March 2012

Study: Amputation Rates Down In Patients With Diabetes Over 40

By Brian McCurdy, Senior Editor

The prevalence of diabetes has increased in recent years and is projected to keep rising. However, a recent study in Diabetes Care may offer a silver lining: Non-traumatic lower extremity amputation rates have fallen in patients with diabetes over the age of 40.

   Authors found the age-adjusted amputation discharge rate per 1,000 people with diabetes over the age of 40 decreased from 11.2 in 1996 to 3.9 in 2008 while amputation rates among people without diagnosed diabetes had changed little.

   Valerie Schade, DPM, AACFAS, notes that innovations in wound care may facilitate the preservation of functional limbs with a partial foot amputation instead of major amputation of the extremity.

   “With the vast array of advanced local wound care products and multiple negative pressure wound therapy devices currently available for use, reconstruction of an ulcerated foot is more of a reality then the prior days of amputation of the extremity,” notes Dr. Schade, the Chief of the Limb Preservation Service and Director of the Complex Lower Extremity Surgery and Research Fellowship at Madigan Healthcare System in Tacoma, Wash.

   Lee C. Rogers, DPM, concurs, citing advanced products such as VAC therapy (KCI), Regranex (Healthpoint Biotherapeutics), Apligraf (Organogenesis) and Dermagraft (Advanced BioHealing).

   Dr. Rogers, the Co-Director of the Amputation Prevention Center, Valley Presbyterian Hospital in Los Angeles, also cites “improved education, including several respected meetings and a virtual explosion in literature for preventing amputations” in explaining the decrease in amputations. Similarly, as more patients with diabetes are getting regular foot examinations from their primary care physicians and education about diabetic foot care, Monica Schweinberger, DPM, says this leads to earlier referral for specialty foot care in high-risk patients, which can help prevent amputation.

   Dr. Schweinberger notes that insurance coverage for extra depth shoes and orthotics for patients with diabetes can provide better accommodation for foot deformities. Dr. Rogers also cites the effectiveness of the Medicare Diabetic Shoe Bill.

Will The Amputation Trend Continue Or Reverse?

The study authors note that the increased incidence of diabetes “may have resulted in a greater number of individuals with milder disease, detected earlier in the disease process, who have not had diabetes long enough to develop complications. Once these patients with new-onset, milder disease have had diabetes long enough, it is possible that the encouraging trends in … amputations will reverse.”

   Although a longer duration of the disease can lead to a greater potential for complications to occur, with education and the development of specialized teams and centers to prevent lower extremity amputation, a continuing decrease in diabetic amputation “does not appear to be an unobtainable goal,” maintains Dr. Schade.

   Dr. Schweinberger concurs that a longer duration of diabetes leads to a greater likelihood of developing complications such as peripheral neuropathy and peripheral arterial disease, which could increase the risk of amputation.

   “However, with earlier diagnosis and treatment of diabetes, more frequent foot screening and foot care education, in addition to more aggressive management of patients with ulceration or at high risk for ulcer or amputation, I would hope that we would not see a significant increase in lower extremity amputation over time,” says Dr. Schweinberger, who is affiliated with the Cheyenne Veterans Affairs Medical Center in Cheyenne, Wyo.

OCPM May Be Merging With Kent State

By Brian McCurdy, Senior Editor

The Ohio College of Podiatric Medicine (OCPM) is in talks to merge with Kent State University. In a joint statement between the schools, OCPM views the merger as a component of a strategic plan “to take the podiatric school to the next level in teaching and research.” The merger is tentatively slated to occur in July.

   The Ohio College of Podiatric Medicine is developing a six- to seven-year direct admission track to podiatric medicine, according to college President Thomas V. Melillo, DPM. He says that track would include a fixed curriculum to ensure students have an appropriate science background followed by podiatric instruction.
As part of a state college, the podiatric program would be eligible for future state funding, according to Dr. Melillo.

   “This increased revenue, additional students and additional educational programs coupled with the cost savings enjoyed by administrative services being performed at a centralized location should prove to be major benefits to our college,” explains Dr. Melillo.

   Podiatric students will be able to take advantage of Kent State’s programs by pursuing dual degree programs such as Masters in Business Administration, Masters in Public Health and PhD programs in various sciences, emphasizes Dr. Melillo. He also says college faculty and students will have a chance to engage in research programs in areas like public health, engineering, biomaterials and, of course, sports medicine. Podiatric students will also have access to Kent State’s sports program, which he says “will probably lead to a new area of specialization in the DPM program.”

   Dr. Melillo notes that the podiatry college will also have access to Kent State’s 40,000-student base for recruitment and admissions. The schools’ joint statement notes that OCPM annually graduates approximately 110 DPM students.

Can The Keller Procedure Work For Neuropathic Hallux Ulcers?

By Danielle Chicano

In recent years, physicians have considered a modified Keller procedure for neuropathic plantar ulcers of the hallux in patients with diabetes. A recent review concludes that the modified Keller procedure can effectively offload the hallux while promoting healing and preventing recurrence.

   The retrospective review, which will be presented as a poster at the Symposium on Advanced Wound Care Spring/Wound Healing Society (SAWC Spring/WHS), consists of 13 patients who underwent a modified Keller procedure for recalcitrant neuropathic diabetic ulcers of the hallux from 2009 to 2011 with an average follow-up of 11 months. Researchers excluded patients with active soft tissue infections or osteomyelitis.

   The authors noted all ulcers healed within two months postoperatively. They did note two cases of infection and two cases of wound dehiscence. In one case, the ulcer recurred and in another case, a transfer ulcer of the second toe developed, according to the poster abstract.

   William Fishco, DPM, FACFAS, says possible complications associated with the Keller procedure include: cock-up hallux (hallux malleus), stress fracture to the second metatarsal, Charcot arthropathy and flail toe (hallux). However, Dr. Fishco says there are modifications one can make to the procedure to reduce the risk of these complications.

   “Modifications to the Keller include suturing the long flexor tendon to the base of the proximal phalanx as well as suturing the capsule onto the phalanx. These techniques help make the toe more stable,” notes Dr. Fishco, who is in private practice in Phoenix and is a faculty member of the Podiatry Institute.

   Dr. Fishco says the key advantage of the Keller procedure is increasing the range of motion of the great toe joint, which reduces pressure to the plantar hallux. Although half of his patients with plantar neuropathic ulcerations of the hallux fail conservative attempts at offloading with shoes and orthotics, Dr. Fishco does exercise caution in regard to using the Keller procedure in patients with hallux ulcerations.

   “I do use this surgery from time to time, particularly in very sedentary population groups due to the instability of the toe that occurs with this procedure,” explains Dr. Fishco.

   While Dr. Fishco says the Keller procedure should be entertained in patients with a sub-hallux ulcer, he notes alternative surgical options including any procedure (such as a cheilectomy and/or decompression osteotomy) that can increase range of motion of the great joint. If this type of surgery fails, he says one can perform a Keller procedure later. “I think of the Keller as my last resort procedure knowing that there are some serious potential complications that may occur,” notes Dr. Fishco.

Study Assesses High-Resolution Diagnostic Ultrasound For Detecting Osteomyelitis

By Danielle Chicano

A new study abstract, submitted for the SAWC Spring/WHS in April, concludes that high-resolution diagnostic ultrasound may be a useful alternative to magnetic resonance imaging (MRI) when diagnosing chronic osteomyelitis in an outpatient setting.

   The study looked at 80 cases of patients with chronic wounds and a clinical suspicion of bone infection. Researchers utilized MRI and a high-resolution diagnostic ultrasound scanner equipped with a 7 to 13 MHz linear array transducer.

   The MRI showed 100 percent sensitivity, 75 percent specificity, 82.9 percent positive predictive values and 100 percent negative predictive values, according to the study. The high-resolution diagnostic ultrasound scan in comparison showed 97 percent sensitivity, 93.8 percent specificity, 96.6 percent positive predictive values and 97 percent negative predictive values.

   When the high-resolution diagnostic ultrasound device is serviced by a trained clinician, study researchers say this modality has three times less the cost of an MRI and can effectively diagnose chronic osteomyelitis.

   Kazu Suzuki, DPM, CWS, notes additional advantages to using this type of machine in an outpatient setting.

   “A speedy ‘point of care’ diagnostic study is a big advantage in being able to do an ultrasound imaging study while seeing a patient in your clinic when you suspect a bone infection as opposed to booking a patient for MRI,” explains Dr. Suzuki. He also notes the high cost and timeliness issues of booking an MRI, which may take up to a week of turnaround time to obtain the final diagnosis.

   The study addresses the fact that practitioners will require training for using the high-resolution diagnostic ultrasound.

   “Ultrasound study will be ‘operator dependent.’ When (clinicians) are not familiar with operating the machine and interpreting the images it produces, the sensitivity and specificity of the study may be less ideal,” notes Dr. Suzuki, the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers in Los Angeles.

   Dr. Suzuki notes he is not familiar with any further studies with high-resolution diagnostic ultrasound. However, he currently relies more often on MRI for the diagnosis of osteomyelitis. The study also notes that further studies are needed to correlate high-resolution diagnostic ultrasound to leukocyte bone scans and histopathology. The leukocyte bone scan and bone scans in general are becoming more obsolete and less favored for diagnosing osteomyelitis due to low specificity, says Dr. Suzuki.

   The SAWC Spring/WHS will be held from April 19 to 22 in Atlanta. For more info, visit

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