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Granuloma annulare is a rare skin condition sometimes associated with diabetes mellitus. The natural history including diagnosis and therapy are discussed and a case is presented.
The Costs of Diabetic Foot
The Economic Case for the Limb Salvage Team
In 2007, the treatment of diabetes and its complications in the United States generated at least $116 billion in direct costs; at least 33% of these costs were linked to the treatment of foot ulcers. Although the team approach to diabetic foot problems is effective in preventing lower-extremity amputations, the costs associated with implementing a diabetic-foot–care team are not well understood. An analysis of these costs provides the basis for this report.
Diabetic foot problems impose a major economic burden, and costs increase disproportionately to the severity of the condition. Compared with diabetic patients without foot ulcers, the cost of care for those with foot ulcers is 5.4 times higher in the year after the first ulcer episode and 2.8 times higher in the second year. Costs for treating the highest-grade ulcers are 8 times higher than are those for treating low-grade ulcers. Patients with diabetic foot ulcers require more frequent emergency department visits and are more commonly admitted to the hospital, requiring longer lengths of stay. Implementation of the team approach to manage diabetic foot ulcers in a given region or health-care system has been reported to reduce long-term amputation rates 62% to 82%. Limb salvage efforts may include aggressive therapy such as revascularization procedures and advanced wound-healing modalities. Although these procedures are costly, the team approach gradually leads to improved screening and prevention programs and earlier interventions and, thus, seems to reduce long-term costs.
To date, aggressive limb preservation management for patients with diabetic foot ulcers has not usually been paired with adequate reimbursement. It is essential to direct efforts in patient-caregiver education to allow early recognition and management of all diabetic foot problems and to build integrated pathways of care that facilitate timely access to limb salvage procedures. Increasing evidence suggests that the costs of implementing diabetic foot teams can be offset in the long term by improved access to care and reductions in foot complications and amputation rates. (J Am Podiatr Med Assoc 100(5): 335–341, 2010)
Background: Studies have shown that personal and economic reasons determine whether clinicians use diagnostic technology in their routine clinical biomechanical practice. This study aimed to identify the biomechanical management plan of local clinicians in relation to management of the diabetic high-risk foot and to investigate whether diagnostic technology is being used to determine the effectiveness of dispensed prescription orthoses in view of ulcer prevention.
Methods: A mixed-methodologic approach was adopted in this study. A retrospective quantitative study was also conducted to access records of patients attending the biomechanics clinic at a local health biomechanics clinic. Outcomes of interest included the number and percentage of patients attending the biomechanics clinic, source of referral to this clinic, age and gender of patients, clinical diagnosis, management plan, and referral pathway. Following a phenomenologic approach, four experienced clinicians working in the private, primary, and tertiary health sectors were interviewed. Thematic analysis was used to analyze and interpret data.
Results: Only low-risk patients living with diabetes mellitus were referred for a comprehensive biomechanical examination; the majority were referred by podiatrists. There was no record of diabetic high-risk patients being referred for a detailed biomechanical assessment within the health service. This study also confirmed that, because of the expenses and laborious work involved when using diagnostic technology to assess foot pressures, interviewed clinicians based their treatment plan and tested the efficiency of dispensed offloading devices on the basis of clinical experience and visual observation only.
Conclusions: Waiting for signs of ulceration can be too late for the high-risk foot. A change in clinical practice is recommended where the integration of diagnostic technology, together with standard care, in view of ulcer prevention is warranted.
Background: It is well documented that diabetes has a systemic impact on bone mineral density. Recent literature has evaluated the relationship between the development of Charcot neuroarthropathy and reduced local bone mineral density; however, it is not clear if there is an association between osteoporosis/osteopenia and Charcot onset, or, even further, location of neuroarthropathic breakdown.
Methods: We retrospectively identified and assessed 39 patients with 41 feet (4 bilateral) with a history of Charcot breakdown who underwent a bone mineral density scan over a 15-year period. Demographic, radiographic, and bone mineral density information was analyzed.
Results: The average patient age at the time of bone mineral density scan was 53.44 ± 8.09 years, and 52.77 ± 8.19 years at the time of Charcot diagnosis. Four feet were considered Sanders-Frykberg I (9.3%), 17 were Sanders-Frykberg II (39.5%), ten were Sanders-Frykberg III (23.3%), and 12 were Sanders-Frkyberg IV/V (27.9%). Neuroarthropathic breakdown of the rearfoot region (Sanders-Frykberg IV/V) was found to be associated and preceded by osteoporosis and osteopenia at the hip as demonstrated by a lower Z-score (P = 0.05). Charcot neuroarthropathy was not associated with poor bone health or loss of bone mineral density at the femoral neck, forearm, or lumbar spine.
Conclusions: We believe that the present findings suggest a possible relationship between osteoporosis/osteopenia and the location of CN development. With these findings in mind, we conclude that patients with diabetic skeletal fragility may benefit from treatment of underlying poor bone mineral density to prevent the onset of Charcot neuroarthropathy.
Background: Diabetic neuropathy leads to progressive loss of sensation, lower-limb distal muscle atrophy, autonomic impairment, and gait alterations that overload feet. This overload has been associated with plantar ulcers even with consistent daily use of shoes. We sought to investigate and compare the influence of diabetic neuropathy and plantar ulcers in the clinical history of diabetic neuropathic patients on plantar sensitivity, symptoms, and plantar pressure distribution during gait while patients wore their everyday shoes.
Methods: Patients were categorized into three groups: a control group (CG; n = 15), diabetic patients with a history of neuropathic ulceration (DUG; n = 8), and diabetic patients without a history of ulceration (DG; n = 10). Plantar pressure variables were measured by Pedar System shoe insoles in five plantar regions during gait while patients wore their own shoes.
Results: No statistical difference between neuropathic patients with and without a history of plantar ulcers was found in relation to symptoms, tactile sensitivity, and duration of diabetes. Diabetic patients without ulceration presented the lowest pressure–time integral under the heel (72.1 ± 16.1 kPa × sec; P = .0456). Diabetic patients with a history of ulceration presented a higher pressure–time integral at the midfoot compared to patients in the control group (59.6 ± 23.6 kPa × sec × 45.8 ± 10.4 kPa × sec; P = .099), and at the lateral forefoot compared to diabetic patients without ulceration (70.9 ± 17.7 kPa sec × 113.2 ± 61.1 kPa × sec, P = .0193). Diabetic patients with ulceration also presented the lowest weight load under the hallux (0.06 ± 0.02%, P = .0042).
Conclusions: Although presenting a larger midfoot area, diabetic neuropathic patients presented greater pressure–time integrals and relative loads over this region. Diabetic patients with ulceration presented an altered dynamic plantar pressure pattern characterized by overload even when wearing daily shoes. Overload associated with a clinical history of plantar ulcers indicates future appearance of plantar ulcers. (J Am Podiatr Med Assoc 99(4): 285–294, 2009)
DermACELL: Human Acellular Dermal Matrix Allograft
A Case Report
Diabetes often causes ulcers on the feet of diabetic patients. A 56-year-old, insulin-dependent, diabetic woman presented to the wound care center with a Wagner grade 3 ulcer of the right heel. She reported a 3-week history of ulceration with moderate drainage and odor and had a history of ulceration and osteomyelitis in the contralateral limb. Rigorous wound care, including hospitalization; surgical incision and drainage; intravenous antibiotic drug therapy; vacuum-assisted therapy; and a new room temperature, sterile, human acellular dermal matrix graft were used to heal the wound, save her limb, and restore her activities of daily living. This case presentation involves alternative treatment of a diabetic foot ulcer with this new acellular dermal matrix, DermACELL.
Background
Diabetic foot ulcers combined with ischemia and infection can be difficult to treat. Few studies have quantified the level of blood supply and infection control required to treat such complex diabetic foot ulcers. We aimed to propose an index for ischemia and infection control in diabetic chronic limb-threatening ischemia (CLTI) with forefoot osteomyelitis.
Methods
We retrospectively evaluated 30 patients with diabetic CLTI combined with forefoot osteomyelitis who were treated surgically from January 2009 to December 2016. After 44 surgeries, we compared patient background (age, sex, hemodialysis), infection status (preoperative and 1- and 2-week postoperative C-reactive protein [CRP] levels), surgical bone margin (with or without osteomyelitis), vascular supply (skin perfusion pressure), ulcer size (wound grade 0–3 using the Society for Vascular Surgery Wound, Ischemia, and foot Infection classification), and time to wound healing between patients with healing ulcers and those with nonhealing ulcers.
Results
Preoperative CRP levels and the ratio of ulcers classified as wound grade 3 were significantly lower and skin perfusion pressure was significantly higher in the healing group than in the nonhealing group (P < .05). No other significant differences were found between groups.
Conclusions
This study demonstrates that debridement should be performed first to control infection if the preoperative CRP level is greater than 40 mg/L. Skin perfusion pressure of 55 mm Hg is strongly associated with successful treatment. We believe that this research could improve the likelihood of salvaging limbs in patients with diabetes with CLTI.
Bullosis diabeticorum is a rare complication of long-standing diabetes mellitus. Bullous lesions, which appear like burn-induced blisters, occur suddenly without trauma in the feet. These bullae heal spontaneously without scarring; however, recurrence is common. The etiology of bullosis diabeticorum remains unknown. Several theories exist as to causal and contributory factors related to this cutaneous manifestation of diabetes mellitus.
Background
The preferred primary treatment of toe osteomyelitis in diabetic patients is controversial. We compared the outcome of primary nonoperative antibiotic treatment versus digital amputation in patients with diabetes-related chronic digital osteomyelitis.
Methods
We conducted a retrospective medical record review of patients treated for digital osteomyelitis at a single center. Patients were divided into two groups according to initial treatment: 1) nonoperative treatment with intravenous antibiotics and 2) amputation of the involved toe or ray. Duration of hospitalization, number of rehospitalizations, and rate of below- or above-the-knee major amputations were evaluated.
Results
The nonoperative group comprised 39 patients and the operative group included 21 patients. The mean ± SD total duration of hospitalization was 24.05 ± 15.43 and 20.67 ± 15.97 days, respectively (P = .43). The mean ± SD number of rehospitalizations after infection recurrence was 2.62 ± 1.63 and 1.67 ± 1.24, respectively (P = .02). During follow-up, the involved digit was eventually amputated in 13 of the 39 nonoperatively treated patients (33.3%). The rate of major amputation (above- or below-knee amputation was four of 39 (10.3%) and three of 21 (14.3%), respectively (P = .69).
Conclusions
Despite a higher rate of rehospitalizations and a high failure rate, in patients with mild and limited digital foot osteomyelitis in the absence of sepsis it may be reasonable to offer a primary nonoperative treatment for digital osteomyelitis of the foot.
People suffering from diabetes are at risk of developing foot ulcerations which, if left untreated, could also lead to amputation. Monitoring of the foot temperature can help in the prevention of these foot complications, and various studies have shown that elevated temperatures may be indicative of ulceration. Over the years, there have been various devices that were designed for foot temperature monitoring, for both clinical and home use. The technologies used included infrared thermometry, liquid crystal thermography, infrared thermography, and a vast range of analogue and digital temperature sensors incorporated into different measurement platforms. All these systems are able to collect thermal data from the foot, with some being able to acquire data only when the foot is stationary and others being able to acquire data from the foot in motion, which can give more in-depth insight into any emerging problems. The aim of this review is to evaluate the available literature related to the technologies used in these systems, outlining the benefits of each and what further developments may be required to make the foot temperature analysis more effective.
