Search Results
Background:
We sought to evaluate the relationship between baseline hemoglobin A1c (HbA1c) level and clinical outcomes, including foot ulcer outcome (resolved versus unresolved) and wound-healing time, in individuals with type 2 diabetes.
Methods:
A prospective observational study was conducted on 99 patients presenting with a diabetic foot ulceration. Patient and ulcer characteristics were recorded. Patients were followed up for a maximum of 1 year.
Results:
After 1 year of follow-up, 77% of ulcers healed and 23% did not heal. Although this study demonstrated that the baseline HbA1c reading was not a significant predictor of foot ulcer outcome (P = .603, resolved versus amputated), on further statistical analyses, when HbA1c was compared with the time taken for complete ulcer healing in the resolved group (n = 77), it proved to be significant (P = .009).
Conclusions:
These findings have important implications for clinical practice, especially in an outpatient setting. Improving glycemic control may improve ulcer outcomes. Prediction of outcome may be helpful for health-care professionals in individualizing and optimizing clinical assessment and management of patients. Identification of determinants of outcome could result in improved health outcomes, improved quality of life, and fewer diabetes-related foot complications.
Background: We used a model of lower-extremity ulceration to determine the impact of a podiatric lead limb preservation team on identified relationships among risk factors, predictors of ulceration, amputation, and clinical outcomes of lower-extremity disease in patients with diabetes mellitus.
Methods: A total of 485 patients with diabetes mellitus were randomly selected from the diabetic population and included in this retrospective cohort study. Patients were then stratified into two groups: those who received specialty podiatric medical care and those who did not. Data covering a 5-year period were collected using electronic medical records and chart abstraction to capture detailed treatment characteristics, ulcer status, and surgical outcomes.
Results: Overall, the frequencies of inpatient and outpatient encounters and the durations of hospital stays were significantly greater with increasing wound depth and in the presence of infection. In addition, the overall ulcer incidence was greater in patients with callus (34.3% versus 10.3%, P < .0001) with and without neuropathy (20.4% and 4.1%, P < .0001). Among patients treated in a specialty multidiscipline podiatric medical setting, the proportion of all amputations that were “minor” was significantly increased (33.7% versus 67.3%, P = .0006), and survival was significantly improved (19.5% versus 7.7%, P < .0001).
Conclusions: Early identification of individuals at increased risk for lower-extremity ulceration and subsequent referral for advanced multidiscipline podiatric medical specialty care may decrease rates of ulceration and proximal amputation and improve survival in patients with diabetes mellitus who are at high risk for ulceration and limb loss. (J Am Podiatr Med Assoc 100(4): 235–241, 2010)
The Fitting of Amputated and Nonamputated Diabetic Feet
A French Experience at the Villiers-Saint-Denis Hospital
The Villiers-Saint-Denis Hospital in France specializes in the rehabilitation of and fitting of orthoses for lower-limb amputees, who frequently have diabetes mellitus. The percentage of partial-foot amputations has increased relative to the percentage of transtibial or transfemoral amputations. This article describes a complete range of orthoses and prostheses, adapted to each patient, that allow recovery of the standing position, gait ability, and physical activity. (J Am Podiatr Med Assoc 93(3): 221-228, 2003)
Background:
There is an increased prevalence of foot ulceration in patients with diabetes, leading to hospitalization. Early wound closure is necessary to prevent further infections and, ultimately, lower-limb amputations. There is no current evidence stating that an elevated preoperative hemoglobin A1c (HbA1c) level is a contraindication to skin grafting. The purpose of this review was to determine whether elevated HbA1c levels are a contraindication to the application of skin grafts in diabetic patients.
Methods:
A retrospective review was performed of 53 consecutive patients who underwent split-thickness skin graft application to the lower extremity between January 1, 2012, and December 31, 2015. A uniform surgical technique was used across all of the patients. A comparison of HbA1c levels between failed and healed skin grafts was reviewed.
Results:
Of 43 surgical sites (41 patients) that met the inclusion criteria, 27 healed with greater than 90% graft take and 16 had a skin graft that failed. There was no statistically significant difference in HbA1c levels in the group that healed a skin graft compared with the group in which skin graft failed to adhere.
Conclusions:
Preliminary data suggest that an elevated HbA1c level is not a contraindication to application of a skin graft. The benefits of early wound closure outweigh the risks of skin graft application in patients with diabetes.
Background:
Elevated dynamic plantar pressures are a consistent finding in diabetic patients with peripheral neuropathy, with implications for plantar foot ulceration. This study aimed to investigate whether a first-ray amputation affects plantar pressures and plantar pressure distribution patterns in individuals living with diabetes and peripheral neuropathy.
Methods:
A nonexperimental matched-subject design was conducted. Twenty patients living with diabetes and peripheral neuropathy were recruited. Group 1 (n = 10) had a first-ray amputation and group 2 (n = 10) had an intact foot with no history of ulceration. Plantar foot pressures and pressure-time integrals were measured under the second to fourth metatarsophalangeal joints, fifth metatarsophalangeal joint, and heel using a pressure platform.
Results:
Peak plantar pressures under the second to fourth metatarsophalangeal joints were significantly higher in participants with a first-ray amputation (P = .008). However, differences under the fifth metatarsophalangeal joint (P = .734) and heel (P = .273) were nonsignificant. Pressure-time integrals were significantly higher under the second to fourth metatarsophalangeal joints in participants with a first-ray amputation (P = .016) and in the heel in the control group (P = .046).
Conclusions:
Plantar pressures and pressure-time integrals seem to be significantly higher in patients with diabetic peripheral neuropathy and a first-ray amputation compared with those with diabetic neuropathy and an intact foot. Routine plantar pressure screening, orthotic prescription, and education should be recommended in patients with a first-ray amputation.
Background:
We sought to determine patient and ulcer characteristics that predict wound healing in patients living with diabetes.
Methods:
A prospective observational study was conducted on 99 patients presenting with diabetic foot ulceration. Patient and ulcer characteristics were recorded. Patients were followed up for a maximum of 1 year.
Results:
After 1 year of follow-up, ulcer characteristics were more predictive of ulcer healing than were patient characteristics. Seventy-seven percent of ulcers had healed and 23% had not healed. Independent predictors of nonhealing were ulcer stage (P = .003), presence of biofilm (P = .020), and ulcer depth (P = .028). Although this study demonstrated that the baseline hemoglobin A1c reading at the start of the study was not a significant predictor of foot ulcer outcome (P = .603, resolved versus amputated), on further statistical analyses, when hemoglobin A1c was compared with the time taken for complete ulcer healing (n = 77), it proved to be significant (P = .009).
Conclusions:
The factors influencing healing are ulcer stage, presence of biofilm, and ulcer depth. These findings have important implications for clinical practice, especially in an outpatient setting. Prediction of outcome may be helpful for health-care professionals in individualizing and optimizing clinical assessment and management of patients. Identification of determinants of outcome could result in improved health outcomes, improved quality of life, and fewer diabetes-related foot complications.
Background: This study reevaluates the previously reported subjective benefits of surgical nerve decompression in diabetes with an easily observable, fully objective outcome measure to eliminate the placebo effect and observer bias.
Methods: A retrospective review was conducted of a series of 75 feet in 65 patients with diabetes and previous neuropathic ulcer who had surgical decompressions of the peroneal and posterior tibial nerve branches at anatomical fibro-osseous tunnels. After a minimum of 12 months of follow-up, the incidence of ipsilateral ulcer was assessed.
Results: Postoperatively, four ulcer recurrences and four new-site ulcers developed in 187 patient-years. Mean follow-up was 2.49 years (range, 1–13 years). The combined linear annual risk of ipsilateral recurrence and new ulcer is 4.28%, the lowest reported in the scientific literature.
Conclusions: Surgical decompression of lower-extremity nerves of high-risk feet at fibro-osseous anatomical tunnels was followed by a low annual incidence of ulcer recurrence. This objective outcome measure suggests benefits of nerve decompression in diabetic neuropathy, as have previous reports using pain and sensory change as subjective measures. Unrecognized nerve entrapment may frequently coexist with diabetic sensorimotor peripheral neuropathy in patients with diabetic foot ulcer. (J Am Podiatr Med Assoc 100(2): 111–115, 2010)
Background: We sought to determine the incidence of tinea pedis in patients with otherwise asymptomatic pedal interdigital macerations. Both diabetic and nondiabetic populations were compared. Age and body mass index were also examined for their significance.
Methods: Fungal cultures of skin scrapings from 80 patients (77 male and 3 female; mean age, 65 years) with interdigital macerations were performed; 40 patients had previously been diagnosed with type 2 diabetes and 40 did not have diabetes.
Results: Cultures revealed a 40% prevalence of tinea pedis in the total study population. The prevalence in the nondiabetic group was 37.5% and 42.5% for the diabetic group. This was not a statistically significant difference. Among patients with interdigital macerations that yielded positive fungal cultures, those in the nondiabetic group were 6.3 years older than those in the diabetic group. It was also observed that the nondiabetic patients with interdigital macerations yielding positive fungal cultures were 9.1 years older than patients with negative fungal cultures in the nondiabetic group.
Conclusion: The results of this study provide the practitioner with a guide for treating pedal interdigital macerations. Because the likelihood of a tinea pedis infection is 40%, it seems prudent to treat these macerations with an antifungal agent. In regard to age, the results suggest that as nondiabetic patients age, the likelihood of an otherwise asymptomatic interdigital maceration yielding a positive fungal culture increases, and that diabetic patients may be susceptible to interdigital fungal infections at a younger age than those without diabetes. (J Am Podiatr Med Assoc 98(5): 353–356, 2008)
Background:
Charcot neuroarthropathy (CN), or the Charcot foot, is a complication usually associated with diabetes that frequently results in changes in foot shape and structure that have an effect on function and risk of ulceration. This study aimed to assess foot shape and asymmetry in CN using the Foot Posture Index (FPI-6).
Methods:
Case notes of patients with CN seen in a diabetic orthotic clinic were reviewed, and available FPI-6 data were analyzed. A comparison group of patients with diabetes without CN was also identified. Groups were compared according to published ranges of foot posture and asymmetry using the Fisher exact test.
Results:
Twenty-seven patients with CN with 28 affected feet and a comparison group of 27 patients with diabetes only were identified. There was large variation in FPI-6 scores in affected (1 to 12) and unaffected (–1 to 10) feet. Mean scores for affected feet (6.82) and unaffected feet (5.05) differed significantly (P = .005). Considering all FPI-6 scores as positive numbers to indicate mean absolute difference between affected and unaffected feet, CN-affected feet differed by a mean of 3.00 points from unaffected feet. Patients in the CN group were less likely to have asymmetry in the normal range than the comparison group (P = .0146).
Conclusions:
This study provides new data on foot shape after CN. Patients with CN have feet that are significantly asymmetrical, and the affected foot may be more pronated or supinated. Feet affected by CN are characterized by shape, which is more frequently outside the normal range. The FPI-6 may be suitable for more widespread use in assessment and outcome measurement.
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)
