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Study Shows Severe Early Outcomes Of COVID-19 In Patients With Diabetes

In a recent study involving over 1,300 patients with diabetes and COVID-19 at 53 hospitals in France, researchers found that 29 percent of the patients needed intubation for assisted mechanical ventilation and/or died within seven days of hospitalization.

The authors of the study, published in Diabetologia, also found that body mass index (BMI) was an independent factor contributing to the severity of COVID-19 infection. The average age of patients in the study was 70 and two-thirds of the patients were men, according to the study. Researchers noted that 89 percent of the study patients had type 2 diabetes. 

When looking at other potential risk factors for poor outcomes in this patient cohort, researchers found that glycemic control (measured by hemoglobin A1c) was not associated with the severity of symptoms. However, they found that age, micro- and macrovascular complications, sleep apnea, dyspnea and certain laboratory values did have an impact on COVID-19 outcomes in this study.

Lee C. Rogers, DPM says this study shows that diabetes is a leading risk factor for more extreme complications of COVID-19 infection, including death.

“Since many of our patients have diabetes and an elevated BMI, also identified as a risk factor, podiatrists do play an active role in helping prevent deaths and complications in this high-risk group by performing services in lower-risk settings,” notes Dr. Rogers, the Chief Medical Officer for the Amputation Prevention Experts Health Network.

Windy Cole, DPM relates that this study is the first specifically dedicated to patients with diabetes who are hospitalized with COVID-19. 

“Podiatric care remains vital during the pandemic as we provide essential care to this at-risk population,” maintains Dr. Cole, an Adjunct Professor and Director of Wound Care Research at the Kent State University College of Podiatric Medicine. “Using these new findings to implement a triage system, podiatric physicians can continue to manage these patients while helping to reduce the risk of acquiring COVID-19 infection.”

By incorporating the aforementioned triage system, Dr. Cole says podiatrists may be able to perform telemedicine and home visits to help mitigate risk for vulnerable patients with diabetes while reserving in-person visits for higher acuity patients. 

Dr. Rogers agrees and refers to a diabetic foot triage system that he co-authored earlier this year in the Journal of the American Podiatric Medical Association

“(This system) can aid the podiatrist in determining the urgency of the visit and the setting in which to provide care,” relates Dr. Rogers. 

He says the home and the physician’s office are lower risk care settings in comparison to inpatient care. Services possible in the home include wound debridements, application of grafts and total contact casts, according to Dr. Rogers. In the office setting, he shares that there is good guidance from the Centers for Disease Control and Prevention (CDC), which outlines steps to reduce community transmission of COVID-19 infections while treating patients at outpatient facilities and the physician’s office. 

Dr. Rogers maintains that telemedicine cannot replace all best practices in wound care as debridement and customized offloading are not possible in that setting. However, he does believe telemedicine will help providers triage patients more quickly, avoid ER utilization and may extend the time interval between visits if one employs telemedicine to help monitor for infections.

Dr. Cole says physicians should also pay additional attention to patients who exhibit signs and symptoms of advanced complications of diabetes when determining the utility of telemedicine versus in-office visits. 

“Identifying at-risk patients using these specific prognostic factors can help clinicians better manage and care for our patients with diabetes during the pandemic and beyond,” emphasizes Dr. Cole.

Are Split-Thickness Skin Grafts A Viable Option For The Plantar Foot?

When surgeons emphasize proper patient selection and offloading, split-thickness skin grafts on the plantar surface of the foot can be effective in achieving durable coverage and closure along with acceptable recurrence rates, according to a recent study in the Journal of Foot and Ankle Surgery

The retrospective study involved 182 patients who had split-thickness skin grafting of the lower extremity. The patients with plantar ulcers (52) became the case cohort and those with non-plantar ulcers (130) became the controls. Researchers found that healing at 30 days did not differ significantly between the groups nor did time to full healing or recurrence. The only statistically significant differences found were healing at 60, 90 and 365 days (21 percent versus 45 percent; 33 percent versus 49 percent; and 38 percent versus 64 percent respectively).

Paul J. Kim, DPM, MS shares that old dogma suggests that surgeons should avoid split-thickness skin grafting on the plantar surface of the foot but he says this concept is not based on true evidence. 

“A split-thickness skin graft is the gold standard for soft tissue coverage regardless of anatomical location,” relates Dr. Kim, a Professor in the Departments of Plastic Surgery and Orthopedic Surgery at the University of Texas Southwestern. “The fear is that the plantar surface is at risk due to its weightbearing function, which could lead to graft shear or destruction.”

Dr. Kim reminds surgeons that protecting the area of the graft for four to six weeks postoperatively through dressing selection and offloading may prevent shearing. He also points out that it is important to focus on long-term protective shoe gear and to evaluate and address biomechanical abnormalities as well. 

This study supports the reliability and safety of outcomes associated with split-thickness skin grafts of the plantar foot, states Dr. Kim. 

“Even if you don’t get 100 percent take, this is okay,” explains Dr. Kim. “Any reduction in wound size is a win.”

He says the ultimate predictors of success in such cases are wound bed preparation and vigilant postoperative monitoring. Also, a scaffold with a dermal xenograft or allograft may be necessary to provide depth reduction prior to application of the skin graft, according to Dr. Kim. In his experience in performing several hundred split-thickness skin grafts, he says the risk of donor site complications is rare and those that do occur are easy to address. Dr. Kim adds that the patient should be aware that the donor site may exhibit persistent hypopigmentation. 

Dr. Kim encourages surgeons to examine their state scope of practice laws as they relate to skin graft harvesting. However, he maintains that the procedure itself is technically very simple with harvest possible in areas other than the anterolateral thigh, such as the calf and arch of the foot.

What Is The Impact Of Incisional Approach On Ankle Arthroplasty Outcomes?

Is an anterior approach or a lateral approach superior for total ankle replacement (TAR) procedures? 

For a recent study published in Foot and Ankle International, researchers examined 115 TAR cases and followed the patients for two years to evaluate the reoperation rate for each of these incisional cohorts. The cases included 67 anterior and 48 lateral operations. The lateral approach group had more reoperations (33) than the anterior approach group (seven) with reoperation types in the lateral group including gutter debridement, lateral hardware removal, soft tissue reconstruction and irrigation debridement.

Ashim Wadehra, DPM, AACFAS relates that he most commonly uses an anterior approach when performing TARs and finds minimal complications and reoperations when doing so. 

“The anterior incision allows for direct access to the joint along with access to the gutters for debridement,” explains Dr. Wadehra, a fellowship-trained foot and ankle surgeon in private practice in Detroit. 

While Dr. Wadehra notes that a lateral approach is appropriate in some cases, he says it requires a fibular osteotomy and subsequent repair during the procedure in order to properly access the ankle joint, putting the patient at risk for non-union and hardware irritation. He acknowledges that the anterior approach has its risks as well, especially wound complications.

“As the study authors mentioned, I use meticulous dissection with no heavy retraction to minimize trauma to the soft tissues,” states Dr. Wadehra. “With copious irrigation and good closure over the retinaculum, I do not often have complications with this approach.”

He shares that in his experience, the most important part of the closure to avoid complication and reoperation is that of the retinaculum. Any failure with this closure will cause the extensor tendons and, more commonly, the tibialis anterior tendon to bowstring, putting pressure under the incision, according to Dr. Wadehra.

He adds that dressing selection is also crucial, especially for the anterior incision. Dr. Wadehra prefers Xeroform® followed by a gauze layer with no wrinkles to avoid skin and incision irritation.

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By Jennifer Spector, DPM, FACFAS, Associate Editor
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