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.
Matthew E. Wise, Elizabeth Bancroft, Ernest J. Clement, Susan Hathaway, Patricia High, Moon Kim, Emily Lutterloh, Joseph F. Perz, Lynne M. Sehulster, Clara Tyson, Mary Beth White-Comstock, and Barbara Montana
Unsafe practices are an underestimated contributor to the disease burden of bloodborne viruses. Outbreaks associated with failures in basic infection prevention have been identified in nonhospital settings with increased frequency in the United States during the past 15 years, representing an alarming trend and indicating that the challenge of providing consistently safe care is not always met. As has been the case with most medical specialties, public health investigations by state and local health departments, and the Centers for Disease Control and Prevention, have identified some instances of unsafe practices that have placed podiatric medical patients at risk for viral, bacterial, and fungal infections. All health-care providers, including podiatric physicians, must make infection prevention a priority in any setting in which care is delivered.
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)
Retrospective and prospective studies have shown that elevated plantar pressure is a causative factor in the development of many plantar ulcers in diabetic patients and that ulceration is often a precursor of lower-extremity amputation. Herein, we review the evidence that relieving areas of elevated plantar pressure (off-loading) can prevent and heal plantar ulceration.
There is no consensus in the literature concerning the role of off-loading through footwear in the primary or secondary prevention of ulcers. This is likely due to the diversity of intervention and control conditions tested, the lack of information about off-loading efficacy of the footwear used, and the absence of a target pressure threshold for off-loading. Uncomplicated plantar ulcers should heal in 6 to 8 weeks with adequate off-loading. Total-contact casts and other nonremovable devices are most effective because they eliminate the problem of nonadherence to recommendations for using a removable device. Conventional or standard therapeutic footwear is not effective in ulcer healing. Recent US and European surveys show that there is a large discrepancy between guidelines and clinical practice in off-loading diabetic foot ulcers. Many clinics continue to use methods that are known to be ineffective or that have not been proved to be effective while ignoring methods that have demonstrated efficacy.
A variety of strategies are proposed to address this situation, notably the adoption and implementation of recently established international guidelines, which are evidence based and specific, by professional societies in the United States and Europe. Such an approach would improve the often poor current expectations for healing diabetic plantar ulcers. (J Am Podiatr Med Assoc 100(5): 360–368, 2010)
Fifteen percent of individuals with diabetes will likely develop foot ulcers in their lifetime, and approximately 15% to 20% of these ulcers are estimated to result in lower extremity amputation. Techniques to prevent lower extremity amputation range from the simple but often neglected foot inspection to complicated vascular and reconstructive foot surgery. Appropriate management can prevent and heal diabetic foot ulcers, thereby greatly decreasing the amputation rate and medical care costs. Prevention is the key to treatment. The author discusses general guidelines for foot screening and identifies three specific goals for prevention of amputation: 1) identification of at risk individuals needing prevention and the specific factors placing them at risk; 2) protection of the foot against the adverse effects of external forces (pressure, friction, and shear); and 3) reduction of the incidence of diabetic foot ulcers through educational programs.
Given the age-related decline in foot strength and flexibility, and the emerging evidence that foot problems increase the risk of falls, established guidelines for falls prevention recommend that older adults have their feet examined by a podiatrist as a precautionary measure. However, these guidelines do not specify which intervention activities might be performed. Published in this special issue of JAPMA are nine high-quality articles, including seven original studies and two basic science reviews, focusing on the benefit and impact of footwear and foot and ankle interventions in reducing the risk of falling. The selected studies discuss various relevant questions related to podiatric intervention, including adherence to intervention; preference and perception of older adults in selecting footwear; benefit of insoles, footwear, and nonslip socks in preventing falls; fear of falling related to foot problems; benefit of podiatric surgical intervention; and benefit of foot and ankle exercise in preventing falls. (J Am Podiatr Med Assoc 103(6): 452–456, 2013)
Background: Multiple organizations have issued guidelines to address the prevention, diagnosis, and management of diabetic foot ulcers (DFUs) based on evidence review and expert opinion. We reviewed these guidelines to identify consensus (or lack thereof) on the nature of these recommendations, the strength of the recommendations, and the level of evidence.
Methods: Ovid, PubMed, Web of Science, Cochrane Library, and Embase were searched in October 2018 using the MESH term diabetic foot, the key word diabetic foot, and the filters guideline or practice guideline. To minimize recommendations based on older literature, guidelines published before 2012 were excluded. Articles without recommendations characterized by strength of recommendation and level of evidence related specifically to DFU were also excluded. A manual search for societal recommendations yielded no further documents. Recommendations were ultimately extracted from 12 articles. Strength of evidence and strength of recommendation were noted for each guideline recommendation using the Grading of Recommendations Assessment, Development, and Evaluation system or the Centre for Evidence-Based Medicine system. To address disparate grading systems, we mapped the perceived level of evidence and strength of recommendations onto the American Heart Association guideline classification schema.
Results: Recommendations found in two or more guidelines were collected into a clinical checklist characterized by strength of evidence and strength of recommendation. Areas for future research were identified among recommendations based on minimal evidence, areas of controversy, or areas of clinical care without recommendations.
Conclusions: Through this work we developed a multidisciplinary set of DFU guidelines stratified by strength of recommendation and quality of evidence, created a clinical checklist for busy practitioners, and identified areas for future focused research. This work should be of value to clinicians, guideline-issuing bodies, and researchers. We also formulated a method for the review and integration of guidelines issued by multiple professional bodies.
Through a discussion of the etiology and pathology of diabetic foot lesions with particular emphasis on ulceration and osteoarthropathy, the author will develop a plan for treatment and prevention using a multidisciplinary approach to such problems. Underlying risk factors including neuropathy, ischemia, infection, and, especially high pressures must be evaluated and appropriately ameliorated in order to promote resolution and avoidance of recidivism. Accordingly, conservative management with pressure-relieving devices, topical therapies, and prophylactic surgery on structural deformities plays an integral part in the overall podiatric management of the high-risk foot in diabetes mellitus.
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)