In this study, we aimed to evaluate the potential use of a 3-phase bone scintigraphy method to determine the level of amputation on treatment cost, morbidity and mortality, reamputation rates, and the duration of hospitalization in diabetic foot.
Thirty patients who were admitted to our clinic between September 2008 and July 2009, with diabetic foot were included. All patients were evaluated according to age, gender, diabetes duration, 3-phase bone scintigraphy, Doppler ultrasound, amputation/reamputation levels, and hospitalization periods. Patients underwent 3-phase bone scintigraphy using technetium-99m methylene diphosphonate, and the most distal site of the region displaying perfusion during the perfusion and early blood flow phase was marked as the amputation level. Amputation level was determined by 3-phase bone scintigraphy, Doppler ultrasound, and inspection of the infection-free clear region during surgery.
The amputation levels of the patients were as follows: finger in six (20%), ray amputation in five (16.6%), transmetatarsal in one (3.3%), Lisfranc in two (6.6%), Chopart in seven (23.3%), Syme in one (3.3%), below-the-knee in six (20%), above the knee in one (3.3%), knee disarticulation in one (3.3%), and two patients underwent amputation at other centers. After primary amputation, reamputation was performed on seven patients, and one patient was treated with debridement for wound site problems. No mortality was encountered during study.
We conclude that 3-phase bone scintigraphy prior to surgery could be a useful method to determine the amputation level in a diabetic foot. We conclude that further, comparative, more comprehensive, long-term, and controlled studies are required.
Background: Diabetic foot infections (DFIs) can lead to limb loss and mortality. To improve patient care at a safety-net teaching hospital, we created a multidisciplinary limb salvage service (LSS).
Methods: We recruited a cohort prospectively and compared it to a historical control group. Adults admitted to the newly established LSS for DFI during a 6-month period from 2016 to 2017 were included prospectively. Patients admitted to the LSS had routine endocrine and infectious diseases consultations according to a standardized protocol. A retrospective analysis of patients admitted to the acute care surgical service for DFI before creation of the LSS during an 8-month period from 2014 to 2015 was performed.
Results: A total of 250 patients were divided into two groups: the pre-LSS (n = 92) and the LSS (n = 158) groups. There were no significant differences in baseline characteristics. Although all patients were ultimately diagnosed with diabetes, more patients in the LSS group had hypertension (71% versus 56%; P = .01) and a prior diagnosis of diabetes mellitus (92% versus 63%; P < .001) compared to the pre-LSS group. Significantly, with the LSS, fewer patients underwent a below-the-knee amputation (3.6% versus 13%; P = .001). There was no difference in the length of hospital stay or 30-day readmission rate between the groups. Further broken down into Hispanic versus non-Hispanic, we noted that Hispanics had significantly lower rates of below-the-knee amputations (3.6% versus 13.0%; P = .02) in the LSS cohort.
Conclusions: The initiation of a multidisciplinary LSS decreased the below-the-knee amputation rate in patients with DFIs. Length of stay was not increased, nor was the 30-day readmission rate affected. These results suggest that a robust multidisciplinary LSS dedicated to the management of DFIs is both feasible and effective, even in safety-net hospitals.
The Applicability of Plantar Padding in Reducing Peak Plantar Pressure in the Forefeet of Healthy Adults
Implications for the Foot at Risk
Background: We investigated the effectiveness and durability of two types of plantar padding, the plantar metatarsal pad and the single wing plantar cover, which are commonly used for reducing forefoot plantar pressures.
Methods: Mean peak plantar pressure and impulse at the hallux and at the first, second, third, and fourth metatarsophalangeal joints across both feet were recorded using the two-step method in 18 individuals with normal asymptomatic feet. Plantar paddings were retained for 5 days, and their durability and effectiveness were assessed by repeating the foot plantar measurement at baseline and after 3 and 5 days.
Results: The single wing plantar cover devised from 5-mm felt adhesive padding was effective and durable in reducing peak plantar pressure and impulse at the first metatarsophalangeal joint (P = .001 and P = .015, respectively); however, it was not found to be effective in reducing peak plantar pressure and impulse at the hallux (P = .782 and P = .845, respectively). The plantar metatarsal pad was not effective in reducing plantar forefoot pressure and impulse at the second, third, and fourth metatarsophalangeal joints (P = .310 and P = .174, respectively).
Conclusions: These results imply limited applicability of the single wing plantar cover and the plantar metatarsal pad in reducing hallux pressure and second through fourth metatarsophalangeal joint pressure, respectively. However, the single wing plantar cover remained durable for the 5 days of the trial and was effective in reducing the peak plantar pressure and impulse underneath the first metatarsophalangeal joint.
Background: We aimed to investigate whether a home exercise for self-care program that consists of range of motion (ROM), stretching, and strengthening exercises could improve ROM for foot joints and plantar pressure distribution during walking in diabetic patients to prevent diabetic foot complications.
Methods: Seventy-six diabetic patients were recruited (38 with neuropathy and 38 without neuropathy). Neuropathy and nonneuropathy groups were randomly divided into a home exercise group (n = 19) and a control group (n = 19). Exercise groups performed their own respective training programs for 4 weeks, whereas no training was done in the control group. Total contact area and plantar pressure under six foot areas before and after the exercise program were measured. Ankle and first metatarsophalangeal joint ROM were measured before and after the exercise program.
Results: In the exercise group, there were significant improvements in ROM for the ankle and first metatarsophalangeal joints (P < .001); static pedobarographic values showed significant reduction in right forefoot-medial pressure (P = .010); and significant decreases were seen in dynamic pedobarographic values of peak plantar pressure at the left forefoot medial (P = .007), right forefoot lateral (P = .018), left midfoot (P < .001), and right hindfoot (P = .021) after exercise. No significant positive or negative correlation was found between the neuropathy and nonneuropathy groups (P > .05).
Conclusions: A home exercise program could be an effective preventive method for improving ROM for foot joints and plantar pressure distribution in diabetic patients independent of the presence of neuropathy.
Background: Ultraviolet (UV)-A therapy is a simple, inexpensive, and effective modality for wound healing, with tremendous potential to improve healing and reduce clinical infections in a number of clinical settings. To date, application of UV-A relies on bulky and hard-to-dose lamps that provide inconsistent therapy, thus making it difficult to apply therapy that is appropriate for the patient.
Methods: This study was designed to test the effectiveness of a novel wound therapy device that combines UV-A with traditional negative-pressure wound therapy (NPWT) to promote wound healing. Furthermore, we tested the ability of fiberoptic UV-A delivery to inhibit bacterial proliferation. Finally, we assayed the level of DNA damage that results from UV-A as compared to established UV-C therapies. Wound healing studies were performed in a porcine model using an articulated therapy arm that allows for continued therapy administration over an extended time course. Negative-pressure wound therapy was administered alone or with UV-A fiberoptic therapy for 2 weeks. Dressings were changed twice a week, at which time wound area was assessed.
Results: Data demonstrate that UV-A with NPWT treatment of wounds results in greater healing than NPWT alone. Using the same therapy device, we demonstrate that exposure of Staphylococcus aureus and Pseudomonas aeruginosa to fiberoptic UV-A results in decreased colony area and number of both bacterial strains. Finally, we show that UV-A induces minimal DNA damage in human fibroblasts and no more DNA damage in wound tissue as compare to intact skin.
Conclusions: These data demonstrate that UV-A can decrease bacterial proliferation and promote wound healing when coupled with NPWT.
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)
One hundred eighty-seven type 2 diabetic patients without a history of foot ulceration were followed for a mean period of 3.6 years to investigate the incidence of foot ulceration in a diabetes cohort and to analyze risk factors for foot ulceration by multivariate means. During the study, 10 subjects developed 18 forefoot ulcerations. In multivariate logistic regression, significant predictors for foot ulceration were an elevated vibration perception threshold (VPT) (relative risk [RR] = 25.4), an increased plantar pressure (RR = 6.3), and daily alcohol intake (RR = 5.1). This is the first prospective study to demonstrate plantar pressure and daily alcohol intake as predictors of foot ulceration among patients without previous ulceration. Further, VPT could be confirmed as the strongest predictor for foot ulceration, and it was clearly demonstrated that the more pronounced severity of complications occurred among subjects with elevated VPT. (J Am Podiatr Med Assoc 91(7): 343-350, 2001)
Due to the exponential increase in the quantity and quality of podiatric medicine–related research during the past decade, podiatric physicians are inundated with an insurmountable volume of research relevant to clinical practice. Systematic reviews can refine this literature by using explicit, rigorous, and reproducible methods to identify, critically appraise, and synthesize the best evidence from all clinical trials to answer clearly defined clinical questions. The Cochrane Collaboration is an international not-for-profit organization created to improve the user-friendliness and accessibility of medical literature mainly through preparing and maintaining systematic reviews of health-care interventions. The Cochrane Library currently contains more than 50 podiatric medicine–relevant systematic reviews summarizing and synthesizing evidence from many hundreds of randomized controlled trials evaluating interventions for foot problems. Although more than 60 countries worldwide have open online access to The Cochrane Library, in the United States, only the state of Wyoming has free access to full-text reviews. In an era demanding an evidence-based approach for every clinical intervention, high-quality systematic reviews streamline podiatric medical literature by reducing the time, cost, and training necessary to establish a solid evidence base for practice. (J Am Podiatr Med Assoc 99(3): 260–266, 2009)
Ablative fractional laser is suggested to promote wound healing in diabetic and venous leg ulcers. In this article, we report the treatment outcome of a recalcitrant foot ulceration related to lower leg arteriopathy. A 43-year-old man with typical digital substraction angiographic findings of arteriopathy was admitted to our department after 30 sessions of hyperbaric oxygen therapy. There was heterotopic tissue within the ulcer consistent with osseous metaplasia and mature bone tissue. This tissue was removed with full-field erbium:yttrium-aluminum-garnet laser, and the remaining parts received fractional erbium:yttrium-aluminum-garnet laser for the induction of wound healing. A decrease in ulcer dimensions was achieved by the second month of laser interventions without recurrence in the first-year control.
Malignant melanoma is responsible for more than three-fourths of skin cancer deaths in the United States. Melanomas presenting on acral surfaces are frequently misdiagnosed initially, leading to progression of disease and worse prognosis. This case is presented to reinforce the significance of careful physical examination and early biopsy of atypical ulcerations of the foot.