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A traumatic amputation of a digit as a result of canine mastication and ingestion occurred in a 48-year-old woman with type 2 diabetes and peripheral neuropathy. The injury occurred during sleep and was not felt by the patient. The dangers of sleeping with one’s canine for those with neuropathic wounds are presented, and the literature is reviewed. (J Am Podiatr Med Assoc 101(3): 275–276, 2011)
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-foot–care 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): 335–341, 2010)
A Rare Case Presentation
Bilateral Gangrene of Feet Secondary to Systemic Lupus Erythematosus and Raynaud Phenomenon in an Adolescent
Systemic lupus erythematosus is an autoimmune disorder that affects several organs and systems in the human body. Digital gangrene is known to be a rare and severe complication of systemic lupus erythematosus that could lead to amputation. We report a case of an adolescent who presented with an autoimmune disorder and multiple comorbidities and developed gangrenous toes.
Motivational Interviewing by Podiatric Physicians
A Method for Improving Patient Self-care of the Diabetic Foot
Foot ulceration and lower-extremity amputation are devastating end-stage complications of diabetes. Despite agreement that diabetic foot self-care is a key factor in prevention of ulcers and amputation, there has only been limited success in influencing these behaviors among patients with diabetes. While most efforts have focused on increasing patient knowledge, knowledge and behavior are poorly correlated. Knowledge is necessary but rarely sufficient for behavior change. A key determinant to adherence to self-care behavior is clinician counseling style. Podiatrists are the ideal providers to engage in a brief behavioral intervention with a patient. Motivational interviewing is a well-accepted, evidence-based teachable approach that enhances self-efficacy and increases intrinsic motivation for change and adherence to treatment. This article summarizes some key strategies that can be employed by podiatrists to improve foot self-care. (J Am Podiatr Med Assoc 101(1): 78–84, 2011)
Severely comminuted fractures of the metatarsal bones with significant bone and soft-tissue loss have commonly subjected patients to proximal amputation procedures. We describe two patients who experienced high-energy traumatic injuries to their limbs that resulted in significant destruction of their first and second metatarsal bones with overlying soft-tissue trauma not amenable to local coverage. In both cases, a vascularized free fibular osteocutaneous flap was used to reconstruct the metatarsal bone defect and traumatized soft tissues so that a proximal amputation was avoided. At an average of 14 months of follow-up, both patients had recovered well and regained independent ambulation, with one patient being able to play soccer. We show that the free fibular osteoseptocutaneous flap is useful in reconstructing significant metatarsal bone defects and in avoiding amputations in this patient population. The skin component of the flap may be used to fill soft-tissue losses, and the fibula bone may be osteotomized so that more than one ray may be reconstructed. (J Am Podiatr Med Assoc 101(6): 531–536, 2011)
Charcot’s arthropathy is a devastating condition affecting diabetic patients with peripheral neuropathy, resulting in a foot at risk for ulceration and amputation. Early diagnosis is important for the institution of appropriate treatment, which may help prevent disease progression and foot deformity. This article discusses the pathogenesis and treatment options available for the disorder. (J Am Podiatr Med Assoc 92(7): 381-383, 2002)
Background: Diabetic foot ulcers (DFUs) are the main cause of hospitalizations and amputations in diabetic patients. Failure of standard foot care is the most important cause of impaired DFU healing. Dakin’s solution (DS) is a promising broad-spectrum bactericidal antiseptic for management of DFUs. Studies investigating the efficacy of using DS on the healing process of DFUs are scarce. Accordingly, this is the first evidence-based, randomized, controlled trial conducted to evaluate the effect of using diluted DS compared with the standard care in the management of infected DFUs.
Methods: A randomized controlled trial was conducted to assess the efficacy of DS in the management of infected DFUs. Patients were distributed randomly to the control group (DFUs irrigated with normal saline) or the intervention group (DFUs irrigated with 0.1% DS). Patients were followed for at least 24 weeks for healing, reinfection, or amputations. In vitro antimicrobial testing on DS was performed, including determination of its minimum inhibitory concentration, minimum bactericidal concentration, minimum biofilm inhibitory concentration, minimum biofilm eradication concentration, and suspension test.
Results: Replacing normal saline irrigation in DFU standard care with 0.1% DS followed by soaking the ulcer with commercial sodium hypochlorite (0.08%) after patient discharge significantly improved ulcer healing (P < .001) and decreased the number of amputations and hospitalizations (P < .001). The endpoint of death from any cause (risk ratio, 0.13; P = .029) and the amputation rate (risk ratio, 0.27; P < .001) were also significantly reduced. The effect on ulcer closure (OR, 11.9; P < .001) was significantly enhanced in comparison with the control group. Moreover, DS irrigation for inpatients significantly decreased bacterial load (P < .001). The highest values for the in-vitro analysis of DS were as follows: minimum inhibitory concentration (MIC), 1.44%; minimum bactericidal concentration (MBC), 1.44%; minimum biofilm inhibitory concentration (MBIC), 2.16%; and minimum biofilm eradication concentration (MBEC), 2.87%.
Conclusions: Compared with standard care, diluted DS (0.1%) was more effective in the management of infected DFUs. Dakin’s solution (0.1%) irrigation with debridement followed by standard care is a promising method in the management of infected DFUs.
Background:
The scope of podiatric practice has changed significantly in the past couple of decades. Despite the increased quality of training, many people outside of podiatry may not realize what our scope of practice entails.
Methods:
We conducted a survey consisting of 10 items and asked internal medicine residents at Rush University Medical Center and patients whether they would feel comfortable consulting podiatrists, or being treated for each issue.
Results:
The results for residents are as follows: 1) toenail fungus, 35% yes and 65% no; 2) diabetic wound care, 87.5% yes and 12.5% no; 3) bunion surgery, 90% yes and 10% no; 4) ankle fracture surgery, 25% yes and 75% no; 5) calcaneal fracture surgery, 50% yes and 50% no; 6) tarsal tunnel nerve surgery, 62.5% yes and 37.5% no; 7) lower extremity arterial bypass, 5% yes and 95% no; 8) below-knee amputation, 5% yes and 95% no; 9) transmetatarsal amputation, 67.5% yes and 32.5% no; and 10) venous stasis wound care, 65% yes and 35% no. The results for patients are as follows: 1) toenail fungus, 72.5% yes and 27.5% no; 2) diabetic wound care, 70% yes and 30% no; 3) bunion surgery, 62.5% yes and 37.5% no; 4) ankle fracture surgery, 57.5% yes and 42.5% no; 5) calcaneal fracture surgery, 55% yes and 45% no; 6) tarsal tunnel nerve surgery, 50% yes and 50% no; 7) lower extremity arterial bypass, 32.5% yes and 67.5% no; 8) below-knee amputation, 27.5% yes and 72.5% no; 9) transmetatarsal amputation, 52.5% yes and 47.5% no; and 10) venous stasis wound care, 32.5% yes and 67.5% no.
Conclusions:
Internal medicine residents and patients do not have an accurate perception of the scope of podiatric medicine. This proves that, as a profession, we need to raise awareness about what the podiatric scope of medicine actually entails.
Background:
We assessed the efficacy of customized foot orthotic therapy by comparing reulceration rates, minor amputation rates, and work and daily living activities before and after therapy. Peak plantar pressures and peak plantar impulses were compared with the patients not wearing and wearing their prescribed footwear.
Methods:
One hundred seventeen patients with diabetes were prescribed therapeutic insoles and footwear based on the results of a detailed biomechanical study and were followed for 2 years. All of the patients had a history of foot ulcers, but none had undergone previous orthotic therapy.
Results:
Before treatment, the reulceration rate was 79% and the amputation rate was 54%. Two years after the start of orthotic therapy, the reulceration rate was 15% and the amputation rate was 6%. Orthotic therapy reduced peak plantar pressures in patients with reulcerations and in those without (P < .05), although a significant decrease in peak plantar impulses was achieved only in patients not experiencing reulceration. Sick leave was reduced from 100% to 26%.
Conclusions:
Personalized orthotic therapy targeted at reducing plantar pressures by off-loading protects high-risk patients against reulceration. Treatment reduced the reulceration rate and peak plantar pressures, leading to patients’ return to work or other activities. (J Am Podiatr Med Assoc 103(4): 281-290, 2013)
Testing for Loss of Protective Sensation in Patients with Foot Ulceration
A Cross-sectional Study
Current recommendations for the prevention of foot ulceration and amputation include screening at-risk individuals by testing for loss of protective sensation at eight sites using 10-g (5.07) nylon monofilaments. Yet measurement of the cutaneous pressure threshold to differentiate one-point from two-point static touch stimuli may allow identification of these at-risk individuals earlier in the clinical course of diabetic neuropathy. The present study tested this hypothesis using a prospective, cross-sectional, multicenter design that included sensibility testing of 496 patients with diabetic neuropathy, 17 of whom had a history of ulceration or amputation. Considering the cutaneous pressure threshold of the 5.07 Semmes-Weinstein nylon monofilament to be equivalent to the 95 g/mm2 one-point static touch measured using the Pressure-Specified Sensory Device (Sensory Management Services LLC, Baltimore, Maryland), only 3 of these 17 patients with a history of foot ulceration or amputation would have been identified using the Semmes-Weinstein nylon monofilament screening technique. In contrast, using the Pressure-Specified Sensory Device, all 17 patients were identified as having abnormal sensibility, defined as greater than the 99% confidence limit for age, for two-point static touch on the hallux pulp. We conclude that patients at risk for foot ulceration can best be identified by actual measurement of the cutaneous sensibility of the hallux pulp. (J Am Podiatr Med Assoc 95(5): 469–474, 2005)
