Background: The purpose of this retrospective audit was to compare patient based clinical outcomes to amputation healing outcomes twelve months after a minor foot amputation in people with diabetes.
Methods: Hospital admission and community outpatient data were extracted for all minor foot amputations in people with diabetes in 2017 in the Central Coast Local Health District.
Results: A total 85 minor foot amputations involving 74 people were identified. At the twelve-month follow-up 74% (n=56) of the minor foot amputations healed, 63% (n=41) of the participants achieved a good clinical outcome (healed, no more proximal amputations, or death within the 12 month follow up period), and the mortality rate was 18%. Poor clinical outcomes were associated with those aged greater than 60 (RR 5.75, 95% CI: 0.85 to 38.7, p=0.013), those undergoing a further surgical debridement procedure during their hospital stay (RR 2.42, 95% CI: 1.3 to 4.4, p=0.005) and those who did not attend CCLHD Podiatry clinics post-amputation (RR 2.3, 95% CI: 1.2 to 4.1, p=0.010).
Conclusions: To improve patient based clinical outcomes post-minor foot amputation, targeted follow-up in a high-risk foot clinic, and tailored discharge treatment plans for people aged over 60 or those undergoing a debridement procedure may be considered.
Neuropathic symptoms in patients with diabetes occur commonly and are most often a consequence of the diabetes. Up to 10% of patients with diabetes and neuropathy have an etiology other than diabetes as a cause of their nerve dysfunction. Herein we present a case of vasculitic neuropathy initially misdiagnosed as diabetic neuropathy that led to separate amputations of two toes. This case emphasizes the importance of considering alternative, potentially treatable, causes of peripheral neuropathy in patients with diabetes. (J Am Podiatr Med Assoc 98(4): 322–325, 2008)
Exercise is highly beneficial for persons with diabetes. Similar to many other patients, those with diabetes may be reluctant to exercise given a lack of motivation and proper instruction regarding an exercise prescription. In general, medical providers are poorly equipped to develop an exercise prescription and furnish motivation. Attempts to find activities that not only provide effective aerobic challenges but also are enjoyable to participate in are fraught with difficulty. Hiking as a potential option for a safe and enjoyable activity is discussed, including the possible downsides.
Multiple publications were reviewed using key words.
A review of the literature uncovered limited publications or controlled trials that discussed the use of hiking per se as an activity for the management of diabetes. Newer studies reviewing weightbearing exercise and diabetic polyneuropathy and those discussing the advantages of trekking poles for balance and proprioception are cited in support of the recommendation for hiking as an activity for those with diabetes.
Exercise has been shown to substantially benefit individuals with diabetes, but convincing patients with diabetes to exercise is daunting. Hiking, unlike other, more tedious exercise programs, may be an exercise option that persons with diabetes might find enjoyable. Hiking may encourage balance training and reduced ground reaction forces. These benefits may be augmented by trekking poles, which may likewise counter the concerns of the uneven surfaces that present challenges to the hiker with diabetes.
Lee C. Rogers, Robert G. Frykberg, David G. Armstrong, Andrew J. M. Boulton, Michael Edmonds, Georges Ha Van, Agnes Hartemann, Frances Game, William Jeffcoate, Alexandra Jirkovska, Edward Jude, Stephan Morbach, William B. Morrison, Michael Pinzur, Dario Pitocco, Lee Sanders, Dane K. Wukich, and Luigi Uccioli
The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity. (J Am Podiatr Med Assoc 101(5): 437–446, 2011)
This study sought to identify the nature and extent of diabetes-related knowledge and self-care practices in people living with type 2 diabetes who attend primary-care clinics and to determine whether a correlation between the two exists.
In a nonexperimental prospective study, the Diabetes Knowledge Questionnaire and the Summary of Diabetes Self-care Activities were used to assess knowledge and self-management in 50 patients.
The mean diabetes knowledge score was 14.40 out of a total of 24 and the mean self-care activities score was 2.89 out of a total of 7, indicating a deficit in a number of key areas in the management of diabetes. There was no statistically significant correlation between diabetes knowledge score and diabetes self-care activities (r = 0.190, P = 0.187). On analysis of the individual subscales, a significant relationship resulted between diabetes knowledge score and diet (r = 0.324, P = 0.022) but physical activity (r = 0.179, P = 0.214), blood sugar testing (r = 0.231, P = 0.107) and footcare (r = 0.189, P = 0.189) gave no significant results. On further analysis, education level was significantly correlated to diabetes knowledge score (r = 0.374, P = 0.007) and self-care activities score (r = 0.317, P = 0.025) while age was significantly correlated to diabetes knowledge score (P = 0.008) and self-care activities score (P = 0.035).
Integrating theories of behavior change into educational interventions at the primary-care level may translate to improved care, reduced long-term complications, and better quality of life.
We investigated plantar loading asymmetry during gait in American Indians with and without diabetes and with diabetes and peripheral neuropathy.
A convenience sample of 96 American Indians with and without diabetes was divided into three groups: 20 with diabetes and peripheral neuropathy, 16 with diabetes without peripheral neuropathy, and 60 with no history of diabetes (control group). Plantar loading was measured during barefoot walking across a pressure platform. Five trials were collected per foot during level walking at a self-selected speed using the two-step method. Asymmetry in peak pressure-time integral and peak plantar pressure were calculated from ten plantar regions and compared among groups.
Significant pressure-time integral asymmetry occurred across the forefoot regions in American Indians with diabetes and peripheral neuropathy compared with the other two groups. Significant peak plantar pressure asymmetry occurred in the third metatarsal region in both groups with diabetes (with and without peripheral neuropathy) compared with the control group.
Overall, American Indians with diabetes seemed to show greater asymmetry in plantar loading variables across the forefoot region compared with those in the control group. Specifically, individuals with diabetes and peripheral neuropathy had the greatest amount of forefoot pressure-time integral asymmetry. Significant peak plantar pressure asymmetry occurred in the third metatarsal region of the forefoot in those with diabetes with and without peripheral neuropathy. Loading asymmetry may play a role in the development of foot ulcers in the forefoot region of American Indians with peripheral neuropathy and diabetes. (J Am Podiatr Med Assoc 103(2): 106–112, 2013)
Background: To evaluate clinicians' compliance to follow national guidelines for tetanus vaccination prophylaxis in high-risk foot patients. Methods: We retrospectively evaluated 114 consecutive patients between June 2011 and March 2019 who presented with a foot infection resulting from a puncture injury through the emergency department. Eighty-three patients had diabetes mellitus and 31 patients did not have diabetes mellitus. Electronic medical records were used to collect a broad range of study data on patient demographics, previous medical history, previous tetanus immunization history and tetanus status upon presentation to the emergency department (ED), peripheral arterial disease, sensory neuropathy, laboratory values, and clinical / surgical outcomes. Results: 46.5% of the patients who presented to the ED with a puncture wound did not have up-to-date tetanus immunization. Of those patients, 79.2% received a tetanus-containing vaccine booster, 3.8% received intramuscular tetanus immunoglobulins (TIG), 3.8% received both tetanus-containing vaccine booster and TIG, and 20.8% received no form of tetanus prophylaxis. When comparing data between patients with and without diabetes, there were no statistical significant differences in tetanus prophylaxis. Conclusion: Guidelines for tetanus prophylaxis amongst high-risk foot patients in this study center are not followed in all patients. Patients with DM are at high risks of exposure to tetanus, we recommend physicians to take a detailed tetanus immunization history and vaccinate them if tetanus history is unclear.
We sought to identify the biomechanical characteristics of the feet of patients with diabetes mellitus and the interrelationship with diabetic neuropathy by determining the range of joint mobility and the presence and locations of calluses and foot deformities.
This observational comparative study involved 281 patients with diabetes mellitus who underwent neurologic and vascular examinations. Joint mobility studies were performed, and deformities and hyperkeratosis locations were assessed.
No substantial differences were found between patients with and without neuropathy in joint mobility range. Neuropathy was seen as a risk factor only in the passive range of motion of the first metatarsophalangeal joint (mean ± SD: 57.2° ± 19.5° versus 50.3° ± 22.5°, P = .008). Mean ± SD ankle joint mobility values were similar in both groups (83.0° ± 5.2° versus 82.8° ± 9.3°, P = .826). Patients without neuropathy had a higher rate of foot deformities such as hallux abductus valgus and hammer toes. There was also a higher presence of calluses in patients without neuropathy (82.8% versus 72.6%; P = .039).
Diabetic neuropathy was not related to limited joint mobility and the presence of calluses. Patients with neuropathy did not show a higher risk of any of the deformities examined. These findings suggest that the etiology of biomechanical alterations in diabetic people is complex and may involve several anatomically and pathologically predisposing factors. (J Am Podiatr Med Assoc 101(3): 208–214, 2011)
Transtibial (TTA) and transfemoral (TFA) amputations are rarely considered as distinct events when examining major lower-limb amputation outcomes. The objective of this study was to investigate the relationships among type 2 diabetes, diabetes management strategies, hemoglobin A1c levels, and other health factors related to TTA and TFA.
The retrospective medical record review included abstracting demographic and health-related data from the electronic medical records of 92 patients who received amputation-related services in a Department of Veterans Affairs hospital.
Patients who controlled their diabetes with insulin (with or without other oral agents) were significantly more likely to undergo TTA (adjusted odds ratio [aOR] = 7.63; 95% confidence interval [CI], 1.17–49.97; P = .03) compared with patients who controlled their diabetes through noninsulin medications or by diet. Patients who underwent no previous surgery (aOR = 6.66; 95% CI, 0.89-49.72; P = .06) or partial amputation only (aOR = 15.44; 95% CI, 1.04–228.29; P = .05) compared with a combination of partial amputation and bypass, thrombolectomy, or stent procedures were marginally to statistically significantly more likely to undergo TTA than TFA.
The preferential association between TTA with insulin-dependent diabetes and higher hemoglobin A1c levels versus TFA with previous lower-limb bypasses, stent placement, and thrombolytic interventions distinguishes TTA and TFA as two distinct entities, and awareness of this difference may help clinicians design preventive strategies accordingly.