Search Results
Foot Problems in Older Patients
A Focused Podogeriatric Assessment Study in Ambulatory Care
This study sought to demonstrate the prevalence of foot conditions in older individuals and their association with chronic risk diseases such as diabetes mellitus, peripheral arterial disease, and arthritis, and to develop care plans to reduce complications from local foot problems and chronic diseases. One thousand individuals older than 65 years who were ambulatory and not institutionalized underwent a standardized and validated podogeriatric examination assessment protocol or index. Overall, 74.6% of all patients had a history of pain, 57.2% were receiving current care for diabetes mellitus, 22.9% indicated current care for peripheral vascular disease, 94.2% had onychodystrophy, 64.2% had one or more foot deformities, 64.0% demonstrated some loss of protective sensation, and 81.7% had one or more symptoms and signs of peripheral arterial insufficiency. These findings demonstrate that foot problems in the older population result from disease, disability, and deformity related to multiple chronic diseases as well as changes associated with repetitive use and trauma. Older people are at a high risk of developing foot-related disease and should receive continuing foot assessment, education, surveillance, and care. (J Am Podiatr Med Assoc 94(3): 293–304, 2004)
Background: Diabetes-related lower-extremity amputations are largely preventable. Eighty-five percent of amputations are preceded by a foot ulcer. Effective management of ulcers, which leads to healing, can prevent limb loss.
Methods: In a county hospital, we implemented a six-step approach to the diabetic limb at risk. We calculated the frequency and level of lower-extremity amputations for 12 months before and 12 months after implementation of the amputation prevention program. We also calculated the high-low amputation ratio for the years reviewed. The high-low amputation ratio is a quality measure for the success of amputation prevention measures and is calculated as the ratio of the number of high amputations (limb losses) over the number of low (partial foot) amputations.
Results: The frequency of total amputations increased from 24 in year 1 to 46 in year 2. However, the number of limb losses decreased from 7 to 2 (72%). The high-low amputation ratio decreased eightfold in 1 year, which serves as a marker for limb salvage success.
Conclusions: Improvement in care organization and multidisciplinary-centered protocols can substantially reduce limb losses. (J Am Podiatr Med Assoc 100(2): 101–104, 2010)
Does Footwear Affect Balance?
The Views and Experiences of People with Diabetes and Neuropathy Who Have Fallen
Background:
Despite falls being a major concern for people living with somatosensory deficit, little is known about the perceived impact of footwear and footwear features on balance. Clinical relevance is increased given that therapeutic footwear is often provided to people with diabetes to reduce foot ulcer risk. This qualitative study aims to explore the experiences and views of people with diabetes and neuropathy who have recently fallen to understand whether footwear type is perceived to affect balance or contribute to falling.
Methods:
Sixteen individuals (13 men and three women aged 44–83 years) were purposively sampled from a larger population of potential participants. Audio-recorded, in-depth, semistructured interviews were conducted in participant homes or at a place preferable to them. Once transcribed verbatim, the data were themed, charted, and interpreted using a framework approach.
Results:
Although most participants did not believe that the footwear in which they fell contributed to their fall, most revealed how footwear choice influenced their balance confidence to undertake daily tasks. Most found their therapeutic footwear “difficult” to walk in, “heavy, or “slippery bottomed.” Design recommendations for enhanced balance included a close fit with tight fastening, lightweight, substantial tread, and a firm, molded sole/insole. Complying with these recommendations, the hiking sandal was believed to be the most stable and safe shoe and was frequently worn as a walking aid to reduce fear of falling and boost confidence.
Conclusions:
People with diabetic neuropathy have disease-specific needs and concerns relating to how footwear affects balance. Engaging with patients to address those needs and concerns is likely to improve the feasibility and acceptability of therapeutic footwear to reduce foot ulcer risk and boost balance confidence. (J Am Podiatr Med Assoc 103(6): 508–515, 2013)
Nerve Decompression After Diabetic Foot Ulceration May Protect Against Recurrence
A 3-Year Controlled, Prospective Analysis
Background
Nerve entrapment, common in diabetes, is considered an associated phenomenon without large consequence in the development of diabetes complications such as ulceration, infection, amputation, and early mortality. This prospective analysis, with controls, of the ulcer recurrence rate after operative nerve decompression (ND) offers an objective perspective on the possibility of frequent occult nerve entrapment in the diabetic foot complication cascade.
Methods
A multicenter cohort of 42 patients with diabetic sensorimotor polyneuropathy, failed pharmacologic pain control, palpable pulses, and at least one positive Tinel's nerve percussion sign was treated with unilateral multiple lower-leg external neurolyses for the indication of pain. All of the patients had healed at least one previous ipsilateral plantar diabetic foot ulceration (DFU). This group was retrospectively evaluated a minimum of 12 months after operative ND and again 3 years later. The recurrence risk of ipsilateral DFU in that period was prospectively analyzed and compared with new ulcer occurrence in the contralateral intact, nonoperated control legs.
Results
Operated legs developed two ulcer recurrences (4.8%), and nine contralateral control legs developed ulcers (21.4%), requiring three amputations. Ulcer risk is 1.6% per patient per year in ND legs and 7% in nonoperated control legs (P = .048).
Conclusions
Adding operative ND at lower-leg fibro-osseous tunnels to standard postulcer treatment resulted in a significantly diminished rate of subsequent DFU in neuropathic high-risk feet. This is prospective, objective evidence that ND can provide valuable ongoing protection from DFU recurrence, even years after primary ulcer healing.
Data from 37 patients who underwent a transmetatarsal amputation from January 1993 to April 1996 were reviewed. The mean age and diabetes duration of the subjects were 54.9 (± 13.2) years and 16.6 (± 8.9) years, respectively. The follow-up period averaged 42.1 (± 11.2) months. At the time of follow-up, 29 (78.4%) of the 37 patients still had foot salvage, 8 (21.6%) had progressed to below-the-knee amputation, and 15 (40.5%) had undergone lower-extremity revascularization. Twelve (80%) of the 15 revascularized patients preserved their transmetatarsal amputation level at a follow-up of 36.4 months. The authors concluded that at a maximum of 3 years follow-up after initial amputation, transmetatarsal amputation was a successful amputation level. (J Am Podiatr Med Assoc 91(10): 533-535, 2001)
Elevated plantar pressures are an important predictor of diabetic foot ulceration. The objective of this study was to determine which clinical examination variables predict high plantar pressures in diabetic feet. In a cross-sectional study of 152 male veterans with diabetes mellitus, data were collected on demographics, comorbid conditions, disease severity, neuropathy status, vascular disease, and orthopedic and gait examinations. Univariate predictors included height, weight, body surface area, body weight per square inch of foot surface area, bunion deformity, hammer toe, Romberg’s sign, insensitivity to monofilament, absent joint position sense, decreased ankle dorsiflexion, and fat pad atrophy. Variables that remained significantly associated with high plantar pressures (≥4 kg/cm2) in multivariate analysis included height, body weight per square inch of foot surface area, Romberg’s sign, and insensitivity to monofilament. These results may be useful in identifying patients who would benefit from interventions designed to decrease plantar foot pressures. (J Am Podiatr Med Assoc 93(5): 367-372, 2003)
Painful peripheral neuropathy is a common complication of diabetes mellitus that can affect almost every tissue of the body. In the absence of a curative therapy for this disorder, pharmacologic or nonpharmacologic tools, or a combination of both, can be used to provide relief of symptoms. This article reviews medications currently used to manage painful diabetic neuropathy. The pathogenesis of painful diabetic neuropathy is described as a basis for understanding medication selection. The literature describing the pharmacologic properties of medications used to treat painful diabetic neuropathy is also reviewed. Comparisons of medication dosages, frequencies, and adverse effects are offered to help with selection of the most appropriate agent for each individual patient. (J Am Podiatr Med Assoc 97(5): 394–401, 2007)
Methicillin-Resistant Staphylococcus aureus Endocarditis from a Diabetic Foot Ulcer
Understanding and Mitigating the Risk
Diabetic foot infections are a common cause of morbidity and mortality in the United States, and successful treatment often requires an aggressive and prolonged approach. Recent work has elucidated the importance of appropriate therapy for a given severity of diabetic foot infection, and highlighted the ongoing risk such patients have for subsequent invasive life-threatening infection should diabetic foot ulcers fail to heal. The authors describe the case of a man with diabetes who had prolonged, delayed healing of a diabetic foot ulcer. The ulcer subsequently became infected by methicillin-resistant Staphylococcus aureus (MRSA). The infection was treated conservatively with oral therapy and minimal debridement. Several months later, he experienced MRSA bloodstream infection and complicating endocarditis. The case highlights the ongoing risk faced by patients when diabetic foot ulcers do not heal promptly, and emphasizes the need for aggressive therapy to promote rapid healing and eradication of MRSA.
Renal failure is defined as a deterioration of kidney function that results in the retention of nitrogenous waste products. It is increasingly prevalent in older populations, individuals with diabetes or hypertension, and postoperative patients. Therefore, podiatric physicians caring for these populations can expect to encounter this condition frequently. This article describes the epidemiology, causes, complications, and appropriate evaluation of renal failure relevant to a practicing podiatric physician. Also highlighted are treatment considerations, renal dosing of medications, and prevention of contrast nephropathy. (J Am Podiatr Med Assoc 94(2): 168-176, 2004)
Background: A feasibility study was conducted to characterize the effects of noncontact low-frequency ultrasound therapy for chronic, recalcitrant lower-leg and foot ulcerations.
Methods: The study was an open-label, nonrandomized, baseline-controlled clinical case series. Patients were initially treated with the Mayo Clinic standard of care before the addition of or the switch to noncontact low-frequency ultrasound therapy. We analyzed the medical records of 51 patients (median ± SD age, 72 ± 15 years) with one or more of the following conditions: diabetes mellitus, neuropathy, limb ischemia, chronic renal insufficiency, venous disease, and inflammatory connective tissue disease. All of the patients had lower-extremity ulcers, 20% had a history of amputation, and 65% had diabetes. Of all the wounds, 63% had a multifactorial etiology, and 65% had associated transcutaneous oximetry levels below 30 mm Hg.
Results: The mean ± SD treatment time of wounds during the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 9.8 ± 5.5 weeks versus 5.5 ± 2.8 weeks (P < .0001). Initial and end measurements were recorded, and percent volume reduction of the wound was calculated. The mean ± SD percent volume reduction in the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 37.3% ± 18.6% versus 94.9% ± 9.8% (P < .0001).
Conclusions: Using noncontact low-frequency ultrasound improved the rate of healing and closure in recalcitrant lower-extremity ulcerations. (J Am Podiatr Med Assoc 97(2): 95–101, 2007)
