This review discusses some of the significant studies and events from the 61st American Diabetes Association’s Scientific Symposium. Many of the issues raised at the meeting will form building blocks for future research into offloading, footwear, wound classification, wound healing, tissue engineering, and psychological aspects of therapy and prevention. (J Am Podiatr Med Assoc 92(1): 2-6, 2002)
Background: This study was undertaken to assess the benefits of negative-pressure wound therapy (NPWT) versus traditional wound therapies in reducing the incidence of lower-extremity amputations in patients with diabetic foot ulcers.
Methods: Administrative claims data for patients with diabetic foot ulcers from commercial payers (n = 3,524) and Medicare (n = 12,795) were retrospectively analyzed. Patients were divided into NPWT and control/traditional therapy groups on the basis of administrative codes. Risk-adjustment procedures were then performed to match patient risk categories (through total treatment costs) and wound severities (through debridement depth).
Results: The incidence of amputations in the NPWT groups was lower than that in the control groups. For the cost-based risk-adjustment analysis, amputation incidences with NPWT versus traditional therapy were 35% lower in the Medicare sample (10.8% versus 16.6%; P = .0077) and 34% lower in the commercial payer sample (14.1% versus 21.4%; P = .0951). Whereas overall amputation rates increased progressively with increasing wound debridement depth in both control groups, the same increasing trend did not occur in the NPWT groups.
Conclusions: Patients with diabetic foot ulcers in the Medicare sample treated with NPWT had a lower incidence of amputations than those undergoing traditional wound therapy; this finding was evident in wounds of varying depth in both populations studied. (J Am Podiatr Med Assoc 97(5): 351–359, 2007)
Heparin is an anticoagulant commonly used to treat and prevent deep venous thrombosis. Heparin-induced thrombocytopenia and possible thrombosis are serious complications associated with its use. This can occasionally complicate treatment of patients undergoing podiatric surgery. Heparin-induced thrombocytopenia is often not immediately recognized and is underreported in podiatric medicine literature. The goal of this case report is to highlight the multiple risk factors associated with the development of heparin-induced thrombocytopenia and to aid with early recognition, understanding of pathogenesis, and treatment options. (J Am Podiatr Med Assoc 103(1): 67–72, 2013)
Linezolid, a mild monoamine oxidase inhibitor, is a commonly used antibiotic drug for the treatment of complicated skin and skin structure infections, including diabetic foot infections. Use of linezolid has been associated with serotonin syndrome, a potentially life-threatening condition typically caused by the combination of two or more medications with serotonergic properties, due to increased serotonin release. The goals of this article are to highlight the risk factors associated with the development of serotonin syndrome related to the use of linezolid and to aid in its prevention and early diagnosis. In this case series we report on two hospitalized patients who, while being treated with linezolid for pedal infections, developed serotonin syndrome. Both individuals were also undergoing treatment with at least one serotonergic agent for depression and had received this medication within 2 weeks of starting the antibiotic drug therapy. In these individuals, we noted agitation, confusion, tremors, and tachycardia within a few days of initiation of linezolid therapy. Owing to the risk of serotonin toxicity, care should be taken when prescribing linezolid in conjunction with any other serotonergic agent. Although serotonin syndrome is an infrequent complication, it can be potentially life threatening. Therefore, risks and benefits of therapy should be weighed before use.
Surgical intervention for chronic deformities and ulcerations has become an important component in the management of patients with diabetes mellitus. Such patients are no longer relegated to wearing cumbersome braces or footwear for deformities that might otherwise be easily corrected. Although surgical intervention in these often high-risk individuals is not without risk, the outcomes are fairly predictable when patients are properly selected and evaluated. In this brief review, we discuss the rationale and indications for diabetic foot surgery, focusing on the surgical decompression of deformities that frequently lead to foot ulcers. (J Am Podiatr Med Assoc 100(5): 369–384, 2010)
Multiple offloading modalities are currently used in the management of diabetic plantar foot ulcerations. A relatively new device, the Rocker Insole, was tested for its ability to relieve plantar forefoot pressures when inserted into a surgical boot as compared to a patient’s customary footwear and the surgical boot alone. The Rocker Insole significantly reduced forefoot pressures by 48% when worn inside the surgical boot. Mean peak pressures unexpectedly increased 12% when the surgical boot was worn alone. This preliminary investigation suggests that when worn in conjunction with a surgical boot, the Rocker Insole can effectively offload plantar forefoot pressures and may be useful in the management of plantar metatarsal ulcerations. (J Am Podiatr Med Assoc 92(1): 48-53, 2002)
There are no conclusive data to support the contention that diabetic patients have an increased frequency of ankle equinus compared with their nondiabetic counterparts. Additionally, a presumed contributing cause of foot ulceration is ankle joint equinus. Therefore, we sought to determine whether persons with diabetes have a higher prevalence of ankle joint equinus than do nondiabetic persons.
A prospective pilot survey of 102 outpatients (43 diabetic and 59 nondiabetic) was conducted. Demographic and historical data were obtained. Each patient underwent a standard lower-extremity examination, including the use of a biplane goniometer to measure ankle joint range of motion.
Equinus, defined as ankle dorsiflexion measured at 0° or less, was found in 24.5% of the overall population. In the diabetes cohort, 16 of 43 patients (37.2%) were affected compared with 9 of 59 nondiabetic participants (15.3%) (P = .011). There was a threefold risk of equinus in the diabetic population (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.28–8.44; P < .013). The equinus group had a history of ulceration in 52.0% compared with 20.8% of the nonequinus group (P = .003). Equinus, therefore, imparted a fourfold risk of ulceration (OR, 4.13; 95% CI, 1.58–10.77; P < .004). We also found a 2.8 times risk of equinus in patients with peripheral neuropathy (OR, 2.8; 95% CI, 1.11–7.09; P < .029).
Equinus may be more prevalent in diabetic patients than previously reported. Although we cannot prove causality, we found a significant association between equinus and ulceration. (J Am Podiatr Med Assoc 102(2): 84–88, 2012)
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.