How Long-Term Primary Podiatric Care Can Reduce Diabetic Pedal Complications
At the recent annual meeting of the American Podiatric Medical Association (APMA), Gibson and colleagues presented an elegant study confirming what is well known to all podiatric physicians. In patients with diabetes, the study authors noted that “care by podiatrists appears to prevent or delay lower extremity amputation and hospitalization.”1
Podiatric care may include the use of advanced limb salvage interventions in the presence of limb threatening infections or ischemia. However, no matter how exciting these advances are, primary podiatric care on a long-term basis remains the mainstay to prevent or minimize the complications that require advanced interventions. Effective long-term primary podiatric care is far more desirable for the patient than the risk and disability associated with aggressive limb salvage.
Foot surgeries, wound care and vascular interventions are necessary elements of limb salvage. Equally important is the fact that education, prescription shoes, orthotics and callus care at regular intervals are required to prevent further significant ulcerations, infection, hospitalization and possible amputation. Such care is essential after surgery for ulcerative lesions and must be provided by a podiatric physician who is willing to take on longitudinal care for high-risk patients with diabetes.
What The Literature Reveals
High-risk patients with diabetes continue to present on a daily basis at our clinics at the Edward Hines, Jr. Veterans Affairs Hospital and the Loyola University Medical Center. In addition to patients at a high risk of ulcers, others with low-grade chronic ulceration can remain free of infection and avoid amputation if they are under regular podiatric care.
My group demonstrated this in a 2001 review of 233 patients admitted to our hospitals with foot ulceration.2 Ulcerated patients in this series who received care in a podiatry clinic were far less likely to undergo surgery or amputation in comparison to those who had not received podiatric care prior to admission for infected foot ulcerations.
There are approximately 24 million people in the United States with diabetes and 1.6 million new cases are diagnosed each year.3 Researchers have estimated that 15 percent of these patients will have a diabetic foot ulcer during their lifetime, automatically putting them at high risk for further ulceration or amputation.4
Diabetes is the most frequent cause of renal failure with over 178,000 people on chronic dialysis.3 A recent study by Ndip and colleagues indicated that 95 percent of a group of 466 patients on dialysis in the United States and United Kingdom were at high risk for lower limb complications.5 In another study involving 150 patients on dialysis and 150 patients with previous foot ulceration or amputation, Lavery and co-workers found that only 30 percent of the study patients received preventative podiatric care.6
As we advance in our abilities to utilize sophisticated diagnostic and surgical interventions for treating diabetic foot complications, we must not lose sight of the fact that longitudinal primary podiatric care remains the cornerstone of prevention. Primary podiatric evaluation and management services should be a part of all diabetes care programs to prevent or minimize first episodes of diabetic foot ulceration and limb-threatening infection.
Such services are even more essential for patients with complications like renal failure or previous limb threatening ulceration and infection. Advanced healing and reconstructive techniques have little value to the patient if a subsequent focal pressure callus leads to ulceration and further limb-threatening infection. Diabetic neuropathy and vascular disease associated with even minor foot deformity are chronic conditions requiring longitudinal care.