Tag Archives: diabetic foot

Conservative surgical management in an extreme diabetic foot case

by JM García-Sánchez1, A Ruiz-Valls1, A Sánchez-García1, A Pérez-García1

The Foot and Ankle Online Journal 11 (1): 2

Diabetes mellitus is one of the most prevalent diseases worldwide and an important cause of morbidity and mortality. Of relevance, due to its complicated management, morbidity and cost associated, is the diabetic foot. Here we present a case of a 51 year-old male diagnosed with  long-standing decompensated Diabetes mellitus with a 2 year history of a foot ulcer. After debridement of the ulcer, preservation of the bony structure was achieved by covering it with a fillet flap. The therapeutic management in patients with advanced diabetic foot should be individualized based on patient characteristics. Oftentimes, conservative amputations entail the need of complex surgical techniques, however, it allows the patient to retain their independence and an improved quality of life.

Keywords: diabetic foot, ulcer,  diabetes mellitus, fillet flap

ISSN 1941-6806
doi: 10.3827/faoj.2018.1101.0002

1 – Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Universitari i Politèctnic la Fe, Valencia, Spain.
* – Corresponding author: alejruvall@gmail.com


Diabetes mellitus (DM) is one of the most common diseases worldwide with a global prevalence of 8.5%, and increasing every year. Sustained hyperglycemia derives in numerous complications, mostly caused by macro and microangiopathy [1], of special importance are Diabetic Foot Ulcers (DFUs).

Diabetic Foot Ulcers represent an important healthcare issue due to the elevated morbidity, complexity of its management and elevated costs associated with this disease [2]. DFUs have a global prevalence of 6.3% and have a higher prevalence in DM type 2 and male patients [3]. Neuropathy is the most important risk factor for the development of DFUs. Moreover, the addition of different factors such as the of loss of skin integrity, existence of foot deformities (Hallux Valgus, Charcot’s arthropathy, etc.), and peripheral vascular disease ultimately lead to the formation of DFUs [4].  

The course of healing the DFU is arduous due to the impaired cicatrization and granulation processes in these patients, which is frequently complicated with superimposed infections.  Some cases, especially when osteomyelitis is present, require limb amputation as the sole therapeutic option. However, it is imperative to remain as conservative as possible, since amputations suppose a great psychological and functional impact that can pose a decrease in quality of life.

Here we present a case of a patient with a complicated DFU that was managed with conservative surgical treatment without undergoing amputation.

Case Report

A 51 year old male was first evaluated in the outpatient setting for a 1-year history of a DFU on the right foot. His medical history included a atrial fibrillation, dyslipidemia, hypertension, and a poorly controlled insulin-dependent DM with development of retinopathy, nephropathy and cardiac disease. The patient was also an active smoker with over 30 years of smoking history. A transmetatarsal amputation from the 2nd to the 5th toes on the right foot was previously carried out in a different hospital due to inadequate healing of a DFU. The surgical wound was complicated with a dehiscence, which remained as an ulcer that impeded the patient from ambulating.

The physical examination showed a lateral subluxation of the first metatarsophalangeal joint, an ulcer on the amputation stump, with granulation on the base and no inflammatory signs, proliferative signs, dermatosclerosis or hyperpigmentation of the skin edges (Figure 1). Additionally, the patient presented signs of chronic venous insufficiency, hence the induration hindered lower limb distal pulse examination. Plantar protective sensation was severely diminished.

An MRI was performed, which showed findings suggestive of osteomyelitis of the remnants of the 3rd, 4th and 5th toe, the anterior portion of the cuboid bone, and the navicular bone of the right foot. These findings were later confirmed with a gamma scan. The CTA scan showed bilateral permeability of the aortoiliac, femoropopliteal, and distal infrapopliteal trunks.

Given these findings a new surgical approach was conducted, with resection of the remnants of the 2nd to 5th toes, cuboid bone, cuneiform bones, as well as the anterior portion of the navicular bone (Figure 2), a fillet flap from the hallucis and the plantar skin was performed to provide coverage of the cutaneous defect (Figure 3).

The pathology report indicated the presence of a verrucous squamous cell carcinoma. However, no infiltrative component was seen in the specimen and the margins were disease free.

Figure 1 A 51 year old male with a lateral luxation of the metatarsophalangeal joint of the hallucis (Left). Ulcer presence on the amputation stump (Right). Frontal (Left) and plantar (Right) view.

Figure 2 Surgical excision of the remnants of the 2nd to 5th toes, cuboid bone, cuneiform bones, as well as the anterior portion of the navicular bone.

The postoperative course was uneventful with a favorable healing towards the resolution of the surgical wound, which was supported by a tight glucose control and a smoking cessation program. Two months after the intervention the patient has a healthy-appearing stump that allows ambulation (Figure 4).

Figure 3 Foot defect after resection (Left). Coverage with a fillet flap from the hallucis and the plantar skin (Right).

Figure 4 Postoperative result two months after the intervention. Frontal (Left) and posterior (Right) view.

Discussion

Complicated diabetic foot poses a risk of amputation and early mortality in diabetic patients. With a 10-fold increase in amputation rate of the lower limb for diabetic patients, according to WHO. Furthermore, the mortality rate is also increased 3-fold within a year of the amputation compared to non-amputated diabetic patients [6].

The course of DFUs is usually difficult owing to a deficient granulation and cicatrization, and commonly complicated with superimposed infections. DFUs that persist over time can sometimes lead to malignant transformation; most frequently squamous cell carcinoma [5]. All of these result in wide surgical excisions and, sometimes inevitably amputations.

There are different amputation levels of the lower limb, those that result in above-the-ankle amputation are considered major amputations, and those that spare the ankle are defined as minor amputations [7]. Regarding amputation-related-mortality, Evans et al, showed a mortality of 20% in the 2-year follow-up after a minor amputation compared to the 52% seen in patients who underwent a major amputation [8].

Numerous studies support the need to be as surgically conservative as possible, with limb conservation procedures, since energetic output is increased progressively as an amputation becomes more proximal [9]. Moreover, several patients present with several comorbidities, as in the case presented, and are non-candidates for rehabilitation after major amputations. Hence, preservation of the majority of the limb with partial minor amputations can result in an improved functional status [10]. Likewise, minor amputations may confer the possibility to ambulate for short distances without the need of prosthesis, allowing the patient to perform many daily-living activities, and thus, having a major impact on quality of life [8].  In some cases, in order to achieve minor amputations, the complexity of the surgical techniques is considerably higher and are often unconventional procedures that surgeons might not be familiarized with. In the case presented, due to patient conditions, impaired sensibility, presence of osteomyelitis, and the condition of the foot soft tissues, initially the decision was to perform a major amputation. Nevertheless, the scarce possibilities for adaptation to a prosthetic device and ambulation after amputation, a more conservative approach was planned. Therefore, preservation of the non-osteomyelitic bone and coverage of the skin defect with an adipocutaneous fillet flap from the hallux and the plantar surface provided a stable coverage without any added morbidity.

The fillet flap is well described in the literature as an alternative for large defects that require coverage without sacrificing the length of the extremity [11].  It provides superb mechanical stability plus an added quasi-normal sensitivity to the stump. Additionally, utilizing plantar tissue also provides an excellent, and long-lasting, surface for the stump [12].

Conclusion

Diabetic patients with DFUs should undergo individualized treatment based on their characteristics. In certain cases, a more conservative amputation, despite being more technically challenging, allows the patient to have a better quality of life as well as more independence.

Conflict of interest declaration

No conflict of interest to disclose.

References

  1. Pérez NF, Pérez CV, Llanes JA. Las amputaciones de dedos abiertas y cerradas: su evolución en el pie diabético. Rev Cuba Angiol Cir Vasc. 2010;11(1):89–100.
  2. Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med. 2017 Mar;49(2):106–16.
  3. Al-Rubeaan K, Al Derwish M, Ouizi S, Youssef AM, Subhani SN, Ibrahim HM, et al. Diabetic foot complications and their risk factors from a large retrospective cohort study. PloS One. 2015;10(5):e0124446.
  4. Allen L, Powell-Cope G, Mbah A, Bulat T, Njoh E. A Retrospective Review of Adverse Events Related to Diabetic Foot Ulcers. Ostomy Wound Manage. 2017 Jun;63(6):30–3.
  5. Scatena A, Zampa V, Fanelli G, Iacopi E, Piaggesi A. A Metastatic Squamous Cell Carcinoma in a Diabetic Foot: Case Report. Int J Low Extrem Wounds. 2016 Jun;15(2):155–7.
  6. Hoffstad O, Mitra N, Walsh J, Margolis DJ. Diabetes, Lower-Extremity Amputation, and Death. Diabetes Care. 2015 Oct;38(10):1852–7.
  7. Wukich DK, Hobizal KB, Brooks MM. Severity of Diabetic Foot Infection and Rate of Limb Salvage. Foot Ankle Int. 2013 Mar;34(3):351–8.
  8. Evans KK, Attinger CE, Al-Attar A, Salgado C, Chu CK, Mardini S, et al. The importance of limb preservation in the diabetic population. J Diabetes Complications. 2011 Jul;25(4):227–31.
  9. Czerniecki JM, Morgenroth DC. Metabolic energy expenditure of ambulation in lower extremity amputees: what have we learned and what are the next steps? Disabil Rehabil. 2017 Jan 16;39(2):143–51.
  10. Pinzur MS, Gold J, Schwartz D, Gross N. Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopedics. 1992 Sep;15(9):1033-1036.
  11. Chung S-R, Wong KL, Cheah AEJ. The lateral lesser toe fillet flap for diabetic foot soft tissue closure: surgical technique and case report. Diabetic Foot Ankle. 2014 Jan;5(1):25732.
  12. Janssen D, Adolfsson T, Mani M, Rodriguez-Lorenzo A. Use of a pedicled fillet foot flap for knee preservation in severe lower extremity trauma: A case report and literature review. Case Rep Plast Surg Hand Surg. 2015 Dec 23;2(3–4):73–6.

Bilateral Charcot neuroarthropathy, a challenge for diagnosis and treatment

by Nathalie Denecker1*, Dimitri Aerden2, Michel De Maeseneer3pdflrg

The Foot and Ankle Online Journal 9 (1): 6

Charcot neuroarthropathy is a devastating foot disorder whose differential diagnosis with infectious, bone or articular disease is difficult. We report a rare case of a woman with diabetes who developed bilateral Charcot neuroarthropathy after erysipelas of her left leg and subsequent trauma, which complicated diagnosis as well as efficient off-loading.

Key words: bilateral Charcot foot, diabetic foot, diabetic neuropathy, off-loading

ISSN 1941-6806
doi: 10.3827/faoj.2016.0901.0006

1,2 – UZ Brussel, Diabetic foot clinic, Laarbeeklaan, 101, 1090 Brussel, BELGIE
3 – UZ Brussel, Radiology department Laarbeeklaan, 101, 1090 Brussel, BELGIE
* – Correspondence: Nathalie Denecker nathalie.denecker@uzbrussel.be


Charcot neuroarthropathy (CN) of the foot is a rare but debilitating disorder that affects bones, joints and soft tissues and leads to significant deformity unless diagnosis is established early. We report a case of bilateral synchronous CN that proved particularly challenging because diagnosis was obfuscated 1) by bilateral symptomatology and 2) a preceding erysipelas. In addition, we had no prior experience in off-loading both limbs simultaneously.

Case report

A 58-year old woman with insulin dependent type 2 diabetes and lower limb neuropathy presented to the emergency department with fever and erythema of the left leg. The limb was erythematous and warm with a plantar neuropathic ulcer on the left hallux. Distal pulses were detected bilaterally. Blood sampling showed overt inflammation. The diagnosis of erysipelas was established with the toe ulcer as entry point. A wound smear revealed Pseudomonas aeruginosa for which intravenous antibiotics were administered for 8 days. She returned with increased oedema and pain of her leg two weeks later, although inflammatory blood parameters had normalised.

Ten days later inflammatory symptoms had persisted and spread to the contralateral foot and ankle: both feet now were swollen, red and warm, and some bruises from a recent trauma were detected. X-rays of both feet were normal. A bone scintigraphy with SPECT-CT (Single Photon Emission Computed Tomography) was suggestive for CN of both feet, with tracer uptake in the midfoot (Figure 1a) and small bony fragments on CT (Figure 1b). Hotspots over the 2nd metatarsal heads bilaterally raised the possibility of underlying osteomyelitis.

Bilateral immobilization with total contact casts (TCC) was deemed impracticable. Hence, the left foot was treated with a removable air-cushioned cast (Aircast®) but this required the patient to be hospitalized. Oedema of the tarsus and metatarsal bases shown on magnetic resonance imaging (MRI) confirmed bilateral CN (Figure 2a) but osteomyelitis of the 2nd metatarsal head was rejected by leucocyte scan with SPECT-CT. Transfer to a rehabilitation centre and regular ambulatory appointments to renew the TCC were initiated. Three months later clinical inflammatory signs and oedema of the midfoot on control MRI had decreased, although increased oedema was observed at the talar bone bilaterally (Figure 2b). Off-loading was continued with bilateral Aircast® walkers for another 3 months until orthopaedic shoes became available. Final ambulatory rehabilitation was satisfactory.

1a1b

Figure 1 (a) Bone scintigraphy shows tracer uptake in the midfoot and 2nd metatarsal heads bilaterally. (b) Irregular margins and bone fragments in the midfoot are seen on SPECT-CT.

Discussion

Charcot neuroarthropathy or Charcot foot is a devastating complication of neuropathy which is mostly seen as a rare complication of longstanding diabetes [1-5]. Men and women are equally affected [2,6]. Until recently, the prevailing hypothesis for pathogenesis was neurotraumatic or neurovascular [2,7,8]. Authors have observed however that CN is also associated with an enhanced inflammatory response, presumably triggered by minor trauma, prior infection, ulceration or foot surgery. Pro-inflammatory cytokines (TNF-α, IL-1ß) are released and lead to increased expression of receptor activator of nuclear factor-κB (RANK) ligand, thereby activating NF-κB (Nuclear Factor κB), a potent promotor of osteoclastic activity which promotes osteolysis and fractures [1,2,8,9].

The prevalence of CN is underestimated but affects less than 1% of all patients with diabetes [6,8-10]. Moreover, local inflammation is inhibited by limited arterial inflow, a frequent occurrence in patients prone to macrovascular disease [9]. Ipsilateral recurrence of CN is rare [10]. Over several years, contralateral CN may occur in 20% to 30% [6,7,11]. Off-loading of the index foot has been suggested as the initiating event that may develop CN at the contralateral foot [11].

2a2b

Figure 2 (a) MRI of the right foot initially shows bone marrow oedema of the tarsus and metatarsal bases. (b) Three months later oedema in the original regions has improved but is now more prominent in the talar bone.

Diagnosis of acute Charcot foot is primarily established clinically because no specific laboratory tests are available: a unilateral red, warm, swollen foot that is remarkably painless due to neuropathy. Differential diagnosis should be made with infection (cellulitis, osteomyelitis, arthritis, abscess), acute gout, deep venous thrombosis and trauma (sprain, fracture) [1-4,11,12]. Imaging techniques are helpful but X-rays lack sensitivity during the first weeks. The sensitivity of bone scintigraphy is superior and its low specificity is improved by SPECT-CT. MRI has diagnostic accuracy in the early stages and allows differentiation from osteomyelitis [1-3,11]. According to literature, the diagnosis of CN may be missed in 79% and delayed up to 29 weeks [11]. Unfortunately, early recognition of CN and prompt treatment is mandatory to prevent foot deformation.

Rapid immobilisation of the affected foot is paramount and accomplished best by TCC, the gold standard for off-loading [1,13]. A removable pneumatic walker achieves comparable off-loading but non-compliance remains a problem [4,10]. Immobilisation is advised until clinical signs have resolved and a temperature difference of <2°C between feet is recorded [1,9,14]. In general, this occurs after 3-12 months, with 6 months being most common [10,11,14]. Bisphosphonates which inhibit bone resorption have been suggested as adjunctive therapy but current data do not support their routine use [5].

Bilateral synchronous CN as reported in the presented case is not only an extremely rare occurrence, but also greatly complicates diagnosis and subsequent immobilisation/off-loading. To our knowledge, only one similar case has previously been reported: a man in which contralateral CN presumably was elicited two weeks after off-loading his index foot with a TCC [12]. In our case, a skin infection probably triggered CN on the index side which unfortunately also delayed diagnosis. On the contralateral side both the overloading of the right foot due to pain on the left side, or trauma may have been the trigger for CN. The number of radiological exams that had to be performed, and their conflicting findings demonstrate how difficult a diagnosis can be. Long-term immobilisation and off-loading of both limbs was extremely debilitating to our patient and justified hospitalisation in a rehabilitation centre.

In summary, diagnosis of acute Charcot foot is challenging, especially when triggered by prior infection or trauma. Bilateral CN, although extremely rare, further complicates the diagnosis as well as efficient off-loading and immobilisation.

References

  1. Rogers LC, Frykberg RG, Armstrong DG, Boulton AJM, Edmonds M, Van Ha et al. The Charcot Foot in Diabetes. Diabetes Care 2011; 34(9): 2123–2129. (PubMed)
  2. Gouveri E, Papanas N. Charcot osteoarthropathy in diabetes: A brief review with an emphasis on clinical practice. World J Diabetes 2011; 2(5): 59–65. (PubMed)
  3. Botek G, Anderson MA, Taylor R. Charcot neuroarthropathy: An often overlooked complication of diabetes. Cleve Clin J Med 2010; 77(9): 593-599. (PubMed)
  4. Pinzur MS. Current concepts review: Charcot arthropathy of the foot and ankle. Foot Ankle Int 2007; 28(8):952-9. (PubMed)
  5. Richard JL, Almasri M, Schuldiner S. Treatment of acute Charcot foot with bisphosphonates: a systematic review of the literature. Diabetologia 2012; 55: 1258–1264. (PubMed)
  6. Hartemann-Heurtier A, Van GH, Grimaldi A. The Charcot foot. Lancet 2002; 360: 1776-1779. (PubMed)
  7. Jeffcoate W, Lima J, Nobrega L. The Charcot foot. Diabet Med 2000; 17(4): 253-258. (PubMed)
  8. Molines L, Darmon P, Raccah D. Charcot’s foot: Newest findings on its pathophysiology, diagnosis and treatment. Diabetes Metab 2010; 36(4): 251–255. (PubMed)
  9. Jeffcoate WJ. Theories concerning the pathogenesis of the acute charcot foot suggest future therapy. Curr Diab Rep 2005; 5(6): 430-435. (PubMed)
  10. Christensen TM, Gade-Rasmussen B, Pedersen LW, Hommel E, Holstein PE, Svendsen OL. Duration of off-loading and recurrence rate in Charcot osteo-arthropathy treated with less restrictive regimen with removable walker. J Diabetes Complications 2012; 26(5): 430-434. (PubMed)
  11. Milne TE, Rogers JR, Kinnear EM, Martin HV, Lazzarini PA, Quinton TR et al. Developing an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-Arthropathy: a systematic review. J Foot Ankle Res 2013; 6(1): 30. (PubMed)
  12. Fauzi AA, Yang CT. Bilateral diabetic Charcot foot. Aust Fam Physician 2013; 42(1-2):55-56. (PubMed)
  13. Ramanujam CL, Facaros Z. An overview of conservative treatment options for diabetic Charcot foot neuroarthropathy. Diabet Foot Ankle 2011; 2:1-5. (PubMed)
  14. Moura-Neto A, Fernandes TD, Zantut-Wittmann DE, Trevisan RO, Sakaki MH, Santos ALG et al. Charcot foot: skin temperature as a good clinical parameter for predicting disease outcome. Diabetes Res Clin Pract 2012; 96(2): e11–14. (PubMed)

Foot Infections in the Veterans Health Administration

by Priya P. Sundararajan DPM, FACFAS1, Barbara M. Porter DPM2, Keith A. Grant Ph.D3, Jeffrey M. Robbins DPM4pdflrg

The Foot and Ankle Online Journal 8 (3): 1

BACKGROUND: Foot infections represent a major health concern in the Veterans Health Administration as they often may lead to limb loss. A majority of these infections are associated with diabetes in the form of diabetic foot ulcers. The diabetic foot infection is associated with a substantial mortality rate and often requires amputation to fully address the nidus of infection.
METHODS: A retrospective chart analysis of all surgeries to treat foot infections in an 18-month period was conducted. Multiple variables- patient location, preventative primary care diabetic foot screenings, routine follow-up by a foot-care specialist, and pre-operative hospital admission- were reviewed and recorded. The data was analyzed using a one-tailed z-test and chi-squared tests. The one-tailed z-test provided a facility-specific data analysis highlighting areas which may benefit from education or assistance in terms of resource allocation. The chi-squared tests reveal generalizable findings regarding the association among primary care diabetic foot screenings, routine follow-up by a foot-care specialist, and the need for pre-operative admission.
RESULTS: Results show an absence of routine follow-up by a foot-care specialist is associated with a statistically higher rate of patients requiring pre-operative admission. Conversely, those patients with routine follow-up required fewer admissions. Though not significant at conventional levels, a higher percentage of patients without the primary care diabetic foot exams also lacked specialty follow-up and necessitated pre-operative hospital admission when compared to patients with the screenings.
CONCLUSION: This study provides an example of methodology reviewing pedal infection-related surgical data to perform effective limb loss prevention in the VHA setting. The generalizable results elucidate the role of the primary care and foot-care specialists in preventative medicine thereby avoiding a hospital admission. The current study suggests that a close, collaborative, patient-centered approach between primary care and podiatry results in better outcomes for patients.

Key words infection, ulcer, diabetic foot, veteran, amputation

ISSN 1941-6806
doi: 10.3827/faoj.2015.0803.0001

Address correspondence to: Priya P. Sundararajan DPM, FACFAS
[1] Director of Podiatry, Wilmington VA Medical Center, Department of Surgery, 302-994-2511, 1601 Kirkwood Highway Wilmington, DE 19805, Priya.Sundararajan@va.gov
[2] Podiatric Surgeon, Wilmington VA Medical Center, Department of Surgery,  302-994-2511, 1601 Kirkwood Highway Wilmington, DE 19805, Barbara.Porter3@va.gov
[3] Assistant Professor, James Madison University Department of Political Science, 540-568-4336, 91 E Grace St., MSC 7705 Harrisonburg, VA 22807, GrantKA@jmu.edu
[4] Director, Podiatry Service Veterans Affairs Central Office; Professor of Podiatric Medicine, Kent State University College of Podiatric Medicine; Clinical Assistant Professor, Case Western Reserve University School of Medicine; 216-791-3800, Louis Stokes VA Medical Center, 10701 East Boulevard Cleveland, OH 44106, Jeffrey.Robbins@va.gov


Foot infections are a major health issue in the Veterans Health Administration as they often jeopardize limb preservation and shorten the patient’s lifespan. A majority of these infections are associated with diabetes in the form of diabetic foot ulcers (DFU). The excessively high 5-year mortality rate associated with patients with diabetic ulcers reaches upwards of 55% [1]. With chronicity, the DFU transitions to bone infection. A festering oste-omyelitis further propagates the pedal nidus of infec-tion resulting in a statistically higher rate of fatal sys-temic disease such as heart attack or stroke [2,3,4]. Consequently, 45% of all patients with a diabetic ulcer require surgery, often times a pedal amputation, to address the nidus of infection and reach resolution of symptoms [5]. Effective preventative care can maximize limb preservation and improve life expectancy.

As the single largest health care system in the United States, the Veterans Health Administration (VHA) is working to meet the complex needs of this dramatically increasing pathology [6]. Primary care providers, podiatric surgeons, general surgeons, vascular surgeons, infectious disease physicians, and wound care nurses are integrated in the treatment of the diabetic foot infection.  In the enormity of the VHA system, providers can be oblivious to the amputation-related statistics that may improve patient outcomes.  A facility-specific assessment allows providers to better understand the events leading up to the amputation and prevent long-term loss of follow-up. Such evidence can inform future strategies to effect better prevention and management of the DFU pathology. The aim of this study is two-fold: 1) to provide an example of a retrospective statistical analysis assessing facility-specific data regarding preventative care and patient outcomes for the benefit of other VHA facilities and 2) to understand the associations among preventative primary care diabetic (PC DM) foot exams, routine follow-up by a foot-care specialist, and pre-operative hospital admission in the VHA setting.

Methods

A retrospective analysis of all surgeries to address pedal ulceration infections between January 1, 2013 and June 30, 2014 were analyzed using one-tailed z-tests and chi-squared tests. The following data was collected for each infection-related pedal surgery: chronological surgery number, chronological patient number, location following the patient, whether a preventative PC DM foot exam was performed, whether the patient’s condition required pre-operative hospital admission, if so the date of admission and the reason necessitating admission, dates of podiatric/surgical/wound care follow-ups the patient had prior to admission or surgery (in the case of no admission), whether the patient was routinely followed or not followed by a foot-care specialist prior to surgery, the date of surgery, and an update regarding the patient’s condition.  Patients who went on to have further limb amputation or endured further complication related to the pedal infection were classified as “poor prognosis.” On the contrary, patients who healed the surgical sites were classified as “healed surgical site.” A description of the data collected is detailed and summarized in Table 1 (see supplement within PDF). Table 1 was analyzed using both one-tailed z-tests (Table 2) to understand facility-specific trends and chi-squared tests (Table 3-5) to examine the association between PC DM foot screenings, routine follow-up by a foot-care specialist, and pre-operative hospital admissions.

The locations from which the patient was referred included the main medical center: Wilmington, surrounding community based outpatient clinics (CBOC) A, B, C, and D, and a nursing home: Community Living Center (CLC). The CBOC facility location was withheld for this publication. Some patients were also referred from the neighboring Coatesville VA medical center.  Patient follow-up data was not readily available from this facility, leading to the exclusion of patients originating from this location from the analysis. The variables (PC DM foot screening, specialty follow-up, admission, and surgery) measured in each facility were compared against each location’s outpatient population share as the base value (Table 2). Additional analysis was also performed to test for dependencies between the variables: preventative PC DM foot exams, specialty follow-up prior to surgery, and pre-operative hospital admissions (Tables 3-5).

The PC DM foot exam is a clinical reminder to be completed by the primary care provider as required by “VA/DoD Clinical Practice Guidelines for the Management of Diabetes Mellitus in Primary Care“ [7]. This reminder ensures that DFU prevention is performed in the primary care sector. This alert is only activated at the anniversary of the patient’s last exam. The alert remains active until the test is performed by the provider at which point the test is de-activated for another calendar year.  If the PC DM foot exam was either not performed or performed within a week of admission or surgery, the exam was considered non-preventative as it served no preventative use once the patient required surgical intervention.

table2

Table 2 One-tailed test comparing the variables measured in each location. Statistical significant findings are in bold.  Down-arrow: Findings are statistically lower than expected. Up-arrow: Findings are statistically higher than expected.

table3

Table 3 Χ2 = 9.9676, p = 0.008.  A statistically significant relationship was found between patients who were not followed by a foot-care specialist and those who were admitted.

The specialty follow-up dates, (as listed in column 5 in Table 1), dictated if the patient was adequately followed by a foot-care specialist (as noted in the adjacent column, column 6). By recording the patients’ last 3 podiatry, surgery, or wound care visits, the investigators were able to assess if the patient had regular follow-ups prior to surgery.  At these visits, all components of the diabetic foot exam were assessed. ADA guidelines suggest that a high-risk patient with a history of amputation or ulceration be seen by a specialist every 1-2 months [8]. To give the patients and providers some leeway, the patient was considered “not followed” if he/she was not seen within 3 months preceding admission or surgery.

table4

Table 4 Χ2 = 2.0563, p=0.152. No statistically significant association was found between patients who did not have a PC DM foot screening and those who were not followed by a foot-care specialist. However a higher percentage of patients who had a PC DM foot exam were also followed by a foot-care specialist. The converse also held true.

 table5

Table 5 Χ2 = 1.6067, p=0.205. No statistically significant association was found between patients who did not have a PC DM foot screening and those who were admitted. However a higher percentage of patients with no PC DM foot exam were admitted compared to patients with a PC DM foot exam. Similarly, most of the patients who were not admitted had a prior PC DM foot screening.

Results

Over the 18-month period, 53 surgeries were performed to treat foot infections on 44 patients. Of these surgeries, 92% were amputations (n=49). Fifty-six percent of the surgeries (n=30) required pre-operative admission. Of the admissions, 95.8% occurred secondary to a foot infection. Only 3.7% of the surgeries were performed on non-diabetic patients (n=2). Forty-four percent of the surgeries were performed on patients who were not followed regularly (<3 months). As a result of foot infection, 7.5% of the pedal surgeries (n=4) were associated with further limb amputation. Five of the surgeries were classified as “poor prognosis”, i.e. the patient was expected to or did lose limb or life and was associated with an unresolved pedal infection. One of these patients, healed the surgical site but subsequently developed severe hypotension, multiple bodily pressure lesions, and died from septic shock.

The one-tailed z-test was used to identify patterns within the variables that were disproportionate to that facility’s population share.  For example, a CBOC serving 15% of the population would be expected to account for 15% of the performed surgeries.  This location-specific analysis demonstrates significantly fewer infection-related pedal surgeries, missing PC DM foot exams, and pre-operative admissions out of the Wilmington facility than would be expected relative to its population share alone (table 1).  In contrast, CBOC A has a significantly higher rate of surgeries, missing PC DM foot exams, and admissions than its population share would suggest.  CBOC C also has more admissions than would be expected, but the number of surgeries and missing PC DM foot exams are not overly disproportionate to its population. Additionally, a higher than expected number of patients were regularly followed in CBOC C prior to surgery. As expected with the typical nursing home population, the CLC has a higher rate of surgery, specialty follow-up, pre-operative admissions, and poor prognosis (60%).  No significant findings were noted in CBOC B and D.

Although the above results are idiosyncratic to the Wilmington medical center and surrounding CBOCs, patterns identified in the aggregate data are generalizable to other VHA systems. Chi-squared tests were used to assess bivariate statistical dependencies in which the presence or absence of one factor influences the rate with which another factor occurs. Analysis confirmed a significant relationship (p=0.008) between patients who were not followed by a foot-care specialist to those who necessitate pre-operative admission (table 2). The observed relationship suggests that high-risk patients who are not routinely followed by a foot-care specialist are more likely to require admission than those who are routinely followed. In fact, the odds of a patient without routine specialty follow-up requiring pre-operative admission is roughly 7.5 times higher than for a followed patient.  No statistically significant relationship was found between patients without PC DM foot screenings and those followed (p=0.152) and admitted (p=0.205) at conventional levels (table 3, 4). However based on percentages, certain trends among these variables seem apparent.  Patients without the preventative PC DM foot screenings tended to also lack follow-up by a foot-care specialist (table 3). The converse also held true. Similarly, a higher percentage of the patients without the PC DM foot exam required pre-operative hospital admission when compared to patients with the screening (Table 4).

The Wilmington facility was associated with statistically fewer infection-related pedal surgeries, fewer missing PC DM foot exams, and fewer admissions than its population share would suggest. This site had fewer adverse events preceding the patient’s surgery and overall fared better in the preventative arena than its CBOC counterparts. These comparatively better outcomes coincided with the most resource-intensive location. As a result, the Wilmington facility assisted in the evaluation in slow or non-healing ulcer patients from the CBOC facilities.

The overlap between CBOC C patients who required surgery and those were admitted was 100%. Moreover, 85% of these surgeries were associated with routine follow-up prior to surgery. These clinical outcomes are suggestive of a lack of efficacy in preventative care in this location.  In CBOC A, 87.5% of surgeries required pre-operative admission, which is significantly higher than would be expected based on its population share. Our solution was to request the foot-care specialists in both CBOC A and C to send all non-healing ulcers with a duration greater than 3 months to Wilmington for evaluation and possible treatment.  In terms of resource allocation, funds for part-time nail technician were requested for CBOC A and C to allow the providers to focus on the higher risk patient population. Additionally, 75% of surgeries out of CBOC A did not have preventative PC DM foot evaluations in the year prior to surgery. Our remedy was to present a facility-wide educational lecture discussing these results and the importance of preventative care in the treatment of DFU.

As expected, patients residing in the CLC were associated with a higher rate of pedal surgery with subsequent limb amputation. With its census of patients who are elderly, immobilized, poorly-vascularized, non-responsive, or systemically complicated, a proper treatment addressing the nidus of infection is often not accomplished. We advised the dedicated CLC wound care nurse who performs weekly wound assessments to consult podiatric or general surgery for new wounds in a timely manner. In addition, the Wilmington wound care nurses have assisted in CLC management and prevention of ulcers.

Discussion

The current study demonstrates the value of collaboration between primary care and specialty care for the treatment of diabetic foot infections in the VHA setting. It is the first in its class to present an example of methodology reviewing pedal amputation and infection-related surgical data for limb loss prevention in the integrated VHA system. This facility-specific research focusing on the circumstances surrounding surgery was conducted to assess the efficacy of preventative measures and effect change to better patient outcomes. As it stands today, data collection and analysis for the purpose of limb preservation is not a routine occurrence in the VHA. The present study uses the data collected to highlight areas of concern and allow implementation of minor changes to effectively manage high-risk diabetic patients.  This methodology can be applied in any facility and may directly impact departmental reorganization, resource allocation, and provider or patient education. The present research is also suggestive of a collaborative relationship between of primary care and foot-care specialists in the management and mitigation of diabetic pedal infections. Prior to this study, the associations of these variables and the need for pre-operative hospital admission were not evident. Our results encourage a partnership between primary care providers and foot-care specialists, including podiatrists, general surgeons, and wound care specialists for early detection of pedal infections, thereby minimizing the need for pre-operative hospital admissions in VHA facilities.

Results indicate CBOC A was associated with a higher rate of surgical interventions for foot infections as well as a lower rate of completed preventative PC DM foot exams. One explanation suggests that fewer providers examining the diabetic foot may lead to undetected foot ulcers, propagate the infection, and result in an amputation. Previous studies have indicated that an increased number of providers examining the diabetic foot resulted in fewer infection-related surgeries [9,10]. A study originating in Sweden demonstrates a lower amputation rate in a region in which patients were referred by a variety of providers in contrast to only referrals from general practitioners, suggesting that the more providers examine the diabetic foot, the earlier infection is treated [9]. Another analysis documents the reduced rate of amputation with early detection of DFU [11]. With the addition of nail technicians, we increase the number of providers examining the diabetic foot. Along with the current study, these investigations illustrate the importance of cross-collaboration between specialties for the early detection and subsequent referral to a specialized diabetic wound care team.

Patients originating from CBOC C were routinely followed prior to surgery but nonetheless required admission prior to surgical intervention. This finding questions the efficacy of preventative treatment received in this facility and is suggestive of the need for education, resources, or further referral to a more specialized team. Similarly, CBOC A was associated with a significantly higher than expected rate of surgeries and admissions. As a hospital admission rather than an outpatient consult usually confers a more serious infection, the presumption that superficial infections are permitted to devolve into deeper more consequential infections is suggested. One plausible hypothesis to explain the higher rate of amputations is that care may not be adequately appropriated for the higher risk patients. Often times, VA podiatric providers are inundated with the lower risk routine nail patients leaving limited resources available for the higher risk patients with ulcers.  The American Diabetes Association task force recommends that high-risk patients (history of ulceration/amputation) be evaluated by a foot-care specialist every 1-2 months, whereas low risk diabetic patients may be evaluated annually by a primary care provider or specialist when necessary [8,12-14]. The addition of a nail technician in CBOC A and C could offload the low-risk patients allowing the providers to focus on the patients at a higher risk for amputation. Moreover, the request for the CBOC facilities to refer their long-standing DFU (> 3months) to the Wilmington facility benefits the CBOC patients. With the Wilmington facility having statistically lower rates of infection-related surgeries and admissions, the patients in the lesser performing facilities are likely to have more positive clinical outcomes with an earlier referral.

The purpose of the study was not necessarily to avoid pedal amputation but to maintain optimal compliance in the events preceding the surgery. Many providers have associated the word “amputation” with a negative connotation as in the case of “amputation prevention.” However evidence-based medicine suggests that patients who avoid amputation and live with chronic osteomyelitis generate a chronic inflammatory response by triggering vascular atherosclerosis [3,15]. A population-based study in a cohort of 23 million studied the relationship between chronic osteomyelitis and coronary heart disease [15]. Once the researchers controlled for age, gender, hypertension, diabetes, hyperlipidemia, and stroke between the control and chronic osteomyelitis cohorts, they found a significantly elevated risk of heart disease- a 95% increase- as compared to the control population [15]. Similar findings were supported in a meta-analysis study evaluating the association of the DFU and cardiovascular mortality [3]. Results showed a substantially increased risk of all-cause mortality, fatal myocardial infarction, and fatal stroke in patients with DFU [3]. These studies are among the growing number of studies that support a timely resolution of the DFU thereby preventing limb loss and increasing life expectancy [3,15-20]. The 30-day mortality rate, cardiovascular outcomes, and pulmonary events associated with a pedal amputation is substantially lower (4x) than below-knee or above knee amputations [17-20]. The goal is not simply to avoid amputation but to recognize the time-sensitivity of reaching a permanent resolution, thereby broadening our perspective to prioritize limb and life preservation.

Results derived from the full dataset suggest that the more high risk patients are followed by foot-care specialists, the less likely the infection will progress to a degree that necessitates admission (table 2). On the patient-level, routine follow-up generally translates to earlier detection of infection or vascular impairment, fewer systemic complications, and lower potential for nosocomial infections. From the facility standpoint, a substantial financial and economic burden can be obviated for each avoidable hospitalization.  Studies show that on average each hospital admission for a pedal amputation costs the facility is approximately $32,000 [21]. This confirms the role of foot-care specialists in the treatment of diabetic foot infection and limb loss prevention as documented in previous studies [22,23]. The present study also demonstrates a positive trend between PC DM foot screenings and follow-up by a foot-care specialist in the VHA setting (table 3). Thus the domino effect between the absence of PC DM foot screening and patients necessitating pre-operative admission is evident. The direct impact of fewer PC DM foot screenings and a higher rate of admission follows a negative trend, though not statistically significant at a conventional level (table 4). The current study, specific to the VHA system, is among the increasing evidence supporting the interdepartmental collaboration to improve patient outcomes and reduce complications [23-25].

Limitations to this study are inherent to any retrospective analysis in that all variables cannot be examined. Regarding the one-tailed z-test, extraneous variables such a provider methodology, patient non-compliance, reason for lacking specialty follow-up, or location-specific resources such as casts, grafts, or personnel assistance were not assessed. However, these extrinsic factors do not diminish current results highlighting areas that may benefit from assistance or modification. This study provides perspective in regards to the number of surgeries rather than the number of patients. Therefore, some patients had repeat infection-related surgeries; this variable was not assessed.  In regards to the chi-squared tests, the variables studied (specialty follow-up, PC DM foot assessments, and pre-operative admission) are generalizable among the VHA facilities nationwide. However, small sample size biases against statistically significant results. For example, the findings regarding PC DM foot screenings and specialty follow-up or admissions are likely to be significant by conventional standards with a larger sample following the current trends. Future research specific to the treatment of pedal infections or DFU may help determine which strategies and wound therapies will improve amputation prevention in this high-risk population. We encourage all VHA facilities to retrospectively assess the variables affecting patient outcomes and study the associations between these variables to better patient outcomes.

In summary, by focusing on the situations surrounding the surgical treatment of pedal infections or amputation, each facility is able to perform self-assessments to improve patient care. We believe that only with a self-investigative approach can limb preservation be legitimately pursued. By assessing relevant variables we demonstrate the value of foot-care specialists and primary care providers in the treatment of diabetic foot infections in a VHA facility. This patient-centered approach facilitates earlier detection of infection, mitigates systemic complications, decreases the economic burden to the facility, and ultimately minimizes limb loss.  With interdepartmental collaboration, we are able to prioritize limb preservation for veterans who have already sacrificed so much.

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