The economic burden of diabetic foot and ankle disorders

Etiology, diagnosis, complications, and treatments of diabetic foot

Background: Diabetic foot is one of the complications of diabetes mellitus, accompanied by infection, ulcer, deformity, and neuropathic arthropathy. The prevalence of diabetic foot is approximately 10% to 20% in adult diabetic patients over 30 years. Patients with diabetic foot show decreased life quality due to long-term treatment and hospital admission for various complications. Therefore, it is important to understand the etiology of diabetic foot and to prevent the accompanying complications.Current Concepts: Multiple complications of diabetic foot such as ulcers, infections, and deformities are derived from neuropathy (sensory, motor, and autonomic nerves) and angiopathy. Careful physical and radiologic examinations and laboratory evaluations are necessary to diagnose diabetic foot. Dressings, surgical decompressions, antibiotics, and vascular interventions are helpful for the treatment of ulcers in diabetic foot. Maintaining proper blood glucose levels and medication help control the neuropathies. Furthermore, patients should be educated on careful foot care to prevent complications.Discussion and Conclusion: Diabetic foot and its accompanying complications are difficult to treat and decrease patients’ quality of life. To prevent complications of diabetic foot, management of blood glucose, patient education on self-foot care, screening of high-risk factors, and cooperation of various medical specialists are needed.

A systematic review of ankle fracture treatment modalities in diabetic patients

AIM

This systematic review evaluated the surgical outcomes of various ankle fracture treatment modalities in patients with Diabetes Mellitus as well as the methodological quality of the studies.

METHODS

For our review, four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). The overall methodological quality of the studies was assessed with the Coleman Methodology Score. Data regarding diabetic ankle fractures were pooled into three outcomes groups for comparison: (1) the standard fixation cohort with management of diabetic ankle fractures using ORIF with small or mini fragment internal fixation techniques following AO principles, (2) the minimally invasive cohort with diabetic ankle fracture management utilizing percutaneous cannulated screws or intramedullary fixation, and (3) the combined construct cohort treated with a combination of ORIF and another construct (transarticular or external fixation).

RESULTS

The search strategy identified 2228 potential studies from the four databases and 11 were included in the final review. Compared to the standard fixation cohort, the minimally invasive cohort had increased risk of hardware breakage or migration and the combined constructs cohort had increased risk of hardware breakage or migration, surgical site infection and nonunion. Limb salvage rates were similar for the standard fixation and minimally invasive cohorts; however, the combined constructs cohort had a significantly lower limb salvage rate compared to that of the standard fixation cohort. The mean Coleman Methodology Score indicated the quality of the studies in the review was poor and consistent with its limitations.

DISCUSSION

The overall quality of published studies on operative treatment of diabetic ankle fractures is low. Treating diabetic ankle fractures operatively results in a high number of complications regardless of fixation method. However, limb salvage rates remain high overall at 97.9% at a mean follow-up of 21.7 months. To achieve improved limb salvage rates and decrease complications, it is critical is to follow basic AO principles, respect the soft tissue envelope or utilize minimally invasive techniques, and be wary that certain combined constructs may be associated with higher complication rates.

LEVEL OF EVIDENCE

2.

Outcomes after foot surgery in people with a diabetic foot ulcer and a 12-month follow-up

OBJECTIVE

The aim of this study was to retrospectively measure the outcomes of foot-sparing surgery at one year follow-up for patients with diabetic foot ulcers (DFUs). We assessed wound healing and the need for further surgery in relation to the variables that influence healing.

METHOD

Data were retrospectively collected by reviewing the electronic files of patients attending the Wound Expert Clinic (WEC). Outcomes of surgical debridement, toe, ray and transmetatarsal amputations were assessed.

RESULTS

A total of 129 cases in 121 patients were identified for inclusion. The results demonstrated that complete wound healing was reached in 52% (61/117) of the patients within 12 months. The need for additional surgery or for major amputation was 56% (n=72/129) and 30% (n=39/129) respectively. The need for an additional procedure was particularly high after surgical debridement (75%, 33/44) and transmetatarsal amputation (64%, 7/11). Risk factors for non-healing or for a major amputation were: infection (p=0.01), ischaemia (p=0.01), a history of peripheral arterial occlusive disease (p<0.01) and smoking (p=0.01). Additional findings were that not all patients underwent vascular assessment and in half of the patients there was a delay in undergoing revascularisation.

CONCLUSION

The results of the study reveal some areas for improvement including timely revascularisation and performance of multiple debridement procedures if needed in order to save a limb.

Evaluation of Peripheral Neuropathy of Unknown Origin in an Outpatient Foot and Ankle Practice

BACKGROUND

The foot and ankle surgeon can see peripheral neuropathy in the treatment of foot and ankle conditions. The purpose of this study was (1) to evaluate the demographics and presenting complaints of patients diagnosed with idiopathic peripheral neuropathy during an examination by a foot and ankle surgeon and (2) to identify the type and frequency of subsequent diagnosis of medical causes of neuropathy.

METHODS

This was a retrospective study of patients diagnosed with idiopathic peripheral neuropathy in our practice between January 1997 and December 2008. Ninety-five patients were identified, and demographic data, presenting complaints, and medical comorbidities were extracted from the medical record. Examination findings of decreased sensation to Semmes Weinstein 5.07 monofilament testing were documented, and electromyogram and nerve conduction study results were reviewed when available. Laboratory values were noted, as were neurologic evaluations performed to diagnose medical conditions associated with peripheral neuropathy.

RESULTS

The most common presentation was foot pain, in 36 patients (38%). Ninety-one patients had Semmes Weinstein 5.07 monofilament testing, with loss of protective sensation reported in 75 of the 91 tested (82%). Only 30 of the 95 patients had electromyogram and nerve conduction study results available, with a test positive for peripheral neuropathy in 20 of the 30 tested. Thirty-two patients were evaluated by a neurologist. A specific cause was identified in 12 of the 32 seen by a neurologist. Of the total group of 95 patients, 31 patients (33%) were diagnosed with a condition that may be associated with peripheral neuropathy.

CONCLUSIONS

Thirty-three percent of the patients presenting to our clinic and given a diagnosis of idiopathic peripheral neuropathy were ultimately diagnosed with a medical cause of neuropathy-most commonly, diabetes. For those patients with idiopathic neuropathy, a spectrum of disease was encountered, including pain, ulcer, infection, and Charcot neuroarthropathy.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Competing in value-based health care: keys to winning the foot race

The US health care system is transitioning to a value-based model of health care in which providers will be rewarded for delivering services that achieve excellent clinical outcomes with efficient cost utilization. The concept of "value" in health care (defined as health outcomes achieved per dollar spent) is rapidly spreading as physicians and health systems brace for the paradigm shift from "fee-for-volume" to "fee-for-value" reimbursement. What constitutes good value versus poor value in health care remains nebulous at this time. Various specialties across medicine and within orthopaedics are seeking to better demonstrate value delivered to patients, payers, and policy makers. The objective of this article is to develop a framework for defining and measuring value in foot and ankle surgery. In this new era of health care, we believe that a working knowledge of value and its determinants will be imperative for foot and ankle surgeons to unify research and quality improvement efforts so as to demonstrate the value of services rendered within the subspecialty.

LEVEL OF EVIDENCE

Level V, expert opinion.

Economic burden of foot and ankle surgery in the US Medicare population

BACKGROUND

Musculoskeletal diseases affecting the foot and ankle are common and can result in debilitating pain and chronic disability. The purpose of this study was to estimate the economic burden associated with operative interventions targeting these afflictions in the Medicare population.

METHODS

Procedure incidence was determined using data from Medicare Part B National Summary Data Files (for 2000-2011). Health care and productivity costs were estimated for each year using an incidence-based cost model, using demographic information from 10 633 patient encounters at the University of Iowa Hospitals and Clinics over the period January 1, 2000, to December 31, 2010.

RESULTS

The estimated economic burden of foot and ankle surgery in the Medicare population was $11 billion in 2011, up 38.2% since 2000. Direct health care costs were responsible for only 11% of this total, while indirect productivity costs contributed the remainder. Procedures targeting the foot accounted for over two-thirds of total economic burden, or $7.6 billion. Treatments for fracture and dislocation contributed the most to overall economic burden (31.0% of total), followed by reconstructive procedures (30.7%) and amputations (13.3%).

CONCLUSION

Even in an older population, considerable productivity losses are associated with foot and ankle surgery. An increasing share of the population older than 65 expects to be fit to work, making disability in older Americans more monetarily important. At the same time, trends in chronic disease mean that the incidence of foot and ankle problems is likely to increase in the Medicare population.

LEVEL OF EVIDENCE

Level III, economic analysis.

Autologous G-CSF-mobilized peripheral blood CD34+ cell therapy for diabetic patients with chronic nonhealing ulcer

Recently, animal studies have demonstrated the efficacy of endothelial progenitor cell (EPC) therapy for diabetic wound healing. Based on these preclinical studies, we performed a prospective clinical trial phase I/IIa study of autologous G-CSF-mobilized peripheral blood (PB) CD34(+) cell transplantation for nonhealing diabetic foot patients. Diabetic patients with nonhealing foot ulcers were treated with 2 × 10(7) cells of G-CSF-mobilized PB CD34(+) cells as EPC-enriched population. Safety and efficacy (wound closure and vascular perfusion) were evaluated 12 weeks posttherapy and further followed for complete wound closure and recurrence. A total of five patients were enrolled. Although minor amputation and recurrence were seen in three out of five patients, no death, other serious adverse events, or major amputation was seen following transplantation. Complete wound closure was observed at an average of 18 weeks with increased vascular perfusion in all patients. The outcomes of this prospective clinical study indicate the safety and feasibility of CD34(+) cell therapy in patients with diabetic nonhealing wounds.

An algorithm for limb salvage for diabetic foot ulcers

The treatment of diabetic foot ulceration is complex with multiple considerations often leading to limb amputation. This article presents the usefulness of a multidisciplinary approach along with an algorithm to manage and salvage diabetic foot ulcers from amputation. This algorithm is a step-by-step guide to manage the diabetic foot ulcer and can help one in the selection of patients for limb salvage reconstruction.

Diabetes cost model of a hospital in Thailand

OBJECTIVE

This study aims to formulate a cost model from a provider perspective regarding the direct medical costs for diabetic patients who received care in a 30-bed public hospital in Thailand during the fiscal year of 2001.

METHODS

This study is a retrospective prevalence-based cost of illness study. Data were collected by reviewing the medical record of each patient for the whole year. The statistical analysis employed was the stepwise multiple regression method.

RESULTS

The study covered 186 diabetic patients. It was found that the average cost of caring for a diabetic patient per year was 6331 Thai baht (THB) at 2001 prices (approximately 40 THB = US 1 dollar). A major portion of this cost was spent for pharmacy services, which accounted for 45% of the whole cost, followed by outpatient services (24%), inpatient services (16%), and laboratory investigation (11%). Regarding the model for forecasting the cost, the type of diabetes and its accompanying complications, i.e., hyperlipidemia, cardiovascular accident, hypertension, hyperglycemia, hypoglycemia, gangrene, and diabetic foot, were considered as significant predictor variables (adjusted R(2) = 0.48). The quantitative effects in monetary term of these significant predictors were also demonstrated.

CONCLUSIONS

The results could be beneficial in forecasting the economic burden of diabetes mellitus in Thailand. Furthermore, the results could be used as a financial tool for cost control and disease management at the community hospital level.

Foot and ankle problems of Aboriginal and non-Aboriginal diabetic patients with end-stage renal disease

BACKGROUND

There is little information available about the profile of lower extremity morbidity in diabetic patients with end-stage renal disease (ESRD) in the Canadian Aboriginal and non-Aboriginal population.

METHOD

A retrospective review of medical records in 127 diabetic patients on hemodialysis at a tertiary health care center was performed. Patient interviews and physical examinations were performed in 77 of these patients (36 Aboriginal, 41 non-Aboriginal), and followup evaluation was done in 39 patients at an average of 1 year later.

RESULTS

Aboriginal patients were an average of 7 years younger than non-Aboriginal patients. Comorbidities of diabetes and ESRD were frequent. Peripheral neuropathy and inability to occlude the vessels were present in the majority of feet. Lower extremity complications were frequent, including prior foot ulcer in the majority of patients and an amputation in more than one fourth of the patients. Aboriginal patients had a significantly greater frequency of prior foot ulcer, mean number of foot ulcers per patient, amputation, prior osteomyelitis, and Charcot foot than non-Aboriginal patients. Almost all patients were at risk for future foot ulcer, but many patients did not inspect their feet daily. Home care was significantly less frequently available for Aboriginal than non-Aboriginal patients. The majority of patients had inadequate custom or prefabricated shoes and did not wear insoles on the day of examination. Aboriginal patients cited financial cost, insufficient family support, and language barriers as reasons for inadequate foot care and footwear more frequently than non-Aboriginal subjects. A significantly smaller frequency of Aboriginal patients had good knowledge of footwear or diet than non-Aboriginal patients.

CONCLUSIONS

Lower extremity complications were significantly more frequent in Aboriginal than non-Aboriginal diabetic patients with ESRD. Financial cost and knowledge deficit were barriers to adequate foot care and footwear. These findings support the need for a formal foot care and footwear program for this high-risk population.

Clinical management of diabetic foot infection: diagnostics, therapeutics and the future

Diabetic foot infection accounts for a substantial global burden of morbidity, psychosocial disruption and economic cost. Recommendations for best practice are continuously evolving in parallel with improvements in imaging modalities, development and clinical use of new antimicrobial agents and data surrounding novel adjunctive strategies. We discuss this complex group of infections with a particular emphasis on medical management of osteomyelitis, while also highlighting the importance of a broad multidisciplinary approach to eradicating infection.

Treatment for diabetic foot ulcers

People with diabetes develop foot ulcers because of neuropathy (sensory, motor, and autonomic deficits), ischaemia, or both. The initiating injury may be from acute mechanical or thermal trauma or from repetitively or continuously applied mechanical stress. Patients with clinically significant limb ischaemia should be assessed by a vascular surgeon to determine the need for angioplasty, stenting, or femorodistal bypass. When infection complicates a foot ulcer, the combination can be limb or life-threatening. Infection is defined clinically, but wound cultures reveal the causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and should aim to cure the infection, not to heal the wound. Alleviation of the mechanical load on ulcers (off-loading) should always be a part of treatment. Neuropathic ulcers typically heal in 6 weeks with total contact casting, because it effectively relieves pressure at the ulcer site and enforces patient compliance. The success of other approaches to off-loading similarly depends on the patients' adherence to the effectiveness of pressure relief. Surgery to heal ulcers and prevent recurrence can include tenotomy, tendon lengthening, reconstruction, or removal of bony prominences. However, these procedures may result in secondary ulceration and other complications. Ulcer recurrence rates are high, but appropriate education for patients, the provision of posthealing footwear, and regular foot care can reduce rates of re-ulceration.

The global burden of diabetic foot disease

Diabetic foot problems are common throughout the world, resulting in major economic consequences for the patients, their families, and society. Foot ulcers are more likely to be of neuropathic origin, and therefore eminently preventable, in developing countries, which will experience the greatest rise in the prevalence of type 2 diabetes in the next 20 years. People at greatest risk of ulceration can easily be identified by careful clinical examination of the feet: education and frequent follow-up is indicated for these patients. When assessing the economic effects of diabetic foot disease, it is important to remember that rates of recurrence of foot ulcers are very high, being greater than 50% after 3 years. Costing should therefore include not only the immediate ulcer episode, but also social services, home care, and subsequent ulcer episodes. A broader view of total resource use should include some estimate of quality of life and the final outcome. An integrated care approach with regular screening and education of patients at risk requires low expenditure and has the potential to reduce the cost of health care.