Although total-contact cast (TCC) systems are considered the gold standard for off-loading plantar ulcers, less than 6% of patients with diabetic foot ulcers receive them due to negative perceptions of special technique requirements and time investment in their application and removal. We compared the ease of use and casting time of four TCC systems.
Four novice casters applied each of the four TCC systems three times using the manufacturer's written instructions for cast application and removal of each cast type. For each TCC system, casters also provided ratings of quality and effectiveness, their level of confidence in applying each system, and overall ease of use.
The time to complete the first application of each cast type was not different among TCC systems. However, by the third application, TCC-EZ had a significantly faster application time than the other three TCC systems. In addition, TCC-EZ was considered better overall in packaging and instructions, quality of cast components, and casting method than the other TCC systems. Half of the casters rated TCC-EZ and MedE-Kast as the easiest to apply after the third and final trial, and TCC-EZ and MedE-Kast were rated as being the cast chosen to use in the casters' clinical practices.
One of the obstacles to use of TCC systems, despite being recognized as the gold standard of off-loading, is the perception of a prolonged learning curve on application. This study demonstrated that TCC-EZ can be applied by novice casters in less than 14 minutes after their third application experience.
The coronavirus disease of 2019 pandemic is driving significant change in the health-care system and disrupting the best practices for diabetic limb preservation, leaving large numbers of patients without care. Patients with diabetes and foot ulcers are at increased risk for infections, hospitalization, amputations, and death. Podiatric care is associated with fewer diabetes-related amputations, emergency room visits, hospitalizations, length-of-stay, and costs. However, podiatrists must mobilize and adopt the new paradigm of shifts away from hospital care to community-based care. Implementing the proposed Pandemic Diabetic Foot Triage System, in-home visits, higher acuity office visits, telemedicine, and remote patient monitoring can help podiatrists manage patients while reducing the coronavirus disease of 2019 risk. The goal of podiatrists during the pandemic is to reduce the burden on the health-care system by keeping diabetic foot and wound patients safe, functional, and at home.
Insoles are commonly used to assist in the prevention of diabetic neuropathic foot ulceration. Insole replacement is often triggered only when foot lesions deteriorate, an indicator that functional performance is comprised and patients are exposed to unnecessary ulcer risk. We investigated the durability of insoles used for ulcer prevention in neuropathic diabetic feet over 12 months.
Sixty neuropathic individuals with diabetes were provided with insoles and footwear. Insole durability over 12 months was evaluated using an in-shoe pressure measurement device and through repeated measurement of material depth at the first metatarsal head and the heel seat. Analysis of variance was performed to assess change across time (at issue, 6 months, and 12 months).
Analyses were conducted using all available data (n = 43) and compliant data (n = 18). No significant difference was found in the reduction of mean peak pressure tested across time (P < .05). For both sites, significant differences in insole depth were identified between issue and 6 months and between issue and 12 months but not between 6 and 12 months (P < .05). Most insole compression occurred during the initial 6 months.
Visual material compression does not seem to be a reliable indicator of insole usefulness. Frequency of insole replacement is best informed by a functional review of effect determined using an in-shoe pressure measurement system. These results suggest that insoles for diabetic neuropathic patients can be effective in maintaining peak pressure reduction for 12 months regardless of wear frequency.
Emergency department visits for lower extremity complications of diabetes are extremely common throughout the world. Surprisingly, recent data suggest that such visits generate an 81.2% hospital admission rate with an annual bill of at least $1.2 billion in the United States alone. The likelihood of amputation and other subsequent adverse outcomes is strongly associated with three factors: 1) wound severity (degree of tissue loss), 2) ischemia, and 3) foot infection. Using these factors, this article outlines the basic principles needed to create an evidence-based, rapid foot assessment for diabetic foot ulcers presenting to the emergency department, and suggests the establishment of a “hot foot line” for an organized, expeditious response from limb salvage team members. We present a nearly immediate assessment and referral system for patients with atraumatic tissue loss below the knee that has the potential to vastly expedite lower extremity triage in the emergency room setting through greater collaboration and organization.
A case report is presented of a 65-year-old diabetic woman with an 18-month history of a penetrating ulcer of the plantar aspect of the first metatarsal head with associated sepsis of the first metatarsophalangeal joint and adjacent underlying osteomyelitis. Salvage of the first metatarsophalangeal joint was performed through aggressive soft-tissue and osseous debridement, external fixation with antibiotic-loaded polymethyl methacrylate bone cement, and delayed interpositional autogenous iliac crest bone graft arthrodesis. Osseous incorporation of the interposed bone graft occurred 12 weeks postoperatively. No soft-tissue or osseous complications occurred during the postoperative period, and at 1-year follow-up there was no evidence of ulceration recurrence, transfer ulceration, shoe-fit problems, or gait abnormalities. A detailed review of the literature on the use of external fixation and interpositional bone graft distraction arthrodesis of the first metatarsophalangeal joint is presented. (J Am Podiatr Med Assoc 94(5): 492–498, 2004)
This randomized, prospective, multicenter, open-label study was designed to test whether a topical, electrolyzed, superoxidized solution (Microcyn Rx) is a safe and effective treatment for mildly infected diabetic foot ulcers.
Sixty-seven patients with ulcers were randomized into three groups. Patients with wounds irrigated with Microcyn Rx alone were compared with patients treated with oral levofloxacin plus normal saline wound irrigation and with patients treated with oral levofloxacin plus Microcyn Rx wound irrigation. Patients were evaluated on day 3, at the end of treatment on day 10 (visit 3), and 14 days after completion of therapy for test of cure (visit 4).
In the intention-to-treat sample at visit 3, the clinical success rate was higher in the Microcyn Rx alone group (75.0%) than in the saline plus levofloxacin group (57.1%) or in the Microcyn Rx plus levofloxacin group (64.0%). Results at visit 4 were similar. In the clinically evaluable population, the clinical success rate at visit 3 (end of treatment) for patients treated with Microcyn Rx alone was 77.8% versus 61.1% for the levofloxacin group. The clinical success rate at visit 4 (test of cure) for patients treated with Microcyn Rx alone was 93.3% versus 56.3% for levofloxacin plus saline–treated patients. This study was not statistically powered, but the high clinical success rate (93.3%) and the P value (P = .033) suggest that the difference is meaningfully positive for Microcyn Rx–treated patients.
Microcyn Rx is safe and at least as effective as oral levofloxacin for mild diabetic foot infections. (J Am Podiatr Med Assoc 101(6): 484–496, 2011)
We report an unusual case of Aeromonas hydrophilia septicemia in a nonmobile diabetic patient secondary to contaminated well water used for bathing with a portal of entry through chronic forefoot and heel ulcers. To date, there are no documented cases similar to this patient's presentation. Aeromonas hydrophilia is commonly distributed among aquatic environments and tends to be found during warmer months. It is a rare cause of disease but can be life threatening and deadly, as in our case, in immunocompromised individuals. As podiatric physicians, we must remain diligent and have a high index of suspicion to identify patients at risk for this rare but serious infection and administer treatment aggressively to limit morbidity and mortality.
The structure, classification, function, and regulation of matrix metalloproteinases in normal and abnormal wound healing is discussed. Results from key studies suggest that neutrophil-derived matrix metalloproteinase 8 (MMP-8) is the predominant collagenase present in normal healing wounds, and that overexpression and activation of this collagenase may be involved in the pathogenesis of nonhealing chronic leg ulcers. Excessive collagenolytic activity in these chronic wounds is possible because of the reduced levels of tissue inhibitor metalloproteinase 1 (TIMP-1). However, until recently, there have been no studies evaluating levels of matrix metalloproteinase or tissue inhibitors of metalloproteinase activity in chronic diabetic foot wounds. Improving basic knowledge and pharmaceutical intervention in this area ultimately may help clinicians identify and proactively intervene in an effort to prevent normal wounds from becoming chronic. This may prevent the high prevalence of morbidity associated with this significant health problem. (J Am Podiatr Med Assoc 92(1): 12-18, 2002)
Background: Treatment of diabetic foot wounds remains a major health-care issue, with diabetic foot ulcers representing the most common causal pathway to lower-extremity amputation. Although several investigations have examined topical collagen-based dressings, none have specifically looked at equine pericardium. We, therefore, evaluated the effect of the equine pericardium dressing on neuropathic foot wounds.
Methods: Twenty-three consecutive patients with 34 neuropathic foot wounds were evaluated as part of a pilot study. An equine pericardium dressing was applied in a standard manner, and the patients followed a standard postapplication treatment protocol. Changes in wound size were recorded when the equine dressing was removed and 4 and 12 weeks after application. Patients underwent dressing changes every 3 to 4 days until healed or for 12 weeks.
Results: Thirty-two wounds in 22 patients were prospectively available for evaluation. On enrollment, the median wound size was 299 mm2. When the equine material was removed (mean, 2.9 weeks), 30 of the wounds (94%) had improved, with a median size of 115 mm2 and an average reduction in size of 44.3% (P < .0001). At 4 weeks, the average decrease in wound size was 52.3% (P < .0001). At 12 weeks, 15 wounds (47%) had healed.
Conclusions: This first report of equine pericardium used to treat neuropathic foot ulcerations demonstrates that the equine pericardium dressing is a safe and beneficial treatment for neuropathic wounds. (J Am Podiatr Med Assoc 99(4): 301–305, 2009)
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)