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Foot infection is the single most common reason for hospitalization of the diabetic patient. A combination of host factors, including neuropathy, angiopathy, and immunopathy, combine to make the diabetic foot infection the most severe infection commonly seen by podiatrists. If inadequately treated, the likelihood of morbidity or mortality is high. The presence of anaerobic bacteria as a predominant type of organism makes diagnosis and antibiotic selection complicated.
During walking, the center of body mass must pass from behind the weightbearing foot to in front of it. For this to take place, the foot must function as a sagittal plane pivot. Because the range required for this motion is approximately five times as great as both frontal and transverse plane motion, its evaluation should become an essential part of a podiatric biomechanical assessment. Lack of proper sagittal plane motion and its sequelae are described.
The proper prescription and utilization of therapeutic footwear is crucial to successful prevention of diabetic foot complications. The author reviews shoe alternatives' characteristics and proper fit. The concept of foot risk categories is explained and appropriate shoe selections are discussed.
Pressure ulcers of the heel are a major and growing health-care problem. Although prevention and aggressive local wound care and pressure reduction remain the gold standard for treatment of most heel ulcers, recalcitrant wounds may require surgical intervention. Limb salvage when dealing with heel ulcers remains a challenge. Nine feet (eight patients) that underwent partial calcanectomy for chronic nonhealing heel ulcers were evaluated retrospectively. Complete healing occurred in seven of nine feet. Patients who were ambulatory before surgery remained ambulatory after healing. (J Am Podiatr Med Assoc 95(4): 335–341, 2005)
Background: Off-loading excessive pressure is essential to healing diabetic foot ulcers. However, many patients are not compliant in using prescribed footwear or off-loading devices. We sought to validate a method of objectively measuring off-loading compliance via activity monitors.
Methods: For 4 days, a single subject maintained a written compliance diary concerning use of a removable cast walker. He also wore a hip-mounted activity monitor during all waking hours. An additional activity monitor remained mounted on the cast walker at all times. At the conclusion of the 4 days, the time-stamped hip activity data were independently coded for walker compliance by the compliance diary and by using the time-stamped walker activity data.
Results: An intraclass reliability of 0.93 was found between diary-coded and walker monitor–coded activity.
Conclusions: These results support the use of this dual activity monitor approach for assessing off-loading compliance. An advantage of this approach versus a patient-maintained diary is that the monitors are not susceptible to incorrect patient recall or a patient’s desire to please a caregiver by reporting inflated compliance. Furthermore, these results seem to lend support to existing reports in the literature using similar methods. (J Am Podiatr Med Assoc 99(2): 100–103, 2009)
Surgical Treatment of Pressure Ulcers of the Heel in Skilled Nursing Facilities
A 12-Year Retrospective Study of 57 Patients
Background: Chronic nonhealing pressure ulcers of the heel in nursing homes are frequent occurrences among bedridden patients with lower-extremity contractures of varying degrees of severity. Conservative local wound care for these patients can be time consuming, ineffective, costly, and may only delay an eventual major leg amputation. This study evaluates the efficacy of limb salvage surgical procedures, partial calcanectomy, total calcanectomy, and excision of the entire calcaneus and talus, for heel ulcers.
Methods: We performed a retrospective review of 57 nursing home residents who had chronic infected nonhealing pressure ulcers of the heel that we had treated over 12 years. Forty-three patients underwent partial calcanectomy, nine underwent total calcanectomy, and five underwent excision of the entire calcaneus and talus. Average postoperative follow-up was 15 months. Also included in this study are representative surgical cases.
Results: Forty-three patients completed follow-up. Complete healing occurred in 25 patients (58%). Failure to resolve the heel ulcer owing to persistent infection, or recurrence was seen in 18 patients (42%) who eventually had a below-the-knee or above-the-knee amputation. All of the patients with heel pressure ulcers were found to have lower-extremity contractures.
Conclusions: In the nonambulatory contracted patient with a heel ulcer, partial or total calcanectomy or excision of the entire calcaneus and talus offer a viable alternative not only for resolution of infection but also for prevention of limb loss. An aggressive plan must also be instituted to address the lower-extremity contractures in order to prevent recurrence. (J Am Podiatr Med Assoc 101(2): 167–175, 2011)
Introduction
The Challenge of Peripheral Arterial Disease in People with Diabetes: A Call to Action
Background: The removal of necrotic tissue from chronic wounds is required for wound healing to occur. Hydrodebridement (jet lavage) and superoxidized aqueous solution have been independently used for debriding wounds. We sought to investigate the use of superoxidized aqueous solution with a jet lavage system.
Methods: Twenty patients with diabetic foot ulcers were randomly assigned in a 1:1 ratio to receive jet lavage debridement with either superoxidized aqueous solution or standard saline weekly.
Results: There was no significant difference between the two treatments in the reduction of bacterial load or wound size in 4 weeks. No adverse reactions were reported for either treatment.
Conclusions: The use of superoxidized aqueous solution for jet lavage debridement seemed to be as safe and effective as saline. Future investigations should concentrate on whether superoxidized aqueous solution may reduce the bacterial air contamination associated with hydrodebridement. (J Am Podiatr Med Assoc 101(2): 124–126, 2011)
