This study compares the potential benefit of fifth metatarsal head resection versus standard conservative treatment of plantar ulcerations in people with diabetes mellitus. Using a retrospective cohort model, we abstracted data from 40 patients (22 cases and 18 controls) treated for uninfected, nonischemic diabetic foot wounds beneath the fifth metatarsal head. There were no significant differences in sex, age, duration of diabetes mellitus, or degree of glucose control between cases and controls. Patients who underwent a fifth metatarsal head resection healed significantly faster (mean ± SD, 5.8 ± 2.9 versus 8.7 ± 4.3 weeks). Patients were much less likely to reulcerate during the period of evaluation in the surgical group (4.5% versus 27.8%). The results of this study suggest that fifth metatarsal head resection is a potentially effective treatment in patients at high risk of ulceration and reulceration. (J Am Podiatr Med Assoc 95(4): 353–356, 2005)
There is increasing pressure from industry to use advanced wound care products and technologies. Many are very expensive but promise to reduce overall costs associated with wound care. Compelling anecdotal evidence is provided that inevitably shows wounds that failed all other treatments but responded positively to the subject product. Evidence-based medicine is the standard by which physician-scientists must make their clinical care decisions. In an attempt to provide policy makers with the most current evidence on advanced wound care products, the Department of Veteran Affairs conducted an Evidence-based Synthesis Program review of advanced wound care products. This paper suggests how to take this information and apply it to policy to drive evidence-based care to improve outcomes and fiduciary responsibility.
Maggot debridement therapy is rapidly increasing in popularity at major diabetic foot and wound care centers worldwide. However, we are unaware of specific guidelines on the short-term storage of larvae. We sought to evaluate differences in maggot motility over time in larvae refrigerated versus those stored at room temperature. We also introduce a simple surrogate method for evaluating maggot vitality that may be useful for in vivo studies if validated in future works. We randomly selected ten larvae from the same shipment at ten different times in 9 days. Larvae were placed on a translucent acetate grid, and their total excursion in 30 sec was measured. This was converted into a Maggot Motility Index. In the refrigerated group, the index remained at or above 40 mm/min for approximately 60 hours from baseline, when there was a significant decrease. This same phenomenon occurred during the first 12 hours in the nonrefrigerated group. There were significant differences in motility between refrigerated and nonrefrigerated larvae immediately after baseline until day 8. Larvae are more practical for repeated clinical use if kept refrigerated between applications. (J Am Podiatr Med Assoc 94(4): 353–355, 2004)
Desmoplastic fibroblastomas are benign and uncommon soft-tissue tumors. They are typically slow-growing, painless masses found in adult men. Rapidly growing masses have been previously reported, but are more rare. A 56-year-old man presented with a rapidly growing mass in his left foot, which was diagnosed as a desmoplastic fibroblastoma after pathologic evaluation. Although many case reports have been published in the dermatology literature, it is important to be aware of this benign neoplasm to avoid confusion with other rapidly growing malignant soft-tissue masses reported in the podiatry literature.
The Diabetic Foot 2001
A Summary of the Proceedings of the American Diabetes Association’s 61st Scientific Symposium
This review discusses some of the significant studies and events from the 61st American Diabetes Association’s Scientific Symposium. Many of the issues raised at the meeting will form building blocks for future research into offloading, footwear, wound classification, wound healing, tissue engineering, and psychological aspects of therapy and prevention. (J Am Podiatr Med Assoc 92(1): 2-6, 2002)
Background: We evaluated the cost of treating neuroischemic ulcers of the lower extremity in patients with peripheral artery disease by using medical and hospital claims records submitted for reimbursement to payers (private insurance, Medicare, Medicaid).
Methods: Adjudicated claims and remittance data on claims that include submitted charges, line items paid by insurers directly to providers and patient payments of copays, deductibles and co-insurance were used. Eligible patients from a commercial database containing more than 60% of US patients with health insurance were analyzed. Patient selection, performed using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, yielded a study population of 42,837 unique anonymized patients.
Results: Using the metric of “submitted charges” to overcome differences in levels of reimbursement across insurance payers and Medicare/Medicaid, we identified 34,348 patients with ulcers with an average treatment cost of $94,100 per patient ($41,800 annualized) The costliest ulcer subtype was nonpressure ulcer of the heel/midfoot among 13,184 patients with $121,400 per patient ($53,900 annualized), 29% higher than across all ulcer types. The subset of 22,281 ulcer patients who also had a surgical procedure incurred costs of $121,000 per patient ($53,800 annualized). The costliest surgical codes were complications of vascular prosthetic devices, implants, grafts among 6444 patients with $146,900 per patient ($65,300 annualized). The combination of most expensive ulcer and most expensive surgery yielded a cohort of 2355 patients with the highest average cost of $177,400 per patient ($78,800 annualized).
Conclusions: The resource burden for management of neuroischemic ulcers of the lower extremity in patients with peripheral artery disease is substantial. Mitigating this burden may help reduce significant resource utilization.
Matrix metalloproteinases (MMPs) degrade extracellular matrix components. Increased MMP-9 content in diabetic skin contributes to skin vulnerability and refractory foot ulcers. To identify ways to decrease MMP-9 levels in skin, inhibition of MMP-9 expression in dermal fibroblasts using small interfering RNA was investigated in vitro.
A full-thickness wound was created on the midback of streptozotocin-induced diabetic rats; skin biopsies were performed 3 days later. Skin MMP-9 expression was observed by immunohistochemical analysis. Dermal fibroblasts from 1-day-old normal Sprague Dawley rats cultured with high glucose and homocysteine concentrations were transfected with small interfering RNA complexes. Cells were collected 30, 48, and 72 hours after transfection, and reverse transcription–polymerase chain reaction, Western blot analysis, and gelatin zymography for MMP-9 were performed.
Expression of MMP-9 was increased in diabetic rat skin, especially around wounds. After 30-, 48-, and 72-hour transfection with each MMP-9–specific small interfering RNA, reverse transcription–polymerase chain reaction showed markedly decreased MMP-9 messenger RNA expression, protein abundance, and activity. Of four MMP-9 small interfering RNAs, one sequence had a stable high inhibition rate (>70% at 30 and 48 hours after transfection).
Expression of MMP-9 was increased in diabetic rat skin, especially around wounds, and was markedly inhibited after MMP-9 small interfering RNA transfection in vitro (P < .05). These findings may provide new treatments for diabetic skin wounds. (J Am Podiatr Med Assoc 102(4): 299–308, 2012)
At the end of an anatomical peninsula, the foot in diabetes is prone to short- and long-term complications involving neuropathy, vasculopathy, and infection. Effective management requires an interdisciplinary effort focusing on this triad. Herein, we describe the key factors leading to foot complications and the critical skill sets required to assemble a team to care for them. Although specific attention is given to a conjoined model involving podiatric medicine and vascular surgery, the so-called toe and flow model, we further outline three separate programmatic models of care—basic, intermediate, and center of excellence—that can be implemented in the developed and developing world. (J Am Podiatr Med Assoc 100(5): 342–348, 2010)