How Long-Term Primary Podiatric Care Can Reduce Diabetic Pedal Complications
She has remained stable and plantigrade. The patient has demonstrated no plantar prominences and no ulceration of the left foot to date, except for a distal third toe ulcer, which resolved with local care. She received a prescription custom orthotic along with inlay depth shoes.
The patient continues her regular podiatric visits. There have been no significant ulcerations or infections since 2006. At each visit, she receives encouragement for her diligent efforts to control her diabetes, reminders about the adverse effects of smoking and advice to inspect her feet frequently. The physician evaluates vascular status, sensation, skin condition and deformities at each visit. Her pressure calluses undergo evaluation for ulceration and the podiatric physician pares down her calluses. The podiatrist inspects her shoes and orthotics, and provides prescriptions for footwear replacement as needed.
Over the years, the patient has become quite knowledgeable about her foot condition and the need to observe and seek attention for any foot abnormalities she detects between visits. Her clinical course to this date has been marked by several limb-threatening complications of diabetes that could have led to major amputation. However, self-examination and early intervention have minimized her morbidity.
Recognizing Conditions That Increase Amputation Risk
This patient has exhibited loss of sensation, deformity and a past history of ulceration, which places her in a high risk category for amputation risk, according to the International Working Group on the Diabetic Foot.7 The patient also has peripheral vascular disease.
According to the American Diabetes Association, the following conditions are associated with an increased risk of amputation:4
• peripheral neuropathy;
• altered biomechanics;
• pressure callus;
• limited joint mobility, bony deformity, severe nail pathology;
• peripheral vascular disease; and/or
• a history of ulcer or amputation.
Again, the patient exhibited virtually all of these findings. She potentially could have undergone bilateral amputations but her longitudinal podiatric medical, orthotic and surgical care for the past 21 years has enabled her to reduce her risk of lower extremity amputation.
Dr. Sage is a Professor and the Chief of the Section of Podiatry at the Department of Orthopaedic Surgery and Rehabilitation at the Loyola University Stritch School of Medicine in Maywood, Ill.
Dr. Steinberg is an Associate Professor in the Department of Plastic 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.
For further reading, see “How To Address Vascular Complications With Lower Extremity Wounds” in the July 2008 issue of Podiatry Today. To access the archives, visit www.podiatrytoday.com.