL
Total lymphocyte count < 1,500/mm3
Which of the following patients with type 2 diabetes mellitus is most likely to develop a foot ulcer?
54-year-old female unable to feel the presence of a 5.07 Semmes-Weinstein monofilament on the plantar aspect of the foot
63-year-old male with transcutaneous oxygen pressures (TcpO2) of 30 mm Hg
51-year-old male with ratio of ankle to brachial pressures of < 0.6
71-year-old male with serum albumin of 3.1 g/dL
60-year-old with autonomic dysfunction leads to drying of skin due to lack of normal glandular function
A 45-year-old diabetic male has a Wagner type 3 heel ulcer shown in Figure A that measures 4x2cm and is recalcitrant to debridements and total contact casting for 4 months. The patient has palpable pulses, active drainage at the ulcer, and does not have protective sensation with a 5.07 Semmes-Weinstein filament. Radiograph and MRI (sagittal and axial) images are shown in Figures B-D respectively. In addition to bone culture biopsy, debridement and antibiotic therapy, what surgical intervention is most appropriate?
Soft tissue fasciocutaneous flap coverage
Below knee amputation
Soft tissue free flap coverage
A 44-year-old male with long standing insulin dependent diabetes complains of a non-healing plantar foot ulcer. The ulcer is shown in Figure A. The second metatarsal head can be probed at the base of the wound, and he lacks plantar sensation. Laboratory work-up for infection is negative. Which of the following is the best initial treatment?
Ray resection and primary wound closure
Oral antibiotics and local wound care
Local wound care and non-weight bearing in a removable boot
Surgical debridement, dressing changes, and IV antibiotics
MRI of the foot to evaluate for underlying osteomyelitis
A 55-year-old female with longstanding type I diabetes presents for evaluation of her left foot, which is shown in Figure A. On exam, the soft tissue infection extends to the metatarsals plantarly, and there is a palpable posterior tibial artery pulse. She is otherwise medically stable, and without sepsis. Which of the following treatment options will most likely result in definitive management of her forefoot gangrene and allow the highest level of functional activity after surgery?
Below the knee amputation
Above the knee amputation
Extensive soft-tissue debridement, local wound care, and antibiotic therapy
Options for Achilles Tendon Lengthening: Michael Clare, MD(CSFA #23, 2017)