Risk of foot complications in long-term diabetic patients with and without ESRD: a preliminary study

OBJECTIVE: The purpose of this preliminary study was to generate hypotheses for future research about the relationship between ESRD and foot complications in patients with long-term diabetes. DESIGN: A cross-sectional prevalence study was conducted comparing a sample of long-term diabetic patients with ESRD to a sample of long-term diabetic patients without ESRD. SAMPLE/SETTING: A convenience sample of 132 patients with long-term diabetes (> 15 years), with (N = 60) and without (N = 72) ESRD, was selected from ambulatory care settings and dialysis units. METHODS: Data were collected by chart audit, structured interview, and physical examination. RESULTS: Foot complications were greater in individuals with diabetes and ESRD (25%) than in diabetic individuals without ESRD (10%) (p = 0.02). Neither neuropathy, past or current smoking, race, gender, nor age were significantly associated with current foot complications (either current infection, ulcer, gangrene, or amputation). CONCLUSIONS: Research is needed to better understand foot complications in persons with long-term diabetes and ESRD so that the effectiveness of nursing and medical interventions to stabilize or prevent foot complications can be evaluated.     

Diabetic foot ulcers: prevention, diagnosis and classification

Diabetic ulcers are the most common foot injuries leading to lower extremity amputation. Family physicians have a pivotal role in the prevention or early diagnosis of diabetic foot complications. Management of the diabetic foot requires a thorough knowledge of the major risk factors for amputation, frequent routine evaluation and meticulous preventive maintenance. The most common risk factors for ulcer formation include diabetic neuropathy, structural foot deformity and peripheral arterial occlusive disease. A careful physical examination, buttressed by monofilament testing for neuropathy and noninvasive testing for arterial insufficiency, can identify patients at risk for foot ulcers and appropriately classify patients who already have ulcers or other diabetic foot complications. Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation. Adherence to a systematic regimen of diagnosis and classification can improve communication between family physicians and diabetes subspecialists and facilitate appropriate treatment of complications. This team approach may ultimately lead to a reduction in lower extremity amputations related to diabetes.     

The contribution of non-insulin-dependent diabetes to lower-extremity amputation in the community

BACKGROUND: Despite the significant public health burden of lower-extremity amputations in diabetes mellitus, few data are available on the epidemiology of lower-extremity amputations in diabetes mellitus in the community setting. METHODS: A retrospective incidence cohort study based in Rochester, Minn, was conducted. RESULTS: Among the 2015 diabetic individuals free of lower-extremity amputation at the diagnosis of diabetes mellitus, 57 individuals underwent 79 lower-extremity amputations (incidence, 375 per 100,000 person-years; 95% confidence interval, 297 to 467). Among the 1826 patients with non-insulin-dependent diabetes mellitus, 52 underwent 73 lower-extremity amputations, and the subsequent incidence of lower-extremity amputation among these residents was 388 per 100,000 person-years (95% confidence interval, 304 to 487). Of the 137 insulin-dependent diabetic patients, four subsequently underwent five lower-extremity amputations (incidence, 283 per 100,000 person-years; 95% confidence interval, 92 to 659). Twenty-five years after the diagnosis of diabetes mellitus, the cumulative risk of one lower-extremity amputation was 11.2% in insulin-dependent diabetes mellitus and 11.0% in non-insulin-dependent diabetes mellitus. When compared with lower-extremity amputation rates for Rochester residents without diabetes, patients with non-insulin-dependent diabetes mellitus were nearly 400 times more likely to undergo an initial transphalangeal amputation (rate ratio, 378.8) and had almost a 12-fold increased risk of a below-knee amputation (rate ratio, 11.8). In this community, more than 60% of lower-extremity amputations were attributable to non-insulin-dependent diabetes mellitus. CONCLUSIONS: These population-based data document the magnitude of the elevated risk of lower-extremity amputation among diabetic individuals. Efforts should be made to identify more precisely risk factors for amputation in diabetes and to intervene in the processes leading to amputation.     

Diabetic foot--an attempt at defining the risk factors for amputation]

The study included 65 patients--42 males and 23 females aged 67 +/- 17 with the diabetic foot syndrome. They were divided into 2 groups: those who underwent amputation (25 patients) and 40 who were treated conservatively. Amputations were preceded most frequently by ulceration (17 cases), phlegmona (5 cases) or dry necrosis (3 cases). The high percentage of amputations in the studied patients could be explained, at least in part, by poor general condition and advanced local changes. In the group of patients, who underwent amputation--in relation to those treated conservatively a decrease in filtration function was found (46.0 +/- 24.3 vs 89.5 +/- 26.2) and a higher percentage in the prevalence of microalbuminuria or proteinuria (80% vs 45%) as well as a higher percentage of cigarettes smokers in this group (72% vs 40%). The majority of the studied patients was characterized by poor education, lack of self-control of glycaemia, no efficient metabolic control of diabetes, measured by glycated haemoglobin and the presence of neuropathy and retinopathy. In addition, in 4 patients among the whole studied group (including 1 patient who underwent amputation), diabetes was newly diagnosed. These results indicate the necessity of improving education, early diagnosis of insulin independent diabetes, more frequent foot examinations and the elimination of amputation risk factors. Prophylaxis of diabetes foot associated with the proper treatment of diabetes is a necessary condition for decreasing of the amputation rate according to St. Vincent Declaration.     

The diabetic foot. Optimal prevention and treatment can halve the risk of amputation

Almost half of all lower leg amputations are performed in patients with diabetes. In over 70 per cent of these cases, amputation is precipitated by progression of foot ulceration to deep gangrenous infection. Most foot ulcers are preceded by trauma, usually due to ill-fitting shoes, and are precipitated by sensory motor neuropathy with varying degrees of peripheral vascular disease. The Swedish Medical Research Council and the Swedish Institute for Health Services Development arranged a conference on diabetic foot problems in April 1998, the purpose of which was to arrive at a consensus regarding the prevention and management of diabetic foot. It was concluded that a satisfactory multidisciplinary approach should include regular control of feet and footwear, preventive foot care (education, footwear, chiropody), continuous follow-up of high-risk feet, and early recognition of revascularisation. Continuous registration of amputation, irrespective of type, cause and site, might substantially reduce the amputation rate among diabetics. Were such an approach to reduce the incidence of diabetes-related amputation by 50 per cent, annual costs for the management of diabetic foot in Sweden would be reduce by SEK 400 million (the value of improved quality of life not taken into consideration).     

The University of Texas Health Science Center at San Antonio: experience with foot surgery in diabetics

The authors present their experience, at the University of Texas Health Science Center at San Antonio, with foot surgery in patients with diabetes mellitus. It is important to note that the results that follow are a reflection of the authors' experience with foot surgery in these patients from 1980 to 1985. The authors report two separate groups of patients: those who underwent elective foot surgery and those who underwent ablative foot surgery for an infected diabetic foot with necrosis. Also reviewed is the etiology of diabetic foot deformities and ulcerations. It has been the authors' experience that elective prophylactic surgery in patients with diabetes and an intact vascular status produces good results. Patients with an infected diabetic foot, providing they demonstrate adequate vascular status, have a high percentage of healing with early surgical intervention.     

Potential economic benefits of lower-extremity amputation prevention strategies in diabetes

OBJECTIVE: To estimate the potential economic benefits of selected strategies from published literature--educational interventions, multidisciplinary clinics, and insurance coverage for therapeutic shoes--to reduce the incidence of lower-extremity amputation among individuals with diabetes. RESEARCH DESIGN AND METHODS: We developed a model to estimate the expected incidence and associated costs of lower-extremity amputation in a hypothetical cohort of 10,000 people with diabetes. Prevention strategies were assumed to be targeted at individuals with a history of foot ulcer, and benefits were estimated over a period of 3 years. RESULTS: The total potential economic benefits (discounted at 5%) of strategies to reduce amputation risk ranged from $2.0 to $3.0 million ($2,900 to $4,442 per person with a history of foot ulcer) over 3 years. Benefits were highest for educational interventions. Most benefits were found to accrue among individuals aged > or = 70 years. CONCLUSIONS: Strategies to reduce the risk of lower-extremity amputation may generate substantial economic benefits and should be a standard component of routine diabetes care. Benefits may best be achieved through a partnership of government, private payers, health care service providers and producers, and individuals with diabetes.     

Know how--diabetic foot ulceration

Diabetes is a complex metabolic disease which can give rise to many tissue complications. The foot is particularly vulnerable to circulatory and neurological disorders, so that even minor trauma can lead to ulceration and infection. Careful observation and assessment of these wounds is essential to ensure the integrity of the limb is not threatened, which could result in amputation. A multidisciplinary team approach is the key to successful management of diabetic foot ulceration.     

Prevalence and risk factors for diabetes and diabetes-related amputations in American Indians in southern Arizona

OBJECTIVE: To describe the prevalence of NIDDM and LEA using data from a computer-based patient data base. RESEARCH DESIGN AND METHODS: Diabetic patients with and without LEA, and nondiabetic patients were identified by computer search. Charts of diabetic patients were reviewed for confirmation of diagnosis of diabetes and diabetes-related amputation. The diabetic and nondiabetic populations were described, and certain risk factors were identified. RESULTS: The overall prevalence of NIDDM in this tribe in 1985-1986 was 18.3/100 adults (> or = 18 yr of age), whereas the prevalence of LEA/100 adults with NIDDM was 10.3%. Females were 1.3 times as likely to have diagnosed diabetes as males (95% CI 1.2-1.4), and males with diabetes were 1.4 times more likely to have had LEA than females with diabetes (95% CI 1.1-1.9). CONCLUSIONS: Automated health-care delivery data base used for this tribe can be used to maintain surveillance for diabetes and amputations in diabetic patients. Effective programs to prevent complications of diabetes, such as LEA, in this tribe are urgently needed.     

The value of total contact casting in treatment of neuropathic foot ulcers in diabetic patients

Neuropathic foot ulcers in diabetic patients pose great difficulties in treatment. Total contact casting is one of the available methods. It is thought to distribute the pressure evenly over the entire surface of the foot. The purpose of the study was the evaluation of the total contact casting as a method of treatment of neuropathic foot ulcers in diabetic patients. Ten diabetic patients with neuropathic foot ulcers were treated with total contact casting. The inclusion criteria were good arterial blood supply and the absence of bone, joints or surrounding soft tissue infection. The mean area of the ulcers was 1.9 cm2 (1.3-3.6 cm2). The average duration of the ulcer prior to commencement of the treatment was 10 months. Total contact cast was applied after thorough surgical debridement and covering of the ulcer with occlusive dressing. The casts were changed every six to ten days. The ulcers healed in 9 out of 10 treated patients. The healing time averaged two months. In one patient development of soft tissue infection necessitated discontinuation of the treatment and performing open ray amputation. In four patients superficial ulcerations of the skin of the dorsal aspect of the toes developed. They resulted in prolonged duration of the treatment. Total contact casting in adequately qualified and reliable patients is safe and effective method of treatment of neuropathic foot ulcers in diabetes.     

Foot problems in diabetes

Prevention and care of diabetic foot complications continue to represent a major challenge to the treating clinician. Neuropathy, infection, deformity, and vascular insufficiency threaten the diabetic foot and the overall functional well being of the diabetic patient. Although foot problems in diabetes cannot be eradicated completely, the opportunity exists to diagnose and manage diabetic foot conditions effectively, to educate and motivate patients to care for their feet, to minimize complications, and to decrease health care costs.     

Spontaneous arterial thrombosis in association with pancreatic carcinoma: diagnosis and interventional management

BACKGROUND: Soft tissue sarcomas of the hands and feet present a challenge for limb-preserving resections. METHODS: A retrospective review of 19 patients with sarcomas of the hand or foot was done. Wide or local excision was performed in 14 patients (74%), and amputation in 5 patients (26%). Of the latter group, three amputations involved a digit or toe, and two (10%) were major amputations (one Syme amputation and one below-knee amputation). When the minimum surgical margin was narrow (1 to 2 mm), adjuvant radiation was given postoperatively (n = 4). RESULTS: Local recurrence was observed in four patients (21%). Two of these required an amputation for local control. Local recurrence was observed in one of four patients (25%) treated with marginal resection and radiation and three of 15 (20%) of those with resection alone. CONCLUSIONS: A sizable percentage (37%) of patients with soft tissue sarcomas of the hand and foot ultimately required an amputation, although often the amputation was a minor one involving only a toe or a digit. Limb preservation was successful in the majority of patients (63%). The local recurrence rate was 21%, which may be improved with more frequent use of adjuvant therapy. The 5-year survival rate was 82%, which is better than that usually quoted for overall extremity soft tissue sarcomas.     

Management of the diabetic patient: causes of leg ulceration

The diabetic patient is at risk of developing numerous complications, including foot ulceration. The ulcer may contain a neuropathic and ischaemic element. Regular preventive checks can assist in early detection of foot problems. Failing eye sight and absence of sensation often result in patients relying on the healthcare professional detecting abnormalities on their behalf. The long-term effects of foot ulceration in the diabetic patient are immobility, septicaemia and amputation. Treatment options exist for the neuropathic and ischaemic foot but they vary in complexity. Accurate assessment and early recognition of the clinical signs of neuropathy and ischaemic ulceration will ensure early detection and optimum treatment interventions for the diabetic patient.     

Parvovirus B19 quiescence during the course of human immunodeficiency virus infection in persons with hemophilia

One hundred and seventy patients with major lower limb amputation (MLLA) presenting to The National Prosthetic-Orthotic Centre (NPOC) in Khartoum over a 1-year period were studied. There were 141 males and 29 females giving a M:F ratio of 4.9: 1.0, with mean age of 37 years (range 5-72 years). Forty-one patients (24%) underwent amputation of diabetic septic foot, 30 patients (17.6%) underwent amputation as a result of trauma from road traffic accidents and Madura foot, and war injuries accounted for 29 amputations (17%). One hundred and eleven patients had below knee amputation (BKA), 52 had above knee amputation (AKA) and seven patients had Syme's amputation. Diabetic amputees had higher rate of revisional surgery compared with others because of sepsis and/or flap necrosis. Stump pain was reported by amputees with excessive scarring of the stump and those with undue prominence of bony ends. There are two types of prostheses provided by the NPOC for both BKA and AKA: the peg leg and the conventional prostheses. The Syme's amputees were fitted with either simple hoof or articulated prostheses with solid ankle cushion heel (SACH). The peg leg consists of a leather lined side bearing metal socket connected to a rocker base by side steels. It is used by the country natives as it suits different weather and job conditions, particularly farming, and it can be repaired locally. The urban population use the conventional prostheses which is lighter in weight, can be put on and taken off easily and is cosmetically acceptable. However, these prostheses are more expensive and require frequent repair or replacement. The functional outcome of patient's rehabilitation with the prostheses was significantly affected by the level and indication of amputation. Those with BKA and those amputated because of trauma or Madura foot experienced better functional outcome compared with the diabetics, independent of age. 50% of patients with the AKA and 19% of those with BKA reported poor functional outcome. Surgeons should be more involved with the long-term evaluation of functional outcome in such patients, to offer help if feasible and to modify their technique for future procedures.     

Transmetatarsal amputation

We have reviewed the records of 25 patients who underwent a transmetatarsal amputation at San Francisco General Hospital. The average patient age was 63 years old. Twelve of the patients were diabetic, while transmetatarsal amputations were performed in eleven with simple arteriosclerosis. Two patients underwent amputations for either trauma or nonhealing ulcer. Thirteen of the patients healed their amputation, and twelve of these became ambulatory. Eleven required higher amputation, because of nonhealing due to infection in seven and progressive ischemia in four. One patient died on the first postoperative day of pneumonia. The failure group was younger, contained more diabetics, and had a higher incidence of infection. The operative procedure of transmetatarsal amputation is described. We believe that patients with distal gangrene without spreading infection should be considered for transmetatarsal amputation, reserving initial below-knee amputation for those with greater involvement of the foot.     

Foot lesions in patients with diabetes mellitus

Diabetic foot ulcers are common. If treatment is delayed or is inappropriate, the lesions can become infected, resulting in gangrene and amputation. Physicians and clinics that perform aggressive therapy for these ulcers, provide revascularization when indicated, practice a team approach, suggest the use of therapeutic shoes, and repeatedly educate patients in foot care have reduced their amputation rates by 50% or greater. Goals of the United States Department of Health for the year 2000 include a 40% reduction in the amputation rate in patients with diabetes. This should be the goal of everyone providing care for patients with diabetes.     

The Charcot foot in diabetes: six key points

The Charcot foot commonly goes unrecognized, particularly in the acute phase, until severe complications occur. Early recognition and diagnosis, immediate immobilization and a lifelong program of preventive care can minimize the morbidity associated with this potentially devastating complication of diabetic neuropathy. If unrecognized or improperly managed, the Charcot foot can have disastrous consequences, including amputation. The acute Charcot foot is usually painless and may mimic cellulitis or deep venous thrombosis. Although the initial radiograph may be normal, making diagnosis difficult, immediate detection and immobilization of the foot are essential in the management of the Charcot foot. A lifelong program of patient education, protective footwear and routine foot care is required to prevent complications such as foot ulceration.     

The natural history of great toe amputations

The purpose of this study is to report the prevalence of reamputation following resection of the great toe and first ray in adults with diabetes. We abstracted the medical records of 90 diabetic great-toe and first-ray amputees admitted between 1981 and 1991. The most common etiologies of initial amputations were ulcer with soft tissue infection (39%), ulcer with osteomyelitis (32%), and puncture wounds (12%). Sixty percent of all patients had a second amputation, 21% had a third, and 7% had a fourth. Fifteen percent of the patients who had a second amputation had it contralaterally. Seventeen percent subsequently underwent a below-knee amputation and 11% had a Transmetatarsal amputation on the same extremity, 3% had a below-knee amputation, and 2% a transmetatarsal amputation contralaterally. The mean time from the first to the second amputation was approximately 10 months. The results of this study suggest that a large proportion of patients undergoing an amputation at the level of the great toe or first ray have subsequent amputations in the first year following the initial procedure. Additionally, it appears that the contralateral foot may be at significant risk for distal amputation following resection of the hallux or first day.     

The prevalence of foot ulceration and its correlates in type 2 diabetic patients: a population-based study

The prevalence of peripheral neuropathy, peripheral vascular disease, and foot ulceration in Type 2 diabetic patients in the community were determined in a community-based study. Eight hundred and eleven subjects (404 male, 407 female, mean age 65.4 (range 34-90) years, diabetes duration 7.4 (0-50) years) from 37 general practices in three UK cities were studied. Neuropathy was diagnosed clinically using modified neuropathy disability scores which were ascertained using structured interviews and clinical examinations by one observer in each city. Peripheral vascular disease was diagnosed if a history of revascularization was present or > or = 2 foot pulses were absent. History of current or previous foot ulceration was recorded. The prevalence of neuropathy was 41.6% (95% confidence limits 38.3-44.9%) and the prevalence of PVD, 11% (9.1-13.7%). Forty-eight percent of neuropathic patients reported significant neuropathic symptoms. Forty-three patients (5.3% (3.8-6.8%)) had current or past foot ulcers; 20 of these were pure neuropathic ulcers, 13 neuroischaemic, 5 pure vascular, and 5 were unclassified. Multiple logistic regression showed history of amputation, neuropathy disability score, and peripheral vascular disease to be significantly associated with foot ulceration after adjusting for age and diabetes duration. A substantial proportion of Type 2 diabetic patients, often elderly patients who do not attend hospitals, suffered from peripheral neuropathy and peripheral vascular disease. These patients are at risk of foot ulceration and may benefit from preventive footcare.     

Reliability of F-scan in-shoe measurements of plantar pressure

Research by our group and others indicates that many amputations of the lower limb occur after foot ulceration in patients with diabetes. It has been proposed that diabetic foot ulcers are mainly caused by repetitive trauma in areas of high plantar pressure during walking. Recent technology permits in-shoe measurement of plantar pressure. We assessed the reliability of the F-Scan in-shoe system for measurement of plantar pressure (Tekscan Inc., Boston, MA) in 51 subjects from a cohort of 977 diabetic veterans enrolled in a prospective study of risk factors for foot ulceration and amputation (the Seattle Diabetic Foot Study). Subjects were tested twice, wearing their own shoes. We used the coefficient of variation (CV) and the intra-class correlation coefficient (ICC) to estimate the reliability of F-Scan measurements of pressure. Peak pressure over the metatarsal heads proved to have the best indices of reliability, with CVs of 0.150 and 0.155, and ICCs of 0.755 and 0.751. Coefficients of variation for the heel, whole foot, and hallux ranged from 0.148 to 0.240, with ICCs ranging from 0.493 to 0.832. By published standards, peak pressures over the metatarsal heads and right hallux met the criteria for excellent reliability. Our ICCs for high pressures under the foot, heel, metatarsal heads, and hallux, and for peak pressures under the heel and left hallux represented fair-to-good reliability. No F-Scan plantar measurements could be judged by these criteria as having poor reliability. This clinical study found that for elderly patients with diabetes who were wearing their own shoes and were tested on two different days with different insoles, the F-Scan insole system was generally reliable for measurements of high pressure and peak pressure.