Diabetic Foot Information and Resources

Which diabetic patients should receive diabetic care?

In the day of rationing, this study by McGill et al from Australia, suggests that all should be treated for the best gain for the $. (Which diabetic patients should receive podiatry care? An objective analysis. M. McGill, L. Molyneaux and D. K. Yue; Internal Medicine Journal Volume 35 Issue 8 Page 451). They conclude that: "Provision of podiatry care to diabetic patients should not be only economically based, but should also be directed to those with reduced sensation, especially where there is a previous history of ulceration or amputation"

Comments here.

Two other recent publication on the diabetic foot were:

Effect of Initial Weight-Bearing in a Total Contact Cast on Healing of Diabetic Foot Ulcers (Jnl of Bone & Joint Surgery)

Gait characteristics in people with type 2 diabetes mellitus. (Eur J Appl Physiol)

Manual of Diabetic Foot Care (Mike Edmonds, Ali Foster & Lee Sanders) wins the British Medical Association Medical book of the Year (Press release).

Buy this book from:

Amazon.com
Amazon Canada
Amazon United Kingdom

Recent abstracts on diabetic foot include:

The cost of managing diabetic foot ulceration in an Irish hospital.

Assessment of Toe Blood Pressure Is an Effective Screening Method to Identify Diabetes Patients with Lower Extremity Arterial Disease.

Debridement and primary closure of nonhealing foot wounds.

Skin Blood Flow in Diabetic Dermopathy.

The challenge of multicenter studies in diabetic patients with foot infections.

Combined reconstruction of the diabetic foot including revascularization and free-tissue transfer.

Discussion on the Diabetic Foot at Podiatry Arena:

Toe Blood Pressure To Identify Arterial Disease

Diabetic Foot Book Wins Medical Book of the Year

Inadequate footwear tripled risk for amputation

Use of 10g monofilament in diabetic foot assessment

TcPO2 usage in surgery and wound care

Home Monitoring of Foot Skin Temperatures to Prevent Ulceration

Recent new articles:

Plantar foot surface temperatures with use of insoles.

Validation of a system of foot ulcer classification in diabetes mellitus.

Reduction of plantar peak pressure by limiting stride length in diabetic patients.

Dorsal Mobility and First Ray Stiffness in Patients with Diabetes Mellitus.

Use of a Torque-Range-of-Motion Device for Objective Differentiation of Diabetic from Normal Feet in Adults.

Antibiotic therapy for diabetic foot infections: comparison of cephalosporines with chinolones.

Plantar Fat-Pad Displacement in Neuropathic Diabetic Patients With Toe Deformity.

Atrophy of Foot Muscles A measure of diabetic neuropathy.

Thermal Thresholds Predict Painfulness of Diabetic Neuropathies.

The most signficant publication on our understanding of diabetic foot complications in a while has got to be this one from Dave Armstrong:

Variability in Activity May Precede Diabetic Foot Ulceration:

They evaluated 100 consecutive individuals with diabetes. The subjects used a high-capacity continuous computerized activity monitor. Data was collected 25 weeks. Eight of the subjects ulcerated during the evaluation period. The average daily activity was significantly lower in individuals who ulcerated compared with individuals who did not ulcerate. There was a large difference in variability between groups. The coefficient of variation was significantly greater in the ulceration group compared with the no ulceration group. In the 2 weeks preceding the ulcerative event, the coefficient of variation increased even further, but there was no significant difference in average daily activity during that period. The results of this study suggest that individuals with diabetes who develop ulceration may actually have a lower overall activity than their counterparts with no ulceration, but the quality of that activity may be more variable. Perhaps modulating the "peaks and valleys" of activity in this population through some form of feedback might prove to reduce risk for ulceration in this very-high-risk population. (More)

Dave has been busy with media interviews following this with Reuters and ABC News on maggot therapy.

Other new publications on the diabetic foot in the last 2 months:

Journal of Foot and Ankle Surgery

The DEPA scoring system and its correlation with the healing rate of diabetic foot ulcers.
Effect of a diode laser on wound healing by using diabetic and nondiabetic mice.
Podiatry Today
Using Serologic Screening To Identify And Monitor At-Risk Charcot Patients.

External Fixation: Is It The Answer For Diabetic Limb Salvage?

A Guide To Bracing For Charcot.
Advances in Skin and Wound Care
Reversal of Diabetic Peripheral Neuropathy and New Wound Incidence: The Role of MIRE.

The Use of Telemedicine in the Management of Diabetes-Related Foot Ulceration.

Diabetes Care

Incidence of Lower-Extremity Amputation in American Indians: The Strong Heart Study.
Are We Underestimating Diabetes-Related Lower-Extremity Amputation Rates?: Results and benefits of the first prospective study.
Variability in Activity May Precede Diabetic Foot Ulceration.

Impact of Achilles Tendon Lengthening on Functional Limitations and Perceived Disability in People With a Neuropathic Plantar Ulcer.

Prevalence of Lower-Extremity Disease in the U.S. Adult Population 40 Years of Age With and Without Diabetes.
Muscle Weakness and Foot Deformities in Diabetes.
Effectiveness of Diabetic Therapeutic Footwear in Preventing Reulceration
Diabetic Medicine

Amelanotic malignant melanoma disguised as a diabetic foot ulcer. (A timely remnder in this one).
Swab cultures accurately identify bacterial pathogens in diabetic foot wounds not involving bone.
Diabetic foot ulcer and multidrug-resistant organisms: risk factors and impact.

Endocrine Practice

Improvement of sensory impairment in patients with peripheral neuropathy.
Clinical Biomechanics

Pressure relief and load redistribution by custom-made insoles in diabetic patients with neuropathy and foot deformity.

Journal of Wound Care

Nutritional supplementation for diabetic foot ulcers: the first RCT.

Ostomy/Wound Management

Diabetic Heel Ulcers: A Major Risk Factor for Lower Extremity Amputation.

Maluf et al, in the Journal of Bone and Joint Surgery report in tendon achilles lengthening for the treatment of neuropathic ulcers causing a temporary reduction in forefoot pressure associated with changes in plantar flexor power rather than ankle motion during gait (link).

A full text article in Podiatry Today discusses a new study on the use of therapeutic footwear in diabetes (link).

Zimney et al in Experimental & Clinical Endocrinology & Diabetes report on a study that looked at the effects of ulcer size on the wound radius reductions and healing times in neuropathic diabetic foot ulcers. They found that wound radius reductions and the time needed for healing are affected by the ulcer area, a measure of ulcer size, in neuropathic diabetic foot ulcers. The calculation of the weekly wound radius reduction for different ulcer areas may be a useful tool in daily clinical practice to identify ulcers who do not respond adequately to the treatment (link).

In Medical and Biological Engineering and Computing, Thomas et al develope a model for the three-dimensional stress analysis for the mechanics of plantar ulcers in diabetic neuropathy. They suggest that ratios of high gradients and relative gradients of stresses due to changes in soft-tissue properties may be responsible for the development of plantar ulcers in diabetic neuropathic feet (link).

The Diabetic Foot journal can be accessed online via Looksmart. The most recent issue includes:

* Surgical treatment of chronic osteomyelitis of the neuropathic toe (link).
* Survey of hospital admissions related to diabetic foot disease (link).
* Diagnosing and managing chronic painful diabetic neuropathy (link).

In the most recent The Journal of Bone and Joint Surgery, Saltzman et al report data that supports the testing of diabetic patients for protective sensation may be simplified to testing under both first metatarsal heads with a 4.5-g monofilament rather than the the current recommended screening protocol requires 10-g monofilament testing of ten foot sites (link).

In Diabetes Care, Ortegon et al report in their markov analysis to estimate the lifetime health and economic effects of optimal prevention and treatment of the diabetic foot. They found that improved survival, reduced diabetic foot complications, and that it is cost-effective and even cost saving compared with standard care (link). Zimny et al reported data that showed diabetic patients with an at-risk foot have reduced joint mobility and elevated PTIs on the plantar forefoot, placing them at risk for subsequent ulceration. Therefore, LJM may be a possible factor in causing high plantar pressures and may contribute to foot ulceration in the susceptible neuropathic at-risk foot (link). Two other paper in the same issue of Diabetes Care report on Low-Intensity Laser Therapy for Painful Symptoms of Diabetic Sensorimotor Polyneuropathy (link) and  Prophylactic Gene Therapy With Human Tissue Kallikrein Ameliorates Limb Ischemia Recovery in Type 1 Diabetic Mice (link).

The Journal of Foot and Ankle Surgery has a paper on Usefulness of a brief assessment battery for early detection of Charcot foot deformity (link).

Their have been a number of recent developments in the understanding of type 1 diabetes - these are summarised in the British Medical Journal (link).

Two full text articles in the latest Podiatry Today:

The most interesting is on on activity monitoring by Katherine Holtz-Neiderer and David Armstrong. As repetitive stress plays a significant role in recurring plantar foot ulcers among patients with diabetes, the authors examine the use of pedometers in assessing patient activity and explore the idea of “dosing” activity (link). The second is a point/counterpoint on use of plantar skin flaps on diabetic ulcers. Two authors (Gary Jolly and Thomas Zgonis) say yes as skin flaps can be a viable option if conservative wound care fails. The other author (David Armstrong) says no, as he believes these flaps are unnecessary in many cases, emphasizing that the keys to healing involve addressing the underlying cause(s) of the wound (link).

There are two relevant papers in the latest Archives of Physical Medicine and Rehabilitation - both to do with gait and stability in those with diabetes.  One by Menz et al showed that older people with neuropathy have an impaired ability to stabilize their body when walking on irregular surfaces, even if they adopt a more conservative gait pattern (link).  The other one by Maluf et al provide support for the clinical evaluation of peak pressure during level walking as being an efficient method to screen for maximum levels of stress on the foot as patients with diabetes perform their daily activities (link).

In the Journal of the American Podiatric Medical Association, Abouaesha et al reports on a study 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. They found that 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 (link).

What is an acceptable rates of treatment failure in osteomyelitis involving the diabetic foot? In Clinical Infectious Diseases, Perencevich et al report on a survey of infectious disease specialists to determine this. They report that the median acceptable failure rate was 18.1% (link).

In the most recent Diabetes Care, Viswanathan et al compared the effectiveness of different types of footwear insoles in the diabetic neuropathic foot. Patients who were using therapeutic footwear showed lower foot pressure (group 1, 6.9 ± 3.6; group 2, 6.2 ± 3.9; and group 3, 6.8 ± 6.1 kPa; P = 0.0001), while those who used the nontherapeutic footwear showed an increased foot pressure (group 4, 40.7 ± 20.5 kPa; P = 0.008). The occurrence of new lesions was significantly higher in patients in group 4 (33%) when compared with that of all other groups (4%). They concluded that therapeutic footwear is useful to reduce new ulceration and consequently the amputation rate in the diabetic population (link).

Several bits of diabetic foot information have just been published at Medscape:

* the first is a news story on topical L-arginine cream improves blood flow and temperature in the feet (link)

* there is a reprint of a case report on a patient with diabetic neuropathy who got frostbite (link)

* they have also published a reprint from Wounds, a project looking at the effect of the Scotchcast Boot and the Aircast Device on foot pressures of the contralateral foot. The authors found that offloading devices do not seem to alter foot pressures on the contralateral foot (link)