Search Results
Background: Charcot neuroarthropathy (CN) is a devastating complication of some diseases affecting the peripheral nervous system. Initial subjective and objective presentation of the disease can be variable. Common among all presentations seems to be uncontrolled inflammation yielding dislocations and/or fractures. The exact cause remains the subject of much debate.
Methods: Our study retrospectively looks at the function of olfactory function in consecutive patients with CN and compares the findings with a nonaffected population. The University of Pennsylvania Smell Identification Test was used to assess olfaction and document microsomia.
Results: Twenty consecutive patients presenting with CN demonstrated significant (P < .0001) microsomia when compared to an unaffected population with diabetes.
Conclusions: Microsomia is strongly associated with CN. This finding may be correlated to voltage-gated sodium 1.7 channel impairment and appears to be a candidate precursor for the development of CN.
A prospective epidemiologic survey on the prevalence of foot disease in Hong Kong found foot disease in 64% of patients screened. All of the patients were ethnically Chinese. Of the conditions specified in the questionnaire, fungal foot infection, tinea pedis, and toenail onychomycosis were the most frequently encountered conditions, followed by metatarsal corns, eczema, psoriasis, and pes planus. Vascular disease, osteoarticular pathology, diabetes mellitus, obesity, atopy, and participation in sports were the main factors coexisting with the foot conditions. Of the study population, 17% and 21% reported that their quality of life was affected by pain and discomfort, respectively. These percentages are much lower than those obtained in other studies; it may therefore be inferred that foot complaints are being neglected by the ethnic Chinese population in Hong Kong. (J Am Podiatr Med Assoc 92(8): 450-456, 2002)
Background: We sought to examine the economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers by evaluating cost outcomes for patients with diabetic foot ulcer who did and did not receive care from a podiatric physician in the year before the onset of a foot ulcer.
Methods: We analyzed the economic value among commercially insured patients and Medicare-eligible patients with employer-sponsored supplemental medical benefits using the MarketScan Databases. The analysis consisted of two parts. In part I, we examined cost or savings per patient associated with care by podiatric physicians using propensity score matching and regression techniques; in part II, we extrapolated cost or savings to populations.
Results: Matched and regression-adjusted results indicated that patients who visited a podiatric physician had $13,474 lower costs in commercial plans and $3,624 lower costs in Medicare plans during 2-year follow-up (P < .01 for both). A positive net present value of increasing the share of patients at risk for diabetic foot ulcer by 1% was found, with a range of $1.2 to $17.7 million for employer-sponsored plans and $1.0 to $12.7 million for Medicare plans.
Conclusions: These findings suggest that podiatric medical care can reduce the disease and economic burdens of diabetes. (J Am Podiatr Med Assoc 101(2): 93–115, 2011)
This case report presents a rare postoperative dislocation of the fifth metatarsal base following a healed open partial fourth and fifth ray amputation of a 62-year-old male veteran with poorly controlled diabetes mellitus. The dislocated fifth metatarsal base subsequently created a chronic ulceration and an inhibition of normal gait. The patient was taken to the operating room where the fifth metatarsal base was resected with transfer of the peroneus brevis tendon to the cuboid to maintain biomechanical stability. (J Am Podiatr Med Assoc 102(1): 71–74, 2012)
A Diabetic Foot Ulcer Pilot Study
Does Silicone Gel Sheeting Reduce the Incidence of Reulceration?
Background: Silicone gel sheeting is an effective therapeutic intervention in the management of scar tissue. This pilot study was designed to examine the effect of silicone gel sheeting in preventing reulceration at former wound sites in diabetic patients.
Methods: Thirty patients with diabetes and a healed plantar neuropathic foot ulcer were enrolled and investigated in this randomized controlled trial. Participants with a newly healed ulcer were assigned to use either silicone gel sheeting or emollient cream daily for 3 months.
Results: Compared with emollient cream use, the use of silicone gel sheeting did not diminish and may have potentially increased the risk of reulceration.
Conclusions: Silicone gel sheeting does not seem to reduce the risk of reulceration in diabetic patients. The results of this trial should be viewed with caution given the small sample size. (J Am Podiatr Med Assoc 101(2): 116–123, 2011)
Background
The definition of equinus varies from less than 0° to less than 25° of dorsiflexion with the foot at 90° to the leg. Despite its pervasive nature and broad association with many lower-extremity conditions, the prevalence of ankle equinus is unclear. Furthermore, there are few data to suggest whether equinus is predominantly a bilateral finding or isolated to the affected limb only.
Methods
We conducted a prospective cohort study examining consecutive patients attending a single foot and ankle specialty practice. Participation involved an assessment of ankle joint range of motion by a single rater with more than 25 years of clinical experience. We defined ankle equinus as ankle joint dorsiflexion range of motion less than or equal to 0° and severe equinus as less than or equal to –5°. Patients who had previously experienced an Achilles tendon rupture, undergone posterior group lengthening (ie, Achilles tendon or gastrocnemius muscle lengthening), or had conservative or surgical treatment of equinus previously were excluded.
Results
Of 249 included patients, 61% were female and 79% nondiabetic. The prevalence of ankle equinus was 73% [183 of 249], and nearly all of these patients had bilateral restriction of ankle joint range of motion (prevalence of bilateral ankle equinus was 98.4% [180 of 183] among those with equinus). We also found that ankle equinus was more common in patients with diabetes, higher body mass indexes (BMIs), or overuse symptoms.
Conclusions
The prevalence of ankle equinus in this sample was higher than previously reported, and nearly all of these patients had bilateral involvement. These data suggest that many people attending foot/ankle specialty clinics will have ankle equinus, and select groups (diabetes, increased BMI, overuse symptoms) are increasingly likely.
Cost-Effectiveness of Becaplermin Gel on Diabetic Foot Ulcer Healing
Changes in Wound Surface Area
Background: A comparison of the cost-effectiveness of becaplermin plus good wound care (BGWC) versus good wound care (GWC) alone in treating patients with diabetic foot ulcers (DFUs) may enable physicians and health-care decision makers in the United States to make better-informed choices about treating DFUs, which currently contribute to a substantial portion of the economic burden of diabetes.
Methods: Data from three phase III trials were used to predict expected 1-year costs and outcomes, including the average percentage reduction from baseline in wound surface area (WSA), the direct costs of DFU therapy, and the cost per cm2 of WSA reduction.
Results: At 20 weeks, the BGWC group had a statistically greater probability of complete wound closure than the GWC group (50% versus 35%; P = .015). Based on reported WSA reduction rates, DFUs in the BGWC group were predicted to close by 100% at 27 weeks, and those in the GWC group were predicted to close by 88% at 52 weeks. The GWC group had higher total estimated 1-year direct cost of DFU care ($6,809 versus $4,414) and higher cost per cm2 of wound closure ($3,501 versus $2,006).
Conclusions: Becaplermin plus good wound care demonstrated economic dominance compared with GWC by providing better clinical outcomes via faster reduction in WSA and higher rates of closure at a lower direct cost.
Previous anatomic studies of the medial heel region were done on embalmed human cadavers. Here, the innervation of the medial heel region was studied by dissecting living tissue with the use of 3.5-power loupe magnification during decompression of the medial ankle for tarsal tunnel syndrome in 85 feet. The medial heel was found to be innervated by just one medial calcaneal nerve in 37% of the feet, by two medial calcaneal nerves in 41%, by three medial calcaneal nerves in 19%, and by four medial calcaneal nerves in 3%. An origin for a medial calcaneal nerve from the medial plantar nerve was found in 46% of the feet. This nerve most often innervates the skin of the posteromedial arch, where it is at risk for injury during calcaneal spur removal or plantar fasciotomy. Knowledge of the variations in location of the medial calcaneal nerves may prevent neuroma formation during surgery and provide insight into the variability of heel symptoms associated with tarsal tunnel syndrome. (J Am Podiatr Med Assoc 92(2): 97-101, 2002)
Osteolysis, caused by active resorption of bone matrix by osteoclasts, can be primary or can develop secondary to a variety of disease processes. An elevated level of inflammatory cytokines in the local milieu and increased blood flow secondary to infection or autonomic neuropathy stimulate the osteoclasts and cause bone loss in the diabetic foot. Charcot's neuroarthropathy and osteomyelitis are well-known foot complications of diabetes, and secondary osteolysis has largely been underappreciated and, hence, underreported. Plain radiographs, an initial component in the evaluation of the diabetic foot, may not successfully differentiate secondary osteolysis from osteomyelitis. We describe a patient with phalangeal osteolysis secondary to soft-tissue infection in whom a correct and timely diagnosis helped avoid unnecessary surgical interventions.
Background: Neurologic screening tests are often used to identify and stratify patients at risk for diabetic foot complications such as infections, ulcers, and amputations. Two of the most commonly cited methods are the 5.07 Semmes-Weinstein monofilament (SWM) for loss of protective sensation and vibratory sensation testing. The aim of this study was to determine whether combined SWM and the timed vibration test (TVT) more effectively predicts diabetic foot ulcer (DFU) development compared with each test alone.
Methods: An electronic medical record database search was performed restricted to podiatric medical clinic patients with diabetes and DFU ICD-10 diagnosis codes. Of 200 patients who met the criteria, 24 developed DFUs. A statistical analysis was performed comparing the SWM and TVT at various cutoff times and the combined SWM/TVT in their ability to predict DFUs.
Results: Statistical analysis revealed that the TVT cutoff time of less than 4 sec was superior to the other times for prediction of DFUs. The combined SWM/TVT results at less than 4 sec were superior to each test individually: sensitivity, 87.5%; specificity, 84.7%; positive predictive value, 43.8%; and receiver operating characteristics area under the curve, 0.86.
Conclusions: The SWM combined with TVT was shown to be superior compared with either test alone in discriminating DFU risk. In addition, the TVT cutoff time of less than 4 sec proved to have greater diagnostic yield than other times, including 0 sec. This unexpected finding might impact providers relying on the absence of vibration sensation via tuning fork testing as an optimal marker of DFU risk.
