We sought to develop a consensus statement for the use of off-loading in the management of diabetic foot ulcers (DFUs).
A literature search of PubMed for evidence regarding off-loading of DFUs was initially conducted, followed by a meeting of authors on March 15, 2013, in Philadelphia, Pennsylvania, to draft consensus statements and recommendations using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach to assess quality of evidence and develop strength of recommendations for each consensus statement.
Evidence is clear that adequate off-loading increases the likelihood of DFU healing and that increased clinician use of effective off-loading is necessary. Recommendations are included to guide clinicians on the optimal use of off-loading based on an initial comprehensive patient/wound assessment and the necessity to improve patient adherence with off-loading devices.
The likelihood of DFU healing is increased with off-loading adherence, and, current evidence favors the use of nonremovable casts or fixed ankle walking braces as optimum off-loading modalities. There currently exists a gap between what the evidence supports regarding the efficacy of DFU off-loading and what is performed in clinical practice despite expert consensus on the standard of care.
Metabolic disorders are known to alter the mechanical properties of tendons. We sought to evaluate the prevalence of asymptomatic Achilles tendon enthesopathic changes in patients with type 2 diabetes mellitus (T2DM) without peripheral neuropathy.
We recruited 43 patients with T2DM and 40 controls. Neuropathy was excluded with the Michigan Neuropathy Scoring Instrument. Bilateral ultrasonography of the Achilles tendon enthesis was performed.
Patients with T2DM had a higher prevalence of hypoechogenicity (26.7% versus 2.5%; P = .0001), entheseal thickening (24.4% versus 8.7%; P = .007), and enthesophytes (74.4% versus 57.5%; P = .02). No differences were found in the number of patients with erosions (1.2% versus 0%; P > .99), cortical irregularities (11.6% versus 3.7%; P = .09), bursitis (5.8% versus 3.7%; P = .72), or tears (2.3% versus 1.2%; P > .99). The mean ± SD sum of abnormalities was higher in patients with T2DM (1.5 ± 1.1 versus 0.7 ± 0.6; P < .0001), as was the percentage of bilateral involvement (72.1% versus 45.0%; P = .01). Mean ± SD thickness did not differ between patients and controls (4.4 ± 1.1 mm versus 4.2 ± 0.8 mm; P = .07).
According to our data, there is an elevated prevalence of asymptomatic Achilles tendon enthesopathic changes in patients with T2DM independent of peripheral neuropathy.
A prospective, randomized study was conducted to determine the effect of biofeedback-assisted relaxation training on foot ulcer healing. For patients with chronic nonhealing foot ulcers, medical care was combined with a standardized biofeedback-assisted relaxation training program in the experimental group. The intervention was designed to increase peripheral perfusion, thereby promoting healing. A total of 32 patients with chronic nonhealing ulcers participated in the study. In the experimental group, 14 out of 16 ulcers (87.5%) healed, as compared with 7 out of 16 ulcers (43.8%) in the control group. (J Am Podiatr Med Assoc 91(3): 132-141, 2001)
Studies on obtaining donor skin graft using intravenous sedation for patients undergoing major foot surgeries in the same operating room visit have not previously been reported. The objective of this retrospective study is to demonstrate that intravenous sedation in this setting is both adequate and safe in patients undergoing skin graft reconstruction of the lower extremities in which donor skin graft is harvested from the same patient in one operating room visit.
Medical records of 79 patients who underwent skin graft reconstruction of the lower extremities by one surgeon at the Yale New Haven Health System between November 1, 2008, and July 31, 2014, were reviewed. The patients' demographic characteristics, American Society of Anesthesiologists class, comorbid conditions, intraoperative analgesic administration, estimated blood loss, total operating room time, total postanesthesia care unit time, and postoperative complications within the first 72 hours were reviewed.
This study found minimal blood loss and no postoperative complications, defined as any pulmonary or cardiac events, bleeding, admission to the intensive care unit, or requirement for invasive monitoring, in patients who underwent major foot surgery in conjunction with full-thickness skin graft.
We propose that given the short duration and peripheral nature of the procedures, patients can safely undergo skin graft donor harvesting and skin graft reconstruction procedures with intravenous sedation regardless of American Society of Anesthesiologists class in one operating room visit.
One relatively universal functional goal after major lower-limb amputation is ambulation in a prosthesis. This retrospective, observational investigation sought to 1) determine what percentage of patients successfully walked in a prosthesis within 1 year after major limb amputation and 2) assess which patient factors might be associated with ambulation at an urban US tertiary-care hospital.
A retrospective medical record review was performed to identify consecutive patients undergoing major lower-limb amputation.
The overall rate of ambulation in a prosthesis was 29.94% (50.0% of those with unilateral below-the-knee amputation [BKA] and 20.0% of those with unilateral above-the-knee amputation [AKA]). In 24.81% of patients with unilateral BKA or AKA, a secondary surgical procedure of the amputation site was required. In those with unilateral BKA or AKA, statistically significant factors associated with ambulation included male sex (odds ratio [OR] = 2.50) and at least 6 months of outpatient follow-up (OR = 8.10), survival for at least 1 postoperative year (OR = 8.98), ambulatory preamputation (OR = 14.40), returned home after the amputation (OR = 6.12), and healing of the amputation primarily without a secondary surgical procedure (OR = 3.62). Those who had a history of dementia (OR = 0.00), a history of peripheral arterial disease (OR = 0.35), and a preamputation history of ipsilateral limb revascularization (OR = 0.14) were less likely to walk. We also observed that patients with a history of outpatient evaluation by a podiatric physician before major amputation were 2.63 times as likely to undergo BKA as opposed to AKA and were 2.90 times as likely to walk after these procedures.
These results add to the body of knowledge regarding outcomes after major amputation and could be useful in the education and consent of patients faced with major amputation.
Diabetic foot infections (DFIs) are the most common cause of hospitalization for patients with diabetes. Studies have shown diabetic patients have high readmission rates. It is important to identify variables that contribute to readmission. This study aimed to investigate clinical variables associated with 30-day hospital readmission in patients with DFI.
We conducted a retrospective study of adults admitted to the hospital for DFI between July 1, 2012, and July 1, 2015. We identified patients by International Classification of Diseases, Ninth Revision codes and randomly selected 35% of medical records for review. Patients were excluded if they did not have a DFI by review, were pregnant, or were incarcerated. The primary outcome was 30-day readmission. Data collected included baseline demographics, medical comorbidities, substance abuse, homelessness, tobacco use, and laboratory and surgical pathology data. Univariate and multivariate logistic regression models were used to identify independent predictors.
Of 140 included patients, 106 (76%) were male. Median age was 55 years and length of stay (LOS) was 7 days. In univariate analysis, 31 patients (22%) were readmitted in the 30 days after the index hospitalization. Factors associated with readmission included treatment failure, elevated C-reactive protein level, and hospital LOS (P < .05). In multivariate analyses, LOS and treatment failure were independent predictors of readmission.
The 30-day readmission rate for patients with DFI is high. Treatment failure, C-reactive protein, and LOS are independently associated with readmission. More work is needed to determine reasons for readmission so that appropriate measures can be taken before discharge.
Background: The diabetic foot is one of the main complications of diabetes mellitus, with a high risk of minor or major amputation. The preclinical foot lesions of patients without foot complaints were compared with healthy controls and analyzed.
Methods: This study was conducted with 89 diabetic patients from an endocrinology clinic and 35 nondiabetic control patients. The patients were asked about the presence, types, and durations of pedal complaints; acquired and congenital foot deformities; and atrophy. Patient gaits were inspected for any swelling; skin and nail changes were also recorded. Ranges of articular motion, deformities, crepitations, and any painful perceptions were noted.
Results: The differences between groups were significant for sensorial defects, joint changes of the foot, nail abnormalities, and neuropathic changes.
Conclusions: Every patient with an established diagnosis of diabetes can be considered a potential sufferer of diabetic foot for whom medical therapy and foot protection programs are indicated. (J Am Podiatr Med Assoc 99(2): 114–120, 2009)
Insufficient information exists about the nature of toe-brachial indices (TBIs) and how best to obtain them, yet their validity may be particularly important for the identification and management of peripheral artery disease and cardiovascular disease risk. We explore ways in which valid TBI measurements might be obtained.
The TBI data were recorded from 97 people with subnormal toe pressures. Most people provided three TBI readings from each foot on six different occasions over a 6-month period. The foot with the lower baseline TBI was noted.
For most people, only small inconsistencies existed among the three readings taken from each foot on a single occasion, and there were no consistent differences based on sequence. However, for some people there were noticeable and unsystematic differences among the measures. Selecting any specific one of the three readings based on its sequential position, or averaging specific readings, did not yield TBIs that were unequivocally typical for a person, and taking the lowest reading of each set seemed to offer the most expedient solution in this context. That permitted baseline descriptive statistics to be produced for both the higher and lower pressure feet, between which there was a statistically significant TBI difference.
Accurate and consistent TBI readings cannot be assumed for people with subnormal toe pressures, and taking only a single reading or indiscriminately averaging readings seems inadvisable. Two readings and, if they are discrepant, additional readings, are recommended for each foot, ideally on several occasions, and careful consideration should be given to determine the most representative reading for each foot. Cuff sizes and other sources of inaccuracy or distortion should not be ignored, and standardized protocols for obtaining TBIs are recommended.
Onychocryptosis is a pathologic condition of the nail apparatus in which the toenail damages the nail fold. It is a common condition provoking pain, inflammation, and functional limitation. It principally occurs in the hallux. Onychocryptosis is one of the most frequent complaints regarding the foot and accounts for many clinical consultations. The disorder has been classified in terms of the stages of the pathologic condition. In our practice, we discovered a clinical entity that was not previously classified in the literature. We classify onychocryptosis into stages I, IIa, IIb, III, and the new stage IV. A treatment plan is offered for each stage of this classification, with both general and specific indications given. In onychocryptosis treatment, it is important to select the surgical technique best suited to the patient’s particular clinical situation. (J Am Podiatr Med Assoc 97(5): 389–393, 2007)
The relationship between hyperglycemia and adverse outcomes after surgery has been widely documented. Long-term glucose control has been recognized as a risk factor for postoperative complications. In the foot and ankle literature, long-term glycemic control as a potential perioperative risk factor is not well studied. Our goal was to investigate whether hemoglobin A1c (HbA1c) level was independently associated with postoperative complications in a retrospective cohort study.
Three hundred twenty-two patients with a diagnosis of diabetes mellitus were enrolled in the study to assess risk factors associated with postoperative foot and ankle surgery complications.
Bivariate analyses showed that HbA1c level and having at least one comorbidity were associated with postoperative infections. However, after adjusting for other covariates, the only significant factor was HbA1c level, with each increment of 1% increasing the odds of infection by a factor of 1.59 (95% confidence interval [CI], 1.28–1.99). For postoperative wound-healing complications, bivariate analyses showed that body mass index, having at least one comorbidity, and HbA1c level were significant factors. After adjusting for other covariates, the only significant factors for developing postoperative wound complications were having at least one comorbidity (odds ratio, 2.03; 95% CI, 1.22–3.37) and HbA1c level (each 1% increment) (odds ratio, 1.25; 95% CI, 1.02–1.53).
In this retrospective study, HbA1c level had the strongest association with postoperative foot and ankle surgery complications in patients with diabetes.