Comparison of post amputation outcome in patients with type 2 diabetes from specialized foot care centres in three developing countries.

OBJECTIVE: To evaluate post amputation outcome and associated complications in type 2 diabetic patients who had undergone major amputations in developing countries. PATIENTS AND METHODS: A total of 526 (M:F; 369:157) subjects from three centers [India (IND), n=194, Bangladesh (BAN) n=177 and Tanzania (TAN) n=155 who had undergone amputation and subsequently visited the hospital were included in this analysis. Details on foot problems and associated complications were recorded. RESULTS: The prevalence of amputations was similar in all centres. The history of minor amputation and foot deformity was high in BAN. Recurrence of foot ulceration was more in TAN (30%) than in IND (9%) and BAN (11%). Re-amputation rate was similar in all groups (3%). The use of artificial limb was most in BAN (97%). Myocardial infarction was more prevalent in IND (15%). In Tanzania, 31% had died during the follow-up period and it was 16% and 5% in IND and BAN. The causes of death were infection due to septicemia and cardiovascular events which finally led to multisystem organ failure. CONCLUSION: The outcome following a major diabetic foot amputation was compared in three developing countries. Recurrence of foot infection was common in Tanzania. The most frequent causes of death were infection and cardiovascular events.

Limited joint mobility and plantar pressure in type 1 diabetic subjects in India.

AIM: Limited joint mobility and plantar pressure in the foot has not been assessed in type 1 diabetes. The aim of this study was to investigate the joint mobility and plantar foot pressure in Asian Indian type 1 diabetic subjects and to see its association with duration of diabetes. MATERIAL AND METHODS: The joint mobility and plantar pressure were measured in 115 consecutive subjects attending the foot clinic. The study groups were: Control- non diabetic controls (n=40) (M:F 19:21) and type 1 diabetic patients (n=75) (M:F 42:33). Joint mobility was assessed using a goniometer at two sites, in the subtalar joint and in the hallux. Plantar pressure was measured using the RS-Scan platform system. Data obtained on the metatarsal heads were used for analysis. RESULTS: Patients with type 1 diabetes had significantly lesser joint mobility (p < 0.0001) and higher plantar pressure (p < 0.0001) compared with the control group. Duration of diabetes had an inverse association with joint mobility (p < 0.0001). The degree of joint mobility was more restricted in patients with longer duration of diabetes. Plantar pressure increased with increasing duration of diabetes. CONCLUSION: In conclusion, type 1 diabetic patients in India had limited joint mobility which decreased further with longer duration of diabetes and they had high plantar pressure also.

Amputation prevention initiative in South India: positive impact of foot care education.

OBJECTIVE: To determine whether intensive treatment and education strategies for type 2 diabetic patients with high-risk diabetic foot disease helps in preventing foot amputations. RESEARCH DESIGN AND METHODS: Participants included 4,872 consecutive type 2 diabetic patients (male-to-female ratio 3,422:1,450, mean (+/-SD) age 60.5 +/- 8.8 years, mean duration of diabetes 13.7 +/- 7.6 years) with high-risk diabetic foot disease. The patients were categorized as high-risk subjects according to the International Consensus on the Diabetic Foot. The three study groups were subjects with diabetes and neuropathy (group 1; n = 2,871), diabetic neuropathy with deformity (group 2; n = 235), and diabetic neuropathy with deformity and foot ulceration or peripheral vascular disease (group 3; n = 1,766). Neuropathy was diagnosed by biothesiometry. Peripheral vascular disease was diagnosed as an ankle brachial index <0.8. All the subjects were educated regarding diabetic foot disease and its complications and prevention. They were also instructed to visit the center if any sign of new lesions appeared. RESULTS: Among the 1,259 group 3 subjects who came for follow-up, 718 (57%) strictly followed the advice given and 541 (43%) did not. Ulcers present during the recruitment had healed in 585 (82%) subjects who followed the advice, but in only 269 (50%) subjects who did not. A significantly larger proportion of subjects who did not follow the advice developed new problems (26%) and required surgical procedures (14%) compared with those who followed the advice (5 and 3%, respectively). CONCLUSIONS: Strategies such as intensive management and foot care education are helpful in preventing newer problems and surgery in diabetic foot disease.

Effectiveness of different types of footwear insoles for the diabetic neuropathic foot: a follow-up study.

OBJECTIVE: To compare the effectiveness of different types of footwear insoles in the diabetic neuropathic foot. RESEARCH DESIGN AND METHODS: A sample of 241 consecutive diabetic patients (158 men and 83 women, age 57.5 +/- 9.6 years [mean +/- SD], and mean duration of diabetes 12.3 +/- 7.2 years) attending the foot clinic with previous foot ulceration and those considered at high risk of foot ulceration were included in the study. The study groups consisted of group 1, patients provided with sandals with insoles made with microcellular rubber (n = 100); group 2, with sandals with polyurethane foam (n = 59); group 3, with molded insoles (n = 32); and group 4, with their own footwear containing leather board insoles (n = 50). Neuropathy status was assessed using a biothesiometer. Plantar pressure was measured using the RS Scan inshoe pressure measurement system. Data obtained from the metatarsal heads were used as the peak pressure. The state of the sandals was assessed after 9 months. The patients were considered to have had an ulcer relapse when either a new ulcer appeared at the site of a previous one or a new foot ulcer appeared in a different area. RESULTS: Patients who were using therapeutic footwear showed lower foot pressure (group 1, 6.9 +/- 3.6; group 2, 6.2 +/- 3.9; and group 3, 6.8 +/- 6.1 kPa; P = 0.0001), while those who used the nontherapeutic footwear showed an increased foot pressure (group 4, 40.7 +/- 20.5 kPa; P = 0.008). The occurrence of new lesions was significantly higher in patients in group 4 (33%) when compared with that of all other groups (4%). CONCLUSION: Therapeutic footwear is useful to reduce new ulceration and consequently the amputation rate in the diabetic population.