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      Lower Extremity Function following Partial Calcanectomy in High-Risk Limb Salvage Patients

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          Abstract

          Partial calcanectomy (PC) is an established limb salvage procedure for treatment of deep heel ulceration with concomitant calcaneal osteomyelitis. The purpose of this study is to determine if a relationship exists between the amount of calcaneus removed during PC and the resulting lower extremity function and limb salvage outcomes. Consecutive PC patients were retrospectively divided into two cohorts defined by the amount of calcaneus resected before wound closure: patients in cohort 1 retained = 50% of calcaneus, while patients in cohort 2 underwent resection of >50% of the calcaneus. The Lower Extremity Function Scale (LEFS) was used to assess postoperative lower extremity function. The average amount of calcaneus resected was 13% ± 9.2 (1–39%) and 74% ± 19.5 (51–100) in cohorts 1 and 2, respectively ( P < 0.0001). Below knee amputation was performed in 7 (28%) and 5 (29%) of subjects in cohorts 1 and 2, respectively ( P = 1.0). The average LEFS score was 33.9 ± 15.0 for subjects in cohort 1 and 36.2 ± 19.9 for the subjects cohort 2 ( P = 0.8257) which correlates to “moderate to quite a bit of difficulty.” Our study suggests that regardless of the amount of calcaneus resected, PC provides a viable treatment option for high-risk patients with calcaneal osteomyelitis.

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          The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network.

          J M Binkley, P Stratford, S A Lott … (1999)
          The purpose of this study was to assess the reliability, construct validity, and sensitivity to change of the Lower Extremity Functional Scale (LEFS). The LEFS was administered to 107 patients with lower-extremity musculoskeletal dysfunction referred to 12 outpatient physical therapy clinics. The LEFS was administered during the initial assessment, 24 to 48 hours following the initial assessment, and then at weekly intervals for 4 weeks. The SF-36 (acute version) was administered during the initial assessment and at weekly intervals. A type 2,1 intraclass correlation coefficient was used to estimate test-retest reliability. Pearson correlations and one-way analyses of variance were used to examine construct validity. Spearman rank-order correlation coefficients were used to examine the relationship between an independent prognostic rating of change for each patient and change in the LEFS and SF-36 scores. Test-retest reliability of the LEFS scores was excellent (R = .94 [95% lower limit confidence interval (CI) = .89]). Correlations between the LEFS and the SF-36 physical function subscale and physical component score were r=.80 (95% lower limit CI = .73) and r = .64 (95% lower limit CI = .54), respectively. There was a higher correlation between the prognostic rating of change and the LEFS than between the prognostic rating of change and the SF-36 physical function score. The potential error associated with a score on the LEFS at a given point in time is +/-5.3 scale points (90% CI), the minimal detectable change is 9 scale points (90% CI), and the minimal clinically important difference is 9 scale points (90% CI). The LEFS is reliable, and construct validity was supported by comparison with the SF-36. The sensitivity to change of the LEFS was superior to that of the SF-36 in this population. The LEFS is efficient to administer and score and is applicable for research purposes and clinical decision making for individual patients.
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            Correlates of Quality of Life in Older Adults With Diabetes

            Neda Laiteerapong, Andrew Karter, Jennifer Liu … (2011)
            OBJECTIVE To evaluate associations between health-related quality of life (HRQL) and geriatric syndromes, diabetes complications, and hypoglycemia in older adults with diabetes. RESEARCH DESIGN AND METHODS A race-stratified random sample of 6,317 adults with type 2 or type 1 diabetes, aged 60 to 75 years, enrolled in Kaiser Permanente Northern California, who completed a survey that included a HRQL instrument based on the Short Form 8-item health survey. Administrative records were used to ascertain diagnoses of geriatric syndromes, diabetes complications, and hypoglycemia. Associations were estimated between HRQL and exposures in exposure-specific and combined exposure models (any syndrome, any complication, or hypoglycemia). Conservatively, differences of ≥3 points were considered the minimally important difference in HRQL scores. RESULTS HRQL was lower with nearly all exposures of interest. The lowest physical HRQL was associated with amputation. In combined exposure models, geriatric syndromes (−5.3 [95% CI −5.8 to −4.8], P < 0.001) and diabetes complications (−3.5 [−4.0 to −2.9], P < 0.001) were associated with lower physical HRQL. The lowest mental HRQL was associated with depression, underweight (BMI <18 kg/m2), amputation, and hypoglycemia. In combined exposure models, only hypoglycemia was associated with lower mental HRQL (−4.0 [−7.0 to −1.1], P = 0.008). CONCLUSIONS Geriatric syndromes and hypoglycemia are associated with lower HRQL to a comparable degree as diabetes complications. Addressing geriatric syndromes and avoiding hypoglycemia should be given as high a priority as preventing diabetes complications in older adults with diabetes.
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              The importance of limb preservation in the diabetic population.

              Karen Kim Evans, Christopher Attinger, Ali Al-Attar … (2016)
              Limb salvage in the diabetic population is complex, controversial, costly and variable throughout the world. Within the diabetic population, the indications and morbidity surrounding major leg amputation have not been well defined. A retrospective study of the Georgetown Limb Salvage Registry was conducted to determine outcomes in diabetic patients undergoing proximal forefoot/midfoot (PF/M) amputations and to help define the indications for major leg amputation in ambulatory diabetic patients. Of the 937 ambulatory diabetic patients identified during this time period, 808 who presented with superficial ulcers or distal forefoot disease and who did not go on to PF/M or higher amputation were eliminated. Records of 88 patients (92 limbs) in the PF/M amputation group and 25 patients in the below the knee amputation (BKA) group were reviewed (no above knee amputations were performed). At 2 years in the PF/M amputation group, 80% (70/88) of patients were still alive, 73% (68/92) of the limbs remained intact, and 64% of patients (56/88) were ambulatory. In contrast, in the BKA population at 2 years, 52% (13/25) of patients were deceased and 64% (16/25) were ambulating with a prosthetic limb (or had been ambulating at the time of death). The only statistically significant difference between these two groups was the presence of Charcot collapse and rear-foot disease in the BKA group. Aggressive efforts at salvage with PF/M amputation procedures should be entertained prior to higher level amputations due to the increased morbidity and mortality evidenced. Published by Elsevier Inc.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Diabetes Res
                Journal ID (iso-abbrev): J Diabetes Res
                Journal ID (publisher-id): JDR
                Title: Journal of Diabetes Research
                Publisher: Hindawi Publishing Corporation
                ISSN (Print): 2314-6745
                ISSN (Electronic): 2314-6753
                Publication date (Print): 2015
                Publication date (Electronic): 27 January 2015
                Volume: 2015
                Electronic Location Identifier: 432164
                Affiliations
                1Department of Plastic Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Road Northwest, Washington, DC 20007, USA
                2Department of Plastic Surgery, Georgetown University School of Medicine, 3800 Reservoir Road Northwest, Washington, DC 20007, USA
                3Associated Podiatrists of Greenwich, 46 Milbank Avenue, Greenwich, CT 06830, USA
                Author notes

                Academic Editor: Francesco Chiarelli

                Article
                DOI: 10.1155/2015/432164
                PMC ID: 4322665
                PubMed ID: 25692151
                SO-VID: df311012-78a2-458a-a8df-4bd164cd5f96
                Copyright © Copyright © 2015 Noah G. Oliver et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 17 November 2014
                Date accepted : 31 December 2014
                Categories
                Subject: Research Article

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