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- Author or Editor: Andrew J. M. Boulton x
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Throughout our medical training, we are taught how to manage patients who present with symptoms: perform a clinical examination, make a diagnosis, and develop a management plan. However, virtually no time is spent on teaching us how to manage patients who have no symptoms because they have lost the ability to feel pain, that is, patients with peripheral neuropathy. The lifetime incidence of foot ulceration in people with diabetes has been estimated to be as high as 25%, and a variety of contributory factors result in a foot being at risk for ulceration. Most important among these factors is peripheral neuropathy, or the loss of the ability to feel pain, temperature, or pressure sensation in the feet and lower legs. Up to 50% of older type 2 diabetic patients have evidence of sensory loss, putting them at risk for foot ulceration. If we are to succeed in reducing the high incidence of foot ulcers, regular screening for peripheral neuropathy is vital in all patients with diabetes. Those found to have any risk factors for foot ulceration require special education and more frequent review, particularly by podiatric physicians. The key message is, therefore, that neuropathic symptoms correlate poorly with sensory loss and that their absence must never be equated with lack of risk of foot ulceration. If we are to succeed in reducing the high incidence of foot ulceration and particularly recurrent ulceration, we must realize that with loss of pain there is also diminished motivation in the healing and prevention of injury. (J Am Podiatr Med Assoc 100(5): 349–352, 2010)
Charcot’s arthropathy is a devastating condition affecting diabetic patients with peripheral neuropathy, resulting in a foot at risk for ulceration and amputation. Early diagnosis is important for the institution of appropriate treatment, which may help prevent disease progression and foot deformity. This article discusses the pathogenesis and treatment options available for the disorder. (J Am Podiatr Med Assoc 92(7): 381-383, 2002)
Background: Off-loading excessive pressure is essential to healing diabetic foot ulcers. However, many patients are not compliant in using prescribed footwear or off-loading devices. We sought to validate a method of objectively measuring off-loading compliance via activity monitors.
Methods: For 4 days, a single subject maintained a written compliance diary concerning use of a removable cast walker. He also wore a hip-mounted activity monitor during all waking hours. An additional activity monitor remained mounted on the cast walker at all times. At the conclusion of the 4 days, the time-stamped hip activity data were independently coded for walker compliance by the compliance diary and by using the time-stamped walker activity data.
Results: An intraclass reliability of 0.93 was found between diary-coded and walker monitor–coded activity.
Conclusions: These results support the use of this dual activity monitor approach for assessing off-loading compliance. An advantage of this approach versus a patient-maintained diary is that the monitors are not susceptible to incorrect patient recall or a patient’s desire to please a caregiver by reporting inflated compliance. Furthermore, these results seem to lend support to existing reports in the literature using similar methods. (J Am Podiatr Med Assoc 99(2): 100–103, 2009)
The authors undertook a study to evaluate the prevalence of ankle equinus and its potential relationship to high plantar pressure in a large, urban population with diabetes mellitus. The first 1,666 consecutive people with diabetes (50.3% male; mean [±SD] age, 69.1 ± 11.1 years) presenting to a large, urban, managed-care outpatient clinic were enrolled in this longitudinal, 2-year outcomes study. Patients received a standardized medical and musculoskeletal assessment at the time of enrollment, including evaluation at an onsite gait laboratory. Equinus was defined as less than 0° of dorsiflexion at the ankle. The overall prevalence of equinus in this population was 10.3%. Patients with equinus had significantly higher peak plantar pressures than those without the deformity and were at nearly three times greater risk for presenting with elevated plantar pressures. There were no significant differences in age, weight, or sex between the two groups. However, patients with equinus had a significantly longer duration of diabetes than those without equinus. Having a high index of suspicion for this deformity and subsequently addressing it through conservative or surgical means may help to reduce the risk of foot ulceration and amputation. (J Am Podiatr Med Assoc 92(9): 479-482, 2002)
The aim of this study was to evaluate whether high plantar foot pressures can be predicted from measurements of plantar soft-tissue thickness in the forefoot of diabetic patients with neuropathy. A total of 157 diabetic patients with neuropathy and at least one palpable foot pulse but without a history of foot ulceration were invited to participate in the study. Plantar tissue thickness was measured bilaterally at each metatarsal head, with patients standing on the same standardized platform. Plantar pressures were measured during barefoot walking using the optical pedobarograph. Receiver operating characteristic analysis was used to determine the plantar tissue thickness predictive of elevated peak plantar pressure. Tissue thickness cutoff values of 11.05, 7.85, 6.65, 6.55, and 5.05 mm for metatarsal heads 1 through 5, respectively, predict plantar pressure at each respective site greater than 700 kPa, with sensitivity between 73% and 97% and specificity between 52% and 84%. When tissue thickness was used to predict pressure greater than 1,000 kPa, similar results were observed, indicating that high pressure at different levels could be predicted from similar tissue thickness cutoff values. The results of the study indicate that high plantar pressure can be predicted from plantar tissue thickness with high sensitivity and specificity. (J Am Podiatr Med Assoc 94(1): 39-42, 2004)
Background: The removal of necrotic tissue from chronic wounds is required for wound healing to occur. Hydrodebridement (jet lavage) and superoxidized aqueous solution have been independently used for debriding wounds. We sought to investigate the use of superoxidized aqueous solution with a jet lavage system.
Methods: Twenty patients with diabetic foot ulcers were randomly assigned in a 1:1 ratio to receive jet lavage debridement with either superoxidized aqueous solution or standard saline weekly.
Results: There was no significant difference between the two treatments in the reduction of bacterial load or wound size in 4 weeks. No adverse reactions were reported for either treatment.
Conclusions: The use of superoxidized aqueous solution for jet lavage debridement seemed to be as safe and effective as saline. Future investigations should concentrate on whether superoxidized aqueous solution may reduce the bacterial air contamination associated with hydrodebridement. (J Am Podiatr Med Assoc 101(2): 124–126, 2011)
Maggot Debridement Therapy
A Primer
Treatment of chronic wounds of the lower extremity requires a systematic, multidisciplinary approach as well as flexibility in order to achieve acceptable, consistent short-term and long-term results. Maggots, once considered an obsolete therapeutic modality, can be a useful addition to the armamentarium of the foot and ankle specialist. This article describes the use of maggot debridement therapy for intractable wounds of the lower extremity. (J Am Podiatr Med Assoc 92(7): 398-401, 2002)
Wound debridement, when systematically performed, may be as important as off-loading in reducing the prevalence of chronic inflammatory by-products in a wound and thus in converting a chronic wound into an acute one. Although it has been suggested that aggressive surgical debridement of wounds may be beneficial, there have been few, if any, technical descriptions of this aspect of therapy. It is therefore the purpose of this article to describe the general principles, process, and technique of outpatient surgical debridement of noninfected, nonischemic neuropathic diabetic foot wounds performed at the authors’ institutions. The authors hope to foster further discussion leading to improvement in the process and the prevalence of such debridement. (J Am Podiatr Med Assoc 92(7): 402-404, 2002)
Addressing pressure reduction in the treatment of diabetic foot wounds is a critical component of therapy. The total-contact cast has proven to be the gold standard of treatment because of its ability to reduce pressure and facilitate patient adherence to the off-loading regimen. Removable cast walkers have proven to be as effective as total-contact casts in pressure reduction, but this has not translated into equivalent time to healing. A simple technique to convert the removable cast walker into a device that is not as easily detached from the lower extremity, thereby encouraging the use of this device over a 24-hour period, is presented in this article. The procedure involves wrapping the cast walker with cohesive bandage or plaster of Paris. In the authors’ opinion, this technique addresses many of the disadvantages of the total-contact cast, resulting in an adequate compromise in this aspect of care. (J Am Podiatr Med Assoc 92(7): 405-408, 2002)
