The Diabetic Foot Goals in Remission - Podiatry Management Online The Diabetic Foot in Remission These

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    4.7% to 8.5%.1 Within the diabetic population the incidence of diabetic foot ulcers (DFUs) has been reported to be 4-10%, with a one-in-four risk of ulceration during an individual’s lifetime.2,3

    Incidence and Cost of Diabetic Foot infections Developed and developing na- tions alike loom on the edge of a global diabetes epidemic. Diabe- tes-related ulcerations continue to challenge healthcare systems by re-

    maining common, costly, and recal- citrant. In the past 30 years, the inci- dence of diabetes among the world’s adult population has nearly quadru- pled, rising to over 422 million adults worldwide. During this same time global prevalence increased from

    Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Con- tinuing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $26.00 per topic) or 2) per year, for the special rate of $210 (you save $50). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. You can also take this and other exams on the Internet at If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 124. Other than those entities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manu- scripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at bblock@ Following this article, an answer sheet and full set of instructions are provided (pg. 124).—Editor

    Continued on page 116

    Goals and Objectives

    After completing this CME the reader should be able to:

    1) Understand the impact of diabetes-related foot ulcers on the global health system

    2) Review current conserva- tive and surgical methods for preventing repeat ulcerative episodes

    3) Consider advanced surgi- cal techniques such as silicone implants and fat transplants for maintaining ulcer remission

    4) Review the benefits of a multi-disciplinary practice in treating ulcerations and prevent- ing repeat episodes

    The Diabetic Foot in Remission

    These medical and surgical management strategies

    can extend ulcer-free days.

    By John D. Miller, DPM,

    DaviD C. hatCh Jr., DPM,

    anD DaviD G. arMstronG,

    DPM, MD, PhD

    CMe / WOUND ManaGeMent

  • the promotion of their own health. Due to the astonishingly high re- currence of DFU, often comparable to rates of cancer, language when discussing preventative treatment of DFUs should be as clear and stark as that of cancers.21 Healed DFUs should be explained to be in “remission”, as

    Diabetes-related foot ulcers and amputations cost the U.S. healthcare system up to $17 billion annually, surpassing the direct costs of the five most expensive cancers.4-7 Of the sum of diabetic inpatient care charges, foot ulcerations are a significant source of expenditures, often leading to admissions totaling upwards of $100,000 in charges.8-10 It has been re- ported that as much as 25-50% of all costs related to inpatient care among the diabetic population may be di- rectly related to diabetic foot ulcers.11 These costs inflate with the presence of peripheral arterial disease to near- ly four times the cost of purely neu- ropathic wounds.12

    Annual recurrence rates of dia- betic ulcerations have been reported as high as 34%, 61%, and 70% at one, three, and five years, respec- tively, with recurrence rates as high as 20% to 58% within one year.13,14 Existing prevention methods have the potential to decrease the risk of am- putation for diabetic patients with a history of ulcer by 50%.15 It has also been demonstrated that a 25% reduc- tion in the incidence of foot ulcers through the implementation of basic preventative clinical care would ne- gate the cost of program implementa- tion of such a program.16 It is to this

    end that we outline innovations in the management of the diabetic foot ulcer (DFU) and discuss the course of diabetic foot remission.

    Current Screening Strategies The American Diabetes Associ- ation recommends that all patients with diabetes see a lower extremity specialist for foot screenings at rou- tine intervals depending on need; at least every six months for the most basic evaluation or at least every two months for those at greater risk for DFUs.17 At these visitations, clinicians

    evaluate a patient’s continued risk for ulceration by evaluating a pa- tient’s neurological and vascular sta- tus as well as reviewing prior history of foot ulcers to create an overall pic- ture of ulcerative risk.18,19

    Clinical application of risk strat- ification guidelines such as the So- ciety for Vascular Surgery’s WIfI (wound, ischemia, and foot infec- tion) classification20 aid this process by correlating certain risk parame- ters with end-outcome probabilities. This information proves particular- ly useful during patient education and clarification of how they fit the spectrum of amputation and mortal risk. This information is not only requisite in understanding clinical prognosis, but may be further moti- vation to take early action towards

    www.podiatrym.comAUGUST 2016 | PODIATRY MANAGEMENT


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    Remission (from page 115)

    Continued on page 117

    Figure 1: Plantar-flexed metatarsal heads are common manifestations of high-pressure areas that lead to ulceration. Conservative and sur- gical methods to prophylactically offload these areas are crucial to the prevention of return ulcerations to the patient in remission.

    Figure 2: Wound secondary to peak forces sub- 3rd metatarsal head. Without proper offloading, plantar wounds will persist indefinitely and often result in infection requiring amputation.

    Figure 3: Rigid digital contractions produce numerous high-friction areas in footgear for the creation of ulcers. Preventative management of these deformities by conservative and surgical methods is crucial to avoid foot ulcers.

    In the past 30 years, the incidence of diabetes among the world’s adult population has nearly quadrupled,

    rising to over 422 million adults worldwide.

  • high peak plantar pressure.24,37 However, that practice does not parallel the podiatric standard of care as only 2-11% of care centers and podiatry practitioners surveyed utilize TCCs for primary off-load- ing.38-40 Additionally, despite proven efficacy, Cavanagh and Bus26 also found clinicians worldwide resisting the implementation of TCC devices in these cases, presumably because of the increased time, cost, and expertise required for proper application.

    Surgical Methods of Off-loading Common neurologic and mus- culoskeletal sequelae of the diabetic process lead to multiple areas of ab- normal foot structure that cause areas of higher pressure, which in turn are at great risk for re-ulceration.41-43 The most common deformities in the diabetic patient include local nerve entrapment, tightness of the Achilles tendon, and hammer and claw-toe deformities. With rates of infection status-post digital surgeries in patients with diabetes similar to those of pa- tients without diabetes, surgical op- tions in any patient with obstreperous wound recurrence should be consid- ered.44 Critical to the success of the pa- tient in remission is adequate pre-op- erative amputation planning. Figures 4a and 4b demonstrate a patient in

    which a violation of the ‘too few toes principle’ for digital amputation plan- ning likely led to his re-ulceration.

    Nerve Decompression A small demographic of diabet- ic patients who have symptoms of nerve entrapment may benefit from nerve release surgery with a main hypothesis of correction being the

    abatement of recurrence and “active prevention” becomes the focus of care once a DFU has healed.21

    With this mindset, increasing pa- tient knowledge regarding the im- portance of self-care and daily foot exams is key to their overall success

    in maintaining DFU remission. Cur- rent patient guidelines for daily care include inspection of the feet, use of diabetic socks to reduce friction, foot exercises to promote circulation, and application of any topical antifungal or hydrating lotions as necessary. At- risk patients should be informed to avoid self-damaging behaviors such as barefoot walking, using ill-fitting footwear, poor glycemic control, or delaying regular medical professional foot inspection and nail care.18

    Reducing Peak Plantar Pressures Among the strongest risk factors for ulcer development are repetitive stresses on the fe