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4.  Virtualizing the Assessment: A Novel Pragmatic Paradigm to Evaluate Lower Extremity Joint Perception in Diabetes 
Gerontology  2012;58(5):463-471.
Background
Persons with diabetes have a higher risk of falls and fall related injuries. People with diabetes often develop peripheral neuropathy (DPN) as well as nerve damage throughout the body. In particular, reduced lower extremity proprioception due to DPN may cause a misjudgment of foot position and thus increase the risk of fall.
Objective
An innovative virtual obstacle crossing (VOC) paradigm using wearable sensors was developed in attempt to assess lower extremity position perception damage due to DPN.
Methods
Sixty-seven participants (Age: 55.4±8.9; BMI: 28.1±5.8) including diabetes with and without DPN as well as aged matched healthy controls were recruited. Severity of neuropathy was quantified using vibratory perception threshold (VPT) test. The ability of perception of lower extremity was quantified by measuring obstacle crossing success rate (OCSR), toe-obstacle clearance (TOC), and reaction time (TR) while crossing a series of virtual obstacles with heights at 10% and 20% of the subject’s leg length.
Results
No significant difference was found between groups for age and BMI. The data revealed that DPN subjects had a significantly lower OCSR compared to diabetes with no neuropathy and controls at obstacle size of 10% (p<0.05). DPN subjects also demonstrated longer TR compared to other groups and for both obstacle sizes. In addition TOC was reduced in neuropathy groups. Interestingly, a significant correlation between TR and VPT (r=0.5, p<10-5) was observed indicating delay in reaction by increasing neuropathy severity. The delay becomes more pronounced by increasing the size of obstacle. Using regression model suggests that the change in reaction time between obstacle sizes of 10% and 20% of leg size is the most sensitive predictors for neuropathy severity with an odds ratio of 2.70 (p=0.02).
Conclusion
The findings demonstrate proof of concept of virtual reality application as a promising method for objective assessment of neuropathy severity, however; a further study is warranted to establish a stronger relationship between the measured parameters and neuropathy.
doi:10.1159/000338095
PMCID: PMC3955209  PMID: 22572476
Virtual Reality; Diabetes Peripheral Neuropathy; Lower Extremity Joint Perception; Body Worn Sensors; Fall Prevention; Obstacle crossing
5.  The system of care for the diabetic foot: objectives, outcomes, and opportunities 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.21847.
Most cases of lower extremity limb loss in the United States occur among people with diabetes who have a diabetic foot ulcer (DFU). These DFUs and the associated limb loss that may occur lead to excess healthcare costs and have a large negative impact on mobility, psychosocial well-being, and quality of life. The strategies for DFU prevention and management are evolving, but the implementation of these prevention and management strategies remains challenging. Barriers to implementation include poor access to primary medical care; patient beliefs and lack of adherence to medical advice; delays in DFU recognition; limited healthcare resources and practice heterogeneity of specialists. Herein, we review the contemporary outcomes of DFU prevention and management to provide a framework for prioritizing quality improvement efforts within a resource-limited healthcare environment.
doi:10.3402/dfa.v4i0.21847
PMCID: PMC3796020  PMID: 24130936
foot ulcer; diabetes; peripheral vascular disease; diabetic neuropathy; delivery of healthcare; physician's practice patterns
6.  Long-Term Prognosis of Diabetic Foot Patients and Their Limbs 
Diabetes Care  2012;35(10):2021-2027.
OBJECTIVE
There is a dearth of long-term data regarding patient and limb survival in patients with diabetic foot ulcers (DFUs). The purpose of our study was therefore to prospectively investigate the limb and person survival of DFU patients during a follow-up period of more than 10 years.
RESEARCH DESIGN AND METHODS
Two hundred forty-seven patients with DFUs and without previous major amputation consecutively presenting to a single diabetes center between June 1998 and December 1999 were included in this study and followed up until May 2011. Mean patient age was 68.8 ± 10.9 years, 58.7% were male, and 55.5% had peripheral arterial disease (PAD). Times to first major amputation and to death were analyzed with Kaplan-Meier curves and Cox multiple regression.
RESULTS
A first major amputation occurred in 38 patients (15.4%) during follow-up. All but one of these patients had evidence of PAD at inclusion in the study, and 51.4% had severe PAD [ankle-brachial pressure index ≤0.4]). Age (hazard ratio [HR] per year, 1.05 [95% CI, 1.01–1.10]), being on dialysis (3.51 [1.02–12.07]), and PAD (35.34 [4.81–259.79]) were significant predictors for first major amputation. Cumulative mortalities at years 1, 3, 5, and 10 were 15.4, 33.1, 45.8, and 70.4%, respectively. Significant predictors for death were age (HR per year, 1.08 [95% CI, 1.06–1.10]), male sex ([1.18–2.32]), chronic renal insufficiency (1.83 [1.25–2.66]), dialysis (6.43 [3.14–13.16]), and PAD (1.44 [1.05–1.98]).
CONCLUSIONS
Although long-term limb salvage in this modern series of diabetic foot patients is favorable, long-term survival remains poor, especially among patients with PAD or renal insufficiency.
doi:10.2337/dc12-0200
PMCID: PMC3447849  PMID: 22815299
7.  A tale of two soles: sociomechanical and biomechanical considerations in diabetic limb salvage and amputation decision-making in the worst of times 
Diabetic Foot & Ankle  2012;3:10.3402/dfa.v3i0.18633.
Foot ulcerations complicated by infection are the major cause of limb loss in people with diabetes. This is especially true in those patients with severe sepsis. Determining whether to amputate or attempt to salvage a limb often requires in depth evaluation of each individual patient's physical, mental, and socioeconomic status. The current report presents and juxtaposes two similar patients, admitted to the same service at the same time with severe diabetic foot infections complicated by sepsis. We describe in detail the similarities and differences in the clinical presentation, extent of infection, etiology, and socioeconomic concerns that ultimately led to divergent clinical decisions regarding the choices of attempting diabetic limb salvage versus primary amputation and prompt rehabilitation.
doi:10.3402/dfa.v3i0.18633
PMCID: PMC3464045  PMID: 23050063
diabetic foot; Charcot arthropathy; diabetic limb salvage; diabetic foot infection; amputation
8.  The Charcot Foot in Diabetes 
Diabetes Care  2011;34(9):2123-2129.
The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.
doi:10.2337/dc11-0844
PMCID: PMC3161273  PMID: 21868781
9.  Plantar Temperature Response to Walking in Diabetes with and without Acute Charcot: The Charcot Activity Response Test 
Journal of Aging Research  2012;2012:140968.
Objective. Asymmetric plantar temperature differences secondary to inflammation is a hallmark for the diagnosis and treatment response of Charcot foot syndrome. However, little attention has been given to temperature response to activity. We examined dynamic changes in plantar temperature (PT) as a function of graduated walking activity to quantify thermal responses during the first 200 steps. Methods. Fifteen individuals with Acute Charcot neuroarthropathy (CN) and 17 non-CN participants with type 2 diabetes and peripheral neuropathy were recruited. All participants walked for two predefined paths of 50 and 150 steps. A thermal image was acquired at baseline after acclimatization and immediately after each walking trial. The PT response as a function of number of steps was examined using a validated wearable sensor technology. The hot spot temperature was identified by the 95th percentile of measured temperature at each anatomical region (hind/mid/forefoot). Results. During initial activity, the PT was reduced in all participants, but the temperature drop for the nonaffected foot was 1.9 times greater than the affected side in CN group (P = 0.04). Interestingly, the PT in CN was sharply increased after 50 steps for both feet, while no difference was observed in non-CN between 50 and 200 steps. Conclusions. The variability in thermal response to the graduated walking activity between Charcot and non-Charcot feet warrants future investigation to provide further insight into the correlation between thermal response and ulcer/Charcot development. This stress test may be helpful to differentiate CN and its response to treatment earlier in its course.
doi:10.1155/2012/140968
PMCID: PMC3413979  PMID: 22900177
10.  Adventitious Bursae Underlying Chronic Wounds: Another Possible Deterrent to Healing 
Eplasty  2012;12:e14.
Adventitious bursae typically develop in areas of chronic frictional irritation, usually under bony prominences. Although adventitious bursae are generally well understood, there is a paucity of data on effects of bursae underlying chronic wounds in neuropathic patients. This manuscripts reviews 4 clinical cases, each with a neuropathic patient with adventitious bursae underlying chronic nonhealing wound and strategies for treatment.
PMCID: PMC3286309  PMID: 22389747
11.  Wound Inflammatory Index: A “Proof of Concept” Study to Assess Wound Healing Trajectory 
Diabetes around the globe results in one major limb amputation every 30 seconds, over 2500 limbs lost per day. The underlying pathophysiology sometimes leads to a chronic inflammatory stage, which may prevent appropriate healing, and therefore, the need for a clear strategy for assessing and classifying wounds and wound healing cannot be overstated. Temperature is a surrogate marker for inflammation. Quantitative thermography using a numerical index provides a useful way to assess wound healing. Advances in technology have afforded the availability of low-cost, high-resolution thermal imaging systems, which can be used to quantify sensitive changes on the skin surface and may be particularly useful to develop monitoring strategies for wounds. This article provides a standardized technique for calculating a thermal index (TI) supported with a case report from assessment of a diabetic foot ulcer. In this single case study, the TI/wound inflammatory index indicates a shift from negative to positive (p < .05) before it reaches zero.
PMCID: PMC2909505  PMID: 20663437
diabetic foot ulcers; thermal index; thermography; thermometry; wound healing
12.  Digital Planimetry Results in More Accurate Wound Measurements: A Comparison to Standard Ruler Measurements 
Background
Cutaneous wound measurements are important to track the healing of a wound and direct appropriate therapy. The most commonly used method to calculate wound area is an estimation by multiplying the longest length by the widest width. Other devices can provide an accurate and precise measurement of the true area (TA). This study aim was to compare wound areas calculated by computerized planimetry with standard area estimation by multiplying the longest length by the widest width (l × w).
Methods
We reviewed the wound records of 10 patients with circular or oval wounds and estimated the area with the l × w method. We compared this with the TA obtained by a specialized planimetric camera.
Results
Average wound size was 4.3 cm2 by l × w estimation and 3 cm2 by TA calculation. We found the l × w method overestimated wound area an average of 41%.
Conclusions
Standard, manual (l × w) measurement of cutaneous wounds inaccurately overestimates wound area by roughly 40%.
PMCID: PMC2909508  PMID: 20663440
planimetry; Silhouette; ulcer; wound measurement
13.  The Micrograft Concept for Wound Healing: Strategies and Applications 
The standard of care for wound coverage is to use an autologous skin graft. However, large or chronic wounds become an exceptionally challenging problem especially when donor sites are limited. It is important that the clinician be aware of various treatment modalities for wound care and incorporate those methods appropriately in the proper clinical context. This report reviews an alternative to traditional meshed skin grafting for wound coverage: micrografting. The physiological concept of micrografting, along with historical context, and the evolution of the technique are discussed, as well as studies needed for micrograft characterization and future applications of the technique.
PMCID: PMC2909510  PMID: 20663442
diabetic foot ulcers; micrografting; wound healing
14.  Novel Use of Insulin in Continuous-Instillation Negative Pressure Wound Therapy as “Wound Chemotherapy” 
Negative pressure wound therapy (NPWT) is frequently employed in the treatment of complex wounds. A variety of wound chemotherapeutic agents such as insulin, which acts as a growth factor, may prove helpful in treatment as well. We present a case report in which insulin was used as a chemotherapeutic agent in continuous-instillation NPWT. To our knowledge, this is the first report in the literature describing this method of delivery.
PMCID: PMC2909511  PMID: 20663443
diabetic foot ulcers; insulin; negative pressure wound therapy; wound chemotherapy
15.  Liquid Silicone to Mitigate Plantar Pedal Pressure: A Literature Review 
Disruption of the body’s plantar fat pad can occur as a result of one of three mechanisms: simple fat pad atrophy associated with age-related degeneration, steroid use, or collagen vascular disease. Actual or relative displacement in to the underlying osseous prominences may be seen in association with structural deformity of the foot. Disease states such as diabetes may alter the normal structural integrity of soft tissues through nonenzymatic glycation leading to increased stiffness and thus reduced attenuating capacity. Fat pad atrophy, regardless of the cause, is often associated with substantial emotional, physical, productivity, and financial losses. In situations where the patient is sensate, the resultant skin on bone situation is extremely painful, especially when walking.
PMCID: PMC2909515  PMID: 20663447
atrophy; augmentation; pressure; silicone
16.  FaceTime for Physicians: Using Real Time Mobile Phone–Based Videoconferencing to Augment Diagnosis and Care in Telemedicine 
Eplasty  2011;11:e23.
Objective/Background: Telemedicine has, even in its infancy, had an impact on the provision of healthcare, particularly in rural communities. However, this often relies on an expensive and ponderous infrastructure that reduces the rapid use and spontaneity for consultations. Methods: Using postoperative and intraoperative examples, we describe the use of one rapid and widely available technology (iPhone FaceTime, Cupertino, California). Results: The device, in allowing “one button connection” similar to making a phone call, reduced the need for preplanning that is generally required for real-time telemedicine consultation. Conclusions: The ability to communicate quickly with something that is an afterthought has the potential to alter how we work with our colleagues and patients. Just as with the iPod in music and the laptop in computing, it is not the change in technology, but the change in form factor and ubiquity that alters this landscape.
PMCID: PMC3087505  PMID: 21559249
17.  Partial Calcanectomy in High-Risk Patients With Diabetes: Use and Utility of a “Hurricane” Incisional Approach 
Eplasty  2010;10:e17.
Introduction: Plantar heel ulcers in people with diabetes represent a difficult challenge to the treating physician. They become even more difficult with underlying osteomyelitis. When this infection is in the calcaneus it typically results in a partial or total calcanectomy or even more frequently, high-level amputation. Methods: In this article, we describe a novel serpentine incisional approach to the plantar and (if necessary) posterior heel allowing for ample exposure and facilitating closure predominantly along relaxed skin tension lines. Results: We present several representative case examples in which a hurricane incision has been used to treat and provide closure to plantar-based calcaneal ulcers. Discussion: The use of this incision, which resembles a satellite view of a hurricane, was successful in achieving a desired partial calcanectomy and wound closure. This may be an additional tool in the armamentarium of the surgeon to assist in healing and amputation prevention.
PMCID: PMC2817571  PMID: 20165545
18.  Wound Chemotherapy by the Use of Negative Pressure Wound Therapy and Infusion 
Eplasty  2010;10:e9.
Introduction: Although the use of negative pressure wound therapy (NPWT) is broadly efficacious, it may foster some potentially adverse complications. This is particularly true in patients with diabetes who have a wound colonized with aerobic organisms. Traditional antiseptics have been proven useful to combat such bacteria but require removal of some NPWT devices to be effective. Methods: In this article, we describe a method of “wound chemotherapy” by combining NPWT and a continuous infusion of Dakins' 0.5% solution either as a standardized technique in one device (ITI Sved) or as a modification of standard technique in another (KCI VAC) NPWT device. The twin goals of both techniques are to effectively reduce bacterial burden and to promote progressive wound healing. Results: We present several representative case examples of our provisional experience with continuous streaming therapy through 2 foam-based negative pressure devices. Discussion: Wound chemotherapy was successfully applied to patients with diabetes, without adverse reactions, complications, or recolonization during the course of treatment. We believe this to be a promising method to derive the benefits of NPWT without the frequent adverse sequela of wound colonization.
PMCID: PMC2806786  PMID: 20090841
19.  Use of Pressure Offloading Devices in Diabetic Foot Ulcers 
Diabetes Care  2008;31(11):2118-2119.
OBJECTIVE—Pressure mitigation is crucial for the healing of plantar diabetic foot ulcers. We therefore discuss characteristics and considerations associated with the use of offloading devices.
RESEARCH DESIGN AND METHODS—A diabetic foot ulcer management survey was sent to foot clinics in all 50 states and the District of Columbia in 2005. A total of 901 geographically diverse centers responded. The survey recorded information regarding usage frequency and characteristics of assessment and treatment of diabetic foot ulcers in each center.
RESULTS—Of the 895 respondents who treat diabetic foot ulcers, shoe modifications (41.2%, P < 0.03) were the most common form of pressure mitigation, whereas total contact casts were used by only 1.7% of the centers.
CONCLUSIONS—This study reports the usage and characteristics of offloading devices in the care of diabetic foot ulcers in a broadly distributed geographic sample. Less than 2% of specialists use what has been termed the “gold standard” (total contact cast) for treating the majority of diabetic foot ulcers.
doi:10.2337/dc08-0771
PMCID: PMC2571059  PMID: 18694976
21.  A Method of External Fixation to Offload and Protect the Foot Following Reconstruction in High-Risk Patients: The SALSAstand 
Eplasty  2009;9:e21.
Introduction: The course of wound healing in high-risk patients with diabetes, particularly those with peripheral arterial disease and renal failure, is often prolonged and fraught with complications. Traditional methods of offloading the posterior foot or holding correction in place following diabetic foot reconstruction include various padded and bolstering devices. Methods: In this article, we describe a method (SALSAstand) to effectively elevate, offload, and protect the foot with an external fixation device, while also promoting flap healing, maintaining tendon correction, and limiting the tendon retraction and contracture that is commonly seen following a foot-salvage procedure in high-risk patients. Results: Not applicable. Discussion: The SALSAstand device has been successfully utilized on many patients in our service to accomplish the aforementioned goals in this most challenging patient population.
PMCID: PMC2697004  PMID: 19578534
22.  The Diabetic Rapid Response Acute Foot Team: 7 Essential Skills for Targeted Limb Salvage 
Eplasty  2009;9:e15.
Objective: People with diabetes are prone to develop lower-extremity ulcerations and infections, both of which serve as major risk factors for limb amputation. The development of lower-extremity complications of diabetes is associated with increased morbidity and mortality. Recently, there has been increasing interest in the development of interdisciplinary teams to manage the myriad factors that complicate the treatment of high-risk patients, particularly in the perihospitalization period. Methods: This article presents 7 essential skills that necessarily allow the limb salvage team to appropriately manage the most common presenting comorbidities in patients with diabetes, including vasculopathy, infection, and deformity. Results: Seven essentials skills have been demonstrated to promote the greatest salvage outcomes, and these are the ability to (1) perform hemodynamic and anatomic vascular assessment with revascularization, as necessary; (2) perform neurologic workup; (3) perform site-appropriate culture technique; (4) perform wound assessment and staging/grading of infection and ischemia; (5) perform site-specific bedside and intraoperative incision and debridement; (6) initiate and modify culture-specific and patient-appropriate antibiotic therapy; and (7) perform appropriate postoperative monitoring to reduce risk of reulceration and infection. Conclusions: Utilization of these 7 essential skills as the core basis for interdisciplinary limb salvage team models will provide clinicians guidance when establishing such teams. Interdisciplinary teams have been demonstrated to improve quality and efficiency of patient care, thus improving overall outcomes and reducing amputation rates.
PMCID: PMC2680239  PMID: 19436764

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