The Amputation Prevention Initiative is a project conducted jointly by the Massachusetts Public Health Association and the Massachusetts Podiatric Medical Society that seeks to study methods to reduce nontraumatic lower-extremity amputations from diabetes.
To determine the rate of diabetes-related lower-extremity amputations in Massachusetts and identify the groups most at risk, hospital billing and discharge data were analyzed. To examine the components of the diabetic foot examination routinely performed by general practitioners, surveys were conducted in conjunction with physician meetings in Massachusetts (n = 149) and in six other states (n = 490).
The average age-adjusted number of diabetes-related lower-extremity amputations in 2004 was 30.8 per 100,000 and 5.3 per 1,000 diabetic patients in MA, with high-risk groups being identified as men and black individuals. Among the general practitioners surveyed in Massachusetts, only 2.01% reported routinely conducting all four key components of the diabetic foot examination, with 28.86% reporting not performing any components.
These findings suggest that many general practitioners may be failing to perform the major components of the diabetic foot examination believed to prevent foot ulcers and lower-extremity amputations.
Background: Falls in older people are a major public health problem, and there is increasing evidence that foot problems and inappropriate footwear increase the risk of falls. Several multidisciplinary prevention clinics have been established to address the problem of falls; however, the role of podiatry in these clinics has not been clearly defined. The aims of this study were to determine the level of podiatric involvement in multidisciplinary falls clinics in Australia and to describe the assessments undertaken and interventions provided by podiatrists in these settings.
Methods: A database of falls clinics was developed through consultation with departments of health in each state and territory. Clinic managers were contacted and surveyed as to whether the clinic incorporated podiatry services. If so, the podiatrists were contacted and asked to complete a brief questionnaire regarding their level of involvement and the assessment procedures and interventions offered.
Results: Of the 36 clinics contacted, 25 completed the survey. Only four of these clinics reported direct podiatric involvement. Despite the limited involvement of podiatry in these clinics, all of the clinic managers stated that they considered podiatry to have an important role to play in falls prevention. Podiatry service provision in falls clinics varied considerably in relation to eligibility criteria, assessments undertaken, and interventions provided.
Conclusions: Despite the recognition that foot problems and inappropriate footwear are risk factors for falls, podiatry currently has a relatively minor and poorly defined role in multidisciplinary falls-prevention clinics in Australia. (J Am Podiatr Med Assoc 97(5): 377–384, 2007)
Background: In diabetic patients with complications from peripheral neuropathy, the hyperpressure areas can rapidly lead to ulcerative lesions in the absence of protective sensation. Partial digital silicone orthoses could provide an innovative and functional therapeutic solution in the management of preulcerative areas of the forefoot in neuropathic diabetic patients. We clinically tested this hypothesis.
Methods: Digital off-loading silicone padding was prepared for 89 neuropathic patients with deformities and localized hyperkeratosis in the forefoot. After 3 months and in basal conditions, the number of areas of hyperkeratosis was evaluated together with the hardness of the skin, the number of active lesions, and any adverse events associated with use of the orthosis. The patients were compared to a control group of 78 randomized patients undergoing standard therapy. In a subgroup of 10 patients, a static and dynamic biomechanical evaluation was also conducted with a computerized podobarometric platform.
Results: Both the number of lesions and the prevalence of hyperkeratosis and skin hardness were significantly lower (P < .01) in the group treated with the silicone orthoses than in the control group. No adverse events were reported during the 3 months of observation. The podobarometric analysis highlighted a significant (P < .001) reduction of peak pressure in the areas undergoing orthotic correction.
Conclusions: Silicone padding is effective and safe in the prevention of lesions in neuropathic patients at high risk of ulceration and significantly reduces the incidence of new lesions in the 3-month follow-up period compared to standard treatment. (J Am Podiatr Med Assoc 99(1): 28–34, 2009)
This study analyzed the histologic effects of and host response to subdermally injected liquid silicone to augment soft-tissue cushioning of the bony prominences of the foot. A total of 148 postmortem and surgical specimens of pedal skin with attached soft tissue were obtained from 49 patients between July 1, 1974, and November 30, 2002. The longest period that silicone was in vivo was 38 years. The specimens were then processed into paraffin blocks and examined for specific findings. The variables considered included distribution of silicone within the tissue, host response, migration to regional lymph nodes, and viability of the host tissue after treatment. The host response to silicone therapy consisted primarily of delicate-to-robust fibrous deposition and histiocytic phagocytosis, with eventual formation of well-formed elliptic fibrous pads. The response in the foot appears different from that in the breast and other areas of the body previously studied. No examples of granulomas, chronic lymphoplasmacytic inflammation, or granulation tissue formation were seen, with only rare foreign-body giant cells present. Silicone injections in fat pads for the treatment of atrophy and loss of viable tissue show a histologically stable and biologically tolerated host response that is effective, with no evidence of any systemic changes. (J Am Podiatr Med Assoc 94(6): 550–557, 2004)
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)
Pressure ulcers of the heel are a major and growing health-care problem. Although prevention and aggressive local wound care and pressure reduction remain the gold standard for treatment of most heel ulcers, recalcitrant wounds may require surgical intervention. Limb salvage when dealing with heel ulcers remains a challenge. Nine feet (eight patients) that underwent partial calcanectomy for chronic nonhealing heel ulcers were evaluated retrospectively. Complete healing occurred in seven of nine feet. Patients who were ambulatory before surgery remained ambulatory after healing. (J Am Podiatr Med Assoc 95(4): 335–341, 2005)
Insoles are commonly used to assist in the prevention of diabetic neuropathic foot ulceration. Insole replacement is often triggered only when foot lesions deteriorate, an indicator that functional performance is comprised and patients are exposed to unnecessary ulcer risk. We investigated the durability of insoles used for ulcer prevention in neuropathic diabetic feet over 12 months.
Sixty neuropathic individuals with diabetes were provided with insoles and footwear. Insole durability over 12 months was evaluated using an in-shoe pressure measurement device and through repeated measurement of material depth at the first metatarsal head and the heel seat. Analysis of variance was performed to assess change across time (at issue, 6 months, and 12 months).
Analyses were conducted using all available data (n = 43) and compliant data (n = 18). No significant difference was found in the reduction of mean peak pressure tested across time (P < .05). For both sites, significant differences in insole depth were identified between issue and 6 months and between issue and 12 months but not between 6 and 12 months (P < .05). Most insole compression occurred during the initial 6 months.
Visual material compression does not seem to be a reliable indicator of insole usefulness. Frequency of insole replacement is best informed by a functional review of effect determined using an in-shoe pressure measurement system. These results suggest that insoles for diabetic neuropathic patients can be effective in maintaining peak pressure reduction for 12 months regardless of wear frequency.
One hundred thirty-two female basketball players were observed for lower-extremity overuse injury between 1993 and 2004. Athletes studied between 1993 and 1996 did not receive foot orthotic devices and composed the control group. The treatment group comprised athletes studied between 1996 and 2004. Athletes in the treatment group were given a foot orthotic device before participation in basketball. Data analysis included lower-extremity overuse injury rates and the effect of foot orthotic devices on lower-extremity overuse injury rates by means of an incidence density ratio. The control group had a lower-extremity overuse injury rate of 5.37 per 1,000 exposures, and the treatment group had a rate of 6.44 per 1,000 exposures. The incidence density ratio was not significant (P = .44). This study rejects the concept that foot orthotic devices may assist in prevention of lower-extremity overuse injury in female basketball players. (J Am Podiatr Med Assoc 96(5): 408–412, 2006)
Joint hypermobility is a connective tissue disorder that increases joint range of motion. Plantar pressure and foot loading patterns may change with joint hypermobility. We aimed to analyze static plantar pressure in young females with and without joint hypermobility.
Joint laxity in 27 young females was assessed cross sectionally using the Beighton and Horan Joint Mobility Index. Participants were divided into the hypermobility (score, 4–9) and no hypermobility (score, 0–3) groups according to their scores. Static plantar pressure and forces were recorded using a pedobarographic mat system.
Higher peak pressures (P = .01) and peak pressure gradients (P = .025) were observed in the nondominant foot in the hypermobility group. According to the comparison of dominant and nondominant feet in each group, the hypermobility group showed significantly higher peak pressures (P = .046), peak pressure gradients (P = .041), and total force values (P = .028) in the nondominant foot.
The plantar pressure and loading patterns vary in young females with joint hypermobility. Evaluation of plantar loading as an injury prevention tool in individuals with joint hypermobility syndrome can be suggested.
Background: Chronic nonhealing pressure ulcers of the heel in nursing homes are frequent occurrences among bedridden patients with lower-extremity contractures of varying degrees of severity. Conservative local wound care for these patients can be time consuming, ineffective, costly, and may only delay an eventual major leg amputation. This study evaluates the efficacy of limb salvage surgical procedures, partial calcanectomy, total calcanectomy, and excision of the entire calcaneus and talus, for heel ulcers.
Methods: We performed a retrospective review of 57 nursing home residents who had chronic infected nonhealing pressure ulcers of the heel that we had treated over 12 years. Forty-three patients underwent partial calcanectomy, nine underwent total calcanectomy, and five underwent excision of the entire calcaneus and talus. Average postoperative follow-up was 15 months. Also included in this study are representative surgical cases.
Results: Forty-three patients completed follow-up. Complete healing occurred in 25 patients (58%). Failure to resolve the heel ulcer owing to persistent infection, or recurrence was seen in 18 patients (42%) who eventually had a below-the-knee or above-the-knee amputation. All of the patients with heel pressure ulcers were found to have lower-extremity contractures.
Conclusions: In the nonambulatory contracted patient with a heel ulcer, partial or total calcanectomy or excision of the entire calcaneus and talus offer a viable alternative not only for resolution of infection but also for prevention of limb loss. An aggressive plan must also be instituted to address the lower-extremity contractures in order to prevent recurrence. (J Am Podiatr Med Assoc 101(2): 167–175, 2011)