Foot ulcer risk is lower in South-Asian and african-Caribbean compared with European diabetic patients in the U.K.: the North-West diabetes foot care study

OBJECTIVE: To determine 1) foot ulcer rates for European, South-Asian, and African-Caribbean diabetic patients in the U.K and 2) the contribution of neuropathy and peripheral arterial disease (PAD) differences to altered ulcer risk between the groups. RESEARCH DESIGN AND METHODS: In this U.K. population-based study, we screened 15,692 type 1 and type 2 diabetic patients in the community health care setting for foot ulcers, foot deformities, neuropathy, and PAD plus other characteristics. In total, 13,409 were European (85.5%), 1,866 were South Asian (11.9%), and 371 were African Caribbean (2.4%). RESULTS: The age-adjusted prevalence of diabetic foot ulcers (past or present) for Europeans, South Asians, and African Caribbeans was 5.5, 1.8, and 2.7%, respectively (P < 0.0001). Asians and African Caribbeans had less neuropathy, PAD, and foot deformities than Europeans (P = 0.003). The unadjusted risk of ulcer (odds ratio [OR]) for Asians versus Europeans was 0.29 (95% CI 0.20-0.41) (P < 0.0001). PAD, neuropathy, foot deformities, and insulin use attenuated the age-adjusted OR from 0.32 to 0.52 (0.35-0.76) (P < 0.0001). African-Caribbean versus European ulcer risk in males was attenuated from 0.60 to 0.71 by vibration sensation. CONCLUSIONS: South Asians with diabetes in the U.K. have about one-third the risk of foot ulcers of Europeans. The lower levels of PAD, neuropathy, insulin usage, and foot deformities of the Asians account for approximately half of this reduced foot ulcer risk. Lower neuropathy is the main contributor to the reduced African-Caribbean ulcer rate, particularly in men. The reasons for these ethnic differences warrant further investigation.     

Clinical correlates of plantar pressure among diabetic veterans.

OBJECTIVE: To assess the relationship between diabetes characteristics, medical history, foot deformity, sensory neuropathy, and plantar foot pressure. RESEARCH DESIGN AND METHODS: There were 517 subjects from a cohort of diabetic veterans enrolled in a prospective study of risk factors for foot complications who contributed 1,017 limbs for study. We interviewed subjects to collect data on demographics, diabetes characteristics, and medical history. A research nurse practitioner performed a directed physical exam of the lower extremities, assessing foot deformities and including quantitative sensory testing with a 5.07 monofilament. In-shoe foot-pressure measurements were obtained with F-scan insoles on subjects wearing their own footwear while walking 10 m at their usual pace. RESULTS: In univariate analyses, significant associations were seen between at least one measure of plantar pressure and body mass, sex, race, age, insulin use, certain foot deformities, plantar callus, and sensory neuropathy. Diabetes duration, HbA1c, and history of foot ulcer or amputation were unrelated to plantar pressure. In multiple regression analyses, body mass measured as log (weight), insulin use, white race, male sex, plantar callus, and diabetes duration were significantly related to certain pressures. Foot deformities were related primarily to forefoot pressures. With high pressure at two or more sites defined as the outcome, only body mass remained statistically significant as a predictor of this outcome in a backwards elimination logistic regression model. CONCLUSIONS: High in-shoe plantar pressure in diabetic subjects can be predicted in part from readily available clinical characteristics. The mechanisms by which these characteristics may be related to plantar pressure require further study.     

Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings.

OBJECTIVE: To determine the frequency and constellations of anatomic, pathophysiologic, and environmental factors involved in the development of incident diabetic foot ulcers in patients with diabetes and no history of foot ulcers from Manchester, U.K., and Seattle, Washington, research settings. RESEARCH DESIGN AND METHODS: The Rothman model of causation was applied to the diabetic foot ulcer condition. The presence of structural deformities, peripheral neuropathy, ischemia, infection, edema, and callus formation was determined for diabetic individuals with incident foot ulcers in Manchester and Seattle. Demographic, health, diabetes, and ulcer data were ascertained for each patient. A multidisciplinary group of foot specialists blinded to patient identity independently reviewed detailed abstracts to determine component and sufficient causes present and contributing to the development of each patient's foot ulcer. A modified Delphi process assisted the group in reaching consensus on component causes for each patient. Estimates of the proportion of ulcers that could be ascribed to each component cause were computed. RESULTS: From among 92 study patients from Manchester and 56 from Seattle, 32 unique causal pathways were identified. A critical triad (neuropathy, minor foot trauma, foot deformity) was present in > 63% of patient's causal pathways to foot ulcers. The components edema and ischemia contributed to the development of 37 and 35% of foot ulcers, respectively. Callus formation was associated with ulcer development in 30% of the pathways. Two unitary causes of ulcer were identified, with trauma and edema accounting for 6 and < 1% of ulcers, respectively. The majority of the lesions were on the plantar toes, forefoot, and midfoot. CONCLUSIONS: The most frequent component causes for lower-extremity ulcers were trauma, neuropathy, and deformity, which were present in a majority of patients. Clinicians are encouraged to use proven strategies to prevent and decrease the impact of modifiable conditions leading to foot ulcers in patients with diabetes.     

Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers.

OBJECTIVE: To identify risk factors for lower-extremity amputation (LEA) in individuals with diabetes and to estimate the incidence of LEA. RESEARCH DESIGN AND METHODS: This is a prospective study of 776 U.S. veterans in a general medicine clinic in Seattle, Washington. The outcome was first LEA during follow-up. Potential risk factors evaluated in proportional hazards models included, among others, peripheral vascular disease (PVD), sensory neuropathy, former LEA, foot deformities and ulcers, diabetes duration and treatment, and hyperglycemia. RESULTS: Associated with an increased risk for LEA were PVD defined as transcutaneous oxygen < or = 50 mmHg (relative risk [RR] = 3.0, 95% CI 1.3-7.1), insensitivity to monofilament testing (RR = 2.9, odds ratio = 1.1-7.8), lower-extremity ulcers (RR = 2.5, CI 1.1-5.4), former LEA, and treatment with insulin when controlling for duration of diabetes and other factors in the model. PVD defined as absent or diminished lower-extremity pulses or an ankle arm index < or = 0.8 was also associated with a significantly higher risk of LEA in separate models. Foot ulcers were associated with an increased ipsilateral risk of amputation. The age-adjusted incidence among men only for LEA standardized to the 1991 U.S. male diabetic population was 11.3/1,000 patient-years. CONCLUSIONS: This prospective study shows that peripheral sensory neuropathy, PVD, foot ulcers (particularly if they appear on the same side as the eventual LEA), former amputation, and treatment with insulin are independent risk factors for LEA in patients with diabetes.     

Muscle weakness and foot deformities in diabetes: relationship to neuropathy and foot ulceration in caucasian diabetic men

OBJECTIVE: To examine the relationships among muscle weakness, foot deformities, and peroneal and tibial nerve conduction velocity in diabetic and nondiabetic men. RESEARCH DESIGN AND METHODS: A neuropathic and foot evaluation was undertaken in 10 nondiabetic control subjects (group C) and in 36 consecutive diabetic patients attending Diabetes Centre clinics, including 10 diabetic control subjects (group D), 15 diabetic neuropathic patients (group DN), and 11 diabetic patients with a history of ulceration (group DU). Neuropathy was defined as a peroneal motor nerve conduction <40 m/s. Muscle weakness was assessed in seven intrinsic and seven extrinsic muscles of the foot using a semiquantitative score (max score per muscle = 3). Foot deformities were assessed using a foot deformity score (max score = 3). A higher score indicated increased muscle weakness or more severe foot deformities. Muscle weakness and foot deformities were assessed without prior knowledge of patient and neuropathy status. RESULTS: Peroneal and tibial nerve conduction velocity were associated with weakness in muscles innervated by, respectively, the peroneal and tibial nerve (r = -0.70 and r = -0.51, P < 0.01) and foot deformities (r = -0.60 and r = -0.59, P < 0.001). The DN and DU groups had more weakness in intrinsic and extrinsic muscles compared with the C and D groups. Muscles innervated by the tibial nerve had a greater proportional muscle weakness than those innervated by the peroneal nerve in the DN and DU groups. The DN and DU patients had more foot deformities (median food deformity score [interquartile range]) (3 [2-3] and 2 [2-3]) compared with D and C patients (0 [0-0.75] and 0 [0-0]). CONCLUSIONS: Important relationships have been shown between motor nerve conduction deficit and muscle weakness; however, it is still not clear whether abnormal nerve function, leading to a decrease in muscle strength, could be responsible for the development of foot deformities.     

Assessment and treatment of diabetic foot ulcer

BACKGROUND AND OBJECTIVES: Foot ulcers are one of the main complications in diabetes mellitus, with a 15% lifetime risk in all diabetic patients. The rate of lower extremity amputation among diabetic patients is 17-40 times higher than in non-diabetics. A critical triad of neuropathy, minor foot trauma and foot deformity was found in > 63% of diabetic foot ulcers (DFU). Peripheral vascular disease (PVD) has been identified in 30% of foot ulcers. We present a comprehensive assessment and the treatment of DFUs. We also want to notify physicians not to ignore foot assessment and examinations in patients with diabetes. METHODS: We conducted this study on DFU on the basis of: pathogenesis and risk factors, assessment and physical examination, paraclinic assessment, treatment, cost and mortality and prevention. RESULTS AND FINDINGS: Approximately 20% of hospital admissions among diabetic patients are the result of foot problems. Diabetic foot assessment should include dermatological, vascular, neurological and musculoskeletal systems. There are three basic treatments for management of DFU: (i) debridement; (ii) antibiotics and (iii) revascularization. The cost to treat one simple ulcer is $5000 to $8000. CONCLUSION: Awareness of physicians about foot problems in diabetic patients, clinical examination and paraclinical assessment, regular foot examination, patient education, simple hygienic practices and provision of appropriate footwear combined with prompt treatment of minor injuries can decrease ulcer occurrence by 50%.     

Transcutaneous oxygen tension and toe blood pressure as predictors for outcome of diabetic foot ulcers.

OBJECTIVE: The present study was undertaken to compare the predictive values of transcutaneous oxygen tension (TcPO2) and toe blood pressure (TBP) measurements for ulcer healing in patients with diabetes and chronic foot ulcers. RESEARCH DESIGN AND METHODS: Investigated prospectively were 50 diabetic patients (37 men) with chronic foot ulcers. The age was 61 +/- 12 (mean +/- SD), and the diabetes duration was 26 +/- 14 years. TBP (mmHg) was measured in dig I and TcPO2 (mmHg) at the dorsum of the foot. Ulcer healing was continuously evaluated by measuring the ulcer area every 4-6 weeks. After a follow-up time of 12 months, the patients were divided into three groups according to clinical outcome: healed with intact skin, improved ulcer healing, or impaired ulcer healing. RESULTS: Of the 13 patients who deteriorated, 11 had TcPO2 < 25 mmHg, while 34 of the 37 patients who improved had TcPO2 > or = 25 mmHg. The sensitivity and specificity for TcPO2 were 85 and 92%, respectively, when a cutoff level of 25 mmHg was used for determination of outcome of ulcer healing (healing or nonhealing). The corresponding values for TBP at 30 mmHg were 15 and 97%. Measurement of TcPO2 provided a higher positive predictive value (79%) than TBP (67%). CONCLUSIONS: The results indicate that TcPO2 is a better predictor for ulcer healing than TBP in diabetic patients with chronic foot ulcers, and that the probability of ulcer healing is low when TcPO2 is < 25 mmHg.     

Prevalence of foot pathology and lower extremity complications in a diabetic outpatient clinic

Multiple risk factors interplay in the formation of foot ulceration and/or limb amputation in the diabetic patient. This study defines the prevalence of foot pathology, lower extremity complications, and known risk factors for ulceration in a cross-sectional analysis of 92 diabetic patients in a Veterans Affairs Metabolic Clinic. Sixteen percent of patients had a history of lower extremity complications including pedal ulceration and/or amputation, previously requiring 1480 hospital days of care. Sixty-eight percent of patients had structural pathology in the foot, including: 51 percent callus, 32 percent hammertoes, 8 percent bunions, and 1 percent Charcot foot. Thirty-four percent of patients were insensate, while 25 percent had autonomic neuropathy. Twenty-two percent of patients had atherosclerosis obliterans as defined by an ankle brachial index less than 0.9; 13 percent suffered from intermittent claudication. The following pathologies were significantly more prevalent in diabetic patients with a history of ulceration and/or amputation compared to those patients without ulceration or amputation: hammertoe deformity (p less than .0001), abnormal cutaneous pressure sensation (p less than .05), abnormal R-R interval (p less than .05), intermittent claudication (p less than .05), and abnormal ankle brachial index (p less than .05). An important finding was that 41 percent of insensate patients were not aware of their sensory deficit. In addition, two-thirds of the patients with vascular disease had palpable pulses. All patients with diabetes should be entered into a basic foot education program. The high prevalence of lower extremity pathology coupled with the inadequacy of history and physical examination in detecting neuropathy and vascular disease emphasize the need for vigorous screening to determine whether patients are at high risk of ulceration/amputation. These patients should be entered into aggressive prophylactic treatment programs.     

Overview of Diabetic Foot Care for the Nurse Practitioner

Foot and ankle complications of diabetes result in significant morbidity, mortality, and health care expenditure. Diabetes may result in foot deformity, neuropathy, and peripheral artery disease with risk of callus, foot ulcer, infection, and subsequent amputation. Appropriate patient education, medical management, and use of therapeutic footwear can prevent many diabetic foot complications. Nurse practitioners are key members of foot care teams in both primary and specialty care. The nurse practitioner managing a patient’s diabetes is an appropriate provider to certify the need for diabetic shoes and should be authorized to do so to provide quality care without unnecessary delay.     

Home monitoring of foot skin temperatures to prevent ulceration

OBJECTIVE: To evaluate the effectiveness of at-home infrared temperature monitoring as a preventative tool in individuals at high risk for diabetes-related lower-extremity ulceration and amputation. RESEARCH DESIGN AND METHODS: Eighty-five patients who fit diabetic foot risk category 2 or 3 (neuropathy and foot deformity or previous history of ulceration or partial foot amputation) were randomized into a standard therapy group (n = 41) or an enhanced therapy group (n = 44). Standard therapy consisted of therapeutic footwear, diabetic foot education, and regular foot evaluation by a podiatrist. Enhanced therapy included the addition of a handheld infrared skin thermometer to measure temperatures on the sole of the foot in the morning and evening. Elevated temperatures (>4 degrees F compared with the opposite foot) were considered to be "at risk" of ulceration due to inflammation at the site of measurement. When foot temperatures were elevated, subjects were instructed to reduce their activity and contact the study nurse. Study subjects were followed for 6 months. RESULTS: The enhanced therapy group had significantly fewer diabetic foot complications (enhanced therapy group 2% vs. standard therapy group 20%, P = 0.01, odds ratio 10.3, 95% CI 1.2-85.3). There were seven ulcers and two Charcot fractures among standard therapy patients and one ulcer in the enhanced therapy group. CONCLUSIONS: These results suggest that at-home patient self-monitoring with daily foot temperatures may be an effective adjunctive tool to prevent foot complications in individuals at high risk for lower-extremity ulceration and amputation.     

Assessment of the diabetic foot using spiral computed tomography imaging and plantar pressure measurements: a technical report

Persons with diabetes mellitus (DM) and peripheral neuropathy are at high risk for skin breakdown due to unnoticed excessive pressures to the plantar foot during walking. We developed methods that combined spiral x-ray computed tomography (SXCT) imaging and plantar pressure analysis to quantify internal foot structure and external pressure during plantar loading. Methods were tested using a subject with DM who had a plantar ulcer, and a healthy control. SXCT measurements were within 2 mm of truth and SXCT plantar recordings were within 6.5% of walking trials. Hammer toe deformity (second toe), severe atrophy of the intrinsic muscles and less contact area during plantar loading, and a peak plantar pressure three times greater at the site of the ulcer were measured in the diabetic foot as compared with the healthy control. This preliminary investigation suggests that these methods are accurate for structural and pressure measurements of diabetic and healthy feet.     

Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot

OBJECTIVE: To evaluate the effectiveness of a diabetic foot risk classification system by the International Working Group on the Diabetic Foot to predict clinical outcomes. RESEARCH DESIGN AND METHODS: A total of 225 diabetic patients were initially evaluated as part of a prospective case-control study at the University of Texas Health Science Center at San Antonio. Complete records were available for 213 patients for follow-up evaluation after 29 months. Upon enrollment, subjects were stratified into four risk groups based on the presence of risk factors according to the consensus of the International Working Group on the Diabetic Foot. Group 0 consisted of subjects without neuropathy, group 1 consisted of patients with neuropathy but without deformity or peripheral vascular disease (PVD), group 2 consisted of subjects with neuropathy and deformity or PVD, and group 3 consisted of patients with a history of foot ulceration or a lower-extremity amputation. RESULTS: Upon enrollment, patients in higher-risk groups had longer duration of diabetes, worse glycemic control, vascular and neuropathic variables, and more systemic complications of diabetes. During 3 years of follow-up, ulceration occurred in 5.1, 14.3, 18.8, and 55.8% of the patients in groups 0, 1, 2, and 3, respectively (linear-by-linear association, P < 0.001). All amputations were found in Groups 2 and 3 (3.1 and 20.9%, P < 0.001). CONCLUSIONS: The foot risk classification of the International Working Group on the Diabetic Foot predicts ulceration and amputation and can function as a tool to prevent lower-extremity complications of diabetes.     

Healing times of pedal ulcers in diabetic immunosuppressed patients after transplantation.

OBJECTIVE: To compare the healing time of neuropathic plantar ulcers treated by total-contact casting (TCC) in diabetic, immunosuppressed patients after organ transplantation with the healing time of plantar ulcers in control nonimmunosuppressed patients. DESIGN: A case-control design with the control group matched for age, race, sex, body dimensions (height, weight, and body mass index), presence of sensory neuropathy, foot deformity presence and location, and pedal ulcer area and depth. SETTING: An outpatient physical therapy clinic in a regional tertiary-care hospital and academic medical center. PARTICIPANTS: Nine patients with chronic diabetes mellitus and a previous organ transplantation who were currently receiving lifelong immunosuppressive drug therapy were treated for a neuropathic plantar ulcer by means of TCC. Fourteen group-matched control subjects with diabetes mellitus and a plantar ulcer but who had never had an organ transplantation and were not taking immunosuppressive agents were also studied. INTERVENTIONS: TCC with partial weight-bearing using an assistive device until ulcers healed. MAIN OUTCOME MEASURE: Healing time was defined as the number of days in the total-contact cast until the skin completely closed. RESULTS: All diabetic foot ulcers healed with casting. Immunosuppressed/transplanted patients healed in a mean time of 111 +/- 25 days; ulcers of control subjects healed in 47 +/- 18 days (p < .05). All patients returned to ambulation using prescribed therapeutic footwear. None of the patients required a lower extremity amputation throughout the follow-up period. CONCLUSIONS: TCC is a highly effective and rapid method of healing neuropathic pedal ulcers in diabetic immunosuppressed/transplantation patients, although it may take several weeks longer than it would for patients who were not immunocompromised.     

Amputation prevention initiative in South India: positive impact of foot care education

OBJECTIVE: To determine whether intensive treatment and education strategies for type 2 diabetic patients with high-risk diabetic foot disease helps in preventing foot amputations. RESEARCH DESIGN AND METHODS: Participants included 4,872 consecutive type 2 diabetic patients (male-to-female ratio 3,422:1,450, mean (+/-SD) age 60.5 +/- 8.8 years, mean duration of diabetes 13.7 +/- 7.6 years) with high-risk diabetic foot disease. The patients were categorized as high-risk subjects according to the International Consensus on the Diabetic Foot. The three study groups were subjects with diabetes and neuropathy (group 1; n = 2,871), diabetic neuropathy with deformity (group 2; n = 235), and diabetic neuropathy with deformity and foot ulceration or peripheral vascular disease (group 3; n = 1,766). Neuropathy was diagnosed by biothesiometry. Peripheral vascular disease was diagnosed as an ankle brachial index <0.8. All the subjects were educated regarding diabetic foot disease and its complications and prevention. They were also instructed to visit the center if any sign of new lesions appeared. RESULTS: Among the 1,259 group 3 subjects who came for follow-up, 718 (57%) strictly followed the advice given and 541 (43%) did not. Ulcers present during the recruitment had healed in 585 (82%) subjects who followed the advice, but in only 269 (50%) subjects who did not. A significantly larger proportion of subjects who did not follow the advice developed new problems (26%) and required surgical procedures (14%) compared with those who followed the advice (5 and 3%, respectively). CONCLUSIONS: Strategies such as intensive management and foot care education are helpful in preventing newer problems and surgery in diabetic foot disease.     

Practical management of diabetic foot

Prevention and the correct treatment of the diabetic foot have important social and economic consequences. Risk stratification is essential for choosing the appropriate treatment strategy. History and careful clinical examination identify the risk in each individual patient with diabetes. Peripheral neuropathy (PNP), foot deformation, peripheral arterial disease (PAD) and a history of previous ulcer or amputation are the most important risk factors. PAD must be diagnosed and treated by percutan transluminal angioplasty or bypass surgery where necessary. Primary foot deformation or secondary due to PNP require shoe modifications. Good metabolic control of diabetes and treatment of other cardiovascular risk factors (dyslipidemia, hypertension) delay or prevent the development of PNP and PAD. Therefore an early multidisciplinary approach is essential for each patient with diabetes and foot problems. In the presence of a foot ulcer, it's important to diagnose osteomyelitis by clinical or radiological examination. The choice and duration of antibiotic treatment and surgical intervention depends on the localisation and extension of infection around the ulcer and the presence of osteomyelitis. In case of limb threatening infection, the patient should be referred to a specialized treatment facility immediately.     

The development and validation of a neuropathy- and foot ulcer-specific quality of life instrument

OBJECTIVE: The purpose of this study was to develop a questionnaire that measures patients' perceptions of the impact of diabetic peripheral neuropathy and foot ulcers on their quality of life and to assess the psychometric properties of this instrument in a sample of patients with varying severity and symptomatology of diabetic peripheral neuropathy. RESEARCH DESIGN AND METHODS: The neuropathy- and foot ulcer-specific quality of life instrument (NeuroQoL), generated from interviews with patients with (n = 47) and without (n = 15) diabetic peripheral neuropathy, was administered to 418 consecutive patients with diabetic peripheral neuropathy (35% with foot ulcer history) attending either U.K. (n = 290) or U.S. (n = 128) diabetes centers. Psychometric tests of NeuroQoL included factor analyses and internal consistency of scales; a series of multivariate analyses were performed to establish its criterion, construct, and incremental validity. Results were compared with those obtained using the Short Form (SF)-12 measure of health-related functioning. RESULTS: Factor analyses of NeuroQoL revealed three physical symptom measures and two psychosocial functioning measures with good reliability (alpha = 0.86-0.95). NeuroQoL was more strongly associated with measures of neuropathic severity than SF-12, more fully mediated the relationship of diabetic peripheral neuropathy with overall quality of life, and significantly increased explained variance in overall quality of life over SF-12. CONCLUSIONS: NeuroQoL reliably captures the key dimensions of the patients' experience of diabetic peripheral neuropathy and is a valid tool for studying the impact of neuropathy and foot ulceration on quality of life.     

Mid foot kinetics characterize structural polymorphism in diabetic foot disease

BACKGROUND: Diabetic foot disease is characterized by progressive foot deformities that lead to amputation and disabling morbidity. The purpose is to investigate the classification of two distinct phenotypes of mid foot structural polymorphism in individuals using plantar kinetic and pressure distribution and tarsal bone density assessments. METHODS: Twenty-two individuals (26 ft) with diabetes mellitus, peripheral neuropathy and at least one mid foot deformity were compared to 29 age-, gender- and race-matched healthy controls (58 ft). Eleven subjects with diabetes mellitus and peripheral neuropathy (11 ft) had lateral deformity; 11 subjects (15 ft) had medial deformity. Each subject had calcaneal bone mineral density and plantar force and pressure assessments walking barefoot over an EMED-ST P-2 platform. FINDINGS: Control subjects had lower mid foot vertical forces and pressures despite significantly higher preferred walking speed. In subjects with diabetes and neuropathy, maximum vertical force was 6-fold greater, force-time integral 9.5-fold greater, peak pressure 6.7-fold higher, pressure-time integral was 9.7-fold greater, contact area 2-fold greater and contact time 1.9-fold higher than controls. Pressure values were larger in involved vs uninvolved (P0.05). During stance in the mid foot, subjects with medial column phenotype showed greater pressure in the medial mask; subjects with lateral column phenotype had greater pressures in the lateral mask (P<0.05). Calcaneal bone density was lower for the deformity foot vs the non-deformity foot; bone mineral density was lower in medial column phenotype vs lateral column phenotype (P=0.02). INTERPRETATION: Diabetic foot disease can be classified as stereotypical, structurally-distinct phenotypes of deformities of the medial and lateral columns of the mid foot. Assessments of pedal bone density and plantar mid foot force and pressure during barefoot walking can characterize the structural polymorphic phenotypes and may assist the foot care specialist in clinical decision making.     

Prediction of diabetic foot ulcer occurrence using commonly available clinical information: the Seattle Diabetic Foot Study

OBJECTIVE: The ability of readily available clinical information to predict the occurrence of diabetic foot ulcer has not been extensively studied. We conducted a prospective study of the individual and combined effects of commonly available clinical information in the prediction of diabetic foot ulcer occurrence. RESEARCH DESIGN AND METHODS: We followed 1,285 diabetic veterans without foot ulcer for this outcome with annual clinical evaluations and quarterly mailed questionnaires to identify foot problems. At baseline we assessed age; race; weight; current smoking; diabetes duration and treatment; HbA(1c) (A1C); visual acuity; history of laser photocoagulation treatment, foot ulcer, and amputation; foot shape; claudication; foot insensitivity to the 10-g monofilament; foot callus; pedal edema; hallux limitus; tinea pedis; and onychomycosis. Cox proportional hazards modeling was used with backwards stepwise elimination to develop a prediction model for the first foot ulcer occurrence after the baseline examination. RESULTS: At baseline, subjects were 62.4 years of age on average and 98% male. Mean follow-up duration was 3.38 years, during which time 216 foot ulcers occurred, for an incidence of 5.0/100 person-years. Significant predictors (P 相似文献   

Relationship between foot type, foot deformity, and ulcer occurrence in the high-risk diabetic foot

We hypothesized an association between foot type, foot deformity, and foot ulceration and conducted an analysis of a well-characterized, high-risk diabetic population of 398 subjects. The average age was 62 years of age and 74% of the study population were males. Foot-type distributions were 19.5% pes cavus (high arch), 51.5% neutrally aligned (normal arch), and 29.0% pes planus (low arch). We quantified the presence of hallux valgus (23.9%), hammer/claw toes (46.7%), and hallux limitus (24.4%). A significant association was found between foot type and hallux valgus (p = 0.003); pes planus feet had the highest prevalence as compared with neutrally aligned feet (odds ratio [OR] = 2.43, p = 0.0006). Foot type was also significantly associated with fixed hammer/claw toes (p = 0.01); pes cavus feet had the highest prevalence as compared with neutrally aligned feet (OR = 3.89, p = 0.001). Foot type was also significantly associated with hallux limitus (p = 0.006) with pes planus feet having the highest prevalence as compared with neutrally aligned feet (OR = 2.19, p = 0.003). However, foot type was not significantly related to any ulcer outcome (p = 0.7). Fixed hammer/claw toes (OR = 3.91, p = 0.003) and hallux limitus (OR = 3.02, p = 0.006) were associated with increased risk of any ulcer occurrence. This study affirms that foot type and foot deformity are related and that foot deformities are associated with ulcer occurrence.     

Hyperbaric oxygenation accelerates the healing rate of nonischemic chronic diabetic foot ulcers: a prospective randomized study

OBJECTIVE: To study the effect of systemic hyperbaric oxygenation (HBO) therapy on the healing course of nonischemic chronic diabetic foot ulcers. RESEARCH DESIGN AND METHODS: From 1999 to 2000, 28 patients (average age 60.2 +/- 9.7 years, diabetes duration 18.2 +/- 6.6 years), of whom 87% had type 2 diabetes, demonstrating chronic Wagner grades I-III foot ulcers without clinical symptoms of arteriopathy, were studied. They were randomized to undergo HBO because their ulcers did not improve over 3 months of full standard treatment. All the patients demonstrated signs of neuropathy. HBO was applied twice a day, 5 days a week for 2 weeks; each session lasted 90 min at 2.5 ATA (absolute temperature air). The main parameter studied was the size of the foot ulcer measured on tracing graphs with a computer. It was evaluated before HBO and at day 15 and 30 after the baseline. RESULTS: HBO was well tolerated in all but one patient (barotraumatic otitis). The transcutaneous oxygen pressure (TcPO(2)) measured on the dorsum of the feet of the patients was 45.6 +/- 18.1 mmHg (room air). During HBO, the TcPO(2) measured around the ulcer increased significantly from 21.9 +/- 12.1 to 454.2 +/- 128.1 mmHg (P < 0.001). At day 15 (i.e., after completion of HBO), the size of ulcers decreased significantly in the HBO group (41.8 +/- 25.5 vs. 21.7 +/- 16.9% in the control group [P = 0.037]). Such a difference could no longer be observed at day 30 (48.1 +/- 30.3 vs. 41.7 +/- 27.3%). Four weeks later, complete healing was observed in two patients having undergone HBO and none in the control group. CONCLUSIONS: In addition to standard multidisciplinary management, HBO doubles the mean healing rate of nonischemic chronic foot ulcers in selected diabetic patients. The time dependence of the effect of HBO warrants further investigations.