Foot & Ankle International

Foot ulcers in individuals with diabetes often are the precursors to lower extremity amputation. The multidisciplinary team approach is highly effective in the prevention and treatment of diabetic foot morbidity. This article focuses on the role of the orthopaedic surgeon as a member of the wound care team for the diabetic foot.

Few topics in diabetic wound management generate as much “heated” discussion as hyperbaric oxygen (HBO). Hyperbaric oxygen is an intermittent inhalation therapy in which the patient breathes oxygen at greater than 1 atm of pressure. This requires placement of the patient into a sealed vessel (chamber) which is capable of withstanding pressurization. This article discusses the role of HBO as an adjunct to the management of diabetic problem foot wounds from evidenced-based, approved (by Medicare) indications and cost-effectiveness perspectives.

Successful management of patients with diabetic foot ulcers requires a multidisciplinary approach in which team members use their unique skills to achieve wound healing and prevent wound recurrence. This article describes the role of the nurse specialist and defines the roles of the baccalaureate-prepared wound care nurse specialist and the master's -prepared wound care nurse specialist. A case presentation highlights the role of the nurse practitioner in the outpatient wound clinic setting.

Physicians specializing in the care of patients with lower extremity disorders are acutely aware of the many adverse effects of diabetes mellitus and its secondary complications on all body systems. However, the disease has a devastating socioeconomic impact, as well. An estimated $98 billion in direct and indirect medical costs was spent on diabetes in 1997 in the United States. With a growing older population, cases of diabetes mellitus will certainly increase. The economic impact and clinical effectiveness of patient evaluation, preventive strategies, and treatment options are discussed.

Thirty-four patients with diabetes who attended a university diabetic foot clinic for treatment of a foot ulcer completed the American Academy of Orthopaedic Surgeons Musculoskeletal Outcomes Measure. The purpose of the study was to measure the impact of foot ulcers in patients with diabetes on the physical, mental, emotional, and social aspects of patients' lives. Thirty had at least a high school education. Only six were employed at the time. Nineteen were retired or disabled due to poor health. Sixteen were obese, 10 were considered overweight, and eight had a BMI within the acceptable range. Subjects had an average of four to five bodily systems affected by comorbid illness for which they were receiving treatment, some of which limited their activities. Approximately 85% of the study population required some type of ambulatory assist device or were unable to ambulate independently. The study population was significantly limited in performing all physical activities, especially those requiring use of the foot and ankle, and viewed their own health as being significantly worse than that of the general population. All stated that their foot/ankle disease interfered with their lives. Pain was not a significant component of their disability. The results of this study confirm the hypothesis that foot ulcers in patients with diabetes have a negative impact on quality of life in affected individuals.

Background: Foot-specific patient education is an essential element of a health system diabetic foot program. Foot-specific patient education must be individualized, because of cognitive deficits in individuals with long-standing diabetes. Methods: Two hundred and two consecutive patients attending diabetic foot specialty clinics were asked to provide demographics and complete a 10-question multiple-choice questionnaire. All attended the clinics because of their high-risk status for the development of diabetic foot infection or ulcers. All received ongoing foot-specific patient education. Results: In spite of this ongoing patient education program, only approximately 80% were able to respond appropriately to simple questions related to the care of their “at-risk” feet. Conclusion: This simple quality initiative reinforces the notion that patients with diabetes who are at risk for the development of diabetic foot ulcers should receive ongoing foot-specific patient education. This information needs to be constantly reinforced, as retention drops with time.

This article describes the extent of coverage and the process of obtaining Medicare coverage for prescription footwear for patients with diabetes and reflects policies in effect as of April 1, 2004.

Charcot arthropathy is a destructive process, most commonly affecting joints of the foot and ankle in diabetics with peripheral neuropathy. Affected individuals present with swelling, warmth, and erythema, often without history of trauma. Bony fragmentation, fracture, and dislocation progress to foot deformity, bony prominence, and instability. This often causes ulceration and deep infection that may necessitate amputation. Instability or deformity may limit the ability to use standard footwear. Treatment is focused on providing a stable and plantigrade foot for functional ambulation with accommodative footwear and orthoses. Historically, treatment had included nonweightbearing immobilization for the acute phase, and surgery had been reserved only for infection, unresolved skin ulceration, or deformity that precluded the use of therapeutic footwear. Current controversies include weightbearing in the acute or reparative phases and early surgical stabilization. Foot-specific patient education and continued periodic monitoring may reduce the morbidity and associated expense of treating the complications of this disorder and may improve the quality of life in this complex patient population.

The American Orthopaedic Foot and Ankle Society “Diabetic Foot Care” patient education leaflet was revised to improve the layout and emphasis of key concepts of preventive care. This included review of daily foot and shoe examination, danger signs, daily washing and foot care, shoe fitting, medical care, and avoidance of dangerous acts. The leaflet was expanded to occupy two sides of a page, retaining the capability of production in tear-off sheet format to facilitate distribution to patients in the clinical office. Furthermore, the leaflet was translated into 19 other languages for diabetic patients in the United States and around the world with limited English language comprehension.

Foot infection is the most common reason for hospital admission of diabetic patients in the United States. Foot ulceration leads to deep infection, sepsis, and lower extremity amputation. Prophylactic foot care has been shown to decrease patient morbidity, decrease the utilization of expensive resources, and decrease the risk for amputation and premature death. The Diabetes Committee of the American Orthopaedic Foot and Ankle Society has developed guidelines for the implementation of this type of prophylactic foot care. The screening examination includes evaluation for peripheral neuropathy, skin integrity, ulcers or wounds, deformity, vascular insufficiency, and footwear. Foot-specific patient education includes instruction on self-examination and foot care practices. Individualized foot-specific patient education is indicated for patients with peripheral neuropathy. Treatment is outlined based on risk level, which is determined by the presence of peripheral neuropathy, deformity, and ulcer history. Treatment combines patient education, orthoses, footwear, and a timetable for ongoing skin and nail care. Ulcer care includes paring of calluses, debridement of infected or nonviable tissue, dressings, and off-loading. Specialty assistance may be required from a vascular surgeon, orthopaedic surgeon, podiatrist, endocrinologist/diabetologist, infectious disease consultant, radiologist, and pedorthist.