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Biomedical subjects

Elly Trepman

Publications and source records attributed to Elly Trepman.

At least 19 recordsLinked to original sources
PubMed2006

Revascularization for peripheral vascular disease in Aboriginal and non-Aboriginal patients.

BACKGROUND: Canadian Aboriginal subjects have a higher prevalence of diabetes, renal disease, and lower extremity amputation than non-Aboriginal subjects. However, limited information is available about patient outcomes for arterial bypass surgery in Canadian Aboriginal compared with non-Aboriginal subjects. METHODS: A retrospective study of all patients undergoing revascularization for peripheral vascular disease at a tertiary care referral center was performed. RESULTS: A total of 828 procedures were performed on 678 patients between 1995 and 2002: 108 (13%) procedures on 84 (12%) Aboriginal patients and 720 (87%) procedures on 594 (88%) non-Aboriginal patients. Aboriginal patients had a higher prevalence of diabetes, chronic renal failure, and end-stage renal disease than non-Aboriginal patients. Aboriginal patients presented with more serious complications (gangrene [Aboriginal, 63 [58%] of 108 patients; non-Aboriginal, 112 [16%] of 720 patients; P < .0001] and nonhealing ulcer [Aboriginal, 29 [27%] of 108 patients; non-Aboriginal, 131 [18%] of 720 patients; P < .05]) and required urgent or emergency revascularization (Aboriginal, 47 [49%] of 95 patients; non-Aboriginal, 228 [36%] of 634 patients; P < .02) more frequently than non-Aboriginal patients. The 60-month patient mortality was similar for both groups (Aboriginal, 20 [24%] of 84 patients; non-Aboriginal, 160 [27%] of 594 patients; not significant), but Aboriginal patients had loss of limb more frequently (Aboriginal, 19 [18%] of 108 patients; non-Aboriginal, 62 [9%] of 720 patients; P < .0001) and had loss of primary graft patency more frequently (Aboriginal, 39 [36%] of 108 patients; non-Aboriginal, 155 [22%] of 720 patients; P < .0001) than non-Aboriginal patients. CONCLUSIONS: Canadian Aboriginal subjects had worse outcomes with revascularization than non-Aboriginal subjects, but ethnicity and diabetes were not independent risk factors for poor outcome. Multivariate analysis showed that the poor outcomes in mortality, limb salvage, and primary graft patency among Aboriginal patients undergoing revascularization may be attributed to renal disease and a more advanced mode of presentation of peripheral vascular disease complications at the time of intervention.

Age Distribution↗
PubMed2006

Quality of life of adults with unhealed and healed diabetic foot ulcers.

BACKGROUND: Diabetic foot ulcers cause major treatment morbidity and cost of care. This study evaluated quality of life in patients with unhealed and healed diabetic foot ulcers. METHODS: This was a cross-sectional study of adult diabetic patients (age 45 years or older) treated in a tertiary care foot clinic who had foot ulcers within the preceding 2 years. Patients with other diabetic complications or conditions that would potentially affect quality of life were excluded. Two patient groups of comparable age, gender distribution, and duration of diabetes were studied: 57 patients with unhealed ulcers (minimum duration, 6 months) and 47 patients with healed ulcers. Telephone interviews were done using the Short Form 12 (SF-12) (both groups) and a Cardiff Wound Impact Scale (CWIS) (unhealed ulcer group). RESULTS: The mean SF-12 Physical Component Summary score was significantly lower for the group with unhealed ulcers (unhealed, 35 +/- 8 points; healed, 39 +/- 10 points; p = 0.04); these scores for both groups were significantly lower than published Short Form 36 (SF-36) scores for general, diabetic, and hypertensive populations. The mean SF-12 Mental Component Summary scores of the groups did not differ significantly from each other or from published population scores. CWIS responses showed that patients with unhealed ulcers were frustrated with healing and had anxiety about the wounds, resulting in marked negative impact on the average Well-being Component Score (35 +/- 6 points). CONCLUSIONS: Individuals with diabetic foot ulcers experience profound compromise of physical quality of life, which is worse in those with unhealed ulcers.

Adaptation, Psychological↗
PubMed2006

Effect of foot and ankle position on tarsal tunnel compartment volume.

BACKGROUND: Tarsal tunnel pressure is increased when the foot and ankle are positioned in eversion or inversion from neutral, aggravating symptoms of tarsal tunnel syndrome in some patients. Space-occupying lesions may cause tarsal tunnel syndrome. We hypothesized that positional change of the foot and ankle from neutral to eversion or inversion causes decreased tarsal tunnel compartment volume that may aggravate symptoms of posterior tibial nerve entrapment. METHODS: MRI of 13 ankles in nine healthy subjects in three positions (neutral, eversion, inversion) were obtained with respect to the malleolar-calcaneal plane; this plane was defined by the distal tip of the anterior colliculus of the medial malleolus, the medial tubercle of the posterior calcaneal tuberosity, and the lateral tubercle of the posterior calcaneal tuberosity. The borders of the tarsal tunnel noted on the MRI were traced with a computer digitizing apparatus to determine the cross-sectional area of the tarsal tunnel on each image, and the slice thickness and interspace distance for the seven central images were used to calculate tarsal tunnel volume. RESULTS: The mean tarsal tunnel volume was significantly greater when the foot and ankle were in neutral position (21.5 +/- 0.9 cm(3)) than in either full eversion (18.0 +/- 0.9 cm(3); p = or < 0.001) or inversion (20.3 +/- 1.0 cm(3); p = or < 0.001). CONCLUSIONS: The results support the hypothesis that eversion and inversion of the foot and ankle cause decreased compartment volume of the tarsal tunnel and increased tarsal tunnel pressure that may contribute to symptoms of posterior tibial nerve entrapment in tarsal tunnel syndrome. CLINICAL RELEVANCE: Neutral immobilization of the foot and ankle may relieve symptoms of posterior tibial nerve entrapment in tarsal tunnel syndrome by minimizing pressure on the nerve and maximizing tarsal tunnel compartment volume available for the nerve.

Adult↗
PubMed2006

Oral antimicrobial therapy for diabetic foot osteomyelitis.

BACKGROUND: Osteomyelitis in the foot of a diabetic individual is a common complication of peripheral neuropathy, peripheral vascular disease, and infection. Operative facilities and home intravenous antibiotic therapy programs may not be available in remote or rural communities. Limited data are available regarding the treatment results of oral antimicrobial therapy, with or without limited office debridement for diabetic foot osteomyelitis. METHODS: This retrospective medical record review of 325 consecutive diabetic patients who were evaluated at a multidisciplinary foot clinic identified 94 (29%) patients with 117 episodes of osteomyelitis. The most common group of organisms isolated were aerobic gram-positive cocci, and the single most frequent organism was Staphylococcus aureus. A mean of 1.6 +/- 0.8 (range 1 to 4) pathogens were recovered per episode of osteomyelitis. Therapy was guided by culture results. There were 93 episodes of osteomyelitis (79 patients) that were treated with a mean of 3 +/- 1 oral antimicrobial agents (with or without an initial short course of intravenous antimicrobial agents) and had adequate followup to evaluate outcome of treatment; office treatment included bone debridement in 26 (28%) and toe amputation in nine (10%) of the 93 episodes (79 patients). RESULTS: Of the 93 episodes treated with oral antimicrobial agents (with or without an initial short course of intravenous antimicrobial agents), 75 (80.5%) episodes were put into remission. Mean duration of oral antimicrobial therapy was 40 +/- 30 weeks. Mean relapse-free followup duration was 50 +/- 50 weeks. CONCLUSIONS: Diabetic foot osteomyelitis was effectively managed with oral antimicrobial therapy with or without limited office debridement in most patients. This regimen may be especially useful in communities where infectious disease specialists and operative resources are limited.

Administration, Oral↗
PubMed2006

Diabetic foot complications in a northern Canadian Aboriginal community.

BACKGROUND: Limited access to basic foot care and protective footwear may contribute to diabetic foot complications. The purpose of this study was to determine the prevalence of foot complications, ongoing foot care, and footwear use in diabetic subjects in a remote northern Canadian Aboriginal community. METHODS: This was a cross-sectional cohort study of 169 diabetic people, including interview, physical examination, and retrospective chart review. RESULTS: The mean age of the 169 diabetic individuals in the study was 56 +/- 12 years and their duration of diabetes 10 +/- 7 years. There were 139 (82%) individuals who had 418 diabetic foot complications (average, 3.0 complications per subject with complications), including toenail pathology, foot and ankle deformities, calluses, impaired pulses, neuropathy, past or present ulcer, amputation, and Charcot arthropathy. Risk classification showed that 69 (41%) individuals were at risk for future ulceration. Fifty-five (33%) individuals had inadequate footwear for their foot risk category, and only 11 (17%) of 66 individuals in the higher risk categories (categories 2 and 3) had suitable footwear. In a 7-year period, only 0.7 screening foot examinations per diabetic subject per year were documented. However, during this period, foot problems accounted for 498 (18%) local emergency room visits, 359 (16%) hospitalization days, 109 (11%) nonemergency transfers, and 4 (6%) emergency transfers to a tertiary care hospital. CONCLUSIONS: Foot and ankle complications of diabetes in this remote Aboriginal community were common and associated with substantial morbidity. Preventive diabetic foot screening examinations and footwear were inadequate. The results suggest that programs for prevention and early detection of complications are needed, including foot screening, provision of appropriate footwear, and foot care.

Cohort Studies↗
PubMed2005

Disability and quality of life in Canadian aboriginal and non-aboriginal diabetic lower-extremity amputees.

OBJECTIVE: To compare and contrast disability and quality of life (QOL) in Aboriginal and non-Aboriginal subjects with diabetes who had lower-extremity amputation (LEA) and were living in urban and rural communities in Canada. DESIGN: Descriptive study using an interviewer-administered questionnaire and hospital medical record review. SETTING: Tertiary care center. PARTICIPANTS: Forty-four diabetic subjects (minimum age, 18 y) not receiving dialysis, including 21 Aboriginal (8 urban, 13 rural) and 23 non-Aboriginal (16 urban, 7 rural) subjects. Subjects were living in their current residence and had undergone LEA above the level of the ankle 6 months or more before interview. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Qualitative and quantitative data about symptoms, impairment, and QOL. RESULTS: Aboriginal subjects were younger than non-Aboriginal subjects at the time of diabetes diagnosis (Aboriginal, 42+/-10 y; non-Aboriginal, 52+/-14 y; P<.005) and first major LEA (Aboriginal, 57+/-7 y; non-Aboriginal, 64+/-11 y; P<.015). All subjects received rehabilitation after amputation. More rural non-Aboriginal subjects (83%) used their prosthesis both in and outside the home for all movements than other subjects (P<.048). Rural non-Aboriginal subjects had the lowest and urban non-Aboriginal subjects had the highest frequency of walking-aid use outside the home. Assistance with personal care was required by a minority of subjects, but assistance with daily housework was required by the majority of subjects. Qualitative analysis revealed that participants were, in most cases, comfortable with their postamputation life. CONCLUSIONS: Although the majority of participants in this study generally felt satisfied with their current status, major functional changes were noted after LEA that had a large negative impact on QOL.

Adolescent↗
PubMed2005

Current topics review: Charcot neuroarthropathy of the foot and ankle.

Charcot arthropathy is a destructive process, most commonly affecting joints of the foot and ankle in diabetics with peripheral neuropathy. Affected individuals present with swelling, warmth, and erythema, often without history of trauma. Bony fragmentation, fracture, and dislocation progress to foot deformity, bony prominence, and instability. This often causes ulceration and deep infection that may necessitate amputation. Instability or deformity may limit the ability to use standard footwear. Treatment is focused on providing a stable and plantigrade foot for functional ambulation with accommodative footwear and orthoses. Historically, treatment had included nonweightbearing immobilization for the acute phase, and surgery had been reserved only for infection, unresolved skin ulceration, or deformity that precluded the use of therapeutic footwear. Current controversies include weightbearing in the acute or reparative phases and early surgical stabilization. Foot-specific patient education and continued periodic monitoring may reduce the morbidity and associated expense of treating the complications of this disorder and may improve the quality of life in this complex patient population.

Ankle Joint↗
PubMed2005

Diabetic foot care: multilingual translation of a patient education leaflet.

The American Orthopaedic Foot and Ankle Society "Diabetic Foot Care" patient education leaflet was revised to improve the layout and emphasis of key concepts of preventive care. This included review of daily foot and shoe examination, danger signs, daily washing and foot care, shoe fitting, medical care, and avoidance of dangerous acts. The leaflet was expanded to occupy two sides of a page, retaining the capability of production in tear-off sheet format to facilitate distribution to patients in the clinical office. Furthermore, the leaflet was translated into 19 other languages for diabetic patients in the United States and around the world with limited English language comprehension.

Diabetic Foot↗
PubMed2005

Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society.

Foot infection is the most common reason for hospital admission of diabetic patients in the United States. Foot ulceration leads to deep infection, sepsis, and lower extremity amputation. Prophylactic foot care has been shown to decrease patient morbidity, decrease the utilization of expensive resources, and decrease the risk for amputation and premature death. The Diabetes Committee of the American Orthopaedic Foot and Ankle Society has developed guidelines for the implementation of this type of prophylactic foot care. The screening examination includes evaluation for peripheral neuropathy, skin integrity, ulcers or wounds, deformity, vascular insufficiency, and footwear. Foot-specific patient education includes instruction on self-examination and foot care practices. Individualized foot-specific patient education is indicated for patients with peripheral neuropathy. Treatment is outlined based on risk level, which is determined by the presence of peripheral neuropathy, deformity, and ulcer history. Treatment combines patient education, orthoses, footwear, and a timetable for ongoing skin and nail care. Ulcer care includes paring of calluses, debridement of infected or nonviable tissue, dressings, and off-loading. Specialty assistance may be required from a vascular surgeon, orthopaedic surgeon, podiatrist, endocrinologist/diabetologist, infectious disease consultant, radiologist, and pedorthist.

Diabetic Foot↗
PubMed2005

Stability of Lisfranc joints in ballet pointe position.

BACKGROUND: Ballerinas develop stress fractures at the second metatarsal base associated with dancing en pointe. The purpose of this study was to evaluate the relative importance of the pointe shoe and the tarsometatarsal ligaments in Lisfranc joint stability en pointe. METHODS: Eleven cadaver feet were dressed with pointe shoes, loaded in foot flat with ligaments intact, and loaded en pointe before and after sequential sectioning of the dorsal, interosseous, and plantar ligaments between the first and second metatarsals and cuneiforms. Relative motion between the first and second metatarsals and cuneiforms was determined radiographically. RESULTS: No significant displacement of the Lisfranc joints occurred when the shod foot with intact ligaments was loaded in the foot flat or en pointe positions. Serial sectioning of the ligaments from dorsal to plantar in the shod foot en pointe demonstrated no change in alignment after the dorsal and interosseous ligaments were cut, but a significant change in alignment between the second metatarsal and second cuneiform was noted after the plantar ligament was cut (p < 0.0001). Removal of the pointe shoe after cutting the ligaments and applying a minimal (1 to 2 kg) load resulted in complete subluxation and diastasis through the first-second intermetatarsal and intercuneiform region. Replacing the shoe improved alignment en pointe with similar loading. CONCLUSIONS: Both the pointe shoe and Lisfranc ligaments are important for Lisfranc region stability in feet en pointe. The plantar ligaments are major stabilizers of the Lisfranc region in the loaded, shod foot en pointe. Selection of a pointe shoe with adequate support may limit susceptibility to stress fracture of the second metatarsal base in ballerinas.

Cadaver↗
PubMed2005

Arthroscopic treatment of anterior ankle impingement syndrome in dancers.

BACKGROUND: The purpose of this study was to evaluate the results of arthroscopic treatment of anterior bony and soft-tissue impingement of the ankle in elite dancers. METHODS: The study is a case series retrospectively reviewed. In the period between 1990 and 1999, 11 elite dancers (12 ankles) had ankle arthroscopy after a diagnosis of anterior ankle impingement that markedly interfered with their dancing. Initial nonoperative treatment failed in all subjects. Previous ankle trauma was noted in all subjects. There were seven women and four men (average age 28 years). Tibiotalar exostoses were radiographically noted in six ankles. Standard anteromedial and anterolateral arthroscopic portals and instrumentation were used for resection of bone spurs and debridement of impinging soft tissues. Patients were nonweightbearing for 5 days after surgery and had postoperative physiotherapy. RESULTS: Nine dancers returned to full dance activity at an average of 7 weeks after surgery. One patient did not return to dance performance because of concurrent unrelated orthopaedic problems, but he resumed work as a dance teacher; he developed a recurrent anterior tibial spur that was successfully resected at a second arthroscopy 9 years later. Another dancer developed postoperative scar-tissue impingement and stiffness; she had a repeat arthroscopy 4 months after the initial procedure and subsequently returned to dance performance. All patients eventually had marked postoperative improvement in pain relief and dance performance. CONCLUSIONS: Arthroscopic debridement is an effective method for the treatment of bony and soft-tissue anterior ankle impingement syndrome in dancers and has minimal morbidity.

Adult↗