To The Editor:
Regarding the article entitled "Factors Associated with
Bone Regrowth Following Diabetes-Related Partial Amputation of the
Foot" (81-A: 1561-1573, Nov. 1999), by Armstrong et al.,
I would like to offer a few suggestions.
The patients in this study were characterized by the presence
of autonomic neuropathy. According to several authors, autonomic
neuropathy results in sympathetic paralysis and loss of vasomotor function1-4. The resultant shunting causes
extra blood flow through bone that results in the stimulation of osteoclasts.
In the case of a fracture, osteoclasts provoke the healing process.
The use of manual bone-cutting instruments for partial amputation
of a ray may produce both small fractures at the cutting site and
extensive stripping of the periosteum. On the other hand, the use
of power instruments produces no fractures at the cutting level
and results in less stripping of the periosteum.
Elevation of temperature at the cutting site also affects circulation
in the area. Based on the findings of Nilsson and Granström5 and those of Grundnes et al.6, we can assume that the higher the
blood flow in the fractured area, the greater the resultant callus.
According to the above-mentioned parameters, we consider that
bone regrowth in diabetic patients after surgery involving the use
of manual bone-cutting instruments represents nothing more than
large callus formation due to the occurrence of incidental fractures
during osteotomy.
—Christos Alexandropoulos, MDOrthopaedic
Department
"Laiko" General Hospital of Athens
17, St. Thomas Street
11527 Athens, Greece
D.G. Armstrong replies:
I greatly appreciate the commentary offered by Dr. Alexandropoulos
with regard to hypertrophic bone in patients with diabetes. I believe
that his theory regarding callus formation is a logical and compelling
one. Regardless of the specific etiology involved, it is my hope
that further dialogue on this subject will raise awareness of the
clinical significance of this not infrequent sequela of osseous
resection in patients with diabetes mellitus.
—David G. Armstrong, DPMDepartment
of Surgery
Southern Arizona Veterans Affairs Medical Center
3601 South Sixth Avenue
Tucson, AZ 85750
E-mail address: armstrong@usa.net