Proactive Measures To Prevent Diabetic Complications
Reducing The Risk Of Post-Treatment Complications
We like to tell our patients and the public that regular foot care prevents amputations and this is true to a significant extent. However, even non-invasive office care of the diabetic patient carries certain risks. Ulcerations, infections or amputations may still occur in spite of our best efforts. Unintended nicks, lacerations or abrasions can and do happen. Subsequent infection at points of treatment, such as callus or nail grooves, can develop. Subsequent blistering, ulceration or necrosis of chronic pressure points can occur after treatment, and the patient may even perceive them as the results of podiatric care. Lastly, one can uncover previously undiagnosed ulceration upon the debridement of a keratosis. If the patient is not adequately informed about the condition, he or she may think the debridement caused the ulceration. In order to manage the risk of diabetic foot care, it is important to take a pertinent history on all patients before any treatment. Likewise, examine the foot and explain any potentially ulcerative findings to the patient. If one suspects there is an underlying ulceration beneath a hemorrhagic callus, inform the patient before debridement so he or she realizes the abnormal condition preceded the podiatric care. In the event that inadvertent injury occurs, inform the patient and provide proper treatment. This may mean nothing more than applying an antiseptic and a Band-Aid. However, more high-risk situations may require dressings and a healing shoe. Instruct the patient in home care and provide short-term follow-up until the injury heals. Patients with diabetes who contact the office with a new problem may require urgent care. One should see patients with acute injuries or suspected infections the same day. If this is not possible, make a referral to the local emergency room. For first aid, advise the patient to keep the affected area clean and stay off the foot until he or she obtains medical evaluation. Document recommendations and patient responses. One can initiate appropriate care when seeing the patient in the office unless the condition is limb threatening and requires hospitalization.
Patients with diabetes who suffer minor trauma from causes such as focal pressure keratosis may go on to ulcerate. Faulty healing of such an ulceration may result from inadequate pressure relief due to neuropathy, vascular disease or infection. This triad of minor trauma, ulcer and faulty healing may lead to the majority of the 80,000 or more diabetes-related amputations that occur in the United States each year. Evaluation and management of minor trauma triggers like foot deformity, pressure callus and undetected injury may prevent many of these amputations not to mention hospitalizations and home bound illnesses related to diabetic foot complications. All patients with diabetes should undergo foot screening exams once a year. Those with risk factors, such as PVD, neuropathy, foot deformity and especially focal pressure keratosis, require podiatric referral and regular evaluation and management. Patients should have appropriate interventions in order to control keratosis and protect pressure points. These interventions may include debridement, shoe and orthotic prescription, counseling and education, and corrective surgery. When such an outpatient management program is in place, expected outcomes include a decreased need for surgery, hospitalization or amputation among patients with diabetic ulcers. A proactive program should decrease the severity of ulcers as well as the overall incidence of ulceration. This kind of proactive approach constitutes medical management of serious foot conditions and is not routine care. Dr. Sage is a Professor and Chief of the Section of Podiatry at the Department of Orthopaedic Surgery and Rehabilitation at the Loyola University Stritch School of Medicine. He is also a Staff Podiatrist at Edward Hines Jr. Veterans Affairs Hospital. Dr. Steinberg is an Assistant Professor in the Department of Surgery at the Georgetown University School of Medicine in Washington, D.C. He is a Fellow of the American College of Foot and Ankle Surgeons.