In the moment: Footcare
Diabetes care found lacking
Studies target education, complications
by Jordana Bieze Foster
Across the spectrum of lower-extremity diabetes care—from education to conservative intervention to surgery—practitioners have plenty of room for improvement, according to research presented in February at the annual meeting of the American College of Foot and Ankle Surgeons.
What may be most surprising is that these shortfalls are occurring even in centers that specialize in collaborative, multi-disciplinary care of high-risk patients.
Researchers from one such institution, Scott & White Healthcare in Temple, TX, reviewed 450 high-risk diabetic patients with at least 30 months of follow up and found that very few were given what the authors considered “appropriate foot care.”
One-third of the patients had diabetic neuropathy and peripheral vascular disease, one-third had diabetes and were on dialysis, and one-third had a history of diabetic ulceration. Despite being at high risk for diabetic foot complications, however, fewer than one-third of the patients visted a podiatric clinic and only 14% were given prescription shoes or insoles.
Scott & White, which is also affiliated with Texas A&M University, has one of the first nationally certified diabetes education programs in the state. But fewer than 3% of patients in the study even began a diabetes education course, and no patients in the group with the history of ulceration were referred for education.
“The collaboration needed to provide services to these patients does not happen very well even in this type of system,” said Nathan Hunt, DPM, a research fellow at Scott & White, who presented the findings at the ACFAS meeting. “In most places, it probably happens even less often.”
Improvement may come from establishing set treatment protocols for patients in this population, along with better communication and follow up, Hunt said.
In commenting on the study, Troy J. Boffeli, DPM, head of foot and ankle surgery and podiatry at HealthPartners in St. Paul, MN, underscored Hunt’s conclusion.
“[The study] does show we’re not doing what we’re saying we’re doing,” Boffeli said.
Additional research from Scott & White also indicates high complication rates in patients with diabetes following conservative treatment for ankle fracture.
In a study of 74 patients with diabetes and 64 without diabetes, investigators found that those with diabetes were 34 times more likely to have a nonunion and 24 times more likely to develop Charcot neuroarthropathy.
Charcot foot itself is another problematic area, particularly when it comes to evidence-based medicine. A University of Pittsburgh review of 95 articles on surgical management of Charcot neuroarthropathy found level IV and level V evidence only, and no studies with either randomization or control groups. They also found that five surgeons accounted for 55% of all results reported and a single surgeon accounted for 31.2%.
“There’s no evidence that reconstructing is more effective than a below-knee amputation, for example,” said Nicholas J. Lowery, DPM, a resident in the division of foot and ankle surgery at the university, who presented the group’s findings at the ACFAS meeting.
One thing that won’t help Charcot outcomes is delayed diagnosis, according to another study from the University of Pittsburgh. Investigators identified 22 feet with Charcot neuroarthropathy that had been initially misdiagnosed, with the most common diagnosis being ankle sprain.
Seven limbs did not progress beyond stage 0, with an average delay of 4.1 weeks. Of those, only one developed a complication, a midfoot ulcer during total contact cast treatment.
Fifteen limbs progressed to stage 1, with an average delay of 8.7 weeks. Ten required surgery, and 10 of 15 developed other complications, with an average of 1.2 complications per limb.
The findings are consistent with those of a German study published in the December 2005 issue of Diabetic Medicine, which reported a significantly higher fracture rate in Charcot patients whose referrals were delayed by misdiagnosis.
External shoe cut-out reduces forefoot pressure in patients with metatarsalgia
An external shoe modification significantly redirects pressure from the forefoot and improves function in patients with metatarsalgia, according to preliminary findings from Missouri State University and CoxHealth in Springfield, MO.
The Hunt Metatarsal External Shoe Cut-out, invented by Gary Hunt, DPT, CPed, features a 5-mm thick sheet of crepe applied to the outsole of a shoe, with a cut-out of about 4-6 cm in diameter to provide space between the outsole and the ground directly under the symptomatic area.
In five patients (six feet) with symptomatic metatarsalgia, the investigators found that five to six weeks of using the HMESC along with plantar flexor stretching was associated with statistically significant decreases in mean peak forefoot pressure (28.6%) and pressure-time integral (23.9%) compared to baseline levels. They also found significant increases (29.2%) in function as measured using the Lower Extremity Function Scale.
The findings were presented in February at the annual Combined Sections Meeting of the American Physical Therapy Association and published in the January issue of the Journal of Prosthetics & Orthotics.
Surgeries on adult acquired flatfoot reflect less commitment to bracing
Patients with adult acquired flatfoot deformity may not be allowed enough time for conservative care to be effective before undergoing surgery, according to research from the Western Pennsylvania Hospital in Pittsburgh.
Investigators retrospectively reviewed treatment records of 64 patients with adult acquired flatfoot. More than two-thirds of patients received physical therapy (44/64) and anti-inflammatory medications (43/64). Overall, 50 patients received a brace of some sort, including fracture brace immobilization in 28 patients and a low-articulating ankle foot orthosis in 43 patients. The mean duration of LAFO use was 3.7 months.
However, brace utilization patterns differed in the eight patients who underwent surgery. In that subset of patients, only three received bracing of any kind, two received a low-articulating AFO, and the mean duration of LAFO use was just two months.
The findings, presented in a poster at the ACFAS meeting in February, suggest that practitioners may want to exercise more patience with these patients.
“We feel that initial nonoperative care for this deformity is too often inadequately pursued prior to surgical intervention,” the authors wrote.
Physical therapy improves functional outcomes, ROM after bunionectomy
Research from the Weil Foot and Ankle Insitute in Des Plaines, IL, offers further evidence that physical therapy after bunionectomy can significantly improve outcomes.
In 55 patients who had undergone scarf bunionectomy, investigators found that those who received physical therapy had significantly higher levels of function and fewer activity limitations at their follow-up office visit than those who did not have physical therapy. The results were presented in February at the annual ACFAS meeting.
Forty four patients (representing surgery on 65 feet) performed physical therapy after the procedure, while 11 patients (14 feet) did not. On the Foot Function Index (FFI), in which higher scores reflect greater impairment, the physical therapy group significantly outperformed the control group at follow up with regard to total FFI score (28.4 vs 58.2) and frequency of activity limitations (4.3 vs 8.3). The PT group also had lower pain scores than the control group (13.2 vs 22.3), a difference that approached statistical significance.
On the ACFAS Universal Foot and Ankle Scoring System outcome measure (module 1: first metatarsophalangeal joint and first ray), in which higher scores reflect less impairment, the PT group significantly outscored the control group with regard to total score (82.2 vs 71.8), functional capacities (11.8 vs 9.2), and function (23.9 vs 18.6).
In the PT group, 63 of 65 feet achieved 0° or more of plantar flexion range of motion, compared to 11 of 14 feet in the control group. Dorsiflexion ROM was 60° or greater in 39 feet (65%) in the PT group and five feet (45.5%) in the control group.
The findings are consistent with those of an Austrian study published in the September issue of Physical Therapy (see “Rehab enhances HV results”). Although that study did not utilize a control group, the authors reported significant improvements in first MPJ range of motion and function between pre-operative assessments and six month follow up in 30 patients who underwent physical therapy following either Austin or scarf osteotomy.
The Austrian study also found that physical therapy was associated with significant improvements in weight bearing at the great toe and first metatarsal head, both in terms of maximum force levels and force-time integral. Previous plantar pressure studies have documented a lack of weightbearing in the medial forefoot and first ray following bunionectomy without physical therapy.