Background: We used a model of lower-extremity ulceration to determine the impact of a podiatric lead limb preservation team on identified relationships among risk factors, predictors of ulceration, amputation, and clinical outcomes of lower-extremity disease in patients with diabetes mellitus.
Methods: A total of 485 patients with diabetes mellitus were randomly selected from the diabetic population and included in this retrospective cohort study. Patients were then stratified into two groups: those who received specialty podiatric medical care and those who did not. Data covering a 5-year period were collected using electronic medical records and chart abstraction to capture detailed treatment characteristics, ulcer status, and surgical outcomes.
Results: Overall, the frequencies of inpatient and outpatient encounters and the durations of hospital stays were significantly greater with increasing wound depth and in the presence of infection. In addition, the overall ulcer incidence was greater in patients with callus (34.3% versus 10.3%, P < .0001) with and without neuropathy (20.4% and 4.1%, P < .0001). Among patients treated in a specialty multidiscipline podiatric medical setting, the proportion of all amputations that were “minor” was significantly increased (33.7% versus 67.3%, P = .0006), and survival was significantly improved (19.5% versus 7.7%, P < .0001).
Conclusions: Early identification of individuals at increased risk for lower-extremity ulceration and subsequent referral for advanced multidiscipline podiatric medical specialty care may decrease rates of ulceration and proximal amputation and improve survival in patients with diabetes mellitus who are at high risk for ulceration and limb loss. (J Am Podiatr Med Assoc 100(4): 235–241, 2010)
Although the literature is replete with recommendations for people with diabetes—particularly those with neuropathy, ischemia, or both—to avoid caring for corns and calluses on their own feet, there are virtually no reports of damage associated with this care. The purpose of this article is to report on the potential perils of personal pedicures in the presence of peripheral neuropathy by using a case-based example. In this article, we report on the inappropriate use of a Ped Egg personal pedicure device that led to limb-threatening lesions in a gentleman with diabetic peripheral sensory neuropathy. (J Am Podiatr Med Assoc 103(5): 448–450, 2013)
With the growing prevalence worldwide of diabetes mellitus and hyperglycemia, hospital-based health-care professionals will encounter patients with these conditions with increasing frequency. It is well known that long-term control of blood glucose reduces the rate and severity of complications in patients with diabetes, but there is also mounting evidence that even short-term glycemic control in hospitalized diabetic patients can significantly lower morbidity and mortality in many areas, from nosocomial infection to postoperative course. The results of traditional approaches to controlling blood glucose in hospitalized patients have been disappointing owing to a variety of factors, including the use of oral agents that are difficult or dangerous to use in inpatients, older insulin preparations with unphysiologic modes of action, and even provider reluctance to accept glycemic control as an essential element of the care of the diabetic hospitalized patient. This article provides guidelines for the effective management of hyperglycemia in these patients throughout the hospital stay, with specific recommendations for the perioperative, operative, and postoperative periods. (J Am Podiatr Med Assoc 94(2): 135-148, 2004)
Peripheral neuropathy can be a devastating complication of diabetes mellitus. This article describes surgical decompression as a means of restoring sensation and relieving painful neuropathy symptoms. A prospective study was performed involving patients diagnosed as having type 1 or type 2 diabetes with lower-extremity peripheral neuropathy. The neuropathy diagnosis was confirmed using quantitative sensory testing. Visual analog scales were used for subjective assessment before and after surgery. Treatment consisted of external and as-needed internal neurolysis of the common peroneal, deep peroneal, tibial, medial plantar, lateral plantar, and calcaneal nerves. Subjective pain perception and objective sensibility were significantly improved in most patients who underwent the described decompression. Surgical decompression of multiple peripheral nerves in the lower extremities is a valid and effective method of providing symptomatic relief of neuropathy pain and restoring sensation. (J Am Podiatr Med Assoc 95(5): 446–450, 2005)
The Villiers-Saint-Denis Hospital in France specializes in the rehabilitation of and fitting of orthoses for lower-limb amputees, who frequently have diabetes mellitus. The percentage of partial-foot amputations has increased relative to the percentage of transtibial or transfemoral amputations. This article describes a complete range of orthoses and prostheses, adapted to each patient, that allow recovery of the standing position, gait ability, and physical activity. (J Am Podiatr Med Assoc 93(3): 221-228, 2003)
Surgical intervention for chronic deformities and ulcerations has become an important component in the management of patients with diabetes mellitus. Such patients are no longer relegated to wearing cumbersome braces or footwear for deformities that might otherwise be easily corrected. Although surgical intervention in these often high-risk individuals is not without risk, the outcomes are fairly predictable when patients are properly selected and evaluated. In this brief review, we discuss the rationale and indications for diabetic foot surgery, focusing on the surgical decompression of deformities that frequently lead to foot ulcers. (J Am Podiatr Med Assoc 100(5): 369–384, 2010)
The etiology of ulcerations related to increased plantar pressure in patients with diabetes mellitus is complex but frequently includes a component of gastrocnemius soleus equinus. One viable treatment option is percutaneous tendo Achillis lengthening as a means of increasing dorsiflexory range of motion and decreasing forefoot shear forces. This article presents three case reports illustrating the importance of reducing plantar pressure as a crucial component of treatment of diabetic forefoot ulcerations. (J Am Podiatr Med Assoc 95(3): 281–284, 2005)
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.
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.
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.
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.
There are no conclusive data to support the contention that diabetic patients have an increased frequency of ankle equinus compared with their nondiabetic counterparts. Additionally, a presumed contributing cause of foot ulceration is ankle joint equinus. Therefore, we sought to determine whether persons with diabetes have a higher prevalence of ankle joint equinus than do nondiabetic persons.
A prospective pilot survey of 102 outpatients (43 diabetic and 59 nondiabetic) was conducted. Demographic and historical data were obtained. Each patient underwent a standard lower-extremity examination, including the use of a biplane goniometer to measure ankle joint range of motion.
Equinus, defined as ankle dorsiflexion measured at 0° or less, was found in 24.5% of the overall population. In the diabetes cohort, 16 of 43 patients (37.2%) were affected compared with 9 of 59 nondiabetic participants (15.3%) (P = .011). There was a threefold risk of equinus in the diabetic population (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.28–8.44; P < .013). The equinus group had a history of ulceration in 52.0% compared with 20.8% of the nonequinus group (P = .003). Equinus, therefore, imparted a fourfold risk of ulceration (OR, 4.13; 95% CI, 1.58–10.77; P < .004). We also found a 2.8 times risk of equinus in patients with peripheral neuropathy (OR, 2.8; 95% CI, 1.11–7.09; P < .029).
Equinus may be more prevalent in diabetic patients than previously reported. Although we cannot prove causality, we found a significant association between equinus and ulceration. (J Am Podiatr Med Assoc 102(2): 84–88, 2012)
Elevated dynamic plantar pressures are a consistent finding in diabetic patients with peripheral neuropathy, with implications for plantar foot ulceration. This study aimed to investigate whether a first-ray amputation affects plantar pressures and plantar pressure distribution patterns in individuals living with diabetes and peripheral neuropathy.
A nonexperimental matched-subject design was conducted. Twenty patients living with diabetes and peripheral neuropathy were recruited. Group 1 (n = 10) had a first-ray amputation and group 2 (n = 10) had an intact foot with no history of ulceration. Plantar foot pressures and pressure-time integrals were measured under the second to fourth metatarsophalangeal joints, fifth metatarsophalangeal joint, and heel using a pressure platform.
Peak plantar pressures under the second to fourth metatarsophalangeal joints were significantly higher in participants with a first-ray amputation (P = .008). However, differences under the fifth metatarsophalangeal joint (P = .734) and heel (P = .273) were nonsignificant. Pressure-time integrals were significantly higher under the second to fourth metatarsophalangeal joints in participants with a first-ray amputation (P = .016) and in the heel in the control group (P = .046).
Plantar pressures and pressure-time integrals seem to be significantly higher in patients with diabetic peripheral neuropathy and a first-ray amputation compared with those with diabetic neuropathy and an intact foot. Routine plantar pressure screening, orthotic prescription, and education should be recommended in patients with a first-ray amputation.