Radiologic case study. Acute Achilles tendon rupture.
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Achilles Tendon↗
Biomedical subjects
L A Lavery
Publications and source records attributed to L A Lavery.
Electric stimulation as an adjunct to heal diabetic foot ulcers: a randomized clinical trial.
OBJECTIVE: To evaluate high-voltage, pulse-galvanic electric stimulation as an adjunct to healing diabetic foot ulcers. DESIGN: Randomized, double-blind, placebo-controlled pilot trial. SETTING: University medical center. PATIENTS: Forty patients with diabetic foot ulcers, consecutively sampled. Twenty patients each assigned to treatment and placebo groups. Five patients (2 treated, 3 placebo) withdrew because of severe infection. INTERVENTIONS: Electric stimulation through a microcomputer every night for 8 hours. The placebo group used identical functioning units that delivered no current. Additional wound care consisted of weekly débridements, topical hydrogel, and off-loading with removable cast walkers. Patients were followed for 12 weeks or until healing, whichever occurred first. MAIN OUTCOME MEASURES: Proportion of wounds that healed during the study period. Compliance with use of device (in hr/wk), rate of wound healing, and time until healing. RESULTS: Sixty-five percent of the patients healed in the group treated with stimulation, whereas 35% healed with placebo (p = .058). After stratification by compliance, a significant difference was identified among compliant patients in the treatment group (71% healed), noncompliant patients in the treatment group (50% healed), compliant patients in the placebo group (39% healed), and noncompliant patients in the placebo group (29% healed, linear-by-linear association = 4.32, p = .038). There was no significant difference in compliance between the 2 groups. CONCLUSION: Electric simulation enhances wound healing when used in conjunction with appropriate off-loading and local wound care.
Diabetic Foot↗
Functional status of persons with diabetes-related lower-extremity amputations.
OBJECTIVE: It is reasonable to predict that diabetes-related lower-extremity amputations have a detrimental impact on quality of life. However, we are unaware of any study in the medical literature describing the functional level of diabetic patients with amputations. The objective of this study was to evaluate amputations among diabetic patients and to determine the functional level of these patients with the Sickness Impact Profile (SIP). RESEARCH DESIGN AND METHODS: We enrolled 124 patients with diabetes. Case subjects (n = 35) were defined as patients who had undergone amputation of the lower-extremity, and control subjects (n = 89) were defined as patients who had not undergone amputation. Study participants received a standard history and physical examination. RESULTS: Both the physical dimension scores (33.5 +/- 14.9 vs. 22.3 +/- 14.7, P < 0.001) and the total SIP scores (27.6 +/- 9.9 vs. 22.5 +/- 10.3, P = 0.013) were significantly higher for amputees. However, the psychosocial dimension scores were not significantly different between case and control subjects (14.9 +/- 8.9 vs. 15.2 +/- 10.0, P > 0.05). Post hoc analysis showed that the group of patients who had undergone transtibial amputation had a significantly higher total impairment score than patients who had not undergone amputation (P = 0.039). This is in contrast to patients with toe or midfoot amputations, for whom total impairment scores were not significantly higher than those for the control subjects. Interestingly, bilateral amputees did not have significantly higher scores on either SIP dimension compared with unilateral amputees. CONCLUSIONS: These findings exemplify the detrimental physical and psychosocial health status of patients with diabetes-related lower-extremity amputation.
Activities of Daily Living↗
Off-loading the diabetic foot wound: a randomized clinical trial.
OBJECTIVE: To compare the effectiveness of total-contact casts (TCCs), removable cast walkers (RCWs), and half-shoes to heal neuropathic foot ulcerations in individuals with diabetes. RESEARCH DESIGN AND METHODS: In this prospective clinical trial, 63 patients with superficial noninfected, nonischemic diabetic plantar foot ulcers were randomized to one of three off-loading modalities: TCC, half-shoe, or RCW. Outcomes were assessed at wound healing or at 12 weeks, whichever came first. Primary outcome measures included proportion of complete wound healing at 12 weeks and activity (defined as steps per day). RESULTS: The proportions of healing for patients treated with TCC, RCW, and half-shoe were 89.5, 65.0, and 58.3%, respectively. A significantly higher proportion of patients were healed by 12 weeks in the TCC group when compared with the two other modalities (89.5 vs. 61.4%, P = 0.026, odds ratio 5.4, 95% CI 1.1-26.1). There was also a significant difference in survival distribution (time to healing) between patients treated with a TCC and both an RCW (P = 0.033) and half-shoe (P = 0.012). Patients were significantly less active in the TCC (600.1 +/- 320.0 daily steps) compared with the half-shoe (1,461.8 +/- 1,452.3 daily steps, P = 0.04). There was no significant difference in the average number of steps between the TCC and the RCW (767.6 +/- 563.3 daily steps, P = 0.67) or the RCW and the half-shoe (P = 0.15). CONCLUSIONS: The TCC seems to heal a higher proportion of wounds in a shorter amount of time than two other widely used off-loading modalities, the RCW and the half-shoe.
Casts, Surgical↗
Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot.
OBJECTIVE: To evaluate the effectiveness of a diabetic foot risk classification system by the International Working Group on the Diabetic Foot to predict clinical outcomes. RESEARCH DESIGN AND METHODS: A total of 225 diabetic patients were initially evaluated as part of a prospective case-control study at the University of Texas Health Science Center at San Antonio. Complete records were available for 213 patients for follow-up evaluation after 29 months. Upon enrollment, subjects were stratified into four risk groups based on the presence of risk factors according to the consensus of the International Working Group on the Diabetic Foot. Group 0 consisted of subjects without neuropathy, group 1 consisted of patients with neuropathy but without deformity or peripheral vascular disease (PVD), group 2 consisted of subjects with neuropathy and deformity or PVD, and group 3 consisted of patients with a history of foot ulceration or a lower-extremity amputation. RESULTS: Upon enrollment, patients in higher-risk groups had longer duration of diabetes, worse glycemic control, vascular and neuropathic variables, and more systemic complications of diabetes. During 3 years of follow-up, ulceration occurred in 5.1, 14.3, 18.8, and 55.8% of the patients in groups 0, 1, 2, and 3, respectively (linear-by-linear association, P < 0.001). All amputations were found in Groups 2 and 3 (3.1 and 20.9%, P < 0.001). CONCLUSIONS: The foot risk classification of the International Working Group on the Diabetic Foot predicts ulceration and amputation and can function as a tool to prevent lower-extremity complications of diabetes.
Blood Pressure↗
Reliability of digital videometry and acetate tracing in measuring the surface area of cutaneous wounds.
PURPOSE: The purpose of this study was to evaluate the reliability of digital videometry and acetate tracing in the measurement of cutaneous wound area. METHODS: Four clinicians used both digital videometry and acetate tracing to measure five wounds that were artificially created on a cadaver specimen. In addition, the clinicians used an analog centimeter ruler to determine a rough estimate of the area of each wound. The wounds were measured a total of five times with each measurement instrument using a non-sequential repeat measures design. Associations between the three wound measurement techniques were examined with Pearson correlation coefficients. In addition, intraclass correlation coefficients (ICC) were calculated for each pair of the three measurement techniques. RESULTS: Correlation between the measurement systems for all raters combined yielded Pearson r-values of 0.93 for ruler and acetate, 0.95 for ruler and digital and 0.97 for acetate and digital. Furthermore, the average measure ICC between acetate and digital was 0.94, between acetate and ruler was 0.76 and between digital and ruler was 0.57. CONCLUSION: These results suggest that wound area measurements obtained using digital videometry and acetate tracing are very similar and both techniques can be used interchangeably in either clinical or research settings.
Acetates↗
Systemic hyperbaric oxygen therapy: lower-extremity wound healing and the diabetic foot.
OBJECTIVE: To document peer-reviewed medical publications that have reported on hyperbaric oxygen (HBO) therapy as an adjunct to standard lower-extremity wound care, focusing on publications dealing with the diabetic foot. RESEARCH DESIGN AND METHODS: A review of the medical literature was conducted using MEDLINE. Research articles involving HBO treatment and the diabetic foot were critiqued to identify factors that may have been a source of bias. RESULTS: Of the published reports on human studies, seven involved diabetes-related foot pathology. Five of these studies, two of which were randomized, included a control group that did not receive HBO therapy The controlled diabetic foot studies included an average of 28 subjects in the HBO therapy group (range 10-62) and an average of 16.2 subjects in the non-HBO control group (range 5-33). Most of the published reports have several potential sources of bias, including, but not limited to, inadequate evaluation of comorbid conditions relevant to wound healing, small sample size, and poor documentation of wound size or severity. Four of the seven reports involving the diabetic foot were published by a group of researchers at the University of Milan between 1987 and 1996. CONCLUSIONS: Additional randomized placebo-controlled clinical trials in large diabetic populations would further lend credence to the presumption that HBO therapy improves clinical outcomes. Given the relatively high cost of this treatment modality, perhaps a more acute awareness of the medical literature would reduce the economic burden that HBO therapy imposes on care providers that are financially at risk.
Clinical Trials as Topic↗
Diabetes-related lower-extremity amputations disproportionately affect Blacks and Mexican Americans.
BACKGROUND: We sought to identify the age-adjusted incidence of lower-extremity amputation (LEA) in Mexican Americans, blacks, and non-Hispanic whites with diabetes in south Texas. METHODS: We summarized medical records for hospitalizations for LEAs for 1993 in six metropolitan statistical areas in south Texas. RESULTS: Age-adjusted incidence per 10,000 patients with diabetes was 146.59 in blacks, 60.68 in non-Hispanic whites, and 94.08 in Mexican Americans. Of the patients, 47% of amputees had a history of amputation, and 17.7% were hospitalized more than once during 1993. Mexican Americans had more diabetes-related amputations (85.9%) than blacks (74.7%) or non-Hispanic whites (56.3%). CONCLUSIONS: This study is the first to identify the incidence of diabetes-related lower-extremity amputations in minorities using primary data. Minorities had both a higher incidence and proportion of diabetes-related, LEAs compared with non-Hispanic whites. Public health initiatives and national strategies, such as Healthy People 2000 and 2010, need to specifically focus on high-risk populations and high-risk geographic areas to decrease the frequency of amputation and reamputation.
Black or African American↗
Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings.
OBJECTIVE: To determine the frequency and constellations of anatomic, pathophysiologic, and environmental factors involved in the development of incident diabetic foot ulcers in patients with diabetes and no history of foot ulcers from Manchester, U.K., and Seattle, Washington, research settings. RESEARCH DESIGN AND METHODS: The Rothman model of causation was applied to the diabetic foot ulcer condition. The presence of structural deformities, peripheral neuropathy, ischemia, infection, edema, and callus formation was determined for diabetic individuals with incident foot ulcers in Manchester and Seattle. Demographic, health, diabetes, and ulcer data were ascertained for each patient. A multidisciplinary group of foot specialists blinded to patient identity independently reviewed detailed abstracts to determine component and sufficient causes present and contributing to the development of each patient's foot ulcer. A modified Delphi process assisted the group in reaching consensus on component causes for each patient. Estimates of the proportion of ulcers that could be ascribed to each component cause were computed. RESULTS: From among 92 study patients from Manchester and 56 from Seattle, 32 unique causal pathways were identified. A critical triad (neuropathy, minor foot trauma, foot deformity) was present in > 63% of patient's causal pathways to foot ulcers. The components edema and ischemia contributed to the development of 37 and 35% of foot ulcers, respectively. Callus formation was associated with ulcer development in 30% of the pathways. Two unitary causes of ulcer were identified, with trauma and edema accounting for 6 and < 1% of ulcers, respectively. The majority of the lesions were on the plantar toes, forefoot, and midfoot. CONCLUSIONS: The most frequent component causes for lower-extremity ulcers were trauma, neuropathy, and deformity, which were present in a majority of patients. Clinicians are encouraged to use proven strategies to prevent and decrease the impact of modifiable conditions leading to foot ulcers in patients with diabetes.
Adult↗
Effects of diabetes mellitus on the biomechanical properties of human ankle cartilage.
Metabolic changes attributable to diabetes mellitus affect numerous organ systems in the body. For example, patients with diabetes have an increased number of musculoskeletal injuries and afflictions compared with patients without diabetes and experience more morbidity associated with injury and treatment. Although diabetes also may afflict articular cartilage, no studies have shown a conclusive link between diabetes and cartilage structural integrity. The objective of this study was to obtain and compare the intrinsic material properties of human ankle articular cartilage from patients with diabetes and those without diabetes. These biomechanical properties (aggregate modulus, Poisson's ratio, shear modulus, and permeability) were found to differ significantly between specimens from patients with diabetes and patients without diabetes. Specifically, cartilage from patients with diabetes was significantly softer and more permeable than cartilage from control subjects. For example, in the central portion of the talus, cartilage from patients with diabetes had a 38% smaller aggregate modulus, 37% smaller shear modulus, and 111% larger permeability than did tissue from patients without diabetes. These results provide evidence that joint pathologic processes in patients with diabetes may be associated with compromised structural integrity of articular cartilage.
Adolescent↗
Diabetic foot ulcers: prevention, diagnosis and classification.
Diabetic ulcers are the most common foot injuries leading to lower extremity amputation. Family physicians have a pivotal role in the prevention or early diagnosis of diabetic foot complications. Management of the diabetic foot requires a thorough knowledge of the major risk factors for amputation, frequent routine evaluation and meticulous preventive maintenance. The most common risk factors for ulcer formation include diabetic neuropathy, structural foot deformity and peripheral arterial occlusive disease. A careful physical examination, buttressed by monofilament testing for neuropathy and noninvasive testing for arterial insufficiency, can identify patients at risk for foot ulcers and appropriately classify patients who already have ulcers or other diabetic foot complications. Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation. Adherence to a systematic regimen of diagnosis and classification can improve communication between family physicians and diabetes subspecialists and facilitate appropriate treatment of complications. This team approach may ultimately lead to a reduction in lower extremity amputations related to diabetes.
Amputation, Surgical↗
Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration.
OBJECTIVE: To evaluate the sensitivity and specificity of 3 sensory perception testing instruments to screen for risk of diabetic foot ulceration. METHODS: This case-control study prospectively measured the degree of peripheral sensory neuropathy in diabetic patients with and without foot ulcers. We enrolled 115 age-matched diabetic patients (40% male) with a case-control ratio of approximately 1:3 (30 cases and 85 controls) from a tertiary care diabetic foot specialty clinic. Cases were defined as individuals who had an existing foot ulceration or a history of a recently (< 4 weeks) healed foot ulceration. Controls were defined as subjects with no foot ulceration history. Using receiver operating characteristic analysis, we evaluated the sensitivity and specificity of 2 commonly used nephropathy assessment tools (vibration perception threshold testing and the Semmes-Weinstein 10-g monofilament wire system) and a 4-question verbal neuropathy score to evaluate for presence of foot ulceration. RESULTS: A vibration perception threshold testing using 25 V and lack of perception at 4 or more sites using the Semmes-Weinstein 10-g monofilament wire system had a significantly higher specificity than neuropathy score used. The neuropathy score was most sensitive when 1 or more answers were affirmative. When modalities were combined, particularly the monofilament wire system plus vibration perception threshold testing and the neuropathy score plus the monofilament wire system, there was a substantial increase in specificity with little or no diminution in sensitivity. CONCLUSIONS: The early detection of peripheral neuropathy or loss of "protective sensation" is paramount to instituting a structured treatment plan to prevent lower extremity amputation. The results of our study suggest that all 3 sensory perception testing instruments are sensitive in identifying patients at risk for ulceration. Combining modalities appears to increase specificity with very little or no diminution in sensitivity.
Adult↗
Practical criteria for screening patients at high risk for diabetic foot ulceration.
BACKGROUND: A comprehensive understanding of clinical risk factors for developing foot ulcerations would help clinicians to categorize patients by their risk status and schedule intervention resources accordingly to prevent amputation. OBJECTIVE: To evaluate risk factors for foot ulcerations among persons with diabetes mellitus. METHOD: We enrolled 225 age-matched patients, 46.7% male, with a ratio of approximately 1:2 cases: controls (76 case-patients and 149 control subjects). Case-patients were defined as subjects who met the enrollment criteria and who had an existing foot ulceration or a recent history of a foot ulceration. Control subjects were defined as subjects with no history of foot ulceration. A stepwise logistic regression model was used for analysis. RESULTS: An elevated plantar pressure (> 65 N/cm2), history of amputation, lengthy duration of diabetes (> 10 years), foot deformities (hallux rigidus or hammer toes), male sex, poor diabetes control (glycosylated hemoglobin > 9%), 1 or more subjective symptoms of neuropathy, and an elevated vibration perception threshold (> 25 V) were significantly associated with foot ulceration. In addition, 59 patients (78%) with ulceration had a rigid deformity directly associated with the site of ulceration. No significant associations were noted between vascular disease, level of formal education, nephropathy, retinopathy, impaired vision, or obesity and foot ulceration on multivariate analysis. CONCLUSIONS: Neuropathy, foot deformity, high plantar pressures, and a history of amputation are significantly associated with the presence of foot ulceration. Although vascular and renal disease may result in delayed wound healing and subsequent amputation, they are not significant risk factors for the development of diabetic foot ulceration.
Adult↗
Risk factors for diabetic foot ulceration: a logical approach to treatment.
Appropriate management of the diabetic foot in a multidisciplinary setting requires knowledge of the risk factors leading to ulceration and limb loss. This article will review the most common risk factors for ulceration and present a validated, treatment-based method to appropriately communicate both the status of the diabetic wound and, more important, the patient's location on a spectrum of risk for amputation.
Diabetic Foot↗
Acute Charcot's arthropathy of the foot and ankle.
With the possible exception of osteomyelitis, Charcot's arthropathy is perhaps the most debilitating orthopedic sequela of diabetes mellitus. For this reason, early diagnosis and aggressive, noncompromising immobilization, pressure reduction, and consistent follow-through are paramount to effecting an acceptable result.
Algorithms↗
Risk factors for above-knee amputations in diabetes mellitus.
BACKGROUND: Above-knee amputation (AKA) is a common complication in diabetics, mostly after one or more lower level amputations (LEAs) have been done. The aim of this study was to identify risk factors for AKAs among diabetics. METHODS: We abstracted 1,800 medical records of hospitalizations for LEA. Kaplan's comorbidity classification was used to rank disease severity. We used both univariate and multivariate models to identify risk factors for AKA. RESULTS: Of the 1,043 diabetic amputees in this study, 22% had AKA. Variables associated with AKA were locomotor impairment, severe anemia, history of lower extremity bypass surgery, body mass index (BMI) < 20 kg/m2, female sex, cerebrovascular disease, cardiovascular disease, and SGOT > 40 U/L. CONCLUSIONS: Most of these risk factors represent end-stage processes and do not have good treatment alternatives. Perhaps one of the practical applications of these data is not to describe risk of proximal amputations but instead to look more closely at candidates who should be considered for distal procedures.
Activities of Daily Living↗
Elevated peak plantar pressures in patients who have Charcot arthropathy.
Although diabetes and peripheral neuropathy are perhaps the most important risk factors for neuropathic osteoarthropathy, we hypothesized that peak plantar pressures may also be higher in patients who have this condition. We are unaware of any reports in the medical literature that have specifically addressed this hypothesis. We obtained data from the medical records of 164 diabetic patients who had been managed in a multidisciplinary tertiary-care diabetic foot-specialty clinic. We then divided the patients into four groups: those who had acute Charcot arthropathy, those who had neuropathic ulceration, those who had neuropathy without ulceration, and those who had neither neuropathy nor ulceration. The peak plantar pressures were significantly higher in the patients who had acute Charcot arthropathy and those who had a neuropathic ulcer (p < 0.001 for both) compared with the pressures in those who had no history of arthropathy and those who had neuropathy without ulceration. With the numbers available, we could not detect a significant difference in the peak pressure between the affected and the unaffected foot in the patients who had Charcot arthropathy (mean [and standard deviation], 100+/-8.5 compared with 101+/-9.6 newtons per square centimeter; p > 0.05). However, the mean peak pressure was significantly higher on the ulcerated side than on the contralateral side in the patients who had a neuropathic ulcer (90+/-18.8 compared with 86+/-20.7 newtons per square centimeter; p < 0.02). Although the midfoot was the site of maximum involvement in all patients who had Charcot arthropathy, the peak plantar pressure was on the forefoot, suggesting that the forefoot may function as a lever, forcing collapse in the midfoot.
Acute Disease↗
Role of neuropathy and high foot pressures in diabetic foot ulceration.
OBJECTIVE: High plantar foot pressures in association with peripheral neuropathy have been ascertained to be important risk factors for ulceration in the diabetic foot. Most studies investigating these parameters have been limited by their size and the homogeneity of study subjects. The objective of this study was therefore to ascertain the risk of ulceration associated with high foot pressures and peripheral neuropathy in a large and diverse diabetic population. RESEARCH DESIGN AND METHODS: We studied a cross-sectional group of 251 diabetic patients of Caucasian (group C) (n=121), black (group B) (n=36), and Hispanic (group H) (n=94) racial origins with an overall age of 58.5+/-12.5 years (range 20-83). There was an equal distribution of men and women across the entire study population. All patients underwent a complete medical history and lower extremity evaluation for neuropathy and foot pressures. Neuropathic parameters were dichotomized (0/1) into two high-risk variables: patients with a vibration perception threshold (VPT) > or =25 V were categorized as HiVPT (n=132) and those with Semmes-Weinstein monofilament tests > or =5.07 were classified as HiSWF (n=190). The mean dynamic foot pressures of three footsteps were measured using the F-scan mat system with patients walking without shoes. Maximum plantar pressures were dichotomized into a high-pressure variable (Pmax6) indicating those subjects with pressures > or =6 kg/cm2 (n=96). A total of 99 patients had a current or prior history of ulceration at baseline. RESULTS: Joint mobility was significantly greater in the Hispanic cohort compared with the other groups at the first metatarsal-phalangeal joint (C 67+/-23 degrees, B 69+/-23 degrees, H 82+/-23 degrees, P=0.000), while the subtalar joint mobility was reduced in the Caucasian group (C 21+/-8 degrees, B 26+/-7 degrees, H 27+/-11 degrees, P=0.000). Maximum plantar foot pressures were significantly higher in the Caucasian group (C 6.7+/-2.9 kg/cm2, B 5.7+/-2.8 kg/cm2, H 4.4+/-1.9 kg/cm2, P=0.000). Univariate logistic regression for Pmax6 on the history of ulceration yielded an odds ratio (OR) of 3.9 (P=0.000). For HiVPT, the OR was 11.7 (P=0.000), and for HiSWF the OR was 9.6 (P=0.000). Controlling for age, diabetes duration, sex, and race (all P < 0.05), multivariate logistic regression yielded the following significant associations with ulceration: Pmax6 (OR=2.1, P=0.002), HiVPT (OR=4.4, P=0.000), and HiSWF (OR=4.1, P=0.000). CONCLUSIONS: We conclude that both high foot pressures (> or =6 kg/cm2) and neuropathy are independently associated with ulceration in a diverse diabetic population, with the latter having the greater magnitude of effect. In black and Hispanic diabetic patients especially, joint mobility and plantar pressures are less predictive of ulceration than in Caucasians.
Adult↗