Cost of diabetes-related amputations in minorities.

The objective of this study was to identify the direct cost and length of hospitalization of diabetes-related lower extremity amputations among Hispanics, African Americans, non-Hispanic whites, and Asians. The authors used a database from the office of Statewide Planning and Development in California that identified all hospitalizations for lower extremity amputations in the state in 1991. Amputation level was defined by the ICD-9-CM codes 84.11-84.18. The total hospital charges for diabetes-related lower extremity amputations for the state of California in 1991 was $141 million. The mean hospital charge (HC) per patient with all ethnic groups combined was $27,930; and the mean length of stay (LOS) was 15.9 days. African Americans had significantly higher mean charges ($32,383) and longer stays (17.3 days) compared to all other ethnic groups (p < .05). Toe-level amputations had lower HC (p < .05) and LOS (p < .01) than other amputation levels for all race groups. One-quarter of the population received multiple amputations during their hospital stay. These patients incurred significantly higher hospital charges ($44,731) and stayed in the hospital longer (23.4 days) than those receiving only a single amputation. There was a considerable variation in the HC and LOS among ethnic groups by level of amputation. The direct charges reported in this study suggest considerably higher overall direct costs than have been previously reported in the medical literature. The greater burden of disease experienced by African Americans is probably related to their higher amputation cost and longer hospitalization.

Is postural instability exacerbated by off-loading devices in high risk diabetics with foot ulcers?

Pressure reduction is of pivotal importance in any treatment plan designed to heal diabetic foot ulcers. However, to our knowledge, no work has evaluated the effect of ambulatory pressure reducing devices on postural stability (PS) in high risk diabetics. Therefore, the purpose of this study was to compare PS associated with 5 off-loading strategies: total contact casts with cast boot, total contact casts with heel, removable cast walker, half-shoes, and canvas shoes using a repeat measure design. Twenty-six diabetic patients with foot ulcers were enrolled in the study. Using a digital pressure platform, the degree of sway was measured as total deviation of center of force. Three 30 second trials were evaluated using Turkey's studentized range test for multiple comparisons (alpha = 0.05). Sway was significantly greater with total contact casts with heel compared to other devices. While total contact casting remains the gold standard with which to treat neuropathic ulcers, care should be taken when placing patients in any devices that may exacerbate postural instability. The results suggest that total contact casts with an incorporated rubber heel may indeed accentuate sway. It is therefore recommended that the rubber heel be eliminated in lieu of a protective cast boot when using this modality.

Total contact casts: pressure reduction at ulcer sites and the effect on the contralateral foot.

OBJECTIVE: To compare the effectiveness of total contact casts with a cast boot (TCCB), total contact casts with a cast heel (TCCH), and therapeutic XtraDepth shoes (XDS) to reduce ulcer site pressures and to determine if total contact casts increase contralateral pressures. DESIGN: Repeat measure design with 40 replications nested within each treatment for each patient. METHODS: Peak contralateral foot pressures and ulcer site pressures under the 1st metatarsal (1MET; n = 10), 2nd to 5th metatarsals (2-5MET; n = 10), and great toe (GT; n = 5) were compared using the Novel-Pedar system and three treatments: TCCB, TCCH, and XDS. Baseline pressures were established using canvas oxfords. RESULTS: There was no difference in pressure reduction with TCCH vs. TCCB for 1MET or GT ulcers, but TCCH reduced pressure better for 2-5MET ulcers (p < .001). Contralateral pressures were not elevated in either TCC group. CONCLUSIONS: TCCH were superior to TCCB in reducing 2-5MET ulcer pressures and equivalent to TCCB for 1MET and GT ulcers. Contralateral pressures are not increased by TCC use.

Reducing plantar pressure in the neuropathic foot. A comparison of footwear.

OBJECTIVE: To compare the effectiveness of therapeutic, comfort, and athletic shoes with and without viscoelastic insoles. RESEARCH DESIGN AND METHODS: We compared pressure reduction at ulcer sites under the hallux (n = 10), first metatarsal (n = 10), and lesser metatarsals (n = 12), using extra-depth, athletic, and comfort shoes with and without viscoelastic insoles. A rubber-soled canvas oxford was used to establish baseline pressure values. RESULTS: When used in conjunction with a viscoelastic insole, all shoe types reduced mean peak plantar pressure better than their non-insoled counterparts (P < 0.05). Consistently, comfort shoes reduced pressure significantly better than both the cross trainers and extra-depth shoes for ulcers under the first and lesser metatarsals (P < 0.05). For each shoe type, the addition of the viscoelastic insole provided a significant reduction in mean peak pressure (P < 0.05). Compared with stock insoles, viscoelastic insoles reduced pressures an additional 5.4-20.1% at ulcer sites. The same trend was also observed at regions of the foot not associated with an ulceration. CONCLUSIONS: When used in conjunction with a viscoelastic insole, both the comfort and athletic cross-trainer shoes studied were as, if not more, effective than commonly prescribed therapeutic shoes in reducing mean peak first and lesser metatarsal pressures. Furthermore, comfort shoes were as effective as therapeutic shoes in reducing pressure under the great toe. Both of these shoe types may be viable options to prevent the development or recurrence of foot ulcers.

1997 William J. Stickel Bronze Award. Comparison of strategies for reducing pressure at the site of neuropathic ulcers.

Few scientific data are available on the effectiveness of commonly used modalities for reducing pressure at the site of neuropathic ulcers in persons with diabetes mellitus. The authors' aim was to compare the effectiveness of total contact casts, half-shoes, rigid-soled postoperative shoes, accommodative dressings made of felt and polyethylene foam, and removable walking casts in reducing peak plantar foot pressures at the site of neuropathic ulcerations in diabetics. Using an in-shoe pressure-measurement system, data from 32 midgait steps were collected for each treatment. There was a consistent pattern in the devices' effectiveness in reducing foot pressures at ulcer sites under the great toe and ball of the foot. Removable walking casts were as effective as or more effective than total contact casts. Half-shoes were consistently the third most effective modality, followed by accommodative dressings and rigid-soled postoperative shoes.

Effectiveness of diabetic insoles to reduce foot pressures.

The F-Scan system was used to measure peak plantar pressures in 11 diabetics each with a unilateral great toe amputation and an intact contralateral extremity (nonamputated), to evaluate the effectiveness of five footwear-insole strategies: 1) extra-depth shoes without an insole, 2) extra-depth shoes with a Plastizote insole, 3) extra-depth shoes with a Plastizote insole and a metatarsal pad, 4) extra-depth shoes with a Plastizote insole and a medial longitudinal arch pad, and 5) extra-depth shoes with a Plastizote insole and a combination of metatarsal pad and arch pad. When we compared extra-depth shoes with and without insoles, peak pressures were significantly reduced with insoles under the first metatarsal, the lesser metatarsals, and the heel (p < 0.001) in feet with and without an amputation, as well as under the great toe on the contralateral foot (nonamputated, p < 0.001), but not under the lesser toes (giant toe, p = 0.088; nonamputated, p = 0.763). There was no significant difference between the different insole modifications.

A quantitative assessment of healing sandals and postoperative shoes in offloading the neuropathic diabetic foot.

The purpose of this report is to compare plantar pressures between custom healing sandals and postoperative shoes using unmodified prescription shoe gear as a control. Using a repeat measures design, we recorded the plantar forefoot pressures of eight patients classified as diabetic foot category 1 (neuropathy, no significant deformity, no history of ulceration) with each ambulating in three devices: 1) unmodified prescription shoe gear, 2) postoperative shoe gear, and 3) a custom-fabricated healing sandal. Each subject served as his or her own control. The healing sandal significantly reduced plantar forefoot pressure in all areas of the forefoot except the fifth metatarsal head. The postoperative shoe did not significantly reduce pressure at any site in the forefoot when compared with unmodified prescription shoe gear.

Reducing dynamic foot pressures in high-risk diabetic subjects with foot ulcerations. A comparison of treatments.

OBJECTIVE: To compare the effectiveness of total contact casts, commercially available therapeutic shoes, and removable walking casts to reduce mean peak plantar foot pressures at the site of neuropathic ulcerations in diabetic subjects. RESEARCH DESIGN AND METHODS: We compared the reduction in peak plantar pressures at ulcer sites under the great toe (n = 5), first metatarsal (n = 10), and second through fifth metatarsals (n = 10) using six treatments: total contact casts (TCCs), DH Pressure Relief Walkers (DH), Aircast Pneumatic Walkers, Three D Dura-Steppers (3D), CAM Walkers, and P.W. Minor Xtra Depth shoes. A rubber sole canvas oxford was used to establish baseline pressure values. The canvas oxford could be viewed as a worse-case scenario for this patient population. With the EMED Pedar in-shoe pressure measurement system, data for 40 steps were collected for each treatment. We used Tukey's Studentized Range Test for simultaneous multiple comparisons to compare treatments. RESULTS: DH Pressure Relief Walkers reduced plantar pressures significantly better than other commercially available treatments for ulcers under the first metatarsal, second through fifth metatarsals, and great toe (P < 0.05). There was not a significant difference in mean peak plantar pressures between TCCs and DHs at any of the forefoot ulcer sites. CONCLUSIONS: DH Pressure Relief Walkers were as effective as total contact casts to reduce foot pressures at ulcer sites and may be an effective practical addition in the treatment of foot ulcers.

The development of foot deformities and ulcers after great toe amputation in diabetes.

OBJECTIVE: Our aim was to compare the prevalence and severity of foot deformities and the development of ulcerations in patients after a great toe amputations. RESEARCH DESIGN AND METHODS: We evaluated the presence of deformities of the toes and metatarsophalangeal joints (MTPJs) in patients with a great toe amputation who had an intact unamputated contralateral foot. The contralateral foot served as the patient's own control. We used a binomial test for paired data to compare the presence of deformity and ulcer formation and Fisher's exact test to compare joint flexibility in toes and MTPJs with foot deformities. RESULTS: There were more deformities of the second (P = 0.012) and third (P = 0.002) toes and lesser MTPJs (P < 0.05) and more rigid deformities of the second (P = 0.002) and third (P = 0.016) toes and second MTPJs (P = 0.035) in feet with great toe amputations. New ulcers were more common in feet that had an amputation (P = 0.002). CONCLUSIONS: We concluded that amputation of the great toe contributes to the development of deformities of the second and third toes and lesser MTPJs and new ulcer formation in patients with diabetes. When deformities were present, the second and third toes and second MTPJ were more severe in feet with a great toe amputation.

Increased foot pressures after great toe amputation in diabetes.

OBJECTIVE: To compare peak pressures on the sole of the foot in non-insulin-dependent diabetic patients with isolated, unilateral amputations of the great toe and first metatarsal with the patients' contralateral, intact foot. RESEARCH DESIGN AND METHODS: Eleven patients with a unilateral great toe and partial first metatarsal amputation of at least 6 months duration were evaluated with the F-Scan in-shoe pressure measurement system. Patients were studied in the same brand and style of footwear--a thin, rubber-soled, canvas boat shoe. We compared mean peak plantar foot pressures under the first metatarsal, lesser metatarsals, lesser toes, and heel in feet with and without a great toe amputation using the Wilcoxon's matched pairs signed-rank test. RESULTS: Peak foot pressures were significantly higher under the first metatarsal head (P = 0.046), lesser metatarsal heads (P < 0.001), and toes (P < 0.001) in feet with a great toe amputation compared with the contralateral foot without an amputation. Pressure under the heel was higher on the contralateral foot (P < 0.01). CONCLUSIONS: After a great toe amputation, pressure distribution of the foot is significantly altered. Because preamputation risk factors such as peripheral neuropathy, foot deformity, and limited joint mobility for many of these patients remain unchanged, an increase in foot pressures contributes to an increased risk of reulceration and reamputation in these patients.