Preventive foot-care practices, such as annual foot examinations by a health-care provider, can substantially reduce the risk of lower-extremity amputations. We examined the level of preventive foot-care practices (reported rates of having at least one foot examination by a physician) among patients with diabetes mellitus in North Carolina and determined the factors associated with these practices. Of 1,245 adult respondents to the 1997 to 2001 North Carolina Behavioral Risk Factor Surveillance System, 71.6% reported that they had had their feet examined within the past year, a rate that is much higher than that previously reported by Bell and colleagues in the same population for 1994 to 1995 (61.7%). Foot care was more common among insulin users than nonusers, those having diabetes for 20 years or longer than those having diabetes for less than 10 years, blacks than whites, and those who self-monitored their blood glucose level daily than those who did not. The results of this study indicate that diabetes educational services can be directed at populations at high risk of ignoring the recommended foot-care practices indicated in these analyses, thereby reducing diabetes-related lower-extremity complications. (J Am Podiatr Med Assoc 94(5): 483–491, 2004)
Background: People with diabetic foot ulcers report poor quality of life. However, prospective studies that chart quality of life from the onset of diabetic foot ulcers are lacking. We describe change in quality of life in a cohort of people with diabetes and their first foot ulcer during 18 months and its association with adverse outcomes.
Methods: In this prospective cohort study of adults with their first diabetic foot ulcer, the main outcome was change in Medical Outcomes Study 36-Item Short Form Health Survey scores between baseline and 18-month follow-up. We recorded baseline demographics, diabetes characteristics, depression, and diabetic foot outcomes and mortality at 18 months.
Results: In 253 people with diabetes and their first ulcer, there were 40 deaths (15.8%), 36 amputations (15.5%), 99 recurrences (43.2%), and 52 nonhealing ulcers (21.9%). The 36-Item Short Form Health Survey response rate of survivors at 18 months was 78% (n = 157). There was a 5- to 6-point deterioration in mental component summary scores in people who did not heal (adjusted mean difference, −6.54; 95% confidence interval, −12.64 to −0.44) or had recurrent ulcers (adjusted mean difference, −5.30; 95% confidence interval, −9.87 to −0.73) and a nonsignificant reduction in those amputated (adjusted mean difference, −5.00; 95% confidence interval, −11.15 to 1.14).
Conclusions: Quality of life deteriorates in people with diabetes whose first foot ulcer recurs or does not heal within 18 months. (J Am Podiatr Med Assoc 99(5): 406–414, 2009)
A 42-year-old woman presented to the emergency department with progressive painful discoloration of the digits of her right foot and symptoms previously diagnosed as neuroma. She was admitted to the hospital for dorsalis pedis arterial occlusion and ischemic foot pain. Despite attempts to restore perfusion to the right leg, ischemia of the right foot persisted and progressed to digital gangrene. The patient subsequently required right transmetatarsal amputation and eventually below-the-knee amputation. After extensive inpatient vascular and hematologic work-up of this otherwise healthy woman, test results revealed that she had protein S deficiency, hepatitis C, and human immunodeficiency virus type 1. In addition to describing this patient’s evaluation and treatment, we review protein S deficiency, including its correlation with human immunodeficiency virus type 1 infection and laboratory diagnosis. This case promotes awareness of protein S deficiency and serves as a reminder to the physician treating patients with vascular compromise and a history of human immunodeficiency virus type 1 to include protein S deficiency in the differential diagnosis. (J Am Podiatr Med Assoc 97(2): 151–155, 2007)
The comorbidities of diabetes mellitus were evaluated in an Asian American population with podiatric symptoms living in southern California. The three most common nonpedal complaints in men were blurred vision (73.6%), hypertension (64.1%), and erectile dysfunction (52.3%) and in women were blurred vision (84.5%), incontinence (71.5%), and low-back pain with radiculopathy-like symptoms (56.5%). The most significant finding was that only 3.2% of all patients had any previous knowledge or understanding of the risks of foot infection, ulceration, and amputation secondary to diabetes mellitus. The prevalence of diabetes mellitus in ethnic populations once considered practically exempt continues to rise steadily, and Asians living in the United States are becoming casualties of diabetes mellitus and its complications. (J Am Podiatr Med Assoc 93(1): 37-41, 2003)
Diabetic foot ulcer (DFU) is a serious health problem. Major amputation increases the risk of mortality in patients with DFU; therefore, treatment methods other than major amputation come to the fore for these patients. Graft applications create an appropriate environment for the reproduction of epithelial cells. Similarly, epidermal growth factor (EGF) also stimulates epithelization and increases epidermis formation. In this study, we aimed to compare patients with DFU treated with EGF and those treated with a split-thickness skin graft.
Patients who were treated for DFU in the general surgery clinic were included in the study. The patients were evaluated retrospectively according to their demographic characteristics, wound characteristics, duration of treatment, and treatment modalities.
There were 26 patients in the EGF group and 21 patients in the graft group. The mean duration of treatment was 7 weeks (4-8 weeks) in the EGF group and 5.3 weeks (4-8 weeks) in the graft group (P < .05). In the EGF group, wound healing could not be achieved in one patient during the study period. In the graft group, no recovery was achieved in three patients (14.2%) in the donor site. Graft loss was detected in four patients (19%), and partial graft loss was observed in three patients (14.2%). The DFU of these patients were on the soles (85.7%). These patients have multiple comorbidities.
EGF application may be preferred to avoid graft complications in the graft area and the donor site, especially in elderly patients with multiple comorbidities and wounds on the soles.
We sought to determine patient and ulcer characteristics that predict wound healing in patients living with diabetes.
A prospective observational study was conducted on 99 patients presenting with diabetic foot ulceration. Patient and ulcer characteristics were recorded. Patients were followed up for a maximum of 1 year.
After 1 year of follow-up, ulcer characteristics were more predictive of ulcer healing than were patient characteristics. Seventy-seven percent of ulcers had healed and 23% had not healed. Independent predictors of nonhealing were ulcer stage (P = .003), presence of biofilm (P = .020), and ulcer depth (P = .028). Although this study demonstrated that the baseline hemoglobin A1c reading at the start of the study was not a significant predictor of foot ulcer outcome (P = .603, resolved versus amputated), on further statistical analyses, when hemoglobin A1c was compared with the time taken for complete ulcer healing (n = 77), it proved to be significant (P = .009).
The factors influencing healing are ulcer stage, presence of biofilm, and ulcer depth. These findings have important implications for clinical practice, especially in an outpatient setting. Prediction of outcome may be helpful for health-care professionals in individualizing and optimizing clinical assessment and management of patients. Identification of determinants of outcome could result in improved health outcomes, improved quality of life, and fewer diabetes-related foot complications.
Diabetic foot disease frequently leads to substantial long-term complications, imposing a huge socioeconomic burden on available resources and health-care systems. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common underlying pathways that lead to skin breakdown, often setting the stage for limb-threatening infection. Individuals with diabetes presenting with foot infection warrant optimal surgical management to affect limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. In addition, the initial surgical intervention or series of interventions must be coupled with appropriate systemic metabolic management as part of an integrated, multidisciplinary team. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health-care systems. This article presents a stepwise approach to the diagnosis and treatment of diabetic foot infections with emphasis on the appropriate use of surgical interventions and includes the following key elements: incision, wound investigation, debridement, wound irrigation and lavage, and definitive wound closure. (J Am Podiatr Med Assoc 100(5): 401–405, 2010)
Charcot’s neuroarthropathy is a relatively common disease in patients with diabetic neuropathy. If unrecognized or left untreated, Charcot’s neuroarthropathy can result in a severely misshapen and unstable foot and ankle. Ulceration, soft-tissue infection, and osteomyelitis frequently ensue, and partial or complete amputation of the foot is not uncommon. A high index of suspicion and proper interpretation of clinical and diagnostic findings are essential to establish a timely and accurate diagnosis and to institute appropriate treatment. The pathogenesis of neuroarthropathy is reviewed and diagnosis and treatment of the stage 0 diabetic Charcot foot are presented. (J Am Podiatr Med Assoc 92(4): 210-220, 2002)
Leiomyosarcoma is a very rare malignant tumor, with only 28 new cases diagnosed in the United States each year. The prognosis varies, with average 5-year survival of 65%. Although most leiomyosarcomas occur in the lower extremity, there is a paucity in the literature on these sarcomas in the foot. Only 15 cases of leiomyosarcoma in the foot have been reported in the literature since the mid-1930s. We describe a 31-year-old man with a history of an ingrown toenail and nonhealing pyogenic granuloma. His clinical presentation suggested atypical tissue. Biopsy findings confirmed the diagnosis of spindle cell sarcoma, specifically, leiomyosarcoma. The patient was treated with amputation of the affected hallux and adjuvant therapy. The similar presentations of a pyogenic granuloma and a malignant tumor necessitate a thorough differential diagnosis with even common foot ailments. (J Am Podiatr Med Assoc 97(6): 475–479, 2007)
Desmoid-type fibromatosis (DF) is an aggressive (myo)fibroblastic neoplasm with an infiltrative growth pattern and a tendency for local recurrence. It is rarely seen at the foot. The aim of this retrospective study was to analyze clinical presentation, therapy, and outcomes in a consecutive series of four patients with DF at the foot.
From 1994 to 2014, four patients had been surgically treated. The resection margin was marginal or even intralesional in all. One patient already had local recurrence at first presentation. The end point was either local recurrence or progression of residual disease.
The mean patient age was 27 years. In one patient, marginal excision healed the disease. In another patient, local recurrence after marginal resection necessitated distal phalanx amputation. Two other patients showed stable disease after either adjuvant radiotherapy or treatment with nonsteroidal anti-inflammatory drugs and tamoxifen.
If surgery is necessary, operative margins are less important than keeping function for the patient. Radiotherapy might be an option to avoid major amputation. The role of adjuvant radiotherapy is controversially discussed. A watchful wait-and-see policy seems to be justified by the published data but may be difficult for DF at the foot.