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Orthopedists should assume educator role with patients with diabetic foot disease

Three foot and ankle specialists present the main orthopedic responsibilities for preventing and managing diabetic foot disease.

Issue: February 2006

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Diabetic foot problems continue to increase in the United States. Of the 16 million Americans with diabetes, 25% have peripheral neuropathy and a third of those patients face risks for developing an ulcer, Michael S. Pinzur, MD, of Loyola University in Chicago, told Orthopedics Today.

�Once a diabetic gets a foot ulcer, their risk for going on to a lower extremity amputation is increased by a factor of eight,� he said. What�s more, between 30% and 50% of lower extremity amputees will undergo amputation for the opposite limb within five years.

With these increasing numbers, orthopedists have begun to play a larger role in wound healing, minimizing amputation risk and preventing new or recurring wounds. They are vital members of a team that provides all necessary care to diabetic patients, including ophthalmologists and vascular surgeons, among others.

To find out the main orthopedic responsibilities in diabetic foot care, Orthopedics Today spoke with three surgeons who have extensive experience in the area. What follows is their expert guidance in treating the diabetic patient.

The diabetic patient

Primary care doctors refer diabetic patients to an orthopedic surgeon for foot disease or the same complaints as any other patient, usually hip and knee problems, Steven Douglas K. Ross, MD, American Orthopedic Foot and Ankle Society (AOFAS) vice president, told Orthopedics Today.

Ross, who is also an Orthopedics Today editorial board member, said that in his practice, he usually sees diabetic patients with skin and toenail problems, ulcerations or Charcot or neuropathic arthropathy patients.

[Diabetic patients] have decreased ability to fight infections, so [they have] a higher incidence of in-grown toenails, � complications with being dysvascular, loss of blood supply � and of course the consequences related to their loss of protective sensation,� Ross said.

Neurofunction loss also causes muscle strength loss in the foot, which increases toe deformities and creates pressure spots that can cause ulcers, he said.

Education

When these patients visit the office for a diabetic foot disease problem or another orthopedic issue, the orthopedist can educate them on how to perform a foot exam or inspection, Carol Frey, MD, of the Orthopedic Foot and Ankle Center in Manhattan Beach, Calif., told Orthopedics Today.

Frey, who is also an Orthopedics Today editorial board member, suggested: �Have a check list in your office to give to the diabetic patient on �Care of the Feet.��

Often, diabetic patients develop hyperglycemia, which leads to diminished blood supply and a decreased protective sensation. �The orthopedist is in a unique position to provide an understanding of how diabetes affects the musculoskeletal system, especially the foot and ankle,� Ross said.

Daily activities and repetitive strain can damage diabetic patients� feet. Orthopedists could teach them to protect their feet using other senses. �They have to learn a program of visualizing their feet, washing their feet carefully each day, inspecting their feet to make sure there�s no evidence of rubbing or irritation on the deformities,� Ross said. �And of course, reinforcing their need to have excellent control of their hyperglycemia.�

Pinzur, however, said that the education and counseling might be better received from a diabetic educator and not the physician. Literature shows that patients better retain information from a nurse or someone other than a physician. �The most mature systems will have the diabetic educator involved in teaching the patient all those preventive measures they need to know to take care of their feet,� he said.

Solving the problem

Orthopedists also need to identify diabetic patients at risk for lower extremity amputations, Pinzur said. One red flag: those patient with a previous amputation, foot infection or ulcer. Peripheral neuropathy, common among patients who�ve had diabetes for 10 years or more, is another high-risk factor.

Physicians measure peripheral neuropathy by �insensitivity to the Semmes-Weinstein 5.07 monofilament, [which] applies 10 grams of pressure to points in the foot,� Pinzur said. �If you cannot feel 10 grams of pressure, then you don�t have protective sensation and you are at risk for developing a foot ulcer.�

Other risk factors include foot deformities, severe bunions or hammertoes and poor blood supply.

Once orthopedists identify the at-risk patients, diagnostic and therapeutic programs can help resolve the underlying cause of complaint, Ross said. �We tend to be doctors of episodic care primarily,� he said. �We�re dealing with a specific problem, so the key is making sure you understand why the patient has that particular problem, whether it�s deformity � or whether it�s ulceration or even the Charcot arthropathy patient.�

Pinzur said the orthopedic surgeon should also refer necessary patients to a vascular surgeon to improve blood supply � typically those patients with ischemic pain from decreased blood supply or a non-healing ulcer.

Diabetic patients usually have vision problems or limited mobility, requiring assistance from family members or a caregiver for routine hygiene, such as nail trimming or foot inspection, Ross said. Health care personnel, including the primary care physician, nurse practitioner or podiatrist, arrange for this assistance and perform routine checks to ensure prevention of pressure problems or ulceration.

Orthopedists may also perform occasional or routine foot checks. �A thorough evaluation of the feet is essential and includes a vascular exam and sensory exam,� Frey said. �It is a good and practical idea to purchase a sensory testing nylon filament.�

The AOFAS Diabetes Committee compiled a list of Guidelines for Diabetic Foot Care suggesting how often an orthopedist should examine a patient, based on risk status. �The real high-risk people need to be seen once a month,� Pinzur said. �People at very low risk may be seen once a year or twice a year. � The higher risk people, I may need to see more often and � I may need to do a more involved exam.�

Ross explained, however, that Medicare does not cover routine foot care, unless the patient meets certain criteria, such as the dysvascular foot or neuropathy. �Those patients [who don�t meet the criteria] tend to stay with their primary care physician, who is encouraged to see the patient on a routine basis and as part of their routine examination of the patient, they would include a foot exam,� he said.

Prescribing footwear

Shoe wear and orthosis recommendations are primarily orthopedic responsibilities. When patients lose protective sensation, they should wear shoes fitted by a professional to provide adequate room and appropriate fit, Ross said.

�Be aware that the appearance of a callus is the first stage of a diabetic ulcer and signals the need for accommodative shoe wear, such as cushioned shoes and soft, molded insoles,� Frey said.

Accommodative shoe wear, such as an extra-depth shoe with an appropriate insert, avoids stress and strain on bony prominences in the foot and protects against ulceration. Orthopedists should prescribe footwear based on the patient�s foot shape, deformities and complication potential, Ross said.

�We can greatly decrease the risk for [patients] developing an ulcer and infection,� Pinzur said. �Therapeutic footwear will prevent them � statistically significantly prevent them � from developing a foot infection. If we prevent foot infection or ulcers, we decrease their risk for amputation significantly.�

He recommends prophylactic correction of deformities not accommodated with a therapeutic shoe.

Treating ulcers, infections

Early and aggressive treatment of skin lesions and open wounds or infections also falls under the orthopedist�s responsibilities list. Ulcers tend to heal slowly, Ross said, because they are usually in high-pressure areas and neuropathic patients sometimes walk on the ulceration against doctor�s orders, making it more difficult for the wound to heal.

�If you have cooperative people with good control of their diabetes and adequate blood supply, they usually will heal, but it depends on the size of the wound,� he said.

To treat ulcers, Pinzur said, orthopedists use different bracing methods to offload and remove pressure from the wound. �We may use medicated dressings � antibiotics by mouth or intravenously,� he said. �And we may do something surgical to remove infection.�

According to Frey, skin swab cultures are inaccurate and bone biopsy provides a more definite culture to indicate antibiotic coverage. �Any abscess is considered an emergency and should be drained surgically,� she said.

Amputation sometimes required

Unfortunately, some diabetic patients have non-healing wounds, severe wounds affecting the bone or gangrenous wounds from blood supply loss. These instances typically call for amputation.

�Nationally, more amputations are being done by general surgeons and vascular surgeons,� Pinzur said. �I have a bias that the orthopedic surgeon does a better job, because we�re more focused on function.�

�The training of an orthopedist is such that an amputation is a reconstructive surgery in order to return the patient to their highest level of care,� Ross said. �The orthopedist is in a unique position to understand the rehabilitation requirements of any of the levels of amputation.�

Pinzur said it comes down to the most competent physician for performing the amputation � as with any of the orthopedic responsibilities for diabetic foot care. �You need to have designated orthopedic surgeons within the community who are interested and are willing to take care of diabetics,� Pinzur said.

For more information:

• Pinzur M, Slovenkai M, Trepman E, Shields N. Guidelines for diabetic foot care: Recommendations endorsed by the Diabetes Committee of the American Orthopedic Foot and Ankle Society. Foot Ankle Int. 2005;26:113-119.