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Clinicians caring for chronic wounds can easily overlook nutritional status. Patients with diabetes are at high risk for primary and secondary malnutrition. Although profiles exist defining the extent of the deficiency, the process of wound healing and the interactions of the macronutrients and micronutrients necessary to accomplish it must first be understood. In elderly patients with diabetes, additional factors such as liver and renal function, the interdependence of the immune system, and protein synthesis, also must be considered. This article provides a practical format to assist clinicians in better evaluating this often difficult-to-assess area of care. (J Am Podiatr Med Assoc 92(1): 38-47, 2002)
Background: Diabetes-related peripheral neuropathy (DPN) and limited joint mobility of the foot and ankle are implicated in the development of increased plantar pressures and diabetes-related foot ulcers. The extent of this relationship has not been conclusively established. We aimed to determine the relationship between ankle joint and first metatarsophalangeal joint dorsiflexion range of motion and DPN using a cross-sectional observational study design.
Methods: Primary outcomes were DPN status, ankle joint range of motion (extended and flexed knee lunge tests), and nonweightbearing first metatarsophalangeal joint range of motion. Correlations were performed using Pearson r, and hierarchical regression analyses were undertaken to determine the independent contribution of DPN to the variance in dorsiflexion range of motion of ankle and first metatarsophalangeal joints using standardized β regression coefficients, controlling for age, sex, body mass index, diabetes duration, and hemoglobin A1c level.
Results: One hundred one community-dwelling participants (mean ± SD age, 65.0 ± 11.2 years; 55 men; 97% type 2 diabetes; mean ± SD diabetes duration, 8.7 ± 7.8 years; 23% with DPN) were recruited. Diabetes-related peripheral neuropathy demonstrated significant correlations with reduced range of motion at the ankle joint (knee extended: r = –0.53; P < .001 and knee flexed: r = –0.50; P < .001) and the first metatarsophalangeal joint (r = –0.37; P < .001). Also, DPN made significant, unique contributions to the regression models for range of motion at the ankle joint (knee extended: r2 change = 0.121; β = –0.48; P < .001 and knee flexed: r2 change = 0.109; β = –0.45; P < .001) and first metatarsophalangeal joint (r2 change = 0.037; β = –0.26; P = .048).
Conclusions: These findings suggest that DPN contributes to reduced ankle and first metatarsophalangeal joint range of motion. Due to the established link between reduced ankle and first metatarsophalangeal joint range of motion and risk of diabetes-related foot ulcer, we recommend that clinicians assess dorsiflexion range of motion at these joints as part of routine foot assessment in people with diabetes, especially those with DPN.
Globally, approximately 436 million adults aged 20 to 79 years are living with diabetes. 1 Diabetes is the leading cause of lower-limb amputation and is associated with a lifetime incidence of diabetes-related foot ulcer (DFU) of up to 34%. 2 Diabetes-related peripheral neuropathy (DPN) affects approximately 30% to 50% of people with diabetes 3 and is one of the most significant risk factors for the development of DFU and amputation. 4 Diabetes-related peripheral neuropathy occurs as a result of neural ischemia and perineural edema causing neural demyelination, affecting nerve conductivity. 5 In the presence of DPN, intrinsic foot muscle wasting can lead to the development of foot deformities such as digital clawing, which, when coupled with structural and functional changes to the skin, make it less resistant to shear forces and further increase plantar pressure and risk of DFU. 6 , 7
Background: We sought to determine the frequency of toenail onychomycosis in diabetic patients, to identify the causative agents, and to evaluate the epidemiologic risk factors.
Methods: Data regarding patients’ diabetic characteristics were recorded by the attending internal medicine clinician. Clinical examinations of patients’ toenails were performed by a dermatologist, and specimens were collected from the nails to establish the onycomycotic abnormality. All of the specimens were analyzed by direct microscopy and culture.
Results: Of 321 patients with type 2 diabetes mellitus, clinical onychomycosis was diagnosed in 162; 41 of those diagnoses were confirmed mycologically. Of the isolated fungi, 23 were yeasts and 18 were dermatophytes. Significant correlations were found between the frequency of onychomycosis and retinopathy, neuropathy, obesity, family history, and duration of diabetes. However, no correlation was found with sex, age, educational level, occupation, area of residence, levels of hemoglobin A1c and fasting blood glucose, and nephropathy. The most frequently isolated agents from clinical specimens were yeasts.
Conclusions: Long-term control of glycemia to prevent chronic complications and obesity and to promote education about the importance of foot and nail care should be essential components in preventing onychomycosis and its potential complications, such as secondary foot lesions, in patients with diabetes mellitus. (J Am Podiatr Med Assoc 101(1): 49–54, 2011)
The timely and accurate noninvasive assessment of peripheral arterial disease is a critical component of a limb preservation initiative in patients with diabetes mellitus. Noninvasive vascular studies can be useful in screening patients with diabetes for peripheral arterial disease. In patients with clinical signs or symptoms, noninvasive vascular studies provide crucial information on the presence, location, and severity of peripheral arterial disease and an objective assessment of the potential for primary healing of an index wound or a surgical incision. Appropriately selected noninvasive vascular studies are important in the decision-making process to determine whether and what type of intervention might be most appropriate given the clinical circumstances. Hemodynamic monitoring is likewise important after either an endovascular procedure or a surgical bypass. Surveillance studies, usually with a combination of physiologic testing and imaging with duplex ultrasound, accurately identify recurrent disease before the occurrence of thrombosis, allowing targeted reintervention. Noninvasive vascular studies can be broadly grouped into three general categories: physiologic or hemodynamic measurements, anatomical imaging, and measurements of tissue perfusion. These types of tests and suggestions for their appropriate application in patients with diabetes are reviewed. (J Am Podiatr Med Assoc 100(5): 406–411, 2010)
This investigation evaluates the effects of diabetes on the mechanical properties of human bone, specifically, the tibia. Seven diabetic and seven nondiabetic human (male) cadaveric distal tibiae were used in this study. The average age of the diabetic cadaveric samples was 51 years (range, 46–61 years), and the average age of the nondiabetic cadaveric samples was 75 years (range, 67–85 years). Three-point bending tests for strength and stiffness were performed on a small sample of each distal tibia. Each specimen was loaded at a constant rate until failure. From the recorded curve of load versus displacement, the ultimate and yield strength of bone and the bending modulus of bone were calculated. The diabetic samples were generally weaker than the older, nondiabetic samples, but no statistically significant differences were found in the elastic modulus (P = .29), yield strength (P = .90), ultimate strength (P = .46), and fracture toughness (P = .78), leading to speculation that diabetes has an effect similar to that of aging on the musculoskeletal system. (J Am Podiatr Med Assoc 96(2): 91–95, 2006)
A traumatic amputation of a digit as a result of canine mastication and ingestion occurred in a 48-year-old woman with type 2 diabetes and peripheral neuropathy. The injury occurred during sleep and was not felt by the patient. The dangers of sleeping with one’s canine for those with neuropathic wounds are presented, and the literature is reviewed. (J Am Podiatr Med Assoc 101(3): 275–276, 2011)
Endovascular therapy has increasingly become the initial clinical option for the treatment of lower-extremity peripheral arterial occlusive disease not only for patients with claudication but also for those with critical limb ischemia. Despite this major clinical practice paradigm shift, the outcomes of endovascular therapy for peripheral arterial disease are difficult to evaluate and compare with established surgical benchmarks because of the lack of prospective randomized trials, incomplete characterization of indications for intervention, mixing of arterial segments and extent of disease treated, the multiplicity of endovascular therapy techniques used, the exclusion of early treatment failures, crossover to open bypass during follow-up, and the frequent lack of intermediate and long-term patency and limb salvage rates in life-table format. These data limitations are especially problematic when one tries to assess the outcomes of endovascular therapy in patients with diabetes. The purpose of the present article is to succinctly review and objectively analyze available data regarding the results of endovascular therapy in patients with diabetes. (J Am Podiatr Med Assoc 100(5): 424–428, 2010)
Dosing Activity and Return to Preulcer Function in Diabetes-Related Foot Ulcer Remission
Patient Recommendations and Guidance from the Limb Preservation Consortium at USC and the Rancho Los Amigos National Rehabilitation Center
Diabetes-related foot ulcers are a leading cause of global morbidity, mortality, and health-care costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year after healing, and most occur in the first 3 months after wound healing. Hence, this period after ulceration is called “remission” due to this risk of reulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health-related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate off-loading and monitoring in people with a recently healed foot ulcer, foot reconstruction, or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring, which can identify dangerous “hotspots” prone to recurrence. By understanding areas at risk, patients are empowered to maximize ulcer-free days and to enable an improved quality of life. This perspective outlines a unified strategy to treat patients in the remission period after ulceration and aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patients to ensure a safe transition to footwear and return to activity.
Background:
Split-thickness skin grafts can be used for foot wound closure in diabetic and nondiabetic patients. It is unknown whether this procedure is reliable for all diabetic patients, with or without comorbidities of diabetes, including cardiovascular disease, neuropathy, retinopathy, and nephropathy.
Methods:
We retrospectively reviewed 203 patients who underwent this procedure to determine significant differences in healing time, postoperative infection, and need for revisional surgery and to create a predictive model to identify diabetic patients who are likely to have a successful outcome.
Results:
Overall, compared with nondiabetic patients, diabetic patients experienced a significantly higher risk of delayed healing time and postoperative complication/infection and, hence, are more likely to require revisional surgery after undergoing the initial split-thickness skin graft procedure. These differences seemed to be related more to the presence of comorbidities than to diabetic status itself. Diabetic patients with preexisting comorbidities experienced a significantly increased risk of delayed healing time and postoperative infection and a higher need for revisional surgery compared with nondiabetic patients or diabetic patients without comorbidities. However, there were no significant differences in outcome between diabetic patients without comorbidities and nondiabetic patients.
Conclusions:
For individuals with diabetes but without exclusionary comorbidities, split-thickness skin grafting may be considered an effective surgical alternative to other prolonged treatment options currently used in this patient population. (J Am Podiatr Med Assoc 103(3): 223–232, 2013)
Fifteen percent of individuals with diabetes will likely develop foot ulcers in their lifetime, and approximately 15% to 20% of these ulcers are estimated to result in lower extremity amputation. Techniques to prevent lower extremity amputation range from the simple but often neglected foot inspection to complicated vascular and reconstructive foot surgery. Appropriate management can prevent and heal diabetic foot ulcers, thereby greatly decreasing the amputation rate and medical care costs. Prevention is the key to treatment. The author discusses general guidelines for foot screening and identifies three specific goals for prevention of amputation: 1) identification of at risk individuals needing prevention and the specific factors placing them at risk; 2) protection of the foot against the adverse effects of external forces (pressure, friction, and shear); and 3) reduction of the incidence of diabetic foot ulcers through educational programs.
