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- Author or Editor: Lawrence A. Lavery x
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Background:
Dialysis therapy is associated with an increased incidence of lower-extremity wounds and amputations. We compared the incidence of foot ulcers and amputations before and after the start of dialysis.
Methods:
We evaluated 150 consecutive diabetic patients receiving dialysis and compared the incidence of foot complications 30 months before and after initiation of hemodialysis. We used claims data for diabetes, ulceration, and dialysis and abstracted medical records to verify diagnoses and dates of ulcers and amputations. We compared initial and cumulative ulcer/amputation incidence to account for multiple events in the same person over time. We used the same formula to determine the incidence rate difference and 95% confidence intervals (CIs) to compare new ulcers and amputations during the study.
Results:
There was no significant difference in the incidence of first foot ulcers before (91.7 per 1,000 patient-years; 95% CI, 73.7ā112.3 per 1,000 patient-years) and after (82.7; 95% CI, 65.7ā102.3) the start of hemodialysis. The incidence of cumulative ulcers was significantly higher before (304.0 per 1,000 patient-years; 95% CI, 270.8ā340.2) compared with after (210.7 per 1,000 patient-years; 95% CI, 183.0ā240.9) dialysis. There was no difference in the incidence of first amputation before (29.3 per 1,000 patient-years; 95% CI, 1 9.4ā41.7 per 1,000 patient-years) and after (37.3 per 1,000 patient-years; 95% CI, 19.4ā41.7 per 1,000 patient-years) dialysis or in the cumulative incidence of amputations before (61.3 per 1,000 patient-years; 95% CI, 46.7ā8.4 per 1,000 patient-years) and after (58.7 per 1,000 patient-years; 95% CI, 44.5ā75.5 per 1,000 patient-years) dialysis.
Conclusions:
There was no increase in the incidence of ulcers or amputations after beginning hemodialysis.
The Costs of Diabetic Foot
The Economic Case for the Limb Salvage Team
In 2007, the treatment of diabetes and its complications in the United States generated at least $116 billion in direct costs; at least 33% of these costs were linked to the treatment of foot ulcers. Although the team approach to diabetic foot problems is effective in preventing lower-extremity amputations, the costs associated with implementing a diabetic-footācare team are not well understood. An analysis of these costs provides the basis for this report.
Diabetic foot problems impose a major economic burden, and costs increase disproportionately to the severity of the condition. Compared with diabetic patients without foot ulcers, the cost of care for those with foot ulcers is 5.4 times higher in the year after the first ulcer episode and 2.8 times higher in the second year. Costs for treating the highest-grade ulcers are 8 times higher than are those for treating low-grade ulcers. Patients with diabetic foot ulcers require more frequent emergency department visits and are more commonly admitted to the hospital, requiring longer lengths of stay. Implementation of the team approach to manage diabetic foot ulcers in a given region or health-care system has been reported to reduce long-term amputation rates 62% to 82%. Limb salvage efforts may include aggressive therapy such as revascularization procedures and advanced wound-healing modalities. Although these procedures are costly, the team approach gradually leads to improved screening and prevention programs and earlier interventions and, thus, seems to reduce long-term costs.
To date, aggressive limb preservation management for patients with diabetic foot ulcers has not usually been paired with adequate reimbursement. It is essential to direct efforts in patient-caregiver education to allow early recognition and management of all diabetic foot problems and to build integrated pathways of care that facilitate timely access to limb salvage procedures. Increasing evidence suggests that the costs of implementing diabetic foot teams can be offset in the long term by improved access to care and reductions in foot complications and amputation rates. (J Am Podiatr Med Assoc 100(5): 335ā341, 2010)
The authors undertook a study to evaluate the prevalence of ankle equinus and its potential relationship to high plantar pressure in a large, urban population with diabetes mellitus. The first 1,666 consecutive people with diabetes (50.3% male; mean [Ā±SD] age, 69.1 Ā± 11.1 years) presenting to a large, urban, managed-care outpatient clinic were enrolled in this longitudinal, 2-year outcomes study. Patients received a standardized medical and musculoskeletal assessment at the time of enrollment, including evaluation at an onsite gait laboratory. Equinus was defined as less than 0Ā° of dorsiflexion at the ankle. The overall prevalence of equinus in this population was 10.3%. Patients with equinus had significantly higher peak plantar pressures than those without the deformity and were at nearly three times greater risk for presenting with elevated plantar pressures. There were no significant differences in age, weight, or sex between the two groups. However, patients with equinus had a significantly longer duration of diabetes than those without equinus. Having a high index of suspicion for this deformity and subsequently addressing it through conservative or surgical means may help to reduce the risk of foot ulceration and amputation. (J Am Podiatr Med Assoc 92(9): 479-482, 2002)
Background: To evaluate complications and risk factors for nonunion in patients with diabetes after ankle fracture.
Methods: We conducted a retrospective study of 139 patients with diabetes and ankle fractures followed for 1 year. We evaluated the incidence of wounds, infections, nonunions, Charcotās arthropathy, and amputations. We determined Fracture severity (unimalleolar, bimalleolar, trimalleolar), nonunion, and Charcotās arthropathy from radiographs. Nonunion was defined as a fracture that did not heal within 6 months of fracture. Analysis of variance was used to compare continuous variables, and Ļ2 tests to compare dichotomous variables, with Ī± = 0.05. Logistic regression was performed with a binary variable representing nonunions as the dependent variable.
Results: Complications were common: nonunion (24.5%), Charcotās arthropathy (7.9%), wounds (5.2%), wound site infection (17.3%), and leg amputation (2.2%). Patients with nonunions were more likely to be male (55.9% versus 29.5%; P = .005), have sensory neuropathy (76.5% versus 32.4%; P < .001), have end-stage renal disease (17.6% versus 2.9%; P < .001), and use insulin (73.5% versus 40.1%; P < .001), Ī²-blockers (58.8% versus 39.0%; P = .049), and corticosteroids (26.5% versus 9.5%; P = .02). Among patients with nonunion, there was an increased risk of wounds (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.46ā7.73), infection (OR, 2.04; 95% CI, 0.72ā5.61), amputation (OR, 7.74; 95% CI, 1.01ā100.23), and long-term bracing (OR, 9.51; 95% CI, 3.8ā23.8). In the logistic regression analysis, four factors were associated with fracture nonunion: dialysis (OR, 7.7; 95% CI, 1.7ā35.2), insulin use (OR, 3.3; 95% CI, 1.5ā7.4), corticosteroid use (OR, 4.9; 95% CI, 1.4ā18.0), and ankle fracture severity (bimalleolar or trimalleolar fracture) (OR, 2.5; 95% CI, 1.1ā5.4).
Conclusions: These results demonstrate risk factors for nonunions: dialysis, insulin use, and fracture severity after ankle fracture in patients with diabetes.
Background:
There is an increased prevalence of foot ulceration in patients with diabetes, leading to hospitalization. Early wound closure is necessary to prevent further infections and, ultimately, lower-limb amputations. There is no current evidence stating that an elevated preoperative hemoglobin A1c (HbA1c) level is a contraindication to skin grafting. The purpose of this review was to determine whether elevated HbA1c levels are a contraindication to the application of skin grafts in diabetic patients.
Methods:
A retrospective review was performed of 53 consecutive patients who underwent split-thickness skin graft application to the lower extremity between January 1, 2012, and December 31, 2015. A uniform surgical technique was used across all of the patients. A comparison of HbA1c levels between failed and healed skin grafts was reviewed.
Results:
Of 43 surgical sites (41 patients) that met the inclusion criteria, 27 healed with greater than 90% graft take and 16 had a skin graft that failed. There was no statistically significant difference in HbA1c levels in the group that healed a skin graft compared with the group in which skin graft failed to adhere.
Conclusions:
Preliminary data suggest that an elevated HbA1c level is not a contraindication to application of a skin graft. The benefits of early wound closure outweigh the risks of skin graft application in patients with diabetes.
The Role of Interdisciplinary Team Approach in the Management of the Diabetic Foot
A Joint Statement from the Society for Vascular Surgery and the American Podiatric Medical Association
The Society for Vascular Surgery (SVS) and the American Podiatric Medical Association (APMA) recognize the beneficial impact of a multidisciplinary team approach on the care of patients with critical limb ischemia, especially in the diabetic population. As a first step in identifying clinical issues and questions important to both memberships, and to work together to find solutions that will benefit the shared patient, the two organizations appointed a representative group to write a joint statement on the importance of multidisciplinary team approach to the care of the diabetic foot. (J Am Podiatr Med Assoc 100(4): 309ā311, 2010)
This prospective longitudinal study assessed whether baseline mean skin temperature measurements are useful in predicting the most common foot-related complications of diabetes mellitus. We evaluated the mean of baseline skin temperatures taken bilaterally from six plantar sites in 1,588 patients with diabetes. There was no difference in skin temperature based on neuropathy, foot laterality, or foot risk category or between people with and without foot deformity and elevated plantar foot pressure. Whereas people with Charcotās arthropathy had slightly but significantly higher mean temperatures (84.8Ā° Ā± 3.5Ā° F versus 82.5Ā° Ā± 4.7Ā° F), this was not true for those who developed ulcers or infections or who underwent amputations. The presence of vascular disease was not associated with lower skin temperatures. Mexican Americans (83.0Ā° Ā± 4.6Ā° F) and blacks (83.6Ā° Ā± 4.5Ā° F) had higher mean skin temperatures at baseline than did non-Hispanic whites (81.8Ā° Ā± 4.6Ā° F). Baseline measurement of nonfocal mean skin temperatures is not an effective means of screening people for future events. Regular assessment of skin temperatures, using the contralateral site as a physiologic control, may be a better use of this technology. (J Am Podiatr Med Assoc 93(6): 443-447, 2003)
The use of bioengineered tissue and topical subatmospheric pressure therapy have both been widely accepted as adjunctive therapies for the treatment of noninfected, nonischemic diabetic foot wounds. This article describes a temporally overlapping method of care that includes a period of simultaneous application of bioengineered tissue (Apligraf, Novartis Pharmaceuticals Corp, East Hanover, New Jersey) and subatmospheric pressure therapy delivered through the VAC (Vacuum Assisted Closure) system (KCI, Inc, San Antonio, Texas). Future descriptive and analytic works may test the hypothesis that combined therapies used at different and often overlapping periods during the wound-healing cycle may be more effective than a single modality. (J Am Podiatr Med Assoc 92(7): 395-397, 2002)
The COVID-19 pandemic is driving significant change in the healthcare system and disrupting the best practices for diabetic limb preservation, leaving large numbers of patients without care. Patients with diabetes and foot ulcers are at increased risk for infections, hospitalization, amputations, and death. Podiatric care is associated with fewer diabetes-related amputations, ER visits, hospitalizations, length-of-stay, and costs. But podiatrists must mobilize and adopt the new paradigm of shifts away from hospital care to community-based care. Implementing the proposed Pandemic Diabetic Foot Triage System, in-home visits, higher acuity office visits, telemedicine, and remote patient monitoring can help podiatrists manage patients while reducing the COVID-19 risk. The goal of podiatrists during the pandemic is to reduce the burden on the healthcare system by keeping diabetic foot and wound patients safe, functional, and at home.
