Pursuing Optimal Outcomes For Patients With Diabetes

The sheer numbers continue to astonish and surprise. During a lecture at the recent Annual Meeting of the American College of Foot and Ankle Surgeons, John Steinberg, DPM, noted 18.2 million people in the United States have diabetes and approximately half of them are undiagnosed. The associated complications with this disease are well known, but the latest statistics are particularly chilling. Heart disease reportedly affects people with diabetes twice as often as those who do not have diabetes. Current statistics also reveal that two out of three people with diabetes will die from a heart attack or stroke. This is all the more disturbing given the predictions from current epidemiological studies that anywhere from 250 to 300 million people worldwide will have diabetes by the year 2025. With these statistics in mind, we present our 4th Annual Diabetes Treatment theme issue, which features a collection of thought-provoking articles on different aspects of managing the diabetic foot. Leading off the issue is our cover story (see “Reassessing The Impact Of Diabetic Footwear” on page 36), which was penned by Guy Pupp, DPM and Peter Wilusz, DPM. While a controversial study in the Journal of the American Medical Association sparked a lot of spirited discussion on this topic a couple of years ago, our cover story offers a practical review of preventive and post-op indications for therapeutic shoes and other devices. For example, the authors note indications for a Charcot Restraint Orthotic Walker (CROW) include offloading of an open ulcer and post-surgical protection and transition following foot and ankle reconstruction for diabetic patients. Citing studies on the subject, they note the CROW brace can “decrease plantar, forefoot and midfoot pressures by approximately 50 percent.” Citing the patellar weightbearing brace (PTB) as a potential “mainstay in offloading the diabetic foot,” Drs. Pupp and Wilusz say using this device can facilitate up to a 90 percent reduction in plantar pressures. Addressing pressure and repetitive stress is critical in treating and preventing recurrence of diabetic foot ulcerations. With this in mind, David G. Armstrong, DPM, and Katherine Holtz-Neiderer, DPM, examine using pedometers in gauging patient activity and compliance. (See “Activity Monitoring: Can It Bolster Patient Compliance?” on page 52.) Not only could the use of pedometers identify problems with weightbearing compliance, but the authors note this activity monitoring can help identify surges and patterns of activity that patients may not even think twice about or be aware of when discussing their activity with podiatrists. As the authors point out, they feel pedometers can be especially important in monitoring patients with diabetes and neuropathy as they have a higher risk for plantar ulcers. More specifically, Drs. Armstrong and Holtz-Neiderer note facilitating a more gradual increase in activity among patients with diabetes and a previous ulceration may help reinforce tissue durability. This issue also marks the return of our Point-Counterpoint forum (see “Plantar Skin Flaps On Diabetic Ulcers: Are They Worth It?” on page 44), as Dr. Armstrong engages in debate with Gary Jolly, DPM, and Thomas Zgonis, DPM. While Dr. Armstrong feels the flaps are unnecessary in many cases, Drs. Jolly and Zgonis argue they can be a helpful alternative as the flaps can offer a better match to the unique soft tissue properties of weightbearing areas. Granted, the statistics on the increasing prevalence of diabetes are incredibly daunting, but it’s reassuring to know that DPMs continue to explore all possible treatment avenues in order to achieve optimal outcomes for their patients with diabetes.